Occupational Therapy – Adults & Older Adults (Sync Session 2) Study Notes

Opening & Session Logistics

  • Session start time 11:0211{:}02; instructor prompts timely attendance.
  • Reminder: Sync-Session 2 handout available in course module; includes two case studies to be completed and posted as reply to previous reflection (due Friday night, i.e., the holiday).
  • Flow of class
    • Individual work on Case 1 (≈10 min) → large-group debrief.
    • Break-out rooms for Case 2 (≈10 min) → large-group debrief.
    • Q&A; class ends at top of the hour.

Prayer & Ethical Orientation

  • Student-led written prayer (Serenity Prayer cited) asks for:
    • Wisdom, patience, grace in OT practice.
    • Advocacy for client independence while honoring dignity.
    • Empathy toward loss, pain, life transitions.
    • Blessings on instructors (insight), classmates (unity), self (endurance).
  • Frames session within values of compassion, peace, healing—relevant to OT’s holistic & ethical mandate.

Case Study 1 — James (55-y/o Waste-Management Worker)

Client Snapshot
  • Age 5555, right-hand dominant, employed in physically demanding job.
  • Lives with wife (full-time nurse) + 2 high-school athletes.
  • Two-story townhome; all bedrooms upstairs.
Mechanism of Injury & Present Medical Status
  • Fell off truck → mild TBI + left hip fracture.
  • Posterior total hip replacement; Post-op Day 1 in acute care.
  • S/S: anxious, intermittent SOB; hematocrit 28%28\% (low).
  • Wife worried about lower-body dressing; husband dislikes spousal assistance.
Evaluation Strategy
  • Rapid acute-care style: time-efficient occupational profile during inevitable pauses (e.g., waiting for lab draw, linen change, med lines re-arranged).
  • Pre-session chart & nurse consult: captures updates not yet charted.
  • Core screens/tests
    • Vital signs before/during activity (BP, HR, RR, SpO2SpO_2).
    • Pain scale; incision/hip integrity.
    • Brief neuro screen (vision, cognition, sensation) for mild TBI.
    • Bed mobility observation → seated EOB tolerance.
    • UE MMT/ROM; uninvolved LE MMT/ROM; involved LE within hip precautions.
    • Functional ADL enquiry (quick COPM-style Qs) if time.
Key Precautions & Contraindications
  • Posterior hip precautions — avoid:
    \begin{aligned}
    \text{Hip flexion} &> 90^{\circ}\
    \text{Adduction across midline}\
    \text{Internal rotation beyond neutral}
    \end{aligned}
  • Possible weight-bearing restrictions (verify order: WBAT vs PWB/NWB).
  • Orthostatic intolerance: low Hct → anemia-related syncope; monitor for “sheet-white” facial pallor.
  • Fall risk amplified by combined TBI + new arthroplasty + narcotics.
  • Pain, swelling, post-anesthesia fog.
Lab Values / Vitals to Monitor
  • Hematocrit 28%28\% (normal ≈ 36–48%36–48\%) ⇒ anticipate fatigue, SOB.
  • Hemoglobin, platelet count, INR (bleeding risk), WBC (infection).
  • HR, BP trends (orthostatic), SpO2SpO_2 esp. during ambulation.
Assessment Tools (Examples)
  • Manual Muscle Testing, goniometry.
  • Brief MoCA / orientation Qs for cognition.
  • FIM quick scoring or AM-PAC “6-Clicks.”
  • Functional Reach / Romberg if safe.
Intervention Plans & Materials
  • Priority: early mobilization + safe ADL engagement within hip rules & cardio tolerance.
  • Teaching lower-body dressing sequence: long-handled reacher, sock-aid, dressing stick.
  • Transfer/bed-mobility coaching; energy conservation & pacing for anemia/SOB.
  • Rehearse toilet & tub transfer with raised seat, shower bench.
  • Anxiety management: therapeutic use of self, graded exposure, breathing cues.
Teaching Challenges & Strategies
  • Independent personality + cognitive clouding;
  • Frame AE as temporary performance boosters, not disability markers.
  • Use demonstration–practice–feedback cycles; one new tool at a time.
Occupation / Environment Modifications
  • Raised toilet seat (height ≥ 46–48 cm46–48\text{ cm} to maintain <90^{\circ} flexion).
  • Stair negotiation: teach step-to pattern with railing if WBAT; delay if WB limited.
  • Seated dressing, footwear with elastic laces/Velcro.
  • Shower chair, hand-held shower.
Discharge Planning Logic
  • Recommended: In-patient Rehab (IRF) because
    • Multiple active issues (TBI, low Hct, new THR).
    • Likely able to tolerate 3 h3\text{ h} therapy/day given premorbid fitness.
    • Clear home goal & strong family support — IRF intensity expedites return.
  • Alternate if older/low endurance: SNF.
  • Need for documented rationale during interdisciplinary meeting; respect differing PT/SLP views.

Case Study 2 — Kim (35-y/o, Vent-Dependent Post-Suicide Attempt)

Client Snapshot
  • Age 3535; deliberate OD on pills + EtOH; found by neighbor.
  • On vent via ETT, scheduled for tracheostomy + PEG placement.
  • DX: Staph infection, RLL infiltrate (pneumonia risk), sacral skin breakdown
  • Cleared for edge-of-bed (EOB) activity & transfers; minimal support.
Evaluation Approach
  • Chart review: psych notes, vent settings, antibiotic regimen, wound consult, lab trends.
  • Interprofessional huddle: nursing clarifies which lines/tubes may be disconnected vs portable.
  • Communication barriers → use:
    • Writing board/clipboard, yes–no signals, eye-gaze board.
    • Assess cognition via non-verbal responses (e.g., CAM-ICU, thumbs-up to commands).
  • Occupational profile goals: identify supports (family, friends, church, peer groups) & meaningful occupations (use Activity Card Sort or brief leisure inventory).
Precautions / Contraindications
  • Multiple lines: ETT/trach, IVs, ABG line, chest tubes; risk of accidental extubation.
  • Vent tubing arm/boom position must follow pt during mobilization.
  • Infection control: Contact precautions for Staph.
  • Aspiration risk once PEG in use → maintain HOB ≥ 45∘45^{\circ} during feeding.
  • Skin integrity: sacral wound, bony prominences.
  • Suicidal ideation: may require 1:1 sitter or restraints; must verify physicians’ restraint orders (renewed q 24 h).
Lab / Vitals Surveillance
  • WBC, CRP (infection trajectory).
  • Temperature (fever), SpO2, vent settings (FiO2, PEEP).
  • Hemodynamics: MAP >65\text{ mmHg} when mobilizing.
  • ABG values (pH,PaO<em>2,PaCO</em>2)\bigl(pH, PaO<em>2, PaCO</em>2\bigr).
Assessments & Models
  • Kawa Model: narratives of life-flow & supports, visual river drawing.
  • Activity Card Sort (bedside adapted).
  • Brief anxiety/depression screen (PHQ-2 via written answers).
  • Skin risk: Braden Scale.
Intervention Ideas
  • Early progressive mobility protocol: start with sitting endurance, trunk control, weight-shift.
  • Bed-level leisure: adapted craft, music via tablet, journaling (cognitive engagement).
  • Family or peer video calls to reinforce social support.
  • Graded self-care once trach cuff deflated: face washing with mirror, UE AROM with IV poles managed.
  • Coping & mental-health referral: integrate psych-OT, mindfulness scripts.
Discharge Path & Rationale
  • Likely destination: Long-Term Acute Care Hospital (LTACH)
    • Needs prolonged vent-weaning & IV antibiotics.
    • Cannot yet tolerate 3 h3\text{ h} daily therapy required by IRF rule (≥15 h/wk)\bigl(\ge15\text{ h}/wk\bigr).
  • IRF considered once medically stable & participating ≥ 3 disciplines.

Cross-Case Clinical Reasoning Principles

  • Acute Care Time Economy: goal is safe mobilization + information gathering; profiles must be concise.
  • Vital sign guardrails (general):
    • Resting HR <120 / >40<120\,/\,>40 bpm concern.
    • SBP <90<90 or >180>180 mmHg caution.
    • SpO2 <90\% stop & rest; titrate O2 per MD order.
  • Posterior hip precautions derive from risk of posterior dislocation when hip placed in flexion + adduction + IR.
  • Orthostatic hypotension common post-arthroplasty due to blood loss; look for diaphoresis, facial blanching.
  • Paper-pencil cog tests may not capture real-world deficits—need functional context (kitchen, shower).
  • Restraints: last resort; require MD order renewed every 24 h24\text{ h}; OT must document temporary removal & re-application.

Collaboration & Communication

  • Always consult nursing before entering room; updates may precede EMR.
  • Interdisciplinary team meetings: articulate OT discharge rationale (function, cognition, environment) & respect differing perspectives; provide concrete examples (e.g., oven incident vs MoCA score).
  • Document clearly: vitals, activity tolerated, lines managed, patient/family education, cognitive responses.

Ethical & Person-Centered Themes

  • Balancing independence vs safety: patients may refuse AE; use motivational interviewing.
  • Dignity & trauma-informed care post-suicide attempt; avoid judgmental language.
  • Cultural/faith supports (prayer at session start) can be integrated if client-directed.

Exam Study Tips

  • Be able to list hip precautions, typical lab norms, and explain why they matter.
  • Practice writing a SOAP note for each case.
  • Memorize levels of care (Acute → LTACH → IRF → SNF → HH → OP).
  • Draft sample goals using COAST format:
    • "Within 1 wk, James will don pants using sock-aid & reacher with max 1 verbal cue while maintaining hip flexion <90^{\circ}."
  • Review Kawa & Activity Card Sort steps; know when verbal communication limits dictate adaptation.