分數一般評估

Report
吉翔護理之家個案報告
PGY導師:陳揚卿醫師
PGY學員:譚永超(原屬科別: 萬芳內科)
2010-03-29
個案基本資料

姓名:林文華

年齡:39歲 (出生日期:1971-01-03)

教育程度:大專畢業

語言:台, 國語

職業:服務業,電話諮詢
個案基本資料

婚姻:未婚

宗教:無

個性:善談,性格堅強積極

收案日期:2005-03-12

資料來源:案主
個案主訴



四肢感覺異常併無力需輪椅助行。
小便失禁及便秘,長期使用軟便藥,使用導尿管。
因長期下肢水腫,需要長期使用利尿劑。
個案病史(1)


2001年秋因興趣加入化妝訓練,後因有手汗的緣故,
無法繼續訓練,因不想半途而廢而就就醫,醫師建議
施行除汗腺手術。後因手術後常常出現全身無力,頭
暈,期間持續醫,但也無法改善。
2003年於一次郊遊中發生意外,從山上滾下,意外發
生時病人巳失去意識,後來由直昇機救治並送往醫院
救治,手術後雖能保住性命,但因傷及頸部C3,C4,導
致半身不遂。
個案病史(2)




病人在意外發生後三個月期間,情緒常常不穩,
後來經家人和宗教團體支持,方能慢慢接事。
因小便無法控制,長期使用導尿管。
雙手的行動上有所改善,能進行一些簡單的抓
握的動作,下肢需電動輪椅助行。
個案於 2005年轉入護理之家療養。
個案病史(3)

意外發生後兩年期間,個案常因泌尿道感染,
多次進出醫院,曾有考慮是否進行Suprapubic
cystostomy,但因長期傷口照謢,並沒有施行
手術。後來訪尋中醫,定期服用中藥,感染情
況得以改善
個案過去病史

住院


Urinary tract infection
開刀

Traumatic spinal cord injury s/p transection
個案個人史





Smoking(-)
Alcohol consumption(-)
Betel nut chewing(-)
Drug or food allergy: denied
Travel or animal contact history: denied
個案病史

現在用藥



Dilantin 100mg 1# qd
Furide 40mg 0.5# qd
Bisacodyl (Bisacodyl 5mg) 2# bid
血液檢查2009-08

CBC, SMA




Uric acid 5.3
Alb 3.8
Hb 13.2
U/A



Clear, yellow
Bacteria +++
WBC 20-30
血液檢查2009-08







ACTH: 43.9(之前有懷疑過adrenal insufficiency)
Free T4: 1.29
TSH: 1.06
Cortisol: 13.1
Prolactin: 23.8
Renin: 2.06
Aldosterone: 124.8
個案診斷

2005



Traumatic spinal cord injury(C3-C4) s/p
transection
Frequent urinary tract infection
Hepatitis B carrier
日常生活巴氏量表 (Barthel Index)
進食
需別人協助取用或切好食物或使用進食輔具
5
移位
需別人協助才能坐起,或需別人幫忙才可移位
0
個人衛生
需別人協助刷牙、洗臉、洗手及梳頭髮
0
如廁
無法自行完成如厠過程
0
洗澡
無法自行完成沐浴
0
平地走動
獨立操作輪椅,可行走50公尺以上
5
上下樓梯
無法上下樓梯
0
穿脫衣褲鞋襪
無法自行穿脫
0
大便控制
偶爾會失禁,使用塞劑時需要別人幫忙
5
小便控制
長期用尿管
0
總分(100)
15
迷你營養評估簡式MNA-SF
MNA-SF=12 正常
迷你營養評估 MNA
一般評估
分數
7. 可以獨立生活 (非住在護理之家
或醫院) 0分=否 ; 1分=是
0
8. 每天需服用三種以上的處方藥物
0分=是 ; 1分=否
0
9. 褥瘡或皮膚潰瘍
0分=是 ; 1分=否
1
10. 一天中可以吃幾餐完整的餐食
0分 = 1餐 ; 1分 = 2餐
2分 = 3餐
2
迷你營養評估 MNA
一般評估
11. 蛋白質攝取量
每天至少攝取一份乳製品(牛奶、乳酪、優酪乳)
是■ 否□
每週攝取兩份以上的豆類或蛋類 是■ 否
每天均吃些肉、魚、雞鴨類
是■ 否
分數
1
0.0分 = 0 或1個是
0.5分 = 2個是
1.0分 = 3個是
12. 每天至少攝取二份或二份以上的蔬菜
或水果 0分=否 ; 1分=是
13. 每天攝取多少液體 (包括開水、果汁、 咖啡、
茶、牛奶) (一杯 = 240 c.c.)
0.0分 = 少於三杯
0.5分 = 3 ~ 5杯
1.0分 = 大於5杯
14. 進食的形式
0分 = 無人協助則無法進食
1分 = 可以自己進食但較吃力
2分 = 可以自己進食
1
0.5
0
迷你營養評估 MNA
一般評估
分數
15. 他們覺得自己營養方面有沒有問題?
0分 = 覺得自己營養非常不好
1分 = 不太清楚或營養不太好
2分 = 覺得自己沒有營業問題
2
16. 與其他同年齡的人比較,他們認為自己的
健康狀況如何?
0.0 分 = 不如同年齡的人
0.5 分 = 不知道
1.0 分 = 和同年齡的人差不多
2.0 分 = 比同年齡的人好
1
17. 臂中圍MAC:
公分
0.0分 = MAC < 21
0.5分 = MAC 21 ~ 21.9
1.0分 = MAC ≧ 22
1
18. 小腿圍C.C.:
0分 = C.C. < 31
1分 = C.C. ≧ 31
1
公分
總分 22.5/30 正常
Discussion
Rehabilitation of Persons With Spinal
Cord Injuries
Common Medical Problems

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Thromboembolic disease
Autonomic dysfunction
Neuropathic pain
Neurogenic bladder dysfunction
Neurogenic bowel
Heterotopic bone formation
Pressure ulceration
Spasticity
Thromboembolic disease


The risk of death from PE during the first year
following SCI is more than 200 times that for
the general population.
DVT most commonly occurs in the weeks
following SCI, with a much lower risk in
persons with chronic injury.
Autonomic dysfunction



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Problems are most common in those with
injuries to level T6 and above
Orthostatic hypotension
Bradycardia
autonomic hyperreflexia
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


lethal complication
patients with spinal injuries above T7
bladder and bowel distention
headache in the presence of elevated blood
pressure
Neurogenic bladder dysfunction
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Detrusor-sphincter dyssynergy



unable to cause efficient voiding
Urinary tract calculi
Hydronephrosis
Mortality

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Mortality is highest in the first year after injury
In the past


At present



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urinary tract disease and renal failure
pneumonia
Nonischemic heart disease
Sepsis
Pulmonary embolus

leading causes of death for younger patient (paraplegia)
Functional Rehabilitation



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Neurologic recovery
Patients can be classified based on the ASIA
impairment scale from A to E
(1) recovery within the zone of injury
(2) recovery below the zone of injury

The zone of injury is typically considered the first
3 abnormal dermatomes or myotomes.
ASIA impairment scale
Expected levels of function

Expectations according to injury level

A person with tetraplegia with injury above the
level of C5 is dependent upon others for activities
such as feeding, dressing, and bathing, and
requires the availability of an attendant at all times
Expected functional recovery following complete spinal cord injury by spinal level
Activities of daily living
Mobility/locomotion
C1-C4
Feeding possible with balanced forearm orthoses
Computer access by tongue, breath, voice controls
Weight shifts with power tilt and recline chair
Mouth stick use
Operate power chair with tongue, chin, or breath
controller
C5
Drink from cup, feed with static splints and setup
Oral/facial hygiene, writing, typing with equipment
Dressing upper body possible
Side-to-side weight shifts
Propel chair with hand rim projections short distances on
smooth surfaces
Power chair with hand controller
C6
Feed, dress upper body with setup
Dressing lower body possible
Forward weight shifts
Bed mobility with equipment
Level surface transfers with assistance
Propel indoors with coated hand rims
C7
Independent feeding, dressing, bathing with adaptive
equipment, built-up utensils
Independent bed mobility, level surface transfers
Wheelchair use outdoors (power chair for school or work)
C8
Independent in feeding, dressing, bathing
Bowel and bladder care with setup
Propel chair, including curbs and wheelies
Wheelchair-to-car transfers
T1
Independent in all self-care
Transfer from floor to wheelchair
Spinal
level
T2-L1
Stand with braces for exercise
L2
Potential for swing-to gait with long leg braces indoors
Use of forearm crutches
L3
Potential for community ambulation
Potential for ambulation with short leg braces
L4-S1
Potential for ambulation without assistive devices
Sip and puff straws, which are activated by
blowing and sucking air, can help control
everything from the phone to the TV
A powered wheelchair is commonly used by tetraplegics. In
many cases, there is very subtle control left in one or both
hands -- combine that with an extremely sensitive joystick,
and wheelchair control is possible.
Gait

Functional ambulation may become possible
for patients admitted with ASIA B tetraplegia.


Sparing of sacral pin sensation may indicate a
favorable prognosis
Most patients with no lower extremity function are
not trained in gait
Upper extremity reconstructive surgery

Offers the opportunity to utilize an innervated
but nonessential muscle to provide a lost
function.


not considered until a year following injury
well developed for the upper limb but not for the
lower limb
Example

A person with a spinal injury level of C5 may
have good shoulder control and strong elbow
flexion. Active elbow extension is lacking,
making overhead activity impossible. Such a
person may benefit from a transfer procedure
to the triceps tendon. One of the muscles
available for transfer is the posterior deltoid.
Functional neuromuscular stimulation

Electrical stimulation of intact peripheral
nerves



increases contraction in muscles paralyzed by
upper motor neuron injury.
transcutaneous, percutaneous, or implanted
electrodes.
Stimulation can be useful for exercise and for
function.


Functional neuromuscular stimulation (FNS)
can be used in the upper extremity to provide
lateral pinch and palmar grasp to persons
with, for example, C5 and C6 tetraplegia.
Upper extremity FNS often is combined with
tendon transfer surgery
Prognosis
One-Year Follow-up Frankel Grade
Admission*
Frankel Grade
A
B
C
D
A
84%
8%
5%
3%
B
10%
30%
29%
31%
C
2%
2%
25%
67%
D
2%
1%
2%
85%
Life In The Community

Fertility



most women typically experience amenorrhea that
can last for up to a year.
SCI does not contraindicate pregnancy
No prospective studies have examined fertility
rates or pregnancy complications in these patients.
Sexuality


Vaginal vasocongestion can occur in
response to local stimulation
Women with complete injuries above T6


do not demonstrate vaginal vasocongestion in
response to psychogenic stimulation alone
the isolation of the brain from the sympathetic
outflow to the genitals
References

Chronic complications of spinal cord injury


UpToDate updated: Sep, 2009
Rehabilitation of Persons With Spinal Cord
Injuries

E-medicine Updated: Nov 4, 2009

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