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Name: Danielle Oberg

Case: Winston

Date: 4/21/2014

1. Diagnosis, Referral, Setting, Reimbursement, LOS

63-year-old male with medical history of: CHF, COPD, Type II diabetes, OA, gout, and TKA (x3
years prior). Being seen in a Salt Lake City Transitional Care Unit. He was admitted yesterday
following a brief stay at a community hospital for pneumonia. Physician predicts LOS to be 3 weeks.
Services are being funded by Medicaid.
5. Diagnosis and Expected Course

Pneumonia: Lung infection, chronic diseases

(such as COPD, heart disease and diabetes)
increase the likelihood of getting pneumonia.
Symptoms include: cough, fever, chest pain,
malaise, shortness of breath, etc. Treatment
usually includes antibiotics, respiratory therapy,
and oxygen therapy.
CHF: chronic condition, heart is unable to
effectively eject blood to the rest of the body,
fluid builds up in the lungs, liver, GI tract, and
extremities. Symptoms include: cough, fatigue,
shortness of breath, swollen feet and ankles,
weight gain, arrhythmia. etc. Treatment usually
consists of monitoring and self-care, medications
to treat symptoms, surgery. Gets worse over
time, can try to control symptoms and delay
COPD: chronic, symptoms worsen over time.
Symptoms include: cough (ongoing), shortness of
breath, wheezing, chest tightness, etc. There is
no cure, treatment involves relieving symptoms
and includes medications, oxygen therapy,
lifestyle changes, or surgery. Leading cause is
smoking and disease gets worse more rapidly if
smoking continues. May lead to other
complications such as arrhythmia, pneumonia,
heart failure, etc.
Type II Diabetes: chronic, most common form
of diabetes, characterized by high levels of
glucose in the blood d/t insulin resistance of the
cells. Early symptoms include: increased thirst
and urination, hunger, fatigue, blurred vision, etc.
Treatment goals are to lower blood glucose levels
and prevent further complications. Can usually
be managed by activity and nutrition. Skills to
learn are how to manage blood sugar, diet and

6. Scientific Reasoning & Evidence

List the barriers to performance typical of this
Decreased endurance to complete tasks
Sensory loss (neuropathy) makes it
difficult for fine motor tasks and gait.
Respiratory issues (SOB, wheezing,
cough) make it difficult to carry out
certain activities and for long periods of
Limit amount of active physical activity
that can be done
Sore and stiff joints decrease abilities to
perform physical demands during tasks
Decreased ability of heart limits types and
duration of activities
Decreased vision limits participation and
ability to perform tasks, read, drive, etc.

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Conditions class
Mayo clinic

Revised 1/7/13

weight control, regular physical activity, and

medications. Complications include: vision
problems, skin sores and infections, hypertension,
hypercholesterolemia, neuropathy, kidney
Osteoarthritis: chronic condition, involves joint
cartilage break down. Sore or stiff joints, stiffness
after resting, pain that is worse after activity or
end of the day. Pain may come and go, symptoms
differ for individuals. No cure, medication to
relieve pain, PT and OT, possibly surgery if bad
Gout: Type of arthritis, characterized by sudden
burning pain, stiffness, and swelling in a joint
(usually a big toe, but can occur in other joints).
Attacks can reoccur if not treated and can last
days to weeks. Caused by excessive uric acid in
the blood. Usually treat symptoms with
medication and try manage gout and levels of uric
acid in joints with medication and diet.
Total Knee Arthroplasty: Usually performed to
relieve pain and restore function in knees that
have been damaged by arthritis or injury. The
bone and cartilage are removed and replaced with
an artificial joint. Artificial knees can wear out
and are at higher risk with excessive weight.
7. Practice Models Guiding Assessment and
1. PEO

Outcome of the model is to obtain congruence
between person, occupation, and environment for
maximal performance. Allows for changes to be
made in the environment, with the individual, or
to the occupation. We would be able to make
changes to context or optimize his environments,
address his needs and to build the skills he needs
by providing him with supports and strategies for
performance (such as energy conservation), or
modify the task for him to be able to perform
better have maximum satisfaction in his
occupational performance and be able to function
more independently.

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2. Biomechanical

The model addresses underlying impairments

that limit performance in occupations. Restores
and improves activity performance. It focuses
on strength, endurance, and ROM. We would
utilize compensatory strategies and activity
adaptation to enable participation and to limit
pain and inflammation due to arthritis and gout.
We would want to provide adaptive equipment to
enable participation in daily occupations due to
strength and endurance deficits. We would
definitely want to focus on endurance and
strengthening to improve performance in tasks
and not exacerbate the COPD and CHF.


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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
Meal preparation/cooking

1. MMT

2. Stereognosis assessment

3. Activity Checklist


Rationale/How will you use this information

Cooking is a task that was identified by the client
on the COPM as one he is having difficulties
with. I believe this would be a good task to use
during evaluation because it will give me an idea
of which aspects of the task and his performance
he is having problems with. By having a cooking
task that involves multiple steps, it would allow
me to get an idea of his cognition as well as his
overall endurance. I would want to meal prep to
involve the client using utensils or manipulation
of ingredients (such as cutting) to evaluate fine
motor skills. The task would allow me to see if
vision impacts his performance, especially if he
needs to read directions or a recipe. I could use
information gathered from the performance to
guide practice and identify barriers to his
performance and make connections on how they
impact other tasks.
Rationale/What is being Assessed
I would want to get an idea of the clients current
strength in his bilateral UE. I could use my
findings to evaluate how strength is affecting his
occupational performance. I would be able to
identify where we need to work on strengthening.
This would be a simple assessment to look at
whether his symptoms or sensory loss affect his
ability to identify and manipulate objects in his
hands. We could use this assessment throughout
treatment as well to track progress.
This would allow me to get an idea of activities
the client is involved in or enjoys and try to
incorporate it more into treatment. I may be able
to identify areas to address that were no brought
up in the COPM.
This would let me see his current AROM and
where he is at functionally. Although no
problems are reported in the referral, because of
his arthritis I would want to see if he is limited in
his ROM due to pain and joint damage. I could
use PROM to assess if there is a difference with
ROM vs. the active movement without gravity
and with minimizing pain.

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5. Vision screen

6. Physical Performance Test

Because of reports of decreased vision and his

diagnosis, it is probable that vision may be
affecting his vision may be affecting his
occupational performance. I would want to
perform a basic vision screen to see if I could
identify what part of his vision is impaired and
how it is affecting his occupations. I would also
be able to make referrals as needed from
This is a basic and simple test that would let me
look at fine motor and gross motor movements
with walking so that I am able to see how he is
functioning. I would be able to evaluate how his
decreased endurance and sensation affect these
tasks of physical performance. I could use this to
guide practice and create goals.

17. Intervention Plan

Lives alone in small trailer
Motivated to return to living
Not many social supports

Services funded by Medicaid

Pets and grandson require care
Able to successfully live
Multiple diagnoses that affect performance
Continues to drink and smoke despite contraindications
Able to take care of animals
from diagnoses (i.e. CHF and COPD)
and grandson
Past of multiple hospitalizations over the past few years
Difficulty regulating blood sugars
Fatigues quickly
Continuing declining health
Progressive vision loss


Practice Model for each goal

1. LTG:
In 3 weeks, client will implement use of adaptive strategies
for decreased sensation and endurance to complete complex
meal preparation with modified independence.
In 2 weeks, client will use at least one energy conservation
strategy with minimal verbal cueing to complete simple meal

PEO, Biomechanical

PEO, biomechanical


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In 1 week, client will use adaptive strategies for safety and

decreased sensation to cut fruit independently and safely.

2. LTG:
In 3 weeks, client will use adaptive strategies and equipment
as needed to complete dressing, including donning coveralls.
In two weeks, client will independently zip up coveralls using
adaptive strategies and equipment as needed due to decreased
sensation and fine motor.
In one week, client will independently implement at least one
energy conservation strategy during dressing to keep fatigue
no higher than baseline.
3. LTG:
In three weeks, client will shower with modified independence
using adaptive strategies and equipment for fatigue and safety.

PEO, biomechanical

PEO, biomechanical

PEO, biomechanical

PEO, biomechanical

PEO, biomechanical

In two weeks, client will use adaptive equipment and strategies PEO, biomechanical
for safety with minimal cueing during shower due to decreased
strength, sensation and vision.
In one week, client will complete shower using at least one
energy conservation strategy with minimal cueing to maintain
fatigue no higher than baseline.

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PEO, biomechanical

Revised 1/7/13

18. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do?
Identify Approaches
The session will focus on working on client
completing meal preparation. The session will begin
with preparatory activities to work on strength and
endurance. Client will perform various repetitions
using free weights to strengthen UE and improve
endurance. Exercises can include bicep curls,
pronation supination, forward punches, etc. Client
will then be taken to kitchen to aide in meal
preparation. Client will be reminded of healthy
options and recommendations for meals and the
importance of learning to prepare meals keeping in
mind his diabetes. The client will be asked to
prepare whole wheat pasta and fruit salad. Client
and therapist will discuss and review energy
conservations strategies such as organization,
pacing, taking breaks, etc. Client will be asked to
implement strategies that work for him as needed
and to identify verbally to the therapist when he is
feeling fatigued. Client will boil water, add and
cook pasta. While patient is waiting for water to
boil and pasta to cook, client will cut various fruit to
make a small fruit salad. Client will drain pasta and
warm up sauce in the microwave. Client will
identify moments of fatigue and implement energy
conservation strategies throughout task as needed.
Client will use adaptive strategies during cutting to
compensate for decreased sensation and fine motor.
Therapist will provide cueing and physical assist as
needed. Adaptive equipment will be available as
needed. Following task, client and therapist will
discuss how things went and identify strengths and
areas of improvement. Therapist and client will
discuss strategies used and their effect during the
task. Client will be reminded about importance of a
diabetic conscious meal and maintaining portion size
that is appropriate. Client will be able to enjoy meal

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Based on which

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2. What will you do?

Identify Approaches

Client will be seen in morning to assist with shower.

Prior to shower, client and therapist will review
strategies for safety and energy conservation during
shower. Client will get into shower using grab bars
and strategies for safety. Client will use strategies
when checking water temperature for safety due to
decreased sensation. Client will shower using
shower chair. Client will have access to adaptive
equipment such as reacher and long handled sponge
and will use as needed. Therapist will provide
verbal cueing for reminders for safety and energy
conservation as needed. Therapist will provide
physical assist as needed to assist in washing and
safety. With completion of shower, client will use
strategies for safety when exiting the shower.
Following shower, client and therapist will discuss
how things went and the strategies used. Therapist
and client will identify areas to improve upon and
evaluate use of strategies and change as needed.
Client will assess performance and his satisfaction
with overall (including his level of fatigue).

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Based on which

Revised 1/7/13