Medical History and Occupational Performance Issues - Case Study Example

Name: Class: Instructor: Date: Introduction: This case study report is about Mrs. Sarah. Mrs. Sarah is not a genuine name but rather a pseudonym that will be used throughout the report. Mrs. Sarah and an OT student met during the student’s placement in community X health center; which is a pseudonym to use throughout. In this case study, Sarah’s background will be explained and her current occupational performance. Also, the report will provide information about occupational therapy, long and short terms goals and with an explanation of suitable interventions, the rationality of each goal and referrals. Client background: Mrs. Sarah is a 51-year-old woman. She is referred by Community rehabilitation center OT for follow-up of major bathroom modifications. Sarah also functions in new Office of Housing (OOH) property. Medical history: Complex medical history that impact on her mobility and transfer including: Turner’s mosaic syndrome. It is a Turner disorder which is an uncommon chromosomal issue that influences females. The turmoil is described by halfway or complete misfortune (restraining infrastructure) of one of the X chromosomes. It can conceivably build up a wide assortment of indications, influencing a wide range of organ frameworks. Basic side effects incorporate short stature and untimely ovarian disappointment, which can bring about the inability to achieve adolescence. Paget’s disease. This is a ceaseless condition that causes anomalous expansion and debilitating of bone. Any part of the skeleton can be influenced, yet the most widely recognized destinations incorporate the skull, spine, pelvis, thigh bone, skin and the bone of the upper arm. Decreased bone density (Osteopenia). Abnormally high concentration of parathyroid hormone in the blood (Hyperparathyroidism). Hypothyroidism: the inability of the thyroid gland to make enough thyroid hormone to keep the body running normally. Asthma Depression/anxiety Low back pain Left shoulder surgery 2014 Right facial surgery 2014 Multiple investigations re: reason of falls Social history: Mrs. Sarah lives with her husband, stepdaughter, and a step grandchild in OOH property. Recently they relocated from OOH property on Disability Support Pension (DSP). Her husband receives career allowance and career payment. None of them has formal services in place currently. Occupational therapy assessments: 1- Occupational therapy functional assessment: Self-report and observation standardized assessment used to investigate current mobility and functional status for the consumers. For assessment findings see below. Current occupational performance: Mobility: Sarah is independent and mainly stays indoors without aids (tends to walk with the help of furniture). When in outdoors, Mrs. Sarah normally walks with the help of a 4-wheeled walking frame (4WF) (given increased time). Personal tasks: Mrs. Sarah is independent toileting, grooming, and feeding. She is using shower stool and therefore, she requires maximum assistance for showering her lower limb and back due to her left shoulder range of motion, back pain and shower recess space. Also, a maximum assistance is needed for dressing her lower body and managing medication, which is provided by the husband. She reported that she experience difficulties when getting out from the bed and sometimes when going to the toilet. Domestic tasks: Mrs. Sarah is able to complete some house chores like cleaning tasks with time. However, she needs assistance especially for heavy cleaning such as vacuuming that is provided by her family. Mrs. Sarah cooks independently but she takes increased time. Sarah requires assistance for laundry tasks. Community tasks: Mainly Sarah walks independently to the local shops with 4WF under the escort of a family member. Sarah has a Taxi card concession but unfortunately, her husband and stepdaughter do not know how to drive. After she completes shopping the family member who had accompanied her helps in paying the bill. Sarah likes gaming especially she enjoys playing PlayStation. She also likes walking and reading magazines. 2- Home assessment: A standardized assessment used to collect information about current status of consumers house in regards to the access, bathroom, toilet, kitchen, bedroom and seating area. Assessment findings: Access: There are 2 steps in the front door and 1 step in the back door with rail, which is not stable. Bathroom: Has shower recess with 3 sliding shower door and vertical rail. Also has towel rail on the way to the hand washbasin. Sarah reported that she holds this rail sometimes when walking to the wash-basin. The toilet is cubicle. Sarah reported that she finds it difficult to get off the toilet. Bedroom: Sarah has a queen bedroom with commode beside and she reported that it is difficult to get out. Seating: the sitting couch has arms but Sarah reported she finds it difficult to get off from her sitting position. Summary of occupational performance issues: Sarah doesn’t feel safe using her 4WF due to the breaks is not working well. Also using backdoor access and walking in the bathroom to the hand wash basin is a task and difficult. She is unable to take her medication independently. Due to her left shoulder surgery, shoulder range causing motion limitation and her back pains; Sarah requires assistance when showering her back and lower limbs and when fitting to the shower recess. Mrs. Sarah requires assistance when dressing her lower body. She finds it difficulty getting off toilet cubicle, bed, and lounge chair. Long-term goals: Mrs. Sarah wants to be independent, completing her personal tasks and mobilizing safely as soon as possible to increase her confidence and comfort throughout the day. The following long-term goals were stated according to her current occupational performance issues and Sarah’s priority. Considering the nature of the occupational therapy services that is provided by primary care department in X community health center, the following long-term goals were realized: 1- Sarah will be able to shower by herself with less help by the end of week 8. 2- She will be able to get off the toilet, bed and lounge chair more easily by the end of 7 weeks. 3- Mrs. Sarah will dress her lower limb, body and be able to manage her medication without help by the end of 6 weeks. 4- Will be safely using back access, 4 WF and walking to the hand wash-basin in the bathroom by the end of week 8. Short-term goals: 1.1 – Sarah will be fitting to shower recess and using her shower stool with enough space by the end of week 5. Interventions: remove the existing vertical rail from shower recess and replace existing 3 slides shower door with a curtain or swing-style door. Rational: Mrs. Sarah’s shower recess has limited space, as it is located beside the bath. It has 800 mm in length and 780mm width. So, remove the existing vertical rail from shower recess. The position of this rail impacts on Mrs. Sarah use of her shower stool. As she reported she can't use her right hand to reach left shoulder and back area. Also, replace existing 3 slides shower door with a curtain or swing-style door to improve the access space for Mrs. Sarah. 2.1- Sarah will be able to wash her back and legs independently by the end of week 2. Intervention: Long handle sponge (Austcare Economy Long Handled Bath Sponge). Rational: Mrs. Sarah requires assistance from her husband to shower her back and legs due to her left shoulder range of motion limitation and back pain. Long handle sponge (Austcare Economy Long Handled Bath Sponge) will help Sarah to reach concerns area and increase her independence showering. 3.2- Mrs. Sarah will be to able get off from toilet seat easily by the end of week 5. Intervention: install bilateral hand grip rails in the toilet cubicle. Rational: Mrs. Sarah can push on the rail for assistance to stand, or can hold the rails while lowering onto the toilet seat. Currently, Sarah is using toilet paper holder to get off toilet which is not safe and might cause a fall. 4.2 will be able to get off her bed easily by the end of week 3. Intervention: provided bed stick to Mrs. Sarah Rational: Provision of a bed stick and education on the use of bed mechanics to support Sarah's independence with getting in and out of bed. As she reported that she needs time to get out bed and sometimes holding the edge of commode beside. 5.2 Mrs. Sarah will be able getting off lounge chair easily by the end of 6 weeks. Intervention: A chair with armrests; Anza Euro High back Chair; Model 10480. Rational: the current lounge chair is a bit low and causing more difficult to get out and direct pressure towards the pelvis rather than distributing it evenly along the thighs. A chair with armrests that is Anza Euro High back Chair; Model 10480 provision to Mrs. Sarah will make her chair transfer easy and without pain. 6.3 Will be able wearing socks without assistance by the end of week 2. Intervention: Provision of a Home craft Dorking Sock & Stocking Aids; Model AA4650. Rational: Mrs. Sarah is dependent in wearing sock at the moment due to her shoulder limitation and back pain. After provision and practice using (Home craft Dorking Sock & Stocking Aids; Model AA4650), Sarah will be able to wear socks independently. 7.3 By the end of week 3, Mrs. Sarah will be able wearing her pants independently. Intervention: Mrs. Sarah should be provided with a Dressing stick especially Hills Healthcare Equipment Dressing Stick will provide to Mrs. Sarah. Rational: The dressing stick is essentially utilized as a part of putting on jeans. It is an augmented compass of the hand that will snare onto the gap. The leg is put into the leg opening utilizing the snare end of the stick. Once arranged precisely, the gap is pulled up the leg until it can be effortlessly come to. The dressing stick is a lightweight tool allows Mrs. Sarah to dress without bending and will be able to use it by the end of 3 weeks after training sessions. 8.3 Mrs. Sarah will be managing her medication by the end of week 2. Intervention: Medication Webster pack; Webster-pack® Community should be provided to Mrs. Sarah. Rational: Sarah used to have different medications in the different time and reported she is dependent to take her medication for that reason. Medication Webster pack; Webster-pack® Community will be provided to Mrs. Sarah, so she does not need to recognize what medication that she need to take at any time of day and will make sure that she take prescribed dose correctly. 9.4 will be safely used back access by the end of week 6. Intervention: repair of existing rail at back access. Rational: back access rail is missing a fixing point to the brick wall and does not appear to be securely attached. This might cause a fall especially in wet weather or dislocated from the wall when Sarah use it. 10.4 Mrs. Sarah will be safely walking to hand washbasin by the end of week 6. Intervention: replace existing towel rail in the bathroom with grab rail. Rational: Mrs. Sarah holds onto this rail when walking to the sink and in its current state this towel rail is not structurally sound since it may cause Sarah to fall. While handrail is strong enough to take Sarah’s weight and is designed to be installed in the wet area. Referrals: Physiotherapy: Mrs. Sarah will be referred to physiotherapy clinic at the community center. This referral aims at increase Sarah’s muscle endurance, balance, and mobility. The physical therapist can teach Sarah appropriate home exercises to strengthen her back and minimize back pain. Also, the process of repairing the 4WF wheel chair will be discussed. Office of Housing (OOH): As OOH is the owner of Sarah's house, a request for home modification to be submitted by the occupational therapist. OHH has their architects to take measurements and funding resource to support their consumer who is eligible to receive funds for modification. National Disability Insurance Scheme (NDIS): NDIS is an independent statutory agency, which supports Australians who have the significant and permanent disability and their families with careers. There are requirements needed for one to receive support from NDIS. These are: to be an Australia resident, be under 65 years old and lives in the coverage area by NDIS. Also, need a weakness or condition that is liable to be perpetual and that prevents you from doing everyday things by you. Mrs. Sarah is eligible to receive funds from NDIS for assistive devices that she needs to be independent in most daily life tasks like self-care devices and seating chair. Following up: Ongoing phone calls each 2 weeks will be made by the occupational therapist to review the outcome of interventions. Home visit to be completed by the occupational therapist in 9 weeks to complete occupational therapy functional assessment. Conclusion: This case study report demonstrated Mrs. Sarah's background, medical history, and current occupational performance issues. Appropriate long and short term goals explained with possible interventions. Moreover, Sarah's referrals and following up plan explained. Next project propose question: How is home dose modification an effective intervention to prevent falls for older people with mobility issues? Read More