Mary is a 72-year-old White woman of Italian descent who recently underwent a left hip replacement. She also has osteoarthritis, hypertension, and a history of urinary tract infections. Mary had elective replacement surgery at the urging of her orthopedic surgeon because she had been suffering with progressively worse pain in the left hip over the past 2 years and had finally decided she could not tolerate it any longer. She had canceled the surgery once before, thinking she could do without it.

Mary has been becoming noticeably less active because of the hip pain for the past 8 months. Before hospitalization, Mary had been independent in all her meaningful ccupa-tions; however, she did mention that it has been taking her much longer to do her morning routine and daily tasks because of the hip pain. She had been able to ambulate without a device until approximately 2 months ago, when she decided to borrow a cane from her sister and use it "to lean on." She also found herself going upstairs only when she had to, such as to use the bathroom. Mary admits to cutting down on her coffee in the morning and other drinks throughout the day to help keep the trips to thebathroom to a minimum. She also has reduced her errand running and driving and has been sleeping poorly because of anxiety over the surgery and the outcome. Mary is a religious woman and has attended the same church for more than 35 years. Mary lives alone in the suburbs in her own home, which has 5 stairs in the entrance and 12 stairs to the, second floor where her bedroom and the only bathroom are; the laundry room is in the basement, which has a steep wooden staircase with only one handrail, on the left side.

She has never been married and has no children. Mary has a sister who lives within walking distance from her home, but Mary says she started driving over recently instead of walking the two blocks for the visit.

Mary moved to the United States from Italy 55 years ago. She had been a nanny and a preschool teacher most of her career and retired 7 years ago at age 65. She had been socially active before her surgery. She plays cribbage once a week with three other women and is a volunteer at the town library, where she conducts children's reading and story hours. She is distressed that the story times are going to be canceled because of her surgery and spoke with hostility of the others at the library for not filling in while she is in the hospital. Mary is a kind woman with a strong sense of right and wrong. She speaks frequently about how wrong itis to allow the children to go without their stories and how wrong it is for the others at the library to be so selfish. Mary seems to have a hard time letting go of feelings that bother her, and she deals with it by talking about it with anyone who will listen. She can often be seen telling the housekeepers and dietary aides as they enter and exit her room about the inconsideration of the other library volunteers. Mary seems to use her issue of choice to avoid conversations regarding her surgery and recovery.

Mary had an uncomplicated total hip replacement sur-gery. The acetabulum and femoral head and neck were replaced using a posterolateral approach. Mary has had no complications from her surgery and was moved from the acute portion of the hospital to the transitional care unit after 3 days. Mary initially hoped she would be able to go home directly after surgery. She agreed to move onto the transitional care unit after she and her sister realized that she would not be able to be at home safely. Mary's goals for her stay are to return home, to be able to drive, and to resume her life as it was before the surgery. She said she wants to walk without a cane and be able to get up and down stairs without pain. Her discharge plans are to return home with services in 1 to 2 weeks. Mary will be followed at the transitional care unit by the physiatrist in charge.

Her team will include PT, OT, nursing, nutrition, and social services.

Mary was evaluated by OT on the day of her admission to the transitional care unit through chart review, inter-view, observation of her completing functional activity, and assessment of UE motor strength and active range of motion (AROM). She was pleasant and cooperative but needed to be redirected to remain focused. The evaluation revealed no deficits in cognition, perception, sensation, or hearing, but these were not formally tested. She wears glasses at all times. Mary had some decreased AROM in both shoulders, possibly due to the osteoarthritis. Her AROM was at approximately 2/3 range for all shoulder motions. She had no range limitation in the elbows or wrist but could not make a full fist on the left hand without slight pain in the metacarpophalangeal joints. She had a full grasp in the right hand, which is her dominant hand. Mary had 3- strength in the shoulders and 3+ in the elbows and wrists and right hand. Her right hand was stronger than her left hand, but both were functional. Her UE coordination was intact for both gross and fine motor. Mary had pain of 6 of 10 in the left hip only during motion. She had to adhere to total hip precautions and was allowed only partial weight bearing on the affected extremity. Mary did not like to talk about the surgery and would not look at the incision. Whennurse came in to give her medication and to check on or change the dressing, Mary would either turn and look the other way or close her eyes.

Mary had some slight edema in her left LE. She was at risk for skin breakdown because of the limited motion of her hip and her sleeping position at night. Her bed mobility was fair. She rolled in bed with moderate assistance, bracing herself for pain the whole time. She moved from supine to sit with moderate assistance. She seemed afraid to place any weight on her left leg and performed her transfers slowly and hesitantly. Mary used a standard walker with wheels for her transfers. She transferred from bed to chair with the maximum assistance of one person. She clung tightly to the therapist the entire time and did little to help herself through the transfer She transferred in a squat-pivot manner instead of a stand-pivot, which she should have been able to do. She performed toilet transfers at the same level of ability. She used a wheelchair for long distances only.

Mary was able to perform her upper body bathing and dressing independently, but in a seated position due to her standing endurance. She was not able to perform her lower body self-care because of her hip precautions. Mary states she was scared to "pop it out" and have to go through "it"again. The occupational therapist attempted to explain 1 the long-handled adaptive equipment to her, but she has declined until "the time is right for my leg." Mary said she is willing to work with OT as long as she does not have to use any "gadgets."

Write out a specific intervention plan for Mary's first week of intervention, including the frequency of OT sessions.