Occupational Therapy Evaluation Report and Initial Intervention Plan

Background Information

Client’s name or initials: N.L.

Date of referral: 1/17/2019

Date of Report: 1/24/2019

Date of birth &/or age: 09/04/1949 (69 years old)

Primary intervention diagnosis/concern: L CVA in March 2017 with R hemiparesis.

Secondary concerns/diagnosis: none stated

Precautions/contraindications: Requires cane or walker for functional mobility around her apartment

and motorized scooter for longer distances.

Medications: none known

Reason for referral to OT: Address right hemiparesis impacting her ability to complete preferred IADLs.

Therapist: Lauren Beck, OTS

_____________________________________________________________________________________

Subjective: When asked about spirituality, client stated, “[bible study] feeds my soul.”

Objective: Client was seen 1/17/2019 and 1/24/2019 for comprehensive occupational therapy

evaluation.

Occupational profile: N.L. is a 69-year-old woman who experienced a CVA in March of 2017. She has

received some physical and occupational therapy in the past, it has been a year since she last sought out

services. Since the stroke, N.L., has been unable to use her right upper extremity while completing ADLs,

IADLs, and participating in social events. She uses adaptive equipment (cane, walker, and motorized

scooter) for functional mobility in completing ADLs and IADLs. She is seeking services at the University of

Utah Life Skills Center in order to increase function in her right upper extremity.
 N.L. currently lives in a senior living community where meals and activities are provided and

transportation is provided to doctors’ appointments. N.L. has four children and eight grandchildren,

most of which live in the Philippines, one child and grandchild reside nearby. In 2015 N.L. was widowed,

that experience led her to seek employment caring for the elderly. Prior to her initial retirement, N.L. did

clerical work for 30 years in the Philippines and the U.S. Although she has been working with vocational

rehab, N.L. reports her inability to open heavy doors as a barrier to employment and has been unable to

return to work since the CVA. Eventually, she would like to regain independence by obtaining a part-

time job and living on her own again.

N.L values independence and having social opportunities. She feels both have altered since her CVA.

She has distanced herself from close family and friends since they “do too much for her.” She wants to

demonstrate her ability to accomplish tasks on her own. Although her morning and nightly routines take

considerable time, N.L completes most ADLs independently and completes some household chores such

as taking out the trash and doing her laundry. She feels a sense of accomplishment being able to do

them on her own. Before moving to the senior living facility, she independently rode trax and the city

bus during periods of good weather. Her current location is not convenient to the trax station. Social

opportunities are more difficult due to her inability to open heavy public restroom doors. Although

friends offer to drive her to social events, they cannot transport her scooter.

N.L. values her roles as a mother and grandmother. She speaks to her children and grandchildren

often using Facebook messenger. Friendship and social opportunities are important to her, especially

her support group for people who are experiencing aphasia. She looks forward to therapy and the

weekly support group to break up her week and give her an excuse to leave the senior living facility. She

has a routine of playing games with other residents after lunch and dinner each day. N.L. has a habit of

sleeping in and skipping breakfast in order to reduce her caloric intake.

 N.L. sees the senior living facility as a barrier to her independence. She feels confident she could

maintain an apartment and eat her meals at the mall food court. The winter season is a barrier to social

participation and employment. She cites right hemiplegia as a barrier to most ADLs and IADLs stating she

has to take rests while completing tasks due to safety risks of falling. N.L. sees her family and old friends

as a barrier to her independence, doing more for her than she would like. In contrast she sees her new

friends at senior living to be like family, support group friends, and spiritual beliefs to be a support to

her recovery. She has good SES, enough to afford her current living standard.

N.L. would like occupational therapy to increase her ability to use her RUE and increase her ability to

perform ADLS, IADLs, and participate in social events.

Administered Assessments:

The following assessments were administered:

 Modified COPM: A semi-structured interview to determine the client’s main occupational

concerns and priorities for intervention, level of performance, and satisfaction with their

performance.

 COPM results are recorded in the table that follows. N.L. was eager to share her

experiences with us. In the beginning of the interview words came quickly for her.

Towards the end it was more difficult for her to recall words and she began repeating

her previous statements. She identified increased use of her RUE as her main goal. She

is anxious to cut her own nails, mend clothing, open public restroom doors, and increase

her safety while performing ADLs and IADLs.

 Occupational Concerns/Priorities Importance Performance Satisfaction
(1 not important at (1 poor performance (1 not satisfied at
all – 10 extremely – 10 very good all- 10 extremely
important) performance) satisfied)

1. Improve ability to complete ADL’s 8 1 3

(trim nails, use fork and knife)
2. Complete home maintenance 8 1 2
tasks (mending clothes)
3. Increase ability to open doors 9 2 4
within public buildings
(community social participation)
4. Increase feelings of safety while 7 5 6
performing daily tasks at home
(functional mobility)
Totals: 32/4=8 9/4=2.25 15/4=3.75

 The PASS is a client-centered, performance-based, criterion-reference, observational tool that

assists occupational therapy practitioners to objectively document occupational performance

and plan occupation-based interventions for adolescent, adult, and older adult populations in a

variety of settings. The client was given Task # C12: IADL-P: Taking Out the Garbage (Heavy

Housework).

 Modified trash bag from 6 lbs., to 2 lbs. to simulate average weight of trash the patient
transports daily.
 Subtask #8 was not included in this assessment.
 Client used cane for functional mobility during this task.
 The following table summarizes her PASS score.

Subtask Independence Safety Data Adequacy Data

Subtask Scores (Scored from Unsafe Observations (Scored (Scored from 0-3)
0-3) from 0-3)
Process Quality
#1 3

#2 3
#3 3
#4 2 x x x
 #5 3
#6 3
#7 3 x
Summary 20/7= 2.86 1 1
Scores

Client independently maintained balance without the use of her cane to bend down, pick up trash bag,

and stand back up before retrieving her cane. She required min A to hold open the door after repeatedly

pulling open the door and it bumping into her. To re-enter the room, client opened the door with

significant force and quickly walked through before the door shut.

Observations:
Nail clipping: Using an adapted nail clipper attached to a board, client independently applied pressure

with left hand to clip right hand.

PROM: During the PASS and nail clipping client held RUE close to her trunk, elbow flexed, and hand near

her chest. PROM was given starting in her scapula, then shoulder, next elbow, and finally wrist and

fingers for 7 min. Movement in her fingers, wrist, and elbow was observed after PROM.

Flashlight: Client independently took out batteries in a medium flashlight using left hand to twist, place

flashlight in her right hand, and replace batteries.

Cleaning counter and wall: Client independently sprayed the counter top and wall and wiped down
counter and wall with LUE. When encouraged to use her right-hand client put the rag in RUE and wiped
counter top and wall with limited ROM.
Assessment:
Client has many strengths that will support her participation in desired occupations. N.L. is
motivated to come to weekly sessions and has a hopeful outlook on increasing independence. Her
aphasia support group and friends in her senior community offer strength and support. She has a
favorable SES and reliable transportation to get to therapy. She has made significant changes in her life
before the CVA such as moving to the US to start over which required an adaptive skill set.
Currently barriers to occupational performance include high tone in RUE and LUE. As demonstrated by
her guarded posture, limited ROM in RUE, lack of RUE incorporation into various tasks and use of
cane/scooter for functional mobility. Living in a senior community requires her involvement in few
IADLs, it will be difficult for her to work on improving her skills when someone else is currently cooking
 and cleaning for her. Although her friends and family would like to help N.L., doing too much for her is a
barrier to her occupational participation and independence. The motorized scooter requires less
physical activity and decreases her total amount of daily exercise. She has been to the Life Skills Clinic
before and is not currently working on the home program that was provided for her.
Other barriers to participation in preferred activities is the time of year. N.L. is anxious about falling in
the snow, therefore she does not go out to more social events or seek employment during this season.
Transportation is limited. Paratransit leaves her waiting for long periods of time in the cold, the
community van is for medical appointments only, the bus stop is too far away, and she does not drive.
Building accessibility is an issue. She is unable to manage a cane or scooter and pull an industrial door
open long enough to enter the doorway. This limits her ability to enter certain buildings and open
bathroom doors. Her desire for complete independence. She is unwilling to ask others to open
bathroom doors or to help with other tasks. She is nearly two years post-stroke. Although change is still
possible, she has developed habits of nonuse of RUE, it will take conscious and continuous effort to
regain more functionality of that extremity.
Plan:
N.L will benefit from skilled occupational therapy services to incorporate her RUE in tasks in order

to increase her participation in ADLs /IADLs such as basic home maintenance activities and increase

participation in social events. Skilled occupational therapy services are recommended 1x/week for 1

hour sessions, until March 7, 2019.

Goals
LTG1: By discharge, client will independently use RUE to complete basic home maintenance tasks
using adaptive equipment for mobility.
STG1: In 4 weeks, client will demonstrate decreased muscle tone in RUE to independently mend clothing
with the use of adaptive equipment.
STG2: In 2 weeks, client will independently use RUE to stabilize body while completing standing household
chores.

**HINTs: each column should have 3-5 bulleted measures.

***It’s easier if you fill out the “0” column (Goal measures – LTG/Measurement Criteria – STO) first, then the “-
2” column (Baseline performance) and then fill in the rest of the columns in between.
Distal Outcome (LTG): By -2 -1 0 +1 +2
discharge, client will (Baseline) (Goal)
independently use RUE Much Less Less Expected Better Much Better
to complete basic home Level
maintenance tasks using Level of assist: Level of Level of assist: Level of
adaptive equipment for (min A) assist: Level of assist: (I) assist: (I)
mobility. RUE: does not (min A) (I) RUE: RUE:
incorporate in RUE: incorporates incorporates
task minimally in 100% task
 Task: basic incorporates RUE: in 100% of Task:
home in task incorporates task moderate
maintenance Task: basic in 75% of task Task: basic home
A/E: scooter, home Task: basic home maintenance
walker, cane maintenance home maintenance A/E: cane
A/E: scooter, maintenance A/E: walker,
walker, cane A/E: scooter, cane
walker, cane
(Occupation/Target Does not Incorporate Increases use Increases use Increase
Behavior) currently RUE in home of RUE in of RUE in complexity of
participate in maintenance home home maintenance
Home maintenance home tasks maintenance maintenance task
maintenance tasks tasks
projects

Proximal Outcomes (STGs) Measurement Criteria Baseline

1. In 4 weeks, client will Level of assist: (I) Level of assist: Dependent

demonstrate decreased
muscle tone in RUE to Muscle tone in RUE: decreased Muscle tone in RUE: High tone
independently mend Home maintenance task: Home maintenance task: unable to
clothing with the use of successfully mending clothing mend clothing
adaptive equipment.
Type of adaptive equipment Does not use adaptive equipment
used

2. In 2 weeks, client will
independently use RUE to
stabilize body while completing a
standing household chore.
Level of assist: (I)
RUE use: weight bearing to
stabilize body
Body Position while performing
activity
Level of assist: Min physical assist, min
verbal prompts
RUE use: holds close to trunk, does not
use
Rides scooter to throw away trash, does
not complete other household chores

**HINTs: each column should have 3-5 bulleted measures.

***It’s easier if you fill out the “0” column (Goal measures – LTG/Measurement Criteria – STO) first, then the “-
2” column (Baseline performance) and then fill in the rest of the columns in between.
Distal Outcome -2 -1 0 +1 +2
(LTG): By discharge, (Baseline) (Goal)
client will use Much Less Less Expected Level Better Much Better
compensatory
strategies to Level of assist: Level of assist: Level of assist: Level of assist: Level of assist:
independently N/A (min A) (I) (I) (I)
attend community A/E: N/A A/E: cane or A/E: scooter, A/E: scooter, A/E: scooter,
events using Event: none walker walker, or cane walker, or cane walker, or cane
adaptive Transportation: Event: church Event: church, Event: church, Event: church,
equipment for none Transportation: mall mall mall, friend’s
mobility. Frequency: Friend’s car Transportation: Transportation: house
0 times/month public transit Use of Transportation:
alternative friend’s car,
 Restroom: Restroom: transportation public transit,
enters/exits enters/exits (I) such as uber/Lyft, or
with min A Frequency: Uber/Lyft paratransit
Frequency: 2 times/month Restroom: Restroom:
1 times/month enters/exits (I) enters/exits (I)
Frequency: Frequency:
3 times/month 4 times/month
(Occupation/Target Social events Accept assist to Use of Use of Use of
Behavior) attended are get to social compensatory compensatory compensatory
medical in events more strategies to strategies to strategies to
nature or at frequently access access access
senior living restroom restroom restroom
apartments

Use public Add new Use a variety of

transit to transportation transportation
transport options to methods to
scooter and repertoire attend events
expand event more
venues frequently.

Proximal Outcomes (STGs) Measurement Criteria Baseline

1. In 2 weeks, client Level of assist: (I) Level of assist: mod A

will implement
compensatory Compensatory strategies: used to Compensatory strategies: not used when
strategies to move door of public restroom attempting to move door of public
independently restroom
Restroom access: enters and exits
move a heavy door public restroom Restroom access: cannot enter or exit
to access public public restroom
restrooms using Mobility: scooter, cane, or walker
adaptive equipment Mobility: scooter
for mobility.

2. In 4 weeks, client Level of assist: (I) Level of assist: N/A

will implement use of
alternative transportation to Transportation: public Transportation: does not currently use
facilitate independent transportation, alternative public transportation, alternative
attendance of social events. transportation, rides with friends transportation, or ride with friends

Attendance: to event of choice Attendance: N/A

Mobility: scooter, walker, or cane Mobility: N/A

Provide A/E:
N.L. will be provided with adapted fingernail clippers in order for her to clip her nails
independently.
Research:

Person, Environment, Occupation Model (PEO): To more fully participate in preferred occupations,

N.L. will benefit from adapting her environment, learning strategies to participate in preferred

occupations, using adaptive equipment to reach maximum congruence of her person, the

occupation, and the environment (Law et al. 1996).

Biomechanical Model: Modalities will be used to prepare N.L. for participation in activities.

Intervention will be based around desired occupations, therapeutic activities have the potential to

remediate non-use in impaired extremity and will improve performance in all occupations

(McMillan, 2011).

Rehabilitation model: N.L. will develop compensatory strategies and become proficient in using

adaptive equipment for full participation in activities she enjoys (Gillen, 2014).

Based on limited time with N.L. we would like to give her compensatory strategies that may

be applied to many different activities and occupations. PROM will enable N.L. to make the most of

the time we have in therapy and helping her problem solve ways to incorporate the RUE into daily

tasks will make a long-term difference in her recovery. It is anticipated N.L. will improve

occupational performance after receiving interventions which incorporate occupation into therapy

(Skubik-Peplaski, 2016).

Lauren Beck, OTS date: 1/26/19

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& E. S. Cohn (Eds.), Willard and Spackman's occupational therapy (12th ed., pp. 322-341).

Philadelphia: Lippincott Williams & Wilkins.

Law, M., Cooper, B. A., 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.

McMillan, I. R. (2011). The biomechanical frame of reference in occupational therapy. In E. A. S. Duncan

(Ed.), Foundations for practice in occupational therapy (5th ed., pp. 179-194). Edinburgh: Churchill

Livingstone.

Skubik-Peplaski, C., Stroud, R., Howell, D., Custer, M., Sawaki, L. (2016). Effective Interventions for Stroke

Recovery: Comparing Modified Constraint-Induced With Occupation-Based Interventions. American

Journal of Occupational Therapy, 70, 1. doi: 10.5014/ajot.2016.70S1-RP101B.

https://ajot.aota.org/article.aspx?articleid=2582776&resultClick=3