Case review

Name/age/primary diagnosis
SH/54/Phenomena

Reason for referral
Anxiety/?cognitive impairment

Medical Hx:RA

Social situ: Lives alone/Near Friends and Mother (walking distance)
Has a pet cat

Prior OT input:
Home environment set up/adaptive cutlery

Supports before admission: HH/PC 2/24.

How managing before admission: up and down days, assistance with most daily tasks e.g. showering, meal prep, cleaning. Independent mobility but has a wheel chair at home

Assistance on ward (mobility/self cares) - Independent mobility, d/c from PT; Full assistance of 1 on ward

OT input this admission/ Assessment(s): initial interview/functional tx assessment
Shower assessment.

Problems identified:

1) SH is struggling with alot of pain and is quite anxious about this.
2) SH is sick of being positive
3) SOBOE
4) SH has difficulty griping, doing bilateral hand skills, and manipulating small objects
5) SH overdoes things on "good days"

NIL evidence of any significant cognitive problem other that mild short term memory impairment

Beliefs: SH likes to keep her house tidy; do as much as she can; not be a burden on anyone.

Intervention:

1) Education about pain - "it is real"
2) Education about energy conservation - pacing/planning/prioritsing
3) Discussion about relaxation

Outcomes:

SH really appreciated the discussions and education and knows that pacing and not over doing things will decrease the chance of being in extreme pain. She has to decide for herself if she will take on the information and put to practice some of the energy conservation techniques.

SH has adequate supports in situ and her home environment is set up for her from prior OT input


Plan

D/C from OT