RT Assessment
Client name (use alias for confidentiality)
Age
Gender
Primary Diagnosis
(* The dx/s that caused the admission of the client)
Identifying Data
John Smith
51 y/o
♂
Lumbar Spondylosis
Secondary Diagnoses
(* Other dx/s that are still active – the person is still experiencing – that are
not the primary reason for admission of the client)
Depression, HTN, DM, Morbid Obesity
Past medical history
(* Other dx/s that the client had in the past that are no longer active)
Sciatica
Education
City & State of residence
Employment status & occupation
Social roles
Reasons for Admission
(*what is the main reason the person is at you particular facility; e.g., respite,
decreased independence in functioning, rehabilitation)
High School Degree
Philadelphia, PA; lives in a multilevel home with brothers
Currently employed; Bus driver for the School District of Philadelphia
Brother, single, no children
Rehabilitation
Estimated length of stay (ELOS)
(*if in long term care, write “N/A, long term care”)
Reason for referral to RT
(*the reason for referral will vary by setting, please be sure to talk with your
supervisor to find out the specific reason for RT treatment/services; why does
Rec Therapy clients at this facility?)
3 weeks
Development of a healthy leisure lifestyle for health promotion.
Disability Review
Review each of the client’s primary diagnoses and secondary diagnoses and answer the following questions in a format most easily understandable for you
(can be paragraph or bulleted format). Please summarize, do not cut and paste from your source data. What is the disease/illness/disorder? What causes it?
What are the symptoms? What is the prognosis? How is it treated? Are there any conditions/diagnosis that are frequent co-occurring with this primary dx?
How do you foresee this information guiding/affecting your assessment process? How do you foresee this information affecting/impacting your tx plan and
interventions with the client. Use professional sources (journal articles, professional texts, national organization websites) and cite the sources (if using a
website, provide the direct link and if using a journal article or text provide the full references in APA format)
Primary Diagnoses: Cause, Symptoms, Prognosis, Treatment, Common CoHow does this information guide/inform your assessment process?
Occurring Conditions
How do you foresee this information affecting your tx plan/implementation?
The pt’s 1° dx is Lumbar Spondylosis. This is when the lumbar region of the
From this information we know that there is no way to reverse the
spine degenerates, causing bone spurs, degenerating interverbral disks, and
degenerated spine from the Lumbar Spondylosis. The lower back pain can be
possible stiffening in the spine. This dx is usually because of the wear and tear manageable through proper tx. We should look into forms of RT tx that will
of the spine’s bones and ligaments over time with age. Nerve compression
↑the pt’s overall mood and quality of life in order to get his mind off of his
from the Lumbar Spondylosis causes back pain. Other symptoms of this dx
back pain. This could be done by using the Leisure Interest Measure (LIM) to
may include disc herniation, sciatica, weakness in extremities, and numbness. find out the type of leisure activities the pt enjoys and by asking the pt
Prognosis of Lumbar Spondylosis is not good because the degenerated spine
questions that will help us find out the pt’s interests (e.g., what is your
cannot grow back. However, this dx may be manageable if the pt follows a tx
favorite thing to do in your free time?). Throughout tx we also need to be
that focuses on ↑’ing the lower back pain. Medications, exercise, chiropractic mindful of the pt’s condition and take precaution when developing a tx plan
therapy, acupuncture, injections, and surgery, are some of the ways to treat
so that it doesn’t involve any extraneous activity that could cause the pt to be
the lower back pain caused by Lumbar Spondylosis. It is common for other
in pain.
conditions to occur with this dx that also act as symptoms. These conditions
are sciatica, lower back pain, and numbness.
emedicine health. (2010, April 16). Retrieved from
http://www.emedicinehealth.com/script/main/art.asp?articlekey=60176
Secondary Diagnoses: Cause, Symptoms, Prognosis, Treatment, Common CoOccurring Conditions
Depression has no known cause however is probably involved with heredity,
neurotransmitter levels, neuroendocrine function, and psychosocial factors.
Individuals with depression often experience symptoms of sadness, cognitive
and psychomotor dysfunction, poor concentration, fatigue, and loss of
pleasure and sexual desire. If this dx is treated, there is a good outcome.
However if left untreated, the individual is at risk for other mental disorders
to develop and is possibly at risk for suicide. Depression can be treated by
support, psychotherapy, and drugs. It is necessary for a physician to offer
support until there are noticeable improvements in the pt’s depressive
symptoms. The physician should try and see the pt weekly or biweekly to
provide education and to monitor progress. Psychotherapy tx is primarily
cognitive-behavioral therapy. Drug txs may be SSRIs, serotoninnorepinephrine reuptake inhibitors, heterocyclic antidepressants, and MAOIs.
Conditions that commonly occur with this dx are anxiety issues and panic
attacks.
Coryell, W. (2012, November). Merck manual. Retrieved from
http://www.merckmanuals.com/professional/psychiatric_disorders/
mood_disorders/depressive_disorders.html?qt=depression&alt=sh
Hypertension, or high blood pressure, may be due to a renal disorder.
Otherwise, there is no known cause. Symptoms of hypertension are not
present unless it persists for a long period of time or if there is a target organ
complication. Symptom that may occur include dizziness, flushed faces,
headache, fatigue, epistaxis, and anxiety. Severe hypertension can be fatal
and cause severe cardiovascular, neurological, renal, and retinal problems. By
using treatment such as weight loss, exercise, smoking cessation, an increased
intake of fruits and vegetables, a decreased intake of salts, and a limited use
of alcohol most of the complications caused by hypertension can be
prevented. One must monitor his or her blood pressure through hypertension
treatment, and activities used for intervention should involve minimal stress
as to not exacerbate the hypertension further.
Bakris, G. (2010, January). Overview of hypertension. Retrieved from
http://www.merckmanuals.com/professional/cardiovascular_disorders/
hypertension/overview_of_hypertension.html?qt=hypertension&alt=sh
How does this information guide/inform your assessment process?
How do you foresee this information affecting your tx plan/implementation?
From this information we know that the pt’s 2° dx are crucial to the RT tx plan.
We can use this information about depression, HTN, DM, and morbid obesity
to develop a tx plan that focuses on ↑’ing these dxs. We need to pay specific
attention to the pt’s depression by admitting the Beck Depression Inventory
to act as a baseline for developing a tx plan that will appropriately address
↑’ing his mood and overall quality of life. We also need to monitor any
physical activity in tx because of the pt’s HTN and morbid obesity. We can use
education as a tx technique so that we can teach the pt healthy behaviors to
help the pt recover from his DM and morbid obesity.
Diabetes Mellitus is a disorder when not enough insulin is produced to meet
the needs of abnormally high glucose levels in an individual’s body. The pt has
T2DM, which is when the body develops resistance to the effects of insulin
that is produced by the pancreas. DM is caused by malnutrition, obesity, and
genetics. Symptoms include ↑’d urination and thirst, fatigue, possible blurred
vision, and dehydration. If tx properly, the outcome for DM is good and pt will
be able to make a full recovery. DM is tx by maintaining a healthy diet,
exercising, drugs, and monitoring blood sugar levels. Obesity is a common cooccurring condition
Kishore, P. (2008, June). The merck manual home health handbook. Retrieved
from
http://www.merckmanuals.com/home/hormonal_and_metabolic_disorders/
diabetes_mellitus_dm/diabetes_mellitus.html
Morbid Obesity is an accumulation of excessive body fat to the greatest
extent. It is caused by consuming too many calories that aren’t burned off in
physical activity. It is also caused by physical inactivity, poor diet, and genetic
factors. Symptoms include change in overall appearance, shortness of breath,
snoring, skin abnormalities, and joint and back pain. Prognosis is good and a
full recovery can occur with proper tx, ↑ nutrition, and exercise. Tx includes
forming a healthier and more nutritious diet, ↑ physical activity, and behavior
modification to assist with weight loss and maintenance. Common occurring
problems include high chol levels, high BP, metabolic syndrome, coronary
artery disease, heart failure, diabetes, Ca, gallbladder disorders, low
testosterone level, varicose veins, fatty liver, hepatitis, cirrhosis, blood clots,
asthma, sleep apnea, kidney disorders, arthritis, gout, low back pain, joint
disorders, depression and anxiety.
Youdim, A. (2008, August). The merck manual health handbook. Retrieved
from http://www.merckmanuals.com/home/disorders_of_nutrition/
obesity_and_the_metabolic_syndrome/obesity.html
Functional Skills Assessment
Using the facility RT assessment tool, secondary sources (e.g. chart, family, etc.), and/or a standardized RT assessment tool, conduct a functional skills
assessment of your client and list your assessment findings in the chart below.
Areas of Client Functioning
Assessment tool/source/method utilized (e.g., medical
Assessment Findings (Measureable Baselines)
chart review, observation within activity, discussion
Write measureable baselines of assessment findings. Prior to
with a specific team member/team/physician, client or
each baseline, indicate the source where you obtained the
family interview, standardized assessment tool, etc),
information using the below codes:
along with a description of WHY you chose this
O = observation
tool/method. Do not cut and paste examples from A&D MC = medical record
course. Explain your thought process and what you
T = standardized assessment tool performed by you
were hoping to gain from each particular source.
P = patient hx (anything told to you by the family, other team
members, etc)
SR: items told to you by the client
Physical functioning
Cognitive functioning
Medical Chart: I reviewed notes in pt hx in order to
obtain client’s baseline of physical functioning abilities
to develop appropriate expectations for RT assessment.
MC: Pt is able to move all extremities WFL
MC:B/L lower leg weakness
MC: Has occasional pain in lower back w/ score of 5 on a pain
scale of 1-10 (10 being most painful)
MC: OOB to w/c c Max A
MC: WBAT
Observation: Throughout the interview, I observed pt’s
overall physical functioning to see if there were any
noticeable impairments or limitations not noted in
medical chart. Observing if pt has physical functioning
deficits will establish a baseline of understanding pt’s
functioning, which will help in setting tx goals and help
determine appropriate activities for tx.
O: Pt morbidly obese and depends on w/c for mobility
O: Dynamic and static sitting balance in w/c WFL
Medical Chart: I reviewed material in the Medical Chart
to look for basic cognitive fx’ing and cognitive skills such
as alertness, attention, and orientation. This
information will help me develop an appropriate RT
session based on the pt’s baseline cognitive abilities.
MC: Awake, alert, oriented x3
Observation: Throughout interview observed pt’s
overall cognitive functioning to see if there were any
noticeable impairments or limitations not noted in
medical chart. Observing pt’s possible cognitive
functioning deficits will establish a baseline of
understanding pt’s functioning, which will help in
setting tx goals and help determine appropriate
activities for tx.
O: Sustained attention throughout entire interview
O: Pt exhibited concept formation by expressing imaginative
and creative thoughts and ideas throughout entire RT session
O: No deficits observed
Speech/language functioning
Medical Chart: I reviewed the Medical Chart to know
what to expect from the pt, verbally. This is necessary
to determine if any adaptations need to be made in RT
assessment prior to seeing the pt.
MC: Reception to spoken language: WFL
MC: Reception of body language: WFL
MC: Expression of spoken language: WFL
MC: Producing body language: WFL
Psychological/emotional functioning
Medical Chart: I reviewed notes in pt hx to determine if
there were any psychological or emotional deficits in
the pt. This is necessary so that I can prepare myself for
the RT session to look for symptoms of any mental
impairment need to be addressed in the assessment.
MC: 2° dx of depression
Observation: After looking at the medical chart, I knew
that the pt has a 2° dx of depression. This information
prepared me to look for symptoms of sadness, feelings
of worthlessness, loss of pleasure, and other possible
symptoms of depression in RT session.
O: Pt seemed pleasurable and cooperative despite dx
O: Pt did not exhibit negative emotion in RT session
Beck Depression Inventory: I used this assessment tool
to have a better understanding of the pt’s depressive
symptoms. This assessment tool determines the extent
of the pt’s depression. It measures if the pt’s ups and
downs are considered normal, if the pt has a mild mood
disturbance, borderline clinical depression, severe
depression, or extreme depression. I can use this
information to develop a tx plan that will appropriately
address ↑’ing his mood and overall quality of life.
T: The Beck Depression Inventory indicates that the pt has a
Mild Mood Disturbance (10.5); however pt provided scores
that were of high self worth and perseverated on his religion
which may act as a coping mechanism. i.e., “I’m not worried
about my future because it’s with Jesus,” “Jesus is what
makes me happy.” RT to further explore.
Sensory functioning
Social functioning
Medical Chart: I reviewed the medical chart to know if
any of the pt’s senses were impaired so that I could be
prepared for the RT session and make adaptations if
necessary.
MC: Sensory functioning WFL
Observation: Throughout RT session observed pt’s
overall sensory functioning to see if there were any
noticeable impairments or limitations not noted in
medical chart.
O: No deficits observed
Medical Chart: From reviewing the pt’s medical chart I
was able to gather that the client has a “good support
system.” With this information from the medical chart, I
knew what to expect and what to note from our first
meeting. Knowing that he is socially active made
observing important behaviors easier.
O: Ability to maintain eye contact throughout RT session
O: Initiates conversation c no prompting
O: Engages in & maintains conversation throughout entire RT
session
P: Pastor from church visits pt often
P: Good relationship with brothers
P: Was the primary caregiver to mother and father for the
two years leading to their death.
O: Very social to hospital staff
Interview: I interviewed the pt on his perceived support
from his family and friends. This was necessary in order
to get the pt’s perspective on his social environment in
to see if social support was an issue that needed to be
addressed in RT session.
Self-care functioning
Medical Chart: I reviewed the px medical chart in order
to see his baseline of self-care functioning. This is
important information to know before my initial
meeting c the pt so that I can know issues that could
possibly rise during our time together.
MC: Dressing min A
MC: Grooming min A
MC: Toileting min A
Leisure functioning (e.g.,
standardized leisure assessment
findings such as the LIM, LMS, LAM,
LSM; the Leisure Lifestyle Review
(below) – be sure to interpret your
overall clinical opinion of the client’s
leisure lifestyle; and facility leisure
assessment
Interview: I interviewed the pt in order to assess his
leisure interests and find out which activities are most
important to him. By interviewing the pt I wanted to
gain some direction on how to plan his interventions
and measure how important specific aspects of his daily
leisure life are. This is helpful for the RT session so that I
will be able to implicate the activities that he is most
interested in throughout his RT rehabilitation process.
P: Very passionate about his Christian religion
P: Enjoys music
P: Loves architecture and home improvement TV shows
P: Hates shopping
Leisure Interest Measure (LIM): I used the LIM to gather
information about the pt’s interests so that I could look
into potential activities for the pt’s RT session that will
hold his interest. The LIM is an interest measure used to
rate activities that an individual does, does not, likes,
and prefers to do. This tool rates an activity from Never
True to Always True (1-5) and classifies activity interests
into domains. The results state which types of activities
the pt likes to do the most and the least, based on the
rated responses.
T: Leisure Interest Measure (LIM) indicates a range of
interests. Pt had the highest interest in the Artistic Domain
(D=4.75), the Social Domain (F=4.5), followed by the Cultural
Domain (G-4.25). The pt showed a slightly lower interest in
the Service Domain (3.75), and had lowest scores in the
Physical Domain (A=2.25), the Outdoor Domain (B=1.5), and
the Mechanical Domain (C=1.25). High scores indicate high
interest. Low scores indicate low interest and may indicate a
need for education about specific activities within those
domains.
Leisure Lifestyle Review
Identify leisure interests and activity patterns for your client. Each activity should be coded as a current, past and/or future interest.
Current (C), Past (P), &
Activity
How often
With who
Where
Other notations
Future (F) interests (list in
this order)
C
Watch Television
Every day
Himself
His house
Especially watches TV
show “This Old House.”
Enjoys shows about
home design the most.
C
Church
As often as possible
Himself, friends, family Fellowship Jehovah
Calls church “heaven on
Fellow Baptist Church
earth.” Perseverates
about Jesus and
Christianity. Passionate
and knowledgeable
about his religion.
C
Listen to music
As much as possible
By himself, friends,
Everywhere
Pt is very passionate
family
about music. Showed
me several music
videos. Specifically
enjoys Jazz and Rock &
Roll. Enjoys going to
concerts.
C
Watch Sports
As much as possible
By himself, brothers,
friends
By himself
Home, in stadiums
C
Being creative /
imaginative
All of the time
P
Caregiver to mother and
father
Every day until their
death (for 2 years)
By himself
His parent’s home
P
Play sports
Seasonally
By himself, with friends
High school
P
Eat out at restaurants
As much as possible
Friends and family
All restaurants
F
Become physically active
All of the time
By himself
Everywhere
Everywhere
Particularly enjoys
watching football.
Throughout entire
assessment client kept
speaking of imaginary
scenarios about his
dream life (including
having a butler, an
excessive wardrobe,
having an enormous
house, and saving every
cat in the world),
described impeccable
architecture of his
dream hotel he wishes
to own, and vividly
described how he
wishes to meet with
God when he gets to
heaven.
Enjoyed taking care of
parents. Made him
value life.
Played hockey and ran
track.
Doesn’t eat out
anymore because of
diet restrictions due to
his DM and morbid
obesity.
Pt is very health
conscious because of
his 2◦ dx of DM and
morbid obesity. Desires
to lose weight and
enjoy engaging in
physical activity.
RT Assessment Findings
Using your assessment information, prioritize major areas of concern that you would have for your client. Consider if the individual has a potential need for
treatment in any of the following areas: skill development/restoration/adaptation/maintenance, education/training/counseling, health promotion, community
integration, coping strategies, and/or behavior modification. Be sure to consider the client’s diagnoses (abilities, challenges, course of the disease/illness),
intrapersonal, interpersonal, and structural facilitators and barriers that could impact your treatment plan, and the client’s length of stay and discharge plan (in
other words, consider the realistic nature of your major concerns).
Major Concerns
Given your assessment findings, what are the priorities for treatment/service? Why is this need a priority? Explain how it relates to participation in healthy
List one in each box.
leisure activities, as well as how it relates to health promotion, secondary
prevention, and/or quality of life.
Education about Physical Activity Techniques
Educating the pt about enjoyable ways to become physically active is
important because the pt is morbidly obese and at risk for death. The pt
wishes to engage in exercise and physical activities in the future that are
enjoyable but doesn’t know how to find pleasure in physical activity.
Educating the client about healthy leisure activities is beneficial to the pt
because it promotes good health habits. As a result of this education, the pt
may possibly participate in more physical leisure activities regularly which
may reduce his risk for death, may help treat his 2° dx, and improve his
quality of life.
Coping Strategies
The pt has 2° dx of depression, so it is necessary to teach the pt different
coping strategies for dealing with his depression. Coping strategies are a
major concern for tx because it will improve the pt’s quality of life by
potentially improving his mood and ridding him of depression.
Community Integration
In the LIM, the pt indicated that he has high interest in the artistic and social
domain. It would be extremely beneficial to introduce him to leisure
activities in the community that will provide him with opportunities to
participate in these domains. The pt may be more motivated to participate
in physical activity if it is in a community setting that involves artistic aspects
and socialization. Community Integration may improve his quality of life by
providing him with opportunities to socialize with other individuals and to
participate in healthy physical activity.