Loretta is a 72-year old married woman who incurred a cerebral thrombosis resulting in a cerebrovascular accident (CVA) 3 months ago.

She lives in a modest home with her husband. Loretta was active before her CVA, volunteering 10 hours a week at a local charity thrift store, walking a miles a day with friends, and caring for her husband, who is diabetic and has poor vision. She was independent with all of the indoor home management activities. She and her husband have a gardener, but Loretta enjoyed gardening with potted plants. The CVA resulted in an ataxic gait, mild dysarthria (slurred speech), dysphagia (swallowing deficits), and slight hand incoordination. Loretta is easily frustrated and concerned about how she and her husband will manage, since her adult children live 5 hours away. She was referred to OT for evaluation and training in ADLs and IADLs and for treatment for dysphagia. The initial evaluation process involved an interview with the client and her husband to create an occupational profile. Based on the priorities and problems identified by the client and her husband, the occupational performance analysis included the use of Kitchen Task Assessment and an ADL performance evaluation. The evaluation was completed in a 1-hour session. Loretta became restless after 15 minutes, but with redirection continued to attend to the tasks. Loretta is independent in eating, upper body dressing, and grooming while seated. Loretta is independent in toileting. She has been receiving maximum assistance for lower body dressing and bathing. She has difficulty with handwriting, use of the telephone and handling keys. She requires moderate assistance to walk, using a front-wheeled walker (FWW), but is independent with wheelchair mobility on flat surfaces. Her visual fields are intact. She has no visual-spatial deficit. Her upper extremity strength and range of motion are within normal limits (WNL). Hand coordination is mildly impaired, as demonstrated with moderate difficulty pushing buttons on the phone and show tying. She is able to stand while holding on to a stable surface but cannot use her hands for a task while standing. Results of the Kitchen Task Assessment demonstrated deficits in organization of the task, at which point she required physical assistance. Loretta is highly motivated and has the potential to do simple, hot meal preparation and basic self-care independently, except for showering, for which she requires supervision. A swallow assessment demonstrated moderately impaired tongue coordination and minimal delay with a swallow. Loretta has already modified her diet by selecting very soft foods and slightly thickened liquids. Progress Report Loretta has attended OT two times a week for 4 weeks. She is generally cooperative and motivated, although periodically she becomes discouraged as she continues to have an ataxic gait and requires the use of the wheelchair for independent mobility. Treatment has focused on lower extremity dressing, oral-motor exercises to improve swallowing and simple meal preparation. Loretta has made significant progress in the treatment program. She has progressed from maximum assistance with lower extremity dressing to independent while seated. She has improved from chair-level grooming to standing with one-hand stabilization while using the other to brush her hair and teeth. Progress has been made from maximum assistance with bathing to supervised with transfer to a shower seat. From moderate difficulty with

use of phone, she has progressed to independent, and from dependent with oralmotor exercises she has progressed to supervised. Loretta is now independent in cold meal preparation after initially requiring maximum assistance. Loretta continues to require a soft diet and slightly thickened liquids because of swallowing difficulties. She is consistent with use of safety techniques for swallowing. She continues to have impaired hand coordination but is learning compensatory techniques to adapt her method of performing various ADL tasks as demonstrated with her progress in ADLs. Occupational therapy has coordinated treatment and goals with the physical therapist and social worker. The therapist has recommended that the social worker refer the clients husband to a low vision center for evaluation, since he was dependent on his wife and never received instruction in low vision training. His independence will relieve some of Lorettas burden on caregiving. Occupational therapy will focus on hot meal preparation, bed making, and exploring leisure interests with gardening, long with continuing to work toward improvement of oral-motor and hand coordination.