OCCT 506: Clinical Reasoning about Occupation Form #5 Student: Activity: Cooking macaroni and cheese Date: 10/9/12

Client-Activity Intervention Plan Directions: This assignment is to be completed individually. Choose someone that has a disability and observe them performing an occupational activity. Complete the following sections based on your observations. Clients Occupational Profile Cindy is a 33 year old female with a diagnosis of Cerebral Palsy and Lymes Disease. Cindy has been referred for an occupational therapy evaluation by her program called The Developmental Disability Waiver Program (DD Waiver) in New Mexico. She has been living in her current home for 33 years, along with her parents. Her parents are her primary caregivers and she has an assistant during the day. She enjoys swimming, shopping, listening to music, working on the computer, and reading. Her primary concerns involve manipulating her upper extremities (particularly on the right side). In addition, she would like to become more independent in her ability to cook. Strengths: She lives with her parents in a wheelchair accessible home and has a wheelchair accessible van. She has a therapeutic pool and an IBOT wheelchair that allows her climb chairs. She has a supportive and stimulating home environment She has the ability to craw and creep in order to move around She is able to complete brushing her hair and teeth, applying make-up, bathing with a shower hose (after she has been transferred), navigating her electric chair (with left hand), and eating. She has great communication and has the ability to talk to others well. Weaknesses: She has difficulty with ADLs including cooking, cleaning, dressing, computer use, and walking.

Client Information

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 She is unable to transfer herself independently She has primitive reflexes that interfere with her motor skills She has contractures in her elbow joints, tightness in supination and pronation, and limited range of motion. The New Mexico Developmental Disabilities Supports Division, 810 San Mateo, PO Box 26110, Santa Fe, New Mexico 87502-6110. (505) 476-8973 Reason for referral: Applied for state assistance from the program Diagnoses: Cerebral Palsy and Lymes Disease Physician contact info: Dr. Synder University of New Mexico Neurology (505) 272-2111 The goal of the activity is to learn how to make macaroni and cheese independently. The client is completing this because she wants to become more independent in making dinner. Within 8 weeks, Cindy will improve bilateral coordination and trunk and arm mobility and strength to incorporate the pasta and the water together on the stove within 15 minutes, 3 out of 4 opportunities. Within 2 weeks, Cindy will improve her bilateral coordination and trunk and arm mobility in order to reach into the pantry and pull out supplies with 75-100% accuracy with 3 out of 4 opportunities. The practitioners role involves rearranging the supplies to make them more accessible for Cindy to reach. They will also use hand over hand assistance breaking down the activity into manageable tasks for Cindy. They will also give her verbal directions and cueing as necessary. Cindy and the practitioner will both be involved in the preparation. The practitioner will prepare the activity for the first two sessions and then require Cindys assistance after. This will help her improve her independence in reaching and gathering supplies The required preparation time is 30-40 minutes. 1. The practitioner will have to gather all supplies required(10-20

Referral Information

Activity Description

Describe the goal of the activity and why the client is completing it Long-Term Goal

Intervention Goals

Short Term Goal

Practitioners role

Activity Preparation

Personnel required to complete the preparation

Required preparation steps and time for each step

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 minutes) 2. The practitioner will prepare the kitchen so that Cindy can maneuver her wheelchair around.(10 minutes) 3. The practitioner will have to make sure all the supplies are accessible to her and are within her reach (10 minutes) A large open kitchen will be needed with space for Cindy to manipulate her wheelchair. The kitchen will need to be well lite, ventilated and away from distractions and noise. Materials required are: Water (wet), Noodles (hard, smooth) Cheese (soft, cold) Milk (wet, creamy, heavy) Salt/pepper (salty, peppery) Butter (soft, creamy, light) Tools required: Pan (heavy, loud) Spatula (might, rubbery, soft) Dishes ( heavy, glass, smooth) Measuring cup (light, small) Strainer (light, plastic) Equipment required: Stove (hot, heavy, large) Counter (large, smooth, hard) Precaution include allergies ( food allergies, plastic allergies),extra sensitive skin, and medications(for pain), and getting burned from the stove Contraindications would include dislocations, broken bones, pain, and severe food allergies Personnel required are Cindy and the practitioner. The practitioner will be there to prepare the environment and to guide her. The practitioner will also help her transfer items that are too heavy. Cindy will be doing
(Modified from Hersch, Lamport, & Coffey, 2005)

Required place and space

Required materials

Required equipment

Safety precautions

Activity Implementation

Personnel required

OCCT 506: Clinical Reasoning about Occupation Form #5 everything on her own until she asks for help. She will be preparing the recipe on her own as much as possible. After first two sessions, she will start preparing her own environment as much as possible with as little help as possible. The setting and location will be in Cindys kitchen in her home with her tools and equipment. She has an adaptive kitchen made specifically for her. She is also more comfortable in her space and this is where she will be doing all of her cooking. Space required is a large open kitchen with a low counter. The counter needs to be at the level of Cindy for accessibility. The kitchen needs light, ventilation and away from noise and other distractions. It also needs to be at a comfortable temperature. Materials required are: Water (wet) Noodles (hard, smooth) Cheese (soft, cold) Milk (wet, creamy, heavy) Salt/pepper (salty, peppery) Butter (soft, creamy, light) Tools required: Pan (heavy, loud) Spatula (might, rubbery, soft) Dishes ( heavy, glass, smooth) Measuring cup (light, small) Strainer (plastic, light, ) Equipment required: Stove (hot, heavy, large) Counter (large, smooth, hard) 1. Pick out recipe of choice for macaroni and cheese (3 minutes) 2. Retrieve supplies needed from pantry and refrigerator (10 minutes) 3. In pan add water and turn on stove medium to high. (10 minutes)
(Modified from Hersch, Lamport, & Coffey, 2005)

Setting and location

Space required

Required materials

Required equipment

Required steps and time for each step

OCCT 506: Clinical Reasoning about Occupation Form #5 4. Allow water to boil (5 minutes) 5. Add noodles and allow to cook (12-15 minutes) 6. Once noodles are cooked, turn off stove and drain noodles in a strainer in sink. (5 minutes) 7. Transfer noodles back into pan and place on stove again. Turn stove on medium to low. (5 minutes) 8. Add butter, milk, and cheese and allow to cook and melt all together (5 minutes) 9. Turn off stove, and put final product into a bowl (3 minutes) 10. Transfer bowl to table and enjoy! (5 minutes) Total time 1 hour and 15 minutes Safety precautions Precautions would include allergies ( food allergies, plastic allergies),extra sensitive skin, and medications(for pain), and getting burned from the stove Contraindications would include dislocations, broken bones, pain, and severe food allergies Describe how the activity overall fits The activity of cooking macaroni and cheese fits into each of the into the domain(s) of occupational domains of occupational therapy. Cindys ADLs that are related to this therapy in detail. Consider: activity include eating, feeding, and functional mobility. IADLs, which includes meal preparation and cleanup, and shopping for supplies, Areas of Occupation education, leisure (exploration and participation), and social Client Factors participation (cooking with/ for family and friends). Performance Skills Client factors that are taken into account are Cindys values and beliefs. Performance Patterns She values the time she gets to spend with her family in the kitchen and Context & Environment she also values making dinner for her family. She believes that she will Activity Demands be more independent if she can cook for herself and for her family. Cindy has higher-level cognitive function, good attention and memory skills, and good thought formation and emotional functioning. Cindy is tired a lot and has lower levels of arousal. She is conscious but has a low energy level due to her antibiotic treatment for Lymes disease. This also affects her drive because she becomes frustrated and quits. Cindy has her visual functions to see what she is doing, her hearing to

Domain

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 hear others, her tasting to taste what she is cooking, and pain to sense any localized pain and thermal awareness. Cindy has limited function in neuromusculoskeletal and movement-related functions. She has limited range of motion in upper extremities joints (particularly on the right side), limited joint stability, little muscle power, low muscle tone, little muscle endurance, motor reflexes, and involuntary movement reactions. Immunological functions are affected because her immune system is down due to her antibiotic treatment. Additional functions that are affected are physical endurance, stamina and fatigability due to her diagnosis. Cindy has good voice and speech functions to let her aid know what her needs and wants are. Her endocrine functions are affected due to her thyroid issues that also affect her energy levels. Cindy also needs to be aware her skin breakage and pressure sores. Body structures that are needed for this activity include nervous system structures for motor and sensory movements, her eyes, ears, and related structures to look at and read the recipe, structures involved in voice and speech are to instruct her aid or ask for help, and structures related to movement in order to reach and obtain the supplies. Activity demands that are related to this activity include objects and their properties. Materials required are: water (wet), noodles (hard, smooth), cheese (soft, cold), milk (wet, creamy, heavy), salt/pepper (salty, peppery), butter (soft, creamy, light). Tools required: pan (heavy, loud), spatula (might, rubbery, soft), dishes (heavy, glass, smooth), measuring cup (light, small), strainer (plastic, light). Equipment required includes a stove (hot, heavy, and large) and a counter (large, smooth, and hard). Space required is a large open kitchen with a low counter. The counter needs to be at the level of Cindy for accessibility. The kitchen needs lightening and away from noise and other distractions. It also needs to be at a comfortable temperature. Social demands include following the recipe step by step. Sequence and timing includes 1. Pick out recipe of choice for macaroni and cheese (3 minutes)

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 2. Retrieve supplies needed from pantry and refrigerator (10 minutes) 3. In pan add water and turn on stove medium to high. (10 minutes) 4. Allow water to boil (5 minutes) 5. Add noodles and allow to cook (12-15 minutes) 6. Once noodles are cooked, turn off stove and drain noodles in a strainer in sink. (5 minutes) 7. Transfer noodles back into pan and place on stove again. Turn stove on medium to low. (5 minutes) 8. Add butter, milk, and cheese and allow to cook and melt all together (5 minutes) 9. Turn off stove, and put final product into a bowl (3 minutes) 10. Transfer bowl to table and enjoy! (5 minutes) Total time 1 hour and 15 minutes Required actions and performance skills include feeling the heat from the stove, determining how to move limbs for reaching and grabbing supplies and pots, gripping onto supplies and incorporating them together. Required body functions include Cindys higher-level cognitive function, good attention and memory skills, and good thought formation and emotional functioning. Cindy is tired a lot and has lower level of arousal. She is conscious but has a low energy level due to her antibiotic treatment for Lymes disease. This also affects her drive because she becomes frustrated and quits. Cindy has her visual functions to see what she is doing, her hearing to hear others, her tasting to taste what she is cooking, and pain to sense any localized pain and thermal awareness. Cindy has limited function in neuromusculoskeletal and movement-related functions. She has limited range of motion in upper extremities joints (particularly on the right side), limited joint stability, little muscle power, low muscle tone, little muscle endurance, motor reflexes, and involuntary movement reactions. Immunological functions are affected because her immune system is down due to her antibiotic treatment. Additional functions that are affected are physical endurance, stamina and fatigability due to her diagnosis. Cindy has

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 good voice and speech functions to let her aid know what her needs and wants are. Her endocrine functions are affected due to her thyroid issues that also affect her energy levels. Cindy also needs to be aware her skin breakage and pressure sores. Body structures that are needed for this activity include nervous system structures for motor and sensory movements, her eyes, ears, and related structures to look at and read the recipe, structures involved in in voice and speech to instruct her aid or ask for help, and structures related to movement in order to reach and obtain the supplies. Performance skills involved are motor and praxis which includes bending and reaching for supplies and pots, coordinating body movements in order to incorporate ingredients. Maintaining balance and endurance, adjusting posture and body position in response to fatigue, manipulating supplies and materials required for the recipe. Sensory perceptual skills include positioning the body in comfortable position, hearing and asking for help from the aid, locating supplies by touch and discriminating objects, and timing the appropriate moment to add the ingredients. Emotional and regulation skills include controlling anger towards others when frustrated and persisting in a task despite fatigue. Cognitive skills includes selecting tools and supplies for the recipe, sequencing the tasks in order of the recipe, multitasking when reading the recipe, adding ingredients, socializing, and focusing on movements. Communication and social skills include looking at the therapist when talking, maintaining acceptable physical space during activity, and asking questions during session. Performance patterns that are involved are rituals that include helping family members prepare holiday meals on certain days of the year. Contexts and environments involved are cultural which include cooking special meals with family that are culturally meaningful. Personal involved is Cindy is a 33 year old female with a high school diploma. Virtual includes finding recipes online and through emails from friends. Physical involves cooking the meal in Cindys kitchen and having

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 adapted equipment available to her. Social involves Cindy making dinner for family and friends. The occupational profile was used to achieve therapy outcomes by learning what Cindy liked to do and what she wanted to work on. One of her main interest and goals included becoming more independent in the kitchen and cooking dinner for her family. This allowed Cindy to be a part of the planning process in which she was able to choose what type of activity to participate in. She chose to make macaroni and cheese because it is one of her favorite dishes. The activity preparation helped achieve occupational therapy outcomes because Cindys participation and performance is required in preparing the environment. After the first two sessions, Cindy was involved in setting up her environment with as little help as possible. This allowed her to know her surroundings and where her supplies were located. This also helped her practice retrieving the supplies she needed so she could be more independent. The activity implementation was utilized to achieve occupational therapy outcomes because it focused on Cindys overall goals of becoming more independent in the kitchen while working on improving bilateral coordination, trunk and arm mobility, and upper extremity strength. C. was excited to come to therapy to work on cooking. C. has been in Kansas City getting treatment for Lymes Disease. C. has not been feeling well and tired due to new antibiotics. Increased stress due to flying back and forth from Kansas City to Albuquerque. C. participated in cooking activity for 60 minutes with hand over hand assistance. She was able to flex and protract her shoulder for reaching to gather supplies but needed hand over hand assistance with strength in holding the supplies in hand. She was able to read and follow recipe independently. Needed maximum assistance in adding water and noodles to pan as well as straining the noodles. Needed moderate assistance in opening cheese and unwrapping butter. Was 100% independent in stirring for 30 seconds and then needed hand over hand

Discuss how you have utilized the occupational profile, activity preparation, and activity implementation to achieve occupational therapy outcomes.

Process

Subjective

Objective SOAP Note

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 assistance to finish. C. fatigued and slow during session. C is demonstrating difficulty with reaching and grabbing supplies during activity. C. is able to verbally communicate problems that arise during session and is cognitively able to instruct therapists for assistance. She continues to demonstrate difficulty with hand manipulation and grasp strength after 30 seconds of stirring. C. has 20 degree contracture on the right elbow, which makes it difficult for her when reaching. With continued skilled OT intervention, C. will continue to progress in upper extremity mobility and strength, bilateral coordination, hand strength and grasp strength, and endurance to improve her performance and participation in daily living that will enable her to become more independent. Address upper extremity mobility and strength by completing cooking activities. Address bilateral coordination by catching and throwing tennis balls. Address hand strength by using theraputty.

Assessment

Plan

(Modified from Hersch, Lamport, & Coffey, 2005)