BACKGROUND INFORMATION: Date of Report: 10-29-11 (Pre-surgery interview) Evaluation Date: 11-17-11 Client's name: Mary German Date of birth &/or age: 7-23-30 Date of referral: 10-31-11 M F Primary intervention diagnosis/concern: R Hip Replacement Secondary diagnosis/concern: Hypertension, Arthritis in right hand, primarily R D2, knee arthroscopy
Reason for referral to OT: (or questions to be answered)
Therapist:Lindsay Barker S/OT, Laura German S/OT, Aaron Jacobs S/OT, Kendra Paulus S/OT, Morgan Podach S/OT, Sabreana Wright S/OT
FINDINGS Occupational profile:(Describe the client's occupational history and experience, patterns of living, interests, values and needs that are relevant to the current situation.)
Pre-Surgery Report
Mary is an 81 year old woman who is experiencing pain in her hip. She is scheduled to have a right hip replacement on 10-31-2011. She has also had a left knee arthroscopy, and she experiences arthritis in her right hand, primarily in her 2nd digit. She attributes the arthritis to her work with wires and flowers in the flower shop. She was diagnosed with hypertension a few years ago during a physical with her doctor. Mary states that she experiences pain the most when moving in and out of her bed. She states that when she is moving, the pain is about a 9 out of 10; however, when she is sitting she does not feel any pain at all.
Mary lives with her husband in a one story home. There is one step to get into their front door and 2 stairs inside the home. A typical day for Mary consists of waking up around 9am (it used to be earlier, but she does not get up as early because she cannot go anywhere). She has been staying inside her home because the pain has become too much to handle. She is able to get around the house with the use of a walker. Mary also has raised her chair and uses seat cushions to raise her hips above her knee. Mary was independent in all ADL's prior to her hip pain. She uses a reacher for dressing, and also has her own sock aide. She has two grab bars, a raised toilet seat and a shower seat in her bathroom. Mary's husband does most of the cooking; however, when he is not home she has trouble transferring dishes from one place to another.
Mary has been given hip replacement precautions by her doctor and was instructed to work on upper body strength through using weights. She uses 2lb dumbbells at this time and performs exercises at her will. Mary is frustrated by the pain and her lack of mobility. She wishes to get back out into the community and enjoy the things she likes to do. Mary enjoys sewing, painting (does not do this much anymore), going to work ( she works at her son's flower shop, putting arrangements together or taking phone calls), going to church, and visiting family and friends.
Problems and concerns: (Listed by client)
Lack of endurance and fatigue (due to lack of mobility)
Bed mobility
Getting in and out of bathtub
Pain
Lack of mobility
Decreased strength
Post-Surgery Report (11-17-11)3 weeks post surgery, Cl reports being a 1-2 out of 10 on the pain scale, as opposed to 9 out of 10 before the surgery when she reported the pain as being "bone on bone." She is glad that she had the surgery, and said that she should have done it two years earlier. Mary elaborated on her R D2 arthritis, noting that it does not affect her functional ability, but does cause pain from time to time. She states that her husband is a great support, and has been doing most of the work around the house, including the cooking. As of now, her main goals include getting out of the nursing home being able to walk with a cane instead of walker, and increasing her endurance. At home she hopes to finish a quilt, draw, bake cookies, go shopping, and gamble! More than anything, she wants to put the "life" back into living- to be able to enjoy her roles as wife, friend, mother of 5, grandmother of 11, and great-grandmother of almost 2.
Progress Toward Goals So Far; Reasons for Progress or Lack Thereof in:
Areas of occupation: ADL's: - Client is able to dress and undress using zippers, buttons, and fasteners. She utilizes assitive devices such as a reacher, shoehorn, and sock aid. - Client uses a walker for most mobility. For longer distances she utilizes a wheelchair. She does not seem to have difficulty with transferring to bed, chair, or toilet. - Eating, feeding, bowel and bladder management, personal care devices, personal hygiene, and grooming are not affected.
IADL's:- Client is married and lives with her husband.- She communicated well during the evaluation.-Meal preparation-Shopping-Home management Rest & Sleep:-Experience trouble with sleep patterns while in rehab because she had to stay on the facilities schedule. Work:- Flower Shop (needs to drive to get there). Leisure:-Painting-Sewing-Electronic card games-Traveling-Gambeling-Spending time with family and friends Social Participation:-Attending church-Going out to eat with friends and family-Hosting family parties Performance Skills: Motor/Praxis: Dynamic balance in standing and ambulating is compromised due to general deconditioning of R hip. Increasing strength and endurance will improve this area. Sensory-Perceptual: WFL EmotionalRegulation: WFL Cognitive: WFL Communication/Social: WFL
Performancepatterns: Habits: Using grab bars to complete toileting, 3 step gait with walker, reaching behind with arms in sitting, using shoe horn to don leopard print slippers. Routines: Morning ADL schedule, work everyday, evening television/hobbies. Currently adhering to routines scheduled at the nursing home: meal times, OT/PT therapy schedule, hit button to use the restroom/ambulate around the room, planned activities. Rituals: Planned yearly activities w/in church, family functions, and traveling. Roles: Mother, grandmother, great grandmother, wife, florist, and friend.
Activitydemands: Activity of ambulating through nursing home Objects and their properties: walker shoes gait belt
glasses
Space demands: nursing home 2-person room: bed, chair, bathroom, low lighting large hallways noisy
Social demands: friendly roommate and other residents socially appropriate behavior
Sequence and timing: 3 step sequence: walker, right foot, left foot pivoting
Required actions and performance skills: gripping walker control of walker controlling LE limbs proper gait cycle balance Required body functions: moblility of joints level of conciousness strength of UE Required body structures:
the whole body:
arms
hands
fingers
eyes
nose
trunk
legs
feet
toes
Clientfactors:
Values/Beliefs/Spirituality: Christian faith Body Function: Mental functions and global mental functions are in tact, but were impacted by medications post surgery. Sensory functions including seeing (WFL with glasses), hearing, taste, vestibular, proprioception, touch, temperature, and pressure are all WFL. Pain discrimination indicates need for further testing secondary to the results of the pain awareness test. Neuromusculoskeletal and movement related functions such as joint mobility, joint stability, muscle power, muscle tone, muscle endurance, motor reflexes, involuntary movement reactions, control of voluntary movement, and gait patterns are all impacted in the R hip. Cardiovascular, hematological, immunological, and respiratory system function are all WFL with the exception of cardiovascular endurance secondary to deconditioning as a result from immobilization.Voice and speech functions such as fluency and rhythm and alternative vocalization functions are intact. Digestive, metabolic and endocrine system functions, as well as genitourinary and genital and reproductive functions are intact. Skin and related structure functions are WNL. Body Structures:
Structures of the nervous system: WFL
Eyes, ears and related structures: WFL
Structures involved in voice and speech: WFL
Structures of the cardiovascular, immunological, and respiratory systems: Intact w/ exception of deconditioning of cardiovascular system secondary to immobilization.PMH also includes hypertension.
Structures related to the digestive, metabolic, and endocrine systems: WFL
Structures related to the genitourinary and reproductive systems: WFL
Structures related to movement: bones, muscles, ligaments, and tendons in R hip impacted.
Skin and related structures: Intact
Contexts: Cultural:Catholic, values family, good work ethic, values independence, and importance of social participation. Personal:81 y/o, middle-class female, who has a high school diploma and works at the family flower shop. Temporal:Worked for 51 years as a Florist, married for 58 years Virtual:Uses cellphone (calls only), computer, and plays electronic card games. Physical:Lives in single story house in a small town. Social:Married with 5 grown children, 11 grandchildren and almost 2 great grandchildren.
Equipment/Orthotics issued or recommended: See Adaptive Equipment page
Home program/training:
-No formal HEP from OT, but can work on strengthening and ROM of the UE and LE.
OCCUPATIONAL THERAPY INTERVENTION PLAN
INTERPRETATION Analysis of occupational performance: (Describe the barriers and challenges, supports and strengths.)
Strengths:
Supportive husband and family that live in close by
Motivated to return home
Follows directions and follows hip precautions
Independent prior to hip replacement
Utilizes Assisted devices for ADL’s
Cognition Intact
Challenges:
Fatigue and endurance have been compromised due to lack of mobility prior to surgery
Old age slows the recovery time
PLAN
Long Term Goals:
Client will ↑ dynamic stability in R hip to ambulate Mod I with cane in 4-6 weeks.
Client will effectively identify and use two adaptive devices while showering in 4-6 weeks.
Client will be mod I in returning to previous occupation as a florist in 4-6 weeks.
Short Term Goals
1a. Client will transition from using walker to using cane to walk to bathroom with Mod I in 3 weeks. 1b. Client will complete a simple painting in standing in 2 weeks, increasing the consecutive time she stands each session. 1c. Client will be mod I in ambulation from car to church with rolling walker in 2 weeks.
2a. Client will transfer mod I into shower chair in 2 weeks. 2b. Client will utilize a long-handled sponge during showering routine while observing hip precautions by 2 weeks.
3a. Client will transfer mod I into vehicle in 2 weeks.
3b. Client will create a centerpiece for the dining area with set-up and supervision with two rest breaks in 2 weeks.
Methods/Intervention Type
Re-mediate/Restore and Adapt /Modify
Expected frequency, duration and intensity:
-Can receive home health care Occupational Therapy as needed
Location of and approach to intervention:
-Client will continue inpatient rehabilitation at Vancrest Health Care Center in Delphos, OH.
Anticipated discontinuation environment:
-Client will return home following facility protocol for hip replacement. Normally, client's transition from walker to cane in 2-4 weeks and unassisted in 4-6 weeks.
BACKGROUND INFORMATION:Date of Report: 10-29-11 (Pre-surgery interview)
Evaluation Date: 11-17-11
Client's name: Mary German
Date of birth &/or age: 7-23-30
Date of referral: 10-31-11 M F
Primary intervention diagnosis/concern: R Hip Replacement
Secondary diagnosis/concern: Hypertension, Arthritis in right hand, primarily R D2, knee arthroscopy
Reason for referral to OT: (or questions to be answered)
Therapist:Lindsay Barker S/OT, Laura German S/OT, Aaron Jacobs S/OT, Kendra Paulus S/OT, Morgan Podach S/OT, Sabreana Wright S/OTFINDINGS
Occupational profile: (Describe the client's occupational history and experience, patterns of living, interests, values and needs that are relevant to the current situation.)
Pre-Surgery Report
Mary is an 81 year old woman who is experiencing pain in her hip. She is scheduled to have a right hip replacement on 10-31-2011. She has also had a left knee arthroscopy, and she experiences arthritis in her right hand, primarily in her 2nd digit. She attributes the arthritis to her work with wires and flowers in the flower shop. She was diagnosed with hypertension a few years ago during a physical with her doctor. Mary states that she experiences pain the most when moving in and out of her bed. She states that when she is moving, the pain is about a 9 out of 10; however, when she is sitting she does not feel any pain at all.
Mary lives with her husband in a one story home. There is one step to get into their front door and 2 stairs inside the home. A typical day for Mary consists of waking up around 9am (it used to be earlier, but she does not get up as early because she cannot go anywhere). She has been staying inside her home because the pain has become too much to handle. She is able to get around the house with the use of a walker. Mary also has raised her chair and uses seat cushions to raise her hips above her knee. Mary was independent in all ADL's prior to her hip pain. She uses a reacher for dressing, and also has her own sock aide. She has two grab bars, a raised toilet seat and a shower seat in her bathroom. Mary's husband does most of the cooking; however, when he is not home she has trouble transferring dishes from one place to another.
Mary has been given hip replacement precautions by her doctor and was instructed to work on upper body strength through using weights. She uses 2lb dumbbells at this time and performs exercises at her will. Mary is frustrated by the pain and her lack of mobility. She wishes to get back out into the community and enjoy the things she likes to do. Mary enjoys sewing, painting (does not do this much anymore), going to work ( she works at her son's flower shop, putting arrangements together or taking phone calls), going to church, and visiting family and friends.
Problems and concerns: (Listed by client)
Post-Surgery Report (11-17-11)3 weeks post surgery, Cl reports being a 1-2 out of 10 on the pain scale, as opposed to 9 out of 10 before the surgery when she reported the pain as being "bone on bone." She is glad that she had the surgery, and said that she should have done it two years earlier. Mary elaborated on her R D2 arthritis, noting that it does not affect her functional ability, but does cause pain from time to time. She states that her husband is a great support, and has been doing most of the work around the house, including the cooking. As of now, her main goals include getting out of the nursing home being able to walk with a cane instead of walker, and increasing her endurance. At home she hopes to finish a quilt, draw, bake cookies, go shopping, and gamble! More than anything, she wants to put the "life" back into living- to be able to enjoy her roles as wife, friend, mother of 5, grandmother of 11, and great-grandmother of almost 2.
Progress Toward Goals So Far; Reasons for Progress or Lack Thereof in:
Areas of occupation:ADL's:
- Client is able to dress and undress using zippers, buttons, and fasteners. She utilizes assitive devices such as a reacher, shoehorn, and sock aid.
- Client uses a walker for most mobility. For longer distances she utilizes a wheelchair. She does not seem to have difficulty with transferring to bed, chair, or toilet.
- Eating, feeding, bowel and bladder management, personal care devices, personal hygiene, and grooming are not affected.
IADL's:- Client is married and lives with her husband.- She communicated well during the evaluation.-Meal preparation-Shopping-Home management
Rest & Sleep:-Experience trouble with sleep patterns while in rehab because she had to stay on the facilities schedule.
Work:- Flower Shop (needs to drive to get there).
Leisure:-Painting-Sewing-Electronic card games-Traveling-Gambeling-Spending time with family and friends
Social Participation:-Attending church-Going out to eat with friends and family-Hosting family parties
Performance Skills:
Motor/Praxis: Dynamic balance in standing and ambulating is compromised due to general deconditioning of R hip. Increasing strength and endurance will improve this area.
Sensory-Perceptual: WFL
Emotional Regulation: WFL
Cognitive: WFL
Communication/Social: WFL
Performance patterns:Habits: Using grab bars to complete toileting, 3 step gait with walker, reaching behind with arms in sitting, using shoe horn to don leopard print slippers.
Routines: Morning ADL schedule, work everyday, evening television/hobbies. Currently adhering to routines scheduled at the nursing home: meal times, OT/PT therapy schedule, hit button to use the restroom/ambulate around the room, planned activities.
Rituals: Planned yearly activities w/in church, family functions, and traveling.
Roles: Mother, grandmother, great grandmother, wife, florist, and friend.
Activity demands: Activity of ambulating through nursing homeObjects and their properties:
walker
shoes
gait belt
glasses
Space demands:
nursing home 2-person room: bed, chair, bathroom, low lighting
large hallways
noisy
Social demands:
friendly
roommate and other residents
socially appropriate behavior
Sequence and timing:
3 step sequence: walker, right foot, left foot
pivoting
Required actions and performance skills:
gripping walker
control of walker
controlling LE limbs
proper gait cycle
balance
Required body functions:
moblility of joints
level of conciousness
strength of UE
Required body structures:
the whole body:
arms
hands
fingers
eyes
nose
trunk
legs
feet
toes
Client factors:
Values/Beliefs/Spirituality: Christian faithBody Function: Mental functions and global mental functions are in tact, but were impacted by medications post surgery. Sensory functions including seeing (WFL with glasses), hearing, taste, vestibular, proprioception, touch, temperature, and pressure are all WFL. Pain discrimination indicates need for further testing secondary to the results of the pain awareness test. Neuromusculoskeletal and movement related functions such as joint mobility, joint stability, muscle power, muscle tone, muscle endurance, motor reflexes, involuntary movement reactions, control of voluntary movement, and gait patterns are all impacted in the R hip. Cardiovascular, hematological, immunological, and respiratory system function are all WFL with the exception of cardiovascular endurance secondary to deconditioning as a result from immobilization.Voice and speech functions such as fluency and rhythm and alternative vocalization functions are intact. Digestive, metabolic and endocrine system functions, as well as genitourinary and genital and reproductive functions are intact. Skin and related structure functions are WNL.
Body Structures:
Contexts:Cultural:Catholic, values family, good work ethic, values independence, and importance of social participation.
Personal:81 y/o, middle-class female, who has a high school diploma and works at the family flower shop.
Temporal:Worked for 51 years as a Florist, married for 58 years
Virtual:Uses cellphone (calls only), computer, and plays electronic card games.
Physical:Lives in single story house in a small town.
Social:Married with 5 grown children, 11 grandchildren and almost 2 great grandchildren.
Equipment/Orthotics issued or recommended: See Adaptive Equipment page
Home program/training:-No formal HEP from OT, but can work on strengthening and ROM of the UE and LE.
OCCUPATIONAL THERAPY INTERVENTION PLAN
INTERPRETATIONAnalysis of occupational performance: (Describe the barriers and challenges, supports and strengths.)
Strengths:- Supportive husband and family that live in close by
- Motivated to return home
- Follows directions and follows hip precautions
- Independent prior to hip replacement
- Utilizes Assisted devices for ADL’s
Challenges:Cognition Intact
PLAN
Long Term Goals:Short Term Goals
1a. Client will transition from using walker to using cane to walk to bathroom with Mod I in 3 weeks.1b. Client will complete a simple painting in standing in 2 weeks, increasing the consecutive time she stands each session.
1c. Client will be mod I in ambulation from car to church with rolling walker in 2 weeks.
2a. Client will transfer mod I into shower chair in 2 weeks.
2b. Client will utilize a long-handled sponge during showering routine while observing hip precautions by 2 weeks.
3a. Client will transfer mod I into vehicle in 2 weeks.
3b. Client will create a centerpiece for the dining area with set-up and supervision with two rest breaks in 2 weeks.
Methods/Intervention Type
Re-mediate/Restore and Adapt /Modify
Expected frequency, duration and intensity:-Can receive home health care Occupational Therapy as needed
Location of and approach to intervention:
-Client will continue inpatient rehabilitation at Vancrest Health Care Center in Delphos, OH.
Anticipated discontinuation environment:
-Client will return home following facility protocol for hip replacement. Normally, client's transition from walker to cane in 2-4 weeks and unassisted in 4-6 weeks.