Hello.My name is Sandy Nieves. I am honored to let you know that I will beyour occupational therapist. In my skilled nature, it is normal forme to conduct interviews and pertinent medical evaluations on you.Therefore, Mr. Scott, feel free to tell me any information you thinkmight be supportive in helping you therapeutically. I am aprofessional, bound by the occupational therapist’s code of ethicswhich means that any health information you divulge will be strictlyconfidential. In addition to the chart review I have already done onyour case, I will be asking you a series of questions pertaining toyour mobility and safety. Scott is right handed and needs glasses forreading because his vision is impaired to some extent although hishearing is WFL. His skin has reddened spots (bruises), with slightedema on the RLE. His general posture is slanted forward, with hishead down. What’s more, Scott maintains balance sitting unsupportedduring ADL’s. When standing during ADL’s, Scott is givenassistance to stand, walk, and reach out to things on elevatedsurfaces. His respiratory status is WFL and muscle tone is normal.Also, Scott’s fine motor skills are still intact although hisgross motor coordination is significantly diminished.
Mr.Scott is 67 year old, admitted from Larkin Hospital with a diagnosisof a right THR. PMH includes herniated discs, LBP, osteoarthritis,gout, and BPH. The main reason for Scott’s current referral isdecreased functionality in mobility and participation in ADL’s.Basically, Scott is experiencing a decrease in strength, reduced ADLparticipation, increased need for assistance from caregivers,decreased range in motion, and reduced balance. Before surgery, Scottmentioned that he was self-sufficient in all ADLs and had perfectfunctional mobility. Therefore, he was executing his grooming,eating, bathing, LB dressing, UB dressing, and toileting functions.However, after surgery, Scott’s level of autonomy decreased to thepoint of entirely depending on others for the execution of all ADL’s.
Theother factor that exacerbates Scott’s medical condition is hiscurrent place of residence. He lives in a two story townhouse withhis mother. Considering that their townhouse has stairs, Scott’sbedroom is on the second floor. Thus, these stairs act as a hindranceto Scott’s ability to utilize all of his occupational potential. Hecannot walk up and down the stairs without assistance or around theneighborhood. I performed a FIM examination on Scott, to determinethe degree of assistance he required when performing functionalmobility, performing ADL’s, and transfers. The FIM scores were(values in brackets): eating (5Set up),toileting (2Max A),bathing (2Max A),UB dressing (4Min A),LB dressing (2Mix A),grooming (4Min A)and toilet transfer (2Max A).In his state, Scott’s major desire is to be able to once again,become independent with execution of ADL’s. Per se, Scott wants toperform his bathing, eating, toileting, UL dressing, UB dressing, andgrooming functions. Bearing in mind that Scott’s hobby is strollingaround the neighborhood on a daily basis, he desires to have theability to independently and safely walk as part of his exercisingroutine.
Accordingto Webber et al. (2016), mental functions, including the ability tosequence complex pattern movements, regulation of behavior,motivation, and interpreting incoming stimuli can also affect motorfunctions. The authors note that these mental factors must beconsidered in any OT performance evaluation. To this effect, Iperformed an examination of Scott’s mental state using the MMSE. Iperformed this test because my patient’s chart did not containsubstantial PMH. The test was instrumental in helping me determinewhether Scott was oriented cognitively. Scott received the maximumscore of 30/30 implying that his mental state is intact. At thispoint, I ruled out mental issues as causative factors of his medicalcondition.
Thesecond test I performed on Scott was a visual clinical observation ofhow he was executing ADL’s. According to Clark (2014), anoccupational-based practitioner can assess ROM, motor control, andmuscle strength during the performance of ordinary ADL’s. I askedScott to perform motions associated with functional tasks to identifyany signs of muscle weakness, difficulty in movement and performancepatterns, and difficulty in compensatory motions used for function. Iprocured this dynamic performance analysis to diagnose occupationalperformance problems in Scott by understanding his challenges in hiscontext, the tasks performed, and the environment. Clark (2014)points out that it is important for an occupational therapist toassess the ROM, muscle strength, and motor control in how theirclients perform ADL’s. These activities are meaningfulinterventional goals with regard to improving occupationalperformance in patients (Clark, 2014).
Thethird evaluation I performed on Scott was the OB FMA. In accordanceto Craik (2016), the OB FMA entails the assessment of a patient’supper and lower extremities. To this effect, I assessed Scott’supper and lower extremities occupational functions. In his lowerextremity, I examined the hip complex with regard to abductionand adduction,flexionand extension,and internaland externalrotation (Craik,2016). I also examined his knee’s flexionand extension,in addition to his ankle and foot with respect to dorsiflexionand plantarflexionand inversionand eversion(Craik,2016). In his UB, I examined the shoulder complex with specificregard to flectionand abduction,horizontaladductionand abduction,and extensionand abduction(Craik,2016). Moreover, I assessed the functionality of his knees withregard to pronationand supinationpositioningof the hands and flexionand extension.In his LB, I also checked the wrists and hands for normal flectionand abduction(Craik,2016).
Modelsand Frames of Reference
Inmy professional capacity, I chose three models and frames ofreference to guide my thinking processes when making decisions on howto evaluate and treat Scott: MOHO, biomechanical, and rehabilitativeFORs. According to Lee Bunting (2016), the biomechanical FOR is basedon the assumption that a client’s impairment is musculoskeletal innature. I made this assumption centered on the fact that he hadinitially suffered from a right THR. The second FOR I used for Scottwas the rehabilitative kind of FOR. It is the opinion of Lee Bunting(2016) that rehabilitative FOR makes the assumption that a client’sdisabilities are associated with sensorimotor, neuromotor, orneurodevelopment disorders like acquired brain injuries. Judging bymy clinical observation of Scott, I arrived at the decision to employthis FOR. The third FOR I used to evaluate Scott was MOHO. LeeBunting (2016) perceptively states that MOHO addresses three majorpatient immobility issues: occupational identity, occupationalcompetence, and occupational setting. This model assists in therehabilitation of patients by developing an elaborate plan of apatient’s occupational rehabilitation (Lee Bunting, 2016). In thisregard, I chose this model because it will assist me develop anostentatious rehabilitation plan for Scott.
Scott will complete commode/toilet transfers with Mod (A) and 25% verbal prompts for being lifted up from the chair, for appropriate foot/hand placement, and for employment of strategies with condensed risks for falls (Target: 10/29/16).
Scott will efficiently and safely perform LB and UB dressing with Mod (A) and 25% verbal prompts for the appropriate employment of AD so as to execute LB ADLs with amplified safety and independence (Target: 10/29/16).
Scott will portray standardized gait patterns while securely ambulating 50 feet on flat planes with Min (A) employing AD with reduced odds of falls with the ability to maintain self-balance for the execution of ADL’s (Target: 10/29/16).
Scott will complete toilet/commode transfers with Min (A) and occasional verbal cues for push up from arms of chair, for correct hand/foot placement and for use of compensatory strategies with reduced risks for falls (Target: 01/15/17).
Scott will efficiently and safely perform UB and LB dressing with Min (A) and occasional verbal cues for the correct usage of AD, for use of compensatory approaches in order to independently perform LB ABD’s with increased independence and safety (Target: 01/15/17).
Scott will display normal gait pattern while securely ambulating 200 feet on flat planes with amplified autonomy using AD with reduced odds for falls and with ability to autonomously achieve and maintain balance for ADL’s (Target: 01/15/17).
Mr.Scott is my 67 year old patient, recently admitted from LarkinHospital with a diagnosis of a right THR. PMH includes LBP, herniateddiscs, osteoarthritis, gout, and BPH. Scott is currently under mycare because he is experiencing a decrease in strength, reduced ADLparticipation, decreased range in motion, reduced balance, andincreased need for assistance from caregivers. Before surgery, Scottmentioned that he was self-sufficient in executing his eating,grooming, bathing, toileting, UB dressing, and LB dressing functions.However, after surgery, Scott’s degree of independence diminishedto the point of entirely depending on others for the successfulexecution of ADL’s. Therefore, Scott’s main desire is to have theability to independently and safely walk as part of his exercisingroutine. To determine the degree of assistance Scott required whenexecuting ADLs, I performed a FIM test on him. Moreover, I performeda MMSE to determine whether Scott’s condition is exacerbated byunderlying mental factors. He passed the MMSE test with a score of30/30 implying that Scott’s cognitive function is intact. What’smore, I performed clinical and the OB FMA evaluations on Scott, todiscern his immobility challenges in his context. Using three FORs toguide my therapeutic thought processes, I was able to evaluate andgenerate an operative treatment plan for my patient. With projectedtreatment outcomes, I am positive that Scott will fully regainindependence in executing ADLs with Min A by the expected dates ofrecuperation. After the rehabilitation process is complete, I amconfident that Scott will experience increased strength, increasedADL participation, increased range in motion, and most of all,decreased need for assistance from caregivers by the projected dates.
Clarke,A. (2014). Pre-Screening Elderly Drivers With Intervention. Physical& In Geriatrics,32(2),179-181. http://dx.doi.org/10.3109/02703181.2014.919153
Craik,C. (2016). Occupational therapy as a career: Variety and challenge.BritishJournal Of ,79(10),583-583. http://dx.doi.org/10.1177/0308022616668197
LeeBunting, K. (2016). Book Review: Bruce and Borgs psychosocial framesof reference: Theories, models and approaches for occupation-basedpractice. CanadianJournal Of .http://dx.doi.org/10.1177/0008417416660734
Weber,C., Schwieterman, M., Fier, K., Berni, J., Swartz, N., Phillips, R.,& Reneker, J. (2016). Reliability and Validity of the FunctionalGait Assessment: A Systematic Review. Physical& In Geriatrics,34(1),88-103. http://dx.doi.org/10.3109/02703181.2015.1128509
ADL-Activities of Daily Living
BPH-Benign Prostatic Hyperplasia
FIM-Functional Index Measures
FOR-Frames of Reference
LBP-Lower Back Pain
MMSE-Mini-Mental State Examination
MOHO-Models of Human Occupation
OBFMA- Occupation-Based Functional Motion Assessment
PMH-Patient Medical History
THR-Total Hip Replacement