Please enable JavaScript.
Coggle requires JavaScript to display documents.
Ruby Jane Smith (Problem List (Receding gums cause ill-fitting dentures to…
Ruby Jane Smith
Problem List
Receding gums cause ill-fitting dentures to slip in and out while chewing food
Erosion of remaining teeth due to acid when experiencing reflux
Constant sore throat and hoarseness due to regular reflux episodes
Bad breath leading to increased self-consciousness
Difficulty swallowing desired food
Heartburn after meals and drinking coffee and soda
Relies on daughter for transportation due to low vision and osteoarthritis pain in UEs
Difficulty with social situations that involve eating/drinking
Occupational Performance Deficits
Swallowing/eating
Difficulty moving food from mouth to stomach due to ineffective LES function
Social participation
Decreased engagement with friends/family due to embarrassment of dental/oral hygiene and GERD symptoms
Community mobility
Relies on daughter for transportation; possibly causing the daughter to feel caregiver burden
Health management and maintenance
Limited participation in routines that promote health and wellness (regular exercise, appropriate nutrition, behaviors that decrease health risks)
Personal hygiene/grooming
Brushing and flossing teeth, cleaning and reinserting dental orthotics
Meal preparation
Limited preparation of well-balanced meals
Sleep
Inappropriate sleep hygiene and restful sleep that is disturbed by GERD symptoms
Occupational Profile
86-year old female who lives alone
2 year history of GERD affecting quality of life and has not been improved with OTC PPI therapies
GERD may be caused by a weakened sphincter muscle between stomach and esophagus leading to the inability to fully close and prevent stomach contents from traveling back into the esophagus (Collins, 2018)
Client has been advised that GERD requires lifestyle changes, medications, or surgery
Roles: Widow, grandmother, pet owner
Habits: Drinks 2-3 sodas per day, eats McDonald's breakfast every morning, watches TV 2 hrs every night before going to sleep around 11 PM - 1 AM
Routines: Feeds cat, asks daughter to drive her to McDonald's for breakfast and coffee every morning, attends the local senior center from 11 AM - 3 PM, spends time with grandchildren after they come home from school, eats dinner with daughter's family 4-5 times per week, feeds cat dinner, watches TV before bed (usually has difficulty falling asleep)
Strengths List
Modified independent ambulation with rollator
Manages physician appointments (sets, attends, and follows up with appointments)
Social participation with friends at senior center and family almost everyday
Independent with most ADLs and IADLs
Dependable family (daughter)
Assessments
FIM
18-item assessment that measures the functional status of the client based on the level of assistance she requires from total assistance to total independence
Examines bowel and bladder control, transfers, locomotion, communication, social cognition, and self-care activities
COPM
Semi-structured interview that allows the client to identify everyday living activities that are important to her and express her self-perception of her performance and satisfaction with her performance over a duration of time
Cranial Nerve IX and X Testing
Have client say "Ah" to evaluate symmetrical soft palate elevation movement
Examine for uvular displacement
Determine if voice is hoarse or nasal
Client's voice is hoarse
Have client cough and swallow to determine if there is a bovine cough, which indicates recurrent laryngeal
Examine gag reflex by stimulating back of throat on each side (sensory: CN IX, motor: CN X)
Barium Swallow Examination: used in general hospital to evaluate client's worsening GERD and dyspepsia symptoms
Findings is seen in the image as metaplastic and premalignant in the mid or distal esophagus in which squamous epithelium is replaced by columnar epithelium
Indicates Barrett's Esophagus
Results as a chronic exposure to acid (Shaheen, 2015)
Columnar epithelium is more resistant to acid breakdown than original squamous cells (Shaheen, 2015)
May be an adaptive change in response to reflux (Shaheen, 2015)
Potentially a result of mucosal healing in an environment of constant reflux
Lower esophageal sphincter (LES), 3-4 cm distal to esophagus, failed to fully contract at rest, possibly due to a decrease in intrinsic muscle tone or loss of extrinsic cholinergic innervation
LES is the primary barrier to reflux; therefore, client's GERD symptoms is most likely due to impaired LES contraction
Double-contrast portion of the examination showed upper-thoracic esophagus and LES when the esophagus was fully distended, which led to the diagnosis of erosive esophagitis as exhibited by the granularity of the mucosa and thickened folds due to edema and inflammation as well as erosions and stricture
Clinical Observation
Client is compliant but irritable during assessment/OT session. Client presents with major discomfort from GERD symptoms and is on a progressive diet and may be given medications PO. Even though client is on progressive diet, she still experienced a reflux episode during the session. However, client expresses reluctance to alter diet because she has always had the same diet that consists of her desired food and drink. Client also constantly readjusted dentures, which indicates that dentures are an ill fit. Client is very close with her daughter who provides transportation to the client as needed. Client expresses decreased desire to perform social participation due to symptoms of GERD and oral issues (bad breath and dental problems).
Intervention Strategies
Swallow techniques: Use effortful swallow to facilitate swallow by activating posterior tongue, pacing to control bolus, or Masako technique by holding tongue forward during swallow
Grade up: Practice effortful swallowing prior to eating and then use Masako technique and pacing during eating to encourage safe swallow
Grade down: Practice pacing technique with soft/pureed food to control bolus in preparation for consumption of actual food
Positioning: Chin tucked to neutral, head rotated, slightly reclined but mostly upright or side-lying to right side with positioning devices such as wedges or bolsters
Grade up: Client will independently perform positioning for safe swallow
Grade down: Client will receive physical and verbal assistance with positioning while eating for safe swallow
VitalStim® application while eating to facilitate sphincter control, protection of airway, swallowing action, and propelling food backward
Grade up: Client will eat recommended food items to decrease GERD with VitalStim application for 10 min
Grade down: Client will eat preferred food items with VitalStim application for 5 min
Electrical stimulation of LES effectively controls esophageal acid exposure and decreases GERD symptoms as well as the need for PPI medications (Rodriguez, Rodriguez, Gomez, Netto, & Crowell 2016)
Oral care: Acquire well-fit dentures, avoid brushing teeth immediately after reflux episode to avoid damaging tooth enamel further, chew sugar free gum to promote salivation, rinse vigorously with water to dilute acid in mouth, rinse with baking soda to neutralize acid (Oral Health Library, n.d.)
Grade up: Client will rinse with baking soda instead of brushing teeth after reflux episode and chew sugar free gum to promote salivation and reduce acidity in mouth
Grade down: Client will refrain from brushing teeth after reflux episode (she always feels inclined to) and vigorously rinse with water instead
Individuals with GERD may experience oral cavity issues such as oral dryness, acid and bitter taste, glossalgia, halitosis, dental cavities, gingivitis, or inflamed oral mucosal regions (Watanabe et al., 2017)
Diet/texture modifications: Implement meal options that will lower symptoms of GERD and avoid consumption of food that encourages symptoms of GERD
Grade up: Eat only recommended food such as lean meat, baked goods, non-citrus fruits, and fresh vegetables (no onions or tomatoes) all meals per day
Grade down: Because client is very used to routine, changing up her meal options can be difficult. Introduce recommended food options for one meal per day
Goals
LTG 1: Within 4 days, client will independently demonstrate appropriate positioning technique with minimal discomfort related to acid reflux to facilitate participation in eating tasks.
STG 1: Within 2 days, client will demonstrate appropriate positioning technique with minimal discomfort related to acid reflux using moderate A of 4-5 verbal cues to facilitate participation in eating tasks.
STG 2: Within 2 days, client will demonstrate and verbalize appropriate nutritional meal choices with moderate A of 4-5 verbal cues to reduce GERD symptoms and increase participation in health management and maintenance.
LTG 2: Within 4 days, client will independently demonstrate and verbalize appropriate nutritional meal choices to reduce GERD symptoms and increase participation in health management and maintenance.