Pair Treatment Plan #2

Samantha & Katherine

Patient name: Jessie

Diagnosis: right MCA stroke
PMH: preeclampsia, migraines, pregnancy
Psycho Social/ Family situation: Pt. is 26 y.o. with a 1-month-old daughter and lives with
her husband who assists her. Her mother also assists. She is a bank teller and enjoys
dancing, online shopping and scrapbooking in her free time. She lives in a two-story
house with two steps to enter. Her bedroom and bathroom are on the first floor. She
has a walk-in shower.
Precautions: fall risk, no PROM greater than 90 degrees in L shoulder
Patient’s stated goals: change and dress daughter, return to work
Medical Cause/ Description of Diagnosis:
Pt. experienced a right middle cerebral artery stroke due to preeclampsia during and
immediately after the birth of her daughter. She exhibited difficulty with basic and
complex problem solving, L UE AROM limitations, no supination or pronation or fine
motor grasps. She also exhibited decreased sensation and muscle strength in her L UE.
Preeclampsia is a condition during pregnancy characterized by high blood pressure and
signs of organ system damage (most often the liver or kidneys) thought to be caused by
poor development of placental blood supply. This onset can be gradual or quick, and the
only solution is to deliver the baby. Symptoms often include blood pressure above
140/90, severe headaches, pain in upper abdomen, shortness of breath, changes in
vision, nausea, thrombocytopenia, impaired liver function and excess protein in urine.
Preeclampsia can cause fetal growth restriction, placental abruption, premature birth,
cardiovascular disease, and body system damage (including stroke). This pt. experienced
a right MCA stroke due to her preeclampsia. A right MCA stroke due to preeclampsia is
caused by the burst of a blood vessel (hemorrhage) in the middle cerebral artery due to
a sudden spike in blood pressure. This has the highest rate of mortality out of all stroke
types. Symptoms of a stroke include facial drooping on one side, arm weakness, sudden
difficulty speaking or confusion, sudden vision problems, loss of balance or
coordination, dizziness, and sudden severe headache. A right MCA stroke may cause a
decrease in strength, movement, or sensation in the left side of the body, problems with
attention, memory or judgement, problems with vision, and aphasia. The long-term
effects of a right MCA stroke are unknown as it depends on where the stroke occurred
in the MCA, the severity, and rehabilitation access.

Models or Frame of Reference:

The Rehabilitative/Compensatory frame of reference is aimed at helping an individual
become as independent as possible despite their impairment. This can be through
adapting the tasks, providing adaptive devices, modifying the environment, and training
family on tasks she will need assistance with. This approach may be used when there is
not a high expectation for improvement, but it allows for greater initial independence
and encourages remediation. Adaptive devices that could be used for her are grab bars
to assist with transfer to and balance while using the restroom, a wheelchair to improve
mobility through occupations, a shower bench to allow for easier transfer to the bath,
and a long-handled loofah to assist with reaching areas that would otherwise be
impossible because of her ROM limitations. Adaption of the environment may include
removing throw rugs to prevent tripping or interference with the wheelchair, and
placing items she needs at chest height or lower due to the issue with shoulder flexion.
Because her mother and husband are helping with her recovery, they are educated on
precautions, proper transfer assistance, and methods to aid with bathing, toileting,
standing, and dressing to promote independence. The frame of reference may change
after precautions are lifted to a biomechanical frame of reference to focus on
strengthening and endurance her recovery.

Priority Intervention STG LTG

Impairment/ Activity
Limitations/
Problem Areas
Independence in 1. Pt. will practice Pt. will demonstrate Pt will perform seating
bathing dynamic sitting seated UE bathing bathing with long-
balance while routine with min assist handled loofah while
seated on using long-handled supervised.
shower bench. loofah as needed.
She will shift
her weight
from right
buttocks to left
buttocks while
reaching under
bottom with a
washcloth to
facilitate this
portion of the
shower
routine. Pt. will
hold shifted
weight on each
buttock for 10
seconds for 2
sets each side.
2. Pt. will perform
wrist
supination and
pronation
exercises with
1 lb dumbbell 8
repetitions x 2
sets. This will
 will improve
pt.'s ability to
supinate and
pronate while
washing self in
bathing
routine.
3. Pt. will practice
washing UE's
using a long-
handled loofah
while sitting on
shower bench.
This will
promote
independence
in UE bathing.
She will use her
right hand,
which does not
have ROM
precautions to
practice
reaching both
UE with the
loofah. She will
also reach her
chest and
perineal area,
while adhering
to safety
precautions
throughout.
Independence in meal 1. Pt. will work on Pt. will measure Pt. will prepare simple
preparation dynamic sitting ingredients necessary meal with supervision
balance in her for preparing simple while seated in
wheelchair by meal with min assist wheelchair.
reaching across while seated in
her body to wheelchair.
pick up food
items on the
counter. She
will perform
this activity 5
times on each
side to increase
independence
in gathering
food, while
maintain her
 sitting balance.
2. Pt. will make
brownies to
work on
supination and
pronation of
wrist required
to pour the
correct amount
of ingredients
in the bowl.
This will allow
pt. to increase
her
independence
in simple meal
preparation.
3. Pt. will work on
reaching into
the fridge or
cabinet to
retrieve items
for a planned
meal while
seated in
wheelchair.
She will
retrieve the
needed items
without losing
her balance.
She will adhere
to safety
precautions of
L UE
throughout.
Independence in 1. Pt. will work on Pt. will perform Pt will perform toileting
toileting dynamic sitting perineal hygiene routine independently.
balance while portion of toileting
sitting on the routine with supervision
toilet by for safety.
practicing side
to side weight
shift from left
side of
buttocks to the
right as pt.
reaches under
bottom with
toilet paper.
2. Pt. will perform
"head
 shoulders
knees and
toes" dance
first while
seated (then
standing as
possible) 2 reps
x 3 sets to
practice
changing
center of
balance as
necessary in
pulling down
and up pants in
toileting
routine.
3. Pt. will practice
utilizing grab
bars installed
on each side of
the toilet to
assist with
balance during
the toileting
routine. Pt. Will
first practice
perineal
hygiene with
utilization of
grab bars
during weight
shift to prevent
loss of balance
and work up to
utilizing them
to don and doff
pants.

Independence in fine 1. Since pt. has Pt. will demonstrate Pt. will demonstrate
motor control kyphotic increased fine motor improved fine-motor
posture which control by zipping jacket control by fastening
limits proximal completely with min front-button shirt
stability, thus assist to increase self- independently to
distal mobility care ability. increase self-care
(fine motor ability.
control),
posture will be
addressed via
standing at
wall with heels,
 buttocks,
shoulders, and
head against it.
She will hold
this for 1
minute x 3
repetitions
with support
from therapist
as needed for
balance.
2. Pt. will retrieve
5 coins from
blue theraputty
to challenge
fine motor
grasp
necessary to
participate in
self-care
activities such
as dressing.
3. Pt. will create a
scrapbook
page with use
of stickers and
pens. She will
utilize 2
pictures with 4
tape stickers to
attach pictures,
5 decorate
stickers, and 1
heading
written with a
pen. This will
challenge her
fine motor
ability to
remove
backing on
stickers and
grasp a pen.
These skills are
necessary
when grasping
and
manipulating
fasteners to
don and doff
clothing.