Occupational Therapy (Geriatric) Kawa Model Case

Occupational Therapy Case Presentation (Geriatrics)

Prepared by: Teoh Jou Yin (A 118729)Occupational Therapy ProgrammeFaculty of Allied Health SciencesNational University of Malaysia

Occupational Therapy: Helping people live lives THEIR way.

~ British Association of Occupational Therapy

Demographic Data

Name: N

Age: 80

Marital Status: Married

Race: Chinese

Religion: Taoist

Diagnosis: CVA w/ Expressive Aphasia

Date of Referral: 24 June 2010

Date Seen: 29 July 2010

Cerebral Vascular Accident (Stroke / CVA)

A stroke is a sudden onset of neurologic deficit due to disruption of vascular function. This may be caused by partial or total blockage of blood vessels to the brain by a hemorrhage, or blood clot, of the brain.

There are three groups who are at a high risk for stroke. People with transient or mild neurologic events, those with a cardiac disease that predisposes to embolism, and asymptomatic people with a carotid bruit (indicating a blockage) comprise this group. Those who have experienced TIAs (transient ischemic attacks) also have a high risk for stroke. TIAs are indications of cerebrovascular disease and are a warning that a CVA could occur at any time.

(Source: Encyclopedia of the aging and the elderly.)

What is Occupational Therapy’s role?

To FACILITATE / ENABLE / EMPOWER clients to engage and participate in life processes and activities that are important and of value to them, i.e. to do the things in life that they want to do and need to do.

(Teoh et al. 2010)

How to do that?

CONCEPTUAL MODEL

OF PRACTICE

Conceptual models of practice describe phenomena of interest like “occupation” or “occupational performance”, guide treatment approaches by easily allowing therapists to focus on the right problem areas, and help to predict outcomes in clinical interventions.

(Iwama 2010)

The Kawa Model

The essence of the Kawa Model (Iwama 2006) is basically to enable occupational therapists everywhere to “just ask the client how they want to live their lives so that it is more meaningful to them, and look together with them at what we can do to achieve that.”

The Kawa Model can be used as a conceptual model of practice, frame of reference, assessment tool and modality. (Iwama 2010)

It can be used with any population since it is based on the client's own perceptions of what is important to them, and the only possible contraindication is an occupational therapist unskilled in the therapeutic use of self.

DISCUSS THE KAWA MODEL ON FACEBOOK!

http://facebook.com/KawaModel


OCCUPATIONAL THERAPY

PERFORMANCE FRAMEWORK

A summary of interrelated constructs that represent and guide occupational therapy practice and articulate occupational therapy’s

contribution to promoting health and participation through engagement in occupation.

(AOTA 2008)

Areas of Occupation-Activities of daily living (ADL)- Instrumental activities of daily living (IADL)- Rest and sleep- Education- Work- Play- Leisure- Social participation

Client Factors-Values, beliefs and spirituality- Body functions- Body Structures

Context & Environment-Cultural- Personal- Physical- Social- Temporal- Virtual

Performance Skills-Sensory perceptual skills- Motor and praxis skills- Emotional regulation skills- Cognitive skills- Communication & social skills

Performance Patterns-Habits- Routines- Roles- Rituals

Activity Demands-Objects used and time properties- Space demands- Social demands- Sequencing and timing- Required actions- Required body functions- Required body structures

EVALUATION

SUBJECTIVE EVALUATION

STEP 1: FIND OUT WHAT THE CLIENTS WANT AND NEED.

Kawa Interview (27/7/2010, 25/8/2010) – http://facebook.com/KawaModel

Blue - river - life processes and overall occupationsRed - river walls and floor - environments, social & physicalLilac - rocks - circumstances that block life flow and cause dysfunction/disabilityYellow - driftwood - personal resources that can be assets or liabilities.


Life Flow / Overall OccupationsSignificant events and activities that the client regards as important,

meaningful and of value.

Past(Medical Hx)

Client was admitted for CVA at 15 June 2010 with sudden onset of expressive aphasia.Client was diagnosed with basal ganglia calcification, enlarged ventricles, and cerebral atrophy.Client was previously amputated due to DM on 1st and 2nd right toe in Hospital Ampang a few years ago (family cannot recall.)Client also had left BKA due to DM on 24/4/2009 at HSB.Client sits on w/c, no mobility because of bilateral upper limb weakness.Client has hx of IHD, DM, and uncontrolled BP.Client had dysphagia (cannot swallow) and fed by tube.

Previous medications: C gemfibrozil 300mg BD, T aspirin 150mg OD, T amlodipine 10mg OD, T losartan 100mg OD, T Glucovance (metformin 500mg & glibenclamide 2.5g) 1 tab BD, T Vit B1, B6, B12, 1/1 OD.



Present(Medical Hx)

Client is dysfunctional in right eye and left eyesight impaired.Client wears glasses.Client still has aphasia but now able to swallow liquids.Client has not been examined by medical doctors in HSB specific to her diagnosis since discharge.Client is supposed to visit doctor on 26/8/2010.Medical services client currently engages include occupational therapy and acupuncture (3 times a week, home visits.)Client also goes to pharmacy for minor ailments, i.e. fever, sore throat, flu, etc.



Past(Occupational Hx)

Client used to work as a rubber tapper.After retirement, client was a homemaker.Client spent most of her time in household mx, i.e. cleaning and cooking for family.Client’s hobby was to socialise with friends.

Present(Occupational Hx)

Client stopped socialising with friends after amputation.Client is totally dependent on meal preparation and home mx.Client is totally dependent on family for community mx, i.e. transportation, shopping and finances.Client is completely dependent in functional mobility i.e. moving w/c due to bilateral arm weakness.Client wears diapers, totally dependent on caregivers to change.

EnvironmentsThe variety of interrelated conditions surrounding the client in which

the client’s daily life activities occur. (AOTA 2008)

Physical(Home)

Client and family stay in Chinese New Village.Standalone house, cement, squatting toilet, single storey.W/c cannot fit into bathroom, leave outside and transfer client into chair to bathe.Client’s husband uses commode, cannot squat.Location 30 minutes to hospital, no public transport.No nearby health facilities, nearest pharmacy 30 minutes away.

Social(Family Hx)

Client and husband (88) stay together with eldest son (widower, 60s) and their 4 grown grandchildren.Eldest son used to be odd job labourer.3 elder grandchildren are working in factories, youngest (25) is caregiver at home.3 other children stay away with their own families. They help out occasionally (i.e. bring mom to hospital.)Caregivers used to leave pt behind during OT tx.

Personal Assets & Liabilities(Client & Family)

Personality Traits Client: Peaceful, diligent, hardworking, relaxed.Client’s husband: Bad temper, demanding, domineering.Client’s eldest son: Good natured, sensible, responsible.Client’s younger son: Domineering, rough, choleric.

Financial & Material Resources

Client’s primary caregiver (eldest son) no longer works – retirement. Client’s other caregiver, youngest grand daugther does not work either.Client and family depend on 3 grandchildren for expenses.Caregivers don’t have car, need to rent car to come to hospital (RM70.00/trip to and fro.)Clients primary expenses are on milk power ( costs RM 70.00 per tin and finishes in one week and diapers (2 boxes per month.)Acupuncture RM60.00 per session (3x/week)

Beliefs, values and principles

Client and family pray to Guan Yin.Client’s eldest son believes in making the best he can.Client’s eldest son believes in taking care of his parents.

Obstructions to Life FlowOccupational performance difficulties

Client’s son (primary caregiver) feels difficult having to handle both elderly parents at home.Client is unable to alert caregivers of bowel and bladder movements as well as any other immediate needs.

Fears and concerns Primary caregiver (client’s son) is in his 60s.Only 2 caregivers – worried that if anything happens to one of them, the other unable to cope.

Inconvenient circumstances

- Financial difficulties.- Language barrier causing communication difficulty for caregivers and professionals.-Client’s husband (88) is also significantly dependent on caregivers, able to ambulate with assistance, unable to squat, bad temper.

Impairments / Medical Conditions

Client wishes to have a prosthesis made, feels self conscious about stump.Client is unable to recognise items in 2D form after stroke (according to family.) Client can recognise the physical items themselves but cannot recognise pictures. (only detected on 25/8/2010)

EVALUATION

OBJECTIVE EVALUATION

STEP 2: VERIFYING THE DETAILS.

AREAS OF OCCUPATION

Categories articulating “the many types of occupations in which clients might engage” (AOTA 2008)

Activities of daily living (ADL), Instrumental activities of daily living (IADL), Rest and sleep, Education, Work, Play, Leisure, Social participation

Areas of Occupation

1. Activities of Daily Living (MBI) – 25.8.2010

Activity Score Description

Personal Hygiene 3/5 Moderate Help Required

Bathing 1/5 Substantial Help Required

Feeding 5/10 Moderate Help Required

Toileting 0/10 In diapers

Stair Climbing 0 Unable to climb stairs.

Dressing 2/10 Substantial Help Required.

Bowel Control 0/10 In diapers

Bladder Control 0/10 In diapers

Chair/Bed Transfer 0/15 Unable to transfer

Wheelchair 0/15 Unable to mobilise

Total 11/100 Total dependency

INTERPRETATION

Identifying and prioritising AIMS.

STEP 3: IDENTIFYING AND PRIORITISING AIMS.

Prioritised Problem List Short Term Goals

Safety concerns: Client is unable to alert family of emergencies.

To enable client to have a form of communication to alert family of emergencies.

Client-caregiver communication concerns due to aphasia.

To enable caregivers to address client needs.

Client-professional communication concerns due to language barrier.

To address caregiver-professional communication difficulties

Caregiver stress. To address caregiver needs and concerns and facilitate psychosocial/emotional support

Long Term Goals

To ensure client receives optimal care appropriate to her condition to the end of her life. To maintain current level of functioning and prevent unnecessary deterioration.

INTERVENTION

STEP 4: OCCUPATIONAL THERAPY TREATMENT PLANNING

Problem: Safety concerns - Client is unable to alert family of emergencies.Aim: To enable client to communicate with family during emergencies.

Cause:Expressive aphasia. Client unable to talk at all.

Solution:Caregivers are advised to get client a bell or alarm to help her communicate with them when she is experiencing discomfort or danger.

Rationale:

With client’s current fragile condition (polypharmacy, old age, multiple medical conditions - diabetes, heart disease, inconsistent BP, etc) client is always at risk for developing safety issues (falls, fainting, myocardial infarction, more strokes, etc.)

Safety first.

Assessed: 25.8.2010

Implemented: 25.8.2010

Problem: Client-caregiver communication difficulties.Aim: To enable caregivers to address client needs.

Cause:Expressive aphasia. Client unable to talk at all.

Solution:Prescription of a graphic communication tool, i.e. communication board or talking mat, with large pictures and words.

Rationale and implementation:

Client is illiterate, has low education and visual impairments.

Client still retains use of hands, is able to use hands to hold pieces of paper, flip them and point.

Client to use pointing of pictures as form of communication.

Assessed: 27.7.2010


Problem: Caregiver-Professional communication difficulties.Aim: To address caregiver-professional communication difficulties.

Cause:Language Barrier – Caregivers only able to communicate in Mandarin, Hakka and very elementary Malay.

Solution:Family conference guided by Kawa framework.

Implementation:

By use of the Kawa Interview, client and caregiver experiences are assessed and addressed as a collective by occupational therapist who understands their language.

Findings are then translated into English and notes are written to be passed to health professionals concerned (i.e. rehab doctor.)

Assessed: 25.8.2010


Problem: Caregiver Stress.Aim: To address caregiver needs and concerns and facilitate psychosocial/emotional

support . Cause:Caregivers face difficulty discussing problems with health professionals to get proper guidance.

Solution:Family conference guided by Kawa framework.

Implementation:

By use of the Kawa Interview, client and caregiver experiences are assessed and addressed as a collective.

The Kawa interview provides opportunities for the caregivers to express their feelings and concerns to professionals which they otherwise might not have brought up to be addressed.

Assessed: 25.8.2010


Outcomes (25/8/2010)- Client was unable to use graphic communication tool designed by therapist

as client had visual difficulties.- Family was satisfied with conference and appreciated the valuable

opportunity to express feelings and concerns.

(2/9/2010)- Family has received referral letter from doctor to make OKU card, is finalizing

application procedures.- Family has has also become more cooperative and enthusiastic towards

occupational therapy tx, making sure to accompany client and discuss developments with occupational therapists.

Prognosis

Poor. Client and family have excessive external environment constraints that are outside of control. Client also has multiple complications coupled with aging.

Awareness and education is most important and wellbeing of caregivers must be taken into account.

Future Plans

Regular reassessments.Maintain basic body functions.Palliative care.Caregiver education for grand daugther (2nd primary caregiver.)“Design Your Life” activity for client/caregiver collaboration in goal setting.

Once one has crossed the threshold of personal ADLs, the space has already been occupied … So why not seize the opportunity to discuss the things that matter the most?

(Christiansen 2010)

Further Questions or Discussion?


Dr Michael Iwama will be happy to hear from you.

(As well as 1000+ OTs from 6 continents all around the world.)


Occupational Therapy (Geriatric) Kawa Model Case

Health & Medicine

Transcript of Occupational Therapy (Geriatric) Kawa Model Case