Interpreting Evaluation- Margie

Student Name: Katelyn Hennis

Review the results of the initial evaluation and the home evaluation. Take note of
anything that could be a possible concern for this patient.

1. Utilizing the results of the evaluations identify what deficits are affecting
Margie’s performance. What aspects of the functional tasks might be difficult for
Margie upon returning home? Identify at least two in each area, describing
potential performance difficulties. Identify what deficits might be contributing to
the task difficulty (performance skills, body structure/function, context) and what
you saw in the documents provided to support these findings.

ADL Describe performance Contributing deficits

Difficulty
1. LE Dressing  Dependent with Performance skills:
putting on TED hose Stabilizes, lifts, transports,
 Dependent with reaches, endures
tying shoes
 Max assistance Body structures:
required for donning Pain: 4/10 reported
pants and shoes joint mobility: ROM R LE,
 Limited mobility R UE
and ROM in right muscle power
knee could impair muscle endurance
ability to don and Involuntary movement
doff LE clothing reactions: might have
 Reported pain in impaired postural support
right knee while trying to balance
 Shouldn’t force R
knee to bend for LE Contexts:
dressing due to Products: lack of adaptive
possible post-op equipment in the home
precautions
 Only able to stand
for 1 minute.
 Limited R UE
mobility and
strength my limit
how much
assistance her UE
can provide w/
dressing
 2. Toileting  Only able to stand Performance skills:
for 1 minute, which stabilizes, lifts, reaches,
limits the amount of aligns, coordinates, endures
time to carefully
remove pants while Body structures:
standing Pain: 4/10 reported
 Impaired R UE Joint mobility: ROM R LE,
mobility and R UE
strength impacts Muscle power
ability to remove Muscle endurance
pants Involuntary movement
 Pain and limited reactions: balance
ROM in R knee
impacts standing, Contexts:
and clothing Products: lack of adaptive
removal equipment in the home
 Lack of stability and
limited weight
baring; requires
mod. Assistance

IADL Describe performance Contributing deficits

Difficulty
1. Household cleaning  Moderate assistance Performance skills:
required for house Stabilizes, lifts, reaches,
cleaning coordinates, endures,
 Difficult to transports
maneuver around
the house with Body Structures:
carpeting and use of Pain: 4/10
either FWW or W/C Joint mobility: ROM R LE,
 Cannot stand for R UE
longer than 1 minute Muscle power
without resting Muscle endurance
 Does not have full Involuntary movement
ROM in R UE, reactions: balance
which could make
cleaning tasks Contexts:
difficult Products: lack of adaptive
equipment at home
Indoor and outdoor human
made environments: carpet,
throw rugs, crowded and
cluttered areas
 2. Yard  Primarily dependent Performance skills:
work/gardening on a W/C for Stabilizes, lifts, reaches,
mobility endures, bends, moves
 Cannot stand for
more than 1 minute Body structures:
due to balance, Pain: 4/10
making outside Joint mobility: ROM R LE,
uneven surfaces R UE
difficult Muscle power
 Limited ROM and Muscle endurance
possible no Involuntary movement
excessive bending interactions: balance
precautions with R
knee, which could Contexts:
make stairs difficult Physical geography:
 Pain in R knee possible uneven ground
 Limited ROM in R near garden
UE impacting Products:
various gardening Lacks adaptive equipment
tasks for gardening tasks
Outdoor environment:
Lacks W/C accessible
access to the garden

Productivity Describe performance Contributing deficits

(work/volunteer) Difficulty
1. Part time job as a  Pain in right knee Performance skills:
cashier  Can’t stand for stabilizes, reaches, lifts,
longer than 1 minute moves, endures
 Limited ROM in R
UE could limit tasks Body Structures:
required at her job Pain: 4/10
 Relies on a W/C for Joint mobility: ROM R LE,
longer distance R UE
mobility Muscle power
 Cannot currently Muscle endurance
drive to occupation Involuntary muscle
 Requires Mod. interactions: balance
assistance for
transitions Contexts:
Indoor environment: Drug
store may lack W/C
accessible access and work
 areas
Support: may not have
anyone at work who can
provide mod. assistance
during transfers

 Pain in R knee may Performance Skills:

impact motivation to stabilize, endures
2. Volunteer work with attend
church group  R LE limited ROM Body Structures:
 Endures standing for Pain: 4/10
1 minute, which Joint mobility: ROM R LE,
impacts any tasks R UE
that require standing Muscle endurance
 Limited R UE ROM Involuntary muscle
 Relies on W/C for interaction: balance
longer stints of
transportation Contexts:
 Requires moderate Support: dependent on
assistance for someone being available to
transitions transport her and help with
transitions
Outdoor environment:
possible uneven surfaces
and lack of W/C accessible
environments
Indoor environment:
possible lack of W/C
accessible environments and
adaptive equipment

Socialization Describe performance Contributing deficits

Difficulty
1. Peer group  The limited ROM in Performance skills:
participation (bunco her dominant R UE stabilizes, reaches, endures
group) may limit her ability
to roll the dice or Body structures:
reach across the Pain: 4/10
table Joint mobility: ROM R LE,
 Transporting herself R UE
to game night is Muscle endurance
impacted by not Involuntary muscle
driving and the need interaction: balance
for mod. Assistance
 with transfers Contexts:
 W/C dependent with Support: may not be anyone
longer distances to help transport her to
 Pain may impact game night
motivation to Products: lack of adaptive
participate equipment to help her play;
location of game night may
lack W/C accessibility
Indoor environment: may
lack W/C accessible door
frames, entrances, or spaces
2. Community  W/C dependent with Performance skills:
participation (church longer distances stabilizes, endures
every Sunday)  Pain may impact
motivation to attend Body structures:
 Unable to drive Pain: 4/10
 Mod. assist needed Joint mobility: ROM R LE,
for transfers R UE
 Cannot stand for Muscle endurance
longer than 1 minute Involuntary muscle
interaction: balance

Contexts:
Support: may not be anyone
to help transfer her to
church and provide CG
assist when needed
Outdoor environment: could
have uneven surfaces and
lack W/C accessibility

Community Access Describe performance Contributing deficits

Difficulty
1. Driving  R knee has limited Performance skills:
mobility and may be stabilize, moves, reaches,
in a brace post- endures
surgery that prevents
safe driving Body structures:
 Pain in R knee Pain: 4/10
 W/C dependent for Joint mobility: ROM R LE,
long distances R UE
(getting to her car Muscle endurance
from her house and Muscle power
from her car to her Involuntary muscle
 destination) interactions: balance
 Decreased ROM in
R UE may impact Contexts:
driving ability Products: lack adaptive
 Need for mod. equipment needed to drive
Assistance during and effectively get into and
transitions to and out of the car
from her W/C Car may not be W/C
accessible
Outdoor environment:
uneven surfaces, steps, and
home lacks W/C accessible
entrances and exits
Support: someone will be
needed to provide assistance
with transitions
Products and technology:
personal indoor and outdoor
mobility and transportation
equipment

2. Public transportation  R knee has limited Performance skills:

(may want to use mobility and may be stabilize, endures
this if car is not an in a brace post-
option; this will also surgery, which Body structures:
be impacted by impacts mobility Pain in knee: 4/10
deficits)  Pain in R knee Joint mobility: ROM R LE,
 W/C dependent for R UE
long distances Muscle endurance
(getting to a public Muscle power
transit location and Involuntary muscle
from that location to interactions: balance
her destination)
 Need for assistance Contexts:
during transitions to Outside environments:
and from her W/C access to public transit
might have uneven surfaces
or difficult terrain to
navigate
Products and technology:
personal indoor and outdoor
mobility and transportation
equipment; W/C accessible
transportation services
 3. How would you prioritize your concerns? What areas could you reasonably
address given this treatment setting, the projected length of stay, and frequency of
treatment Justify your answers.

I would first address toileting because it is an important ADL and strategies could be
taught and practiced in the four-day time frame to help Margie become fully independent
with this occupation. I would then encourage the balance and undressing strategies
developed for toileting for LE dressing. Working on Margie’s stability and developing
strategies, which will help her safely complete ADLs, but will also be generalizable to
other household tasks will be the focus

The time frame I have to work with Margie totals four hours and spans four days. This is
a very limited amount of time, which is why I think the focus should be on ADLs that she
will have to perform daily. Some of the strategies that will be taught and practiced during
her time in therapy will be generalizable by targeting her stability and how to complete
tasks with post-op precautions and limited ROM.

4. Document a brief summary of the evaluation results as you might present them in
a treatment team meeting.

Margie is a 60-year-old female who is on the rehab floor after a R TKA. After an
initial evaluation I found Margie to be independent with most ADLs; however, her
impaired stability and limited ROM are impacting her ability for LE dressing and
toileting. ROM is limited in her R knee due to the TKA. It is also impaired in her R UE,
which may be limiting her ability to reach and interact with task objects. Transfers are
currently requiring moderate assistance and SBA is needed while ambulating short
distances. She can currently endure one minute of standing, which is impacting her
ability to complete tasks such as LE dressing, doffing pants while toileting, and
household management tasks. Her impaired standing will also impact her ability to
independently navigate her home upon discharge. Limited standing and possible post-op
precautions require her to use a W/C most of the time. Other IADLs, socialization
involvements, and community access has been impacted by her current ability level and
should be focused on during home health or outpatient therapy after discharge. A home
evaluation has also been conducted and her home will require modifications to be W/C
accessible and safe for her return. Adaptive equipment should also be provided along
with education on AE use.