BETTER REHAB CASE STUDY

Better rehab

OCCUPATIONAL THERAPY CASE STUDY

RAQUEL DA SILVA

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REsponding to Dennis

additional information

Top four priorities

soap note

TASK ONE

RESPONDING TO DENNIS

When you arrive to Dennis’ home, Dennis says, “I’m so excited! I haven’t seen a Physio in years. What are you going to do for my shoulder?” How will you respond to Dennis, and explain the role of an Occupational Therapist?

TASK ONE

I would respond to Dennis in the following way:

'Hi Dennis, I'm excited to meet you too. I'm sorry to hear about your shoulder. My name is Raquel, I'm an Occupational Therapist. Although I'm not a physiotherapist, there are things I can do to help you with your shoulder pain. We can discuss some options during our session today.'

tASK ONE

Following this introduction I would continue with:

'As an Occupational Therapist I help people to achieve their goals. For example, during our session today I will look at your home environment, equipment and how you are currently transferring to see if these are still working for you. We will also discuss and begin the process of working towards getting you into your own home.'

TASK TWO

What additional information would you need to seek from Dennis or his family?

• Specifics around Dennis’ shoulder pain e.g. when is it at its worst? When did the pain start? How long has it been occurring? What activities are painful? How is the pain currently been managed?

• As there has been limited engagement with therapy services since the initial injury, I would want to know the following: What services have you previously accessed? How long did you engage in these services? Are you currently accessing or interested in accessing other services? If so, which services and what is the primary goal of these services?

• Understanding Dennis' expectations of occupational therapy e.g. what goals/outcomes are you hoping to achieve through occupational therapy? How long are you expecting to engage with occupational therapy? Do you have a timeline in mind? For example, do you expect your primary goal to be addressed within a certain amount of sessions?

TASK TWO

What additional information would you need to seek from Dennis or his family?

• Exploring Dennis' occupational participation and him as an occupational being e.g. what does a ‘normal’ day look like for you? What occupations do you engage in? What do these occupations look like and how much support is provided? Is there opportunity to allow you (Dennis) to be more independent when completing such occupations?

• Understanding Dennis' current knowledge and how much him and his family would like to participate in therapy. What is Dennis and/or his family willing and able to do (have knowledge to do) to progress therapy? E.g. have they began discussing potentially accessing formal support? Have they looked at housing options?

• Exploring expectations around moving out e.g. his current finances, how support will be provided, specifics around what he is looking for (e.g. suburb, amount of rooms and bathrooms, renting or buying a house, house or an apartment etc.).

The above is a short list of additional information I would collect from Dennis and his family.

task three

top four priorities

Considering all the information you know about Dennis thus far and his primary goal to move out of home. List what you might think are the top four priorities to explore further with Dennis and a short explanation why.

task three

priority one

Addressing his current assistive technology.

Although Dennis is reluctant to trial or change his current equipment, it is incredibly important that he has access to equipment that is safe and will support him to participate in his daily occupations. Additionally, as participation in personal activities of daily living contribute to well-being and self-maintanence, I see it as the foundation for Dennis to be able to achieve his priority NDIS goal. Currently his damaged and ill-fitting equipment is having a negative affect on his musculoskeletal system as it is contributing to his right shoulder pain. As he constantly repositions himself when in the wheelchair, the equipment is also resulting in reduced participation in occupations and difficulty when mobilsiing. In order to address this priority I would not remove his current equipment until he was happy with the new trialled equipment. I would also complete a wheelchair assessment (as his anthropometrics may have changed since his injury) and trial multiple options to allow him choice and ownership of the decision.

task three

priority two

breaking down his priority goal into smaller more managable goals.

A personal saying I use often is: 'the best way to eat an elephant, is to do it one bite at a time.' This saying perfectly sums up Dennis' priority NDIS goal. To move into your own home is a milestone step in any person's life and it can be a very stressful and exciting time. As a therapist I would want to guide Dennis through and explore what this goal means and looks like to him. Following this we would breakdown the various areas that would go into this large goal including home management, meal preparation, and community access in order to develop a plan for each area together. Developing life skills (capacity building) requires time, frequent and repetitive education, and task repetition, so developing clear goals and a solid plan at the beginning of the occupational therapy process is crucial to Dennis acquiring the necessary skills to achieve his NDIS priority goal.

task three

priority three

Understanding his and his family's current knowledge and how they want to participate in therapy.

Before beginning our journey together I would want to understand their current knowledge and experience (client expertise). By knowing this, I will be able to tailor my education and plan to suit their strengths and weaknesses. Additionally, I would also want to understand how they want to participate in therapy. Not every person participates in therapy the same way. Some people are more disciplined and/or independent when completing tasks or activities at home or between sessions. While others require more 'hands-on' support and guidance to achieve their goals. Understanding what they want, are able to do and are comfortable to complete independently, is an important key to success. Understanding a client's desired participation level towards therapy can also impact timelines for long-term goals similar to Dennis'.

task three

priority Four

Exploring and establishing personal and community supports.

A key determinant of success for Dennis will be having an effective and reliable support system outside of his immediate family. Therefore, exploring what supports are available to Dennis through his personal networks and in his community is an important step. Such networks can take time to explore, establish and maintain hence it is important to start as soon as possible.

TASk four

Outline a brief progress note (in SOAP format) outlining the conversations with Dennis and relevant assessment details from the case study including your proposed plan.

Client (Mr Dennis) seen by Occupational Therapist (R. Da Silva) at Client's home. Consent granted. Mr Dennis and his mother, Anne, present during session. Subjective: Dennis expressed concerns around his shoulder pain. He reported this pain had been ongoing for ‘a few months’ and that he currently manages the pain through Panadol and by reducing his engagement in daily occupations. Dennis reported that he would like to be referred to physiotherapy to address his shoulder pain. When discussing Dennis’ priority NDIS goal: to be able to move into his own home, Dennis’ mother (Anne) reported that she was ‘anxious and nervous’ and that she ‘did not know how it would be possible’. Dennis also expressed feeling ‘anxious’ but that he was also ‘excited to have some freedom and space from his parents’.

TASk four

Objective: Discussion regarding personal activities of daily living (PADLs) and completion of transfers

• Dennis reported that following: Set-up assistance is provided by his parents for showering and dressing. Dennis is independent in grooming tasks including brushing his teeth and shaving his face.

• Sequencing task/planning: No concerns reported by Dennis or Anne.
• Upper Limb: Dennis reported he has recently reduced use of his right upper limb during PADLs including hair washing and hair brushing secondary to shoulder pain when upper limb is raised. No other concerns expressed.
• Dennis completed the following transfers: 1) Lying on back to seated in bed was completed with moderate assistance. 2) Pivot transfer from wheelchair to chair was completed with supervision. Dennis was able to independently articulate steps and support required for each transfer correctly prior to completion.
• Attention: Dennis attended to 50 minute session.

Equipment review:

• Mobile shower commode: Seat cushion is splitting and frame is rusty. Commode remains in shower when not in use.
• Dennis has access to ensuite bathroom which he solely uses.
• Manual wheelchair: Backrest was torn, which has been temporarily fixed with tape. The armrests and footrests of the wheelchair are bent and difficult to remove and replace during transfers. Dennis reported requiring to constantly reposition himself when seated in wheelchair which has resulted in increased difficulty mobilising in his wheelchair.
• Insight: With verbal prompting Dennis was able to identify that trialling new equipment would be beneficial.

TASk four

Simple hot drink preparation

• Dennis was able to complete simple hot drink preparation with set-up assistance.
• Dennis was instructed to make 1x black coffee and 2x white teas with 1x sugar each.
• Set-up: He completed the task in sequential order. Dennis collected all refrigerated items required at once. He requested and received assistance to collect 3x cups from above countertop cabinets. Family reported that they typically would ensure 2x cups remained on countertop for Dennis to use. Once each step was completed, Dennis would leave the used container/item open on the countertop. He did not require any prompting to initiate cleaning.
• Sequencing: He independently sequenced task, asking for assistance when required.
• Attention: Dennis was able to both sustain attention on task and divide his attention between answering questions and completing the task.
• Memory (immediate recall): He was able to independently recall 3/3 items correctly.
• Memory (delayed recall): Dennis completed 3/3 items correctly on first trial.
• Problem solving: Dennis recognised that the kettle was not turned on at the wall, fixed the error and proceeded to turn on the kettle.
• Dennis reported pain when lifting kettle to pour hot water.
• Efficiency/processing time: He completed 3x hot drinks in ~7 minutes.

Discussion regarding NDIS goal, domestic activities of daily living (DADLs) and community participation

• Dennis reported requiring full assistance for community participation, meal preparation and cleaning.
• Anne reported that she completes all meal preparation.
• Dennis reported that he has very limited experience and knowledge with meal preparation and home management.
• Dennis is independent with personal money/finance managment.
• Dennis does not have any formal supports in place. Dennis and his family have not explored accessing formal supports prior.
• Dennis and his family reported not knowing where to start to achieve his NDIS priority goal.

TASk four

Assessment:

• Dennis is able to complete PADLs and simple hot drink preparation with set up assistance.
• Dennis is able to complete grooming tasks independently.
• Dennis requires maximum assistance with community participation and DADLs.
• Dennis' shoulder pain is impacting on and reducing his occupational engagment and performance during PADLs and DADLs.
• Dennis had no difficulty with sustained, alternating and divided attention.
• Dennis requires moderate assistance to move from lying on back to seated in bed due to decreased core strength.
• Dennis is reluctant to trial new equipment but with verbal prompting he was able to identify that trailing new equipment can be beneficial to reduce shoulder pain and increase safety.
• Dennis and his family have not begun to explore formal support or discuss Dennis' priority goal of moving out.

Plan:

• Wheelchair assessment and prescription (trialling multiple options).
• Trial a mobile shower commode.
• Goal setting to breakdown NDIS priority goal into small goals by continuing today's discussion with the aim of establishing a clear plan to address main challenges in achieving this goal e.g. home mangement, meal preparation, community access, money management etc. A clear plan will include activity modification (where applicable) and education.
• Dennis/his family will begin to explore potential financial budgets and identify challenges to achieve NDIS priority goal in preparation for our next session.

• Referral to physiotherapy to address shoulder pain.
• Functional assessments e.g. kitchen, home management, shopping etc.