adult rehab - case applications

case 1:

Mr. Jones is employed full-time as an auto mechanic. He enjoys taking exercise classes, gardening, and playing with his grandchildren in his free time. He is a 65-year-old man who lives with his wife of 35 years in a one-story home. Together, Mr. and Mrs. Jones have 2 adult daughters who live in neighboring communities, and 3 active grandchildren. Mr. Jones was admitted to the acute hospital for a right total knee arthroplasty. An order for OT to evaluate and treat was received POD#1. He is independent with his basic ADL activities and requires supervision for ADL transfers with the use of a rolling walker. He has received post-operative education regarding post-surgical precautions. He will be in the hospital for a total of 2 days. 

where will you recommend Mr. Jones go at discharge and why?

a. outpatient OT

b. home without any further OT services

c. inpatient acute rehab (inpatient rehab facility) 

d. assisted living 

b. home without any further OT services

Case 2:
Mrs. Smith has been widowed for 15 years and currently lives alone in her single-family home. She leads a fairly active life, but also enjoys watching Jeopardy, The Price is Right, and Wheel of Fortune during the weekdays and visits with friends and family on the weekends. She still drives independently and enjoys driving to her golfing tournaments on the weekends. Her daughter and son-in-law live 45 minutes away from her and she talks to her daughter on the phone every few days. She was found on the floor, by her daughter (who came by when Mrs. Smith failed to answer telephone calls), and she had been there for three days. The paramedics
were called and upon arrival at the ER, Mrs. Smith was found to be dehydrated and confused, and had suffered a L hip fracture during the fall. Mrs. Smith’s hip fracture was treated surgically, and post-operatively she developed pneumonia and incontinence. She is also experiencing some post-operative cognitive problems, including confusion and paranoia. You received a referral for OT evaluation and treatment. Mrs. Smith is assisted with most basic ADL at this time, her gross upper extremity strength is F+ to G (3+/5 to 4/5), and her endurance is very limited.

Mrs. Smith is on day two of a projected 5-day stay. What is your plan, and where will you recommend she go upon discharge? Why?

a. long term care / nursing home

b. inpatient acute rehab

c. snf

d. home with home health care

b. inpatient acute rehab

Case 3:
Mr. Thomas was previously a marriage and family therapist working in a small group near Pepperdine University in Southern California. On his way to work one day 17 years ago, he was in a motor vehicle accident (MVA) which resulted in his sustaining a spinal cord injury with resultant C5 complete tetraplegia. Since his discharge from the rehabilitation facility, he has lived at home and has been cared for by well-trained, around-the-clock caregivers, who he pays for privately from a large post-accident settlement. Mr. Thomas needs assistance with feeding and is able to work on the computer once he is set up. He loves to work on the computer, and
routinely loses track of time when doing so. This resulted in the development of a large pressure ulcer which was treated with myocutaneous flap surgery. His wound dehisced approximately 3 weeks post-flap, and conservative treatment is now being employed at home to attempt closure of the open wound along the suture line. Mr. Thomas is 58 years old, has a tracheostomy, a pacemaker, and has had multiple hospitalizations over the past 3 years. He was admitted to the hospital with difficulty breathing, fever and lethargy. He was diagnosed with a lung abscess and total body sepsis. Over the past 3 weeks, his condition has continued to decline, and he is significantly less responsive. He is now on a ventilator full-time, and on a
cooling blanket to control the fever. His condition does not appear to be changing.

Where will he be discharged and why?

a. inpatient acute rehab (inpatient rehab facility) 

b. snf / transitional care unit

c. long term care hospital

d. extended care facility

c. long term care hospital

Case 4:
Jenna is a bright and active freshman in college. She is not sure what her career will be, but she is interested in forestry or the technical aspects of radio and television studio operations. She is a twenty-year-old female who sustained a C6 complete spinal cord injury in a motor vehicle accident. Jenna enjoys sports, art and popular music. . At this time, Jenna has good (4) strength in the key muscles at C4 and C5, and Fair + (3+) strength in the radial wrist extensors, clavicular pectoralis, and serratus anterior. She has P- (2-) strength in the triceps and extensor digitorum communis (EDC). Sharp/dull discrimination is intact at the C6 dermatome and above,
impaired at C7, and absent at C8 and below. Proprioception is intact at the shoulder and elbow, impaired at the wrist, and absent in the fingers and thumb. Jenna’s medical problems as a result of the accident, such as bladder and bowel control, are stabilized, and all precautions are in force to prevent pressure sores. She is able to sit in a wheelchair with support of a special cushion for periods of up to 4 hours a day. In addition, she must wear a short Philadelphia collar/neck brace at all times, (in and out of bed) for neck stabilization. Nursing service reports that Jenna makes little effort to help with any of her self-care activities and is presently dependent to maximum assistance in all ADL and ADL transfers. Jenna demonstrates a rather flippant, carefree attitude toward her problems, which seems to be an effort to cover
up a deep anxiety about her physical condition and the future. Occupational therapy is ordered for this patient with aims to increase functional independence, aid with adjustment to disability, and improve muscle strength.

What might be the trajectory for Jenna’s recovery in terms of her continuum of care? Why?

a. snf

b. outpatient OT

c. home with home health care

d. inpatient acute rehab / inpatient rehab facility

d. inpatient acute rehab / inpatient rehab facility

Case 5:
Betty was born in Nebraska. She married her high school sweetheart and they moved to California so he could pursue his career as an engineer. Betty managed the household and raised her children until they were grown and moved out. Betty’s son is married and has two children. Her daughter is not married; both children live out of state and visit during the holidays. Betty lives in the home that she and her husband bought 45 years ago in Long Beach. Her husband passed away two years ago. She says she is “managing all right by myself,” though she says she misses him terribly. Betty is an 80-year-old woman who has in-home support services for 5 hours per day. She lives alone and requires assistance to care for her one-story
home. Betty used to enjoy cooking, crocheting, and knitting gifts for her family and friends, but has not been engaging in these occupations recently.

Betty has osteoarthritis in her right hip, which has worsened over time. She reports that it has been more and more painful during the past few months. Prior to her hospitalization and subsequent total hip replacement surgery, she stated that it became difficult to walk. Betty has a history of coronary artery disease and had coronary artery bypass surgery 13 years ago. Betty was referred to you for occupational therapy.

Upon assessment, you find that she is oriented to person only. She is alert and able to follow only simple instructions. Her memory and problem-solving abilities are impaired. She wears glasses. She has good use of both upper extremities, and AROM is WFL. Her UE strength and coordination are adequate for her daily needs and sensation is intact. Upon self-care assessment, you note that Betty requires set-up assistance in feeding herself (particularly with cutting food and opening containers) and requires verbal cues for completion. She requires
minimal verbal cues for grooming. She needs minimum assistance for UE bathing and UE dressing. She needs maximum assistance for LE bathing and maximal assistance with LE dressing. Maximum assistance of two therapists is required for ADL transfers. She cannot recall or incorporate any of the hip precautions into her daily activities, which were prescribed by the orthopedic surgeon. Her activity tolerance is poor. During treatment she consistently complaints of 10/10 pain in the surgical hip and you are worried about how she will do at home, living by herself. Her orthopedic surgeon has cleared her to bear weight (“weightbear”) on her right leg as much as tolerated (WBAT).

What will you recommend for Betty at discharge and why?

a. snf

b. assisted living

c. inpatient acute rehab 

d. home with home health care 

a. snf

______ would be identified as a limitation

a. pre-diabetes

b. lives in a 3-story condo

c. decreased activity tolerance

d. decreased strength in the UEs

e. use of sequential compression devices on RLE

c. decreased activity tolerance

which of the following would NOT be identified as an asset?

a. positive support system and disposition

b. independent with ADL

c. patient was independent prior to admission

d. bilateral UE ROM/strength intact

e. all of the above would be identified as assets

b. independent with ADL

which of the following would be addressed in the intervention plan for this patient? 

a. UE strengthening

b. community reintegration 

c. ADLs

d. all of the above

e. b and c only

c. ADLs

which of the following would most likely NOT be included in this patient’s intervention plan of care?

a. lower body dressing training

b. driver’s rehab

c. toilet transfers

d. adaptive equipment needs assessment

e. patient/family education

b. driver’s rehab

which of the following would be a logical LTG for barb?

a. Pt. will remember her hip precautions regularly in 4 days.

b. Pt. will be independent with lower body dressing in 1 week.

c. Pt. will require supervision / stand-by assistance for feeding in 2 days.

d. Pt. will demonstrate intact higher-level cognitive skills in 1 week.

b. Pt. will be independent with lower body dressing in 1 week.

Based upon the portion of the intervention session you observed in the video, which of the following best describes Paul’s activity tolerance?

a. In a five minute treatment session with one rest break, Paul’s oxygen saturation was 97% and his heart rate was 79 bpm during the activity of donning a sock while sitting, after the first 3 minutes.
b. Paul easily tolerated 5 minutes of dressing activity (donning sock) in sitting.
c. Paul required stand-by assistance for lower body dressing using adaptive equipment.
d. Paul tolerated 5 minutes of lower body dressing activity (donning sock) in sitting using adaptive equipment with one rest break

a. In a five minute treatment session with one rest break, Paul’s oxygen saturation was 97% and his heart rate was 79 bpm during the activity of donning a sock while sitting, after the first 3 minutes.

Which of the following observations during Paul’s session could indicate to the clinician that Paul is experiencing difficulty with activity tolerance?

a. Paul required adaptive equipment for lower body dressing.
b. Paul’s facial expression at the end of the session.
c. Paul is on a ventilator.
d. Paul’s oxygen saturation was 97% and his heart rate was 79 bpm

b. Paul’s facial expression at the end of the session.

What would be the best “next step” in assessing Paul’s activity tolerance during ADLs?

a. Assessing Paul’s ability to complete bathing in sitting using a transfer tub bench
b. Assessing Paul’s ability to stand at the sink to shave and brush his teeth
c. Assessing Paul’s ability to transfer into a bedside chair for a grooming activity
d. Assessing Paul’s ability to doff his hospital gown while lying in bed

c. Assessing Paul’s ability to transfer into a bedside chair for a grooming activity

Which of the following scenarios would warrant termination of the treatment, and notification to the nurse or physician, about Paul’s status? During the occupational therapy intervention session, Paul:

a. Tells you that he is too tired and would prefer to have therapy another time
b. Asks you if he can sit down because he says he feels that he “can’t catch his breath;” you check his respiration rate, and it is 20 respirations per minute
c. Tells you that he feels dizzy and light-headed; you check his blood pressure and find that the systolic pressure is now significantly below the resting systolic pressure you took prior to the intervention
d. Has a temperature of 98.4 degrees F

c. Tells you that he feels dizzy and light-headed; you check his blood pressure and find that the systolic pressure is now significantly below the resting systolic pressure you took prior to the intervention

The next day you return to work with Paul. He says that he has been anticipating your return and ready for therapy this morning because he would like to shave. He said, “I’m starting to look like my cats from the shelter!”

Prior to beginning the intervention, you assess his vital signs and record the following: BP: 130/90, RR is 18 respirations per minute, and HR is 86 beats per minute. During the 15-minute self-care intervention, Paul asks if he can take a break and appears diaphoretic. You decide to re-assess his vitals: BP is 172/120, RR is 30 respirations per minute, and HR is 119 beats per minute. What would you do next?

a. Continue with the intervention as planned
b. Continue with the intervention; however, help Paul back to bed and ask him to
complete the task from a semi-reclined position
c. Call a “Code Blue” because Paul needs cardiac support and resuscitation
d. Terminate the intervention session, send the rehabilitation aide to find Paul’s nurse, and then help him back to bed.

d. Terminate the intervention session, send the rehabilitation aide to find Paul’s nurse, and then help him back to bed.

t o assess Regina’s shoulder flexion strength, you initially position her_____________________.

a. in standing
b. in sitting
c. in supine in bed

b. in sitting

Regina’s (L) UE PROM is as follows:
Shoulder flexion: 0 - 130 ̊
Shoulder extension 0 - 20 ̊
Shoulder abduction: 0 - 110 ̊
Shoulder adduction: WNL
Elbow: WNL
Wrist: WNL
Hand: WNL

Regina is able to actively move her left shoulder from 0 – 130 ̊ in flexion against gravity. Your next step in the muscle testing procedure would be to  ____________.

a. apply resistance to Regina’s (L) UE.
b. record Regina’s (L) shoulder flexor strength as F (3/5).
c. place Regina in a gravity-eliminated position for testing (L) shoulder flexion

a. apply resistance to Regina’s (L) UE.

Regina’s (L) UE PROM is as follows:
Shoulder flexion: 0 - 130 ̊
Shoulder extension 0 - 20 ̊
Shoulder abduction: 0 - 110 ̊
Shoulder adduction: WNL
Elbow: WNL
Wrist: WNL
Hand: WNL

Regina is able to actively move her (L) shoulder into 0-90 ̊ abduction against gravity. Your next step in the muscle testing would be to ________________________.

a. record Regina’s shoulder abduction strength as F- (3-/5)
b. position Regina in a gravity-eliminated position for testing (L) shoulder abduction
c. record Regina’s shoulder abduction strength as P (2/5)

b. position Regina in a gravity-eliminated position for testing (L) shoulder abduction

Regina’s (L) UE PROM is as follows:
Shoulder flexion: 0 - 130 ̊
Shoulder extension 0 - 20 ̊
Shoulder abduction: 0 - 110 ̊
Shoulder adduction: WNL
Elbow: WNL
Wrist: WNL
Hand: WNL

When you test Regina’s (L) elbow strength, she is able to fully flex her elbow against gravity. Your next step would be to ___________________________.

a. place Regina’s elbow flexors in a gravity eliminated position
b. record Regina’s elbow flexor strength as Good (4/5)
c. apply resistance to Regina’s forearm at the end of her flexion range

c. apply resistance to Regina’s forearm at the end of her flexion range

Which of the following activities might be utilized to further screen Regina’s oculomotor skills?

a. ask her to look at the clock and report the time
b. follow the tip of a pen
c. ask her to fixate on a target in the room and to indicate if and when another target is presented

b. follow the tip of a pen

Which of the following would be indicative of Regina’s memory being intact?

a. verbalizing the 3 posterior hip replacement precautions
b. following directions given by the therapist
c. knowing she’s in the hospital for a hip replacement surgery

a. verbalizing the 3 posterior hip replacement precautions

To screen for ____________________________ you would sit behind Regina and ask her to look straight ahead while you wiggle your fingers on her left side, right side, or both simultaneously to see if Regina responds correctly to the stimulus.

a. visual acuity
b. oculomotor skills
c. visual fields

c. visual fields

As you continue with the Canadian Occupational Performance Measure to help identify Regina's OT goals, she is able to verbally identify four goals while simultaneously knitting a pair of gloves for her son when he returns from overseas in a few months. This is an example of ________________.

a. sustained attention
b. selective attention
c. divided attention
d. alternating attention

c. divided attention

During the evaluation, Regina's daughter-in-law enters the room. Regina says to the
occupational therapist, "I'd like for you to meet my daughter-in-law, Rhonda." She turns to Rhonda and says, "Were you able to find a spot in the hospital parking lot? I heard it can get quite crowded. I'm so glad you could be here for the OT evaluation. They're going to help me work on moving around the house safely again so you won't have to worry about me. I don't know when they'll let me go home though. What day is it today?"

On the evaluation form, how would you indicate Regina's orientation?
a. Oriented x1
b. Oriented x2
c. Oriented x3
d. Oriented x

c. Oriented x3 (oriented to person, place, and circumstance; not clear if she's
oriented to the date)Dre – Part E

During Regina’s hospitalization in an acute care hospital setting,
_____________________________ will be billed for rehabilitation services.

a. Medicare – Part A
b. Medicare – Part B
c. Medicare – Part C
d. Medicare – Part D
e. Medicare – Part E

a. Medicare – Part A

An occupational therapist is working with a patient who is recovering from a total hip replacement. The therapist would like to use the occupation of getting dressed and grade the activity up, since the patient could benefit from a more challenging approach.

Which of the following interventions would be best?

a. Have the patient use the front-wheeled walker (FWW) to get the clothes from
the dresser/closet before initiating the activity
b. Have the patient wear tighter clothes
c. Have the patient do the activity without adaptive equipment
d. Add weighted wrist cuffs to the patient’s arms
e. All of the above would be best for grading up the occupation of dressing

a. Have the patient use the front-wheeled walker (FWW) to get the clothes from
the dresser/closet before initiating the activity

An occupational therapist is working with a patient who is recovering from a total hip replacement. The therapist would like to use the occupation of toileting and grade the activity down, since the patient could benefit from a less challenging approach.

Which of the following interventions would be best?

a. Have the therapist provide more physical assistance
b. Have the therapist provide more verbal cues
c. Have the therapist provide more physical assistance and verbal cues
d. Use a bedside commode with a raised toilet seat closer to the bed, instead of
having the patient walk to the bathroom
e. a, b, or c would be best to grade the activity down

d. Use a bedside commode with a raised toilet seat closer to the bed, instead of
having the patient walk to the bathroom

An occupational therapist is working with a patient who is recovering from a total hip replacement. The therapist would like to use the occupation of bathing and grade the activity up, since the patient could benefit from a more challenging approach. Which of the following interventions would be best?

a. Have the patient step into the shower without a non-skid mat
b. Have the patient sit on a shower chair during the shower
c. Have the patient take a sponge bath at bedside
d. Tell the patient not to use the grab bars when stepping into and out of the bathtub
e. Have the patient use a walker basket to collect all of their supplies and toiletries prior to taking a shower

e. Have the patient use a walker basket to collect all of their supplies and toiletries prior to taking a shower

An occupational therapist is working with a patient who is recovering from a stroke. The therapist would like to use the occupation of meal preparation, since that is one of the most favorite occupations described by the patient. The patient could benefit from a less challenging approach. Which of the following interventions would be best for the therapist to grade down the activity?

a. The therapist should provide more physical assistance during the activity so the patient does not have to initiate as much with their affected side
b. The therapist should provide more verbal cues during the activity so the patient
does not have to think about each step independently
c. The therapist should have the patient perform the meal preparation activity in
bed with a bedside table as a working surface
d. The therapist should have a chair close by in the kitchen and have the patient sit down if the patient fatigues during the activity
e. Recommend that the patient’s spouse do all of the meal preparation until the
patient is feeling more like themselves again.

An occupational therapist is working with a patient who had a C6 spinal cord injury. The therapist would like to use the occupation of eating to work on tenodesis grasp and needs to grade the activity up because the patient could benefit from a more challenging approach. Which of the following interventions would be best for the therapist to grade up the activity?

a. Use a different colored cup during the next meal
b. Use a taller cup during the next meal
c. Use a wider cup during the next meal
d. Use a narrower cup during the next meal
e. Use a straw in the cup during the next meal

An occupational therapist is working with a patient who just had a kidney transplant and is experiencing decreased endurance. The goal for the intervention session is to build up or improve activity tolerance prior to discharge from the hospital. Which of the following interventions would be best for the therapist to work on improving activity tolerance during the patient’s hospitalization?

a. Have the patient walk around the nurses’ station without an assistive device
b. Provide less verbal cues on functional mobility techniques while using the front-
wheeled walker
c. Have the patient walk to the bathroom and stand up during grooming activities
instead of sitting down
d. Take a wheelchair and follow the patient as they walk around the nurses’ station.
e. Have the patient sit in the bedside chair to complete dressing activities

An occupational therapist is working with a patient who has just had an exacerbation of chronic obstructive pulmonary disease and is interested in learning energy conservation techniques during meal preparation prior to discharge home from the hospital. Which of the following interventions would be best for the therapist to teach the patient?

a. Keep a high stool close by during meal preparation in the kitchen
b. Write the expiration date in larger print on vegetable packages
c. Recommend that the patient not use their assistive device for functional mobility
in small spaces like the kitchen
d. Put the most used ingredients on the bottom shelves of the refrigerator
e. All of the above would be appropriate for this patient to conserve energy during
meal preparation