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Running head: OCCUPATIONAL PROFILE & INTERVENTION PLAN 1

Occupational Profile & Intervention Plan


Brandon M. Roberson
Touro University Nevada













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Occupational Profile
Client
Robin Stark is a 36 year old female currently attending the Enable Program at
Opportunity Village (OV). Both of her parents tragically passed away a few years ago and ever
since then, Clark County Public Guardian has been her legal guardian. Robins mother was very
active in her treatment sessions before her sudden passing. Robin has a brother, who is not
allowed to visit her, unless strict protocols are followed. Robins brother was suspected of
killing her mother but there was not substantial evidence to convict him. He has a criminal
history and has inquired about taking the money the state allots his sister every month. Robin
was born with profound mental retardation as her charts labeled it, but that diagnosis has since
then has been relabeled as a severe intellectual disability. Robin also suffers from cerebral
atrophy, ataxia, seizures, pulmonary hypertension and an unknown genetic syndrome. The client
does not need pureed foods or thicket in liquids, but does need verbal cues to eat slower and to
drink with a straw due to swallowing precautions. Robin is allergic to the medications Thorazine
and Erythromycin, as well as bee stings, which possess a serious, potentially fatal problem, as
there are numerous flowering trees near the entrance to group home where she resides.
Reason for Services
Robin is seeking services, per recommendation from a developmental specialist, to
become more independent in her activities of daily living (ADLs), instrumental activities of daily
living (IADLs), and increase her social interaction/participation. The client has expressed, non-
verbally through determined trial and error, she would like to live an independent life. The staff
has noted this desire by witnessing Robin attempt to transfer independently, and constantly
engaging in ADLs such as preparing meals, and household chores such as laundry.
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Areas of Occupation
Robins areas of occupation which are successful would be rest and sleep, work, play,
leisure and social participation. Rest or sleep were never mentioned anywhere in her long and
detailed medical charts (and was not observed at OV), so by using clinical judgment and until
documented or observed otherwise, Robins rest and sleep do not appear to be causing any
additional problems or risks. Social participation could be classified as successful as well as a
potential risk. First, the mere fact that she enjoys being around others and going on outings
demonstrates how much of a social butterfly she really is. Another indicator is one of the eight
documented words she uses on a regular basis is in fact, outing. These acts, along with the fact
she smiles, waves and says, Hi to essentially everyone who walks into the same room as her,
help to illustrate how her social participation is successful. While at OV Robin participates in
office activities (work), by placing letters in envelopes. Although she was unable to successful
seal the envelopes, if this were her actual job (like working on an assembly line), she would be
able to perform the duties, just at a slower pace. Play and leisure can be discussed together for
this purpose in that she can participate in both but may struggle if she needed to select and or
identify appropriate play or leisure activities.
The clients areas of occupations which cause problems or risk would include the
remainder of said occupations, being: ADLs, IADLs, education, and as discussed earlier,
possibly social participation, play, and leisure to a certain degree. Robin is dependent with her
ADLs, but when she tries to complete them on her own without supervision; it can create a very
large problem, not only for her but those around her. She has been known to attempt transfers
and perform certain ADLs independently resulting in her falling and injuring herself. As for her
IADLs she loves to participate in meal preparation and cleanup and performs them adequately,
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but these only include a fraction of ones IADLs. Knowing her past and current medical history
it can be deduced that she would have a difficult time with child rearing, driving and community
mobility, and safety and emergency maintenance. It has also been documented that Robin
requires assistance in taking her daily medications, which would fall under the IADL category of
health management and maintenance. Education poses a potential problem due to her specific
diagnosis and lack of communication skills required to be successful in a formal or informal
educational setting. She has the ability to learn and comprehend certain information, but as for
Participating in academic, nonacademic, extracurricular, and vocational educational activities,
the level of comprehension is limited (American Occupational Therapy Association (AOTA),
2014, p. S20). She would also struggle with the other aspects of education which include,
Identifying topics and methods for obtaining topic-related information or skills and
Participating in informal classes, programs, and activities that provided instruction or training in
identified areas of interest (AOTA, 2014, p. S20). Social participation, play and leisure are all
occupations which could pose risks for Robin if her caregiver was unaware of her precautions.
Living in a sunny environment, chances are that Robin participates in some type of outdoor
activities. If she were to get stung by a bee while outside in a group for social participation,
playing around with water guns, or just taking a leisurely break, the effects could be fatal.
Between allergic reactions to bees and having a history of seizures Robin will require constant
supervision to minimize the risks associated with these specific occupations.
Context and Environment
Robin was only observed during her six hours while at OV and not at her living facility.
She was in a wheelchair, and the facilities were accessible to this type of durable medical
equipment (DME). The environment she was surrounded by, besides being noisy at times, was
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very conducive to maintain or even improving her overall physical and cognitive performance.
OV is very well maintained environment, despite the staff and clients not utilizing it to its full
potential.
Occupational History
Robins occupational history is a very long and detailed one. She was born with a severe
intellectual disability (ID) and an unknown genetic syndrome. Over the span of her life other
medical complications arose: cerebral atrophy, ataxia, seizures, pulmonary hypertension, as well
as having swallowing precautions. The great thing for Robin is that her mother was very
involved in her life, as well as with her treatments, until a few years ago when her mother
tragically passed away. Not only did her father pass away around the same time as her mother,
but it was also suspected that Robins brother was the one responsible for her mothers death.
After the passing of both parents, and no other competent family to care for her, Robins legal
guardian became Clark County. Being that Robin was born with an ID (among other medical
complications), and not having knowledgeable living relatives, it would be almost impossible to
establish previous patterns of engagement in occupations and the meanings she could associate
to them. What is known on the other hand is that, over the course of her time at OV, she has
been known to be interested in preparing meals, completing household chores, arts and crafts,
simulated office work, watching television, playing with water guns outside, swimming in the
pool, and loves to go on just about any type of community outing. As mentioned before it would
be difficult to understand the value she places in each of these specific activities due to the lack
of communication skills. Due to the lack of visitation between her brother and herself her role as
a sister is nearly non-existence.
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Clients priorities and Desired Outcomes
Robins documented desired outcome is to live an independent life, and because of her
diagnosis it is reasonably safe to conclude that she will not be able to live completely
independent. In her medical charts it states that Robin prefers to do everything independently,
and she has even been known to attempt transfers by herself, showing just how dedicated she
really is with wanting to be independent but also the problems in which that dedication can
create. Just because that is the only recorded outcome, that does not mean that is all she would
like to get out of her time at OV. From goals that have been written with her in mind, it is safe to
conclude that a priority of hers would be to increase her self-care skills as well as safety. With
Robins love for being around others and outings, it would also seem that social participation and
making friends is high on her priority list. If the client was not interested in social activities she
would probably not greet individuals upon entering the room. Saying, Hi and waving are not
gestures people typically use to develop peer bonding if they are not interested in socializing.
Occupational Analysis
Context/Setting
Due to the fact that OV does not have an occupational therapist (OT) on staff, Robin was
not under direct supervision of an OT. This outpatient adult day care service is a not-for-
profit organization that serves people in the Southern Nevada community with intellectual
disabilities, to enhance their lives and the lives of the families who love them, as stated on the
OV website (Overview section, para. 1). The OV website also states, Through vocational
training, community employment, day services, advocacy, arts and social recreation, citizens
with severe disabilities are able to find new friends, realize future career paths, seek
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independence and community integration and unleash creative passions (Overview section,
para. 1). With a state of the art building, numerous rooms for different activities, and indoor and
outdoor stage, physically the setting was immaculate. On paper this setting sounds extremely
beneficial to clients suffering from intellectual disabilities, but my experience in the OV Enable
Program was not as inviting. The Enable Program consisted of three attached rooms where
clients would roam to and from pretty much as they pleased. The number of clients wandering
between rooms is quite overwhelming, making it difficult to closely monitor them. Despite the
relatively small size, and numerous safety hazards present in the room, the setting has a great
potential to promote independence, occupational performance, as well as education, if utilized to
its full potential.
Observed Activity
My first day at OV I observed Robin completing a six-piece puzzle consisting of different
shapes and colors. Distractions aside, she completed the puzzle independently by efficiently
problem-solving and rotating the puzzle pieces to fit into their appropriate positions. As
mentioned in her medical charts, she does not thrive in noisy or chaotic environments, shedding
light as to why she was distracted, not to misinterpret her performance of the activity.
Considering this was my first time witnessing her complete this activity I was shocked at the lack
of challenge this presented her, I assumed she would struggle a little with the task. Being
thoroughly impressed I was excited to see what she was able to accomplish the next week I
observed. Upon arrival the next week I was shocked to see Robin completing the exact same
puzzle she excelled at during the prior week. It was saddening to observe her acting uninterested
and unchallenged by this activity that was most likely placed in front of her with no further
thought to her mastery of the puzzle. In order to progress with her intervention plan she should
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have been challenged in order to promote independence, improve self-efficacy, all while aiming
to improve occupational performance.
Key Observations
As briefly discussed in the previous section, my initial thought while observing Robin
completing the six-piece puzzle was she was very successful at performing the activity in a
timely and efficient manner. What I did not know at the time was this activity was no longer
challenging her appropriately. The first time observing the client complete this activity she
seemed distracted by the sheer chaos taking place around her, what I later concluded could have
just also been her being bored because the activity was no longer intriguing to her. Her
wheelchair which did not seem appropriately fitted for her, was hindering her in being
successfully engaged in the activity by not offering proper support. All of these observations
along with the fact she was not receiving adequate interaction from staff, are all key reasons her
occupational performance was hindered, during this activity.
Reason for OT Services
The client was not directly seeking OT services but there are definitely reasons she would
benefit from skilled OT treatment. With the help of an OT, Robin would receive one-on-one
treatment sessions to address improvements in her self-care skills, while trying to help her
become as independent as possible. According to the Occupational Therapy Practice Framework
(OTPF) the domains most significantly impacting Robins ability to successfully engage in
occupations based on my observations would be her: occupations, client factors, performance
skills, and context and environment (AOTA, 2014).
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Occupation is defined as the daily life activities in which people engage and are
influenced by the interplay among client factors, performance skills, and performance patterns.
Since these are all interrelated, the fact her client factors, and performance skills are impacted
and she is unable to do something she wants, it also affects her occupations, Occupation is used
to mean all the things people want, need, or have to do (AOTA, 2014, p. S5)
Robins body functions and body structures are affecting her ability to successfully
engage in occupations due to the fact that these client factors are negatively influenced because
of the presence of illness, disease, deprivation, disability, and life experiences (AOTA, 2014). I
do not feel it would be fair to assume her values, beliefs, or spirituality are negatively impacting
her ability to engage in occupations successfully strictly because according to her charts and
participation she seems interested in becoming as independent as possible. Body structures and
body functions are interrelated (AOTA, 2014), showing that because she has deficits involving
her blood vessels (hypertension) supporting her cardiovascular function she will probably also be
suffering from discrepancies in other areas as well (such as her cognitive functions). Having
these client factors interrupted can influence performance in occupations
Performance skills include motor skills, process skills, and social interaction skills and
can be described as the clients demonstrated abilities (AOTA, 2014). It is also said that a
change in one performance skill can affect other performance skills, meaning her diagnosed
ataxia (affecting her motor skills) can have an impact on other aspects of her performance skills
(AOTA, 2014). As discussed before, she was not being challenged with the puzzle she was
completing, which I believe that in itself is hindering her processing skills. body structures,
as well as personal and environmental contexts, converge and emerge as occupational
performance skills. In addition, body functions, such as mental, sensory, neuromuscular, and
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movement-related functions, are identified as the capacities that reside within the person and also
converge with structures and environmental contexts to emerge as performance skills (AOTA,
2014, p. S7).
While observing Robin at OV I noticed certain context and environmental disruptions
hindering her occupational performance. The first and most readily noticed, being her
wheelchair not fitted properly for her. By improving and fitting a wheelchair specifically for her,
it may increase her performance along with self-efficacy, while preventing other structural
integrity issue which may arise. I also notice that during lunch time the sheer amount of clients
in the lunch room compared to the minimal staff, created a concern, not only for her since she
requires supervision and setup for feeding, but for the other clients as well. Because of the lack
of one-on-one interaction she was receiving it could very well impact the management of her
medications and cause her to take receive them at different times.
Problem List
Problem Statements
1. Client is dependent with ADLs due to difficulty with memory and sequencing.
2. Client requires maximal assistance with medication management due to decreased
memory functioning.
3. Client requires supervision with feeding due to swallowing precautions.
4. Client is dependent in ambulation due to ataxia and decreased activity tolerance.
5. Client requires moderate assistance with communication due to limited vocabulary and
communication skills.
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With Robin wanting to become as independent as possible, her ADLs are the
activities requiring the most assistance from staff, it would be most important to decrease
her required assistance level to improve her independence. Next would be medication
management, especially due to the decreased direct staff interaction with her while at
OV. If she was getting constant one-on-one time with staff and or faculty, this problem
statement would not be ranked near as high, but in order to decrease her seizures from
reoccurring, this problem is crucial and needs to be addressed appropriately. Robin
requires supervision whilst eating due to her swallowing precautions, but this problem is
slowly being dealt with. By verbally cuing her to slow down while eating her precut
food, Robin has increased her independence with eating. As previously discussed with
the limited direct supervision she is receiving, staff may not always be monitoring her
eating habits, putting her at risk for choking and aspiration. By making this a priority she
would become more independent and may no longer need supervision while eating. This
problem statement discussing her dependence level with functional ambulation would
typically be one of the first and most important issues to address, but using clinical
reasoning it was decided that due to her living situation at the group home, along with the
advanced stage of her diagnosis, she would most likely always require some form of
supervision to ambulate. Since this is something she may never quite master, it was
decided to focus on other problem areas to improve her self-efficacy and helping her
acquire some independence before attempting more difficult goals. One of the symptoms
of intellectual disabilities is talking late and or having trouble talking (Intellectual
Disability, 2014). With that taken into account the few words Robin does know and
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employ is impressive but if she were able to learn more sign language or use other forms
of communicate it could improve her quality of life (QOL).
Intervention Plan & Outcomes
Long Term Goals
1. Robin will brush her teeth with less than two verbal cues using a step-by-step picture
diagram within six treatment sessions.
2. Robin will take medications with setup by utilizing medication helper pill reminder and a
watch by the completion of six sessions.
Short Term Goals
1. Robin will be able to identify the correct sequential order of steps required to brush teeth
times with less than two verbal cues by two weeks.
2. Robin will brush her teeth with hand over hand assistance with no more than four verbal
cues by four weeks.
3. Robin will demonstrate knowledge of the day of the week by pointing to the day on a
weekly calendar times by three weeks.
4. Robin will correctly respond to the medication timer on her watch when it goes off by
acknowledging that this signifies it is time to take her medication with two or less verbal
cues by five weeks.
Intervention Ideas
1. Have the client participate in matching pictures with appropriate steps for brushing her
teeth (Obremski & Wehmeyer, 2010). Due to not having sufficient knowledge of whether
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or not she was able to perform this earlier in her life or if her mother assisted her I feel
the appropriate intervention approach would be establish/restore. By utilizing this
approach the OT, with assistance from Robin, would design a plan to change client
variables to establish a skill or ability she has not yet developed or restoring an ability
that may be impaired (AOTA, 2014, p. S33). The outcome I hope to achieve through this
intervention plan would be increasing her well-being.
2. Because it is noted the client is able to perform new tasks with demonstration, repetition
and reminders, having the OT demonstrate and educate the client regarding proper teeth
brushing techniques she will have a better idea of what is expected of her before
attempting hand-over-hand training (Kpper & Hamilton, 2013). By teaching Robin
proper teeth brushing techniques, assuming she does not suffer from tooth decay,
gingivitis, or similar diseases affecting the mouth the intervention approach would
promotion of health. The outcome I hope to achieve through this intervention plan would
be participation in her ADLs.
3. Since the client is able to say yes and no, by answering a simple question such as, Is
today Monday? while pointing to the day on a weekly calendar, she would be able to
demonstrate and practice comprehension of the days of the week (Intellectual
Disabilities, 2013). By compensating and adapting the method Robin takes to realize the
specific day of the week, the appropriate intervention approach would be modification.
The outcome I hope to achieve through this intervention plan would be participation.
4. By setting up her watch to beep every day at the same time and educating her to take her
medications as soon as the watch goes off, it will act as a reminder for her, regardless of
the level of supervision. This intervention plan could essentially fall under
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establish/restore, maintain, modify, and even prevention. By setting her watch to notify
her of the proper time to take her medications, that skill is being established. By
continuing to take her medication, she is able to maintain and preserve the performance
capabilities she has regained since being on her medication. By having her utilize her
watch as a reminder instead of relying on the staff, her routine is being modified or
adapted to promote independence (SagePub, 2012). And also by continuing to take her
medication regularly, seizures as well as other disabilities are being prevented. Each of
these intervention approaches would be appropriate, but perhaps the most appropriate
would be establish, considering this alternative way of taking her medications would be
very new to her. The outcome I hope to achieve through this intervention plan would be
improving her QOL through participation.
Precautions
The general precaution for Robin would be to make sure she is following the just-right
challenge. Having things done for her for so long could cause her to become depressed if she is
tries to accomplish activities too difficult too quickly. Other precautions would relate to the
current medication she is taking and how that impacts her. Since her medication list was not
documented it would be crucial to rule it out as a possible side-effect versus her response to a
certain situation or activity. When outside, always making sure she has her Epi-Pen in her bag
could be the difference for life and death for her since of her severe allergic reaction to bee
stings.
Frequency and Duration of Intervention Plan
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Having an OT come into OV and work with Robin for one hour, three days a week for
four weeks would be conducive in order to facilitate her reaching her goals on maximum
independence with her ADLs.
Grading Up/Grading Down
One way to grade up the intervention plan requiring her to identify the correct day of the
week could be accomplished by not having the days of the week in the proper order. By cutting
up pieces of paper and writing the days of week on them (or cutting the weekly calendar), when
mixed around on the table, it would her to properly sequence the days of the week and select
which day it currently is by process of elimination. A way to grade down could be to cross out
the days as they pass, making it easier and quicker to identify the day of the week it currently is.
Model
The model most appropriate for Robin would most likely be the Allens Cognitive
Disabilities model. This model can be used with any client who displays cognitive functioning
problems which affect functional performance of tasks (Toglia, Goslisz, & Goverover, 2009). It
is important to remember with this model that the goal is not to change the client but to instead
change the environment and activities to meet the specific cognitive level of the client (just right
challenge) (Toglia, Goslisz, & Goverover, 2009). This model focuses on identifying the
individuals current cognitive abilities and their implications for performance, independence, and
the need for assistance. With this information the OT is able to identify realistic goals that match
the clients cognitive functioning (Toglia, Goslisz, & Goverover, 2009). As for the intervention
utilizing this cognitive model, activities are used to stimulate the clients highest cognitive level
while therapy concentrates on maintaining the highest level of function (Toglia, Goslisz, &
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Goverover, 2009). All of the environmental and activity adaptions are made to compensate for
deficits and allow the greatest degree of independence (Toglia, Goslisz, & Goverover, 2009),
which is exactly what Robins goal consisted of.
Client/Caregiver Training
Without proper training of the staff in contact with Robin, her adaptions could render
useless. The staff needs to be trained by an OT to develop an understanding of Robins abilities,
deficits, and overall care needs. This knowledge may already be present in certain settings, but
considering only needing a high school diploma to be employed at OV, the level of
training/knowledge is minimal. The staff receives training such as cardiopulmonary
resuscitation (CPR) and automated external defibrillator (AED), but besides that it is my belief
they do not receive enough outside training to adequately be working with people who suffer
from intellectual disabilities. Every one of these clients is unique and requires special
individualized supervision and assistance requirements that may take years to master, so I think
it would be beneficial for the staff and clients if the caregivers were to receive additional
training. For the case of Robin, it would be helpful if the caregivers in contact with her at OV
were informed by an OT of her abilities, deficits, and overall care needs. With this knowledge
they would be able to help implement a better learning environment.
Response to Interventions
Considering OV is a non-for-profit organization, buying numerous assessment tools to
establish a baseline and monitor progress for all individuals there would be very costly. With
that in mind Robins (as with all clients in attendance) progress towards her goals will be
monitored through an informal assessment, observation. Observation has numerous benefits: not
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a lot of needed planning, less stressful for students (because they do not realize they are
undergoing an assessment), the data is received immediately, and as mentioned earlier it is
inexpensive. By counting the number of verbal cues it takes for her to properly identify the
sequence for brushing her teeth or how long it takes her to identify the correct day of the week,
these observations will prove to be a good indicator for the OT of her progress towards her goals.













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