Elizabeth Hares-Intervention Plan

Running head: OCCUPATIONAL PROFILE & INTERVENTION PLAN 1
Occupational Profile & Intervention Plan

Touro University Nevada
Elizabeth Hares

OCCUPATIONAL PROFILE & INTERVENTION PLAN 2

Occupational Profile
The client P. Brown is a 76 year old female who lives with her husband of 41 years.
The client has two children who are now older adults living in another state and only visit during
the holidays. The client is close friends with her two neighbors who are the same age and share
the same interests. The client is seeking services after suffering a CVA resulting in left
hemiplegia post status 3 months. Since suffering the CVA, the client has right side paresis and a
contracture in her right dominant hand that impacts many of her chosen occupations. Before her
CVA, the client was diagnosed with Rheumatoid Arthritis, predominantly in the hands and
knees. The client experiences stiffness in the knee joints and has a hard time bending over for
many activities. The client recently had a fall from losing her balance in the shower and now
requires assistance from her husband for safety. The client is not able to drive due to her right
side weakness and is scared to get back to driving. The client has a good network of support
from her friends at the stroke support group and individuals she has met in therapy, but has
trouble attending the group and meeting with friends due to difficulties finding transportation.
Since suffering her CVA, the client is having difficulties in many of her occupations.
Currently, the client has her husband help her with bathing and grooming activities. The client is
able to assist her husband in cooking activities by reading her recipes to her husband and helping
create the weekly grocery list. The clients right hand contracture has poor range of motion and
impacts many fine and gross motor activities using the right upper extremity. The client has
concerns with her ADLs such as bathing and grooming. She is also concerned that she will not
be able to get back to regularly attending her support groups, cake classes, and choir concerts.
The client does not have difficulties in ambulation and uses a quad cane for balance and right
side weakness. The client does not have concerns with functional mobility and is able to move

around the house without difficulties. The client is modified independent for many activities of
daily living such as toileting, eating, and dressing. The client requires assistance for grooming
and personal hygiene and needs help from her husband to wash many areas of the clients body
due to weakness and poor balance. The client is experiencing problems in her leisure occupations
and instrumental activities of daily living. The client is having difficulty preparing foods in the
kitchen and cooking for her husband. In addition to cooking, home management is also a
problem for the client. She has her husband take care of the house, water the yard, and do most
laundry and house cleaning. The client would like to return to ironing and laundry to relieve
stress from her husband. Leisure activities with her friends have been difficult for the client due
to weakness in the right side, which impacts her ability to drive and get to and from places. The
client depends on her husband to take her to her classes and misses many classes throughout the
week because her husband works part-time.
The client lives in a small, one-story home with her husband. The size of the home
enables the client to move around the home without fatigue. The client uses a large shower with
an extendable, hand-held showerhead installed, which reduces some of the demands of bathing,
but she still requires assistance from her husband to complete all bathing tasks. Since her
husband works part-time, she is left home alone without transportation three times per week. The
kitchen the client works in is very small and does not give the client enough space to stand with
her quad cane and maneuver around the counter space safely; this factor inhibits her occupation
of meal prep and cooking for her husband.
Mrs. Brown attends cake decorating classes with her neighbor and stroke support groups
through her outpatient rehab facility. Ms. Brown sings in her church choir three times a week and
enjoys teaching Sunday school once a month. When Ms. Brown has free time, she enjoys

crocheting clothing for newborn babies in the NICU. The client attends church with her husband
every Sunday. She also enjoys reading in the backyard and baking. The client is interested in
learning new cake recipes and trying new cake decorating tools and methods. The client feels it
is important for her to get back to cooking new recipes and baking for her husband and friends.
She feels that cooking will allow her to regain responsibilities in her marriage. The client also is
very passionate about attending church choir meetings. This is a place where she receives
support and motivation to return to her occupations and achieve her goals. This support is vital in
her recovery and going to church gives the client a sense of meaning and independence.
The client has stated that bathing without her husbands assistance and getting back to
baking and cooking are her top priorities. She would like to get back to bringing new and unique
baked goods to church when she attends Sunday morning Mass. Since these baking classes are
important to the client, transportation to and from these classes is a concern for the client, and
she would like to find a way to make it to her classes when her husband is working. The client
would like to learn more about the bus system near her house and learn the routes and times that
would enable her to get to church meetings independently. She feels like a burden needing her
husband to drive her to meetings and bathe her, and her goals are centered on increasing her
independence and reducing that burden.
Occupational Analysis
Mrs. Brown is receiving skilled OT services in an outpatient rehabilitation facility that
specializes in stroke and hand contractures. The client receives OT three times a week and
usually works in a smaller room one-on-one with an Occupational Therapist. In therapy, the
client currently performs table-top activities to increase range of motion in right upper extremity.
The rehabilitation facility has a large gym to work on gross motor activities, many tables for fine

motor table-top activities, and modern technology including E-Stim to work on functional
extension of the fingers. Mrs. Brown was observed transferring different size beads out of a large
box into a smaller box using tweezers. The client had trouble with smaller beads and pinching
the tweezers enough to grasp the bead. The activity required that the client flex her shoulder to
bring the arm up over the box to retrieve the beads. After retrieving the beads, the client was
required to adduct the shoulder to bring the beads on the left side of her body where the smaller
box was located. At times, Mrs. Brown used her left hand to hold her right arm up during the
activity for stability when picking up the beads. During the activity, the client was experiencing
frustration and was trying very hard to pick the beads up.
This bead activity proved to be very difficult for the client, and required various types of
movement in the involved arm. The client was motivated to complete the activity but was getting
frustrated. The client currently has sensory disturbances and weakness in the upper right arm.
This impacts her ability to lift the arm or feel where in the hand the tweezers are located.
Weakness in the muscles of the upper arm (biceps & deltoids) affects the clients ability to flex
the shoulder enough to transfer the beads out of the box. The client compensates for this by
lifting her right arm with her left hand. This technique allows the client to complete the activity
and still promotes movement of the arm albeit passively since she does not have the ability to lift
the arm all the way up. The client is able to use a pincer grasp to hold the tweezers, but her grasp
is very weak. Occasionally the beads would fall out of the tweezers because she was not able to
hold the grasp long enough to transfer the bead. Out of 25 beads, she was able to transfer 17
within a five minute time period. The client is able to flex the shoulder actively to around 80
degrees, enough to reach table height for the activity. This level of shoulder flexion falls below
functional limits and impacts the clients abilities to engage in many occupations.

Mrs. Brown is experiencing limitations in many areas of her life. According to the OTPF
3
rd
Edition, the clients right upper extremity weakness and contracture of the right digits is
affecting multiple domains. These domains include many areas of occupation, client factors, and
performance skills. The areas of occupations that are impacting the clients daily life are ADLs,
leisure activities with her neighbor and friends, IADLs such as meal preparation and house
management, and social participation within the community. The client factors that have been
impacted by her CVA include multiple body functions. Foremost, the client is having trouble
with sensory functions; her decreased touch affects her ability to feel objects textures,
temperature, and location within in the hand. Deficits in the sensory functions make fine motor
activities such as cooking, crocheting, and bathing more difficult. The clients
neuromusculosekeletal functions such as joint stability, joint mobility, and muscle power have
also been affected by weakness resulting from the CVA, impacting the clients ability to
complete full AROM required for many occupations. Many performance skills are providing
barriers for the client to complete her occupations; specific performance skills include motor
skills. The client has trouble reaching with the right upper extremity, stabilizing the arm,
gripping, and manipulation of objects required for fine motor activities. Limitations in these
domains significantly impact the clients ability to engage in her chosen occupations which give
meaning to the client. These limitations should be addressed in therapy to improve her quality of
life and occupational engagement.
Problem List
Problems that directly affect the clients areas of occupation are listed below. These
problem statements should be used to guide treatment and treatment goals in collaboration with
the client. The following problem statements are in order of priority and reflect the clients goals

of treatment. 1) The client requires MAX (A) for baking activities due to decreased motor skills
and weakness in R UE. The client would like to gain independence in baking activities so that
she is able to return to cake classes and start baking for her husband at home and her church.
Getting the client back into baking will allow her to attend her weekly classes, increase her social
participation, and allow her to gain more responsibilities in her marriage. 2) The client requires
MOD (A) with assistance from her husband to wash 4/10 body areas due to RA stiffness and
pain in knee joints. The client currently receives assistance from her husband when bathing in the
shower. Mr. Brown washes four areas of the clients body and washes her hair. The client has
trouble standing while showering and experiences pain in the knee joints when standing too long.
Bending over to wash her perineal area and legs are difficult for the client. Mr. Brown goes to
work early in the morning, and if the client wants to shower, she has to get up before Mr. Brown
leaves so she is able to be clean for the day. Increasing her ability to bathe without Mr. Brown
will allow her to bathe with modified independence using home modifications and adaptions. 3)
The client is unable to complete laundry tasks due to limited AROM and contracture in the R
UE. Returning to house management is important to the client. This will allow the client to take
on more tasks around the house, decreasing the stress on her husband and giving her a feeling of
self-efficacy. 4) The client is unable to complete crocheting due to a weak grasp and contracture
in R hand. The client takes pride in crocheting in her free time and finds stress relief in this
occupation. Addressing the performance skills needed for crocheting and increasing her
independence for these skills will allow her to get back to crocheting with friends and making
blankets for babies in the NICU. 5) Client requires MIN (A) for grooming activities due to
limited AROM in R UE and decreased grip strength. Regaining independence in personal
hygiene and grooming skills is important to the client. Mrs. Brown would like to brush her hair

throughout the day or wash her face and hands without assistance from her husband. Being able
to groom herself before going to church and cake classes is one of the more important and
meaningful goals to the client because it would improve her independence and ability to
participate in activities she enjoys.
Intervention Plan & Outcomes
Long term and short term goals for the client provide the therapist with a way to measure
a clients progression. Appropriate goals and interventions for Mrs. Brown address the
previously stated problem statements. Below are the goals and corresponding interventions that
will be used to reach treatment goals throughout a period of 5 weeks in outpatient treatment.
1) LTG 1. The client will decorate half a dozen cupcakes in her kitchen using A/E with
supervision from husband within 5 weeks.
a. STG 1. The client will bake a dozen cupcakes MIN (A) using a three step box set
and A/E within 3 weeks.
i. Intervention A (Modify Approach). The client will choose her
husbands favorite cake flavor in a box set. The client will bring in the box
set to treatment, and the practitioner will work with the client to setup
tools and materials needed to make the box set. In a seated position, the
client will prepare the cake batter, pour the cake batter into the muffin pan,
and bake the cupcakes. The practitioner will educate the client on adaptive
equipment and techniques to use during the baking process such as use of
a universal cuff with a wooden spatula to allow the client to mix the batter
with her involved hand and arm, stabilizing the bowl with the non-
involved arm. Hand over hand technique may be used to promote PROM

and involvement for tasks that are too difficult for the client. Grading up
and down may be needed for the client to complete the activity.
b. STG 2.The client will decorate three premade cupcakes MIN (A) using A/E
within 2 weeks.
i. Intervention B (Restore Approach). Using premade cupcakes purchased
at a local grocery store, the client will use pre-made icing in a zip lock bag
with a hole to squeeze out the icing onto cupcakes as the client prefers.
Food colorings can be used for the clients preference for decorating the
cupcakes. Different sprinkles can be placed on the table, and the client can
reach with the involved side to pinch sprinkles of her choice using a pincer
grasp to retrieve sprinkles and place them on top of the cupcakes. The
importance of this intervention is to work on functional reaching during
the task and picking up the sprinkles with her involved hand promoting
use of the involved arm and hand to decrease chances of learned non-use.
If the client has cake decorating tools at home, the client will bring them
in to use for the cupcakes. Educating the client on adaptive use of these
tools with A/E to use during cupcake decorating will be beneficial and
involve more carry-over into the home setting. The use of a universal cuff
for her icing brushes or tools can increase the clients engagement in cake
decorating.
2) LTG 2. The client will bathe herself MOD (I) with A/E & DME in home shower within 5
weeks.

a. STG 3.The client will complete grooming activities at sink SUP using A/E within
3 weeks.
i. Intervention C (Compensatory approach). The client will be seated at a
sink in the bathroom. Using adaptive equipment, the practitioner will work
on functional ROM using a wash cloth to wash the clients face using the
involved arm. Adaptive techniques may be used to enable the client to
hold the towel to complete face washing. An arm mobilizer may increase
the clients independence when washing her face and brushing her hair.
Having the client stabilize the involved arm with the non-involved arm
during face-washing and hair-brushing should be promoted as a
compensatory technique for the client to complete her grooming tasks at
home independently. Education on simple home modifications should be
incorporated into treatment, such as pump soaps and shampoo, suction
pads for grooming tools, electric toothbrushes, and easy-to-open lotions
and toothpaste. Having the client use compensatory strategies increases
bilateral upper extremity involvement.
b. STG 4. The client will bathe 8/10 body areas SUP using DME and A/E in shower
within 3 weeks.
i. Intervention D (Modify approach). Since the intervention setting is an
outpatient rehabilitation facility, teaching the client motor control and use
of adaptive equipment for showering can increase the clients skills when
bathing in the home setting. The client will be seated in a chair and will be
recommended a compatible shower chair for home-use. Sitting upright,

the client will use a loofa that contains a string around the sponge that will
go around the clients involved hand. The client may use her left arm to
stabilize the involved arm while completing this activity to promote use of
the involved hand and arm. If the client is not using the left arm to
stabilize the involved arm, bilateral use of the upper extremity is
recommended when completing bathing activities. Using this loofa, the
client will practice washing areas of her body that are currently giving her
trouble. These areas include the lower legs. The client will practice
reaching for simulated bathing materials such as soap, shampoo, or a
towel. The practitioner should encourage the client to apply soap or
shampoo with the left arm and scrub the body with the involved arm
incorporating the use of both upper extremities and functional reaching in
the activities. Since the client has fallen in the shower before, educating
the client on safe transfer techniques in and out of the shower would be
beneficial. Recommending DME and A/E such as a shower chair, handle
bars, and a non-slip shower mat can increase the clients safety during
shower transfers and bathing.
Evidence for Interventions
The interventions provided for the client have been supported by current research
focusing on interventions for stroke populations. A majority of the research has been conducted
on contractures resulting from stroke, hemiplegia, and the effect a stroke has on the quality of
life for these individuals. For Intervention A, a modify approach was taken to enable the client to
complete baking cupcakes with less activity demands. The modify approach requires

modification of the environment and use of adaptive equipment to substitute a skill that the client
is having trouble with. According to Ways of Living: Adaptive Strategies for special needs by
Christiansen & Matuska (2004), activities can be accomplished in more than one way. Training
in the use of adaptive equipment can improve and maintain occupational performance
(Christiansen & Matuska, 2004). Some commonly used adaptive equipment for stroke patients
include electric mixers, pan handle stabilizers, apron with front pockets, and use of a wheeled
cart. The use of adaptive techniques such as stabilizing bowls by securing them in between your
legs while you stir and using a cart to take fewer trips during the cooking process decreases the
activity demands. Evidence of adaptive equipment and techniques in the kitchen will provide
support for further techniques and equipment recommendations for Mrs. Brown during
Intervention A. These techniques provide the therapist with a foundation to grow upon,
providing more client-centered adaptive techniques and equipment that meet the needs of Mrs.
Brown to complete baking the cupcakes.
For Intervention B, a remediate approach was used to promote improvement in the
clients AROM in the shoulder during functional activities. A contracture has formed secondary
to CVA. Promoting use of the arm and hand will improve movement and motor skills within the
involved side. Incorporating the use of her favorite occupation as a way to increase AROM is
important in the intervention, providing the client with an end-goal to work towards. Grading of
the activity should be completed to ensure the client does not experience failed attempts which
may result in decreased self-efficacy and learned non-use. According to a study conducted by
Schaefer, DeJong, Cherry, and Lang (2012) Grip Type and Task Goal Modify Reach-to-Grasp
Performance in Post-Stroke Hemiparesis, different movement patterns may be elicited through
different grip types and task goals (Schaefer, DeJong, Cherry, & Lang 2012). The study looked

at sixteen adults with post stroke hemiparesis and their movement patterns when grasping
cylindrical items using a 3-finger or palmer grip to achieve a task goal. This task goal was to
hold or lift the item. Results from the study suggest that even with arm impairment resulting
from a CVA, reaching and grasping performance can still be modified on how and why the
object will be grasped. Learning about how different movement contexts influence performance
poststroke may assist therapist in planning how and when to practice during task specific upper
extremity training (Schaefer, DeJong, Cherry, & Lang 2012). This study can guide the
practitioner working with Mrs. Brown on the specific end-goal being achieved during the reach
and grasp activity. For this intervention, the end-goal is to reach toward the sprinkles and pinch
some of the sprinkles to transfer onto the cupcake. Is it recommended to observe how the clients
grip may affect the clients ability to reach during a functional activity. These observations may
have further implications on future treatment sessions.
For Intervention C, a compensatory approach was taken to allow the client to reach her
grooming goals. According to Christiansen & Matuska (2004), the compensatory model
emphasizes achieving independence in occupations; clients with persistent activity limitations
should be educated on compensatory techniques for performing occupations meaningful to the
client. The therapist should incorporate use of the involved extremity. Having the client stabilize
the involved arm using the non-involved arm to complete activities promotes use of involved
extremity and may be used for activities of daily living and occupations that are important to the
client. Usually compensatory techniques should be used with clients who have poor prognosis
for return of function and involve techniques that work around the affected extremity. The
technique used in the intervention involves using the affected extremity but compensating for the
lack of the clients ability to flex the shoulder. This is achieved by stabilizing the involved arm

with the non-involved arm. This is not a traditional compensatory approach because the involved
limb is still being utilized in the task, although the task still requires compensation from the non-
involved limb to increase ROM.
For Intervention D, an establish approach was taken to complete bathing activities in the
shower. Emphasis will be placed on a motor-control theory. According to Christiansen &
Matuska (2004), treatments guided by motor-control focus on the practice of functional tasks as
a way to organize motor behavior (Christiansen & Matuska, 2004). Using the motor-control
theory, the practitioner will modify the demands of the bathing activity, such as having the client
in a seated position to maximize the clients motor performance. When using the motor-control
theory to guide treatment, it is important to practice the activity in a natural context. For the
client, addressing all components of bathing that are giving the client difficulties is most
effective. For example, the client is having trouble washing the perineal area and both legs.
Working with the client on all components of washing the legs is more effective than working on
one task required for washing the legs including applying soap to the loofa, scrubbing the legs
from top to bottom, and washing off the soap using the hand-held showerhead. The Post-stroke
Rehabilitation Guideline Panel (1995) recommends that clients who have functional deficits and
some voluntary movements of the involved arm be encouraged to use the limb in functional
tasks. The motor-control theory will allow Mrs. Brown to establish motor-control, sensorimotor
relationships, and improve functional performance (Christiansen & Matuska, 2004).
Intervention Outcomes
The outcomes of the intervention that the client and practitioner aim to achieve are
increased improvement in occupational performance and quality of life. Improvement in the

clients occupational performance addresses the clients current occupational performance to find
a way to promote engagement in occupations through different techniques e.g. compensatory
strategies and adaptive equipment. Achieving these outcomes will allow the client to complete
her bathing activities without assistance from her husband, enable the client to complete
grooming activities on her schedule, and engage in her chosen leisure activities. An additional
intervention outcome that treatment aims to achieve is an improvement in quality of life for the
client. It was important for the client that she is able to not rely on her husband to get ready for
the day or bathe herself when she is in the mood to shower. She also felt it was important to be
able to spend her free time cake decorating and crocheting at home when her husband is at work.
By addressing the clients goals for increased health and functioning through self-care
capabilities, the client will become more satisfied with her daily routine and increase her quality
of life and feelings of self-efficacy.
Precautions and Contraindications
Some precautions that must be taken into consideration when treating the client are
secondary diagnoses such has her RA, shoulder pain, and fall risks. Careful review of the clients
chart should be done before choosing appropriate treatment activities because the client has
comorbidities. Mrs. Brown has difficulty with movement of the involved shoulder; it is advised
to mobilize the shoulder joint before ranging the movement of the clients involved shoulder. An
additional precaution that should be considered is the clients fall risk. The client has difficulty
with balance when standing due to right side weakness and has a history of falls in the shower.
Before starting shower activities, scanning the environment for safety risks is advised and
education on safe shower transfers and mobility should be given to the client.

Frequency and Duration of Treatment
The client will attend outpatient treatment for 60 minutes twice a week for 3 months.
Grading Treatments
During treatment, it is beneficial to the client to grade the activity up and down for a just
right challenge. To grade up Intervention A, the practitioner may have the client set up the tools
and materials needed to make the box cake set. This may include retrieving eggs, measuring
cups, and measure out the oil for the batter. The practitioner may also have the client stand to
complete the activity to work on endurance while standing at the kitchen. To grade down the
activity, the practitioner can have the client verbalize the items needed for the activity and the
practitioner can set up the tools and materials. The practitioner may have the client use an
electric mixer to mix the batter instead of manually mixing the batter for the cupcakes. Grading
the activity will allow the client to complete the activity at an optimal performance level that
meets the clients skills.
Primary Framework
The primary framework that will be the foundation of intervention planning will be the
MOHO model, which includes the clients volition, habituation, and performance capacity. The
client is experiencing difficulties in her occupational performance, and the MOHO model
focuses on the clients motivations, routines, habits, and the influence of the environment on the
clients occupational performance. Mrs. Browns motivations, daily routines, and environment
influence her performance. Her motivation to be more independent in self-care and current

performance capacity affect her ability to achieve increased independence. Her desire to attend
church meetings and use of her home modifications to complete bathing activities can improve
her overall occupational performance. These factors are taken into consideration when creating a
treatment plan for the client to provide a client-centered and holistic treatment. To make goals
realistic, client-centered, and achievable, these factors must be considered to meet the needs to
the client and keep the client motivated to return to treatment and achieve her treatment goals.
Client & Caregiver Education
Providing education to the client and her husband is a vital part of treatment. The clients
performance can be improved with adaptive equipment and DME. Education on the equipment
and its use can affect the clients engagement in these occupations. Providing education to the
clients husband will enable her husband to be more involved in treatment and provide assistance
to Mrs. Brown at home if the client requires help with the adaptive equipment and its use. For the
client to transition from reliance on her husband to modified independence in her self-care
activities with adaptive equipment help from the husband will be needed. Education on safe
transfers during bathing is vital. If the client wants to be more independent in bathing, she will be
bathing without supervision and will need to be as safe as possible. Recommendations for grab
bars and a shower chair should be given to the client and her husband.
Response to Intervention
To measure the clients progress in all treatment goals, formal assessments and
questionnaires are utilized. The clients progress towards ADL goals will be measured by the
ADL profile assessment to measure the clients bathing and self-care skills. Using the personal
care section of the ADL profile will allow the practitioner to observe the clients skills in bathing

and grooming. The ADL profile can be completed in the home setting or in a rehab setting. To
measure the clients satisfaction in her leisure activities such as baking, the COPM or Stroke
Specific Quality of life scale can be utilized. The COPM and Stroke specific quality of life scale
can be used as an outcome measure to assess the patients quality of life for leisure and social
roles. These assessments may be given at the beginning of treatment to create a baseline for
treatment goals, and then given again for re-evaluations or discharge.


References
AOTA. (2014). Occupational therapy practice framework: Domain and process (3rd ed.).
American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. http://dx .doi .org/10
.5014/ajot .2014 .682006
Christiansen, Charles, and Kathleen M. Matuska. "Adaptive Strategies Following Stroke." Ways of
living: adaptive strategies for special needs. 3rd ed. Bethesda, MD: American Occupational
Therapy Association, 2004. 241-257. Print.
Schaefer, Sydney Y., Stacey L. DeJong, Kendra M. Cherry, and Catharine E. Lang. "Grip Type and Task
Goal Modify Reach-to-Grasp Performance in Post-Stroke Hemiparesis." Human Kinetics 16
(2012): 245-264. EBSCO Host. Web. 29 May 2014.

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Running head: OCCUPATIONAL PROFILE & INTERVENTION PLAN 1

Occupational Profile & Intervention Plan

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