Using the Person-Environment-Occupation-Performance (PEOP) model, I will discuss the evaluation, interventions, outcomes, and reflections of Mr. J. Mr. J is a 58-year-old right-handed African-American male. He had a stroke in July of 2016, with residual left-sided weakness and balance impairments, and has been readmitted with a new stroke. Mr. J is familiar to me, having been the primary occupational therapist during his previous in-patient rehabilitation admission. Mr. J presented to an acute care hospital on November 8, 2017, status post a mechanical fall resulting in left arm and hip pain, and an unclear report if he had experienced any loss of consciousness. Upon admission to the acute care hospital, Mr. J was also noted to have an …show more content…
J sees as his strengths, what problem areas he is currently experiencing, and what goals he would like to address during his rehabilitation stay. At the time of the occupational therapy (OT) evaluation, Mr. J required contact guard assistance (CGA) with toileting tasks; taking a seated shower with standing for perineal care using upper extremity support on a grab-bar; CGA with total body dressing at seated level to include socks and shoes with standing clothing management; and independence with self-feeding, and grooming tasks. He also required CGA with all functional mobility at ambulatory level with the use of a rolling walker (RW). From my skilled assessment of Mr. J’s current function, I saw deficits in the following client factors, impairments in mental functions such as safety awareness and insight into deficits; impairments in muscle and movement functions such as standing balance, left upper extremity weakness with a light touch and proprioception changes, and poor activity tolerance. When provided with the opportunity to define his deficit areas and goals, Mr. J reports left arm and leg weakness as his only deficit areas and his goal to strengthen …show more content…
J was familiar with interventions and activities he had participated in during his last admission. He had participated in a seated yoga program and activities that heavily involved neuromusculoskeletal and movement-related factors and expressed interest in continued participation in those interventions. I promptly signed Mr. J for yoga class and scheduled him for an extra thirty minutes a day with an OT aide to work specifically on strengthening and coordination activities for his left arm. This allowed for sixty minutes to focus on other performance areas he found valuable. These activities included, reducing the level of supervision required with all self-care tasks which requires dynamic standing balance, whole body strength and endurance, and environmental and body safety awareness; and accessing the vending machine which requires balance and endurance for functional ambulation, navigating high volume and varied surface environments, money management, and time management. Knowing Mr. J’s limited insight and safety awareness I planned my treatment sessions and wrote functional goals to address this and in an attempt to help him gain skills that would allow him to be as safe and functional within his environment. Mr. J also verbalized a desire to “get his life together” and eventually return to gainful employment in the community. Unfortunately, because of his high level of physical