Running head: OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile and Intervention Plan

Evelyn Babaroudi
Touro University Nevada

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile
Client Description
The patient is 78-years-old, male, and serves the Las Vegas area as a clergyman. The
patient lives with a housemate in a single-story home (SSH) in Henderson, Nevada. The patient
attends church Thursday through Sunday. His pastoral duties consist of teaching, conducting
ceremonial duties, and providing counseling and care to members of the church who require
assistance. The patient has a strong sense of connectedness to his community and frequently
engages in religious group activities that facilitate social interaction and closeness to church
members. The patient is originally from England and moved to Nevada 22 years ago. His
immediate family still lives in England, however frequently keeps in touch through phone, email,
and Skype.
Reason for Services
The patient requires treatment in the inpatient rehab facility (IRF) for late effects of a
cerebrovascular accident (CVA) that occurred in January of 2015. Review of the brain magnetic
resonance imaging (MRI) revealed acute infarction of the right fronto-parietal lobe, resulting in
left hemiplegia, left hemianopia, and left sided neglect. The patient also presents with mild
dysarthria and mild, left facial droop. His medical history includes hypertension and reactive
depression. The patients prior level of function was independent in all areas of self-care. The
patients treatment goal is to increase neuroplasticity in the brain.
Areas of Occupations
The patients lack of autonomy in self-care is a primary cause of prolonged IRF
placement. As previously stated, he has a history of hypertension and reactive depression. The
patient has decreased independence in functional mobility, bathing, dressing, grooming, and

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toileting. He has decreased activity tolerance, strength, endurance, and increased levels of
fatigue. The patient is also unable to walk or stand without support. His decreased standing
balance and activity tolerance results in a high risk of falls. The patient presents with mild
dysarthria, therefore has difficulty speaking. The patient has developed left-sided neglect due to
left hemiparesis and left hemianopia from the CVA. This has reduced possibility of independent
living and increased potential of injury. The patients prior level of function was independent in
all ADLs and IADLs.
The patient is well alert and oriented. His memory, attention, and safety awareness is
within normal limits. The patients receptive language is intact and he is able to cooperate well
during treatment. He has no complaints of pain or discomfort. The patient has strong interaction
skills that allow him to work well with others, a skills that is crucial for building progress. The
patient demonstrates a cooperative attitude among the therapists he is working with. The skilled
staff express how amicable he is despite his condition and admire his hard work and enthusiasm.
The patients desire to return to home to his church and garden where he engages in meaningful
activities serve as a source of motivation for him.
Contexts and Environments
Prior to the CVA, the patients primary environments were his work, home, and
community. As previously stated, the patient lives with a housemate in a SSH in Henderson,
Nevada. The patients house is very tidy and uncluttered. The patient engages in many
productive activities in the home that support his daily life, such as home establishment and
management. The patient has a large garden in the backyard where he spend most of his day.
The patient enjoys working with or being close to nature and engaging in garden-related tasks,
such as planting, harvesting, and growing, as well as tending to his small vegetable garden. The

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patient finds this to be intrinsically motivating and therapeutic. There are no stairs in the garden
or backyard, therefore the patient is able to enter and exit the area without any difficulty. The
patients other role include providing care for his pet golden retriever. The patient walks his dog
around the neighborhood for 15 minutes each night. The neighborhood is in a gated suburban
community and is generally very safe and quiet. The patient also enjoys bowling, a sport he was
introduced to after moving to the United States.
The patient uses private transportation to travel to church. The patient attends church
every Sabbath, and three additional days during the week to teach, conduct ceremonial duties,
and counseling to church members. The patients typical work schedule is Thursday through
Sunday. The patient must maneuver five steps, with bilateral railings, to enter and exit the
church. The church is typically a very peaceful environment. The patient thoroughly enjoys
interacting with church members and participating in religious group activities. The client enjoys
the social aspects of volunteering at church and helping others in need.
Occupational History
The patient has been living in Nevada for the past 22 years. The patient stated that his
primary role is to serve the Catholic Church. He values his role as a clergyman very highly and
feels that religion is the central aspect of his life. His inability to return home to his community
and to engage in religious activities has exacerbated symptoms of depression and feelings of
loneliness. His participation in the church community has made a positive impact on his life,
therefore he wishes to return home to reengage in religious and spiritual activities.
The patient reports that the IRF, the program he is currently attending, is not conducive to
his needs and desires. He finds it difficult to adapt to his new environment where he is unable
engage in meaningful activities, such as bowling, attending church, gardening, and spending time

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with his pet golden retriever. Although he feels a sense of detachment from his environment, he
does appreciate the hospital staff and all the letters of support he continues to receive from
church members. The patients get well cards are displayed on the shelf beside his closet. He
expressed that their thoughtful letters and cards serve as a source of motivation for him. The
patient has a strong record of commitment to improving the church community. Prior to the
CVA, he was in the process of helping the church design and construct a new church building in
the community. His work with the local church speaks to a selfless devotion to improving the
lives of those that surround him. His strong orientation towards the church demonstrates good
potential to making progress and returning home to his prior living situation.
Clients Priorities and Desired Outcomes
The patients goal is to increase his level of independence in all areas of ADL and IADL
function. The patient stated that he is concerned about falling, as he is not as strong or steady as
he used to be. He identified returning to church and being able to continue gardening, which is
one of his most valued activities, as his two top priorities to address during treatment.
Occupational Analysis
Context/Setting
The clients current setting is the IRF which features an interdisciplinary rehabilitation
team that includes the physician and other team members as needed, such as a nurse,
occupational therapist (OT), physical therapist (PT), speech therapist (SLP), and so forth. The
physician is responsible for the overall supervision of the patients treatment and must approve
the patients plan of care prior to any implementation. The patient currently receives treatment
three hours per day, five hours per week. Although the IRF is set in a hospital setting, the facility
does provide the opportunity to perform functional activities. A skills lab, an open and shared

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environment, is available for therapists to use in order to implement functional activities, such as
cooking, cleaning, and baking.
At the IRF, there are 38 beds available from the total of 110 acute care beds in the facility.
Currently, the facility is undergoing construction, therefore noise levels can occasionally increase
or distract patients. Typically, ADL activities are performed in the patients hospital room with
the door closed to minimize potential noise or distractions. The patient has a private room,
therefore the therapist is able to fully accommodate the patients needs and therapeutic concerns.
Treatment sessions that focus on exercise and strengthening typically occur in the rehab gym
where other patients and therapists are present. The patient is yet to practice IADL activities in
the skills lab since the focus of intervention is currently on ADL function. The patient hopes
looks forward to treatment sessions in skills lab where he can practice functional activities.
Activity, Performance, and Key Observations
The patient was seen seated in a wheelchair for instruction in ADL. The patient
participated in a dressing activity during the treatment session at the IRF. The OT helped the
patient work on upper-body (UB) dressing using over-the-head technique while seated at
wheelchair level. Flaccidity of the affected left upper-extremity (UE) was noted during the
treatment session. A pillow was placed under the involved side to decrease possibility of
subluxation. The patient was able to perform UB dressing with moderate assistance, but required
maximal assistance to don the left sleeve of his shirt. He was able to don the right sleeve of the
shirt with minimal assistance using verbal and tactile cues.
The OT was seated on the involved side of the patient, providing verbal cues and handover-hand (HOH) assistance when needed. The patient appeared to have difficulty incorporating
the left, affected UE into the activity. The OT provided physical assistance and encouraged the

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patient to use the left UE. Although the therapist simplified components of the task and provided
clear verbal and visual instruction, the patient still required HOH to don the left sleeve of his
shirt on the involved side. Frequent rest breaks were incorporated throughout the activity to help
address increased levels of fatigue and low endurance. Through dynamic observation, it was
evident that the patients involved arm was significantly impacted with limited movement, which
inhibited his ability to perform dressing.
Impacted Domains of the OTPF
The patient presents significant deficits in various aspects of domain that intrinsically
intertwine to affect his overall functioning, well-being, and quality of life. These domains
include: occupations, client factors, performance skills, performance patterns, and context and
environment. The different occupations in which the patient previously engaged in and presents
challenges with include all areas of ADL, including bathing, dressing, toileting, grooming, and
functional mobility. Given challenges with basic skills required for self-care, the patient is also
unable to complete IADLs that are of more complex interaction, including providing care of pets,
home establishment and management, and participation in religious and spiritual activities. All
of the mentioned activities are meaningful to the patient and support his daily life in the home
and community.
Client factors are intrinsic to the patient and influence engagement in meaningful
occupations. The neuromusculoskeletal and movement-related functions impacted include
muscle tone due to flaccidity of left UE. In addition to this, the patients muscle endurance and
voluntary movement involving fine and gross motor control have also been impacted following
the CVA. In regards to performance skills the patient presents significant challenges in areas of
motor skills such as coordination, movement, endurance, and walking. Performance patterns

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involving the roles and routines of the patient have also been affected, including his volunteer
work as a clergyman at the local Catholic Church. His routine is also impacted, as he previously
attended church from Thursday through Sunday. Lastly, his virtual and social context have been
impacted as has not been able to communicate with family members in England through Skype,
email, or phone.
Problem List
Problem Statement #1:
Patient is unable to dress self 2 P trunk stability & muscle strength in L UE.
Problem Statement #2:
Patient is unable to complete functional mobility safely 2 P standing balance &
activity tolerance.
Problem Statement #3:
Patient is unable to perform bathing 2 to P core strength & ROM in L UE.
Problem Statement #4:
Patient is unable to groom self 2 fatigue & endurance.
Problem Statement #5:
Patient is unable to perform gardening 2 hand function & muscle strength in L UE.
Prioritization & Justification of Problem List
The patients left hemiparesis has led to significant problems with occupational
performance, including areas of ADL and IADL function. The top priorities of treatment are to
provide a safe environment in which the patient is able to practice skills that will enable him to
reengage in meaningful occupations. In order for this to occur, it is important to target issues that
inhibit daily function, such as strength and balance, and implement intervention strategies that
will address functional limitations interfering with occupational performance.

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The functional problem areas listed above are critical to address in preparing the patient
return home independently and safely. For this reason, the broad scope of self-care skills need to
be considered and made a particular focus of intervention. The patients priority is to return to his
prior level of function so that he is able to independently manage his day-to-day activities, as
well as engage in meaningful activities. Dressing and functional mobility are two very important
components of ADL to address given the patients desire to build autonomy in self-care. As
previously stated, he would like to be able to move and perform his morning routine of dressing
independently. In addition to this, the patient lives alone without a caregiver, therefore it is
important for him to build skills that allow him to be more self-sufficient.
It is important for the patient to be able to dress himself and move around independently
during performance of everyday activities before engaging in more complex activities, such as
gardening and providing care for his pet golden retriever. Although the top functional problems
target ADL function, activities can still focus on building skills that are important to performing
IADL. Therefore, the patients values and interests are still taken into consideration and will be
incorporated in the treatment plan by implementing interventions that are meaningful and
motivating to the patient.
Intervention Plan and Outcomes
Long-Term Goal 1: Pt. will demonstrate dressing SPV using A/E within 2 wks.
Short-Term Goal 1A: Pt. will don & doff pants Min A using reacher & dressing stick
within 5x sessions.
Intervention: Patient will perform virtual practice of Nintendos Wii Sports. Clinical use
of Wii bowling from a seated position will help improve clinical measures of balance & motor
function in patient. Interactive video game intervention will help support trunk stability in

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patient who demonstrates fall risks & difficulty with bending & reaching for LE dressing. Wii
bowling simulation provides an effective approach to balance training. Activity requires similar
movements needed for LE dressing from a seated position. Activity provides repetition of
movement and encourages weight shift. More importantly, it serves as a functional balance
activity to increase confidence with ADL activities.
Grading Up: Patient will perform activity from a standing position utilizing FWW for
stability & support.
Grading Down: Patient will continue to perform activity from a seated position. Patient
will utilize front wheel walker (FWW) with right hand for stability & support, while
manipulating controller in left UE.
Approach: This therapeutic activity will use a combined approach of restore and modify
to help increase the patients UE function and capacity to utilize A/E for engaging in the
occupation of dressing until further progress is made. Clinical use of Wii bowling will help
restore balance & reach, two important skills that have been impaired following the patients
CVA. Implementation of the interactive video game, using the controller to bowl, will help
address hemiparesis & loss of motor function in patients left UE. Movements restored and
gained in virtual contexts will potentially transfer to real-life environments in which the patient is
able to perform LE dressing.
Evidence: According to Nilsen et al. (2015), nonimmersive video game systems, such as
the Wii, can improve UE function and activity and participation in patients with motor
impairments after stroke. These virtual reality (VR) environments provide training and exercise
of the affected UE using goal-directed activities requiring repetition of task-specific movements
that is beneficial for motor learning and allows patients to refine or correct patterns of

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movement. Moreover, in a research study discussing the effectiveness of Wii gaming in stroke
rehabilitation, Saposnik et al. (2010) assert that VR games offer a safe and feasible alternative to
implement rehabilitation therapy and to promote motor recovery in patients following a stroke.
Outcome: The potential outcome is for the patient to improve his occupational
performance of dressing. Implementation of the intervention will help address trunk stability and
balance, two important skills that are needed to bend and reach for LE dressing. Improving these
skills will allow the patient to complete self-care more safely and independently with use of A/E.
Short-Term Goal 1B: Pt. will don & doff button-up shirt Min A using button-hook
within 5x sessions.
Intervention: The patient will receive instruction and training in UE dressing with use of
button-hook. Information will be presented through use of verbal and visual demonstration. The
patient will practice using the button-hook from a seated position to ensure safety, and will be
encouraged to incorporate the affected extremity in all aspects of the activity. Frequent rest
breaks will be incorporated to help pace the patient and maintain symptoms of fatigue. The
patient will problem-solve next step of task in sequence utilizing verbal and tactile cues as
needed. The activity can also be performed bilaterally, with use of the unaffected hand guiding
the affected hand through the activity.
Approach: This intervention utilizes aspects of restore and modify to address the patients
desired outcomes. Given the patients left hemiparesis, A/E is introduced as a compensatory
technique to dressing while use of the affected extremity is encouraged throughout the activity to
address impairments and goals that have been identified. The intervention will aim to modify the
current context or demands of the activity by using compensatory techniques to help the patient

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perform the activity of dressing. The affected extremity will still be incorporated in the activity
for rehabilitation purposes and for restoring muscle control and strength that has been impaired.
Evidence: According to Wolf and Berkenmeier (2011), Compensation through the use of
the unaffected side to perform ADLs is common as part of routine stroke care. Therapists should
encourage use of the affected extremity when possible; when unable, they should use
compensatory strategies with the unaffected side (p. 288). A/E training can be viewed as a
compensatory technique to promoting ADL function. Since the patient does not have a caregiver
and is likely to be unsupervised after discharge from the IRF, it is important to teach and
implement A/E so that he is able to perform the activity of dressing both independently and
safely. It is crucial for the patient to participate in several education and training sessions prior to
discharge in order to ensure that compensatory strategies are properly learned. Throughout the
intervention process, the patient should still be encouraged to incorporate the affected extremity
into different components of the activity.
Outcome: Through the intervention process, the patient will improve his ability to selfdress. This will help support self-care autonomy and ADL function, which is required to return
home and perform day-to-day activities with better safety and independence.
Long-Term Goal 2: Pt. will complete functional mobility safely SPV using FWW within 2 wks.
Short-Term Goal 2A: Pt. will transfer SC Min A using FWW for safety within 5x
session.
Intervention: Patient will perform gardening from a standing position using a FWW for
support. The intervention will help address standing balance and bilateral UE strength through
use of a planting activity, which is meaningful to the patient. The patient will pot plants on a
counter with the therapists standing beside the patient on the involved side, guiding the affected

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extremity in normal patterns of movement. The plants can be positioned at different levels of
reach on the counter to increases the patients weight shift and UE function. A wheelchair will
be positioned behind the patient for rest breaks. This planting activity will help increase activity
tolerance, balance, and hand function required for performing safe transfers. Gardening is an
activity that is familiar and meaningful to the patient, and provides repetition of movement
needed to increase motor function, which can improve the patients overall function.
Approach: This intervention approach will help restore the patients balance, trunk
stability, and UE function in order to perform safe and functional transfers. It is important for the
patient to remediate these skills in order to increase safety and independence in ADL function.
Evidence: In suggesting treatment strategies for patients with motor impairment after
stroke, Davis (2009) states, Select activities requiring repetition of movement. Repetition is
beneficial for motor learning and, at the same time, gives you more opportunity to refine, correct,
and guide your patients patterns of movement during the activity. Gardening is an activity that
requires repetition of movement and can help build the patients UE function. The therapist can
use HOH assistance to guide the patients affected extremity in normal patterns of movement.
Repetition and continuity enable patients who have experienced a stroke build skills required for
performance of everyday activities. Selecting meaningful activities allow patients to problemsolve and generalize skills to real-life scenarios. In regards to the patient performing the activity
on a counter-top, Davis (2006) explains, Contact with a solid surface encourages better trunk
and limb control with fearful patients (p. 9). The counter provides support and stability for the
patient while performing the activity from a standing position.
Outcome: The potential outcome is participation in safe and functional transfers. Through
the intervention process, the patient will recover the skill and ability to perform self-care and

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functional mobility with increased safety and independence. Continuous practice and
participation with use of DME will enable the patient to build functional independence in
movement during performance of everyday activities.
Short-Term Goal 2B: Pt. will transfer safely 3:1 commode for toileting Min A
utilizing FWW for safety within 5x sessions.
Intervention: The patient will receive education and training regarding safe and functional
transfers with use of DME. The therapist will provide clear, concise information on utilizing
FWW and 3:1 commode, and education regarding the proper technique and form to use to
perform the transfer safely. The patient will practice the activity in a safe environment and
problem-solve the steps of the task in sequence utilizing verbal and physical cues as needed. Rest
breaks will be incorporated to help manage symptoms of fatigue.
Approach: This intervention uses a modified approach to increase the patients level of
independence in safe and functional transfers through use of DME. Education and training will
be provided to help the patient complete a toileting routine. The activity will be modified
through implementation of a FWW and 3:1 commode to support ADL function.
Evidence: According to Wolf and Birkenmeier (2011), Prescribing and training clients in
the use of assistive devices and adapted equipment is one way occupational therapists try to
improve and maintain occupational performance (p. 289). Implementation of DME and A/E is
common in patients with motor impairments after stroke as it provides a tool that increases
performance in ADL function. Thus, it allows them to complete self-care activities more
independently and safely despite loss of function.
Outcome: The targeted outcome is improvement in occupational performance.
Intervention implementation will enable the patient to perform toileting independently and

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safely. Given the patients left hemiparesis, as well as decreased balance and activity tolerance,
this intervention will potentially improve the patients occupational performance and capacity to
complete safe and functional transfers.
Precautions
Prior to treatment, appropriate safety precautions should be taken into consideration to
protect the patient. Since the patient has a past medical history of hypertension, treatment
recommendations should include monitoring the patients vital signs prior to, during and
following activity. This includes the patients blood pressure (BP), oxygen (O2) saturation level,
heart rate, and respiratory rate. Significant increase in blood pressure or heart rate can indicate
intolerance to intervention, therefore it is important to incorporate rest breaks when needed. If
signs or symptoms are present, make sure to elevate the head, monitor and document vital signs,
and notify a nurse or doctor if needed.
Frequency & Duration
The patient will receive Tx. for 90 min daily 5x/wk for 2 wks for skilled instruction in
dressing and functional mobility DME & A/E to & safety D/C. Focus will be on
activity tolerance, standing balance, strengthening L UE, & utilizing DME & A/E with safety.
Pt. will practice dressing A/E & performing transfers DME to achieve optimum level of in
ADL & IADL function. In addition to OT, the patient will also receive physical therapy, speech
therapy, and 24 hr rehabilitation nursing supervision. This treatment could not be provided at a
lower level of care.
Primary Framework
Theory significant influences the process of treatment by providing a framework within
which the therapist can evaluate and assess the needs of the patient. It enables the therapist to

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view each patient from a distinctive lens, and in doing so, it provides guidance in implementing
an effective intervention plan. The Occupational Therapy Task-Oriented Approach (OT-TOA)
was the most applicable model to increase the patients occupational performance, and to
increase efficiency of compensatory strategies used to perform functional activities. Due to the
patients left hemiparesis and weakness in the left UE, as well as decreased balance, activity
tolerance, and trunk stability, the OT-TOA poses potential benefits in enabling the patient to
achieve functional independence.
The OT-TOA is rooted in the model of motor control and theories of motor learning
(Cohn & Coster, 2014). The theory aims to help individuals with motor impairment increase
efficiency in task performance and restore the skills needed to engage in meaningful occupations.
The OT-TOA is unique in that it highlights the role of the patient and uses real life activities to
promote success. The theory follows the principle that movement is influenced by personal and
environmental factors, and that in order to fulfill desired roles, one must be able to meet the
demands of the tasks associated with the role (Cohn & Coster, 2014). For example, since
gardening is a meaningful activity to the patient, the activity of potting plants is likely to increase
motivation and therefore promote progress. As indicated above, an essential aspect of the OTTOA is individualizing the treatment plan by tailoring the intervention to what is purposeful to
the patient.
The OT-TOA also emphasizes the importance of intervention occurring in a natural
environment. Despite the clinical setting in which the patient is in (IRF), therapists can replicate
a functional activity in a natural environment (e.g., gardening in the skills lab). According to
Cohn and Coster (2014), a natural context promotes more flexible patterns of movement. The
OT-TOA helped guide intervention efforts for the patient by implementing functional activities in

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a natural setting to maximize the patients motor performance. Therapeutic activities such as
gardening and Wii bowling were incorporated into the intervention to encourage repetition of
movement, which is needed for motor learnings. Implementing meaningful activities in a natural
context provides the patient with opportunities to improve his overall performance in ADL and
IADL function.
Client/Caregiver Training & Education
The patient will continue to receive training and education regarding use of DME & A/E
for ADL and IADL function. The therapist will impart knowledge and information regarding
transfer techniques and equipment use. The patient will practice utilizing FWW, 3:1 commode,
reacher, dressing stick, and button-hook to improve mastery of self-care skills. The therapist will
assess the patients progress and take into consideration skill level when implementing future
interventions and activities. If further training is needed, the patient will continue to participate in
functional activities with use of DME and A/E in a safe environment. The priority of treatment
is to maximize the patients safety and independence in functional mobility and dressing in order
to achieve self-care autonomy, therefore as much training and education that is needed will be
provided.
Clients Response to the Intervention
The patients response to treatment is an important component of therapy. Assessment
and reassessment will be used to monitor the patients progress towards goals and identified
outcomes. The patients response to treatment will be recorded daily through use of a therapy
log with information regarding attendance and participation in therapy. Review of the
intervention process, as well as the patients gains and progress toward targeted outcomes, will
be monitored to ensure that the demands of the activity and the skills of the patient coincide.

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Reinforcement and grading of activities will also be implemented to provide the right level of
challenge and learning that is needed to achieve functional independence.

References
Davis, J. Z. (2006). Task selection and enriched environments: A functional upper extremity
training program for stroke survivors. Topics in Stroke Rehabilitation, 13(3), 1-11.
doi:10.1310/D91V-2NEY-6FL5-26Y2

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Nilsen, D. M., Gillen, G., Geller, D., Hreha, K., Osei, E., & Saleem, G. T. (2015). Effectiveness
of interventions to improve occupational performance of people with motor impairments
after stroke: An evidence-based review. American Journal of Occupational Therapy, 69,
6901180030. http://dx.doi.org/10.5014/ajot.2015.011965
Poole, J. L. (2011). Enabling performance and participation for persons with movement
disorders. In C. H. Christiansen & K. M. Matuska (Eds.), Ways of living: Intervention
strategies to enable participation (4th ed., p. 288-289). Bethesda, MD: American
Occupational Therapy Association

Saposnik, G., Teasell, R., Mamdani, M., Hall, J., McIlroy, W., Cheung, D., . . . Bayley, M.
(2010). Effectiveness of Virtual Reality Using Wii Gaming Technology in Stroke
Rehabilitation: A Pilot Randomized Clinical Trial and Proof of Principle. Stroke.
doi:10.1161/STROKEAHA.110.584979