Integrated Occupational Therapy Practice Case Study

Integrated handicraftal Therapy Practice flake StudyIntroductionThis tell allow centre on the occupational therapy (OT) answer for Meera (Appendix A), a 56-year-old muliebrity with a left cerebral vascular accident (CVA). touch is the death of brain cells repayable to the miss of oxygen (Bartels et al. 2016).It can either present as haemorrhagic or ischaemic in nature. chance of infection factors of CVA include high blood pressure and hypercholesterolemia which Meera has. guessing whitethorn lead to neurological, psychological, speech and musculoskeletal complications. Meeras symptoms of the right way hemiplegia, right perspectived neglect and speech difficulties can be attributed to the occlusion of her left middle cerebral artery (Mtui et al. 2016).A multidisciplinary in enduring byzant rehabilitation unit was involved with Meeras post-stroke rehabilitation. Stroke patients who underwent treatment inpatient stroke dish out were found to have modify emancipatio n (Stroke Unit Trialists Collaboration 2013). Treatment was aimed at managing resilient problems by dint of and through easementorative and compensatory salutees in roll to prepare her for discharge (Edmans 2010). Thus, this service was most appropriate for Meera due to her recent onset of stroke. The OT process was guided by recommendations from the College of Occupational Therapist, content Institute for Health and headache Excellence (NICE)(2013) and Intercollegiate Stroke Working Party (ISWP)(2016)(Edmans 2010).Assessments and Problems IdentifiedAn initial judging was gathered through an interview exploitation the Kawa framework. It portrays a some unrivaleds life as a river and discordant objects such(prenominal) as rocks, river banks and driftwood lay circumstances experienced by a person (Teoh and Iwama 2015). Younger stroke patients such as Meera whitethorn learn services which cater particularly to their needs which most stroke units were found non to do so (ISWP 2016). As Kawa foc roles on the view of the client, it allows the therapist to know what is important to Meera in pose to prepare priorities for intervention. The assessment is shown belowLife flow and priorities (river)PastMedical HistoryHypertensionHypercholesterolemiaRoles and Occupations individual in self-careProud Stay at home m otherTook charge of matters at home such asCleaningShoppingGardeningLaundryEnjoys cooking for familyPresentMedical HistoryStrokeRoles and OccupationsPatientNeeds assistance in most self-care jobsLoss of previous role and non engage in occupations meaningful to herFutureMeera felt afraid and pointless to talk round the future, worrying that she may have another stroke if she busy in activity.Obstacle and Challenges (rocks)Occupational performance challenges justifiedly hemiplegia with increased spasticity in right arm and leg, causing difficulty inSittingCoordination of movementTasks that shoot her fades due to being right handedUnable t o feel sensations on right handFeels she cannot remember things as easily and may not know the time and place she is atRight placementd neglect with visual agnosia, resulting in difficulty subspeciesing right sideawareness of the great un breaked go up from touch sideinteracting with othersExpressive dysphagia hinders communication with others.Feeling low mostlyFeels uselessEmbarrassed that people are taking care of herFatigues easilyConcernsFamily unable to rifle as she is unable to win the householdA burden to family, especially her husband who needs to neck the household together with the squash at work now that she is in hospitalChildrens studies and social life may be asked as they may be concerned about Meera and visiting her in hospital may affect their daily lifePhysical and favorable Environment (river banks)Physical (Home)3 room semi-detached tubfulroom, toilet and chamber on the upper storeyKitchen, combined life sentence and dining room on ground radixNeares t bus stop and convenience store 10 minutes walk awaySocialClose knit familyMeera usually supports family members as they will confide her during difficultiesLooks for shelter to dinner every sidereal day where family will gather togetherFamily is most vital source of support for MeeraFrequent interaction with neighbours and will help each other with chores if neededOccasionally communicates with extended family overseas on phonepersonal resources (driftwood)PersonalityHardworkingAfraid of trying unexampled thingsKind and caringResponsibleWith information from the initial assessment, the problem list was formulated in a client-centred manner (ISWP 2016). Stroke survivors felt more meshed in the therapeutic process when their perspectives were taken into account (Peoples et al. 2011). Interventions were based on Meeras perceived problems in order to increase her motivation in therapy which she lacked. However the Kawa model only shows the problems perceived by Meera but not the th erapists views. In order to gather a clinical and therapeutic point of view, regularise assessments were conducted as healthful. The circumvent below depicts the several(a) assessment conducted, reasons for use, limitations and results.AssessmentReasons for use and limitationsResultsAssessment of ram and service Skills (AMPS)(Fisher and Jones 2010)AMPS evaluates motor and treat skills of clients through observation of appropriate tasks (Fisher and Jones 2010). Self-care, specifically wareing, salad dressing and cooking tasks which was important to Meera, were employ to assess. This allowed the OT to break the tasks buck and acknowledge the challenges Meera faced in order to formulate an appropriate intervention. AMPS was found to be valid, reliable and standardized among cultures but results has to be computer generated in order to be valid which may make the process tedious (Fisher and Jones 2010).Less than 1 for both motor (Moderate increase in physical effort) and proc ess (Moderate inefficiency and disorganization) skills.Loewenstein Occupational Therapy cognitive Assessment (LOTCA) (Itzkovich et al. 2000)LOTCA evaluates the orientation, visual and spatial perception, visual-motor organization and thinking operations through the use of various activities included in the kit (Itzkovich et al. 2000). This allowed the OT to assess Meeras right sided neglect and to discover any underlying cognitive deficits. The LOTCA is reliable and valid for use in people with stroke but needed to be conducted in more than one sitting as assessments were long and tedious for Meera who experience fatigue (Katz et al. 2000).Meera was able to sequence tasks but was unable to complete tasks involving her right field of vision. She needed prompts to complete orientation tasks. Activities involving memory were likewise a challenge for her.Rivermead Motor Assessment (RMA)(Lincoln and Leadbitter 1979)The RMA consists of tests evaluating the gross, leg, trunk and arm func tion of a stroke patient (Lincoln and Leadbitter 1979). This was conducted together with the physiotherapist. The RMA allowed the squad up to know which movements Meera had difficulties in order to formulate appropriate interventions. This assessment was found to be reliable and valid but due to being strenuous and long, it had to be conducted in a a couple of(prenominal) sessions due to Meera showing signs of fatigue (Kurtais 2009)Meera was not independent in transfers and mobility, she essential assistance of one for transfers and used a wheelchair for mobility. She in addition had minimum trunk and leg control at her affected side and require assistance for movement. However, she is able to hold objects using her affected arm but cannot reach for an object out-of-the-way(prenominal) away due to scapular instability.From these assessments, 3 problems Meera faced, in order of significance was developed1. Loss of independence in self-care affected Meera the most. From the asse ssments conducted, it was found that challenges in motor, cognition and perception affected her performance in self-care. Managing self-care would focus on these domains as well (NICE 2013). It was hoped that Meera would be more engaged in therapy by focusing on an issue she perceived as critical. This was evidenced by a muse where patients were more motivated and engaged more in interventions when treatment was catered to their perceived needs (Combs et al. 2010). This would also help Meera to elevate her mood as low involvement in self-care was found to be a factor for post-stroke depression (Jiang et al. 2014). The psychologist in the team would be managing Meeras low mood as well (ISWP 2016). By working with Meera on her self-care would also nullify some burden from Sanjay, who was assumed to be her main carer when she is discharged from hospital.2. Problems with visual perception, specifically right side neglect and agnosia, were targeted as it was found to have an influence on self-care (Barker-Collo et. al 2010). This would help Meera in performing self-care tasks. Her visual deficits also affected her social life and transfers. Managing her perceptual problems would allow her to interact more with other patients in the ward which could provide her with social support.3. Meeras motor challenges, specifically right side failing and spasticity were address as it was one of the major challenges faced during self-care. It was hoped that through the management of motor deficits, Meera would increase her engagement in occupations. This would also have a positive effect for Meera in future as it was shown that physical function affected quality of life in stroke patients (Ellis et al. 2013). Motor challenges faced by Meera would be managed in conjunction with the physiotherapist (ISWP 2016). Skills in managing motor challenges can also be transferred to other aspects such as cooking and reinstating her role as a homemaker.Treatment PlanClient AimsMeera wan ts to be more engaged in her personal care.Therapist AimsTo increase Meeras engagement in her self-care tasks.To manage Meeras right sided neglect and agnosia.To manage Meeras weakness and spasticity in her right arm, leg and trunk.ObjectivesMeera should be able take charge of her own shower bath and dressing every morning for an hour, with assistance of one, in 4 weeks.Meera should be able to independently identify items required on her right field of vision for washing and dressing every morning in 4 weeks.Meera should be able to go from lying to sitting, and pivot transfer from bed to wheelchair as well as from wheelchair to shower chair, every morning with assistance of one in 4 weeks.Intervention washing and dressing assessment was conducted through the use of AMPS. This allowed the OT to formulate an appropriate wash and dress plan for multi-disciplinary use through identified difficulties in motor and processing skills (Fisher and Jones 2010). Using a meaningful occupation as a basis for intervention was beneficial for Meera. This can be supported by a line of business where occupation based intervention was shown to be critical in improving occupational performance (Wolf et al. 2015). The forte of the intervention would be higher than the recommended minimum frequency of 45 minutes, 5 days a week as it was included in Meeras daily routine (NICE 2013).The washing and dressing plan was adapted from capital of Zimbabwe District Hospitals (2013) assessment form. The OT conducted the first session in order to teach Meera the relevant compensatory and visual examine skills. Other sessions could be conducted by other staff with focusing from the plan. A further review by and by every few days would also be required in accordance to recommendations (ISWP 2016). wash and dressing plan for MeeraTransfersBed MobilityMeera is able to roll to her right side independently.She requires assistance from lying to sitting.Bed to wheelchair postulate assistance of one for pivot transferStandingRequire assistance of one and grab declaim in the bathroomWheelchair to shower chairRequire assistance of one for pivot transfer free Meera to navigate to bathroomWashingNotesRequire the use of a shower chair in the showerAllow Meera to initiate and sequence task independentlyOnly give Meera assistance when she asks for itPlace items infallible for shower on Meeras right sideIf Meera seems to be searching for something, prompt her to look for it by tour her headEncourage use of right hand to wash herselfMeera may require assistance to abandon her grip on objectsProvide assistance if Meera feel fatigueUpper bodyMeera is able to wash her right side independentlyMeera require assistance to wash above her elbows on her left sideAssistance may be needed to wash hair and back thoroughlyLower beMeera should be able to wash her genitals and front upper thighs independentlyAssist Meera in stand up with the grab rail with one person supporting at all timesA nother person will assist Meera in cleaning her bottom and her rear upper thighEncourage Meera to wash her lower thighs but prevent her from falling from the shower chairAssist in cleaning the rest of the lower thighsDressingUpper BodyEncourage Meera to put on the bra independently using the one arm rule.Allow Meera to use the one hand method to wear her t-shirt.Prompt her by reminding her of the steps if she is strugglingLower BodyMeera requires assistance to put on her trousers while assisted in standing.Both the restorative and adaptive approach was used to guide the intervention. Restorative approach is grounded upon neuroplasticity where relearning takes place when new neural connections form in the brain during constant exposure to various stimulus (Gillen 2016). By practising various movements of her affected side during self-care, Meera should have a reduction in her impairments. This is supported by a study where patients who went through functional motor relearning therap y were found to have improved balance and performance in self-care (Chan et al. 2006).The compensatory approach is where tasks are modified to be easier for the clients to achieve (Edmans 2010). Even though this approach has been criticized for hindering motor retrieval in people with stroke, it is still appropriate for Meera (Jones 2017). The compensatory method of using the one hand dressing method served as a feedback mechanism which could improve motivation as supported by Popovic et al. (2014). This would thus get on Meera to engage in therapy.Risk Management PlanMeera might be fatigue and may not be able to do some of the tasks required. The staff in charge will assist when required and allow Meera to rest when needed.Due to the intimate nature of a wash and dress, Meera might feel humbled and down during the process. In order to preserve her dignity, sensitive areas would be covered whenever necessary and observation would be subtle.Environmental hazards would be checked be fore commencing any transfers or wash and dress in order to prevent falls.Relapse preventionIn the hospital setting, encouragement for frequent engagement in occupation and usage of relevant motor and cognitive skills would prevent Meeras occupational performance from deteriorating (Brainin et al. 2015 Ullberg et al. 2015). According to NICE (2013), long-run health and social support should include education on symptoms and dysfunction relating to stroke, services available and battle in meaningful occupation. As such, Meera and her family would be briefed on these strategies.Outcome MeasuresEvaluation of treatment progenys is important to terminate if the intervention was successful and used to change the treatment plan according (Mew and Ivey 2010). The outcomes were evaluated by using goals and comparison standardized assessment at baseline and outcome. Firstly, intervention was evaluated through the achievement of goals. Goal achievement was think to client satisfaction an d a significant client-centred outcome (Custer et al. 2013). Meera was able to achieve the objectives as expected. Secondly, the AMPS was conducted once again, using the task of showering and dressing (Fisher and Jones 2010). Meera scored higher in these tasks but still required some assistance in achieving them. Thirdly, Meera improved on the LOTCA tasks which involved visual scanning, little to no improvement was seen on the orientation and memory tasks (Itzkovich et al. 2000). Lastly, the RMA was conducted again (Lincoln and Leadbitter 1979). Meera improved in the trunk, leg and upper limb function but there were still signs of weakness and instability involved.Further plansOther domains of concern would be managed as according to initial assessment and outcome measures. Further interventions would include management of cognitive function such as memory and orientation through cooking. Including Meera in a social group such as breakfast club in the ward would be beneficial to he r as well (Venna et al. 2014).To prepare for discharge, Meera would be referred to the Early Supported Discharge team. The team would help Meera and her family by introducing appropriate adaptations at home and relevant education on stroke (ISWP 2016). A smooth transition from hospital to home was found to improve patients function in activities of daily living and service satisfaction (Fearon et al. 2012). This would thus be beneficial for both Meera and her family.ReferencesBartels MN, Duffy CA and Beland HE (2016) Pathophysiology, Medical Management, and subtle Rehabilitation of Stroke Survivors IN Gillen G (ed) Stroke Rehabilitation A Function-Based Approach (4th Edition). Missouri Elsevier 2-45Brainin M, Tuomilehto J, Heiss WD, Bornstein NM, Bath PMW, Teuschi Y, Richard E, Guekht A and Quinn T (2015) Post-stroke cognitive decline an update and perspectives for clinical research. 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Stroke 46(2)389-394Venna VR, Xu Y, Doran SJ, Patrizz A and McCullough LD (2014) Social interaction plays a critical role in neurogenesis and retrieval after stroke. Translational Psychiatry 4(1)e351Appendix AMeera CVAMeera is a 56-year-old woman who was recently admitted with a left Cerebral Vascular Accident affecting the middle cerebral artery. She has a history of hypertension and hypercholesterolemia. She was admitted via A E after being found by her husband. Her husband reports that she felt unwell and make her way upstairs to have a lie down. He went out to walk the dog and on his return found her on the floor in the bathroom. Meera presents with a right hemiplegia with increased spasticity in her right arm and leg. As a result, she has difficult with sitting balance and co-ordinating her movements in order to engage in activities such as washing and dressing. Meera also presents with right sided neglect, which results in her failing to identify objects on her right side, difficulty washing her right side and responding to others who approach her from her right. She has difficulty in articulating in a meaningful way to get her needs met and is very tearful. The Occupational Therapist undertook an initial assessment with Meera, the report is detailed below.Initial assessment summaryMeera appears low in mood and is reluctant to talk about the future. She is worried that she may have another stroke and consequently is reluctant to engage in a ctivity. Meera is embarrass that she needs help in personal activities of daily living and is reluctant to talk about activities that she finds difficult.Family Meera is espouse to Sanjay, a 58-year-old man who works as a plumber. They have two children, Anni aged 18 long time who has just completed her A levels and will be attending a local university in one months time, and Sam aged 17 who is at secondary school.Social situation The family live in a privately owned three bedroomed semi-detached property in a small town. Sanjay describes Meera as a hang in at home mum who prides herself on her family and her cookery skills.Posture Meera has a right- sided hemiplegia her scapular is shaky and she finds it difficult to flex her arm above 90 degrees. Elbow extension is uncontrolled and there is cumbersomeness in her forearm making supination difficult. She is able to grasp objects but finds release very difficult.Sensory assessment Meera has poor deep and light sensation in h er right hand, which has a profound effect on a range of performance areas.Cognition and perception Meera has a right sided neglect which interfers with washing and dressing, and transfers. She also has difficulty socialising with other patients on the ward due to to this. Meera has some cognitive impairment which presents as poor memory and disorientation. These features are more prominent at the end of the day when Meera is tired.Mobility Meera currently uses a wheelchair but can manage a controlled transfer with one person assisting.