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Running head: OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile and Intervention Plan


Kristen D. Kincaid
Touro University Nevada

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile
Client
The client is a 66 year-old man. He has been married for 39 years and lives with this
wife. They have 2 grown children ages 37 and 35; one lives in Las Vegas while the other lives in
Hawaii. The client is very attached to his family and says that family is what life is all about. The
client hosts family dinners on the weekend with his wife, son and grandchildren. Prior to his
injury, the client worked full time as a supervising custodian for the Clark county school district.
The client states that his job requires him to manage a team of workers 50% of the time and the
rest of the time he performes manual labor requiring the strength and function of bilateral upper
extremities. The client reports that he is generally in good health, but does have a history of
blood clots, high blood pressure and an artificial aortic valve. He client currently takes Coumadin
to thin his blood. Client is left hand dominant.
Reason for Services
The client is seeking services for multiple hematomas on his left arm that have not
resolved. The injury occurred 3/25/2013. The client reports that while visiting his son in Hawaii,
he was caught in an undertow while swimming. The undertow caught him and slammed the left
side of his body into a large rock multiple times. The client developed multiple hematomas on
his left arm that causing pain and decreased function. The client was referred to hand therapy for
modalities to promote digit motion and restore functional use of his left arm and hand. The goal
of therapy is to have the client return to full duty at work and engage in all previous occupations
that are currently limited secondary to the injury.

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupations
The client reports that prior to the injury he was independent in all ALDs and worked full
time on full duty. Two weeks after the injury, the client reports that he is able to complete most
ADLs with minimal assistance. However, he also reports that his wife assists him with self-care
activities approximately 50% of the time. The client reports that he is unable to open jars, hold
items in his left hand, carry bags in his left hand, cut meat or use a computer with his left hand.
In addition, the clients chief complaints are swelling, weakness, loss of function, loss of motion
and a pain level of 5/10. Since the injury, the client has been unable to return to work due to the
dysfunction in his left upper extremity. The client is very motivated to return to work. He
acknowledges that he can rely on the team he oversees to complete more of the physical labor
while he focuses on the management, but states that he enjoys the physical component of his job.
He values the ability to lift and perform custodial tasks at work and states that it is very
important to him that he return to work with full capabilities. The client also reports that the
injury has impacted his ability to perform yard work at his home. He has had to hire a temporary
gardening service, and is unsatisfied with the work they perform. He is anxious about it and
would like to return to caring for his yard, but reports that the lack of strength in his left arm and
pain prevent him from engaging in this activity. The areas of occupation that are successful for
the client include most self-care tasks. The areas of occupation that are causing problems are the
ones that require dexterity, grip strength, and endurance of the left upper extremity.
Environment
The client has a very supportive home environment. He lives with his wife of 39 years in
a single story ranch home Henderson, Las Vegas. His wife doesnt work outside the house, so she
is available to help the client with anything he is unable to do himself. The client can perform

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

most basic needs himself, but should the need arise, he can ask his wife for assistance. In
addition, the clients son and his family live nearby. Therefore, if the client or his wife needs
assistance with anything that requires a great deal of strength, they can call upon their son for
help. One potential downfall of this is that while the client can perform most ADLs
independently and requires some assistance with other tasks, like meal preparation, his wife
generally will do them for him before he has a change to complete them for himself. This affects
the number of opportunities the client can use his involved arm and hand to engage in activities;
thus limiting instances that the client can increase hand strength, ROM, and dexterity at home in
preparation for the clients reengagement in desired occupation, like preparing a weekend dinner.
The clients work environment is also very supportive. He is a supervisor at work, and his
employer will allow him to return to employment on light duty if all desired therapy goals are
not met. The client works for the school district which, is thus far, being very accommodating
with allowing time off for the client to heal. The clients socioeconomic environment allows him
to pay for a yard service company to care for his property until his hand heals completely.
Ironically, this economic advantage may be his inhibiting participation in a desired occupation.
With adaptation or assistance from his wife, the client would likely be able to successfully
engage in yard management at this time. However, because he has the monetary means, he likely
wont resume this desired occupation until he regains all lost grip strength.
Occupational History
The clients current life roles are that of the primary income generator of the house, a
husband, a father, a grandfather, and a homeowner. The client has worked for the majority of his
life and has been the sole income for his family since his first child was born. Prior to his career
with the school district, the client worked for a moving company in Las Vegas. The job was

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

physically demanding, but the client said it was also very rewarding because he never had to go
to the gym and was in great shape. Through interacting with the client, I got a sense that the
return of his strength is very important to him and that he believes that men should be strong.
Although the client feels secure financially and is assured that he can return to his job after
therapy, he states that he doesnt know what to do with himself while at home. Working gives the
client a purpose and helps the client meet the role of provider to his family. The client says he
doesnt feel right staying home all day and that he would rather be at work. As a homeowner, the
client feels that he should be able to complete routine maintenance of the yard and house. He has
expressed irritation with the company he hired to provide lawn service and feels that he does a
better job himself. In addition, the client is annoyed that when he hand waters his bushes and
flowers, he has to have his wife turn on the spigot due to lack of hand strength. He states that he
doesnt like asking for his wifes help with outside chores because those are a mans duties. In
addition, the client relayed how frustrated he was that he couldnt fix a light switch that broke at
home. He stated that he tried to use his right hand, which is non-dominant, to unscrew the light
switch, and that be became extremely frustrated. He values being able to repair simple objects
around his house.
The client views himself as the head of the family and hosts weekend dinners every
week. He usually barbecues in the summer or is in charge of another dish. He explains that these
dinners are very important to keeping the family together. He says that his own father left when
he was very young, and that he never wanted to leave his family like that. Therefore, he makes it
a priority in his life to be there for his family. He also stated that he wanted his wife to always be
there for their children and thats why he asked her not to work after they were born. The client
states that his role as a husband includes providing financial security, home maintenance, and

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

completing tasks that his wife may not have the strength to do herself. He said that he usually
opens the jars or carries the heavy groceries in from the car. Although he can still carry in the
groceries from the car using his right hand, he doesnt feel that he is currently doing enough for
his wife and says that she takes care of me. The client states that he feels useless for much of
the day because he is unable to perform the activities that are part of his life roles. He admits that
his days are boring and unproductive since he cant engage in any of his normal pastimes, and
frequently states that he is excited to return to work.
Clients Priorities and Desired Outcomes
One of the clients top priorities is to return to work at full capacity. The client
acknowledges the fact that he may be able to return to partial work capacity, but he says this is
unacceptable for him. He said he likes the managing of the custodial work crew but that he needs
to be in the field working alongside his crew. The job requires him to operate machinery like a
floor buffer and to routinely pick up heavy items. Therefore, one of the outcomes that he desires
from therapy is to regain his grip strength to pre-injury levels. In addition, the client wants his
hand strength and wrist ROM to return so that he can care for his large yard at home. The client
states that this is a favorite past time of his. At the current time, the client is unable to turn on the
hose spigot independently to water his bushes. In addition, he doesnt have the hand strength to
operate the shears needed to trim his hedges. The client states that he has hired gardening crew
while he recovers, but is not happy with their work and looks forward to resuming the activity.
Another priority of the client is to increase his wrist ROM so that he can cook the weekend
family dinners. With summer months approaching, the client states that he wants to be able to
flip burgers and steaks on the grill for his family. Therefore, functional outcomes for the client
include the ability to pronate, supinate, extend, and flex his wrist.

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Analysis
Setting of Occupational Therapy Services
The client received hand therapy services by an occupational therapist at Matt Smith
Physical Therapy Clinic in Henderson, Nevada. This is an outpatient setting that sees clients for
both physical therapy and hand therapy.
Observation and Clients Performance of Activity
I observed the client doing 3 exercise activities and receiving 3 modalities. Due to the
nature of the setting and its very biomechanical approach, I was unable to observe the client
performing any functionally or occupation based activities. The activity that I focused on was the
client working with the Theraputty to increase hand strength. The client was told to manipulate
the Theraputty in order to increase hand strength. The client did as he was instructed, but because
of the nature of the activity, he didnt seem very motivated to engage in it. When I sat with the
client and talked to him, he looked like he was more active with the Theraputty than when I was
observing him from afar. Despite the fact that this client was very motivated in therapy and to
return to work, the activity was not engaging and I observed the client looking at the timer
frequently. I assume this was done to see how much longer he had to engage in the task. When I
was not sitting and talking to the client, he would look out the window and seemed detracted
from the activity. I observed his hand from both afar, and when I engaged in conversation with
him, and it looked like he contracted his fist more when I was near him and serving as a physical
reminder to engage in therapy.
Domains Limiting the Client
Based on the clients diagnosis and the reasons he is seeking occupational therapy
services, there are many domains that are affecting the clients ability to engage in occupations.

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

The client values hard work in life, because of this, he arrived to therapy motivated and
compliant. In addition, because he values hard work, he readily agreed to perform the at-home
exercise plan that the occupational therapist gave him. The client also believes that his hard work
in therapy will pay off and his arm and hand will return to pre-injury function, allowing him to
engage in all his previous occupations. The client also has intact energy and drive that promotes
his engagement in therapy and the home exercise plan. Domains that are limiting the clients
engagement in occupation include his ability to localize pain. The client reports that the pain in
his left upper extremity and hand is a 5/10 and that it increases with activity. The pain limits what
activities the client can participate in. The clients neuromusculoskeletal and movement-related
functions are also impacting his ability to perform previous occupations. The clients radiocarpal
joint is limited in ROM, especially in flexion and extension. Radial and ulnar deviation are
almost within functional limits, however, when the joint is moved through its available ROM, it
causes significant pain to the client. The clients muscle strength in his left upper extremity has
also been impacted by the injury. On the grip test, the client is capable of sixty pounds of force
with his right hand and only 4 pounds of force with his left hand. The client reports that prior to
the injury his left arm was stronger than his right. The weakness is interfering with the clients
occupations of work and leisure. In addition, the clients muscle endurance has been affected by
the injury. The client states that when he does try to use his left upper extremity in activities, that
it tires easily. Therefore, the client states that using the affected side becomes cumbersome and
admits that for this reason, he avoids using the arm. The clients injury caused multiple
hematomas to form on his arm. This is part of the cardiovascular system, and although this isnt
directly limiting the clients engagement in occupations, the client reports that seeing the
hematomas reminds him that his arm was injured. This observation limits the amount the client

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uses the arm even when pain is not present. The visual reminder of the injury is enough to limit
the clients engagement in previous occupations (AOTA, 2008).
Problem List
1. Client is unable to grasp and lift an item weighing over 3 pounds due to L hand weakness and
pain.
a. Regaining hand strength to grasp items is very important to the client because his
custodial job requires him to lift heavy objects frequently. The clients job description
requires that he be able to lift 50 pounds. Returning to work is a top priority for the
client.
2. Client is unable to open the hose bib spigot due to a decrease in L hand grip strength and
wrist ROM.
a. In addition to returning to work, the client would also like to engage in yard and
home maintenance without the assistance of his wife. Part of this activity is turning
on the hose to hand water certain plants in the yard. The client doesnt believe the
yard maintenance company he hired is doing an adequate job, and would like to
return to perform this activity himself. Furthermore, the limited wrist ROM inhibits
the client from performing other home maintenance tasks, like tightening a screw.
3. Client is unable to operate shears due to a decrease in left hand strength.
a. The ability to operate shears is needed for both the clients work and home
maintenance duties. However, it is less of an issue for the client as it does not need to
be performed as frequently as the two above mentioned tasks. The client needs to
operate shears to cut materials at work and to prune his bushes at home.
4. Client is unable to flip food items when cooking due to pain and stiffness when pronating and
supinating the left wrist.
a. The weather has been getting warmer, and the client expressed an interest in returning
to his role as the head cook at his weekend family dinners. He wants to start
barbecuing as soon as possible, but knows that he wont be able to flip the

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hamburgers and ribs at this point in time. This is important to him, but not as high of
a priority as returning to work and to perform his own yard maintenance. For the time
being, the client said he is fine with his son performing most of the food preparation
duties while he watches.
5. Client is unable to type on the computer using the left hand due to swelling and pain.
a. Operating a computer with the assistance of this left hand is something the client
would like to be able to return to doing; however, he can sufficiently operate the
computer keyboard with only his right hand if given additional time. In addition, it is
not as high of a priority because the client doesnt have to do much typing at work
except for the occasional email at home for web surfing. Both tasks are able to be
performed at this time, but not as efficiently as the client would like.
Intervention Plan & Outcomes
Long-term Goals
1. Client will (I) achieve a 50 pound grip score when his left hand is tested with Grip
Dynamometer by 6/4/2014.
2. Client will be able to (I) turn on his tightly closed hose spigot s pain by 6/4/2015.
Short-term Goals
1. Client will (I) achieve a 15 pound grip score when his left hand is tested with Grip
Dynamometer by 5/7/2014.
2. Client will (I) achieve a 35 pound grip score when his left hand is tested with Grip
Dynamometer by 5/21/2014.
3. Client will be able to (I) screw and unscrew a large bolt at table height by 5/7/2014.
4. Client will be able to (I) unscrew a new plastic jar of peanut butter by 5/21/2014.
Intervention Ideas

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1. Client will knead pizza dough to increase hand strength, provide a stretch to the wrist
while in extension, and move the wrist joint through available ROM. Later, the skill can
be utilized when preparing weekend family dinners.
a. Restore an ability that has been impaired
b. Participation of essential job duties
c. Grading of the activity
i. To grade the activity up, the client can also stretch the pizza dough onto
the pan. This will increase the time spent performing the task thereby
increasing the clients endurance and strength. Furthermore, the graded up
activity will fine motor manipulation.
ii. To grade the activity down, the client can mix by hand the initial
ingredients and then transfer to a mixer to complete the heavy kneading
that requires more strength. In this example, the strength and endurance
requirements are lessened by transferring the dough to a mixer.
2. Client will use a spring loaded hand stapling gun to attach fabric to a wooden plank as a
decorative piece for his wife.
a. Restore an ability that has been impaired
b. Participation of essential job duties
3. Client will assemble a simple wooden spice rack by screwing the pieces together with a
screwdriver.
a. Restore an ability that has been impaired.
b. Homeowner role competence
4. Client will learn to tie different knots that can be used at work or home.
a. Restore an ability that has been impaired.
b. Homeowner role competence
Evidence to Support Interventions
In order to gain muscle strength, the client must perform muscle contraction against
resistance. This movement must also have the body part move through the available ROM. The
device by which the resistance is applied can vary, but as strength increases, the resistance
applied to the muscle should also increase. This is based on the principle that to increase

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strength, the muscle must contract against maximal resistance. However, depending on the
desired outcome, the resistance, number of reputations, frequency of training and speed of
movement can vary. For the purpose of the interventions used with this particular client, the
overload principle is utilized. This basis of this principle is that muscles must be taxed beyond
usually daily activity to improve in performance and strength (Breines, 2013).
To make the concepts addressed above fit within the realm of occupational therapy the
exercise must be embedded within a purposeful or occupational-based activity. Numerous studies
provide evidence that clients are more likely to choose, and perform better, those activities which
embed exercise within them when compared to rote. The clients occupational profile should be
taken into account when creating interventions that focus on the clients goals and increase client
buy-in. Crafts in particular provide a great medium to include in the clients therapy session.
Crafts can be graded from light to heavy resistance and improve both gross and fine dexterity.
Crafts have been found to have a high level of client acceptance and the end product can provide
a sense of accomplishment to the client (Kasch, 2013).
Based on these principles, one intervention directed the client to knead pizza dough in
order to increase overall hand and grip strength. The activity can be graded up or down
depending on the amount of water used in the recipe, whether a mechanical mixer is used, or if
the client is required to spread the dough in a pan. The dough is the object providing resistance to
the clients left hand and fingers. Kneading dough is a repetitive activity which will allow for an
opportunity for the client to contract his hand against more resistance than he typically does.
Therefore, this should increase the targeted muscles strength. Besides allowing for improvements
in strength, the activity also promotes the movement of the wrist joint through its available
ROM. Furthermore, when the client uses the heel of his hand to knead the dough, it will place

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the wrist in extension and cause the client to perform an active slow stretch. In addition, because
the client enjoys cooking one a week for his family, the activity is purposeful for the client. This
will promote engagement and compliance (Breines, 2013).
The next intervention engages the client in a craft that he can take home with him after
the therapy session. The client will be provided with a plank that he can then stable cloth to in
order to make a decorative piece of art. The spring-loaded staple gun will be the method of
providing resistance. Different staple guns are on the market and have variable requirements of
hand strength in order to operate. Therefore, the hand therapy clinic should have at least three
hand staplers to provide the client with the correct resistance. In the hand therapy clinic, Cando
Digi-Flex Hand/Finger Exerciser is often used to increase grip strength. However the rote
exercise may not be meaningful to the client. By using the staple gun in a craft, the client will
engage in repetitive muscle contraction against resistance, thus increasing hand grip strength
(Breines, 2013). Furthermore, the client will be engaged in a craft, which evidence suggests is
well accepted by clients. After the craft is completed, the client may feel accomplish or proud
(Kasch, 2013). Therefore, the craft may not only address grip strength but may benefit a clients
psychosocial state.
The third intervention has the client assembling a simple wooden spice rack. The spice
rack is assembled with screws and a screwdriver. The motion required for operating the
screwdriver is one which will promote movement of the wrist through its available ROM,
supination and pronation. Since using a screw driver is a low-load and high-repetition
movement, it is effective for building endurance. In addition, because the movement is
embedded in a craft, it promotes the client to engage in the full ROM available which will aid in
decreasing stiffness (Breines, 2013).

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The final intervention that will be used with this client is teaching him simple knots that
can be utilized at his home or work. Knots have been found to be particularly useful in hand
therapy for improving a clients fine dexterity and finger strength (Kasch, 2013). Furthermore,
they allow for an intervention that can be easily graded depending on the clients current
abilities. The activity can be graded down by using a large gauge rope, or graded up by using a
finer string. In addition, besides working on the clients biomechanical goals, they are also
engaged in learning a new, functional skill that can be applied to other areas of their life.
In addition to the interventions discussed above, the client will receive modalities to help
decrease pain, increase circulation, decrease edema, increase ROM, and to increase overall
function (Breines, 2013). The modalities chosen for the client by the therapist are moist hot
packs, paraffin wax and ultrasound.
Precautions and/or Contraindications
The client is in good health and the only precaution that needs to be followed is for pain.
If the client reports a sharp increase in pain, the therapy or exercise should be stopped
immediately, and the occupational therapist and client will need to address what caused the pain.
In addition, while using thermal modalities, the therapist should be aware of the
contraindications of using heat on acute inflammatory conditions, decreased sensation, or use
with an older client (Breines, 2013).
Frequency and Duration
The client will be advised to attend hand therapy twice a week for a total of 6 weeks.
Each session will run for 60 minutes. In addition, the client will be given a written home exercise
plan that should be completed 3 times a day, with each session taking roughly 4 minutes.
Practice Framework

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The biomechanical frame of reference is utilized with this client because his central
nervous system is intact, but he has deficits in his musculoskeletal systems. The biomechanical
approach is commonly used in hand therapy to restore function to clients. The functions that are
focused on with this frame of reference are strength, endurance and range of motion needed to
engage in occupations. Typically, changes in the above mentioned functions result from exercise,
activity and physical agent modalities. Research supports the use of the biomechanical frame of
reference to reach the goals of increasing body strength and endurance by using repetitive
exercises and providing a gradual increase in resistance (OBrien & Hussey, 2012). The use of
this frame of reference guided the goal setting for this client because his long term goal is to
increase his grip strength. At the completion of therapy, the clients grip strength and ROM will
be assessed and compared to the baseline measurements taken before any intervention to
determine whether the clients goals have been met. All the interventions suggested for use with
this client have the underlying goal of increasing strength and ROM of the clients left hand and
wrist.
Client Training and Education
The client was educated on the interaction between the blood thinner that he normally
takes and the severity of the hematomas he sustained. The client was advised not to return to
work until normal function has returned or his doctor cleared him of the restriction. While
working with the client in therapy, the occupational therapist explained how the activities or
modalities will benefit the client. Moist hot pack and ultrasound are modalities that are
performed with this client. The client was told that the goals of administering the moist hot pack
and thermal ultrasound during therapy are to decrease pain, increase circulation and tissue repair
and increase soft tissue extensibility (Breines, 2013). Furthermore, the client was educated about

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the goals that each intervention is trying to achieve, like an increase in hand strength or an
increase in wrist ROM. In addition, the client was given a written home exercise plan that he
should perform 3 times a day. The occupational therapist educated the client on how to perform
the exercises correctly by first showing him the correct way and then asking him to demonstrate.
Finally, the client was educated on what to expect as his injury continues to heal and what
benefits to expect from hand therapy. This way the client will have a sense of what pain and
function levels to expect in the upcoming weeks.
Clients Response to Interventions
The clients response to interventions will be monitored in a by comparing scores after an
intervention to baseline scores taken when the client was first seen for his evaluation. The
occupational therapist will measure the clients grip strength using the Grip Dynamotmeter. If the
clients grip strength improves, we can assume that the interventions that focused on grip
strength were beneficial. In addition, ROM baselines for both right and left wrist and fingers
were taken and will be compared to ROM after intervention. Furthermore, the girth of the
clients arm and wrist were measured at varies points to allow for documentation of edema both
before and after treatment. Finally, the client is asked to rate their pain on a scale of 0-10 every
time they are seen for treatment. This self-reported measure of pain is then compared to the
baseline.

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References
AOTA. (2008). Occupational therapy practice framework: Domain and process (2nd ed.).
American Journal of Occupational Therapy, 62, 625-683.
Breines. E. B. (2013). Therapeutic occupations and modalities. In H. M. Pendleton, & W. SchultKrohn (Eds.), Pedrettis occupational therapy practice skills for dysfunction (7th ed., pp. 729754). St. Louis, MO: Elsevier.
Kasch, M. C., & Walsh, J. M. (2013). Hand and upper extremity Injuries. In H. M. Pendleton, &
W. Schult-Krohn (Eds.), Pedrettis occupational therapy practice skills for dysfunction
(7th ed., pp. 1037-1073). St. Louis, MO: Elsevier.
OBrien, J., & Hussey, S. (2012). Models of practice and frames of reference. In K. Falk & J.
Gower (Eds.), Introduction to occupational therapy (4th ed., pp. 135-143). St.
Louis, MO: Mosby