Treatment Plan for Betty - OT Strategy

1 Diane Makovsky Treatment Plan for Betty Patient: Betty Smith DOB: 11-6-19 Admit Date to This Facility: 10-6-11. MRN: 22222 Age: 85. Roles: Parent, grandmother, great grandmother, traveler Barriers: Barriers in Client Factors: Body Functions Mental functions Anxiety Slower processing speed, but able to follow with repetition of directions Sensory functions and pain Cataract in left (L) eye Blurred images to left side of visual field Visual field loss (VFL) in peripheral vision Neuromusculoskeletal Arthritis Bilateral total hip replacement (B THR).

2 B total knee replacement (B TKR). Most all upper extremity movement restricted; specifically: o B shoulder flexion (Flex) active range of motion (AROM) restricted o B abduction (Abd) AROM restricted o B wrist Flex restricted o L elbow Flex limited o L wrist extension (Ext) limited Cardiovascular, hematological, immunological, and respiratory Hypertension Diabetic Myelopathy type II. Chronic Renal insufficiency Sleep Apnea Chronic Lower Extremity (LE) edema; currently present in L hand, 4+, and L. foot, 2+. L foot pain 4/10.

3 Digestive, metabolic, and endocrine systems Hypothyroidism Obesity Gastroesophageal Reflux Disease (GERD). Diane Makovsky Genitourinary and reproductive functions Chronic Renal insufficiency Barriers in Areas of Occupation: Bathing Dressing Bed mobility Ranges from minimum assist (Min A) to maximum assist (Max A) in all activities of daily living (ADLs). Numbness in B hands Hurrying or changes in direction of motion puts client at risk of falls Strengths: Strengths in Client Factors: Body Functions Mental functions Oriented to person, place, and date Able to follow commands after one repetition of directions Client scored 9 out of 33 on the Short Blessed Test, which is the designation for moderately impaired (with a scale of normal being 0-8; moderately impaired 9- 19; and severely impaired 20-33).

4 Client's biggest mental difficulty appears to be orienting to time, which should be monitored as it may be related to recent surgery and hospitalization. Sensory functions and pain Pursuits intact within all ranges Except for L foot, no pain reported during functional mobility and ADL tasks. Neuromusculoskeletal Grasp strength while lower than the mean for age 75+ is within one standard deviation of the norm for both hands (Flinn, Latham, & Podolski, 2008, p 173). Skin and related-structure functions No areas of concern Strengths in Areas of Occupation: Proximity, support , and offers from her daughter to help with ADLs and IADLs until client is able to complete by herself.

5 Daughter had been providing some support for ADLs and IADLs prior to surgery. Patient can read and listen to tapes. Patient can play with her grandchildren and great-grandchildren, which provides social interactions. Patient is optimistic, and looking forward to regaining abilities so as to take a trip. Diane Makovsky Client Problem Areas (most important to client). Problem/Cause Statements 1. Occupational performance: Upper body dressing Problem: Dependent (Dep). Causes: Limited AROM of B shoulder Flex (L 25 , R 50 ) and numbness and difficulty of B grasp; elbow and wrist strength As a result of: (diagnosis) Impingement of spinal cord.

6 2. Occupational performance: Lower body dressing Problem: Dep Causes: B grasp difficulties due to numbness, peripheral field loss and blurred images in L visual field, limited AROM for B shoulder Flex (L 25 , R 50 ), limited AROM for B. shoulder Abd (L 15 , R 37 ), limited AROM for B external rotation (L 52 , R 71 ). As a result of: Edema in L hand and L foot, and impingement of spinal cord that limits UE strength, and visual field loss. 3. Occupational performance: Bathing Problem: Requires Max A. Cause: Unable to reach due to limited AROM of B UE.

7 (Client is at increased fall risk, with regard to mobility, getting into and out of shower or bath due to limited UE. AROM.). As a result of: Impingement of spinal cord, which has limited UE AROM. 4. Occupational performance: Getting into bed Problem: Moderate (Mod) A bed mobility Cause: Edema present in L hand (4+) and L foot (2+), numbness and difficulty of B hand grasp, significant loss of AROM for B UE so unable to help lift legs As a result of: Impingement of spinal cord and edema. 5. Occupational performance: Client is limited in her ability to cook Problem: Due to lack of strength and UE AROM to obtain functional performance (client rates herself on Canadian Occupational Performance Measure (COPM) as a 2 on performance and 3 on satisfaction).

8 Cause: Limited AROM of B UE and strength (MMT -2 for L shoulder flexion, extension, abduction, and 3+ or less for all B UE), limited B grasp due to L hand edema and numbness, also LE impairment As a result of: Impingement of spinal cord, and accompanying loss of UE AROM and strength. Diane Makovsky Solutions to Problem Areas Upper body dressing 1: Treatment method: Use UE range of motion passive range of motion (PROM) and AROM exercises along with client's own resistive weight to increase range of motion and strength Solution: that will enable client to raise her own arms high enough to Outcome: enable client to move from threading arms to donning a cardigan, blouse, or other open-fronted UE garment.

9 2: Treatment method: Educate client how to don a pullover shirt, by putting a sleeve over one arm first, in an energy efficient and methodically way, (A good description is provided by Ryan and Sullivan (2011, p. 725) for those recovering from stroke. Although client has not suffered a stroke, she has limited B UE AROM and so dressing one arm at a time may be a good way of conserving energy.). Solution: will give the client an adaptive technique to make it easier to Outcome: enable client to dress her own upper body.

10 Lower body dressing 1: Treatment method: Educating the client in how to use a reacher Solution: will enable putting the sock or trouser leg on an adaptive device Outcome: so as to gain control of the clothing to enable maneuvering foot into clothing, either sock or trousers, to begin the lower dressing process. Success will be getting both feet through trouser bottoms. 2: Treatment method: Implement the Lighthouse Strategy (Gillen & Rubio, 2011, p. 517) with the client Solution: to teach her to watch out for items to her left side and those in her peripheral- vision-loss areas Outcome: so she will be able to adapt to partial loss of peripheral vision and limitation in neck movements and so be more independent showing general improvement in ADLs such as walking without bumping into things.