Student Name: Melissa Zepeda Case: #4 Shannon Date: 2/15/17

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Diagnosis: Right-sided MCA CVA
Referral: Neurologist Dr. Lewis
Setting: Acute care
Reimbursement: Student healthcare insurance
LOS: Treatment 2x/day for 1 week

2. Pragmatic Factors to Consider

Condition post-partum: Shannon gave birth to her son 4 days ago, it is likely that her body
is still recovering from the shock of birth and resultant hormonal changes. Therapy should
take into account her post-partum physical condition and changes in mood.
Transition to motherhood: The client is a 23 yr. old woman who just had her first child,
therapy should take into account the psychosocial effects of having her child but not being
able to see or care for her child in the way she had expected prior to her CVA.
Recommendations for discharge: The therapist must use assess the clients potential
during therapy to plan for discharge in order to maximize the clients recovery. Although
the family would like to see Shannon go directly home the therapist should take into
account the level of support the client would have at home.

3. Context: Occupational Profile & Current Occupations

Cultural: Shannon is a young wife and mother
She plans on being a stay at home mom
Fitness oriented
Physical: She is in a hospital room
She lives in University student housing
Social: Her father is with her in the hospital for support
Her mother is currently watching her baby
Shannon is married
Lives in a community with other young families
Personal: 23 yr. old female
New mother of a baby boy
Wife, newlywed
Daughter
Not planning on working
Temporal: Shannon had her CVA one day after giving birth to her son
She was unconscious in the ICU for 3 days
She has been married for 18 months
Her son was born 4 days ago
Virtual: May have access to smartphone/ computer for communication with family
Prior Occupations:
Independent with ADL & IADL, enjoyed oil painting, taught Zumba classes, general
homemaking

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Current Occupations:
Dependent for ADL & IADL, MaxA to move her L side, Unable to sit unsupported,
4. Top Three Client/Family Goals and Priorities
1. Return home
2. Care for her son
3. Safety
5. Diagnosis and Expected
Course
Diagnosis: Right sided MCA
CVA. CVA is an interruption of
the bloodflow to the brain
resulting in varying degrees in
loss of contralateral motor
coordination. A blockage located
specifically in the R Middle
Cerebral Artery would interrupt
bloodflow to most of the R
lateral surface of the brain
including the primary motor
cortex, premotor cortex,
supplemental motor cortex,
primary sensory cortex, and
association cortices (Brocas &
Wernickes depending on
dominance)
Expected Course: While it is
possible for individuals to regain
a portion of lost motor
coordnination back after
experiencing a R CVA,
remediation depends on
rehabilitation services.
10% of stroke survivors recover
almost completely
25% recover with minor
impairments
40% experience moderate to
severe impairments requiring
special care
10% require care in a nursing
home or other long-term care
facility
6. Scientific Reasoning & Evidence
List the barriers to performance typical of this
diagnosis:
Scientific reasoning:
1) Brouwer, B., & Ambury, P. (1994). Upper extremity
weight-bearing effect on corticospinal excitability
following stroke. Archives Of Physical Medicine &
Rehabilitation, 75(8), 861-866.
Research shows that biofeedback from weight
bearing exercises received in the hemiplegic upper
extremity following stroke may normalize
corticospinal facilitation of the flexor carpi ulnaris
muscle. Therapeutic interventions that involve
weight bearing through hemiplegic UEs should be
used in order to increase the strength of involved
motor neurons.
2) Hildebrand, M. W. (2015). Effectiveness of
interventions for adults with psychological or emotional
impairment after stroke: An evidence-based review.
American Journal of Occupational Therapy, 69,
6901180050. http://dx.doi.org/10.5014/
ajot.2015.012054
Research shows that mental health aspects following
stroke should not be overlooked in occupational
therapy interventions. The use of motivational
interviewing behavioral techniques, problem solving
techniques, education and care support and
coordination techniques can be beneficial to improve
depression, anxiety, and health related quality of life
in patients after stroke. Techniques that address the
psychosocial aspects of life post-stroke should be
implemented into treatment in order to address the
persons motivation and drive to engage in therapy.
3) Thieme Atlas of Anatomy: Head and Neuroanatomy &
Neuroanatomy notes Spring 2016.
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15% die shortly after the stroke
Common Symptoms:
- poor judgement (impulsive)
- spatial/perceptual changes
- decreased awareness
- left neglect
- apraxia
R MCA specific symptoms
Left hemiplegia affecting
the arm and the face
more than the leg
Hemisensory loss
Potential for aphasia
Spatial agnosia
7. Practice Models Guiding
Assessment and Treatment
1. PEO
2. Motor Control
Information concerning the distribution of the
middle cerebral artery and resultant deficits of an
interruption in blood flow.
Barriers to performance: Loss of left sided motor
coordination and sensation, impulsive behavior, decreased
spatial awareness especially to L side, Inability to
understand shapes/ objects (spatial agnosia), mood changes,
depending on hemisphere dominance aphasia may be
present (expressive or receptive).
Rationale
By using the Person Environment Occupation model I
hope to target an improvement in Shannons occupational
performance. This model focuses on breaking down
personal, environmental and/or occupational barriers in a
persons life that are impeding their ability to perform
their desired tasks. For Shannon specifically I would
focus on personal barriers such as: her inability to
voluntarily control her L side, her L neglect, her receptive
aphasia, decreased sensation, and decreased postural
control for sitting balance. Environmental barriers such as
her unfamiliar hospital room away from her family and
occupational barriers that include fulfilling her role as a
new mother in a way she expected. Keeping the
transaction of all these aspects of Shannons life and
prognosis in mind I will create interventions for her
specifically to improve her occupational performance and
ability to live her most fulfilling life.
By using the Motor Control model I hope to restore
Shannon's ability to use coordinated movement patterns
on her Left affected side in order to increase her
occupational performance and safety. Repetition of
functional movement pattens in the context of
occupations for individuals with CNS impairments
improves ability to control voluntary movement in their
affected limbs. Shannon's Left hemiplegic side should be
used as much as possible in therapy in order to renew
neural pathways within the affected portion of her Right
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3. Rehabilitation
cerebrum. Repetitive task-specific training has also been
shown to be beneficial for individuals spatial neglect
secondary to acute CVA.
The rehabilitation model focuses on a client's ability to
return to fullest functioning through using their current
abilities coupled with A/E and technology to accomplish
optimal occupational performance. Many of the tasks
Shannon currently struggles with can be made easier for
her through the use of adaptive equipment for completing
ADL. Compensatory strategies can also be utilized in
order to increase Shannons safety and awareness for
completing tasks.

8. Specific Areas of Occupation

What do you know?
Affected areas of occupation:
Dependence w/ ADL & IADL: Due to
lack of left sided motor coordination and
sensation, impulsive behavior, decreased
spatial awareness especially to L side,
inability to understand shapes/ objects and What other disciplines does she see
apraxia the client is unable to complete
any of her occupations independently.
Social participation: The client would like How much does she know about her
to see her newborn son and other family
but cannot currently leave the hospital.
What do you know?: Shannon is a 23 yr. old
woman who experienced a right MCA CVA
4 days ago, 1 day after giving birth to her
first child, Riley. Shannon is currently in
acute care, OT services are needed to
evaluate and discharge her to the most
appropriate next setting for her condition and What are her parents outlook on the
prognosis. Shannons parents are very
supportive and are caring for her newborn
son while she is confined to the hospital.
Upon initial observation Shannon
demonstrated dependence with all ADL &
IADL occupations and requires significant
assistance to move safely.
What do you need to know?
I need to know what her prior level of
functioning was
What are her priorities for treatment
I need to know what her expectations for
therapy are
I need to know what occupations are
meaningful for her
prognosis
How does she feel
If she has been transferred yet and what
that looks like (level of assistance)
I need to know how long her parents can
stay with her
What is her parents condition like, ages,
function, availability
whole situation
I need to evaluate her post-partum
condition
Was she planning on breastfeeding
Were there any birth complications
Was her son born on time, premature?
Does her son have any special needs
What is her sons current condition
I need to see if she is able to self-feed or
what her level of assistance is
I want to know what her level of
assistance is with bowel and bladder care

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 I need to know if she has a catheter,
colostomy or any other b&b lines
Episiotomy?
I need to know what sort of medication
she is on
I need to know if there is any medical
equipment she currently needs (i.e
oxygen) that she would need to bring
with her when she is discharged.
I need to know the general setup of her
home
Are there any safety measures in place
for her impulsive behavior
How has her sleep been
What has she been doing during the day
while in the hospital
I want to know if she has a supportive
friends
Has anyone other than her father been to
visit her
Has she been able to hold her baby since
being unconscious in the ICU
Has her husband been supportive
How many hours a day is he in class
How does he feel about taking over more
of the child care duties in the relationship
What is his outlook on the whole
situation
Who is supporting her and her husband
financially while he is in grad school?
Are finances an issue
Does she ever use a computer or
technology

9. Performance Skills
What do you know? What do you need to know?
Performance skills most impacted: Motor Is she physically fit
skills, process skills & social interaction Which is her dominant hand
skills. Has she been able to do anything for her
self since becoming conscious again
What do you know?: Before her Right MCA How is her memory
CVA Shannon was able to complete all her How is her affect
ADL & IADL occupations independently in How is her speech
order to complete household tasks, do her oil
Where does she see her midline
painting and to occasionally teach Zumba
I would want to see how much of a

5
classes. She functioned independently
throughout her day and was healthy enough to
be able to support a growing baby. She now
requires assistance for all daily occupations
due to her lack of left sided motor
coordination and sensation, impulsive
behavior, decreased spatial awareness
especially to L side, inability to understand
shapes/ objects and apraxia. Upon observation
she required MaxA to move her left side and
was unable to sit unsupported. She
demonstrated impulsive behavior when given
instructions and has difficulty judging spatial
relations.
10. Performance Patterns Habits, Routines, Rituals, Roles
What do you know?
Pertinent Info:
Routines: She does not work at a traditional
job during the day but will occasionally teach
Zumba classes for additional income.
Roles: Shannon is a wife, new mother and
daughter.
What do you know?: Shannon and her
husband have only been married for a year
and a half. This medical event in Shannons
life affects her ability to fulfill all her desired
roles and life the sort of life she expected.
11. Activity Demands for the Client Goals and Priorities
What do you know?
Occupation: Feeding her son a bottle
Physical In order to feed her son a bottle
Shannon must be able to sit up in bed while
leaning against the headboard. She must sit
for a period of time with her baby propped
slightly up on a pillow in front of her on her
pusher she is
What do you need to know?
What did her typical days look like
Was she planning on being a stay at
home mom
How many children do her and her
husband plan on having
How did she contribute in her marriage
prior to her CVA
Does she feel she has support at home
What other disciplines does she see in the
hospital and how often
Where does she teach Zumba classes
How long has she taught Zumba classes
How is the housework typically divided
between her and her husband
Are there certain tasks she is solely
responsible for in the home
Has she worked in the past
Does she plan on working in the future
What do you need to know?
How much does her son weigh
Is this a priority for her
How long does he usually feed for
How often doe he usually feed
throughout the day
Are there any precautions concerning
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lap. The babys head is on her L side to using her son in therapy
ensure Shannons R hand is in line with the Is this plausible, should we start with a
babys mouth orientation. She must use her R doll
arm /hand to support a bottle with proper Layout of her hospital room
force and attention. She must remain attended Type of bed she is in currently
throughout the feeding to ensure her baby is (adjustable, rails?)
still sucking and the bottle is at an appropriate What were her plans for feeding her son
angle. prior to her CVA
Social Shannon must attend to verbal cues How is her son being fed currently
from the therapist in order to attend to her L Does she still have her milk supply
side during the feeding. She will be
encouraged to interact with her son as he is
feeding to establish a bond.
Psychosocial Shannon must understand that
she will not be perfect at first, and that even
new mothers who have not experienced a
CVA might have trouble feeding at first.
Emotional Shannon must remain patient
with her current abilities. She must also
recognize that her expectations for what life
with a new baby would be like are no longer
going to be true. She will also have to deal
with the emotions surrounding not being able
to breast feed her infant if that is what she
wanted originally. She may believe she is less
of a mother because she is not able to care for
her infant in the way society deems the
best.

What do you know?: Shannon is a new

mother and has expressed a desire to be able
care for her son as soon as possible. Feeding
her son will allow her to gain a sense of self-
efficacy in her capabilities and allow her to
establish greater bonds with him over time.

12. Client Factors Values, Beliefs, Spirituality

What do you know?
Involved: Shannons motivation to engage in
therapy is influenced by her desire to care for
her newborn son. Shannon understands that
every day she is not with her son is time she
is not able to bond with him while he is
forming crucial attachments. She has a very
What do you need to know?
Does she consider herself a spiritual
person
What does she value in her life
Is she a religious person
Does she have siblings
Where is her husband

7
strong sense of family; her parents have Who was with her when she was
dropped everything in order to travel a long unconscious
distance to support her. Are there other things that motivate her
What sort of life does she see for herself
What do you know?: in 5 years
Shannon is sad/upset by the fact that Does she have any possible employment
she is stuck in the hospital instead of interests
with her son
Shannons father stays with her during
the day
Shannons mother is caring for the
baby during the day
No mention of her husbands presence
either in the home or the hospital

13. Client Factors Body Functions & Structures

What do you know? What do you need to know?
Involved: Attention, emotional, What is her medical history
proprioceptive functions, touch functions, Did she give birth vaginally or through
muscle power, tone, and endurance, C-section
involuntary movement reactions, control of If she gave birth by C-section are there
voluntary movement, and structure of the any abdominal precautions
nervous system. Does she have any comorbid conditions
Is she aware that she is pushing towards
What do you know?: one side
Loss of sensation and motor control on How much is she able to move her L LE
contralesional (Left) side How much is she able to move her L UE
Left neglect I would want to assess her L neglect
Low tone in L arm I would want to assess tone
Poor sitting balance I would want to assess the strength in
Pushing towards her affected L side both UEs and LEs
Spatial agnosia I would want to assess her cognition
Apraxia I would like to know how she is doing
Impulsive behavior emotionally since giving birth
Mood changes What are her perceived deficits
Physical weakness due to post-partum I would want to test her sensation
condition

14. Evaluation: What assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize on occupation to observe the client perform
Observed Occupation Rationale/How will you use this information
I would want to observe Shannon eating a Information from this observation will help
meal while sitting upright in her hospital bed. me gain an understanding of her
R UE function (any sensation loss?)
If she is able to accurately judge the

8

Method/Tool
1. PROM & AROM on her L side
2. Nottingham Sensory Assessment
distance from her plate to her bowl
If she has any movement in her L UE to
stabilize a plate
Observation of her plate while she is
eating will give me an idea of the extent
of her L neglect
Does she have adequate lip closure
Watching her in sitting while her arms
are preoccupied will give me an idea of
her sitting balance
Does she require assistance for any
portion of the task
Information from this observation will help
me gain a greater understanding of her
function in a daily occupation
Rationale/What is begin assessed
In order to test Shannons movement I will
first test her PROM. Because she is in acute
care, testing passive movement first will
allow Shannon to see her L side moving and
may increase her awareness of the limb and
her sense of self-efficacy. As I am passively
moving her L arm & leg, I will be able to feel
her tone and determine whether I should ask
her to actively move her L UE & L LE.
AROM testing will allow me to see what
Shannon is able to do on her own. Because
MCA strokes often affect the contralateral UE
more than the LE it will be important for me
to test both because her ability in her arm is
not necessarily the same as in her leg.
Information obtained from ROM testing will
allow me to determine a baseline for her
ability to control voluntary movement in her
L side.
Performing the Nottingham Sensory
Assessment on Shannons R and L upper
extremities will allow me to gain a greater
understanding of any sensory deficits present
after her CVA. The assessment tests tactile
sensation, kinesthetic sensations and
stereognosis. There is a chance that sensory
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3. Fugl-Meyer Motor function portion
4. Fluff test
5. Right /Left orientation test
6. Minnesota Spatial Relations Test
loss secondary to her CVA is present on both
sides of her body. The test is performed on
both sides of the body and assesses the
patients awareness of sensation. Information
obtained from performing this test will allow
me to gain a greater understanding of whether
Shannons current difficulties are partially
due to decreased sensation in one or both of
her UEs.
To test Shannons motor function in her L UE
I will administer the motor function portion of
the Fugl-Meyer assessment. Information
obtained from this test will allow me to
determine a baseline measurement for her
overall movement abilities in her hemiplegic
UE. This information can be used throughout
treatment in order to create interventions that
are the just right challenge for her with her
current abilities.
To test Shannons attention to her L side I
will perform the Fluff test. The fluff test will
be used because it is sensitive to mild body
representational deficits. Information
collected from this test will allow me to
understand the extent of Shannons L neglect
especially concerning body recognition.
To assess Shannons perception of body
scheme and cognition I will administer the
R/L orientation test. The test also includes a
section for apraxia. Information collected on
this test will allow me to determine whether
Shannons odd behavior during initial
observation is due to apraxia. This test will
also allow me to see if she can follow
commands and has an understanding of her
body scheme.
To assess Shannons spatial relations I will
have her complete the MSRT. Her score on
the assessment will give me a baseline
measurement of her abilities concerning
spatial relations and compare her score to
norms. This will help me determine whether
Shannons difficultly reaching for the bowl
during initial observation was due to spatial
agnosia.
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15. CPT Evaluation Code: Justification:
High Complexity Occupational profile: Complicated circumstances due to
97167 recent birth, more potential issues. There are a lot of
issues surrounding her diagnosis and role demands
(HIGH).
Assessment of Occ. Performance: 5 or more
performance deficits, comprehensive look at her daily
functioning and what it will take for her to live
independently again. (HIGH)
Clinical Reasoning: Shannons recent CVA has
disrupted her life significantly and she will require
skilled occupational therapy to address a few different
areas of occupation in order to live to his fullest level of
independence. (HIGH)

16. Projected Outcomes: Type of Outcome

1. I would anticipate that Shannon would 1. Occupational performance/ Quality of
have an increased ability to address her L life
side and voluntarily control her L UE for
dressing occupations

2. I would anticipate that Shannon would 2. Occupational performance/ Quality of

have an increased ability to wash her face
through the use of compensatory
strategies and increased use of her L UE
as a stabilizer.
3. I would anticipate that Shannon would
have an increased ability to move safely
through utilization of compensatory
strategies
Discharge setting: Inpatient rehab.
life
3. Occupational performance
Rationale: As much as I would love to send
Shannon home to be with her baby, she
requires much more extensive therapy than
what home health can do with 20 visits per
year. Her parents have expressed a desire to
help and have been very supportive so far but
caretaking can take a toll on a caregiver
especially when Shannon is currently
dependent for many ADL. Her parents are
also currently taking care of her son, sending
Shannon home would be very hard on them.
Home with outpatient might be hard for her
parents to manage transportation wise based
on many appointments and coordinating with

11
 the baby. Based on her current level of
functioning she would benefit from a more
intensive therapy schedule. Shannon is
currently too low functioning to qualify for
transitional rehab.
*Depending on progress made, I expect that
Shannon will be able to return home after
spending 3-4 weeks in inpatient acute with
3hrs of therapy a day. With inpatient rehab all
of her services will be in the same building
and she will get the level of treatment she
needs in order to return home as quickly as
possible.

17. Resources and Team Members

Community Resources
I would refer Shannon to a stroke support group, maybe for parents specifically if we can
find one. Online resources can be compiled for A/E, and YouTube videos of hemiplegic
mothers caring for their children might be useful. Shannon might also benefit from seeing
a counselor for difficulties concerning mental adjustment to her prognosis.

Other Team Members

Neurologist, nurses, her mother and father, and her husband

18. Intervention Plan

Barriers Supports
Husband is not able to spend time with her in the Supportive parents are
hospital taking care of their
Not best for a newborn baby to spend time visiting on daughters needs while she
acute is in the hospital
Shannon has not spent much time with her newborn Parents are willing to help
son and this is a critical time for bonding with therapy and understand
Shannons parents are visiting from out of town and the need for therapy
may not be able to stay for an extended amount of time Access to healthcare
Situation is emotional Therapy implemented early
Client has just given birth and might have physical Client is ready and willing
weakness post-partum to engage in therapy

Goals Practice model for each goal

1. LTG: By discharge client will don a pullover shirt with PEO
SU assist while sitting supported in bed Rehabilitation

1a. STG: In 3 days client will utilize adaptive Rehabilitation

strategies to place her L UE in her sleeve with mod
VCs to attend to her L side

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 1b. STG: In 5 days client will utilize adaptive Rehabilitation
techniques with min VCs to pull the remainder of
her shirt over her body and check for problems on
her L side.
2. LTG: By discharge client will independently wash her PEO
face each day while sitting supported in bed with SU Rehabilitation
assist to assemble supplies. Biomechanical
2a. STG: In 2 days client will independently utilize Rehabilitation
self-cueing strategies in order to turn her head to
the left and locate supplies on the table.
2b. STG: In 5 days client will use her L UE to stabilize Biomechanical
the water bowl with mod VCs in order to maintain
position while washing her face.
3. LTG: By discharge client will safely transition from PEO
supine to sitting EOB for dressing with min VCs. Rehabilitation
3a. STG: In 2 days client will use self-cueing strategies Rehabilitation
with max VCs in order to adjust the head of the
bed to sit up.
3b. STG: In 5 days client will utilize a checklist with Rehabilitation
mod VCs in order to clear her surroundings before
moving to the side of the bed.

19. Treatment Sessions: Plan for the first two 45-minute treatment sessions:
1. What will you do? Identify Approaches Based on which
*Session will take place in the morning goal(s)?
Introduction to therapy (10 minutes) Establish & restore,
Reiteration of clients priorities for treatment. We modify 1, 3
will spend the first portion of the session
discussing her outlook on her prognosis and I will
address any fears or doubts she might have
concerning her ability to fulfill her role as a
mother. Therapist will stress the idea that the only
way she will be able to eventually care for her
son is if she is able to take care of herself first,
until then her son is being cared for by his loving
grandparents.

Supine to sit (15 minutes)

I will then ask the client to listen carefully to
directions and to not move until I say so. I will be
talking to her in her R visual field. I will give her
instructions in steps and not give her new steps
until she has finished the prior step to ensure that
she is moving safely. I will first ask her to move
the head of her bed up. Once she has finished this
I will ask her to scan her surroundings to make

13
sure that there are no obstacles in the way of the
sides of the bed, the top of the bed or the foot of
the bed. During this step I will be moving closer
to her midline. I will give VCs as needed in order
to check each space and attend to her L side.
Once she has cleared or noted any obstacles for
me to clear I will give her the next step. I will
then ask her to grip the R side rail with her R arm.
The next step will be for her to scoot herself from
the middle of the bed to the side of the bed using
her legs and her R hand on the rail to move.
During this movement I will ask the client to do
the most she can with her unaffected side and her
L leg. Once she is on the side of the bed I will ask
her to pivot her weight in order to sit on the edge
of the bed while still holding on to the R side rail.
I will then lower the bed so her feet are square on
the ground in order to help her hold her balance.
Once on the EOB I will let the client take a break
and relax a little before I have her do the steps in
reverse order to sit back in bed for our next
activity. Physical assistance will be given to help
her bring her L leg from the floor back to the side
of the bed safely.

Dressing (15 minutes)

Once the client is back in bed and sitting
supported in an upright position I will have her
don a shirt. Pillows are placed on her L side to
decrease her leaning. As she is settling in I will
roll a standing mirror into her room and place it at
the foot of her bed. I will give the client
instructions in steps in order to increase her
compliance and safety. I will first ask her to doff
her hospital gown. I will place a shirt on her lap
that has been rolled up to expose the L sleeve
hole. The therapist will then assist the client to
place her L UE in the sleeve using her R UE.
Although she might be able to do this step with
her R UE I will assist at first in order to increase
her awareness of steps and overall understanding
of the task to be completed. Once she has
completed this step I will ask her to use her R UE
to move the bunched sleeve up her L arm till it is
past her elbow. I will encourage the client to
watch her movements and L UE placement in the

14
mirror to ensure that her L arm is fully in the
sleeve. I will then ask her to pull the bottom of
the shirt on the L side over her L shoulder. I will
then encourage her to check her L side in the
mirror to make sure she has gotten the correct
placement. I will then ask her to pull the shirt
over her head, and then push her R UE through
the R sleeve. I will then ask her to check the
mirror to look for places where she should pull
down or fix her shirt. The client can either
continue to wear the shirt or she can doff the shirt
and return to her hospital gown.

Discussion with father (5 minutes)

I will spend time at the end of the session talking
with the clients father to gain an understanding
of how things are going at home and to help
solidify the need for Shannon to engage in
therapy to increase her likelihood of returning
home sooner.

2. What will you do? Identify approaches Based on which

goal(s)?
*Therapy will take place in the afternoon around Establish & restore,
lunch time Modify 2
Checking in (5 minutes)
Therapist will spend some time at the beginning
of the session discussing how the client has been
feeling since the OT session that morning. If the
client is feeling sad or upset the therapist will
recommend ways in which she can see and
interact with her son virtually with a smartphone
or tablet.

Using her L UE functionally (20 minutes)

When the client receives her food the therapist
will help her eat. The therapist will give the client
steps to follow and will only give steps once the
client has completed the prior steps. In order to
get the client into the correct position for self-
feeding the therapist will ask her to raise the head
of the bed all the way up. The therapist will then
ask the client to scan her bed and surroundings to
make sure there arent any obstacles in the way
before the bedside table is brought over. The

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therapist will encourage the client to scan her L
side as well by moving into that field and asking
her to look towards her. Once obstacles have been
identified and removed the tray will be slid over.
After the food is uncovered the therapist will
place pillows on the L side of the client in order
to reduce her leaning. The therapist will position
the clients L UE onto the bedside table to L of
the food plate and ask her to keep it there while
she is eating to keep her plate steady. As she is
eating with her R hand the therapist will
encourage her to look at her L UE on her table
and use that to determine the border of the plate
and to make sure she was eating the food on that
side of the plate. VCs will be given throughout
the activity in order to bring her attention to her L
side. Physical assistance might be needed in order
to hold her L UE on the table to the side of the
plate. Once she has finished her meal the bedside
table will be removed but the client will remain
sitting in an upright supported position in bed.

Weight bearing (10 minutes)

As the client is sitting up I will explain the theory
behind weight bearing. I will assist the client into
a position where she is sitting in bed but no
longer supported. I will encourage her to place
her L hand on the bed and extend her elbow, I
will ask her to do the same on her R side till she
is supporting her body fully through both her
UEs. I will give VCs as necessary for her to
maintain the proper position and depending on
her ability to maintain her balance I may grade
the activity up in by having her wipe down the
table with her R hand while supporting herself
with her L UE. During this time we will have a
discussion about her discharge. I will have a
candid discussion with her about her prognosis
and the strengths and barriers I have seen in her
life. I will ask her to tell me what she feels would
be best and I will take that into consideration as I
make my recommendation.

End discussion and HW (10 minutes)

At the end of the session the client and I will
determine motivating ways for her to check her L

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side more often. These will be given as HW to
increase her use of self-cueing strategies during
times when I am not there for therapy and for
safety during tasks. I will stress the importance of
attending to her L side and put it in context of
eventually caring for her son.

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