The Shirt Bunched at His Chest
Mr. Okafor, 74, is ten days post-stroke with right-sided weakness and mild aphasia; he understands what is said to him and can make his needs known in short phrases. He can sit on the edge of the bed and stand with one person assisting. Occupational therapy has set a goal that he dress himself with setup and verbal cues. It is 7:10 a.m.; he is wearing a loose short-sleeved shirt and elastic-waist pants, and breakfast trays come at 7:40. He insists, "I do it," but after eight minutes the shirt is bunched at his chest, his right arm is hanging, and he is breathing hard and muttering in frustration. His right shoulder has been painful when moved since yesterday.
1. How should you have set up the task and sequenced it so he could succeed? Include how the affected arm is handled.
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Position and setup: sit him on the edge of the bed or in a chair, feet flat, hips square, no sliding forward. Lay the shirt open across his lap with the right sleeve nearest his right hand, so the next reach is obvious rather than a puzzle.
Sequence - affected side first going on, affected side last coming off:
- Slide the right hand and arm into the right sleeve first, then draw the sleeve up over the shoulder.
- Bring the shirt around his back and put the left arm in.
- Pants and underwear: right leg first, then left; undressing is the reverse.
The right arm: support it at the forearm and elbow, close to the shoulder, and never hold him by the hand or wrist or pull it through a sleeve. After a stroke the shoulder joint is flaccid with poor ligament support; tugging on that arm is how shoulders subluxate and become painful for months. Keep the arm supported on his lap or a pillow between steps.
Give one verbal cue at a time and pause - aphasia affects output, not comprehension.
2. He is stuck, frustrated, and the trays are in ten minutes. Do you finish dressing him? Justify your answer.
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Do not take over. Taking the shirt from his hands teaches him that effort leads to loss of control, and it removes the repetitions that are the entire point of a restorative goal. Dressing practice is therapy, not housekeeping.
Instead, change the task, not the goal:
- Break it down: "Put your right hand in first. Now push."
- Use backward chaining - do the hard middle steps yourself so he completes the last step and finishes with success.
- Offer a choice rather than a rescue: "Do you want me to guide the sleeve up to your elbow, or do you want to try once more?"
- Let him rest a minute; fatigue after a stroke is real and eight minutes of effort is a lot on day ten.
On the time pressure: finish the shirt, then let him rest while you bring the tray, or ask a co-worker to start the tray. Eating 5 or 10 minutes later is far less costly than losing a functional goal. If the rush is unavoidable, negotiate explicitly: "Let's get the shirt on together now and practice the pants after breakfast."
Document the actual level of help - setup and cues, or minimum assist with the last step - so OT can see progress.
3. What do you do about the painful right shoulder, both now and on the next shift?
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Stop and look before you continue. New or worsening shoulder pain after a stroke may mean subluxation, a strain from a transfer, or positioning damage. Do not push through it, and do not test the range of motion to "see how bad it is."
Report it to the nurse today - new pain is a change in status, and the care plan and therapy goals may need to change until it is assessed.
Protect that arm in everything you do:
- Never lift, pull, or roll him by the right arm.
- During transfers, hold at the waistband or around the trunk and shoulder, not the arm.
- When he sits, support the right arm on a lap tray or pillow so its weight is not hanging from the joint.
- Promote active range of motion he performs himself within comfort, and follow the nurse's or therapist's directions for any passive movement - no overhead stretches on a painful shoulder.
Hand off explicitly: "Right shoulder painful since yesterday, report made, do not pull that arm." Grocery-list handoffs get residents hurt; specific ones don't.