KAWA MODEL FACULTY OF HEALTH SCIENCES NAME: KHOR WAI ON MATRIX NUMBER: A124590PROGRAM/YEAR: OCCUPATIONAL THERAPY/ 4TH YEAR SUBJECT: NNNK 4065 ORIENTATION AND MOBILITY CLINICAL PLACEMENT
INTRODUCTION• According to ICD – 9: – Retinitis Pigmentosa (RP) is a name to a group of hereditary disease that cause degeneration of retina. – Progressive deterioration: 1. Loss of night or low light vision due to affected Rod. 2. Peripheral vision may deteriorate until left only straight-ahead or “tunnel vision”. 3. Cones concentrated in the center of the retina (macula) may slowly lose function, resulting in central blurred vision lacking color perception. – A form of RP known as Ushers syndrome also causes nerve damage creating deafness. – Research underway for artificial retina & replacement of defective genes.
PRELIMINARY INFORMATION DescriptionName Mr. MAge 54Gender MaleMarital status MarriedRace MalayReligion IslamOccupation Admin assistantDiagnosis Retinitis PigmentosaDate referred to OT clinic 19.4.12Referred by Optometrist
KAWA MODEL Ryuboku (Driftwood) Mizu (Water) Iwa (Rocks)KAWA Model was used as conceptual model of practice, frame of Torimaki: Kawa noreference, assessment tool soku –heki (riverand modality to this client. side-wall) and Kawa no zoko (river floor)
Mr. M’s Kawa Phase 1: Active and disease free. Phase 2: married life,Phase 4: Accident, DM started after. RP gets severe affecting more aspects of life Phase 3: surgery at both legs. Blur vision and hearing problem started, RP detected.
WATER (Life Flow and Overall Occupations)Subjectively:• Family History: Client – Among siblings, client was the only one with RP. – Married at the age of 25.
WATER (Life Flow and Overall Occupations)• Medical History: – Blur vision and partial hearing loss started since 2004 – detected RP – Surgical history: both leg surgery in year 2004 due to swelling at both legs. – Other illnesses: • DM 20 years back (Insulin injection) • HPT (Given medication) – Medication: • Insulin injection
WATER (Life Flow and Overall Occupations)• Work History: – Pre-morbid • Client was a bus driver – One secondary school for over 10 years. . – Post-morbid • Switch job to administrative assistant in the same school year 2009. • Not planning to retire so soon.• Leisure: – Pre-morbid • Gardening, travel around and jog in evening at park. – Post-morbid • Watching television, reading newspaper, and listening to radio.
WATER (Life Flow and Overall Occupations)• Routine: Time Working Days Week Days 7.00 am Wake up, bath and Wake up, bath, watch breakfast television and breakfast 8.00 am – 10.00 am Go to work Newspaper and nap 10.00am – 12.00pm Go back home and Lunch, newspaper and lunch television 12.00pm – 3.00pm Newspaper and nap Newspaper and relax 3.00pm – 5.00pm Go back to work Listen to radio and nap 5.00pm – 10.00pm Dinner, television, and Dinner, television and newspaper radio 10.00pm Sleeps Sleeps* Client read 3 sets of newspapers a day.
WATER (Life Flow and Overall Occupations)Objectively:• Self Care – ADL using MBI scored 98/100 indicating minimum dependency level – minimal supervision for stair climbing. – IADL scored 6/6, fully independent. • Phone, shopping, housekeeping, mode of transportation, medications, and finances.
ROCKS Subjectively: Visual Risk of limitation falls Feel helplessUnable to travel around freely Weakness at legs Berg’s Balance Test biVABA Cross sectional view Mr. M’s river diagram
ROCKS(Obstacles and challenges, Circumstances that block life flow and cause dysfunction/disability)Objectively:• Balance – Assessed using Berg’s Balance Test scoring 40/56 indicates medium risk of falls.• From assessment, noted that client losses balance when: – Sudden change of position. – Standing with feet together or in-front of each other. – Standing with one leg. – Standing for more than 10 minutes.
ROCKS(Obstacles and challenges, Circumstances that block life flow and cause dysfunction/disability)• From file: – Distance vision RE 6/12 and LE 6/12 – Near vision N20@ 40 cm – able to read newspaper without glasses on. i. 1/12 for Right eye.• Visual – Assessed using biVABA. ii. 1/12 for Left eye.• From assessment, noted that: iii. 1/4 for both eyes together – Visual acuity – Snellen chart – Client’s pupil does not constrict instantly in respond to light stimulation. ( 1 – 2 minutes to respond) – Size of pupil changes very slightly in respond to accommodation. – Visual field – unable to see in all 6 position for red dot. – Kinetic 2 person confrontation test, client has limited vertical visual field – only less than 10 degree for both eyes.
RIVER WALLS & FLOORFriends School House Colleagues principle Children Wife & physical environmentCross sectional view Family WorkMr. M’s river diagram
RIVER WALLS & FLOOR (Physical and Social Environment)• Social Environment: 1. Family – Staying with wife, son and daughter. – Currently son is the one that drives client around. – Children has limited knowledge about client’s condition and technique in sighted guide. – If necessary, son will take leave to bring client for medical check up, close relationship with client – can joke around. – Wife will stop work and stay at home to take care of client soon.
RIVER WALLS & FLOOR (Physical and Social Environment) 2. Friends – His used to go out and hang out with friends at restaurant. 3. Work – Other colleagues that were new wasn’t satisfy with client. – Client’s office table was situated at the end of the room with clutters and narrow pathway. – Client was not given much work in office.• House Environment: – 4th floor Flat without lift. – Cemented stairs with handle. – 2 Sitting toilet.
Strong sense Stable Motivated to Reluctant to of financial remain active take medication responsibility income Self copingReluctant to use skill walking aids DRIFTWOOD Cross sectional view Mr. M’s river diagram
Strong sense Stable Motivated to Reluctant to of financial remain active take medication responsibility income Self coping Reluctant to use skill walking aids Visual Risk of limitation falls Feel helplessUnable to travel around freely Weakness Friends at legs School House Colleagues principle Children Wife & physical environment Cross sectional view Family Work Mr. M’s river diagram
PROBLEM IDENTIFICATION1) Client was not taking other medication – not knowing implication.2) Client reluctant to use walking aids – dignity.3) Client was unable to travel freely - limited visual function and has medium risk of fall due to weakness at both legs. Visual function limitation includes: i. Response to light. ii. Response to accommodation. iii. Limitation on vertical visual field.4) Misunderstanding between client and colleagues due to lack of psycho-education for both client and colleagues.5) Feeling helpless - not able to perform effectively at work.
TREATMENT AIMSShort Term Goal:1. Educate client and care-giver – importance of medication intake and the condition itself.2. Reduce risk of falls – home and community.3. To improve client’s mobility around community.4. Increase client’s efficiency in work.5. Improve social interaction between client and other colleagues in work place.
Strong sense Stable Motivated to Reluctant to of financial remain active take medication responsibility income Self coping Reluctant to use skill walking aids 1 Visual Risk of limitation falls Feel helplessUnable to travel around freely 2 4 5 Weakness Friends at legs 3 School House Colleagues principle Children Wife & physical environment Cross sectional view Family Work Mr. M’s river diagram
Strong sense Stable Motivated to of financial remain active responsibility income Self coping skill Visual Risk of limitation fallsUnable to travel around freely Weakness Friends at legs School House Colleagues principle Children Wife & physical environment Cross sectional view Family Work Mr. M’s river diagram
TREATMENT AIMSLong Term Goal:1. Pre-retirement plan for client.2. Improve quality of life.
TREATMENTTreatment implemented: (10.5.12)1. Education to both client and care-giver (son) about the condition includes: (STG 1) Etiology Progression Client’s current functionality level2. Environmental (home) modification recommendation: (STG 2) Marking and labeling technique. (E.g., stairs) Lighting
TREATMENTTreatment implemented: (17.5.12)3. Teach client and care-giver sighted guide technique: (STG 3) Approaching narrow space Approaching stairs Guiding client to sit on chair Approaching a doorway.4. Further assess on client’s color perception – Assessment: non-standardized (using 6 different colored rings) – Results: client able to recognize red, green, orange but seeing yellow as white, blue as greenish blue, and pink as orange-light red.
TREATMENT5. Expose client to walking aids that are suitable to client including education on it. (STG 2) – Method: Consulted with client without showing. – Results: Client re-considered and agreed to try.Future plan:6. Home visit – possible physical environment & identification with client on possible purposeful activities. (STG 2 & 3)7. Work place visit: (STG 4 & 5) Job place physical environment modification and task modification. Educate other colleagues and employer about client’s condition.
TREATMENTBased on LTG:LTG 1• Pre-retirement planning – preparation in exploring and then legitimize a new activity patterning for retirement.• Elements for successful retirement: life roles, purposeful activity, and maximizing function. – Alternative: volunteerism or part-time employment. – New interest exploration.LTG 2• Orientation and Mobility program – with cane.
PROGNOSISRehabilitative: (Good)• Cooperative and compliant to treatment given.• Strong family support.• Client was very motivated to improve himself.*RP is a degenerative disorder.*Client has other illnesses other than RP.
REFERENCES:1. International Classification of Disease (ICD-9-CM: 362.1, 362.74, 362.76)2. Mitchell S., Maxine S., & Stephen G., 2007. Low Vision Rehabilitation: A Practical Guide for Occupational Therapy. SLACK Incorporated.3. Sandra C., 2003. Elder Care in Occupational Therapy. 2nd Edition. SLACK Incorporated.4. Michael K. Iwama, 2006. The Kawa Model: Culturally Relevant Occupational Therapy. Churchill Livingstone Elsevier.