Dickson Occupational Profile

Running head: OCCUPATIONAL PROFILE & INTERVENTION PLAN 1
Occupational Profile & Intervention Plan

Breanna Dickson
Touro University Nevada
OCCUPATIONAL PROFILE & INTERVENTION PLAN 2

Occupational Profile
The client is a 67 year old African-American woman. She is single and lives in single-
story home in North Las Vegas with her 19 year old granddaughter. The client does not drive and
relies on her granddaughter to take her to appointments and shopping. Her friends visit her on a
weekly basis and she enjoys playing card games with them.
The client is in a long-term acute care hospital due to complications from a right-sided
ischemic CVA she incurred three months prior. According to the American Stroke Association,
paralysis on the left side of the body, vision problems, inquisitive behavioral style, and memory
loss can all be effects of a right-sided stroke (Effects of Stroke, 2012). The client has been in the
hospital for two weeks and has not been able to get out of bed due to fatigue and weakness.
Currently, she relies on nursing staff to complete her activities of daily living (ADLs) due to her
left-sided weakness, known as hemiparesis, and decreased endurance. She wants to be able to
complete her ADLs independently but is afraid she has lost her endurance for out of bed
activities.
During her initial occupational therapy evaluation in her hospital room, the client was
awake, oriented, and not in pain. She demonstrated good fine motor coordination with her right
dominant hand but had poor fine motor coordination with her left hand. She was able to sit at the
edge of the bed from the supine position with Mod A and could tolerate sitting upright. The
client said she is too fearful to attempt a shower and needs assistance transferring to the
commode due to her postural insecurity. She also needs assistance for dressing and feeding. The
client also stated that it takes her longer to do things than it did prior to her stroke which is
frustrating.

It is important to examine which contexts are most supportive and inhibitory for the
client. The cultural and personal contexts are supportive of the clients participation and
engagement in occupations because she considers herself to be a strong, independent woman and
wants to maintain that perspective. It is unknown for how long she has been single, but it is clear
that she takes pride in her ability to take care of herself without the help from a spouse. On the
other hand, the clients temporal context is proving to be inhibitory of her ability to engage in
participation since she has not been out of bed since arriving at the hospital two weeks ago.
In terms of physical environments, the hospital setting is supportive of the clients
participation and engagement in occupations due to the accessibility of the nursing staff,
therapists, durable medical equipment (DME), and assistive devices. At this stage, the clients
home setting is both supportive and inhibitory. The clients home is supportive since she lives in
a single-story home without any stairs but her home is also inhibitory since the clients
granddaughter is gone for most of the day and they do not have any DME or assistive devices in
the home. Although the client did not have visitors during her therapy sessions, she has close
friends that visit her at home often so it is safe to assume that a social environment would be
supportive.
The client is a retired licensed practical nurse. She enjoys talking on the phone and
playing cards with friends. The client loves to get dressed up for bridge tournaments at the local
community center with her friends. When she is not with her friends, she enjoys watching
television. The client lives with her granddaughter and is responsible for tidying up the house
while she is at school. She relies on her granddaughter to take her to the grocery store and her
doctors appointments since she does not drive.

The client stated her goal for therapy is to increase her endurance and be independent in
taking care of herself. She stated she wants to make sure she will be as independent as she was
prior to being admitted to the hospital so as not burden her granddaughter any further. The client
wants to be able to get dressed, have her friends come over, and play cards again without
assistance. Although the client prides herself on being autonomous, she is not opposed to using
DME and assistive devices.
Occupational Analysis
The client participated in a 30 minute occupational therapy session to address ADLs in
her hospital room at the long-term acute care facility where she was staying. When asked to don
a shirt, the client needed assistance to pull her affected extremity through the sleeve of her shirt
and down over her trunk. When asked to don her pants, she needed assistance throughout due to
her poor dynamic sitting balance. The client was unable to don socks due to poor trunk control.
The clients left-side hemiparesis also affected her ability to transfer to and from the wheelchair
independently. The client was able to comb her hair independently with her right hand but
needed assistance setting up her toothbrush since she was not using her left hand secondary to
neglect.
Due to the nature of the setting, only participation in ADL activities was observed. The
client demonstrated impairments in the areas of dressing, functional mobility, and personal
hygiene. In terms of client factors, the clients impaired joint mobility, muscle endurance, and
muscle power of her left side impacted her ability to participate in ADL activities. For
performance skills, the client appeared to demonstrate intact process skills and social interaction
skills but had obvious difficulty with motor skills. Specifically, the client demonstrated problems

stabilizing, reaching, bending, coordinating, and enduring. In terms of performance patterns, the
clients postural insecurity and fear of falling was likely leading to unsafe habits in the form of
maladaptive movement patterns. However, the clients role as friend to others was supportive of
her engagement in ADL activities since she was eager to socialize with her friends once again.
Problem List
1. Client requires Max A for LE dressing due to poor dynamic sitting balance and left-side
hemiparesis.
2. Client requires Max A in UE dressing secondary to left-side neglect.
3. Client requires Mod A for wheelchair transfers secondary to left-side hemiparesis.
4. Client requires Mod A in bed mobility due to decreased left-side UE and LE strength.
5. Client required Min A for personal hygiene tasks due to left-side hemiparesis.
The clients list of problem statements was prioritized by the amount of assistance
needed. The client needs to be as independent as possible for her to return home, so the areas
where she needs most assistance need to be addressed early on. The majority of her problems
stem from her left-side hemiparesis. If the occupational therapist is able to address this early on,
it is likely smaller problem areas, such as endurance, will correct themselves without having to
be explicitly addressed.
Intervention Plan & Outcomes
Long-Term Goal (LTG)
1. Client will complete LE dressing Mod I due to longer time in 4 weeks.
2. Client will complete UE dressing Mod I due to longer time in 4 weeks.

Short-Term Goals (STG)
1. Client will don and doff socks with Mod I using a sock aid in 2 weeks.
2. Client will don and doff pants with Min A at edge of bed in 2 weeks.
3. Client will don and doff brassiere using hemi-dressing techniques with Mod I in 2 weeks.
4. Client will don and doff shirt with Min A at edge of bed in 2 weeks.
Interventions
First STG. To address the first STG, it would be appropriate to teach the client proper
use of adaptive equipment for lower-body dressing. Although dynamic balance will hopefully be
remediated through therapy, it is still important to respect the clients autonomy and empower
her to complete LE dressing through the use of adaptive equipment as independently as possible
until her deficits are restored. The occupational therapist can begin by bringing different types of
adaptive equipment for LE dressing for the client to try. For the purposes of this intervention,
donning and doffing socks has proven to be the most challenging for the client so it should be
addressed first. The occupational therapist can then introduce the client to the sock-aid and
explain the ideology behind it. Then the therapist should visually demonstrate how to use the
sock-aid and how to adapt the sock-aid so it can be used with one hand. Finally, the therapist
should have the client demonstrate while resolving any problems or concerns by the client. Once
the client is competent in use of the sock-aid, the therapist may choose to introduce other
adaptive equipment.
Justification. Foti and Koketsu (2013) discuss the role of the occupational therapist in
ADLs. The authors mention that sometimes the occupational therapist has to explore a variety of
assistive devices to reach a solution for specific ADL problems. For ADL deficits related to
limited range of motion (ROM) or strength, the authors identify compensating for the lack of

joint excursion and reach through use of adaptive equipment as a solution. Specifically, long-
handled dressing sticks, extended handle reachers, and sock aids are identified as adaptive
equipment that can be used for LE dressing. The authors also conclude that if the client has
potential for improvement of specific deficits, remediation and restoration treatments should also
be considered.
Precautions. Before providing the client with adaptive equipment, it is important to
assess for sensory, perceptual, and cognitive deficits to establish appropriate teaching methods to
facilitate learning (Foti & Kokestsu, 2013). Once the occupational therapist determines the client
is eligible for adaptive equipment, there are little precautions with adaptive equipment as long
the client is competent in use. It may also be good idea to provide the client with a hand-out on
how to use the adaptive equipment since memory loss can be affected by right-sided stroke as
mentioned previously.
Second STG. To address the second STG, it would be appropriate to use functional
balance activities to increase dynamic balance, decrease postural insecurity, and increase
confidence. The purpose of the activities should be to facilitate weight-shifting while reaching.
For example, the client can play a card game while sitting at the edge of bed where she will have
to reach laterally and across midline to pick-up cards from a deck. While the client is reaching
with the less-affected UE, it is important to have her weight bear on her affected UE. Moreover,
to address the clients postural insecurity, the client can stand on the affected LE in front of the
sink while holding on to the back of a chair for support. From there, the client can complete
grooming activities in this position and practice alternating the standing leg throughout. Finally,
the client can sit in a chair and lean forward and laterally to pick up items from the floor, such as
clothing prior to dressing.

Justification. The purpose of the descriptive correlational study by Kim and Park (2013)
was to determine a causal relationship among balance self-efficacy, balance, and activities of
daily living (ADLs) in individuals with stroke. The authors hypothesized that balance self-
efficacy and balance variables would influence ADLs and that ADLs would mediate balance
through balance self-efficacy in community residents with stroke. They found balance self-
efficacy has a significant direct effect on balance and a significant indirect effect on ADL
through balance. To conclude, the authors propose implications for rehabilitation; occupational
therapists should assess balance efficacy as well as balance ability and choose interventions that
use a combination of balance training and balance self-efficacy enhancement to improve ADL
performance in individuals with stroke.
Precautions. Before any functional balance activities are initiated, it is important that the
occupational therapist educate the client on establishing a neutral starting alignment. For
example, the client should have non-slip socks on, feet firmly on the ground, equal weight
bearing through both ischial tuberosities, an erect spine, and neutral to anterior pelvic tilt (Gillen,
2013). The occupational therapist should encourage the client to challenge themselves while
listening to their body and stopping when they need to. Finally, the client should always be
supervised when performing functional balance activities due to the risk of fall.
Third STG. To address the third STG, it would be important to teach the client how to
don a brassiere using hemi-dressing techniques. These include fastening the brassiere in the
front, using the strong arm to thread the weak arm through the brassiere strap, and pulling the
strap on the affected side over the shoulder with the stronger arm (Foti & Kokestsu, 2013). Since
this would most likely be learned quickly, it would also be appropriate to incorporate functional
activities to increase bilateral coordination. To start, the client can play a card game where she

holds cards in one hand while drawing from the deck with the other hand. In addition, the client
can make and knead bread dough with both hands for her granddaughter to take home to bake.
Finally the client can use both hands to braid her granddaughters hair when she comes to visit.
In all of these activities, the therapist or client can provided hand-over-hand assistance to the
affected UE if needed.
Justification. The purpose of the meta-analysis by Cauraugh, Lodha, Naik, and Summers
(2010) was to determine the cumulative effect of bilateral arm training on motor capabilities post
stroke. The authors included 25 studies across all three stages of stroke recovery for intervention
studies that used bilateral arm movements as a training treatment. For bilateral training
techniques, six studies used pure bilateral, seven studies used bilateral arm training with
rhythmic auditory cueing, seven studies used coupled bilateral and EMG-triggered
neuromuscular stimulation, and five studies used active and/or passive movements, including
robotics. The authors found strong evidence supporting bilateral arm training with the mention
that two coupled protocols, rhythmic alternating movements and active stimulation, are most
effective.
Precautions. Fortunately, there are not many precautions when addressing bilateral
coordination. If the client has sensory deficits in the impaired UE, it is important to monitor the
skin for signs of tissue damage. The occupational therapist should also provide encouragement to
ensure the client is engaging the affect side throughout the activities.
Fourth STG. To address the fourth STG, it would be appropriate to use constraint-
induced movement therapy (CIMT) while completing functional activities to improve motor
recovery and increase left UE use. Current literature suggests wearing a mitt on the less-affected
extremity while performing repetitive, functional tasks several hours a day for ten to fifteen days

(Behrens, 2011). Since therapy sessions in the long-term acute care setting typically only last
thirty-minutes at a time, the nursing staff would have to be on board with this plan. For example,
the occupational therapist can place the mitt on the client, explain the tasks they want the client
to engage in, and then come back or alert the nursing staff to remove the mitt after three hours
have passed. Examples of repetitive, functional tasks include completing jigsaw puzzles, playing
solitaire, feeding, and typing on a computer.
Justification. The purpose of the single-blind, randomized control trial by Wolf et al.
(2006) was to compare the effects of a two week program of constraint induced movement
therapy (CIMT) to customary care on improvement in upper-extremity function among patients
who had a first stroke within the previous 3 to 9 months. The authors recruited 222 individuals
with ischemic stroke; 106 in the CIMT group and 116 in the control group. The CIMT group
wore a restraining mitt on the less-affected hand 90% of their waking time while engaging in
shaping and repetitive tasks involving functional activities performed continuously for 15-20
minutes. The control group received anywhere from no treatment after concluding formal
rehabilitation to pharmacologic or physiotherapeutic interventions. The authors used the Wolf
Motor Function Test (WMFT) and Motor Activity Log (MAL) to measure outcomes. The CIMT
group showed greater improvements on both the MAL and WMFT than the control group.
Precautions. The occupational therapist should document that the client has 10 degrees
of wrist extension, 10 degrees of finger extension in any two fingers, and 10 degrees of thumb
abduction since that is part of the inclusion criteria to be eligible for CIMT (Gillen, 2013). Based
on informal observations of the impaired UE, the client is believed to meet these criteria and
would eligible. It is important that the occupational therapist monitor for signs of fatigue.
Although the mitt should be properly fitted for the less-affected UE, it is important to look for

redness, pain, or swelling as they may be indications of pressure sores. Finally, the therapist
should explain the benefits of CIMT and encourage the client to maintain the regimen.
Approach
When choosing an intervention approach, the establish/ restore approach seemed most
appropriate. It is likely the client had good dynamic balance and no left-sided neglect prior to the
left-side hemiparesis caused by her stroke. The goal of this intervention plan is to restore the
clients dynamic balance and bilateral coordination so that she can complete ADL activities, such
as dressing, safely and independently. Additionally, the modify approach was included in this
intervention plan. The client is unable to complete LE dressing independently so teaching the
client how to use adaptive equipment will help her to attain independence. Although the clients
underlying problems will likely be remediated, the client mentioned that she is frustrated with
having to rely on others to dress her, so by using adaptive equipment, the client can enjoy a
present level of modified independence.
Outcomes
The desired outcomes for this intervention plan include improvement in occupational
performance, prevention, quality of life, and participation. By teaching the client proper use of
adaptive equipment, increasing her dynamic balance, encouraging bilateral coordination, and
reducing left-sided neglect, the clients independence will increase and her occupational
performance will be improved. Likewise, the clients balance deficits and left-sided neglect put
her at risk for falls, so by addressing these deficits, this intervention targets fall prevention.
Quality of life and participation are intertwined because the more the client is able to participate
in her ADL activities, the better quality of life she perceives. The client is a strong, independent

woman, so it is not only important that she is able to maintain that perspective for others, but for
her own psychological prosperity as well.
Frequency
The frequency and duration of occupational therapy treatment sessions in the long-term
acute care setting are typically 30 minutes a day, four to five times a week. Due to the nature of
the interventions, many of them can be combined in one treatment session. For example, the
therapist may take the first half of the session teaching the client proper use of adaptive
equipment and hemi-dressing techniques and use the other half for functional balance
techniques. In addition, the client may learn how to use adaptive equipment quickly so that
intervention should be addressed early-on and stopped once competency is reached to allow
more time for other interventions.
Since bilateral coordination and CIMT are being addressed together, it is important that
the occupational therapist plan those sessions accordingly. For example, the occupational
therapist should implement CIMT at the end of a session and begin the next days session with
bilateral coordination exercises. The CIMT will help with the motor recovery of the clients left
UE but being able to use both hands together is the ultimate goal. The therapist should use their
clinical judgment and input from the client to decide what intervention, or combination of
interventions, they want to address that day.
Grading
The intervention of increasing dynamic balance can be easily graded up and down. For
example, playing cards and feeding while seated can be utilized first, followed by wiping
countertops and reaching to the floor for shoes which require more weight-shifting. Additionally,

the seated position can be graded as well. The client can begin sitting in a high-back chair,
followed by sitting at the edge of bed, and possibly progressing to sitting on a large therapy ball.
In addition, the standing balance activities can also be graded. The client can begin standing with
both feet on the floor, slowly adding in graded weight-shifts until she is completely weight-
bearing on the affected LE. Additionally, the client can start with both hands holding on to the
back of a chair for support and then progress to only using one hand. Finally, the occupational
therapist can extend how far the client will have to reach for items to complete functional
activities if the client requires more challenge (Gillen, 2013).
Framework
The primary framework that was chosen for this intervention plan is the task-oriented
approach. This framework was chosen because according to Kovic and Schultz-Krohn (2013),
current research indicates that a beneficial way to achieve a successful client-centered outcome is
to include interventions that address how the client interacts with the environment and the task.
This approach is supported by applied neuroscience concepts that imply that skilled interaction
associated with a clients environment and task performance may direct cortical changes and
facilitate neuromuscular recovery. In the task-oriented approach, the occupational therapist may
apply motor learning concepts, adapt, or otherwise facilitate successful completion of an
occupation-based goal. In applying the task-oriented approach, the occupational therapist is
incorporating understanding of neuroscience concepts while simultaneously addressing
performance skill deficits (Kovic & Schultz-Krohn, 2013).
Goal planning was accomplished by addressing the clients performance skill deficits to
increase her occupational performance. Kovic and Schultz-Krohn (2013) say that skilled learning

occurs through the use of adaptations and strategies that facilitate an adaptive response and this
response has been shown to occur with the use of the task-oriented approach. Although some
motor learning concepts were applied, the interventions focused mainly on using strategies to
facilitate an adaptive response during functional tasks. The performance skills that were most
inhibitory of the clients ability to participate in occupations were stabilizing, reaching, bending,
coordinating, and enduring. Each intervention tried to address these in some way while
incorporating compensatory techniques and adaptations.
Client and Caregiver Education
Client education needs to be addressed for each of the four interventions. As mentioned
previously, handouts can be given to client explaining how to use the adaptive equipment. In
addition, handouts can also be provided demonstrating dynamic balance and bilateral
coordination exercises. However, if handouts are utilized, it would be important to clearly
indicate which exercises the client can perform alone and which ones she needs to have
supervision for. Furthermore, when addressing CIMT it is important to explain the benefits and
reasoning to the client and nursing staff. It may also be useful to educate the client and nursing
staff on the CIMT wear schedule by posting a copy of the schedule in the clients room.
As important as it is to educate the client during the intervention process, it is just as
important to educate the clients 19 year old granddaughter since she is her primary caregiver.
Since the client does not drive, it would be useful to provide the granddaughter with a list of
stores along with approximate costs for adaptive equipment in case the client would still benefit
from adaptive equipment upon discharge. In addition, along with the balance and bilateral
coordination exercise handout, it would be important to provide education to the granddaughter

on how to properly do these exercises so that she can correct the client if she notices any
improper body mechanics. Finally, it would be wise to provided literature to the granddaughter
on the use of CIMT and encourage her to ask questions if any arise throughout the intervention
process.
Response to Intervention
The clients response to intervention will be monitored throughout the intervention
process through use of formal and informal assessments and observations. Gillen (2013)
recommends a top-down approach to assessment which begins with inquiry into role
competency, tasks that define a person, and problems that interfere with occupational
performance. The Arnadottir Occupational Therapy Neurobheavioral Evaluation (A-ONE) is an
assessment tool that objectively documents how dysfunction of client factors affect ADL and
mobility tasks by evaluating neglect syndromes, sequencing dysfunctions, agnosias, and apraxias
(Gillen, 2013). Although the initial evaluation had already occurred at the time of intervention
planning, the A-ONE would have been ideal to use as part of the initial evaluation for planning
client-centered goals.
The response to interventions will be measured through the use of the Functional
Independence Measure (FIM) prior to beginning interventions and again after two weeks for
reevaluation. The FIM is a measure of disability in performing ADLs that evaluates performance
for motor and cognitive functioning (Gillen, 2013). Although the FIM assesses many of the ADL
areas that the interventions are trying to remediate, it would also be helpful to use specific
assessments for certain interventions to ensure the interventions are working as planned.

To measure the response to the second intervention of increasing functional balance, it
would be appropriate to utilize the Berg Balance Scale. The Berg Balance Scale is composed of
14 items that involve static, dynamic, sitting, and standing balance activities. Performance on
items are scored on a zero to four point ordinal scale with four being the highest functioning and
zero being the lowest (Gillen, 2013). Furthermore, the Test valuant les Membres suprieurs des
Personnes ges (TEMPA) assessment would be appropriate for measuring response to the third
intervention of increasing bilateral coordination. The TEMPA measures bilateral and unilateral
UE performance through nine standardized tasks (Gillen, 2013). Finally, the Arm Motor Ability
Test (AMAT) has been identified by Gillen (2013) as a tool that has been used to document
outcomes of CIMT. The AMAT evaluates arm functional mobility and quality of movement
during performance of 28 tasks (Gillen, 2013). All of the previously mentioned assessments
should be utilized prior to beginning the interventions and again during reevaluation.


References
Behrens, B. (2011). Constrain-induce movement therapy. Retrieved from Mercer County
Community College: http://www.mccc.edu/~behrensb/documents/Constrain-
InduceMovementTherapyCIMTorCI.pdf
Cauraugh, J. H., Lodha, N., Naik, S. K., & Summers, J. J. (2010). Bilateral movement training
and stroke motor recovery progress: a structured review and meta-analysis. Human
movement science, 29(5), 853-870. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2889142/
Effects of Stroke. (2012). Retrieved from American Stroke Association:
http://www.strokeassociation.org/STROKEORG/AboutStroke/EffectsofStroke/Effects-
of-Stroke_UCM_308534_SubHomePage.jsp
Foti, D., & Kokestsu, J. (2013). Activities of daily living. In H. Penleton, & W. Schultz-Krohn,
Pedretti's occupational therapy:Practice skills for physical dysfunction (pp. 157-230). St.
Louis: Elsevier.
Gillen, G. (2013). Cerebrovascular accident/stroke. In H. Pendleton, & W. Schultz-Krohn,
Pedretti's Occupational Therapy:Practice skills for physical dysfunction (pp. 845-877).
St. Louis: Elsevier.
Kim, J. H., & Park, E. Y. (2013). Balance self-efficacy in relation to balance and activities of
daily living in community residents with stroke. Disability & Rehabilitation, 1-5.
Retrieved from http://web.b.ebscohost.com/ehost/detail?sid=bd0e71c1-326d-47c2-becb-
24cf4111c838%40sessionmgr113&vid=6&hid=124

Kovic, M., & Schultz-Krohn, W. (2013). Performance skills: Definitions and evaluation in the
context of the occupational therapy framework. In H. Pendleton, & W. Schultz-Krohn,
Pedretti's occupational therapy: Practice skills for physical dysfunction (pp. 451-459).
St. Louis: Elsevier.
Wolf, S. L., Winstein, C. J., Miller, J. P., Taub, E., Uswatte, G., Morris, D., ... & EXCITE
investigators. (2006). Effect of constraint-induced movement therapy on upper extremity
function 3 to 9 months after stroke: the EXCITE randomized clinical trial. Jama, 296(17),
2095-2104. Retrieved from http://www.uni.edu/gabriele/page4/files/constraint-induced-
movement-therapy.pdf

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Running head: OCCUPATIONAL PROFILE & INTERVENTION PLAN 1

Occupational Profile & Intervention Plan

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