Rhonda Case Study

3.
NORTHLAND COMMUNITY AND TECHNICAL COLLEGE

OCCUPATIONAL THERAPY ASSISTANT PROGRAM
Case Study Assignment
Case Study Complete the following Chart
Name, Age and Identifying
Information:
Rhonda is a 63 year old African American single female who lives with a dog and parrot.
Description of Diagnosis:
Rhonda underwent a coronary artery bypass graph (CABG) after being diagnosed with three blocked coronary arteries two weeks
ago. A CABG is a procedure used to treat blocked coronary arteries, which improves the blood flow to the heart. She has
additional diagnoses of congestive heart failure, diabetes, hypothyroidism, and schizophrenia. She experiences chest pain with
minimal exertion.
Rhonda is worried about her parrot and dog that are at home. She currently lives in a second story apartment alone with no laundry
facilities. She does not have any immediate family members in the area. She works part-time as a convenience clerk, which
requires moving boxes, stocking the shelves, and managing the cash register. She also attends a day hospital two days a week.
Rhonda takes medication for her schizophrenia and usually does well as long as she stays on her medication. She occasionally
drives short distances to run errands. She currently continues to have pain in the sternum and rates it as 6/10 on the pain scale.
Pertinent information in treatment of

Diagnosis:
Type of Setting:
Transitional care unit
Frequency/Duration of OT:
60 minutes daily for two weeks.
Clients assets:
Rhonda enjoys painting, scrapbooking, cooking and spending time with her animals. Her hearing, sensation, and perception are all
intact.
Work IADLs Sleep Education Play ADLs Leisure Social participation

*List All Skills/Areas that need Addressed: Use the Practice Framework to identify these areas. Prioritize List in order of
importance) (*Physical Health and Psychosocial)
Area of Occupation Affected
1
2
3
4
Poor endurance in all functional activities

Sit to stand w/ MOA
MIA ambulating w/ rolling walker due to LE weakness
Congestive heart failure, diabetes, hypothyroidism, schizophrenia
5
6
7
8
9
2nd floor walk-up apartment

No laundry facilities
Job consisting of moving boxes, stocking shelves
Worried about her animals
Pain in the sternum 6/10
1
0
Can only move from sit to supine by raising the head of the bed
ADLs, IADLs, Work, Leisure

ADLs, IADLs, Social Participation
ADLs, IADLs, Social Participation
Work, IADLs, Sleep, ADLs, Leisure,
Social participation
Work, IADLs
IADLs
Work
IADLs
ADLs, IADLs, Leisure, Work, Sleep,
Social Participation
ADLs, IADLs
Pick the Top 3 Physical Health Based Problems

Problem #1 (Skills/Areas that need Addressed: Use
the Practice Framework to identify these areas.)
Create a Short Term Goal to Address the Problem:
Create a Long Term Goal to Address the Problem
Poor endurance in all functional activities
Rhonda will increase endurance by 50% to complete 3 Rhonda will increase endurance to complete all work-related
craft projects that require UE ROM and strength in
tasks in five weeks.
two weeks.
Treatment Ideas Related to Physical Health*: Describe the two main Treatments you would complete to address the Problem Area. Be specific, included detailed
instructions/steps to complete the treatment.
Identify the Following for each Treatment:
#1
#2
Type of Intervention: Preparatory, Purposeful, or Occupation Based

Identify the Intervention Approach: Health Promotion, Remediation/Restoration, Maintain, Compensation/Adaptation, Disability Prevention
Primary Frame of Reference utilized: Rehabilitative, NDT, Developmental, Biomechanical, Sensory Integration, Motor Control,
*It is important to address psychosocial concerns as well, and can be used when working on the physical health problems.
Purpose for Selected Treatment/Specific
-Rhonda will make a braided fleece dog toy for her dog at home.
She will pick out the fabrics that she wants to use for the toy. She will Skills/Areas addressed:
This will work on increasing her endurance by
then have to cut the correct amount of fabric needed with scissors.
pulling each piece tight and cutting the thick fabric
Therapist will demonstrate how to braid and tie off. She will then be
with scissors. This incorporates her likes as she has a
dog at home that she is worried about.
able to give to her dog when she goes home. When she is discharged
Therapist will keep track of sharps as patient is
she will be able to play tug-of-war with him and continue to work on
diagnosed with schizophrenia.
endurance.
Type of Intervention:
Occupation based
Intervention Approach:
Establish/restore
Primary Frame of Reference:
Rehabilitative
-Rhonda will complete giant memory game on the wall.

Large pictures will be taped on the wall and flipped over. She will have to reach and move around to pick each card. She
will have to successfully match two cards and go until there are no more left. If they do not match, she will have to tape
them back to their original spot. To grade the activity, more cards will be added with harder pictures.

Skills/Areas addressed:
This will not only address some of Rhondas
cognitive deficits, but it will incorporate working on
increasing her UE ROM and fatigue
Purposeful
Compensation/Adaptation
Rehabilitative
Sit to stand w/ MOA
Rhonda will stand up from a chair with MIA in two

Rhonda will stand up from a chair with SBA in five weeks.
weeks.
#1

Primary Frame of Reference utilized: Rehabilitative, NDT, Developmental, Biomechanical, Sensory Integration, Motor Control, Neuro-developmental
-Rhonda will make three scrapbook pages.
Rhonda will complete three different scrapbook pages. She will only be allowed to use one item at a time. If she is done
This will be working on sit to stands in a functional
with the item, she has to stand up, return the item, and then get a new one. She will not be allowed to have more than one
way. She will be working on one of her favorite
item on her table. Various tools will be placed around the room. She will need pictures of family, friends, and pets,
leisure activities as well.
stickers, glue, paper, etc.
Occupation based
Remediation/restoration
Rehabilitative
#2
-Rhonda will make a simple recipe

Rhonda will choose a simple recipe to make for lunch. She will have to gather each ingredient.
Every time she adds a new ingredient or picks up a new tool, she has to do 5 squats, or as tolerated. She will do this until
her recipe is completed.

This will work on engaging her core and increasing
her LE strength. She will also be engaging in one of
her favorite leisure activities.
Occupation based
Remediaton/restoration

MIA ambulating w/ rolling walker due to LE weakness
Rhonda will use rolling walker with SBA while

Rhonda will ambulate 100 feet to her car independently in 5
completing functional activities, such as cooking, in
weeks.
two weeks.
#1

Primary Frame of Reference utilized: Rehabilitative, NDT, Developmental, Biomechanical, Sensory Integration, Motor Control, Neuro-developmental
-Rhonda will complete an obstacle course with her walker
Rhonda will go through a taped off obstacle course that will include:
The purpose of this intervention is to get Rhonda
Cones to weave through, different inclines, small set of stairs, different textures (carpet, sand, hardwood) short
comfortable and confident ambulating with the
rolling walker. This obstacle course will require
and long distances, tight areas to fit through, bending and reaching for objects throughout the course.
As she increases her independence the walker will be removed for portions of the obstacle course, and eventually endurance and LE strength and practicing work
related activities.
all together eliminated.
Occupation Based
Compensation/adaptation
Biomechanical
#2
-Rhonda will make a walking schedule.

She will make a walking schedule to implement at least 2x a day. She will pick a course to walk with her walker for a few
feet, then walk a shorter distance without her walker, with therapist standing there for CGA. When she is getting fatigued
she will incorporate breathing exercises (pursed lip) to increase her oxygen levels and walk longer. She will then make a
plan for a schedule when she gets home that she can do. She will write down times and her route for the day.

This will increase Rhondas independence with
walking and getting rid of the walker. Incorporating
breathing exercises will help with fatigue and
increase Oxygen levels.
Purposeful
Compensation/adaptation
Rehabilitative
Additional Treatment Ideas: (Make a brief list of all other treatment ideas you would use when working with this individual.
Apply ice/heat to painful area
Energy conservation
Tai Chi
Yoga-focusing on the breathing aspect
Journal each day
Make a weekly schedule with scrapbooking supplies
Playing small version of basketball to reach

Educating on medication management
Educating on community mobility
Dowel exercises
Theraband exercises
Provide the APA Citation for 1 EBP article that you feel provides an appropriate treatment method for this diagnosis, describe the treatment
method and why you chose it (Refer to Rubric for more Details):
Wilke, N., & Sheldahl, L. (1985). Use of Simulated Work Testing in Cardiac Rehabilitation: A Case Report. American Journal of Occupational
Therapy, 39, 327-330.
This was a case report about a male who underwent two-vessel coronary artery bypass surgery. The patients therapist evaluated his physical job
demands to determine whether he would be able to go back to work. They stimulated unloading building materials from a delivery truck through a
repetitive weight lifting task-it required him to lift boxes of a certain weight all while monitoring his heart, blood pressure, and fatigue. It was
recommended that he return as part time in order to adjust before coming back fulltime. The occupational therapist met with the patient and his wife
to go over at home routines/exercises he could do in order to reduce the original stress that caused the heart issues. It was followed up a year later and
the patient reported no further issues/problems returning to work.
I thought this was a good study done because the therapist addressed the stress he was experiencing, which would cause further heart issues if it was
not addressed. The patient was successful in returning back to a job that required some physical demands after changing and adapting stressful things
in his daily life.
Identify the Health Professionals that would be important to collaborate with in regards to this patient and discuss why (Refer to Rubric for
more details):
Role of OTAs collaborating with the following individuals:
Respiratory therapist: monitor breathing/techniques to complete during sessions when fatigued
Physical Therapist: work on increasing overall endurance and strength by having a collaborative session
Cardiac doctors: monitor her CABG and what signs and symptoms to be aware of
Regular doctors: check in on her medication for Schizophrenia, monitor diabetes
Social worker: help Rhonda figure out current living situation, what kind of options she has for her medical bills, what to do with her animals, etc.
Weekly Treatment Documentation: Document as if you completed 5 days of treatment.

Patient Name: Rhonda
Precautions: Oxygen levels, diagnosis of CHF, diabetes-sugar levels, and

Schizophrenia-medication
Treatment Diagnosis: CABG
Charges:
Total Visit Time
Date: 4/6
Date: 4/7
Date: 4/8
Date: 4/9
Date: 4/10
Ther. Ex 60/4
Ther. Act 30/2

Neuro 30/2
Ther. Ex 60/4
Ther. Act 30/2

Neuro 30/2
Ther. Ex 60/4
60
60
60
60
60
Total Times Codes
60
Pt. completed 20
repetitions of squats and
used walker for support.
Pt. completed 6 step
recipe with rolling
walker. Pt. required MIA
when completing squat to
stand 75% of the time.
Pt. required education on
posture and correct
positioning during
squats. Pt. fatigued 30
minutes into session and
reported pain in sternum.
60
Pt. completed 25
repetitions of squats
and used walker for
support. Pt. completed
6 step recipe with
rolling walker. Pt.
required MIA when
completing squat to
Pt. fatigued 40
minutes into session
and reported pain in
sternum.
60
Pt. matched 20
memory cards in 30
minutes while
completing shoulder
flexion/extension,
shoulder ab/add,
horiz ab/add
continuously. Pt.
completed
therapeutic craft that
required UE strength.
Pt. fatigued 45
minutes into session
sternum.
60
Pt. completed 30
repetitions of squats and
used walker for support.
Pt. completed 6 step
recipe with rolling
walker. Pt. required SBA
when completing squat to
Pt. fatigued 45 minutes
into session and reported
pain.
Pain Response:
6/10
Pt. reported pain midway
through session, took
break and pain
medication was
administered by nurses
60
Pt. matched 10
memory cards in 20
minutes while
completing shoulder
flexion/extension,
shoulder ab/add,
horiz ab/add
continuously. Pt.
required break at the
end of matching
session. Pt.
completed
therapeutic craft that
required UE strength
sternum.
6/10
Pt. reported pain
midway through
session, took break
and pain medication
was administered by
nurses, applied ice to
area.
BS
6/10
Pt. received medicine
at beginning of
treatment, took break
midway through and
applied ice.
5/10
Pt. received medicine
at beginning of
treatment, took break
midway through. Pt.
stated she did not
want ice.
4/10
Pt. received medicine at
beginning of treatment,
took short break at end of
Tx. Pt. stated she did not
want ice
BS
BS
Clinicians Initials
BS
BS
Clinicians Signature:
Bailly Sager OTAS 4-3-2015
Document Billing/Charges:
Patients Name: Rhonda Start Date: 4/6/2015
Frequency: OT: 60 min/day PT: 50 min/day ST: _______
Concurrent Therapy: C Group Therapy: G
Rug Level: N/A
Physical Therapy
Modality
10
50
50
50
50
50
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Provider
Occupational Therapy
Modality
60
Th Ex
Th Act
Neuro
60
30
30
Provider
60
30
30
60
120
180
240
300
BS
BS
BS
BS
BS
Speech
Modality
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
110
220
330
440
550
Provider
Daily Total
Assessment
Period Total
Write a SOAP Note Based off the 1 week of treatment documented above.
SOAP Note:
S: Rhonda reported a 6/10 pain rating at the beginning of the week and stated a pain level of 4/10 on Friday afternoon. Pt stated she is worried about her two animals at home and
wishes she could be at home with them.
O: Rhonda increased the number of squats from 20 to 30 in five days. Pt. completed flexion/extension, shoulder ab/add, horiz ab/add continuously while participating in memory
game. Patient was able to increase her card matches from 10 to 20 in 2 days time. Patient fatigued in each of her sessions and required breaks throughout. Pt. reported pain level to
be at a 6 on Monday and was reduced to a 4 by Friday. Patient required pain medication midway through first two sessions and received pain medication before her sessions for
the rest of the week. Ice was applied for the first three days and patient refused Thursday and Friday. Rhonda completed therapeutic craft activity for her dog. Pt. decreased
assistance in squat exercise in five days time.
A: Rhonda shows improvement in squats as evidenced by increasing the number by 10 in five days. She shows increase in balance and endurance after completing UE and LE
exercises. Pt. was able to decrease her pain level through medication, ice and taking breaks when needed. Pt. is actively participating in all therapy sessions and has made it known
that she wants to be home as soon as possible. Pt. currently is not able to be discharged as evidenced by decreased endurance and easily fatigued.
P: It is recommended that Rhonda continue with skilled occupational therapy services for 60 minutes a day to continue working on increasing UE muscle strength, LE endurance
energy conservation, decreasing fatigue, increasing independence in all transfers and functional ambulation in order to be independent at discharge.
Bailly Sager OTAS 4-3-15
Document when you would recommend Discharge to the OTR/L and the process you need to follow:
Discharge would be recommended when Rhonda reaches her goals of SBA with sit to stands, ambulating without a walker, and increasing overall endurance to return to her job. It
is recommended that Rhonda complete a home evaluation before discharge as well to see if changes need to be made. This will be achieved through occupational therapy services
60 minutes daily for the next 2 weeks.
Write a Discharge Summary
Discharge Summary:
1. Client information:
a. Name: Rhonda
b. Age: 63
c. Gender: Female
d. Diagnosis: CABG
e. Precautions: diagnosis of congestive heart failure, diabetes, Schizophrenia
f. Contraindications: medication for Schizophrenia and pain medication
2. Summary of intervention process:
a. Date of initial service: 4-6-2015
b. Final service: 4-17-2015
c. Frequency/ number of sessions: 60 minutes a day
Summary of intervention process: Rhonda completed occupational therapy services for two weeks with COTA and OTR staff. Their approach was meant to increase her
endurance and educate on energy conservation. Rhonda consulted with her therapists after a home evaluation was completed and it was recommended that she have a
caretaker to check in on her weekly. Rhonda got into contact with her sister as she did not want to hire a stranger to come into her home. She has decided to move in with
her sister who can continue to increase her endurance and manage her medications. Rhonda is sad to leave her job but stated she is in the process of finding a new one that
does not require so much physical demands. Rhonda completed therapeutic craft activities that involved her leisure activities and her pets. She was very happy and eager to
complete these activities to return home. She completed UE ROM endurance activities through memory games as she continues to have trouble with recalling recent events.
Rhonda reports occasional pain in her sternum, but applies ice or heat to reduce.
Recommendations: It is recommended that Rhonda be discharged from skilled occupational therapy services after reaching all of her set goals and completing a home
evaluation to accommodate her needs. After consulting with a social worker and OTR/L and COTA, Rhonda has decided to move to be closer to her sister who has a two
story home with a bathroom and bedroom on the first floor for Rhonda. Rhonda is happy with decision as she gets to bring her animals with her.
Rhonda was give information on resources in her new town and support groups online and information on job opportunities. Rhondas sister was also given information on
support groups in order to better prepare herself. Rhonda was give information on how to contact the occupational therapy department with any further questions and
concerns.

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3.

NORTHLAND COMMUNITY AND TECHNICAL COLLEGE

Pertinent information in treatment of

Transitional care unit

60 minutes daily for two weeks.

Work IADLs Sleep Education Play ADLs Leisure Social participation

Area of Occupation Affected

Poor endurance in all functional activities

2nd floor walk-up apartment

ADLs, IADLs, Work, Leisure

Pick the Top 3 Physical Health Based Problems

Create a Short Term Goal to Address the Problem:

Create a Long Term Goal to Address the Problem

Poor endurance in all functional activities

Type of Intervention: Preparatory, Purposeful, or Occupation Based

-Rhonda will complete giant memory game on the wall.

Purpose for Selected Treatment/Specific

Create a Short Term Goal to Address the Problem:

Create a Long Term Goal to Address the Problem

Sit to stand w/ MOA

Rhonda will stand up from a chair with MIA in two

Type of Intervention: Preparatory, Purposeful, or Occupation Based

-Rhonda will make a simple recipe

Purpose for Selected Treatment/Specific

Problem #3 (Skills/Areas that need Addressed: Use

Create a Short Term Goal to Address the Problem:

Create a Long Term Goal to Address the Problem

MIA ambulating w/ rolling walker due to LE weakness

Rhonda will use rolling walker with SBA while

Type of Intervention: Preparatory, Purposeful, or Occupation Based

-Rhonda will make a walking schedule.

Purpose for Selected Treatment/Specific

Playing small version of basketball to reach

Weekly Treatment Documentation: Document as if you completed 5 days of treatment.

Precautions: Oxygen levels, diagnosis of CHF, diabetes-sugar levels, and

Treatment Diagnosis: CABG

Total Visit Time

Ther. Act 30/2

Ther. Act 30/2

Total Times Codes

Bailly Sager OTAS 4-3-2015

Rug Level: N/A

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