Running head: OCCUPATIONAL PROFILE & INTERVENTION PLAN

Occupational Profile & Intervention Plan

Breanna Dickson
Touro University Nevada

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Introduction
Mrs. Mendoza is a client who was recently seen for occupational therapy services in a
skilled nursing facility. Her past medical history includes coronary artery disease (CAD),
hypertension, diabetes mellitus, and hypertriglyceridemia. The purpose of this paper is to provide
information on the clients history, concerns, and priorities, and also discuss feasible
interventions that would improve the clients quality of life through engagement in occupations.
Occupational Profile
The client is a 60 year old Latina woman. She is considered to be morbidly obese at 54
and 350 lbs. Although able to ambulate, the client would fatigue easily and chose to use a powerchair to get around for the past 15 years. She is married and lives in a single story home in North
Las Vegas with her husband. She has four children and 20 grandchildren that live in the area and
visit often.
The client is in a skilled nursing facility recovering from a coronary artery bypass graft of
four vessels (CABG x4) procedure. Her doctor has ordered her to follow sternal precautions for
eight weeks while healing from the surgery. Currently, she relies on nursing staff to complete
most of her activities of daily living (ADLs) due to her sternal precautions, decreased endurance,
and large body mass. The client has expressed a desire to be able to complete her ADLs
independently but fatigues easily and is fearful about putting too much stress on her heart.
The client appeared despondent but was willing to participate in therapy. The client
describes a typical day as being spent in bed, watching television, eating microwavable meals,
and transferring to her bedside commode when needed. Her grandchildren visit often and she
would like to be able to play with them, but feels limited by her condition. The client also
mentioned that she is not satisfied with her current lifestyle and often feels depressed.

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The client has always been a homemaker who was primarily responsible for childrearing,
household cleaning, and meal preparation. The client talked about how busy she was when her
children were living at home and when they moved out is when she began to notice her patterns
of inactivity. The client remarked that she was once a great cook and would spend hours a day in
the kitchen but preparing meals has become too strenuous for her in recent years. She joked that
her husband would leave her if he met another woman that could make menudo like she did. The
client said her house has gone to hell since she has given up trying to maintain household
cleanliness due to her lethargy. She desires to become more active and live a healthier lifestyle.
The client stated her goal for therapy is to become more independent in ADLs and to make
healthier choices.
Contexts and Environments
It is important to consider which contexts are most supportive and inhibitory for the client.
The cultural context is supportive for the client, as she has a strong support system through her
large Latino family. However, her cultural context may also be inhibitory since her family may
feel the need to do things for her rather than let her complete activities independently. The
clients personal context is supportive since she is still relatively young and has a strong desire to
change her lifestyle. On the other hand, the clients temporal context is inhibitory since she has
had a sedentary life for over fifteen years.
In addition to contexts, it is important to consider the clients physical and social
environments. The physical environment of the skilled nursing facility is supportive since she
has access to walkers, adaptive equipment, parallel bars, and therapists to guide her in the
recovery process. Based on what is known about the clients home, she will likely need some
home modification in order for her house to become a supportive physical environment. The

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social environment is also supportive for the client. The client says she gets to spend time with
all of her grandchildren at least once a week and that her family is a big motivating factor in her
recovery and lifestyle change.
Occupational Analysis
The client participated in a 50 minute occupational therapy session to address her ability to
perform ADLs and transfers in her room at the skilled nursing facility. The client was awake,
oriented, and reported a 6 out of 10 pain level prior to her medication. She was able to sit at the
edge of bed from supine with minimum assistance (Min A) and could tolerate sitting upright. She
was able to complete a stand pivot transfer from the bed to a bariatric wheelchair and to a
bedside commode with contact-guard assistance (CGA), for safety. She is independent in
clothing management while toileting but requires total assistance (TA) to wipe her perineum. The
client requires maximum assistance (Max A) for upper-extremity (UE) and lower-extremity (LE)
dressing due to her sternal precautions and since her large body mass interferes with her ability
to reach past her mid-thighs. The client mentions that she dresses independently but sometimes
needs a little help getting on her pants at home. She is able to ambulate with a front-wheel
walker (FWW) for approximately 10 feet before requiring a rest break. The client is able to feed
herself but had relied on her husband to complete bathing prior to being admitted. She is able to
apply make-up and comb her hair independently while seated. She required verbal cueing for
sternal precautions throughout the evaluation.
Domains Impacted
Due to the nature of the setting, only participation in ADL activities was observed. The client
demonstrated impairments in the areas of toilet hygiene, functional mobility, and dressing. In
examination of client factors, the client does not demonstrate any deficit with mental or sensory

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functions. The clients joint mobility is limited by her body mass and sternal precautions.
Although a formal manual muscle test was not completed, it is likely that the clients muscle
power and endurance are impaired from inactivity. In addition, the clients large body mass
interferes with gait pattern and balance while ambulating. The clients cardiovascular and
respiratory systems are severely impaired as evidence by her diagnosis and fatigability.
The client also demonstrates impairment in performance skills for bending, reaching, and
enduring due to her large body mass. In terms of performance patterns, the clients pattern of
inactivity likely stem from her maladapted habits and routines. It is not known how the clients
rituals affect her occupational performance but the clients role as parent and grandparent is
supporting of her engagement in ADL activities; she is eager to cook for her family and play with
her grandchildren.
Problem List
1. Clients self-reported depression interferes with motivation to complete ADLs independently.
2. Client requires Max A for UE/LE dressing due to sternal precautions and large body mass.
3. Client requires TA for toilet hygiene due to inability to reach perineum because of large body
mass.
4. Client requires Min A for bed mobility due to sternal precautions and large body mass.
5. Client requires CGA for toilet transfers for safety due to impaired balance and endurance.
Justification
The clients list of problem statements were prioritized by the amount of assistance
needed both physically and psychosocially. It is paramount to address the clients perceived wellbeing prior to addressing musculoskeletal impairments; not only will the client be less motivated
to recover if she is experiencing depression, but she could be at risk for harming herself if her

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depression is not treated. The clients ability to dress herself was prioritized over her ability to
wipe her perineum since she required total assistance for toilet hygiene prior to being admitted.
The majority of the clients problems stem from her sternal precautions and large body mass so if
the occupational therapist is able to address these early on, smaller problem areas, such as
endurance, will likely correct themselves without needing to be explicitly addressed.

Intervention Plan and Outcomes

Long-Term Goals (LTG)
1. Client will independently complete significant lifestyle changes to enable engagement in
meaningful occupations in 4 weeks.
2. Client will complete UE/LE dressing Mod I with adaptive equipment while following
sternal precautions in 4 weeks.
Short-Term Goals (STG)
1. Client will identify and create a plan to change 4 aspects of her life related to diet and
exercise independently in 2 weeks.
2. Client will ambulate 50 ft. with FWW with minimal rest breaks to facilitate engagement in
meaningful activities in 2 weeks.
3. Client will verbalize and demonstrate 4/4 sternal precautions independently in 2 weeks.
4. Client will complete UE/LE dressing with set up and adaptive equipment while following
sternal precautions in 2 weeks.
Interventions
First STG. To address the first short-term goal, it would be appropriate to design a
lifestyle modification program with the client. This intervention takes an establish/restore
approach focused on building the goal-setting, self-monitoring, planning, stress management and
feedback skills needed for successful life change. The occupational therapist is skilled at helping
the client to identify their problem areas and can assist the client in making concrete, attainable

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goals. Any lifestyle modification program should be tailored to the client but there are some
common protocols the occupational therapist can follow. For example, the occupational therapist
can create individualized therapeutic exercise plans, grade functional tasks to progressively
increase physical endurance, implement healthy routines related to mealtime and food shopping,
and organize wellness groups for the client and their family (Cozzolino, Henshaw, Kleumper, &
Hill-Hermann, 2012). The outcomes of this intervention include prevention, health and wellness,
quality of life, and well-being. Healthier life choices, such as diet and exercise, can prevent
further cardiac deterioration and lead to improved health and wellness. By setting and achieving
personal health and fitness goals, the clients quality of life and well-being will increase greatly.
Justification. The purpose of the meta-analysis by Janssen, De Gucht, Dusseldorp, and
Maes (2012) was to determine the efficacy of lifestyle modification programs from 1999 to 2009
for coronary artery disease patients. The authors examined 23 randomized control trials that
focused on either behavior modification, stress management, physical training, or all of the
previously mentioned. The authors found that lifestyle modification programs contributed to
decreased rate of mortality, re-infarction, readmission, and risk factors. In addition, they found
that lifestyle modification programs that included goal-setting, self-monitoring, planning and
feedback techniques had greater improvements in exercise and dietary behaviors than programs
that did not. The authors conclude that the evidence confirms that lifestyle modification
programs are more beneficial than routine clinical care alone.
Second STG. To address the second short-term goal, it would be appropriate to increase
endurance for activity tolerance through physical activity. This intervention takes an
establish/restore approach with a focus on restoring the clients cardiorespiratory endurance to
enable participation in meaningful activities. Since the client is able to ambulate and wants a
more active lifestyle, standing and functional ambulation should be incorporated into the clients

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daily activities. For example, the client can stand at the sink while doing her hair and make-up.
In addition, the client mentioned that she used to prepare meals for her family, so the
occupational therapist can have the client ambulate with a FWW for safety to gather supplies for
a cooking activity. The client has mentioned that she enjoyed cooking and has a desire to be able
to play with her grandchildren. Both of these activities should be incorporated into the
intervention as an incentive for the clients participation. The outcomes of this intervention focus
on health and wellness, quality of life, and participation. Standing and walking increases cardiac
endurance and promotes weight loss which leads to improved health and wellness. As the client
loses weight and becomes more active, her quality of life will increase. Finally, an increase in
endurance will enable her to participate in activities than she once relinquished due to her
condition.
Justification. The purpose of the randomized trial by Jakicic, Marcus, Gallagher,
Napolitano, and Lang (2003) was to compare the effects of different intensities and durations of
exercise on 12-month cardiorespiratory fitness and weight loss. The study analyzed 184
sedentary women who were randomized to four exercise groups: vigorous intensity/high
duration; moderate intensity/high duration; moderate intensity/moderate duration; or vigorous
intensity/high duration. Walking was encouraged as the primary mode of exercise for all groups
and treadmills were provided to all participants. Participants were also instructed to reduce
caloric intake so as to not exceed 1500 kcal a day. At the end of the 12-month trial, the authors
found significant weight loss and increased cardiorespiratory fitness in all exercise groups with
no significant difference between groups.
Third STG. To address the third short-term goal, it would be appropriate to educate the
client on sternal precautions and ways to follow precautions during every day activities. This
intervention takes a prevention approach with a focus on preventing further injury to the surgical

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site and thus allowing for a faster degree of recovery. It is possible for exact sternal precautions
to vary between facilities, but common precautions include avoiding Valsalva maneuvers, not
lifting more than 10-lbs, avoiding rapid movement of the upper portion of the body, and wearing
compressive hoes (Matthews, 2013). The occupational therapist can start by verbalizing each
precaution and then asking the client to repeat the precautions. Then the occupational therapist
can demonstrate guidelines for bed mobility, transfers, dressing, and other areas that may be
impaired. Afterwards, the client should demonstrate their competency by performing proper
technique while the therapist gives feedback as necessary. The outcomes of this intervention
focus on prevention and participation. The client will feel safe knowing that they can participate
in meaningful activities while preventing any further injury.
Justification. The purpose of the literature review by Brocki, Thorup, and Andreasen
(2010) was to identify mechanical stress factors that cause sternal instability and infection in
order to create evidence-based guidelines for activity following sternotomy. The authors note that
many patients are fearful of hurting themselves after surgery and avoid normal daily activities.
From this review, the authors deliver several recommendations for the first six to eight weeks
after surgery: patients with sternal precautions should be taught self-hugging when coughing
and sneezing, patients should use the elbow-method during transfers from supine to sitting in
order to minimize pain from the lower sternum, individuals with BMI 35 should wear a
supportive vest for sternal protection, and patients should avoid stretching both arms backwards
at the same time. The authors feel these precautions will make sense to the patient and support
their autonomy. To conclude, the authors emphasize the importance of individualized counseling
for each client in regards to precautions and desired daily activities to improve quality of life
during recovery.

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Fourth STG. To address the fourth short-term goal, it would be appropriate to teach the
client use of adaptive equipment for dressing. This intervention takes a modification approach
with a focus on compensating for the clients limited reach. Items of adaptive equipment that
would be beneficial for the client include an extra-long dressing stick, long-handled shoe horn,
and aluminum reacher. The occupational therapist should explain the purpose of each item while
demonstrating proper utilization. The occupational therapist should then have the client practice
using each item and encourage problem-solving when necessary. In addition, the occupational
therapist can help the client to determine where to store these items for easy retrieval. The
outcomes of this intervention focus on improving occupational performance and increasing
quality of life. Being able to dress with only the help of adaptive equipment will help to restore
the clients autonomy and lead to an increase in confidence which will likely carry over to other
areas of occupation.
Justification. The purpose of the analysis by Reynolds, Saito, and Crimmins (2005) was
to estimate the effect of obesity on both the length of life and length of nondisabled life for older
Americans. The authors base active life expectancy on the ability to perform basic personal care
(ADL) and independent living. Nondisabled is defined in this study as being independent in all
ADLs and disabled is defined as needing assistance for at least one ADL. The authors examined
data from the first three waves of the Asset and Health Dynamics Among the Oldest Old
(AHEAD) study. They found that for both women and men, those who were obese had a
significantly higher probability of becoming disabled across the older ages and lived more years
with a disability than those were not obese. The authors conclude that needing personal
assistance to complete ADL tasks is difficult for both the patient and caregiver and that future
research should focus on the causes and treatment of obesity.
Precautions & Contraindications

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The client is recovering from a CABG procedure, so it important to follow physician
mandated sternal precautions for the length of her recovery. In addition, the client is morbidly
obese so it is vital that the occupational therapist gather the necessary bariatric items such as a
wheelchair, walker, gait belt, and blood pressure cuff prior to entering the clients room. Since
the client has cardiac precautions, the occupational therapist should be observant of any signs of
cardiac distress, such as dyspnea, angina, or diaphoresis, throughout the treatment session. It may
also be beneficial for the occupational therapist to utilize the Borg Rate of Perceived Exertion
Scale to monitor fatigue throughout an intervention. Although none were indicated in the clients
chart, it is important that the occupational therapist check for any metabolic equivalent of task
(MET) level restrictions before beginning therapy. As always, heart rate and blood pressure
should be recorded before, during, and after the client engages in therapy (Matthews, 2013).
Frequency & Duration
The frequency and duration of occupational therapy treatment sessions for this skilled
nursing facility are typically 60 minutes a day, three to four times a week. Due to the nature of
the interventions, it is possible for two interventions to be combined in one treatment session.
For example, after the occupational therapist educates the client on sternal precautions, they can
introduce adaptive equipment for dressing. Once a short-term goal is achieved, the occupational
therapist may choose to discontinue that intervention to allow for greater time to be spent on
where the client still struggles.
Grading
The intervention of increasing endurance through physical activity can be easily graded
up or down. To grade the activity down, the occupational therapist can work on standing
tolerance with a chair placed closely behind the client so that the client is able to take frequent
rest breaks. In addition, the occupational therapist can encourage the client to ambulate short
distances, such as from the bed to bathroom, if longer distances are too strenuous. To grade the

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activity up, the occupational therapist can encourage the client to toss a ball back and forth with
her grandchildren while standing. In addition, the occupational therapist can encourage the client
to take fewer breaks or increase her speed during ambulation activities. The occupational
therapist should collaborate with the client to determine the just-right challenge.
Framework
The primary framework that was chosen for this intervention plan is transtheoretical
model (TTM). This model focuses on change that occurs in six stages: precontemplation,
contemplation, preparation, action, maintenance, and termination. The processes that individuals
use to progress through the stages include self-reevaluation, self-liberation, helping relationships,
stimulus control, and reinforcement management. These processes acted as the pillars for
intervention planning (Pizzi, Reitz, & Scaffa, 2013).
The client is currently in the preparation stage which means she has demonstrated some
initiative to plan change strategies and is ready to take action in the very near future. The client
has evidenced her willingness to change by speaking to the occupational therapist about her
concerns and agreeing to participate in therapy. Once the client begins her treatment plan, she
will be in the action stage which is defined by overt manifestations of lifestyle modification. The
action stage lasts six months before the individual is considered to be in the maintenance stage
(Pizzi, Reitz, & Scaffa, 2013). Although the client is only scheduled to remain at the facility for
four weeks, the occupational therapist will be able to provide her with the skills necessary to
continue to follow her plan once she is discharged home.
Albeit this model appears only to correlate with the clients first long-term goal, it can be
applied to the second long-term goal as well. The client will only be following sternal
precautions for a short time, so it is not necessary to design the entire plan around a single
intervention. In addition, the clients body mass creates the need for adaptive equipment to be
used when dressing. However, since this intervention plan is focused on health promotion, the

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client will likely lose weight as a result of her healthier choices and may not need to use adaptive
equipment continuously. Guiding the client through change by empowering her with the skills
needed to make and maintain favorable choices is what will be most beneficial for this client.
Client and Caregiver Education
Client and caregiver education should be addressed for each of the four interventions.
According to Matthews (2013), family education should include cardiac anatomy, management
of symptoms, risk factors, diet, exercise, and energy conservation. The client comes from a
Latino family, so when utilizing handouts, the occupational therapist should ask the family for a
preferred language.
For the first intervention of lifestyle modification, it is important to explain the benefits
and evidence that support these programs to both the client and caregiver. It may also be helpful
to give the client and caregiver a few handouts with examples of programs available so that they
can decide which type of plan would be most beneficial. These handouts can also be given to the
treating physician, other therapists, and nursing staff so that the entire interdisciplinary team can
be supportive of the client.
For the second intervention of increasing endurance through physical activity, it would be
important to provide the client and caregiver with a handout explaining the signs of cardiac
distress and the steps to take if they notice them occurring. The occupational therapist should
inform both the client and caregiver on what activities the client is safe to do without a therapist
and which activities should not be attempted unsupervised. In addition, the occupational therapist
should inform the family on how to set up the environment for approved tasks, such as having
the call light nearby, ensuring the floor is free of tripping hazards, and making sure the client has
a safe place to sit should she become fatigued.
To address the third intervention of education on sternal precautions, the occupational
therapist can post a handout in the clients room with pictures illustrating what movements
should be avoided. It is important to explain the risks of not adhering to the precautions and what

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the client and caregiver should do if the client feels pain or discomfort at her surgery site. To
check for understanding, the occupational therapist can demonstrate a movement and ask the
caregiver to identify whether the movement is compliant or a violation of sternal precautions.
To address the final intervention of use of adaptive equipment, the occupational therapist
can provide the client and caregiver with a handout that explains how to use each item. The
client previously relied on her husband to assist her with dressing but now wants to become
independent. Therefore, it is important to explain to the caregiver how the adaptive equipment
will benefit the client and the importance of not providing assistance unless necessary. Finally,
information on where the client can obtain the adaptive equipment once discharged should be
provided to the family.
Response to Intervention
The clients response to intervention will be monitored throughout the intervention
process through use of formal and informal assessments and observations. The main outcome
measure used at the clients skilled nursing facility is the Barthel Index. This measure would be
appropriate to use to track improvements in the clients functional independence. The Barthel
Index is a measure of disability in performing ADLs such as toileting, feeding, dressing,
grooming, transfers, and mobility (Gillen, 2013). Although the functional aspects of the
interventions focus mainly on dressing and mobility, the occupational therapist would likely see
improvements in other performance areas due to increased motivation and conditioning.
To track improvements in the clients perceived well-being, it would be beneficial to
utilize the Canadian Occupational Performance Measure (COPM). The COPM is a standardized
outcome measure used to detect change in a client's self-perception of occupational performance
over time. This semi-structured interview is used to examine the clients perceived performance
abilities as well as the clients satisfaction with their performance (Law et al., 2005). Although

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the initial evaluation had already occurred at the time of intervention planning, the COPM would
have been ideal to use as part of the initial evaluation for planning client-centered goals.
The Barthel Index and COPM are beneficial for measuring broad aspects of client
improvement but it would also be advantageous to have objective measurements of factors
related to cardiac health. For example, before beginning the lifestyle modification program, the
occupational therapist should record the clients blood pressure, heart rate, body mass index
(BMI), muscle strength, and cholesterol levels. These factors should be recorded periodically
throughout treatment to monitor improvements. Having objective measurements of improvement
will be beneficial for increasing the clients confidence and gaining support from the
interdisciplinary team.
Conclusion
Mrs. Mendoza is a 60 year old grandmother who suffers from morbid obesity and CAD.
She is hopeful that with occupational therapy, she will be able to identify and implement changes
needed to live a healthier life. At the end of her stay at the skilled nursing facility, she will likely
be discharged home and instructed to follow-up at an outpatient facility for cardiac rehabilitation
and monitoring. Additionally, the occupational therapist should provide her with psychosocial
counseling resources. Mrs. Mendozas desire to change, willingness to participate in therapy, and
supportive family demonstrates that she has good potential to be able to return home safely.

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References
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