Occupational Therapy Evaluation Report and Initial Intervention

Plan
BACKGROUND INFORMATION
Date of Report: 2/18/14

Clients name or initials: Jeff

Date of birth &/or age: 39y

Primary intervention diagnosis/concern: Traumatic Brain injury
Secondary diagnosis/concern: Visual field cut (tunnel vision)
Reason for referral to OT: Community Client
Therapist: Philip Lamoreaux, OTS
S: Client states I am a little afraid of playing with the kids because Im afraid they
will hurt me.
OCCUPATIONAL PROFILE:
The Client is a 39 year old male with a traumatic brain injury from a motorcycle
accident 6 months ago. The client is currently seeing an occupational therapist at an
outpatient clinic. His goals have been to improve scanning. The client is a father of 3
children. Client is seeking therapy in order to improve executive function in
everyday activities. Client is currently mobile and able to participate in all ADLs.
Client is able to participate in play with his children, wash the dishes, navigate
through TV stations, and go on family outings. Client has tunnel vision in right eye,
and 21/50 acuity. Client unable to open left eyelid, but has normal vision in left eye,
but the eye is stuck looking laterally. Then client was in inpatient rehab for 6 weeks.
Since then he has been at home going to outpatient therapy. His wife is very
supportive and intent on helping him get better. He has lived in his current house

for the past three years, which helps in his ability to get around the house. He does
however live isolated from the city, which provides less interaction with other
individuals. His children are both supports and inhibitors due to their desire to play
with him, but do not know the limitations of his deficits. They interact with him as if
he does not have a vision deficit.
Client worked for the city of Bluffdale doing construction and maintenance
prior to injury. Client was also a truck driver prior to that. Client stated the desire
to get back to work, as well as help his wife out with whatever she needs. Client
enjoys working on cars, hiking, going on picnics, and riding motorcycles. Client
remembers everything leading up to the accident, however, can only remember up
to a week currently. He is able to remember some major activities with family since
the accident. Currently the clients spouse reminds him to do ADLs and IADLs.
Currently the client desires to get back to work as well as help his wife out with
whatever she needs.
Currently the client describes his day as he gets up, eats breakfast, showers,
and watches TV all day. Then he eats dinner and does whatever his wife asks him
until it is time to go to sleep. According to the clients wife she has to ask him to do
every task. Once asked, the client requires minimal cues to complete the task
depending on its complexity. He is physically capable to help with any physical task
around the home.

O: Client was seen twice for occupational therapy services for 90 minutes.

OCCUPATIONAL PERFORMANCE:
Client was observed maneuvering around the house and was able to get from
one room to another. Client ran into a lamp that was in a different place than
normal due to his tunnel vision when transitioning between rooms. When asked
questions the client is able to answer in whole sentences and understands many of
his limitations. When given a task client is able to do all the steps within the
particular task. However, when given multiple tasks client does not initiate doing
the second task. Client was observed cleaning the kitchen floor. He scanned the
floor and picked up all the items and put them in the sink or away. The client was
then asked to clean the dishes. Client cleaned the dishes thoroughly and put them
on the rack to dry without any cues. He did not clean the dishes that were on the left
side of the sink. The EFPT, and MOCA were administered in our intervention
session in order to obtain more information.
Client addressed goals that were given in the Canadian Occupational
Performance Measure (COPM).
Occupational performance
problems
Increased communication
with spouse
Community mobility
Ride motorcycle
Contributing to activities
with family
Working on cars

Performance

Satisfaction

Is overall performance score was 1.8 and his satisfaction with those activities score
was 1.6. Client stated many times that he wanted to improve and help his wife out
with whatever he could. Client stated he knew his limitations and was not satisfied
with how he was performing at the moment. The Clients wife was given the COPM
in another room.
Occupational Performance
problems
Contribute through paid
or unpaid work
Play with kids
Get back to active
activities such as hiking,
fixing cars, etc
Find activities to do with
friends
Initiate conversations
with others more

Performance

Satisfaction

The client was given the simple cooking portion of the Executive Function
Performance Test (EFPT). Client scored a 12 and finished the task in 10 minutes.
Client was independent in beginning the task. Client required both verbal direct
instruction and physical assistance in the execution of the task. Client spent most
time on reading the instructions with his magnifying glass. The student gave him
direct verbal cues regarding the instructions of making oatmeal. After explaining
the instructions the client completed steps without cues. Once on the stove client
turned on the wrong burner, at which point the student intervened to turn off the
wrong burner due to a cutting board over the turned on burner. The client then
turned on the correct burner and asked therapist to set the timer. The student
asked how he knew that was the right one and he stated I memorized it. Client

stirred the oatmeal every 1 minute. While stirring, the client got a phone call. Client
answered the phone and continued stirring the pot while talking on the phone.
When timer went off the client turned off the burner and looked at the student.
The client was given the Montreal Cognitive Assessment (MOCA) in order to
assess his executive function further. The client scored below average with a 14/30
overall score. The clients strengths were in the attention, and memory categories
by obtaining perfect scores. The client scored lower than average in the
visuoconstructional, alternating trail making, verbal fluency, abstraction, and
orientation categories. The client was average in the naming sections.
A:

The COPM was given to both the client and spouse in order to assess insight

in the client. The client had relatively good awareness secondary to lack of insight.
This was shown in his third goal, which was to ride a motorcycle. Due to the clients
lack of vision added to his lack of insight, he should know that riding will be
improbable. However, the client was able to recognize his inability to initiate
activities and wanted to help his wife out around the house. That goal was not rated
as important to him as the five specified on the COPM.
The COPM was given to the clients spouse in order to look at insight, as well
as what her goals are for therapy. The COPM indicated the client has difficulty with
initiation. The five goals made by the spouse were focused around having him be
more independent and require less cueing. The most important goals identified by
the clients wife were focused on having the client initiate participation within the
home in order to be more active and help her with responsibilities around the
house.

The simple meal cooking section was chosen and adapted from the EFPT in
order to be easier for the client to read. Due to vision deficits the instructions were
made larger, but in the same format as the regular EFPT instructions. The client
scored 12 out of a possible 25 points. For this test, the lower the points received,
the more independent the individual in the given task. The client required direct
instruction for organizing, sequencing, and judgment. The high score in these areas
correlate with what the clients wife stated in the COPM as her concerns. The client
requires a moderate amount of direct verbal cues in order to complete tasks to the
satisfaction of his wife.
The MOCA results localized the areas of cognition that the client has difficulty
with. The client had difficult trail making, possibly secondary to vision deficit.
Similarly, the client had difficulty with visuoconstructional skills secondary to
vision. The cube was most difficult secondary to difficulty with abstract thinking.
The client was able to identify each animal if he used his magnifying glass. The
animal he missed was due to not using his magnifying glass. The client showed
ability to memorize and focus on the task being asked. The client was able to
identify relationships between the pair of words, but not the most obvious ones due
to some concrete thinking. The client was unable to identify the year, month, or
day. This could be secondary to long term memory, but could also be due to lack of
interest. Clients working memory seems to be within normal limits.
SUPPORTS AND BARRIERS:
The clients wife is very supportive and willing to help in any way she can.
The client is currently seeing occupational therapy on top of the students. The client

has many friends that make an effort to interact. The client is motivated to get
better. The client has many interests. The clients home is very familiar and easy for
him to get around. The clients vision restrictions make it difficult for him moving
forward. His two young children pose as a difficulty due to their level of active play.
His fear of getting hurt by his kids limits what types of games he plays.
P: It is recommended that the client receive occupational therapy 1x/week for 7
weeks. As chosen by the client and his spouse therapy will be focused on improving
Initiations, and interacting with family.
GOALS:
LTG 1: By session 7, client will demonstrate increased initiation by following
morning and evening routines by using compensatory strategies with minimum
verbal cues.

STG: By session 5, client will demonstrate increased initiation by following a

morning routine by using compensatory strategies with moderate verbal cues.

STG: By session 3, client will demonstrate increased initiation by following a

morning routine with moderate verbal cues.

LTG 2: By discharge client will plan and participate in an age appropriate activity
with his sons using compensatory strategies with minimal verbal cues.

STG: Client will plan a play activity for him and his sons with minimum verbal cues
in 6 sessions.

STG: By session 4, client will initiate in a play activity with sons by using
compensatory strategies with moderate verbal cues.

A) Process of setting goals:

An informal interview was initiated during the first meeting in order to obtain more
information about the client and spouse. The client expressed his desire to get back
to doing the active things he used to do. Being cooped up in the house has been very
difficulty for him. As we administered the COPMs we were able to get their
individual goals. Then as we brought them both back together we discussed the
goals both the client and his wife had identified. Then we came up with our top two
goals that we would work on. The tope two goals that were decided upon were
having a morning routine that he could initiate himself, and play more games with
his kids.
B) Practice models used:
PEO: Used to obtain optimal congruence between the person, occupation, and the
environment.
Postulates of change:
1. Persons perceptions and beliefs about the environment and occupation
influence subsequent occupational performance; therefore it is important
to understand the persons priorities and perspectives.

2. Change in the person, environment or occupation can improve

occupational performance.
3. The environment is easier to change than the person.
Dynamic Interactional Model of Cognition Rehabilitation: Improve cognition by
understanding and changing the underlying conditions and processing strategies
that influence performance. Purpose is to decrease activity limitations and enhance
participation in daily activities.

Postulates of change:
1. Cognition is viewed as modifiable and as a process of ongoing learning
and change that takes place with experience
2. Response to cues for doing tasks and guidance strategies during dynamic
assessment helps to determine the potential and type of assistance
needed for learning.
3. Non-threatening atmosphere allows for change
4. Clients self-awareness affects the processing strategies used during
occupational performance-change happens by increasing a persons selfawareness. Self-awareness may be assessed with use of daily logs or
journals.
C) Research evidence:
Article Title: Personal digital assistants as cognitive aids for individuals with
severe traumatic brain injury: A community-based trial
Authors: Tony Gentry, Joseph Wallace, Connie Kvarfordt, & Kathleen Bodisch Lynch

The research study consisted of 23 men and women living in the community that
had a traumatic brain injury (TBI). The purpose was to see the benefit of using
personal digital assistants (PDA) as cognitive aids and improving participation in
everyday life tasks. Each individual was trained on how to use the PDA and asked
to transfer all appointments and paper reminders into the device. The results of the
COPM stated an increase from 2.86 mean in performance to 7.28. An increase in
satisfaction was also observed from 1.59 to 6.73. According to the CHART-R, which
is a self-assessment rating scale showed an increase in cognitive independence. The
overall result was in support of using PDAs in order to increase participation in
everyday life tasks.
D) Intervention plan
1 visit every other week for 7 visits total, 90-120 minutes each visit
1) Initial evaluation/interview, Administration of COPM, and clinical
observation of occupational task performance.
2) Administered the MOCA and a portion of the EFPT. Introduced Personal
assistive device as an aid to remind him to check his morning routine.
Created a morning routine binder and discussed assistive technology to
enhance low vision. Family chore chart created together with sons in order
to facilitate family participation. Wife educated on positive feedback as she
reminds him to do his morning routine.
3) Assessing progress and success of morning routine schedule. Introduce
auditory schedule as option to compensate for low vision. Provide materials

and cueing to increase play with sons. Education of spouse and client
regarding strengths and weaknesses, as well as strategies for compensation.
Introduce strategies to increase play with sons daily. Education of wife on
levels of cueing in order to help her increase husbands independence.
4) Introduce evening routine in addition to the morning routine client is already
doing. Assessment of strategies and determine which ones are working best.
Follow up on strategies to initiate play with sons.
5) Client will plan out activity to do with his sons. Educate client and spouse on
strategies to decrease the amount of cues being required for initiation of
routines and playing with sons. Adjust strategies as needed.
6) Assess effectiveness of strategies being used for routines and playing with
sons. Check completion of LTG2 by having client plan and participate in one
of the activities his sons like to do. This will involve everyone playing in the
game together. Education on ways to continue facilitation of more social
participation activities and how to increase initiation of them by client.
7) Discharge session-Give further education and strategies and administer post
intervention assessments of the MoCA, EFPT, and COPM.

Location of intervention:

Intervention will take place at clients home

Anticipated D/C environment:

As client is currently living in his own home and will remain there with his family
after discharge.

____________________________________________

2/20/2013

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