INTERVENTION PLAN FOR COMMUNITY CLIENT WITH REFLECTION

Copy/paste one LTG and the matching STG from your evaluation SOAP note. This will be the goal set around which you design your treatment session.
For this and all subsequent weeks, please answer the following questions before designing your treatment plan for the next week. If you were unable to see
your client the past week, you do not need to answer these questions. Answer the questions based on the treatment that you implemented:

What went well with your treatment? Did things go as you planned or not? Explain. What will you do differently with this next treatment plan?

What went well during last weeks session had a lot to do with focusing on her passion for boxing. A volunteer was able to wear a punching mitt in which client
was able to be in a seated position to “punch”. This focused on the client factors of activating the L UE in a functional task specifically targeting the triceps and
shoulder abductors and flexors. 80’s music was played, and she was engaged in the task and motivated to perform punches. She was able to get her arm into
an abducted position and extend it with assistance from the vibration tool. I think things went better than planned. This week I may incorporate music into the
session that she relates to as part of a motivator during therapy as well as focusing on that basic reaching movement so that triceps are truly activating and that
the services continue to be skilled and beneficial.

Long-Term Goal: In 4 weeks, client will independently close her L car door with her L UE with sue of adaptive
equipment

Short-Term Goal: In 2 weeks, client will independently reach to touch her car door when opened halfway with
her L UE using A/E

Describe client factors relevant to
occupational performance
problem in the goals you selected
Treatment will focus on improving
her control of the voluntary
movement in her L UE and
implement those movements into
daily tasks. The movement of her L
UE is as follows:
Client has a slight increase in tone in
her L shoulder and a more marked
increase in tone in her elbows, wrist,
List and provide rationale for the
OPM and CPM you will be using in
this treatment relevant to this
client’s goals
PEO Model is applicable to our client
in a variety of ways. This model
focuses on the person, their
environment, and the occupation they
are performing. Improving her
occupational performance will follow
the theory of finding harmony with
their ability to perform the task,
modifying the environment to
increase independence, and in the
Describe the skilled OT session
you will use to address the client
factors in the first column.
Pet Care: Client will be participating
in a reaching task involving her L UE
while in a seated position. The focus
of this activity will be on activating
triceps, shoulder flexors and
abductors, and wrist supination when
elbow is flexed at 90 degrees. Client
will be seated in a chair in front of
the mat where a cat bowl will be
placed. To the left of the cat bowl will
Describe one (and only one) way
you can grade the activity in your
treatment session up and down
on one client factor
Client factor:
Control of Voluntary Motor Control
of the LUE to activate triceps for
elbow extension, and target
shoulder flexion, shoulder
abduction, and forearm supination.
Grade Up: Raise the surface of
where the cat bowl is placed,
moving the activity from the mat to
the table to focus on elbow
extension while shoulder is at 90
degrees flexion.
Grade Down: Position the Cat bowl
closer to client so that she does not
& fingers. No tone is notated during
in wrist & finger flexion. She has
partial movement in most of her
hand and fingers when in flexion but
is unable to extend her wrist or
fingers. Her ability to extend her
elbow increases after tone has been
managed and she has stretched.
Shoulder: She has normal shoulder
elevation, retraction & abduction.
Shoulder flexion & extension has a
score of +1 in tone based on the
Ashworth scale indicating a slight
increase in muscle tone.
Elbow: She has partial movement in
elbow extension & no movement in
elbow flexion, both score a 2 in tone
based on the Ashworth scale
indicating a more marked increase
of muscle tone in most of the ROM.
Wrist: She has no wrist movement,
and it scored a 2 in tone in wrist
extension based on the Ashworth
scale indicating a more marked
increase of muscle tone in most of
the ROM. She scored of 0 in wrist
flexion indicating no tone. When
shoulder flexion is at 0 degrees and
her elbow is at 90 degrees her wrist
can come to neutral or mid
supination (very little active
supination). When she flexes her
shoulder to 90 and extends her
elbow her wrist naturally moves into
a pronated position.
Fingers: Finger extension is scored
as a 2 indicated a more marked
increase of muscle tone in most of
the ROM and a score of 0 in finger
flexion indicating no tone.
occupation itself. Her L UE & L LE
have been affected by her R CVA in
2017 and implementing the PEO
model by teaching her compensatory
strategies, providing adaptive
equipment, & increased use of her L
UE will improve her functional mobility
in bathing tasks and increase
independence in getting out of the
tub.
Motor Control Model: The Motor
Control Model is tailored for
individuals who have a acquired a
form of brain injury or Central
Nervous System (CNS) New motor
patterns are learned during
movement and this model focuses on
neuroplasticity. Postulates for change
incorporate the need for the client to
problem-solve so that they can readily
find solutions to challenges
encountered in new environments,
tasks can be broken down or done to
master them, and that repetition is
key to motor learning. Through
repetition and use of the L UE in
occupation-based activities, she will
gradually gain more function as new
motor pathways develop.
be a Ziploc bag full of cat food. She require full extension and only
will be required to position her L UE partial shoulder flexion.
at her side at 0 degrees shoulder
flexion & 90 degrees elbow flexion
with her wrist in a neutral/mid
supinated position. She will use her
right hand to cross over to the left to
scoop up the cat food to work on
shifting her weight in a seated
position. She will position the cup of
cat food with her right hand into her
left hand. She will then activate her
triceps and shoulder flexors to bring
her arm into extension downward
toward the cat bowl at a 45-degree
angle and as soon as she is fully
extended, and the cup is over the cat
bowl she will maintain the extended
position in an isometric contraction
for 5 seconds. She is not expected to
poor the cat food. (Feel for triceps
activation, and provide cues as
needed to prevent compensatory
trunk movements). She will return
her arm into 0 degrees shoulder
flexion and 90 degrees elbow
extension and then bring her hand
into as much supination as she can
and hold the isometric contraction.
Throughout the session, the cat bowl
or her will be positioned gradually to
the left to promote and work on
elbow extension while her shoulder
is abducted. She will repeat the task
until she fatigues. She will be able to
take breaks to manage the tone as
needed while performing the task.