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Occupational Profile
Client
Kathy is a 65-year-old Michigan native who currently lives in Las Vegas, Nevada since
her retirement. She was the owner of a successful company that sold automobile materials as
well as farm vehicles. She lives with her husband of 39 years and their Chihuahua. The both of
them often travel between both of their homes at in Nevada and Michigan. She is the mother of
two daughters and one son as well as the grandmother of 5 children. Kathy was admitted to the
hospital for a total knee replacement arthroplasty (TKA) on her left leg because of the
development of osteoarthritis. Other than the complications with her knee, Kathy is also
diagnosed with type two diabetes and coronary artery disease.
Services Seeking and Concerns
Kathy initially had a TKA in late 2013 because she was experiencing severe pain through
the development of her osteoarthritis. She was very concerned about the fact that she was still
feeling pain. Kathy was distressed because her primary physician was unable to determine the
why her pain persisted after surgery. After another year of knee pain, Kathy sustained severe
muscle weakness in her left leg. Fortunately, Kathy was eventually able to advocate for herself
by receiving a second opinion from another orthopedic surgeon. She learned that she was
allergic to materials used for her first TKA and was then able to get a second surgery to replace
the first one with a different type of material. Although Kathys surgery was considered a
success, she is seeking rehabilitative services because she sustains a diminished strength in her
left leg as well as overall endurance due to the year of knee pain and decreased activity.
Furthermore, Kathy was a good candidate for occupational therapy (OT) because her pain has
caused her to become dependent on her husband for taking care of her and their home.
her and her husband, Kathy is the one who plans outings and events with their friends. Although
she has only been living in Las Vegas for less than a year, she has already created a social
network of friends whom she met at church. She is a very active member of her Christian
community and sings in the choir at church. Both Kathy and her husband are always
participating in church events and volunteering with their group of friends. Kathys husband
explains that her friendly and social energy has helped the both of them find meaningful
activities in their lives after retirement. Most of Kathys current barriers to occupations is caused
by her knee pain and decreased endurance. Although Kathy would like to go to more outings
with her husband and friends, she feels like a burden because she cannot tolerate extended
periods of physical activity. Furthermore, Kathy also admits that she is beginning to disengage
in her roles in church because she does not want others to worry about her.
Occupational History
Kathy is no stranger to difficult, manual labor because she grew up on a farm with her
family. From an early age, Kathy rode on horses and helped her family manage the farm.
However, Kathy explains that there was more to running a farm than growing vegetables and
raising animals. Her father also taught her how to manage the farm as a business with employees
and marketing to local grocery stores. Working in a farm inspired Kathy to have a business of
her own when she got older. During her young adulthood, Kathy managed to be a mother of
three while running her own company. She explained that she rarely took the time to relax and
take care of herself. Kathy realized how much work was affecting her health during her mid-40s.
Due to all of the stress by from work and home, Kathy suffered a myocardial infarction and
required a coronary artery bypass graft. This event had a profound impact on Kathys life
because it helped her realize that there was more to life than work. Since her MI Kathy began
taking more vacations to travel around the world and spend quality time with her family.
and chores throughout the past year. Kathy feels extreme guilt for the burden of her husband,
especially because chores are starting to become more taxing to him as he ages as well. Kathy
also helps take care of a few of her grandchildren during the summer while they are on vacation.
Taking care of her grandchildren in the summer was an annual tradition that Kathy looked
forward to doing every year ever since she has retired. However, she was unable to let her
grandchildren visit her this summer because she was bedbound for most days and would not
have been able to keep up with them. Kathy explains that the past month has been very difficult
for her because she has lost a lot of the responsibilities that make her feel important within the
family.
Patterns of Engagement
Kathy described herself as a workaholic when she was a young adult. To run her own
business, she had many sleepless nights and spent very little time with her family. The stress of
having her own company had eventually caught up with her when she suffered a myocardial
infarction. Although this was a very scary event, Kathy is thankful that it happened because it
helped her realize that she needed to slow down and appreciate her life. Since her heart attack,
Kathy has been spending more of her time and energy in meaningful activities. It is paramount
to her to spend her evenings with her husband as well as her dog to spend dinner with and go on
walks. She devotes more of her energy to her Christian faith by volunteering for church
activities as well as praying in the chapel. Unfortunately, Kathy has slowly been disengaging in
all of her occupations due to her knee pain and generalized weakness. Furthermore, Kathy rarely
left her bed because of pain during the weeks prior to surgery. Due to her bad experience after
her first surgery, Kathy is worried that she will sustain a permanent debility.
respiratory therapy, and speech-language pathology. Patients who are referred to OT are
typically seen three to five times within the span of a week or until they are able to be
discharged. The JRC is a unit of the hospital for patients who have recently undergone a type of
orthopedic surgery. Most individuals in the JRC are typically not under critical conditions;
however, they are closely monitored by a healthcare team and are given basic medical attention.
The JRC unit within this hospital puts an emphasis on fall prevention for rehabilitation and
provides classes ran by an occupational therapist (OT) or physical therapist for patients after
surgery. Kathy is currently staying in a private room that has a hospital bed with a couch and
chair for visitors. She was very comfortable and warm within her room because unlike many
hospitals, the patients at Saint Rose are able to control the thermostat in their room.
Furthermore, ambulation is a difficult task because there is very little floor space and Kathy is
attached to an IV and catheter bag. Saint Rose also takes extra precautions in case of the event
of a fall. There are cushioned mats in every room. However, these mats may be a hazard because
patients could easily trip over it if they attempted to get out of bed. Kathy uses a continuous
passive motion machine on a scheduled time and is required to wear a knee immobilizer every
time she is ambulating or transferring.
Activity Observation of Clients Performance
At the time of observation, Kathys was evaluated her performance in various self-care
activities and functional mobility after she had undergone a surgery the night before. Upon
arrival for an initial evaluation, Kathy was already up in bed and ready for therapy early in the
morning. Kathy was still in a lot of pain from her surgery and was recently taken off nerve
blockers. After the OT had introduced herself, she made sure to put on a knee immobilizer and
check Kathys vital signs that appeared to be normal. Kathy was educated about her post-knee
surgery precautions prior to any movement. A knee immobilizer was placed on Kathys leg, and
she was then instructed to move to the edge of the bed. She raised the head of the hospital bed to
help sit her up because she was still weak after surgery. She also required extra time and
assistance from the OT to lift her surgical leg to get to the edge of the bed.
According to her surgeons precautions, Kathy is able to bear weight on her surgical leg
as tolerated. Kathy was then instructed to transfer to a chair next to her. She required some
assistance from the OT to get from a sit to standing position with a front wheel walker.
However, she was able to turn her body toward the chair and sit down on her own. It was
noticeable at the time that Kathy was compensating for her leg pain during the transfer because
she was bearing a lot of her weight on her hands through the handles of her walker instead of her
legs. Kathy then completed a sponge bathing tasks in which she was able to perform
independently throughout her whole upper body and pelvis. Kathy was unable to attempt
bathing her lower extremities because it was still wrapped from surgery.
The OT then instructed Kathy to change out of her hospital gown and into regular
clothes. Kathy was able to complete all upper body dressing on her own. However, she had a
great difficulty completing lower body dressing. It was challenging for Kathy to put on her
shorts because she could not lift her leg to put it through the leg sleeve. The OT then helped her
complete lower body dressing, as she stood up with a walker. When instructed to put on socks,
Kathy had a difficulty bending over to reach her feet. The OT then showed her how to use a
Reacher and Sock-aid to help her complete this activity. Although Kathy was able to accomplish
putting the sock on her right foot, the OT helped her put a sock through her left foot was because
she could not lift her leg. Throughout the dressing activity, Kathy was seen wincing; however,
when asked about her pain she only reported a pain of two on a scale of ten.
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In the middle of the treatment sessions, Kathy expressed that she was ready to get up and
start standing. However, the OT noticed she was showing physical symptoms of fatigue and
asked Kathy to catch her breath before proceeding therapy. The OT checked her heart rate and
saw that it spiked from 80 beats per minute to 120. After a break, the OT instructed Kathy to
ambulate to the bathroom. Kathy required a lot of assistance to help her get from a sit to standing
position and needed several cues to push from the chair instead of the walker. Once standing,
Kathy was able to ambulate to the bathroom with contact guard assistance. At the bathroom,
Kathy stood in front of the sink with her walker to complete activities of self-care. Selfgrooming tasks included tooth brushing, wiping face with a wet towel, combing her hair, and
putting on her facial cream. While brushing her teeth and wiping her face, Kathy was able to use
her right hand to complete the activities but heavily relied on the walker to maintain her balance
with her other. Throughout her self-grooming activity, Kathys face starting to get red and
appeared to be wincing. Kathy continued to express that she was not feeling any pain or fatigue
despite her facial expressions. Using her clinical judgment, the OT asked Kathy to sit down for
the rest of therapy. Kathy was able to complete all of the tasks for combing her hair and putting
on facial cream independently. She appeared upset at herself and expressed that she was
disappointed that she was unable to do everything standing up. The OT then helped Kathy return
to the hospital room chair as she explained to her that endurance strengthening and healing after
a TKA will take some time. She was then left in a hospital chair with her phone and call button
within reach.
Key Observations
It was apparent that Kathys pain, weeks of bed rest, and surgery has significantly
contributed to her decreased activity tolerance and lower body strength. In order get up in bed
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the bed, Kathy uses compensatory strategies by raising the head of the hospital bed. Weakness of
the left lower extremity was noticeable. In order to scoot toward the edge of the bed, she
required the assistance of the OT to bring her left leg. There was a significant difference
between Kathys performance in activities of daily living (ADL) while seated compared to
standing. Kathy was independent while completing all upper body dressing and bathing.
However, her activity tolerance decreased once she is brought to a standing position. Kathy was
highly dependent on her upper body strength to push up from a chair in order to stand and
required several verbal cues to utilize her right leg. While standing, Kathy showed signs of
fatigue immediately. With a standing activity tolerance of only five minutes, Kathys heart and
respiratory rate increased significantly while in the bathroom for a self-grooming task. With this
in mind, Kathy requires frequent rest breaks throughout a session. Another key observation is
that Kathy fails to report an accurate measure of the level of difficulty or pain she has while
performing self-care tasks. Kathy consistently reported that her pain was only at a level of two
out of ten despite her facial expressions of discomfort and insisted on continuing standing
activities. The OT had to give Kathy several verbal cues to slow down and not push herself too
hard. Although it is beneficial for Kathy to have a very hard-working attitude during therapy, it
is important for the OT to know what the client can tolerate before she is over exerted.
Significant Impact
One of the client factors that has helped Kathy throughout her career and life is her value
for working hard toward goals. Although Kathys values keep her motivated to resume her
occupations, she has a tendency to push herself too much, too soon. Kathys surgical knee joint
functioning had very limited mobility and stability because it was still quite fragile. She requires
extra attention to safety during functional mobility in order avoid any rotation of her knee joint.
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Kathys muscle functions were affected from the TKA. With a decreased muscle power and
endurance in her lower extremities, Kathys safety was at risk during transfers and functional
mobility. Additionally, the declines in her respiratory and cardiovascular system functions from
her prolonged bed rest has contributed to her short activity tolerance. Kathy was only out of
surgery for less than 24 hours during the time of her evaluation. Kathy continued to push herself
toward standing activities and ambulation event though her current musculoskeletal and
movement conditions may not support it. Kathys emotional regulation was impacted because
she is easily frustrated with herself if she is not able to complete tasks while standing. Kathy
will require a discussion about a realistic pace toward rehabilitation Although Kathys work ethic
is a valuable attribute, it has impacted her judgement about her own abilities.
Problem List
1.
2.
3.
4.
5.
Priorities
Problem 1 is a high priority because activity tolerance is a strong indicator of Kathys
ability to engage in all occupations and will help build the foundation toward all of her other
goals. According to Kathys physician orders, she can weight bear as tolerated on her surgical
leg; however, she can only stand up to five minutes. After weeks of being bedbound and
undergoing surgery, Kathys has become dependent on her husband to take of her. Basic ADLs
of self-care is addressed because it is vital part Kathys everyday routine and is often the first
steps toward independence. Kathy needs to be able to build her activity tolerance, strength, and
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core muscles are currently too weak to raise her body from the bed and lack the lower body
strength to lift her left leg when scooting to the edge of the bed with a knee immobilizer
independently. However, this is not listed as a top priority to address because Kathy has already
developed her own compensatory strategies to rise her upper body to get up in bed and she is
complacent with about her husband providing minimal assistance to lift her leg at home. Lastly,
problem five is a priority because of its importance to Kathy. It is vital to Kathys life that she is
able to participate in activities that enable her religious values. This problem statement is placed
last because it may not be feasible to address within the acute care setting. However, education
regarding energy conservation techniques in order to preserve strength and endurance in order to
participate in church activities may be provided.
Intervention Plan and Outcomes
Long-Term Goals, Short-Term Goals, and Interventions
Long-term goal one. Pt will tolerate 15 min of standing activity while completing
ADLs & IADLs c Min (A) using FWW by 5 tx sessions.
Short-term goal one. Pt will tolerate 7 min of standing activity while completing selfgrooming routine in bathroom c Min (A) using FWW by 3 tx sessions.
Intervention one. For this intervention, Kathy will stand in front of her closet utilizing a
front wheel walker for stability and have a bag of her clothes on a table next to her. Kathy will
then demonstrate taking her clothes from her bag, putting them on hangers, and placing it in her
closet. This intervention may also be reversed by taking clothes off the hangers in the closet and
folding it to put back inside her bag. A wheelchair may be placed behind Kathy if she would ever
need a rest break. This intervention will be utilized as an occupation as a means. It helps address
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the activity tolerance and dynamic standing that would be required to complete self-grooming
while in front of the mirror of a bathroom.
By having Kathy participate in a standing functional activity while standing, it helps
challenge her musculoskeletal deficits to regain strength in her lower extremities. The approach
to this intervention will be to restore the lower extremity strength in Kathys surgical knee and
activity tolerance. As Kathys surgical site heals, she should be encouraged to increase her
weight bearing tolerance. Furthermore, research has found that individuals who participate in
intensive rehabilitation after a knee operation had better quadriceps strength and functional
performance compared to a non-treatment group (Bade & Lapsley, 2011). The expected
outcome of this intervention is to improve occupational performance in standing tolerance while
completing ADL and IADL tasks.
Short-term goal two. Patient will tolerate 7 minutes of a standing IADL task c Min (A)
using FWW by 4 tx sessions.
Intervention two. Kathy had mentioned that she strongly desires to be able to decrease the
caregiver burden of her husband by helping him manage their home. Making the bed is one way
that Kathy can help contribute to her familys household chore routine. For this intervention,
Kathy will utilize a front wheel walker to assist with balance due to weight bearing precautions.
Kathy will have to remove the existing sheets from her bed as well as the pillow covers and place
them in the laundry basket while standing. She will obtain new sheets, fold them using both
upper extremities, and place them on the bed. Kathy will then get her pillows and place them
inside the new pillow covers. Helping Kathy complete household chores is a significant
occupation because it is an activity that helps contribute to her role as a wife and homemaker.
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During this activity, Kathy would be working on the strengthening her lower extremities while
standing as well as her balance and endurance. With this in mind, a restore approach will be
utilized to help increase the activity tolerance that she had lost from surgery and prolonged bed
rest. According to Brienes (2013), using interventions that are more goal directed with
purposeful activities help increase the motivation for rehabilitation in comparison to rote
strengthening exercises. The expected outcome of this intervention is to improve occupational
performance in IADLs and improved quality of life through the participation of activities
regarding her role as a wife.
Intervention two with grading. This intervention could easily be modified in order to
adhere Kathys abilities. To grade this intervention down, the hospital could be raised to limit
the amount of trunk flexion required to obtain the sheets and pillow covers. With the bed raised,
Kathy can utilize the bed surface as a place to weight bear in order to gain stability when
standing. Furthermore, the sheets may be partially folded and placed onto the bed. Kathy can
complete the folding activity with one hand on the walker and the other being used fold the
sheet. In order grade this activity up, Kathy may spread the sheet of blanket instead onto the bed
of folding it, forcing Kathy to reach outside of her base of support to spread the blanket across
the bed in order to challenge her trunk stability during dynamic standing. Kathy could also be
challenged to ambulate to both sides of the bed in order to spread the blanket.
Long-term goal two. Pt will complete LB dressing c Mod (I) using a reacher, dressing
stick, & sock aid by 5 tx sessions.
Short-term goal three. Pt will demonstrate understanding of compensatory strategies &
appropriate use of A/E for dressing c (I) by 2 tx sessions.
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Intervention three. Kathy will be educated on compensatory strategies that will help
minimize pain during dressing. Some of the techniques included will be pushing up with the
non-operated leg to get into a standing position or utilizing stretchable and looser fitting clothing
to ease the task of dressing. Practical considerations prior to dressing will also be addressed such
as taking medication or donning a knee immobilizer. Furthermore, Kathy will be instructed on
how to use adaptive equipment in a hip kit including a reacher, long handled shoe horn, sock aid,
dressing stick, and leg lifter. Kathy will be asked to teach back the appropriate use of adaptive
equipment and compensatory strategies that were taught. Problem-solving strategies will be
facilitated by giving Kathy hypothetical scenarios and asking how she would respond utilizing
the techniques learned in therapy.
It is common for patients who have undergone knee surgery to report higher levels of
pain in comparison to hip replacements (Lawson & Murphy, 2013). Kathy may not remain in
acute care long enough for her pain to completely subside. This intervention will utilize an
establish approach in order to develop new dressing methods that adhere to Kathys knee pain
and surgical precautions. Implementing the use of compensatory strategies is vital to helping her
become independent in her basic ADLs sooner while minimizing her levels of pain. Thorough
patient education and a client-centered approach is critical to the efficacy of compensatory
strategies. Research has found that effective adaptive equipment utility requires adequate
training as well as implementing a device that is a good fit between the person and his or her
environment (Krakowsky & Finlayson, 2001). The expected outcome will to improve
occupational performance in self-dressing.
Short-term goal four. Pt will don shoes and socks c Min (A) using a reacher, shoe horn,
and sock aid by 3 tx sessions.
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educate Kathy as well as her husband about the importance of pacing herself, recognizing signs
of fatigue, and energy conservation techniques while engaging in everyday activities.
Frequency and Duration
Given the nature of treatment within acute care, Kathy will be only seeing services for a
few treatment sessions. Kathy will receive OT between three to five times during her stay at
Saint Rose Hospital within the span of a week. Treatment sessions will take up to one hour in
length. Kathys exact time of discharge will most likely depend on how long it will take her to
become medically stable.
Model
In order to be discharged home, Kathy must have the basic physical ability to complete
functional mobility tasks and transfers in order to navigate safely at home. Kathy will most likely
not be in the acute care setting long enough for her surgical knee to be fully regain functioning.
Utilizing the occupation adaptation model will help guide therapists to keep Kathys pain and
safety precautions in mind during the post-surgery healing process. Teaching Kathy
compensatory strategies and how to utilize adaptive equipment will help enable her to resume
occupations sooner as she regains strength and endurance during the healing process. This will
help Kathy to maximize the success in an activity immediately after her TKA through the
adaptation of how she performs the occupation.
Caregiver or Staff Training
When Kathy is discharged from the hospital, she will be trained in a home exercise
program to help build her strength and endurance as she continues to heal from her TKR after
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discharge. Kathy will be educated on the expected progression of her knee mobilization as she
heals as well as be encouraged to return to going on walks with her husband and dog. To prevent
any injury, Kathys husband will also be trained on how to safely provide minimal assist his wife
during bed mobility using proper body mechanics if needed at the time of discharge.
Monitoring and Assessing Client Response
An OT will be assessed and monitored Kathys response to treatment at every session.
Kathys blood pressure and oxygen levels will be monitored during standing functional activities
to assess activity tolerance. Furthermore, levels of pain will also be evaluated multiple times
during activity throughout a treatment session. Improvement will be demonstrated when she
meets her short and long term goals.
References
Bade, M. J., & Stevens-Lapsley, J. E. (2011). Early High-Intensity Rehabilitation Following
Total Knee Arthroplasty Improves Outcomes. Journal of Orthopaedic & Sports Physical
Therapy, 41(12), 932-941. doi: 10.2519/jospt.2011.3734
Brienes, E.B. (2013). Therapeutic occupations and modalities. In H. M. Pendleton, & W. SchultKrohn (Eds.), Pedrettis occupational therapy: Practice skills for dysfunction (7th ed., pp.
729-754). St. Louis, MO: Elsevier
Krakowsky, L., & Finlayson, M. (2001). Factors affecting older adults use of adaptive
equipment: Review of literature. American Journal of Occupational Therapy, 55(3), 303310. doi:10.5014/ajot.55.3.303
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Lawson, S. & Murphy, L.F. (2013). Hipfractures and lower extremity joint replacement. In H.
M. Pendleton, & W. Schult-Krohn (Eds.), Pedrettis occupational therapy: Practice skills
for dysfunction (7th ed., pp. 1074-1090). St. Louis, MO: Elsevier
Thomas, W. N., Pinkelman, L. A., & Gardine, C. J. (2010). The reasons for noncompliance with
adaptive equipment in patients returning home after a total hip replacement. Physical &
Occupational Therapy in Geriatrics, 28(2), 170-180. doi: 10.3109/02703181003698593