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Evidence-Based Intervention Plan Chrys Quiroz Touro University Nevada

EVIDENCE-BASED INTERVENTION PLAN Client Review Ms. Snowden is 58 years old and was admitted to the acute hospital for a right total hip

arthroplasty (THA) with a posterolateral approach secondary to degenerative joint disease. She is currently employed as a Blackjack dealer in the casino industry but is taking time off to recover from her recent surgery. Ms. Snowdens difficulties lie in adhering to her total hip precautions (THP). These precautions include no internal rotation or abduction of her affected lower extremity and withholding from hip flexion past 90 degrees. Considering that this was Ms. Snowdens first elective THA surgery, she struggled with remembering these precautions, as well as implementing the use of her newly issued adaptive equipment (AE) and durable medical equipment (DME). After discussing with Ms. Snowden regarding her goals of functional independence, it was found that her occupational challenges involved activities of daily living (ADLs). More specifically, occupational therapy (OT) services focusing on the activities of toilet transfers, lower body dressing, shower transfers, meal preparation, and community mobility. Ms. Snowden discussed her wishes to be independent in activities that involve her modesty such as toileting and dressing. This is because she currently lives alone in a one bedroom apartment. She mentioned her best friends daughter and daughter-in-law who may stop by to check up on her but she does not wish to have them assist her in these ADLs. Ms. Snowden is currently receiving occupational therapy services within the setting of an acute hospital. Since it is likely that she will be discharged within a couple of days, it is imperative to teach her safe and proper techniques of using the AE and DME, as well as complying with the THP. The OT will provide Ms. Snowden with the skill set necessary to function independently once discharged, and will also strive to increase her awareness of the implications of not following the THP. It is essential to establish confidence within Ms. Snowden, in regard to her use of these newly acquired

EVIDENCE-BASED INTERVENTION PLAN equipment, so that she can independently engage in her daily occupations listed above.

Therefore, OT services will mainly focus on teaching Ms. Snowden how to participate in ADLs, while properly using the AE and DME. Five Problem Statements 1. Client requires stand-by assistance to perform toilet transfers secondary to decreased safety awareness following hip precautions. 2. Client is unable to safely perform lower body dressing secondary to decreased AROM in right lower extremity. 3. Client requires stand-by assistance to perform shower transfers secondary to decreased safety awareness following hip precautions. 4. Client requires stand-by assistance for meal preparation secondary to decreased standing tolerance. 5. Client is unable to access the community secondary to decreased safety awareness following hip precautions via entering and exiting a vehicle. Goals and Interventions Long-term and Short-term Goals 1. Client will safely and correctly perform toilet transfers, using the appropriate DME and adhering to3/3 hip precautions, with modified independence, by 1 week. a. Client will participate and tolerate at least 5 minutes of functional mobility using a FWW, with modified independence, by 2 days. b. Client will correctly choose and demonstrate appropriate DME, involved in toilet transfers, while adhering to THP, with CGA, by 4 days.

EVIDENCE-BASED INTERVENTION PLAN 2. Client will safely and correctly perform lower body dressing, using the appropriate DME and AE and adhering to3/3 hip precautions, with modified independence, by 1 week. a. Client will recall 3/3 THP, independently with no verbal cues, when prompted, by 1 day. b. Client will correctly choose and demonstrate appropriate AE and DME

involved in lower body dressing, while adhering to 3/3 THP, with supervision, by 3 days. Interventions and Evidence-Based Research The following interventions have been rearranged from the order stated above to reflect progression of days in the hospital. In order to address the long-term goal of lower body dressing, a short-term goal of recalling 3/3 THP will be set to confirm that Ms. Snowden understands each concept. Jackson & Schkade (2001) discuss the role of teaching concepts such as hip precautions, and independence in mobility and ADLs in patients with hip fractures. Therefore, it is important to integrate patient education within the treatment session. The OT will facilitate confidence within Ms. Snowden and her capability to adhere to the precautions 100% of the time by reiterating and reviewing the use of the AE and DME throughout her hospital stay. Throughout the intervention, the OT will attempt to develop therapeutic rapport with Ms. Snowden by collaborating and involving her within the process. The therapy session will begin with the OT reiterating the THP to the patient (given that other hospital personnel have already introduced her to each concept). However, the OT will go in-depth with each THP and explain why it must be followed. This will be done to establish motivation in the client to want to follow the THP, due to the knowledge of the


repercussions. Next, the OT will go over the purpose and function of each AE and DME that will be recommended for use during her recovery period. The OT will also ask Ms. Snowden to complete a simple demonstration of either the sock aid or leg lifter to evaluate understanding. Lastly, to reinforce what was learned during the last 25 minutes, the OT will ask Ms. Snowden to state the three THP that were discussed in the beginning of the session. This will allow time to have passed and require Ms. Snowden to recall from memory the THP. In order to facilitate functional mobility, it is important to increase Ms. Snowdens activity and standing tolerance. In addition, this short-term goal addresses the long-term goal of toilet transfers because functional mobility works on balance, which is essential for independence in toilet transfers. The goal of this treatment session is to have Ms. Snowden out of bed and walking. According to Novalis, Messenger, & Morris (2000), functional mobility is stated as an occupational therapy benchmark within the pathways of patients undergoing orthopedic (hip) surgeries. Therefore, it would be beneficial to address this occupation as it will influence engagement in a variety of activities such as transfers and participation in ADLs. To begin this intervention, the OT will work with Ms. Snowden to help her participate in bed mobility, with CGA if needed, in order to sit bedside. Next, the OT will observe Ms. Snowden in her approach to transition from sit to stand, using a FWW. During this time, the OT will address any precautions that may have been violated and reiterate the importance of abiding by this THP. After Ms. Snowden has reached a standing position, the OT will instruct the patient to walk to the bathroom, which is located inside of the patients room, and help her with self-care activities of the patients choice. This occupation will allow the patient to work on standing tolerance during the activity, as well as complete an ADL that the patient finds meaningful. Once the

EVIDENCE-BASED INTERVENTION PLAN activity is completed, the patient will walk back to her bed using the FWW, and can resume watching television or rest. The next intervention that will address Ms. Snowdens modified independence in lower body dressing is the ability to choose and demonstrate the appropriate AE and DME for the given activity. According to Rogers & Holm (1992), factors that influence AE use and disuse is the patient, their living environment, the OT administering the AE, and the equipment itself. Therefore, it is imperative for the OT to implement the use of the AE early on, in order to allow sufficient time for Ms. Snowden to master its function. This intervention will begin with the OT asking Ms. Snowden if there is any clarification needed for the AE or DME that have been

introduced in prior treatment sessions. Then, the OT will lay out each of the devices and ask Ms. Snowden to problem solve and consider which of the devices will be needed to complete lower body dressing. It would be ideal for Ms. Snowden to choose the lower body dressing stick, reacher, long handled shoe horn and sock aid for this activity. Once Ms. Snowden has correctly chosen the devices, the OT will supervise the patient as she initiates lower body dressing, while using the AE and following the THP. The intervention will conclude with the OT asking Ms. Snowden her level of comfort and confidence in using the devices independently. The final intervention will lead to Ms. Snowdens modified independence in toilet transfers. Ms. Snowden will choose and demonstrate the appropriate DME that is involved in this activity. A study involving patient who had undergone a THA which was conducted by Seeger & Fisher (1982). It was found that patients were able to be independent in ADLs after they were discharged from their hospital and that use of the adaptive equipment was very high (p. 503). In order to complete a toilet transfer successfully, Ms. Snowden will need to use her FWW, a raised toilet seat, and possibly grab bars for additional balance. The frequency of patients who


utilized a raised toilet seat status post THA were 91%, which was the highest among all adaptive equipment listed in the study (Seeger & Fisher, 1982). This intervention will begin with the OT asking Ms. Snowden to recall from memory all of the AE and DME that she has been introduced to since the beginning of therapy. Ms. Snowden will also be asked to state the purpose and how to use the AE and DME. After, the OT will ask Ms. Snowden to consider which of the AE and DME she can use to engage in toilet transfers. Once she has correctly stated the appropriate equipment, Ms. Snowden will walk to the bathroom and demonstrate how to properly use the raised toilet seat and grab bars, while following the THP. However, if Ms. Snowden is not feeling motivated to complete this activity, the OT can simply facilitate a purposeful activity and have Ms. Snowden simulate the correct way of sitting on a raised surface (possibly her bed or bedside commode), to ensure that she is capable of the activity and aware of the THP. Grading the Intervention The intervention that involves choosing and demonstrating the correct AE during lower body dressing can be graded up and graded down. In order to grade this intervention up, the OT can withhold from reviewing the AE and DME use at the beginning of the intervention. This will make the activity of recalling each of the equipment harder for the patient. An additional way to grade the activity up would be to include various equipment that is not typically provided in a hip kit. For example, a bottom reacher for toilet hygiene can be laid out for the patient to problem solve and conclude that it would not be ideal to use with lower body dressing. In order to grade the intervention down, the OT can lay out a limited amount of equipment from the hip kit to allow ease in Ms. Snowdens attempt at narrowing the appropriate AE for the activity.

EVIDENCE-BASED INTERVENTION PLAN Precautions and/or Contraindications The client must follow the precautions set for any individual who undergoes a THA . These three precautions are to ensure that the hip joint is able to heal properly and that the artificial head of the femur does not dislodge from the socket or acetabulum of the pelvis. Therefore, Ms. Snowden must ensure that she does not flex past 90 degrees at the hip, and internally rotate or abduct her affected lower extremity, whenever she is engaging in an occupation. Additionally, specific to Ms. Snowdens intervention plan, another precaution is to ensure that she does not participate in intensive or strenuous intervention treatments since she

will still need to build up activity and standing tolerance, as well as balance. It is important to set up a solid foundation for her to engage in these occupations safely and correctly. These include having a wide base of support and instructing her to weight bear as tolerated. Lastly, since Ms. Snowden is currently under pain medication, a precaution for the OT would be to remain hypervigilant and observant regarding the amount of effort she is providing in each activity. The morphine may mask underlying pain that she is not able to experience, due to the numbing effect of the medication. This may provide Ms. Snowden with the superficial ability to continue and proceed with treatment. Even if she is willing, her body may not be able to handle such activity. Frequency and Duration Occupational therapy services will occur five times a week for one week. Due to the setting being in an acute hospital, skilled training will be implemented for approximately 30 minutes each day. It is a possibility that Ms. Snowden will be discharged earlier than a week if the doctors see that her recovery is going well. In addition, interventions are scheduled for about 30 minutes each treatment session because there is a high volume of patients on the caseload of one occupational therapist within the acute hospital. Therefore, it is important to provide the

EVIDENCE-BASED INTERVENTION PLAN skilled therapy needed within a fairly small time frame, in order to accommodate for the other patients that need to be seen and treated. Rehabilitation Frame of Reference The rehabilitation frame of reference is the primary frame of reference utilized throughout the interventions because of Ms. Snowdens current level of functioning. Since there are THP that must be followed, adaptive techniques must be used in order to adhere to the precautions and prevent from further damage. Though Ms. Snowdens current state is not permanent (in terms of her capability to eventually reach full independence) the OT must focus on providing training in special equipment to facilitate independence for the time being. This frame of reference guides intervention planning because Ms. Snowdens safety is of extreme importance when she is independently engaging in her chosen occupations. The methods of this frame of reference involve changing the context or environmental modifications (Jacobs & Jacobs, 2009). This is observed in the interventions by utilizing various DME such as the raised toilet seat and training the client in the use of these modifications. The use of the AE and DME will allow for Ms. Snowden to adapt to the occupational challenges that she encounters. Client/Caregiver Training and Education As mentioned through one of the interventions, client education is imperative in order to facilitate proper recovery status post THA. A client who is cognizant of the implications of breaking a THP will hopefully adhere to the use of the AE and DME throughout the recovery

process. Half of the interventions discussed above directly involve patient training of the AE and DME and education of the THP. The other two interventions indirectly involve patient training and education, but essentially addresses this aspect through the coaching of the given activity. For example, when Ms. Snowden is utilizing her FWW during functional mobility, the OT will



consistently be providing feedback and assistance in how to correctly use the DME with proper body mechanics. Aside from the discussed interventions, the OT can also work with the patient to address other functional activities that may be interrupted due to the THP. For example, Ms. Snowden may eventually need to access a vehicle. The OT can provide training and education in this activity. Lastly, since Ms. Snowden lives alone, the OT will not have to provide caregiver instruction directly to another individual. However, since Ms. Snowden stated that her daughterin-law and best friends daughter may periodically stop by her home, it would be helpful to provide Ms. Snowden with ideas for how they can provide her assistance. For example, in the area of meal preparation, the daughter-in-law and best friends daughter can prepare food within Zip-lock bags and put the entire meal in a plastic bag. Then, they can write what meal the plastic bag contains. This will allow Ms. Snowden easy access to food by allowing her to simply walk to the refrigerator, hang the plastic bag onto her FWW, and walk back to her desired area. This will eliminate the need for Ms. Snowden to engage in standing for long periods of time, which may be detrimental to her current health status. Assessment of Progress Ms. Snowdens response to the interventions will be monitored and assessed through demonstrating her understanding of the concepts. It is not sufficient for Ms. Snowden to simply state the function or how to use the equipment. Rather, the OT will request for Ms. Snowden to demonstrate the proper and correct way of using the equipment to show her competence. In addition, evaluating for safety throughout the activity will show that Ms. Snowden can participate and engage in this activities independently, once discharged, and deter from her having to be readmitted to the hospital due to not following the THP. The OT will also ask Ms. Snowden, at the conclusion of each treatment session, her level of comfort in using the AE and



following the THP. This will allow the OT to gauge where the therapy is headed and whether the intervention needs to be more intensive or if the goals are being met.



American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683. Jackson, J. P., & Schkade, J. K. (2001). Occupational Adaptation model versus biomechanical rehabilitation model in the treatment of patients with hip fractures. American Journal of Occupational Therapy, 55, 531537. Retrieved from Jacobs, K. & Jacobs, L. (2009). Quick reference dictionary for occupational therapy (5th ed.). Thorofare, NJ: Slack Incorporated. Novalis, S. D., Messenger, M. F., & Morris, L. (2000). Occupational therapy benchmarks within orthopedic (hip) critical pathways. American Journal of Occupational Therapy, 54, 155 158. Retrieved from Rogers, J. C. & Holm, M. B. (1992). Assistive technology device use in patients with rheumatic disease: a literature review. American Journal of Occupational Therapy, 46(2), 120-127. Retrieved from Seeger, M. S. & Fisher, L. A. (1982). Adaptive equipment used in the rehabilitation of hip arthroplasty patients. American Journal of Occupational Therapy, 36(8), 503-508. Retrieved from