200909 復健科案例聯合討論會.pptVIP

Major Diagnosis:  Traumatic, closed head injury, complicated with bilateral SDH of hemisphere sulci and right frontal ICH, complicated with brain edema with left midline shift Status post ICP monitor implantation on 2009/08/03 Right F-T-P craniectomy on 2009/08/04 Right frontal and temporal partial lobectomy to remove ICH on 08/04 Major diagnosis Organic brain syndrome, presented with personality and behavioral changes Intermittent disorientation Self-talking Restless behavior Easily hot temper Agitation Poor sleep, fair appetite Rehabilitation Planning Physical therapy Passive ROM Stretching training Endurance training Ambulation training Poor rehabilitation potential Assessment (9/7 at 5G ward) Urine / stool: incontinence / incontinence, on diaper No NG tube, no Foley tube, no tracheostomy Swallowing: no dysphagia Speech: mild dysarthria Comprehension: poor fluency/ repetition/ naming: unable Br. stage: Right Left UE(P): V II UE(D): V II LE : V II Functional status: rolling: good; sitting: fair; standing: poor; walking: unable Katz index of ADL: bathing:D; dressing: A; toileting: D; transfer: D; feeding: A Assessment (9/14 at 5G ward) Urine / stool: continence / continence No NG tube, no Foley tube , no tracheostomy Swallowing: no dysphagia Speech: no dysarthria Fair comprehension and spontaneous speech Poor fluency/repetition/naming pressure sore: nil Br. stage: Right Left UE(P): VI IV UE(D): VI IV LE : VI III Functional status: rolling: good; sitting: fair; standing: poor; walking: poor Katz index of ADL: bathing:A; dressing:I; toileting:A; transfer:A; feeding:I Rehabilitation Plan Physical Therapy: 傾斜床訓練: 75度* 30分鐘 促進訓練: 肌耐力訓練 平衡訓練: 坐姿平衡訓練 被動性關節運動與牽拉運動 轉位及移位訓練 運動治療 姿勢擺位與矯正訓練: 軀幹與頭部控制訓練　 Occupational therapy: Posture training ADL training Moving training Pre