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Occupational Profile and Occupational Analysis Nicole Quisao Touro University Nevada

Occupational Profile and Occupational Analysis Occupational Profile Marilynn is a 76 year-old woman born in Laramie, Wyoming who lives at home with her husband in an age-restricted retirement community in Las Vegas, Nevada. Following her cerebral vascular accident (CVA), Marilynns husband took the role of caregiver. Regarding other relevant family members, Abby has three adult children and five grandchildren who live in various parts of the United States. Marilynn also receives support from her friends within the retirement community. In March of 2011, Marilynn experienced a CVA while eating dinner with her husband at home. Her husband quickly recognized that she was demonstrating symptoms of a CVA, stating that he noticed her face was distorted. He provided her with two aspirin tablets and went directly to the hospital. Marilynn also has the following conditions: diabetes mellitus, hypertension, hypothyroidism, dysphagia, and high cholesterol. Marilynns physician also determined that she is at risk for falls and pressure sores. Prior to the CVA, Marilynns primary concerns centered on spending time with her husband, children, and grandchildren, as well as socializing with friends and cross-stitching. Marilynns retirement community hosted a variety of events including knitting, cross-stitch, and pastry clubs. Marilynn use to go out to eat and attend exercise classes with her friends from the retirement community. Her primary occupations were cross-stitching, cooking meals, and doing housework. She spent most of her free time creating cross-stitch pieces to provide as gifts to family members and loved ones. Marilynns interest in in cross-stitching was not only a hobby, it was also a passion. She spent many hours perfecting her pieces. The cross-stitch patterns that she completed were intricate and at an advanced level.

Current Concern Marilynns current concerns relative to engaging in her occupations are focused on increasing her independence. Marilynn has the ability to complete most of her activities of daily living (ADLs), but often requires assistance from her husband to complete grooming and hygiene tasks. Marilynn would like to wash her hands independently following toilet use. She often gets fatigued and loses bilateral upper extremity coordination when washing her hands. Additionally, Marilynn was the primary cook in her household prior to the stroke; she would like to continue this role. The areas of occupation impacted by Marilynns CVA impairments include: ADLs, instrumental activities of daily living (IADLs), rest and sleep, work, leisure, and social participation. Occupational Performance Activities of daily living. Marilynn experiences difficulty with various ADLs including: bathing, grooming and hygiene, and eating. Bathing is impacted by decreased endurance and bilateral upper extremity coordination. She often requires assistance to wash her hair. Marilynn has difficulty in grooming and hygiene as a result of decreased endurance, standing activity tolerance, and bilateral upper extremity coordination. She has difficulty washing her hands after using the bathroom. Additionally, Marilynn is successful in functional mobility; she uses a single point cane. Marilynn requires assistance to cut tough meat, and takes frequent breaks due to decreased activity tolerance, endurance, and instability. Instrumental activities of daily living. Participation in IADLs is impacted during care of others, community mobility, financial management, health management and maintenance, home establishment and management, and meal preparation. Marilynn attempts to initiate and complete IADLs independently each day. She typically requires assistance from her husband to

complete each activity. She relies on him for community mobility and financial management. Marilynn plans meals, but has difficulty executing plans due to endurance, bilateral upper extremity coordination, and scanning abilities. Breaks are taken due to decreased activity tolerance, and endurance. Rest and sleep. Marilynn is currently unable to sleep through the night as a result of anxiety due to her husbands upcoming surgery. Additionally, Marilynn remains uncomfortable throughout the night due to shoulder pain. Work. Marilynns ability to work has been impacted by her CVA. However, prior to the CVA, Marilynn had already been retired. She remains at home during most days, and considers her role in the retirement community as her work. Leisure. Marilynn is unable to participate in her previously meaningful leisure activities including completing cross-stitch projects to give to her loved ones. Difficulty is due to visual deficits, scanning issues, decreased endurance, and divided attention. Marilynn perseverates on her previous abilities, which impedes her ability to complete tasks. Social participation. Marilynn no longer attends her retirement community meetings of due to decreased bilateral upper extremity coordination, decreased vision, decreased scanning, and divided attention. She was previously the social chair for her cross-stitch club. Contexts and Environment Cultural. Marilynn appreciates her retirement community neighborhoods cultural environment. She is unable to attend monthly fitness classes with her friends at the retirement community and misses going out to eat with her supportive friends. Personal. Marilynn lives at home with her husband in an age-restricted community. She and her husband moved to Nevada from Wyoming 10 years ago. Marilynn has three children and

five grandchildren; she often Skype video chats with them, as they live all around the United States. Her family members are all supportive. Temporal. Marilynn is retired from work, and she considers her roles in the cross-stitch, knitting, and pastry club as her work. She has positive relationships with the club members, currently cites them as her extended family. Virtual. Marilynns relatives live in different parts of the United States. She previously enjoyed calling her relatives on the phone and on Skype. She now feels uncomfortable having her relatives see her on video due to various physically apparent deficits; she primarily utilizes the phone for contact. Physical. The built physical environment of her home accommodates her impairments. Due to her decreased endurance, she spends most of her time on the first floor. Walking up stairs has become taxing for her body. The natural environment of her home provides natural lighting. Social. Marilynns social environment consists primarily of her husband at home, family via telephone, and her friends at the age-restricted community. She had many responsibilities associated with her position of social chair of the cross-stitch club including; organizing meetings and planning gatherings. Her friends in the community look forward to her return to club monthly meetings. Occupational History Marilynn values her occupations as a wife, mother, grandmother, and community member. She wants to be present in her normal routines again. She struggles to accept her less active life. She previously shared many duties and responsibilities with her husband, though recently she relies on her husband for assistance with many of her occupations. Marilynn is passionate about cross-stitching, cooking, and baking for loved ones. She attempts to help her

husband cook meals, but has trouble sustaining the entire activity. She feels as though she is a burden on her husband and fears that she is becoming useless. Marilyn demonstrates low selfesteem and often puts herself down. Marilynns participation and roles in her community are priorities; she hopes to return to these occupations. Priorities and Desired Outcomes Marilynn is seeking services in order to return to her prior level of functioning and to resume participation in meaningful occupations. She does not want to rely on her husband; he recently underwent a surgical procedure, and she is concerned about his health. Marilynn wants to get back to cooking and preparing meals for her husband and friends. Marilynn is most apprehensive to return to is cross-stitching. She feels depressed that she is no longer able to make cross-stitch pieces for family and friends. She wishes she could complete a cross-stitch project again, but stated that she knows she will not be able to. Since the CVA, Marilynn has not attempted to cross-stitch. Occupational Analysis The occupation observed was personal hygiene and grooming in the outpatient rehabilitation setting. Specifically, Marilynn performed hand washing following toilet use in a public bathroom. Marilynns main functional limitations during the activity include: decreased endurance, activity tolerance, bilateral upper extremity coordination, divided attention, scanning difficulties, and decreased vision. Other areas of occupation that may be affected include: bathing, dressing, care of others, home management, meal preparation, social participation, and leisure participation. The following sections outline Marilynns participation in personal hygiene and grooming in relation to aspects of the Occupational Therapy Practice Frameworks domain (American Occupational Therapy Association, 2008).

Deficits in Body Functions Mental functions. Regarding specific mental functions, Marilynns higher cognitive functioning is intact. However, she demonstrates deficits in divided attention, short-term memory, and self-esteem. She needs extra time and verbal cues to complete tasks of divided attention. Marilyn often requires several clarifications before completing a task. Overall, she demonstrates decreased self-esteem throughout her daily life. She views herself as unintelligent and often says the phrase I give up, I cant do it when a task or activity becomes difficult. Regarding global mental functions, consciousness and orientation are intact, but she displays decreased energy and drive during functional task performance. Sensory functions and pain. Marilynn has difficulty with visual acuity. Additionally, she has several pairs of corrective glasses that she utilizes for various tasks. She demonstrates deficits in visual scanning, and has a hard time cross-stitching as it requires saccadic eye movements. Marilynn demonstrates deficits in vestibular functions and reports feeling nervous and unstable during functional mobility. Marilynn describes feeling pain in her left shoulder. Neuromusculoskeletal and movement related functions. Marilynn demonstrates decreased joint mobility, muscle tone, and muscle endurance in her left upper extremity during grooming and hygiene activities. She has a difficult time controlling her voluntary movements during hand washing. She exhibits decreased muscle endurance in both upper and lower extremities throughout the activity and cannot sustain the entire duration of the activity. She feels comforted when her wheelchair is nearby for frequent rest breaks. Cardiovascular and respiratory functions. Marilynn demonstrates deficits related to the cardiovascular and respiratory system including hypertension, decreased physical endurance and aerobic capacity. She fatigues quickly and requires frequent rest breaks.

Voice and speech functions. Voice and speech function deficits are not evident. Digestive, metabolic, and endocrine system functions. Digestive, metabolic, and endocrine system function deficits are not evident during this occupation. Skin and related-structure functions. Skin and related structure function deficits are not evident during this occupation. Activity Demands Objects and their properties. Materials required for this activity include water, soap, and a paper towel. Required equipment includes a sink, faucet, and necessary plumbing, which are standard and accessible in the most public restrooms. To accommodate for rest breaks, Marilynn brings her four wheel walker into the bathroom. Space demands. A bathroom with ample space to ensure safety is necessary for completion of the task. Marilynn requires intermittent breaks during the activity, thus an open space next to the sink may be useful to accommodate her walker. Proper lighting is required for Marilynn to be visually aware of the activity, the tools, equipment, as well as materials. Social demands. In the clinic setting during Marilynns treatment session, social demands are minimally relevant. She directly interacts with her occupational therapist and may briefly encounter other health care professionals or clients in passing. However, in the public restroom, Marilynn may be required to interact with other individuals. Sequence and timing. The sequence of steps required during this activity include turning on the faucet, rinsing hands, applying hand soap, lathering soap for the appropriate amount of time, thoroughly rinsing the hands, obtaining paper towels to dry the hands, utilizing a new paper towel to turn off the faucet, then walking to the trash bin to dispose of the paper towel.

Required actions or skills. The skills and actions include motor and praxis skills to manipulate appropriate materials and equipment. Marilynn would need to be able to turn the faucet on and off, and manipulate the soap dispenser. Sequencing and pacing ability as well as judgment would be necessary to safely perform the activity. Determining the appropriate amount of soap and the appropriate temperature of water would be required to complete the activity. Cognitive skills and emotional stability to persist would increase the ability to sustain attention, select appropriate materials, and be aware of the need for rest breaks. Performance Patterns Habits. Habits relevant to hand washing may include setting a consistent water temperature from day to day, applying soap after rinsing hands, or taking breaks at a particular point during the activity. Routines. Routines relevant to the activity may include going the bathroom at a specific time during the treatment session. Marilyn typically goes to the bathroom at the very beginning of her treatment session, or at the halfway point. Marilynn may follow a specific sequence of steps to complete hand washing. Rituals. Rituals are not applicable during the hand washing activity. Roles. Marilynn is a wife to her husband. She defines her role by engaging in homemaking and home maintenance. Marilynn now relies of her husband for assistance with many of her previous occupations. She would like to return to her roles within the community. Performance Skills Motor and praxis. Motor skills required for hand washing include: manipulating the faucet handles to turn on the water, the soap dispenser to dispense soap, and towel dispenser to obtain towel. Marilynn needs to coordinate her body movements to wash her hands while

maintaining balance. Praxis skilled-purposeful movements include: carrying out the appropriate sequence of motor acts, and anticipating environmental changes. Sensory-perceptual. Sensory-perceptual skills required for hand washing include: positioning the body to ensure safety, visually determining the appropriate amount of hand soap, determining the appropriate water temperature, visually distinguishing between the activity materials, and locating materials. Emotional regulation. Marilynn takes frequent rest breaks during the activity due to decreased muscle endurance; she is able to persist through the activity with minimal frustration. She does not respond well emotionally when excessive prompts and cues are provided. She may use relaxation techniques to cope during the activity to appropriately manage and plan. Cognitive skills. Cognitive skills required during the hand washing activity include: selecting the appropriate materials, and sustaining attention during the activity. Communication and social. Communication and social skills may be required if other individuals are waiting in line to wash their hands in the public restroom. However, Marilynn should minimally be able to communicate with the therapist if assistance is required during the activity. Body Functions and Body Structures During the hand washing activity, sensory, motor, praxis, and cognitive performance skills should be considered. Knowledge of the sequence of steps is required. Marilynn should be able to bilaterally manipulate the faucet handle, soap dispenser, and paper towel dispenser. Proper pacing of required movements would be required for energy conservation. Additionally, Marilynn should adjust the water to a suitable temperature. Specific functions influenced by this task includes: divided attention, short-term memory, self-esteem, consciousness, orientation,

visual acuity, visual scanning, joint mobility, muscle tone, muscle endurance, control of voluntary movements, cardiovascular and respiratory function such as endurance and aerobic capacity. Anatomical structures that support function include: eye related structures, structures related to cardiovascular, respiratory, and metabolic systems, voice and speech structures, movement-related structures, Furthermore, awareness of skin integrity may be relevant when utilizing various temperatures of water, and soap materials. Contexts and Environments Cultural. Marilynn believes that she should be as independent as possible in order to contribute to the care and support of her family. She strives to endure the activity of hand washing. She wants to maintain normal expectations related to hygiene. Personal. Marilynn has been an active participant in her age-restricted retirement community organizations. She would like to return to her previous home duties and to normal participation in her typical occupations once she is physically able to engage and tolerate. Temporal. Marilynn currently resides in an age-restricted retirement community and completes her daily activities including grooming and hygiene within her home bathroom. During her occupational therapy sessions, she utilizes the clinics public restroom. She intends to return to her normal patterns of daily living. Virtual. The virtual context and environment is not applicable during this activity. Physical. The physical environment related to performance of hand washing includes: the built public bathroom environment which includes a sink, faucet, and stalls with toilets. The terrain is another important consideration, as Marilynn may use her walker within the bathroom. The built environment of her home bathroom is similarly equipped. Additionally, the natural sensory qualities of the environment should be considered.

Social. The social context may be applicable if other individuals in the bathroom are waiting in line to use the sink or other required materials. Problem Statements The following statements demonstrate functional limitations that Marilynn has experienced as a result of her CVA. 1. Client unable to complete leisure activity due to BUE coordination, scanning abilities, vision, endurance, and divided attention deficits. 2. Client unable to complete standing grooming and hygiene task due to endurance, standing activity tolerance, and BUE coordination. 3. Client requires mod in home maintenance and management due to endurance and activity tolerance. 4. Client requires mod in meal preparation due to endurance, BUE coordination, and scanning abilities. 5. Client unable to engage in social participation due to endurance, and divided attention. Justification of Problem Statement Prioritization Prioritization of problem statements is centered on the significance of meaningful occupations as highlighted by Marilynn. These occupational concerns, goals, and desired outcomes were gathered during treatment sessions. The first problem statement, related to leisure participation, would allow Marilynn to resume her meaningful leisure occupations, particularly in cross-stitching. This is important not only due to the emotional ties related to the task, but also because it addresses many of Marilynns physical deficits. Next, Marilynn emphasized her desire to eliminate the burden of ADLs on her husband. Marilynn has struggled with completion of

hand washing; therefore it is second on the list. The third problem statement is next due to Marilynns desire to relieve the burden from her husband in the household. She would also like to return to cooking meals for her husband. It is lower on her priority list because her husband does not mind completing the tasks while she is still recovering. Marilynn is currently content with her level of social participation, but stated that her last priority it to eventually re-immerse herself into social activities. Overall, the problem statements are aimed to address Marilynns desires to reestablish independence and increase participation in her meaningful occupations and activities.

References American Occupational Therapy Association (2008). Occupational therapy practice framework: Domain and Process (2nd ed.). Baltimore, MD: AOTA Press.

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