Running head: MS.

J CASE STUDY

Amputation Case Study Megan McCarthy The University of Scranton

Running head: MS. J CASE STUDY Synopsis: KR is a thirty-year-old female who sustained a left and right BK

amputation secondary to gangrenous. After the bi-lateral amputation was conducted, a skin graft closure was performed to weeks after surgery to properly secure the wounds. PMH includes: intravenous drug use, endocarditis, hepatitis B and C, chronic liver disease, and sepsis. Occupational therapy services were provided three days after surgery to evaluate and help the client meet her needs. During the therapy session, clinicians stated that KR could only demonstrate bed mobility and bilateral UE ROM due to pain and fatigue. It was also noted that both amputations have flexion contractures, her sitting balance is fair, and there is a considerable amount of patient education that needs to be addressed in terms of long term care. Occupational therapists (OTs) are trained clinicians in the use of therapeutic occupation-based interventions. One dimension of this approach is to teach compensatory techniques for an activity, which provides clients with adaptive ways to complete desired tasks. Typically some of the services that occupational therapists provide to citizens with lower extremity amputees are progressive functional mobility training, teaching proper transferring techniques, limb pain/sensation management, and patient education (2011). Some sociopolitical considerations that pertain to KRs situation is that she is homeless and has no medical insure. The first obstacle would be to find out if the client qualifies for Medicaid or supplemental security income. In KRs case, being eligible for supplemental security income is going to be a complicated task due to her age, homelessness, and drug abuse. The patient will need to thoroughly discuss her situation with a social worker to find out what her options are in terms of continued

Running head: MS. J CASE STUDY care and other community-based services that may be available (Burt, Wilkins & Mauch). One lifestyle issue that KR may face, after a proper assessment is conducted, is the

required use of assistive ambulatory device/s such as prosthetics, wheelchair, walker, or quad cane. Along with a mobility device/s, depending on KRs stability and performance, she may need to incorporate the use of additional adaptive equipment to complete activities. Some examples of adaptive equipment that the client may find beneficial are a long handled reacher and extended tub bench. Also, due to her noncompliance with past drug rehabilitation and medications, her ability to self-care needs to be further examined in order to conclude if KR is capable of being independent. Using the provided referral sources and data collected, the main focus of Ms. KRs OT treatment plan will be based on her current status, needs, and goals that the client has determine for herself with the help of the therapist. The outcome of this focus is to help the client reach optimal performance in ADLs and mobilize safely and efficiently throughout her environment. KRs competency will be fully evaluated and then both the patient and therapist will develop an intervention plan. After the initial evaluation, a COTA can be integrated into the treatment plan to help conduct intervention activities. Some activity examples that a COTA could be given are to educate KR on her amputations, teach her compensatory techniques, and practice how to safely ambulate and transfer with the use of an assistive device. Other professionals that may provide services to KR are a physical therapist, social worker, and COTA. Working with an interdisciplinary team creates a positive

Running head: MS. J CASE STUDY atmosphere where clinicians can collaborate and ultimately decide the best treatment for the patient. In order to properly establish STGs and LTGs for KRs intervention, the patients occupational profile, evaluation, and assessment of her needs will all be considered. In this particular case, goal projections for ADLs and functional transfers have already been predetermined for KR. Many tasks mentioned in the clients goal projection involve transferring, and teaching KR adaptive, safe ways to complete transfers is very critical to obtaining her independence. For example, getting in and out of a bathtub is a common task that involves multiple safety hazards. Educating a

client how to properly accomplish this task by utilizing objects such as, sliding board, extended tub bench and/or grab bars will greatly reduce safety risk and assist the client in successfully completing the activity. Another major area that must be addressed is the clients flexion contractures through properly positioning, wrapping, and exercising the extremities. Lastly, a goal of grooming and hygiene will help to reduce infection and integrate proper wound care into the clients daily routine. All goals will be written by using the FEAST method and will be measurable and rationale. Designing interventions and goals based on a theoretical standpoint is important in order to display validity in the therapists chosen treatment approach. It is important to consider multiple theories and frame of references (FOR) to accurately target the multidimensional aspects of a person needs for functional independency. Some of the theories and FORs chosen for KR are the biomechanical model, MOHO, and lifestyle performance model. These approaches were selected to target all of KRs needs and

Running head: MS. J CASE STUDY to incorporate them in the therapeutic process. The biomechanical was chosen to focus on the clients body mechanics and upper body strength. This also will allow

for particular focus on releasing KRs flexion contractures and help her become more mobile. The MOHO was chosen to incorporate a holistic approach into the treatment intervention. This will look at KRs volition, habituation, and her performance capacity within the contexts of her home environment and living situation. Using the MOHO will help to detect what adaptations need to be made to KRs environment. Lastly, the lifestyle performance model incorporates her interests, activity patterns, and individualized needs into the intervention plan. This enables the client to successfully sustain or achieve a personal identity within the integrated adaptations (Fidler, 1996). The evaluation process must be consistently repetitious in order to accurately record a patients progress. A weekly evaluation will be completed, which includes standardized and non-standardized assessments, observations, and both formal and informal feedback from the client and caregivers. Finding if a change or termination of treatment is warranted will be established through the therapists findings in the weekly assessment of the client. After a reassessment is conducted, an interdisciplinary team meeting will occur to evaluate the progress of the patient. The team will determine the following: if the goals are being meet within the stated time, has the intervention plan been working and, if so, do they need to be upgraded or downgraded, and if a discharge date has been assigned to the client or is long term care being considered.

Running head: MS. J CASE STUDY The interdisciplinary team involved in the treatment of KR will establish a detailed

action plan. Goals will be written and a recommended activity will be provided using STWD occupational therapy services activity description sheets. Short-term goals and long-term goals such as, safely and independently completing a front w/c to toilet transfer by the end of treatment will be included in the plan. All occupations that pose affected due to the patients condition will be addressed and multiple therapeutic strategies will be implemented. Please refer to the attached STWD forms for additional information regarding KRs action plan. There are many resources available to KR that allocate additional information on amputees and services for the uninsured. For example, the Amputee Coalation of America provides a tip sheet on different organizations and way to receive funding for prosthetics. A list of resources have been provided per below: http://www.amputee-coalition.org/fact_sheets/assist_orgs.html http://www.oandp.com/resources/organizations/barr/history/ http://www.hanger.com/prosthetics/experience/pages/peersupport.aspx http://home.comcast.net/~n2fc/natamp/tips.html

Running head: MS. J CASE STUDY References (2011). Retrieved from

http://www.brighamandwomens.org/Patients_Visitors/pcs/RehabilitationServices /Physical Therapy Standards of Care and Protocols/General - LE Amputation.pdf (2011). Retrieved from Centers for Medicare and Medicaid website: http://www.medicare.gov/Pubs/pdf/10153.pdf Bonder, B., & Bello-Haas, V. (2009). Functional performance in older adults. (3 ed.). Philadelphia: F.A. Davis Company. Burt, M., Wilkins, C., & Mauch, D. (n.d.). Retrieved from website:http://aspe.hhs.gov/daltcp/reports/2012/ChrHomls2.pdf Fidler, G. (1996). Life-style performance: from profile to conceptual model. The American Journal of Occupational Therapy, 50(2), 140-147. Retrieved from http://ajot.aotapress.net/content/50/2/139.full.pdf Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). The American Journal of Occupational Therapy, 62, 625-683.

Running head: MS. J CASE STUDY

Mini-case Case Study Development Clinical Reasoning Process Activity Description Related Goal: KR will complete a forward w/c toilet transfer with minimal assistance and 1 verbal cue by the end of two weeks. Activity Name: Wheelchair to Toilet Transfer

Materials and Supplies Wheelchair Toilet

Positioning Considerations Sitting

Steps to Activity Completion: Bring pt. into the bathroom Ask pt. to position herself and lock her w/c breaks. Ask pt. to complete transfer (therapist will assist and guard as needed). Once pt. is securely on the toilet, ask pt. to safely transfer back to w/c. Rationale for Activity Choice: The rationale for this activity is to work on strength, balance, endurance, and the pts. ability to transfer onto different surfaces. Toileting can be a difficult task for a bilateral LE amputee and it is important that the client can perform this task safely and efficiently. Feedback

Therapists Strategies

Parameters to Monitor/ Safety Considerations

Therapist will: Give cues and Monitor pts. BP assistance as needed. Look for signs of fatigue Upgrade and downgrade Observe to make sure pt. activity as needed does not seem off balance and is properly positioned Monitor any safety precautions that may to reduce any fall risks become apparent during the engagement of the activity. Suggestions for Upgrading Decrease verbal cues: Suggestions for Downgrading: Increase verbal cues Give maximal assistance Perform task with the lid down

Give CGA Make client practice with the lid up Have pt. practice reaching for toilet paper. Incorporate the task of hand washing.

Running head: MS. J CASE STUDY

Mini-case Case Study Development Clinical Reasoning Process Activity Description Related Goal: Client will take part in an exercise program for two weeks and will be able to complete 6 exercises in 30mins by the end of the second week. Activity Name: Exercise Program Materials and Supplies: Wheelchair Weights Theraband Mats Positioning Considerations: Sitting Supine Prone Sidelying Steps to Activity Completion: Pt. will engage in an exercise program 3xs a week for 30mins per session. Pt. will perform various exercises to engage in a complete total body workout to increase strength, endurance, balance, and reduce flexion contractures. Rationale for Activity Choice: The rationale for this activity is to work on the pt.s overall strength, endurance, balance, and to work on getting rid of the pt.s flexion contractures. Being that the pt. may not get funding for prosthetics, it is important that she builds up her strength so she can mobilize herself.

Therapists Strategies: Therapist will: Demonstrate exercise. Give cues and assistance as needed. Upgrade and downgrade activity as needed Monitor any safety precautions that may become apparent during the engagement of activity. Suggestions for Upgrading Give only one visual cue per exercise Give no assistance Incorporate more advanced exercises and complete them against gravity.

Parameters to Monitor/ Safety Considerations: Monitor pts. BP. Look for signs of fatigue. Observe to make sure pt. does not seem off balance, is properly positioned, and is in correct formation while completing the exercises.

Suggestions for Downgrading Maximize cueing Give minimal assistance Perform exercises in non-gravitational planes

Feedback

Running head: MS. J CASE STUDY

10

Mini-case Case Study Development Clinical Reasoning Process Activity Description Related Goal: Client will work on proper LE hygiene by engaging in a bathing/wound care activity and will be able to complete this independently by the end of treatment. Activity Name: Hygiene Activity

Materials and Supplies: Cleanser Bathing gloves (if preferred) Dressings Gauze Coband

Positioning Considerations: Sitting

Steps to Activity Completion: Client will bath LE. Apply any ointments or medications (only if prescribe by the physician). Pt. will apply any dressings that are needed. Pt. will properly secure dressings on LEs. Rationale for Activity Choice: The rationale for this activity is to educate the patient and to make sure they can properly take care of their amputations before being discharge. It is important to maintain proper hygiene to reduce the risk of infection or other set backs that may be caused by improper hygiene. Also, it is important to properly form/shape the stumps in case KR can get funding for prosthetics in the future.

Therapists Strategies:

Parameters to Monitor/ Safety Considerations:

Give cues and assistance as needed. Monitor pts. BP Upgrade and downgrade Look for signs of activity as needed. fatigue Monitor any safety Observe to make sure precautions that may pt. does not seem off become apparent during balance, is properly the engagement of positioned, and is not activity. causing any harm to their wounds or LEs. Make sure dressings are wrapped properly around pt.s LEs. If not therapist will rewrap bandages. Suggestions for Downgrading: Give minimal cueing Give CGA Visually show pt. how to properly wrap their stump before they engage in the task.

Suggestions for Upgrading: Client will complete task independently with no cues or assistance Pt. could be in charge of getting/picking out all the items needed for the task

Feedback: