Individual Treatment Plans

Patient name: J.L.

Diagnosis: R MCA Stroke
PMH: Migraines
Psycho Social/ Family situation: J.L. lives in a two-story house with her
husband and 1-month-old daughter. Her mother and husband assist
her when necessary. The house has two stories, two steps to enter, and
bedroom/bathroom on the first floor.
Precautions: None stated
Patients stated goals: Return to job as bank teller, change and dress
daughter

Medical Cause/ Description of Diagnosis: A stroke occurs when an

artery in the brain has an obstruction. The Right Middle Cerebral Artery
(R MCA), a major cerebral artery, provides blood to a large portion of
the right hemisphere. Because the artery serves multiple areas of the
brain, obstructions resulting in a stroke in the R MCA can result in
deficits and losses in many locations, leading to a variety of presenting
signs and symptoms. Larger categories of deficits include movement,
sensation, memory, judgment, attention, vision, and speech. Signs and
symptoms will present on the left side of the body and could include a
lack ability to move body part, lack of body movement awareness,
inability detect touch, confusion, difficulty orienting self to time or
surroundings, ignoring left field of vision, and presentation of aphasia
(non-fluent, global, or fluent). Consistent with any type of stroke signs
and symptoms depend on the location of stroke.

Models or Frame of Reference: J.L.s treatment will focus on the

concepts of the Canadian Model of Occupational Performance (COPM).
This model focuses on the unique factors of the client and the manner
in which he or she interacts with the environment. J.L.s environment
allows for intervention activities to target her interactions with her
environment such as managing her home, performing basic ADL/IADLs,
caring for her daughter, and working as a bank teller. The COPM also
provides an opportunity for J.L. to reflect on and gauge her satisfaction
in occupational performance, creating a collaborative effort when
determining goals. With the COPM, J.L., through her evaluation of her
own occupational performance, can have some input as to what she
would like to work on during treatment sessions.
Priority Intervention STG LTG
Impairment/ Activity
Limitations/
Problem
Areas
Decreased basic 1. Patient will Patient will Patient will
problem solving plan an outfit demonstrate basic demonstrate basic
for herself problem solving problem solving by
based on a through brushing performing
daily weather teeth with morning routine
forecast to supervision. independently.
allow for
basic
problem
solving.
2. Patient will
select items
needed for
tooth
brushing
when
presented
with various
household
items.
3. Patient will
create and
rehearse
script for
morning
tasks,
including UE
dressing, LE
dressing,
grooming,
and tooth
brushing.
Decreased 1. Patient will Patient will have Patient will have
Supination/Pronatio increase supination/pronatio supination/pronatio
n of L UE supination/pr n AAROM at 35 n AROM at 40
onation degrees. degrees.
AROM
through
passively
stretching
muscles
around this
joint.
Supination/Pr
 onation
stretching
2. Patient will
strengthen
supination/pr
onation
muscles by
using a 1-
pound hand
weight to
perform 3
reps of 10
isotonic
supination/pr
onation
exercises.
3. Patient will
practice
supination/pr
onation
through
pouring rice
into child
proof cup in
preparation
for return as
caregiver of
child
Decreased 1. Patient will Patient will Patient will
participation in create a ambulate 50ft with demonstrate
home checklist of small quad base increased
management weekly cane to independence in
housecleanin demonstrate home
g tasks that increased management
must be endurance needed through
completed to for independence ambulating 75 ft
increase level in home with mod I.
of management.
independenc
e of home
management
.
2. Patient will
increase
shoulder
AROM
through
performing
AAROM
shoulder
flexion with
the therapist.
3. Patient will
perform 3
reps of 5,
 carrying a
two-pound
hand weight
a distance of
40 feet, with
small base
quad cane for
support, to
increase
endurance
needed for
independenc
e in home
management
.
Decreased fine 1. Patient will Patient will Patient will
motor practice fine demonstrate demonstrate
motor grasp increased fine increased fine
by picking up motor through motor by changing
5 each of: managing 15 a diaper on a doll
quarters, snaps on child independently in
nickels, onesie sleeper in preparation for
dimes, and preparation for return as caregiver
pennies in care of child. of child.
preparation
for return to
work as bank
teller.
2. Patient will
remove 10
marbles from
medium
strength
theraputty to
strengthen
hand and
increase fine
motor.
3. Patient will
dress and
undress doll.
Doll will be
wearing
outfits similar
to those worn
by the
patients
daughter to
allow for
increased
fine motor
practice with
snaps and
sticky strips
on childrens
clothing and
diapers in
preparation
for return as
caregiver of
child.