occupational therapy case study assignment

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Occupational Therapy, Case Study Example

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Occupational Therapy: A Client Centered Analysis and Project Planning

Client Demographic and Medical Information

The client is a female who lives alone in her own apartment. She has had a post open reduction internal fixation on the right femur fracture and from it has developed respiratory abnormalities along the way. The said health status has been a result of a past accident while the client was on vacation. After the accident, the client had an operation on her right leg and was then transferred to another hospital later on due to the swelling of the operated leg. From there the swelling has imposed another form of problem which resulted to her respiratory function abnormalities.

Target Point of Development: Goal of Therapy (Daily Activities)

The client basically wants to function normally again especially when it comes to moving the legs freely and specifically breathing normally with no specific hindrances to the function of the respiratory system. Considerably, the process by which the therapy entails to respond to these problems is through imposing regular slow-walking activities that would gradually increase in time-length as the client begins to adapt to the therapy’s everyday nature. Along with that comes the daily breathing exercise that shall be imposed so as to make sure that the client’s breathing process would be further defined for improvement. Like the first type of development, the client’s breathing exercise shall first pick up from slow and short span of therapies towards longer spans hence increasing the capability of the client to perform long term breathing exercises.

Other Goals

Short Term Goals:

Activity: Assistance  to patient when it comes to dressing herself up [this shall include a 20 to 30 minute dressing up so as to make a considerable approach in helping the patient train to do the task]

Rationale: Patient expresses her desire to dress on her own without assistance later on but accepts the fact that as of now she needs to practice regularly to be able to attain the said state.

Activity: Assistance to patient when walking to and from her own kitchen and dining room. [the distance is pretty close and the activity is expected to be held at least three times per day with at least 10 minute session each practice]

Rationale: The client asks that she be assisted to walk around the house freely after the therapy

Long Term Goals:

Activity: Walking outside the house within the neighborhood for at least 10 minutes each day

Rationale: The patient wants to be able to walk around the neighborhood freely as she follows the pattern of recovery that the therapy intends to impose on her current health status.

Activity: The therapy shall involve a more defined way of allowing the patient gain full control of herself especially when it comes to standing up. The activity shall involve points of development in a gradual manner that includes standing freely for three minutes and later on shall adjust up to five-ten minute practices.

Rationale: Patient asks for assistance in standing up for long minutes without the need to feel extensive pain.

Occupational Therapy Interventions

Preparatory Method

The client should be specifically prepared in three different aspects of development specifically considering physical, mental and emotional factors of individuality. This will help the client inhibit a positive outlook of the situation that she is supposed to undergo during the entire therapy session. With the assumption of mental preparedness, the OT attendant could provide a summation of the goals that are to be achieved in the course hence giving the client an overview of what she would expect to happen after the application of the process of development being imposed through the therapy. This ideal assumption of development could be further imposed in the aspect of emotional and physical preparedness.

Purposeful Activity

In the process of preparation, it is important to have a correlative talk with the client which shall further help her redefine her being alongside the developments that she is supposed to incur through the time frame being completed for the therapy. The purpose of this approach is to make sure that the client knows what she is supposed to expect and further help her make a list of goals she herself would like to accomplish during and after the therapy sessions.

Treatment Session

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Related Topics

• Occupational safety and health
• Occupational therapy

• About the Project
• Introduction to the ICF
• Introduction to the ICF Core Sets
• Introduction to ICF-based Documentation Tools and Rehab-Cycle
• 01 | Goal-Setting
• 02 | Independence
• 04 | Health Behaviour
• 05 | SCI in Older Persons
• 06 | Recovery After Traumatic SCI
• 07 | Return-to-Work
• 08 | Community Reintegration
• 09 | Sports in Rehabilitation
• 10 | Walking Recovery
• 11 | Care in Low and Middle-Resource Countries
• 12 | SCI and Environmental Accessibility
• 13 | SCI in Adolescence and Peer Relationships
• 14 | Bowel and Bladder Management
• 15 | Psychological Issues And SCI
• 16 | Time-Related Aspects
• 17 | Motivation And Rehabilitation
• 18 | Social Service Support In SCI Rehabilitation
• 19 | SCI And Chronic Pain Management
• 20 | Rights For Persons With Disability

Case Studies

• Assignment and Intervention

While the nurse, physical therapist (PT) and occupational therapist (OT) were responsible for most of the interventions during Stefan’s three-week rehabilitation programme, a number of intervention targets were also addressed by the physician, psychologist and other health professionals.

Interventions Targeting Mobility

Specific interventions to improve mobility were performed by both the OT and the PT. While the PT focused on addressing intervention targets from the body functions perspective, the OT provided interventions that targeted activities and participation. For example, the PT performed manual therapy to improve joint mobility (b710), guided Stefan in completing regular circuit training to increase muscle power (b730), especially in his arms, and muscle strength training to improve supportive functions of his arms (b7603). The PT also provided body balance training to help Stefan enhance his ability to maintain a sitting position (d4153). These intervention targets, in turn, were essential for improving Stefan's transferring skills. Transferring to and from the wheelchair (d420) – a crucial skill for being independent in daily living – was addressed by the OT, as well as by the PT and nurse, through instruction and regular transfer training.

"...the interventions provided also aimed at optimising the amount of time Stefan needed for indoor and outdoor mobility."

The OT also provided city training, in both individual and group sessions, to help Stefan improve his outdoor mobility, specifically his abilities to manoeuvre the wheelchair in different locations (d460) such as streets, railway stations, trains, elevators. The group activities included Stefan's participation in a wheelchair club, weekly group counselling sessions during brunch, and visits to the circus, a zoo and a local lakeside café. Additionally, Stefan contributed to a group project that helped train his ability to plan tasks and actions, effective communication, and cooperation with others toward achieving a common goal.

Using public transportation (d470), specifically the train, was difficult for Stefan. Getting into an elevator at the train station with the Swiss-Trac TM was almost impossible since it took too much time to completely manoeuvre his wheelchair and Swiss-Trac TM into the elevator before the doors closed. Once inside the train Stefan took a lot of time to undock the Swiss-Trac TM and take a place in the wheelchair compartment. Moreover, he was afraid of moving around in his wheelchair in the train. These are among the mobility problems that slowed Stefan down in everyday life. Thus, the interventions provided also aimed at optimising the amount of time Stefan needed for indoor and outdoor mobility.

In addition to the PT, OT, and the nurse, the physician also provided interventions to address Stefan's mobility issues i.e. the physician prescribed medication to reduce the spasticity Stefan had been experiencing.

Interventions Targeting Self-Care

The physician together with the nurse also contributed to addressing the problems Stefan had with toileting (d530), specifically the body functions aspects of toileting. The physician conducted regular clinical examinations, while the nurse assisted Stefan with using a device to clear his bowel and in applying the condom catheter, and provided related instruction. The nurse was also instrumental in addressing other intervention targets in self-care together with the OT.

Shaving with the electric shaver is difficult for Stefan, since he doesn’t know how much pressure is needed. It takes him about ten minutes to finish shaving – much longer than another person would require.

Stefan’s OT at the time of assessment

To improve Stefan’s independence in self-care, the nurse and OT provided instruction and self-management training in caring for body parts (d520), dressing (d540), eating (d550), and looking after his health (d570). The OT assisted Stefan in finding compensation strategies to independently perform self-care activities and in a time-efficient manner.

Interventions Targeting Contextual Factors

Members of the rehabilitation team coordinated their interventions to address contextual (environmental and personal) factors that impacted Stefan's independence in mobility and self-care. For example, both the PT and OT were involved in clarifying the ideal assistive devices for use in daily living (e1151).

Stefan had difficulties docking the Swiss-Trac TM to his wheelchair. Subsequently, a special funnel was attached that facilitated his handling of the wheelchair.

Stefan’s OT

With regard to Stefan's personal factors, a psychologist provided counselling to help improve Stefan’s assertiveness and self-confidence. This was supported by the group activities led by the nurse, PT and/or OT.

An Overview of Assignment and Intervention

Each of the intervention targets was assigned to one or more of the rehabilitation team members. The ICF Intervention Table provided an at-a-glance overview of the assignment of the intervention target to the respective team member(s) as well as the ICF qualifier values defined for the first value and goal value as documented on the ICF Categorical Profile.{BITTE BEIM "ICF CATEGORICAL PROFILE" EINEN ANKER zum 3. Absatz unter Goal-setting/Determination of Intervention Targets, der mit "These three goals..." anfängt, SETZEN. DANKE DIR.} See table 3.

Table 3: ICF Intervention Table; Doc = physician; PT = Physical Therapist; OT = Occupational Therapist; Psych = Psychologist; Others = Sports Therapist, Dietary Specialist, or Orthopaedic Technology Specialist. The first value refers to the rating at the initial assessment, the goal value refers to the rating that should be achieved after the intervention, and the final value refers to the actual rating at the second assessment or evaluation. ICF qualifiers were used to determine these ratings (0 = no problem to 4 = complete problem) in the intervention targets. For the intervention targets representing the environmental and personal factors, the plus sign next to the value indicates a facilitator.

Time-Related Aspects

• General Introduction
• Stefan’s Story
• Goal-setting/Determination of Intervention Targets
• PDF Download

Introduction

ICF Research Branch c/o Swiss Paraplegic Research Guido A. Zäch Strasse 4 6207 Nottwil (Switzerland) Tel. +41 41 939 66 31 www.icf-research-branch.org www.icf-core-sets.org

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Occupational Therapy Assignment: 1129869

Acute care assignment.

My patient: patient C

Age: 59 years

Diagnosis: Multiple sclerosis

Therapy Note Requirements

Three occupational therapy notes that every occupational therapist should have regardless of the setting they are working in are:

• Their signature
• The date on which they are assessing the patients and
• The time of patient treatment so that the professional could not be liable for something which happened after the time of their treatment (Lipskaya-Velikovsky, Kotler & Krupa, 2016).

Social History and Prior Level of Function

While working with patients, it is important that the occupational therapists develop a template for the questionnaires that would be used to ask the patient few questions related to their social and health history with level of functionality. This is also an important aspect as it would help to develop the evaluation process of the occupational therapy implemented upon the patient. The questionnaire would be as follows:

Name: Peter Mitchell

Marital status: married for 20 years and lives with adult children and wife

Employment: retired

• Both the children of Peter lives nearby their house however they are busy in their professional life due to which they are unable to take care of their parents.
• The patient has two storey house and the patient’s room is at the second floor. However, they have shifted him to the ground floor for his safety and prevent his falls.
• The patient is unable to move without any help and hence, he is completely dependent upon his wife and children for his locomotion and activities of daily life.
• The patient had multiple history of falls due to which his physical health has been affected.
• The patient mentioned that he wants to receive support at him home as it would effective for him.

ADL and Transfer

• As the patient chosen for the simulation is Patient C (59 years) with multiple sclerosis, the ADL that would be chosen for its assessment and evaluation would be locomotion.
• Chosen ADL: Locomotion devices
• Devices chosen are: walkers and other walking aids, crutches wheelchairs
• As per Nilsen et al. (2015) majority of the patients that suffer from the complications of multiple sclerosis, are independent and their level of personal- ADL and instrumental- ADL are moderate. However, their primary complication is associated with their locomotion and self- care abilities (Swanson, 2015).
• Hence, through the help of assessment and evaluation of this patient’s ability to move from one location to another would help to understand the functional independence measurement (FIM) and as an occupational therapist, I would be able to decide the interventions that I would be implementing for the health and wellbeing of the patient involved in the care process (Felipe et al., 2019).
• For this purpose, I would be requiring the simultaneous evaluation of the patient’s health so that while assessing his functional and motor skills, his health conditions could be assessed.
• He would be provided with effective training so that his balance and ability o move freely could increase.
• The first aspect that should be considered while evaluating or treating the patient condition is the severity of his multiple sclerosis condition that has affected his social history (Swanson, 2015).
• The patient is suffering from vision issues due to which he is unable to communicate with anyone around him. Hence, in the process, his family members should be included. It was mentioned in social and health history that till the age of 45, the patient was a regular swimmer and hence, his endurance power is adequate to undergo a moderate occupational therapy (Sinogui et al., 2019).
•  However, upon admission, numbness in his right leg was observed due to which, this aspect should be considered as the third factor. The fourth and fifth factors that would be considered would be his financial inabilities and his language barrier due to which, the patient should be provided with occupational therapy in the presence of a translator and his family member (Nilsen et al.., 2015).

Nilsen, D., Gillen, G., Arbesman, M., & Lieberman, D. (2015). Occupational Therapy interventions for adults with stroke.  American Journal of Occupational Therapy ,  69 (5), 6905395010p1-6905395010p3.

Sinogui, C., Barzo, M., Zrelak, P., Murphy, R., Jennings, A., & Hartman, J. (2019). Abstract TP182: Physical Therapy/Occupational Therapy Evaluation Within the First 24-Hours for Patients Who Have Received Intravenous Alteplase.  Stroke ,  50 (Suppl_1), ATP182-ATP182.

Felipe, F. A., de Carvalho, F. O., Silva, É. R., Santos, N. G. L., Fontes, P. A., de Almeida, A. S., … & de Souza Araújo, A. A. (2019). Evaluation instruments for physical therapy using virtual reality in stroke patients: a systematic review.  Physiotherapy .

Swanson, C. M. (2015). Outpatient treadmill-based locomotor and dynamic balance retraining after intraoperative stroke.

Lipskaya-Velikovsky, L., Kotler, M., & Krupa, T. (2016). Description of and Preliminary Findings for Occupational Connections, an Intervention for Inpatient Psychiatry Settings.  American Journal of Occupational Therapy ,  70 (6), 7006350010p1-7006350010p5.

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