Student

Name: Philip Lamoreaux

Case: Wendell

Date: 4/17/2014

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Diagnosis: Pneumonia
Secondary diagnosis: CHF, COPD, Type II diabetes, OA, Gout, and a TKA (3 years ago)
Referral:
Setting: Salt Lake City Transitional Care Unit
Reimbursement: Medicaid
LOS: 3 weeks
5. Diagnosis and Expected Course

6. Scientific Reasoning & Evidence

List the barriers to performance typical of this
diagnosis:
Pneumonia: (we would most likely not be given Barriers/symptoms:
the referral because of pneumonia, but
Fever, sweating and shaking chills
because of the way it is affecting his ability to
Fluid filled cough
perform his ADLs)
Chest pain when breathing deep.
This is a lung infection that is caused by bacteria
Shortness of breath
or viruses. The lungs generally fill up with fluid
Fatigue and muscle aches
or pus, which causes the individual to cough up
Nausea, vomiting or diarrhea
pus or phlegm. Pneumonia can be either mild, or
Headaches
life-threatening depending on the individual and
their immune systems.
Wendells situation is a compound of many
There are four types of pneumonia: Communityissues. Many of the conditions Wendell is
acquired, hospital-acquired, Health care-acquired, experiencing have similar symptoms and
and aspiration pneumonia. There is very little
probably affect his ability to do the meaningful
difference between them except where they are
tasks identified in the COPM. Because Wendell
acquired. Wendell has community-acquired.
lives at home I am worried about the weakness
Prognosis: through medication, pneumonia is
and shortness of breath he experiences when
treatable in most individuals. There are a few
doing tasks. Wendell currently rates his ability to
complications that can happen such as bacteria in bath and clean as a 2/10, which could be related
the bloodstream, lung abscess, fluid build up
to the weakness and lack of oxygen he is getting
around the lungs, and difficulty breathing (not
into his body. Wendell could also benefit from a
getting enough oxygen).
diet plan in order to help him control his diabetes,
which is one of those conditions that affect his
overall health. Another issue to consider is that
Wendell scored a 22 on the MoCA. 26 is
considered normal, which concerns me about
what cognitive areas he may have deficits in.
They could affect his ability to take care of
himself. Managing his diabetes could be difficult
for him to manage if he has some cognitive
difficulty. I do have concern for why he has
difficulty dressing his LE. It could be a strength
issue, or ROM issue. He also complains of
neuropathy in both his fingers and toes.

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Secondary medical problems: Congestive Heart

Failure (CHF)
This diagnosis is used when any of the four
chambers of the heart lose their ability to pump
the amount of blood entering them.
Prognosis: CHF happens over a long period of
time. In order to compensate for the inability to
pump blood through the body, the heart enlarges,
develops more mass, and pumps faster. This is a
natural compensation and only prevents
symptoms for a couple years. CHF is generally
controlled with medications, or surgery.

Symptoms include:
SOB
Pain in abdomen
Difficulty sleeping
Loss of appetite
Increased fatigue (He is experiencing)

Chronic Obstructive Pulmonary Disease: used

as an umbrella term for conditions that block the
airflow enough to interfere with normal
breathing. Conditions that fall under this
umbrella are chronic bronchitis and emphysema.
Bronchitis produces mucus that obstructs airflow,
while emphysema ruins the alveolar walls. Each
prevents the absorption of oxygen into the
bloodstream.
Prognosis: This is a slow progressing condition
and has four stages.
1. Individuals at risk of COPD: Normal lung
function, but have chronic cough and
sputum production
2. Mild COPD: mild limitation to airflow,
but individual may not experience any
symptoms.
3. Moderate COPD: the blockage of air is
producing symptoms of SOB upon
exertion.
4. Severe COPD: All symptoms are severe
and exacerbations could be life
threatening.
Type II diabetes: Diabetes is when a persons
body is unable to control the sugar level in the
blood. Type II diabetes is when an Individuals
body doe not produce enough insulin, or ignores
the insulin. This is hazardous because the body
cannot control the level of sugar in the blood and
can really harm an individuals kidneys, nerves
and heart. Wendell does not take care of this.
Drinking beers can increase his blood sugars and
he has 3 of them everyday.

Symptoms:
Chronic cough
Shortness of breath (he is experiencing)
Weakness (he is experiencing)

7. Practice Models Guiding Assessment and

Rationale

Symptoms:
Frequent urination (if functional mobility
is affected this can be an issue)
Extreme fatigue (what he is experiencing)
Blurry vision (symptom identified)
Tingling, pain, or numbness in hand/feet
(Type II, which he is experiencing)

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Treatment
1. PEO

2. Biomechanical/Rehabilitation model

The PEO Model works really well with Wendell

because it allows you to affect many contextual
areas. With Wendell I would like to affect
change in all three areas. I would like to
incorporate energy conservation strategies,
strengthen muscles, and provide cognitive
strategies in order for Wendell to become
Independent enough to go back home. This
would require me to help strengthen wendells
muscles, which is affecting the person. I would
then like to teach him energy conservation
strategies regarding cleaning, bathing, and
dressing, which would affect the occupation, and
environment. I wonder how much Wendell will
actually change because he seems very stubborn,
however, I would like to go over his environment
and see if I can help him make some changes that
will save energy.
I will use this model because it allows for
increased task performance, the use of
adaptation, and compensatory strategies in order
to achieve maximal function in performance of
tasks. Because Wendell has received the correct
medical attention before this point he has the
potential to improve his situation. At this
moment nursing staff is controlling his blood
sugar and his pneumonia has been treated by
medication. Wendell is going to need to utilize
compensatory strategies in order to have
increased function. This model also allows me to
utilize adaptive equipment like an electronic
reminder to check his blood sugar.

14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform
Observed Occupation

Rationale/How will you use this information

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Bathroom Care

Method/Tool
1. AROM/PROM

2. Depression Inventory

3. Independent Living Scale (ILS)

4. Executive Function Performance Test

Having Wendell do his normal bathroom routine

in the evening will allow me to glean lots of
knowledge about how he does tasks, and where I
can give him some strategies to save energy. It
will also allow me to obtain an idea about where
he is at regarding ROM, strength, and endurance.
An activity like brushing his teeth will allow me
to see how his neuropathy is affecting his fine
motor skills as well. I will also be able to see
how much help he requires during clothing
management when I ask him to go to the
bathroom in preparation for going to bed. During
this observation of bathroom care I will try and
give him suggestions on how to change the
environment like adding a chair, or get a cup to
spit into.
Rationale/What is being Assessed
I would like to do this as a basic screening
because I do not know how well he is able to
move his joints. I do not know if this is a factor
regarding his inability to dress, and shower
himself. This would be mainly a screen upon
meeting him for the first time.
Even though Wendell seems adamant that he will
return home, I want to know how he is doing
regarding being in the hospital and knowing that
he will have to go home on oxygen. I want to see
how he is coping with all of the visits to the
hospital and now having to be in the transitional
care unit.
This test I though would be appropriate for
obtaining knowledge about Wendells memory,
orientation, and how he manages money, home,
transportation, health and safety, and social
adjustment. The difficult part about this test is
that it will take upwards to 45 minutes to
administer. The information I would obtain from
the test would benefit me in knowing how he will
fair at home, as well as his insight to his abilities.
I would only like to use the paying bills section
of this task. During the ILS I would obtain some
information on how he would write out a check,
but I want to see his ability to pay his bills. I
would like to see what area in cognition may
affected. This would be part of the further
testing because of the score on the MoCA.

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5.Physical Performance Test

This test is a very functional test that will allow

me to obtain lots of information on how well
Wendell will be able to perform different types
of tasks. What I will need to be careful about is
the fact that he is experiencing fatigue and has
SOB. I will need to make sure he is getting
oxygen during this assessment, as well as make
sure that he takes breaks in between the different
tasks. One of the major pieces of information I
will obtain from this assessment is how Wendell
does his dressing.

17. Intervention Plan

Barriers
Lives alone
His medical Hx
Smokes and drinks everyday
His weight of 273 pounds
Lives with two dogs and three cats that rely on him to
eat.
His son and how he is taken advantage of.
His stubborn attitude of being alone
Not taking care of his diabetes II
SOB
Weakness
Obtained a 22 on the MoCA (decreased cognition, but
we are unaware of what areas he scored low in.
Further assessment is required in this area.)
Goals

Supports
In a transitional care unit
Motivated to get back to his
home.
Supportive staff (nurse, OT,
aides)
Hard working
Self-supported and has lived
alone successfully for many
years.
Medical benefits
Unsure, but would assume he
is able to do things
independently, but fatigues
easily.

Practice Model for each goal

1. LTG:
Client will use energy conservation techniques, such as pacing
and changing the environment, in order to do bathroom ADLs
with no fatigue within 3 weeks.
STG:
The client will use pacing to achieve a 4/10 fatigue score
during showering within 10 days.

PEO/Biomechanical Rehabilitation
model

PEO/Biomechanical Rehabilitation
model

STG:
Client will use prioritizing to perform two bathroom ADLs and PEO/Biomechanical Rehabilitation
report a fatigue score of 6/10 within one week.
model

2. LTG:
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Client will use modified strategies in order to dress LEs,

including socks, and strap-on shoes, with modified
independence within 3 weeks.

PEO/Biomechanical Rehabilitation
model

STG:
In 2 weeks client will don button up pants by using pacing to
achieve zero fatigue.

PEO/Biomechanical Rehabilitation
model

STG:
Client will don socks and work boots with 5/10 fatigue score
by using adaptive equipment within 1 week.

PEO/Biomechanical Rehabilitation
model

3. LTG:
Client will demonstrate knowledge of energy conservation
techniques to clean up a hot meal with zero fatigue by D/C.
STG:
Client will demonstrate knowledge and efficiency of planning
when cleaning and drying the equipment used for making
cookies with a 4/10 or less fatigue score within 2 weeks.
STG:
Within 1 week client will use positioning during two evening
ADLs in order to achieve a 5/10 fatigue score.

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PEO/Biomechanical Rehabilitation
model

PEO/Biomechanical Rehabilitation
model

PEO/Biomechanical Rehabilitation
model

Revised 1/7/13

18. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do?
Identify Approaches
The purpose of the very first session will be to
Prevent
discuss with Wendell different strategies that he can Modify
use in order to decrease the amount of energy used
during activities. This will allow him to do more
throughout the day and not exacerbate his symptoms
from all his diagnosis. The first strategy I will teach
him is prioritizing. I will then have him practice the
technique by figuring out how to prioritize brushing
his teeth and doing his toilet cares. We will talk
about what are the most important parts of the tasks.
At this point we will talk about getting help for setup in preparation for going home. Then we will talk
about different types of toothpastes that may use less
exertion. After prioritizing I will have him go
through the bathroom cares. I would suggest that
doing toilet care is most important and is the farthest
away. I will suggest that he sit down in order to
save energy and rest because of the walk from the
bed to the toilet. After using the toilet I will have
him stand and go to the sink and grab the toothpaste
and toothbrush. I will have him sit down and apply
the toothpaste and reach to turn on the water and wet
his brush. Then I will have him sit while brushing
his teeth. After he brushes I will have him stand to
spit. If he does not have enough energy then I will
have him spit in a cup and I will assist with dumping
everything. We will then make it back to the bed or
chair. This will be the first half hour of the day.
2. What will you do?
Identify Approaches

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Based on which
goal(s)?
Client will use
prioritizing to perform
two bathroom ADLs
and report a fatigue
score of 6/10 within
one week.

Based on which
goal(s)?

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The second half hour of the day we will learn pacing

while making a small batch of cookies for the nurses
at the facility. Wendell really likes his nurses and
thought this would be fun and I explained how it
would help him work on his goal of being able to
clean up after himself. I will have already set
everything up and measured it out beforehand
because I just want to work on pacing and not push
Wendell too much. I will explain about pacing and
how it is about not rushing, decrease strain, listen to
body, taking frequent breaks, and elongating heavy
parts of the task over time. We will be working on
taking breaks during the task today. The first part
will be putting everything into the mixer. I will
have Wendell do this while sitting at the table.
Once it is all put in the bowl and started I will have
him take a rest. I will have him try and mix the
dough for a few seconds and then take a break.
After taking a few breaks I will help him put the
cookies on the sheet and have him turn on the oven.
I will then put the cookies in the oven. The mixing
of the dough may have been a lot for him. I will
then have him pace washing the bowls and scoop. I
will have him wash one, then sit down and have a
break. After doing this the cookies should be done.
I will pull them out and put the cookies on a plate to
cool. I will then have Wendell wash the cookie
sheet. This will be the end of our session and I will
have him walk back to his room with breaks in
between. We will pass the nurses station and I will
have him give the cookies to the staff. He will not
have one because of his diabetes not being under
control yet.

Prevent
Modify

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Client will demonstrate

knowledge of energy
conservation
techniques to clean up
a hot meal with zero
fatigue by D/C.

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