Running head: OCCUPATIONAL PROFILE & INTERVENTION PLAN 1

Transcription

1 Running head: OCCUPATIONAL PROFILE & INTERVENTION PLAN 1 Occupational Profile & Intervention Plan: Mr. Mason Natalie M. Noss Touro University Nevada

2 OCCUPATIONAL PROFILE & INTERVENTION PLAN 2 Occupational Profile The Patient Mr. Mason, the patient, is a 72 year-old male who was admitted to Complex Care Hospital in Las Vegas due to debility following complications while recovering from gastric cancer post gastrectomy. The patient was previously admitted to University Medical Center (UMC) and following his surgery, the patient discharged to Complex Care long-term acute care hospital (LTAC) for continued recovery. Currently he is being fed through a nasogastric tube, on a ventilator, utilizes a Foley catheter, and is unable to control his bowels. The patient also has had a long medical history including prostate cancer, diabetes, peripheral vascular disease, one cerebral vascular accident, atrial fibrillation, and hypertension. Mr. Mason has not been living independently for over 6 months and has plans to live with his adult daughter in her home after discharge. At Complex Care Hospital, the patient is receiving occupational therapy (OT) services to address the overall effects of debility and deconditioning as a result of his complex medical history and recent hospitalization. During his initial evaluation (IE), the therapist determined that he qualifies for OT services to address his functional limitations in terms of daily self-care occupations while he receives intensive nursing, respiratory therapy (RT), speech therapy (ST), and physical therapy (PT). While interviewing the patient, he explained that he does not expect to miraculously be completely independent in all his daily activities and he stated that he has come to terms with getting older. Overall, he explained that he is just tired of being in hospitals and hopes to be able to be with his daughter and grandchildren for a couple more solid years. The patient explained that he would like to be able to use the restroom on his own but is unsure that that will happen since his surgery. He stated that mainly his concerns with daily life are that

3 OCCUPATIONAL PROFILE & INTERVENTION PLAN 3 he does not want his care to be his daughter s burden. He hopes that once living with her he can at least complete the more, what he called private tasks like putting on his clothing and moving in and out of bed. Currently the patient reports not feeling successful in many daily activities and this is directly the result of his many medical complications. The patient is experiencing many barriers to his occupations which include being deconditioned, his inability to breathe sufficiently independently, his inability to feed independently, and his incontinence. All of these barriers result in struggles to complete what others may think of as easy tasks. Also, his current context in the LTAC acts as a barrier according to the patient. His daughter does not like for her children to visit the facility and this significantly disrupts the patient s social interaction with his family at this time. The patient stated repeatedly that he is most excited to be able to be back around family as soon as he can. Occupational History & Desired Outcomes The patient moved to Las Vegas from Detroit over 20 years ago and worked as an electrician for most of his life. He and his wife had two children; his wife has since passed and his son currently lives on the east coast with his family. Mr. Mason has been moved out of his apartment for many months now, but his daughter s home was only a couple of blocks away from it. Mr. Mason loved to be close by to be able to see his daughter and her family frequently, but he does value solidarity as well. He reports that his father was in the military and as a child they moved around frequently. It was noticeable through many interactions with Mr. Mason that he is a man who speaks carefully and has a great deal of pride. He very much values his family and knows spending time together is important, but he never wants to feel like he is intruding on his daughter s family time. He values hard work as apparent through his many years as an

4 OCCUPATIONAL PROFILE & INTERVENTION PLAN 4 electrician; he stated that he did not retire until 67 years old as his health began to decline. When asked what he likes to fill up his time with, he stated that lately he mainly watches television or completes cross-word puzzles but other than that he doesn t have many hobbies lately. He did mention that he used to be a bowler and played on teams from the time he was a teenager up through adulthood but slowly stopped playing due to the physical demands and lack of time for hobbies. Mr. Mason considers his roles to be that of father, grandfather, and friend. He stated that he has a close, small circle of friends whom he doesn t see that frequently anymore but many of them used to live in the same apartment complex as him. His patterns of occupational engagement have definitely shifted as well. For example, Mr. Mason does not participate in many of his leisure occupations any more (e.g. meeting with friends or bowling) but rather spends more time sedentary as he has aged. Mr. Mason has a desire to be able to independently complete all activities of daily living (ADLs), but is realistic in accepting that he may require assistance for many of them. He wishes to be able to do as much as he can on his own to prevent from having his daughter carry such a burden. Being such a proud man he specifically prioritizes the more personal occupations, as stated previously, such as lower body dressing and toileting. He even stated that he felt that there is no reason that his daughter should have to change a father s diaper. Because he wishes to be as close to independent as possible, he recognizes that he will have to make life changes in order to prevent further decline. He is currently being seen by a dietician in the hospital who is working with him on understanding how his food choices affect his overall health and wellness; particularly associated with his diabetes and high blood pressure. He would also like to be able to have enough energy to play with his grandchildren or at least be able to watch them without being supervised in order to enhance his role as a grandfather. Mr. Mason has extremely

5 OCCUPATIONAL PROFILE & INTERVENTION PLAN 5 reasonable desired outcomes that he would like to achieve, and with continued services which will be available to him as long as he shows justification for skilled OT, will most likely be covered by Medicare. Ensuring that Mr. Mason can be allowed to have reasonable access to participate in the occupations that he wants and needs to do will be extremely beneficial to his overall occupational performance, quality of life, and well-being. Simply having the availability of an able person such as his daughter and having an environment which will foster the ability to practice ADLs safely will already aim to provide Mr. Mason with occupational justice to work towards all his goals. Occupational Performance Key Observations The patient was observed receiving skilled OT intervention at Complex Care LTAC in Las Vegas in his hospital room. Sessions typically ran for an hour where interventions focused on building up the patient s activity tolerance to complete ADLs. Prior to entering the patient s room, his chart was reviewed and certain lab levels were within appropriate ranges for therapy and it was noted that Mr. Mason had failed his Barium swallow test the day before. Upon entering the patient s room, the patient was awake in supine in the hospital bed with the back raised to about a 45 degree angle. Mr. Mason was able to communicate with his OT to answer how he was doing, but could not speak above a whisper due to his ventilator. The patient explained that he was not experiencing any pain at the moment and agreed to begin therapy for the day. Session began by getting the patient out of bed and into the wheelchair with the hopes that he could be up in the chair for about an hour since he had not been seated out of bed more than once since admission.

6 OCCUPATIONAL PROFILE & INTERVENTION PLAN 6 The bed was lowered flat and the OT was going to place a brief on the patient before moving on since the patient indicated that he has not been aware during voiding. The OT instructed the patient on how to roll side to side using his arms as much as possible to grab the bed rails to hold his position. Mr. Mason began rolling but needed help from the OT to initiate the movement. He rolled towards his right side and slowly moved his left arm to reach for the bed rail. The patient could not grasp onto the rail quick enough before his body rolled back to supine. The OT instructed the patient that we would try again and reminded him to be patient with the process. Upon rolling to the right again the OT counted to instruct the patient when to reach his arm out. The OT used one of his arms to keep the patient s body sidelying while the other hand was used to direct the patient s arm to grasp the bed rail. The OT needed to maintain the patient s body in that sidelying position while placing the brief on the bed. Rolling towards the left side required the same amount of assistance from the OT until the brief was completely placed on. It was observed that the patient was tired and needed a moment before the next step of the transfer was initiated. The OT kept an eye on the vitals and noticed that his oxygen saturation was fine at 95% and that his blood pressure had remained fairly steady. The patient indicated that he was ready to try more with the OT, and the OT explained that now we would try the same rolling movement. The patient received significant assistance once again to roll sidelying as his trunk would roll back towards supine. In order to move completely to edge of bed (EOB) the patient required Maximum (A). The therapist tried to have the patient prop his arms up on the bed to push his trunk against gravity, but the patient s body kept falling back towards the bed as he could not maintain that position on his own. Once at the EOB the patient indicated that he needed suction, the OT paged RT to come to perform suctioning before moving forward.

7 OCCUPATIONAL PROFILE & INTERVENTION PLAN 7 Afterwards, therapy resumed by asking Mr. Mason to try and put on his socks before he would be transferred to the wheelchair. Mr. Mason presented with Poor static sitting balance and required Moderate (A) to maintain seated EOB on his own while his OT retrieved the socks. Mr. Mason was then instructed on lifting up his leg to cross over his other leg so that he wouldn t have to lean over to put on his socks. Mr. Mason was able to lift up his left leg fairly well to bend over his right leg, but could not maintain it there independently. The OT then placed the sock on to avoid further over exertion since he hadn t been active for quite some time. The OT explained that he would like to see him try to do the same (cross leg over) with his right leg. Mr. Mason could not get his leg to move far enough to cross over and the OT placed that sock on with his right foot flat on the floor; overall requiring Maximum (A) to don socks. Further observation of lower extremity dressing (i.e. pants and shoes) was not completed due to the observed performance donning socks. The patient was then able to follow the directions of the OT as far as where to place his hands, feet, and to bend his knees adequately in order to prepare for the transfer to the wheelchair. However, the transfer from bed to wheelchair required Maximum (A) to be successful. The patient reported feeling slightly dizzy from the movement and was asked to take a couple of moments to get settled into the new position, while the monitors were checked. After a break, Mr. Mason was presented with a warm washcloth to try and wash his face and the top of his head. He was able to lift the washcloth to his face and wipe slowly. His right arm, which seemed to be his dominant hand, was able to reach up towards his face fully and as high as up to his forehead. In order to reach the top of his head he required some assistance and indicated that he was too tired to finish wiping over his head. At the end of the session, Mr. Mason was given

8 OCCUPATIONAL PROFILE & INTERVENTION PLAN 8 the option to remain in the wheelchair or if he would like to be back in bed. He chose to stay in the wheelchair and indicated that he felt okay but tired and reported no pain. Impacted Domains Based on observations from the described intervention session, many domains of the American Occupational Therapy Association s (AOTA) Occupational Therapy Practice Framework (OTPF) (2014) are impacted and therefore limit the patient s success in occupations. Many client factors are impacting Mr. Mason s ability to independently participate in all ADLs such as bathing, toileting, dressing, swallowing, feeding, functional mobility, and grooming (AOTA, 2014). Additionally, based on lack of access for visits from his grandchildren, engagement in social participation with his family becomes limited. Most notable client factors that limit his performance are within body functions. Impacted body functions related to neuromusculoskeletal functions such as joint mobility is apparent in the decreased range of motion (ROM) of the patient s right lower extremity which affected his ability to independently don his sock. Muscle functions such as power and endurance of Mr. Mason s upper extremity, lower extremity, and core muscles are weakened by long-term deconditioning. The patient s inability to sustain powerful muscle contractions affects his ability to sustain seated positions without support that is needed for transfers, dressing, and grooming tasks discussed previously (AOTA, 2014). Control of voluntary movement such as overall gross motor control are affected and limit his success in completing bed mobility, functional transfers, dressing tasks, feeding/swallowing and grooming. This is mostly shown through the patient s inability to control movements necessary to perform those occupations such as upper extremity, lower extremity, and trunk control. The patient s functions and sensations of his cardiovascular and respiratory systems,

9 OCCUPATIONAL PROFILE & INTERVENTION PLAN 9 particularly his endurance, stamina, and fatigability all significantly limit his abilities to perform successful occupations. The limitations that these client factors place on the patient are apparent from observing him during interventions described above such as the patient s reports of feeling tired and requiring many breaks to complete activities such as when wiping his face and head. Lastly, digestive and genitourinary functions are affecting the patient s ability to complete toileting tasks independently leading him to require a Foley catheter and utilize briefs. Overall, these client factors of body functions that were observed to be impacted can be addressed in skilled OT intervention to improve the patient s participation in occupations (AOTA, 2014). Problem Statements 1. Patient requires MAX (A) to perform functional transfers 2 poor trunk strength. 2. Patient requires MAX (A) to complete LE dressing 2 deconditioning. 3. Patient requires MOD (A) to complete UE dressing 2 decreased UE strength. 4. Patient requires Total (A) for toileting 2 incontinence. 5. Patient requires nasogastric feeding tube 2 atrophied oral muscles. Justification of Problem Statements Problem Statement 1 was chosen to be of most importance as apparent through observing the patient s performance in functional transfers. It was noticeable that the patient s inability to maintain his trunk against gravity required a high level of assistance throughout practicing rolling from supine to sidelying and all the way through transferring to the wheelchair. Components of bed mobility that are encompassed within functional transfers must be addressed in order for the patient to then be able to engage in occupations outside of the bed and outside of the hospital room environment. The core is especially important in all activities because it will provide proximal stability that is necessary for distal mobility (Granacher, Gollhofer,

10 OCCUPATIONAL PROFILE & INTERVENTION PLAN 10 Hortobagyi, Kressig, & Muehlbauer, 2013). The patient s trunk strength must be addressed through interventions because trunk strength is required to perform other static and dynamic movements other than transfers that will enhance the patient s engagement in occupations; such as functional mobility, dressing, and grooming tasks. The patient s overall deconditioning is a prime factor that inhibits his successful performance in occupations. Experiencing medical complications for the past 6 months, years of intermittent hospitalizations, being ventilated, intense medications, and bed rest all have affected the patient s overall endurance and strength. Deconditioning cannot only affect functional status but also health related quality of life (Chang, Wang, Wu, Wu, & Wu, 2006). Addressing this contributing factor will be imperative to the patient s overall success in many occupations but will also help to ensure he regains a positive quality of life after discharge. Addressing this limitation within specifically the occupation of lower extremity dressing was chosen to be more important than upper extremity dressing based on the patient s preference. The patient explained through interview that he prioritizes being able to complete more private and personal daily tasks on his own because he doesn t want his daughter to have to complete them for him. Addressing Problem Statement 2 will ensure the patient s wants are being met and will hopefully provide spillover effects to other occupations by addressing the deconditioning. Addressing Problem Statement 3 (upper extremity dressing due to decreased strength) was chosen as less importance than lower extremity dressing based on observation of the patient s performance. Lower extremity dressing required more assistance than upper extremity dressing for the patient. Upper extremity strength should be addressed and is important for success in many occupations; however, with interventions focused on Problem Statements 1 and 2, upper extremity strength will be facilitated indirectly as will be seen in invention descriptions.

11 OCCUPATIONAL PROFILE & INTERVENTION PLAN 11 Most importantly, the patient values independence in dressing his lower body over his upper body, once again ensuring the intervention sessions remain client-centered. Based on the patient s current performance and recommendations from the interdisciplinary team Problem Statements 4 and 5 are of the least importance at this time. Addressing the patient s incontinence is important, but it may be correlated with the complications regarding his gastrectomy. Additionally, the patient has failed his Barium swallow test and is therefore not ready to begin feeding interventions based on recommendations from ST. If he was able to begin feeding and no longer on a liquid diet, perhaps he may be able to then work on a toileting program. However, at this time they are prioritize at the end of the problems list and may be revisited as he progresses. Intervention Plan Problem Statement 1 Patient requires MAX (A) to perform functional transfers 2 poor trunk strength. Long-term Goal 1 Patient will require Sup to transfer EOB standing using FWW by 4 weeks. Short-term Goal 1. Patient will require MOD (A) to transition from recumbent positions EOB using bed rails by 2 weeks. Intervention. This intervention will utilize an Establish, restore (remediation, restoration) approach to restore the patient s impaired trunk strength in order to improve bed mobility skills (AOTA, 2014). This will include educating the patient on the importance of mastering bed mobility in order to be able to do other daily activities. Also, training will occur by teaching the patient how to properly place his arms through and on the bed rails in order to assist in moving himself into sidelying from recumbent positions in the hospital bed. As long as the patient is

12 OCCUPATIONAL PROFILE & INTERVENTION PLAN 12 vented this practice will take place in the hospital room. Utilizing strengthening within an activity such as rolling which uses the upper portion of the trunk to strengthen the abdomen is an effective strategy (Gillen, 2013). Practiced use of this rolling technique against gravity can increase strengthening immensely as well, which will be completed through maintaining the trunk in sidelying (Gillen, 2013). A preparatory task that will be utilized in conjunction with the occupational practice above will be to perform reaching while in a supported seated position in a wheelchair. The patient can be seated in a wheelchair with the therapist supporting to complete a cross-word puzzle. The cross-word puzzle (paper or book) will be on one side of the table and the writing utensil on the other side of the table all within elongated arms distances. Practicing reaching outside of arm s length during seated activities has been shown to overall improve function in individuals after stroke, who tend to experience decreased trunk control (Gillen, 2013). The patient can complete the cross-word on his own for enjoyment and while reaching to bring the items closer to himself this will promote his weight-shifting and turning of his trunk which will work to strengthen abdominal muscles. The puzzle can also be completed while the patient has his torso twisted in one direction with support from the therapist. Through this intervention the outcome that will hopefully be achieved is Improvement of Occupational performance (AOTA, 2014). This intervention will target trunk strength which is limited for the patient in order to improve the patient s involvement in the occupation of functional transfers. Additionally, upper extremity strength will also be indirectly addressed in terms of using the bed rails to maintain different positions within the bed. Short-term Goal 2. Patient will require MOD (A) to perform sit stand from EOB using FWW by 2 weeks.

13 OCCUPATIONAL PROFILE & INTERVENTION PLAN 13 Intervention. The following intervention will utilize an Establish, restore (remediation, restoration) approach to remediate the patient s decreased trunk muscle strength to enhance participation in moving from sit to stand (AOTA, 2014). Utilization of lower trunk rotation and trunk strengthening programs which incorporate shifting ones balance have been shown to increase balance, functional performance, and decrease falls in older adults (Granacher et al., 2013). Core strength and stability have been shown to play a role in both sports related movements and activities of daily life (Granacher et al., 2013). In this intervention, the patient will receive training on the proper hand placement on the FWW as well as proper foot placement and bend of the knees in order to prepare for a safe transfer to standing. The OT will be providing assistance by use of a gait belt. Before performing the actual transfer practice, the patient will be seated EOB with support from the therapist. The patient will perform weightshifting by having the patient place his arms together on either side of his body on the bed to practice supporting himself in that leaned position. Incorporating the slight trunk rotation and position against gravity will work towards strengthening the trunk in order to move further against gravity when coming to a standing position. Moreover, the patient will participate in skilled occupational practice of the sit to stand technique as led by his therapist. Practicing the transfer component will incorporate a challenged repeated practice to ensure the skill is acquired. Additionally, therapeutic exercises completed through lower extremity weight-bearing equipment can be utilized as a preparatory task to allow the patient to perform leg presses while supported. The equipment can be brought to the patient s room and once transferred to the equipment the process of weight-bearing through the legs will help ensure that his lower extremities are strong, stable pillars for his trunk to act on when moving from sit to stand as the component of the overall transfer. Overall, this intervention idea

14 OCCUPATIONAL PROFILE & INTERVENTION PLAN 14 will aim to provide Improvement of Occupational performance by further ensuring that decreased trunk strength is targeted, as well as lower extremity strength to supplement trunk stability and strength (AOTA, 2014). Addressing this limitation will help the patient then be able to perform functional transfers as independently safely as he can. Problem Statement 2 Patient requires MAX (A) to complete LE dressing 2 deconditioning. Long-term Goal 2 Patient will require Min (A) to don pants, socks, & shoes EOB by 4 weeks. Short-term Goal 1. Patient will require MOD (A) to don pants, socks, & shoes EOB by 2 weeks. Intervention. This intervention will utilize an Establish, restore (remediation, restoration) and Modify (compensation, adaptation) approach (AOTA, 2014). Re-introducing the patient slowly into activity will aim to address the deconditioning effects that have occurred since his hospitalizations. The intervention will begin by utilizing a preparatory task of the arm bicycle for 5 minutes at a low resistance. The table-top arm bicycle can be brought into the patient s room and while in a seated position in the wheelchair the patient will use the equipment to begin incorporating exercise back into daily life. According to Chang et al. (2006), prolonged ventilation, as seen in this client, can have significant effects on overall conditioning and functional status. For a population of individuals 53 years and older who were deconditioned post ventilation, upper extremity exercises that included ROM and against gravity movements showed improvements in ambulation and functional status as measured by the Barthel Index of Activities of Daily Living (Chang et al., 2006). The arm bicycle will facilitate the patient s upper extremity ROM through shoulder flexion and extension and wrist and finger flexion. This

15 OCCUPATIONAL PROFILE & INTERVENTION PLAN 15 preparatory task will last for about 5 minutes, or as tolerated by patient, while the therapist monitors vitals throughout. The preparatory task must be in conjunction with the occupational practice and training on safe techniques for donning pants, socks, and shoes. The patient will be instructed on how to safely and steadily sit at EOB to perform dressing. At this point the OT will be presenting the items to the patient while providing assistance to maintain balance as needed. The patient will also be introduced and instructed on the use of adaptive equipment (AE) such as a sock aid, dressing stick, and reacher. Utilizing these AE will help to reduce the amount of excessive flexion at the hip that the patient may not be strong enough to complete at this stage of his recovery. This will be a great introduction into the exerting activity of lower body dressing and allow the patient to be able to complete these dressing tasks with assistance from the OT, in a modified, less taxing way. The outcomes of Improvement in Occupational Performance and Well-being are the aims of this intervention (AOTA, 2014). It is desired that this intervention will help the patient s overall well-being because he will be closer to independently completing lower body dressing which is one of his desired outcomes. Short-term Goal 2. Patient will maintain Fair dynamic sitting balance for 5 minutes during seated activity by 2 weeks. Intervention. This intervention idea will utilize an Establish, restore (remediation, restoration) approach by restoring the patient s endurance, strength, and activity tolerance that occurred from deconditioning (AOTA, 2014). The patient will play the Nintendo Wii bowling game while seated in the wheelchair in his hospital room (as he is still vented). The patient will play the game while maintaining upright position for up to 5 minutes to reintroduce Mr. Mason to activity while engaging in a valued past hobby. The use of the Wii can promote activity

16 OCCUPATIONAL PROFILE & INTERVENTION PLAN 16 engagement in older adults who can no longer physically perform the sport, maintaining the client-centeredness of the intervention (Marston, Greenlay, & Van Hoof, 2013). Using the Wii controller to mimic movements of bowling utilizes upper extremity ROM, strength, and endurance to maintain activity throughout the game duration. Implementing Wii gaming into everyday life of older adults in residential facilities showed in the study overall physical and health improvements (Marston et al., 2013). This intervention aims to reach the outcomes of Improvement of Occupational performance, Quality of life, Participation, Well-being, and Occupational justice through providing remediation of skills and access to highly desired occupations (AOTA, 2014). The intervention can be graded down by decreasing the amount of time participating in the activity. Conversely, this intervention can be graded up by increasing the time that the patient plays the game from 5 to 10 minutes. Additionally, the patient may be moved to a chair without arms to grade up the activity by requiring the patient to right himself by using his core more than utilizing his arms on the arm rests. This will add increased challenges to the patient s seated balance. Depending on the patient s status that day the just right challenge will have to be adjusted to provide appropriate taxing on his cardiovascular and musculoskeletal systems. Precautions & Contraindications Throughout the above interventions it will be imperative to ensure that the patient s vitals remain stable. Oxygen saturation, blood pressure, and heart rate should all be checked throughout activity by viewing the monitors. Labs should also be checked prior to working with patient through chart review. Particularly, Prothrombine Time (PT) and international normalized ratio (INR) should be checked to ensure clotting and bleeding is avoided as he is at risk from immobilization. The patient is not currently under specific contact or droplet precautions, but

17 OCCUPATIONAL PROFILE & INTERVENTION PLAN 17 universal precautions of gloves and hand washing should be followed throughout all interactions with the patient. Special attention should also be placed on noticing when the patient may need suction by the RT staff. Mr. Mason is usually able to indicate when that is necessary; any therapist working with him should respond in a timely manner by paging RT as soon as possible. Special attention will need to be placed on the nasogastric feeding tube, specifically understanding that the patient must be positioned at around 30 degrees tilt in the bed while the tube is administering liquid. Prior to beginning therapy sessions, the feeding should be placed on hold before moving the patient; and inform nursing when he is ready to resume feeding after therapy has concluded. Overall safety precautions should be followed throughout the interventions, for example avoiding falls, taking breaks, and managing lines. Frequency & Duration of Intervention Plan The patient will typically be seen for OT services for 1-hour to 1.5-hour sessions around 3-5 days per week for the duration of 4-6 weeks. The average length of stay varies by patient but tends to be around 28 days at this facility. Length of sessions will vary at times depending on patient condition at the time, fatigue levels, lab work, and referral status. Due to the complex nature of Mr. Mason s current medical status (i.e. ventilator, feeding tube, and catheterization) his length of stay may be extended even after OT goals have been achieved. Goals may also change to include feeding or toileting outcomes but this will again depend on nursing, RT, and physician recommendations. Depending on how successful Mr. Mason is at reaching his goals the referral may be extended or he will be ready for discharge to either a skilled nursing facility (SNF) to continue receiving rehabilitation services without such intense medical management, or be discharged home with potential outpatient services.

18 OCCUPATIONAL PROFILE & INTERVENTION PLAN 18 Biomechanical Frame of Reference The Biomechanical frame of reference (FOR) focuses on the underlying impairments to occupational performance in terms of limitations in strength, ROM, endurance, and muscle contractions. Utilizing this FOR, the patient s performance in occupations was observed in terms of which movements were required to complete the occupational activities as well as which limitations were inhibiting that success. Through analyzing the activity components the intervention plan was created to address the limitations of client factors of strength, endurance, and overall deconditioning. Working on improving those client factors will carry over to the successful participation of the overall tasks which the skills comprise. For example, addressing deficits in trunk/core strength is the focus of interventions outlined under Long-term Goal 1 since trunk strength is necessary to complete each task of functional transfers (Schultz-Krohn & Pendleton, 2013; Breines, 2013). Patient Education Education will be consistent in therapy sessions with both the patient and his daughter. The patient will receive education on the proper use of durable medical equipment as needed, the importance of monitoring his own signs and symptoms, and recognizing when to take breaks from activity. The patient will be instructed in the use of AE that can be used to limit fatigue through modified activities. Most importantly, the patient will receive step-by-step instruction on proper body mechanics, feet, and hand placement in order to aid the OT in safe transfers. This education will allow the patient to take part in his care while ensuring his safety. Educating his daughter on the helpful and safe ways that she can assist her father through transfers will be imperative to his continued success if discharged home.

19 OCCUPATIONAL PROFILE & INTERVENTION PLAN 19 Response Format The patient s response to intervention will be monitored through skilled observation by the treating OT. Daily documentation will be completed following daily sessions commenting on notable observations, pain levels, and the patient s performance. The use of Functional Independence Measure (FIM) ratings will be utilized to assess the patient s daily function. FIM ratings will be used to score items regarding self-care and transfers, specifically, lower body dressing and bed to standing transfers. Ideally narratives will also be provided to include detailed descriptions of the patient s performance and allow the OT to have adequate information to present to the patient s physician when necessary. After the completion of 2 weeks, an informal observation based re-assessment will occur. Through use of clinical reasoning and comparison of FIM scores, it will be determined whether all Short-term Goals were met. Based on these findings, new goals will be developed to address Long-term Goals 1 and 2. The OT will also continue to communicate with nursing, PT, RT, and ST to have a more complete understanding of the patient s status throughout.

20 OCCUPATIONAL PROFILE & INTERVENTION PLAN 20 References American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. Breines, E. B. (2013). Therapuetic occupations and modalities. In H.M. Pendleton, & W. Schultz-Krohn (Eds.), Pedretti s occupational therapy: Practice skills for physical dysfunction (7th ed., pp ). St. Louis: Mosby, Inc. Chang, L., Wang, L., Wu, C., Wu, H., & Wu, Y. (2006). Effects of physical training on functional status in patients with prolonged mechanical ventilation. Physical Therapy, 86(9), doi: /pli Gillen, G. (2013). Cerebrovascular accident/stroke. In H.M. Pendleton, & W. Schultz-Krohn (Eds.), Pedretti s occupational therapy: Practice skills for physical dysfunction (7th ed., pp ). St. Louis: Mosby, Inc. Granacher, U., Gollhofer, A., Hortobagyi, T., Kressig, R. W., & Muehlbauer, T. (2013). The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: A systematic review. Sports Medicine, 43, doi: /s Marston, H. R., Greenlay, S., & Van Hoof, J. (2013). Understanding the Nintendo Wii and Microsoft Kinect consoles in long-term care facilities. Technology and Disability, 25, doi: /TAD Schultz-Krohn, W., & Pendleton, H. M. (2013). Application of the Occupational Therapy Practice Framework to physical dysfunction. In H.M. Pendleton, & W. Schultz-Krohn

21 OCCUPATIONAL PROFILE & INTERVENTION PLAN 21 (Eds.), Pedretti s occupational therapy: Practice skills for physical dysfunction (7th ed., pp ). St. Louis: Mosby, Inc.