FIELDWORK I ASSIGNMENT

Client Evaluation from site

Complete an occupational profile on a client at your site. This should be a different client than the person
used in your SOAP assignment. In some settings it may appear appropriate to ask these questions to the
client directly, in other settings it may be more appropriate to talk to a caregiver. Once you are done with
the occupational profile, complete the Analysis of Occupational Performance. Please enter the
information you gather under the headings in this form, you do not need to write it out narrative style.

Occupational Profile
Who is the client? What is his or her occupational history, life experiences, or previous patterns of
engagement that influence who they are today? (2 points)

Client is an 79-year-old female who fell in her home while walking back to the bathroom. She currently
lives in an ALF where she receives some assistance with daily tasks. She is a previously healthy woman,
but had a back surgery several years ago which has affected her ability walk. When she fell, she lay on the
floor for almost five hours and tried to get up several times with no success. Her fall did not result in any
major injuries, just bruises, fatigue, and general health decline. She spent a few days in the hospital before
being discharged to transitional rehab. She is currently retired but worked as a music teacher for most of
her life. She was previously married, but her husband passed away several years ago. She spends most of
her day watching TV and participating in the different activities and social events that take place at her
ALF.

What is the reason for referral for this client? Why are they seeking services? (1 point)

This client is receiving services due to a recent fall which has led to a decline in her health. She needs to
regain some independence in daily tasks before returning to her ALF.

What are the client’s and/or family member’s current concerns and goals for the intervention? (2 points)

The client’s goals for therapy include being able to return to The Wellington, her ALF, and being able to be
more independent in her self-care tasks. Her main concern is being able to go to the bathroom by herself
and not needing anyone to help her so she can go when she needs to. She is also concerned about falling
again and would like to be safer when she is at home.

What occupations does the client currently identify as important or meaningful? (2 points)

Client identified toileting, showering, and dressing as important self-care tasks that she likes to be more
independent with. She also loves to play piano and the organ and finds this activity very meaningful. The
client also has one brother and spending time with him is extremely meaningful to her.

What occupations is the client currently successful in. Why? What difficulties is the client currently
having with his/her daily occupations? (2 points)

The client is currently successful in self-feeding, wheelchair management, UE dressing, and brushing her
teeth and other grooming activities. The client is able to perform these activities safely, completely
independently, and successfully on a daily basis. Client is struggling with safety and performance of
toileting, LE dressing, showering, functional mobility (specifically transfers and ambulation). Client
currently requires Mod-Max (A) for all of these activities. Prior to her fall she was IND-Min (A) with all of
her BADLs.

What contexts support engagement in the desired occupations? What contexts inhibit participation? (ie
cultural, personal, physical, social, temporal and/or virtual) (1 point)
The client’s assisted living facility provides assistance with daily routines including showering, dressing,
and providing her with daily meals. This allows the client to still maintain her independence, but get
assistance with tasks when needed. Since her home is designed with seniors in mind, her environment has
AE readily available such grab bars in the shower and by the toilet, shower chair, and accessible living
spaces. The client also uses a wheelchair for most of her mobility and when walking, she uses a walker.
While the facility has social activities, the client often feels lonely and lacks the social participation that
she enjoys. While the facility has complimentary transportation, she also rarely leaves her home which
leaves her feeling isolated at times.

Analysis of Occupational Performance

Select a specific occupation that the client is having difficulty with to analyze:
________toileting________ (1 point)

From the Practice Framework, determine 3 client factors that are most impaired. Describe how the
impairment of each client factor affects performance of the occupation you selected to analyze (4 points)

Strength: the client has overall decreased full-body strength due to her fall and spending time in the
hospital, her decreased strength affects her ability to transfer onto the toilet (requires Mod A) and stand
and pull up her brief and pants after toileting (requires Mod A)

Balance: the client has poor standing balance which affects her ability to safely transfer to the toilet and
stand during clothing management, the client also currently stands to clean herself during toileting and
her poor standing balance makes this task difficult

ROM: the client has decreased ROM in her back (unable to stand up all the way straight) and in her right
shoulder which affects her ability to clean herself during toileting, the toilet is positioned so that the grab
bar in on the left side, so the client must hold onto the grab bar with her left hand to stand and clean
herself, due to her limited ROM in her right shoulder and stooped posture, she is currently unable to
reach around to clean herself

Specifically describe one way you, as an occupational therapist, would evaluate or quantify the client’s
current performance of the identified occupation. (2 points)

Client requires Mod (A) with toileting.

Design and describe at least two treatment sessions that you could use as an occupational therapist to
improve performance in this occupation. (4 points, do not describe a treatment your supervisor did, this
needs to be your own design)

1. Instruct and educate the client in using AE to help clean herself during toileting, including using
something like a Bottom Buddy. This will help the client to facilitate her functional reach to
increase her independence with clean-up during toileting. The client could practice apply
cleaning materials to the device, releasing them, and positioning the device while seated on the
toilet.
2. Have the client stand in front of a mat table with their FWW in front of them. Place cones at the
client’s knee level on the mat on both sides. Have the client hold onto the walker with each hand
while bending down and picking up the cone with the other. This will simulate the motion and
skills needed to perform clothing management with one hand during toileting while using the
grab bar for safety with the other hand.

Write a Long Term Goal that is appropriate for this person that addresses the identified occupation. Goals
should be measurable, related to the occupation, and have a stated deadline for completion. (3
points)

Client will complete toileting with CGA and the use of AE.
Write two Short Term Goals that lead to the above Long Term Goal. Short terms goals should build
directly toward the achievement of the long term goal. (6 points for two SMART goals)

Client will perform clean-up during toileting with MIN A and the use of AE.

Client will perform clothing management IND during toileting.