Running head: PROFILE AND ANALYSIS

Occupational Profile and Occupational Analysis James Stewart Touro University Nevada OCCT 651

PROFILE AND ANALYSIS Occupational Profile

This occupational profile was developed based on an interview with the clients wife. The client, Mr. Green, required great exertion and effort to communicate with others. Also, when he spoke, it was usually too quiet and soft to understand. Who is the Client? Mr. Green is a six-foot eight-inch, 66-year old retired accountant who has lived in Las Vegas since retiring. He and his wife have moved to Las Vegas in order to be closer to family. He retired only one year ago. He has spent much of that year vacationing, performing desired leisure activities, attending sporting events, and visiting family. He and his wife were unable to have any children. They chose not to adopt children. However, they have spent much time with nieces and nephew; Mr. Green considers them as his children and grandchildren. Mr. Greens wife currently does not have any health problems. Why is the Client Seeking Services, and What are the Clients Current Concerns Relative to Engaging in Occupations and in Daily Life Activities? Mr. Green suffered a severe traumatic brain injury (TBI) from motor vehicle accident (MVA) caused by a drunk driver. He was the only one in the car, so no other family members or friends have been injured. While at the acute care hospital, the doctors performed a craniectomy because the swelling in his brain was too great. Mr. Green has since been transferred to Care Meridian because of his unstable medical condition. His wife reports that her greatest concern for him is to survive this accident without too many lasting impairments. She stated that she wants to have her husband back at home with her. She also hopes that he will be happy and somewhat independent again. What Areas of Occupation are Successful and What Areas are Causing Problems or Risks?

PROFILE AND ANALYSIS

Mr. Green is currently experiencing limited success in all areas of occupations. His main area of occupation is currently rest and sleep because he is recovering from his accident. He is currently unable to perform any occupations in the areas of leisure, work, education, or instrumental activities of daily living (IADLs; American Occupational Therapy Association [AOTA], 2008). He is also severely limited in his ability to perform activities of daily living (ADLs). The only aspect of ADLs that he can somewhat participate in is bed mobility tasks (AOTA, 2008). He also performs a limited amount of social participation in which he can interact with therapists and family members for small amounts of time. However, it requires great effort to perform any of either of these occupations. What Contexts and Environments Support or Inhibit Participation and Engagement in Desired Occupations? Mr. Green appears to better engage and participate in his current occupations, mostly bed mobility, when his family members are present. He performs tasks more spontaneously during this time. For instance, when on the tilt table, he attempted to raise his arm to the ceiling without being prompted by either the occupational therapist (OT) or physical therapist (PT). Also, he performs better when he is not in pain or while under a high dosage of medication. This tends to decrease his level of alertness and consciousness. Mr. Green shows the best engagement and participation during the early afternoon and the worst engagement and participation during the early morning hours. What is the Clients Occupational History? Mr. Greens past occupational history has mainly included work, family, volunteering, and hobbies. Mr. Green worked as an accountant for 35 years for several different companies, but has since retired. Most of that job included working on a computer, calculating numbers,

PROFILE AND ANALYSIS writing reports, and interpersonal skills. He enjoyed his career, but has been happy to retire as well. He loves to be with family, especially playing with his nieces and nephews. He has taken them out for camping, sports games, and to watch movies. Not having children himself, Mr. Green has sought to help out other children through volunteering, such as the Big Brothers Big

Sister program. His wife states that family and volunteering has been the great joy in his life. Mr. Green is also an avid sports enthusiast. He enjoys watching football, basketball, and baseball. He enjoys watching sports with friends and family, especially during football season. Since retiring he has taken up other hobbies as well such as gardening, writing, and reading. These are activities that he has been longing to perform during his retirement period. What are the Clients Priorities and Desired Outcomes? Mr. Greens wife hopes that he will be somewhat independent, but realizes this may take months to years because of the severity of the brain injury. Her desired outcomes are that he will be mostly independent in transfers and self-care tasks before coming home. This is because she is about five-feet two-inches tall compared to his six-foot eight-inches in height. Currently at this setting, her priorities are that he will be able to get out of bed and move around, have longer periods of alert time, and be able to move his arms more. Occupational Analysis The occupation that I observed Mr. Green perform was bed mobility, transferring from supine to the edge of the bed (EOB). This activity would fall under the area of occupation of ADLs because it is within the area of functional mobility. The following questions will be based on this activity and analyzed by the information provided by the Occupational Therapy Practice Framework: Domain and Process 2nd Edition (AOTA, 2008). What Deficits Exist in Each of the Body Function Categories?

PROFILE AND ANALYSIS

Mr. Green appeared to have significant deficits in the area of mental functions. He lacked higher level cognitive abilities like divided attention abilities, judgment skills, and cognitive flexibility. He could hold attention for only brief periods, about one to two minutes. He also appeared to have deficits in long-term memory because he could not remember certain events. He showed significant deficits in perception of sensory input. It took at least 30 seconds for him to process sensory input of any kind. Mr. Green showed no signs of emotion or any experience of self and time. Mr. Green appeared to be orientated to place and person, but not oriented to time and self. He lacked energy and drive and appeared lethargic. He spends most of his time sleeping and often asleep during therapy sessions. As described above, Mr. Green showed deficits in his ability to process sensory information. He especially showed delays in his ability to comprehend verbal communication. He appears to have some loss of either his visual acuity or visual fields. He has also lost some vestibular function because he has been bedridden for such long periods of time. Mr. Green had pain in his left hip, but from unknown causes. He shows no deficits in taste, smell, proprioceptive, touch, or temperature and pressure functions as could be seen. Mr. Green shows limited active range of motion (AROM) in his upper extremities from lack of muscle strength and neurological damage. However, he has full passive range of motion in his upper extremities (PROM). He showed signs of a subluxation in his right shoulder joint. His muscles have atrophied from disuse, causing decreased muscle power and endurance. Mr. Green shows signs of flaccid muscle tone. Mr. Green is not able to walk at this time, so gait patterns cannot be observed. Mr. Green shows no deficits in the areas of motor reflexes, control of voluntary movement, or involuntary movement reactions.

PROFILE AND ANALYSIS Mr. Green had increased blood pressure and increased heart rate during treatment. His heart rhythm appeared to be normal, but his depth of respiration seemed shallow. Mr. Green hooked up to an oxygen tank, showing decreased oxygen levels in his body. This means that he shows decreased capacity for aerobic functions and physical endurance as well as increased

fatigability (AOTA, 2008). His voice is a soft whisper when he speaks and barely intelligible. He uses only short sentences when he does speak. He is currently fed through an NG-tube. He also lacks voluntary control of his bladder. Mr. Green showed signs of skin breakdown from prolonged inactivity and lying in bed which could lead to severe pressure sores in the future. Hair and nails appear to be intact. Discuss the Activity Demands of this Task The activity of transferring from supine to the EOB required the use of the hospital bed, two therapists, and a cranial helmet. The hospital bed was specialized for persons of aboveaverage height, could move up and down as a whole or in sections, had a slippery surface, and was controlled by a remote. One therapist was about five-feet four inches and the other therapist was about five-feet eleven inches. The cranial helmet was white, fit snugly around Mr. Greens head, and had a Velcro chin strap for support. No materials were used. The location of the activity was indoors. The indoor environment seemed to be of normal indoor temperature, had good lighting, and was somewhat stuffy. The environment was also somewhat clustered. There were several tubes and cords connected to Mr. Green as well as several pillows and a blanket on the bed. As many of these environmental hazards were removed that could be. The social demands of the activity required Mr. Green to stay socially appropriate. This meant that he needed to keep aggression under control if he was frustrated by his lack of

PROFILE AND ANALYSIS

independence and that he needed to be comfortable with close contact and touch. He also needed to follow verbal cues and reciprocate that he understood the command. Mr. Green performed as much of the activity as he could. The sequencing of the activity was as follows. First, the therapists needed to place the cranial helmet over Mr. Greens head. Second, they removed all environmental obstacles such as pillows and the blanket. Third, they slowly raised the head of the bed. Fourth, they helped swing Mr. Greens legs to the edge of the bed. Fifth, they raised his back off the raised head of the bed. Sixth, they helped him rotate his trunk and swing his legs. Seventh, they helped him scoot forward so that his feet were flat on the floor. Eighth, they helped him sit up at the EOB with the support of a therapist. Timing of the activity involved sitting at the EOB as Mr. Green could tolerate, but with the goal of at least five minutes. Required actions by Mr. Green were to lift his head off the bed, move his legs to the EOB, move his body into a seated position, and scoot his body to the EOB. Identify the Performance Patterns Related to the Task and Your Client Before his injury, Mr. Green had most likely been in the habit of getting out of bed by rolling to the side and then moving into a sitting position at the EOB. It is hoped that because this habit has been ingrained in his brain over time that his muscles will perform the actions from memory. The process of getting out of bed is also a part of the overall morning routine. It is the usually the first start to persons day after waking up. Once out of bed, he will be able to improve on the rest of aspects of his morning routine. Getting out bed in order to perform a morning routine will help Mr. Green gain a sense of independence in his role as a human being, which will allow him to focus on other roles such as husband and uncle. Identify the Performance Skills which are required for this Task

PROFILE AND ANALYSIS

Motor skills that are required by this task are to lift the head off the bed, move the legs to the EOB, rotate the trunk, and stay up in a seated position. Sensory-perceptual skills needed for this task are to position the body in the correct placement, locate where to place the legs and arms, and time the movement of the body to the EOB correctly. Emotional regulation skills of the task are to persist through the task even though it is difficult and use relaxation techniques if necessary to keep the body calm and relaxed. One cognitive skill required by the task is to sequence tasks in proper order such as waiting for the head of the bed to rise before lifting the head off the bed. Another cognitive skill needed is to judge when breaks may be needed to rest because of pain or fatigue. Communication and social skills required by the task are to ask for help if needed and to do so by verbally speaking or through gestures. Identify the Body Functions and Body Structures Primarily Influenced by this Task Both specific and global mental functions are influenced by this task. Specific mental functions are that Mr. Green needs to maintain attention to the task of transferring to the EOB, remember how to move to the EOB, and have the ability to emotionally cope when fatigue sets in or from the loss of independence. Global mental functions are that he needs to be aroused and conscious, as well as show motivation to continue in order to improve his independence in this task. As shown, Mr. Green shows deficits in his ability to emotionally cope with difficult tasks, maintain attention to tasks, and remember tasks. Sensory functions influenced by this task are that Mr. Green needs to see where the EOB is located, have an awareness of his body in space, and have minimal pain when moving to the EOB. Mr. Green shows deficits in this area because he feels pain in his left hip and has some sort of visual loss.

PROFILE AND ANALYSIS Movement-related functions influenced by this task are that Mr. Green needs to have moderate ROM of the upper extremities, moderate ROM in the lower extremities, adequate muscles strength to move the upper and lower extremities, adequate muscle endurance to

maintain a seated position for at least five minutes, and voluntary control of muscles of the upper and lower extremities. Mr. Green shows deficits in his limited ROM of both upper extremities, some instability his right glenohumeral joint, and decreased strength in his muscles. Cardiovascular and respiratory functions influenced by this task are that Mr. Green needs to have a stable heart rate during movement, have adequate blood pressure, have adequate oxygen levels, and maintain breathing while performing the activity. As shown, Mr. Green shows deficits in that he has high blood pressure, high heart rate levels, and decreased oxygen levels. Body structures influenced by this task are the nervous system for communication between brain commands and muscle movement, eyes to locate objects and ears to hear verbal cues from the therapists, intact cardiovascular and respiratory systems for adequate blood pressure and oxygen throughout the task, skin that is not prone to injury easily, and all structures related to movement including the extremities and trunk. Comment on the Contexts that Specifically Relate to the Performance of this Intervention All of the contexts in the OTPF relate to Mr. Green performing the task of transferring to the EOB except the virtual context. This context does not apply because there is no involvement of cell phones, computers, or other types of electronic communication during the activity. In the cultural context, Mr. Green most likely places independence as one of his highest priorities because he is an American. He will be motivated to perform the task of transferring to the EOB because it is the first step in regaining his independence. This also relates to the personal context

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as well. At his age of 66-years old, he most likely views himself as having more years to live and as someone who can still be independent. He will not view himself as the middle old or oldest old adult who anticipates greater dependence on others because of health problems. As noted previously, Mr. Green participates better when therapy sessions are held during the afternoon. For the temporal context, the therapist should note this and seek to perform treatment during this time. Physically, Mr. Green is located in a long-term care facility. He will have nursing, OT, PT, and speech therapy (ST) throughout his stay. Some of these disciplines may help support his independence by allowing him to perform part of the task of sitting at the EOB; other disciplines may simply perform the task for him. The social context is one of the most influential for Mr. Green. He loves his family and loves to spend time with them. He is motivated when they are with him. He performs better when they are around to support and encourage him. It provides him an extra strength and desire to improve and get better. He is also an uncle to many nieces and nephews. Knowing that he must improve in order to see them again will motivate him to work hard in therapy. He will push himself to become independent in sitting on the EOB because of the influence of his family. Problem List Identify at Least 5 Different Problems Relevant to the Client and State These in the Format of a Problem Statement 1. Client requires total (A) to t/f supine EOB 2 AROM & muscle strength of BUE. 2. Client requires max (A) to sit EOB 2 AROM & muscle strength of the trunk. 3. Client is unable to grab clothing items for dressing 2 AROM & muscle strength of BUE. 4. Client is unable to write his name 2 AROM & coordination of RUE.

PROFILE AND ANALYSIS 5. Client requires total (A) to don cranial helmet 2 AROM & coordination of BUE. Prioritize Your Problem List and Justify Your Reasoning The first two problem statements have been listed because addressing these areas first

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will help the client improve the most. When addressed, they will eventually help the client to get up out of bed. Mr. Greens wife also expressed that this is one of her priorities for her husband right now. Addressing these problems also utilizes the principle to focus on making improvements proximal to distal. Transferring to the edge of the bed and then sitting on the edge of the bed focus on trunk strength and control. Gaining this function back first will allow better improvements in upper extremity strength, range of motion, and coordination. The next two problem statements focus on the use of the upper extremity. After regaining trunk control and the ability to get out of bed, this is the next logical option. To grasp items is easier to perform than coordinating the use of a writing utensil. Hence, the grasping of clothing items has been placed before the writing of his name. Having Mr. Green write his name has been included in the list because this was one of the new occupations he began after retiring. The donning of the cranial helmet has been placed last because of safety. To have Mr. Green practice the donning of the cranial helmet is contraindicated because he could inadvertently damage the brain. It is better to have the therapists or caregivers perform this task for him so that the helmet is placed safely.

PROFILE AND ANALYSIS References

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American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683.