Leah Rosler

Individual Treatment Plans

Patient name: Alex

Diagnosis: Polytrauma and TBI post MVA
PMH: None reported
Psycho Social/ Family situation: currently attends college and lives with 2 roommates in
an apartment; he plans to live with his parents until he is independent with ADL/ IADL
tasks and return to school. Parents home is a 2-story house with 2 steps to enter,
bedroom and bathroom on the second floor, and the shower is a tub shower
combination
Precautions: L Hip precautions, TTWB L LE, fall risk
Patients stated goals: get back to school, move back in with roommates, independent in
ADL and IADLs, driving

Medical Cause/ Description of Diagnosis:

Alex is diagnosed with polytrauma and a TBI following a MVA in which he was struck by
an SUV at a high rate of speed. Alex lost consciousness LOC after hitting his head on
steering wheel. Polytrauma can be defined by an individual experiencing injury to
multiple body parts and organ systems (2 or more severe injuries in one body area). In
Alexs case he suffered from a TBI as well as sustaining a L pelvic fracture, L orbital wall
and nasal bone fracture. As it was in Alexs case, TBI is a common combination with
polytrauma. A traumatic brain injury is an injury to the brain as a result of an external
mechanical force that can lead to either temporary or permanent impairments. TBI can
affect all aspects of life including impairments in cognitive, physical, and psychosocial
functions. Symptoms of a TBI can include headaches, nausea, dizziness, problems
walking, fatigue, irritability, memory problems, problems paying attention and problems
with thinking skills. Alex is alert and oriented x4, follows one and multiple step
directions, demonstrates appropriate safety awareness, short term memory, and basic
problem solving, but demonstrates decreased long term memory and novel/ complex
problem solving.

Models or Frame of Reference:

Alexs treatment plan will primarily be based upon the rehabilitative frame of reference.
The rehabilitative frame of reference is used when aiming at making people as
independent as possible in spite of any residual impairment. It consists of compensatory
strategies, environmental adaptation and combines both physical and psychosocial
aspects. Different rehabilitative methods include changing the task or changing the
context. In Alexs situation we will have to adapt his environment to help him become
more successful and we will also have to use adaptive equipment to compensate for his
hip precautions. The rehabilitative frame of reference is a bridge to independence and
in Alexs case he is looking to eventually go back to school and drive, both allowing him
to be a more independent 19 year old again. The rehabilitative frame of reference is
applicable in regards to Alexs intervention activities because we will be focusing on his
whole self. We will be considering his emotional state, strengthening his body,
compensating, using adaptive equipment, and doing ADL/ IADL directed tasks.

Priority Intervention STG LTG

Impairment/ Activity
Limitations/
Problem Areas
Lower body Dressing 1. Educate and train Alex will perform a Alex will perform a
Alex (and have him modified independent modified independent
perform) in how to use (because of the use of lower body dressing
a sock donner so he is adaptive equipment task (because of the use
able to successfully put such as reacher and of adaptive equipment
on his socks. sock donner) dressing such as reacher and
task by donning a pair sock donner) by putting
2. Educate and train of pants. on socks, shoes,
Alex (and have him underwear, and pants.
perform) in how to use
a reacher/ claw to grasp
and pull his pants up
past his knees so he is
able to put on pants
without breaking hip
precautions.

3. Have Alex practice

folding clothes and
placing them in drawers
while using his walker.
This will increase his
endurance and standing
balance to be able to
fully dress himself.
Bathing 1. Train and have Alex Alex will perform a Alex will perform a
practice using long modified independent modified independent
handled sponge so he is (because of his use of (because of his use of
able to successfully the long handed sponge the long handed sponge
wash his lower which is considered which is considered
extremities while adaptive equipment) adaptive equipment)
bathing. bathing task by bathing task by
washing, rinsing, and washing, rinsing and
2. Work on Alexs drying his lower drying his entire body.
dynamic sitting balance extremities with the use
while reaching for of a long handled
objects outside of his sponge.
reach so that he is able
to reach the shampoo,
body wash, and sponge
etc that may require
reaching while bathing.
 3. Alex will practice
reaching while both
sitting and standing
(with his walker) to
improve his ability to
reach for items in the
shower while he is
bathing.
Toileting 1. Alex will sit in a chair Alex will perform an Alex will independently
and practice reaching independent toileting perform the entire
for and picking up items activity by sitting and process of toileting
placed behind his back balancing on the toilet, including pulling down
so he is able to wipe his rotate his trunk, and pants, sitting on toilet,
bottom while cleaning stand back up. gathering toilet paper,
after toileting. successfully wiping,
disposing of toilet
2. Alex will practice paper, standing up,
standing up from a pulling up pants, and
sitting position to build flushing the toilet.
his leg strength to stand
up from the toilet
without breaking his hip
precautions.

3. Alex will practice

static sitting balance on
a chair or bed to
replicate the balance
that it will require for
him to sit on the toilet
without falling off or
exerting too much
energy.
Grooming 1. Alex will perform UE Alex will perform a Alex will perform a
dumbbell exercises modified independent modified independent
(including tricep (because of he is using grooming task (because
extensions) to help his adapted tooth of he is using his
increase his endurance brush) grooming task by adapted tooth brush) by
and strength to be able brushing his teeth. performing his morning
to successfully hold a routine consisting of:
brush and brush his brushing his teeth,
hair. shaving, washing his
face, and brushing his
2. Alex will practice hair.
standing with his walker
in front of a mirror
while brushing his teeth
to work on his standing
balance so he is able to
independently brush his
teeth
 3. Alex will practice
holding and
manipulating an
adapted toothbrush.
The toothbrush will
have a significantly
thicker handle so he
would not have to
utilize his fine motor
skills are precisely to
grasp the toothbrush.
Meal preparation 1. Alex will put away Alex will perform a meal Alex will perform an
dishes to practice preparation task by independent meal
reaching and navigating independently preparation task by
throughout the kitchen preparing his own following a cookie
while using his walker. simple, cold lunch recipe to mix together
(consisting of items such cookie batter.
2. Alex will as a sandwich, fruit,
independently make a vegetables, snack and
peanut butter and jelly anything else Alex
sandwich to help with would like).
his ability to
independently prepare
a meal.

3. Alex will successfully

take out and put away a
set of silverware to
work on his fine motor
coordination so he is
able to independently
handle utensils used in
meal preparation.
Group Peer Feedback

Reviewing Group Member Name: Kerri Metzel

1. What did you like about your group members completed assignment?
Description of diagnosis was very good. I liked the way you described polytrauma and
TBI and that you linked that they are common to be experienced together. The
reasoning for the approach used is explained and justified very well. The descriptions of
the uses and purpose of the approach are great. Your activities were explained well and
related to the area of focus in a logical and OT related manner.

2. What did you learn or something you can use from you group members assignment?
I thought that the level of depth in the description of the patients family situation was
really good information to include. The LTG were well thought out and I thought it was
good that you had time frames for all of them.

3. What do you recommended your group member would change about their
completed assignment?
Since you chose the biomechanical model I would have maybe tried to think of more
activities related to that model. Some activities were clearly biomechanic and were
really good activities. A lot seemed more rehabilitative so I would consider that when
selecting your approach and activities to try and match them up more. Your STG for
meal prep seems like a pretty big short term goal, maybe break it down to a smaller
goal like collecting all ingredient for the recipe or just being able to mix ingredient.
Reviewing Group Member Name: Meredith Schulz

1. What did you like about your group members completed assignment?
Leah had a strong justification for the use of the Biomechanical frame of reference.
Leahs activities are of a wide variety and will work well as backups for each other if one
doesnt work out. Her goals are all good and sound very reasonable!
2. What did you learn or something you can use from you group members assignment?
Its a good idea to have very different activities so that if one of them is eliminated for
some reason, it doesnt eliminate the rest of the activities as well!
3. What do you recommended your group member would change about their
completed assignment?
As I was reading the assignment at first, I was reading the activities as if they were
supposed to be remediation activities but a lot of them seemed compensatory. In the
beginning they were more compensatory, but towards the later activities, they seemed
to fit the Biomechanical frame of reference better. They didnt seem to all match the
frame of reference, but thats up to her to decide!
 Grading rubric for individual treatment plan

Excellent Good Fair Poor Incomplete

35-32 31-28 27-25 24-21 20-17
Short Short Short Short No description
paragraph paragraph paragraph paragraph of medical
description of description of description of a description of a cause of
medical cause medical cause medical medical patients
of patients of patients diagnosis diagnosis diagnosis
primary secondary
diagnosis diagnosis
Short Short Short Short No description
paragraph paragraph paragraph paragraph of approach
description of description of description of description of and principle to
appropriate inappropriate appropriate an appropriate an be used in
approach and approach and approach and approach and intervention
principle to be principle to be principle principle
used in used in
intervention intervention
Identify at least Identify 3 Identify 2 Identify 1 Identify no
4 priority and impairments impairments impairments impairments
appropriate priority and priority and priority and
impairments appropriate appropriate appropriate
impairments impairments impairments
Provide at least Provide at least Provide at least Provides no Does not
3 appropriate 2 appropriate 1 appropriate appropriate provide any
treatment treatment treatment treatment treatment
activities for activities for activities for activities for activities for
each each each each each
impairment impairment impairment impairment impairment
Provide an Provide an Provide an Provide an Does not
appropriate appropriate inappropriate inappropriate provide a short
short term and short term or short term or short term and term and long
long term goal long term goal long term goal long term goal term goal for
for each for each for each for each each
impairment impairment impairment impairment impairment

Your score: