Client:

Frances James, MRN: 001122 - inpatient rehabilitation ward

Implications of Diagnosis

Outline the implications of the client’s diagnosis on their occupational performance Max 100 words.

Frances is diagnosed with early-stage dementia. Her MoCA score indicated mild cognitive impairment, particularly in attention and delayed recall, consistent with difficulties observed during self-care.

An L5 fracture and back pain contribute to difficulty bending and reaching, affecting lower-limb showering and dressing (Inose et al., 2022). Reduced attention, memory, and sequencing contribute to difficulty locating items and completing self-care activities. Frances reported poor sleep due to lower back pain. She has reduced participation in bowling and has stopped cooking complex meals, affecting productivity. Cognitive impairment can affect initiation, planning, and participation in IADLs and leisure occupations (Cipriani et al., 2020).

Assessments

Outline the assessments to be used for your client. Indicate the findings the client obtained and provide clinical interpretation. Max 200 words – consider use of tables to display results only (table only not in word limit)

The FIM was completed collaboratively by the MDT. In contrast, lower-body dressing, problem-solving, and memory were completed by the OT due to their relevance to Frances’s identified occupational performance difficulties.

Frances’s FIM scores indicated moderate assistance required during lower-body dressing (3/7), minimal assistance required for memory (4/7), and supervision for problem-solving (5/7). Although she demonstrated stronger problem-solving skills, she required physical assistance and verbal prompting to complete aspects of lower-body dressing. The findings were directly used to inform the choice of lower-body dressing as the priority area of intervention.

During meal preparation, Frances demonstrated difficulties locating items, sequencing steps, and required verbal cueing, indicating cognitive difficulties affecting her functional performance.

Justification

Demonstrate your clinical reasoning and justification for the choice of your assessments. Max 250 words

The FIM was selected to assess Frances’s level of functional independence during lower-body dressing. It is a standardized assessment and is used in inpatient rehabilitation settings to set goals and evaluate outcomes. The FIM uses an 18-item, 7-point scale with scores ranging from 1 to 7.

Evidence indicates that the FIM is a valid and reliable assessment. A study showed that across 20 impairment categories, the internal consistency was high, with Cronbach’s alpha ranging from 0.88 to 0.97 for the total FIM, 0.86 to 0.97 for the motor FIM, and 0.86 to 0.95 for the cognitive FIM. The study also demonstrated good convergent validity of 95.8% for motor FIM items (Stineman, 1996).

The FIM is appropriate for Frances as the rehabilitation setting provides the equipment and environment required to observe her functional performance. It requires training; therefore, administration will be provided under the supervision of an OT supervisor who has completed the training. The FIM typically ranges from 30 to 45 minutes, depending on the patient (Zeltzer, 2011).

The non-standardized functional meal preparation assessment was selected using task analysis to provide an observation of Frances’s performance during a simulated real-life IADL. Performance-based assessments reflect real-world functions that are influenced by environmental factors, activity demands, and cognitive ability (Lee et al., 2025).  Observation of IADL performance provides information regarding functional abilities that may not be identified through a standardized assessment (Rawtaer et al., 2021). This is appropriate for Frances, as an observation assessed how her difficulties with planning, sequencing, and locating items impact meal preparation within a simulated rehabilitation environment.

Occupational Performance Problem Statements

Select 2 problem areas that you will be addressing in your treatment plan. Write 2 occupational performance problem statements. (no word limit)

• Frances has difficulty dressing her lower body independently due to difficulty bending and reaching, associated with an L5 fracture and lower back pain.
• Frances has difficulty preparing a simple meal independently due to difficulties with planning, sequencing, and item location.

Goals

Write 2 SMART goals that align with your problem statements (no word limit)

1

Frances will independently dress her lower body while seated on a chair, using an Ezy Reacher and a visual sequence, taking a 5-minute break as required, by 25 November 2026

2

Frances will independently prepare a simple meal (e.g. making a soup) in the rehabilitation kitchen within 30 minutes, using a step-by-step visual sequence and taking a 5-minute break as required, by 25 November 2026.

Intervention - Max 350 words

Prior to session:

• Obtain Ezy Reacher.
• ID confirmed, consent obtained.
• Select loose-fitting outfit.
• Set up a chair with armrests.
• Ensure the environment is free from fall hazards.
• Location: rehab pre-treatment room.

Session 1: simulated lower-body dressing and introduction

• Time/duration: 40 mins, 10:00 am.
• People: OT student, Frances.
• Equipment: Ezy Reacher, chair with armrests, pants/underwear, visual sequence.
• Approach: adaptation/compensation, skill acquisition.
• Intervention:
• Set up a simulated lower-body dressing with Frances seated on a chair with armrests and clothes positioned near her.
• Model and educate Frances on using the Ezy Reacher to dress herself.
• Introduce the step-by-step visual sequence and explain each step to her. Frances will practice using the Ezy Reacher and putting the clothes over her feet while avoiding bending forward.
• Provide prompts and cues as required.

Session 2: Dressing sequencing.

• Time/duration: 40 mins, 10:00 am.
• People: OT student, Frances.
• Equipment: Ezy Reacher, chair with armrests, pants/underwear, visual sequence.
• Approach: Skill acquisition, task adaptation.
• Intervention:
• Frances will practice completing each step seated using the visual sequence and Ezy Reacher. Frances will practice identifying the next step before referring to the visual sequence. Clothes will be within reach.
• Frances will practice pulling the clothes over her feet and legs while maintaining an upright trunk.
• Verbal prompts, cues, and rest breaks will be provided as required. Monitor sequencing, technique, and fatigue.

Session 3: ADL retraining.

• Time/duration: 30 mins, 10:00 am.
• People: OT student, Frances.
• Equipment: Ezy Reacher, chair with armrests, pants/underwear, visual sequence, PUF, PB.
• Approach: Skill acquisition, education.
• Intervention:
• Frances will practice completing dressing in manageable steps and taking a 5-minute break as needed.
• She will practice pulling the clothes past her knees, completing STS using the chair armrests, PUF, and the PB, and pulling them over her hips.
• Educate Frances on pacing and gradually reduce verbal prompts as sequencing improves.

Session 4: full lower-body dressing

• Time/duration: 20 mins, 10:00 am.
• People: OT student, Frances.
• Equipment: Ezy Reacher, chair with armrests, pants/underwear, visual sequence, PUF, PB.
• Approach: Skill acquisition, adaptation/compensation
• Intervention:
• Frances will complete full lower-body dressing, using the visual sequence and Ezy Reacher, while seated, to pass the clothes over her feet and legs, then completing STS to pull them over her hips.
• Help only when required and feedback regarding equipment use.
• Monitor safety, sequencing, pain, and fatigue.
• Provide written instructions regarding equipment use, a copy of the visual sequence and purchasing options for the Ezy Reacher. With consent, contact her daughter regarding equipment options and dressing strategies for carryover.

Justification for intervention

Provide justification and evidence to support the approach Max 250 words

A compensation/adaptation and skill acquisition approach was selected to address Frances’s difficulties with lower-body dressing and to promote repeated practice. The Ezy Reacher and seated dressing techniques were selected to reduce forward bending and reaching, addressing the physical demands of dressing. The PUF and PB were used as part of the safety strategies for STS during dressing. Assistive technology, including dressing aids, can improve independence, participation, and safety in daily activities (American Journal of Occupational Therapy, 2024).

The visual sequence was incorporated to support Frances’s difficulties with sequencing and memory and reduce reliance on verbal prompting. Cannings et al. (2024) stated that breaking activities into smaller steps supports task completion and independence for people living with dementia.

Energy conservation and pacing were incorporated to manage pain-related fatigue and support safe, sustained participation in self-care (Barakou et al., 2023). Seated dressing and bending avoidance support Frances’s safety, given her fall history. Verbal prompting was initially provided to support task completion, with prompts gradually reduced as Frances demonstrated increased independence.

Written education and involvement of Frances’s daughter support carryover of the Ezy Reacher and dressing strategies beyond the short time period in the inpatient setting. This will facilitate continued use of compensatory strategies following discharge. These strategies aim to improve Frances’s independence while supporting safe discharge planning.

Re-Evaluation

Outline how you will measure the achievement of your goals and effectiveness of your intervention. What will you do next? Provide the scores obtained by your client and clinical interpretation. Max 150 words

The FIM is re-administered after four weeks to evaluate Frances’s progress and independence. Her lower-body dressing score is compared with her admission score (3/7). At discharge, Frances scored 6/7, indicating modified independence using an Ezy Reacher. Her problem-solving remained the same at 5/7, and her memory increased from 4/7 to 5/7, indicating reduced prompting required during dressing. This demonstrates that Frances has achieved her goal of completing lower-body dressing using the Ezy Reacher and visual sequence without physical assistance. OT will liaise with Frances’s daughter regarding ongoing support at home, provide options for equipment purchase, and refer her to community OT for ongoing support. After discharge, further OT intervention may be needed to monitor continued use of the Ezy Reacher, visual supports, and safety strategies in Frances's home environment. This will help to identify if there are changes in cognitive function or physical ability that impact occupational participation.

Justification for re-evaluation

(Provide justification and evidence to support the approach) Max 200 words

Given the established validity and reliability of the FIM, it was selected as an outcome to evaluate changes in Frances’s functional independence following intervention. Re-administering the FIM allows comparison of scores and identifies changes in the level of assistance required for lower-body dressing, problem-solving, and memory. This is relevant to Frances’s intervention, which aims to reduce physical assistance and verbal prompting during lower-body dressing through the use of the visual sequence and an Ezy Reacher. FIM has demonstrated responsiveness to functional changes in older adults undergoing inpatient rehabilitation, supporting its use as an outcome measure (Arcolin et al., 2023). It is also used to measure functional changes between admission and discharge (Scott et al., 2024).

The FIM was selected over the Barthel Index (BI) because it evaluates both motor and cognitive aspects and provides a 7-point scale reflecting the level of assistance required. In contrast, the BI, although it assesses physical ADLs, uses a 5-point scale and does not indicate the level of assistance required. Evidence suggests that the FIM has a lower floor effect than the BI and demonstrates changes over time (Lee et al., 2022). This makes the FIM appropriate for Frances, as it enables changes in her level of assistance and independence over time.