Student

Name: Jessica Smith Case: #4 – Shannon Date: 2/11/18

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Shannon is a 23-year-old woman admitted to the hospital 3 days prior following a right sided MCA
CVA. The CVA happened one day after the delivery of her first child (Riley). Shannon was initially
unresponsive for 3 days in the ICU, but is now responsive and ready for therapy (she is currently 4
days post-delivery of her first child, and 3 days-post stroke). She was referred by her Neurologist
(Dr. Lewis) to be evaluated by Occupational Therapy as part of the acute medical admissions unit.
Shannon’s current length of stay (LOS) will be 1 week with treatment 2x/day. Upon completion of
an initial assessment and evaluation period (the 1 week), OT will provide referral recommendations
to Neurologist. These referral recommendations will help determine the most appropriate discharge
setting for Shannon based on her current condition; she may be sent to an inpatient rehab setting, sent
to a transitional rehab facility, or may be sent home with either outpatient treatment or home health
treatment.
- Reimbursement will be paid by Shannon’s husband’s student healthcare insurance.

2. Pragmatic Factors to Consider

- Client’s schedule, husband’s schedule, parent’s (Roger and wife)
CVA happened 1 day after the delivery of her first child, and caused her to be unconscious in
the ICU for 3 days. (was it a medically induced coma/cold therapy, to decrease further
progression of stroke?)
- Post-stroke, Acute phase precautions (i.e. orthostatic hypotension, etc.)
- ICU schedule (OT/Therapy is a low priority for this department; all other tests and medical
necessities are prioritized over therapy)
- Status of Shannon (and Riley) post-delivery (were there any complications from
pregnancy/delivery? Was delivery full-term? Is Shannon on any medications that may have
influenced or are still influencing her current situation/stroke? etc.)
- Client (and family) want her to get back home ASAP.
- She needs to bond with her infant, spend some time with him and performing meaningful but
basic/safe tasks with baby (skin-to-skin time, somewhat holding him (while in side-lying),
possibly breast feeding, talking to him/interacting with him, etc.)
-

3. Context: Occupational Profile & Current Occupations

Cultural:

Physical:

Social:

Personal:

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Temporal: She has had NO opportunity to bond with her child.
- Was the labor full-term? Were there any complications with her delivery? Did
she deliver in the hospital? Was it a long drawn out labor? Did something with
the labor/pregnancy directly cause the CVA (i.e. did she have any screening
performed at the beginning of her pregnancy identifying possible risk factors
resulting from her medical history, genetics, etc. – or did her student health
insurance even cover any pre-natal care?)
Virtual:

Prior Occupations:
Zumba teacher and oil painter

Current Occupations:
New Mom (although not having had the opportunity to interact with infant much/if at all yet.)

4: Top Three Client/Family Goals and Priorities

1. Shannon wants to be able to take care of her son (newborn) Riley

2. Roger (Shannon’s father) wants Shannon to get to a point where she can return home to be with
her son, and states that they will figure everything else out after that.
3. ???

5. Diagnosis and 6. Scientific Reasoning & Evidence

Expected Course List the barriers to performance typical of this diagnosis:
- Left inattention
Right-sided MCA CVA - Left sided hemiparesis
- Motor and sensation deficits (of the ipsilateral side – Left side of
From Guillen - Stroke body)
- Possible language deficits
MCA is most common - Possible pusher’s syndrome?
cause of stroke - Cognitive deficits
- Apraxia
Loss of blood flow
causing tissue death in According to Guillen, MCAs affect both upper and lower trunks including
areas of cerebral cortex the following patterns of impairment:
supplied by the Middle - Contralateral hemiplegia
Cerebral Artery. - Hemi sensory loss
- Visual field impairment
- Poor conjugate gaze

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Ischemia in area causes - Ideational apraxia
impairments (as listed to - Lack of judgement
the right) - Perseveration
- Field dependency
Pronounced deviation of - Impaired organization of behavior
head and neck toward - Depression
side on which lesion is - Lability
located - Apathy
- Visual field deficits
Perceptual deficits likely - Upper and lower trunk dysfunction
Specific impairments during a R MCA CVA
Function can return days - LEFT UNILATERAL BODY /VISUAL NEGLECT
or years post-stroke - Anosognosia
- Visual spatial impairment
- Unilateral motor apraxia

7. Practice Models Guiding Assessment and Rationale

Treatment

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1. PEO PEO is a relevant model to use with Shannon
due to how her recent MCA CVA that has
affected the congruence between the Person -
(Shannon), the Environment - (her being in the
ICU instead of returning to home after the
delivery of her first child 4 days ago), and then
with the Occupations, (such as being a new
mother with a brand new baby at home, which is
affecting her role competence!; but also, the
CVA is affecting her ability to indepedently
perform self-care tasks, ADLs, IADLs, mobility,
and much more).
PEO can help to guide assessment and treatment
by being aware that sometimes, it is easier (and
more appropriate) to begin with changes to the
E, or the O, rather than to the P. For example.
PEO can help therapist to understand that
adapting the task or environment by suggesting
an environmental modification (such as using
the hospital bed to raise HOB to work on upright
sitting tolerance) is likey a better starting point
than attempting to jump straight into changing
the person, while also making it occuaption
based and important to Shannon by
incoorperating child rearing tasks/skills, while
focusing on using compensatory strategies for
functional bed mobility, and basic ADL tasks.

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2. Rehabilitation Model – with a motor control
component
3. Biomechanical Frame of Reference
8. Specific Areas of Occupation
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The use of the Rehabilitation Model with
Shannon is to address her motor difficulties,
weakness and hemiparesis of her left side. This
is relevant to Shannon because it is important for
her to begin to utilize adaptive
techniques/compensatory strategies and
adaptations to the environment or occupation in
order to improve independence and functional
abilities, while she is recovering and
rehabilitating post-stroke; once this acute phase
of rehab is complete, client should be working
towards using additional AE for dressing, self-
care, mobility, etc. It is important to help
Shannon begin to utilize various techniques,
compensatory strategies, and environmental
modifications in her immediate environment in
order to increase her independence and
maximize performance and participation in
occupations.
The motor control component would help to
emphasize practice of learning motor
movements and control of movement during
occupational tasks (such as how to use body/
current motor abilities to enhance quality and
effectiveness of movement in a functional
activity. It is important for Shannon to gain
voluntary, motor control to participate in
occupations in differing contexts and
environments.
The use of the Biomechanical Frame of
Reference is important to use with Shannon due
to her R MCA CVA. It would be important to
enhance occupational performance through
increasing strength (especially in affected (left)
UE and LE, as well as trunk strength for postural
stability), assessing and possibly increasing
(prevent decrease of) ROM (AROM & PROM)
in order to keep her affected side as functional as
possible, so as function and movement have the
potential to increase as she begins to regain
some losses from CVA. Each of these things is
also important for Shannon as she begins to heal
in preparation for discharge to another
rehabilitation department, and especially as she
will need her strength and functional movements
in order to care for her newborn baby.
Revised 1/9/17
 What do you know? What do you need to know?

9. Performance Skills
What do you know? What do you need to know?

10. Performance Patterns-Habits, Routines, Rituals, Roles

What do you know? What do you need to know?

11. Activity Demands for the Client Goals and Priorities (CHOOSE 1)
What do you know? What do you need to know?

12. Client Factors- Values, Beliefs, Spirituality

What do you know? What do you need to know?

13. Client Factors- Body Functions & Structures

What do you know? What do you need to know?

14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform

Observed Occupation Rationale/How will you use this information

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I would like to observe Shannon eating a simple
meal (any of her hospital meals should do – it is
important to make sure the meal is within her
nutritional plan in the hospital – so no outside
foods should be used)
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I would like to observe Shannon eating a simple
meal (one of her hospital meals would do fine) –
within the nutritional plan appropriate for her
(solids, soft mechanical diet, etc.). By observing
Shannon eating, I can see how her left
inattention is affecting her eating (is she only
eating foods from one side of her plate/tray). I
can observe her sitting tolerance in bed, as well
as can observe to see if she is pushing at all
during eating, or how is her trunk stability, is she
able to maintain balance while (most likely)
using her right hand to self-feed. I would want
to let Shannon and her family (whoever is there)
know that it is important for me to see how
much of the task Shannon can do on her own,
and only to provide assistance when really
needed. Watching this task would also provide
me with an opportunity to observe how she is
interacting with tools (silverware, cups, etc) and
how she is managing their use (how is her
ideational apraxia impacting how she is
performing feeding/eating task, how is she
compensating for this/is she compensating for
this? Is she able to independently feed herself at
all?). Watching her eat will also (likely) provide
me with an opportunity to see some sensation
abilities (i.e. if she gets food on her face, is she
aware of it, does she wipe it off? Is she aware
bilaterally?). This task will also allow me to
observe any weight shifts Shannon is currently
doing, and will let me see how she is reaching
for items (this will help me determine what is
most important to address first in therapy; what
is the most challenging parts of eating?), and
finally, this meal will give me an opportunity
(potentially) to further assess if Shannon is
having impulsivity problems (i.e. does she begin
tipping a cup to drink before the cup reaches her
mouth causing a spill?). This activity
observation will help me determine level of
assist she may need, will help me to see if/how
family is assisting Shannon currently, and will
also give me an opportunity to strike up a
conversation with her to gain more background
information and begin to build a therapeutic
relationship with her, getting her to “buy in” to
the therapy/ recovery process. Plus, she will
have to be able to feed her baby (eventually), so
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Method/Tool
1. MMT BUE – (PT to likely do MMT for
LE)
& weaknesses are, evaluate her paresis, as well as
Bilateral AROM & PROM through the
UE
2. Sensation Testing (localization of touch,
stereognosis, and proprioception) BUE, Face and
Trunk (possibly in some BLE)
Page 8 of 16
this could be a motivational piece for Shannon
as well!
Rationale/What is being Assessed
Performing BUE MMT will help determine Commented [JS1]: This should have been the Ashworth Scale
baseline, will help to assess where strength and
functional possibilities. MMT will help
determine which muscle groups may benefit the
most from strength exercises, and will help to
determine which muscle groups are still eliciting
a slight response.
It would also be important to assess AROM and
PROM on both UE. Assessing ROM post-stroke
is especially important to evaluate for any
abnormal tone or spasticity and to further assess
Shannon’s appearance of left sided flaccidity. It
is important to assess what client can do actively
in each joint; this will help to know what is
possible functionally and can thus help to know
what strategies would be the most beneficial to
use. It is also important keep those joints
moving in the UEs to promote functional use
and to keep joint capsules from tightening up.
Teaching ROM and strengthening exercises to
the family and Shannon will be important steps
in the rehabilitation process to regain as much
function as is possible as movement returns.
Localization of Touch (light touch – possibly
using Monofilaments) to test for light touch on
affected side of body, most specifically testing
face, and comparing bilaterally for UEs
(especially hand), and LEs (especially food for
skin integrity on feet d/t decreased sensation),
and trunk on affected side.
Proprioception & Stereognosis are often affected
by stroke! I would ask Shannon questions about
how her affected arm/side feels now vs how it
felt prior to the stroke (self-perception of
sensory loss)
I would want to test proprioception by having
client close eyes and as I move her affected arm,
I would want her to match the positioning with
her unaffected arm.
I would test stereognosis by placing objects in
her affected hand, closing her hand and seeing if
she can identify it.
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3.
Arnadottir Occupational Therapy
Neurobehavioral Evaluation (A-ONE)-
4.
Neurobehavioral Cognitive Status Examination
5. mental health screen
6. Fugal-Meyer Assessment of Motor Recovery
I will use the A-ONE assessment to help
objectively identify dysfunction of client factors
(such as left-sided neglect, apraxia and spatial
dysfunction) as they relate to self-care function
and independence – this would be important to
be aware of when planning discharge.
- I would want to use this as a quick mental
status screening test to evaluate domains of
orientation, attention, comprehension, naming,
construction, memory, calculation, judgement
and repetition. It would be good to quickly look
at how Shannon is cognitively and assess what
has been affected as a result of her CVA
To address possible post-partum depression
coupled with possible post-stroke depression
(and anxiety) – possible (likely) referral to seek
additional services – i.e. psychologist. She has
had a very traumatic experience over the past
few days. It is apparent already that she is
(obviously) having a hard time coping with the
situation. It is important to instill hope in her
(and her family), but also it is very important to
get her the help she needs (emotionally, and
mentally).
I would use this motor function evaluation to Commented [JS2]: It would have been better to do the
Ashworth Scale to assess TONE!!
score domains of pain, ROM, sensation and
volitional movement and balance. While I plan
to evaluate some of these things above, the
results of this assessment will help to determine
likelihood of return of function.

15. CPT Evaluation Code: Justification

97166 – Moderate This would be coded as having Moderate Complexity because the
Complexity occupational profile and medical history will only require an expanded
review at this time (not extensive) to evaluate health before, during and
after pregnancy, and expand on the delivery (complications? full-term?
Etc.). However, both the assessment and the clinical decision making
would be high due to the complexity of stroke and how many
performance deficits it impacts.

16. Projected Outcomes: Type of Outcome

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 - Improved ADL and some Basic IADL tasks performance - Prevention (of
- Improve functional/bed mobility further decline)
- Increase awareness to left side and decrease pusher’s

Discharge plan! - Occupational

performance
- If she is able to tolerate 3 hours of therapy per day, it would be
most appropriate to discharge Shannon to an Inpatient
Rehabilitation department. Due to her young age, and her high - Role Competence
motivation to return home and fulfill her role as a new mother, (beginning stages
it is likely that Shannon would be a good candidate for Inpatient only! – specifics
Rehabilitation to address functional mobility, ADL skills, basic will come with
IADL skills, and to learn strategies to safely and independently continued therapy)
care for her newborn.

- If she is not able to tolerate 3 hours of therapy per day, it would

be most appropriate to discharge Shannon to a Sub-Acute Care
(transitional rehab) facility until she has built up the
stamina/tolerance to be successful in Inpatient Rehabilitation, or
possibly until she has recovered enough to be successful in a
home health or outpatient therapy setting.

17. Resources and Team Members

- Shannon, her husband (and her new born baby … in some ways)
- Shannon’s parents
- Neuro-ICU team (Neurologist, Nursing staff, Speech Language Pathologists (consult with or
refer to for oral motor screen/dysphagia screen), Physical Therapy, Psychologist, Social
Worker, etc.)
- OBGYN/ midwife/ Pediatrician (whichever health care practitioners are assisting with her
infant’s care and whoever knows if there are any specific needs her infant has/requires)
- Support groups (for mothers with stroke)

18. Intervention Plan

Barriers Supports
- Husband is in graduate school – has a lot on his plate and - Her parents are willing to help
likely has time restrictions with his program (will his with whatever they can
program grant him a grace period to spend some time - Has health insurance (even if
away from school without compromising his position in not high quality)
the program?) - Shannon likely has motivation
- Limitations likely present in student health insurance (it is to work hard in therapy to make
possible that these limitations may have prevented improvements so that she can
Shannon from seeking high quality pre-natal testing that care for her newborn
may have identified her as at-risk for stroke)

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 - Possible (likely) mental health concerns – i.e. postpartum - Seeking additional services and
(post-stroke) depression has familial support to assist in
- Being a first-time mother… comes with a lot of role recovery (for now)
changes and this increases the number of this she is not - She is young and (likely)
able to be independent with at this time. resilient/healthy, which
- Family may be timid about allowing Shannon to spend hopefully will increase chances
time figuring out how to safely interact with, bond with, of improved functional abilities.
and provide care to her newborn son. -
- Living situation (student housing is likely not fully
accessible, which may be difficult during her recovery)
- Difficulty holding/manipulating objects d/t inattention
and hemiparesis of left extremities
- Possible lack of strength, endurance, or ROM may
contribute to requiring assistance with more complex
tasks.
- Any possible side effects from being in a coma for a few
days.

Goals Practice Model for each goal Commented [JS3]:

1. LTG: Within 7 days, client will improve bed mobility by Rehabilitation (with motor control
moving from supine to sitting at EOB with compensatory component), Biomechanical and
strategies and Mod A to manage hemiparetic left side of body. some PEO

1a. STG: Within 4 days, client will improve bed mobility by Rehabilitation (with motor control
rolling into side-lying onto unaffected side with compensatory component), Biomechanical and
strategies and Min A to manage hemiparetic left side of body some PEO
during the move.

1b.STG: Within 2 days, client will improve bed mobility by Rehabilitation (with motor control
rolling into side-lying on her affected side while maintaining component), Biomechanical and Commented [JS4]: Use RIGHT or LEFT instead of affected and
unaffected arm/side
safety to prevent shoulder impingement, with supervision for some PEO
safety.

2. LTG: Within 7 days, client will maintain balance for 20 Biomechanical

minutes while at EOB in unsupported sitting position, using
compensatory strategies and contact guard assist for safety.
Commented [JS5]: Good, fair, poor, etc. (levels of sitting
tolerance that Jeanette and Beth taught us awhile ago.. ?) – these
words specify so you don’t have to say things like “unsupported”
Commented [JS6R5]: Should have specified dynamic or static
specified..

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2a. STG: Within 3 days, client will tolerate sitting upright in Biomechanical
bed at a 90-degree angle for 30 minutes in preparation for
engaging in self-care.

2b. STG: Within 5 days, client will independently rearrange PEO

items in her environment in preparation for safe bed mobility
and pre-transfer skills.

3. LTG: Within 7 days, client will increase independence in Rehabilitation (with motor control
self-care tasks requiring Mod VCs for correct completion of component), Biomechanical and
task. some PEO

3a.STG: Within 5 days, client will increase use of her left UE Rehabilitation (with motor control
during self-care tasks with Mod VCs. component), Biomechanical and
some PEO

3b. STG: Within 4 days, client will improve attention to her Rehabilitation (with motor control
left side by locating 3 items from left side with mod VCs component), Biomechanical and Commented [JS7]: Would do better if they were picking it up
and using it! Instead
during self-care tasks. some PEO

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19. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do? Identify Approaches Based on which
goal(s)?

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To address inattention…? Establish, Restore,
Prevent
Task specific training
Reaching task to affected side (pushers?)

In this treatment session, I would have Shannon

perform some basic self-care tasks (brushing her
teeth and combing her hair) from a supported sitting
position in bed (if her endurance and tolerance for
this day allowed for her to be sitting EOB, this
alteration could be easily made) – the focus is to
help her tolerate sitting up throughout the activity,
not to focus on maintaining balance in unsupported
sitting, for right now.

I would want to address Shannon’s inattention to

her left side during this task, and would therefore
set up the supplies on her tray table so that most
items were placed slightly or completely in her left
field of vision. I would also stand on her left side,
and if possible, may place brightly colored items on
the left side as well to help draw attention to the
environment to her left.

I would ask Shannon to try using (lifting) her

affected arm to the table (although unsure if this is
realistic until after further assessment), I would let
her try to do as much as she an with her affected
arm before stepping in to assist. If she can or
cannot lift her arm onto the table, I will still want
her arm to be placed on the table (it will receive a
little weight bearing this way, but mostly, I want to
keep her arm in her line of vision.) I would also set
up the supplies needed for the task on the far side of
her left arm (on the table), this will cause Shannon
to have to cross over left arm with right arm every
time she reaches for something (i.e. her toothpaste).
preferably we would be able to get Shannon to at
least use her affected side to stabilize the kidney
basin for spitting into after brushing teeth.

This session would also be important for task-

specific training. Helping Shannon problem-solve
and figure out how best to use her body in its
current condition to be able to become more
functionally independent.

Throughout the task, I will continue to provide

prompting and instruction while standing off to her

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left side. I will ask Shannon to first brush her teeth,
providing prompting (when needed) to scan the
entire table to find which items she needs. As
needed, I may need to provide coaching and have a
conversation with Shannon to help her figure out
how to appropriately use toothbrush, etc. to perform
self-care task. I would also like to address
Shannon’s pushing by keeping right hand busy,
providing support, and possibly taking breaks to
weight bear more on her affected side to attempt to
re-orient herself to where her actual midline/middle
of gravity is.
2. What will you do? Identify Approaches Based on which
goal(s)?
In this session, I would be working on introducing Establish/Restore, 1a, 1b, 2b
bed mobility and working to increase Shannon’s Modify, Prevent
independence with safe bed mobility. (I would
prefer if at least one of Shannon’s family members
be there, as they will be primary caregivers during
the rehabilitation process, so it is important for
them to be present and aware of safety risks, what
they can help with, etc.)

I would begin by talking about modifying the

environment before working on the mobility
(moving the tray table out of the way, lowering the
head of the bed, the importance of managing the
lines/IVs/monitors she is hooked up to.)

Once the environment was ready, I would begin by

having Shannon roll her body towards her affected
side (providing assistance and teaching family
member how to give her an appropriate amount of
assistance while still challenging her – and
explaining the importance of her being challenged
(within reason) so that she can recover her strength
and independence. At this time, I would also be
providing assistance and education about proper
placement/positioning of Shannon’s affected
shoulder, and how it should be positioned to
prevent impingement.

I would practice rolling back and forth to that side a

few times, and depending on time permitting and
client’s endurance, I would like to also introduce
rolling onto her unaffected side into a side-lying
position. I would provide more assistance during
this roll as I would mainly want to show Shannon
how she can use her affected and unaffected sides

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to work together and move together to roll. As this
side is more difficult to roll to, this portion may be
more education and would be less focused on
Shannon moving herself without assistance during
this session.

To make this session more functional, I would

explain possible tasks that Shannon can perform
from a side-lying position. I can have her reach to
her bedside table to reach her phone or the call light
or to get her book. I can show her (with a
simulated pillow) that when in side-lying on her
affected side, she can ask her family to lay her baby
next to her and she can spend some time bonding
with him and talking to him (although, it is
important to stress that someone else be present in
the room for the time being as Shannon may need
assistance if something were to happen). In these
positions, client will also be weight bearing, and
laying on affected side can help to increase
awareness to that side.

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