NAME: KHOR WAI ON

MATRIX NUMBER: A124590

PROGRAM/YEAR: OCCUPATIONAL THERAPY/ 4TH YEAR

SUBJECT: NNNK 4065 ORIENTATION AND MOBILITY CLINICAL PLACEMENT

FACULTY OF HEALTH SCIENCES

KAWA MODEL

• 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 Usher's syndrome also causes

nerve damage creating deafness.

– Research underway for artificial retina & replacement

of defective genes.

INTRODUCTION

PRELIMINARY INFORMATION

Description

Name Mr. M

Age 54

Gender Male

Marital status Married

Race Malay

Religion Islam

Occupation Admin assistant

Diagnosis Retinitis Pigmentosa

Date referred to OT clinic 19.4.12

Referred by Optometrist

KAWA MODEL

KAWA Model was used as

conceptual model of

practice, frame of

reference, assessment tool

and modality to this client.

Mizu (Water)

Torimaki: Kawa no

soku –heki (river

side-wall) and Kawa

no zoko (river floor)

Iwa (Rocks)

Ryuboku

(Driftwood)

Phase 2: married life,

DM started after.Phase 4: Accident,

RP gets severe

affecting more

aspects of life

Phase 1: Active and

disease free.

Phase 3: surgery at both legs.

Blur vision and hearing

problem started, RP detected.

Mr. M’s Kawa

WATER (Life Flow and Overall Occupations)

Subjectively:

• Family History:

– Among siblings, client was the only one with RP.

– Married at the age of 25.

Client

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

• 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.

WATER (Life Flow and Overall Occupations)

• Leisure:

– Pre-morbid

• Gardening, travel around and jog in evening at park.

– Post-morbid

• Watching television, reading newspaper, and listening to radio.

• Routine:

WATER (Life Flow and Overall Occupations)

Time Working Days Week Days

7.00 am Wake up, bath and

breakfast

Wake up, bath, watch

television and breakfast

8.00 am – 10.00 am Go to work Newspaper and nap

10.00am – 12.00pm Go back home and

lunch

Lunch, newspaper and

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

newspaper

Dinner, television and

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.

Cross sectional view Mr. M’s river diagram

Visual

limitation

Unable to travel

around freely

Risk of

falls

ROCKS

Subjectively:

Weakness

at legs

Feel helpless

Berg’s Balance Test biVABA

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)

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.

• Visual – Assessed using biVABA.

• From assessment, noted that:– 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.

i. 1/12 for Right eye.

ii. 1/12 for Left eye.

iii. 1/4 for both eyes

together

Cross sectional view

Mr. M’s river diagram

Friends

Wife

House

WorkFamily

Colleagues

& physical

environment

School

principle

Children

RIVER WALLS & FLOOR

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.

• House Environment:– 4th floor Flat without lift.

– Cemented stairs with handle.

– 2 Sitting toilet.

RIVER WALLS & FLOOR(Physical and Social Environment)

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.

2. Friends– His used to go out and hang out with friends at restaurant.

Cross sectional view

Mr. M’s river diagram

Stable

financial

income

Reluctant to use

walking aids

Strong sense

of

responsibility

Reluctant to

take medication

Self coping

skill

Motivated to

remain active

DRIFTWOOD

Cross sectional view

Mr. M’s river diagram

Visual

limitation

Unable to travel

around freely

Risk of

falls

Friends

Wife

House

WorkFamily

Stable

financial

income

Reluctant to use

walking aids

Strong sense

of

responsibility

Reluctant to

take medication

Self coping

skill

Motivated to

remain active

Colleagues

& physical

environment

School

principle

Children

Weakness

at legs

Feel helpless

PROBLEM IDENTIFICATION

1) 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 AIMS

Short 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.

Cross sectional view

Mr. M’s river diagram

Visual

limitation

Weakness

at legs

Feel helplessUnable to travel

around freely

Risk of

falls

Friends

Wife

House

WorkFamily

Stable

financial

income

Reluctant to use

walking aids

Strong sense

of

responsibility

Reluctant to

take medication

Self coping

skill

Motivated to

remain active

Colleagues

& physical

environment

School

principle

Children

1

2

3

45

Cross sectional view

Mr. M’s river diagram

Visual

limitation

Weakness

at legs

Unable to travel

around freely

Risk of

falls

Friends

Wife

House

WorkFamily

Stable

financial

income

Strong sense

of

responsibility

Self coping

skill

Motivated to

remain active

Colleagues

& physical

environment

School

principle

Children

TREATMENT AIMS

Long Term Goal:

1. Pre-retirement plan for client.

2. Improve quality of life.

TREATMENT

Treatment 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 level

2. Environmental (home) modification

recommendation: (STG 2)

Marking and labeling technique. (E.g., stairs)

Lighting

TREATMENT

Treatment 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.

TREATMENT

5. 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.

TREATMENT

Based 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.

PROGNOSIS

Rehabilitative: (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.