Student

Name: Sam Adams Case: Cognition Final Date: 4/25/2017

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Troy, R CVA, type I diabetes, wears glasses, referred by NPO after request from his mother, home
health/community setting, treating 2x/week for 6 weeks.

7. Practice Models Guiding Assessment and Rationale

Treatment
1. PEO This model considers the relationship between
the person, the occupation, and their environment
and works to increase congruence in these areas
to improve satisfaction and occupational
performance. This approach is applicable in
Troys case because his environment (how his
home is set up, the community), how he
performs occupations (how he takes care of his
son, changes his sheets, cleans the bathroom, and
pays his bills), and his client factors and
performance skills related to those occupations
(higher-level cognition, attention, memory, left
hemiparesis, and limited joint mobility in LUE)
will need to be considered and modified to
increase his independence and occupational
performance.
2. DIM This model postulates that cognition is
modifiable, and uses a hierarchy of cuing to
increase occupational performance. If a client is
struggling during a task, the therapist can
facilitate performance by providing cues,
teaching strategies, or reducing the demands of
the activity. This model will be helpful in Troys
case because of his cognitive dysfunction and
limited insight, which can be addressed using the
hierarchy of cuing to increase his occupational
performance in caring for his son, maintaining
his apartment, and paying his bills. I will also use
this model to help develop Troys insight and
self-awareness so that he can utilize strategies as
needed in his daily routine.
14. Evaluation: What Assessment tools and other means of assessment will you use?
Methods/Tools Rationale/What is being Assessed

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HOEA Home evaluation to identify accessibility,
sanitation, food storage, safety issues, and
lighting problems within the home that could be
modified to support his occupational
performance.

PASS: IADL (Money Management) Bill Paying Baseline measure for independence, safety,
by Check, Checkbook Balancing, and Mailing quality, process, and outcomes related to paying
Bills; IADL (Heavy Housework) Changing Bed his bills, housework, and environmental
Linens; and IADL Home Safety subtests. awareness.

CAM Evaluate his cognition to identify specific deficit

areas such as attention, memory, following
directions, foresight, planning, judgement, and
problems solving as they relate to occupational
performance.

MMT/AROM/PROM testing of LUE Baseline measure of ROM and muscle strength

as an indicator of dysfunction and barrier to
occupational performance

Modified Ashworth Scale Measure of tone in LUE.

Goals Practice Model for each goal

1. LTG:
By discharge, client will independently clean his bathroom PEO, DIM
twice a week using memory aids.

STG:
In two weeks, client will initiate cleaning his bathroom using PEO, DIM
memory aids with minimal cueing.

STG:
In four weeks, client will use a checklist to thoroughly clean PEO, DIM
his bathroom with moderate cueing to perform all of the items
on the list.

2. LTG:
By discharge, client will change his sons diapers with PEO, DIM
modified independence.

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 STG:
In two weeks, client will check to see if his son needs a diaper PEO, DIM
change every two hours while in his care, using memory aids
with minimal cuing.
STG:
In four weeks, client will use compensatory strategies to put on PEO, DIM
his sons diaper correctly with moderate cueing and physical
support.

1. Treatment Sessions: Plan for first two 45-minute treatment sessions

Approach:
Remedial, compensatory, or combination.

Generally compensatory.

Needed Materials/Equipment:

Paper, pen/pencil, Troys cellphone, glass cleaner, paper towels, toilet bowl cleaner, toilet brush, all-
purpose cleaner, or other cleaning supplies he has available.

Specific Set-up requirements/Directions:

For this session, we will go to Troys bathroom and I will have him help create a checklist of tasks for
cleaning his bathroom. The therapist starts by asking him how often and how well he thinks he cleans
his bathroom, we will then discuss the importance of him maintaining his apartment (and bathroom) in
order to continue renting it. The therapist will then discuss the purpose of a checklist and will write
down the items that Troy comes up with and use cuing to produce an appropriate list. Troy will then
perform the items on the list and practice checking them off. As he performs the different tasks, the
therapist will note any difficulties he has (cognitively, physically, or safety concerns) and will suggest
compensatory strategies, such as task modification or using adaptive equipment, to enhance his
performance. Troy will perform all of the items on the checklist, with the therapist providing as little
assistance as possible. The therapist will type up the bathroom checklist and secure it on his mirror to
reference as he cleans. The therapist will also help Troy set up an alarm on his phone twice a week as a
reminder to clean his bathroom and designate those two days as bathroom cleaning day on his
calendar. The therapist will also instruct him to complete all of the items on his checklist before moving
on to a different activity.

Therapist Role:

Teaching Troy compensatory strategies (using alarms and checklists) to support his occupational
performance; increasing his self-awareness; promoting safety; cuing him to generate appropriate ideas,
attend to the task, complete all of the steps, and terminate the task appropriately. Supporting him as
needed physically and cognitively to successfully complete the activity.

One suggestion for Grading task up:

The therapist will have Troy set up an alarm on his phone to remind him to clean his bathroom, and he

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will have to do so without following a checklist.

One suggestion for Grading task down:

Troy will only be expected to complete one of the bathroom tasks, such as cleaning the toilet or wiping
down the mirror, instead of cleaning the entire bathroom.

2. Treatment Sessions: Plan for first two 45-minute treatment sessions

Approach:

Remedial and compensatory

Needed Materials/Equipment:

Baby doll, diapers, wipes, changing table (or some other type of raised changing area), television (or
some other type of background distraction like a radio), A Baby Diaper Troubleshooting Guide or
other handout, and Troys cellphone.

Specific Set-up requirements/Directions:

The session will begin with the therapist discussing childcare with Troy, such as how often he should be
checking his sons diaper (every 2 hours unless he smells that his son needs to be changed sooner), the
importance of changing his son often (avoid diaper rash), different types and sizes of diapers, how to
avoid diaper leaks (buying the right size and fastening the diaper tightly), and compensatory strategies to
use while changing his sons diaper (integrating his LUE to stabilize during the task, giving the baby a
toy to play with while he is changing him to keep the baby distracted). The therapist will provide Troy
with a handout with writing and pictures discussing these issues that he can reference, and the therapist
will help Troy set up an alarm on his phone to remind him to check his sons diaper every couple of
hours. Troy will then practice diapering the baby doll. The therapist will have the TV on and the
supplies around the room, and will discuss how the environment can support or inhibit his success. The
therapist will then have Troy practice modifying his environment (turning off the TV or radio and
gathering all necessary supplies before starting), providing cuing as needed. Troy will then practice
having a diaper out and ready before he starts, getting out wipes and wiping the baby, using his LUE to
stabilize the diaper as he unfolds and flattens it with his RUE, orienting the diaper correctly, sliding the
diaper under the baby with his RUE, stabilizing the front of the diaper with his LUE as he pulls the tabs
with his RUE and fastens them to the front, and fastening the diaper tightly to avoid leaks. The therapist
will provide cuing and physical support as needed to help Troy complete the activity correctly. Troy will
practice this process 5+ (as much as time permits) times with the doll. The therapist will instruct Troy to
practice using the alarm on his phone to begin regularly check his sons diaper as part of his daily
routine. The therapist will also coordinate the next session for when he has his son with him, so that they
can practice the task with the baby under the supervision of the therapist.

Therapist Role:

Educating Troy about issues related to childcare, and teaching him compensatory strategies to help
increase his involvement in the care of his son. Providing cues to help him learn the task and increase his

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independence in it. Provide physical support as needed to ensure safety of Troy and the child.

One suggestion for Grading task up:

Troy will practice the task with his son, and will have to put on the diaper correctly while also attending
to the wiggling baby.

One suggestion for Grading task down:

The diaper will be prepared and the wipes will already be laid out for Troy, so he will only have to focus
on putting the diaper on the doll.

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