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Group Case Study: Shawn Heather Dalrymple, Stephanie Perry-Brideau, Sheena Marquez, Meg Isagholi, Casey Walker OCCT 520: Occupation Skills Lab
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Areas of Occupation Affected Activities of Daily Living: a) Bathing and Showering: The client is 3 years and 7 months therefore he will need moderate assistance (mod. a ) when bathing or showering. The child’s parents should be aware of the Gtube to avoid infection. b) Bowel and Bladder Management: Shawn is potty trained however, he needs mod. a to sit on the toilet. c) Dressing: Due to developmental delay and right upper extremity (RUE) spasticity, he needs mod. a with dressing. d) Eating: Shawn is fed primarily via gastrostomy tube (G-tube). A recent swallow study indicated penetration of thin liquids. e) Feeding: The action of bringing food from plate or cup to mouth is not a problem; however, swallowing is a problem which is why he is fed with a G-tube. f) Functional Mobility: His right side of the body is weak, but his mobility is affected because he is not yet walking. He army crawls with increasing distance due to his improved ability to weight bear on his upper extremities (UEs). g) Personal Device Care: Attention to the G-tube to is necessary to avoid irritation and clogging. Shawn has a thumb spica splint with supinator strap that requires following a wearing schedule. 3. Rest and Sleep: Shawn’s multiple medications and right multi-cystic kidney disease with related pain affect his rest and sleep. 4. Play: Shawn enjoys rough and tumble play, such as swinging and other sensory based activities. He likes to explore tactile items. He may have delayed complex imaginary play due to his medical problems and lack of social interaction with peers. In terms of constructive play, Shawn is able to use both hands to release objects; however, he still needs mod. a for grading pressure when stacking blocks or completing puzzles. 5. Leisure: Shawn is producing scribbles using a crayon with a palmar grasping pattern therefore we can assume due to his immature grasp that he is developmentally delayed in fine motor skills. 6. Social Participation: Shawn provides adequate eye contact during communication, except when peers are around. Speech therapy is addressing his diagnosed oral motor delays. 7. Community: Shawn is close with his older brother and parents. He also interacts with peers but is easily distracted. Movement, Postural Reactions and Reflexes Shawn’s flexibility is within functional limits (WFL) with the exception of his RUE. The use of neurodevelopmental treatments (NDT) and stretching can increase his range of motion (ROM) and overall function. Shawn uses the army crawl method of ambulation and he can independently get into
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and maintain a quadruped position. His ability to crawl and maintain quadruped demonstrate motor coordination WFL. Shawn struggles with muscular coordination of the extensor muscles in the RUE, which are needed to increase his endurance for maintaining hand extension. Shawn struggles with grading the muscular power and strength needed for different activities. Shawn exhibits increased tone in the RUE which affects his coordination, endurance and fine motor dexterity. He also struggles with postural tone. Further evaluation of his anticipatory postural control, protective reactions, righting reactions and equilibrium reactions would be needed for specifics; however, based on his enjoyment in swinging, it can be assumed that most of his postural reactions are on track for his gross motor abilities. Shawn’s ability to change his head position in space during swinging and different movement patterns, such as into and out of quadruped and army crawl positions, indicates his reflexes are intact and effective. Sensory Integration and Self-Regulation Issues Shawn appears to be exhibiting delays in some areas of sensory integration and self-regulation, while showing progress in others. To explain, Shawn is experiencing difficulty with grading movement with his fine motor skills however, has shown significant progress with his attention and motivation to engage in fine motor activities. Shawn is also experiencing poor tactile perception and discrimination as he is having difficulty with fine motor tasks such as coloring (Michelle, 2010). He is demonstrating poor muscle tone and/or coordination according to his suggested developmental skills for his age group. In addition to poor muscle tone and coordination, play is being affected and he presents issues with play. He is unable to engage in appropriate play for his age; however shows great interest when playing with sensory based activities and exploring different tactile items. He demonstrates this by participating in sensorimotor exploration by putting things in his mouth. Also, when Shawn’s peers are present in the room his ability to maintain visual attention is difficult for him because of noise and/or sound disturbance. Lastly, due to Shawn’s method of consuming nutrients through the G-tube and non-oral feeding, he experiences a hypersensitivity to oral input. Assessments for Evaluation To assess Shawn, we decided to use the Peabody Developmental Motor Scales because it tests the domains of gross and fine motor in children from birth to 5 years of age. The Peabody contains six subtests which include Reflexes, Stationary, Locomotion, Object Manipulation, Grasping, and VisualMotor Integration. We chose to use the Peabody assessment because it is appropriate for Shawn’s age and it will address his current delays in gross motor, fine motor, object manipulation, and visual motor integration (Markusic, 2011).The feeding assessment for Shawn consisted of a thorough case history, a mealtime questionnaire provided by his parents as well as clinical observation of Shawn’s body and oral structures at rest and when he was performing oral motor tasks. We decided to use the Oral Motor Case History assessment from, Oral Motor Assessment and Treatment: Ages and Stages by Diane Bahr as well as the Parent Mealtime Questionnaire for Tube Feedings and Beginning Oral Feedings from PreFeeding Skills by Suzanne Evans Morris and Marsha Dunn Klein. The case history, questionnaire, and
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clinical observations allowed us to assess Shawnâ€™s speech, body posture, stability, responses to sensory input, respiratory control as well as movement, strength, coordination and accuracy of his jaw, lips/cheeks/ and tongue. An oral motor assessment was needed to identify muscle function and motor planning and coordination issues. A childâ€™s body posture, muscle tone, stability, coordination, responses to sensory input and respiratory control are all vital for development and refinement of oral motor and feeding skills. Functional Problem Statements 1) Client has difficulty maintaining visual attention while performing swinging and performing tactile exploration with peers present due to sensory processing issues. 2) Client has difficulty extending his right hand, including wrist and fingers, in a weight bearing position and has an immature grasping pattern due to mild spasticity. 3) Client requires mod. a when stacking blocks or completing puzzles due to poor postural stability and inability to properly grade pressure and right hemiparesis. 4) Client is experiencing oral hypersensitivity due to the G-Tube and penetration of only thin liquids. 5) Client requires mod. a performing ADLs, such as dressing and grooming, due to right hemiparesis, developmental delays, and mild spasticity. Family/Caregiver/Child Goals 1) 2) 3) 4) 5)
I would like for Shawn to have the ability and desire to play more often with his peers and older brother. I would like for Shawn to have his G-tube removed and be able to eat normally. I would like my child to start eating purees and eventually start incorporating solid finger foods. I would like for Shawn to have the strength and ability to walk. I would like Shawn to be able to gain function in his right arm in order to do every day activities such as getting dressed and play. Occupational Therapy Goals, Objectives & Activities
1. Client will be able to reduce sensitivity to different oral stimuli with mod. a by use of oral textured tools and proper lip closure within 12 weeks in order to work towards medical clearance for removal of the G-Tube. a. Objective 1: Client will be able to tolerate oral stimuli with max. a by use of light touch directly on the mouth within 6 weeks in order to prepare for internal oral stimuli. i. Activity 1: Have the child swing horizontally while sitting on a platform swing within an inner tube. Child will swing towards the therapist while therapist sings a song and pauses the swing intermittently to provide light touch on the childâ€™s mouth and lips. This will help to prepare for internal oral stimuli.
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ii. Activity 2: Provide child with different food options, such as peanut butter, mashed potatoes and frosting. Place a dab of different foods onto different external areas of his mouth. Have child use only tongue to lick off the dabs off food. This promotes tongue lateralization which is necessary for feeding and eating. b. Objective 2: Client will able to reduce sensitivity to internal oral stimuli with mod a by use of only light texturized oral tools with proper lip closure within 10 weeks. i. Activity 1: Therapist will push the child on the swing while singing a song together to work on proper lip closer, such as “Apples and Bananas”. This song requires mouthing the words “I like to eat Apples and Bananas” by replacing the letter “a” in “Apples and Bananas” with all of the different vowels. Working on mouthing different mouth shapes will help address proper lip closure. ii. Activity 2: Provide child with clear cups that are filled with color dyed water and insert straws into each cup. Have the child blow bubbles into each cup by placing mouth on the straws. Having the child use straws to blow bubbles will help address working on proper lip closure. 2. Client will be able to self-feed and eat pureed food on a spoon by using LUE with min a within 24 weeks to reduce hypersensitivity. a. Objective 1: Client will be able to use LUE control to bring spoon to mouth containing food with mod a within 8 weeks. i. Activity 1: Have the child sit in front of a table with a utensil in LUE. Place a container with small items and toys on the child’s right side and ask child to scoop out specific items and transfer them into an empty container on child’s left side. This addresses motor control and coordination required for selffeeding by learning to control the spoon while balancing the food. ii. Activity 2: Have the child sit in front of a table with the Feed the Animals game, have the child use utensils provided in the game to grip food and balance the food in order to place the food into the animal’s mouths. b. Objective 2: Client will be able to take a bite from a spoon with lip closure with SBA within 16 weeks. i. Activity 1: Place different liquids inside 3 different sippy cups that have spouts or straws. Have child take 3 sips from each cup which addresses internal jaw stabilization at tempomandibular joint, as well as the coordination needed for sucking. ii. Activity 2: Present child with three food options to choose from and using a Safe-Feeder, allow child to explore the flavor and texture of the food, as well as working on oral strength and coordination. A Safe-Feeder is a small hand-held device to insert pieces of food into a piece of netting that allows the child to suck, munch and chew new foods. This addresses transitioning food from spoon to mouth because it is working on different oral motor and chewing skills.
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3. Client will have more functional use of right hand during play as indicated by using the right hand as a stabilizer during bilateral UE play within 24 weeks. a. Objective 1: Client will be able to I assume quad position while weight bearing for 3 min within 6 weeks. i. Activity 1: Have child prone in hammock swing with the swing coming up below his chest. Child will be weight bearing on the floor and using his UE to pull himself forward while swinging and imitating therapistâ€™s funny faces. This will work on his UE spasticity because proprioception and weight bearing are being used to reduce the spasticity. This activity will also work on increasing his postural tone by engaging his back and neck extensors while strengthening his shoulder girdle as he weight bears on his hands. Incorporating funny faces works to engage the child while working on activation of facial and oral muscles and tongue lateralization. ii. Activity 2: Using a Tic-Tac-Toe game on the floor, have client assume crosslegged position with trunk extended while weight bearing on right hand while using left hand to throw bean bags contra-laterally across midline. This activity addresses his RUE spasticity because proprioception and weight bearing are being used to reduce the spasticity. b. Objective 2: Client will be able to use RUE with a palmer grasp to grip and release objects with mod a within 16 weeks. i. Activity 1: Using different shaped and colored blocks, have child stack blocks to match the therapists towers using the same blocks. This activity addresses bilateral coordination and proper grading for grip and release because he is required to grip the blocks, stack them with proper pressure, and release the blocks. ii. Activity 2: Using a large-pieced Lego set that requires pushing the pieces together, have the child build large towers followed by disassembling the tower. This activity addresses bilateral coordination and proper grading for grip and release because the child is required to grip the Legos, push them together, stack them, and then pull them apart.
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Treatment Plan/Session 1. Preparatory Activity Description: Have the child swing horizontally while sitting on a platform swing within an inner tube. Child will swing towards the therapist while therapist sings a song and pauses the swing intermittently to provide light touch on the child’s mouth and lips. This will help to prepare for internal oral stimuli. This activity will prepare the child for the other activities and addresses the following: a. LTG #1: Client will be able to reduce sensitivity to different oral stimuli with mod. a by use of oral textured tools and proper lip closure within 12 weeks in order to work towards medical clearance for removal of the G-Tube. b. Objective #1: Client will be able to tolerate oral stimuli with max. a by use of light touch directly on the mouth within 6 weeks in order to prepare for internal oral stimuli. 2. Activity Description: Using a Tic-Tac-Toe game on the floor, have client assume cross-legged position with trunk extended while weight bearing on right hand while using left hand to throw bean bags contra-laterally across midline. This activity addresses his RUE spasticity because proprioception and weight bearing are being used to reduce the spasticity. This activity addresses: a. LTG #3: Client will have more functional use of right hand during play as indicated by using the right hand as a stabilizer during bilateral UE play within 24 weeks. b. Objective 1: Client will be able to I assume quad position while weight bearing for 3 min within 6 weeks. 3. Activity Description: Have the child sit in front of a table with a utensil in LUE. Place a container with small items and toys on the child’s right side and ask child to scoop out specific items and transfer them into an empty container on child’s left side. This addresses motor control and coordination required for self-feeding by learning to control the spoon while balancing the food. This activity addresses: a. LTG #2: Client will be able to self-feed and eat pureed food on a spoon by using LUE with min a within 24 weeks to reduce hypersensitivity. b. Objective #1: Client will be able to use LUE control to bring spoon to mouth containing food with mod a within 8 weeks. 4. Activity Description: Provide child with clear cups that are filled with color dyed water and insert straws into each cup. Have the child blow bubbles into each cup by placing mouth on the straws. This activity addresses: a. LTG #1: Client will be able to reduce sensitivity to different oral stimuli with mod. a by use of oral textured tools and proper lip closure within 12 weeks in order to work towards medical clearance for removal of the G-Tube. b. Objective #2: Client will able to reduce sensitivity to internal oral stimuli with mod a by use of only light texturized oral tools with proper lip closure within 10 weeks.
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SOAP Note S: O:
Client reports, “This is lots of fun!” after blowing bubbles into the cups of colored water. Shawn participated in a 60-minute OT session at outpatient clinic to address oral stimuli, oral motor skills, RUE spasticity and feeding difficulties. Oral Stimuli: Shawn participated in 15 min of swinging horizontally while receiving oral stimuli of a light touch on lips and mouth. He was able to tolerate 20 light touches and also sang along with the therapist for entire duration of activity. Oral Motor: Shawn required mod. a when holding the cup with RUE while blowing bubbles. He focused on the assigned task for 10 min before becoming fatigued and asking for a break. He was able to blow bubbles I in each of the 7 colored cups and only required 1 verbal and 1 physical cue to demonstrate how the activity was to be performed. Feeding Difficulties: Shawn was able to successfully balance and transfer 6 out of 10 small toys from one container to the other using his LUE c min a . He required 3 verbal cues to be reminded to attempt the task with his LUE. Shawn took 15 min to complete this activity. RUE Spasticity: Shawn was able to assume quad for 2 min c mod a . He maintained a weight bearing position and successfully completed the Tic-Tac-Toe bean bag activity by throwing 5 bags. Shawn used his L hand to throw the bags across midline. Shawn’s RUE spasticity hinders his ability to feed himself as well as assuming quad for a prolonged period of time. Limited balance when using his LUE makes transferring food on a utensil from plate to mouth difficult. However, Shawn demonstrates eagerness and joy with smiling and squealing when reaching the food to his mouth and trying new oral textures. He is demonstrating progress in ability to maintain quad for the duration of entire activity. Client will benefit from continued skilled OT intervention to increase functional use of RUE, work on oral motor skills, and increase feeding independence. Shawn will continue to be seen 1x/wk for 60-minute sessions to improve oral motor skills, increase tolerance to oral stimuli, increase functional use of RUE and address feeding difficulties.
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Post-Discharge Environment and Recommendations
After 6 months of therapy, Shawn is able to assume quad independently for at least 5 minutes. Skilled instruction was given to parents to continue a home exercise program that includes continuing sensory based activities, ambulation skills, feeding and eating activities and oral motor functioning. After 12 weeks of therapy Shawn was able to self-feed and consume pureed foods and is now working on incorporating solid foods into his diet. Shawn can now independently transfer food from a utensil into his mouth with proper lip closure, but still needs to work on coordinating oral motor skills for chewing and swallowing. A pre-school kit with adaptive equipment has been recommended and includes adapted utensils, Dycem mats, scooper plates, and pencil grip. In continued efforts to reduce the hypersensitivity of Shawn’s mouth and increase oral stimulation, a mouth box has been suggested to the parent. The mouth box can include items such as: Nuk brush, whistles, teething toys, chew tubes, and bubbles. Some parent education about these devices may be necessary. Ensure that home environment provides adequate space and accessibility for Shawn to get around and assume quad. A list of suggested adaptive devices was sent home with the parents that included equipment to promote performing independent ADLs such as grip bars and a step stool. Shawn needs to continue to be seen in outpatient occupational therapy to continue progressing towards appropriate developmental milestones.
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Justification of Treatment 1. Our interventions of addressing feeding and progress towards removal of the g-tube are supported by the article titled, “Early Intervention to Promote Oral Feeding in Patients with Intracerebral Hemmorage: A Retrospective Cohort Study”. In this article it states that: “Stroke often alters a patient’s dietary intake because of both dysphagia and impaired consciousness…Although swallowing difficulties generally improve naturally and quickly, in approximately 10% of patients, problems may persist for six or more months…To provide adequate nutrition, the insertion of a nasograstric tube or a percutaneous endoscopic gastrostomy may be performed in patients, [but] there is a high incidence of chest infection and death associated with both methods of tube feeding” (Takahata, 2011). This statement is supportive because it addresses the importance of moving Shawn towards removal of the g-tube and progressing towards solid foods and learning to self-feed and eat. 2. For our first long term goal regarding proper lip closure, our activity consisted of using a straw to blow bubbles into cups with different colored water. This intervention is supported by the article titled, “Teaching Chewing: A Structured Approach”, which states that, “The lip control component consisted of teaching the child to close his or her lips first around a licorice stick and eventually suck from a straw” (Eckman, 2008). It is a supporting article because it addresses the fact that in order for a child to progress towards the act of eating, they must first learn to have proper oral motor skills in order to close their lips around a utensil to transfer the food into their mouth. 3. For our last long term goal regarding Shawn’s ability to self-feed and eat, our activity consisted of using a Safe-Feeder for him to explore different tastes and textures. This intervention is supported by the article titled, “Specialized Knowledge and Skills in Feeding, Eating and Swallowing for Occupational Therapy Practice”. This article introduced us to the different impairments and disabilities that can cause feeding and eating problems. We were able to utilize the article’s definitions of feeding, eating and swallowing to guide us towards the progression of each stage. The article states: “Feeding is the term used to describe the process of setting up, arranging, and bringing food or fluid from the plate or cup to the mouth; sometimes called self-feeding. Eating is defined as the ability to keep and manipulate food or fluid in the mouth and swallow it; eating and swallowing are often used interchangeably…Swallowing involves a complicated act in which food, fluid, medication, or saliva is moved from the mouth through the pharynx and esophagus into the stomach” (Frolek, 2006) 4. We used the article, “Specialized Knowledge and Skills in Feeding, Eating and Swallowing for Occupational Therapy Practice” again for support of our overall intervention of feeding and eating. We believed that feeding and eating takes precedence over any other intervention because it is the basic necessity for life. This belief is supported in this article with the statement that, “Feeding and eating, essential to human functioning for nourishment of the body, is a form of social interaction and is involved in many facets of a person’s culture—from leisure to professional activities” (Frolek, 2006).
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References Bahr, C. D. (2001). Oral Motor Assessment and Treatment: Ages and Stages. Needham Heights, MA: Allen & Bacon Danto, A., & Pruzansky, M. (2011). 1001 pediatric treatment activities. Thorofare: SLACK Incorporated. Eckman, N., Williams, K.E., Riegel, K., & Paul, C. (2008). Teaching chewing: A structured approach. The American Journal of Occupational Therapy, 62, 514-521. Frolek Clark, G., Avery-Smith, W., Wold, L., Anthony, P., & Holm, S. (2006). Specialized knowledge and skills in feeding, eating, and swallowing for occupational therapy practice. The American Journal of Occupational Therapy, 61(6), 686-700. Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: writing soap notes. (3rd ed., p. 37). Thorofare, NJ: SLACK Incorporated. Markusic, M. (2011, November 24). How to assess the motor skills in early childhood: Using the pdms. Retrieved from http://www.brighthub.com/education/special/articles/13499.aspx Michelle. (2010). Sensory processing disorder. Retrieved from http://www.sensory-processing disorder.com/sensory-processing-disorder-checklist.html Morris, S.E., & Klein, M.D. (2000). Pre-feeding skills: A comprehensive resource for mealtime development. Austin, TX: Therapy Skills Builders. Takahata, H., Tsutsmi, K., Baba, H., Nagata , I., & Yonekura, M. (2011). Early intervention to promote oral feeding in patients with intracerebral hemorrhage: a retrospective cohort study. BMC Neurology, 11(6).