Running head: OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile and Intervention Plan

Lauren Hoppe
Touro University Nevada

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Occupational Profile
Who is the Patient?
The patient is a retired school teacher from Wisconsin who moved to Las Vegas to be
closer to her two children and five grandchildren. She currently lives with one of her sons and
three grandchildren ages 9, 12 and 15. She enjoys sitting outside on her patio, tending to her
small garden and reading. She is in charge of making her grandchildrens lunches and drops them
off and picks them up from school every day. She also helps her grandchildren with their
homework every night after school. She assists with light housework and cooks dinner almost
every night. She also attends church every Sunday and is part of bible study that meets once a
week.
Reason for Patient Seeking Services and Concerns Relative to Engaging in Occupations
and in Daily Life Activities
The patient was taken to the hospital after overdosing on her medication which caused
non-ST segmented myocardial infarction. Her secondary complications included hypertension,
oxygen dependence, debility and depression. Once stabilized, she was discharged from the
hospital to Horizon Specialty Hospital for further medical treatment. The patient has been in the
hospital and long term facility for over a month which has caused decreased strength and
endurance throughout her entire body. She has a difficult time breathing without oxygen and
needs assistance to perform a sit to stand. Occupational services were ordered by her physician to
increase participation in functional activities such as; upper and lower body dressing, hygiene
tasks, and functional mobility. Currently, the patient requires moderate assistance for lower
extremity dressing, minimum assistance for upper body dressing, and moderate assistance for
transfers from edge of bed to wheel chair.

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Areas of Occupation that are Successful and Areas that are Causing Problems or Risks
The patient is currently independent with bed mobility, feeding and eating, and bowel and
bladder but requires a bedside commode and assistance with transfers to the commode and
steadying assistance when cleaning herself. She is also independent with some hygiene tasks
including; brushing her hair and teeth but, requires set up and needs to adapt her environment to
allow her to sit while performing these activities due to decreased activity tolerance and poor
balance. Her decrease in strength and endurance causes poor balance and decreased activity
tolerance which inhibits her from performing certain ADLs. She has difficulty with upper body
dressing due to poor sitting balance and has a hard time taking her hands off of the bed to pull
her shirt over her head and then down over her torso. Her sitting balance also affects her lower
body dressing because she cannot maintain her balance as she bends down to put her pants on.
She is able to use a reacher to help in this area but continued to have problems pulling the pants
up over her hips and required assistance. Her functional mobility is impaired and she is only
able to walk five to ten feet with a forward wheel walker and contact guard assist before she
becomes fatigued. She also requires maximum lifting assistance for transfers from edge of bed to
wheelchair and to the three in one commode and requires lifting assistance to perform a sit to
stand. Her current medical status leads her to reside in the hospital where she is dependent on
others for many of her IADLs or is unable to perform them altogether. Throughout her hospital
stay, she has also become depressed and requires anti-depressant medications.
Context and Environments that Support or Inhibit Participation/Engagement in Desired
Occupations
The long term acute care setting (LTAC) where she currently resides is both a supporting
environment and inhibiting environment. It supports all her medical needs and she receives 24

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hour assistance from the nurses and also receives occupational therapy and physical therapy five
times per week. However, it is not her natural environment so all the skills she learns in the
facility will have to be transferred to her home setting which could present a challenge. In the
hospital she has optimal room to make transfers, her bed raises and lowers to adjust for her
height, and the hospital is completely wheelchair accessible where some of her home areas may
not be. The hospital is also limiting because it takes her out of her normal social context and can
isolate her from her family and friends who may not have the ability to come visit her in the
hospital which is impacting her emotional stability and contributing to her depression. The
hospital also takes away some of her roles and routines. She no longer has the means to care for
her grandchildren or participate in her usual routines. She does however have the supporting
environment of the occupational therapists that come in five times a week to increase her
strength and endurance to increase independence with functional mobility and ADL
performance.
The Patients Occupational History
The patient is a 63 year old female who was living with her son and three grandchildren
in a two story home in Las Vegas. Her other son also lives in Las Vegas and has two sons of his
own, but she doesnt get to see them very much. She is now retired but was previously a school
teacher in Wisconsin for 25 years and moved to Las Vegas 10 years ago to be closer to her
family. She enjoys helping her grandchildren with homework, enjoys reading, watching TV and
tending to her small garden in her backyard. She helps out around the house by performing light
house work and cooking dinner almost every night for the family.
The Patients Priorities and Desired Outcomes

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The patient is extremely tired of being in a hospital setting and desperately wants to go
home. She would like to regain the strength she has lost so that she can manage her garden. One
of her biggest concerns is being a burden on her family so she would like to be able to perform
all of her ADLs and transfers without assistance from her family and she is willing to use
adaptive equipment if needed.
Occupational Analysis
Context/Setting of Occupational Therapy Services
The setting of therapy took place in the patients room at Horizon Ridge Specialty
Hospital. Her room was a single standard hospital room that included; a hospital bed, a sink
located outside the bathroom, and a bathroom complete with a walk in shower. Also located in
her room was a wheelchair and walker along with an oxygen tank so that she could go around the
hospital during therapy or accompanied by a nurse.
Activity Observed and Patients Performance during Activity
During an occupational therapy treatment session the patient performed a dressing
activity by donning her pants and socks. She was able to don her socks with moderate assistance
from the occupational therapist (OT) while lying in bed by bringing her foot up one at a time.
The OT helped by holding her foot while the patient slipped her socks on. The OT also had to
help get the socks over the patients toes and then the patient was able to pull them on the rest of
the way. To don her pants she sat edge of bed with contact guard assist and used a reacher to grab
her pants from the ground and open up her pant legs. She was given instruction on how to don
her pants by the OT and then proceeded to use the reacher and one hand to open her pants and
slip her leg into the pant legs one at a time. She then was instructed to stand up using her walker
and required assistance from the therapist to do so. After she was standing she pulled up her

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pants over her hips but needed some assistance from the OT to pull her pants up around her
waist.
Key Observations from the Performance of the Occupation or Activity
The patient was able to don her socks with moderate assistance from the therapist to
stabilize her trunk. The client struggled with donning her pants due to decreased trunk strength
which lead to an inability to maintain her center of gravity while leaning forward to thread her
pants over her feet. This is why she was brought a reacher to assist her with dressing. She also
lacked the strength to transfer independently from a sit to stand. Although, once she was standing
she was able remain standing with only contact guard assist from the OT, but fatigued quickly
and was returned to the edge of bed after completing her lower extremity dressing task.
Domains of the OTPF Impacting Ability to Engage in Occupations
Currently, the patient is experiencing major changes in her life secondary to her medical
status. This has affected many areas of her life including her occupations, performance skills,
performance patterns and the context and environment in which these areas are taking place. Her
occupations being affected include; her activities of daily living (ADLs), instrumental activities
of daily living (IADLs), leisure activities and social participation. Due to her overall condition,
she is very weak and does not have a high level of activity tolerance, creating difficulty when
performing any sort of ADL such as; grooming and bathing activities.
Her environment is currently the LTAC hospital room where she has little access to
leisure activities outside of TV or books, and little social interaction besides the nurses, therapists
and occasional family members that come to visit. The hospital rooms dont even have
telephones patients can use to call family or friends if they so desired. Her IADLs are affected
because she is no longer able or in an environment where she can cook, clean or care for others.

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All of these impacts have also affected her performance patterns including; her roles and
routines. In this particular setting she no longer has the means to care for others and instead is the
one being cared for. She also no longer has her own set routine as she is brought breakfast, lunch
and dinner at a set time every day to her room and no longer can decide for herself when it is
time to eat or what she will eat. Her inability to perform her own ADLs has also hindered her
routine because she can no longer brush her teeth in the morning or wash her face and must rely
on the nursing staff to complete this task.
Problem Statements
Problem List
1. Patient requires Max (A) from sit to stand due to decreased lower extremity strength.
2. Patient requires MOD (A) in LE dressing due to decreased trunk stability and lack of
adaptive equipment.
3. Patient requires MOD (A) while toileting due to inability to maintain balance while
cleaning.
4. Patient requires MOD (A) in grooming due to decreased upper extremity weakness.
5. Patient requires Max (A) in bathing due to decreased activity tolerance.
Justification of Problem List
The problem statements listed above are ranked order based on what is most important to
work on for the patient to reach her goals. The first problem statement is the patient requiring
maximum assistance to perform a sit to stand. This is an important problem to work on because
the patient lives with family and will have some assistance at home, but for most of the day she
will be by herself when her son is at work and grandchildren are at school. In order to increase
her independence and decrease her reliance on other to care for her she will need to be able to
transfer by herself. Improving her ability to perform a sit to stand with less assistance will be the
first step in improving her functional mobility which will enable her to participate in ADLs and

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IADLs. Without increasing her independence in ADLs, her reliance on others will increase and
her functional capacity will decrease. Also, this will cause a lot of stress on her caregivers and
can increase the chance for injury to her or her caregivers.
The second area of intervention is increasing her independence in lower extremity
dressing. This is a critical skill to improve independence because she will need to perform this
task every day and in order decrease reliance on her caregivers and increase her independence
she will need OT services to increase trunk strength and education on adaptive devices she can
use in order to perform this task independently.
The next priority is to increase her independence with toileting. This is usually a huge
burden on the family caregivers and can be very embarrassing for the patient to get assistance
with, making it one of the top priorities of intervention. The fourth priority will be to work on her
independence with grooming. This is also a task she will need to perform every day and is
important to her to be able to complete independently. The next, will be to increase her
independence with bathing. Currently, she requires maximum assistance to transfer onto the
shower chair and then assistance to wash her lower extremities and contact guard assist for
stabilization. This is a lower priority because she will not need to perform this task every day and
increasing her independence with transfers, as mentioned is the first functional statement, will
also increase her ability to transfer to the shower chair.
Intervention Plan & Outcomes
Intervention Plan/Goal 1

Long Term Goal 1: Patient will perform transfer from EOB to w/c Min (A)

using FWW in 6 weeks.

Short Term Goal 1: Patient will perform sit to stand MOD (A) using FWW in 3
weeks.

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Intervention 1: A preparatory method will be used to educate the patient on proper

use of her FWW. The intervention will be followed with therapeutic exercise to
increase lower extremity strength in order to increase independence with sit to
stand transfer. An occupation based intervention will then be performed by having
the patient stand at sink while working on simple ADL such as; brushing her teeth

or combing her hair.

Short Term Goal 2: Patient will perform transfer from EOB to w/c MOD (A)

using FWW in 3 weeks.

Intervention 2: In this intervention the patient will be educated in proper transfer
training techniques. The patient will also participate in transfer training to
increase participation in functional activities. Education will also be provided to
the patients family members and caregivers on proper transfer training. The
family members will then practice transferring patient under supervision of the
therapist if the family members are willing and able.

Intervention Plan/Goal 2

Long Term Goal 2: Patient will perform lower extremity dressing Mod (I) using

a reacher in 6 weeks.
Short Term Goal 3: Patient will perform lower extremity dressing Min (A) using

a reacher in 3 weeks.
Intervention 3: For this intervention the patient will be given training on lower
body dressing and using a reacher to aid in dressing. The patient will also be
educated on proper use of reacher. The patient will then perform lower body

dressing using reacher to don pants.

Short Term Goal 4: Patient will sit EOB for 5 min Min (A) arm support in 3
weeks.

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Intervention 4: The patient will perform balance and trunk stabilization exercises
to improve sitting tolerance for enhancement in ADL participation. The patient
will then participate in an occupation based intervention by potting a small plant
while sitting in a chair to improve static sitting tolerance and to help engage the
patient in therapy by using a meaningful occupation.

Justification for Intervention 1

The first part of this intervention will be to educate the patient on proper use of her
forward wheel walker (FWW). This will be done to ensure safety of the patient while using the
device and to assure correct use of the device. The second part of the intervention will be done to
increase the patients lower extremity strength. Therapeutic exercise will be used as a preparatory
method and will consist of body weight exercises such as marching while seated and exercises
using resistance bands to increase strength in the patients upper and lower legs. Research has
shown that lower extremity strength and power are directly correlated to the patients functional
limitations. Therefore, increasing lower extremity strength it will increase independence in
transfers which will then lead to an increase in functional activity (Puthoff & Nielson, 2007).
The next part of the intervention will use an occupation based strategy to increase the
patients lower extremity strength. The patient will stand at sink while performing a simple ADL
task. Standing at the sink will help the patient to weight bare through her lower extremities and
participating in an ADL activity will make the task functional and bring meaning to the task. A
simple ADL task will be used to provide a just right challenge for the patient. Standing at the
edge of sink will be difficult enough for the patient so having the patient perform a simple ADL
will keep frustration level down and allow for completion of the task. Research has also shown

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that performing functional and meaningful tasks as part of an intervention will produce better
outcomes (Shearer & Guthrie, 2013).
Justification for Intervention 2
The second intervention will address patient education on transfer techniques and
performing transfers safely. Transfer safety is one of the most important skills for older adults
because it is one of the major areas of concerns for this population and is a large determinant on
their location of discharge and the level of assistance they will need. If unable to transfer safely
patients can be injured secondary to falls or can injury their caregivers. Proper education on
transfers is important to prevent injury. To ensure proper education the OT should understand
what the patients learning style is and teach to the transfer techniques according to their
particular learning styles (Carrier, Levasseur, Bdard & Desrosiers, 2012).
Following transfer education the patient will then perform the actual transfer in order to
practice with the therapist and ensure proper techniques are being used. During this time the OT
can assess additional issues or concerns of the transfers that need to be addressed. If family
members are present the OT will also include them in this intervention so that they are prepared
for transfers that could be performed at home. This patients primary goal is to return home and
because of this it is important to make sure that the family members and primary caregivers are
also well educated and comfortable performing transfers. This will help to ensure safety in the
home and help to prevent further injury (Carrier et al., 2012).
Justification for Intervention 3
A study conducted by Shearer & Guthrie (2013) researched the effect of an individualized
activity of daily living program on improved functional outcomes and improve the participants
independence at discharge in an acute care setting. The study was done in hopes of proving that

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patients in an acute care setting would benefit from an ADL program to increase the participants
participation in functional activities and to increase the chance of older adults being discharged
back into the home rather than to a setting with higher level of care. The results of the study
found performing ADL training three times a week increased the participants independence in
functional transfers and ambulation. The participants also showed improvement when
performing sit to stand transfers during dressing or showering and were able to attempt a higher
level of involvement in washing, drying and dressing. This ADL training also decreased the need
for assistance while performing functional ambulation activities. The study also showed clinical
significance of participants who participated in the ADL training being discharged to a lower
level of care more frequently than those participants in the control group who did not participate
in the ADL training (Shearer & Guthrie, 2013).
Educating and training the patient on proper technique for lower body dressing should
increase her level of independence with dressing so she will require less assistance upon
discharge. This will also allow her to become familiar with the adaptive equipment so that when
she is discharged she will feel comfortable using it and will be more likely to use it upon
discharge (Shearer & Guthrie, 2013).
Justification for Intervention 4
Due to the patients acute onset of her medical condition she has become less mobile,
decreasing her activity tolerance. Her cardiorespiratory and muscular endurance has also
declined. Increasing her mobility will increase her ability to participate in ADLs and eventually
lead to participation in other areas of life such as IADLs and leisure activities. In order to
increase participation with therapy performing meaningful activities for the patient will be more
beneficial. Research has shown participating in meaningful activities is more effective than non-

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meaningful activities and increases the patients involvement in the therapy sessions and
therefore generates better outcomes (Chippendale & Seagal, 2013).
The a study done by Chippendale & Seagal (2013) research was compiled to see if
activities of daily living or leisure activities would increase participation in therapy while
performing a functional standing activity. The study defined leisure activities as activities that
were chosen by the patient to enhance motivation, relaxation and enjoyment. They also stated
leisure activities help to distract an individual from any other concerns in life at that time and can
distract them from the pain or discomfort therapy may cause. This distraction can allow the
patient to tolerate therapy longer, increasing its outcomes. Although ADLs are crucial for
independent living they may not be an enjoyable or meaningful activity for the patient. In this
setting it is very restrictive when it comes to the accessibility of leisure activities and causes
depression in many of the patients. Integrating leisure activities into a therapy session can bring
back a sense of joy to the patient they could have lost upon admission into the hospital. It can
also help the therapist develop a deeper therapeutic rapport with the patient which can also help
the patient achieve their goals of therapy (Chippendale & Seagal, 2013).
Intervention Approach
Each one of the four interventions mentioned above used an establish/restore method
(AOTA, 2014). The first intervention was to educate proper use of a FWW and then to perform
therapeutic exercise to increase lower extremity strength as well as an occupation based activity
that will also improve lower extremity strength. This intervention will help to establish proper
use of a FWW and restore lower extremity strength that was lost secondary to prolonged bed
rest. Restoring lower extremity strength will increase independence with transfers and functional
activities.

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The second intervention also uses an establish/restore approach. The second intervention
is the patient will be educated in proper transfer training techniques and to participate in transfer
training to increase participation in functional activities. Educating the patients family members
and caregivers on proper transfer training and having the family members practice transferring
the patient is also part of the intervention. Educating the patient and the patients family
members will help to reestablish the patients independence and reach her goal of transferring to
edge of bed with minimum assistance. Since she will still need some assistance with transfers it
is important to establish an education plan to ensure proper assistance is given to the patient upon
discharge.
The third intervention will establish a technique that will increase the patients
independence in lower extremity dressing. Providing training of the adaptive equipment will
help the patient continue to dress herself independently as she is restoring her overall strength
and endurance.
The fourth intervention will help to restore the patients core strength and sitting
tolerance. This will help to restore her ability to dress herself without the use of adaptive
equipment and will also increase her independence (AOTA, 2014).
Intervention Outcomes
Through the four interventions mentioned above the desired outcome would be to
improve occupational performance by enhancing the patients ability to transfer with minimal
assistance and increase independence with lower extremity dressing. When the patient regains
her ability to transfer from edge of bed to the wheel chair this will give her greater mobility and
decrease her need for constant assistance. In hopes of increasing her independence with this

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transfer she will also develop the strength to transfer from the wheelchair to other surfaces with
proper instruction and supervision from an OT.
Improvement in lower extremity dressing is also the desired outcome from the two
interventions to be used for this goal. The two interventions are aimed at increasing performance
in dressing by improving the patients trunk stability and sitting tolerance and improving
independence with the use of an assistive device to independently don lower extremity clothing
(AOTA, 2014).
Precautions and/or Contraindications for Patient or Intervention Plan
Precautions and contraindications for treatment for this patient include monitoring
oxygen levels, heart rate, fatigue, pain and skin breakdown due to prolonged bed rest. This
patient is oxygen dependent but will soon start the process of being weaned off. Oxygen
saturation levels should be monitored throughout the treatment session and the OT needs to
remember that they will have to work around an oxygen tank and adjust treatments accordingly.
Heart rate should also be monitored throughout the treatment session due to her acute non-ST
myocardial infarction to ensure the heart rate has no arrhythmias and determine if her heart rate
is in a good range for therapy (60-100 bpm).
Fatigue levels should also be monitored, the patient has been in the hospital for a
prolonged period of time which has caused muscle atrophy and decreased activity tolerance.
Monitoring the patient for any kind of skin breakdown is also essential in this setting due to
increased time in bed. Pain should also be assessed before each treatment session to ensure
patient is able to participate in treatment session and no new exacerbations are present.
Frequency and Duration of Intervention Plan

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Occupational therapy treatment sessions will occur five times per week for thirty
minutes. Treatment will take place in the patients hospital room or will occur in the therapy
gym. Each treatment session will be focused on the goals mentioned above.
Grading Up and Grading Down of One Intervention
One intervention to be performed is to increase sitting tolerance and trunk stability. This
will be accomplished by having the patient sit in a chair while planting a flower. To grade this
activity down the therapist could give stabilizing support for the patient around the waist to help
with sitting stabilization. The therapist could also help pot the plant or have some of the steps to
potting completed for the patient in order to decrease the amount of time required to complete
the activity.
To grade up this intervention the therapist could position the patient in the chair so her
back is not receiving any support from the chair in order to increase sitting difficulty. The
therapist could also add steps to the planting process by having the patient paint the pot prior to
planting in order to increase duration of the activity. One way the therapist could add steps would
be to have the patient decorate the pot for the flowers and then have her plant the flower.
Primary Framework Utilized
PEOP Model was used to help guide intervention planning for this patient. This model
takes into account the person, environment and occupations of interest. It also considers the
occupational performance as the primary desired outcome. The intervention written for this
patient encompasses her personal values, interests, skills and abilities by incorporating the
patients personal goals of therapy as well as incorporating meaningful activities into therapy.
Her physical, social and cultural environment was considered when determining treatment. Her
physical environment both limits and enhances her therapy sessions by providing adequate

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equipment, assistance and meets her medical needs, but lacks a naturalistic environment and
limits social support. The primary focus of intervention was focused on occupations that the
patient was having the most difficulty performing. These included subtasks of occupations
including mobility issues and lower extremity dressing difficulties. Her interventions were also
gradable to provide the appropriate level of difficulty for the patient to ensure a goodness of fit
for the patient.
Patient/Caregiver Training and Education in the Intervention Plan
Patient and caregiver training and education will be given during intervention treatment
for proper transfer training and proper use of all durable medical equipment and adaptive devices
issued to the patient. The patient hopes to be able to return to home with her family so caregiver
training in transfers will be very important since the patient will most likely still need some
assistance for transfers. In order for the patient and caregiver to be safe when she is returned
home it will be crucial to train family members in proper transfer techniques using good body
mechanics to reduce the risk of injury to both the patient and the caregivers.
Monitoring of Patient Response to Intervention and Assessment towards Progression of
Goals
The patients long term goal of transferring from edge of bed to wheelchair with
minimum assistance will be monitored by the level of assistance needed to complete a transfer.
Clinical judgment was used to assess level of independence upon initial evaluation of the patient
and will be used to assess progression of all transfers. The patient will also be assessed using
clinical judgment by the therapist for her lower body dressing goal. A standardized assessment
could be used by the therapist such as the Functional Independence Measure (FIM) to provide
observable data for documentation of the patients progress. The FIM is a standardized

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assessment that measures level of assistance in many different areas including dressing, transfers
and participation in ADLs (Rogers, Gwinn & Holm, 2001).

References
Carrier, A., Levasseur, M., Bdard, D., & Desrosiers, J. (2012). Clinical reasoning process
underlying choice of teaching strategies: A framework to improve occupational
therapists' transfer skill interventions. Australian Occupational Therapy Journal, 59(5),
355-366. doi:10.1111/j.1440-1630.2012.01017.x
Chippendale, T. T., & Segal, R. R. (2002). A pilot study of the effectiveness of using leisure

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versus activities of daily living to increase standing tolerance in the elderly

population. Physical & Occupational Therapy In Geriatrics, 21(2), 41-56.
Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of
Occupational Therapy, 68(Suppl. 1), S1-S48. http://dx.doi.org/10.5014/ajot.2014.682006
Puthoff, M., & Nielsen, D. (2007). Relationships among impairments in lower-extremity
strength and power, functional limitations, and disability in older adults. Physical
Therapy, 87(10), 1334-1347. doi:10.2522/ptj.20060176
Rogers, J., Gwinn, S., Holm, M. (2001). Comparing activities of daily living assessment
instruments: FIM, MDS, OASIS, MDS-PAC. Physical & Occupational Therapy In
Geriatrics, 18(3), 1-25.
Shearer, T., & Guthrie, S. (2013). Facilitating early activities of daily living retraining to prevent
functional decline in older adults.Australian Occupational Therapy Journal, 60(5), 319325. doi:10.1111/1440-1630.12070