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Abbie Beutler


Name: Bruce Jensen
Medical History: 6 bypass surgeries, 3 strokes, HOH with bilateral hearing
Reason for Referral: Overall weakness especially on L and balance
Medication: Lisinopril
Other diagnosis of concern: none
DOB: 12/24/1931
Age: 84
Evaluation Date: 1/29/2016 & 2/5/2016
S: To look at that (clock) makes a difference. Wife says she thinks if her husband can
do simple household tasks again his confidence will improve e.g. dishes, laundry,
O: Client was seen 1/29/2016 & 2/5/2016 for a comprehensive occupational therapy
evaluation due to concerns about clients ability to participate in ADLs and IADLs. A
semi-structured interview, an observation of occupational performance, and portions of
the LOTCA were conducted.
Occupational Profile:
BJ is an 84-year-old male that lives with his wife and dog. Since the stroke, 18 months
ago, BJ has experienced a lot of fatigue and is unable to drive. His wife, JJ takes him to
all his appointments, fixes his meals and helps him get dressed for the day. He is very
dependent on her.
Before BJ retired he was an Architect and designed school campuses. When he was not
working he spent his time going to musicals and appreciating art. He also enjoyed
drawing in his free time. Spatial orientation has been difficult for the client since his
stroke so drawing is no longer enjoyable. His wife would like to see him get back to it in
some way but does not know how.
During the interview client, wife, and therapists identified the 3 main areas of concerns to
establish therapy goals. The 3 areas were, dressing, hanging up clothes and putting dishes
in dishwasher. Overall weakness especially on the L side and balance will also be areas of
focus during these occupations, as that was the reason for referral.
Client reported a typical day includes waking up at 8:30. His wife takes blood pressure
and client walks, with his cane, to the bathroom to take his pills. Client then returns to
bed and rests. Wakes up again, showers independently and gets dressed with max assist
for set up. This process takes about 2 hours. He rests again before he eats the toast and
eggs. His wife prepares all of his meals for him. He then rests again until lunch. After
lunch he has physical therapy 2x a week and speech 1x a week. When he gets home he is
very fatigued and takes a rest before dinner. During the night client wakes 3-5 times to go

to the restroom. This has been discussed with the M.D. and BJ has been advised not to
drink water too close to bedtime.
Observation of Occupational Performance: Client was asked to hang 2 shirts on
hangers. When client was handed the first shirt, he independently put it on the hanger
with only 1 VC to adjust the alignment. The second shirt was tossed on the chair for the
client to hang up. Client hung shirt on hanger sideways with the sleeves in the front and
back. Client needed 5 verbal non-directive cues to recognize it was incorrect. He started
over in the process by taking shirt off hanger and identifying the shirts parts. Once he
verbally identified the sleeves, front and back with 3 VC he was able to successfully hang
it up. Client was not observed doing his other goals of dressing and putting dishes away
due to time restraints.
Environmental assessment: The client and his wife were asked about their home during
the interview. They have lived in 3-story condo for 45 years. There are 14 steps to each
level. The upstairs has their bedroom and bathroom. The main level has a kitchen, dining
room and living area. The basement has a laundry room and there are 3 more steps down
to the garage and home exit. A support for the client is that all stairways have railings.
The bathroom has a tub shower with shower bench that the wife thinks is too low for BJ.
Although client would like to be able to walk around his neighborhood with his dog, he is
unable to because he tends to get lost.
His environment can present as a barrier for BJ because he already feels fatigue for most
of his waking hours. Although he is able to climb stairs using handrails this climbing may
contribute to his fatigue.
Memory Test: Five words were said to the client. He was asked to repeat them back 2x
and was instructed to remember them and that he would be asked to repeat them 5-10
minutes later. Halfway through client was able to repeat back 2 words I and needed 1
nondirective verbal cue for 1 word and had no recollection of the other 2 words.
LOTCA: The Lowenstein Occupational Therapy Cognitive Assessment is a standardized
test that was developed as a measure of basic cognitive skills and visual perception in
older adults with neurological impairment. The visual perception and the visuomotor
organization were the sections tested the results are shown below:
LOTCA Battery: Scoring
Score rated on a 1-4 scale
(1 being low 4 being high)
Visual Perception
Object Identification
Shape Identification
Overlapping Figures
Object Constancy
Visuomotor Organization
Copying Geometric Forms
Two-Dimensional Model


Pegboard Construction
Colored Black-Design
Plain Block-Design
Reproduction of a Puzzle
Drawing a Clock


A: When client was hanging shirts he had difficulty identifying how the shirt should be
on the hanger. With this observation combined with the LOTCA results it is evident that
the client has issues with visuomotor organization and slight left neglect (hyperattentive
to the right). During the evaluation, client talked out loud to process steps for each task
when asked what his process is. This aided in him recognizing mistakes and completing
the task. His visuomotor organization and poor processing have led him to have difficulty
with household activities e.g. laundry, dressing and dishes. With evidence from the
memory test client short-term memory is affected secondary to stroke. By the end of the
60-minute session client was fatigued as demonstrated by perseveration on final test task.
P: Client will be seen for skilled occupational therapy services 1x a week for 6 sessions.
Client will be trained on processing skills to support him during daily tasks. These
processing skills include handling, initiating without hesitation. Strategies will also be
implemented to aid him in his memory. Additional observations will occur throughout
therapy and adjustments will be made accordingly.
LTG: By discharge client will be able to independently complete dressing with preferred
STG: In 3 weeks client will correctly identify front of shirt with no more than 2 VC.
STG: In 3 weeks client will don shirt with no more than 3 VC.
LTG: By discharge client will be able to perform home management skills (laundry &
dishes) independently by using compensatory strategies.
STG: In 3 weeks client will independently be able to properly hang up shirts.
STG: In 3 weeks client will complete dishwasher routine with no more than 5 VC.
Practice Model & Justification
PEO This model aids patients in finding congruence with themselves,
their environment and occupation. It works very well for those who are
not happy with their occupational performance. A persons belief about
how improving a particular occupation will influence how well they will
engage. Now that the clients prioritized occupations are identified his
environment can be used to enable function in these areas. BJ (person)
will work in congruence with his environment (wife and adaptive
techniques) with his occupations (dressing, laundry and dishes).

DIM This model uses cuing, gestures etc. to challenge the clients problem solving skills.
Cognition is modified as an ongoing process and can be improved with experience and
the proper support or cues. Researchhasshownthatoneofthebestwaystolearnisto

With each activity we will set it up so client has to turn to left or acknowledge left to
gather items in order to help with left neglect.
Educate/discuss memory strategies he can use to improve short term memory
Occupation Based Activities:
o Have him practice identifying front and back of clothes
Learn strategies to identify front from back
Help him be able to choose own clothing
o Hanging up clothes
Try having him talk his way through activity
Increase or decrease verbal cueing as needed
o Putting dishes in dishwasher
Stimulate dishwasher with drying rack
Watch him and discuss what difficulties are
Home evaluation
o Go to home and assess to see if there are any areas of concern
o Watch client perform some activities
o See if things change in home environment what are the challenges?
Explore energy conservation techniques to help with fatigue
Gillen, G., Nilsen, D. M., Attridge, J., Banakos, E., Morgan, M., Winterbottom, L., &
York, W. (2015). Effectiveness of interventions to improve occupational performance
of people with cognitive impairments after stroke: An evidence-based review.
American Journal of Occupational Therapy, 69, 6901180040.
Gillen et al (2015) did a systematic review of effective interventions for
persons that have had a stroke. They categorized each intervention type as its own.
Researchers found that cognitive strategy training (CST) were effective. CSTs consisted
of internal and external compensatory approaches for ADLs. Data showed that the CST
group showed greater improvement on nontrained tasks. This shows that CST helps
clients generalize skills learned. This will work beautifully with BJ as we implement the

DIM during the therapeutic process and provide cues and gestures as he goes about his
tasks. This support will aid him in processing on his own.
Nilsen, D., Gillen, G., Arbesman, M., & Lieberman, D. (2015). Occupational Therapy
Interventions for Adults With Stroke. American Journal of Occupational Therapy, 69(5),
This article is relevant to BJs therapeutic process because it is a review that gathered the
most effective interventions for patients that have experienced stroke. For ADL
improvement the most research supports interventions that are occupation-based.
Although this study was done in an inpatient setting we still find it relevant because we
can use these same strategies in our outpatient clinic with the resources we have. We plan
to on using occupation-based practice to help BJ become independent in his ADLs
Education: The main educational piece for BJ is make sure he understands how important
it is to keep working and trying and not relies completely on his wife. BJ often mentions
he could not survive without his wife and we want to ensure him that he can be capable
of a more independent life with modified independence.