Running head: OCCUPATIONAL PROFILE AND ANALYSIS

Occupational Profile and Analysis Yara Bezgina Touro University Nevada

OCCUPATIONAL PROFILE AND ANALYSIS

Occupational Profile and Analysis Introduction The client is a 60 year old Caucasian female attending an outpatient hand therapy clinic three times a week for functional rehabilitation purposes. Client has been attending clinic for two months. Clients current diagnosis is amputations of thumb, middle and index finger, excessive scarring due to skin grafts, and history of compartment syndrome. In addition, client suffers from Chronic Obstructive Pulmonary Disease (COPD). Clients task analysis is based on hand writing activity. Client Factors: Personal and Family Client reports that her biggest value in life is being there for her family and she values her independence. Client believes that her motivation and faith in God will help her to achieve her goals, and will guide her through recovery process. Client states that Sunday church and caring for her family are very important for her sense of wellbeing. Clients social support consists of her husband that resides with her in two bedroom apartment. Clients husband has been helping her through recovery process by driving her to the clinic, and by taking over some of the activities she has difficulty performing at home. Client also has an older sibling, a brother that recently suffered cerebrovascular accident and lives in the apartment next door. Becoming an immediate caregiver was a life changing event for the client. Current Concerns According to client, her main concern is her ability to re-establish independence in previously performed tasks and gain back right hand coordination and fine motor agility. Client reports anxiety and depression due to inability to be able to complete meal preparation, perform work duties, and take care of her older brother. Client has been out of work for three months, and is concerned about not being able to perform her job that requires secretarial skills such as,

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filing, writing, and printing. Client also reported feeling bored and inadequate on a number of occasions, and stated that she cannot participate in knitting and sewing activities that were a part of her leisure routine. In addition, client reports that her right hand looks unpleasant and scary, and she constantly feels that people look at her, which affects her self-esteem. Areas of Occupation Prior to surgery client managed all of her activities of daily living (ADLs), and instrumental activities of daily living (IADLs) independently. Client prepared meals, and took care of household activities while maintain part time job at Department of Motor Vehicles (DMV). Furthermore, client has been a caregiver for her older brother, and assisted him with meal preparation, light household tasks and grocery shopping. Client also enjoys making sewing patterns and knitting and considers these activities as her main means of relaxations and joy. Occupation at risk are participation in IADLs such as, difficulty preparing meals, cleaning, caregiving, leisure and difficulty performing job required tasks. The loss of mastery and skill in previously enjoyed occupations cause a client great deal of sadness, worthlessness, and depression. Client stopped using her right hand after surgery because of pain and fear to do something wrong, and has given up a lot of her occupations (leisure, work and cooking). In addition, client also expresses concerns about being a good wife and sister, as she stopped performing her usual household duties, and does not know how long her husband can take over her responsibilities. Context and Environment One of the contexts inhibiting clients engagement is her prolonged stay at home. According to client staying at home is boring, and she feels useless because it takes a long time to cook a meal, and she never finishes anything on time. Client reports loss of motivation to do anything

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because she just sleeps all day. Client sees herself as an active individual that enjoys working and is productive throughout the day. Context that supports client engagement in occupations is the social nature of the community she lives in. Client reported when she gets bored at home she plays poker with her neighbors, and visits her friends that live in the same apartment building. She reported that having this social support and opportunity to engage in social interactions, and leisure activities is helpful. Furthermore, clients participation in church activities provides her with emotional and spiritual support. Another context that supports clients engagement in occupations is good communication and relationship with her brother, and she finds it meaningful to be able to stop by his apartment, and read or watch TV together, or help him with some of the activities at the house. Client relies on the help of her family, friends, and husband to help her to get to her goals. Occupational History According to client, she worked at the DMV for the past 20 years. However, due to her surgery causing amputations of her thumb, index and middle finger she is unable to work and compete all of the job tasks on time. Clients daily routines consisted of waking up in the morning to cook breakfast for her husband and brother, followed by five hour work day, after which she came home and spend an hour with her brother assisting his needs. The rest of the evening client spent either cooking dinner, or cleaning, and she always did a little of knitting before going to bed. On Saturday and Sundays client attended church, or engaged in leisure activities such as, finding new patterns for sewing, writing letters to her extended family in Poland, and she sometimes used computer to send an email. One of the clients rituals was to prepare cookies or bake pies for her family and co-workers for big holidays. She also enjoyed knitting scarfs or sweaters to give them as gifts for Christmas or Thanksgiving.

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Priorities and Desired Outcomes According to client her most important priorities are: ability to prepare meals and complete light household activities, return to work , and ability to knit and sew again. Client stated that working on job related tasks would be her main priority, followed by re-learning how to prepare meals fast and efficiently. Client is also considering switching to typing all of her letter if writing continues to be difficult. Client stated that over next couple months she would like to see herself back at work, hopefully as an administrative assistant at DMV. Moreover, client mentioned that she wants to resume her caregiving activities, and continue cooking daily for her husband and brother as she takes pride in her cooking skills. Body Functions Specific Mental Functions Client does not display any problems with sustained attention and is able to stay on task and follow complex commands. Client is able to follow logical train of thought, shows normal behavior regulation, and does not require more than verbal encouragement per session. Client struggles with self esteem and, which affects clients participation in negative way. Client is oriented and aware, with normal levels of arousal. Sensory Functions and Pain Client reports problems with reduced sensory input and occasional abnormal tingling sensations over the dorsum area of the right hand and over metacarpophalangeal (MCP) joint and proximal iterphalangeal joint (PIP) of the index finger. Client reports increased pain sensation, occasional numbness, and sensitivity to light touch over the MCP and extensor area of the middle finger. Client also reports feeling numbness and sensory loss over the palmar surface of the base of the thumb and over palmar regions of MCP joints of index and middle finger.

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Neuromuscular and Movement Related Functions Client presents with 70 degrees of MCP flexion, and 20 degrees of MCP extension of the middle and index finger due to scarring tissue that prevents normal movement. Client presents with overall flaccid tone over the MCP extensor and flexor muscles and displays muscular weakness of the thumb. Client is able to achieve 30 degrees of thumb flexion at carpometacarpal (CMC) joint, and displays partial range of motion for CMC thumb abduction. The client is struggling to achieve functional fist due to reduced range of motion (ROM) of MCP and CMC joints. In addition, client shows skin tightening and excessive scarring over the dorsum and palmar surfaces of the hand due to history of compartment syndrome. Moreover, client presents with weakness of wrist flexors due to prolonged disuse of the hand. Clients partial amputations of thumb, middle, and index finger extend to PIP joints, which reduces clients functional grasp and ability to secure objects in hand. Client shows normal bilateral coordination with fair endurance. Client shows normal good eye to hand coordination, however overall right hand incoordination is caused by muscular weakness and limited ROM over the impaired area. Clients right hand fatigues after 10 minutes of use, and client usually requires 15 seconds of rest before she can continue with the task. Respiratory and Cardiovascular System Function Client shows normal rate, rhythm and rate of respiration. Client does not show any general fatigue during observed activity, however if the activity involved more movement and required more muscle activation the fatigue can present a potential problem. Client reported that she takes frequent breaks during household activities, and fatigue may be related to COPD. The cardiovascular system or circulation may be impaired related to history of compartment syndrome, but client wished not to disclose any more details about her health.

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Skin and Related Structure Functions Client shows presence of excessive scarring tissue over dorsal and palmar aspects of the hand. Client shows normally healed scar tissue over stump amputation area of the thumb middle, and index fingers. In addition clients show scar tissue and hardening of skin extending from the elbow to the wrist of the hand due to history of compartment syndrome. Other Body Functions Client states that he has no history or complains related to immunological systems, digestive and metabolic, reproductive and genitourinary functions. No speech and voice functions disruptions have been observed and reported by the client. Activity Demands Space Demands For participation in individual hand therapy session a medium room or space is required. A room has to be spacious enough to fit a large table and two chairs. It is best if the room is not overcrowded, well ventilated, and with sufficient lighting to help the patient to concentrate on their activity and be able to see the materials and tools. Social Demands Participants are expected to follow general rules at the hand clinic: respecting other clients and therapists at the clinic, speaking in quiet and non-offensive way, avoiding interrupting and speaking over others receiving therapy, and controlling feelings of frustration, and restraining from use of swearing language. Participants are also expected to wait for their turn to use bathroom, gym equipment or special tools or materials used in hand therapy clinic. Participants should be able to engage actively in the task provided by the therapist, and should be able to notify practitioner if the pain or fatigue become unbearable. Participants are expected to maintain attention throughout 60 minute session.

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Sequencing and Timing Participant should be able to arrive on time, discuss with the therapist any current concerns, and report any pain or any changes in functional status. Participant should be able to follow specific steps to initiate and complete hand writing activity such as, gathering supplies for writing (pen, paper, and eraser), picking a correct pen or pencil with adjusted grip that is suitable for them to hold, picking a right sheet of paper, writing words or sentences within the lines of graph paper. Client should be able to complete task with required number of repetitions and should understand when to take a break if feeling fatigued. Client should establish a personal goal on how many words or sentences can be completed before feeling fatigued, and try to achieve this goal within a reasonable time limit. Required Actions and Performance Skills Participant should be able to hear directions, see well enough to initiate writing task and have enough muscular control to move impaired hand and write down words or sentences. Client should be able to have enough coordination to grip and hold modified pen, and enough strength and endurance to write on the paper or apply enough pressure to produce words. Client should have enough tactile feeling in the palm of the hand and over the finger to know if the pen is slipping out and needs to be adjusted. Client should have good eye to hand coordination to initiate movement of the impaired hand, and stay within lines or borders of the paper. Client should be cognitively aware, oriented, and know how to write. Participants should be able to make independent judgments on what words or phrases to write and write in language that is appropriate. Client should be able to sense if activity becomes too painful or too tiring and notify the therapist. Client should be able to answer questions about activity and understand verbal encouragement, pay attention to their actions and stay motivated and on task.

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Required Body Functions Participant should be able to sit in the chair for 60 minutes without feeling tired, sleepy or in pain. Participant should be able to stay conscious, alert, and oriented during the session. Participant should be able to maintain concentration and attention levels to stay on task. Participant should have enough joint mobility and muscle strength of the right hand to be able to hold a pencil with adjusted pencil grip, and preferably experience minimal amount of pain during the activity. Participants should be able to recognize any signs of fatigue, extreme pain or abnormal sensations and notify the therapist. Participant should be able to control their emotions and feelings of frustrations if activity is becoming difficult. Required Body Structures Participant should have intact auditory structures (at least on functional ear) or wear hearing aids. It is preferable that client has intact speech (larynx box) or has an alternative method of communication. Intact visual structures such as eyes and intact structures of the nervous system are needed to be able to participate in the hand writing activity. Participant should have at least one arm, and have at least two functional fingers or partial mobility of the amputated digits to engage in activity. Participant should have bone and muscle integrity of wrist and forearm to be able to coordinate their affected hand. Client should have intact lungs in order to breathe, and maintain normal aerobic capacity during handwriting activity. Structures of the cardiovascular, immunological, and genitourinary systems do not apply to this scenario, but should be functional in order to partake in outpatient hand therapy session. Performance Skills Motor and Praxis Skills Client is able to show a fair level of right hand coordination to complete hand writing activity. However, client struggles with motor control of the thumb, middle and index finger,

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which makes it difficult to secure the pen in the functional handwriting grasp. Once provided with bigger pencil grip client is able to manipulate pen in functional position, and carry out sequential motor act required for writing. Client is able to use praxis skills to anticipate required movement and adjust the pen back in the functional position when it starts slipping out. Sensory and Perceptual Skills Client is able to visually determine correct tools to use, and is able to visually track lines and direction of text when writing. Client is able to sense how tight her grip on the pen is and is able to fill when her grasp is getting weaker. Emotional Regulation Skills Client shows no difficulty expressing her feelings, and is able to monitor her emotions and notify the therapist about pain or when she is ready to take a break. Client is emotionally stable, but lacks self- confidence in her abilities. Client requires occasional motivation and encouragement from the therapist to try harder. Cognitive Skills Client is able to concentrate, and shows good memory and ability to follow complex instruction and guidelines. Client is able to prioritize and sequence steps and talks about relevant information during individualized treatment. Client displays no difficulty shifting and sustaining attention and does not require any cueing, or facilitation. Communication and Social Skills Client is able to answer or responds to therapist in appropriate manner. Client is able to maintain acceptable physical space, and share tools and materials with other clients at the clinic.

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Performance Patterns Habits Client always starts the activity with checking the color of the pen and if using a pencil she always checks the sharpness of the pencil with her fingertip before starting. Client positions paper on the right hand side slightly tilted and uses left hand to secure the paper in place. Routines Clients follows a writing routine by adhering to sequence of steps, such as picking out a correct pen and color, adjusting paper, writing her name and last name from left to right , reading over what she wrote and correcting any mistakes. Rituals One of the clients rituals is to spell out verbally everything that she writes down. Client also makes sure she put all the commas and periods at the end of the sentences. Roles Client has three main dominant roles that are important to her: being a good wife, a caregiver and a role of administrative clerk at DMV. Other important roles in her life are being a good friend and also a member of the church. Moreover, the client has a role as a sister, caregiver and is expected to successfully fulfill social expectations placed on her. Functions and Body Structures Primarily Influenced Body functions primarily influenced are neuromuscular and sensory functions, along with some cognitive functions and emotional regulation. Execution of movement and motor praxis are required to produce movement, and coordinate the direction of the movement. Neuromuscular functions are required for activation of the hand and wrist muscles to engage in writing activity and to increase joint mobility. Joint and muscle functions are required to move digits and wrist through possible ROM. Sensory functions are needed for proprioceptive feedback for the

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positioning of the hand, and tactile feedback for estimates the tightness of the grasp. Furthermore, sensory functions are required in order to sense pain and muscle fatigue. Mental functions are needed for judgment, concept formation, attention and awareness during writing activity. Execution of movement of oral praxis is required to produce speech and articulate ideas, and global mental functions are responsible for alertness, level of arousal, and level of consciousness. Mental functions are also responsible for temperament and emotional stability, and are a necessary component for participation in hand therapy. Voice and speech functions are involved as the client is required to actively participate in therapy session and provide feedback. Contexts That Relate to Performance The hand therapy environment is important for clients performance, as it is set up to provide the client with a supportive and engaging atmosphere. This setting is designed to improve clients fine motor performance and is structured around biomechanical activities that simulate and imitate clients occupations at home. Individualized therapy promotes culture of friendship and support that further facilitates clients engagement in occupations. Clients personal contexts such as, house-caring and secretarial duties correlate to her goals set at the clinic. Clients sociocultural contexts support her participation in occupations as she receives enough social support and help from her husband, and friends. However, this context can also be limiting clients engagement in occupations, as her husband tends to overcompensate by taking over the household activities that the client used to perform, thus limiting clients opportunities to use her right hand outside the clinic. Problem Statements 1) Client requires moderate assistance to complete meal preparation due to inability to operate with right dominant hand related to limited ROM and muscular weakness.

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Re-establishing this skill will help the client to engage in meal preparation for her husband and brother, and will provide client with sense of meaning and pride. Client will be able to transfer these skills to other activities that require different types of grasp or more gross motor control such as, driving, grocery shopping, laundry and etc. 2) Client requires moderate assistance to complete job related tasks such as filing, writing and administrative duties due to loss of strength and ROM of thumb, index and middle finger of the right hand. Working on job related tasks will help the client to re-establish her fine motor skills and grasp synergy, as well as, help her to return to the occupation she previously enjoyed and regain self-confidence in her abilities. This will also help the client to regain fine motor skills that are transferrable to her leisure activities such as, knitting and sewing. 3) Client requires moderate assistance to engage in leisure activities due to loss of muscle strength and coordination of right hand related to partial finger amputations of digits one, two and three. 4) Client requires moderate assistance to complete household chores that are part of her caregiving responsibility due to muscular weakness and loss of range of motion of the right hand. 5) Client is unable to complete handwritten letters to relatives due to right hand incoordination, muscular weakness and decreased range of motion of the digits one, two and three.

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References American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and Process (2nd ed). The American Journal of Occupational Therapy, 62 (6), 650-651