Immigration and Resettlement FW II

Occupational Therapy Weekly Progress Note

Date: 6/13/17
Client: Pulcherie Nodjingoto
Age: 47
Gender: Female
Agency: IRC
Country of Origin: Central African Republic
Agency Therapist or CW: Olga

Residents reactions to this weeks activities:

Client was happy to see MOTS and engaged in tasks, but her demeanor changed and
she appeared tired and in pain after about 45 minutes.

Activities completed and residents response:

Client ambulated to the kitchen for multi-step meal task with modified independence
utilizing walking cane for the blind. Used microwave with min A. Successfully identified already
cooked food that someone had left in the microwave and set it aside
appropriately. Independently managed the microwave including opening and closing the door
and pressing appropriate buttons to cook. Nutrition education provided.
Clients sister was identified as the person who buys food for the house and was asked
questions about diabetes nutrition. Clients sister indicated that she had received no education
on what food was appropriate for diabetes and that she was unable to read in French.
Checked blood sugar with Max VCs from daughter in native language. HOH was used
to twist off lancet device cap and to put lancet into glucose meter. Max A given to clean up.
Client became less responsive and put her head in her hands several times after approx
45 minutes. When asked if she was finished for the day she said good night in French and
pointed to her right kidney and indicated pain.

Summary of strengths/concerns/barriers/progress toward goals:

Client shows great potential for progress towards goals as shown in performance in
checking blood sugar level and preparing multi-step meal using the microwave. Sister being
present and willing to help as needed and receive nutrition education is of benefit to
client. Blindness, low energy levels and dependence on her children inhibit the speed of
progression. Client will benefit from continued practice using glucometer to increase
independence.

Plan for next week:

Client will benefit from continued OT services for one hour per week for 12 weeks in
order to improve diabetes management, use of microwave and familiarity and mobility within the
kitchen.
Goals for next week:
1. Client will practice checking blood sugar level with Min A.
2. MOTS will take food storage containers and provide education to client and family
members on importance of keeping lid on and why.
3. Client will be asked to pull out her guitar and play a song.
4. Client will use microwave to cook multi-step meal.

GAS GOALS:

LTG #1: Meal Prep

-2: Within 12 weeks, client will be able to prepare multi-step meal with total assist using
compensatory strategies.
-1: Within 12 weeks, client will be able to prepare multi-step meal with max A using
compensatory strategies.
0: Within 12 weeks, client will be able to prepare multi-step meal with mod A using
compensatory strategies.
1: Within 12 weeks, client will be able to prepare multi-step meal with min assist using
compensatory strategies.
2: Within 12 weeks, client will be able to prepare multi-step meal independently using
compensatory strategies.

LTG #2: Diabetes Management

-2: Within 12 weeks, client will be able to manage her diabetes with total assist.
-1: Within 12 weeks, client will be able to manage her diabetes with max A.
0: Within 12 weeks, client will be able to manage her diabetes with mod A.
1: Within 12 weeks, client will be able to manage her diabetes with min A.
2. Within 12 weeks, client will be able to manage her diabetes with modified independence.

Katrina Smith, MOTS________________ ____________________________

OT Student signature Supervising OTR/L signature