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Treatment Plan Format

Case Childs Name: Ashley (age 3)

Diagnosis: Anoxic brain injury (TBI) secondary to choking
Therapist Name: Brianna Stemmler
Date of evaluation: 11/21/16
Reason for referral: Ashley was referred to OT per physician and
caregivers to increase independence in occupations following an
anoxic brain injury. She presents with difficulty eating, poor head and
trunk control, hypertonicity and UE contractures, and impaired
communication making it difficult to play and engage in social
participation. Strategies including adaptive equipment and devices
may be implemented.

Summary of performance- strengths:

- Emerging head, neck, and trunk control when positioned
with supports
- When placed in supine, she is able to roll from side to side
- Starting to eat pureed food and demonstrate a few swallows
of food and liquid
- Able to bring her hands and non-food items to midline at her
- No sensory impairments have been identified- she enjoys
- She is easily comforted by her mother. She is able to
establish eye contact following auditory stimuli and
demonstrate social smiling in response to her mothers
attention during tasks such as feeding and play
- Loving and involved family (mother, father, and 3 brothers)
- She does not appear to be experiencing pain
- Able to maintain grasp on a toy (even though it is
- Able to produce vowel sounds
- Maintains a fisted grasp but is easily ranged during passive
range of motion

Summary of performance- areas to work on:

- Although head, neck, and trunk control are emerging, she
has currently has poor postural control and strength which is
impacting her ability to maintain an upright position and eat
- Hypertonicity in UE and LE (L>R), hypotonic trunk, clonus
present, brisk patellar reflexes. During sitting, she tends to
maintain a flexed position and as a result, she has developed
contractures in her elbows and hamstrings
- Unable to use utensils or identify the feeling of hunger which
is delayed for her age. She demonstrates poor oral motor
control and is fed via J-tube. She is unable to actively move
her lips to remove food from a spoon and unable to maintain
lip closure to keep food in her mouth
- Easily agitated during position changes, upright posture, and
ROM of the UE
- Unable to verbalize words and communicate what she wants
which impacts social participation, ADLs, and play
- Cognition is delayed

Treatment plan statement: OT 3x/week for 45 minutes for 6 months

for activities to improve gross and fine motor skills, oral motor skills,
head and trunk control, ROM, tolerance during ADLs, contracture
management, and provision of strategies to improve play skills and
engagement in social interactions. Continued caregiver education will
be provided throughout the treatment to ensure Ashleys safety at
home and collaborate to integrate adaptive equipment into her care.


Long term Short term Hypothesis Intervention What FOR

goal/ objectives to about why method to might you use
category match that LTG the child address that for the
area cant do this hypothesized intervention to
now issue meet that STG?

1. A. Ashley will Decreased Gross motor Biomechanical,

Improve raise her head in neck and task to elicit developmental,
strength response to trunk head sensory
and preferred sensory muscle extension integration
endurance play (ex: tactile, strength against
for play auditory, visual) and gravity to
skills. when positioned endurance, increase
in prone with increased strength,
minimal muscle tone, endurance
assistance in 75% impaired and
of trials. response to awareness of
sensory sensory
stimuli stimuli
needed for
B. Ashley will Decrease Gross motor Biomechanical,
reach using neck, trunk, task to developmental
alternating hands and UE increase UE
while propped on strength, muscle
her forearms in increased strength,
prone to grasp muscle tone, endurance,
preferred toys for impaired ability to
3 minutes with motivation tolerate prone
minimal for positioning,
assistance in 75% purposeful and
of trials. movement awareness of
C. Ashely will be Decreased Fine motor Biomechanical,
able to release muscle task to developmental
play objects (balls, strength promote
toy cars) in a side and grasp and
lying position endurance, release
using appropriate visual and needed for
positioning cognitive play with toys
equipment as attention, and objects in
needed accurately and a side lying
with minimal increased position with
assistance in 75% muscle tone gravity
of trials. eliminated
and ability to
tolerate side
2. Improve A. Ashely will hold Decreased Oral motor Biomechanical,
oral motor a cup oral motor task to rehabilitative,
skills for independently and strength increase oral developmental
feeding. take 3 sips from and head motor
the straw using and neck strength,
adaptive control, coordination,
equipment and decreased and
appropriate UE and grip endurance,
positioning as strength, promote UE
needed with inability to and grip
minimal hold strength,
assistance in 75% cups/utensil increase head
of trials. s and neck
control, and
the ability to
at midline
and use them

B. Ashley will Decreased Oral motor Biomechanical,

demonstrate lip oral motor task to rehabilitative,
closure during muscle promote oral developmental
spoon feeding and strength motor
straw drinking and strength,
using appropriate coordination coordination,
positioning and , decreased and lip
adaptive head and closure
equipment as neck needed to
needed with control, retain food or
minimal presence of drink in her
assistance in 75% primitive mouth and
of trials. reflexes prevent the
(phasic bite, food from
rooting, leaking/spillin
etc.) g out,
increase head
and neck
C. Ashley will use Decreased Oral motor Biomechanical,
active lip oral motor task to rehabilitative,
movement to muscle promote oral developmental
attempt to remove strength motor
food from the and strength and
spoon during coordination lip
feeding using , decreased movements
appropriate head and needed to
positioning and neck identify food
adaptive control, on the spoon,
equipment as inability to remove it
needed with actively from the
minimal open, close, spoon, and
assistance in 75% and bring the food
of trials. manipulate into the
lips to mouth using
remove food the lips
from the
3. Improve A. Ashely will Decreased Visual motor Biomechanical,
visual choose between visual motor task to developmental
motor skills two toys using eye strength promote
for play. movement to and oculomotor
identify a coordination mobility and
preferred toy , visual strength,
during play in an inattention, awareness of
upright seated decreased midline and
position using awareness the ability to
appropriate of sensory scan the
positioning as stimuli, and environment
needed in 75% of decreased to identify a
trials. preference preferred
for play toys play toy, and
attention to
B. Ashley will turn Decreased Visual motor Biomechanical,
towards a play toy visual motor task to help developmental,
in response to strength her identify sensory
auditory stimuli at and auditory integration
midline in a prone coordination stimuli and
position with , decreased attend to it,
minimal verbal UE increase
cues and strength, ability to
appropriate decreased track and/or
positioning as awareness turn towards
needed in 75% of of auditory objects and
trials. stimuli and visually
visual attend to
attention to them,
task increase
tolerance to
C. Ashley will turn Decreased Visual motor Biomechanical,
towards her visual motor task to developmental,
siblings voices strength, promote sensory
and watch their impaired identification integration
play actions using head and of her siblings
appropriate neck faces/voices,
positioning as control, ability to
needed and decreased watch their
minimal verbal awareness movement,
cues in 75% of of sensory and in the
opportunities. stimuli, future engage
difficulty with them in
tracking or play, and
watching increase head
moving and neck
objects/pers control

One sample activity with explanation.

Describe your activity carefully so I can imagine the set-up, the

cues you will use, the materials needed and the position of the
child. What frame(s) of reference are you thinking about with
this activity and this child? How would you grade this activity
up and down for one of the childs presenting issues? (For
example if the child had poor hand strength, grade your activity
up and down to make it require more or less hand strength).

The OT will engage Ashley in an oral motor feeding activity. Ashleys

mother will provide 1 small can of pureed fruit and an adapted cup
with two handles and a straw to drink thickened liquids. The OT will
use an adapted spoon with a flat bowl so Ashley can more easily
remove the food from the spoon with her mouth. Ashely will be seated
upright using appropriate positioning with a tabletop tray attached to
the chair. The OT will sit in a chair directly in front of her and put
gloves on to prepare for feeding. The OT will scoop a bit of pureed
food onto the adapted spoon and using hand-over-hand techniques,
the OT will move the food near Ashleys mouth at midline. The OT will
place it near her mouth but allow Ashley to identify the food herself
and move her lips around the spoon and remove the food from the
spoon. Then, the OT will watch to see if Ashely is able to demonstrate
lip closure and swallow the food appropriately. After each bite, the OT
will wipe Ashleys mouth and then wait until she is ready for the next
bite before bringing more food towards her mouth. During the
session, the OT will record how may swallows Ashley is able to
achieve, her ability to move her lips to get the food into her mouth,
and ability to demonstrate lip closure. Also, the OT will ensure Ashley
remains in an upright seated posture with appropriate head and neck
positioning. After she is finished feeding, the OT will place an adapted
cup with a straw in her hands and use hand-over-hand assistance to
move it towards Ashleys mouth. Ashley will identify the straw, put her
lips around it, take 1-3 sips and swallow the thickened fluid
successfully. Throughout the activity, the OT will provide verbal cues
as needed and remind Ashley that she is doing a great job and to
encourage her to keep it up!

This activity is fitting under the Biomechanical, Rehabilitative,

Developmental, and Sensory Integration (sensory strategies) frame of

Grading up and down

- UP: The OT will spear the food onto the adapted utensil,
place it in Ashleys hand and allow her to bring it to her
mouth independently. Also, the OT can place the adapted cup
on the tray in front of Ashley and allow her to grasp it
independently and bring it to midline at her mouth.

- DOWN: If Ashely struggles to remove the food from the

spoon and demonstrate lip closure independently, the OT will
assist by placing the spoon in Ashleys mouth and scraping
the food off onto her tongue for her. Then, the OT will provide
jaw support to help her maintain lip closure and retain the
food in her mouth. Additionally, the OT will not use hand-
over-hand techniques. The OT will move the utensils and
cups to midline at her mouth for her.

Grading Rubric for the Treatment Plan

Student Name:
Therapist Name:
Date of evaluation:
Reason for referral:
Summary of performance- strengths: 10 points CORRECTLY

Summary of performance- areas to work on: 10 points CORRECTLY


Treatment plan statement: 10 points MUST HAVE AT LEAST 4 TYPES


Sample: OT for 2x week for 3 months for fine motor activities,

independent play, provision of assistive technology, and parent
education for strategies to improve ADL independence in the home.

Long term goal Short term Intervention What FOR
objectives method might you
MUST BE type/category use to
provided to you SETTING AND
Sample: Sample: Johnny
Improve will button 4, 1 Sample: Fine
independence in buttons, motor activities
ADLs independently, in to improve pinch
3 out 4 trials. strength and in-
1. 1 point a. 1 point 5 points each (3) a. 1 point
b. 1 point b. 1 point
c. 1 point c. 1 point
2. 1 point a. 1 point 5 points each (3) a. 1 point
b. 1 point b. 1 point
c. 1 point c. 1 point
3. 1 point a. 1 point 5 points each (3) a. 1 point
b. 1 point b. 1 point
c. 1 point c. 1 point

One sample activity with explanation. 40 points total



PLAYFUL (15 points)



CONCERN (10 points)- grade the activity up and down for the
appropriate thing
Sample: for the buttoning goal above, I could create a dress up relay
activity with buttoning, or any type of activity that works on shift in
prep for buttoning.I would grade it for shift- making that easier and
harder, or grade the buttoning portion easier or harder