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Date implemented:

Clients Initials and Age: H. A. 34 y.o. Time allotted for session: 24 min
9/27/17
Diagnosis and any Precautions: (1) Multiple GSW to abdomen (transverse process L4/L5, medulla of R
kidney); abdominal incision precautions
Goal/s being addressed: (1) In 7 days, pt will perform LE dressing with mod A.
Results (link to activity
Activity Demands Modifications (provided
Specific Objectives for objectives; include
Intervention Activities (setting, materials, and during the activity and
this activity (list 2-3) objective measures of
(5) social requirements) planned for next session)
(5) performance when
(5) (5)
possible) (5)
Activity will take place with
pt in bedside, therapist at
pt bedside. Pt lines will be
managed so as to allow pt Unable to perform on Unable to perform on
to immediately practice same pt d/t unit transfer same pt d/t unit transfer
after education. Family Pt was willing to perform Pt had also sustained a
Pt acceptance of log rolling may be present for support safe bed mobility, but was head injury and needed
Educate patient on log roll principles. and education. easily confused d/t other many VCs to remember
techniques for bed mobility injuries and did not and use proper form. Will
3 minutes Pt demonstration of safe This activity could be demonstrate safe mobility need to re-introduce at
bed mobility. graded by providing each through frequently next session and perform
instruction immediately attempting to twist trunk movements step by step,
before performing the while moving from supine rather than giving all
action or by giving all to sitting. instructions at once.
instructions at once and
gauge ability to follow
multiple step commands.
Perform static sitting Pt ability to tolerate seated Pt will be seated at EOB. Unable to perform on Unable to perform on
balance activity of reading activity for 5 minutes. Family has brought in same pt d/t unit transfer same pt d/t unit transfer
magazine at EOB. magazines and materials
5 minutes Pt vital reaction to position for pt to read, which can be Pt vital signs dropped This pt did not have
change. utilized during session. while seated d/t increased magazines or reading
Assistance may be needed pain. However, when given items. However, during
to support pt back at EOB. cues to take deep breaths, session, pt performed an
vitals returned to baseline. EOB ADL of brushing
The activity could be EOB activity performed for teeth, while maintaining
graded by 5 minutes with pt static sitting balance.
reading/managing larger tolerance.
items (large book or
magazine) or smaller,
more complex items, such
as completing a crossword
or word search.

Pt will be seated on EOB


Unable to perform on
with bedside table to pt R Unable to perform on
same pt d/t unit transfer
side. Items (hospital pants same pt d/t unit transfer
and socks) will be placed
During this session, this
on pt R and L side to allow This activity was not
activity was not addressed
for reaching outside of addressed in the
Perform dynamic sitting Pt ability to tolerate d/t pt status at time of
BOS. intervention session d/t pt
balance activity of reaching movement outside of base session. Pt was unwilling
inability to demonstrate
for dressing items outside of support. to increase challenge and
This activity could be dynamic sitting balance.
of BOS to gather materials therapist did not want to
graded by allowing the When seated at EOB, pt
needed for LE dressing. Pt endurance through perform unsafe activities.
patient to gather fewer experienced increased
5 minutes increased pain. As this was the pts first
items (socks bundled and pain and wished to return
time upright since injury,
pants folded) or allowing to supine. Additionally, pt
next session, pt will be
the pt to Independently was mod A for static sitting
further challenged to
maintain static sitting balance with support at pt
complete dynamic sitting
balance through removing back.
balance activity.
support from back.
Sock aid will be retrieved
Unable to perform on
from therapy stock room to
same pt d/t unit transfer
be used during session.
Socks will be issued from Unable to perform on
Unable to address during
supply room. Pt will remain same pt d/t unit transfer
Pt ability to participate in this session; therapist
Don socks with min A for seated at EOB for donning.
ADL. donned socks for pt. Next
sock aid and threading Pt was unable to
session will continue to
sock onto assistive device. This activity could be participate in ADL.
Pt ability to correctly use address goals determined
5 minutes graded through using Dependent for LE dressing
adaptive equipment. by this evaluation session.
larger socks to decrease activity of donning socks.
AE will be brought in to
difficulty to placing socks Pt declined to attempt I.
perform LE dressing. Pt
on sock aid and self or
education on AE will be
through donning ankle
used at that time.
socks.
Perform LE dressing task Pt acceptance of Pants will be retrieved from Unable to perform on Unable to perform on
of donning pants with mod assistance with ADLs. supply cart on unit. Pt will same pt d/t unit transfer same pt d/t unit transfer
A for threading legs. remain seated at EOB for
7 minutes Pt level of independence in threading of pants. With Pt accepted assistance Activity was not attempted
ADLs with injury. w/w for support, pt will with ADLs, and was willing d/t pt Foley catheter. Per
stand to pull up pants and to allow family members to nursing, this should be
fasten. Family may be help in the future when removed prior to next
present for support and asked. Pt was dependent session, allowing for ADL
education.
This activity could be
graded by donning pants activity. Pt will likely
in LE dressing, unable to
one or two sizes large than progress to this level, but
shift weight to pull up pants
pt size or through donning challenge level does not
d/t increased pain.
pt clothing (pants with match pt ability at this time.
elastic instead of
drawstring).
S/OT name: Audrey Stewart, S/OT

Use the data from the results and modifications columns to write your SOAP note. Add rows for more activities, please erase the red instructions
when filling it out.

Find one peer-reviewed article that supports the intervention you planned/provided. At the bottom of your plan, paste the abstract and
citation and then in your own words describe how this supports your intervention plan. (5)

Bertilsson, A.-S., Ranner, M., von Koch, L., Eriksson, G., Johansson, U., Ytterberg, C., Tham, K. (2014). A client-centred ADL intervention: three-
month follow-up of a randomized controlled trial. Scandinavian Journal of Occupational Therapy, 21(5), 377391. http://doi.org.proxy.lib.ohio-
state.edu/10.3109/11038128.2014.880126

Abstract
Objective: The aim was to study a client-centred activities of daily living (ADL) intervention (CADL) compared with the usual ADL intervention
(UADL) in people with stroke regarding: independence in ADL, perceived participation, life satisfaction, use of home-help service, and satisfaction
with training and, in their significant others, regarding: caregiver burden, life satisfaction, and informal care. Methods: In this multicentre study, 16
rehabilitation units were randomly assigned to deliver CADL or UADL. The occupational therapists who provided the CADL were specifically trained.
Eligible for inclusion were people with stroke treated in a stroke unit 3 months after stroke, dependent in two ADL, not diagnosed with dementia,
and able to understand instructions. Data were collected at inclusion and three months thereafter. To detect a significant difference between the
groups in the Stroke Impact Scale (SIS) domain participation, 280 participants were required. Intention-to- treat analysis was applied. Results: At
three months, there was no difference in the outcomes between the CADL group (n = 129) and the UADL group (n = 151), or their significant others
(n = 87/n = 93) except in the SIS domain emotion in favour of CADL (p = 0.04). Conclusion: The CADL does not appear to bring about short-term
differences in outcomes and longer follow-ups are required.

This article supports my intervention through the data showing that use of traditional, evidence based ADL intervention has similar outcomes
to client-centered ADL intervention. As the activities I planned follow traditional methods of building skills and using task-specific training,
based on these results, they do not negatively impact patient performance or outcomes. For this study, outcomes were focused on
participation in ADLs as an important marker for intervention success. Participation and increased independence in ADLs was my focus for
intervention as well. Although the patient to which the intervention was originally aimed had not experienced a stroke, he did have some
delirium and impaired cognition through decreased safety awareness and insight.
Total: 32 points

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