Running head: OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile and Intervention Plan

Jesse Vallera
Touro University Nevada

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile
Client
The client, Doris, is a 61 year-old female of Anglo-Saxon heritage that lives in
North Las Vegas. Her primary language is English. She is a retiree, but she has had
several jobs in the past such as fast-food services, teacher assistant for several years at a
community college, and she was an artist assistant at an art studio. Doris has been
married to her husband for several decades and her husband is a computer programmer
who is also retired. She has one brother and one sister, but neither of her siblings live in
Nevada. Doris never had children because she traveled a lot in her lifetime, and her
family network is scattered so she never wanted to have the responsibility of caring for
children. She has no pets. The reason Doris and her husband came to Nevada was due to
the fact her sister-in-law had cancer and they wanted to be as supportive as possible.
Need of Services
Doris had a cerebrovascular accident (CVA) on February 18, 2015. Originally,
she was in a hospital engaging in inpatient therapy for several weeks, but now has
transferred home to continue outpatient therapy rehabilitation. The main factors
contributing to her CVA are her right homonymous hemianopia, expressive aphasia, right
upper extremity (RUE) flaccidity, fine motor deficits, and cognitive deficits in short term
memory (STM). She cannot drive so her husband drives her to appointments. Doris is
motivated and she would like to improve her visual skills so that she can perform her
favorite hobbies of doing crafts, painting, and reading paperback novels. Her primary
concern is topographical disorientation, therefore she would like to improve her STM and
spatial awareness to be better oriented with respect to location. In addition, before the
CVA she cooked for her husband twice a day and their favorite meal is chicken pot pie.

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She now has difficulty with cooking due to her RUE flaccidity and problems with handeye coordination.
Areas in Occupations
Successful occupations. Before her CVA she was independent with her activities
of daily living (ADLs), mobility, cognitive skills, and communication skills. After her
CVA, the successful occupations that she can complete are ambulation, mobility, and
transfers. She is also successful in communication with her husband and her speech
remains intact, however, her spouse reports most of what she is trying to explain due to
her expressive aphasia. She has difficulty with reading due to her right hemianopia, but
she is thankful that she can still read her paperback novels, as she compensates by closing
one eye.
Barriers in occupations. The major barrier in her natural environment is her
right hemianopia because this contributes to her right visual field neglect. In her physical
environment it is difficult to navigate in buildings and crowded places due to her right
visual field impairment. In addition, she has impaired STM and quickly forgets where
she is going. Another barrier is her inhibited community mobility and the fact that she
cannot drive. She has difficulty with hand grasping and manipulation due to her RUE
flaccidity and this leads to problems with ADLs and IADLs such as dressing, doing
laundry, meal prep, etc.
Environments and Contexts
In the personal context, Doris is a 61-year-old female and has aches and pains that
she feels are normal for her age so she does not express concern relating to pain while
engaging in OT. She identifies as middle class, and has a high school diploma and an

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associate degree. In her temporal context she is retired and in her stage of life she is still
active at a local Catholic church, she participates in the stroke program, and she is a
caregiver for her sister-in-law. In the cultural context, she has many rituals and routines
for her Catholic tradition (such as prayer, kneeling, singing, etc.). She cooks for her
husband and before the stroke was independent in all ADLs and IADLs. She would like
to resume her cooking so occupational therapy services would be beneficial. Her virtual
context is very challenging because her right visual field is occluded. She has a smart
phone and can type but through further analysis her performance requires assistance to
type on the screen and read text messages.
Doris lives in a one-story house. She has trouble in the physical environment due
to her impaired right visual field. When entering the building, hallway, and the rehab
gym, she sometimes bumps into people on her right side due to low sensation and visual
impairment. After her CVA, she has had moderate expressive aphasia so sometimes she
has difficulty understanding conversations, jokes, and series of commands.
Clients Occupational History
Doris has had various occupations in the past. She has lived in Arkansas,
California, Texas, and Nevada and she went to live in Las Vegas to be a caregiver and
support her sister-in-law who has cancer. She wanted to cook her favorite foods and
drive over to her sister-in-laws house to provide emotional support, watch movies and do
activities together. Driving is an important occupation with her occupational history, but
now it is impossible due to her right visual field impairment. She has created many
forms of art over the years including paintings, sculptures, and modern art, and she loves
to attend art galas and museums for community mobility. She likes other forms of art

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such as the theater, movies, and live music, but her vision is impaired so she doesnt
attend these events as much as she did.
Values
Doris was brought up in a Christian rural area in Arkansas and her denomination
is Presbyterian. She married her husband who is Catholic and she attends the Catholic
Church. She has been going less frequently since her CVA due to the barrier of
community mobility. She is involved in the stroke program to promote purpose and
getting involved in the community. This program allows her to network with other stroke
survivors. In addition there are scheduled leisure activities to promote social
participation.
Interests
Doris has many interests because she is a creative person. As previously
mentioned, she was an assistant in an art studio and she likes to paint many different
styles. She also likes crafts, enjoys wood-working, making jewelry and sculptures. She
likes paperback novels and movies and still does these activities, however she is visually
impaired which affects many activities. She loves to go to restaurants where there is live
music because she likes BBQ (St. Louis style ribs are her favorite) and listening to blues
and bluegrass music. She likes most kinds of music and she attempted to play
instruments but she says she was never very talented.
Roles
Doris has several daily life roles. She is a devoted wife and the caregiver of her
sister-in-law. As previously mentioned, she never had children or pets. She is churchgoing and still plays an active role in her parish. She is a volunteer and a participant in

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the stroke program and through this program is able to engage in leisure activities. She
is an artist and a cook because of her creative personality.
Previously Patterns of Occupational Engagement
Doris had a specific activity pattern she engaged in daily, but after her CVA there
were several obstacles that inhibited her occupational performance. She has a certain
routine around the house to complete her ADLs and IADLs, but now the amount of time
required to complete these occupations has increased. She cuts meat and vegetables, but
now she needs to increase time for meal preparation and her routines have become slow
and awkward. She also has challenges in folding her laundry and now her husband does
it because she has trouble grasping clothing due to her right hand. Prior to her CVA, she
watched a lot of television but now she watches it less because her vision has been
impacted. Before her strokes, she was independent to drive around the community and
do errands while listening to music on the radio but now her husband does her errands.
Clients Priorities and Outcomes
Doris CVA has had an impact on her occupational performance. There are
certain interventions that could improve her well-being and quality of life so that she
could be as independent as possible and take an active role to resume meaningful and
purposeful occupations in her life. The primary focus is to remediate her vision skills,
remediate topographical orientation, and to improve her fine motor skills in hand-eye
coordination. If these outcomes are achieved then she will increase function in her ADLs
and IADLs such as community mobility, meal preparation, etc. Other outcomes to
improve self-efficacy are to navigate in the community in order to enhance social

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participation, taking an active role to be more independent in the household and

community, and to resume her art activities to be creative.
Occupational Analysis
Context in OT Services
Upon initial evaluation, both Doris physical and social environments are
impaired. Many problems have become apparent due to her right hemianopia and her
RUE hemiplegia. As previously mentioned, Doris has neglect in her right visual field
and she is unaware of some people and objects in crowded places, so she must turn
frequently to the right and scan oncoming stimuli. When entering the building, she had
difficulty with navigating her destination in the hallway and the rehab gym. Her physical
environment has barriers to ambulating with vision. In addition, her occupations have
had a negative impact with vision for RUE with respect to handwriting, cutting, etc. Her
virtual context is challenging because her right visual field is occluded so it is also
difficult to communicate and dial phone numbers or read text messages. Moreover, her
social environment has changed after her CVA. The availability of social contact and
interactions with her husband and staff at the rehab gym have been more difficult with
advanced conversations (AOTA, 2014). In addition, she has moderate expressive aphasia
so sometimes she has difficulty understanding directions or understanding a series of
commands.
Activity and Clients Performance
Doris received 60 minutes of treatment sessions, three days per week at
Summerlin outpatient therapy clinic located in Summerlin Hospital. Doris receives OT
and SLP therapy sessions, so she must sign-in at the main office. She has difficulty with

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handwriting in completing client information due to her right hemianopia and her
flaccidity in her right hand because she is right hand dominant. She and her husband
walked across the hallway to the rehabilitation gym because her dynamic standing
tolerance and gait is satisfactory and she does not need durable medical equipment. For
her evaluation, she did several fine motor skill activities such as a 9-hole pegboard, UE
dressing, and handwriting. After the fine motor skill activities, Doris had an additional
evaluation for assessing visual impairments. The visual activities Doris participated in
were telling time using an analog clock, testing visual scanning, and looking at maps to
orient the client. For all of the activities in the evaluation, verbal communication was
assessed to see if the client had a good understanding of verbal commands. She
understood all the commands but sometimes she needed verbal prompting.
Key Observations
Doris was alert and oriented in the rehab gym. She conversed with good eye
contact and responded to questions, but needed verbal prompting frequently. She was
engaged with all activities but needed assistance with most of her performance. The fine
motor skill activities while wielding utensils and handwriting were difficult for the client
and required moderate assistance due to impairment in hand-eye coordination and
flaccidity in her RUE. She had limited range of motion in her right wrist and right hand.
The client completed the 9-hole pegboard, but needed additional time. The visual
activities were challenging when reading, handwriting, or drawing a clock. She missed
several trials due to visual and spatial neglect, which aggravated her frustration.
However, she understood and complied with almost all of the commands. Her dynamic

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balance with sitting, standing and walking was satisfactory and did not need any durable
medical equipment when walking down the hallway.
Domains of OTPF Impacted
Doris has been negatively impacted by her CVA and she needs to improve her
visual and mental functions. According to the OTPF, Doris has impaired visual functions
for her quality of vision, visual acuity, and visual awareness in her physical environment
(AOTA, 2014). She is seeking OT services to improve her visual perception and her
topographic orientation secondary to her right hemianopia and spatial awareness deficits.
Her specific mental functions are impaired with respect to her STM and high-level
cognitive function. These mental function inputs are challenging to memory, sequencing,
spatial awareness, and visual perception all at the same time (AOTA, 2014).
Doris has difficulty with completing tasks in her RUE. The reason for this is that
hand-eye coordination is impaired under the control of voluntary movement function
(AOTA, 2014). Her vision is impaired in the right visual field and in addition her
neuromusculoskeletal and movement-related functions are inhibited secondary to
problems with her joint mobility, join stability, muscle power, muscle tone, and muscle
endurance after her CVA (AOTA, 2014). Her sensory inputs are compromised in terms
of the proprioceptive, touch, and pain sensory functions in her right hand when doing fine
motor skill activities.
Problem List
Problem Statements and Rationales
1. Client requires max A with community mobility due to topographical disorientation,
decrease spatial awareness, and decrease STM.

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Doris primary concern is getting lost. She has difficulty with inconsistently looking at a
map and navigating. Several factors are contributing to her performance including visualperception and visual-cognition. She has difficulty receiving visual information because the
right side of her visual field is neglected. In addition, she has difficulty interpreting the
information and sequencing the steps to orient herself to north, south, east, and west. When she
attempts to find the destination, she forgets the destination about part way through. This is due
to her mental functions that were previously mentioned.
2. Client requires mod A with meal preparation due to fine motor skill impairments.
Doris has difficulty executing fluid movements in her affected right hand. She can grasp
fairly well, but her fine motor skills have been diminished due to flaccidity in her hand. This is a
second priority because her occupations are impeded in her ADLs and IADLs.
3. Client requires mod A with handwriting due to decreased strength, endurance, and
dexterity in her right hand.
Doris right hand is compromised due to her right hemiplegia that caused flaccidity in her
right hand. As previously mentioned above, her right visual field is impaired that has an impact
on hand-eye coordination and thus this will be a third priority.
4. Client requires mod A UE dressing due to decreased hand-eye coordination, visual field
neglect, and decreased fine motor skills.
Doris has difficulty performing most dressing activities. She has trouble with fastening
buttons, tying shoes, and zipping up zippers. This is a fourth priority for increase visual
reception and hand-eye coordination in completed occupations. In addition, Doris will benefit
from repetition to increase fine motor skills.

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5. Client requires min A with verbal communication secondary to expressive aphasia and
cognitive deficits.
Doris has a good vocabulary but many times her sentence structure, word-finding, and
general understanding for verbal reception are inhibited due to her aphasia. This is a fifth
priority because she visited a speech-language-pathologist regularly and this is not her primary
concern in occupational therapy.
Intervention Plan & Outcomes
Long-term Goal #1
Client will navigate in community mobility to find three destinations with SPV and VC in
six weeks.
Short-term goal #1. Client will navigate in community mobility and find three
destinations with min A in three weeks.
Intervention #1. Doris will look at a floor plan at the hospital facility and will locate the
pharmacy, the emergency room and a doctors office. This intervention will use a modify
approach because she will use memory aids and will adhere to each one-minute interval on the
map to reassess orientation (AOTA, 2014). In addition, she will provide verbal cues if she gets
disoriented. These outcomes will enhance occupational performance and will increase her STM,
spatial awareness, and visual perception (AOTA, 2014). Education will be provided to help
learn to turn her head for visual scanning and for safety to prevent her from bumping into other
people.
Literature review. Doris interaction with her environment was disturbed due to her
topographical disorientation, visual perception problems, and impaired STM. These obstacles
limit her everyday activities, which is a primary concern. An article entitled, Overcoming

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Topographical Orientation Deficits in an Elderly Woman with a Right Cerebrovascular Accident

was conducting a treatment with a 67 year old female who had a CVA which resulted in left
hemiparesis and left homonymous hemianopia (Borst & Peterson, 1992). The study conducted
treatment over four weeks consisting of 60 minutes sessions held twice per week. The client was
given a map of the clinic and the therapist asked her to draw a path and negotiate for assistance
to increase right-left discrimination ability. In addition, before the activities, there were warm-up
exercises such as mazes, which was effective in treatment. At the end of the four weeks, she
independently found her way around the clinic 75% of the time and followed three-step
directions without further prompting 75% of the time. The authors noted, ...expressed
satisfaction when she was able to ambulate to a specific destination independently (Borst &
Peterson, 1992, pp.553). In these six weeks of treatment, Doris will become more aware in
topical orientation and she will benefit from community mobility and gain the confidence to
resume her roles more effectively.
Short-term goal #2. Client will look at a community map and write down directions for
three destinations with mod A in three weeks.
Intervention #2. Client will go to a small grocery store and locate three food items. This
is an establish/restore approach in intervention because pre-stroke, she frequently bought items
in the grocery store (AOTA, 2014). She will be provided with a floor map for the grocery store
and she will locate each item with specific instructions for the brand, cost, and size. The client
outcomes will benefit improvement in occupational performance for locating objects, increased
perception of directions, and increasing verbal communication (AOTA, 2014). Education will
be provided to help learn to turn her head for visual scanning and for safety to prevent her from
bumping into other people.

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Literature Review. After a stroke, many clients have impairments in navigating a grocery
store. An article entitled, Training Multitasking in a Virtual Supermarket: A Novel Intervention
After Stroke was done to identify improvements in multitasking to collecting food items in a
virtual supermarket. The study consisted of four participants with ten 60-minutes sessions over a
three-week period and the results showed remarkable improvements ranging from 20.5% to 51.2
% in multitasking. Multitasking in the study was defined it as, the use of strategies aimed at
compensating for executive functions and multitasking difficulties (e.g. writing down the task in
an organized way, categorizing the products into groups before shopping, marking the tasks)
(Rand, Weiss, & Kats, 2009, pp. 539). Doris will benefit from this because she will improve her
STM, visual scanning to detect objects with food items, and will increase spatial awareness.
Long-term Goal #2
Client will cook homemade chicken pot pie from scratch with SPV in six weeks.
Short-term goal #3. Client will cut four ingredients using bilateral UEs with min A in
three weeks.
Intervention #3. Doris will obtain corn and will shuck the husks and cut the corn kernels
off the cob. This approach is an establish/restore intervention because she will remediate her
meal preparation (AOTA, 2014). While shucking corn she must stabilize the corn using a
palmar grasp and finger dexterity to handle the husks. The outcomes she will benefit from are
improvement of occupational performance including increased palmar and digital strength and
endurance in bilateral UEs. When the corn is shucked, she will carefully cut the kernels off with
a knife while visually attending in her right visual field. These outcomes will increase hand-eye
coordination and proper handling of the utensils.

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Literature Review. Meal preparation is important to Doris and she wants to be

independent with this IADL. She would benefit from remediating this occupation because
before the CVA she cooked b.i.d. for her husband. Poole, Hadsek, and Haaland (2011) explored
meal preparation after CVAs in an article entitled, Meal Preparation Abilities After Left or Right
Hemisphere Stroke. Overall reports showed that one year post-stroke, 77% still needed
assistance with meal preparation due to poorer motor performance and longer completion time.
Although the authors were exploring left and right hemisphere lesions, the conclusion stated,
assessment of and training in instrumental ADLs such as meal preparation is critical for
independent living post-stroke. (Poole, Sadek, & Haaland, 2011 pp. 595). Doris had a left
hemisphere lesion which is significantly worse than the right hemisphere according to Poole et.
al. (2011) and she will benefit with this intervention to develop more motor control, finger
dexterity, strength, and endurance in bilateral UEs.
Short-term goal #4. Client will prepare pie crust using bilateral hands with min A in
three weeks.
Intervention #4. Doris will engage in handwriting to improve hand function. Although
the occupation-as-an-end of this short-term goal is kneading dough for the chicken pot pie, the
occupation-as-a-means is to improve hand function and increase finger dexterity, strength, and
endurance in bilateral UEs. This approach is an establish/restore approach for intervention
because the client had previously been proficient at handwriting (AOTA, 2014). This is a
purposeful activity involving writing a check or birthday card, for example, and it will be useful
to have the increased benefits of kneading dough for the task of meal preparation. The outcomes
that these will benefit from are improvements in occupational performance involving increased
visual attention and improved bilateral UEs strength, endurance, and function (AOTA, 2014).

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Literature Review. Doris has a repertoire of occupations and almost all of these
occupations are essential for the use of her bilateral UEs. An article titled, Changes in
hemiplegic grasp following distributed repetitive intervention: a case series, was conducted
using interventions to improve hand function for adults with right-hand dominance and right
hemiplegia. The focus was unilateral and bilateral repetitive movements for 60 minutes at three
times a week over six weeks to find evidence of adaptive cortical plasticity in cortical motor
areas. The assessments were used for the Ashworth scale, the Minnesota manual dexterity test,
nine-hole steadiness tester, and for handwriting with the Jebsen hand function test. There was
sufficient improvement over the six weeks to have effects on repetitive movement. The authors
concluded, increased in grasp force magnitude, gross coordination, functional tasks, writing
pressure and legibility (Conti & Schepens, 2009, pp.212).
Precautions and Contraindications
Overall, there are several precautions necessary to have successful outcomes for these
interventions. The client must be educated on environment hazards and must be vigilant to
perceive moving objects. For example, if an elevator is on the clients right side, she must move
her neck and visually scan because people and/or objects can rush out of the elevator. The client
must frequently visually scan for the need to apply functional mobility interventions and as a
precaution the client will first ambulate around the clinic before preparing to go into the hallway.
The client must ambulate at a slow and steady pace to observe any object in the clients
environment. Another precaution is to visually attend to any sharp objects such as a knife. The
client will be educated to mentally motor plan before executing the hand movement. When
conducting these interventions, any number of observable contraindications could be present.
Breaks will be provided, with possible modification or cessation of the activity, if the client

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becomes overwhelmed by the occupational performance. The client must be advised to rest for a
brief period if the client has fatigue or severe pain caused by using the right hand, RUE or by
visual reception. If contraindications occur such as shortness of breath or high blood pressure,
the client should rest or stop the activity. If the client is confused about orientation, then verbal
cues will be provided.
Frequency and Duration
The frequency and duration for the intervention plan will be 60-minute sessions, three
times a week for six weeks. The treatment will be conducted Monday, Wednesday, and Friday
so as to alternate days and maximize the learning process. Doris has good rehabilitative potential
to increase knowledge in topographical orientation and to provide meaningful and purposeful
activities in bilateral UEs.
Grading Up and Grading Down
In the intervention for the shucking of the corn and cutting the corn kernels, one grading
down activity is to provide set-up with the corn already shucked or to have a device to stabilize
the corn without the need to use a palmar grasp. One device that the client could use is the
adaptive cutting board with a peg to stabilize the corn. If the client is easily able to do this
activity and she has faster and efficient performance, then the activity should be graded up to
incorporate more components in the chicken-pot-pie such as preparing to rinse the carrots and
cut them.
Primary Framework
The Person-Environment-Occupation-Performance model is an appropriate model
because it is based on many holistic components for the person and her environment. To assess
these aspects it is imperative to use therapeutic use of self to gather as much information as

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possible. This model demonstrates that personal intrinsic factors interact with environmental
extrinsic factors to allow occupation and performance (Brown, 2014,). When both the
occupation and the performance are achieved, the main focus is realized and called occupational
performance and participation (Brown, 2014). The occupational performance and participation
is the most effective way to engage all aspects of the client to promote the clients self-efficacy.
Doris intrinsic factors have greatly diminished due to her physiological and neurobehavioral
impairments. Her neurological function is compromised due to her R hemianopia and impaired
integration of visual information. Moreover, her physiological functions have been impacted in
regard to her RUE and have had an effect on hand-eye coordination in the context of increased
flaccidity. Doris extrinsic factors, her natural environment and social systems, have been
compromised, however, she has great social support for her recovery in her occupations. Her
environment has been impacted due to her impaired vision and hand-eye coordination. These
barriers are important to identify interventions to facilitate occupational performance.
Client/Caregiver Training and Education
Education will be provided to instruct Doris with environmental awareness with each of
the interventions. As previously mentioned, an important intervention is for Doris to use
topographic orientation to visually scan the hallway for people and/or objects. The client will
receive education on visual scanning while ambulating in the rehab gym in preparation for the
hallway. In addition, Doris will be instructed to mentally motor plan in order to safely use sharp
objects. Training will be provided to simulate cutting patterns and attend in her visual field. She
will also be given home exercises to implement and improve visual skills and hand-eye
coordination such as handwriting worksheets or hand manipulation tasks. Also, pamphlets will
be provided to address visual impairments with additional resources. Education will be provided

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for her husband to instruct and assist her on her activities to improve orientation and RUE
function. Her husband will be instructed on how to assist her when introducing her to new
places. This will provide an important support system.
Response Monitored and Assessed
Doris will receive skilled OT services and will have documentation with each
intervention for responses. Clinical observation will be assessed to perceive any changes with
her performance abilities. Informal verbal interviews will be conducted with Doris and her
husband to determine the client's current abilities. After three weeks of OT treatment,
reevaluation will be performed to determine if the short-term goals are met. If these goals are
too strenuous or the client has completed her goals too soon, the long-term goals should be
altered and tailored to the clients needs. In addition, Beery VMI can be assessed to detect
progress in intervention. The Beery VMI measures visual perception and motor coordination so
it is suitable for Doris deficits (Beery & Beery, 2010). Beery VMI should be assessed at the
beginning of the treatment and after six weeks to monitor her progress.

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References
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Beery, K., & Beery, N. (2010). The Beery-Buktenica Developmental Test of Visual-Motor
Integration (6th ed.). Bloomington, MN: Pearson.
Borst, M. J., & Peterson, C. Q. (1993). Overcoming Topographical Orientation Deficits in an
Elderly Woman with a Right Cerebrovascular Accident. American Journal of
Occupational Therapy, 47(6), 551-554 doi:10.5014/ajot.47.6.551
Brown, C.E. (2014). Ecological Models in Occupational Therapy. In B. A. B Schell, G. Gillen,
& M. E. Scaffa (Eds.), Willard & Spackmans occupational therapy (12th ed., pp.494502). Philadelphia: Lippincott Williams & Wilkins.
Conti, G. E., & Schepens, S. L. (2009). Changes in hemiplegic grasp following distributed
repetitive intervention: a case series. Occupational Therapy International, 16(3-4), 204217. doi: 10.1002/oti.276
Poole, J. L., Sadek, J., & Haaland, K. Y. (2011). Meal Preparation Abilities After Left or Right
Hemisphere Stroke. Archives of Physical Medicine & Rehabilitation, 92(4), 590-596. doi:
10.1016/j.apmr.2010.11.021
Rand, D., Weiss, P. L., & Katz, N. (2009). Training Multitasking in a Virtual Supermarket: A
Novel Intervention After Stroke. American Journal of Occupational Therapy, 63(5), 535542. doi:10.5014/ajot.63.5.535