Individual Treatment Plan

Patient name:
Diagnosis: L stroke
PMH: obesity, hypertension, type II diabetes
Psycho Social/ Family situation: Pt is a 64 y.o. woman who lives alone in an active living
community. Pt regularly participates in social events and enjoys socialization, grooming
activities of hair and nail prep, watching TV, cooking, eating, and playing bingo. Her
husband passed away three years prior but has two children who visit frequently. Her
apartment is one story and does not have any steps to enter. Pt is independent in
dressing and bowel/bladder control and is modified independent with use of assistive
devices in bathing, toileting, feeding, grooming, transfers and use of stairs. Pt performs
simple tidying and meal prep but has a cleaning person come to vacuum and clean
bathroom. Pt does not drive and depends on daughter or a cab service for
transportation. Pt does not work and is currently on disability but worked at the Ohio
Department of Health prior to her stroke.
Precautions: fall risk, no PROM of R shoulder past 90 degrees
Patient’s stated goals: increased ROM in R UE and R LE, increased R hand dexterity,
increased social participation, host a girl’s night, improved speech

Medical Cause/ Description of Diagnosis:

Pt has experienced 3 left-sided strokes, caused by her history of hypertension, type II

diabetes and obesity. The first stroke was 10 years ago, at the age of 54 y.o., with a
second following one month later and a third six months later. Pt is ambulatory with use
of a cane but has fair dynamic standing balance so also utilizes a scooter to assist. Pt is
modified independent in self-care tasks but requires assistance with cleaning and is
dependent for transportation. Pt has visual impairments on the left half of both visual
fields and overshoots on r side. Pt has significant decreased ROM with no finger
extension and decreased muscle power on her right side. Pt also has decreased complex
problem-solving and LTM.

A left-sided stroke occurs when blood flow is cut off from part of the brain, either
caused by a blood clot or hemorrhage. This interruption causes neurons damage or
death in the area of impact. Risk factors for any type of stroke include high blood
pressure, smoking, obesity, and high cholesterol. Onset of a stroke may cause a severe
headache, one-sided weakness (facial droop), blurred double vision, confusion, and loss
of balance. The long-term impacts are variant and dependent on many factors including
the location and size of the stroke, and the length of time until treatment was received.
A left-sided stroke causes paresis (decreased sensation) or paralysis on the right side of
the body, and may impact speech, language, vision, motor and cognition. Speech and
language deficits may include speech apraxia and aphasia. Vision deficits may include
double vision, right-sided neglect or nystagmus of the eyes. Motor deficits may include
decreased coordination, balance, and spasticity/flaccidity. Cognitive deficits may include
decreased attention, judgement, task sequencing, and ADL/IADL participation. Due to
the extreme nature of these impacts, pts are at a significant safety risk after a stroke.

Models or Frame of Reference:

The Rehabilitative frame of references are utilized to increase pts. participation in ADL’s
and IADL’s through adaptation of tasks, providing adaptive devices, and modifying her
environment. This approach allows for the greatest independence and
increases participation in occupations. Rehabilitative FOR is used when expectation for
improvement is low, as is the case with my pt who is 10 years post stroke.
Adaptive devices may include a reacher to enable self-dressing, a shower bench and
devices to allow for independence in bathing, and a cane to improve balance and safety.
Adaption of the environment may include modifying locations of kitchen items to
prevent high ROM need and colored tape to improve neglect. The frame of
reference may have the ability to shift to biomechanical if PROM and balance improves
significantly to focus on strengthening and endurance.

Priority Intervention Activity STG LTG

Impairment/
Limitations/
Problem Areas
Shoulder AROM 1. Pt will target Pt will demonstrate Pt will demonstrate
increased shoulder increased AAROM of increased AAROM of
AROM by shooting 60 degrees of shoulder 85 degrees of shoulder
paper into the flexion to increase flexion to increase
trashcan like a independence with independence with
basketball with washing face. putting clothes away in
increased distance closet.
between self and
can as pt improves
to increase I’nce in
obtaining items for
meal prep.
2. Pt will target
increased shoulder
AROM by putting
dishes away in
cabinet.
3. Pt will target
increased shoulder
flexion by raising
arm straight out in
front of body 3 x 5
with 1 lb weights to
increase
 independence with
laundry.
4. Pt will target
increased shoulder
abduction by placing
hair clips in hair with
assistance to
increase I’nce in
grooming.
Grooming 1. Pt will target Pt will demonstrate Pt will demonstrate
grooming by improved grooming by improved grooming by
unscrewing nail grasping hairbrush painting nails
polish and painting with right hand and independently with
nails on both hands brushing hair with min use of nail polish
with physical assist. remover as needed.
assistance as
needed.
2. Pt will target
grooming by
combing hair while
looking in mirror to
ensure all areas are
combed. She will
adhere to safety
precautions of R UE
throughout with
assistance as
needed.
3. Pt will target both
motor planning and
fine motor control
by applying lipstick
while looking in
mirror to increase
I’nce in grooming
routine.
Meal Preparation 1. Pt. will target Pt will demonstrate Pt will demonstrate
increased I’nce in improved endurance improved I’nce in meal
meal prep by by standing at sink and prep by cooking a one-
reaching into the washing dishes for 5 pot meal from start to
cabinet at shoulder minutes to increase finish modified
height independence with independently with
to retrieve items for meal prep. use of cane as needed
a planned meal. She for balance.
will retrieve the
needed items
without losing her
balance. She will
adhere to
safety precautions of
R UE throughout.
 2. Pt will target
dynamic standing
balance by picking
items up off floor
and placing in basket
at counter height to
increase I’nce in
meal prep task of
unloading the
dishwasher.
3. Pt will target right
hand dexterity by
cutting green
theraputty with
plastic knife to
increase I’nce with
meal preparation.
Social Participation 1. Pt will target r hand Pt will participate in a Pt will organize a girls
dexterity by picking multi-person card night for her friends by
up bingo chips and game with no more planning a date, time,
placing them on a than two verbal cues location, and one
board to increase to increase social activity independently
ability to participate participation. to increase social
effectively in social participation.
activity. By
increasing
confidence, ability,
and speed in playing
bingo, pt will be
more likely to
participate in these
activities at her
facility.
2. Pt will target
preferred activities
by identifying three
activities offered in
her retirement
community that she
is interested in and
problem-solve to
determine how she
may participate in
these to increase
independence in
social participation.
3. Pt will target
physical activity as a
means to social
involvement by
participating in 5
chair yoga poses:
 cat-cow, spinal twist,
eagle, pigeon, and
foreword bend. By
facilitating ability to
participate in a
leisure activity, pt
will increase
confidence in
participating in
these activities at
her facility and her
ability to follow
multi-step
directions.
4. Pt will target social
interaction by
participating in a
card game of “war”
to practice turn
taking,
communication, and
attention to increase
independence in
social participation.