105
Institutional
Lives in a two bedroom flat in an assisted living facility
Goals
Mr D was unable to express his priorities for rehabilitation therefore the goals were established in his best interest with his wife
Initial Assessment - Contact with Patient's Wife
Patient lives in supported accommodation
Patient's wife confirmed that she completed all domestic activities for patient
Patient was able to complete a shower or strip wash in standing 3 days before being admitted to hospital, patient's wife was concerned that patient was no longer able to complete his self care activity
Initial Assessment - Occupation
Patient was able to complete toileting unassisted however was not able to complete his lower body dressing, highlighting that patient would likely require assistance completing his washing and dressing
Patient's wife advised that patient goes outside everyday for a walk
Patient enjoys going on the exercise bike in the accommodation
Patient was usually orientated to place, not time. Patient had reduced short term and working memory however had a fairly good working memory
Initial Assessment:
Person
Patient had limited participation in leisure activities in hospital due to the hospital environment
Patient was not able to pour a glass of water due to his decreased standing balance.
Patient's decreased sequencing ability indicated that patient may have difficulty preparing a hot drink
Patient was motivated to engage in the therapy session
Patient recognised he was in hospital, did not know the name, unable to state date.
Patient was able to advise where he lived 5 years ago
Plan for Occupational Therapy Initial Assessment
Patient stood from the chair with physical assistance, patient had difficulty fully extending his knees.
Patient was a high falls risk due to not fully extending his knees.
Patient mobilised with close supervision and a rollator frame.
How does the CMOP-E guide an Initial Assessment?
Is the patient motivated to engage in therapy?
Is patient able to express what is important to him?
What is patient's current cognition? This is important to establish if the patient's cognition has changed.
A toileting assessment would be completed, either using a bottle, commode or the toilet depending on patient's standing balance.
Patient's ability to complete lower body dressing would be assessed by asking patient to remove slippers/ socks.
Due to patient's falls history, patient's balance would be assessed
The notes indicate that the patient would be unable to provide a complete accurate account of his previous functional ability due to the diagnosis of vascular dementia. The focus of the initial assessment would therefore be to assess the patient's current functional ability and then follow up with contact with the patient's wife to establish patient's previous functional ability
Cognition
vascular dementia
Acute confusion
Wife reporting short term memory problems
Physical
Poor mobility (recurrent falls)
The patient is being investigated for an infection
The patient was admitted with a mechanical fall
Wife reported patients has had slurred speech and reduced physical ability for 2 days
Previous Cerebral infarction
The Notes stated the following......
Self-care
Usually independent with daily activities
Wife has not managed in the last 2 days prior to admission to hospital
Family members are concerned that the patient's wife is not managing
The patient has been assisted with all personal care on the ward
Screening the Notes
Information from the notes can be categorised into the component areas of the CMOP-E
Reason for OT Order
To assess the patient's current abilities (considered under the component of Occupations)
CMOP-E
Case Study
DME
Using the CMOP-E to lead an occupational therapy assessment for a Patient with a diagnosis of Dementia (Mr D)