Occupational therapy and Nursing

Case: George Crun

A 51-year-old male real estate lawyer began to embezzle money at work,
regularly listing mysterious expenses on his travel reimbursement forms, which
turned out to be purchases of pornographic materials via the internet. When
questioned, he claimed that he used the corporate accounts so that his wife
would not find out about this sexual activity. At about the time that this behavior
was discovered by his partners, a few of the female law clerks complained that
he often made inappropriate comments about their physique and that he stared
at them in a way that made them uncomfortable. His work had dramatically
deteriorated, and rather than working with his clients, he spent most of the day at
work shuffling papers, reading magazines or downloading pornography onto his
computer. He was eventually asked to leave the firm, but made no attempts to
find a new job. His wife and children reported that over the past year he had lost
interest in them and watched television without speaking when at home. He
developed a strong desire for potato chips and gained 15 lbs. His manners
deteriorated, and he stuffed his mouth, often choking at the dinner table. He
insisted on eating food on his plate in a specific order, often with his hands.
Family history revealed that his father and first cousin had died from "Lou
Gehrig's disease."
Setting: Psychiatric inpatient facility

Occupational Therapy

Occupational Therapy Evaluation

Part I.
Client Name: George Crun
Date: 5/12/15
Diagnosis: FTD-MND
Precautions: Safety
Prior functional Status:
Independent in ADLs and IADLs
Medical History:
Unknown
Mental Status/Cognition/Perception
Alert X
commands
Unresponsive

Oriented x__2___ Follows ____ step

Part II

WFL / Impaired / limited/ Intact /

Normal
R/L
Left
Right
Dominant
Coordination
TBA
TBA

Strength

Shoulder
Flexion
Shoulder Abd.
Elbow Flexion
Elbow
Extension
Wrist Flexion

WFL

WFL

WFL
WFL
WFL

WFL
WFL
WFL

Sensation

TBA

TBA

WFL

WFL

Tone

Impaired

Impaired

Wrist Extension

WFL

WFL

Edema

TBA

TBA

Gross Grasp

WFL

WFL

ROM

TBA

TBA

Comments: Subtle atrophy and weakness are noted in UE and LE. Further
assessments are required for coordination, sensation, edema, and ROM.

Part III
Functional Status: I, Mod I, SBA, SPV, MIN A, Mod A, Max A, Dep
Feeding:SBA
Grooming/Hygiene: SBA- shaving
Bathing: SBA
UE Dressing: SBA
LE Dressing: SBA
Toileting: SBA
Transfers: TBA

Static Balance: TBA

Dynamic Balance: TBA
Activity Tolerance: TBA
Comments: Further assessments needed to determine ADL functional status
for transfers, balance and activity tolerance. IADLs presented with difficulty
include cooking, yard work and money management.
Part IV
Problems:
x Decreased Independence
x Decreased function
Decreased ROM
x Decreased cognitive status
Decreased coordination
Decreased balance
Decreased functional transfers
x Decreased safety
Comments: Further assessments needed to determine additional problems.
Goals: (compile 2 LTG(min) and 2 STG(min) for each LTG)
LTG: Within 1 week, client will be modified independent in shaving with use
of an electric razor and no verbal cues to increase independence in
grooming.
STG 1: Within 1 day, client will verbalize 5 steps in sequence to complete the
shaving task with 75% accuracy.
STG 2: Within 2 days, the client will complete shaving task with fewer than 12 verbal cues using an electric razor.
LTG: Within 1 week, client will be mod I in preparing a simple meal with extra
time in order to increase independence in meal preparation.
STG 1: Within 2 days, client will verbalize the steps in sequence to complete
simple meal preparation 2 out of 3 times.
STG 2: Within 3 days, client will demonstrate safety awareness while
preparing a meal with fewer than 1-2 verbal cues.
Part V
Plan of Care
Patient will be followed for treatment X QD ____TIW _____BID
Intervention will include:

_X__ ADL training

___ Balance training

___ ______________________

___ Neuromuscular re-education

______________________

___ Visual/Perceptual training

___

_X__ Cognitive training

______________________

_X__ Patient/caregiver training

___

___ Coordination activities

grab bars, long handled sponge
_X__ Strength/endurance exercise

__X_ Equipment needs

Electric razor, shower chair,

___ Functional transfers

___ UE ROM

Caitlin Barrett, OTS, Sandra Esaac,

OTS, Lina Asfoor, OTS
Therapist(s):

Date: ___5/12/15____

Occupational Therapy
Treatment Plan 1
Client Name: George Crun
Treatment Plan #: 1
Session Length (time): 45 minutes
Problem being addressed: Grooming (shaving)
Main goal of focus for treatment: sequencing, patient/caregiver
education, safety awareness, attention, time management

Purpose of activity(s):
Patient education - educate patient on correct sequence of steps of
shaving task, and how to manipulate the electric shaving device
Caregiver education - educate caregiver on appropriate cues/prompts
and assistive techniques to aid in shaving
Cognitive intervention
Meta-cognitive training - increase awareness of strength and
limitations; planning strategies regarding setup, cleanup, and time
management
Awareness of schedule and time needed for the task, including set up
and cleanup
Verbalize understanding of limitations
Training of specific abilities - increase attention, initiation, memory, and
problem solving when engaging in the task of shaving
Setting up a dilemma to promote problem solving and attention
Verbalize the steps for shaving
Identify correct materials needed for shaving

 Training in specific tasks - training of routine tasks for shaving through

repetition and gradual decreasing cues
Practice shaving task
Respond to visual and tactile cues regarding completion of task
Evaluate need for additional visual cues for sequencing (written steps,
pictures)

Description/Analysis of Treatment Session (Document the details of the

treatment session)(Include list materials needed, position of patient,
environment needed, etc.)
Patient will verbalize his morning routine, and how much time is
appropriate for shaving.
Patient and caregiver education of grooming task including:
manipulation of device, steps of task in the correct sequence (hand-out
with pictures), proper cleaning of device. Patient will verbalize the
steps in the correct sequence, and how to use/ clean the device.
With cuing and prompting from the therapist (handout for visual
reference as well):
Patient will recite and gather materials needed to set up at the sink
Patient will need to properly set up electric razor (plug it in, put on the
head)
Patient will wash face and dry it
Pt will use an electric razor, provided by his wife, and shave with
appropriate technique (in a circular movement with one hand pulling
skin tight)
Patient will properly unplug the razor, clean the shaver, and lubricate it.
Standing Activity(s)- SBA
ADL (s)- Grooming (shaving)

Treatment Plan 2
Client Name: George Crun
Treatment Plan #: 2
Session Length (time): 45 minutes
Problem being addressed: Feeding/eating

Main goal of focus for treatment: further assess feeding problems,

healthy eating education, feeding/eating strategies,
safety/aspiration awareness

Purpose of activity(s): Patients wife reports that patient often

chokes on his food while eating and has gained 15 pounds. After
assessing the patient during lunch the previous day (a meal of
grilled chicken, mashed potatoes and green beans), it was
discovered that he uses his hands to eat, has inappropriate table
manners, unsafe eating pace, and is demonstrating unhealthy
eating habits.
Patient education - educate patient on healthy eating options,
portion control and bite size, use of utensils, appropriate table
manners and eating pace
Feeding skill
Determine appropriate bite sizes and portions
Training on use of utensils
Cognitive feeding/eating strategies
Structure mealtime habits and eating environment (eat at the
table, use a plate or bowl, do not watch television while eating,
etc.)
Proper sequencing (alternating liquids and food, place utensils
down between each bite, chewing and swallowing before taking
another bite, etc.)
Level of awareness/sensation in the oral motor area
Problem-solving (temperature of foods, use of certain utensils
when necessary, etc.)
Initiation and termination of the task
Training in specific tasks - training of routine tasks for
feeding/eating through repetition and gradual decreasing cues
Practice feeding/eating
Respond to verbal cues regarding completion of task
Evaluate need for additional visual cues for sequencing (written
steps, pictures)
Description/Analysis of Treatment Session (Document the details
of the treatment session)(Include list materials needed, position of
patient, environment needed, etc.)
While patient is eating lunch:

Patient will be educated on when and how to use utensils

Patient will demonstrate proper utensil choice and use with verbal

cues
Educate patient about proper bite sizes (fits into a spoon) and the
appropriate sequence of feeding/eating.
Have patient demonstrate the sequence and therapist will provide
verbal cues, if needed
If the patient is unable to follow verbal cues, the therapist will
demonstrate and have the pt repeat the sequence of the task
Pt will be provided with visual cues if needed
Pt will demonstrate proper feeding/eating techniques with cues as
needed
Patient will demonstrate feeding/eating, and therapist will address
specific problematic areas
At the end of the session, assist Pt with meal choice for hospital
stay
Sitting Activity(s) - Supported in a chair
ADL (s) - Feeding/eating

Occupational Therapy
DISCHARGE SUMMARY
Name: George Crun

Diagnosis: Frontotemporal dementia

Date of Initial Treatment:_5/13/2015

Treatment: Cognitive intervention

Number of Treatments: 3

Date of Evaluation: __5/12/2015_____

History, Prior Level of Function: G.C. has an unknown medical history. Clients prior level of function included independence in ADLs
and IADLs.
Therapy Goals

Initial Status

Final Status with Comments

Within 1 week, client will be modified

independent in shaving with use of an
electric razor and no verbal cues to
increase independence in grooming.

Client was SBA in shaving with decreased

awareness of safety.

Client is able to complete shaving task at

a modified independent level with the use
of an electric razor and visual cues.

Within 1 week, client will be independent

in feeding and eating with use of utensils
and appropriate safety awareness.

Client consumed a meal at SBA level with

use of only his hands and requiring
maximum verbal cueing for safety
awareness.

Client is modified independent in feeding

and eating with use of utensils and
requiring moderate verbal cueing for bite
size and sequencing.

Comments about psychosocial performance and responses:

G.C. was agreeable with treatment plan and adhered to recommendations made by the therapist. Client was frustrated with some
verbal cueing during second treatment session.
Goals Met? Yes____ Partial _x___ No____

Reason for Discharge: Physician recommended discharge home because clients wife is available for care. OT still has concerns
regarding patient safety when eating and recommends G.C. continue OT services with Home Health.

Nursing

THE UNIVERSITY OF TEXAS MEDICAL BRANCH

SCHOOL OF NURSING
CLINICAL WORKSHEET AND NURSING CARE PLAN
Student Nurse: Marina Gowid

Pt age: 51

Allergies: NKA, NKDA

Pt gender: Male

Medical Diagnosis: Frontotemporal

Dementia (FTD)

Prior medical history: family history of

Lou Gehrigs disease and Amytrophic
Lateral Sclerosis (ALS)

Prior surgical history: None

PHYSICAL ASSESSMENT

VITAL SIGNS: (Record T,P, R, BP, and

pain rating)

How do the patients vital signs affect

your nursing care?

T-97.6 F (oral)
P-72 bpm
R-18 breaths/min

BP is slightly elevated so it needs to be

monitored.

BP-130/76 mmHg (left arm, sitting)

Pain-0/10

SKIN/NAILS/HAIR

EYES/EARS/NOSE

Skin warm to touch. No lesions Nails

clean and pink. Capillary refill less than 3
seconds bilaterally. Hair evenly
distributed.

Sclera white. Conjunctiva pink. PERRLA &

ROM bilaterally. Ears clear without
obstruction. Clear and moist mucus
membranes in nasal cavity.

MOUTH & THROAT

FACE/HEAD/NECK

Mouth moist. Oropharynx clear.

No bruit. Full active ROM in head and

neck. Pathological brisk snout and jaw
jerk reflexes present.

RESPIRATORY

CARDIOVASCULAR/PERIPHERAL
VASCULAR

Lungs CTA bilaterally.

S1 and S2 present. No murmurs present.
Regular rate and rhythm. No edema
present.
Radial pulse 2+/3+ bilaterally. Brachial
pulse 2+/3+ bilaterally. Dorsalis pedis
pulse 2+/3+ bilaterally. Posterior tibialis
pulse 2+/3+ bilaterally.

GASTROINTESTIVAL/NUTRITION

GU

Bowel sounds present x 4 quadrants.

Poor diet of potato chips and overeating
often choking. Gained 15 lbs in past
month.

Urinary tract function intact per pt can

ambulate and void without assistance.

MUSCULOSKELETAL

NEUROLOGICAL

Full ROM in extremities. Subtle atrophy

and weakness evident in arms and legs.
Plantar reflexes were flexor.

A&O x 4. Cranial nerves intact. 27/30 on

Mini-Mental State Examination (MMSE).

Appropriate/inappropriate
verbal/non-verbal behavior:

Tobacco, Alcohol &/or Drug use

(include type, frequency, and number of
years for each; includes client and
family):

Patient verbal and nonverbal behavior is

inappropriate. Apathetic and indifferent
to tearful wife. Speech fluent but
includes off-color jokes and comments
about examiners old age.

GENERAL IMPRESSION

Pt is A&O x4 sitting on examination

table.

Patient denies using tobacco products,

alcohol, and recreational/illicit drug use.

OTHER SIGNIFICANT INFORMATION

(not included above such as financial
status, occupation/retirement, support
systems, activity/exercise, education
level, cultural considerations etc.)

Financial status-just fired from job for

inappropriate comments to female
employees, and monetary
embezzlement

Activity/exercise-does not exercise and

has gained 15 lbs in the past month
attributed to over eating

Support system-lives with wife

LAB AND OTHER DIAGNOSTIC TESTS

Name of
Test

Normal Values

Patient Values
(indicate with
asterick * if
abnormal)

Rationale for ordering tests

What do these lab

values and test
results tell you
about this client?
MRI

Absent for
structural
abnormalities.

Mild right greater than

left fronto-insular
atrophy*

To ensure patient does not

have any underlying structural
causes.

Pattern of brain
atrophy supports the
diagnosis of
Frontotemporal
Dementia (FTD).
EMG

Absent for
abnormal
electrical activity.

Absent for abnormal

electrical activity.

To evaluate electrical activity

produced by skeletal muscles.

Genetic
blood work

Absent for
mutations.

Absent for tau, TDP42, superoxide

dismutase, and
progranulin mutations.

To ensure patient does not

have any genetic mutations.

CLIENT/FAMILY TEACHING

Educational Need

Content taught

Client/family Response
to Teaching

Patient will be educated

about need to have
caregivers present as
condition progresses.

You will need caregivers

to assist with daily life
activities, maintain safety,
provide transportation,
and help with finances.

Willing to learn.

Patient will be educated

about engaging in regular
cardiovascular exercise.

Being physically active

and exercising a few
times a week will help
with your mood and
thinking skills.

Willing to learn.

Patient will be educated

about making some
adjustments in the home
environment.

It may be helpful to make

some daily living tasks
easier and reduce your
chance of injury by
removing rugs,
maintaining adequate
lighting, and keeping
hallways clear of clutter.

Willing to learn.

Educational Need

Content taught

Client/family Response
to Teaching

Patient will be educated

about having appropriate
support.

In addition, to care from

your family, it may be
beneficial to find a
support group or online
forum that gives you the
opportunity to share your
experiences and feelings
with others who are going
the same thing.

Willing to learn.

Family members will be

educated about ways to
reduce behavior problems
by changing the way they
interact with the patient.

Some objectives for

families to keep in mind
include anticipating needs
and meeting them
promptly, maintaining a
calm environment,
providing structured
routines, and simplifying
daily tasks.

Willing to learn.

Family members will be

educated about the
support options they have.

There are support groups,

respite care, and home
health care agencies that
can provide assistance to
family members.

Willing to learn.

What are the discharge

planning needs of this
client?

Patient will need caregivers to assist with activities of

daily living as his condition progresses.

What are the long term

health care needs based
on the disease process,
the physical assessment,
the clients
understanding and the
psychosocial factors?

Based on the diagnosis of Frontotemporal Dementia

(FTD), the patient will need long term home health care
which will be discussed with the patient and family
members. They will receive various options for support
including respite care and home health care agencies.

What safety factors are

evident in caring for this
patient? Identify at least
two preventive measure
employed to avoid
errors/accidents.

Patient will need to adjust home environment to

prevent falls including removing clutter, maintaining
adequate lighting, and asking for assistance when
ambulating.

Clinical Plan of Care

Client Data
Medical Diagnosis: Frontotemporal Dementia (FTD)
Comorbidities or Risk Factors: N/A

Reason Seeking Health Care: family states patient has lost interest in them,
embezzled money from former employer, behaves compulsively and
inappropriately, and has been overeating with a 15 lb weight gain in the past month

Psychosocial Factors Affecting Care: Loss of job due to presenting symptoms

Cultural Factors Affecting Care: N/A
Spiritual Factors Affecting Care: N/A

Prioritized Nursing Diagnoses Statements

(List the client/families problems real or potential - with related to statement and
as evidence by data to support as needed.)
1. Risk for falls related to muscle atrophy as evidenced by weakness in arms and
legs
2. Impaired social interaction related to cognitive impairment as evidenced by loss
of interest in family and inappropriate comments to female coworkers
3. Imbalanced nutrition related to excessive intake in relation to metabolic need as
evidenced by strong desire for potato chips and 15 lb weight gain

#1
Nursing
Diagnosis:

Risk for falls related to muscle atrophy as evidenced by weakness in arms

and legs

Data to
support:

Subjective: Patient stated feeling twitching in arms and legs

Objective: upon examination, fasciculation was present as well as subtle
atrophy and weakness evident in arms and legs
What is the relationship between the client data and the nursing
diagnosis?
The patient data including subjective and objective measures of the
clinical and physical expressions of muscle weakness support the nursing
diagnosis of risk for falls.

Client
Goals:

Patient will remain free of falls by the end of the week. I will assist the
patient with ambulation and monitor gait and balance with ambulation.
Goal is set at zero falls since any fall can cause injury.

How will
you know
they are
met?
Patient will change environment to minimize incident of falls by the end of
the day. I will assist patient in removing any clutter on the floor,
maintaining adequate lighting, and ensuring the call light is in reach if he
needs to ambulate.

Patient will explain methods to prevent injury by 1600. I will ask patient to
verbalize at least three injury prevention methods after our patient
education session at 1500.

Nursing
Interventions

Rationale with
reference and citations
for each

Nursing Implementation &

Client Response to
Intervention

State whether appropriate or not.

Specific to your client?

1. Comprehensive fall
risk assessment
screening client for
balance and mobility
skills.

1. It is helpful to
determine the clients
functional abilities and
then play for ways to
improve problem areas or
determine methods to
ensure safety (Gray-Miceli,
2008).

1. Implementation appropriate,
patient responsive.

2. Use a high-risk fall

armband/bracelet and
fall risk room sign to
alert staff for increased
vigilance and mobility
assistance.

2. These steps alert the

nursing staff of the
increased risk of falls
(Gray-Miceli & Quigley,
2011).

2. Implementation appropriate,
patient responsive.

3. If client is unsteady,
have two nursing staff
members walk
alongside when
ambulating the client.

3. The client can walk

independently, but the
nurse can rapidly ensure
safety if the knees buckle
(Fortinsky, 2008).

3. Implementation appropriate,
patient responsive.

4. Place a fall-prone
client in a room that is
near the nurses
station.

4. Such placement allows

more frequent observation
of the client (Fortinsky,
2008).

4. Implementation appropriate,
patient responsive.

5. Refer to physical
therapy or other
programs for exercise
programs that target
strength, balance,
flexibility, or
endurance.

5. Programs with at least

two of these components
have been shown to
decrease the rate of
falling and number of
people falling (Gillespie et
al., 2009).

5. Implementation appropriate,
patient responsive.

Evaluation of Goals:

State whether each goal

met or not

State status of each goal or

plan (ongoing, revised,
discontinued)

Provide revisions as
needed.

Goal #1: Patient will remain free of falls by the end of the
week. I will assist the patient with ambulation and
monitor gait and balance with ambulation. Goal is set at
zero falls since any fall can cause injury.
Goal #1 is ongoing and will be continued for remainder of
care.

Goal #2: Patient will change environment to minimize

incident of falls by the end of the day. I will assist patient
in removing any clutter on the floor, maintaining
adequate lighting, and ensuring the call light is in reach if
he needs to ambulate.
Goal #2 is ongoing and will be continued for remainder of
care.

Goal #3: Patient will explain methods to prevent injury by

1600. I will ask patient to verbalize at least three injury
prevention methods after our patient education session at
1500.
Goal #3 is ongoing and has been met.

References

Fortinsky, R.H. (2008). Extent of implementation of evidence-based fall prevention practices for
older patients in home health care. Journal of the American Geriatrics Society,
56(4), 737-743.
Gillespie, L.D. (2009). Interventions for preventing falls in older people living in the community.
Cochrane Database Syst Rev, 2(CD007146).
Gray-Miceli, D. (2008). Preventing falls in acute care. Evidence-based Geriatric Protocols for
Best Practice, 161-198.
Gray-Miceli, D., & Quigley, P.A. (2011). Fall prevention, assessment, diagnoses, and
intervention strategies. Evidence-based Geriatric Nursing Protocols for Best
Practice, 4.