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Tonya occupational profile, Treatment Plan : Grooming and self care,…
Tonya occupational profile
Context
Contextual Factors
Personal Context :She is a 50 year old female that is right hand dominant and lives alone.She owns a 3 year old dog and is also a journalist. She was an active person with dinning out and doing pilates with friends. She was Independent prior to injury.
Cultural Context: Likely values independence, productivity and probably has strong sense of responsibility for her pet she has at home.
Temporal Context : Middle adulthood: productive stage of life, may emphasise work, independence, and social roles with friends.
Virtual Context: Likely relies on computer for work when she is doing journalism.But R wrist fracture impacts typing speed and amount.
Environmental Factors
Physical Environment: The apartment she lives in has stairs which is a fall risk and has no elevator or ramp accesses.May need adaptive equipment like walker or reacher for daily activities.
Social Environment: She is living alone which means she has limited assistance and she has close friends which means she has social support like dinning out and outings.
Within the case the client didn't express any goals. As an OT I can infer that she wants to return to her prior level of function with her ADLs & IADLs. She also would want to return back to her full-time job as a journalist.
Occupational history. Client is a 50 year old women who lives alone with her pet. She enjoys reading books and going out to dinner with her friends. Client doesn't have any past medical history according to the file. She was once independent in ADLs & IADLs before the injury.
Performance patterns. Client role is an journalist for the local paper, where she works. She also plays the role of an caregiver to her 3 year old pet. She has a pattern of meeting with friends for dinner and pilates. C
Strengths and concerns. Some barriers that hinder's Tonya's participation are the R wrist fracture & L patella fracture. she has difficulties with feeding, grooming, and dressing. Some areas she has strength in are reading and socializing with others in the community. Before her condition she worked full-time and cares for her pet.
Reason client is seeking services. Client is seeking services due to a fall outside her apartment. Client received an R wrist fracture & L patella fracture.
Personal interest and values. Client has value in caring for her pet. She also has interest in reading and socializing with he friends at pilates.
Occupations
Activities of Daily Living (ADLs) Includes: Dressing, Personal hygiene and grooming, Toileting and toilet hygiene, Functional mobility
Social Participation: Tonya enjoys reading books, going out to dinner with her friends, and doing Pilates.
Treatment Plan : Grooming and self care
Problem List
Self care - Tonya has difficulty dressing , grooming ,and toileting due to having limited mobility and pain in her wrist and from her knee fracture.
Functional Mobility - She is struggling with moving safety through her home, and using stairs. Especially with now having her L patella fracture.
Meal prep and eating - Tonya is right hand dominant and that is making cutting any type of food difficult and when eating, holding the utensils. This is affecting her independence in meal prep.
Goals
STG: Client will perform grooming task seated at the edge of the bed with minimal assistance within 1 week
LTG: Client will perform grooming task standing in mirror independently within 2 weeks.
Assessments
Standardised : Barthel Index – ADL function / can also use DASH - Measures Upper Body functions like Upper Extremity mobility and strength, role limitations. This will help us assess the functional limitations of her right hand/wrist, which especially relevant since she is R-hand dominant.
Non-Standardised : We can do task observations while she is preforming grooming task, which will assess real-time performance and compensations. and also ask a series of questions about her habits and routines she may have on a daily bases.
Activity Grading
Easier : When getting dressed we could use loose-fitting clothing, sit in chair, use Velcro instead of buttons. When she is using the toilet we can use raised toilet seat, Wall railing to hold on to, pre-moistened wipes, or set up clothing for easier donning.
Harder :Timed grooming routine for return to work readiness, Practice standing balance while dressing, switch to regular clothing as tolerated, or we can decrease equipment used while grooming and encourage full hygiene routine independently.
Addressing Dressing and Toileting
Dressing: Teach one-handed dressing techniques like lay clothes flat on bed, or use affected limb for stabilisation only. Also can use adaptive equipment like reacher, button hook, elastic shoelaces.
Toileting: Use toilet seat riser to reduce strain on L knee. Teach safe sit-stand transfers while using grab bars or walker. Provide toilet paper tongs or Instruct in one-handed hygiene techniques.
client goals
Client Report