Blindness

Blindness?

Blindness is defined as a loss of vision in both eyes that cannot be corrected to better than 10/100 feet or 6/60 meters. The term blindness also applies to loss of peripheral vision so that visual field is restricted to less than a 20 degree angle (tunnel vision). People who had sight but lost it are referred to as adventitiously or newly blinded, whereas people born without sight are said to be congenitally blind.

Cause

There are many possible causes of blindness: a detached retina, diabetic retinopathy, puncture wounds to the eyes, multiple sclerosis, conjunctivitis, retinal hemorage, retinal fibrosis, enucleation,glaucoma, pressure ob the optic nerve, or rubella.

Assessment

Areas

People with visual impairments frequently have multiple handicaps that need to be assessed and managed to improve coping skills.

• range of motion
• hand function and skills-grasp, pinch,and release
• muscle strength
• ambulation and mobility
• postural reflexes and balance/equilibrium reactions
• sensory awareness and discrimination
• auditory localization
• perceptual skills, including directionality and laterality
• self perception
• interpersonal skills
• self-care skills, including oral motor skills
• communication skills
• productivity interests and skills
• leisure interests and skills

Instruments

• Screening for physical and Occupational Therapy Referral
• Activities of daily living scale
• Occupational histiry
• Leisure checklist

Problems

Motor

• The person loses ease of mobility.
• Hand functions that normally rely on visual input are decreased.

Sensory

• The person has a loss of acuity.
• The person ha a los of color vision.
• The person may have no awareness of the environment.
• The person may have light perception only (awareness of light and dark).
• The person may have travel vision but cannot move safely about the environment independently.

Cognitive

Learning problems may occur for persons previosly dependent on sight for gaining most

of their information.

Intrapersonal

• The person has feelings of insecurity.
• The person has feelings of helplessness and hopelessness.
• The person may be depressed .
• The person may become introverted.

Interpersonal

• The person may become dependent to others.
• The person may avoid friends and situations previously enjoyed.

Self-Care

The person may have loss of skills that depend on vision, such as grooming, telling time,

or matching socks, skirt, and blouse.

Productivity

the person may be unable to continue a former occupation or need adjustments in the

working environment.

Leisure

The person may be unable to continue some leisure interests previously enjoyed or need

adjustments to continue them, such as stamp or coin collecting and reading.

Treatment/Management

Motor

• Help the person regain mobility.
• Provide practice in using hands in activities.

Sensory

• Increase the person's skills and awareness of other sensory modalities, including hearing, touch, kinesthesia, proprioception, and vestibulum.

Cognitive

Inform the person of learning options available to the blind, including books on tape and music activities.

Intrapersonal

Improve self-perception through use of creative activities, such as crafts, drama, dance, or music activities.

Interpersonal

• Encourage the person's family to discuss role changes that may occur because of blindness and what roles the person can perform within the family structure.
• Encourage the person to participate in social activities.

Self-Care

Help the person to organize objects needed for activities of daily living, such as marking objects for easy identification and making use of Braille-coded objects, such as watches and timers.

Productivity

• Help the person determine whether previous employment or job interests are feasible with limited or no sight.
• Suggest changes that could be made in the work environment to facilitate continued employment for a person with limited sight.
• help the person explore alternate vocational interests if continuation of present emplotment is not possible.
• Help the person organize home living environment to facilitate management of it.

Leisure

Help the person explore new or redevelop old interests adapted for blind persons, including materials that can be purchased, such as Braille-marked cards.

Precautions

• Safety is a major concern. Always check equipment and the physical environment for possible hazards.
• If blindness is due to diabetic retinopathy, be aware of other problems associated with diabetes, such as poor circulation and loss of tactile sensation.

Prognosis/Outcome

• The person can demonstrate the ability to perform basic activities of daily living independently.
• The person is able to negotiate home and local community without assistance.
• The person is able to engage in productive activities as a worker, student or volunteer.
• The person participates in a variety of leisure activities.

Child Abuse and Neglect

Child Abuse and Neglect

Child abuse and neglect is defined as physical injury, emotional disturbance, sexual abuse, negligence, or maltreatment of a child under the age of 18 by a person who is responsible for the child's welfare.

Cause

Abuse is the breakdown of impulse control in the parent, guardian, or other caregiver.

there are four factors involved:

1. Personalities features-The caregiver experienced lack of affection and support as a child and thus does not know how to provide the same for his or her child, or the caregiver is out of control due to substance abuse or psychotic illness.
2. The difficult or different child- Examples include hyperactive, handicapped, premature, or sickly children or stepchildren.
3. Inadequate support- The caregiver feels isolated or abandoned by relatives or friends who could provide guidance and assistance.
4. Crisis situation- Stress overcomes the caregiver's ability to function.

Neglect is observed in families with multiple problems and disorganized lifestyles. Depression, desertion, drug or alcohol abuse, and chronic medical conditions may be seen in one or more caregivers.

Assessment

Areas

• gross motor development and skills
• fine motor skills, manipulation, dexterity, and bilateral coordination
• muscle strength
• reflex development and maturation
• postural control (use of protective and equilibrium reactions)
• muscle tone
• joint stability and mobility
• sensory registration/awareness
• sensory sensitivity/processing
• perceptual skills ( visual, auditory, tactile, and kinesthetic)
• attending behavior and concentration
• ability to follow directions/sequencing
• motivation or self-initiated activity
• mood or affect
• self-control
• coping skills
• social conduct skills
• daily living skills
• academic readiness or academic skills
• play skills

Instruments

No comprehensive or specific scale for occupational therapist to use assessing child abuse was identified. The following assessments may be useful:

• Bayley Scales of infant development
• Brazelton Neonatal Assessment Scale
• A play scale
• Child abuse potential inventory

Problems

The problems associated with child abuse can be verified and many. The list of problems should be considered as examples and not as comprehensive list.

Motor

• Developmental milestones may be delayed, especially gross and fine motor skills.
• Muscle weakness may be present if nerve or brain damage has occurred.
• Paralysis may be present if nerve or brain damage has occurred.
• Contractures may be present if condition has existed for some time.
• Reduction range of motion may be present, depending on the type of injury.
• Reflex maturation may be incomplete, with primitive reflexes continuing to be present.

Sensory

• Sensory loss may have occurred in vision, hearing, touch proprioception, or kinesthesia and less commonly in taste or smell.
• Body image may fail to develop or an impaired body image may develop.
• Sensory integrative Dysfunction may be present, including developmental dyspraxia and vestibular- bilateral disorder.
• Sensory responses may be hypo- or hyperactive.

Cognitive

• Learning disabilities may be present, including dyslexia, short attention span and hyperkinetic behavior.
• The child may have poor problem- solving skills.

Intrapersonal

• The child may have poor self-image and lack of confidence.
• The child may feel guilty for "causing so much trouble." (note: The child is not the cause but may be made to feel so by repeated statements from one or more adults.)
• The child may have blunted or flat affect.
• The child may lack self-control, such as being sensitive and aggressive or having low tolerance for frustration.
• The child may act helpless or be overly complaint or withdrawn.
• Role identity within family unit may be ill-defined or fluctuating.

Interpersonal

• Parent(s) and child may lack coping skills.
• The child may have delayed development of social interaction and conduct skills.
• the child may be delayed in acquiring speech or vocabulary.
• Bonding between parent and child may be inadequate or lacking.
• The child may lack group interaction skills.

Self-Care

• The child may be delayed in developing activities of daily living, such as dressing, tying shoes, or eating with a fork.
• The child may be unable to perform certain ADLs (activities of daily living) if motor skills are involved.

Productivity

• The child may have developmetal delays in acquiring play skills.
• the child may use less imagination in play.
• The child may be unable to organize play activities.
• The child may show little exploratory behavior in play.

Leisure

The child may have few leisure interests beyond watching television or video.

Treatment/Management

Models of treatment include sensory integration (Ayres), and neurodevelopmental therapy (Bobath).

Motor

• Promote development of groos and fine motor skills according to developmental level.
• Increase muscle strength through progressive resistive exercises.
• Maintain or increase joint range of motion through passive exercises and active involvement in activities.
• Facilitate integration of primitive reflexes.

Sensory

• If sensory loss has occurred, facilitate development of remaining senses.
• Increase body awareness and position in space.
• Is sensory dysfunction is noted, see section on the specific disorder for treatment suggestions.
• Modulate hyper- or hyporesponsiveness to stimuli.

Intrapersonal

• Improve self-image and sense of mastery through use of creative activities ,such as crafts, games, music, dance, or drama.
• Increase self-control by assisting the child to think of alternative approaches to situations and tasks.

Interpersonal

Provide an opportunity for the child to practice social conduct in a group situation.

Self-Care

• promote self-feeding skills.
• Decrease oral motor sensitivity.
• Increase skills in daily living.

Productivity

• Teach parents or caregivers the child's level of play skills and how to participate in play activities with the child.
• Promote development of play skills
• Assist in promoting academic readiness skills.

Leisure

Encourage exploration of interests and developments of leisure skills.

Precautions

Observe a child for signs of any additional abuse or neglect.

Prognosis and Outcome

• Parent or caregiver is able to interact with the child without violent or abusive behavior.
• Parent or caregiver demonstrates knowledge of the child's level of development and adjusts expectations to the child's level of performance.
• Parent or caregiver is able to manage his or her own life situation and stresses without taking anger or frustration out on the child.
• Child demonstrates improved developmental profile in motor, sensory, language, and self-care skills
• Child demonstrates improvement in play skills.

Arthrogryposis Multiplex Congenita

Arthrogryposis Multiplex Congenita

Arthrogryposis multiplex congenita (AMC) is a nonprogressive neuromuscular disorder present birth that is characterized by fibrous ankylosis (contractures) of multiple joints. Muscle development is arrested at some time during the fetal period and fibrous or fatty tissue replaces the muscle, resulting in contractures and abnormal joint surfaces. Types of AMC include neuropathic, myopathic, and mixed.

Cause

The cause of AMC is unknown. The disorder is not genetic; individuals have normal chromosomes. Some cases can be traced to neurogenic causes through histologic and electromyographic evidence, or to myopathic causes through studies of muscle fiber. Other causative agents may include prenatal exposure to adverse environmental agents, maternal infection, abnormal connective tissue, chromosomal or genetic defects, and impaired intrauterine fetal movement.

Assessment

Areas:

• Range of motion.
• Muscle strength.
• Developmental of gross and fine motor skills.
• Developmental of hand skills, grasp, and prehension
• Balance and postural control
• Self-perception
• Family and social support
• Daily living skills
• Play skills




Instruments:

No specific instruments have been developed by occupational therapists to deal with this disorder. The following may be useful:

· Developmental assessment

· Activities of daily living scale

· Play history

Problems

Motor:

• The disorder is usually characterized by rigidity and/or contractures of the joints.Typically, in the upper extremities , the shoulders are adducted and internally rotated, the elbows are extended but occasionally flexed, the forearms are pronated, the wrists are flexed and ulnary deviated, the fingers are flexed, and the thumb is in the palm. In the lower extremities, the hips may be dislocated and are usually flexed and externally rotated, the knees are extended but occasionally flexed, and the feet are in equinovarus.
• There is usually severely limited range of motion in all major joints.
• Muscle weakness usually occurs.
• The person may have absence or atrophy of individual muscle or muscle groups.
• The person may ave gross abnormalities of the chest and spine (myopathic type).
• Other problems include webbing on the ventral aspects of flexed joints, cleft palate, scoliosis, torticollis, facial palsy, limb deformity, and congenital amputation.
• Achievement of gross and fine motor skills is usually delayed
• Development of hand functions is usually delayed.




Sensory

Sensory system is intact, but perceptual skills, such as stereognosis, could be delayed due to lack of opportunity.


Cognitive

Cognition is normal and intelligence is average to above average, but learning could be delayed due to lack of opportunity and many surgical procedures.

Intrapersonal

• Parents, especially the mother, may feel guilt about having a handicapped child.
• Child may have tantrums due to frustrations.

Interpersonal

Family members may reject the "funny looking" child and leave the parents or mother without support.

Self-Care

Development of self-care skills is usually delayed because the patient's hand functions and fine motor skills are now develop.

Productivity

Play skills are usually underdeveloped.

Leisure

See productivity.

Treatment/Management

Motor




• Increase and maintain range of motion through activities, such as exercise and stretching.
• Promote achievement of gross and fine motor skills.
• Improve posture and positioning through the use of adapted equipment, such as corner seats, strollers, swivel buckets, or parapodiums.
• Provide splints to maintain gains in range of motion or serial casts to increase range of motion.

Sensory

Provide opportunities to experience sensory input.

Cognitive




• Provide opportunities for learning and encourage child to explore problem-solving methods.
• Provide information to parents about the disorder and encourage parental participation in the therapy program. They should understand the importance of having the child wear splints until bone matures and continuing range of motion activities everyday so the child maintains use his/her body
• Provide information about community resources and services.
• Provide information about normal growth and development.
• Provide information about architectural and environmental barriers.

Intrapersonal

• Provide opportunities to develop self-perception through the use of creative activities, such as art, crafts, drama, dance, music, and games.
• Encourage parents to express feelings and concerns about the child's condition and welfare.
• Provide instructions in stress-management techniques.

Interpersonal

• Encourage parent-infant bonding.
• Encourage parents to participate in self-help groups.

Self-Care

• Provide self-help devices to assist in the performance of daily living skills. A lazy susan may be used as a plate. Food can be placed around the edge of the plate.
• Adapted equipment may be necessary for grooming, such as extended handles on combs, brushes and toothbrushes.
• Clothing adaptation may be needed to account for various deformities, using Velcro and elastic. Providing large rings on zippers or loops to grasp and large button is also useful.

Productivity

• Promote development of play skills, especially exploratory and manipulative play.
• Assist teachers in determining what, if any, adapted equipment or devices may be needed to assist a child with academic activities. Computers with adapted keyboards may be helpful. the child should be able to attend regular classroom instruction, except for physical education.

Leisure

Usually no special goals or objectives are necessary. The child or an adult will seek those activities that are within the child's functional abilities.

Precautions

Bone structure is fragile. Range of motion and stretching exercises should be carefully monitored.

Prognosis/Outcome

• The person has maximum range of motion possible given structural limitations.
• The person achieves gross and fine motor skills, although the development of skills does not progress normally.
• The person has functional hand skills, although the use of the hands may be unorthodox.
• The person has independently mobility with or without powered mobility.
• The person achieves independence in self-care and daily living skills.
• The person develops productive skills.

Kidney Disease with Dialysis

What is Kidney Disease with Dialysis?

Diseased kidneys are unable to maintain homeostatic balance of water, minerals, and excretion. Toxic end-products accumulate in the blood

and tissue. The kidney also is no longer able to function as an endocrine organ.Dialysis is the process of separating elements in a solution by

diffusion across a semipermeable membrane. The purpose is to reestablish homeostatic balance and decrease the toxic end-products.

Cause

Acute or chronic kidney failure may occur as a result of numerous disorders, including uremic encephalopathy, pericarditis, intractable

metabolic acidosis, congestive heart failure, and hyperkalemia. Persons affected may be of any age. Both sexes are affected equally.

Assessment

Areas

• developmental profile
• muscle strength
• range of motion
• endurance
• fine motor skills, manipulations, dexterity, and bilateral coordination
• sensory registration
• sensory processing
• attention span
• learning skills
• self-concept
• sense of self-mastery or self-control
• mood or affect, especially signs of depression
• social skills
• coping skills
• daily living skills
• productive history, values skills, and interests, including academic and play skills
• leisure skills and interest

Instruments

No specific instruments developed by occupational therapists were identified in the literature. The following types of tests may be useful:

• academic testing
• manual muscle test by groups of muscle
• goniometry
• activities of daily living
• play history
• leisure checklist

Problems

Motor

• The person may have decreased muscle strength.
• The person may have decreased physical endurance and rapid fatigue.
• The may have loss of range of motion.
• The person may have decreased muscle control.
• The person may have decreased fine motor coordination and dexterity.
• The person may have foot drop, trmor, or other signs of peripheral neuropathy.

Sensory

• Loss of sensation may occur.
• Loss of vision or decreased visual acuity may occur.

Cognitive

• The person may have loss of attention span and concentration.
• The person may experience drowsiness.

Intrapersonal

• The person usually experiences a decrease or loss of self-concept, especially mastery and autonomy.
• The person may have lost self-esteem or feelings of self-worth.
• The person may express anger and frustration.
• The person may experience loss of effective coping skills.
• The person may have an increased sense of dependency.
• The person may be depressed.
• The person may express fear of death.
• The person may become irritable and uncooperative.
• The person may become confused and anxious.
• A preschool child may perceive painful medical procedures, hospitalization, and separation from parents as punishment.
• A school-age child may perceive him or herself as different from others.
• The parent or parents may have many of the same problems that the child experiences.

Interpersonal

• The person may experience difficulty relating to authority figures.
• the person may withdraw from social group interaction.
• The person may experience conflict with his or her family related to changing roles.

Self-Care

The person may be unable to perform some activities of daily living due to limited energy or decreased range of motion.

Productivity

The person may be unable to perform productive activities, such as academic work, play, and chores, due to reduced energy level or decreased strength.

Leisure

The person may not engage in favorite leisure activities because of decreased functional abilities.

Treatment/Management

Motor

• Increase muscle strength through graded activities.
• Increase functional range of motion through selected activities within the person's normal activities if possible.
• Increase the person's muscle control.
• Increase coordination and dexterity through selected activities.
• Increase physical endurance through gentle exercises.

Sensory

No specific sensory treatment or management is recommended.

Cognitive

• Instruct the person in concepts of energy conservation and work simplification.
• Instruct the person in concepts of safety associated with dialysis.
• Assist in instructing the person on recommended diet changes and necessary modifications in food preparation.
• Instruct the person in development of a time-management schedule that includes cycles of rest and exercise.
• Select projects that are quick and require a short attention span, such as games, puzzles, mazes, or crosswords for children.

Intrapersonal

• Increase self-concept through successful accomplishment of art, craft, educational, creative writing, or game activities.
• Increase the person's sense of mastery through knowledge about and performance of activities.
• Encourage the person and family members to verbalize feelings of hopelessness, helplessness, and fear of dying.

Interpersonal

• Encourage the person to engage in social activities.
• Assist the person and family to reorganize roles within the family unit, if necessary.
• Encourage the person and family to articipate in a self-help group, if available, in their hospital or community.
• Encourage the person to maintain contact with the outside world if hospitalization is required. Field trips may be useful.

Self-Care

• Maintain or increase independence in self-care activities through the use of work-simplification or time management techniques.
• Provide adapted equipment to assist the person in the performance of self-care activities when indicated.
• Cooking may be useful to increase appetite and reinforce concepts of good nutrition.Check dietary restrictions, such as avoiding salt and chocolate.
• Young children may need to develop skills in dressing and grooming.

Productivity

• Assist the person to modify his or her home and work environment if needed.
• Assist the person to explore alternate interests if current vocation cannot be continued.
• Assist the person to perform other productive roles, including home manager, volunteer, or student, as indicated.
• Encourage the person to continue studies, if student.
• Increase development of play skills. Role playing as a doctor or nurse may relieve a child's fears and anxieties and provide outlet for feelings.

Leisure

• Assist the person to modify existing leisure interests to conform to physical capacities.
• Assist the person to explore new interests that can be performed within physical capacities.

Precautions

Avoid messy or dirty activities since persons with renal disorders may be in poor general health or have a poor immune system.

Prognosis and Outcome

• The person has maintained or increased muscle strength.
• The person has maintained or increased range of motion.
• The person has maintained or increased fine motor dexterity and bilateral coordination.
• The person has maintained or increased physical endurance.
• The person has maintained or increased balance and postural control .
• The person demonstrates use of energy-conservation and work-simplification techniques.
• The person demonstrates Knowledge of safety factors associated with dialysis.
• The person is able to express feelings about dying.
• The person demonstrates a positive self-concept and internal locus of control.
• The person demonstrates stress-management and coping skills.
• The person maintains or increase social interaction skills.
• The person demonstrates productive skills.
• The person demonstrates leisure skills.