Student

Name: Kyle Johnson Case: Wendy Date: 04-03-2019

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Dx: CHF, COPD, Type II diabetes, pneumonia, OA, gout,
Referral: from the community hospital, physician
Setting: SLC transitional Care Unit
Reimbursement: Medicaid
LOS: 3 weeks

2. Pragmatic Factors to Consider

Smoking habits
Hospital Team and Transitional Rehab Team- PT, Social Worker, Nurses, Physicians, nutritionist
Is on oxygen/low oxygen
1-2 days post hospital stay for pneumonia
Has had several shorts stays at hospital for declining health
3 years post TKA
73-year-old female
5’5” and 273 lbs- overweight
Has 2 dogs, 3 cats
Grandson that sometimes lives with her but he also has substance abuse problems
Lives in a very rural area Emory
Lives alone most of the time
Lives in a single wide trailer (small size, bathroom, kitchen etc)
Economic status
Medications she is taking for all her dx
Level of pain/flare ups
Retired rancher
Medicaid requirements/reimbursement for rehabilitation and LOS
Decreased vision
Tingling in toes and fingertips
Physicians instructions/predictions with LOS
LOS 3 weeks
Transitional Rehab facility/policies
Other precautions for all her diagnosis
-shortness of breath/ fatigue
-overall decreased strength
-boot size-gout

3. Context: Occupational Profile & Current Occupations

Cultural:

Physical:

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Social:

Personal:

Temporal:

Virtual:

Prior Occupations:

Current Occupations:

4: Top Three Client/Family Goals and Priorities

1.

2.

3.

5. Diagnosis and Expected 6. Scientific Reasoning & Evidence

Course List the barriers to performance typical of this diagnosis:

Pneumonia-
-chest pain, confusion or
changes in mental awareness
(MAYO clinic), cough with
phlegm, fatigue, fever, sweating,
shaking chills, nausea, vomiting
shortness of breath
-continued treatment- rest,
medications, avoiding smoking
-can take a month or more to
heal
Pneumonia-
-chest pain and discomfort- impact ability to engage and
motivation to participate
-confusion in mental awareness- can have limits, behaviors
difficulties that prevent or impact therapy
-fatigue/ shortness of breath- limits activity tolerance will need to
get a lot of rest
-certain types limit ability to move pt to other locations treatment
may need to be in room.
CHF

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CHF- heart has difficulty
pumping blood as well as it
should.
Shortness of breath
Fatigue
Swelling in legs, ankles and feet
Rapid or irregular heart beat
Reduced ability to exercise
Persistent cough or wheezing
Swelling of abdomen
Increased need to urinate
Rapid weight gain
Lack of appetite and nausea
Difficulty concentrating
-chest pain
COPD- inflammation of the
lining of the bronchial tubes
Makes it hard to breath
Fatigue/ lack of energy
Respiratory infections
Shortness of breath
Blueness of lips
Chest tightness
Coughing and Wheezing with
Mucus production
Medication to open airways,
reduce inflammation, long term
antibiotics
Increases risk of heart disease,
lung cancer
Frequent respiratory infections
Swelling in ankles, feet or legs
4 stages of progression-
increased coughing, shortness of
breath, more flare ups, can
become deadly
Develop depression and limit
activity levels
Can have sleep apnea
Type II Diabetes
-increased thirst
-blood sugar level changes
-if blood sugar levels are off can
lead to fatigue, confusion,
strange behaviors
-frequent urination
-Increased hunger
-Fatigue and shortness of breath will limit level of exertion and
engagement in activities
-Swelling in legs can impact ambulation and movement patterns of
legs or slow movement
-Need to urinate impacts time commitment in needing to be close
to bathroom and need to go often.
-Low energy levels with lack of appetite- prevents full engagement
for longer periods of time in therapy
-Medication- impacts time and management of medications to
reduce or treat symptoms
COPD
https://medlineplus.gov/copd.html
https://www.nhlbi.nih.gov/health-topics/copd
https://www.mayoclinic.org/diseases-conditions/copd/symptoms-
causes/syc-20353679
-Some problems and barriers that will impact are similar to CHF:
swelling in legs, low energy, medications, fatigue and shortness of
breath- all of the symptoms will impact level of engagement
-Medications- need to manage and when to take medications in
optimal way so as to have more activity.
-Medical Equipment- depending on the stage, oxygen tanks and
management of equipment are necessary
-Shortness of breath can impact eating and eating may take a lot
longer to complete.
-may not sleep well and have low levels of energy
TYPE II Diabetes
http://www.diabetes.org/diabetes-basics/type-2/
https://www.mayoclinic.org/diseases-conditions/type-2-
diabetes/symptoms-causes/syc-20351193
-Medication management- takes up time and planning to stay on
track with medications
-Equipment- sometimes have a insulin pumps attached or
continued need to draw and test blood.
-Blood sugar levels high and low impact activity engagement and
are important to monitor, can lead to fatigue, disorientation and
other impacting factors that limit activities
-Fatigue- limits level of activity engagement
-Slow healing and sores/ skin conditions- impact what to focus on
with treatment prevent mobility depending on site of sores
-frequent need to use the bathroom- need to be close to restrooms
or have strategies in place this will limit activities that are outside
those parameters
Osteoarthritis
https://www.mayoclinic.org/diseases-
conditions/osteoarthritis/symptoms-causes/syc-20351925
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-Unintended weight loss
-fatigue
-blurred vision
-Slow healing sores
-Frequent infections
Can lead to other health
concerns- heart and blood
vessel, nerve damage, kidney
damage, eye damage, slow
healing, hearing impairment,
skin conditions, sleep apnea,
increase risk of Alzheimer’s
(MAYO clinic)
Osteoarthritis
-can damage any joint in body
-commonly impacts hands,
knees, hips, and spine
-Symptoms include: pain,
tenderness, stiffness, loss of
flexibility, grating sensation,
bone spurs
-degenerative disease that
worsens over time
-tissue that cushion joints begins
to break down and wear away.
Gout
-painful form of arthritis
-uric acid builds up
-swelling, redness and
tenderness in joints
-sudden attacks can occur
-intense joint pain
-lingering discomfort
-inflammation and redness
-limited ROM
-the rate crystals may collect in
kidneys and cause kidney stones
-medications preventing pain
attacks, reduce imflammation
-left untreated can cause
destruction of joint
7. Practice Models Guiding Assessment and
Treatment
1 PEO
. person (P), the environment (E) and the occupation
https://www.arthritis.org/about-arthritis/types/osteoarthritis/
- Pain, stiffness in joints will limit mobility and prevent
optimal use of joints. This can limit person in wide range
of movement and occupational performance
- Can continue to progress and lessen mobility
- Stiffness in morning can limit morning routines
- Inactivity or overuse can increase pain and discomfort
limiting activity engagement
- Side effects of medication
- Can lead to sedentary lifestyle and weight gain
- Increases risk of falls
- Flare ups of pain- limit movement
- Constant need to have blood tested/drawn
- Depending on method of blood draw/test equipment,
sore area
- medications and pain management -side effects can include
dizziness and lack of balance
- Side effects can include muscle weakness, impaired balance,
decreased functional use- prevents optimal activity levels
Gout
https://www.mayoclinic.org/diseases-conditions/gout/symptoms-
causes/syc-20372897
-medications and pain management -side effects can impact
activity similar to OA
-may impact mobility and ambulation because of joint stiffness
and pain
-pain and discomfort- limit AROM and use of limb/joint as needed
in activities
-lead to sedentary lifestyle and weight gain- lead to low desire to
move—which can lead to depression and mental health concerns
(OA too)
-Increases risk of falls- fear of doing activities
-Flare ups of pain- limit movement
Rationale
Through this model we look at how to make the
(O) more congruent. Changes can be made at any or
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 all of these areas to help improve occupational
performance and client satisfaction. Changes to the
client may include changes to how she interacts and
navigates her body with OA and what can be done to
lower her pain. Additionally, the environment can be
adapted to facilitate more success through adapting
trailer with hand rails, or changes to the foods and
things she eats to help improve her diabetes and
overall health so as to participate in activities like
ranching. This would also include making changes
to the occupation like adapting the time it takes to
get dressed or the steps to completing the task may
need adaption to be more successful and congruent
with the ability of the client considering her
symptoms, characteristics of her home her energy
levels, and what she wants to accomplish.
2 MOHO Through the use of the MOHO we can better
. approach some of the motives, patterns of
performance, and capacities that the client has in
regards to having better overall health. By using
her volition and helping her to desire to do
things she can be helped to set goals towards the
experiences and activities she really wants to do.
We can look at her personal causation, her
values, and interests and see what drives her or
may help her to want to improve her health and
well-being so as to improve occupational
performance and engagement in healthy life
choices.
3 Rehabilitation It is necessary to have some compensatory strategies
. in order to facilitate function in her trailer and
manage fatigue during occupational performance.
This is necessary because of the conditions she
presents with her impaired walking lack of energy,
vision concerns, and overall need for some
assistance with task. Compensatory methods and
adaptive equipment can help her to improve
performance which can help to improve mental
health, and over all outcomes. Through this model
she can use new strategies for approaching healthy
management of her diet and exercise that are
impacting her occupational performance.

8. Specific Areas of Occupation

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

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 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?

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 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

See how long she gives herself to prepare a
meal, what type of ingredients she likes to use,
her level of endurance, how she follows steps to
Cooking and preparing a simple meal (spaghetti cooking, see her mobility and handling of tools.
and steamed vegetables) Check levels of comfort with the tools how her
hands are, if she can stand through task or if she
needs adaptive measures like sitting and having
a cutting board or see what other compensatory
strategies she may need.
Method/Tool Rationale/What is being Assessed
1. Home Evaluation Look at safety of home see what she is able to
do in her home. Check if there are modifications
that can be made like handrails, moving
locations of dishes, cooking tools, etc so as to be
more functional given her deficits. Help to
ensure her continued safety and where
adaptations or changes to her environment can
be made so she can continue to be independent.
2. Mental Health questionnaire Seeing how she is with regards to her wellbeing
and how she feels about herself. See if there is
anything that may be impacting and influencing
her that may account for poor behaviors and
lifestyle choices that then are impacting negative
health. Give idea into levels of anxiety or
depression and overall well being.
3. Sleep questionnaire Asses how much rest she is getting and see how
it may be impacting her overall health (sleep
routine) and overall energy levels needed for
activities during the day.
4. PASS medicine management Use this to asses her ability to manage her own
medications. Can also asses her fine motor skills
and if she is having pain. Through this can
assess level of assistance she might have aspects
of possible cognition deficits during the task.
5. bilateral AROM/PROM - can use in conjunction with pain scale but also
see how much range she has versus able to do.
Gives an idea of what mobility she has and what
level of engagement she is capable of given her
limits especially depends on OA and gout
progression or stages.

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6. 10-point pain scale - Asses her pain levels in connection to her OA
and gout and how pain may be interfering with
comfort in doing things. Done both pre and post
activities/treatments as well as a tool for her to
use during activity level to help determine any
modalities that might be used.

15. CPT Evaluation Code: Justification

moderate complexity -She has a moderate level component for occupational profile and
97166 therapy history.
-has several performance deficits including sensation, mobility, poor
vision, unsteady gait.
-because of all her diagnosis there is more complexity to her and a need
to minimal to moderate modification of tasks through the use of
strategies and assisted devices.

16. Projected Outcomes: Type of Outcome

17. Resources and Team Members

Diabetes nutritionist
Her family- not mentioned but maybe her children/child Philip and his parents
Primary Care physician
Her dogs and cats
People she ranches with
Team at facility- PT, social worker, insurance administrator, aides, nurses, ST,
Addiction recovery/ smokers that quit group
Ranch friends and neighbors
Living with diabetes group
COPD support group

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Online support groups- lung.org, daily strength, etc
Podiatrist- foot doctor
Medicaid
United way services

18. Intervention Plan

Barriers Supports
Fatigue Her strong will to be independent
Shortness of breath Her dogs and cats
Unsteady gait Medicaid paying for care
Smoking habit Wants to go home
Small confines of her home Team at the facility- PT, ST, social
Rural nature of her home worker, administrators, aids, nurses,
Diabetes- regulation of blood sugars- equipment with that, doctors,
having blood drawn all of the time Community hospital staff-nurses,
Lives alone doctors, other team members there
Pain levels Phillip
Flare ups of gout
Pain in joints with OA
Any loss of ROM with OA/gout
Lack of insight/awareness of her situation, deficits
Continued decline of health over past few years (prolonged
poor health habits)
Lower economic status
Low strength
Goals Practice Model for each goal
1. LTG: By d/c client will use energy conservation strategies PEO, Rehab
to prevent fatigue while independently cooking a simple 3 step
meal.

1a.STG: Within 2 weeks client will use adaptive equipment to PEO, Rehab
independently cut vegetables for a meal while seated.

1b.STG: Within 2 weeks client will use compensatory PEO, Rehab

strategies to manage pain when preparing a meal with 3 or
less on 10-point scale per client report.

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2. LTG: By d/c client will use compensatory strategies to PEO, Rehab
independently dress lower body in preferred clothing while
seated.

2a. STG: Within 1-week client will use adaptive equipment to PEO, Rehab
independently don and doff preferred boots while seated.

2b. STG: Within 2 weeks client will use compensatory PEO, Rehab
strategies to independently tie her boots while seated.

3. LTG: By d/c client will use adaptive equipment to complete PEO, Rehab
showering routine while seated.

3a.STG: Within 2 weeks client will use adaptive equipment to PEO, Rehab
independently wash lower body while seated in shower

3b. STG: Within 2 weeks client will use adaptive equipment to PEO, Rehab
transfer out of shower with STA.

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19. Treatment Sessions: Plan for first two 45-minute treatment sessions:
1. What will you do? Donning and doffing Identify Approaches Based on which
shoes/boots goal(s)? 2a, 2b
Preparatory task- Modality- if the osteoarthritis is
in her hands) Use PAMs for 15-20 minutes Establish/Restore
-warm water sock method-pp117 of PAMS Modify
book by Alfred Braccianno
-water is at 99-110 degrees.
-socks for each hand or as needed
-2 tubs with water enough to fully submerge
hands and fingers for 15-20 minutes
-Instruct client flex and extend fingers
during process. Have client reach into water
and grab and squeeze different items.
Squeeze and hold items for a few seconds
each time.
-Educate and instruct client in use of this
method at home to relieve pain, maintain
hand and finger mobility and prevent further
weakening of fingers in preparatory for
occupations that require more movement of
the hands and to address and limit pain
during occupational performance of task.

Putting on shoes and tying laces

Through this process we will figure out what areas
of arthritis are concerning, joint mobility and where
movements for tie shoes is being limited. Though
this process we can begin to problem solve specific
areas in the process that are impacting her success
with tying shoes. If it is only pain the modalities
may be enough. If it is more or there are other areas
like balance, core strength, flexibility etc. other
approaches and methods will need to be used for
those areas of concern including the use of adaptive
equipment.
-Use client’s own boots or shoes depending on need
to grade up or down
-Have client EOB

Model/educate method of lifting leg with pants

onto opposite thigh while seated or have client
attempts this. Can use a leg lifter or have client
reach down and pull pant leg until foot is to level of
other knee and place foot on opposite bent knee.
-show how to tie from the side of the shoe/boot
while foot is on opposite knee.
- after modeling task have client perform the task.

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- perform task on both legs

Adaptive equipment- educate client on use of shoe

horn and if necessary use of grabber to help
facilitate positioning of shoe and foot in the
process.

Education on joint protection- Provide client with

OASIS Hand Osteoarthritis Protecting your hands
handout

2. What will you do? Shower routine Identify Approaches Based on which
goal(s)?
Preparatory task- 10-15 warm sock treatment establish/ Restore
modify 3a, 3b
1- Preview session and educate client on safe
practice using shower chair, hand rails, and
grabber, long sponge and showering
equipment, towels, washcloth during
shower

2- Educate client on energy conservation

strategies while showering and preparing to
shower. Share ideas on gathering and
placing clothing, towels, soaps, shampoos,
grooming and self-care products and
placement in bathroom that would provide
improved location and reduced energy
output in relation to shower. Provide
checklist as needed.

3- Assist client in set up of shower chair and

placement of products and towels with
reach after showering

4- Have client don and doff clothing SBA and

min-mod assist as needed depending on
functional level

5- Provide adequate level of assist to allow

client to transfer onto shower chair using
handrails. Instruct client on good placement
of shower chair in order to reach all care
products, shower controls, and shower head
while seated. Instruct her on feet placement

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 and movement of body through transfer to
chair. Provide assist as needed SBA to min
assist to transfer.

6- Provide guidance in balance and weight

shifting and help client transfer to shower
chair. Make sure client is close enough to
control shower, temperature is ok and that
she is safely seated. Close curtain to provide
privacy but be close by and within reach of
assisting client after seated in chair.

7- Assist client in self-care during shower.

Provide help as needed but allow client to
be independent. Problem solve through
difficult tasks during shower and bathing.
Use grabber and wash cloth and invite client
to participate as much of the self-care and
shower as possible.

8- Assist client in drying lower extremity use

grabber to educate use with towel to dry off
before transferring. Remind client of safety
to have dry surfaces before stepping onto
tile. Use grab bars and AE to assist in
drying and transferring.

9- Have chair in bath area with towel on seat

prepared. Educate client on idea to have
chair nearby to sit and rest after shower.
Problem solve with client regarding her
space in her trailer and what she could use.
Have her sit and dress in pants, shirt, etc.
Assist as needed. Provide education
throughout and based on clients insight,
experience and ability.

Provide handout of energy conservation strategies

- Putting more common and regularly used
items in easy to reach areas
- Categorizing items into areas where they
can be used after one another.
- Etc. Hand out from Jennette’s class
synthesized

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