Running head: OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile
Tonya DeDera
Touro University Nevada

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Occupational Profile

The Patient
The patient is a 51-year-old female who has been married for 25 years and lives in a twostory home with her husband in Las Vegas, NV. The patient and her husband have five adult
children that live in the Las Vegas valley areas. The patient has a total of 14 grandchildren in
ages ranging from one to 14. The patient had worked as a food server for seven years in a casino
restaurant. After leaving her restaurant job this year, the patient began experiencing pain in both
of her hands. On June 01, 2015, the patient who is right hand dominant was complaining of the
pain becoming progressive. After seeing her orthopedic physician, the patient was diagnosed
with bilateral carpal tunnel syndrome (BCTS) and was referred to occupational therapy (OT) at
Select Physical Therapy outpatient rehabilitation for conservative management.
Occupational History, Values, and Interests
The patient is now employed full-time as a cafeteria server with Clark County School
District (CCSD). She is off now due to summer break but hopes to start her new job when
school commences. She reported having worked as a food server in different restaurants in
California prior to moving here. She stated that her local restaurant job here was very laborious,
and she believes the demands of that job caused her injury. She stated that her new job will be
less strenuous manually. When asked about leisure interests, the patient stated that she enjoys
going on vacations once a year, cooking a variety of foods along with her traditional Columbian
foods, and dancing, specifically salsa, with her husband on Friday nights. The patient stated that
she enjoys quality time with her grandchildren. Prior to her injury, she was a caregiver to her
youngest grandson on the weekends while her daughter worked. She went on to state that social
relationships, preparing favorite meals such as Arepas for her grandchildren, family time with

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their adult children, and taking her grandchildren to the park to play ball or play on the swings,
and swimming at the community pool were also primary leisure interests to her.
The patient also discussed life values that she holds dear, such as attending her Christian
church on Sundays with her husband, her independence, health and wellness, being reliable, and
contributing financially to the household. The patient stated that it is important to her to help
care for her youngest grandson once she has recovered from her injury. However, for right now,
she reported that her primary goals are in activities of daily living (ADLs) and instrumental
activities of daily living (IADLs), such as dressing and cooking independently without pain and
weakness.
Roles
The patient identified several roles that she considers to be a very important part of her
life. She reported that she is a Christian, a wife, a mother, a grandmother, a friend, and an
employee. The patient takes pride in being a homemaker and preparing home cooked meals for
her and her husband. She verbalized how maintaining employment is an important role of
sharing financial responsibilities, and because it is also the place where she has met the majority
of her friends and has developed a social network. The patient reported how she has also found
solace within her church community and participates in many volunteer opportunities with her
church group.
Patterns of Engagement in Occupations
In discussing her patterns of engagement in occupations, the patient stated that she
prioritizes what she prefers to do and makes sure those are the things that are incorporated into
her daily routine. The patient stated that she found herself working more once all of her children
had left home. When I asked the patient to describe her typical daily routine that she had at

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home, she reported that her routine was as follows: wake up, shower, brush teeth, fix hair and
make-up, get dressed, make breakfast for her and her husband, make and pack lunches for her
and her husband to take to work, come home, prepare dinner, wash dishes, clean up dining room
and kitchen, watch television or meet with friends, brush teeth, put on pajamas, and go to bed. If
the patient is off from work, she may spend the day running errands after she has given her
husband breakfast and packed his lunch. Home management is another part of the patients daily
routine when she doesnt have to work.
Services Seeking and Concerns
The patient is currently receiving skilled OT services to address the progressive pain and
paresis of both hands and wrists secondary to BCTS. She also presents with numbness and
tingling in right dominant hand more than in her left hand. She expressed that these symptoms
are especially noticed at night. Due to experiencing extreme pain at night, the patient wears a
wrist brace to help her sleep through the night.
The patient expressed concerns in relation to her independent functional status,
particularly in regards to completing self-care skills at home, cooking meals for her husband,
family, or friends, cleaning her home, and being able to participate in activities with her
grandchildren. The patient also stated that she hopes to start her new job on a full recovery from
BCTS. She expressed that her priorities in treatment are to first be able to dress herself without
pain and then to be able to prepare meals without decreased strength in her hands. Resuming
these activities to her prior level of function is a top priority for her.
Areas of Occupation
Successful occupations and Barriers. The patient feels that she is able to complete
ADLs; however, she requires more time to complete ADLs such as dressing, grooming, and

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personal hygiene. This is due to pain that she experiences to accomplish these desired tasks.
Consequently, preparing traditional meals, lifting and transporting pots, pans, and food from one
area to another in the kitchen has proven to be difficult. She and her husband are eating at
restaurants more often, preparing simplistic meals, or her husband has even tried to prepare
meals. She expressed how she appreciates his efforts, but stated that she really needs to get back
to cooking, something that brings great joy and meaning to her life. Any activities requiring
bilateral use of her hands demonstrate difficulty due to pain and diminished strength.
Since her injury, the patient has not had time to engage in other IADLs such as care for
her youngest grandchildren, leisure activities with family and friends, cleaning her home, and
driving. Due to decreased strength and pain in her hands and wrists, she is unable to carry her
youngest grandson and provide him with the proper care that he needs. Home maintenance is
another area that has been impacted by her injury. The patient reports that vacuuming is one of
the most difficult task that she is unable to do. Laundry is something that she still completes, but
she requires frequent breaks from the lifting, transporting, and folding items. The patient reports
driving her vehicle is quite difficult due to hand numbness, pain, and paresthesia. For now, her
husband has been driving her to appointments and to do necessary errands.
Environmental Supports and Barriers
The patient is extremely motivated to have a speedy recovery. The patient is on a three month
summer break from work, which is encouraging her to succeed in OT exercises. During her
treatment session, the patient is showing a good response to treatment having decreased
frequency of symptoms. At home, her physical environment is supportive to her engagement in
occupations. She lives in a two-story home which has the laundry room upstairs. The patient
reported that this situation allows her to complete laundry at a slower pace. The patient has the

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support and motivation from her husband. She is still able to perform light house work, but she
requires her husband to do the vacuuming.

The patient has been well educated on not

overextending herself to the point of creating further injury.

Priorities and Desired Outcomes
The patients main priorities are to engage in activities without experiencing pain and
paresis in order to increase her overall independence in work, leisure, ADLs, and IADLs. Her
primary goals that she verbalized are dressing, cooking, leisure activities with grandchildren and
friends, and returning to work.
Occupational Analysis
Context and Setting
The patient is seen by an occupational therapist at a community-based outpatient
rehabilitation facility. The treatment sessions take place in an open gym that consists of physical
and occupational therapists providing treatment simultaneously to patients. The patient
participates in intensive hand therapy for a one hour session, two times a week. Sometimes the
patients therapy session is done as a concurrent treatment in which the occupational therapist
treats multiple patients at the same time. The patients treatment is focused on a biomechanical
approach with emphasis on increasing strength and endurance, decrease pain, and increasing
ROM.
Activity Observed and Patients Performance
The patient participated in therapeutic exercises along with joint blocking of the
metacarpophalangeals (MCPs), proximal interphalangeals (PIPs), and distal interphalangeals
(DIPs) joints. The therapeutic exercises are designed to increase active range of motion
(AROM) in all hand joints by utilizing the muscle groups involved with fine and gross motor

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function use (Cooper, 2008). The therapeutic exercises included forearm and wrist AROM
exercises, forearm and wrist strengthening exercises using hand weights, forearm and wrist
stretching exercises, and hand strengthening exercises using Theraputty. Joint blocking is
performed the same way as tendon gliding exercises to increase circulation to the carpal tunnel
and to prevent adhesions. The patient has shown much progress throughout treatment. The
frequency of symptoms have decreased since attending therapy. The patient was fully capable
and able to complete the therapeutic exercises independently. During tendon gliding exercises,
AROM of the MCP, PIP, and DIP were within functional limits of the index and middle finger of
both hands. The patient required minimal passive range of motion (PROM) with thumb MCP
and digit three in all joints in both hands.
Key Observations
During the therapeutic exercises, the patient appeared to be highly motivated to do well.
She reported that she was experiencing decreased pain, numbness, and tingling in both hands.
She had no problems at all with completing each activity during the one hour treatment session.
The patient reported that she was very pleased with her treatment and was performing the
required exercises at home. This was evident because she was able to demonstrate more joint
motion during the tendon gliding and median nerve exercises. Overall, symptoms have
decreased during functional activities. However, at night, the pain in her right hand limits her
quality of sleep. When asked about dressing, the patient verbalized, I still need more time to
dress because of pain, but the pain is decreasing a little each day (personal communication,
August 04, 2015).
Significant Impacts

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The domains of American Occupational Therapy Associations (AOTA, 2014)

Occupational Therapy Practice Framework (OTPF), that appear to significantly impact the
patients performance in occupations were client factors, performance skills, and performance
patterns. The patient appears to be most affected by her physical hand motor limitations due to
pain, strength, and active range of motion. Values listed under client factors as the individuals
perceptions, motivations, and driving forces that encourage or influence engagement in
occupations (AOTA, 2014). The patient values her independence and commitments rooted from
culture of what is expected of her as a wife, mother, and grandmother.
During the patients initial evaluation, she demonstrated grip and pinch paresis, limited
ROM in wrist flexion and extension, and limited thumb and digit opposition. These physical
limitations were a result of pain in hand joints, decreased strength, and diminished joint mobility.
The body functions that are limiting the patients physical performance are sensory functions,
neuromusculoskeletal and movement-related functions, and muscle functions (AOTA, 2014).
The patient is unable to independently perform her desired occupations due to pain, limited
strength, and ROM.
Due to the inhibiting body functions, the patient has motor impairments affecting
performance skills. These motor impairments affect her ability to grip, manipulates, lift,
calibrate, transport, and lift objects (AOTA, 2014). The patients inability to perform these skills
has impacted areas of occupation. In relation to performance patterns, her goal to resume roles
immediately has supported her recovery process. The patients occupational goals are being
addressed through occupational therapy services.
Problem List

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A list of prioritized problem statements, goals, and interventions have been developed for
the patient regarding her functional performance in tasks and are stated below:
Problem Statement 1
Patient is unable to independently dress herself due to increased pain with bilateral hand
function.
Problem statement in regards to dressing will be prioritized for the patient, as she
verbalized several times throughout her interview that she would like to be as independent as
possible in self-care activities so that her husband will not have to be burdened with helping her.
Alleviating the pain that the patient sustains when engaging in this activity is of priority.
Problem Statement 2
Patient is unable to prepare meals due to decreased strength in bilateral wrist and hand
function.
Cooking traditional Columbian home cooked meals was verbalized as well several times
throughout the interview. Prior to the injury, the patient was cooking wholesome, nutritious
meals regularly. Now, the patient and her husband are eating microwave dishes, dining out at
restaurant more often, and her husband occasionally prepares a meal. The patient finds this to be
very upsetting because preparing traditional meals for her husband and family brings great joy
and meaning to her life.
Problem Statement 3
Patient is unable to complete grooming and hygiene tasks due to grip and pinch paresis.
Patient complains of grooming and hygiene tasks to be quite laborious and frustrating. The
patient reports something as easy as brushing her hair, shaving her body, and brushing teeth are
very taxing requiring more time to complete.
Problem Statement 4

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Patient is unable to complete vacuuming (home management) task due to increased pain
in her right dominant hand.
Maintaining a beautiful clean home is important to the patient, she has the support from her
husband to help maintain their home. The patient will resume occupational performance in this
area through skilled occupational therapy focusing on strengthening exercises and activities.
Problem Statement 5
Patient is unable to care for her grandchild due to decreased strength with bilateral hand
function.
The patient is unable to provide the level care needed to take care of her youngest grandson.
She was the caregiver to him on the weekends while her daughter worked. Skilled occupational
therapy will address diminished strength and joint mobility focusing on resuming occupational
performance in this area.
Intervention Plan and Outcomes
Long-Term Goal 1
Pt. will complete upper & lower body dressing s pain within 4 wks.
Short-term goal 1. Pt. will complete upper & lower body dressing Mod pain
levels not to exceed 4/10 within 2 wks.
Intervention 1. Patient will participate and be educated in physical agent modalities (PAMs)
focused on decreasing pain levels. The focus of this intervention is supported by a research
article written by Amini (2011), where she reported that PAMs, preparatory methods, can be
effective for improving client factors (physiological and biological structures) that may then lead
to improved capabilities to engage in meaningful occupations. The PAMs utilized will include
paraffin bath, moist hot packs, and ultrasound. The approach to intervention is establish and

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restore because she will restore her prior levels of function of her hands that have been impaired
(AOTA, 2014).
This intervention approach is designed to restore body structures and functions in an
effort to influence ROM, strength, biological, and physiological process (Cleveland, 2011).
Treatment for the patient would consist of conservative therapy. The patient will wear a night
splint to keep the right wrist in neutral position. Secondary to this, the author concluded that
splinting for osteoarthritis (OA) and CTS have been shown to have positive outcomes and should
be included in the treatment plan. Therapeutic exercises such as median nerve gliding and flexor
tendon gliding exercises will improve AROM (Cooper, 2008). Pain will be reduced through pain
management (i.e. ergonomics and energy conservation) and modalities as needed to reduce pain
(Cooper, 2008). Overall, occupational performance will be measured by engagement in the
patients desired activity. In addressing pain management first, the patient will improve in her
functional performance to regain premorbid levels through skilled occupational therapy (AOTA,
2014). The targeted outcome for this intervention would be for the patient to improve in her
occupational performance while dressing as well as health and wellness to improve her overall
quality of life (AOTA, 2014).
Short-term goal 2. Pt. will engage in dressing utilizing A/E Mod within 1 wk. to
bilateral hand & finger function.

Intervention 2. This intervention will focus on increasing upper extremity strength and
improving the patients ability to dress independently. The patient will participate in folding a
load of laundry (washcloths, bath towels, sheets, and pillow cases) from a clothes basket to elicit
an increase in grip and pinch strength with bilateral hand function.
This approach to intervention is to restore an impaired skill based on the patients wants and
needs (AOTA, 2014). This intervention is supported by C. Cooper (2008), wherein the author

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reports that encouraging the patient to utilize upper extremity doing normal activities as
appropriate to the diagnosis of BCTS. Secondary to this, the author concluded that folding
socks and underwear can be upgraded to folding heavy towels and jeans, which require greater
strength and endurance (Cooper, 2008, p. 1132).
The desired outcome for this intervention would be for the patient to improve in her
occupational performance in the area of dressing. According to Amini (2011), patients given
occupation-based treatment had statistically significant higher levels of improvement in areas
assessed than did those who underwent traditional exercise-based treatment.
Long-term Goal 2
Pt. will cook salmon, chopped fresh vegetables, & plantains at home via self-report by
4 wks.
Short-term goal 1. Pt. will chop vegetables using bilateral hand function Mod within

2 wks.
Intervention 1. Patient will use a knife to slice prepared cookie dough, fruits, and
vegetables to incorporate various food densities for the activity. This slicing exercise will
produce an increase in finger dexterity and hand strength. Hand strength is increased by grading
from lesser to greater resistance (Trombly Latham, 2008).
This approach to intervention is establish and restore because she will be restoring the
skill for this specific meal preparation (AOTA, 2014). The patient will be given various items of
resistance from soft to firm to measure finger and hand function. While slicing the items, the
patient must stabilize the knife using a volar grasp, finger dexterity and hand strength utilizing
coordination to handle the food items.
The desired outcomes she will achieve are role competence and quality of life with this
intervention. According to the OTPF, role competence is the ability to effectively meet the

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demands of roles in which the client engages (AOTA, 2014, p. S35). Being able to prepare
traditional home cooked meals gives her pleasure and a sense of purpose. This intervention
would improve occupational performance including increased volar and finger strength and
endurance in bilateral hand function. The outcomes will increase finger and hand coordination
using proper handling of the utensil to allow the patient to engage in her meaningful and
purposeful occupation.
Short-term goal 2. Pt. will prepare Arepas (like tortillas) from scratch Mod within
2 wks.
Intervention 2. Pt. will participate in an activity to increase grip strength. The patient
will practice preparing Arepas. She will obtain dough ingredients and bowl at rehab facility.
Patient will utilize rolling pin and knead the dough to increase grip strength.
This approach to intervention is to establish and restore because the patient had
previously been proficient at preparing this specific meal (AOTA, 2014). This is a meaningful as
well as a purposeful activity utilizing the patients specific goal. If the patient enjoys baking,
then rolling dough with a rolling pin would be a therapeutic occupation to promote grip
function (Cooper, 2008, p. 1132). This intervention is an example of a purposeful and
meaningful activity. As stated previously, the patient enjoyed making this meal for her
grandchildren which they loved. In contrast to having the patient utilize theraputty or exercise
grippers.
A therapist utilizing occupation-as-means to develop an occupation-based treatment plan
to ameliorate a patients impaired skill eventually leading to improved occupational function
(Trombly Latham, 2008). The therapist incorporating a client-centered treatment plan that
motivates engagement in the therapeutic occupation will remediate skills and self-efficacy. Hand

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therapy is identified as isolated exercises performed in a gymnasium clinic; however, some hand
therapists are utilizing a more holistic approach and incorporating meaningful and purposeful
activities into treatments (Cooper, 2008).
The outcome for this intervention would be measured by the patients participation in
desired occupations in ways that are personally satisfying and congruent with expectations with
the culture (AOTA, 2014, p. S35). Utilizing meaningful occupations will motivate engagement
in that activity. The patient finds purpose and pleasure in preparing her traditional meals for her
family. By integrating patient-directed goals and ADLs into hand therapy, the patient will
increase self-efficacy within that role.
Precautions and Contraindications
Precautions and contraindications should be adhered to when applying PAMs and
performing therapeutic exercises during treatment. Precautions for all intervention activities
should adhere to avoiding rigorous forearm rotation or wrist movements and to avoid continued
pinch or forceful grip (Cooper, 2008). A contraindication according to Cooper (2008), patients
with upper extremity impairments arrive to therapy anticipating that the intervention will be
painful and will not share with their therapist if they are experiencing pain. It is imperative that
the OT be aware of body language and facial expressions to avoid further insult to the injury.
Lastly, night splinting to avoid wrist deformities and to relieve pressure at the carpal tunnel
(Cooper, 2008). Skin integrity should be monitored to avoid any skin breakdown or skin
irritation.
Frequency and Duration
The patients physician has referred her to Select Physical Therapy outpatient
rehabilitation for OT services. The physician has ordered one hour conservative management

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treatment sessions two times a week for four weeks. The outlined therapeutic procedures and
services in the plan of care will address the problems and goals identified.
Grading Up and Grading Down
The patient will begin the folding activity seated just folding small washcloths or pillow
cases on a table top. The focus of this activity will be to increase the patients bilateral hand and
finger function. This activity can be graded up by having the patient stand and fold bath towels
and sheets. This will require the patient to use more proximal strength and grip strength by
consistently grasping and releasing the linens.
Primary Framework for the Intervention Plan
The frame of reference (FOR) that will clearly be guiding this intervention plan with this
patient that I will utilize is the biomechanical. The biomechanical FOR is used to help patients
with deficits in the musculoskeletal system (Gillen, 2014). The patient has decreased bilateral
hand strength negatively impacting the patient to participate in activities of daily living. This
patient needs to use a wrist cock up to help her at night with sleeping. The biomechanical FOR
is typically identified with remediation, or improvements in strength, endurance, ROM, and
muscle tone to achieve movement (Gillen, 2014). This FOR uses a bottom up approach. This
FOR views the body as a functioning machine focusing on specific muscle areas of the body that
has been affected by injury or disease to improve occupational performance (Gillen, 2014). The
patient suffers from decrease strength, AROM, and pain. This activity will increase the patients
ability to perform dressing, cooking, and other areas of activities of daily living. The activity
may be graded up or down to suit function. For my goal setting, I utilized the task-oriented
approach FOR. This FOR was appropriate for this patient. According to Gillen (2014), the
major focus of this approach is on goal-directed training using functional tasks, such as everyday

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life activities (e.g. dressing oneself, cooking, washing dishes). This FOR utilizes adaptive or
assistive devices, and environmental modifications. The task-oriented FOR allows the
occupational therapist to recognize the need to view occupational performance holistically. The
foundation for utilizing this FOR is to enable the patient to successfully engage in tasks and
activities associated with her roles and occupations she is expected to do, need to do, and want to
fulfill. Utilizing purposeful and meaningful tasks are primary intervention modalities. The
combination of these two theories allows the therapist to look at the client factors preventing
occupational performance while considering the intrinsic factors that are meaningful and
purposeful to the patient.
Patient Education
Patient education would be an ongoing process throughout the application of the
intervention plan. The patient is educated regarding her diagnosis, prognosis, related pathology,
and plan of care. Education on safety techniques to avoid excessive forearm rotation or wrist
movements and to avoid continued pinch or forceful grip (Cooper, 2008). Instruction on energy
conservation techniques in pacing to avoid fatigue that will promote inflammation again to the
area. Patient is sent home with a pamphlet containing an Independent Home Exercise and SelfCare Program. Tendon and median nerve gliding are exercises that will promote digital and joint
mobility, they are a pillar of most home exercise programs (HEP) along with utilizing PAMs
(Cooper, 2008). The patient reported that her husband bought her a paraffin machine, and she
uses it every day in conjunction with the exercises.
Monitoring and Assessing Patients Response
The patients response to the interventions will be monitored and assessed for progress
using observation, self-report, and measurements. The therapist will re-evaluate the patient and

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progress will be assessed based on effective or ineffective completion of the specific activity.
The intervention can be modified based on the patients abilities and performance. The patient is
asked to fill out a self-report called Patient-Related Hand and Wrist Evaluation (PRHWE) on her
pain levels doing different activities of day. The patient is asked to verbalize if she experiences
any pain doing her treatment session. In addition, measurements will be re-evaluated. A
goniometer will be utilized to obtain MCP, PIP, DIP, and wrist joint measurements. Lastly, a
dynamometer will be utilized to measure grip strength. Through formal or informal assessment
procedures, the therapist will determine if the intervention is effective or if modifications are
needed in specific areas of the treatment.

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References

American Occupational Therapy Association. (2014). 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.
Amini, D. (2011). Occupational therapy interventions for work-related injuries and conditions of
the forearm, wrist, and hand: A systematic review. American Journal of Occupational
Therapy, 65, 2936. doi: 10.5014/ajot.2011.09186
Cleveland, P. (2011). Planning intervention. In C. Christiansen & K. Matuska (Eds.), Ways of
living, intervention strategies to enable participation(4th ed., pp. 89-103). Bethesda, MD:
AOTA Press.
Cooper, C. (2008). Hand impairments. In M. V. Radomski & C. A. Trombly Latham
(Eds.), Occupational therapy for physical dysfunction (6th ed., pp. 1131-1170).
Baltimore, MD: Lippincott, Williams & Wilkins.
Gillen, G. (2014). Motor function and occupational performance. In B. A. Boyt Schell, G. Gillen,
& M. E. Scaffa (Eds), Willard & Spackmans occupational therapy (12th ed., pp. 750778). Baltimore, MD: Lippincott Williams & Wilkins.
Trombly Latham, C. (2008). Occupation: Philosophy and concepts. In M. V. Radomski & C. A.
Trombly Latham (Eds.), Occupational therapy for physical dysfunction (6th ed., 339357). Baltimore, MD: Lippincott, Williams & Wilkins

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