Reason for Services
What is Kim’s primary reason for receiving occupational therapy?
Recovery and rehabilitation following a coronary artery bypass graft (CABG)
What kind of work does Kim do?
Part-time convenience store clerk
What is Kim’s home environment like?
A second-floor walkup apartment with her dog and parrot
What recent changes in Kim’s health impacted her routines?
Fatigue and decreased ability to complete tasks before her surgery
What is Kim’s top goal related to her living situation?
To return home and resume caring for her pets
What secondary diagnoses may impact Kim’s occupational performance?
Congestive heart failure, diabetes, hypothyroidism, and schizophrenia
What are some of Kim’s job responsibilities?
Moving boxes, stocking shelves, and managing the cash register.
What barriers might her home environment present?
Physical access challenges post-surgery due to stairs and no in-unit laundry
What mental health factor is crucial for consistent performance?
Adherence to schizophrenia medication to prevent functional decline
What emotional goal supports Kim’s mental health?
Maintain contact with her pets and structured routine through the day program
Why is energy conservation a likely therapy focus for Kim?
She experiences fatigue with minimal exertion and has a history of heart failure
What was a key factor that limited Kim from finishing college?
She was diagnosed with schizophrenia during her sophomore year
What support system does Kim have nearby?
A neighbor caring for her pets and a sister who lives far away
What personal habits may impact Kim’s therapy outcomes?
Limited social interaction and minimal community engagement
What community-based goal supports Kim’s recovery?
Return to her day hospital program for continued psychosocial support
What is Kim’s goal regarding her home life?
To return home to live independently and care for her pets, Casey and Cleo
What community support program does Kim attend?
A day hospital program 2 days a week with a case manager and psychologist
How does Kim’s social background influence her support system?
She is quiet, socially reserved, and has few close relationships
What self-care activities may be difficult for Kim post-CABG?
Climbing stairs, laundry, and pet care due to energy and mobility demands
What work-related goal might be appropriate?
Resume part-time work tasks as tolerated, with pacing and body mechanics strategies
What services has Kim received?
OT, PT, nursing care
How does Kim manage her schizophrenia?
She takes medication consistently, which helps her maintain stability
Why are Kim’s pets considered a major contextual factor?
They are her primary source of companionship and emotional support
What is Kim’s driving status, and how does it relate to independence?
She drives short distances for errands, supporting her independent living
What occupational therapy goal would address her overall well-being?
Improve endurance and functional capacity for self-care and IADLs