Case 1 A 56-year-old male, Homer Traumatic Brain Injury (Ranchos…
A 56-year-old male, Homer
Traumatic Brain Injury (Ranchos level II) secondary to a motor vehicle accident.
Hospitalized for a month
Transferred to a Skilled Nursing Facility
Tier 2: Problems
Total assist in all ADL's
Homer has a Ranchos Level 2 TBI. Due to multiple deficits in his motor and sensory systems as well as generalized weakness he requires total assist in performing all ADLs and IADLs.
Has made little progress throughout his hosptial stay
Fully dependent for mobility
Has a severe TBI Ranchos Level II TBI
Displays a generalized response to environmental stimuli (Gutman & Schonfeld, 2009).
Will respond inconsistently to visual, auditory, and tactile stimuli (Gutman & Schonfeld, 2009).
Response is slow and generalized (Gutman & Schonfeld, 2009).
He moans when presented with any kind of stimulation (auditory, visual, tactile) and does not display a different response when presented with favored vs. favored stimuli
Cannot verbally communicate
: Caregiver and family about over stimulation. Provide recommendations that only 1-3 people visit him at a time and that environment not be too over stimulating (Erfin Firmawati et al., 2015)
Passive range of motion in upper extremities and lower extremities and through use of orthotics/ splinting
Wife on caregiver techniques such as feeding, dressing, bed mobility, grooming, support groups and resources within the community. Educate the daugther with proper body mechanics to help mother with transfers, and bed mobility (Erfin Firmawati et al., 2015).
Sensory stimulation by educating caregiver to sit patient upright in bed or in wheel chair. Playing his favorite music in his room to restore auditory stimulation (Chuakarn & Jitpanya, 2017).
Bed sores and skin break down by implementing positioning techniques to keep client comfortable and skin integrity intact
: A daily schedule and routine so the patient may have order and a predictable schedule daily. This may include a feeding schedule, bathroom schedule, and hygiene schedule. A visual schedule may be posted in his room to facilitate order.
Tier 5: Outcomes & Long Term Goals
Client will respond in a consistent manner to visual stimuli
Long Term Goal 1 :
Within 6 weeks, Homer will respond to visual stimuli consistently on 3 out of 4 opportunities, for 3 consecutive weeks, with min A, and no more than 2 verbal cues, to facilitate executive functioning.
Maintain PROM in UE and LE and decrease spasticity
Long Term Goal 3:
Within 6 weeks, Homer will demonstrate decreased tone in his lower and upper extremities as shown with a decrease in the Modified Ashworth Scale, in order to prevent skin breakdown and maintain skin integrity for functional mobility.
Caregiver will demonstrate improved competence and ability to care for patient
Long Term Goal 2:
Within 6 weeks, Homer's caregiver will independently demonstrate how to complete transfers, bed mobility, grooming, feeding, and hygiene for Homer as witnessed by the occupational therapist, to facilitate completion of ADLs.
Tier 1: Occupational Profile
Context and environment
Goes bowling weekly with friends
Attends church events
Has several friends that live 45 minutes away
reads the newspaper every morning
56 year old male
Has access to 24 hr care in SNF
Has access to a roll in shower at home
Wood floors throughout his home
Process, Motor, and Social interaction skills cannot be assessed due to Homer's condition and Ranchos level 2 TBI
affects: memory, cognition, perception, thought, emotions & attention (OTPF, 2017)
very limited due to severity of TBI
Being outdoors and hiking
Strong commitment to providing for family prior to the TBI.
Attends church every Sunday with his family
Goes grocery shopping with wife
Helps wife prepare dinner
Prepares Thanksgiving Dinner for his family
Husband, Father, Coworker, Friend
Has community support from his church group who have created a gofundme account to assist with modifiying his home and purchasing adaptive equipment
Good support system from his wife and daughter
Has access to good healthcare (inpatient and skilled nursing facility)
Has referral to OT/PT/ST
Tier 3: Evaluation Tools
Ranchos Los Amigos
. He is a Ranchos Level 2 which means generalized response and requires total assistnce (Gutman & Schonfeld, 2009)
"Responds to repeated auditory stimuli with increased or decreased activity" ("Rancho Los Amigos - Revised", 2018, pg.1).
"Responds to external stimuli with physiological changes generalized, gross body movement and/or not purposeful vocalization" ("Rancho Los Amigos - Revised", 2018, pg.1).
"Responses noted above may be same regardless of type and location of stimulation" ("Rancho Los Amigos - Revised", 2018, pg.1).
Responses may be significantly delayed ("Rancho Los Amigos - Revised", 2018, pg.1).
"Demonstrates generalized reflex response to painful stimuli" ("Rancho Los Amigos - Revised", 2018, pg.1).
Coma Recovery Scale - Revised
: Measuring the patient's response to visual, tactile, auditory, etc. stimuli will enable the therapist to determine the client's progress and current level of functioning (Parten, 2018).
Functional Independence Measure
: FIM will evaluate Homer's occupational performance and track his ADLs and functional status. It will measure the severity of disability based on the burden of care rather than Homer's impairments. The scale rates Homer's performance taking into consideration, his need for assistance from another person or the need for an assistive device ( Radomski & Latham, 2014) .
Glascow Coma Scale
- will measure assess the impairment of conscious level in response to defined stimuli; it takes into consideration the depth of the coma based on its severity (Radomski & Latham, 2014).
Modified Ashworth Scale
: Measuring the level of spasticity present in his limbs will help to measure progress towards gains in the range of motion. It can measure muscle tone or resistance to passive movement (Radomski & Latham, 2014).
Occupational Model / FOR
- The biomechanical model focuses on ROM, strength, and endurance of his upper and lower extremities. This FOR applies to this case because ROM will be vital to keeping his extremities from contractures. Both strength and endurance will be needed as his condition improves (Cole & Tufano, 2008).
- The interaction between the client's abilities, the environmental and the demands of different occupations influences the performance outcome. This can apply to occupation/ADL of feeding. This can help the therapist with the treatment session in a holistic way (Cole & Tufano, 2008).
Rancho Los Amigos - Revised. (n.d.). Retrieved November 27, 2018, from
Gutman, S. A., & Schonfeld, A. B. (2009). Screening adult neurologic populations: A step-by-step instruction manual. Bethesda, MD: AOTA Press.
Firmawati, E., Songwathana, K. & Kitrungrote, L. (2015). Effect of Self-Efficacy Enhancing Education Program on Family Caregivers’ Competencies in Caring for Patients with mild Traumatic Brain Injury in Yogyakarta, Indonesia. Nurse Media: Journal of Nursing, Vol 4, Iss 2, Pp 767-783 (2015), (2), 767.
Parten, C. (2018). Coma Recovery Scale - Revised Assessment of Patients with Brain Injury [Powerpoint slides] Retrieved from
Radomski, M., & Latham, C. (2014). Occupational therapy for physical dysfunction (7th ed., pp. 1-1426). Lippincott Williams & Wilkins, a Wolters Kluwer business.
Wheeler, S., Acord-Vira, A., Arbesman, M., Lieberman, D. (2017). Occupational Therapy Interventions for Adults With Traumatic Brain Injury. American Journal of Occupational Therapy 71(3):7103395010p1-7103395010p3. doi: 10.5014/ajot.2017.713005.
Wheeler, S. (2018). Occupational Therapy Practice Guidelines for Adults with Traumatic Brain Injury. BrainLine. Retrieved from
Chuaykarn, U., & Jitpanya, C. (2017). Effects of Two Sensory Stimulation Models on Recovery in Adults with Severe Traumatic Brain Injury. International Journal of Medical Research and Health Sciences, Vol 6, Iss 8, Pp 69-74 (2017), (8), 69. Retrieved from
Occupational Therapy Practice Framework: Domain and Process (OTPF) (3rd Edition). (2014).
American Journal of Occupational Therapy
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Cole, M. and Tufano, R. (2008). Applied theories in occupational therapy. Thorofare: SLACK.