Occupational Therapy Occupational Profile And Evaluation Plan
Background Information
Date of report: xx/xx/xx Client’s name: Mavis John
Date of birth: xx/xx/xx Date of referral: xx/xx/xx M F
Primary intervention diagnosis/concern: Fall due to increased Blood Pressure
Secondary diagnosis/concern: Unable to walk independently
Reason for referral to OT: Inability to walk adversely affects daily routine
Therapist: Francis Jacob
Assessments performed: Interview
FINDINGS
Occupational Profile:
Mavis is 62 year old woman with no history of any severe illness though she takes daily medicine for controlling her BP. She has been reporting anxiety and nervousness due to high BP since 2 years. Last month she met a fall in her bathroom as she fainted and lost her balance of posture. She slipped in bathroom and since then she feels inability in walking and self care. She reports to have no pain or any other problem while sitting on chair or lying on her bed. She has one daughter who is married and living a happy life. Mavis is helped in her house by her maid and a cook. Her husband is now retired from a high paying job. He is 65 year old with good health. Mavis uses spectacles to see both far and near distances.
Before the fall, Mavis often used to get tired of consistently staying in same posture for prolonged hours. She liked to cook for her family and used to visit church with her husband for offering special prayers. She has been living an active life and liked to go for purchasing groceries and outing with her friends and family. Recently she has been reporting of impaired balance and fatigue.
Mavis lives in double storied house with her husband and one maid. Her cook used to visit her home every morning and goes back in evening after cooking all meals. Her daughter, who is married to a businessman, lives at a distance 10 minutes away from her house. Every year Mavis, her husband and her daughter and son in law used to go to hill stations for visiting and enjoying the pleasant weather in summers. She says that her husband is very supportive and after fall, he helps her in walking till the bathroom, dressing, cleaning and getting food for her from the kitchen. He also helps her in carrying out the activities of daily living.
Mavis is not happy about the feeling that her inability to walk has denied her from doing certain things that she used to do earlier. She cannot go to market, to church, to her daughter. She regrets that she can’t work in kitchen and can’t cook meals for her husband. She feels sad about it and is anxious to walk again. Mavis becomes emotional while reminding of her daughter who closely understands her condition and since she has met a fall, she visits her daily to take care of her and ask for anything required.
Mavis is a home maker just studied up to intermediate. She is very health cautious and used to go for daily walk before she met a fall. She says that, the physician assessed the high BP and imbalance as the most probable cause of her fall. She has never fallen earlier in her lifetime. She does not look obese or overweight, that could have made her to fall. She has a normal body weight. She is very much interested in plants and cleanliness. Her house has a long balcony with different types of plants which she ensures to have watered every day. After the accident, her husband waters the plants and her maid ensures that her house is completely clean before 8 am. After that she prays at home.
Now, she does not go upstairs and stays at ground floor, where there are no stairs and any steep surfaces. She has an air conditioner installed at her bed room which she uses comfortably. She takes her medications post fall to cure her physical injury (at the back) as prescribed by the physician. She has no fracture. She states that they are planning for installation of hold bars in the bathrooms. She regularly performs personalized exercise program to improve her activity level. She has added the occupations of brisk walk within home, yoga, feet movement for strengthening the muscles, balance and coordination exercise along with gait training. She is also attended by Home care physiotherapist to improve her functionality.
As the primary assessments of occupational therapy, the patient is assessed through FIM, Barthel Index, Berg Balance test and COPM.
PLAN
Specific Assessments of areas of occupation, client factors, performance skills, performance patterns, contexts and activity demands.
| Assessment | What it specifically assesses |
| FIM –Functional Independence Measures(Client Factors) | Self-care, Sphincter control, Transfers, Locomotion, Communication, and social cognition. |
| Barthel Index | Activities in Daily living |
| Site Evaluation (Contexts and activity demands) | Bathroom environment, assistive technology installed, tiles, lighting and knowledge of using the devices. |
| Berg Balance Test(Performance skills) | Balance while walking, standing, turning and other functional challenges |
| Canadian Occupational Performance Measure (COPM) | Self care, leisure and productivity |
| Exercise evaluation (area of occupation) | How the exercise has improved the functional ability and likely improvements |
| Extent of Dressing and walking independently(area of occupation) | Performance in activities of daily living, personal hygiene, sleep pattern |
