Forty

Forty-three-year-old (DOB: 08/22/56) S.C. is a right-handed, Caucasian female who is approximately two months status post traumatic brain injury. On August 5, 1999 she was involved in a motor vehicle accident in which she collided with a semi-tractor trailer and required a protracted length of time to retrieve her from her vehicle due to the extensive front-end damage. At the scene she was unresponsive and transported to St. Mary's Medical Center, in West Palm Beach. She was admitted to the coma stimulation program where she remained comatose for 8 weeks. Initial CT head scans demonstrated a right acute subdural hematoma with subarachnoid hemorrhage and herniation and right parietal scalp laceration. Her extensive head trauma necessitated an emergency right frontal and temporoparietal craniotomy wit evacuation of the subdural hematoma. To her torso she sustained a left 7 and 8 rib fracture. Complications during her stabilization period in the Trauma Intensive Care Unit developed when she went into respiratory failure necessitating artificial means of support. A tracheostomy was performed on August 12, 1999.Later during S.C. stay she was transferred to rehabilitation via the coma stimulation program. Her treatment included improving her environmental awareness, increasing cognitive functioning, range of motion, strength and joint function.

With consideration to the available medical records from St. Mary's Medical Center, S.C. is appropriate for a 30-60 day intensive neurocognitive restoration stay at FINR. She will be evaluated by the neurologist and neuropsychiatrist for a restoration treatment plan and her progress will be followed throughout her stay. The neuropsychologist will assess her higher cortical functioning using standardized neuropsychological batteries and recovery recommendations will be offered along with staff inservice. She will have a behavioral protocol to increase the frequency of producing progressive steps towards independent daily functioning. Her protocol will also include decreasing the frequency of inappropriate behaviors. She will be assessed by physical and occupational therapy for a treatment plan to increase her level of independent daily functioning. Speech and language pathology will develop a therapeutic plan to improve her compromised language and speech skills. The nursing department will educate her as to the reason and dosage of her medication. A nurse liaison will coordinate all pertinent records from St. Mary's Medical Center.

Health. S.C. will need a bladder and bowel management program for her moderate problems with incontinence. Stacy will require a dysphagia management program and supervision during mealtime activities. Her current medications include Ranitidine, Peri-Cola, Heparin Sodium, Fosinopril Sodium (Monopril), Nystratin, Divalproex Sodium (Depakote) and Clotrimazole.
Personal and self-care. She continues to require maximal assistance for feeding, grooming, dressing and all hygiene tasks. Strong uses of verbal cues are required for all self-care tasks requiring Occupational therapy sessions to improve functional independence in these areas.
Physical functioning and mobility. S.C. is able to move around in bed to seek comfort. She has the endurance to stand for 2 or 3 minutes per each attempt. She locomotes in a wheelchair but has coordination difficulties. She can transfer out of the bed with minimal assistance but needs maximal assistance for transferring in and out of the bathtub or shower, automobile, and toilet. Physical therapy will develop a treatment plan to increase strength, endurance, coordination and balance.
Cognitive skills. S.C. has a high school education. She will need a neuropsychological assessment to ascertain her higher cortical functioning and to delineate and elucidate the residual sequelae associated with her head trauma and for restoration recommendations. She has diminished capacity for abstract reasoning, concept formation, problem solving, planning and cognitive flexibility. Her judgement for social situation and personal insight is compromised. She has severe difficulty making reasonably safe decisions related to her social, personal and financial matters. Testing will need to assess for memory retrieval and capacity for storage. She is alert, has difficulty attending and cannot concentrate long enough to learn involved procedures. She is oriented to person and place.
Community integration. S.C. requires total assistance for programming of activities and planning entertainment. She is unable to manage personal funds or make purchases without making errors. She is unable to use the telephone to communicate with family and friends nor to access emergency services. She is dependent on others for meal planning, preparation, and cleaning. She will need occupational therapy to retrain her in skills for independent living including meal preparation, household chores and clothing care. She is unable to identify household hazards and emergency situations.
Communication. S.C. has mild difficulty comprehending casual conversation and moderate difficulty communicating her needs and thoughts. She can follow prompts and directions but is easily distracted. She is moderately to severely impaired when attempting to read and communicate in writing. Her speech productions are moderately impaired. The Speech and Language Pathologist is required to assess her current communication skills and for a plan for recovery of skills.
Behavioral adjustment. S.C. has lost the custody of her children and her husband died in an automobile accident earlier this year. Her father is her legal guardian since her accident. She is restless, agitated and has difficulty tolerating frustration. She can be verbally aggressive occasionally when restless and agitated. Her behavioral protocol will be geared towards increasing her frustration tolerance and decreasing the frequency and duration of restlessness and agitation.
Psychosocial. S.C. does not initiate social interaction nor does she desire entertainment. Yet she will express her sadness over not raising and living with her daughter. She will be in group therapy to discuss her sense of loss and need for her family and in individual therapy to discuss her bereavement issues regarding the loss of her husband.
Discharge recommendations. S.C. will return, if skill acquisition is achieved, back home with her father. Her family will be invited to attend aftercare education sessions at FINR to continue with behavioral strategies for stress inoculation and preventive treatment.
Treatment Progress. An update of S.C. has demonstrated improvement in the following areas: Tracking and learning to compensate for visual field disturbance. The client is beginning to orient to what happened to her and why she was admitted to the Florida Institute. Transfers and activities of daily living including dressing are requiring moderate to maximum assistance versus maximum assistance. The treatment staff has seen a noticeable decrease in the client's labile emotions.