Post Stroke Discharge Planning Case Study: Mr. Thompson

  Detailed Background

Mr. Robert Thompson, 68, experienced a moderately severe ischemic stroke in the left middle cerebral artery territory three weeks ago. He was rushed to City General Hospital where he received prompt treatment, including tissue plasminogen activator (tPA) therapy. After initial stabilization in the acute stroke unit, he was transferred to the inpatient rehabilitation unit two weeks ago.

Prior to his stroke, Mr. Thompson was an active retiree who enjoyed gardening, playing golf, and volunteering at the local community center. He lived independently with his wife, Margaret, 65, in a single-story ranch home they've owned for 30 years. The couple has two adult children who live in nearby cities.

 Medical History

  • Hypertension (controlled with medication)

  • Type 2 Diabetes (well-managed through diet and oral medication)

  • Hyperlipidemia

  • Osteoarthritis in both knees

 Stroke Impact and Current Functional Status

The stroke has resulted in several impairments:

1. Motor Function:

  • Right-sided hemiparesis (weakness on the right side of the body)

  • Moderate weakness in right arm (2/5 strength on the Medical Research Council scale)

  • Mild to moderate weakness in right leg (3/5 strength)

  • Walks with a quad cane for short distances (up to 50 feet) with supervision

  • Uses a wheelchair for longer distances

  • Requires minimal assistance for bed to chair transfers

  • Uses a slide board for toilet and bath transfers

2. Speech and Language:

  • Mild expressive aphasia

  • Occasionally struggles to find words or form complete sentences

  • Comprehension is largely intact

3. Cognitive Function:

  • Mild cognitive impairment, particularly in executive function and problem-solving

  • Experiences fatigue-related confusion, especially in the afternoons

4. Sensation:

  • Decreased sensation on the right side of the body

  • Proprioception (awareness of body position) is impaired in the right arm and leg

5. Activities of Daily Living (ADLs):

  • Needs moderate assistance with dressing, particularly with buttons and zippers

  • Requires assistance with bathing, especially for lower body and back

  • Needs help with toileting due to balance issues and difficulty with clothing management

  • Can feed himself with adapted utensils, but may need help with cutting food

6. Instrumental Activities of Daily Living (IADLs):

  • Currently unable to prepare meals, manage medications, or perform housekeeping tasks independently

  • Cannot drive and will need alternative transportation arrangements

 Rehabilitation Progress

  • During his two weeks in inpatient rehabilitation, Mr. Thompson has made steady progress:

  • Improved walking distance from 10 feet to 50 feet with a quad cane

  • Increased independence in bed mobility and sit-to-stand transfers

  • Showing improvements in right arm function, now able to grasp large objects

  • Speech becoming clearer, with fewer instances of word-finding difficulties

  • Demonstrating increased endurance in therapy sessions

 

 Home Assessment Findings

A home assessment was conducted by an occupational therapist to evaluate the Thompson residence for safety and accessibility:

 Exterior

  • Two 6-inch steps at the front entrance without handrails

  • Uneven cobblestone pathway from the driveway to the front door

  • Back entrance has a sliding glass door with a 4-inch threshold

 Living Room

  • Furniture arrangement leaves narrow pathways (less than 32 inches wide in some areas)

  • Thick, plush carpeting may impede wheelchair and walker use

  • Coffee table has sharp corners and is placed in the center of a main walkway

  • Couch and armchairs are low and soft, making sit-to-stand transfers challenging

 Kitchen

  • Standard height countertops (36 inches) and upper cabinets

  • Faucet requires twisting motion to operate

  • Limited space for maneuverability (galley-style kitchen)

  • No seating area for rest breaks during meal preparation

 Bathroom

  • Standard height toilet (15 inches)

  • Bathtub with no grab bars or shower chair

  • Limited space for transfers and caregiver assistance

  • Faucets require fine motor skills to operate

  • Mirror height suitable only for standing use

 Bedroom

  • Queen-sized bed (24 inches high) may be too high and soft for safe transfers

  • Insufficient space on either side of the bed for transfer assistance

  • Clothing stored in a tall dresser and high closet rod

 General Home Features

  • Doorways are 30 inches wide throughout the house

  • Several area rugs without non-slip backing

  • Limited overhead lighting in most rooms

  • Round doorknobs on all doors

 

 Comprehensive Discharge Planning Recommendations

1. Exterior Modifications:

  • Install a modular aluminum ramp at the front entrance with a slope of 1:12

  • Add handrails on both sides of the ramp and existing steps

  • Replace the uneven cobblestone path with a smooth, non-slip surface

  • Install a threshold ramp at the back sliding door

2. Living Room Adjustments:

  • Rearrange furniture to create pathways at least 36 inches wide

  • Remove thick carpeting and replace with low-pile carpeting or non-slip vinyl flooring

  • Replace the coffee table with a round or oval table to eliminate sharp corners

  • Obtain a firm cushion or chair risers to make sit-to-stand transfers easier from the couch and armchairs

3. Kitchen Modifications:

  • Lower a section of countertop to 30 inches or install a pull-out work surface for seated meal preparation

  • Rearrange frequently used items to lower cabinets or open shelving

  • Install D-shaped handles on cabinets and drawers

  • Replace faucet with a lever-style or touch-activated model

  • Add a high stool with back support for rest breaks during meal preparation

  • Install a side-by-side refrigerator for easier access

4. Bathroom Renovations:

  • Install grab bars near the toilet (on the side wall and behind the toilet) and in the shower area

  • Replace the bathtub with a curbless, roll-in shower with a handheld showerhead and fold-down seat

  • If budget constraints prevent a full shower conversion, install a transfer bench for bathtub access

  • Raise the toilet height to 17-19 inches with a raised toilet seat or new comfort-height toilet

  • Install a tilting mirror or add a full-length mirror for seated grooming

  • Replace sink faucets with lever-style handles

5. Bedroom Modifications:

  • Replace the current bed with an adjustable hospital bed for easier positioning and transfers

  • Rearrange the room to allow at least 36 inches of space on both sides of the bed

  • Install bed rails to assist with in-bed mobility and transfers

  • Lower closet rods and install pull-down clothing rods for seated access

  • Add drawer pulls to the dresser for easier opening

6. General Home Safety:

  • Remove all area rugs

  • Ensure all pathways are clear of clutter and at least 36 inches wide

  • Install lever-style door handles throughout the house

  • Improve lighting throughout the home, adding motion-sensor night lights in hallways and the bathroom

  • Widen doorways to at least 32 inches where possible, or install offset hinges to gain extra width

7. Adaptive Equipment Recommendations:

  • Transport wheelchair for longer distances

  • Shower chair or tub transfer bench for bathing

  • Raised toilet seat with armrests

  • Hospital bed

  • Adaptive utensils, plates, and cups for eating

  • Reacher/grabber tool for picking up objects

  • Sock aid and long-handled shoe horn for dressing

  • Hand-held showerhead with extra-long hose

8. Caregiver Support and Training:

Arrange for Margaret to receive training in:

  • Safe transfer techniques

  • Assistance with ADLs

  • Proper wheelchair handling and maintenance

  • Recognition and management of stroke complications

  • Provide information on local stroke support groups and respite care services

  • Connect Margaret with a caregiver support group

  • Arrange for in-home occupational and physical therapy to continue rehabilitation and adjust the home environment as needed

9. Community Resources:

  • Connect the family with the local Center for Independent Living

  • Provide information on community-based stroke recovery programs

  • Arrange for participation in a community exercise program designed for stroke survivors

  • Connect with local volunteer services for assistance with yard work and home maintenance

10. Long-term Planning:

  • Discuss long-term recovery goals and potential for returning to previous activities

  • Provide information on vocational rehabilitation services if return to volunteer work is a goal

  • Discuss driving evaluation timeline and alternative transportation options

  • Review financial planning and insurance coverage for ongoing care needs

12. Technology Integration:

  • Explore smart home devices for voice-activated lighting and temperature control

  • Consider a medical alert system with fall detection

  • Introduce apps for cognitive training and speech therapy practice

By implementing these comprehensive recommendations, Mr. Thompson's transition from the hospital to home can be made safer and more manageable. This plan addresses not only the immediate physical needs but also considers long-term recovery, caregiver support, and community integration. Regular reassessment and adjustment of the plan will be crucial as Mr. Thompson's abilities change and improve over time.

 Expanded Falls Prevention Case Study: Mrs. Johnson

 Mrs. Eleanor Johnson, 82, is a retired schoolteacher who has lived in her two-story colonial home for the past 45 years. She was widowed three years ago and now lives alone. Mrs. Johnson has osteoarthritis in her knees and hips, which causes occasional pain and stiffness. She uses a cane for added stability when walking, especially on uneven surfaces or when her arthritis flares up.

Two weeks ago, Mrs. Johnson experienced a minor fall in her bathroom. While reaching for a towel, she lost her balance and fell, bruising her hip. Although she didn't require hospitalization, this incident alarmed her daughter, Sarah, who lives an hour away. Sarah noticed that her mother had become more hesitant in her movements since the fall and seemed to be losing confidence in her ability to navigate her home safely.

Concerned about her mother's well-being and wanting to prevent future accidents, Sarah arranged for a Home Bound Solutions home safety assessment. Mrs. Johnson agreed, recognizing that some changes might be necessary to maintain her independence and continue living in her beloved home.

  Comprehensive Home Safety Assessment Findings

 Exterior

 Front Entrance

  • Three concrete steps lead to the front door, lacking handrails on either side.

  • The steps are slightly uneven, with the middle step being about half an inch higher than the others.

  • The porch light is dim and doesn't adequately illuminate the steps at night.

 Back Door

  • A single, unmarked step (about 7 inches high) leads to the back door.

  • The step's edge is not clearly visible, especially in low light conditions.

  • The back porch has no lighting.

 

 Interior - Ground Floor

 Entryway

  • A decorative throw rug without non-slip backing is placed just inside the front door.

  • The tile floor in the entryway can become slippery when wet from rain or snow tracked in.

  • The hallway leading from the entryway is cluttered with shoes, umbrellas, and a small table, narrowing the passageway.

 Living Room

  • Two floor lamps have cords that cross main walkways in the room.

  • The large area rug has several wrinkles and curled edges, particularly near frequently used seating areas.

  • Low-seated armchairs make it difficult for Mrs. Johnson to stand up without assistance.

 Kitchen

  • The stove is an older model with controls located at the back, requiring Mrs. Johnson to reach over hot burners to adjust settings.

  • Frequently used items such as plates, glasses, and pantry staples are stored in high cabinets, necessitating the use of a step stool.

  • The kitchen has good overall lighting, but under-cabinet lights are not present, making some countertop work areas dim.

 Downstairs Bathroom

  • The toilet is standard height (about 15 inches), which is low for someone with arthritis.

  • There are no grab bars installed near the toilet or in the shower area.

  • The bathtub has a high side (about 15 inches) and lacks both a non-slip mat and grab bars.

  • Lighting is poor, especially over the tub/shower area, with a single overhead light that casts shadows.

  • The bathroom floor is smooth tile without non-slip mats.

  Interior - Second Floor

 Stairs

  • The staircase has 13 steps and a handrail on only the right side when ascending.

  • The stair treads are bare wood without anti-slip strips or carpeting.

  • The lighting is inadequate, with a single overhead light at the top of the stairs and no switch at the bottom.

 Bedroom

  • The bed height is 15 inches from the floor to the top of the mattress, making it difficult for Mrs. Johnson to get in and out of bed.

  • There's no bedside lamp within easy reach, requiring Mrs. Johnson to cross the dark room to turn on the overhead light.

  • Clutter on the floor includes books, slippers, and a small trash bin, creating tripping hazards.

  • The closet requires use of a small step stool to reach upper shelves and hanging rods.

 

Recommendations for Falls Prevention Intervention

1. Exterior Modifications:

  • Install sturdy handrails on both sides of the front steps, extending slightly beyond the top and bottom steps.

  • Add contrasting color strips to the edges of all steps to increase visibility.

  • Upgrade exterior lighting with motion-sensor lights at both front and back entrances.

  • Install a ramp over the back door step with a gentle slope and non-slip surface.

2. Interior Safety Enhancements:

  • Remove all throw rugs or secure them firmly with non-slip backing and tape.

  • Clear hallways and pathways of clutter, relocating items to storage areas.

  • Rearrange furniture to create wider, unobstructed walking paths.

  • Secure loose electrical cords along walls or under furniture.

3. Bathroom Modifications:

  • Install grab bars near the toilet (on the side wall and behind the toilet) and in the shower/tub area.

  • Add a raised toilet seat or replace the existing toilet with a comfort-height model (17-19 inches).

  • Place non-slip mats inside and outside the bathtub.

  • Consider installing a walk-in shower or a transfer bench for the bathtub.

  • Improve lighting by adding bright, glare-free lights over the sink and shower areas.

4. Kitchen Safety:

  • Rearrange frequently used items to lower cabinets or countertops for easy access.

  • Install pull-out shelves in lower cabinets to improve accessibility.

  • Add under-cabinet lighting to improve visibility for counter tasks.

  • Consider replacing the stove with a model that has front controls or adding knob covers to prevent accidental activation.

5. Staircase Improvements:

  • Install a second handrail on the left side of the staircase.

  • Add non-slip adhesive strips to each stair tread.

  • Improve lighting by installing overhead lights or LED strips along the stairs.

  • Add light switches at both the top and bottom of the stairs.

6. Bedroom Adjustments:

  • Raise the bed height to about 20-23 inches using bed risers or by replacing the mattress and box spring.

  • Install a touch-activated bedside lamp or a remote-controlled light switch near the bed.

  • Clear the floor of all clutter and consider adding more accessible storage solutions.

  • Install a closet organization system that brings items to a more accessible height.

7. General Home Improvements:

  • Increase overall lighting throughout the house, using higher wattage bulbs where appropriate.

  • Install nightlights in hallways, the bathroom, and along the route from bedroom to bathroom.

  • Consider a medical alert system with fall detection for added security.

  • Encourage Mrs. Johnson to wear stable, non-slip footwear inside the house.

8. Lifestyle Recommendations:

  • Suggest an exercise program focusing on balance and strength training, tailored to Mrs. Johnson's abilities.

  • Recommend a medication review with her doctor to identify any prescriptions that might increase fall risk.

  • Encourage regular vision check-ups to ensure her eyesight is optimized.

  • Discuss the importance of staying hydrated and moving carefully, especially when first standing up.

 By implementing these comprehensive changes, Mrs. Johnson's home environment can be significantly improved to reduce fall risks. These modifications, combined with lifestyle adjustments, can help her maintain independence, boost confidence in her daily activities, and enhance overall quality of life while aging in place.