Occupational Therapy Executive Summary

What are you going to do first?

Evaluating Process: First, it is important to review R’s occupational profile for progress from the start of occupational therapy. This is done to determine which assessment fits the needs of R and to ensure that the services rendered fits the client's purpose and goal. Some of the information gathered will include: client's occupational history, ADL patterns, needs and goals, environmental issues, and what the client’s limitations. It is important to evaluate the client’s progress to help facilitate the services that the new occupational therapist will continue. In addition, the client's concerns and interests are assessed in a welcome and open interview to attain additional information that R's family may

have. (Willard & Spackman, 2014).
Background Information:
Name: Royce ( R ) Age: 18 months old Gender: Female
Race: Filipino
Primary Diagnosis: Bilateral Hip dysplasia, Spastic diplegia
Secondary Diagnosis: Developmentally Delay
Precautions and contraindications: R has history of slow weight gain.
Date of referral: September 2nd 2015
Evaluating Team: Dariaun Atkinson, Zenia George,Jonathan Green, Jonkyra Jones

Previous medical history
Client R experienced some complications at birth. Her umbilical cord was wrapped around her neck, causing her distress (Cahill & Bowyer, 2015). She was diagnosed with bilateral hip dysplasia, more pronounced to the left (Cahill & Bowyer, 2015). A pelvic harness was worn 1 month, then hip abduction brace for the following 5 months (Cahill & Bowyer, 2015). The braces restrict movement (Cahill & Bowyer, 2015). She was diagnosed with strabismus and had bilateral eye surgery, followed by eye patching for a couple of months (Cahill & Bowyer, 2015). She received clinic-based PT when she was 8 months old due to her physical and visual concerns (Cahill & Bowyer, 2015). R wears Hip Helpers as well to provide hip stability. R has a history of slow weight gain as a result the family tries to feed R higher calorie foods(Cahill & Bowyer, 2015). Due to slow progress with gross motor skills and concerns with development, the family sought out EI when she was almost 18 months old (Cahill & Bowyer, 2015).
Occupational Profile/Relevant Information
R is an easy going, happy child.

She is easily distracted. She has low muscle tone and lacks stability in her legs. R has many toys and books. She prefers soft dolls and books. Her favorite doll is Bibsy. She participates in toddler class at the public library and park district. Her grandmother also takes her to walk daily as there are playgrounds near the home.

Family: R is only daughter living with two working professionals. Her mother is an engineer and father is an occupational therapist. There are extended family members who live nearby and provide support (Cahill & Bowyer, 2015). While both parents work, R maternal grandmother cares for her on the weekdays (Cahill & Bowyer, 2015). The family lives in a first-floor condominium in a residential neighborhood in a large city (Cahill & Bowyer, 2015). The family speaks English and Taglog (Cahill & Bowyer, 2015).

Areas of Occupation: Play, ADLs,

IALs

Performance Skills: After six months of occupational therapy she began to walk but unsteadily (Cahill & Bowyer, 2015). She pulls out the contents of the kitchen cabinets and toys off the shelves (Cahill & Bowyer, 2015). She shows more interest play and imitates the actions of other(Cahill & Bowyer, 2015).

Additional Notes:

After six months of occupational therapy, R started to ambulate with moderate assistance and engages more with the environment (Cahill & Bowyer, 2015). Her father observed slow but steady progress to communicate and purposeful playing (Cahill & Bowyer, 2015). R’s mother would like her play in typical activities with children her age. She stated it is not easy to find community toddler classes that are a good match for R (Cahill & Bowyer, 2015). One of the outcomes of the IFSP meeting was to encourage play dates(Cahill & Bowyer, 2015). R had scheduled play dates for a month with two children diagnosed with Charge syndrome (Cahill & Bowyer, 2015). They had mild to moderate hearing loss and both has functional vision in one eye and not the other (Cahill & Bowyer, 2015). They have strong fine motor skills unlike R and prefers to play with puzzles, blocks, and other manipulatives (Cahill & Bowyer, 2015). They shy away from children at the park, and have not had much exposure to structured play with peers(Cahill & Bowyer, 2015). The first play date took place at the twins home. The children engages in mostly parallel play (Cahill & Bowyer, 2015).

Assessment for Evaluation:
MMT/ROM assessment: The occupational therapist will use therapeutic use of self child to assess R motor control. When examining ROM we will observe the physical appearance of the child such as symmetry, physical anomalies and stature (O’Brien & Williams, 2010)
Visual motor and Visual perceptions assessments-Erhardet Developmental Vision Assessment (EDVA) and Short Screening Form (EDVA-S)-is used to evaluate visual motor coordination, and to identify delays, gaps in skills and inappropriate patterns in Royce (Asher, Asher, & American Occupational Therapy Association, 2007).
Cognitive assessment & Psychosocial assessment: Bayley Scales of Infant development-is a comprehensive exam for delays in multiple areas including the mental scale, psychomotor scale and behavior scale (Asher, Asher, & American Occupational Therapy Association, 2007).
Educational assessment: The Hawaii Early Learning Profile will be used to determine whether progress is made towards developmental goals towards preschool.

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Which theory, model of practice or frame of reference will you use with this client/patient and why?

The Developmental frame of reference will be used because it assesses developmental milestones. It has been noted that R's developmental age is 8-10 months even though she is 18 months old . The developmental frame of reference is based on the theory of human development in and across all skill areas mainly physical, cognitive, psychological, emotional and psychosocial. Cognitive: Identifies the client’s cognitive level and how to approach intervention. Biomechanical: Loss of Strength and ROM and Tone

Rehabilitation: Provide adaptations and modifications for physical and cognitive dysfunction. Developmental: Theoretical Assumptions Human development occurs in an orderly fashion throughout the cycle. Steps within the developmental process are sequential and none can be skipped. Client-Centered Frame of Reference: This Frame of Reference is developed from the work of Carl Rogers. It views the client as the center of all therapeutic activity, and the client's needs and goals direct the delivery of the Occupational Therapy

Process