Alli Hall

MMT, ROM, & Final Project Assignment

 Patient Chart Review
Patient Name: DES Evaluation Date: 3/2/18

Height: 5’10” Weight: 207 lbs DOB: 11/29/46 Age: 71

Insurance: Medicare Pain: None reported per Pt Allergies: Baclofen

Diagnosis PMH:

Metastatic Neuroendocrine Tumor Metastatic MEN Type 1 of pancreas & liver,

hyperparathyroidism, CVA (hemorrhagic) w/
L hemiparesis, HTN, DM Type 2, GERD, DVT,
seizures, CKD

Precautions Diet Fluids

☐ADA ☒ Thin
Fall ☐Nectar thick
☒ Cardiac
PROM of L UE
☐Renal ☐Honey thick
☐Regular ☐Pudding thick
☐Pureed ☐NPO
☐Mechanical Soft
☐NPO
Prior Level of Function Psychosocial/ Family Situation

Independent Married, lives in a condo with wife, has

known his wife his whole life, father,
grandfather

Home set up: DME Owned:

☒ House/ apartment (condo) ☒ Ambulatory Device: single point cane,
☒ 1 story/ 2 story quad cane w/ SBA
☒ Steps to enter__0 (ramp)____ ☒ AE: L hand brace
☒ Bathroom equipment: shower chair,
hand-held shower
Leisure/ Hobbies/ Interests ADL and IADL Performance Patient’s stated goals

Shooting (competitive skeet Grooming – help w/ setup Pt states he wants to get back to
shooter), reading, TV, being UE Dressing – help w/ setup shooting, get stronger, and get
outdoors LE Dressing – help w/ setup & function back in his L UE
some verbal cues required
Toileting – w/ help/verbal cues
Eating – help to open
containers, cut food, setup
Transfers Ambulation Wheelchair Wheelchair cushion

Contact guard Contact guard w/ None reported per Pt None reported per Pt
single point cane

Postural assessment Sitting Balance Standing Balance

Pelvis: posterior pelvic tilt
Spine: spine flexion, thoracic kyphosis, cervical Impaired static, Impaired static,
protraction impaired dynamic, impaired dynamic,
Scapula: scapular protraction impaired anticipatory, impaired anticipatory,
impaired reactive impaired reactive
Vision Cognition
Pursuits: jerky, full ROM A & O x ____4_______
Saccades: jerky, full ROM Follows: ___multi-________ step directions
Visual Fields: full ROM STM: some cueing required
Left + Right LTM: some cueing required
Routine Problem Solving: independent
Complex Problem Solving: requires helper
 Functional Intervention Occupational Therapy Kit Description
Occupation/ Impairment that Kit Occupation: IADL - Childcare
Addresses Impairment: Decreased fine motor coordination, bilateral
integration of UEs, and UE ROM
Itemized list of contents in kit  (1) baby bottle
 (5) diapers
 Pack of baby wipes
 Container of “formula” (powdered sugar)
 Spray bottle
 (2) snack containers
 Baggie of “food” (beads)
 (1) spoon
 (1) small plate
 (1) baby shampoo
 (1) baby wash
 (1) baby lotion

Pictures of all components of kit

Instructions for use of kit This is a kit to address the IADL of childcare. Many components are
included in the kit and it can be used in the following ways:

 Preparing a Bottle: use spoon to scoop out formula and put

into bottle, add water, and warm up
 Serving a Snack/Meal: use a spoon or hands to get food out
of baggie and serve on plate or put into “to go” snack
containers
  Manipulating “Dirty” Diaper: use spray bottle to wet the
diaper, practice rolling the diaper up, taping it shut, and
discarding without making a mess
 Wipes: Practice getting wipes out of container and wiping
different surfaces
 Shampoo/Body wash/lotion: Practice unscrewing tops,
manipulating in hands, squeezing into hand or onto other
objects

Examples of intervention 1. While in kitchen, ask patient to unscrew bottle lid and place
activities on table. Patient will then open the formula and use the
spoon to scoop 5 scoops of formula into the bottle. Next,
have patient walk to the nearby sink and fill the bottle up
to 5oz with warm water. Re-screw the lid onto the bottle.
2. While seated at table, have patient lay diaper out in front
of them (therapist will wet the diaper with spray bottle).
Instruct patient to use both hands to roll diaper up and use
adhesive tabs to secure diaper closed. Patient will then
carry diaper to the trash to properly dispose of it.
3. While seated at table, ask patient to open both snack
containers. Patient will use spoon to scoop out food
(beads) and fill 2 snack containers half-full to prepare a to-
go snack for their child. Patient will then close containers.
4. While standing at counter, ask patient to practice opening
bottles of shampoo, body wash, and lotion. Next, practice
turning bottle upside down and squeezing contents onto
another object to simulate putting these items on a baby
during bath time.
How kit can be graded for low Grade Up:
and high level patients
 Use smaller spoon to scoop formula or food
 Require more scoops to be completed in activity
 Ask patient to use precise measurements of water in bottle
 Place plate and snack containers at different heights within
space
 Place plate and snack containers away from midline to
challenge balance
 Complete activities in standing

Grade Down:

 Use larger spoon to scoop formula or food

 Only require 1 scoop of formula in bottle
 Fill bottle with unspecified amount of water
 Fill 1 snack container instead of 2
 Place plate and snack containers on dycem so they don’t
move around
Image of Functional Intervention Occupational Therapy Kit
Article that Supports the Functional Intervention Occupational Therapy Kit
 Grading rubric for Final Project
Criteria Ratings Points

ROM and MMT assessments Excellent Good Fair Poor Incomplete __/ 20
fully completed with 20 pts 16 pts 14 pts 12 pts 10 pts points
therapist review and Met All Met most Met some Met A Few Met No
signature
Criteria criteria criteria Criteria Criteria
Patient Chart Review Fully Excellent Good Fair Poor Incomplete __/ 20
and Appropriately 20 pts 16 pts 14 pts 12 pts 10 pts points
Completed and Meets Met All Met most Met some Met A Few Met No
HIPAA standards
Criteria criteria criteria Criteria Criteria
Functional Intervention Excellent Good Fair Poor Incomplete __/ 40
Occupational Therapy Kit 40 pts 32 pts 28 pts 24 pts 20 pts points
directly addresses an ADL/ Met All Met most Met some Met A Few Met No
IADL and impairment, is
Criteria criteria criteria Criteria Criteria
functional for the clinical
setting, and is age
appropriate
Provides 4 examples of Excellent Good Fair Poor Incomplete __/ 40
intervention activities that 40 pts 32 pts 28 pts 24 pts 20 pts points
kit can be used by the Met All Met most Met some Met A Few Met No
clinician and are appropriate
Criteria criteria criteria Criteria Criteria
for the clinical setting
Functional Intervention Excellent Good Fair Poor Incomplete __/ 20
Occupational Therapy Kit 20 pts 16 pts 14 pts 12 pts 10 pts points
can be graded to address Met All Met most Met some Met A Few Met No
high and low level patient
Criteria criteria criteria Criteria Criteria
impairments
Contents are in a clear Excellent Good Fair Poor Incomplete __/ 10
plastic container, lid and 10 pts 8 pts 7 pts 6 pts 5 pts points
container labeled by Met All Met most Met some Met A Few Met No
impairment and occupation,
Criteria criteria criteria Criteria Criteria
“Functional Intervention
Occupational Therapy Kit
Description” in page
protector and taped to
inside of lid of container
Meets infection control Excellent Good Fair Poor Incomplete __/ 10
standards of non-porous 10 pts 8 pts 7 pts 6 pts 5 pts points
materials, and surfaces that Met All Met most Met some Met A Few Met No
can be wiped down with
Criteria criteria criteria Criteria Criteria
disinfecting wipes
Professionally dresses and Excellent Good Fair Poor Incomplete __/ 10
adequately presents 10 pts 8 pts 7 pts 6 pts 5 pts points
description and application Met All Met most Met some Met A Few Met No
of the Functional
Criteria criteria criteria Criteria Criteria
Intervention Occupational
Therapy Kit
Article directly supports the Excellent Good Fair Poor Incomplete __/ 10
Functional Intervention 10 pts 8 pts 7 pts 6 pts 5 pts points
Occupational Therapy Kit Met All Met most Met some Met A Few Met No
implementation
Criteria criteria criteria Criteria Criteria

Total Points:__________