Running head: OCCUPATIONAL PROFILE & INTERVENTION PLAN

Occupational Profile and Intervention Plan

Kerielle L. Williams
Touro University Nevada

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Occupational Profile
The Client
The client is a 39-year-old female who is diagnosed with a cerebrovascular accident
(CVA) or stroke. The client is married and has two children. Prior to the CVA, the client lived
with both her husband and their two children. Since her CVA, the client has moved out of her
home and is temporarily living with her parents in their home. Before the CVA, the client worked
part-time as an office administrator. The client enjoys spending time with her family and friends,
outdoor activities, board games, and going to the movies.
Need for Service
The client is seeking services after experiencing a CVA eight months ago. The client
sustained a severe CVA and was hospitalized for a total of 28 days. She has been discharged
from the acute hospital setting to HealthSouth of Henderson Rehabilitation Hospital where she
has been receiving outpatient therapy services. The client is currently using a wheelchair as her
primary means of mobilization or ambulation. She wears an eye-patch over her right eye, as well
as bilateral upper extremity and bilateral lower extremity splints and orthotics. In addition, the
CVA has left the client with profound speech deficits.
Clients concerns. Although the client is limited with her ability to express her concerns
due to her limited verbal capabilities caused by her weakened facial muscles, her family has
mentioned that they have several concerns regarding her condition. The family states that the
client is nearly dependent in all her activities of daily living (ADLs) as well as her instrumental
activities of daily living (IADLs), and this is the primary concern for them. The family also
mentioned that they are concerned about the clients possible pain level when engaging in
transfers as well as while she is lying supine, specifically when she is attempting to sleep. They

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report that she will cry out in loud moaning as if she is feeling extreme discomfort or pain. The
family also emphasizes that prior to the CVA; the client was extremely involved in raising her
children. They feel that this would be a primary concern for the client if she were able to express
herself verbally. Lastly, the family has expressed their concern in regards to the clients
psychological state. They mention that they fear she may be becoming overly frustrated with her
drastic roles changes and her inability to care for herself and her children. The family is
concerned that she may become depressed in the near future if her performance is not improved
in these areas.
Occupations
Areas of success. Unfortunately, the client is not successful in many areas of occupation,
specifically with her ADLs and IADLs. The areas in which the client is successful in are rest and
swallowing/eating (American Occupational Therapy Association (AOTA), 2014).
Barriers affecting success. The client is dependent in nearly all of her ADLs and IADLs
as well as other areas of occupation such as education, work, play, leisure, and social
participation. The barriers that impact the clients success in these areas include her limited
functional mobility, limited range of motion, poor strength, lack of endurance, weakness, poor
balance, incoordination, and visual deficits (AOTA, 2014).
Aspects supporting engagement. The aspects of the clients context and environment
that support her engagement in her desired occupations include: cultural, personal, temporal,
virtual, and social. The cultural context facilitates her engagement because she is a member of
the American culture. The American culture supports a family household in which one partner
does not work and the other is the primary provider for the family. The client and her family are
able to survive on the income of her husband alone; therefore they are not impacted drastically

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now that she is unable to continue working. The clients personal context is another supporting
aspect in her occupational engagement. The client is a relatively young female from a moderately
high socioeconomic and educational status. This factor tremendously supports her access to
therapeutic services as well as her overall medical health. The temporal context also supports the
client in her chosen occupations because this involves the fact that the client is at the stage of her
life where she still has both of her parents healthy enough to care for her, as well as her husband
who is also willing and able to help provide her care. Lastly, the clients virtual context supports
her engagement with her occupations. This context enables the client to utilize technology such
as her cell phone or iPad in order to broaden her communication with others (AOTA, 2014).
Aspects inhibiting engagement. The clients physical environment is the primary aspect
of her context and environment that inhibits her engagement in her desired occupations. As
previously mentioned, the client was moved from her home with her husband and is currently
living with her parents. The layout and design of the clients home is not an ideal living
environment when considering her physical deficits due to her CVA. Therefore, she has had to
change her entire physical environment in order to accommodate her new needs and disabilities
(AOTA, 2014).
Occupational History
The client was born and raised in Las Vegas and started working as an office
administrator for several small, local businesses after completing her Associates Degree at the
University of Nevada Las Vegas (UNLV). While attending UNLV, the client met her husband.
They have been married for 10 years and now have two girls, ages four and seven. The client
was working full-time as an office administrator until she had her children, in which she then
began working part-time to focus more on her family.

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Daily life roles. The primary roles of the client include being a wife and a mother. The
client also has a large group of friends at her church that she enjoys spending Sundays with. The
client appears motivated to be able to make any and all possible gains in regards to her CVA,
primarily in the areas of ADLs and IADLs.
Values and interests. The clients family reports that the client values family
involvement. They state that this has been her primary focus throughout her life. The clients
family mentioned that she attended church religiously every week and she values her faith very
highly. The clients previous interests revolved around her husband, her children, her parents, her
church, and her close friends. The client has previously expressed interest in traveling the
country with her family on vacations, as well as being actively involved in her childrens
extracurricular activities.
Patterns of Engagement
Prior to the clients CVA, she lived a very active and fulfilling lifestyle. She was the
primary caregiver for her children, as well as the head of the household in terms of meal
preparation, managing finances, and home management. The client was a part-time employee,
where she participated in employment interests and pursuits, employment seeking and
acquisition, as well as job performance. In addition to the previous roles that she participated in,
it was mentioned by the family that the client had an amazing sense of humor as well as an
optimistic personality.
Changes. After the client experienced her CVA, her patterns of engagement in her previous
occupations changed drastically. She is no longer able to participate in her active lifestyle the
way in which she had done before. She is unable to complete the ADLs and IADLs that were
once thought of as automatic to her. An extremely significant change that family and friends of

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the client have noticed is her drastic change in personality and outlook on life. They feel that she
is showing early signs of depression due to her inability to be able to care for herself as well as
the embarrassment that goes along with her dependence. The family suggests that they would
like to address any inabilities that may lead to depression if left unresolved.
Clients Priorities and Targeted Outcomes
Both the client and her familys priorities are for her to be able to return to her home with
her husband and children and regain her ability to complete her ADLs and IADLs. The family
would like to address her toilet hygiene first because they feel that this would be the clients
number one priority. Ideally, her family would like to also work on proper transfer techniques in
order to prevent further injury to the client, as well decrease any pain or discomfort she may have
during transfers. The client and her family voiced that they wish for her to achieve the highest
level of occupational performance that is possible for her diagnosis. The family has expressed
that they would like to take into consideration her psychological state in regards to her overall
motivation to participate fully in her recovery. Overall, the client and her family would like to
see her return to her previous state of functioning as much as possible in hopes to maximize her
quality of life.
As with many conditions, the desired outcome of a CVA is extremely client specific.
There are many factors that come in to play with the prognosis of a client after a CVA. Some of
these factors include the extent of brain damage, the type of CVA, learning ability, previous
personality and intelligence, motivation, and age. The positive factors that will enable the client
to be successful in her prognosis include that the client had a relatively high intelligence level
prior to the CVA, as well as a phenomenal personality, and lots of family support. She is also
only 39 years old, which is considered young to suffer from a CVA. The negative factors that

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will inhibit her prognosis include her type of CVA and amount of brain damage. The client
suffered a hemorrhagic CVA which is most frequently fatal. Thankfully she survived however
she sustained a noteworthy amount of brain damage.
Occupational Analysis
Context/Setting
The setting for the occupational therapy (OT) services is an inpatient and outpatient
rehabilitation facility called HealthSouth of Henderson. The majority of the clients that are seen
at the facility have experienced either a CVA, traumatic brain injury (TBI) or spinal cord injury
(SCI). The OT treatment session was held in the outpatient rehabilitation center gym and the
private ADL therapy room.
Observed Activity and Key Observations
The client was observed during several activities including: preparatory, purposeful, and
occupation-based interventions. The preparatory activity that the client participated in with the
OT was Manual Edema Mobilization (MEM). MEM is a therapeutic method of gentle
stimulation of the lymphatic tissue in hopes to reduce the clients edema associated with a CVA
(Howard, 2008). The MEM activity consisted of the OT instructing the client in a combination of
breathing and movement techniques. After the MEM was completed, the OT then began to have
the client work on weight shifting in her wheelchair as a form of a purposeful activity to prepare
her for functional transferring. The occupation-based activity was done in the ADL therapy
room. This activity consisted of transferring the client from her wheelchair to the toilet and from
the toilet to the wheelchair. The OT and the client were able to complete three successful
transfers. With each transfer, the OT encouraged the client to give as much effort as possible in

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hopes to increase her endurance and strength during this activity. It was apparent that the client
was in some discomfort or pain throughout the entire treatment session.
During the MEM activity, the client required extensive verbal cueing and maximum
assistance. The OT constantly had to remind the client what the next step of the activity was and
how to do it properly. There were several times during the session that the OT had to physically
assist the client physically during the movements in addition to the verbal cueing. The client
needed verbal cueing and moderate assistance during the weight shifting activity. She was able to
shift her weight to the left side more independently than to her right side, however still requiring
physical assistance from the OT. During the transfers, the client needed maximum assistance
from the therapist. The client appeared to understand the steps of the transfer when the OT
reviewed them with her; however, she was physically unable to complete nearly all of the steps
due to her fatigue, weakness, and lack of endurance.
OTPF Domains Impacted
The client is seeking OT services in order to increase her self-care skills, functional
mobility, and overall independence. The client is impacted by all of the domains in the
occupational therapy practice framework (OTPF). The domains that most significantly impact
her ability to engage in her desired activities include client factors, performance skills, and
performance patterns. The client factors that are impacted most based on observations are nearly
all of the body functions and body structures. The client is significantly affected by all of the
performance skills as well, including her motor skills, process skills, and social interaction skills.
Although all of the clients motor skills are impacted by her CVA, the primary motor skill that is
affected is the clients inability to walk. This deficit has arguably affected the client more than
any other. The performance skill that impacts the clients desired occupations most is her
inability to navigate independently in her wheelchair. Lastly, the primary social interaction skill

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that impacts the clients daily life is her inability to speak fluently during a conversation with
others.
Problem List
Problem statements identify the areas of occupation that are limited due to specific
underlying factors (Gateley, 2012). It is a list of problems that can be treated by an OT and
provides a better understanding of the clients problem areas.
Problem Statements
Problem statement one. Client requires Max A ADLs, including toileting, 2 B UE &
B LE weakness & fatigue.
Problem statement two. Client requires Max A transfers 2 impaired balance, lack of
trunk control, & endurance.
Problem statement three. Client requires Max A IADLs such as child rearing, 2 her
cognitive deficits.
Problem statement four. Client requires Max A verbal communication 2 weakened
facial muscles.
Problem statement five. Client requires Mod A sleep hygiene 2 pain & discomfort.
The clients problem statements are prioritized by the problems that most greatly inhibit
her from being able to return to the level in which she was functioning at prior to the CVA. The
client is unable to independently complete her ADLs due to her upper extremities and lower
extremities weakness and fatigue which is a major contributing factor in her dependence for
others. This problem is prioritized first because difficulty with ADLs can lead to helplessness,
depression, and feelings of worthlessness. The other contributing factor to her overall
dependence is her need for maximum assistance in transfers due to her impaired balance, lack of

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trunk control, decreased endurance, and difficulty with sequencing. This problem statement is
listed second due to the fact that difficulty with transferring can lead to frustration for not only
the client, but the caregivers as well. These two problem areas are of top priority for the OT,
client, and family, as well as the focus of the current intervention plan. By determining these
problem areas, the OT will be able to focus on the underlying factors and develop long and short
term goals to improve the clients overall functional performance.
Intervention Plan & Outcomes
When writing goals the OT must ensure that the goals maintain and promote function,
and prevent dysfunction at all times. OT goals are highly individualized and are based on the
clients observed occupational performance problem areas as well as the concerns and priorities
of the client. The clients goals have been determined by the evaluation, assessment, as well as
information from her medical records, occupational profile, occupational analysis, functional
problem statements, and additional information regarding her familys concerns and wishes.
Long-term Goal
Client will complete toileting tasks using 3:1, dressing stick, reacher, & Bottom Buddy
Min A within 2 wks.
Short-term Goal #1. Client will Min A LE dress & undress required during
proper toileting, using dressing stick & reacher within 1 wk.
Intervention. The initial step for the intervention will be for the OT to
collaborate with other OTs with similar patients to work on lower extremities
dressing and undressing as a group-based intervention. The OT will have the
client work on lower extremities dressing and undressing using the dressing stick
and reacher in groups. To ensure that this intervention is client-centered, the OT

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could have the client bring in her favorite pair of pants to make the activity more
meaningful. This group intervention strategy will encourage the client to do her
best with this activity as they work on the tasks with others that are experiencing
the same struggles as them.
According to Christie, Bedford, and McCluskey (2011), Task-specific
practice of dressing tasks in a group setting was feasible and made clinically
significant differences to dressing performance during inpatient rehabilitation
(Christi et al., 2011, p. 364). Christie, Bedford, and McCluskey (2011) conducted
a study with 119 stroke patients that consisted of twice-weekly one-hour
interventions of dressing retraining groups in addition to individual OT treatment
sessions. The study measured Functional Independence Measure (FIM) upper and
lower body dressing items. The study concluded that task-specific practice of
dressing tasks made a clinically important difference to dressing performance
(Christie et al., 2011, p. 367).
Approach. The specific approach for this intervention is establish and
restore. The OT will be aiming to restore the clients previous toileting and toilet
hygiene abilities that have been impaired by the CVA.
Desired outcome. The type of outcome that the OT will aim to achieve
through this intervention is to improve the clients occupational performance. The
goal of the OT will target the clients performance limitation and increase the
occupational performance for the client in regards to toileting and toilet hygiene.
Precautions and contraindications. The major precaution during this
activity would be a potential fall or injury. The OT will have to make sure that the

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client maintains any physical precautions during the activity as to not cause any
further injuries.
Graded up and down. The activity could be graded up or graded down
depending on the difficulty of the chosen clothing to have the client dress and
undress with. The OT could begin the treatment session with loose fitting clothing
as a way of grading the activity down. The OT could grade the activity down
more by setting up the clothing to make the activity easier. The OT could grade
the activity up by having the client dress with tighter fitting clothing and clothing
with zippers or buttons as a way to increase the difficulty level.
Short-term Goal #2. Client will Min A demonstrate toilet hygiene techniques
using the Bottom Buddy within 1 wk.
Intervention. This part of the intervention will consist of upper extremity
weight-bearing, both unilaterally and bilaterally. The OT will have the client
participate in a variety of activities that focus around strengthening the upper
extremities. The goal is for the client to be able to increase her ability to weightbear using her upper extremities during functional activities such as toileting
using adaptive equipment. In order for the client to be successful in proper toilet
hygiene, she will have to weight-bear through her upper extremities on one side
while using the Bottom Buddy with the other hand.
Reistetter, Abrey, Bear-Lehman, and Ottenbacher (2009) conducted a
study to investigate the effect of upper extremity weight-bearing on her upper
extremity impairment functional performance of persons with acquired brain
injuries. Their study consisted of 99 individuals with an acquired brain injury and

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22 individuals without an acquired brain injury. Out of the 99 individuals with an

acquired brain injury, 39 suffered from a CVA. The study measured hand pressure
amongst the participants, and then compared average hand pressure conditions to
the individuals rehabilitation outcomes. The relationships examined were
between upper extremity weight-bearing, FIM motor, FIM cognitive, FIM total
scores, and Fugl-Meyer (FM) right and left upper extremity. This study supports
the benefits of including upper extremity weight-bearing in clients suffering from
an acquired injury such as a CVA (Reistetter et al., 2009).
Approach. The approach for this intervention is establish and restore. The
OT will be focused on restoring the clients previous ability to upper extremity
weight-bearing to successfully complete her self-care desires.
Desired outcome. The type of outcome that the OT would aim to achieve
through this intervention is improvement in occupational performance. The OT
will focus on improving the clients ability to tolerate weight-bearing for
functional activities, specifically her ADLs.
Precautions and contraindications. The precautions the OT should
consider when implementing this portion of the intervention plan would be to
prevent potential injury. The OT will need to make sure that the client is aware
and able to communicate to the OT if she is experiencing any pain during the
weight-bearing activity. The OT will also need to consider fatigue as factor as
well. The OT should start in shorter time increments of upper extremity weightbearing, and allow the client to take a rest break before resuming the activity.
Grading up and down. This activity has the ability to be graded up or
down depending on the reactions from the client. If the OT observes the client

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showing signs of distress or discomfort, the OT could then shorten the time in
which the client participates in the upper extremity weight-bearing and the OT
could incorporate more frequent rest breaks. If the client seems to be tolerating
the activity well, then the OT could increase the time in which the client upper
extremity weight-bearing.
Long-term Goal
Client will transfer Min A using proper body mechanics & identifying & selecting
appropriate DME or A/E specific to the desired transfer within 2 wks.
Short-term Goal #1.Client will transfer W/C 3:1 Mod A using the standpivot technique within 1 wk.
Intervention. This intervention will consist of lower extremity functional
strength training. This functional strength training will include weight-bearing
while standing, isometric muscle strengthening, gait speed, as well as various
items from the Motor Assessment Scale (MAS). Increasing the clients lower
extremity strength is needed in order for the client to complete the stand-pivot
transfers successfully to and from the wheelchair and three-in-one commode.
This intervention is supported by the study conducted by Bale and Strand
(2008). The study was aimed to examine the effect of functional strength training
in sub-acute CVA clients. Bale and Strand (2008) looked at eighteen patients in
the sub-acute phase post CVA in a functional strength training program. The
group participated in functional progressive strength training with their affected
lower extremity. The study concluded that functional strength training of lower
extremities improves physical performance more than traditional training.

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Approach. The approach for this intervention is establish and restore. The
OT will be striving to establish a new skill with the client that has not been
developed yet. The OT will be focusing on introducing the new skill of
transferring safely from a wheelchair to a three-in-one commode. Prior to the
clients CVA she had never participated in a task of this type with the required
durable medical equipment. The OT will be responsible for establishing new
skills that may be unfamiliar to the client.
Desired outcome. The type of outcome that the OT would aim to achieve
through this intervention is improvement in occupational performance. The OT
will strive to increase the clients overall functional performance during the ADL
tasks in which transfers are required.
Precautions and contraindications. The precautions that the OT will need
to be aware of are the potential for falls or possible related injuries. When
participating in the lower extremity strength training the client will be working on
both static and dynamic standing balance. When a client is standing upright, there
is always an increase for possible falls. The OT will have to ensure a safe area in
which to conduct this activity with necessary materials such as a gait belt.
Grading up and down. This activity can be graded up or down in several
ways. The OT could have the client stand for short periods and frequent breaks if
the OT wishes to grade the activity down. The OT could have the client stand for
longer periods while participating in counter-top activities such as grooming or
meal-preparation.

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Short-term Goal #2. Client will transfer W/C bed Mod A using SB within 1
wk.
Intervention. This intervention will focus on improving the clients
postural and trunk control. In order for the client to be successful with transfers to
and from the wheelchair and bed, with the use of the sliding board, the client must
maintain adequate trunk control. The ways in which the OT will work on the
clients postural and trunk control will be through activities such as minitrampoline exercises. The intervention will consist of the client sitting on the
mini-trampoline and reaching for various preferred items. To ensure that this
activity is client-centered, the OT could allow the client to choose the items that
she will reach for. This would make the activity more meaningful to the client.
The items will be placed at various distances around the mini-trampoline in order
to encourage the client to cross midline as well as weight shift in order to reach
the items that are placed out of her reach. The OT will promote the client to
participate in the activity both unilaterally and bilaterally, when appropriate.
Miklitsch, Krewer, Freivogel, and Steube (2013) support this intervention
by investigating the effects of a predefined mini-trampoline program for
increasing postural control, mobility and the ability to perform activities of daily
living after a CVA. This study compared the mini-trampoline program participants
with a control group. The study found that the mini-trampoline group resulted in
significantly increased postural control in patients compared to balance training in
a group (Miklitsch et al., 2013).

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Approach. The approach for this intervention is establish and restore. The
OTs focus will be on establishing and improving the clients postural and trunk
control needed to complete SB transfers.
Desired outcome. The type of outcome that the OT would aim to achieve
through this intervention is improvement in occupational performance. The OT is
focused on improving the clients ability to transfer as independently as possible
during daily activities.
Precautions and contraindications. This intervention has numerous
precautions to consider. The OT will have to secure a safety net around the minitrampoline to ensure that the client does not fall or sustain any fall related injuries.
The OT will need to make sure that the client maintains proper trunk control
throughout the entire activity and should enforce this by having a gait belt on the
client at all times. The OT will have to also make sure that the client does not
acquire secondary injuries by cueing the client to maintain proper form during the
trunk control activities.
Grading up and down. This activity can be graded up and down in several
ways. The OT could have the client reach closer distances while seated on the
mini-trampoline in order to grade the activity down. If the client struggles with
this, the OT could support the client at the hips in order to limit excessive weightshifting and possible loss of balance. In hopes to grade the activity up, the OT
could have the client reach for objects out of reach while crossing midline.
Frequency and Duration

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The client will participate in OT services three days a week for 45 minutes. The client
will receive skilled OT services for a total of six weeks.
Primary Framework.
The primary framework used to guide this intervention plan is the Person Environment
Occupational Performance model (PEOP). This model takes into consideration the person or
intrinsic factors, the environment or extrinsic factors, as well as the clients desired occupations
and the clients performance during these occupations, or occupational performance (Brown,
2014). This model is a top-down approach that emphasizes looking at all the components that
make up the client, and studies how they all relate and interact with one another, and addressing
each of them during the treatment (Brown, 2014). The PEOP is ideal for this intervention
because it takes into consideration the important factors for this specific client, such as her roles,
cognitive ability, and social supports while ensuring that all of these factors are addressed within
the proposed intervention plan.
Client/Caregiver Training and Education
The intervention activities discussed above include education and training the client in
compensatory strategies required to complete her desired occupations. The OT will have to
introduce and explain the adaptive equipment and durable medical equipment to the client as
well as her family members on when to use the specific devices, as well as how to use them
properly. The OT will also have to ensure that the client and the caregivers are all aware of
proper body mechanics when completing transfers in order to reduce the risk of any falls or fall
related injuries. The OT will not only address the training during the treatment sessions but in
addition, he/she will send home literature for the client and caregiver to refer back to while they
are utilizing the new strategies and techniques at home.
Clients Response to the Interventions
The OT will monitor and assess the clients progress in achieving her goals by assessing
the OT daily progress notes and by performing a reassessment half way, or three weeks, after the

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start of the intervention. The OT will review daily progress notes regarding the clients response
to the intervention and reassess goals and intervention strategies as necessary. Upon initial
evaluation, the client was given the standard evaluation that HealthSouth of Henderson
administers to all clients, which is similar to the FIM. The results of her evaluation reflected poor
performance in all areas including self-care, sphincter control, mobility, locomotion,
communication, and social cognition. Therefore, the client will be reassessed half way into the
intervention plan to determine her progress in these particular areas.

References
AOTA. (2014). Occupational therapy practice framework: Domain and process (3rd ed.).
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Bale, M., & Stand, L. (2008). Does functional strength training of the leg in subacute stroke
improve physical performance? A pilot randomized controlled trial. Clinical
Rehabilitation, 22(10-11), 911-921.
Brown, C. (2014). Ecological models in occupational therapy. In B.A.B. Schell, G. Gillen,
&M.E. Scaffa (Eds). Willard and Spackmans occupational therapy (12th ed.,
pp.494-

504). Philadelphia: Lippincott Williams & Wilkins.

Christis, L., Bedford, R., & McCluskey, A. (2011). Task-specific practice of dressing tasks in a

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hospital setting improved dressing performance post-stroke: A feasibility study.

Australian Occupational Therapy Journal 58(5), 364-369. doi:10.1111/j.14401630.2011.00945.x
Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy:
Writing SOAP notes (3nd ed.). Thorofare, NJ: SLACK Incorporated.
Howard, S. (2008).The use of Manual Edema Mobilization for reduction of persistent edema,
Journal of Hand Therapy, 14(4), 291-301.
Miklitsch, C., Krewer, C., Frievogel, S., & Steube, D. (2013). Effects of predefined minitrampoline training programme on balance, mobility and activities of daily living after
stroke: randomized controlled pilot study. Clinical Rehabilitation, 27(10), 939-947.
Reistetter, T., Abreu, B., Bear-Lehman, J., & Ottenbacher, K. (2009). Unilateral and bilateral
upper extremity weight-bearing effect on upper extremity impairment and functional
performance after brain injury. Occupational Therapy International, 16(3-4), 218-231.
doi:10.1002/oti.278

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