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Running head: OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile and Intervention Plan


Jennifer A. Unck
Touro University Nevada

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile
Patient
The patient is Robert, who is a 96 year old male. He lives in a two-story home with his
daughter, son-in-law, and two grandchildren in Las Vegas, Nevada. He has two daughters and
his wife passed away five years ago. The patient is a part owner of a business that he developed
that sales automobile parts. The patient is a retired mechanical engineer and World War II
(WWII) veteran. Due to recent weakness, the patient has suffered a fall that sent him to the
hospital. The patients primary diagnosis is debility. He has mild cognitive impairments,
moderate hearing impairments, and has developed a rash on his body since entering the facility.
The Patients Current Concerns
A major concern that the patient has is he does not want to be dependent on others. He is
worried about losing his independence. He currently has difficulty with transferring from sitting
to standing, and he is concerned he will be unable to get up to perform the occupations he wants.
He has always had control over the things in his life, and he feels that he is weak right now. The
patient would like to get back to taking care of himself and doing the typical occupations of life,
such as getting dressed and showering. Due to the patients current condition, he is frustrated that
he cannot do more things independently, especially cooking and doing home management
activities. The patient is concerned about his strength and falling again, he wants to become
stronger to return to his normal activities of daily living (ADLs).
Patients Success and Barrier Affecting Patients Success
The patient feels successful in occupations such as, socializing with his family, reading,
and upper extremity dressing. A barrier that the patient feels hinders his performance the most is
his decreased strength. This affects his success in lower extremity dressing, transfers, and

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

showering. Another barrier the patient feels is that he fatigues easily, he does not have the
activity tolerance or endurance that he had previously. This limits his function in ADLs and
IADLs and has decreased his quality of life. These barriers are preventing him in performing the
occupations that are meaningful to him such as cooking and performing his daily roles.
What Environment/Context Supports or Inhibits Patients Participation
The physical environmental factors that support the patient in participating in desired
occupations are the natural built surrounding such as, the patients wheelchair, bed, room, and
house. Social environmental factors supporting performance are the patients family support. The
patients daughter is available and willing to assist the patient as needed. It is important to the
patient that he spends time with his family. He has the social support with his friends, partners,
and old colleagues as well. Support within the cultural context includes the standards, beliefs,
and expectations that the patient and family have of one another. The patient has a family
oriented culture and a belief that family should be the top priority which supports social
participation and engagement in roles. The personal contexts that support participations are the
patients socioeconomic status and educational background. When looking at the patients
temporal contexts, having a morning routine at home increased his participation in desired
occupations and promoted a rhythm throughout the day. All these supports help to balance
performance and give the patient motivation to engage in preferred occupations.
The physical environment that inhibits participations includes the risk factors at his home
that could cause safety risks and engagement in occupations. This includes rugs, tight areas, and
no adaptive devices (A/E). The cultural context that hinder participation is, the patients belief
that he should have the ability to perform all occupations independently and when he cannot he
feels frustrated. This can decrease his motivation to perform the activities that are meaningful to

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

him. The patients age is a personal context that inhibits how quickly he can perform
occupations, which intern is a temporal factor as well. The rate at which occupations are
performed could be a deterrent to engagement in specific occupations. Prior to the fall, the
patient was not as slow to perform desired occupations. Since he has severe deficits in the
amount of time it takes to participate and perform in desired activities.
Patients Occupational History
The patient has had many opportunities throughout his life. The patient lived a healthy
childhood and young adult life. He participated in sports and loved to play football, basketball,
and baseball. He always had the ability to fix objects and was a good with his hands. The patient
describes himself as a business oriented person. When the patient was a young man, he was
drafted into WWII where he spent five years as a coast artillery corps man. He was stationed in
Panama at age 26 where he met and married his wife. Upon returning home, the patient chose to
get a higher education in mechanical engineering. This led the patient into building a business
from scratch and patenting many designs he developed. The patient had a successful career in the
automotive industry. The patient and his wife raised two daughters. The patient was an avid
traveler throughout his life and enjoyed taking vacations with his wife and family. In his later
years, the patients wife developed cancer, he took on many of the roles that she had once
performed. These roles included doing the cooking and cleaning the house. He was able to retire
during this time but still had part ownership of his business. When his wife passed away, the
patient lived alone independently for several years. When the patient turned 90, together he and
his daughter decided he would move in with her to be closer to them. The patient has typical agerelated health concerns such as loss of hearing and aching muscles but as been healthy otherwise.

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Patients Values and Interests


The patient values his independence and prides himself in performing occupations on his
own. This is what motivates the patient to continue to work towards optimal occupational
performance in all aspects of his life. He values spending time with his family and enjoys having
family dinner on Sundays when everyone joins together. The patients other daughter lives in
Florida, but he values skyping and talking on the phone with her. Another value that the patient
has is his business that he still has part ownership over. He enjoys talking with his partners about
work and making decision about the company with them when needed.
The patient has developed many interests throughout his life. He likes to work with his
hands doing mechanical work, he will fix his grandchildrens gadgets and faulty parts in cars. He
developed the love for cooking when his wife got sick. He likes to search food magazines for
good recipes and then cook them for his family. The patient likes playing card games with his
family and likes to read mystery novels. The patient loved to travel when he was younger, but
now he still enjoys talking about the places that he has seen.
Patients Daily Life Roles
The patient has many daily roles that contribute to what is meaningful to him. The
patients main roles include being a father and grandfather. Since he is close to his family, he
cherishes these roles the most. Another role the patient has is still consulting with his business
partners in his company. Weekly roles the patient has are making dinner one night a week for his
family, doing his laundry, and cleaning his room and bathroom. These roles are meaningful to
the patient and give him purpose and life satisfaction. Though the patient will continue to have
the roles as a father and grandfather, his weekly roles may be affected due to his fall. His family
may need to take on some of the household roles until the patient can do so.

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Patients Patterns of Engagement in Occupations over Time


The patient explained that the patterns of engagement that stayed consistent throughout
his life included working most days for his company and traveling with his family. The patient
traveled along the east coast when he was in the army and enjoyed taking his family to new
places as they grew older. This developed into a routine for him and his family until his children
grew into adults. As he and his wife grew into middle adulthood, they still continued to travel to
more exotic places.
When the patient was younger his patterns of engagement were geared toward education
and work. When he received his degree, he engaged in working towards patenting his designs
and building his career to provide for his family. Working has been a key pattern of engagement
for him, and he feels satisfied in the business that he built. The patient exclaimed that as he
transitioned to retirement he was not able to travel as much due to his wives illness. Although the
patient was not able to travel and was not working as much, he took on new patterns of
engagement which included spending more time with his daughters and their families.
Many routines that the patient engages in now are centered on his family and his selfcare. His patterns include eating dinner with his family, making dinner for his family, and
performing ADLs and instrumental activities of daily living (IADLs) independently. Due to the
patients diagnosis, the patterns and routines that will be most affected will include his ADLs and
IADLs.
Patients Priorities and Desired Outcomes
The patient expressed that he is concerned that he is unable to get up by himself. His top
priority it to be independent in transferring so he can get around the house when he needs to. He
does not want be a burden on his family. The patient desires to perform the occupations that he

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

had prior to his fall, including ADLs, IADLs, and roles. He emphasized getting dressed and
showering as important ADLs. The patient desires to return home and to regain his strength and
endurance. By addressing these desired outcomes, the client will have better health and actively
engage in making choices to improve wellness. By becoming more independent, the clients
quality of life will be better, and his participation in these activities will automatically increase
because they are important to him. This can increase his sense of independence and increase
occupational performance.
Occupational Analysis
Context/Setting of Occupational Therapy Services
The patient participates in individualized and concurrent occupational therapy sessions at
HealthSouth Rehabilitation Center. The interventions will take place in either the patients room
or the therapy gym that is available. The patient will receive occupational therapy five days a
week for 90 minutes each session. The scheduling of therapy will be done prior to the day of
therapy, so the patient is aware of the time. Due to the patients background in the military, it
will be important to be on time or to notify him if the time changes. The physical environment
will include, but is not limited to the bed, tables, exercise equipment, the patients room, and the
therapy gym. A Different therapist may be working with the patient on different days depending
on the duration of time needed and therapists schedules. The social environment includes the
staff, the therapists, as well as, family and friends that come to visit.
Description of Activity Observed and Patents Occupational Performance
The activity that was observed was the patient taking a shower. This was in a walk-in
shower with a tub transfer bench. The shower had grab bars, and a hand held shower head. The
patient required moderate assistance to transfer from his wheelchair to the tub transfer bench.

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

The patient used the grab bars that were in the shower to help with the transfer. When the shower
was started the patient used the hand held shower head to rinse off. Education was given about
A/E (long handled sponge) to use when performing this activity. The patient was unable to get
all regions of his feet and had a difficult time with the perineal and buttocks regions. The patient
had to take two rest breaks due to decreased activity tolerance and endurance. He needed two
verbal cues to put more soap onto the sponge and to get the unreached areas. When that activity
was completed the patient required assistance to dry his back completely. Precautions were taken
to address safety when transferring the patient back to his wheelchair. Towels were placed under
his feet to decrease the risk of slipping. The patient required moderate assistance transferring
from the tub transfer bench to the wheelchair.
Key Observations from Patients Performance
Through observation of this occupation, it is evident that the patient was fatigued and
required moderate assistance. The patient did not recognize the lack of soap on the sponge during
this activity and verbal cues were needed to address this. Due to the patients rash the patient did
adjust the water temperature and was thorough in the areas of the body that he could reach.
Observations were noted that the patients rash was over his whole body. Redness on the
patients heels was noted as well. The patient exclaimed that he did not have a handheld shower
head, long handled sponge, or tub transfer bench at home.
Patients Diagnosis and the Occupational Therapy Practice Framework Domains
Debility is the main concern that is inhibiting the patients occupational performance.
This is the diagnosis that the patient has been given since he had his fall. This is causing much
dysfunction in his occupations and roles. According to the Occupational Therapy Practice
Framework (OTPF) the domains that have been affected due to the patients diagnosis include

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

occupations, client factors, performance skills, and performance patterns (American


Occupational Therapy Association [AOTA], 2014). Participation in ADLs, IADLs, play, and
leisure have been compromised due the patients recent fall and diagnosis. Body functions that
have affected the patient engagement include: energy level, joint mobility, joint stability, muscle
power, muscle endurance, and skin functions. Some important motor skills that resulted in
deficits include, stabilizes, coordinates, and endures. Due to the patients condition and being in
the inpatient facility, the patient has had a change in his roles and routines affecting optimal
performance.
Problem List
1. Patient requires moderate assistance for functional transfers due to decrease strength in
upper extremity.
2. Patient requires moderate assistance to don and doff lower extremity clothing due to
decreased activity tolerance.
3. Patient requires moderate assistance to shower due to decreased muscle endurance.
4. Patient requires minimal assistance for bed mobility due to decreased upper extremity
and core strength.
5. Patient is unable to manage skin care regimen due to lack of education on decubitus
ulcers.
Justification for Order of Problem List
Functional transfers were prioritized first because the patients desired outcome was to
become independent again with transferring. He is unable to get up by himself and this is
creating dysfunction in his occupational performance. He wants to be more independent in
standing up so that he does not have to rely on his family to assist him. This is the patients main

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priority because he currently does not have the strength to do this. The patients family feels that
if the patient can get up on his own, he will have more motivation to do the other basic
occupations that he once was able to do. Motivation and the clients personal goals are important
when prioritizing the problem list. This occupation is a top priority in this setting and is pertinent
to the patients needs and wants.
The next problem was prioritized second due to the patient exclaiming he wanted to get back
to taking care of himself, and performing his regular ADL routine. He is unable to dress his
lower body independently which cause him frustration and disappointment. This is pertinent
because according to the Model of Human Occupation (MOHO) which was used to determine
the patients goals and interventions, motivation and habituation play an important role for the
patient in getting back to what is meaningful to him. This goal was prioritized higher because it
is important to the patient and will be beneficial to train the patient in using A/E that could help
him do this independently. The facility plays a role in promoting independence in ADLs as well.
Being able to shower without assistance is an important occupation for the patient. This
problem was next due to the importance of showering with privacy when he goes home. Again,
the patient would like to get back to the prior occupations and to shower independently was one
of them. Safety is a major concern when showering so it is prioritized third so the patient will
learn techniques that will help decrease safety risks and enhance performance at home.
The next problem was prioritized due to the patient not having the ability to roll or position
himself comfortably in bed. This would be a problem that would be addressed in inpatient
rehabilitation. This is concerning to the patient since he has been in bed more than usual due to
his fall and increased weakness. This is not prioritized higher due to the patient stating
transferring and ADLs were more important to him, but it is still on the list because it is a basic

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activity that he will be required to perform at home. Due to the contributing factor to this
problem, working on previous problems would intern help with bed mobility as well. This is
important to address because the patient is more sedentary now. Due to this change, secondary
conditions, such as contractures and decubitus ulcers will be more prevalent.
The last problem is addressed due to the patient having pain and redness on his heels because
of prolonged laying position. The patient does not want to have more pain and feels that it would
affect his performance if his heels were to get worse. If the patient continued to develop a
decubitus ulcer it could affect aspects of functional mobility and decreased engagement in
occupations. By educating the patient on the importance of skin integrity and having a skin care
regimen this could prevent further conditions and keep his skin intact making sure no conditions
arise.
Intervention Plan and Outcome
Long Term Goal 1
Patient will demonstrate functional transfers with supervision using a walker within two
weeks.
Short Term Goal 1a. Patient will demonstrate sit to stand transfers with minimal
assistance with a walker within one week
Intervention. The patient will participate in a therapy session focusing on practicing
transfers. To start with the patient will begin by performing wheelchair push-ups and hand held
weights as preparatory activities. These will increase muscle strength needed to perform sit to
stand transfers. Education will be given on the reasoning of these activities for improving
performance. Education will be given on the placement of the patients feet, arms, and body
weight for safe transferring techniques. Demonstration of how the transfer should be performed

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will be given to the patient as well. The patient will practice the sit to stand transfers and will be
given assistance and rests breaks as needed. Transfers will be practiced in different contexts,
such as the toilet seat, tub transfer bench, the wheelchair, and at the edge of the bed. Education
will be given to the patient and caregiver about the use of durable medical equipment (DME) that
would be beneficial for safety. The DME recommended will include a walker, raised toilet seat,
and grab bars. The patient will be educated on the importance of transferring and how it can
facilitate in gaining more upper extremity strength leading to more independence.
Approach. According to the OTPF, this intervention would be a restore and modify
approach (AOTA, 2014). The intervention will use the restore approach by remediating the
patients muscle power ability which is needed to perform the transfers and remediating the skill
of transferring. It would be a modify approach due to the compensatory techniques taught and
adaptive equipment used for transferring.
Evidence. Research has shown that by incorporating DME into an intervention it can
have positive effects on performance. According to Moyers (2011), adding environmental
modification and other safety equipment can improve ADL completion dramatically. The use of
DME can be an important component in occupational performance. It can be the means by which
the patient becomes more independent. By incorporating the different DME into the patients
intervention, he will be safer and have improved performance.
Outcome. When consulting the OTPF, the desired outcomes would be improvement in
occupational performance, quality of life, and increase participation (AOTA, 2014). The
intervention would aim to increase the patient performance with transferring. By working on
what is important to him, his life satisfaction will improve, and his participation in occupations
that are meaningful to him will increase due to improved functional mobility.

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Short Term Goal 1b. Patient will demonstrate a shower transfer with minimal assistance
using a tub transfer bench within one week.
Intervention. The patient will participate in an intervention that will focus on shower
transfers and safety techniques during the shower. The intervention will start with theraband that
will be used as a preparatory activity to increase muscle power that will facilitate more
independence. After, a demonstration will be given on proper transferring techniques using a
grab bar. The patient will participate in transferring to and from the wheelchair to the tub transfer
bench. Assistance, cues, and rest breaks will be given to the patient if needed. Education will be
provided on fall risk and safety precautions that should be taken when transferring. A
conversation on appropriate DME, such as hand held shower head, grab bars and tub transfer
bench, will be had with the patient and his family. An explanation will be given on how the
DME will foster a safer environment and benefit the patient at home. The transfer will be
simulated as closely to the patients home bathroom as possible so the transfer will be familiar to
the home setting.
Approach. The approaches being applied with this intervention are restore and modify
(AOTA, 2014). The intervention looks to remediating the skills necessary for completing the
shower transfer. It is restoring the muscle power in the upper extremities needed for transferring.
The intervention looks at modifying the environment with the adaptive equipment to make the
activity safer and easier for the patient.
Evidence. Research has shown that participation in meaningful occupations has an
important and positive influence on health and well-being (Law, 2012). In the OTPF, it addresses
occupational therapys overarching goal to achieve health, well-being and participation by
actively engaging in occupations (AOTA, 2014). Being able to participate in this activity is

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meaningful to the patient and will provide him with an increased self-esteem and meaning. By
participating in the shower transfers, the patient will have an increase of self-esteem as well as
independence
Outcome. According to the OTPF, the desired outcomes of this intervention are
improvement in occupational performance, well-being, and quality of life (AOTA, 2014). Due to
the patient diagnosis it is important to look at improving the patients abilities, which will then
improve occupational performance. By improving performance, the patient will then be able to
have contentment with himself and have an increase in well-being. This will give him meaning
and return the roles that he previously had. This will then give him a more satisfying quality of
life and give him back the sense of identity he has lost.
Long Term Goal 2
Patient will don and doff lower extremity clothing with supervision using a dressing stick
and reacher within two weeks.
Short Term Goal 2a. Patient will don and doff sweat pants with minimal assistance
using a dressing stick and reacher within one week.
Intervention. The patient will participate in an intervention that focuses on using a
reacher to develop activity tolerance needed to perform lower extremity dressing. The patient
will start with hand held weights as a preparatory activity to build tolerance and strength. The
patient will be educated on the proper techniques and adaptive equipment necessary to tolerate
the activity. A demonstration by the therapist of the proper techniques will be given to make the
patient feels more comfortable in performing the activity. The activity will be having the patient
use the reacher to pick up household items from the floor. The patient will be seated and will
have to weight shift from side to side which is necessary for lower extremity dressing. Rest

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breaks will be incorporated to allow the patient not to get fatigued. Assistance will also be given
to the patient if it is needed during the treatment session. It will be important to educate the
patient and family why this activity will help with dressing and make it easier for the patient to
tolerate. It will be important to create the just right challenge for the patient so that the patient
does not get frustrated or fatigued.
Grading up. This intervention can be graded up by having the patient stand and pick up
the household items. Increasing the amount of items can be another component that could make
the activity more challenging. Decreasing the amount of time the patient has to pick up the items
can increase the difficulty.
Grade Down. By decreasing the amount of items to pick up, the intervention can be
graded down. Decreasing the environmental distractions will limit the difficulty as well.
Increasing the amount of time and giving more frequent rest breaks can be other ways to make
the activity less challenging.
Approach. When applying to the OTPF to the intervention approaches, the approaches
will focus on establish/restore and modify (AOTA, 2014). The intervention will aim to establish
the skills not yet developed that are needed to perform LE dressing and will restore the roles that
the patient had previously done at home. This will also incorporate the modify approach because
the patient will be using the reacher to enhance activity tolerance and performance.
Evidence. There has been evidence to suggest that using occupations as a mean can be
beneficial when working with a client. According to McLaughlin Gray (1998), using occupation
as a means can help guide treatment planning. It is also necessary to enhance underlying
components that may interfere with occupation, but that are not the specific occupations. When
looking at an intervention as a means, the occupation should pertain to the clients sense of self,

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personally meaningful, culturally relevant, and goal-directed. When implementing this


intervention as a means, the patient will be able to work on the same goal and still promote
improvement in occupational performance and will bring meaning to the patient.
Outcome. According to the OTPF, the outcome approaches the will be utilized are
improvement in occupational performance, role competence, and well-being (AOTA, 2014). By
focusing on improving the patients skills the patients activity tolerance will improve as well.
By improving performance, the patient will be more satisfied and have increased independence.
By working on an activity that incorporates the patients roles, this will facilitate engagement in
previous roles and help to restore role competence. Incorporating an occupations that has
meaning to the patient and gives an opportunity for self-determination will promote improved
well-being.
Short Term Goal 2b. Patient will don and doff socks and shoes with adaptive equipment
within one week.
Intervention. During this intervention, the patient will participate in donning and doffing
his shoes and socks. The patient will receive education on compensatory techniques that will
improve the patients independence and activity tolerance. This intervention will incorporate
adaptive equipment to provide a more efficient alternative. A reacher will be used to gather socks
that have been placed on the floor to improve the patients skills in using the reacher. Once the
socks are retrieved, the therapist will educate the patient on how to use the sockaid to don the
socks. A demonstration will be given to show the patient how to use the sockaid efficiently, as
well as, the reacher if necessary. Verbal cues and assistance will be given as needed. Frequent
rest breaks will be given as needed as well. It will be important to educate the patient and
caregiver on the adaptive equipment for safety and to be able to tolerate the activity. It will be

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important to create the just right challenge for the patient so that the patient does not get
frustrated or fatigued.
Approach. When addressing the OPTF, the approaches that were used during this
intervention included establish and modify (AOTA, 2014). The intervention will look at
establishing the skill of using the sock aid to develop activity tolerance and new skills. It will
incorporate the modify approach because the patient will be using an adaption for the activity to
reduce fatigue during the activity and enhance performance.
Evidence. Research has shown that the use of adaptive devices can enhance occupational
performance. According to Moyers (1999), Adaptive equipment can play a major role in
restoring independence in occupational performance and preventing further decline in older
adults. The occupational therapist can play a vital role in recommending the type of adaptive
equipment and how to teach the patient how to use it. Within this intervention, the task of getting
dressed is important to the patient and by using the A/E he will have gained that independence
and satisfaction that he wants.
Outcome. When utilizing the OTPF, the desired outcomes include improvement in
occupational performance and quality of life. This intervention promotes improvement in
occupational performance that leads to a more satisfying life, enhancing hope, self-concept, and
health and functioning.
Precautions/Contraindications
It is important to take into consideration the precautions and contraindications when
working with this patient. Precautions to consider include skin irritation due to the patients rash,
decubitus ulcers from prolonged laying and sitting, fall risks, and fatigue. There are no specific
contraindications with the diagnosis of debility. General contraindications include severe pain,

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decreased cognition, loss of consciousness, or a state of disorientation. If the patient is


experiencing any of these it would be important to stop the intervention until further assessment
is completed.
Frequency and Duration
The intervention frequency and duration will be once a day for 90 minutes. The treatment
session will be five days a week. This will be an appropriate amount of time to achieve the
intervention goals. The patient will be reassessed and reevaluated as necessary to determine
progression, regression, or plateau.
Primary Framework
The model that guided this intervention is the Model of Human Occupation (MOHO).
This model incorporates a holistic approach that looks at volition, habituation, and performance
capacity. The MOHO looks at the mind-body connection and the internal motivation along with
the external component, occupational performance of the individual (Kielhofner, Forsyth,
Kramer, Melton, & Dobson, 2009). Goals were made in collaboration with the patient and
incorporated volition. Habituation, and performance capactity. The patient likes to participate in
leisure activities and want to gain his independence back with his occupations, this provides the
patients motivation to succeed. By being independent in these occupations, the patient can
restore routines and roles that were meaningful to him. Social participation is another motivation
for the patient. It can increase his mind-body performance as well as improve his well-being.
These goals can increase performance capacity and increase the patients quality of life.
Patient/Caregiver Training and Education
Due to the patients condition, it is necessary to educate the family on what the therapist
is working towards and why it is important. It will be beneficial to educate them on letting the

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patient perform as many occupations independently as he can. Due to the patients fall history, it
will be imperative to educate the family on AE that can be used and what home modifications
could be implemented to ensure safety. The patient plan for discharge is to return to living with
his daughter. By incorporating her and her family into the intervention they can help promote
and instill motivation for a more optimal performance. Family and caregivers usually have a
wealth of knowledge that can help plan treatment sessions (Perkinson, Hilton, Morgan, &
Perlmutter, 2011). It will be more beneficial for the patient if the patient-therapist relationship is
open, and there is consistent communication about concerns and improvements being made.
Patient Response to the Intervention
The patients response to the intervention will be monitored by talking to him and his
family and keeping the intervention client-centered. Documentation will be done to justify
services so the patient can continue to participate in the intervention. It will be important to talk
with the patient and family about the just right challenge and how to grade up and down for
interventions. It will be imperative to reevaluate goals and desired outcomes frequently to
reinforce a trusting relationship and to make sure the patient and family know what is going on
throughout the intervention process.

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References
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Kielhofner, G., Forsyth K., Kramer, J. M., Melton, J., & Dobson, E. (2009). The Model of
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Law, M. (2002). Participation in the occupations of everyday life. American Journal of
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