TREATMENT PLAN

Treatment Strategies (what are you going to do with this client to address goals
during an intervention session). Please develop two treatment sessions to address
areas on your problem list. Your sessions should include the
occupations/interventions your client will complete during a 45 minute treatment
session. Please complete the grid below for each treatment session. Please use
treatment plan format below.

Session 1
Session STG: Client will increase independence to minimal assistance during the ADLs
of personal hygiene and grooming, specifically brushing her teeth and washing her face.

Intervention 1: OT will enter room and ask Raquel how she is feeling using the Wong
Baker pain scale. OT will look at Raquels positioning to check for skin integrity. OT will
transfer Raquel from bed to wheelchair using a mechanical lift and then wheel her to the
bathroom positioned in front of the sink and mirror. OT will position Raquel into an
upright seated position in the wheelchair leaning her forward slightly to prevent water or
spit from being aspirated. OT will put antifoam toothpaste on the toothbrush, run it under
water, and shake out excess water to prevent aspiration. OT will place toothbrush in
Raquels R hand and instruct her to bring it up to her mouth and brush her all of her teeth.
OT will observe and provide verbal cues as needed to ensure that she brushes the left and
right sides of her mouth completely. Once Raquel is finished, OT will instruct Raquel to
gently remove the toothbrush from her mouth. OT will wipe Raquels mouth for residual
toothpaste or excess drool. If her mouth is dry, OT will pat the inside of her mouth with a
damp sponge to add moisture. Repeat the last two steps as needed throughout the
duration of the intervention.

Grade intervention 1 up and down

Grade Up: Raquel will put toothpaste on her own toothbrush prior to brushing her teeth
using a toothpaste dispenser.

Grade Down: Raquel will be provided a modified electric toothbrush that vibrates and
has a larger grip/ handle to make performing oral hygiene simpler and more efficient.

Intervention 2: OT will enter room and ask Raquel how she is feeling using the Wong
Baker pain scale. OT will look at Raquels positioning to check for skin integrity. OT will
transfer Raquel from bed to wheelchair using a mechanical lift and then wheel her to the
bathroom positioned in front of the sink and mirror. OT will position Raquel into an
upright seated position in the wheelchair. OT will inform Raquel that she will be washing
her face and incorporating both of her hands using the hand over hand method. OT will
instruct Raquel to place her L arm on her R thigh. Then, OT will dampen a small wash
cloth and place it in Raquels L hand. Then, OT will instruct Raquel to grasp the wash
cloth and her L hand using her R hand. OT will instruct Raquel to move the wash cloth
towards her face using both of her hands. Then, OT will instruct Raquel to gently pat her
face with the wash cloth. OT will instruct Raquel to look in the mirror at herself to make
sure she washes her whole face. OT will provide verbal cues as needed. Once Raquel is
finished, OT will instruct her to gently move her hands towards her lap and then OT will
retrieve the washcloth from her.

Grade intervention 2 up and down

Grade Up: OT will place a dampened wash cloth on the sink in front of Raquel and
instruct her to grasp it independently. Then, OT will instruct her to use the hand over
hand method while she washes her face.

Grade Down: OT will place a washcloth over her L hand and manually move her hand
over her face for her. This will encourage maintenance of personal hygiene and
engagement of her affected L UE.

Treatment Time: 20 minutes

Session 2
Session STG: Within 1 week, client will increase independence with the
ADL of functional mobility to minimal assistance, specifically log rolling
and sitting EOB.

Intervention 1:
OT will enter room and ask Raquel how she is feeling using the Wong Baker pain scale.
OT will look at Raquels positioning to check for skin integrity. OT will instruct Raquel
that they will be practicing log rolling from side to side in her bed. OT will put the guard
rails up and ensure that they are locked. With Raquel lying supine, OT will flex her R
knee so that her foot is rested on the bed. OT will ask Raquel to flex her L knee so her L
foot is also resting on the bed. OT will instruct Raquel to bring her R arm across her
trunk and grasp the L guard rail. Then, the OT will stand on the R side of the bed and
instruct Raquel that she will be rolling onto her L side. OT will count 1, 2, 3 and then
assist Raquel into rolling to her L side by gently guiding her body. Once she has rolled to
her L side, she will remain in that position for 5 seconds. Then, she will roll back to lying
supine and repeat the same process but to the R side. OT will provide assistance as
needed.

Grade intervention 1 up and down

Grade Up: When Raquel log rolls onto her affected and unaffected sides, she will
maintain a side lying position for 15 seconds with a decreased number of verbal cues.

Grade Down: OT will manually position Raquels arm on the guardrail and then provide
moderate assistance and guidance throughout the log roll.

Intervention 2:
OT will enter room and ask Raquel how she is feeling using the Wong Baker pain scale.
OT will look at Raquels positioning to check for skin integrity. OT will explain to
Raquel that she will be sitting up EOB with her legs off the bed. First, using the bed
controls the OT will slowly raise the head of the bed up to a 90 degree angle so Raquel is
moved into a seated position in bed. OT will monitor vitals throughout the process to
ensure she remains stable. Raquel will move her unaffected R leg over the edge of the
bed. The OT will instruct her to place the palm of her R arm on the bed, weight-bear
through it, and try to scoot as close to the edge as she can. OT will place their hands
under Raquels L knee and ankle and gently move it towards the end of the bed so both
legs are off of the bed. OT will reposition Raquels legs so they are straight and in a 90
degree angle. OT will provide verbal cues for Raquel to continue weight-bearing through
her R arm. Raquel will remain seated EOB with OT stabilizing her trunk and affected L
side for one minute.

Grade intervention 2 up and down

Grade Up: OT will engage Raquel in a light ADL activity while she maintains an upright
seated position at EOB.

Grade Down: OT will manually guide Raquel into a seated position reducing the weight-
bearing on her R arm and R side of her body needed to complete the task.

Treatment Time: 20 minutes