Running head: MS. J CASE STUDY 1

Amputation Case Study

Megan McCarthy

The University of Scranton

Running head: MS. J CASE STUDY 2

Synopsis: KR is a thirty-year-old female who sustained a left and right BK

amputation secondary to gangrenous. After the bi-lateral amputation was conducted, a

skin graft closure was performed to weeks after surgery to properly secure the

wounds. PMH includes: intravenous drug use, endocarditis, hepatitis B and C,

chronic liver disease, and sepsis. Occupational therapy services were provided three

days after surgery to evaluate and help the client meet her needs. During the therapy

session, clinicians stated that KR could only demonstrate bed mobility and bilateral

UE ROM due to pain and fatigue. It was also noted that both amputations have

flexion contractures, her sitting balance is fair, and there is a considerable amount of

patient education that needs to be addressed in terms of long term care.

Occupational therapists (OTs) are trained clinicians in the use of therapeutic

occupation-based interventions. One dimension of this approach is to teach

compensatory techniques for an activity, which provides clients with adaptive ways to

complete desired tasks. Typically some of the services that occupational therapists

provide to citizens with lower extremity amputees are progressive functional mobility

training, teaching proper transferring techniques, limb pain/sensation management,

and patient education (2011).

Some sociopolitical considerations that pertain to KR’s situation is that she is

homeless and has no medical insure. The first obstacle would be to find out if the

client qualifies for Medicaid or supplemental security income. In KR’s case, being

eligible for supplemental security income is going to be a complicated task due to her

age, homelessness, and drug abuse. The patient will need to thoroughly discuss her

situation with a social worker to find out what her options are in terms of continued

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care and other community-based services that may be available (Burt, Wilkins &

Mauch).

One lifestyle issue that KR may face, after a proper assessment is conducted, is the

required use of assistive ambulatory device/s such as prosthetics, wheelchair, walker,

or quad cane. Along with a mobility device/s, depending on KR’s stability and

performance, she may need to incorporate the use of additional adaptive equipment to

complete activities. Some examples of adaptive equipment that the client may find

beneficial are a long handled reacher and extended tub bench. Also, due to her

noncompliance with past drug rehabilitation and medications, her ability to self-care

needs to be further examined in order to conclude if KR is capable of being

independent.

Using the provided referral sources and data collected, the main focus of Ms. KR’s

OT treatment plan will be based on her current status, needs, and goals that the client

has determine for herself with the help of the therapist. The outcome of this focus is

to help the client reach optimal performance in ADL’s and mobilize safely and

efficiently throughout her environment. KR’s competency will be fully evaluated and

then both the patient and therapist will develop an intervention plan.

After the initial evaluation, a COTA can be integrated into the treatment plan to help

conduct intervention activities. Some activity examples that a COTA could be given

are to educate KR on her amputations, teach her compensatory techniques, and

practice how to safely ambulate and transfer with the use of an assistive device.

Other professionals that may provide services to KR are a physical therapist, social

worker, and COTA. Working with an interdisciplinary team creates a positive

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atmosphere where clinicians can collaborate and ultimately decide the best treatment

for the patient.

In order to properly establish STGs and LTGs for KR’s intervention, the patient’s

occupational profile, evaluation, and assessment of her needs will all be considered.

In this particular case, goal projections for ADLs and functional transfers have

already been predetermined for KR. Many tasks mentioned in the client’s goal

projection involve transferring, and teaching KR adaptive, safe ways to complete

transfers is very critical to obtaining her independence. For example, getting in and

out of a bathtub is a common task that involves multiple safety hazards. Educating a

client how to properly accomplish this task by utilizing objects such as, sliding board,

extended tub bench and/or grab bars will greatly reduce safety risk and assist the

client in successfully completing the activity. Another major area that must be

addressed is the client’s flexion contractures through properly positioning, wrapping,

and exercising the extremities. Lastly, a goal of grooming and hygiene will help to

reduce infection and integrate proper wound care into the client’s daily routine. All

goals will be written by using the FEAST method and will be measurable and

rationale.

Designing interventions and goals based on a theoretical standpoint is important in

order to display validity in the therapist’s chosen treatment approach. It is important

to consider multiple theories and frame of references (FOR) to accurately target the

multidimensional aspects of a person needs for functional independency. Some of the

theories and FORs chosen for KR are the biomechanical model, MOHO, and lifestyle

performance model. These approaches were selected to target all of KR’s needs and

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to incorporate them in the therapeutic process. The biomechanical was chosen to

focus on the client’s body mechanics and upper body strength. This also will allow

for particular focus on releasing KR’s flexion contractures and help her become more

mobile. The MOHO was chosen to incorporate a holistic approach into the treatment

intervention. This will look at KR’s volition, habituation, and her performance

capacity within the contexts of her home environment and living situation. Using the

MOHO will help to detect what adaptations need to be made to KR’s environment.

Lastly, the lifestyle performance model incorporates her interests, activity patterns,

and individualized needs into the intervention plan. This enables the client to

successfully sustain or “achieve a personal identity” within the integrated adaptations

(Fidler, 1996).

The evaluation process must be consistently repetitious in order to accurately record a

patient’s progress. A weekly evaluation will be completed, which includes

standardized and non-standardized assessments, observations, and both formal and

informal feedback from the client and caregivers.

Finding if a change or termination of treatment is warranted will be established

through the therapist’s findings in the weekly assessment of the client. After a

reassessment is conducted, an interdisciplinary team meeting will occur to evaluate

the progress of the patient. The team will determine the following: if the goals are

being meet within the stated time, has the intervention plan been working and, if so,

do they need to be upgraded or downgraded, and if a discharge date has been assigned

to the client or is long term care being considered.

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The interdisciplinary team involved in the treatment of KR will establish a detailed

action plan. Goals will be written and a recommended activity will be provided using

STWD occupational therapy services activity description sheets. Short-term goals and

long-term goals such as, safely and independently completing a front w/c to toilet

transfer by the end of treatment will be included in the plan. All occupations that pose

affected due to the patient’s condition will be addressed and multiple therapeutic

strategies will be implemented. Please refer to the attached STWD forms for

additional information regarding KR’s action plan.

There are many resources available to KR that allocate additional information on

amputees and services for the uninsured. For example, the Amputee Coalation of

America provides a tip sheet on different organizations and way to receive funding

for prosthetics. A list of resources have been provided per below:

http://www.amputee-coalition.org/fact_sheets/assist_orgs.html

http://www.oandp.com/resources/organizations/barr/history/

http://www.hanger.com/prosthetics/experience/pages/peersupport.aspx

http://home.comcast.net/~n2fc/natamp/tips.html

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References

(2011). Retrieved from

http://www.brighamandwomens.org/Patients_Visitors/pcs/RehabilitationServices

/Physical Therapy Standards of Care and Protocols/General - LE Amputation.pdf

(2011). Retrieved from Centers for Medicare and Medicaid website:

http://www.medicare.gov/Pubs/pdf/10153.pdf

Bonder, B., & Bello-Haas, V. (2009). Functional performance in older adults. (3 ed.).

Philadelphia: F.A. Davis Company.

Burt, M., Wilkins, C., & Mauch, D. (n.d.). Retrieved from

website:http://aspe.hhs.gov/daltcp/reports/2012/ChrHomls2.pdf

Fidler, G. (1996). Life-style performance: from profile to conceptual model. The

American Journal of Occupational Therapy, 50(2), 140-147. Retrieved from

http://ajot.aotapress.net/content/50/2/139.full.pdf

Occupational Therapy Association. (2008). Occupational therapy practice framework:

Domain and process (2nd ed.). The American Journal of Occupational Therapy,

62, 625-683.

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Mini-case Case Study Development – Clinical Reasoning Process – Activity Description

Related Goal: KR will complete a forward w/c toilet transfer with minimal assistance and 1 verbal cue by the end of two weeks.

Activity Name: Wheelchair to Toilet Transfer

Materials and Supplies

Wheelchair Toilet

Positioning Considerations

Sitting

Steps to Activity Completion:

Bring pt. into the bathroom

Ask pt. to position herself and lock her w/c breaks.

Ask pt. to complete transfer (therapist will assist and guard as needed).

Once pt. is securely on the toilet, ask pt. to safely transfer back to w/c.

Therapist’s Strategies

Therapist will: Give cues and

assistance as needed. Upgrade and downgrade

activity as needed Monitor any safety

precautions that may become apparent during the engagement of the activity.

Parameters to Monitor/Safety Considerations

Monitor pts. BP Look for signs of fatigue Observe to make sure pt.

does not seem off balance and is properly positioned to reduce any fall risks

Rationale for Activity Choice:

The rationale for this activity is to work on strength, balance, endurance, and the pts. ability to transfer onto different surfaces. Toileting can be a difficult task for a bilateral LE amputee and it is important that the client can perform this task safely and efficiently.

Suggestions for UpgradingDecrease verbal cues:

Give CGA Make client practice

with the lid up Have pt. practice

reaching for toilet paper. Incorporate the task of

hand washing.

Suggestions for Downgrading:

Increase verbal cues Give maximal

assistance Perform task with the

lid down

Feedback

Running head: MS. J CASE STUDY 9

Mini-case Case Study Development – Clinical Reasoning Process – Activity Description

Related Goal: Client will take part in an exercise program for two weeks and will be able to complete 6 exercises in 30mins by the end of the second week.Activity Name: Exercise Program

Materials and Supplies:

Wheelchair Weights Theraband Mats

Positioning Considerations:

Sitting Supine Prone Sidelying

Steps to Activity Completion:

Pt. will engage in an exercise program 3x’s a week for 30mins per session.

Pt. will perform various exercises to engage in a complete total body workout to increase strength, endurance, balance, and reduce flexion contractures.

Therapist’s Strategies:

Therapist will: Demonstrate exercise. Give cues and assistance as

needed. Upgrade and downgrade activity

as needed Monitor any safety precautions

that may become apparent during the engagement of activity.

Parameters to Monitor/Safety Considerations:

Monitor pts. BP. Look for signs of fatigue. Observe to make sure pt.

does not seem off balance, is properly positioned, and is in correct formation while completing the exercises.

Rationale for Activity Choice:

The rationale for this activity is to work on the pt.’s overall strength, endurance, balance, and to work on getting rid of the pt.’s flexion contractures. Being that the pt. may not get funding for prosthetics, it is important that she builds up her strength so she can mobilize herself.

Suggestions for Upgrading

Give only one visual cue per exercise

Give no assistance Incorporate more advanced

exercises and complete them against gravity.

Suggestions for Downgrading

Maximize cueing Give minimal assistance Perform exercises in

non-gravitational planes

Feedback

Running head: MS. J CASE STUDY 10

Mini-case Case Study Development – Clinical Reasoning Process – Activity Description

Related Goal: Client will work on proper LE hygiene by engaging in a bathing/wound care activity and will be able to complete this independently by the end of treatment.Activity Name: Hygiene Activity

Materials and Supplies:

Cleanser Bathing gloves (if

preferred) Dressings Gauze Coband

Positioning Considerations:

Sitting

Steps to Activity Completion:

Client will bath LE. Apply any ointments or

medications (only if prescribe by the physician).

Pt. will apply any dressings that are needed.

Pt. will properly secure dressings on LEs.

Therapist’s Strategies:

Give cues and assistance as needed.

Upgrade and downgrade activity as needed.

Monitor any safety precautions that may become apparent during the engagement of activity.

Make sure dressings are wrapped properly around pt.’s LEs. If not therapist will rewrap bandages.

Parameters to Monitor/Safety Considerations:

Monitor pts. BP Look for signs of

fatigue Observe to make sure

pt. does not seem off balance, is properly positioned, and is not causing any harm to their wounds or LEs.

Rationale for Activity Choice:

The rationale for this activity is to educate the patient and to make sure they can properly take care of their amputations before being discharge. It is important to maintain proper hygiene to reduce the risk of infection or other set backs that may be caused by improper hygiene. Also, it is important to properly form/shape the stumps in case KR can get funding for prosthetics in the future.

Suggestions for Upgrading:

Client will complete task independently with no cues or assistance

Pt. could be in charge of getting/picking out all the items needed for the task

Suggestions for Downgrading:

Give minimal cueing

Give CGA Visually show pt.

how to properly wrap their stump before they engage in the task.

Feedback: