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Treatment Plan: Case Study #1 “Sam”

Haley Kabo

Department of Occupational Therapy, Duquesne University

OCCT 530 Biomechanical Function

September 21, 2020

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Guiding Conceptual Framework

Both the Biomechanical and Rehabilitation Frames of Reference will be used in order to

guide Sam’s intervention. In the Biomechanical Frame of Reference, areas such as “range of

motion (ROM), strength, and endurance to perform daily life tasks” are addressed (Cole, 2018, p.

163). This applies to Sam due to his significant loss of endurance as a result of his acute

congestive heart failure (CHF). Because the Biomechanical Frame of Reference is remediation

focused, components of Sam’s intervention will aim to restore his loss of strength and endurance

to subsequently restore his function (Cole, 2018). By directly treating his activity tolerance, Sam

will be able to participate in occupations that he has lost function in such as grooming, toileting,

and dressing, which will ultimately increase his independence. In addition to the Biomechanical

Frame of Reference, the Rehabilitation Frame of Reference will also be used. In this frame of

reference, adaptations to areas of movement, strength, and endurance are made in order to

“maximize the level of recovery” (Cole, 2018, p. 164). These adaptations can include providing

the individual with adaptive equipment, altering the task demands, or altering the environment

the task occurs in (Cole, 2018). Due to Sam’s lack of endurance, utilizing these compensatory

strategies to make up for what cannot be remediated during intervention will decrease the

amount of effort that is required for him to engage, and subsequently allow him to complete the

occupations he needs and wants to do, particularly ADLs and his occupation of a computer

programmer.

In addition to the Frames of Reference discussed above, the Ecology of Human

Performance (EHP) Model of Practice will be used to guide Sam’s intervention. In EHP, a

variety of unique person factors interact with the context the individual is in to ultimately

determine if and how they engage in tasks (Dunn, 2017). The interaction between the person and
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their context creates a performance range, or the “number and type” of tasks a person can engage

in (Dunn, 2017, p. 212). While before Sam was previously independent in all daily life functions,

he is now dependent on most things, including his basic ADLs. This change due to his CHF

caused a significant decrease in the size of his performance range because he is unable to

perform a variety of tasks; what was once a typical performance range is now extremely narrow.

By focusing intervention on expanding his performance range, whether that be through

remediation or compensatory factors such as adaptive equipment, Sam’s ability to participate in

required and desired occupations will increase. By designing intervention through the EHP lens,

the OT will be able to expand his performance range to tasks that are important to him, and thus

be client centered.

Strengths and Weaknesses

Sam’s strengths include:

1. Optimistic and motivated about rehab program

2. Was previously independent in all daily life functions

3. Has close relationship with his 3 grown children

4. Computer programming job does not require high physical demand

Sam’s weaknesses include:

1. Current diagnosis of acute CHF

2. PMHx of multiple myocardial infarctions, hypertension, obesity, smoking 2 packs of

cigarettes per day, and Cdiff/MRSA

3. Is on 4 liters of oxygen

4. Has abnormal laboratory values and vital signs

5. Has edema in the LE

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6. Lives alone in a 2-story home

7. Does not exercise regularly

8. Exhibits poor diet/nutrition

9. Is recently divorced which may have emotional implications

10. Computer programming job promotes sedentary lifestyle

Biomechanical Problem List

● Low activity tolerance

○ Shortness of breath

○ Fatigue

● Loss of strength and ROM in the UE

● Loss of ability to engage independently in daily occupations

○ Grooming

○ Toileting (utilizes bed side commode)

○ Transfers

○ Bathing

○ Dressing

○ Functional mobility

Problem/Weakness Assessment Rationale Results

Abnormal vitals and Taking vitals and Before engaging in therapy, it is
lab values reviewing lab important that the OT reviews both
report the lab reports and vital signs to
ensure it is safe for Sam to
participate. Both lab values and
vitals contain pertinent information
to Sam’s health, and engaging in
therapy without precautions when
these values are outside of range can
Vitals
HR
Norm: 60-100 bpm
Sam: 124 bpm while eating
breakfast
Interpretation: Because this is
slightly above normal range, the
OT will check with the RN
before proceeding with therapy.

be extremely dangerous. Therefore,
the OT will ensure that all values are
within therapeutic range and that
precautions are taken when
necessary. Furthermore, because of
Sam’s current medical state and the
fact that physical movement can
significantly alter his vital signs,
vitals will be taken and recorded
during and after therapy as well,
with the OT altering or
discontinuing therapy as necessary.
5
RR:
Norm: 14-20 breaths per minute
Sam: 29 breaths per minute
Interpretation: Sam’s breathing is
labored and should be monitored
throughout therapy for shortness
of breath.
BP:
Norm: 100-140/60-90
Sam: 160/70
Interpretation: Sam has
hypertension systolic. His blood
pressure will be measured
throughout the session to ensure
safety, and he will be monitored
for signs of overexertion as well
as orthostatic hypotension when
changing positions.
Oxygen:
Norm: >95%
Sam: 89% on 4 L of oxygen
while eating breakfast
Interpretation: This slightly low
percentage indicates the
importance of Sam’s
supplemental oxygen. The OT
will ensure Sam has his oxygen
on properly throughout the
session and will monitor his
levels, as well as skin color,
dizziness, shortness of breath,
etc. regularly to ensure safety.
Lab Values
H/H
Norm: >10 g/dL / > 30%
Sam: 8.0 g/dL / 25.2%
Interpretation: Because both
hematocrit and hemoglobin
values are below normal, this
indicates that Sam should only
engage in light exercise.
PT/INR
Norm: 11-12.5 seconds / 0.9-1.1
Sam: 15 seconds / 2.3
Interpretation: Sam’s out of
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range PT/INR indicates that he is

at risk for bleeding. For this
reason, ADLs such as shaving
should not be addressed, and he
should be monitored closely to
avoid bumps and falls.
K
Norm: 3.5-5.0 mEq/L
Sam: 3.4 mEq/L
Interpretation: Slight changes in
potassium levels can be
impactful. Because Sam is
slightly below normal range, he
will need to be cleared by the RN
before engaging in therapy.
During therapy, he will be
monitored for signs of
hypokalemia such as dizziness
and hypotension.
Glucose
Norm: 70-110 mg/dL
Sam: 359 mg/dL
Interpretation: Because Sam is
above 350 mg/dL he is at risk for
diabetic ketoacidosis, and OT
should be held. The following
treatment plan represents a
session after Sam’s values have
returned to within normal range
and he has been cleared by
medical staff.

(Irion, 2004)

Low activity 15 Count Due to the variety of symptoms that 15 Count Breathlessness Score
tolerance Breathlessness Sam experiences in regards to his At rest in supine: 3 breaths
Score low activity tolerance, the OT will At rest EOB sitting: 5 breaths
use 3 quick assessments to gather
Fatigue Severity data on each of the different FSS
Scale (FSS) components he experiences. Score: 48
Interpretation: In FSS, the higher
Borg Scale of The 15 Count Breathlessness Score the score, the more severe the
Perceived Exertion was chosen because it is quick, easy fatigue is and the more it impacts
to administer, and reliable (Williams one’s daily life (Radomski &
et al., 2006). The assessment will Roberts, 2014). The highest
quantify Sam’s breathlessness by score one can get is 63, therefore
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counting the amount of breaths it Sam’s 48 indicates that fatigue

takes for him to count to 15 heavily impacts his life and
(Williams et al., 2006). The ability to participate, and is
assessment will give the OT a something that should be
general idea of how severe his addressed in therapy.
breathlessness is, and because it is
practical and simple, it can be done Borg
at any time in order to continuously Where 6 is no effort at all and 20
monitor his breathlessness. is absolute maximal effort
Feeding: 13
The FSS was chosen in order to gain Moving from wheelchair to bed
a better understanding of the impact and return: 15
fatigue has on Sam. The FSS was Grooming: 12
chosen over other fatigue Getting on and off toilet: 14
assessments because it is a self Bathing self: 15
report, quick to administer, and Walking on level surface: 15
relates fatigue to function by having Dressing: 16
him rate nine statements for EOB Sitting: 14
agreement based on his condition
within the past week (Radomski &
Roberts, 2014). By relating his
fatigue to function, the assessment
will give the OT a better
understanding of how his current
state is impacting his ability to
participate in the occupations he
needs and wants to do (Radomski &
Roberts, 2014).

The Borg Scale of Perceived

Exertion was chosen in order for the
OT to gain a general understanding
of Sam’s perceived exertion when
performing tasks. By understanding
how exerted Sam feels when
performing tasks, the OT will be
able to gauge not only the severity
of his low activity tolerance, but
also what specific activities cause
the most fatigue (Whelan, 2014). In
addition, this scale in specific was
chosen because it has been found to
correlate to heart rate, so by
periodically asking Sam to use this
scale throughout activities, the OT
can monitor for safety and

determine if Sam should continue
(Whelan, 2014). Because a client is
asked to rate their exertion with the
Borg scale while they are doing an
activity, this assessment will be used
during the Barthel as well as
throughout therapy as needed.
Loss of strength and Functional upper Due to Sam’s exacerbation of
ROM extremity AROM congestive heart failure, he may
and strength present ROM and strength
screening limitations as a result of his fatigue,
shortness of breath, etc. Because
these limitations are most likely
more generalized as opposed to a
specific area (such as the wrist), a
screening will be more appropriate
as opposed to taking specific
measurements of every area
(Whelan, 2014). The OT will guide
Sam with verbal and physical
explanations through an UE ROM
screening, which will provide
information on available motion,
symmetry of motion, and time it
takes to complete motion, all of
which are important when these
motions occur during functional
tasks (Whelan, 2014). The OT will
also observe Sam performing
various life tasks during the Barthel
where observations on his ROM and
strength abilities will be taken,
particularly observing to see if they
are sufficient for functional tasks
that Sam must perform. Motions of
the ROM or strength screening that
involve holding the UE above the
head or moving the UE laterally will
not be performed, and no resistance
will be applied due to his phase 1
status.
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During AROM Screening
Shoulder flexion and abduction,
shoulder horizontal abduction
and adduction, and external
rotation were not performed by
Sam during the screening
because of his phase one status.
Elbow flexion and extension:
Within functional limits
Forearm supination and
pronation: Within functional
limits
Wrist flexion and extension:
Within functional limits
Finger flexion and extension:
Within functional limits,
however occurred at a slower
than typical speed and required
increased attention
Finger opposition: Within
functional limits, however
occurred at a slower than typical
speed, required increased
attention including maintaining
eyesight on his fingers at all
time, and could only be
performed one hand at a time
During Barthel
Both functional strength and
ROM were observed during the
Barthel Index assessment.
Throughout the tasks he could

Loss of ability to Barthel Index of The Barthel Index was chosen as an
engage in daily ADL observation/performance based
occupations measure in order to assess Sam’s
ability to perform a variety of
ADLs. By watching Sam perform a
variety of ADLs, the assessment
allows the OT to quantify his level
of dependence through scoring, as
well as make clinical observations
on his abilities and deficits (Furphy
& Stav, 2014). Based on his
performance in regard to his score
obtained, clinical observations such
as available ROM and strength
available while completing the
tasks, and his self-reported feeling
of exertion by using the Borg Scale,
the OT will obtain information that
will help guide where to focus
treatment.
Goals
LTG: Client will increase activity tolerance to 3 minutes in order to complete upper body
dressing while EOB sitting with modified independence of a dressing stick in 5 days.
STG 1: Client will thread his arms through an open-front shirt accurately ¾ times for upper body
dressing with minimal assistance in 3 days.
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perform, ROM appeared to be
within functional limits and did
not impede him from engaging.
During tasks such as grooming
and dressing, strength was
sufficient enough to assist during
tasks, however could not be
sustained for more than 1 minute.
Feeding: 5
Moving from wheelchair to bed
and return: 5
Grooming: 0
Getting on and off toilet: 5
Bathing self: 0
Walking on level surface: 10
Ascend and descend stairs: 0
Dressing: 5
Controlling bowels: 10
Controlling bladder: 15
Total Score: 55/100
Sam’s total score indicates that
he has severe dependence
(Furphy & Stav, 2014). During
the dressing component of the
assessment, Sam verbally
expressed frustration and
embarrassment that he “can’t
even dress himself on his own”
anymore.
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STG 2: Client will utilize the pursed-lip breathing technique ⅔ times when it is needed while

engaging in UB dressing with the supervision of no more than 2 verbal cues in 2 days.

Intervention

Because Sam has C diff and MRSA, Sam will be under contact precautions. Due to this,

the OT will wash his/her hands and don PPE before entering his room. This includes donning a

gown which protects the front of the body, and will be tied at the back of the neck and waist,

ensuring that it is closed. The OT will then don gloves which will go over top of the gown

sleeves. Finally, the OT will wear a mask and facial shield.

Before engaging in therapy with Sam, the OT will obtain his vital signs to ensure that

there are no contraindications for him to participate in therapy. Utilizing the appropriate

equipment, the OT will take and document his heart rate, respiration rate, blood pressure, and

oxygen levels. In order to take his heart rate, the OT will press lightly on the inside of Sam’s

wrist (at the radial artery) with the 2nd and 3rd digits (Huntley, 2014). The OT will count the

number of beats per 10 seconds and multiply this number by 6 in order to get beats per minute

(Huntley, 2014). Without announcing that he/she is measuring respirations, the OT will observe

the number of times Sam’s chest rises for 15 seconds, multiplying by 4 to obtain breaths per

minute. In order to take his blood pressure, the OT will utilize a blood pressure cuff and

stethoscope. The stethoscope will be placed on the brachial pulse at the client’s preferred elbow,

and the cuff will be wrapped around his bicep area (Huntley, 2014). After ensuring that the valve

of the pump is closed, the OT will inflate the cuff above the systolic pressure of 200 mm Hg and

slowly open the valve to release the pressure (Huntley, 2014). Where the needle is when the first

pulse heard will be the systolic pressure, and where the needle is when the pulse sound stops is
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the diastolic pressure (Huntley, 2014). Finally, in order to obtain Sam’s oxygen levels, the OT

will simply place a pulse oximeter on Sam’s index finger and read and interpret the percentage

given (Huntley, 2014). Vitals will also be taken during and after treatment to ensure Sam’s

safety, and any concerns will be documented and reported. In addition to vitals, the OT will also

review Sam’s lab values and interpret them (which has been done in the assessment chart) before

beginning the session.

In order to prepare Sam for occupational performance, the OT will educate him on the

pursed-lip breathing technique. This technique will be used in order to reduce the shortness of

breath he experiences by slowing the pace of his breathing and making each breath more

effective. Furthermore, in a randomized controlled trial by Hochstetter et al., it was found that

incorporating breathing techniques such as the pursed-lip method into the treatment of patients

with cardiovascular (among other) pathologies who are experiencing shortness of breath can

have a positive effect on the patients’ perceived breathlessness (2005). This finding supports the

OT’s choice to teach this technique to Sam as a reduction in the shortness of breath he

experiences will ultimately increase his ability to participate in his needed occupations,

particularly ADLs. In order to teach Sam this technique, the OT will first explain that the

purpose is to reduce the occurrence of shortness of breath, so he is better able to do the things he

needs to do. The OT will inform him that he can use this technique any time he feels short of

breath when engaging in activities such as dressing, grooming, and bathing. The OT will then

verbally explain to Sam the steps of pursed-lip breathing, stating that he should relax his

shoulders and breathe in for two counts through his nose, and then breathe out for four counts

through his mouth repeatedly (Huntley, 2014). Following the verbal explanation, the OT will

demonstrate the breathing technique, ask Sam if he understands, and then confirm by having him
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demonstrate himself. The OT will correct any mistakes to ensure understanding. Finally, the OT

will provide Sam with an informational sheet with the steps to pursed-lip breathing, and remind

him that this technique cannot only be used today during therapy, but also any time he feels short

of breath so he can safely complete daily tasks at home.

After educating Sam on the pursed-lip breathing technique, the OT will engage him in the

purposeful activity of transferring from supine to sitting at the edge of the bed using a log roll

technique. This purposeful activity was chosen for Sam as it allows him to be in a functional

position that is necessary not only for the focus of this session which is upper body dressing, but

other functional activities such as grooming and preparing to stand. Furthermore, in a study by

Ceridon et al., it was found that there is a relationship between postural changes and pulmonary

function, particularly in patients with heart failure (2011). Specifically, patients with CHF in the

supine position have a decline in pulmonary function due to “airway resistance, bronchial

obstruction and expiratory flow limitation” (Ceridon et al., 2011, p. 269). This supports the OTs

decision to bring him into a sitting position as it eliminates these factors thus directly addressing

his shortness of breath, while also placing him in a functional position required to engage in

upper body dressing. Before bringing him into the sitting position, the OT will ask Sam if he is

experiencing any pain and if he feels okay to sit at the edge of the bed. The OT will then explain

to Sam how the transfer will occur, telling him that he will turn his head towards the OT in the

direction that he will be rolling, cross his arms over his chest, bend his legs, roll onto his side,

swing his legs over the edge of the bed, and use his elbows to come up into a sitting position if

possible, ensuring him that the OT will provide assistance as needed. Before engaging in the

transfer, the OT will ensure that the path is clear and that he/she is utilizing proper body

mechanics including bending at the knees and using a wide base of support. Because of his
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weight, an additional person may be required to help carry out the transfer. During the transfer,

the OT will verbally guide Sam and allow him to perform what he can on his own, but provide

support where necessary by using key points of control at the shoulder and pelvic girdle. During

the transfer the OT will also remind Sam to utilize the pursed-lip breathing technique as needed,

and simultaneously monitor him for symptoms of orthostatic hypotension.

Once Sam is EOB sitting, the OT will begin engaging him in the occupation of upper

body dressing. This occupation was chosen for Sam as it is a necessary daily task for him to be

able to complete once he returns home. In addition, it was reported that in the ICU he

experienced increased fatigue when dressing, and Sam particularly expressed frustration when

dressing during the Barthel assessment, making it an important task to work on during therapy.

In a study by Norberg et al., it was found that in persons with CHF, fatigue negatively impacted

the ability to engage in ADLs, which Sam is experiencing (2017). However furthermore, the

study found that individuals with CHF can benefit from learning energy conservation strategies

to manage ADLs, which subsequently can improve independence and quality of performance

(Norberg et al., 2017). This finding supports the OTs decision to engage Sam in upper body

dressing because it provides the OT with the opportunity to educate Sam on energy conservation

techniques while actually performing the occupation, which can ultimately result in increased

independence and quality of performance. The OT will begin by educating Sam on energy

conservation techniques to use when dressing, such as storing clothes within reach, gathering

clothes beforehand, choosing shirts that have open fronts so the shirt does not have to be pulled

over the head, and choosing clothing that is lightweight and loose fitting. Sam will be informed

that these techniques will help him conserve energy and reduce the amount of fatigue and

shortness of breath he feels while dressing. The OT will then have Sam choose an open front
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shirt that he would like to wear for the day. Sam will then thread his arms through the shirt

sleeves independently, while the OT brings the shirt around his back. The OT will provide extra

assistance as needed, but will allow Sam to do as much as he can independently. Sam will then

button up the shirt, with the OT providing hand over hand assistance as needed. Throughout the

dressing task, the OT will also remind Sam to use the pursed-lip breathing technique and take

breaks as necessary. In order to grade up this occupation, Sam can put on a pull-over shirt

instead of an open front shirt. In order to grade it down, Sam can put on an open front shirt that

closes via Velcro instead of buttons.

Once the session is complete, the OT will transfer Sam from EOB sitting back into supine

on his bed. In addition, the OT will doff and dispose of the PPE appropriately and wash his/her

hands before exiting the room.

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References

Ceridon, M. L., Morris, N. R., Olson, T. P., Lalande, S., & Johnson, B. D. (2011). Effect of

supine posture on airway blood flow and pulmonary function in stable heart failure.

Respiratory Physiology & Neurobiology, 178(2), 269-274. https://doi.org/10.1016/

j.resp.2011.06.021

This article was used in order to inform the purposeful activity of transferring Sam from

supine to EOB sitting. It provided evidence about the possible respiratory issues for CHF

patients in supine, thus providing support for bringing Sam into EOB sitting.

Cole, M. (2018). The behavioral cognitive continuum. In M.B. Cole (Ed.), Group dynamics in

occupational therapy: The theoretical basis and practice application of group

intervention (4th ed., pp. 155-180). Slack Incorporated.

This source was used in order to provide support as to why both the Biomechanical and

Rehabilitation Frame of References should be used with Sam, including information on

what each Frame of References focuses on.

Dunn, W. (2017). Ecological model of occupation. In J. Hinojosa, P. Kramer, & C.B. Royeen

(Eds.), Perspectives on human occupation: Theories underlying practice (2nd ed., pp.

207-235). F.A. Davis Company.

This source was used in order to support the use of the Ecology of Human Performance

Model of Practice with Sam. It provided information on how the person, context, and task

all interact to create a performance range, which was then applied to Sam and his current

condition.
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Furphy, K., & Stav, W. (2014). Assessments for ADLs and IADLs, including driving. In E.

Asher (Ed.), Asher’s occupational therapy assessment tools (4th ed., pp. 155-235).

American Occupational Therapy Association.

This source was used in order to learn how the Barthel Index of ADLs is administered,

scored, and what it assesses for in order for it to be applied to Sam.

Hochstetter, J. K., Lewis, J., & Soares-Smith, L. (2005). An investigation into the immediate

impact of breathlessness management on the breathless patient: Randomised controlled

trial. Physiotherapy, 91(3), 178-185. https://doi.org/10.1016/j.physio.2004.11.003

This source was used in order to support teaching Sam the pursed-lip breathing technique.

The article found that breathing techniques are beneficial for patients similar to Sam, and

was thus used in order to support the OTs choice in preparatory activity.

Huntley, N. (2014). Cardiac and pulmonary diseases. In M.V. Radomski & C.A. Trombly

Latham (Eds.), Occupational therapy for physical dysfunction (7th ed., pp. 1300-1326).

Lippincott Williams & Wilkins.

This chapter was utilized in order to inform how to correctly take the necessary vitals on

Sam throughout therapy.

Irion, G. L. (2004). Lab values update. Acute Care Perspectives, 13(1), 2-15.

This article was used in order to obtain the normal values and interpretations of vitals and

lab reports in order to better understand Sam’s current condition and readiness for

therapy.
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Norberg, E. B., Lofgren, B., Boman, K., Wennberg, P., & Brannstorm, M. (2017). A client-

centred programme focusing energy conservation for people with heart failure.

Scandinavian Journal of Occupational Therapy, 24(6), 455-467. https://doi.org/10.1080/

11038128.2016.1272631

This article was used in order to support the OT’s choice in teaching Sam energy

conservation techniques to utilize when he is dressing, as it was found that patients with

heart failure may benefit from such techniques.

Radomski, M.V., & Roberts, P. (2014). Assessing context: Personal, social, cultural and payer-

reimbursement factors. In M.V. Radomski & C.A. Trombly Latham (Eds.), Occupational

therapy for physical dysfunction (7th ed., pp. 50-75). Lippincott Williams & Wilkins.

This chapter was used in order to understand how the FSS is administered and interpreted,

as well as to explain why it would be a useful assessment to use with Sam.

Whelan, L. R. (2014). Assessing abilities and capacities: Range of motion, strength, and

endurance. In M.V. Radomski & C.A. Trombly Latham (Eds.), Occupational therapy for

physical dysfunction (7th ed., pp. 144-241). Lippincott Williams & Wilkins.

This chapter was used in order to understand the Borg Scale of Perceived Exertion, as well

as how, when and why an AROM screening would be used as opposed to formal

goniometry.

Williams, M., De Palma, L., Cafarella, P., & Petkov, J. (2006). Fifteen-count breathlessness

score in adults with COPD. Respirology, 11(5), 627-632.

https://doi.org/10.1111/j.14401843.2006.00895.x
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While this article refers to adults with COPD, it was used in order to describe how the 15

Count Breathlessness Score is administered, as it is administered the same way despite

diagnosis.

Database Search Terms Limits Total Hits # Selected

Google Scholar "fifteen-count None 52 1

breathlessness score"
AND adults

CINHAL (shortness of breath None 13 1

OR dyspnea OR
breathlessness) AND
(pursed lip breathing
OR PBF) NOT COPD

Google Scholar (congestive heart Within the 17,400 1

failure OR CHF OR last 10
heart failure) AND years
(supine to sit OR
sitting OR body
position)

OTDBASE heart failure AND None 3 1

energy conservation