oas case study: mrs. k
TRANSCRIPT
M R S . Ka case study by
SARAH JANE CALUBVANESSA MAE CARZONRAFAEL GARCIA
OCCUPATIONS OF ADULTS AND SENIORS I
is MRS. K?• 63 y/o woman.• Married• Lives with husband• Works part time (clerical work) & babysits
grandchildren.• Independent w/self-care & work tasks.• Enjoys: gardening, knitting, quilting.• Used to attend weekly luncheons w/her friends.
W H O
OT evaluation for tx, pain at R thumb
REFERRALNature of
HISTORYRelevant Medical
Arthritis
Insulin-dependent diabetes
OCD
OT EVALUATION
• Pain Scale• Reported 9/10 initial evaluation
• ROM• Bilateral shoulder/elbow ROM are WNL
• Grip/Pinch Strength• Weak hand grasp, especially in pinches• Instability of CMC & MCP, limited R thumb
opposition
OT Evalua)on Cont.OT EVALUATIONcontinued
• Sensory Assessments (Pin Stick & Temperature)• Impaired sensation for light touch, sharp/
dull, hot/cold in both hands• Arthritic Deformities• Multiple swan neck: L hand digits 2 & 4, R
hand digits 3-5• Multiple RA nodules on both hands
Func)onal Problems
Pt. is always tired & depressed
Unable to bathe & perform self-groom tasks
Unable to carry out household chores
Difficulty preparing meals
No longer attends weekly luncheon with her friends
Functional PROBLEMS
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2
3
4
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Long Term Goal #1
Client will be independent with all hygiene/self-care activities in own home, using A/E and energy conservation strategies with a fatigue level of 5 or less in 4 weeks to increase functional independence and decrease fatigue.
Long-Term GOAL #1
Short Term Goal 1a
Client will tolerate 20 minutes of ADL activity, taking 2-minute breaks every 10 minutes with 0/10 pain in R and L upper extremities during rest and activity, 3x/week for 3 weeks.
Short-term GOAL 1a
Short Term Goal 1b
Client will demonstrate independence with brushing hair and teeth using built-up handles on her hairbrush and toothbrush to compensate for weakened grasp after education for five minutes, 2x/week for 2 weeks.
Short-term GOAL 1b
Long Term Goal #2
Client will be able to independently self-feed for 15 minutes, using built-up utensils, compensatory movements, and UE joint protection strategies without VCs 1x/week for 4 weeks to increase functional independence.
Long-term GOAL #2
Short Term Goal 2a
Client will independently self-feed using built-up utensils for 10 minutes after instruction 1x/week for 2 weeks to increase functional independence.
Short-term GOAL 2a
Short Term Goal 2b
Client will tolerate 10 minutes of wrist and hand exercises to increase strength, ROM, and endurance, which will improve feeding and other ADLs, 3x/week for 3 weeks.
Short-term GOAL 2b
OT Treatment Plan
• Educate client:• Energy conservation & ECWS techniques• Fall risk & prevention strategies• Joint protection• Stress management & relaxation
techniques
OT TREATMENT PLAN
OT Treatment Plan
• ADL/IADL training• A/E to improve grasp & compensate for
muscle atrophy• Pain management techniques • Train in safe/efficient transfers
OT TREATMENT PLANcontinued
OT Treatment Plan
• Splints:• Rest/working hand splint• Wrist cock-up• Finger splint• Ulnar deviation splint• Tri-point splint• Thumb Spica
OT TREATMENT PLANcontinued
Frames of ReferencesFrames of REFERENCEMOHO
Understanding her habits according to her roles.Looking at her volition to make her more self-sufficient in her daily tasks.
PEOChanging the environment to create a greater fit w/the client & occupation to improve occupational performance.
EHPEstablish/restore intervention addresses inability to self-
feed.Adapting/modifying the above task addressed by adding
built up handles.Prevent/create intervention will be addressed by the home
exercise program.
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the ACTIVITY
Client will work on multi-step food preparation in own kitchen by participating in graded cooking tasks to improve safety and independence in meal preparation.
Client will prepare dinner for two (her and her husband) using pre-prepared meals.
Client will prepare dinner for two using pre-cut vegetables and meat.
Client will prepare dinner for two with only one pre-prepared item, utilizing A/E (e.g. rocking knife) to cut vegetables.
Home Program
• Practice energy conservation, work simplification, & safety techniques
• Wear working splints during day activities & resting splint at night.
• Use built up padding for tools during ADL’s.
Home PROGRAM
Discharge Summary
Client achieved all long & short term goals.
Pain reduced from 9/10 to 2/10 & occasionally 7/10.
Fatigue level decreased from 10/10 to 5/10.
Grip strength improved from 42lbs to 50lbs on the R hand and 50lbs to 51lbs on L hand.
Discharge SUMMARY
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T H E E N D