Student

Name: Brynnan Halsey

Case: 6

Date: 4/8/16

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Pneumonia; CHF; COPD; Type II diabetes; OA; Gout
Referred to OT by physician for recovery after pneumonia
Seen in Transitional Care Unit
Medicaid
LOS 1 x per day for 3 weeks

2. Pragmatic Factors to Consider

Client wants be referred to as a female named Winnie possibly could affect insurance payment
LOS
Lives in rural area so not able to do an official home eval
Other health issues which can impact performance (COPD, CHF, Diabetes)
Weight, fatigues easily
Working around lines (O2) and monitoring O2 levels, may need O2 during therapy
Working around other health team members
3. Context: Occupational Profile & Current Occupations

Cultural:

Physical:

Social:

Personal:

Temporal:

Virtual:

Prior Occupations:

Current Occupations:

4: Top Three Client/Family Goals and Priorities

1. Want to be able to dress in preferred clothing independently
2. Independent in showering
3. Independent in cooking
5. Diagnosis and Expected Course
Pneumonia is an infection in the lungs that causes the buildup
of fluid or pus
It is diagnosed using a chest x-ray, blood tests, or sputum text
Symptoms:
Cough
Fever
Chills
Difficulty breathing
Often pneumonia can be treated with medication but if left
untreated or case is very severe then bacteria can get in the
blood, cause an abscess in the lung, fill lungs with more
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6. Scientific Reasoning & Evidence

List the barriers to performance typical of this
diagnosis:
Pneumonia
o Difficulty breathing
Smoking cessation
Increase endurance
medication
Mayo clinic
CHF
o SOB
Increase endurance
Breathing exercises

Revised 1/7/13

fluid, all of which could cause death.

Mayo Clinic

CHF
Congested heart failure when the heart doesnt pump blood
as well as it should. It is also a chronic disease
Diagnosis can be done using blood tests, chest x-ray, ECG,
stress test, CT, MRI, or coronary angiogram
Symptoms:
SOB
Fatigue
Weakness
Swelling in legs ankles and feet
Persistent cough
Increased urination at night
Swelling in th abdomen
Lack of appetite or nausea
Decreased alertness
Chest pain
CHF is chronic but can be treated to help reduce symptoms
but even with treatment heart failure could worsen to the
point that medication or surgical options are no longer
available and the individual will progressively worsen until
death.
COPD
Is a chronic pulmonary disease that causes obstruction of
airflow from the lungs.
Diagnosis is done using pulmonary function tests, chest xray, CT, or through arterial blood gas analysis
Symptoms:
SOB
Wheezing
Chest tightness
Build up of mucus in lungs
Chronic cough
Blueness of lips
Frequent respiratory infections
Lack of energy
Weight loss
COPD is treatable and with proper management symptoms
can be managed and have a good quality of life. If left
unmanaged it can put the individual at risk for respiratory
infections, heart problems, lung caner, high blood pressure,
and depression
Diabetes Type II
Diabetes is disorder in which the body can no longer regulate
blood glucose. The body still produces insulin but the cells
their cells can no longer process it and the sugar builds up in
the blood.
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Fatigue
Energy conservation
techniques
AE
Compensatory strategies
Improved sleep and rest
Weight management
diet
Weakness
Biomechanical approach
increase strength and
endurance
Exercise
Reduce swelling
Stress reduction
Medication

o
o
Mayo Clinic
Pedretti chapter 44

COPD
o SOB
Adjusting posture
Pursed lip breathing
Relaxation techniques
o Lack of energy
Energy conservation
Lifestyle modification
(exercise program,
smoking cessation)
Education
AE
Compensatory strategies
o Surgery (lung volume reduction,
transplant)
Mayo Clinic
Pedretti chapter 44

Type II Diabetes
o Fatigue
Energy conservation
techniques
Managing blood sugar
Diet
Exercise program
Mayo Clinic
OA
o Joint pain stiffness, loss of
flexibility
ROM

Revised 1/7/13

Diagnosis is done through an A1C test, blood sugar test.

Symptoms:
Increased thirst
Frequent urination
Extreme hunger
Weight loss
Fatigue
Irritability
Blurred vision
Slow healing sores
Frequent infections
Type II diabetes can sometimes be reversible with weight
loss. It can be managed by medication and by controlling
your blood sugar, but if left unmanaged can cause several
complications like CVD, nerve damage, kidney damage, eye
damage, skin condition, hearing impairment, and
Alzheimers.

Biomechanical approach
Pain management
Medication
Surgical management
Modality treatments
Education
splinting

Mayo clinic
Pedretti chapter 38
Willard & Spackman appendix 1

OA
Osteoarthritis is a chronic disorder that occurs in the joints
when the protective cartilage on the ends of bones wears
down over time.
Diagnosis is done using x-rays, MRI, blood tests and a joint
fluid analysis
Symptoms:
Joint Pain
Joint Tenderness
Joint stiffness and loss of flexibility
Bone spurs
OA develops fairly slowly at first and worsens over time is
incurable but with treatment can help slow the progression to
reduce pain and increase joint function
All info found at Mayo clinic, Pocket guide to OT
Assessment, Pedretti
7. Practice Models Guiding
Assessment and
Treatment

Rationale

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Revised 1/7/13

1.

PEO

Due to her multiple conditions, Winnie is lacking congruence between her

abilities, the environment and participation in desired occupations. Her COPD,
CHF, diabetes, and OA are affecting her ability to complete daily tasks. She suffers
from fatigue and weakness that negatively impact her ability to ADL, IADL, and
desired leisure activities. The PEO model helps to guide us to evaluate her
environment and observe her abilities and how they affect her occupational
performance. By obtaining this information we can adapt the environment or her
abilities to promote occupational performance and increase participation desired
activities as she returns home alone.
Postulates of change
Barriers to occupational performance can be prevalent in the persons
environment and so interventions can be applied to the environment that
enable the individuals occupational performance in the presence of a
disability. We do not know much about Winnies home environment or
what her daily routine looks like but if we can adapt the environment to
fit her needs then she can gain functional independence resulting in
improved occupational performance and better congruence.
o A persons perceptions and beliefs about the environment and occupation
influence subsequent occupational performance; therefore it is important
to understand the persons priorities and perspectives about their abilities.
It is important to understand what Winnies priorities are and help her to
adapt her abilities to meet those priorities. Right now she wants to be able
to go home and participate in desired hobbies and be independent. It will
be important to help educate on how to improve her health to help
eliminate symptoms that are preventing her from participating in
activities. By helping her to adapt her thinking we can help her improve
her occupational performance and be independent at home. It will be
important to get her to buy into the therapy process so she can have better
success in therapy and get home.
Due to her multiple disorders, Winnies experiences weakness, low endurance and
fatigue very quickly when completing daily tasks. These motor issues will have an
impact on her ADL, IADL, leisure performance. The biomechanical model will be
used to help address motor function and improve ROM, strength and endurance
that can help her perform physical tasks. The rehab model will be used to help
Winnie to learn to use compensatory methods to help promote independence in
occupations and conserve energy.
Postulates of change
o ROM, strength, and endurance affect occupational performance.
Increase in these areas leads to increased occupational
performance and if there is a decrease in these areas then
occupational performance decreases. This is especially important
for Winnie since she lives on a ranch by herself and there is most
likely a lot of physical labor to be done.
o When impairment cannot be rectified then compensatory
strategies and technique can be utilized to restore and an
individuals independence. Because of her many disorders she
may need to use compensatory strategies to complete daily tasks
to help conserve energy and prevent fatigue that may hinder her
ability to complete and participate in desired occupations.
o

2.

Biomechanical/rehab

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Revised 1/7/13

3.

Transtheorectical Model
of Change

Winnie has many lifestyle habits that exacerbate the symptoms of her various
disorders. Smoking especially has a major impact on worsening symptoms of
her CHF and COPD. Her weight and eating habits impact her diabetic
symptoms. This model helps individuals change unhealthy behaviors to more
healthy and positive behaviors that will help improve occupational
performance.
Postulates of change
o Knowing which stage of change a client is currently in will be key in
determining which therapeutic strategies to use. This Is important for
Winnies case to help us understand if she is ready to change and if
not, what strategies we can use to get her on the path to wanting to
make lifestyle changes.
o A growing awareness that the advantages of changing outweigh the
disadvantages. Education will be especially important when using this
model with Winnie. She wants to be able to go home and be
independent but this will be much more difficult without some
lifestyle changes. By educating her about the pros on cons of making
the necessary changes it will increase by in, which will then increase
involvement and motivation to make the necessary changes.
8. Specific Areas of Occupation

What do you know?

What do you need to know?

9. Performance Skills
What do you know?

What do you need to know?

10. Performance Patterns-Habits, Routines, Rituals, Roles

What do you know?

What do you need to know?

11. Activity Demands for the Client Goals and Priorities -

What do you know?
What do you need to know?

12. Client Factors- Values, Beliefs, Spirituality

What do you know?
What do you need to know?

13. Client Factors- Body Functions & Structures

What do you know?
What do you need to know?

14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform
Observed Occupation
Rationale/How will you use this information
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Revised 1/7/13

Showering/getting dressed

Method/Tool
1. ROM, MMT

2.LOTCA

3. Jebson Hand Test

4. PASS-Medication management, bill pay, shopping

5. Home Eval

15. Projected Outcomes:

This will show me what difficulties she is having

with her shower and dressing routine. I will see
how she able to transfer in and out of the shower,
how she is able to handle shower and tells me how
thoroughly she clean her body. With both tasks I
will be able to observe what her AROM is like in
both UE. I can determine her endurance, balance
and what type of adaptive equipment might be
needed. I will be able to observe what kind of
strategies she is already using to complete
showering and dressing and what strategies maybe
useful to implement. Also I will see if there is any
pain that is limiting her performance.
Rationale/What is being Assessed
These tests will be used to provide information
about her PROM, AROM, strength, and tone in all
extremities. This will help us to see how these
areas maybe affecting her occupational
performance and give us an idea, of what kind of
equipment or compensatory strategies may need to
be used to complete occupational tasks. OA and
gout could be affecting her joint mobility.
This assessment will provide an in depth
assessment of Winnies basic cognitive abilities
and visual abilities. Understanding her basic
cognitive abilities like memory will be important
in determining what teaching strategies will be
most successful. It will also be important to
understand her visual perceptual skills that may be
impacted with her decreased vision.
This test will provide insight into her functional
performance in simulated ADL tasks, like eating,
moving and gripping tasks, manipulation of
smaller objects. This will provide an idea of how
functional her grasp is and possibly what AE or
compensatory strategies may need to be used to
complete ADLs. Hand and finger joint could be
affected by OA and Gout
I want to get an idea of how she is able to handle
IADL that are important for living independently
and how much assistance she needs and the type
of the assistance she needs.
A home eval would be important to complete
because she will be discharged to home and we
need to know what supports and barriers are in
the home and what AE may need to be put in
place to ensure safety as he is living alone. This
will have to be informal and done through an
interview with Winnie as is would be very
difficult to actually go to her home. We may
have to see if her nephew can send photos.

Type of Outcome

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16. Resources and Team Members

PT
Nurse
Physician
Case manger
Pharmacist
Respiratory therapist
Support Group in the community
Refer to nutritionist, diabetic specialist

17. Intervention Plan

Barriers
Supports
CHF
Clear goals
COPD
Motivated to get home
Type II diabetes not regulating blood sugar
Pets for social support
OA
Grandson maybe available
Gout
TKA
Obese
Smoker
Drinker
Lives alone
Poor vision
Decreased strength
Goals
Practice Model for each goal
1. LTG: Dressing
By discharge, client will independently complete dressing routine in PEO/Rehab
preferred clothing using compensatory strategies and AE.
STG:
In 2 weeks, will complete lower body dressing in sitting with min A PEO/Rehab
using AE.
STG:
In 1 week, client will be able to don bra with min A utilizing
compensatory strategies.
PEO/Rehab
2. LTG:
By discharge, client will independently complete shower routine
using compensatory strategies and AE.
STG:
In 2 weeks, client will independently and safely transfer in/out of
shower using AE.
STG:
In 2 weeks, client will initiate utilize an energy conservation
technique while in the shower with no more than 1 VC.
3. LTG:
By discharge, client will independently prepare a well-balanced
meal.

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PEO/Rehab
PEO/Rehab
PEO/Rehab
PEO/Transtheoretical

Revised 1/7/13

STG:
In 2 weeks, client will independently initiate adding one fruit and/or
vegetable into a meal.
STG:
In 1 week, client will initiate checking blood sugar before a meal
with no more than 1 VC

PEO/Transtheroretical
PEO/ Transtheoretical

18. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do?
Identify
Approaches
Dressing using compensatory strategies to complete dressing
Establish/Restore
and to help conserve energy.
1. Discussion (15 min)
a. discuss ways she can adapt her dressing routine
to meet her needs. Sitting down, use of adaptive
equipment (shoe horn, sock aid, reacher),
turning bra around to front or buying front clasp
bras, incorporate rest breaks, and, make sure
there is good lighting. Provide handout with
energy conservation techniques to take home.
2. Practice dressing (30 min)
3. Have the client gather clothes
4. Have her sit in chair to doff sleep wear
5. Have her don bra sitting and fastening it in the front and
then turning it around.
6. Have her don shirt.
7. To don stocking while sitting. Have her bring left leg up
so ankle rests on right knee. Put L leg in and pull
stocking up as far as she can. Have her put L leg down
then bring R leg up and don other stocking.
8. Have her don pants while sitting and one leg at time like
she did with stockings.
9. Have her pull pants up as far as she can then stand to
pull them all the way up or if this is difficult have her
continue to sit and move body side to side as she brings
pants up.
10. Have her place her foot on footstool when donning
shoes to bring them closer and possibly using a
shoehorn to slip shoes on.
I will provide physical assistance and verbal cueing as
needed and encourage him to take his time. I will look for
safety issues and what compensatory strategies can be used
in his routine.
2. What will you do?
Identify
Approaches
1) Discussion (15 min)
Establish/
Discuss the importance of managing blood sugar and having Restore
a well balanced diet. These are important factors that can
have appositive effect on her weight management, reduce
diabetic symptoms as well as increase her energy levels Talk
about how to create long lasting lifestyle changes you need
to make small changes a little at a time. Discuss the use of
using a food diary to help monitor food intake. The diary
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Based on which goal(s)?

LTG 1

Based on which goal(s)?

LTG 3

Revised 1/7/13

can also be used to help to log blood sugar levels before

meals and help monitor when to take medications. Client
will be given a handout on blood sugar management, food
diary, a sheet on simple healthy food substitutions
2) Grocery list (30 min)
Have client pick what her favorite meal is when she is home.
Then we can discuss what kind of substitutions or additions
can be added to the meal to make it more well balanced.
Have the client plan the meal menu and then create a
shopping list of ingredients we need to prepare this meal
during our next session.

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Revised 1/7/13