Student

Name: Paige Handley Case: #4 Shannon Date: 2/21/18

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Diagnosis: right side MCA CVA, 3 days post
Referral: Dr. Lewis (neurologist) asks for OT to assess Shannon, determine discharge settings
Past Medical History: had her CVA one day after delivery of first child, initially unconscious, was in
ICU for 3 days, now responsive
Setting: Acute Care
Reimbursement: Husband's student healthcare insurance (Private insurance)
LOS: 2x/day for 1 week.

2. Pragmatic Factors to Consider

Shannon and her family are eagar to get her home- may not be as happy if she is discharged anywhere
else. Family wants to help, but also need to take care of the baby. Husband is in school. She could
have some impulsivity. Seems to have left-sdie neglect and some possible apraxia. She just had a
baby- any complications with that that would cause difficulties in treatment? No work (besides
Zumba) that she needs to get back too, just taking care of herself and the baby. Emotional stability,
Only in facility for 1 week-- what can be accomplished in this time?, Limited in what can be worked
on especially since she is only 3 days post stroke and and she was unconcious until now. Current team
members include parents, husband, nurse, OT, Dr. Lewis, baby. She is 23 years old (very young for a
stroke) could affect speed or recovery and priorities for treatment. She is emotional about what has
happened (post-partum depression?), How long are her parents going to stay and help? Will she have
help at home once they leave? Can she do any ADL's? How is she doing cognitively? Can she
understand others? What does she normally do during the day? What is shy physically capible of
doing right now? How far do her parents have to travel to her each day? Where is the husband? Does
she have any edema? Have the doctors stopped the lesion from getting any worse?

3. Context: Occupational Profile & Current Occupations

Cultural: Family is important, Stay at home mom, Zumba class teacher, painter, She may want
some privacy from her parents,

Physical: Was in ICU for 3 days, Currently in the acute care unit in the hospital, will transition in
1 week to new facility, Wants to go home, lives in university housing- what does this
look like? What floor do they live on?, Will her home be safe and available to her?
Safety concerns?,
Social: Spends times with husband, now has a baby, parents are in town for now, interacts with
medical personel, Zumba teacher, does she have any other social life? What do her
current abilities prevent her from participating in socially?
Personal: 23, female, mother, wife, daughter, stroke survivor,

Temporal: S/P 3 days stroke and 4 days post baby birth, parents are here to see birth of baby- now
to take care of her, Will be seen by OT 2x/day for a week, Just had a baby, husband in
school

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Virtual: Can she use a phone? Would any technology help with her recovery?

Prior Occupations:
Shannon is married and works at home. This might include cleaning, cooking, doing ADL's and
IADL's. She would occasionally teacha Zumba class, spent a fair amount of tiem oil painting and was
preparing to have a baby.
Current Occupations:
Shannon is currently in the hospital, she has a nurse and her family to help her do anything right now.
She showed some ability to wash her face, though this is difficult for her. She can sit up but cannot
keep balance, and she can talk and she seems to understand the therapist. Able to maintain balance
while siting. She is dependent currently on most tasks because this is her first day awake after stroke.

4: Top Three Client/Family Goals and Priorities

1. Taking care of her son

2. Going home

3. ADL's

5. Diagnosis and 6. Scientific Reasoning & Evidence

Expected Course List the barriers to performance typical of this diagnosis:
Right MCA CVA: Ugillen ch 1 and Eval class powerpoint on strokes

Middle cerebral artery Barriers:

(MCA) stroke describes Changes in movement- loss of movement and weakness in left side,
the sudden onset of focal includes mouth tongue, throat, trunk, and limbs
neurologic deficit Changes in sensation-could have no feeling , could hhave no pain or temp
resulting from brain or know where there body is (affected side)
infarction or ischemia in Problems with left side- looking (eyes and head), left neglect issues
the territory supplied by Changes in attention, memory and judgement- may not be able to attend t
the MCA. a task, focus on important things, may have trouble forming new
The MCA is by far the memories, could have motivation, impulsivity or poor judgement,
largest cerebral artery Changes in understanding- may not understand she had a stroke, may not
and is the vessel most be able to stand, could have issues with recognizing people, could have
commonly affected by confusion
cerebrovascular accident. Changes in vision- could have double vision, or lose part of field of vision
The MCA supplies most Changes in speech- possible aphasia, also could have drooping of the
of the outer convex brain mouth and less tongue control to speack
surface, nearly all the
basal ganglia, and the Could have edema,
posterior and anterior
internal capsules.

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Expected Course:
Start in hospital- work on
stopping prgression of
lesion, reducing edema,
treating seixures and
preventing DVT,

Then work on getting any

motion and feeling- work
on proprioception and
weight bearing on left
limbs in treatment, In
treatment, start with tasks
they are most familiar
with,

Could regain almost

eeverything or could
regain only a small
amount of moveemnt and
sensation (different for
everyone), most patients
will learn techniques and
strategies so they can still
be independent.

7. Practice Models Guiding Assessment and Rationale

Treatment
1. PEO PEO was chosen because Shannon is in a new
environment, she has had 2 life changing
experiences and she is going to need to learn how
to adjust her environment and her occupations in
order to go about her daily routines. She has had
changes to her body and her abilities that she will
need to learn how to adjust too. It will also be
important to help her adjust to her new self and
from there, teach her techniques to adapt
occupations and for her to realize how to adpat
the environment in ways that will help her be
more successful.

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2. Motor Control
3. Rehabilatition Model
8. Specific Areas of Occupation
What do you know?
Shannon is alert and can speak, she has left
neglect and was unsure how to wash her face and
use the washcloth, She is weak in her trunk and
slumps to the left when sitting, she is not able to
sit without falling backwards, she needs help
when getting up into sitting position and laying
back down, she has a supportive family who are
ready to help, she has just had a baby and is
emotional about the fact that she cannot see her
child, Shannon does not work a regular schedule,
she planned on being a stay at home mom, she
occasionally teaches Zumba class, she likes to
paint, her husband is in school, her family wants
her to come back home, her mouth is drooped and
her left arm looks flaccid, Before her stroke, she
was capible of doing everything on her own, she
had her parents coming into town just to help
with the baby,
Page 4 of 14
Motor control was chosen because first this is a
good model for stroke patients, but also this is a
good model to use to help the bdoy relearn and
reconnect to use Shannon's left limbs again.
Motor control will be used to help increase
Shannon's ability to control her body, to help her
increase her problem solving skills and to help
her increase her ability to conserve energy so she
is able to accomplish more. This model also
addresses postural contol, which Shannon could
use some help with.
This last model was chosen because not only is it
a good compliment to the motorl control model
but also because the rehab model helps restore
someone's abilities through training. Thie model
focuses on regaining funciton, using energy
conservation, adapting the environment and
using any adaptive equipment. Because Shannon
as weakness and low endurance, it will be
imporant to address energy conservation and use
adaptive techniques to relearn how to perform
tasks and occupations.
What do you need to know?
What is her AROM/PROM in both her arms? IS
she able to use her left hand at all? Does she have
any language deficits? What parts of ADL's can
she do right now? Has she be able to help with
dressing. toileting or feeding? Does her home
have any safety concerns for considering
discharge location? What does she typically
wear? What does it look like for her to do tasks?
What is her trunk stability and endurance look
like? What is limiting her the most to recovery?
How is she doing emotionally as her baby is at
home without her? Does she want to breast feed?
is that possible? Is she cognitively aware of what
has happened? How severe is her neglect? Is her
left leg also affected? Is she able to walk or will
she need a wheelchair? How long will her parents
be there to help? Will her husband be there to
help?
Revised 1/9/17
 9. Performance Skills
What do you know?
Shannon seems to know what movements are
needed to move but is not able to perform them.
She cannot stabilize herself in sitting and requries
a pillow and an angled bed to stabilize in supine.
She needs help with positioning, especially on the
left side, She is not able to bend or rotate her
trunk in full function , she was able to grip the
washcloth with her right hand, she doesn't have
great flow when moving her body, Her endurance
is low with most phsyical tasks, She has limited
attention to her left side, She also doesn't notice
or respond to things on the left side? she didn't
seem to know how to initiate washing her face,
she terminated the activity without finishing the
task, She has some social deficits in looking,
turning toward the left side, expressinv emotion
but has no other apparent social deficits at this
time.
10. Performance Patterns-Habits, Routines, Rituals, Roles
What do you know?
Very little is known about Shannons habits,
routines, and rituals. She was independent and
lived with her husband. She painted in her free
time and occasionally taught Zumba classes. Now
she will have OT come twice a day, she has a
nurse check on her and she has a doctor
Roles: mother, wife, daughter, teacher (zumba),
painter, homemaker, 3 day stroke survivor.
patient
11. Activity Demands for the Client Goals and Priorities
What do you know?
Page 5 of 14
What do you need to know?
Would like to know more about what motor skills
she does have on the left side? Is her right side
affected in any way? How is her trunk control?
Would like to know more about how she is able
to move into different positions and if she has any
use of the limbs on the left? What is causing her
process skill deficits? are there any other process
skills that she has problems with that are
unknown right now? How does she do with
pacing and heeding and choosing? Is there any
navigation issues because of the possible left
neglect? The more informaiton about this the
better to help decide on discharge location
What do you need to know?
What will her routine look like throughout
recovery? What routine is she trying to get back
too? What is her husbands/ parents schedule--
will they be there throughout recovery? Will be
end up being home alone with the baby a lot?
What parts of her routine will easily be
remembered or easiest to get back to? Any habits
that could be helpful for recovery? What rituals
does she need to do to keep up her emotional
stabiliity? What kinds of things will help calm her
or make her happy during this time? Any other
roles that I should be aware of for therapy?
Toileting, feeding, dressing and other ADL's-
what is she able to do and what can't she do and
why? The more informaiton about this the better
to help decide on discharge location.
What do you need to know?
Revised 1/9/17
Dressing: What does she typically wear? does she have any
Relevance and importance to client: Client wants difficulty knowing how to put clothes on (like she
to be able to go home to take care of her baby, but did with the washcloth? At home, where are her
being able to dress herself each day will be clothes? Are they easy to get to? What is she
important to start getting those skills back. capible of doing on her own right now? Does
Objects used and their properties: Knowing Shannon have any difficulty with sequencing and
where each item of clothing is, being able to put timing when it comes to dressing? Does she have
clothes on right part of the body, Use clothes that difficulty with the motor planning needed to
are easiest to put on while learning, Most likley dress? Does she have ennough strength and
sweats and tshitrts wil be used to help teach flexibility to get into position to hemi-dress?
dressing. What wil her left arm be able to help with? How
Space Demands: she will need a bed and/or a long with it take her to get dressed in the
wheelchair/chair to dress in, morning/ Who will help her with this at home
Social Demands: Right now, she will most likely until she is able to do it Independently?
need someone to help her with dressing,
eventually she may be able to do this without any
help
Sequencing and timing: It is easiest to dress the
affected limb first, then the non-effected limb,
with some dressing techniques, it is important to
get placement of the clothing first, before trying
to put them on.
Required actions and performance skills: ability
to move and position body to used hemi-dressing
techniques, needs the manipulation skills to open
shirt and pants to put on, needs the movement in
her right arm to pull clothing on. needs grip,
bedning, positioning reaching and bending and
endurance to complete this task, Currently it is
difficult for Shannon to just sit up on EOB,
Required body functions: movement of arms,
touch functions, knowing how and where to put
clothes, thinking about how to dress in a new
way, able to think and act
Requred body structures: brain, arms, hands, legs,
trunk

12. Client Factors- Values, Beliefs, Spirituality

What do you know? What do you need to know?
Values family, values being a mother, values Does she have any relgious or spritual beliefs that
being at home with her child, values helping with coule help or hinder therapy? Does her family
finances in the house, values health care, values have any conflicting values that would hinder
time for herself (painting), family believes that treatment? Will her need to take care of her son
she will come home soon, limit her in what she will do to treat herself?
What is her motivation like? How does her
possible depression affect her mood and will to
work?

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 13. Client Factors- Body Functions & Structures
What do you know? What do you need to know?
She has some cognitive deficits (will need to What does she have problems with cognitiviely?
know more about what) possibly with Does she have post-partum depression and how
cognitivion, perception. she is very emotional badly? Does she have left neglect? Any pain or
after the stroke and, she just barely regained touch/proprioceptive deficits? Can her left side
consciousness, some visual function deficitts move or is it stable at all? need to know more
(with possible left neglect), has some joint about voluntary control in her muscles on the left
stability and movement to sit, she currently does side, Any voice, organ or skin issues? Any ROM
not have much endurance or muscle power. issues? Will she be able to do what is necessaary
Limited movement, strength, and stiabiliyt in left to take care of her baby on her own?
side. no other health problems besides the stroke
effecting her currenty abilities that is known

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 14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform

Observed Occupation Rationale/How will you use this information

Dressing (UB and LB) I would like to see what movement she is capable
of in her arms legs and trunk. Dressing will give
me a good baseline of not only her movement,
but her endurance level to complete a task (since
she is only 1 day conscious), her ability to pick
up an object and use it properly, her ability to
coordinate movement and thoughts to complete a
task. Especially since she most likely has some
apraxia, it would be good to see how much this
affects her in this task, it would be good to see if
she has any movement in her left extremities.
How well is she able to use her body? Can she
her her hands and fingers at all? I also picked
dressing because right after a stroke, it is good to
start with a task that they have done a lot of times
beucase this is easier to remember than starting
to learn a new task. Things like ADL's are best to
start with while working on imcorporating the
affected side.
Method/Tool Rationale/What is being Assessed
1. Ashworth Scale Even though it was stated that her left arm looked
flaccid, it would still be good to test if she does
have any tone on that side of her body. This will
help give me a better idea of what is possible to
work on with that side and know what to
recommend in the discharge to future therapists
as well. It is also good to have a baseline of
where she is starting since we are the first to treat
her.

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2. Fugl-Meyer with added PROM I liked the Fugl-Meyer because it tests a lof of
things all in one assessment. This assessment
addresses sensation, movement, and pain.
Though she is not expected to have any
movement in her left arm because it looks
flaccid, I still think it is important to see where
her right arms abilities stand and to find out if
she has any sensation on the left side and if she is
in any pain. I also wanted to inlcude PROM as an
addition to this test (most likely instead of the
AROM required for this test) to see what her left
ROM is like. This will give me an idea if she has
any other problems that are causing her arm to be
flaccid and to see what she could be able to do in
the future. Again, I think it is good to get a good
baseline for future treatment.
3. CES-D I wanted to have an assessment that would
address her possible depression. She is very
emotional the first time I go into treatment and
she is very young to have ahd a stroke, and just
had her first baby. These are both life changing
events and it would be very difficult to have them
both happen at the same time. One purpose for
this test is for me to see where she is at
emotionally so I can address that in treatment,
but also it might be good to see if she could
benefit from support groups or a psychiatrist.
4. Apraxia Screen of TULIA (AST) I wanted an assessment that could address
cognition and her possible apraxia. I found this
assessment as on that specifically addressess
Apraxia to narrow down where the deficit may
be and what she has the most difficulty
performing. This test seems very short as well so
it could be a quick view of her deficits.
5. LOTCA I liked the LOTCA because it addressed both
visual and cognition. I wanted an assessment that
would address cognition to see if she had any
other deficits, but also this assessment addresses
visual deficits, which could help see about her
left-neglect. Though longer in assessments, I felt
that this was very important to address because
there very well may be other things that are
causing the way she acts (other than aprxia and
neglect). It wil be important to broaden the types
of tests given as we have just met her and she just
had her stroke.

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6. Motoricity Index and Trunk Control Test The main reason I wanted to do this assessment
was to address her trunk control. Though this
assessment has some arm and leg movement, I
can decide or not whether this should be tested
again or not after the Fugl-Meyer. I want to know
about her trunk control because this will
determine what stratgies to teach her, how I set
up treatment sessions and help me know what her
mobility will be like. I have already seen her sit
at the EOB, but I would like to see if she can roll
and how she does getting up from being in
supine. Increasing her trunk stability and strenght
will really help during treatment.

15. CPT Evaluation Code: Justification

Low Shannon has such a small medical history, especially since she is so
young. She has had a baby and a stroke, which happened at the same
time. All her medical history has been in the past 4 days. This would be
considered in the low category. The performance deficits can be
considered a moderate complexity. This is because her diagnosis
includes some other deficits that are part of having a stroke. She has
neglect, apraxia and she is emotionally unstable after the past couple
days. Also with a stroke, it is hard to tell where her baseline will be
before being tested and how much she can recover because all strokes
are different.I would also put the clinical reasoning at moderate because
you have to figure out what deficits she has and how ti help each of
those in treatment, even though you only see her for a week. Overall,
she would be in the Low category because all 3 would have to be
moderate in order for her to move up.

16. Projected Outcomes: Type of Outcome

Suggested discharge location: inpatient rehab because at this point, I Occupational Performance
don't think she will be ready to move home. In inpatient, she will be Health and wellness
able to receive more services and they will be more intensive to help Quality of Life
her recovery quicker and for her to learn more about what to do once Participation
she goes home. It will be beneficial for family members to either be Role Competence
there for sessions or talk to therapists to understand how to help Well-being
Shannon the best once she is home.
Increase occupational performance. Increased attention to left side,
increase strength and movement (espcially with tasks to get ready for
child rearing), increased ability to do some ADL's with less assistance,
increased participation in therapy, in tasks and in occupations.
increased wellbeing and less depression, increased confidence in
abilities, increased rolve compenence as mother (the goals are
addressing ADL's, but will be helping with the skills needed for child
rearing), increase qualitiy of life as participation and occupational

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performance increase.

17. Resources and Team Members

Team members: mother, father, husband, baby, Dr. Lewis, nurse, OT,

Resources: it would be good for her to work with PT if she is not able to walk or move her leg that
much, She could join a stroke support group or a first time mother's group (to help with any emotional
needs or advice) , looking into a day care would be helpful for her baby if she doesn't have a sitter
while she is recovering on days that she needs, possibley a psychologist if dealing with any depression

18. Intervention Plan

Barriers
She just had a stroke 3 days ago
She had a baby 4 days ago, she is a young mother, Her
insurance might not cover what she needs, her parent's don't
live here- they are only visiting, don't know where husband is,
will need to take care of her baby while recovering, wants to
go home but will need more care before going home, Her
family may want her home earlier than she should (especially
if the parents aren't staying for a long time), Her arm looks
flaccid-won't be of much help yet, was unconsious the past 3
days (may not know what has happened yet), emotionally
mght not be stable, needs assistance with everything currently,
she is young to have had a stroke, only 1 week of therapy,
might have left neglect, most likely will be home alone with
the baby,
Supports
She doesn’t have to go back to work,
her parents are here to help, her
husband may have a flexible
schedule with school, she has
insurance, will be able to get more
care before she goes home, she is
motivated to work to go home to her
baby, will her age help her recovery
speed, She's only 23 and had a
stroke young - she had full ROM
before and could be able to gain that
back.

Goals Practice Model for each goal

1. LTG:

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In 7 days, Shannon will I dress UB using hemi-dressing PEO, Motor control, Rehab,
techniques.

1a.STG:
In 2 days, using her right arm, Shannon will I thread her left PEO, Motor control, Rehab
limb through the sleeve using hemi-dressing techniques.

1b.STG:
In 5 days, Shannon will fasten her bra using compensatory PEO, Motor control, Rehab
strategies with minA.

2. LTG:
In 7 days, Shannon will I self-feed a meal using A/E and PEO, Motor control, Rehab
weight-bearing in left arm in supported sitting.

2a. STG:
In 2 days, Shannon will I set up left arm in weight bearing PEO, Motor control,
before starting a task.

2b. STG:
In 5 days, in a supported sitting position, Shannon will I sit for PEO, Motor control, Rehab
5 minutes to while completing a task.

3. LTG:
In 7 days, Shannon will I wash her entire face with min VP to PEO, Motor control,
complete left side.

3a.STG:
In 3 days, Shannon will wash right side of face with min A to PEO, Motor control,
guide hand in correct pattern.

3b. STG:
In 5 days, Shannon will look to the left to find the washcloth PEO, Motor control,
with min VP.

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19. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do? Identify Approaches Based on which
goal(s)?
This session will consist of dressing and some Restore, Modify, 1, 3
hygiene. Because we cannot fit everything into one
treatment session, we will focus on donning a shirt
and washing face to get ready for the morning. This
would be the first time that Shannon would have to
get dressed one handed so really I just want to work
on teaching her a technique that will work and have
her practice while I support her trunk position (so
she can focus on just on thing). From what I have
seen already, it looks as though teaching this skill
while she is sitting in bed supported might be the
best way to conserve energy. I will teach her how to
move her right hand to position the shirt (or set this
up for her if this is too hard). Then show her how to
use her right arm to thread the left arm through the
sleeve. Here the focus will be for her ot do the right
motions and movements (as she showed difficulty
with before), forcing her to look to the left since we
are using her left hand and to teach her a technique
she can evenutally use on her own. Then assist as
needed and teach how to put shirt over head and put
right arm through. Cue if needed and assist with
balance to help her lean forward to adjust and pull
down the shirt in the back. Though we aren't
working on LB dressing as a goal right now, this
could also be a time to show her a possible dressing
technique to put on pants. Show her and help with
balance to get the body used to the movements and
stregnth required for bridging and pulling up her feet
to her knees. Assist her in getting her pants on while
talking ans moving the body though the positions.
Next work on face washing. As she has already done
this once before, start with cueing to see if she
remembers to look to the left. this time assist her
arm and hand to move in the right movement
patterns to help her body remember where the wash
cloth goes and how to use it. If wanting to practice, I
can place many objects on the right and left and
have her practice finding what tool she would need
for combing her hair, burshing her teeth, etc.
Throughout this activity, when possible move arm
into a weightbearing position so it is at least getting
some proprioception. If she does have some
movement, have her try to move her arm, then assist
the rest of the way. Have family member there as
well to educate them on how to help Shannon

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2. What will you do? Identify Approaches Based on which
goal(s)?
This second treatment plan will be either at Restore, modify 2, 3
breakfast or at lunch as I will be addressing feeding
and her left-neglect. Because she has use of her right
arm, most of what i will be teaching her and helping
facilitate is good placement of her left arm and
attention to the left side of her plate. I would have
her feeding utensil on the left side so she has to look
left to find it (use of dysum and/or a plate guard may
be useful as well). Because this is the first time
feeding, I don't want to make this too difficult so
most of the food will be in the middle of the plate,
while some food is still on the left side. I want the
left arm to be in a weight bearing position on the
table. Because of Shannons weak trunk contol, in
sitting I can have her leaning towards the table,
using the left arm as the support so she doesn't fall
onto the table. This will help with trunk endurance
and also get some proprioception to the left arm.
Use cuing and reminders to look left and to find
where the food is that is missing on the left side of
the plate. Also because of possible apraxia, it will
also be important to address the movement from
plate ot mouth at the beginning so Shannon can feel
that correct motor pattern again and hopefull repeat
it. Use physical assistance as needed and use cueing
fot left side. Again, have a family member there to
teach them how to help with the apraxia and neglect
so they can help at home. Teaching any energy
conservation techniques such as taking a break or
better positioning would also be beneficial for
Shannon.

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