Ruth Walton
Client Evaluation from site
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)
Consuelo (name changed) is a 50 year old female who is receiving occupational therapy after a
panectomy. Consuelo used to like going out and driving her car. She would go to Walmart and
go shopping. In 2013 she was hospitalized for septic shock and was in the ICU for 12 days. When
she was released from the hospital she had her first home health treatment. Since being
hospitalized a year ago she said that her mobility has decreased and now she is not able to leave
her house or do things around her house that she was able to do a year ago. She said that the
infection affected her brain and her vision, but she feels that she is thinking better than she did a
year ago. She is on constant oxygen, receives sponge baths, and has been having trouble with
cleaning after toileting due to swelling in her body and passive insufficiency from tissue due to
being obese. Consuelo uses a FWW to ambulate.
What is the reason for referral for this client? Why are they seeking services? (1 point)
Consuelo is was referred to home health after a panectomy because of safety concerns in
swelling in her legs, mobility around her home, and toileting. Amy Nielsen, the occupational
therapist, has been working with Consuelo to get her to be independent in safe cleansing after
toileting and in being able to independently perform ADLs such as dressing, grooming, and
washing.
What are the client’s and/or family member’s current concerns and goals for the intervention? (2 points)
Consuelo said that if it were not for home health, she would not be able to be in her house
because she cannot do things for herself like take care of cleaning herself. Her range of motion is
limited due to passive insufficiency and she is not able to reach parts of her body to wash them
properly to avoid infection. Her goal is to be able to do more things around her house.
What occupations does the client currently identify as important or meaningful? (2 points)
Consuelo stated that she used to quilt and make intricate pieced quilts, but since she got sick she
has not had the strength nor ability to be able to do them anymore. She got excited because she
said that she is feeling better and has ordered material to make a small lap quilt. She showed
some of the quilts that she had made to us.. This got her up and off the chair and moving around
the apartment. Amy told me later that she has never seen Consuelo get up and move around
before. She also said that she likes watching movies, enjoys being at home on the computer and
shopping online. None of these activities caused her to get as animated as when she was talking
about quilting.
What occupations is the client currently successful in. Why? What difficulties is the client currently
having with his/her daily occupations? (2 points)
Consuelo is successful in sewing on her lap, increased independence in toileting hygiene, and
using the computer. Consuelo has been able to be successful in sewing because she felt that she
has gained some strength after receiving home health. She has been able to have increased
independence in toileting hygiene after adaptations that Amy has shown her, and she enjoy
using the computer.
Consuelo is having difficulty in showering, moving around her house, doing things around her
house, being able to leave her house, and she is not able to drive any more. Consuelo’s edema
and obesity have limited her functions to the point that she cannot leave her house.
What contexts support engagement in the desired occupations? What contexts inhibit participation? (ie
cultural, personal, physical, social, temporal and/or virtual) (1 point)
Consuelo’s motivation both support and inhibit her participation. Amy has been working with
her for a long time and has struggled with getting her to follow treatment plans and
recommendations, but as Consuelo has started to feel better and better about herself, she is
increasing her motivation to participate in her occupations.
Consuelo had an incident that has caused PTSD that inhibits her participation in ADLs.
Analysis of Occupational Performance
Select one occupation from the treatment plan the client is having difficulty with to analyze: _toileting
hygiene____ (1 points)
From the Practice Framework, choose 3 specific performance skills and/or client factors that are most
impaired in this client’s performance of the occupation. Describe how the impairment affects
performance (3 points)
1. Motor skills – Consuelo has difficulty in reaching to cleanse after toileting due to
limited range of motion from passive insufficiency.
2. Emotional regulation skills – Consuelo’s PTSD inhibits her ability to successfully
perform certain ADLs such as toileting.
3. Cognitive skills – Consuelo has a hard time understanding that if she does not
cleanse properly that it could cause infections which could lead to more disability.
What would it take for the client to overcome these difficulties? (1 points for realistic assessment from
the client’s perspective)
Consuelo has started to accept the use of adaptive equipment such as wet wipes and cleaning
from the front instead of the back because it is easier to reach. She was instructed on how to do
this safely so as not to cause an infection.
Specifically describe one way an occupational therapist could evaluate or quantify the client’s current
performance of the identified occupation. (2 points)
The current performance could be quantified by asking the client how many times that she
cleans after toileting and how many infections she has received. The progress could be shown by
the increase in cleaning and decrease in infections.
Describe at least two interventions that can be used by an occupational therapist during treatment to
improve performance in this occupation. (4 points)
Upper body exercises such as theraband to increase the available range of motion to aid in
toileting hygiene.
Standing dynamic tolerance activities to aid in balance while on the toilet cleaning.
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)
LTG: Client in 8 weeks will use modified independence to safely complete toilet hygiene as per
client report.
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)
STG: Client in 4 weeks will independently identify strategies for toilet hygiene as per client
report.
STG: Client in 4 weeks will use modified independence to perform dynamic balance activity.