Contact note for fifth visit

Thursday, February 25, 2016

S: Mother stated, Today he had his stroke two years ago, He has always been stubbornNephew
O: Client was seen today at the Life Skills Clinic to address R hemiplegia. Session began by
completing PROM on RUE with the client in sitting to reduce tone. Weight bearing exercises were
completed on RUE for majority of session. Max A was needed to open hand. Client was able to
independently don a shirt with VC to try buttoning. He attempted one button before shaking his
head and taking the shirt off. Client needed mod A to keep R hand open to complete rolling out of
playdoh with rolling pin. Client engaged in task for 2 min before grunting and pushing away the
rolling pin. He could not be reengaged in the task. The client was then engaged about therapy
priorities, expectations, and motor learning and repetitious tasks. He indicated he wanted to do
exercises for his RUE. A foam splint was fabricated for him to wear at night. Client used RUE to
grip and move a bottle off the table to a chair 3x with max A to keep and open to grip and release.
The importance of doing weight bearing at home was discussed at the end of the session.
A: PROM on RUE was completed in sitting to simulate more functional position. Weight bearing
breaks were used to help reduce RUE tone and open the hand so it could be used functionally used.
Client really enjoys and responds well to weight bearing exercises. Client demonstrated frustration
with functional tasks like the dressing and rolling pin and signified he has little interest in those
types of activities and want to do exercises. This will lead to a more biomechanical intervention
approach in further sessions. The foam splint was made for the client to wear at night to help keep
his hand open. Client needed max A to keep hand open due to the effect of effort induced increased
spasticity when attempting a task. Client
P: Client will continue to need skilled occupational therapy services to address RUE paresis and
function. We will continue to use PROM and weight bearing activities to help manage tone in his
RUE. Bilateral tasks will be used to help incorporate affected RUE as a functional assist to
complete daily occupations. Education of the client and caregiver on SROM ad weight bearing
techniques will also be addressed.
LTG1: In six weeks, client will be able to independently incorporate R UE into bilateral tasks as a
functional assist (e.g. dressing and meal preparation)
STG1: In three weeks, client will stabilize objects with RUE during bilateral with no more than 2
verbal cues.
STG2: In two weeks, client will be able to independently use RUE weight-bearing techniques to
prepare hand for functional tasks.
LTG2: In 6 weeks, client will be able to independently complete dressing with preferred clothing.
STG1: In 3 weeks, client will be able to don a shirt and button with min A using compensatory
strategies.
STG2: In 5 weeks, client will be able to independently incorporate RUE to complete zipper
manipulation for LE dressing.
Brynnan Halsey, OTS

2/25/16