Taylor MacWhade

OCCTHER 7270
OT 7270

Individual Intervention Plan

Assignment Objective: Students will complete an intervention plan for a case study. In this assignment, students will
report the history and interview results, the results and interpretation of the evaluation, and using the attached form,
develop an intervention plan for their patient. This is assignment is a continuation of the skills that students learned in
OT 6210. Be sure to look back on the lectures, assignments, and feedback that was provided in OT 6210 for successful
completion of this assignment.

Occupational therapy evaluation and intervention plan:

Use the information from the case study to complete the evaluation report section (Background information,
Assessments performed, Findings, and Interpretation). If the information required for each section is not stated in the
case study, then complete the section with logical information that would be expected to be seen from that specific
condition.

The format and example of the occupational therapy evaluation and intervention plan is on page 129 of Sames book.

Assessments performed: This is an extensive list of assessments that could be completed with this client. Include
assessments that were mentioned in the case study, as well as assessments that could be completed that are
appropriate for this condition and case study.

Findings

Occupational Profile: Complete a 4-5 sentence paragraph the describes the occupational profile

Areas of Occupation: Provide a 4-5 sentence paragraph of a summary of the client’s performance in areas of occupation.
For each area of occupation (Ex: bathing, toileting, etc.) provide a 1-2 sentence description of the client’s performance. If
the area occupation of was not tested or there is no limitation in these areas, describe why.

Performance Skills: Provide a 4-5 sentence paragraph of a summary of the client’s presentation in performance skills. For
each performance skill (Ex: posture, balance, etc.) provide a 1-2 sentence description of the client’s performance. If the
performance skill was not tested or there is no limitation in these areas, describe why.

Client Factors: Provide a 4-5 sentence paragraph of a summary of the client factors. For each body function and body
structure (Ex: Attention, distractibility, head, neck etc.) provide a 1-2 sentence description of the client’s performance. If
the client factor area was not tested or there is no limitation in these areas, describe why.

Contexts: Provide a 4-5 sentence paragraph of a summary of the contexts.

Interpretation

Strengths: From the information that was stated in the background information and findings, provide a 4-5 sentence
paragraph of a summary of the strengths of the client

Areas in need of intervention: From the information that was stated in the background information and findings, provide
a 4-5 sentence paragraph of a summary of the areas in need of intervention for this client
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Supports to occupational performance: From the information that was stated in the background information and
findings, provide a 4-5 sentence paragraph of a summary of the supports that this client has to complete occupational
performance

Hindrances to occupational performance: From the information that was stated in the background information and
findings, provide a 4-5 sentence paragraph of a summary of the hindrances that this client has to complete occupational
performance

Intervention Plan

All Patient Problem Areas: Provide an extensive list of all of the problem areas that could be addressed with client in the
case study

Priority Occupations to Address During Intervention: Pick two priority areas to address with this client. Be sure to review
from OT 6210 what an appropriate priority occupation to address would be.

STG and LTG: Provide 2 long-term goals and 2 short term goals for each LTG (total of four short term goals) in the ABCD
format (Sames pages 143 – 144). Be sure to review from OT 6210 what an appropriate goal is for the physical
rehabilitation population. Goals MUST be occupation centered and linked to the priority occupation to be address during
interventions.

Intervention Activities: Provide 4 treatment activities for each priority occupation to address. Be sure to review from OT
6210 what appropriate intervention activities could be used. These are activities that you could complete in a full
therapy session (30 – 60 minutes).

Intervention Strategy/Method: For one of the intervention activities provided in the intervention plan, describe in a few
sentences the strategy/ method that is appropriate, and expand on how it would be utilized with this client. This is
where you explain WHY you chose to complete the intervention activity with the client if someone would ask you while
you were completing therapy with the client. (Ex: Splinting, Resistive exercise, Energy conservation, Joint protection
techniques, Functional mobility training, wheelchair fitting and training, Adaptive Equipment, Adaptive Technique,
Coordination activities or practice coordination within ADL, Work Simplification, Home modification, Sensory Re-
education, Physical Agent Modalities, Endurance training, etc.)

Intervention Approach, and Frame of Reference: For the intervention activity that was chosen for the intervention
strategy/ method, describe the approach, and frame of reference for this intervention. This section is explaining WHY
the intervention activity is being completed with this client if someone would ask you while you were completing
therapy with the client. Choose one of the following intervention approaches, and describe in a few sentences why it is
appropriate for this intervention plan

 health promotion
 remediation, restoration
 compensation, adaptation, modification
 Prevention (disability prevention)

Choose a frame of reference (table 5.1 from Chapter 5 in the Sames book) and describe in a few sentences why it is
appropriate for the chosen intervention activity and for this intervention plan.
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OCCTHER 7270
Discharge recommendation and referrals: The discharge plan is what you recommend will happen once the client leaves
your treatment facility. In a 6-8 sentence paragraph, describe the recommendations and referrals that are appropriate
for this client. Recommendations include information regarding family education, available community resources,
accessibility issues and solutions, recommendations for assistive devices/technology including justification; additional
services (type, duration, reason, etc.). Be specific regarding who will be providing care (cues, supervision, etc.), what
education will be done, what equipment vended or recommended. Referrals involve who you would refer your client to
for additional services along the continuum of care. What are the other professionals in the health care team and in the
community would be beneficial to this client to help them to improve and be successful.

Research Support: 1 CAP supporting one of the suggested interventions. Use an appropriate CAP form for the article
chosen (Ex: Qualitative, Quantitative, Systematic Review).

Use pages 4 – 10 of this document to fill out and complete for submission of this assignment. MERGE THE FILES so that
the treatment plan the and CAP are in one document. Only submit this document and the PowerPoint presentation.
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OCCTHER 7270
Occupational Therapy Evaluation Report and Initial Intervention Plan

BACKGROUND INFORMATION:
Client’s name or initials: Paul

Date of report: 9/26/18

Date of birth and/or age: 17 y.o.

Primary intervention diagnosis/concern: Rancho Level 5 TBI

Secondary diagnosis/concern: L orbital fx, L proximal humerus fx, R pelvic fx

Precautions/contraindications: WBAT in his L UE, TTWB in his R LE, and a helmet when OOB

Reason for referral to OT: Decreased L UE strength, R LE strength and ROM, and decreased cognitive
functioning in problem-solving interfere with daily life tasks (bathing, dressing, toileting, etc.) and occupations
involved in being a student.

ASSESSMENTS PERFORMED
Functional Fine Motor Cognition Sensation Quality of Life Pain Vision
Mobility, and Patient
Endurance, Report
Balance,
ADL/IADL
Performance-
Based

 ADL  Box and  MOCA  Light Touch,  Canadian  Numerical  Visual Field
Observation Block Test  Orientation Pin Prick Occupational Scale Testing
 5 times sit to  9 Hole Peg Questions  Proprioception Performance  Wong-Baker  Visual
stand Test x4  Two-point Measure Faces Pursuits
 Timed  Handheld  Motor-Free discrimination (COPM)  Visual  Visual
Stands Test Dynamometer Visual  Sense testing  WHO Quality of Analog Saccades
 30 Second Perceptual (sight, taste, Life-BREF Scale  Convergence/
Sit to Stand Test hear, smell,  Patient Health  FLACC Divergence
Test (MVPT) touch; done Questionnaire Scale  Visual Acuity
 Berg Balance  Clock upon  Goal (Snellen
Scale (minus Drawing admittance) Attainment Chart)
walking Test Scale  Motor Free
portions)  Lowenstein  DASH Visual
 Barthel Index Occupational Perceptual
Therapy Test (MVPT-
 Performance
Cognitive 3)
Assessment Assessment
Self-care (LOTCA)
Skills (PASS)  Mini Mental
 ROM for UE State Exam
 MMT for UE (MMSE)
 Functional  Observation
Independence of ADL tasks
Measure (FIM)
 KATZ Index
of Activities
of Daily
Living
 AM-PAC
*Red and bolded are all of the assessments that were actually administered.
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FINDINGS
Occupational Profile: Paul is a 17. y.o. high school senior. He has a strong support system including his
parents, 4 older siblings, friends from being in the STEM club, and friends from playing on the varsity
basketball team. With his TBI and injuries, Paul is worried that his high school graduation in June may be
delayed. He is also nervous about getting back to his normal level of cognition to be able to study computer
programming at Columbus State Community College next fall. He really wants to regain his independence so
he can take care of himself on his own, play basketball again, and go back to being a “normal” high school
student.

Occupational Analysis
Areas of occupation: Paul is currently wearing sweats most of his days, however, to get back to
school and out of class events, he needs to be able to use buttons and fasteners. His mother is
currently preparing his meals, so he does not have to worry about meal prep or cleaning dishes.
Toileting and bathing are major difficulties for Paul due to the weight-bearing precautions and overall
weakness due to his injuries. He has no issues with grooming, eating, or feeding except requires
supervision due to requiring Min A for problem-solving. Many occupations require extended time for
Paul due to his cognitive and physical limitations, which frustrate Paul since he is aware of his prior
level of independent functioning.

Bathing: Mod A while seated on shower chair; Paul needs to be seated during bathing due to
weight-bearing precautions on R LE, decreased strength and standing balance, and for safety from
falls. He has some limited ROM in his L shoulder flexion and abduction (150°), which would require
assistance when washing certain areas on his body (back, reaching down to lower legs, etc.).

Toileting: Mod A; Due to his R LE weight-bearing precautions and L UE ROM deficits in

shoulder flexion and abduction, toileting is difficult to perform without Mod A to pull his pants up or
possibly perineal care. He also needs assistance for problem-solving occasionally due to his TBI.

Eating: Supervision; Paul has full control of his facial muscles involved in chewing muscles and
is able to swallow on his own. He only needs supervision for safety due to his TBI.

Feeding: Supervision; Paul can perform the ROM in his UE needed for feeding and has the
FMC and hand strength to use utensils and feed himself. He only needs supervision for safety due to
his TBI.

Dressing: Upper Body Dressing- Min A; Lower Body Dressing- Max A; Paul has limited ROM in
his UE making his upper body dressing requiring Min A to help with motions he is limited in (shoulder
flexion and abduction). In lower body dressing, Paul has TTWB limitations in his R LE and decreased
ROM and strength in his L UE making lower body dressing difficult to do on his own to get pants and
undergarments on his legs as well as pulling up.

Functional Mobility: Toilet Transfers- Mod A stand pivot transfer with rolling walker; Due to his
R LE TTWB precautions and his weakness from his incident, Paul would need to use a rolling walker to
assist him and his balance needs to transfer to the toilet. He also needs help to balance himself to pull
his pants down and to get on and off the toilet/chair/bed to get up to the walker.

Grooming: Supervision; Paul can perform the ROM in his UE needed for grooming and has the
FMC and hand strength to use a hair brush, shave, or wash his face by himself. He only needs
supervision for safety due to his TBI.
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Safety: Min A (for verbal cues and reminders); Paul is only oriented to himself and other people
he knows at the moment and follows 2-3 steps commands. Due to this lack of being aware of all things
around him and being Min A with problem-solving, he needs some assistance on safety issues to
prevent falls or other problems that may reinjure himself (for example, following his weight-bearing
precautions or wearing his helmet when OOB).

Handwriting or Keyboarding: Supervision; Paul has the FMC and hand strength to be able to
type or handwrite. He needs supervision for safety due to his TBI.

Meal Prep: Not tested; Due to safety issues concerning his TBI and problem-solving and
because Paul’s mother is the one who does his meal prep, it was not an occupational priority to test at
this time.

Play: Not tested; Paul enjoys playing basketball, but due to his injuries, weight-bearing
precautions, helmet that must be worn when OOB, safety, and brain injury, this area was not tested at
this time.

Other (Describe): See Below.

Education: Min A; Paul is currently Min A in problem-solving so for things involving

education, he is also Min A because he needs to be able to problem solve in order to function and
succeed in occupations involved with school. Paul needs to be able to problem solve in order to get
ready for school, understand his class schedule, and to schedule all of his things he needs to do in
order to have time to do homework, work on projects, attend STEM meetings, and go to basketball
practices and games.

Sleep: Supervision; Paul is able to follow a normal sleep pattern and sleep routine. He
needs supervision for safety due to his TBI.

Social Participation: Supervision; Paul can partake in social interactions with

individuals. He needs supervision for safety due to his TBI, for example, to avoid breaking his weight-
bearing precautions for his R LE of TTWB, L UE of WBAT, and wearing his helmet when OOB.

Performance skills: Paul’s kyphotic posture and imbalance in his L UE demonstrates the muscles
weaknesses and imbalances he has occurring when comparing his L and R UE. His overcompensation of
stronger muscles (traps and pectoralis muscles) of his weak shoulder and back muscles in his L UE cause
tightness and pain due to the pressure he is putting on his neck, shoulders, and back in this hunched posture.
His lack of standing balance, mostly limited due to weakness and being TTWB in his R LE, limit his ability to
perform tasks requiring either static or dynamic balance. All of the reasons mentioned above in both his LE
and UE are reasons for his gross motor coordination to be limited when performing ADL tasks. Paul has some
limitations in his cognitive skills and following directions mainly due to problem-solving limitations and
remembering safety considerations, however, his communication, emotional regulation, visual motor skills, and
social skills were all found to be competent.

Posture: Limited; Paul has suffered a L proximal humerus fx due to his accident, which has
resulted in him developing a more kyphotic posture due to weakness in his L UE. He also has asymmetry with
his scapula and shoulder rising on his L UE compared to his R UE due to more powerful muscles
compensating for the weaker ones that are more likely to be impacted by this type of fx.
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Balance: Limited in static and dynamic standing balance; Paul has maintained his trunk
strength after his accident, so he is able to maintain normal balance in both static and dynamic sit. He has fair
static standing balance due to needing to occasionally hold on to and object for support with his R LE TTWB
precautions, while his dynamic standing balance is fair-poor with his R LE decreased strength and weight-
bearing precautions causing him to be reliant on his L LE for his main source of balance during dynamic
standing activities (Note- Dynamic standing was not thoroughly tested past ADL observation due to R LE
TTWB and safety concerns).

Fine Motor Coordination: Competent; Paul has demonstrated no decrease in strength or ROM
in his wrist and hand. He is able to perform fine motor tasks as instructed, however, shoulder pain
occasionally hinders some motion when performing these fine motor tasks.

Gross Motor Coordination: Limited; Paul has demonstrated weakness and decreased ROM in
his L UE in the shoulder and in his R LE. Both of these limitations have greatly impacted his ability to perform
and coordinate gross motor movements for walking/functional mobility and reaching during ADL tasks, such as
upper and lower body dressing, bathing, and toileting.

Visual Motor Integration: Competent; Paul demonstrates no issues with visual motor
integration. He is able to follow 2-3 step directions on visual memory, visual discrimination, visual closure, and
visual manipulation, but needs more time to process images and directions which is mostly likely due to his
injury, however, this could have also been his baseline since it is unknown.

Following Directions: Competent; Paul can currently follow 2-3 step commands which is
adequate to understand and perform many of the tasks he is doing in therapy. He does need improvement in
accepting more directions at a time in order to complete an entire task without any prompts.

Emotional Regulation: Competent; After suffering his TBI, Paul is at a stage in his recovery
where he is verbally appropriate during treatment sessions with his therapist or any others that may be
present. He does demonstrate frustration easily when performing tasks that he is having difficulty in and needs
improvement in controlling his frustration so it does not potentially hinder his progress in therapy.

Cognitive Skills: Limited; Paul has demonstrated limitations in his cognitive skills following his
TBI, particularly in the area of problem-solving, which he is currently Min A in and needs verbal cues most
often for safety concerns when doing a task. He also has demonstrated some attention issues during tasks
and will occasionally need to be redirected back to the task he is currently partaking in.

Communication and Social Skills: Competent; Paul is able to communicate with others with
no issues. He demonstrates appropriate social skills when interacting with others, but could use improvement
in monitoring and controlling his frustration when he is around others.

Other (describe): No other performance skills were tested or assessed.

Performance patterns: As a high school senior, Paul spends most of his day seated at a desk in a
hunched over position (7-8 hours). He also spends 2-3 hours at home seated on school nights while working
on homework. During basketball season, Paul is running at practice for at least 2 hours 5-6 days per week.
He also has STEM club meetings 1 day per week for an hour where he is walking around or standing in a
hunched over position when working on science projects.
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Client factors: Paul reports pain in his L UE in his shoulder and R pelvis where he had ORIF for
fractures that occurred following his accident, which limit his overall functioning of these limbs. He reports
some pain in his head following his injury, and he is wearing a helmet when OOB to avoid further injury to his
head or brain. Paul has demonstrated overall weakness, decreased endurance, and lack of strength and joint
stability in his L UE and R LE. He has shown some limitations in attention, sequencing, and memory that
make it difficult to perform tasks correctly and efficiently. His other cognitive functions and sensory functions
appear to be normal at this time.

Body Functions

Attention: Impaired; Paul has a slight impairment in his attention due to his brain injury.
During tasks with multiple steps, he occasionally needs to be redirected back to the task or the instruction he
was told in order to complete the task.

Distractibility: Impaired; Similar to his attention during tasks, Paul will occasionally get
distracted by other things going on around him and then has to be redirected back to the task he was partaking
in. He needs to improve on being able to finish a task with minor distractions around.

Memory: Impaired; Paul has a slight impairment to his memory due to his brain injury.
His long-term memory is fairly intact since he remembers how to do everyday tasks (bathing, dressing, etc.)
overall and recognizes family members and people he knows, however, his short-term memory (remember
steps, instructions, safety precautions, etc.) needs improvement in order to ensure his safety before he goes
home.

Sequencing: Impaired; Paul has demonstrated impairment in his ability to sequence

steps during a task or instruction properly due to his impaired problem-solving skills. He understands the task
that he is supposed to do and the purpose of it, yet, he mixes up steps or forgets them at times.

Initiative: Impaired; Paul reports that he has had a lack of energy following his injury.
When performing tasks, he occasionally needs verbal cues to begin a task or starting another step in a task
since he lacks the cognitive ability to know when to do this at times.

Sight: Adequate; After running through a series of visual scans and assessments, Paul
demonstrates no issues with his site (most likely due to his brain injury being in the L frontal parietal area). He
reports being able to see normally and can recognize objects and name them when asked, however, his vision
will continue to be monitored due to the possibility of vision issues arising from his TBI.

Hearing: Adequate; Paul partook in a quick hearing scan to test for hearing issues when
admitted and no impairments were found in his hearing. He reports being able to hear normally and responds
to questions/instructions appropriately when asked them indicating he is hearing what is being said to him.

Smell: Adequate; Paul partook in a quick assessment to assess his sense of smell when
admitted and no impairments were found in his sense of smell. When discussing his meals, he reports what
they smell like and is able to match appropriate smells to food (For example, he was asked what type of shake
he had received at the beginning of the session, and he sniffed it and reported that it smells like vanilla, which
was correct.).

Taste: Adequate; Paul partook in a quick assessment to assess his sense of taste when
admitted and no impairments were found in his sense of smell; When discussing his meals, he reports how
they taste (For example, “The chicken was salty.”).
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Touch: Adequate; Paul went through a quick sensation assessment upon admittance
and no impairments were found in his sensation. He reports being able to feel when/where a touch occurs on
his body and that it feels the same on both sides.

Vestibular: Impaired; Paul has demonstrated some impairment to his vestibular

functions following his injury mainly in the area of sensing when he needs to maintain his balance when
standing. This is due to his overall weakness since the accident and his inability to maintain weight on his R
LE due to his TTWB precautions, limiting him to one side to maintain and detect changes in his standing
balance.

Kinesthetic: Adequate; Paul demonstrates the ability to move his body and muscles
and knows when he is moving a part of his body and what he is moving. His movements are slow, especially
in his injured L UE and R LE, but he is still able to move his body/body parts and understand how they need to
move when needed for a task.

Proprioception: Adequate; Paul demonstrates proprioceptive awareness appropriately.

When told to cover his eyes and then asked where a certain body part is being moved, he accurately describes
where it is positioned (For example, when asked where his arm is after it has been raised, he says, “My arm in
held up.”).

Temperature: Adequate; Paul demonstrates no impairments in identifying temperatures.

When admitted, he was tested for temperature sensation, and was able to correctly identify if an item that was
touching him was “cold” or “warm” (used a towel-covered ice pack and hot pack).

Pain: Adequate; Paul demonstrates the feeling of pain appropriately for his injury. He
understands when pain is felt and indicates to medical staff when and where he is in pain, which is most
frequently in his L UE, R LE, and head.

Muscle Tone: Impaired; Paul demonstrates impaired muscle tone in where he suffered
fractures from his accident. This mainly includes his L UE in his shoulder muscles and his R LE, however, he
has generalized weakness throughout his muscles from being in the hospital.

Reflexes: Impaired; Paul demonstrates an impairment in his muscle reflexes following

his injuries. His reflexes are still present, however, on his injured L UE and R LE, they are delayed and not as
strong due to the weakened muscles in these areas.

Endurance: Impaired; Paul has demonstrated decreased endurance following his

accident due to his overall weakness and deconditioning he has suffered from his injuries and time staying in
the hospital. His lack of strength of his injured L UE and R UE make tasks more taxing on his body to perform
since he is not able to use all of his extremities as he normally would during tasks, as well as his brain injury
making him feel more fatigued than before the accident.

Joint Stability: Impaired; Paul has demonstrated some weakness in his joint stability in
the joints that were fractured following his accident. His injury to his L shoulder has impaired the stability and
motion when performing flexion and abduction of the shoulder, and his R pelvis/hip joint is demonstrating some
joint instability due to lack of strength and movement with his TTWB precautions.

Bilateral Integration: Impaired; Due to his injured L UE and R LE, Paul has
demonstrated impairments in his ability to perform bilateral integration during tasks. He cannot effectively use
his injured sides due to weakness, decreased ROM, and decreased standing balance, forcing him to favor his
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“stronger side” (either R UE or L LE) and not properly perform tasks that involve bilateral integration (For
example, walking, passing things to the other hand, etc.).

Praxis: Adequate; Paul has demonstrated no issues with his praxis skills following his
brain injury. When asked to perform a task or a movement, he understands what you want him to do and then
accurately demonstrates how to do that (For example, when brushing teeth, he knows what the task is and
how to do it and then demonstrates proper flexion of his elbow to be able to bring the toothbrush to his mouth
to carry out the task.).

Other (describe): No other client body functions were tested or assessed.

Body Structure

Head: Movement Limitation; Following his injury, Paul has demonstrated some
limitations in his ability to rotate his head. He indicates there is pain of he puts too much pressure on his L side
of his head.

Neck: Movement Limitation; Paul has demonstrated some limitation in his ability to flex
and laterally flex his neck. This is due to his lack of movement since his injury causing tightness in this area,
and lack of moving his head to avoid pain on the L side of his head.

Shoulders: Movement Limitation; Paul demonstrates ROM limitations in his L UE in his

shoulder in the area of flexion and abduction (150°), and he was 3/5 for MMT in his shoulder. He complains
about pain all throughout his L shoulder, especially if he moves it too far (R shoulder is WFL).

Elbows: Normal; Paul demonstrated no movement limitations or pain in B elbows. B

elbows had ROM WFL and MMT of 4+/5.

Forearms: Normal; Paul demonstrated no movement limitations or pain in B forearms.

B forearms had ROM WFL and MMT of 4+/5.

Wrists: Normal; Paul demonstrated no movement limitations or pain in B wrists. B

wrists had ROM WFL and MMT of 4+/5.

Hands: Normal; Paul demonstrated no movement limitations or pain in B hands. B

hands had ROM WFL and MMT of 4+/5.

Trunk: Normal; Paul demonstrated full control of his trunk movements with no pain. He
has the strength and motion to sit up by himself and maintain his balance by sitting.

Hips: Movement Limitation; With his R pelvis fx, Paul has demonstrated pain and ROM
limitations in his R pelvis. The weakness in his R LE muscles in this area have limited his ability to move and
result him in feeling pain when moving his R hip (L hip is WFL).

Knees: Movement Limitation; Though limited, Paul has demonstrated some decrease
ROM of his R knee due to lack of motion in his R LE following his R pelvis fx. He does not complain of pain in
his R knee, however, due to R LE weakness the overall ROM in his R LE is impaired (L knee is WFL).

Legs: Movement Limitation; Due to his lack of strength in his R LE following his R pelvis
fx, Paul has demonstrated some mild limitations to the movements of his R leg. This is because of a lack of
use in the R LE following his injury and following his TTWB precautions (L leg is WFL).
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Ankles: Normal; Paul has demonstrated full control and movement in B ankles. B ankles
are WFL.

Feet: Normal; Paul has demonstrated full control and movement in B feet. B feet are
WFL.

Other (describe): See Below.

Skin: Normal; No issues were found with Paul’s skin structure or integrity
following his accident or areas he had surgery in (Burr hole surgery in L frontal parietal area where hematoma
was found). All injured areas had proper healing tissue that showed no indication of infection or pressure
ulcers.

Eyes: Normal; No issues in Paul’s eyes were detected following scans and
assessments upon admission. Both eyes move appropriately, however, will continue to monitor eye
movements during activities.

Contexts: Paul spends most of his time seated in in class at desk and chair that do not support proper
posture or allow for more room in case Paul may have a functional mobility devices following release from the
hospital. Reading textbooks and working on homework at school or at home increases his forward posture. If
Paul is not in class, he spends much of his time in the gym for basketball practices. At home, his bedroom is
on the second floor while his parents’ bedroom is on the first floor. There is a half bathroom downstairs and a
full bathroom upstairs with a shower-tub combo.

INTERPRETATION

Strengths: Paul is motivated to get back to his prior level of independence in order that he is able to go back
to school, play basketball, and graduate on time. Even with his injuries to his L UE and R LE, his excellent
muscle tone will help with his reconditioning and overall recovery process. Paul demonstrates great FMC skills
from being in STEM club and working on science and technology projects allowing him to do many tasks
involving FMC with ease and making steps in ADL tasks simpler (for example, being able to grasp and hold on
to objects like clothes or a sponge for dressing or bathing). His cognition is at a higher functioning level
following a brain injury allowing him to be able to understand what is being asked of him in therapy and being
then being able to carry out most tasks. His sensory functions are intact making it easier to process the
environment and understand how to carry out the tasks he is partaking in during therapy

Areas in need of intervention: Paul needs to gain back strength in his muscles in his L UE and R LE in order
to be able to carry out gross motor functions necessary for ADL tasks. He needs to be able to gain ROM that
is WFL in his shoulder to be able to perform reaching tasks that are required of him at school and at home.
Paul must work on improving his overall endurance, strength, and standing balance abilities to be able to
perform tasks in a timely manner and without assistance. Paul needs to work on his problem-solving skills,
attention, and memory in order to make sure he is safe when returning back to his normal everyday activities.

Supports to occupational performance: Paul has many supports to help him stay motivated to recover and
return to school. He is motivated by himself to graduate on time and start college next fall, as well as to be
able to play in his final basketball season as a senior. In addition to self-motivation, Paul’s parents and 4
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siblings are able to help him during his recovery. Paul also has many friends at school in both the STEM club
and varsity basketball team that are supportive in his road to recovery.

Hindrances to occupational performance: Paul demonstrates some frustration concerns that may limit his
progress during therapy and his recovery process. He puts a lot of pressure on himself to get back to his prior
level of functioning and gets frustrated easily and down on himself when a task is difficult. His problem-solving
difficulties and lack of safety awareness put him at risk to reinjure himself which would greatly set back his
recovery. His setup at home and school may also cause problems because it may force him to compensate
for certain tasks if he cannot do something do to an environmental issue (for example, stairs at home, tub-
shower being on second floor, stairs at school, small hallways, etc.). Possibilities of vision issues may also
hinder his performance in being independent in his ADLs and occupations at school.
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INTERVENTION PLAN

All Patient Priority Occupations Long Term Goals Short Term Goals Intervention Intervention Approach, and Frame of
Problem Areas to Address During (2 LTG) Two STGs for each Activities Strategy/Method Reference
Intervention LTG (Adaptive
(total of 4). Techniques, CIMT,
4 activities for each
priority occupation Energy Conservation,
Assistive Devices, etc)
to address

Bathing – Mod A Lower Body 1. Pt will demo 1a. Pt will demo 1. Pt will be For the first The approach of the
Dressing – Max A increased I’nce in increased I’nce in educated on and intervention activity first intervention
Upper Body LB dressing by LB dressing by then practice using (Using a reacher to activity (Using a reacher
Dressing – Min A donning and donning pants a reacher to be able don and doff to don and doff pants),
Lower Body doffing pants using using a reacher to don and doff pants), this is a compensatory
Dressing – Max A AE of a reacher with Mod A within pants. intervention approach which falls
with Min A by 1 week. strategy uses under the Rehabilitative
Toileting – Mod A discharge. 2. Pt will practice sit adaptive devices. FOR. For Paul, the main
2a. Pt will demo to stands for 3x10
For Paul, he is concern for him is to get
Toilet Transfer – 2. Pt will demo increased I’nce in sets from a chair having difficulties him as independent as
Mod A stand pivot increased I’nce in LB dressing by while maintaining with strength and possible in his activities
transfer with rolling LB dressing by standing for 30 TTWB precautions ROM in his R LE and in order for him to go
walker donning and seconds with a on R LE with a L UE, static and back home and return
doffing socks using rolling walker rolling walker to dynamic standing to school. By using
Problem Solving –
a sock aide and following TTWB on practice static and balance, adaptive equipment,
Min A
adaptive R LE to be able to dynamic standing endurance, and such as a reacher to don
Safety – Min A techniques with don and/or doff balance needed to problem-solving in and doff his pants, we
Supervision by pants within 2-3 stand up to don many tasks are adapting the task of
Decreased discharge. therapy sessions. and doff pants. including LB LB dressing to provide
Endurance
2a. Pt will demo 3. Pt will be dressing. Due to his more independence
increased I’nce in educated on and ROM limitations in versus teaching him
LB dressing by then practice using his L UE and pain he normal LB dressing
donning his socks has in this area, techniques. At his stage
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OCCTHER 7270
Decreased L UE using a sock aide a sock aide to be pulling up pants is in his recovery, doing LB
strength and ROM with Min A within 1 able to don socks. going to be a dressing with normal
in shoulder week. difficulty for Paul strategies will take Paul
4. Pt. will be until his shoulder a long time or cause
Decreased R LE 2b. Pt will demo educated on and injury begins to pain with his R LE and L
strength and ROM increased I’nce in then practice the heal and he begins UE fx and his slight
LB dressing by figure-4 technique to get strength issues with his cognitive
Decreased doffing socks using while seated at EOB
Cognition Skills in back. Since he skills at this point in his
a figure-4 to doff his socks. wants to return recovery. To avoid
attention technique with Min home and be able frustration in trying to
Possibility of Visual A within 1 week. to complete tasks complete LB dressing
Impairments independently, using normal
teaching him how techniques without AE,
Decreased static
to use the adaptive we are compensating
(fair) and dynamic
device of a reacher the task for Paul that
standing balance
to don and doff his way he can feel
(poor)
pants will allow him confident in his abilities
to gain that to complete LB dressing
independence in LB with independence and
dressing. Using an efficiency using these
assistive device like strategies to return to
a reacher will also home and school. Once
allow Paul to start he builds confidence
to slowly build up with these techniques
that strength in his and gains back strength
L UE to be able to and endurance, he will
start practice be able to progress back
donning and doffing to normal dressing
his pants without techniques.
use of adaptive
devices when he
returns home.
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Bathing – Mod A 1. Pt will demo 1a. Pt will demo 1. Pt will be For the fourth The approach of the
increased I’nce in increased I’nce in educated on and intervention activity fourth intervention
bathing by bathing by practice using a (ball tosses), this activity (ball tosses) is
completing full completing a full LE long-handled intervention activity the
bathing routine bathing routine sponge to be able uses balance restoration/remediation
using AE of a long- using a long- to wash B LE. training in order to approach under the
handled sponge handled sponge help Paul maintain biomechanical FOR.
and a modified UE and shower chair 2. Pt will practice his balance during While in certain tasks
bathing technique with Min A within 1 on increasing L UE static and dynamic we are compensating in
with supervision by week. shoulder strength standing tasks. order to help Paul gain
and ROM by
discharge. Paul has had overall back his independence
2a. Pt will demo reaching for soaps deconditioning sooner, we also need to
2. Pt will demo increased I’nce in at various heights following his restore his previous
increased I’nce in bathing by while seated in a injuries and being in balance, endurance,
bathing by completing a full UE shower chair for
the hospital and strength abilities in
maintaining bathing routine 3x10 sets to resulting in his order to truly get him
standing balance using a modified prepare for standing balance to back to his prior level of
using grab bars in technique with Min reaching for soap be limited (both functioning for him to
the shower for the A to maintain while bathing. static and dynamic). feel confident in his
length of a full WBAT precautions By working on a ADLs and occupations
shower routine of L UE within 1 3. Pt will be
educated on and task like tossing a at school and home.
( ̴15min) with Min week. and catching a ball Currently, Paul is overall
practice a modified
A by discharge. while maintaining deconditioned following
1a. Pt will demo UE bathing
increased I’nce in technique to avoid his balance while his accident, which has
bathing by breaking WBAT standing with a limited his UE and LE
performing a sit to precautions in L UE walker for safety, it strength and endurance
stand from a as well as to bathe will help him regain to be able to maintain
shower chair with entire UE given L back the ability to both static ad dynamic
grab bars in the UE ROM recognize when his balance during ADL and
shower with Min A limitations. balance shifts and school tasks that Paul
to practice how he needs to engages in on a daily
4. Pt will perform weight shift his basis. By doing an
static/dynamic
ball tosses while body in order to not activity like standing
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OCCTHER 7270
standing balance in standing with a fall during these ball tosses with a
the shower while rolling walker and types of tasks. This wheeled walker, we are
maintaining TTWB maintaining R LE applies to when he using a balance training
precautions in his R TTWB for 3x10 sets would have to exercise to help him
LE within 2-3 to increase stand in a shower rebuilding the strength
therapy sessions. static/dynamic with/or without and endurance he lost
standing balance grab bars and then he has lost from his
2a. Pt will demo needed while weight shift his accident to ultimately
increased I’nce in standing in a body in order to build back up his
bathing by shower. maintain his standing balance
completing full UE
balance when abilities he had prior to
modified bathing reaching for soaps the injury as well.
routine while and bathing tasks Standing ball tosses
standing with grab so he does not fall. mock the static and
bars with Min A
Furthermore, by dynamic standing
within 1 week. doing a balance balance Paul needs in
training task like the shower to be able
ball tosses, he will to maintain a stand to
also be building up wash his hair or reach
his endurance and for soap. By first
strength to prevent applying the motions to
him from feeling a balance training
too fatigued which exercise, Paul will then
would allow him to be able to apply this
maintain his idea of weight shifting
standing balance his body to maintain his
longer for tasks like standing balance to
taking a shower. functional use of
maintaining his standing
balance while taking a
shower.
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DISCHARGE RECOMMEDATIONS /REFERRALS
Paul is to be discharged home with referral to OP OT services to benefit from further treatment in regaining independence in his ADLs and problem-solving
skills, as well as OP PT for functional mobility and strengthening. It is recommended that Paul be fitted with a rolling walking for safety and maintaining TTWB
precautions in his R LE, a long-handled sponge for showering, a shower chair to use while showering to take breaks for fatigue, and a reacher for lower body
dressing. Parents will be educated on assistance and adaptive techniques needed to assist Paul with dressing, toileting, and showering, as well as use in
adaptive equipment. Education includes providing supervision during all tasks, Min verbal cues when problem-solving for safety concerns, and Min A during
dressing, bathing, and toileting. Assistance levels will change with OP OT recommendations. Paul is recommended not to drive at this time until his fractures
heal and his cognitive functions improve. Driver evaluation is recommended once it is believed it is safe for Paul to start driving, which will be determined by
your PCP. A list of community resources and support groups for Paul are provided to help provide social support from others who are in similar situations.

Intervention CAP Article Information (CAP posted on next page; for intervention practicing ADLs and using AE; Interventions 1,3, and 4 for LB Dressing and 1
and 3 for Bathing):

Title: “Early Individualized Postoperative Occupational Therapy Training in 100 Patients Improves ADL after Hip Fracture”

Author: Hagsten et al.

Citation: Hagsten, B., Svensson, O., & Gardulf, A. (2004). Early individualized postoperative occupational therapy training in 100 patients improves ADL after
hip fracture. Acta Orthopaedica Scandinavica, 75(2), 177–183. Retrieved from http://proxy.lib.ohio-
state.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=13385062&site=ehost-live
 Taylor MacWhade
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Methodology Checklist 2: Controlled Trials

SIGN

Study identification: Hagsten, B., Svensson, O., & Gardulf, A. (2004). Early individualized
postoperative occupational therapy training in 100 patients improves ADL after hip fracture. Acta
Orthopaedica Scandinavica, 75(2), 177–183. Retrieved from http://proxy.lib.ohio-
state.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=13385062&site
=ehost-live
Guideline topic: ADL Interventions with or without Key Question No: Reviewer:
AE for individuals with Hip fx Taylor
MacWhade,
S/OT

Before completing this checklist, consider:

1. Is the paper a randomised controlled trial or a controlled clinical trial? If in doubt,
check the study design algorithm available from SIGN and make sure you have the
correct checklist. If it is a controlled clinical trial questions 1.2, 1.3, and 1.4 are not
relevant, and the study cannot be rated higher than 1+
2. Is the paper relevant to key question? Analyse using PICO (Patient or Population
Intervention Comparison Outcome). IF NO REJECT (give reason below). IF YES
complete the checklist.

Reason for rejection: 1. Paper not relevant to key question  2. Other reason  (please
specify):

SECTION 1: INTERNAL VALIDITY

In a well conducted RCT study… Does this study do it?

1.1 The study addresses an appropriate and clearly focused Yes  No 

question. Can’t say

1.2 The assignment of subjects to treatment groups is Yes  No 
randomised. Can’t say

1.3 An adequate concealment method is used. Yes  No 
Can’t say

1.4 The design keeps subjects and investigators ‘blind’ about Yes  No 
treatment allocation. Can’t say

1.5 The treatment and control groups are similar at the start Yes  No 
of the trial. Can’t say □
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1.6 The only difference between groups is the treatment Yes  No 

under investigation. Can’t say

1.7 All relevant outcomes are measured in a standard, valid Yes  No 
and reliable way. Can’t say

1.8 What percentage of the individuals or clusters recruited OT Group = 8%
into each treatment arm of the study dropped out before Non-OT Group = 22%
the study was completed?
1.9 All the subjects are analysed in the groups to which they Yes  No 
were randomly allocated (often referred to as intention to Can’t say Does not
treat analysis).  apply 
1.1 Where the study is carried out at more than one site, Yes  No 
0 results are comparable for all sites. Can’t say Does not
 apply 

SECTION 2: OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimise High quality (++)
bias?
Code as follows: Acceptable (+)

Although researchers were blinded as Low quality (-)

well as patients, nurses and OTs giving Unacceptable – reject 0 
treatments were not blinded which could
result in some limitations. Additionally,
PT still saw the non-OT group which
could have possibly impacted their
functional mobility scores being similar to
the OT group.
2.2 Taking into account clinical Yes, based on the randomization and
considerations, your evaluation of the concealment in this study as well as the
methodology used, and the statistical lack of possibility of contamination, it is
power of the study, are you certain that clear that the individualized ADL training
the overall effect is due to the study with or without adaptive equipment during
intervention? acute rehab is what caused the OT group
to have better scores in performing ADLs
with independence following discharge 2
months later.
2.3 Are the results of this study directly The age of the population does not fit the
applicable to the patient group targeted patient in question (study was for adults
by this guideline? ages 65 and over, whereas the patient in
question is 17). The patient in question is
similar in that he has a pelvis fx (not
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indicated where pelvis fx is, but hip is

included in the pelvis region so similar fx),
needs to get back to independence and
ADL tasks, and needs to think about his
house setup and use of AE to perform
ADLs in order to go home and perform
ADLs independently. Studies on hip fx are
mainly limited to older adults, so applying
this with other factors mentioned in the
discussion about younger patients (having
greater expectations, wanting pain relief)
are some factors to consider with this type
of treatment intervention.

2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own
assessment of the study, and the extent to which it answers your question and mention
any areas of uncertainty raised above.

Based on the strengths of randomization, lack of contamination, concealment of

researchers and participants, and low attrition rates, the results show that for patients
in acute rehab following hip fx surgery, early individualized OT interventions in ADL
training with or without AE training for the home speed up ADL independence to be
discharged home sooner as well as returning to independence in ADL activities at
home (again with or without AE) 2 months following discharge, as compared to not
receiving ADL training by OTs in acute rehab after hip fx surgery.
This study supports the interventions planned for the patient in question of participating
in treatment activities that work directly on ADL tasks, strengthening or endurance
activities involved in ADL tasks, and training on AE or adaptive techniques to be able
to perform ADL tasks with greater independence by discharge to home.
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Grading rubric for Individual Case Study and Intervention Plan

Criteria Ratings Points

Assessments: Assessments Excellent Good Fair Poor Incomplete __/

chosen for patient are 30.0
30.0 pts 24.0 pts 21.0 pts 18.0 pts 15.0 pts
appropriate for condition points
and patient presentation. Met All Met most Met some Met A Few Met No
Multiple assessments are Criteria criteria criteria Criteria Criteria
listed for multiple
impairments.

Findings: Occupational Excellent Good Fair Poor Incomplete __/

Profile: Concise and 10.0
appropriate description of 10.0 pts 8.0 pts 7.0 pts 6.0 pts 5.0 pts
points
Occupational Profile of
Met All Met most Met some Met A Few Met No
patient
Criteria criteria criteria Criteria Criteria

Findings: Occupational Excellent Good Fair Poor Incomplete __/

Analysis: Concise and 30.0
30.0 pts 24.0 pts 21.0 pts 18.0 pts 15.0 pts
appropriate description of points
Areas of occupation, Met All Met most Met some Met A Few Met No
Performance skills, Criteria criteria criteria Criteria Criteria
Performance patterns, Client
factors, Activity demands,
and Contexts

Interpretation: Concise and Excellent Good Fair Poor Incomplete __/

appropriate description of 20.0
20.0 pts 16.0 pts 14.0 pts 12.0 pts 10.0 pts
Strengths, Areas in need of points
intervention, Supports, and Met All Met most Met some Met A Few Met No
Hindrances to occupational Criteria criteria criteria Criteria Criteria
performance
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Problem Areas and Excellent Good Fair Poor Incomplete __/

Priorities: Appropriate and 10.0
10.0 pts 8.0 pts 7.0 pts 6.0 pts 5.0 pts
thorough list of problem points
areas for patient, and Met All Met most Met some Met A Few Met No
appropriate priorities areas Criteria criteria criteria Criteria Criteria
to address in intervention

LTG: Provide two Excellent Good Fair Poor Incomplete __/

appropriate occupation 20.0
20.0 pts 16.0 pts 14.0 pts 12.0 pts 10.0 pts
centered long term goal in points
ABCD format Met All Met most Met some Met A Few Met No
Criteria criteria criteria Criteria Criteria

STG: Provide 2 appropriate Excellent Good Fair Poor Incomplete __/

occupation centered short 20.0
20.0 pts 16.0 pts 14.0 pts 12.0 pts 10.0 pts
term goals for each LTG in points
ABCD format Met All Met most Met some Met A Few Met No
Criteria criteria criteria Criteria Criteria

Intervention Activities: Excellent Good Fair Poor Incomplete __/

Provide 4 appropriate 20.0
20.0 pts 16.0 pts 14.0 pts 12.0 pts 10.0 pts
treatment activities for each points
priority occupation to Met All Met most Met some Met A Few Met No
address. Criteria criteria criteria Criteria Criteria

Intervention Excellent Good Fair Poor Incomplete __/

Strategy/Method: Concisely 20.0
20.0 pts 16.0 pts 14.0 pts 12.0 pts 10.0 pts
and appropriately describes points
why and how the strategy/ Met All Met most Met some Met A Few Met No
method for one of the Criteria criteria criteria Criteria Criteria
intervention activities in the
intervention plan would be
utilized with this client
Intervention Approach, and Excellent Good Fair Poor Incomplete __/
Frame of Reference: 20.0
20.0 pts 16.0 pts 14.0 pts 12.0 pts 10.0 pts
Concisely and appropriately points
describes which approach Met All Met most Met some Met A Few Met No
and frame of reference are Criteria criteria criteria Criteria Criteria
appropriate for the
intervention activity, and
why they are appropriate
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Discharge Plan and Excellent Good Fair Poor Incomplete __/

Referrals: Provides 20.0
20.0 pts 16.0 pts 14.0 pts 12.0 pts 10.0 pts
appropriate discharge plan points
and referral for patient Met All Met most Met some Met A Few Met No
Criteria criteria criteria Criteria Criteria

CAP: Completes all Excellent Good Fair Poor Incomplete __/

information for study 30.0
30.0 pts 24.0 pts 21.0 pts 18.0 pts 15.0 pts
purpose, design, and points
conclusion/ result. Met All Met most Met some Met A Few Met No
Criteria criteria criteria Criteria Criteria
Article Appropriately
supports activities in
intervention plan.

Total Points:__________