Anda di halaman 1dari 12

OCCUPATIONAL THERAPY EVALUATION REPORT AND INITIAL INTERVENTION PLAN

BACKGROUND INFORMATION

Client’s name: XX impact sports as to not cause a second


Date of report: 2/1/2018 brain injury
Age: 44 y/o Current Medications: Zoloft and Ritalin
Primary Intervention Diagnosis: Traumatic Reason for Referral to Occupational
Brain Injury (TBI) from mountain biking Therapy: The client was referred to
accident resulting in short-term memory occupational therapy because he continues
loss to have problems completing his daily
Secondary Diagnosis: Attention Deficit occupations due to his short-term memory
Hyperactivity Disorder (ADHD) and dyslexia loss
Precautions/Contraindications: Doctors Therapist: Ashley Thayn, SOT &
have advised the client to avoiding high Tambra Rasmussen, SOT

S: “I felt tricked last time when you asked what we all did last weekend, I thought about it all

week and even told my fiancé about it.”

O: Occupational Profile:

The client was evaluated on 1/25/2018 and 2/1/2018 at the University of Utah

outpatient setting. The assessments performed were an informal interview, the Canadian

Occupational Performance Measure (COPM), an informal observation of occupational

performance, and a topographical test.

The client is a 44-year-old male who suffered a traumatic brain injury (TBI) four years

ago from a downhill mountain bike racing accident which has affected his short-term memory.

The client is seeking services because his short-term memory impairment is continuing to affect

his daily occupations with his job performance when he is required to memorize sales scripts, in

social interactions when trying to recall names and conversations, forgetting where he placed

1
his car keys and parked his car, when performing grooming tasks such as shaving only half of his

face, and burning food when he forgets that he was cooking dinner for his family.

His memory loss has also negatively affected his interpersonal relationships and career

resulting in a divorce, bankruptcy, job loss, and loss of friends. To just get by in his day-to-day

life, he remarked how people don’t realize how bad his memory is and how he often “fakes it”

to get through work and social situations.

Prior to his accident, he was a chef at Whole Foods who would frequently appear on

Channel 2 for cooking demos. He was an avid adventurist in outdoor sports and recreation,

particularly snowboarding and mountain biking. However, since his injury, he acquired

decreased balance and is not confident in his ability to make quick decisions and adjustments

that mountain biking requires. He now chooses to avoid all high impact sports because he

cannot afford another brain injury. However, he does choose to road bike to work on occasion.

Currently, he resides in Sandy, Utah with his fiancé, their combined four daughters, two

roommates, plus his two Great Danes for emotional support. His typical day includes waking up

to get ready for the day, taking his daughters to school and going to work. He reported he

cannot tell us what he does for work because he can’t remember. For him to recall what he

does for work, it requires him to go into work to read his own notes he left for himself the

previous day that tell him what he needs to do that day.

The client has a good habit of taking notes at work to provide him with information

needed for the next day. He also takes notes digitally on his phone by entering in reminders and

alarms on his calendar for what he needs to accomplish each day. As a backup, his fiancé is also

included in all his iPhone calendar items, so she can also help remind him.

2
While at work, the client interacts with the computer system, internet, email, sticky

notes for personal reminders, and phone while he works in a cubicle. When he arrives for work,

he begins his day by going through emails and then proceeds to call the clients. He attends to

important information for the clients in order to complete sales. He will initiate phone calls to

the clients, and has social interaction skills of approaching, speaking fluently, regulates self, and

concludes in a socially appropriate manner. When giving PowerPoint presentations, he gets

thrown off track when an audience member asks a question. After answering the question, he

cannot remember where he left off. Although he reported that he performs in the top four of

his sales team, he is frustrated that he continually gets passed over for promotions by his

younger coworkers who are right out of college.

Following completing his work day, he picks up their daughters from school, then cooks

dinner with/without his fiancé. Finally, his evening routine includes picking out his clothes for

the next day and watching some shows before retiring to bed.

On the weekends, he enjoys attending parties with his fiancé; however, he reports he

cannot recall people he already met and their meaningful topics of conversation. His fiancé will

step in to explain he has a brain injury. He confided that it is embarrassing to him to both forget

people and have to inform them of his brain injury. Other weekend activities he enjoys are

hiking, spending time with family, and going to the movies—even though he cannot remember

them. His inability to recall movies bothers him because he cannot socially participate in these

conversations at work.

Occupational therapy is relevant and important to the client because he needs to

optimally perform at work to maintain his job, earn money for his family, and meet his own

3
goals. He also wants to interact socially with coworkers, feel a part of the team, remember

names, faces, and topics of conversations. He also reported he desires to be able to function as

normally as possible in his life and not have to rely on faking anything. At work, he is fearful

about being perceived as incompetent. As a result, he is very private about his injury and he

does not want to tell human resources despite that his TBI affects his job performance.

OCCUPATIONAL ANALYSIS:

The client was evaluated at the University of Utah using both standardized and non-

standardized evaluation methods including an informal interview, the Canadian Occupational

Performance Measure (COPM), observation of occupational performance, and a topographical

activity.

Assessments Performed:

The informal interview given to the client addressed his typical day, allergies,

medications, home life, daily routines, personal goals and the Canadian Occupational

Performance Measure. Conclusions obtained from interviewing the client indicated his biggest

challenges are his visual and auditory short-term memory. These skill deficits are affecting his

ability to perform ADLs, complete work tasks, and social participation within his personal life.

The Canadian Occupational Performance Measure (COPM) is a semi-structured

interview that was used to address occupational performance problem areas in self-care,

productivity, and leisure. The top five occupational performance priorities were identified using

a rating system from 1 – 10 (least to most important). The results are listed below.

OCCUPATIONAL PERFORMANCE SATISFACTION


PERFORMANCE PRIORITIES (Scale of 1-10; 1=not (Scale of 1-10; 1=not
performing, satisfied, 10=highly
satisfied)

4
10=performing
independently)
1. Work: remembering the client and 5 3
account details
2. Driving: remembering where he 6 5
parked his car and put his car keys
3. Self-care routines: finishing 7 6
activities completely
4. Work Presentations: effectively 2 2
presenting information w/o getting
distracted
5. Cooking: safely and w/o forgetting 6 7
and burning food
TOTAL 26/5=5.2 23/5=4.6

For the observation of occupational performance, the client participated in a simple

cooking task of making stove-top fudge. We observed him to learn where he may have

difficulties in various steps of completing the task, and difficulties in following directions,

staying on task, and how he handles distractions. We visually placed two ingredients in odd

places to determine if he could remember their location when the recipe required those exact

ingredients. Prior to beginning the cooking task, we asked how he thought he would perform,

he stated he thought he would do fine. During the cooking task, we implemented intended

distractions to see if and how he stayed on task. The cooking task proved was too simple for

him based on his former background as a chef. However, he did require 1 direct verbal cue to

return to the task. He also took 30 min to complete a 20 min recipe because he would stop

what he was doing to talk to us. When the two oddly placed ingredients came up in the recipe,

he was immediately able to find them. We inquired what strategy he used to recall where we

had placed them, he responded that he repeated in his mind, “microwave – pillow, microwave

– pillow”. He completed the cooking task and the recipe turned out perfectly.

5
Finally, the client participated in a topographical activity throughout the building. This

task was chosen because he wants to improve remembering where he parks his car and puts his

car keys. In the task, we walked him through each floor of the building from the bottom to the

top with the client knowing his job was to get back to where we originally started. When at the

top floor, the therapist asked the client how he would get back down to his car, he reported

that normally he would just “walk out the front door and around the building till he found his

car rather than try to backtrack through the building.” The therapist provided 1 direct verbal

cue to start back down the stairs we had just come up. The client pointed out two landmarks he

recognized and did not make a single wrong turn. This task could have been too simple, or he

could have just guessed correctly. An additional challenge we added was when we asked if he

recalled our names; he replied he did not. We then graded this down and asked if he could

remember our faces. He hesitated and then stated he didn’t recognize us yet and added, “I

would not recognize you if out in public unless you told me who you were, that is another

problem I have.”

A: INTERPRETATION:

The client is very high functioning despite his TBI. He is also friendly and engaged in the

therapy process. He has already implemented effective compensatory strategies using his

iPhone calendar and alarm system to remind him of important tasks throughout the day. He

was able to cook well and utilized an alarm to make sure he performed each task with exact

instructions. He is able to perform well when focused on a task.

To mentally perform his job, he requires higher-level cognitive functions to excel

including attention, memory, perception, thought, and consciousness. He demonstrates

6
problems with attending as evidenced from the cooking task. Although he was able to recall

where the ingredients were placed, it was likely due to the simplicity of scenario. At his first

interview he was unable to recall information given at the beginning of the session when asked

again for it at the end of the session. When scenarios become more complex, he displays

limitations with recall. Areas of need for intervention are needed to implement further improve

cognitive strategies for attention and memory to improve his occupational performance.

Supports and Hindrances to Occupational Performance:

Current supports to the client is his fiancé, daughters, two Great Danes, and boss that

works with his memory impairment limitations. Current hindrances to his occupational

performance is his lack of visual and auditory short-term memory and limited attention span.

Also, he does not have insurance, is limited financially, and cannot afford professional services.

While his memory has improved from 20 minutes to 10 hours, it is highly unlikely his memory

will improve with occupational therapy services within 6 more sessions.

Prioritization of Need Areas:

The client’s top areas of need center around improving his strategies to strengthen his

attention and memory ability within the context of work, socializing with coworkers, cooking at

home, completing self-care tasks, and navigating within the community. Priorities derived from

the COPM are to improve in work performance and remembering where he parks his car and

places his car keys.

P: Recommended Intervention Methods and Approaches & Evidence for Treatment:

Organizing Model:

7
The Person Environment Occupation (PEO) model will be implemented to help increase

the client’s satisfaction by improving the congruence of his occupational performance between

himself, his occupations, and his environments to provide support with visual cues and increase

success in occupations most meaningful to him.

Postulates important to our intervention include focusing on his “perceptions and

beliefs about [his] environment and occupations [that] influence subsequent occupational

performance; it is important to understand a person’s priorities and perspectives (Law, Cooper,

Strong, Stewart, Rigby, & Letts, 1996).” This postulate is valuable because the client has verbally

expressed a belief that he cannot do certain things and that “those days are past”. Because we

know how he perceives his abilities, we can provide education with applicable strategies to

strengthen his environment by providing important visual supports within his environment and

regimens to cue him to use his current amount of memory that will improve his occupational

performance.

The second postulate applicable to our client is “the environment is dynamic and can

have an enabling or constraining effect on occupational performance (Law et al., 1996).” This

postulate is valued because addressing needed environmental changes can help to support our

client without expecting internal change of the client. Furthermore, we realize that attempting

to change the person will take more take time and may prove unsuccessful give our time period

that is makes the most sense to set the client up for success with as many environmental and

adaptation strategies as possible to improve successful engagement in his meaningful

occupations.

Complementary Model:

8
The Dynamic Interaction Model (DIM) focuses on internal and external factors of those

with cognitive dysfunction that possess the potential to improve by changing the demands of

the activity, the environment, and application of strategies. This model addresses dynamic

interactions between the person, activity, and the environment. Important postulates we will

center our intervention on are “change can occur as cues, various teaching strategies, and a

reduction of demands are used by the occupational therapist (Toglia, 2011).” This approach

stresses the importance for us as his occupational therapists to provide the best strategies to

create a just right challenge to help him gain additional skills and confidence despite his

impairments. Another important postulate is “performance is improved by changing the

demands of the activity, the environment, application of strategies, and self-awareness (Toglia,

2011).” As we work to find ways to make adaptations to his environment and improve his

environmental and cognitive strategies, this will help to make the client be more successful in

his everyday occupational demands.

Evidence for Treatment:

Doig, Kuipers, Prescott, Cornwell & Fleming (2014) examined how goal planning and the

development of self-awareness affected people that exhibited impaired self-awareness post

traumatic brain injury. Researchers found that engaging a client’s participation in occupation-

based and goal-directed rehabilitation activities appeared to foster increased personal growth

and improved self-awareness related to their injury. Although he does not have problems with

self-awareness, we can utilize goal planning and the principles of self-awareness to educate our

client on deciphering what visual or cognitive strategies he can implement in difficult areas of

his occupational performance.

9
Considering this research outcome, we aimed to create two tasks our client reported

difficulty with, burning food and forgetting where he parked his car and placed his car keys. The

intervention included similar challenges to see how self-aware the client was and what

strategies he implemented to be successful or not in the tasks. First, we created a cooking task

where two ingredients were oddly placed within the client’s view to test his memory when he

got to those ingredients of the recipe. He successfully completed the task, and remarked that

during the cooking task, he continually repeated in his mind, “microwave, pillow, microwave,

pillow” to remember where we oddly placed ingredients were.

Based on the client’s results from his standardized and non-standardized assessments

and concerns expressed by the client, including the observation obtained during the cooking

task and topographical activity, intervention goals will focus on improving attention and

memory strategies to work tasks, social situations, cooking tasks, and ADLs participation

Expected Frequency & Duration of Treatment: It is recommended that the client receive skilled

occupational therapy services for 1 hour a day, 1x per week for 6 total sessions.

Location of Intervention: The University of Utah--520 Wakara Way, Salt Lake City, UT

Anticipation D/C Environment: The client is currently living at home and will be discharged to

home.

GOALS

LTG #1: Within six sessions, the client will independently perform work tasks utilizing memory

strategies to recall the client information.

STG 2: Within four sessions, the client will independently utilize memory strategies during social

interactions to remember names.

10
STG 1: Within two sessions, the client will utilize memory strategies with minimal verbal cues

when recalling daily participation.

LTG #2: Within six sessions, the client will utilize process skills with adaptive strategies to

complete everyday tasks (such as cooking, completing ADL’s, answering email etc.)

STG 2: In four sessions, the client will utilize strategies with minimum verbal cues to sustain

attention to everyday tasks (such as answering email at work, cooking, cleaning etc.)

STG 1: In two sessions, the client will verbalize when the pace of an activity such as cooking is

ineffective and implement strategies to improve pacing with moderate verbal cues. Goal

discontinued.

New goal STG 1: In two sessions, the client will attend to therapy tasks when distractions are

present with minimal verbal cues.

Next Session: 2/8/2019

Therapist Name: Ashley Thayn, SOT

Therapist Signature: ________________

Date: 2/1/2018

11
References

Doig, E., Kuipers, P., Prescott, S., Cornwell, P., & Flaming, J. (2014). Development of self-

awareness after severe traumatic brain injury through participation in occupation-based

rehabilitation: mixed-methods analysis of a case series. American Journal of

Occupational Therapy, 68, 578-588. doi: 10.5014/ajot.2014.010785

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The person-

environment-occupation model: a transactive approach to occupational performance.

Canadian Journal of Occupational Therapy, 63, 9-23.

Toglia, Joan (2011). The dynamical interactional model of cognition in cognitive rehabilitation.

In N. Katz (Ed.), Cognition, occupation, and participation across the lifespan:

neuroscience, neurorehabilitation, and models of intervention in occupational therapy

(pp. 161-195). AOTA Press.

12