Running head: OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile and Intervention Plan

Josee Lundquist
Touro University

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Occupational Profile
Client
Karen is a 43 year old female hospitalized in November with severe abdomen pain, and
diagnosed with a colovesical fistula. Post repair, she developed Clostridium Difficile Colitis
while in the hospital. She has been transferred back and forth between a long term acute hospital
and acute hospital many times with complications from her colovesical fistula repair. She was
recently transferred back to a long term acute hospital in April and currently has a pelvic
hematoma, pelvic abscess, and general debility. To manage her health, she is currently receiving
multiple medications including Norco for pain, Mycamine for a fungal infection, and various
antibiotics including Merrem, and Flagyl. At this time she relies on total parenteral nutrition
(TPN) to receive her nutrition, a Jackson-Pratt (JP) drain attached to her abdomen for drainage of
the surgical site, a colostomy bag, and catheter.
Karen is originally from Colorado and moved to Las Vegas 17 years ago to be closer to
her parents, and more employment opportunities. Prior to her hospitalization, she worked full
time at an insurance company, and plans to return to work after being discharged. She is a single
mother with one son and one daughter who are 12 and eight years old. Karen has a very
supportive boyfriend, who is very involved in her childrens lives and has taken on the
responsibility of caring for them while she is in the hospital. She lives with her boyfriend and
children in a two story condo in the Green Valley area. Her father is very supportive and has been
spending every day at the hospital, and partakes in therapy frequently. Her mother recently
passed away, prior to her hospitalization in November, and it has been very difficult on her and
her father.

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Purpose of Services and current concerns

Karens doctor gave orders to be evaluated by an occupational therapist upon being
transferred from an acute hospital to a long term acute hospital. She is primarily concerned with
her inability to care for herself and children. Particular concerns include her decreased strength,
range of motion, and activity tolerance. She is currently dependent for all transfers due to
decreased strength and fear of falling. In addition, Karen is concerned with her frequent nausea, a
side effect of the medications she is currently prescribed for pain management. The nausea has
been affecting her ability to engage in therapy treatment sessions and occupations of choice.
Occupational Performance
Karen is currently limited in all occupations she has expressed interest in. She is unable
to complete bed mobility and transfers independently, limiting her engagement out of bed with
her family. She requires maximum assist for all activities of daily living (ADLs), including upper
and lower body dressing, grooming and hygiene. Karen is dependent for feeding, toileting, and
functional mobility, using a TPN for nutrition, catheter and colostomy bag for toileting and
Hoyer lift for all transfers. She is unable to participate in any of her instrumental activities of
daily living (IADLs), but has a supportive father and boyfriend to help her with her children and
finances. The limitations of her ADLs and IADLs can be contributed to her decreased strength
and AROM. Her environment has caused a disruption in her sleep patterns and often complains
of extreme fatigue. Throughout the night, nurses are in and out of her room to check on her or
her roommate. Socially, she enjoys spending time with her family each day they visit, especially
her children.
Contexts and environments

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Karens social environment, personal context, and cultural context support her
participation and engagement in desired occupations. The social environment consists of
relationships and expectations of those the client has contact with (American Occupational
Therapy Association [AOTA], 2014). Within her social environment, she has a very supportive
father, boyfriend, and understanding children. Her family is constantly at the hospital
encouraging her to participate in therapy, and helping any way possible. Personal context is
features and attributes of the individual including age, gender, and socioeconomic status (AOTA,
2014). Her personal context supports her participation in desired occupations as well. She is
fairly young, and prior to admission to the hospital, she was very active, and held a full time job
which she plans to return to after discharge. Although she currently is not living in her home, her
boyfriend is in the process of remodeling their two story condo to allow her to live on the main
level of the home until she has regained her strength back. Remodeling her home will increase
the support of her physical environment on her ADL and IADL occupational performance skills
when she returns home. Cultural context is the individuals beliefs, customs, activity patterns,
behavioral standards, and expectations accepted by the society the client is a member of (AOTA,
2014). Karen believes family is everything, and should do everything together, therefor her
motivation to participate in therapy. To address this belief, the therapist must consider the family
and include them in therapy interventions.
Karen currently requires a Hoyer lift to transfer into and out of bed. The physical
environment of the hospital room has very little space, restricting Karens opportunities to
actively participate, with her Hoyer lift, and wheelchair present in the room. The wheelchair
provided at the hospital also restricts Karens functional mobility. She was provided with a
bariatric medical transport wheelchair, which combined with her limited range of motion (ROM)

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and decreased strength, limits her ability to propel the wheelchair independently. This inability to
propel her wheelchair affects her functional mobility.
Occupational history
As a single mother of two children, Karen plans her daily routine around supporting, and
providing for their every need. With as full-time job, Karen wakes up two hours before work to
make her children lunch, check their homework, and make sure they have everything they need
for their extracurricular activities. She then sends them to school on the bus before heading to
work at 8:30 in the morning. After work at 5:00, she picks her children up from school and
prepares dinner while they complete their homework. Karen values her childrens education and
extracurricular activities and strives to be in attendance at all of their sporting events, and club
activities. Karen and her children are very active as a family on the weekends. Karen has enjoyed
playing volleyball, softball, and golf throughout her life into her adult years, and wishes to pass
the love for sports onto her children. She and her son enjoy going to the driving range together,
while she and her daughter have girl's days to do each other's hair and makeup. Her boyfriend
and her are on an adult softball team and play almost every week with friends. She also enjoys
reading, hiking, cooking, scrapbooking, going to the spa with friends, and going on family
vacations.
Priorities and Desired Outcomes
Karen is extremely concerned about her ability to care for herself, as well as her children.
Her priorities while at the long term acute care hospital are to get the medication side effects
under control, and increase strength and ROM in her upper and lower extremities in order to
transfer to a rehabilitation hospital and continue her rehabilitation process. During OT, Karen
would like to focus on increasing her activity tolerance, and strength to be able to independently

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complete bathing, grooming, and feeding tasks. Ultimately Karen wishes to return to her prior
level of living independently, caring for her children, maintaining a full time job, and being
active in the community.
Occupational Analysis
Karen was in her room, laying down in bed with the head of the bed upright at 45
degrees. Her father and boyfriend were present in the room. During the intervention session, I
observed Karen combing her hair and participating in strengthening exercises as a purposeful
activity. Karen required max assistance to flex her shoulder above 70 degrees to reach her head
and comb her hair. Her active range of motion (AROM) is minimal, and the therapist provided
passive range of motion (PROM) to flex her shoulder and raise her arm high enough to reach her
head. With the therapist holding her shoulder and elbow in flexion, Karen was able to hold a
comb and brush her hair for 30 seconds. During the strengthening exercises, Karen had limited
AROM in her shoulders and elbows, and continued to require the therapist to provide PROM.
She was able to complete three repetitions of bicep curls without weights independently, and flex
her should to 70 degrees twice without any weight added. Throughout the intervention, Karen
needed increased motivation from the therapist and family members to participate in combing
her hair and strengthening exercises.
The domains of the occupation therapy practice framework interact with each other to
affect the individuals occupational identity, well-being, and participating in life (AOTA, 2014).
Based on my observations and clinical reasoning, the domains impacting Karens ability to
engage in occupations include several client factors, performance skills, and context and
environments. Client factors that are affecting her performance include her beliefs that she is will
fall if she sits at the edge of the bed, as well as her muscle power and endurance. She has

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substantial weakness in her upper and lower extremities. Her hands, wrists, elbow, and shoulder
all have a manual muscle test score of 2-, determining she can only move partially through ROM
movements. Her coordination of movement is fair due to presence of shaking with intentional
movements, and muscle exertion. As previously discussed, her physical environment also
impedes her occupational engagement. Her hospital room has limited space with her wheelchair
and Hoyer lift present, and her wheelchair does not meet her needs due to the size and style of
chair, inhibiting her ability to participate in functional mobility.
Problem List
The following are the top five problem statements Karen and her therapist would like to focus
occupational therapy sessions on.
1) Patient is unable to complete upper body dressing independently secondary to
decreased active range of motion and activity tolerance.
2) Patient is unable to complete daily grooming activities secondary to decreased
activity tolerance and decreased strength.
3) Patient requires max assist to complete bed mobility secondary to decreased
strength and motivation.
4) Patient requires max assist and increased encouragement to sit at the edge of bed
due to decreased strength and increased anxiety.
5) Patient requires max assist for feeding tasks secondary to decreased AROM, and
decreased strength.
Problem List Justification
Karen's problem list is prioritized accordingly to address her primary concerns; caring for
herself and her children. Before she can start caring for her kids, she needs to be able to complete

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basis self-care skills for herself. She has always taken pride in her appearance as a career woman
and has voiced irritation, not feeling presentable each day at the hospital. To address this, the first
two problem statements focus on the specific ADLs dressing and grooming. She would like to be
able to get out of bed and start engaging in occupations she once participated in with her
children. To do this, it is important that she learns how to safely and independently complete bed
mobility. Eating was placed at the bottom of the problem list because although it is an occupation
she participated in with her children, she is currently receiving her nutrition from a TPN. Due to
her medication side-effects of nausea, eating me exacerbate these side effects and should be
eliminated prior to feeding interventions.
Client Centered Goals and Intervention Plan
Long Term Goal 1
Pt. will complete donning & doffing of shirt (I) overhead within 3 wks.
Short Term Goal 1. Pt. will complete donning & doffing of button up shirt Mod (I) AE
2/3 times within 1 wk.
Intervention. The most appropriate approach for this intervention is modify, to change
the current context and activity demands of the task through adaptation and compensation
(AOTA, 2014). This intervention is to teach Karen how to complete the task of donning and
doffing a button up shirt using equipment she is unfamiliar with to make the task easier. The
intervention session will take place in the morning, when Karen would usually get dressed for
the day. The intervention will begin with discussing Karen's preferences in regard to getting
dressed including what garments she prefers to wear, and how she previously put her shirt on.
After the therapist has considered Karen's preferences, the therapist will show available adaptive
equipment (AE) that may help her with upper body dressing including a long handle reacher,

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dressing stick, and a button hook. Following education of the available devices, the therapist will
demonstrate how to use the AE correctly with a button up shirt. The therapist will then have
Karen, demonstrate donning and doffing the button up shirt three times using the equipment
provided. Demonstrating the donning and doffing of the shirt three times during each session,
will allow us to identify when Karen has reached this short term goal. At the end of the
intervention, the therapist can review the AE and allow her to choose the devices that work best
for her.
The desired outcome through the use of this intervention is improvement to eliminate
or decrease performance limitations (AOTA, 2014). With the use of AE and techniques, Karen's
occupational performance in upper body dressing should be improved and increase her
independence with the ADL task of dressing.
Grading of Intervention. This dressing intervention can be graded up and down to
provide a just right challenge for Karen. To grade the intervention down, a loose fitting
garment with a zipper can be used for upper body dressing instead of a button up shirt. To grade
the activity up, a shirt with smaller buttons can be used, or a shirt that must be donned over the
head. Regardless of the level of intervention Karen needs to meet her just right challenge,
clothing that is familiar to her should be used during the intervention to provide an environment
that is as natural as possible.
Evidence Based. According to Foti and Koketsu (2013), an individual with limited ROM
must compensate for limited reach by utilizing environmental adaptations (p.198). Possible
adaptations include using front-opening garments, a dressing stick, shirts with larger buttons or
zipper, and button hooks (Foti & Koketsu, 2013; Radomski, & Trombly, 2008).

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In a study about collaboration of goals on self-care skills by Gagn and Hoppes (2003),
Functional Independence Measure (FIM) scores were found to increase significantly with upperbody dressing. Other areas of self-care had increased FIM scores, but not as significantly. A
quasi-experimental design was used for the study to explore if communicating goals daily with
the client will increase self-care outcomes, and if all areas of self-care would be affected
similarly by the goal-focused therapy approach (Gagn & Hoppes, 2003, p. 216). Encouraging
Karen to contribute to her goal setting by letting her choose the equipment that will work best for
her, and consistently reviewing the goals with her can increase her collaboration with the
therapist and ultimately increase her likelihood of making greater gains on her FIM scores.
Short Term Goal 2. Client will complete donning & doffing of button up shirt Min (A)
2/ 3 times within 2 wks.
Intervention. The approach to this intervention is establish and restore because Karen
is trying to return to her previous ability of upper body dressing which has been impaired
(AOTA, 2014). Once Karen begins to increase her AROM, she will begin participating in a
dressing specific group with other patients. The group will occur twice a week with two or three
other patients for one hour sessions. The group will address both parts of a dressing task, and
complete dressing tasks. A part of a dressing task may include threading one arm into a shirt
sleeve, or a complete dressing task of donning a shirt. The group members will share techniques
and specific devices that have helped them to complete dressing activities more independently.
The group can increase ones self-efficacy, providing support and help to others, and improving
their own dressing abilities.
Improvement is the desired result for this intervention, to again increase her
occupational performance (AOTA, 2014). The focus of the intervention is to help Karen improve

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her ability and performance of upper body dressing, minimizing the amount of AE required and
reaching previous level of function, independence.
Evidence Based. A study to determine the effectiveness of a group-based, task-specific
dressing retraining program was completed by Christie, Bedford, and McCluskey (2011). The
population in the study was patients who had experienced a stroke and currently in an inpatient
hospital. To determine if the patient's dressing skills and abilities were increasing, the FIM was
used to score them prior to the group and at the end of the study. Overall, the study found that
the task-specific practice of dressing tasks made a "clinically important difference to dressing
performance" (Christie et al., 2011, p. 367). Specifically, the participants FIM scores for upper
body dressing improved greatly comparing the scores prior to the group to when the participants
were discharged after the group. Although this study consisted of patients who had experienced a
stroke, they all were experiencing difficulty with dressing tasks due to deficits. Karens difficulty
with dressing is associated with her decreased strength and ROM in her upper extremities, a
common deficit that accompanies many strokes.
Long Term Goal 2
Client will complete grooming & hygiene activities (I) for 20 minutes no rest breaks
within 3 wks.
Short Term Goal 1. Client will complete brushing teeth Mod (A) > 3 rest breaks within
1 wk.
Intervention. The appropriate approach for this intervention is modify to revise the
activity demands of brushing her teeth (AOTA, 2014). The focus of this intervention is to help
Karen identify the tools and techniques that will most effectively increase her ability to brush her
teeth. To address Karens difficulty brushing her teeth as part of her morning routine, the

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therapist will problem solve with Karen to find the best solution for her. Karen will be educated
on adaptations that can be utilized with her current toothbrush to help her reach the toothbrush to
her mouth, as well as potential benefits of an electric toothbrush and Water-Pik. To address her
decreased activity tolerance, the therapist will also discuss energy conservation techniques with
Karen, to improve her task performance. Handouts will be provided describing specific energy
conservation techniques which may benefit her. After education about adaptations and techniques
has been discussed, Karen and her therapist will collaboratively decide which devices and
techniques will work for her, and have her physically demonstrate understanding of the use of
the equipment and techniques. The outcome for this intervention is improvement to increase
the opportunity of occupational performance (AOTA, 2014). The ultimate goal is to help Karen
brush her teeth as previously performed.
Evidence Based. For hygiene and grooming activities for individuals with decreased
strength and range of motion, Foti and Koketsu (2013) recommend long handle toothbrushes,
Water-Pik, and electric toothbrush to decrease the distance the individual must reach up to their
mouth (p. 200).
A qualitative study was done to determine therapeutic strategies used by occupational
therapists in self-care training. Guidetti and Tham (2002) identified various strategies used for
occupational therapy interventions including; creating trust between the therapist and client,
knowing how to correctly motivate the client, supporting the client to set goals, and encouraging
practice of the self-care tasks. Adjusting the training session to the needs of the client by finding
the best approach to the task, adjusting the physical environment as needed, and using multiple
ways of communication is also recognized as important (Guidetti &Tham, 2002).

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In the intervention, Karen is given different options to increase her independence to brush
her teeth. As the evidence reported, encouraging the client to be involved in setting goals and
interventions increases the possibility of a successful intervention. Providing handouts for energy
conservation is supported within this study, claiming various types of communication can be
useful (Guidetti & Tham, 2002).
Short Term Goal 2. Client will brush hair Mod (I) extended handle brush > 1 rest
break within 2 wks.
Intervention. The approach of this intervention is modify because the AE and
techniques is changing the demands of the task to support successful completion of the task
(AOTA, 2014). Combing hair is a daily task she not only did for herself, but enjoyed helping her
daughter with. To begin this intervention session, education will once again be given about
possible adaptations including a long handle comb. Karen will then be asked to describe the
energy conservation techniques that have been working for her to follow up and confirm she has
been utilizing them. Karen has been unable to fulfill the parenting role she held prior to
hospitalization. In consideration of this, the intervention will then incorporate her daughter
encouraging Karen to brush her daughters hair as she once did. This enjoyable and familiar task
will help increase Karen's tolerance and strength of the brushing motion while also participating
in a meaningful activity. Once Karen has completed brushing her daughters hair, she will then
be asked to brush her own hair. The outcomes of this intervention are participation and
improvement. Through practice, Karen, can improve her ability to not only brush her own hair,
but engage in activities with her daughter. Participation as an outcome is described by AOTA
(2014) as engagement in occupations which are personally satisfying with the individuals

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culture. The task of brushing her daughter's hair and engaging in a familiar activity can be
personally satisfying and beneficial to Karen.
Evidence Based. After someone experiences a personal crisis, Vrkljan and Miller-Polgar
(2001) state that individuals tend to turn to occupations that are meaningful to regain a sense of
control in their lives (p.237). The study consisted of three women who had been diagnosed with
breast cancer, and were recruited through a convenience snowball sample. Through two
interviews with each participant, a common theme found was the idea that the inability to do the
activities important to them caused a disruption in their perception of themselves as capable and
healthy individuals. The three individuals followed up with the notion that participating in
occupations meaningful to them made them feel alive (Vrkljan & Miller-Polga, 2001).
After being admitted to the hospital in November, Karen experienced a series of
traumatic events throughout recovery including surgery where she flat lined and was revived, as
well as multiple transfers between hospitals for infections. Although the study was conducted
with participants diagnosed with cancer, any significant diagnosis that disrupts your life can be
considered a personal crisis. Karens surgery and long recovery has caused a great disruption in
her ability to hold her roles. This disruption of roles and occupations can be seen as a personal
crisis. Facilitating Karens ability to return to previous occupations meaningful to her, such as
combing her daughters hair can give her a sense of control of her life. As previously described,
Karen is upset with her struggle to provide for her children. Helping her engage in some of these
occupations to the best of her abilities may be able to motivate her to continue working towards
other occupations of interest.
Precautions and Contraindications

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The only precaution currently in Karens chart is fall risk due to abdominal debility.
With this in mind, activities requiring her to sit up and engage her core should be closely
monitored to avoid any potential falls. There are no contraindications for her chosen occupations
of grooming and dressing. The therapist should be mindful of her JP drain, colostomy bag,
catheter, and TPN during these interventions to avoid any discomfort, and possible difficulties
that may arise.
Frequency and duration
Karen will receive OT five days a week until discharge. Karen currently has a very low
activity tolerance and fatigues easily, therefore, the intervention sessions will range from 30 to 60
minutes depending on her activity tolerance that day. The flexibility of her treatment sessions is
appropriate because there is no required number of therapy hours she must participate in a day
while at a long term acute hospital. OT services will be provided to address basic ADLs,
strength, ROM, and safety until she can participate in three hours of therapy a day and transfer to
an inpatient rehabilitation facility.
Primary Framework
The primary framework used for this intervention plan was the Ecology of Human
Performance model (EHP). Brown (2014), explains the EHP model consider the person,
environment, and occupation when determining an individual's occupational performance
(p.494). This model guided my interventions taking into consideration the assumption of the
EHP that, "rather than exclusively using interventions that change a person, it is often more
efficient and effective to change the environment or find a person-environment match" (Brown,
2014, p. 499). Furthermore, the EHP model includes five intervention strategies including;
establish/restore, adapt/modify, alter, prevent, and create (Brown, 2014, p. 497). Using these

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intervention strategies in combination with the intervention approaches of the Occupational

Therapy Practice Framework, I was able to develop the most appropriate intervention strategy
approaches. Using the intervention strategies establish/restore, and adapt/modify I was able to set
appropriate goals to help Karen increase her occupational performance skills in desired tasks.
Client and Caregiver Education
Education to the client and caregiver will be provided continually. Education will be
given verbally, and with written instruction to Karen throughout all OT intervention sessions.
Karen's father is present for most of the therapy sessions and will be educated on AE, and energy
conservation techniques to provide support and encouragement outside of therapy treatments.
Education will also be given to Karen, and her family about safety, to minimize the chance of
Karen falling. To ensure Karen and her family understand the education being provided, the
therapist will check up with them regarding equipment and techniques both verbally and through
demonstration.
Response to Interventions
Karen's response to intervention and progress towards goals will be assessed formally an
informally during her OT sessions. During daily OT sessions, the therapist can verbally
communicate and use their observation skills to determine her response and the effectiveness of
the intervention during treatment. The FIM will be utilized to complete a formal re-assessment
every two weeks while at the long term acute hospital, to determine her progress with ADLs. A
formal manual muscle test and ROM re-assessment can also be conducted to chart improvements
in strength and ROM of her upper extremities. Improvements and attainment of goals will be
communicated with other staff, to determine when Karen is appropriate for an inpatient
rehabilitation facility.

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References
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504). Philadelphia: Lippincott Williams & Wilkins.

Christie, L., Bedford, R., & McCluskey, A. (2011). Task-specific practice of dressing tasks in a
hospital setting improved dressing performance post-stroke: A feasibility study.
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232). St. Louis, MO: Elsevier Mosby.

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215-219.

Guidetti, S., & Tham, K. (2002). Therapeutic strategies used by occupational therapists in selfcare training: A qualitative study. Occupational Therapy International, 9(4), 257-276.

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Radomski, M. & Trombly-Latham, C. (2008). Occupational therapy for physical dysfunction.

(6th ed.). Philadelphia: Lippincott Williams and Wilkins.

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