Rationale:This patient presents with both physical and mental health issues that will both have an impact on her ability to return home. The doctor’s statement that “the woman’s potential for returning home is fair to poor”, may be based purely on her physical condition. As the OT has assessed the patient from a physical perspective, it is important to also assess her cognitive and functional abilities as her mental health status could affect her recovery and her ability to function independently regardless of her living situation. An evaluation of  the patient’s cognitive skills, ADL and general functional performance are tools which can be used to evaluate her level of functioning in these areas.

A. Allen Cognitive Levels Screening Test – a test that evaluates the patient’s ability to make decisions, function independently, safely perform basic skills, and learn new skills.
C. Klein-Bell Activities of Daily Living Scale – measures ADL independence to determine current status, change in status, & sub activities to focus on in treatment.
D. Bay Area Functional Performance Evaluation (BaFPE) – developed to assess the general functional performance of patients treated in psychiatric occupational therapy. It consists of two subtests, the Task-Oriented Assessment (TAO) and the Social Interaction Scale. TAO subtest includes evaluating – memory of instructions, organization, attention span, thought disorder, ability to abstract, task completion, motivation and compliance, frustration tolerance, self-confidence, and general affective impression.

B. Mini-Mental State Exam – a widely used test of cognitive function among the elderly; it includes tests of orientation, attention, memory, language. In many settings, it is not an accepted assessment for standardized testing. E.and F. Competency Rating Scale – self-report instrument asks the patient to rate his/her degree of difficulty in a variety of tasks and functions. Occupational Self-Assessment – measures a patient’s perspective on their competence of occupational tasks, the value the patient places on performing each task, and how the environment impacts occupational competence. Both these tests are subjective. Using objective assessments is more reliable, especially when a patient may have a lack of insight or may be manipulative( symptom of personality disorder).
 

Rationale: Even though the woman will be staying at the facility long term, she should still be encouraged to be as independent as possible. Addressing overall strength and endurance, ADL skills, functional mobility and leisure skills will help to ensure that the woman is as active as she can be. Adaptations for cognitive skills will help the woman to complete self-care tasks and participate in activities within the facility. Addressing the woman’s new role as a resident of a nursing home and teaching her coping skills related to that new role can be incorporated into treatment but should not be addressed as a specific goal as this overlaps with goals addressed by the social worker. The OTR® should collaborate with the social worker when addressing this area.

Rationale: People with borderline personality disorder often make statements or take actions that will result in friction between other people. In health care settings, they frequently “play people against each other”, resulting in conflict. Since the student has not had experience dealing with this type of behavior, the OTR® should discuss borderline personality with the student and give her some strategies to use to deal with the woman’s behavior. The strategies will be most effective if all staff members use them and interact with the woman in a consistent manner, so the OTR® should also collaborate with physical therapy to address the woman’s behavior. The behavior can be directly addressed with the woman, but this is not likely to result in a lasting solution as the woman will probably resume her behavior in some other way. The student should be allowed to provide treatment to the woman so that she can learn how to handle this type of behavior.

Rationale: Even if facility staff are familiar with borderline personality disorder, they sometimes become wrapped up in the dysfunctional social situation that the patient creates. Reminding staff members of the nature of borderline personality disorder and the potential for these situations to happen can help prevent their occurrence. The student was very observant in identifying the problem behind the conflict between the nurse case manager and the dietician and she should be praised for her observation. The OTR® should help the student learn how to deal with this type of conflict by working with her to meet with the staff members involved and discuss the problem, as well as to work out a plan with other staff members to manage the woman’s behavior. The OTR® should be present during any efforts of the student to address the situation. If the OTR® addresses the situation without the student present, the student will not learn how to address the problem with other staff and will not see the outcome of her efforts, so the student should be involved in the process.

Rationale: The woman has a diagnosis of cognitive deficits, so evaluating her cognitive status using the Allen Cognitive Levels Screening Test is appropriate. The COPM will provide a comprehensive picture of the woman’s functional abilities. The KELS could also be used to pinpoint more specific skills. The Rabideau Kitchen Evaluation has a normative base of people who have suffered traumatic brain injury, so this test is not appropriate in this situation. The Klein-Bell ADL Scale only addresses basic self-care tasks, and chart review has revealed that the woman is independent with these activities. Since the woman has a dual diagnosis, she may not be the most reliable source for information, so informal interview alone is not sufficient.

Rationale: Providing services to the woman in her home would be best for the woman, who will have an easier time learning new skills in a familiar environment, rather than attempting to generalize information learned in a clinic setting. Her daughters will also be able to observe how the woman does in therapy and will be able to learn how to help guide their mother through certain activities. One advantage of providing services at the outpatient facility, however, might be the ability to include the woman in community outings designed to focus on independent skills in the community. The selection of the place of service should be based on the woman’s treatment goals and anticipated outcome, not on personal preference or convenience. The OTR®’s safety should be considered when scheduling services, but this should not be the primary reason for the selection of the place of service.

Rationale: Since the woman has cognitive deficits, she will benefit from visual reminders of which healthy foods she needs to shop for. Organizing her refrigerator and pantry into food groups with the healthy foods in front will give the woman a visual reminder when her stock of these foods is getting low. Making a chart of healthy foods for the kitchen wall will help the woman to identify and select healthy foods when preparing meals for her family. Organizing the woman’s shopping list into food groups will also help the woman to select foods in each food group. The woman’s 17-year-old daughter is old enough to be aware of the food groups and to assist her mother in selecting healthy foods while grocery shopping. The woman will not learn how to select healthy foods if she is given preplanned shopping lists. A home health aide might assist the woman with learning this skill, but this service might not be available to the woman in her area and there is a chance that the aide would be selecting food items for the woman rather than assisting her in selecting items herself. The woman is not considered home bound and would not qualify for Meals on Wheels. She also would not be able to provide food for her children through this option.

Rationale: Regardless of the actual source or meaning of the information the woman received, the fact that she believes the world is going to end has caused her symptoms to flare and her mood to be volatile. The OTR® should not invalidate the woman’s statement or pressure her to participate in treatment, as the session will probably not be productive and the woman’s symptoms could escalate. The OTR® can offer to help the woman relax by using relaxation techniques. The OTR® should find out why the woman does not want to participate in therapy and should notify the woman’s case manager of her symptoms.