1 Running head: Occupational

Occupational Profile & Analysis Touro University Nevada Kelly Garcia

2 OCCUPATIONAL Occupational Profile & Analysis Occupational Profile Client Mrs. G is a woman in her early 60s who is married and has two dogs. She has been married to her husband for over 33 years and she expresses that they are closer than ever. However, she recalls that for a period of time in their marriage they became very distant and estranged. Currently, her husband is supportive and comes to visit her frequently, despite being sick himself. He was diagnosed with cancer and has been receiving chemotherapy and treatment for the past few months. Although they do not have any children, they have the support of their friends and family in the community. Mrs. G also considers her two dogs a part of her family. Prior to the onset of her medical problems, Mrs. G was working as a nurse and was independent in all ADLs and IADLs. Reason for services & Clients concerns Mrs. G has an extensive list of medical problems which have eventually led to her stay at a long term acute care hospital. She recalls coming home from work one day and then passing out. Her husband called an ambulance after finding her unconscious on the living room floor. Mrs. G had experienced an episode of respiratory failure. She was rushed to a hospital near her home and then discharged to a long term acute facility, where they tried to wean her off a ventilator. After fevers and complications resulting from the weaning, Mrs. G had to return to the hospital for treatment. At the hospital, she was further diagnosed with MRSM and it was found that she had a vegetation in her heart. Mrs. Gs medical diagnosis includes pneumonia, tricuspid valve endocarditis, anemia, encephalopathy, hypertension, hypothyroidism, and COPD. She is

3 OCCUPATIONAL currently seeking services in a long term acute care facility to treat her infection, vegetation, and to be weaned off a tracheostomy and PEG tube. Mrs. G is concerned about the extent that her current health status will interfere with her ability to do things independently and take care of her husband, who is also ill. She is worried because she has complications breathing and she also has recurring pain in her back due to problems with her sciatic nerve. She is only receiving pain medication for her back problems, but she feels it significantly limits her ability to be on her feet. Her concerns relative to engaging in daily occupations are that she will not be able to do the things she used to do, such as shower, get dressed, and drive independently. She is also worried about the amount of time it will take her to do these things. However, despite her concerns she feels that she has made great progress and knows that with the support of her husband she will be able okay. Areas of Occupation Mrs. Gs upper extremity range of motion is within functional limits, which allows her to successfully complete some ADLs while sitting at edge of bed, such as grooming and most of her upper body dressing. She is also cognitively alert and aware of her surroundings. She is able to engage in some leisure activities at her bedside, such as reading and watching television, but any leisure activities requiring standing or increased endurance, such as bingo or baking, she is not able to complete. Currently, she is not experiencing any problems with rest or sleep. Although Mrs. G is recovering well, she still requires assistance and supervision to complete many daily tasks that she was once independent in, due to her limited standing tolerance and strength. For instance, even though her upper extremity ROM is WFL, she does not have enough bilateral upper extremity strength to push her upper body up with her arms during transfers or bed mobility. She is also experiencing difficulty dressing her lower body, showering, toileting,

4 OCCUPATIONAL and her functional mobility is impaired. Her feeding is done through a PEG tube, but she is able to drink water. She also requires a nasal cannula with an oxygen tank to help her breathe in bed and while she ambulates. Additionally, her IADLs have been impaired as she is unable to safely take care of her pets, go shopping, prepare a meal, and maintain her home. As a result of her condition, she is unable to successfully complete her job duties as an infusion nurse and engage in social participation to the extent that she used to. Context & Environment The client has the emotional, social, and economic support of her husband who comes to visit her frequently despite his own illness. She also has the social support of her friends and the rehabilitation therapists who have grown fond of her at the facility. Her environment at home will be a supportive environment to go to because it is a small one story apartment that is already equipped with some adaptive equipment, such as grab rails. Her current context and environment in the long term acute hospital is conducive to her participation and engagement in her desired occupations, because she is receiving the necessary treatment to complete those occupations. Occupational History After going to school and getting her degree, Mrs. G began working as a nurse and has worked as one for most of her life. As mentioned previously, she was actually working as an infusion nurse at a local pharmacy prior to her illness. Although she was contempt with her job, it was exhausting for her sometimes because there were days that she had to work 12 hour shifts. She has been married for over three decades and has lived in Vegas for many years. Her interests include listening to all kinds of music, in particular country and Adele, and reading e-books. She also enjoys playing electronic games on her tablet. At least twice a month, Mrs. G and her husband would go to play bingo at a community recreational center. She enjoyed going there

5 OCCUPATIONAL because she was able to socialize with friends, have fun, and sometimes win prizes. Mrs. G also loves taking care of her dogs, spending quality time with her husband, and baking treats on holidays or special occasions.

Priorities and Desired Outcomes The clients current priorities and desired outcomes revolve around getting better and making enough progress to go home. She is eager to have her tracheostomy and PEG tube removed without any complications; because after they are removed she will finally be able to eat food on her own. She also wants to be able to stand for longer periods of time, in order to take a shower and use the bathroom more independently. She has not been able to properly groom herself since her health deteriorated, which is something that she would like to be able to do again because she wants to look nice for her husband and friends. She also hopes that she will eventually be able to do the things she enjoys, such as cook, bake treats, and go to bingo. Her main goal at the moment is to go home and spend time with her husband and pets. She expects that with the adaptive equipment the insurance is providing and the help of her husband, she will make a fast recovery. Although her work was an important part of her life, she expresses no desire to want to return to work anytime soon. Occupational Analysis: Toileting Due to the nature of the setting where Mrs. G is at, she was observed engaging in the ADL activity of toileting. The Occupational Therapy Practice Framework was used as a guideline in discussing the activity demands, performance patterns, performance skills, body functions, and contexts relevant. Body Function Deficits

6 OCCUPATIONAL Mrs. G does not demonstrate any visible deficits in her mental functions. Her attention, perception, and sequencing are functioning properly, because she is able to follow instructions and respond appropriately to questions. Although no problems are noted with memory, Mrs. G reports difficulty with working memory. Client is able to see, hear, touch, and taste. Her sensory functions are not impaired and she actively reports any pain she feels stemming from her back. Considerable deficits are noted with the clients neuromuscular skeletal and movement related functions. She has decreased upper extremity strength and muscle endurance. She requires a front wheel walker (FWW) to stand and ambulate for support. She does not exhibit any involuntary movements, but has limited standing endurance and kyphotic posture. Client demonstrates deficits in her cardiovascular and respiratory system functions. She requires a nasal cannula and oxygen tank to breath and fatigues easily. She required a sitting break after ambulating approximately 10 feet with a FWW and she suffers from high blood pressure. Activity Demands Objects and their properties In order to complete toileting, Mrs. G required the use of a 3:1 commode, a FWW, and a toilet. These objects are relatively sturdy, large, and smooth. The 3:1 commode is wide and equipped with arm handles, while the FWW is gray and equipped with brakes for safety. The FWW has gray grip handles and the 3:1 commode has white grip handles. Thin, wet, odorless wipes were also used as a part of the completion of this activity. Space demands The space demands of this activity are a bathroom with enough space to allow for the placement of a 3:1 commode on the toilet and to accommodate a FWW. There needs to be adequate lighting to give the person a clear visual field of her surroundings and the room needs

7 OCCUPATIONAL to be at an appropriate temperature to allow the person to complete the activity comfortably. The bathroom also needs to be arranged so that the 3:1 commode is not obstructing the persons reach to the toilet paper or wipes and the wastebasket. Social Demands The social demands of toileting are that individuals are supposed to use the bathroom independently and privately. Once an individual is in the bathroom, the door is closed, and before the individual comes out of the bathroom, the toilet must be flushed. It is also expected that individuals wash their hands with soap at the sink before leaving the bathroom. Sequencing and timing The sequencing and timing of the activity include walking to the bathroom, opening and closing the door, walking to the toilet, pulling appropriate clothes down, sitting on the toilet or 3:1 commode, voiding, cleaning the perineal area with toilet paper or wipes, flushing, getting up from sitting on the toilet, pulling up appropriate clothing, walking to the sink to wash hands, and then finally opening and closing the bathroom door again. Timing depends on the individual, due to the nature of the activity. However, certain steps, such as opening and closing the door, pulling clothes up and down, sitting and standing from the toilet, and walking from the bathroom door to and from the toilet, should not take longer than 5 minutes. A person should also wash their hands for approximately 30 seconds. Required actions and skills The required actions or skills are being able to stand, sit, and walk. A person must be able to open and close the door, grip the FWW if they are using it to ambulate, reach back to the 3:1 commode if they are using one, and sit down. They have to be able to know when they are done voiding in order to clean themselves and determine the appropriate amount of tissue paper or

8 OCCUPATIONAL wipes to use. They also have to be able to reach and flush the toilet; along with have the fine motor skill coordination of pulling their clothes up and down, and turning on and off the sink to wash their hands. Performance Patterns Mrs. Gs performance patterns, related to the activity of toileting, have become hindered due to her health condition. Until recently, Mrs. G could not engage in this activity because she was confined to a diaper. Furthermore, it was difficult to assess her habits when completing this activity because she is learning to use a 3:1 commode and still requires the assistance of a therapist. Therefore, the development of automatic behaviors is still taking place. However, upon standing in front of the toilet Mrs. G automatically pulls her lower body clothing down and sits down. She also pulls her clothing up when she stands and then she flushes the toilet. Prior to her health problems, this was a routine she would engage in daily. Currently, this is a routine she engages in during her 30 minutes of therapy. She does not participate in any rituals before, during, or after completing the activity. Her role when performing this activity is that of an older woman who is recovering in a long term acute care facility and is learning to use adaptive equipment to complete her ADLs. Performance skills Motor skills The motor skills required of Mrs. G to complete toileting, with adaptive equipment, include being able stand, walk, and sit down. She has to be able to go into slight trunk flexion in order to pull her pants down and into trunk extension as she pulls them up. Maintaining her balance as she walks with the FWW and transfers onto the toilet is another motor skill that is required. For the toilet transfer, she has to be able to plan, sequence, and execute the necessary movements to

9 OCCUPATIONAL go from standing to sitting safely on the 3:1 commode. She also has to be able to sit down on the toilet and reach forward, back, or to her side in order to get the toilet paper or wipes. Coordination of her body movements, such as her lower and upper extremities as she stands and walks, is important to complete this activity safely. Fine motor coordination is necessary in order to flush the toilet, turn on the sink, lock the bathroom door, and manipulate her clothing. She also needs to have a functional cylindrical and power grasp to hold onto the FWW, 3:1, and turn the door knob. Sensory Perceptual and Cognitive Skills Mrs. G requires sensory perceptual and cognitive skills to successfully complete this activity. For example, she needs to be able to visually see her surroundings, the bathroom, the 3:1 commode, and the toilet. She also needs to be able to visually determine the appropriate distance between herself and the 3:1 commode before she transfers. Additionally, she needs to be able to visually determine the appropriate amount of toilet paper or wipes necessary to clean her perineal area. It is also important for her to be able to hear or see that the toilet has flushed before she leaves the bathroom. Cognitively, she needs to be able to judge when she needs to use the bathroom and the amount of time it will take her to get there. She needs to know the sequencing of the activity, remember how to use the FWW, and remember how to transfer onto the commode. She also needs to know which materials and tools to use throughout the activity, such as knowing that the toilet wipes are for cleaning herself and that the hand soap is used for her to wash her hands. Communication and Emotional Regulation Skills The communication and interaction skills needed for this activity are limited because it is usually done independently and in private. However due to Mrs. Gs condition, the

10 OCCUPATIONAL communication skills required can revolve around being able to alert others when assistance is needed. Mrs. G currently requires moderate assistance for the toilet transfer and minimal assistance for toileting, so she needs to be able to engage in some social interaction by appropriately answering the therapists questions, maintain eye contact, and acknowledge her suggestions. As for the emotional regulation skills required of the activity, she needs to be able control her frustration and continue with the activity even if she struggles with it. Body Functions and Structures Primarily Influenced The body functions primarily influenced by this task are mental, sensory, neuromusculoskeletal, cardiovascular, and respiratory system functions. Completing this activity requires Mrs. G to have the cognitive capabilities to know how to use the adaptive equipment necessary, to remember the sequencing of the activitys tasks, and to judge her movements accordingly. Her mental functions also influence her level of consciousness and orientation, which is necessary to complete this activity safely. The sensory functions are influenced by this activity because her senses of sight, hearing, touch, smell, and proprioception are all being utilized. Her senses provide her feedback of the environment and allow her to respond appropriately. Neuromusculoskeletal functions are also influenced by this activity because it requires her joints to be mobile, her muscles to be active, and it tests her muscle endurance and strength. Finally, her cardiovascular and respiratory functions are impacted by this activity because it requires her to use her lungs to breathe as her body expends energy and her heart pumps blood faster to get the oxygen flowing. In order to complete this activity with the adaptive equipment mentioned earlier, Mrs. G needs to have her lower extremities and upper extremities intact, along with other skin related and body system structures necessary for healthy functioning.

11 OCCUPATIONAL Contexts Related to Performance Cultural The cultural context, in which Mrs. G completed the activity of toileting, emphasizes independence, good hygiene, indoor plumbing, and privacy. Personal The personal context is that of a woman in her early 60s, who suffered an episode of respiratory failure, and is receiving therapy to help her gain her independence back. In this specific intervention, she is learning how to use adaptive equipment to complete toileting. Physical The physical environment of this activity is in a long term acute care hospitals bathroom. Part of the activity also occurred in the patients hospital room as she walked from her bed to the toilet. Social The social environment related to this activity consists of the interaction between the therapist and Mrs. G, because of the private nature of the treatment session. Temporal This activity occurred in the morning and lasted approximately 30 minutes. The stage of life in which the client is currently a part of is middle adulthood. Virtual Virtual environment does not apply to this activity, because communication occurred through physical contact and not through the use of electronic devices. Problem List

12 OCCUPATIONAL 1. Client requires Mod to complete transfers necessary for functional mobility and ADLs due to decreased upper and LE strength and endurance 2. Client is unable to engage in previous leisure activities due to decreased activity tolerance, standing tolerance, and lower back pain. 3. Client requires Min to complete UB and LB dressing due to limited trunk flexion and decreased activity tolerance. 4. Client is unable to independently complete morning grooming routine, while standing at bathroom sink, due to limited standing tolerance and LE strength. 5. Client requires Min to shower due to decreased standing tolerance and limited trunk flexion. The problem statements identified above are listed based on Mrs. Gs priorities, concerns, and desired outcomes. Her goals of making enough progress in order to go home and to do things as independently as possible were taken into consideration. For example, the first functional problem statement addresses her ability to transfer, which is a precursor to completing many of her ADLs and IADLs. It is also important that she improves on her transfers in order to be discharged home instead of a skilled nursing or assisted living facility. Then the following problem statement addresses her ability to engage in her leisure activities, because it is something that is meaningful to her and the skills improved upon for this functional problem statement can be transferred to her other occupations. After that, the functional problem statements are ranked depending on Mrs. Gs required level of assistance and how they impact her occupational performance.

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