Student

Name: Eva Fish Case: 6-Wendy Date: 03/30/20

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Diagnosis- admitted for pneumonia, has PMH of COPD, CHF, Type 2 Diabetes, OA, gout, and TKA
(3 years ago)
Referral- Physician
Setting- SLC Transitional Care
Reimbursement- Medicaid
LOS- 3 weeks expected

2. Pragmatic Factors to Consider

• Will return to living alone in a rural area
• Early signs of diabetic neuropathy
• Decreasing vision
• Osteoarthritis
• Complex PMH and co-morbidities
• She has quite a few animals to take care of, in addition to her grandson who comes around
occasionally in need of money
• Will likely be going home with O2
• Will need to manage O2 during therapy
• Insurance will want certain outcomes
• May be resistant to change
• Unhealthy habits- typically has 3 beers/night and smokes occasionally
• Likely has a variety of medications to take for managing her myriad of conditions
• MoCA score is slightly below normal- cognition could be an issue, though difficult to say
with just information provided
• Decreased strength and unsteady gait may be a safety concern for independent living
• Schedule of others in the transitional care facility

5. Diagnosis and Expected Course 6. Scientific Reasoning & Evidence

Pneumonia
-Pneumonia results when there is an
infection in one or both lungs, due to
viruses, fungi or bacteria entering them.
Symptoms include chest pain, fever, body
aches, chills, and shaking. Relevant risk
factors include adults over 65, cigarette
smoking, alcohol abuse, and chronic lung
disease such as COPD. Those with COPD
that get pneumonia are at increased risk for
hypoxia, lung failure, kidney damage,
cardiovascular problems, and brain damage.
Recovering from pneumonia depends on the
individual, but can take up to a month or
List the barriers to performance typical of this
diagnosis:
Barriers
• TKA- If she had a fixed weight bearing
prosthesis, she will only be able to do flexion
and extension of the knee.
• CHF- too much activity after an acute episode
can lead to further complications, may also have
shortness of breath and fatigue easily, could be
taking medication
• COPD- shortness of breath (dyspnea) with
exertion and eventually at rest, coughing and
excessive mucus, likely taking medications. If
the person is not getting enough oxygen they
may have signs such as extreme fatigue,

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longer.
Gout
-Gout is a form of arthritis that typically
affects one joint at a time, most frequently
in the great toe, as a result of excessive uric
acid in the body. People with gout will have
periods of flare ups and remission. No cure
exists for gout, though it can be managed
with medication and self-management. It is
characterized by a feeling of intense redness
and heat in the affected joint, swelling, and
pain.
Type 2 diabetes
-Type 2 diabetes occurs when a person’s
body becomes resistant to insulin. There is
not a cure for diabetes, but with proper
management, people can live a full life.
Diabetes management can include a healthy
diet, regular exercise, monitoring blood
sugar levels, and medication management.
Osteoarthritis
-OA is a disease that causes the cartilage in
joints to break down, leading to bone-on-
bone contact that causes joint pain and
stiffness. The two ends of bone eventually
thicken, resulting in the growth of
osteophytes, causing joint deformity. OA
occurs in individual joints. There is no cure
that exists for OA, so treatment focuses on
limiting progression and associated
decrease in functional use of the joint. This
may involve pharmacological treatments.
COPD
-The leading cause of COPD is smoking. It
results from having emphysema and chronic
bronchitis, causing damage to the air sacs of
the lungs. Damage to the lungs caused by
COPD is irreversible and it is a progressive
condition. Bronchitis can also lead to upper
respiratory infections.
CHF
-This can result from CAD or be due to
infection, with the heart weakening over
time. This can lead to fluid build-up in the
lungs and further complications. CHF
cannot be cured, but rather maintained
through diet, medications and rest to
nonproductive cough, confusion, impaired
judgement, and cyanosis. Depression and
anxiety may also result from COPD.
• OA- joint pain, stiffness, tenderness, some
localized inflammation, limited mobility,
crepitus. Stiffness may be more present in the
morning or after a period of inactivity.
• Type 2 diabetes complications- Neuropathy,
vision (cataracts, glaucoma, blindness), slow
healing, fatigue, polydipsia, dysuria
• Gout- Swelling, pain, periods of remission and
flare ups
• Pneumonia- Fatigue, complications including
respiratory failure and sepsis,
Evidence
• CHF- OT can help educate a person on graded
self-care tasks, to help them from overloading
the heart too soon after an acute episode. CHF is
best managed through diet, medications and
rest, which are all areas that OT can and should
address as well.
• COPD- OT can be beneficial to address energy
conservation and breathing techniques as they
relate to I/ADLs, in addition to addressing
psychosocial factors that may result from
COPD. OT can also be involved in pulmonary
rehabilitation, as part of an interdisciplinary
team.
• Type 2 diabetes- Those with type 2 diabetes can
work with an OT to address medication
management, healthy lifestyle changes related
to diet and exercise, and occupational
adaptations as they relate to diabetic conditions
such as neuropathy or decreased vision. OT can
play an important role in helping a person
manage symptoms of type 2 diabetes to prevent
further progression of the disease.
Sources
- Pedretti ch. 38, ch. 44
- https://www.mayoclinic.org/diseases-
conditions/type-2-diabetes/symptoms-
causes/syc-20351193
- https://www.cdc.gov/arthritis/basics/gout.html
- Pyatak, E.A. (2011). The role of occupational
therapy in diabetes self-management
interventions.
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mitigate further weakening.

7. Practice Models Guiding Assessment and Rationale

Treatment
1 PEO PEO is appropriate to use with Wendy to
. address modifications that can be made to her
environment and occupations, to best match her
changing abilities as she ages and her diseases
progress. Using PEO, I would want to address
environmental modifications that can be made to
make daily tasks more accessible for Wendy,
such as grab bars or other home modifications
she may be able to make in her trailer. Her
occupations should also be adapted to promote
successful engagement in them. This could
include using built up cross stitch needles if it is
painful for her, adapting her work boots to be
easier to don, and planning more strenuous tasks
during a time of day that she has most energy
and least stiffness from OA. It could also
include diet and exercise habit changes to better
manage her diabetes. These changes will
promote enhanced engagement in meaningful
occupations and improve congruency between P,
E, and O.
2 Lifestyle Redesign The goal of lifestyle redesign is to help those
. with chronic conditions at risk of occupational
decline (particularly the elderly) to learn new
strategies to generalize to their daily tasks to
increase participation, with an emphasis on
health promotion and self-analysis. This is
appropriate for Wendy as she has chronic health
conditions that could benefit from learning new
strategies to apply to her daily life. This could
include breathing techniques, medication
management, and other compensatory strategies
to continue her engagement in meaningful
occupations and promote her ability to continue
living independently.

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3 Rehabilitation Model Wendy has chronic health conditions that may
. continue to worsen over time without proper
management, so the rehabilitation model would
be appropriate to use with her to address
appropriate adaptive equipment and
compensatory strategies to complete daily tasks.
This may include energy conservation
techniques, breathing strategies to complete
desired tasks, and adaptive equipment that may
aid in her ability to live independently.

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 13. Client Factors- Body Functions & Structures
What do you know? What do you need to know?
Unsteady gait
Decreased strength
Progressively worse vision
Tingling in extremities
Poorly regulated diabetes
MoCA score of 24

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

I would like to see Wendy go through the steps
Shower of showering to observe how she does with
transferring into/out of the shower, observe if
any safety concerns arise such as poor balance,
see how she is able to manipulate shampoo and
conditioner, and get an idea of her strength and
functional ROM necessary for the task. During
this time, I can also observe her for any
shortness of breath and other symptoms of her
conditions that may affect her safety and
independence while showering. I may also be
able to start getting an idea of her cognitive
status during this task, vision impairments, and
other deficits that may be going on.
Method/Tool Rationale/What is being Assessed
1. Vision screen Since Wendy has Type 2 Diabetes and reports
that her vision is progressively worse than two
years ago, I would like to do a basic vision
screen to rule out any diabetes related vision
impairments she may have. If she does have any
visual deficits, it would be important to get her a
referral and the resources she needs to ensure
safety and independence.
2. MMT and ROM Since Wendy has OA, I would like to see what
her strength, active, and passive ROM are in the
affected joints. I would also like to have her go
through a basic functional ROM assessment to
determine if she has the necessary ROM to
complete daily tasks. Wendy complains of
decreased strength, so doing MMT of her UEs
would allow me to determine where she has the
least strength and how I can address that during
therapy. While these assessments do not require
too much exertion, I would monitor her
cardiovascular response to the assessments.

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3. PASS- Medication Management, dressing,
home safety
4. Home evaluation (Home Falls and Accidents
Screening Tool if able to travel to her home)
5. Berg Balance
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Wendy has a lot of co-morbidities that may
require medication, which is why I would want
to assess her ability to manage different
medications as this is an important aspect of
living independently. Dressing is another task I
would want to observe Wendy doing, as this
may be an important ADL to address in our
sessions. I would include the portion of
donning/doffing shoes and socks as well, since
wearing work boots is one of her priorities and
this will provide me with information on what
specifically is difficult for her.
Home safety is important to assess since she will
be transitioning back to living independently
following her stay at transitional rehab.
Since Wendy has had multiple hospital stays in
recent years due to worsening health conditions
and continues to live alone, I think it would be
important to do a home evaluation. If time
allowed for it I would do the home evaluation
myself in person, but if I were not able to drive
all the way to Emory I could do an interview
with Wendy or find a way to set up a FaceTime
call with someone who can walk me through the
home. This could even entail having Wendy
describe areas of her home and/or draw it out
and evaluating the necessary skills for engaging
in her home environment. I want to ensure that
Wendy can safely navigate her home and
provide recommendations for any home
modifications or AE that she may benefit from.
Wendy reported having decreased sensation in
her toes, unsteady gait, and decreased strength.
Due to these complaints, I would want to assess
her balance. Using the Berg will provide me
with information about how she is able to
balance as it relates to functional tasks such as
how she is able to go sit to stand from a chair,
transfers, reaching, picking an object up from the
floor, etc. It will be important to address balance
as it relates to functional tasks to ensure she is
safe to return home.
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6. Brief Pain Inventory (Short form) It is possible that Wendy is experiencing pain as
a result of her medical status, particularly from
having osteoarthritis. She may also have chest
pain from the pneumonia. Therefore, I would use
the brief pain inventory to understand more
about if/when she experiences pain and how we
might be able to decrease pain through
therapeutic adaptations.

15. CPT Evaluation Code: Justification

97168 I believe Wendy’s case to be of high complexity. First off, she lives
alone and wishes to return home after her stay in rehab. She has more
than one comorbidity that affect functional performance, including
decreased vision and sensation secondary to type 2 diabetes. I don’t
know exactly how many deficit areas she has before getting a more
comprehensive understanding of her ability to complete I/ADLs, but I
believe she has 5 or more. Treating her requires a comprehensive chart
review and a higher level of clinical reasoning, due to co-occuring
conditions that will affect her ability to do daily tasks. There are likely
multiple approaches that could be taken with her and all conditions
should be factored into therapy since they will all affect it in different
ways.

17. Resources and Team Members

PT
Nursing
Diabetes specialist
Respiratory therapist
Potentially a referral to optometrist
Community resources that may be available such as diabetes support group
Driving evaluation

18. Intervention Plan

Barriers Supports
- Wants to return home where she lives alone - Motivated to return home
- No social support except for son who is likely - Animals to provide company
unreliable and depends on her and care for
- She may be resistant to change - Will go home with O2
- Pets to take care of - Used to living alone and
- Decreased vision, sensation, unsteady gait and caring for herself
strength are a concern and will affect her ability to live
alone
- Below normal score on MoCA could indicate
cognitive concerns, though cannot definitively
determine this based on score alone
- Overweight and unhealthy lifestyle habits such as

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 smoking and drinking
- May be hard to make some home modifications in
singlewide trailer
- Difficulty regulating blood sugars, may not have good
medication management
- Unsteady gait poses a safety concern
- Lives in a rural area and may not have all necessary
medical resources
- Goal of driving at night may not be a safe IADL to
return to
- Several hospital stays in recent years
Goals Approach and deficit(s) for each goal
1. LTG: By discharge, client will bathe with Mod I. Modify, restore

Decreased strength, unsteady gait,

respiratory symptoms, safety,
vision, decreased sensation

1a.STG: Within 1 week, client will wash hair and body with Modify, restore
min A, using compensatory strategies and AE.
Decreased strength, unsteady gait,
respiratory symptoms, safety,
vision, decreased sensation

1b.STG: Within 2 weeks, client will utilize pursed-lip Modify, restore

breathing techniques to manage respiratory symptoms while
bathing with no more than 2 VC for strategy use. Decreased strength, respiratory
symptoms, safety

2. LTG: By discharge, client will independently incorporate Modify, establish

diabetes self-management strategies into daily routine.
Poorly managed diabetes

2a. STG: Within 1 week, client will independently adhere to Establish

daily medication schedule using compensatory strategies.
Poorly managed diabetes

2b. STG: Within 2 weeks, client will prepare simple preferred Establish
meals, incorporating at least 2 healthy diet changes learned in
therapy. Poorly managed diabetes

3. LTG: By discharge, client will independently dress in Modify

preferred clothing using energy conservation strategies.

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 Decreased strength, unsteady gait,
respiratory symptoms, safety,
vision, decreased sensation

3a.STG: Within 1 week, client will complete UB and LB Modify

dressing with Min A, utilizing compensatory strategies.
Decreased strength, unsteady gait,
respiratory symptoms, safety,
vision, decreased sensation

3b. STG: Within 2 weeks, client will don preferred shoes while Modify
seated with Min A, using compensatory strategies. Decreased strength, unsteady gait,
respiratory symptoms, safety,
vision, decreased sensation

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19. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do? Identify Practice Based on which
Model goal(s)?
This session will take place in Wendy’s room in the
morning, before she has completed her morning Rehabilitation By discharge, client
routine. It will be focused around education and Model will independently
implementation of breathing techniques. First, I dress in preferred
will teach her about pursed-lip breathing. I will go clothing using energy
over how it is done and when it is best to use it, conservation strategies.
such as doing tasks that involve bending, lifting,
climbing stairs, or even during ADLs. I will have Within 2 weeks, client
her practice it until she seems comfortable with it, will utilize pursed-lip
and then we will implement it into her morning breathing techniques to
shower. Assistance will be provided as needed for manage respiratory
undressing, transferring into the shower, and any symptoms while
other necessary components of the task. She will be bathing with no more
provided with a long-handled sponge and any other than 2 VC for strategy
AE that may be of use, in addition to being seated use.
on a shower chair. I will provide reminders to use
pursed-lip breathing when necessary if she begins
to have respiratory symptoms and is not using the
strategies. I will have her oxygen nearby (in a safe
dry space) if she happens to experience any acute
respiratory distress or has fear of being without
oxygen.
After Wendy has finished showering and dried off,
I will go over energy conservation strategies for
self-dressing, such as remaining seated and taking
breaks as needed. I will continue to encourage her
to use the pursed-lip breathing as she works
through getting dressed. She will dress in preferred
clothing.

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2. What will you do? Identify Practice Based on which
Model goal(s)?

Today’s session will be focused around diabetes PEO, Lifestyle Within 1 week, client
education and self-management. I will ask Wendy Redesign will independently
about her current understanding of diabetes and adhere to daily
what she does to manage her symptoms and blood medication schedule
glucose. It would be important to ask what is using compensatory
contributing to her current difficulty with managing strategies.
her blood glucose and how to address it. I will then
provide her with additional information on diabetes By discharge, client
self-management, including a pamphlet that she can will independently
refer to. We will go over the importance of incorporate diabetes
medication management, monitoring blood glucose, self-management
the role of exercise, how to do her own foot checks, strategies into daily
small lifestyle changes, and healthy eating habits. I routine.
will provide her with ideas of simple ways she can
change her daily routine, such as decreasing beer Within 2 weeks, client
consumption from 3 beers/day to 2 and will prepare a simple
incorporating exercise into daily tasks. I will also preferred meal,
have her brainstorm and come up with at least 3 incorporating at least 2
small changes she believes she can make in her healthy diet changes
daily routine to have a healthier lifestyle. Using this learned in therapy.
information, we will discuss ways that she can
incorporate healthy diet changes into meals that she
typically makes at home.
While she likely has nurses that bring her
medications, I would like to go over her current
medication management during this session. We
can go over each of the prescriptions she currently
has and sort them into a pillbox. I will teach her
about strategies such as using alarms as reminders.
We will set up a plan for her to follow when she
gets home and make sure she feels comfortable and
confident with managing her medication.

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