Case Study:
Ellen is a 58-year old Caucasian woman with a diagnosis of right total shoulder replacement. Ellen also has a diagnosis of rheumatoid arthritis. She has a past medical history of bilateral knee replacements and a left hip replacement. Ellen elected to have surgery when the pain and stiffness in her right shoulder had limited her to a point to where she could barely use her right arm. The rheumatoid arthritis had begun affecting her arm about 2 years ago and had gradually progressed to the point where surgery was inevitable. Ellen describes her right arm motion as “minimal” before surgery.
Ellen lives with her sone and his family in an apartment adjoining their home in the suburbs. She and her husband have been divorced for many years and Ellen is used to doing everything for herself. She likes being independent and hates “giving in” to the arthritis. She retired from a job with the telephone company 4 years ago. She had worked there for 25 years as a dispatcher.
Ellen reports a gradual increase in difficulty in performing ADLs before the surgery for the last year and a halt She has needed assistance from her daughter-in-law to wash and brush her hair, dress her upper extremity, and reach into closets and cabinets. She eats dinner with her son and his family, but eats the other meals in her own apartment. She was independent in cold meal prep prior to her surgery. She ambulated with a strait cane because of left lower extremity weakness. She reports this has become difficult since she used the cane on the right side. She reports all daily tasks were difficult and elicited pain throughout the shoulder region. She was unable to continue driving because of her inability to use her right arm to shift gears. Ellen’s favorite leisure activities are bingo and crossword puzzles. She maintained independence in this area.
Ellen underwent surgery to replace the gleohumeral joint. Her surgery was uncomplicated and she was out of the recovery room to the hospital unit the next day when the occupational and physical therapists greeted her. Ellen wore a swath sling on her upper extremity. Her doctor had issued total shoulder precautions, which stated she was allowed external rotation to neutral only and no abduction unless the gleohumeral joint was fully internally rotated. Ellen’s surgeon had warned her to adhere to the precautions stringently. Ellen had not been so careful in the past and had experienced difficulty after her left hip replacement as a result.
The discharge plan is for Ellen to remain at the acute care hospital for 5 days, then return to her home. She will have her rehabilitation from an occupational therapist from the Visiting Nurse Association. While at the hospital, Ellen is to receive services from OT, PT, nursing, nutrition, and social service.
Occupational Therapy Evaluation
Ellen is pleasant and cooperative during the evaluation. She has no cognitive, perceptual, visual, sensory, or hearing deficits. She reports pain in the right shoulder whenever she moves in bed or ambulates. She is wary about removing the sling for the evaluation, but agrees reluctantly to do so. Her AROM in the right UE is as follows: shoulder flexion 25 degrees; extension 15 degrees: internal rotation 45 degrees; external rotation 0 degrees; all with pain she rates as 7 to 8 on a scale of 1 – 10. Her elbow and hand are WFL. She does have slight ulnar drift of the 2-5 MCPs on the left hand. Ellen’s left UE has AROM as follows: shoulder flexion 110 degrees: extension 30 degrees; abduction 100 degrees: horizontal adduction 95 degrees: horizontal abduction 5 degrees: external rotation 40 degrees; internal rotation 80 degrees. Her left elbow and hand status is the same as the right side. She is right-hand dominant. Her coordination is impaired due to her limitation of the right shoulder. She exhibits difficulty with manipulation of small objects because of her arthritis and ulnar drift, but if very persistent in performing tasks as asked.
Ellen still has the sutures in her shoulder where the shoulder was performed. The area is covered by a dressing that nursing is monitoring regularly. The chart reports that the incision is doing well. Ellen has no edema and reports moving her fingers on the right hand all the time to see them from feeling stiff.
Ellen requires moderate assistance to move from supine to sit. She transfers with very minimal assistance and ambulates with her straight cane and close contact guard. She is now using the cane in the left hand because of her surgery and has an unusual gait pattern. She reports feeling light headed and dizzy after getting up to walk or sitting up in the bed. Ellen is using a bedside commode for toiling and is calling for assistance with her transfers.
Ellen is able to feed herself, although she reports having very little appetite since the surgery. She requires moderate to maximum assistance with self-care of the upper body. She needs only minimal assistance for the lower body when performed in bed. She performs toilet hygiene independently. She is dependent for all home-management tasks.
Ellen reports familiarity with OT since she had it in the past with her other surgeries. “I know the ropes, unfortunately,” she jokes. Her goals for OT are to perform all her self-care tasks independently so she won’t need so much help when she returns home. She especially wants to be able to shower herself. “I plan on driving again,” she says, “but that will be awhile.”
