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Running head: OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile
Tonya DeDera
Touro University Nevada

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Occupational Profile

Client
The client is a 74-years-old Caucasian female. She has been divorced for 20 years. The
client lives in a single story home with three dogs. The client worked for 50 years as an
insurance medical examiner and a medical assistant. She has now decided to retire after her
surgery. The client is originally from California, but has made Nevada her home for the past 40
years. The client has two daughters that are married and two grandchildren. Her family is very
important to her and her daughter who also lives in Las Vegas visits her on the weekend with her
two children for dinner and family game night. The client stated, Im happy when Im cooking
for my family, entertaining family and friends, and playing with my dogs. The client was
diagnosed with adenocarcinoma of the colon stage 111B and was admitted to the hospital for
surgery. The client will receive chemotherapy as an outpatient. Two months after surgery, the
client was diagnosed and treated for C. difficile. The client was recently admitted on April 14,
2015 to HealthSouth Rehabilitation Hospital in Las Vegas.
Need for Services
The client has overall muscle weakness due to prolong bed rest from colon surgery and
surgical site infection. She has cognitive deficits with decreased initiation, sequencing, and
problem solving. The client was noted to have decreased upper extremity and core strength that
is negatively impacting safe bed mobility and functional transfer completion. She has decrease
standing balance and her activity tolerance has significantly decreased. She is unable to
complete activities of daily living (ADLs) without assistance. An initial evaluation was
performed on April 15, 2015, and the clients personal main concerns are not being able to walk
and losing her overall independence. She required moderate assistance for bed mobility. The

OCCUPATIONAL PROFILE

client was unable to complete stand pivot transfer from the edge of bed to bedside commode
secondary to increasing pain in neck and bilateral lower extremities with movement. The client
was educated on safety and therapist demonstrated transfer position.
Areas of Occupation
The client requires moderate assistance to complete ADLs such as dressing, toileting and
toilet hygiene, personal hygiene, and functional mobility. This is due to strength deficits in
extremities, balance deficits, impaired activity tolerance, pain limiting function, and mobility
deficits. The client wears briefs because she needs more time to get to the toilet and assistance
with the transfer. Since the surgery, the client has not had time to engage in instrumental
activities of daily living IADLs) such as care for her pets, work, driving, and community
mobility. She reported that she has not been able to rest and sleep from her long hospital stay
where she remained in bed; however, throughout the night the doctors and nurses were
constantly giving her medications, checking her IV, and her vital signs. The client is not able to
engage in leisure occupations at this time, and her social participation includes her family and
friends that are communicating by phone and emailing her while she is receiving treatment at
HealthSouth Rehabilitation Hospital.
Contexts and Environments
The clients physical environment is supportive to her engagement in occupations. She
lives in a one-story home. The entrance to the clients home is level and there are no stairs. The
client has a walk-in-shower and a spacious bathroom making ample room for her front wheeledwalker (FWW) when needed. She has a spacious master bedroom with a walk-in closet. This
will help her in ambulating around with her front wheeled walker to get dressed. The client
stated that she had carpeting around her home and the front wheeled walker would be better

OCCUPATIONAL PROFILE

utilized than a wheelchair. The client has three dogs that she absolutely adores. Her dogs
provide her with companionship and unconditional love that helps in her therapy treatment with
motivation to a speedy recovery to get back home to them. The client is currently alone in a
room secondary to C. diff. The view from her window is of surrounding buildings, and the
nurses station is right outside her door. The room temperature was very cool and clean to avoid
the breeding of the C. diff infection. The clients family and friends have been a great support
system for her. Due to the infection at the time of admittance, the client was unable to have her
love ones visit especially her grandkids. The clients virtual contexts allows her to stay in touch
with her family and friends through the use of her smart phone and IPad. She receives several
photos of grandkids daily keeping her up to date on their doings. The client has a wonderful
group of friends that she hosts card games and plays Bingo with on Tuesday nights. The client is
also a part of a book club within her group. She has been reading the book her friends notified
her to read. Her group plans on going over to her home, bring food for dinner, and have a
discussion on the book.

The clients personal context is inhibiting her engagement in

occupations. The client even implied how she feels that her illnesses has aged her more. The
clients socioeconomic status has changed post-surgery. The client was working up to five days
before surgery, and now, she does not want to return. She discussed how she has a nice
retirement plan that will allow her to discontinue with working. The clients cultural context was
not specifically addressed, but she did mention how she enjoys having her family over for the
holidays such as Christmas and Thanksgiving. However, her activity choices and how she
identifies herself is influenced through cultural context.
Occupational History

OCCUPATIONAL PROFILE

The client attended University of California Los Angeles (UCLA) and graduated with a
degree in science. She worked for fifty years as a medical assistant and an insurance medical
examiner. The client was working prior to surgery at both of these jobs, but now, due to a
decline in health, she does not wish to return. The client plans to have more time to spend it with
family, friends, and her interests. The clients roles are mother, grandmother, and friend. Each of
these roles come with unique responsibilities and sets of behaviors expected by society. The
client owns her home and a vehicle. The clients job entailed her driving to peoples homes and
providing medical exams for the insurance companies. Before starting work, the client walks her
dogs and feeds them. The client enjoys her beautiful garden that she has planted in her front and
back yard. When she is not tending her garden she is out and about with her friends taking in
dinner and a movie. When I asked the client what her most valued activity was she immediately
said, Family! The client reported that she is happy being with family and doing what she was
able to do before her surgery. The day of the clients discharge she was extremely happy because
she told me that she would be seeing her grandkids that she had not seen in a very long time due
to her illnesses.
Priorities and Desired Outcomes
The clients main priority is to go home. The client really wanted to focus on the
weakness in her lower extremities. She said she really wanted to walk and be able to dress her
lower extremities independently. The client also felt that the wheelchair was not conducive to
her environment. She stated how her carpeting would interfere with using the wheelchair. The
client wanted to practice using a front wheel walker. She feels this piece of durable medical
equipment will help her maneuver around her home easier. The client stated that this was
important to her because she does not want to be a burden to her daughter. The clients daughter

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wanted to make sure that prior to her mothers discharge, she will be safe at home alone. When I
asked the client if she would consider returning back to work, she said that she had no desire to
continue working. The client then reiterated what her priorities were and basically she stated that
dressing lower extremities, getting out of bed to the bathroom, and utilizing a front wheeled
walker and a reacher (A/E), and regaining enough strength to go home and live her daily life
independently. These were the goals that mattered the most to the client along with being able to
cook dinners for her daughters family when they visit her on the weekends. The client and I
discussed how occupational therapy could help her attain these goals.
Occupational Analysis
Contexts and Setting
The client is in an acute inpatient rehabilitation hospital with a total of 79 beds. This
facility has a 10 to 14 days length of stay. The clients there can receive occupational therapy five
days a week for one hour and a half session and some weekends. The client has a private room
due to the C. diff infection she contracted following surgery. The client has a television in her
room and a large window that provides ample light during the day and a view of buildings
surrounding the facility.
Activity Observed and Clients Performance
The client was received in her room sitting in her wheelchair. The occupational therapist
introduced me to the client and asked the client if it was okay for me to observe her. The client
agreed that it was fine for me to observe her treatment session. The therapist wanted to observe
how the client transferred from her bed to the wheelchair, so she asked the client to demonstrate
how she performed this transfer. The client required multiple verbal cues for transfer technique
to and from wheelchair to bed including sit to supine and supine to sit. This was secondary to

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decreased initiation and problem solving. The client was able to tolerate the 90 minute OT
session. Although during the functional transfers, she demonstrated balance deficits, decrease in
activity tolerance, and mobility deficits. She demonstrated decreased upper extremity and core
strength negatively impacting safe bed mobility and functional transfer completion. The
therapist educated the client on using bed rails for stability when shifting her weight to sidelying
position to increase independence with bed mobility. Once the client was at the edge of bed, the
therapist had her practice using a reacher and dressing stick to put on a pair of sweat pants. The
client required moderate assistance due to lower extremity weakness from prolonged bed rest.
Instead of standing, the therapist had her pull her pants up from her knees shifting her weight to
each side to get them over her hips. This will also help the client with dynamic sitting balance to
strengthen her core. The client also needed moderate assistance in putting on the hospital socks.
She was unable to lift her foot up to put it into the sock aid. The next area the therapist wanted to
address was transferring from the wheelchair to the toilet. The client propelled the wheelchair to
the toilet with modified independence and completed wheelchair to toilet transfer with
supervision. She required multiple verbal cues to use the grab bars in completing this transfer.
The therapist instructed the client on home management set-up and safety techniques for ADL
completion. The therapist then asked the client if she would be up to going to the rehab gym to
work on strengthening her upper body. The client really did not engage in the upper extremity
exercises which entailed the thera tube and recumbent bike. She wanted to talk more about how
she wants to be independent and not burden her daughter. The therapist also informed her that
their next treatment session would entail using a front wheeled walker (FWW). The client was
motivated to learn how to use this DME because a wheelchair is not conducive within in her

OCCUPATIONAL PROFILE

home environment. The therapist explained that participation in treatment would have her
eventually doing everything independently again.
Key Observations
The fact that the client required multiple verbal cues during functional transfers due to
decreased initiation is a key factor in her rehabilitation process. Her decreased upper bilateral
strength was evident in follow through with bed mobility and transferring from the edge of bed
to the wheelchair. The client wants to walk as her major goal, but she has decreased activity
tolerance to complete lower extremity dressing and transferring from the wheelchair to the bed.
She stated to me during the treatment session that she really wants one more week of
rehabilitation services because she was getting discharged in two days. It was clear that she had
some anxiety about this. The client stated that she was not where she was physically prior to
surgery to go home and be independent. Not only was the clients upper and lower extremities
weak, but she was also suffering from pain in neck, a winging scapula, fatigue, and the port a
cath in the left side of her chest. This device will be used for her outpatient chemotherapy
treatments.
Significant Impacts
One client factor I assumed that has a positive influence are the values of the client that
are the importance of family and her independence. She wants to go home and live
independently, but she would not perform the exercises the therapist asked her to do. Deficits in
body functions are impacting her progress and ability to successfully engage in occupations.
This could have been a result of an impairment in mental function. Based on my observations,
she demonstrated areas of this with problem solving, sequencing, initiation, and emotional
behavior (anxiety). The client complained to me that her neck pain and winging scapula

OCCUPATIONAL PROFILE

prevented her from doing the upper extremity activity. The therapist mentioned to me that the
client never mentioned of shoulder discomfort until the therapist informed her about the winging
her scapula. Other body functions related to movement that are impacting her ability are joint
mobility and stability causing her to use durable medical equipment to widen her base of support.
The client has decreased standing balance and utilizing a front wheeled walker will help her with
functional mobility. The client has decreased muscle power, endurance, and tone and this
disrupts her being able to complete activities of daily living independently. The lower extremity
weakness is limiting her occupational engagement enabling her to need assistance to complete an
activity such as grooming or lower extremity dressing. Due to prolong bed rest, the clients skin
integrity needs to be addressed daily. There are decubitus ulcers that are on her back side, and
the occupational therapist had to educate her on how important it is to weight shift from side to
side every 15 to 20 minutes when she is in her wheelchair to avoid making the area worse.
Motor skills that I observed that are negatively impacting her occupational performance are
decreased ability to stabilize, position, reach, bends, moves, grip, walks, and paces. The process
skills that I viewed deficits in were heeds, due to the fact that she required multiple verbal cues.
During bed mobility, I observed the client demonstrating a decrease in initiates and sequences.
The performance patterns that are impacting her occupational performance are roles, routines,
habits, rituals. The client does not wish to continue working; therefore, her role as an employee
does not exist. She will have to establish a routine that will replace her post surgery schedule
that she has had for 50 years while she worked. Her personal habits have been disrupted due her
debilitating health. The clients physical environment has change. She is required to live with
her daughter for two weeks while she receives occupational therapy through home health. The
client said that she hopes that she will be able to still volunteer at the homeless shelter two days a

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week. She mentioned the holidays and how she is hoping to be able to make Thanksgiving and
Christmas dinner

Problem List
Problems

Client requires multiple VC for bed W/C transfer 2 initiation & problem solving.
Client requires Mod ADLs 2 endurance & LE weakness.
Client needs Mod LE dressing activities EOB 2 UE & core strength.
Client required Mod UE dressing 2 pain in neck & limited ROM 2 to port a cath.
Client required Sup W/C toilet transfer 2 poor motor planning.

Prioritization of Problem List

Client requires multiple VC for bed W/C transfer 2 initiation & problem solving. I
chose this as my first priority based on the clients goals of wanting independence and not
wanting to be a burden to her daughter. This addresses components of executive functioning,
safety awareness, initiation, sequencing, problem solving, and activity tolerance. This is a

problem that I think can be remediated throughout the two week rehabilitation process.
Client requires Mod ADLs 2 endurance & LE weakness. The clients other major
goal was to be able to walk, and in order to meet this goal it is imperative to increase
endurance, standing balance, activity tolerance, muscle tone and strength. The client needs to
increase her endurance and standing balance, and range of motion in order to utilize the
adaptive equipment and durable medical equipment prior to discharge. In addressing this
problem statement, the occupations that are meaningful and purposeful to the client are

attained.
Client needs Mod LE dressing activities EOB 2 UE & core strength. This problem
is assessed immediately and the occupational therapist is able to address it within the clients

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room. This problem can also be ameliorated within the two weeks of therapy treatment

sessions.
Client required Mod UE dressing 2 pain in neck & limited ROM 2 to port a cath. This
problem is important for the client to acknowledge because it involves an activity that is
important to the client; however, this intervention is usual addressed in the beginning of
treatment sessions where therapist will instruct client in upper-body dressing where

compensatory strategies can be utilized.


Client required Sup W/C toilet transfer 2 poor motor planning. This is an important
problem and toileting transfers and toileting hygiene are addressed daily throughout the
intervention process. By addressing this prioritized list the client will increase initiation,
strength, endurance standing balance, and problem solving. The clients priority for walking
would be discussed with the physical therapist. The occupational therapist can relate the
clients needs to the physical therapist to implement into their intervention plan. This
treatment would work in concert with the occupational therapists treatment in functional
mobility.
Intervention Plan and Outcomes

Long-Term Goals and Short-Term Goals


Long-term goal: (1): Client will perform bed W/C transfer Mod using sit pivot
transfer within 2wks.
Short-term goal: (A1) Client will be able to transfer mat W/C 2 or fewer VC for help
problems solving in rehab gym within 1 wk.
Short-term goal: (A2) Client will be able to supine sit EOB Sup for safety techniques &
initiation using log roll technique by 1 wk.

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Long-term goal: (2) Client will be able to stand & perform task for making homemade soup
Mod in rehab kitchen within 2 wks.
Short-term goal: (B1) Client will be able to stand & stir can soup in a pot for 5 min. Sup using
a FWW within 1 wk.
Short-term goal: (B2) Client will complete a task associated making a bowl of cereal & cleanup Sup using a FWW within 1 wk.
Intervention Ideas, Approaches, Evidence, and Outcomes
A1) Client will participate in Jenga game seated at edge of mat to increase upper extremity and
core strength and active range of motion through reaching for wooden peg pieces alternating
support on one arm while actively reaching with another. This intervention will help increase
problem solving deficits and this will also channel what is meaningful to the client. Family
game night was something the client really looked forward in doing with her family. Jenga and
Yahtzee are a few of her grandkids favorite games to play. The approach to intervention is
restore a skill or ability that has been impaired. A study done by Sietsema, Nelson, Mulder,
Mervau-Scheidel, and White (1993) on individuals with traumatic brain injuries compared
10 trials of occupationally embedded intervention (playing Simon, a computer-controlled
game) were compared with 10 trials of rote arm-reach exercise. The results maintained the fact
that occupational embedded intervention are task-specific goals as opposed to the rote exercise
that are just exercise driven. Utilizing a game was in favor of increasing range of motion in
performing a reaching motion as well as strengthening the core. Individuals tend to lose interest
when doing rote exercises. The expected outcome is participation in this desired occupation of
being able to engage in family game night improving in occupational performance.

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A2) Client and daughter will be instructed and trained regarding home environment, equipment
used, and placement in home. Daughter will bring in pictures and measurements of the clients
home for assessment to compare with the facilitys environment. Client will practice using
raised toilet seat and grab bars. The client and daughter will go over safety techniques. The
approach to intervention is create and promote designed to provide enriched contextual and
activity experiences that will enhance performance. According to the authors, Most home
evaluations available from involved organizations ask questions about the home but not about the
client-making the occupational therapists unique insight into the clients needs all the more
important (Christiansen & Matuska, 2011, p.509). The expected outcome is prevention of the
onset and reduce incidence of unhealthy conditions and rick factors, diseases, and injuries
improving occupational performance. B1) Client will stand while potting some flowers to
increase endurance, standing balance, and activity tolerance. This instrumental activity of daily
living (IADL) will be incorporated in to increase motivation. An example would be to have the
client prepare a meal, chop the vegetables, add broth, and poultry (chicken). This approach to
intervention is restoring prior level of activity tolerance. The article states, Gardening has been
equated with positive health outcomes for individuals with physical and mental health issues
(SCEM, 2014, p.3). Occupation as means refers to occupation acting as the therapeutic change
agent to remediate impaired capabilities (Gray, 199, p. 358). The outcomes include
improvement in activity tolerance, dynamic standing balance, and increased participation in
desired occupations in ways that are personally satisfying. The client ultimately wants to prepare
a meal because cooking is what she enjoys and it gives her meaning and purpose in her life to
cook for her family. B2) Client will use energy conservation techniques during meal preparation
and clean up. The client can sit down to complete meal prep instead of standing. She can take

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frequent rest breaks. The client can utilize the front wheeled walker to help with standing
balance and activity tolerance. The approaches to intervention include restoring prior skills and
modifying with durable medical equipment. Energy conservation training is client specific.
Client involvement increases the likelihood of realistic goal attainment (Matthews, 2013, p.
1210). The outcomes of intervention include improvement of activity tolerance and participation
in a desired occupation of meal preparation and cleanup.
Precautions and Contraindications
The client should adhere to safety awareness throughout therapy. The use of proper body
mechanics, and ergonomics when positioning on the edge of bed, ambulation with front wheeled
walker, and avoiding prolong periods in bed to minimize further injury to the skin. The client
has already attained decubitus ulcers. The occupational therapist perform thorough chart reviews
daily before they issue a treatment session with a client. The physician documents precautions
within the clients chart. The client should be asked about her pain levels before treatment
session, during, and after. The severity of an impairment/illness can be an indication of
precautions or contraindications for therapy at that time.
Frequency and Duration
The clients at this facility are given therapy five days a week and some weekends. This
client indicates good rehabilitation potential. She is was motivated and desired occupational
therapy services and was given treatment five days a week excluding the weekends. I strongly
believe that the client will benefit from this frequency. The treatment session should remain 90
minutes but of course, frequent breaks can be implemented. The clients at this facility are
reassessed weekly using the Functional Independence Measure (FIM). The clients main
concerns for treatment are as follows: increase in upper and lower bilateral strength, increased

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initiation with functional transfers to regain prior level of function, and reduce burden of care.
With the clients medical diagnosis of increased debility from a prolong period of bed rest. The
client will benefit from a duration of two weeks of skilled OT services with a plan to discharge
after 10 sessions.
Grading Up and Grading Down
Client participating in Jenga game seated at the edge of a mat intervention to increase
core strength and upper extremity active range of motion through reaching for wood peg pieces
alternating support on one arm while actively reaching with the other. This can be graded up by
applying wrist weights. Reaching farther forward, placing pieces to the side, and up higher will
increase the activity demands. Grading this activity down can be done by utilizing a chair with
supports while she complete the activity. Decreasing the reaching distance of the activity and
weight shift will decrease the activity demands. Allowing the client to take frequent breaks
during the activity will also grade down the activity and the demands.
Primary Framework
The frame of reference that was clearly guiding the intervention with this client that I
utilize would be the biomechanical. The biomechanical frame of reference is used to help clients
with deficits in the musculoskeletal system. The client has decreased upper extremity and core
strength that are negatively impacting the client to participate in activities of daily living. The
biomechanical frame of reference uses a bottom up approach. This frame of reference views the
body as a functioning machine focusing on specific muscle areas of the body that has been
affected by injury or disease to improve occupational performance. The client suffers from
decrease muscle strength, endurance, range of motion, and activity tolerance. This activity will
increase the clients ability to perform functional transfers, dressing, showering, and activities of

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daily living. The activity may be graded up or down to suit function. For my goal setting, I
utilized the rehabilitation frame of reference. This frame of reference was appropriate for this
client. This frame of reference teaches clients how to use compensatory strategies for underlying
deficits that cannot be remediated. This frame of reference utilizes adaptive/assistive devices,
and environmental modifications. The rehabilitation frame of reference allows the occupational
therapist to recognize the need to view occupational performance holistically. The client restores
independence through the use of compensation strategies when the underlying impairment
cannot be restored, and the biomechanical frame of reference is typically identified with
remediation, or improvements in strength, endurance, range of motion, and muscle tone to
achieve movement. This client will need to use assistive/adaptive devices to help her with daily
occupations. The client does not want to burden daughter to help her with dressing and bathing.
The client will need to combine these approaches in occupational therapy intervention beginning
with establishing functional skills through remediation and continuing with modifying the task or
environment (adaptation and compensation) in order to perform occupational performance
within the constraints of a more chronic or ongoing disability.
Client/Caregiver Training and Education
Aging in place is what the client prefers to do. The client wants to remain independent
and not become a burden to her daughter. Therefore, prior to discharge the occupational
therapist should go over the key issues needing to be addressed: (1) ability to participate within
the context of her environment, (2) whether the environment is safe, and (3) what modifications
are needed. The client and her daughter need to be educated on fall prevention, home
modification, proper body mechanics, safe transfer techniques, use of durable medical
equipment, and adaptive equipment (A/E) should be demonstrated and provided to the client and

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her daughter. The client and her family should also be given the resources to purchase the
adaptive equipment and DME should be given to them unless they have already purchased the
equipment. A home exercise and activity program could also be utilized. Work simplification,
pacing (alternate work and rest cycles), ergonomics, and energy conservation should be
discussed in regards to her daily routines and occupations.
Monitored and Assessed Clients Response
The clients response to the interventions will be monitored and assessed for progress
using the Functional Independence Measure (FIM). The FIM instrument measures the patients
assistance needs. The assistance entails the energy/time used in helping dependent needs in
maintaining a better quality of life. The baseline FIM scores are assessed at admission and the
patient gets reassessed at discharge. The FIM is also done weekly for conference. Long-term
and short-term goals will establish clients response and completion will indicate progress. After
each daily occupational therapy session, a daily note is file electronically on the patient. This
provides an indication of progress or lack of through the interventions given. After each
treatment session, the clients pain levels will be document. Improved safety awareness in bed
and functional mobility will be an indicator of cognitive functioning and progression. The upper
extremities will be monitored and assessed using range of motion (ROM) and manual muscle
tests (MMTs).

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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. http://dx.doi.org/10.5014/ajot.2014.682006.
Christiansen, C.H. & Matuska, K.M. (2011). Ways of living: Intervention strategies to enable
participation. (4th ed.). Baltimore, MD: AOTA Press.
Gray, J. M. (1998). Putting occupation into practice: Occupation as ends, occupation as
Mean \s. American Journal of Occupational Therapy, 52(5), 354-364.
Kraskowsky, L. H., & Finlayson, M. (2001). Factors affecting older adults use of adaptive
equipment: review of the literature. American journal of occupational therapy, 55(3),
303-310.
Matthews, M. M. (2013). Cardiac and pulmonary disease. In Pendleton, H.M. & Schultz-Krohn,
W. (Eds), Pedrettis Occupational Therapy: Practice Skills for Physical Dysfunction. (7th
ed.). St. Louis: Mosby, Inc.

SantiagoPalma, J., & Payne, R. (2001). Palliative care and rehabilitation.Cancer, 92(S4), 10491052.
SCEM, C. (2014). Putting the Occupation Back in Occupational Therapy: A Survey of
Occupational Therapy Practitioners Use of Gardening as an Intervention. The Open
Journal of Occupational Therapy, 2(4), 4.
Sietsema, J. M., Nelson, D. L., Mulder, R. M., Mervau-Scheidel, D., & White, B. E. (1993). The
use of a game to promote arm reach in persons with traumatic brain injury. American
Journal of Occupational Therapy, 47(1), 19-24.

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