Professional Documents
Culture Documents
Case Map 6
Case Map 6
Case Map 6
Physical:
Social:
Temporal:
Virtual:
Prior Occupations:
Current Occupations:
2.
3.
COPD is characterized
by damage to the alveolar
wall and inflammation of
the conducting airways
and includes emphysema,
peripheral airway
disease, and chronic
bronchitis. Cigarette
smoking is the primary
cause of COPD. Other
environmental irritants
such as air pollution,
chemical exposure, and
dust are contributory
factors. COPD is a
progressive, chronic
disease. In order to be
diagnosed a medical
history evaluation will be
conducted. Blood work
and an x-ray will also be
performed. Medications
will be prescribed.
Type 2 Diabetes is a
chronic condition that
affects the way the body
metabolizes sugar. It is
cuased when the body
becomes resistant to
insulin when the
pancreas stops producing
enough insulin. This is
could be caused by
genetics/environmental
factors, and weight
gain/inactivity. In order
to diagonse it, a patient
will be given a blood test.
Treatment includes
healthy eating, regular
exercise, diabetes
medication/insulin
Cleaning the counters, sweeping the floor, doing I would want to observe his cleaning abilities
the dishes because he is in transitional rehab in order to
regain strength to return home. He also views
cleaning as one of his top priorities. It is
therefore important to assess the reason he is
here, his decreased strength. I would have him
do a cleaning task like cleaning the kitchen at the
facility including doing the dishes. This is a task
that involves strength and endurance. I would
use this task to evalute his activity tolerance. It
would help me understand how long he can
tolerate standing and working. It would help me
understand the MET level he can endure and for
how long. It would also help me understand how
he is able to grip and manipulate objects like
plates and cleaning supplies. I would use this
information to plan goals and treatment sessions
for him.
Method/Tool Rationale/What is being Assessed
1. Modified Fatigue Impact Scale Wendell has multiple diagnoses that causes him
to be fatigued and have SOB. I would want to
assess his level of fatigue to understand how it is
impacting his daily life habits, role, and routines
including his ADL performance. The fatigue
scale will help us know which specific areas we
should address to help him compensate for
fatigue.
2. Vision screen/ visual acuity Wendell mentioned that his vision is decreasing.
On the COPM, he mentioned that it is getting
harder for him to drive at night. I would want to
assess his vision to see what specific problems
he is having with it. This could help us know
what enviornmental modifications we could
make for him or what compensatory strategies
would be useful for him.
3. Monofilament testing This is a quick and easy to use test to understand
loss of protective sensation. Wendell mentioned
that he is feeling a tingling sensation in his
fingertips and toes. This test will help us
determine the loss of his sensatition which will
allow us to determine client education and
strategies for him to use at home to address this.
5. Medication management portion of the PASS Wendell has a lot of medications to take with all
his coexisting conditions. I would want to assess
how he is doing with managing his medications
by adminitering that portion of the PASS. He has
a hard time managing his diabetes so this could
help us understand why he is having a hard time
with that. This would also tell us a bit about his
vision, his cognition, and his fine motor skills. It
would be especially important to assess his
cognition because he scored in the mild
cognitive impairment range on the MOCA.
Being able to complete his medications is really
important to consider for sending him home
from transitional care.
6. Arthritis hand function test Wendell suffers from both OA and gout. It
would be important to assess how his arthritis
affects his ability to use hands using this
assessment. The information gathered from this
assessment would help us undersand the strength
and fine motor skills he has in order to better
understand how this interfers with his ADLs
such as donning his bra, opening bottles,
manipulating and gripping items, etc.
Resources:
Education and information about diabetes management, breathing techniques, healthy eating
Health tips and videos that can help educate him on how to manage his conditions
Suggestions for home health and future OT services that would benefit him
Recommended home eval
1a.STG:
In 1 week, client will don bra with min assist PEO
1b.STG:
In 1 week, client will don nylons seated at EOB with min PEO
assist
2. LTG:
In 3 weeks, client will shower using mod I. PEO
2a. STG:
In 1 week, client will transfer to shower tub with SBA using PEO
adaptive equipment
2b. STG:
In 1 week, client will independently complete LB washing PEO
using adaptive equipment
3. LTG:
3a.STG:
In 1 week, client will independently use energy conservation OA
techniques while preparing a simple meal
3b. STG:
In 1 week, client will independently identify healthy recipes Lifestyle redesign
he can make at home