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Running Head: LEONS OCCUPATIONAL PROFILE

Leons Occupational Profile & Analysis Corinne Trenholm Touro University, Nevada

LEONS OCCUPATIONAL PROFILE

Occupational Profile The following occupational profile was completed through interviews with caregivers working at the assisted living facility where Leon lives and chart reviews. The Occupational Therapy Practice Framework (2008) was used to guide questions and discussion. Leon is a 73-year-old male who suffered a traumatic brain injury (TBI) after being hit by a car while riding his bike. His chart does not reveal when the accident occurred. His caregivers are also unsure about the date of the accident but one caregiver reports that she thinks it happened almost a year ago. He has a secondary diagnosis of dementia. Leons chart lacks medical records and the severity of his TBI and dementia are unknown. Based on observations it appears that his temporal and frontal lobes have been impacted by his TBI. Leon demonstrates speech, motor, and attention difficulties. Leon currently lives at an assisted living facility for residents with memory loss. His wife and son come to visit him weekly. The caregivers report that his family always provides necessary materials when needed and they communicate well with the staff. They also report that Leon responds well to his family. He has better attention, engagement, and uses more words in their presence. Leon has several caregivers at the assisted living facility that help care for him. Although they are nurturing and respectful, they encourage learned helplessness. They do everything for Leon including grooming, dressing, toileting, feeding, and choosing activities for him to engage in. Leon is non-verbal, however; he has the ability to say a few one word sentences such as no and some 3 word phrases. These short sentences are unpredictable and often arent used to communicate effectively. Based on chart reviews, Leon rode his bike 200 miles every week and enjoyed playing with his grandkids. He ate healthy and was always on the go. His caregivers report that he has difficulty with attention and needs maximal assistance with basic activities of daily living. The caregivers would like

LEONS OCCUPATIONAL PROFILE

Leon to be more engaged in everyday activities. for Leon to get better so he can return home.

The caregivers report that his family is waiting

Occupational Analysis The following occupational analysis was completed through a chart review, observations, and caregiver interviews. The Occupational Therapy Practice Framework (2008) served as a guide to complete this analysis. Body Function Deficits Leon has moderate spasticity in his left upper extremity which makes it difficult for him to use his left arm and hand for bilateral tasks. Leon has severe spasticity in his lower extremities which impacts his ability to stand, walk, and engage in active and passive movement. Frontal lobe damage, as a result of Leons TBI, could also be a cause of his left upper extremity and lower extremity deficits. Leon has fair trunk support. His caregivers report that he can sit for short periods of time at edge of bed independently. Leon is unable to communicate verbally and does not use any other form of communication such as gestures. Leon has urinary and fecal incontinence. It is unknown if his incontinence is due to total incontinence or functional incontinence. Leon requires corrective lenses to help with daily functional vision. Leon is deaf in his left ear and has hearing loss in his right ear. Leon has difficulties attending to people and tasks. Based on limited information related to Leons heath, deficits in cardiovascular, hematological, immunological, respiratory, digestive, metabolic, and endocrine systems are unknown. Activity Demands Leons caregivers report that he loves to eat. Being that food is a strong motivator, feeding is one of the only occupations that Leon actively engages in. Leon has full range of

LEONS OCCUPATIONAL PROFILE

motion and strength along with a variety of grasp patters in his right upper extremity. These strengths give Leon the ability to engage in self-feeding. For the above reasons, Leon was

observed during feeding in order to complete the following occupational analysis. Objects and their properties. Currently, the assisted living facility uses standard porcelain plates. The plates do not have edges and are smooth. These properties make it difficult for Leon to scoop his food while only using one hand. The facility also uses standard four-pronged forks for the majority of their mealtimes. The handles on the forks are thin, light, and smooth. Although Leon can grasp the fork handles, having built-up handles with added weight would make feeding easier and decrease frustration. Using a built-up, weighted spoon instead of a fork would also be beneficial. The table where Leon sits is low and does not have enough depth to allow his wheelchair to fit properly. Having a higher table that is closer to Leons body would enable Leon to eat with more ease and less spilling. The table surface is smooth and slick. This makes one-handed feeding difficult for Leon. Having a Dycem mat or other non-slip surface would help keep Leons plates and bowls in place during feeding. Leon drinks his coffee from a standard mug that has one handle. He also uses light, plastic cups for other liquids. Leon is able to use proper grasp patterns for both glasses without difficulty or spilling. Leon is given a paper napkin during mealtimes that he uses appropriately. Leon doesnt have any food restrictions and eats a variety of foods including meat, fruit, vegetables, and grains. His food is prepared for him in bite size pieces. Space demands. Leon eats his meals in a large open space that is well lit. The tables are arranged with adequate space around them to allow wheelchair access from all directions. This accessibility allows Leon to sit at various tables in the dining hall. The dining room is quiet and contains a solid color wall with a few framed paintings. The simplicity of the room prevents

LEONS OCCUPATIONAL PROFILE

distractions. The dining area is kept at a comfortable temperature and appears to have good ventilation. Social demands. Leon eats his meals in a shared dining room. He must be able to tolerate eating at the same table and near other residents. Due to Leon needing assistance with mealtimes, he must be willing to accept help and cooperate with his caregivers. Sequence and timing. In order for Leon to feed himself, he must be able to sequence the steps required for feeding. These steps include obtaining food, bringing food to his mouth, opening his mouth, putting food in his mouth, and closing his lips and chewing. He must also be able to swallow and repeat these steps. After careful observation, Leon has excellent sequencing skills related to eating. He also demonstrates appropriate timing skills. Leon chews and swallows his food prior to retrieving more food and will clear his throat and mouth with a beverage when needed. Required actions and performance skills. In order to complete self-feeding, Leon must use eye-hand coordination and fine motor skills to locate and retrieve food. This requires that his visual, proprioceptive, and tactile sensations are intact along with motor praxis skills. Functional grasp patterns, muscle strength and endurance, and range of motion in at least one upper extremity are also needed to complete self-feeding. Proprioceptive and tactile perceptions prevent Leon from biting his lips, fingers, and tongue and help with safety from hot food and drinks. Leon must maintain self-regulation and persistence during feeding in order to prevent frustration. Leon also needs to cooperate with his caregivers during mealtimes when help is needed. Although Leon is unable to communicate, communication would be helpful during mealtimes. Communication would allow him to make choices of preferred food and drink items,

LEONS OCCUPATIONAL PROFILE

ask for help or refuse unwanted help, and discuss if he is having difficulties or pain during chewing and swallowing. Required body functions and body structures. During mealtimes Leon must be conscious, have an appetite, be motivated to eat, and feel comfortable and safe during chewing and swallowing. His central and peripheral nervous system need to be working together in order for him to coordinate this activity. Long-term memory, sequencing, and attention skills allow him to complete the steps required for feeding. Being able to distinguish between edible and non-edible food items is also important. As discussed earlier, sensory functions such as proprioception, pain, temperature, sight, and touch are imperative as they prevent injury. Proprioception, sight, and tactile functions also enable Leon to retrieve and chew and swallow food. Although hearing, smell, and taste arent required functions to complete feeding tasks, they are helpful in providing sensory feedback. Leon can use his hearing to help him know when his fork has touched his plate or to respond to verbal prompts from caregivers. Smell and taste can be an extrinsic motivator for continued feeding. Leon needs to be able to have at least 90 degrees of elbow flexion and full elbow extension during self feeding. He also needs to use various grasp patterns such as a lateral pinch and cylindrical grasp. He must have adequate muscle strength and endurance in his upper extremity including his hand, wrist, and fingers. Having hip and neck flexion would be helpful during feeding, but is not necessary. Flexion helps reduce the distance needed to bring food to the mouth and prevents spilling. Although bilateral upper extremity use is beneficial for feeding, it is not required. Communication is another function that isnt required but would increase control and independence. Finally, Leon requires a functioning cardiovascular and respiratory system during feeding. Performance Patterns Related to the Task

LEONS OCCUPATIONAL PROFILE

Habits. There are many habits associated with feeding. Through observations, Leon has several habits that he utilizes during this task. These include how he grasps his utensils, uses a napkin, where he places his cups, and how he chews and swallows food. These automatic behaviors that have manifested over many years of self-feeding positively impact his performance in this occupation. Routines. The assisted living facility follows a strict mealtime routine. This routine allows Leon to understand when he will be engaging in feeding and gives him awareness about what time of the day it is. Mealtimes occur in the same setting with the same tableware. Having consistency helps Leon learn to use the utensils and manipulate the tableware. Rituals and roles. Due to Leons communication and motor delays, it is difficult for Leon to initiate and engage in rituals and roles associated with mealtimes. It is unknown if Leon participated in rituals such as praying before meals or of the roles he engaged in such as cooking meals. Understanding his roles and rituals would make mealtimes more meaningful and could further enhance occupational performance. Relation of the Context Leons chart reveals that his culture consisted of living an active and healthy lifestyle. His wife wrote in his chart that he exercised daily and ate healthy. Understanding that Leon strived to eat healthy should alert his caregivers to continue to provide healthy, balanced meals. Little is known about his food preferences and his caregivers should respond to his cues appropriately. Mealtimes should be provided in a safe environment. This includes furniture, feeding utensils and tableware, and food. Food should be cooked appropriately, served at an appropriate temperature, and cut into bite size pieces. Leon should also be monitored during feeding to ensure safety. Leon responds well to social engagement. The dining hall provides an intimate setting where social engagement with other residents can be encouraged.

LEONS OCCUPATIONAL PROFILE

Problem List Adhering to the guidelines from Gateley & Borcherding (2012) the following problem statements were created and are prioritized from greatest to least. These problem statements are prioritized according to Leons current abilities and his caregivers wants and needs. These problem statements also correspond to goals and interventions that can be carried out in the assisted living facility by an occupational therapist. 1) Client requires Mod (A) during mealtimes 2 coordination & L UE spasticity. 2) Client is unable to communicate verbally & c gestures 2 TBI. 3) Client is unable to use his L UE during BADLs 2 spasticity, coordination, & learned non-use. 4) Client requires Max (A) during grooming 2 attention, coordination, spasticity in L UE, & opportunities for independence. 5) Client requires Max (A) to stand & walk 2 severe spasticity in B LE, muscle strength & endurance, & coordination. During several observations and working with Leon, he shows great potential for independent feeding. He has the motivation and physical capabilities to perform this activity. Leon shows active engagement in his right upper extremity and is able to coordinate the necessary steps. By prioritizing problem statement number one to the top of the list, this gives Leon the opportunity for active engagement to promote independence and pride in his accomplishments. This also allows his caregivers to see Leon as an abled body man who is capable of performing basic activities of daily living. Recognizing his potential will alert his caregivers to encourage engagement in other tasks such as grooming and dressing.

LEONS OCCUPATIONAL PROFILE

Not being able to communicate impacts Leons ability to be in control of his wants and needs and impacts his engagement in all areas of occupation. Without communication, it is hard to assess Leons true potential and include him in intervention planning. Working on functional communication is another top priority as this will help Leon regain self-efficacy and help with further goals and intervention planning. Although speech language

pathologists typically take on the role of helping clients regain communication skills, Leon does not have access to a speech therapist. Creating compensatory strategies for verbal communication such as communication boards, sign language, gestures, or making proper referrals to obtain augmentative communication devices falls within the scope of occupational therapy under communication management. Communication also fits into all areas of occupation as a body function that is needed to effectively engage. Problem statements three and four will help address his caregivers concerns of wanting Leon to show active engagement in daily occupations. By addressing his left upper

extremity spasticity, he will be less likely to develop contractures and more likely to incorporate his left upper extremity into bilateral tasks. Teaching his caregivers how to work with Leon on a daily basis to promote active engagement is imperative to his progress and should be the focus of intervention. Finally, in order to decrease spasticity and increase movement in Leons lower extremities, lower extremity interventions are crucial. Lower extremity interventions prevent contractures and decubitus ulcers, help with blood circulation, and could help Leon regain functional mobility. Leon was able to stand and walk with a front wheel walker when working with his physical therapist. Since his discharge from physical therapy four weeks ago, Leon has not had opportunities to engage in these activities. This restricted movement is

LEONS OCCUPATIONAL PROFILE

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not a symptom that should be ignored. Being that Leon was a cyclist should alert one to understand the importance of regaining lower extremity movement. There are several

stationary bikes that can meet Leons needs and can be used for therapeutic exercise and for leisure. Leon was an active person prior to his accident and regaining as much physical activity would be beneficial for his overall well-being. Conclusion Through an occupational profile, analysis, and development of problems statements, an OT is able to gather and interpret valuable information about their client. This information enables an OT to identify their clients wants, interests, strengths, needs, and priorities. By identifying these factors an OT develops appropriate, client-centered goals and interventions that facilitate engagement in desired and meaningful occupations that enhance ones life.

LEONS OCCUPATIONAL PROFILE

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References American Occupational Therapy Association (2008). Occupational therapy practice framework: Domain and Process (2nd ed.). Baltimore, MD: AOTA Press. Gateley, C., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes. (3rd ed., pp. 37-43). Thorofare, NJ: SLACK Incorporated.

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