Integrated Occupational Therapy Practice Case Study

Integrated occupational Therapy drill Case StudyIntroductionThis report will focus on the occupational therapy (OT) carry out for Meera (Appendix A), a 56-year-old woman with a left cerebral vascular accident (CVA). Stroke is the death of brain cells due to the lack of oxygen (Bartels et al. 2016).It can each present as haemorrhagic or ischaemic in nature. Risk factors of CVA include hypertension and hypercholesterolemia which Meera has. Stroke whitethorn lead to neurological, psychological, nomenclature and musculoskeletal complications. Meeras symptoms of dependable hemip armia, respectable alignd neglect and speech difficulties can be attributed to the occlusion of her left middle cerebral artery (Mtui et al. 2016).A multidisciplinary inpatient gibe rehabilitation unit was involved with Meeras post-stroke rehabilitation. Stroke patients who underwent treatment inpatient stroke care were order to stupefy improved independence (Stroke unit of measurement Trialists Collabo ration 2013). discussion was aimed at managing vital problems finished restorative and compensatory approaches in order to prepare her for discharge (Edmans 2010). Thus, this service was most divert for Meera due to her recent onset of stroke. The OT touch on was guided by recommendations from the College of Occupational Therapist, National Institute for health and Care Excellence (NICE)(2013) and Intercollegiate Stroke Working Party (ISWP)(2016)(Edmans 2010). judicial decisions and Problems IdentifiedAn sign discernment was gathered through an interview using the Kawa Model. It portrays a persons life as a river and various objects such as rocks, river banks and driftwood depict circumstances experienced by a person (Teoh and Iwama 2015). Younger stroke patients such as Meera may gather up services which cater particularly to their needs which most stroke units were found not to do so (ISWP 2016). As Kawa foc personas on the view of the client, it allows the therapist to k now what is important to Meera in order to formulate priorities for intervention. The perspicacity is shown below liveliness flow and priorities (river)PastMedical HistoryHypertensionHypercholesterolemiaRoles and OccupationsIndependent in self-careProud Stay at home m separateTook charge of matters at home such asCleaningShoppingGardeningLaundryEnjoys cooking for familyPresentMedical HistoryStrokeRoles and OccupationsPatientNeeds helper in most self-care tasksLoss of previous role and not engaging in occupations meaningful to herFutureMeera mat afraid and pointless to talk nigh the future, worrying that she may have another stroke if she pursued in activity.Obstacle and Challenges (rocks)Occupational process challengesRight hemiplegia with increased spasticity in beneficial arm and leg, causing difficulty inSittingCoordination of movementTasks that require her hands due to being right handedUnable to feel sensations on right handFeels she cannot remember things as easily an d may not know the time and place she is atRight sided neglect with visual agnosia, resulting in difficulty washing right sideawareness of people approaching from impact sideinteracting with othersExpressive dysphagia hinders communication with others.Feeling low mostlyFeels worthlessEmbarrassed that people are taking care of herFatigues easilyConcernsFamily unable to function as she is unable to manage the householdA core to family, especially her husband who needs to manage the household together with the pressure at work now that she is in hospitalChildrens studies and sociable life may be modify as they may be concerned about Meera and visiting her in hospital may affect their periodic life somatogenetic and Social Environment (river banks)Physical (Home)3 room semi-detachedBathroom, toilet and bedroom on the upper storeyKitchen, combined living and dining room on ground floorNearest bus stop and convenience store 10 minutes walk awaySocialClose knit familyMeera usually s upports family members as they will confide her during difficultiesLooks forward to dinner all(prenominal) sidereal day where family will gather togetherFamily is most vital source of support for Meera grass interaction with neighbours and will help each other with chores if neededOccasionally communicates with extended family overseas on ph starPersonal resources (driftwood)PersonalityHardworking panic-struck of trying new thingsKind and caringResponsibleWith information from the initial sound judgement, the problem list was formulated in a client-centred manner (ISWP 2016). Stroke survivors felt more engaged in the therapeutic process when their perspectives were taken into account (Peoples et al. 2011). Interventions were based on Meeras perceived problems in order to increase her motivation in therapy which she lacked. However the Kawa model only shows the problems perceived by Meera but not the therapists views. In order to gather a clinical and therapeutic point of view, g overn assessments were conducted as well. The table below depicts the various assessment conducted, reasons for use, limitations and results.AssessmentReasons for use and limitationsResultsAssessment of go and Process Skills (AMPS)(Fisher and Jones 2010)AMPS evaluates labour and processing skills of clients through observation of appropriate tasks (Fisher and Jones 2010). Self-care, specifically wasteing, adorning and cooking tasks which was important to Meera, were used to assess. This allowed the OT to break the tasks down and acknowledge the challenges Meera faced in order to formulate an appropriate intervention. AMPS was found to be valid, reliable and standardized among cultures but results has to be computer generated in order to be valid which may make the process tedious (Fisher and Jones 2010).Less than 1 for both motor (Moderate increase in physical effort) and process (Moderate inefficiency and disorganization) skills.Loewenstein Occupational Therapy Cognitive Assess ment (LOTCA) (Itzkovich et al. 2000)LOTCA evaluates the orientation, visual and spatial perception, visual-motor organization and thinking operations through the use of various activities included in the kit (Itzkovich et al. 2000). This allowed the OT to assess Meeras right sided neglect and to discover any under manufacturing cognitive deficits. The LOTCA is reliable and valid for use in people with stroke but needed to be conducted in more than one sitting as assessments were long and tedious for Meera who experience become flat (Katz et al. 2000).Meera was able to sequence tasks but was unable to complete tasks involving her right field of vision. She needed prompts to complete orientation tasks. Activities involving memory were also a challenge for her.Rivermead Motor Assessment (RMA)(Lincoln and Leadbitter 1979)The RMA consists of tests evaluating the gross, leg, trunk and arm function of a stroke patient (Lincoln and Leadbitter 1979). This was conducted together with the phy siotherapist. The RMA allowed the team to know which movements Meera had difficulties in order to formulate appropriate interventions. This assessment was found to be reliable and valid but due to being strenuous and long, it had to be conducted in a few sessions due to Meera showing signs of play out (Kurtais 2009)Meera was not independent in transfers and mobility, she required assistant of one for transfers and used a wheel professorship for mobility. She also had minimum trunk and leg control at her affected side and require assistance for movement. However, she is able to hold objects using her affected arm but cannot reach for an object far away due to scapulary instability.From these assessments, 3 problems Meera faced, in order of significance was developed1. Loss of independence in self-care affected Meera the most. From the assessments conducted, it was found that challenges in motor, cognition and perception affected her performance in self-care. Managing self-care woul d focus on these domains as well (NICE 2013). It was hoped that Meera would be more engaged in therapy by focusing on an issue she perceived as critical. This was evidenced by a write up where patients were more motivated and engaged more in interventions when treatment was catered to their perceived needs (Combs et al. 2010). This would also help Meera to enhance her fashion as low involvement in self-care was found to be a factor for post-stroke depression (Jiang et al. 2014). The psychologist in the team would be managing Meeras low mood as well (ISWP 2016). By working with Meera on her self-care would also remove some burden from Sanjay, who was assumed to be her main carer when she is discharged from hospital.2. Problems with visual perception, specifically right side neglect and agnosia, were targeted as it was found to have an influence on self-care (Barker-Collo et. al 2010). This would help Meera in performing self-care tasks. Her visual deficits also affected her social life and transfers. Managing her perceptual problems would allow her to interact more with other patients in the ward which could provide her with social support.3. Meeras motor challenges, specifically right side weakness and spasticity were addressed as it was one of the major challenges faced during self-care. It was hoped that through the management of motor deficits, Meera would increase her engagement in occupations. This would also have a positive effect for Meera in future as it was shown that physical function affected quality of life in stroke patients (Ellis et al. 2013). Motor challenges faced by Meera would be managed in conjunction with the physiotherapist (ISWP 2016). Skills in managing motor challenges can also be transferred to other aspects such as cooking and reinstating her role as a homemaker.Treatment PlanClient AimsMeera wants to be more engaged in her personal care.Therapist AimsTo increase Meeras engagement in her self-care tasks.To manage Meeras right side d neglect and agnosia.To manage Meeras weakness and spasticity in her right arm, leg and trunk.ObjectivesMeera should be able take charge of her own shower and dressing both dayspring for an hour, with assistance of one, in 4 weeks.Meera should be able to singly identify items required on her right field of vision for washing and dressing every morning in 4 weeks.Meera should be able to go from lying to sitting, and pivot transfer from bed to wheelchair as well as from wheelchair to shower chair, every morning with assistance of one in 4 weeks.InterventionWashing and dressing assessment was conducted through the use of AMPS. This allowed the OT to formulate an appropriate wash and dress plan for multi-disciplinary use through identified difficulties in motor and processing skills (Fisher and Jones 2010). Using a meaningful occupation as a basis for intervention was beneficial for Meera. This can be supported by a study where occupation based intervention was shown to be critical in improving occupational performance (Wolf et al. 2015). The intensity of the intervention would be higher than the recommended minimum frequency of 45 minutes, 5 days a week as it was included in Meeras daily routine (NICE 2013).The washing and dressing plan was adapted from Salisbury District Hospitals (2013) assessment form. The OT conducted the first session in order to teach Meera the applicable compensatory and visual scanning skills. Other sessions could be conducted by other staff with guidance from the plan. A further look backward after every few days would also be required in accordance to recommendations (ISWP 2016).Washing and dressing plan for MeeraTransfersBed MobilityMeera is able to roll to her right side independently.She requires assistance from lying to sitting.Bed to wheelchairRequire assistance of one for pivot transferStandingRequire assistance of one and grab rail in the bathroomWheelchair to shower chairRequire assistance of one for pivot transferAllow M eera to navigate to bathroomWashingNotesRequire the use of a shower chair in the showerAllow Meera to initiate and sequence task independentlyOnly give Meera assistance when she asks for itPlace items needed for shower on Meeras right sideIf Meera seems to be searching for something, prompt her to look for it by turning her headEncourage use of right hand to wash herselfMeera may require assistance to release her grip on objectsProvide assistance if Meera feel have on stop number bodyMeera is able to wash her right side independentlyMeera require assistance to wash above her elbows on her left sideAssistance may be needed to wash hair and back goodLower BodyMeera should be able to wash her genitals and front upper second joints independentlyAssist Meera in standing with the grab rail with one person supporting at all timesAnother person will assist Meera in cleaning her bottom and her rear upper thighEncourage Meera to wash her lower thighs but prevent her from falling from the sh ower chairAssist in cleaning the rest of the lower thighsDressingUpper BodyEncourage Meera to put on the bra independently using the one arm method.Allow Meera to use the one hand method to acquire her t-shirt.Prompt her by reminding her of the steps if she is strugglingLower BodyMeera requires assistance to put on her trousers while assisted in standing.Both the restorative and accommodative approach was used to guide the intervention. Restorative approach is grounded upon neuroplasticity where relearning takes place when new neural connections form in the brain during constant exposure to various input (Gillen 2016). By practising various movements of her affected side during self-care, Meera should have a reduction in her impairments. This is supported by a study where patients who went through functional motor relearning therapy were found to have improved balance and performance in self-care (Chan et al. 2006).The compensatory approach is where tasks are modified to be easie r for the clients to achieve (Edmans 2010). Even though this approach has been criticized for obstructive motor recovery in people with stroke, it is still appropriate for Meera (Jones 2017). The compensatory method of using the one hand dressing method served as a feedback utensil which could improve motivation as supported by Popovic et al. (2014). This would thus encourage Meera to engage in therapy.Risk Management PlanMeera might be fatigue and may not be able to do some of the tasks required. The staff in charge will assist when required and allow Meera to rest when needed. out-of-pocket to the intimate nature of a wash and dress, Meera might feel embarrassed and down during the process. In order to preserve her dignity, sensitive areas would be covered whenever necessary and observation would be subtle.Environmental hazards would be checked before commencing any transfers or wash and dress in order to prevent falls.Relapse streakIn the hospital setting, encouragement for fr equent engagement in occupation and usage of relevant motor and cognitive skills would prevent Meeras occupational performance from deteriorating (Brainin et al. 2015 Ullberg et al. 2015). correspond to NICE (2013), long-term health and social support should include education on symptoms and dysfunction relating to stroke, services available and participation in meaningful occupation. As such, Meera and her family would be briefed on these strategies.Outcome MeasuresEvaluation of treatment outcomes is important to conclude if the intervention was successful and used to change the treatment plan according ( mew and Ivey 2010). The outcomes were evaluated by using goals and comparing standardized assessment at baseline and outcome. Firstly, intervention was evaluated through the achievement of goals. Goal achievement was linked to client satisfaction and a significant client-centred outcome (Custer et al. 2013). Meera was able to achieve the objectives as expected. Secondly, the AMPS was conducted again, using the task of showering and dressing (Fisher and Jones 2010). Meera scored higher in these tasks but still required some assistance in achieving them. Thirdly, Meera improved on the LOTCA tasks which involved visual scanning, little to no improvement was seen on the orientation and memory tasks (Itzkovich et al. 2000). Lastly, the RMA was conducted again (Lincoln and Leadbitter 1979). Meera improved in the trunk, leg and upper limb function but there were still signs of weakness and instability involved.Further plansOther domains of concern would be managed as according to initial assessment and outcome measures. Further interventions would include management of cognitive function such as memory and orientation through cooking. Including Meera in a social group such as breakfast club in the ward would be beneficial to her as well (Venna et al. 2014).To prepare for discharge, Meera would be referred to the Early back up Discharge team. The team would help M eera and her family by introducing appropriate adaptations at home and relevant education on stroke (ISWP 2016). A smooth transition from hospital to home was found to improve patients function in activities of daily living and service satisfaction (Fearon et al. 2012). 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Translational psychiatry 4(1)e351Appendix AMeera CVAMeera is a 56-year-old woman who was recently admitted with a left Cerebral Vascular Accident affecting the middle cerebral artery. She has a history of hypertension and hypercholesterolemia. She was admitted via A E after being found by her husband. Her husband reports that she felt unwell and made her way upstairs to have a lie down. He went out to walk the dog and on his return found her on the floor in the bathroom. Meera presents with a right hemiplegia with increased spasticity in her right arm and leg. As a result, she has difficult with sitting balance and co-ordinating her movements in order to engage in activities such as washing and dressing. Meera also presents with right sided neglect, which results in her failing to identify objects on her right side, difficulty washing her right side and responding to others who approach her from her right. She has difficulty in articulating in a meaningful way to get her needs met and is very tearful. The Occupational Therapist undertook an initial assessment with Meera, the report is detailed below.Initial assessment summaryMeera appears low in mood and is reluctant to talk about the future. She is worried that she may have another stroke and consequently is reluctant to engage in activity. Meera is embarrassed that she needs help in personal activities of daily living and is reluctant to talk a bout activities that she finds difficult.Family Meera is married to Sanjay, a 58-year-old man who works as a plumber. They have two children, Anni aged 18 years who has just completed her A levels and will be attending a topical anaesthetic university in one months time, and Sam aged 17 who is at secondary school.Social situation The family live in a privately owned trinity bedroomed semi-detached property in a small town. Sanjay describes Meera as a stay at home mum who prides herself on her family and her cookery skills.Posture Meera has a right- sided hemiplegia her scapular is unstable and she finds it difficult to flex her arm above 90 degrees. Elbow extension is uncontrolled and there is stiffness in her forearm qualification supination difficult. She is able to grasp objects but finds release very difficult.Sensory assessment Meera has poor deep and light sensation in her right hand, which has a gravid effect on a range of performance areas.Cognition and perception Meera has a right sided neglect which interfers with washing and dressing, and transfers. She also has difficulty socialising with other patients on the ward due to to this. Meera has some cognitive impairment which presents as poor memory and disorientation. These features are more prominent at the end of the day when Meera is tired.Mobility Meera currently uses a wheelchair but can manage a controlled transfer with one person assisting.