A Case Study On Occupational Therapy Assessment and Treatment Planning

A patient, Hussain, a 59-year-old male is on review following a traumatic MVA that led to injuries in his right lower extremity (RLE). Hussain has undergone medical amputation of the said RLE below the knee and is under admission for post-surgical treatment. He, however, has multiple morbidities and is currently undergoing concurrent treatment for various conditions including vertigo, PMHx of DM II, GERD, CAD, HTN, BPH, and asthma. Among the medications that Hussain currently uses, Metformin and Glipizid seem to be the most potentially harmful, and which should be understood for effectively managing the initial evaluation and discharge planning for the patient. Both medications are used for the treatment of high blood sugar, which is commonly caused by type II diabetes (Healthline, 2020; WebMd, 2020). Metformin is used in combination with other interventions, such as exercise. Several side effects, including stomach pain, diarrhea, unusual sleepiness, nausea and difficulty in breathing, are associated with Metformin. It interacts with other drugs used to treat diabetes, high blood pressure, cholesterol drugs, and glaucoma drugs, such as dorzolamide (Healthline, 2020). Glipizid, on the other hand, has vas various side effects, including nausea, diarrhea, vomiting, and constipation, and has serious interactions with diabetic drugs and moderate interactions with antidiabetic drugs, such as oral sulfonamide and hydroxychloroquine (WebMD, 2020). This knowledge concerning the drugs is important for effective treatment planning as it can help ensure patient safety by avoiding administration of drug combinations that can be potentially harmful to patients.

Patient’s Psychosocial Status

Hussain’s occupational profile provides various forms of evidence of his psychosocial status. The most pronounced psychosocial effect is tied to Hussain’s perception about his business, which has resulted in anxiety and insomnia. As a result, he has also exhibited irritability and a sense of suspicion towards medical staff, which could be linked to panic attacks. Holistic treatment would require addressing not only the physical injuries and training the patient on living with the new disability, but also addressing the emotional and psychological issues that come with the new condition (Bondoc et al., 2017). To do this effectively, active listening, participatory communication, and creativity will be used to collect finer details on Hussain’s psychosocial status. Information on patient beliefs, educational and cultural backgrounds, assumptions, and communication practices will be collected by interrogative listening, verbal and non-verbal communications, and both oral and written communication strategies. These diverse strategies will be used because they stand the chance of providing more detailed information for holistic healing.

Patient’s Medical and Surgical History

Hussain’s medical and surgical history is important towards developing treatment plans during initial evaluation. Medical history particularly helps to avoid causing harm to patients by understanding drug interactions and thus avoiding administration of drugs that could have significant negative interactions with those already under use by the patient (Nichol & Nelson, 2020). As Hussain is currently under treatment for conditions such as vertigo, PMHx of DM II, GERD, CAD, HTN, BPH, understanding his medical history would help to ensure that treatment is achieved while avoiding negative interactions in medication. The medical history also helps the therapist gauge the patient’s base lines as his vital signs will depend on the patient’s health condition at the time of examination. Understanding the patient’s surgical history is important towards understanding the extent of invasive procedures the patient has undergone in the past, thus ensuring safety during subsequent procedures.

Drug and Environmental Allergies

From the information collected from Hussain during initial assessment, Hussain has an environmental allergy to latex and is also allergic to shellfish. As such, knowledge on the patient’s drug and environmental allergies can help me monitor the patient’s healing environment, such as by avoiding Hussain’s exposure to latex equipment, such as latex gloves during the treatment process. Such equipment can be wrapped in other materials during use where there are no alternatives. Additionally, meal plans that include shellfish should also be avoided and all staff dealing with Hussain be informed of his allergies. People who might have had contact with shellfish are also to be avoided both during visits from his family and during normal hospital stay periods. This means that all individuals that would potentially be in contact with Hussain have to be asked whether they have or have been touched shell fish within the time frame immediately prior to the visit. The information on the patient’s allergies, therefore, is important for preventing harm to the patient.

Impacts of Patient Information on Rehabilitation and Recovery

From the patient’s occupational profile, the most important piece of information is on the patient’s co-morbidities. The pre-existing patient conditions such as the high blood pressure and diabetes for Hussain, will influence the treatment plan, types of medications to be administered, responses to those medications, and the impacts of those medications, thereby influencing their rehabilitation and recovery (Brennan, McGuire, & Metzler, 2016; Nichol & Nelson, 2020). Comorbidities may also influence Hussain’s performance in certain activities of daily living, which would otherwise be assumed to be caused by the new treatment, such as those that result in fatigue.

The model of human occupation (MOHO) framework is particularly essential for consideration when handling this patient. The framework is a client-centered model that considers both the components of the person and the environment as contributors to effective treatment (Forsyth & Keilhofner, 2006). Under this framework, the patient’s volition, habituation, performance capacity, roles will be considered when planning the treatment. For instance, it will be important to examine Hussain’s beliefs and attitudes towards the treatment process in general, as well as his desire to attain a good enough quality of life for discharge. Accordingly, the therapist will have extensive discussions with him just to gauge his attitudes and motivations towards well-being.


Interview Questions for Occupational Therapy Initial Evaluation (OT IE) for patient Hussain

Besides the questions on the patient’s medical and surgical history and those on his current status, I would ask questions that are directly related to the Hussain’s day-to-day activities. The format of the interview questions will be open ended since open ended questions give the interviewer an opportunity to follow up with additional questions, hence helping to attain information saturation more easily compared to close ended or multiple choice questions (Weller et al., 2018). The questions will also be designed to avoid preempting expected answers and to collect as much information as possible on the patient conditions.

Some of these questions pertain to what a typical day looks like for Hussain; the kind of activities he is engaged in on a day to day basis in the course of his work such as climbing activities; the mode of transport used – this could be whether he drives or uses a driver; access to shower in his home; disabled access to his work environment; the kind of support he thinks would be needed and the best person to provide it; and his beliefs about disability and medication. These questions are essential towards OT IE and formulating treatment plans that not only result in healing of the physical wounds, but also help in developing efficiency in performing self-care and other activities and asking for support where necessary. The questions could be framed as open-ended questions to enable the patient give full details of his feelings, incorporating even his emotions and attitudes towards the treatment in his response.

The questions on the patient’s individual capabilities would be directed to Hussain, while those on occupational practices and beliefs can be directed to both Hussain and his family. During interviews with Hussain as well as his family, it will be important to maintain a neutral tone, devoid of any indications of judgment, particularly on aspects of belief and attitudes. Additionally, the tone will be aimed at empathizing rather than sympathizing with the patient. By inquiring about Hussain’s beliefs, it is expected that the response obtained will incorporate elements of religious and cultural background for the development of a culturally-competent care plan. The responses to these questions will help in discharge planning as the discharge plan will need to incorporate the assistance needed by the patient as well as other instructions on health management practices.

Documenting Interview Responses

Various forms of occupational therapy assessment reports exist. One such format includes two columns, whereby the first column contains the interview objective questions while the second column contains the interview report. I would use a pre-developed report format to help avoid missing out on information pertaining to any of the categories of questions asked. Additionally, I would paraphrase and write short-hand notes from the interview responses, noting down only the bits that have clinical implications. Overall, the reporting tone should correspond to that used in general client reports, which are objective rather than subjective. Emphasis will be made on ensuring that some of the noted observations are from the perspective of the therapist by using terms such as: ‘the patient appeared to…”, “the patient demonstrated…”, and others.

Contextual Set Up

Precautions when Performing a Bedside Occupational Therapy Initial Evaluation (OT IE)

The most basic safety precautions when performing occupational therapy initial evaluation (OT IE) for Hussain will include prevention of physical harm to the patient through practices, such as fall prevention, prevention of allergenic reactions, and prevention of nosocomial infections. Hussain is already at risk because of his comorbidities and should be protected from any exposure to pathogens that can impact negatively on his safety. Particularly, issues such as asthma and hypertension can have negative impacts on his immunity, and exposure to pathogens can trigger negative health outcomes whether through Hussain’s wound or through air and other material-borne pathogens. Allergenic reactions will be avoided by ensuring that Hussain does not come into contact with his allergens such as latex and shellfish. Thus, all services delivered will be done without latex devices and alternatives will be used, and all people coming in contact with the patient will have to ensure that they do not have and have not had contact with shellfish prior to the visit. Fall prevention will be necessary due to the instability occasioned by recent amputation. Precautions such as providing adequate lighting for constrained movement, removing potential stumbling blocks from around the patient’s area of operations, and providing and training the patient on the use of early walking aids will help to address fall prevention.

Safety Precautions when Performing an OT IE

The ranges of safety precautions that can be taken for Hussain are case-specific. First, there is the precaution for fall prevention. For a patient who has been newly amputated, there is a high risk of falling. Hence, measures for fall prevention must be taken both during and after the OT IE. Preventing falls will entail implementation of measures such as assessing Hussain’s level of pain, assisting him to move to a comfortable position, ensuring that all necessities are placed within his easy reach, and developing a comprehensive fall-prevention protocol, as recommended by AHRQ (2013). Secondly, it will be necessary to implement hand hygiene in order to prevent nosocomial infections. Hussain is already an at-risk patient because of the comorbidities he suffers from; hence, any exposure to infections could destabilize his already-fragile system. Other precautions would include avoidance of irritation stimulants because of his anxiety and panic around medical personnel and ensuring effective communication to eliminate the doubts he already has. These would help ensure psychosocial safety for both the patient and the therapist.

Consideration will also be made of existing patient comorbidities with a focus on on-going treatments and post-surgical outcomes. For instance, the placement of the dialysis shunt, the existing vision problems, and the residual limb drainage will all be considered during administration of treatments. The objective will be to avoid harm to the patient by avoiding pressure on already constrained parts of the client’s body.

Initial Evaluation

Clinical Assessments

Various forms of clinical assessments will be necessary for Hussain in this case scenario. The first type of assessment would be on stump hygiene. Assessment of the stump hygiene will involve checking for infection and dressing (Chapleau, 2015). The second assessment will be on amputee pain. The level of pain felt by the amputee should be declining. Pain assessment will help in developing pain-management processes that work for Hussain. While conducting these two forms of assessment, safety precautions have to be taken for preventing infections from the equipment used and surfaces touching the wound and from the wound itself to the equipment.

The specific assessments that will be conducted for the amputee include the range of motion (ROM) for the residual limb, from the knee, will be measured using a goniometer to determine the need for clearance when taking precautions against injury. When using the different tools, consideration should be made of the patient conditions and precautions taken to avoid injury. For instance, since the goniometer has a movable arm, care should be taken to avoid applying it directly on the wounded area.

Other assessments that will be conducted include stability assessment (sitting, standing, and dynamic stability), sensation in the stump based on response to touch, assessments for the presence of ulcers or neuroma, healing of the surgical incision, and the shape of the residual limb. These assessments are conducted mostly by observation/physical examination. Each of these assessments will be an indication of the status of the physical status of the patient, particularly towards healing and infection prevention. Fatigue will be assessed based on patient self-reports, just like pain. On the psychosocial status of the patient, a mini mental state exam will be administered periodically based on observed patient psychosocial reactions.

Activities of Daily Living (ADLs) for Testing

When conducting the initial testing for Hussain, various activities of daily living (ADLs) will be considered for initial testing. Mlinac and Feng (2016) suggest that various ADLs require both cognitive and physical functioning, which ought to be considered in planning treatment hence their consideration. The first is on grooming. Testing on grooming as an ADL would include the consideration of activities such as showering/bathing and shaving, among others, which can be affected by the physical stature of the victim. The second set of ADLs would be the practice of transferring or ambulating. Transferring relates to movement from one place to another, which would be affected as a result of the amputation of the RLE. Thirdly, further assessment would be required on lower body dressing capabilities. Lower wound dressing mostly requires the use of both hands, which may often be hampered as the right hand would be needed to support any assistive device that Hussain uses. Toileting is another ADL that could be considered importance. In this regard, Hussain’s ability to use the toilet may be constrained because of the challenges in physical mobility.

Therapeutic Patient/Provider Education

To facilitate faster healing and self-acceptance, various forms of therapeutic education would be necessary for Hussain. The first would be on patient self-care. This would be aimed at enhancing the patient’s capability to care for himself both within and outside the hospital through fall prevention, grooming, grief for the amputated limb, and prevention of depressive disorders. The self-care therapeutic education would help the patient to attain sustained physical and emotional well-being as part of evidence-based practice (Pantera et al., 2014). Besides the self-care patient education practices, further therapeutic education would be on patient healthcare, which would suit the patient, his family, and healthcare practitioners assigned to the case. This would include aspects of stump hygiene, importance of physical exercise for greater functional capability after amputation, and managing stump musculoskeletal limb pain (Pantera et al., 2014). Other necessary education recommendations include; body representations, physical activity, and self-identity.

Treatment Planning

Vital Signs

For Hussain, vital signs would be taken every four hours until 24 hours after operation to ensure stability as recommended by AMSN (2019). The respiratory rate, basal body temperature, heart rate, pain levels, and blood pressure are some of the vital signs that will be taken for Hussain. The heart rate, blood pressure, and respiratory rate are all particularly essential vital signs for Hussain because of his pre-existing conditions, such as hypertension and diabetes mellitus, for which any slight deviation in the mentioned vital signs could be an indication of danger. The normal oxygen saturation (SPo2) is also an important vital sign because Hussain is asthmatic and would imply the need for therapy if found to be below 88%. These vital signs are also important since the medications Hussain’s current medications are associated with various drug interactions, and any deviation of the vital signs from the norm would require therapy, hence the need for consideration of drug interactions. Because of the pre-existing conditions to take the vital signs and record them could be fatal in case of unprecedented escalation. Recording these vital signs is imperative as a strategy for monitoring treatment as they are often indicators of underlying conditions. For instance, high basal temperature may indicate an infection.

PPEs to Don during Treatment

When rendering surgical site treatment for Hussain, the PPEs to be worn will include gloves for hand protection, whereby two pairs of gloves are recommended to avoid infections; to protect my clothes and body from any infections that may be transferred through body fluids; and a face shield to protect my face, mouth, ears, and nose from any contact with infectious fluids from contact with the patient. The PPEs will protect bothHussain and me from infections as my clothes could also transfer pathogens from other patients or places in the hospital to the patient. The protocols for using all these PPEs are as per the recommendations of the CDC (2004), and will be donned following the guidelines provided by the CDC. Adherence to removal, disposal, and/or sterilization procedures will help in avoiding transference in both directions.


When handling Hussain’s surgical site, the most important precaution will be to prevent infection and avoid injury. Infection prevention will be achieved by maintaining proper hand hygiene and donning sterilized PPEs while handling the patient to avoid transferring infections from other surfaces or patients to Hussain or from him; while injury prevention will be ensured by avoiding exposure to circumstances that can cause falls.

Incorporating Patient Preferences in Treatment

Surgical site treatment requires an understanding of patient preferences, particularly with respect to their cultural and religious beliefs. I would give the patient options in the treatment process and ask for his preferences. I would, however, avoid implementing preferences that are contrary to the code of ethics for healthcare service delivery and those that violate the objective of ensuring patient safety. In such a case, I would politely inform the patient that I would not be able to adhere to his preferences and then explain the reason why.

Treatment Sessions

Treatment Sessions

During every treatment sessions, various pre-existing conditions will be considered in addition to the treatment specific precautions. For instance, Hussain has cataracts, which makes his vision poor, particularly in the left eye. Care will be taken to ensure that the OT is on the right side, where he can be seen clearly during demonstrations and illustrations. Visual scanning will also be performed to establish Hussain’s field of vision for best positioning. Moreover, the therapist will take care not to put too much pressure on his right side due to the positioning of the shunt for Hussain’s dialysis. Since Hussain is allergic to latex, all activities must use non-latex materials such as gloves and other PPEs. The patient’s vital signs, particularly the body temperature, blood pressure, and pain levels will be measured before and after the activity, as well us upon reports of fatigue, due to his vulnerability to harm as a result of pre-existing conditions. The blood pressure will be taken on the arm with no injury, which is on the left side where there is no shunt. The vital signs taken after the activity will help determine the impacts of the said activity on the patient’s health and thus make the decision on whether to proceed or not.

Session 1

The 60 minute treatment session will be held within the hospital grounds. The goal of the session will be to aid Hussain in improving his transfer-ability through the use of early walking aids prior to the decision to fit prosthetics. The preparatory activity for this session will be to put on the necessary PPEs, particularly gloves. Non-latex gloves will thus be used.

The primary ADL oriented activity in this session, namely the practice of transferring (training on using early walking aids) will be conducted for a duration of 30 minutes in each session. For this activity, there will be no need for the use of non-verbal cues as the demonstrations will be physical and will be performed by the therapist. Scott, Condie, Treweek, and Sockalingam (2000) report that transfer trainings using early walking aids can be 5 minute breaks will be taken after every 10 minutes of activity or upon visible fatigue/request by the patient, and are recommended to be taken in a sitting position. The breaks will be documented at every occurrence alongside observations made during each trial.

The exercise-oriented activity will entail 5-7 minutes of limb stretching exercises to build resilience and flexibility in the left limb, which will be expected to bear most of the weight during transfer. No equipment will be needed, and Hussain will be instructed to move at a convenient pace for him and report in case he feels that the exercise is too difficult. The objective of this exercise will be to enhance flexibility and independence during transfer.

Therapeutic education will be delivered verbally for five minutes before initiating the primary activity and through demonstrations during the primary activity; comprehension will be measured based on the patient’s ability to repeat, and questions will be asked.

Precautions will be aimed at fall prevention, and will be achieved by conducting the activity in a relatively flat, non-slippery floor area with no obstructions. A multi-disciplinary approach will also be considered by the therapist since such an activity may magnify pain in the stump and limbs; a multidisciplinary approach would entail administration of pain medication and physical therapy to reduce pain in the stump.

Session 2

Another 60-minute treatment session will be conducted at the bedside with the objective of initiating progress towards Hussain’s independence in grooming, particularly taking care of his wound, as soon as possible. Donning of PPEs should take 5 minutes as the main PPEs will be non-latex gloves.

The ADL oriented primary activity in this treatment session will entail training on putting on a shrinker sock on the amputated limb. An elastic non-latex shrinker sock is described by Manella (1982) as an effective measure for post-operative treatment of amputated limbs as it acts as a dressing, holds the stump tissue to prevent edema and also molds the tissues to facilitate the fitting of prosthetics. Trials will take 10 minutes each. The therapist will train Hussain directly, using both verbal and non-verbal cues. Visual aids showing the position of the shrinker sock, handling it during placement, and the need for the shrinker sock, will be used, and the sessions will be carried out partly in illustration and partly in practice. For the practice, the patient will be under instructions. The feedback on performance will be collected through observation of the patient’s progress in his ability to put on the shrinker sock effectively.

Five-minute breaks will be taken after every trial. The breaks will be taken in a sitting position, with hands drawn along the sides. The patient will also be requested to report in case he feels any discomfort with the activities, and will be closely observed for non-verbal indicators of discomfort. Documentation will not be necessary.

The exercise oriented activity will entail 10 minutes of exercise for arms and hands to enhance comfort and flexibility during arm movement when putting on the shrinker sock. The exercise will mostly involve forward and back, as well as rotational movements of arms, and will not need any supplies. The patient will be requested to report in case he faces any challenges or experiences any pains.

 Therapeutic education will be conducted for 10 minutes before the process initiation to illustrate how to put on the shrinker sock; diagrams and very short notes will be used, and comprehension will be measured through observed performance, as well as by directing the patient on appropriate actions.

In this treatment, the main treatment-specific precaution would be to prevent injury to the stump. This will be achieved through avoiding overcrowding and removal of any objects that may cause injury. The treatment will also incorporate a multidisciplinary approach since the use of the shrinker sock requires the input of the nurse, and possibly, aprosthetist. By incorporating these two in the treatment plan, an interdisciplinary approach to treatment will have been implemented.

Discharge Considerations

The primary discharge consideration for Hussain will be his ability to perform various basic ADL activities such as bathing, transferring, lower body dressing and wound dressing among others. The discharge plans will address three core areas, namely: medication administration for pain management and preexisting conditions; wound-caring and pain-management procedures for the stump; and self-care and support functions for ADLs. For the medication, there will be need to ensure that: there are no adverse interactions between prescribed medications and those that are currently used by the patient; that clear directions are given to the patient and to their families concerning how to use the prescribed medication; and that sufficient dosages of prescription medications are provided. For wound-caring, discharge considerations will involve ensuring that there is someone who can assist in wound management; provision of supplies for would management at home, and directions for proper wound management. Self-care and support functions for ADLs will mostly focus on the self-care deficits in areas of transferring, grooming, toileting, and dressing, among others. There will also be need to advise the family on developing a supportive environment for the patient at home by eliminating potential causes of falls, enhancing lighting and enhancing the floors to support movement for the disabled using walking aids.


The case of Hussain presents an opportunity for understanding the process of occupational therapy, initial assessment, and treatment planning. From an understanding of the patient’s history during the initial assessment, it has become possible to develop an effective treatment plan for the patient, which culminates with discharge considerations. For a recovering amputee such as Hussain, it is evident that key focus areas include self-care, pain management, and medication management.



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