REVIEW REHAB FOR SPINAL CORD INJURY

1)Patient’s Demographics

2) underlying illness

3) Current diagnosis/problems

4)History of the patient for current admission

Alleged fall from staircase on 27/2/23 at 6pm during working

Scan/images done

5)Impairment

i) Neurology examination

-ASIA Chart

-propioception

-sensory examination

ii) Bladder-on CBD

iii) Bowel -does patient able to BO every day, if not, patient on what medication for the BO

iv) feeding-on NG tube

v)Respi-on oxygenation

vi) pain

vii) Skin

6)Functional: required 1 man assist for bed mobility turning side to side and lying to sitting

pADL maximal dependency

SCIM score??

7)Social History

8) Aim : Acute Spinal Cord Injury Rehab

Plan/

1.for raviin enema II/II STAT and OD

2.For supp Ducolax EOD

3.Keep CBD

4.Bowel charting

5.2 hourly turning in bed, ripple matress

6.Physiotherapy-for bed mobility, carer training, breathing exercise, passive ROM, stretching
exercise, secretion management
7.PKEA health screening-FBC/RP/FLP/FBS/UFEME

8.TCA Rehab

9.Refer dietician

10.Refer Occupational therapy-for palmar pocket(left hand), EMS (left side)