OCCT 506: Clinical Reasoning about Occupation Form #5 Student: Chrys Quiroz Activity: Tying shoelaces with one

hand Date: 10/14/12

Client-Activity Intervention Plan Directions: This assignment is to be completed individually. Choose someone that has a disability and observe them performing an occupational activity. Complete the following sections based on your observations. Clients Occupational Profile Sam Kang is 29 year old female who was recently in an accident. Her left arm was severed and led to a complete amputation of the limb. She now has to rely on using her other limbs to complete everyday activities. Her favorite hobby is running and she runs 3 times a week. She will be participating in a competition in a couple months and is seeking services to be able to tie her shoes again. She is currently waiting to be given a prosthetic arm and wont be provided one until after the competition. Since the accident, she has had difficulties with activities that require the use of two hands. With the specific activity of running, she is still successful with being able to run and drink water when thirsty. However, she has trouble with putting on her clothes but has asked to primarily focus on her ability to put on her shoes and tie them. She is concerned that she will have to use running shoes that only have Velcro and does not want to be any different from other runners. Sam is the only child and lives alone. She recently moved to another state to look for a job. Her mother and father live back home but are supportive and visit from time to time. Sam hasnt established any relationships where she moved so she must rely on herself to be able to complete her desired activities. Before the accident, Sam did not have any other injuries or health issues. She is a very healthy individual who takes care of herself physically and emotionally. She does not take any medications or vitamins because she believes they will all come from a healthy diet and exercise. She spends

Client Information

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 most of her time looking for a job and exercising. Sams priorities are to be able to tie her shoes with one hand without using any adaptive equipment. Her targeted outcome will be to successfully tie her shoes independently. Strengths Emotionally stable and accepting of her current disability Able to use her right arm, which is her dominant side to complete some activities Fully functioning right digits Motivated to begin therapy sessions Weaknesses Lives alone and has to rely on herself to complete everyday activities Difficulty with performing occupations that are reliant on or involves both upper extremities Difficulty with tying her shoelaces, which is her main concern Name: Dr. Smith Title: Doctor of Medicine Contact Information: (702) 111-2222 Dr_smith@meadowwest.com Meadow West Hospital Reason for referral: Adapt to new disability and assistance in Activities of Daily Living (ADL)- Dressing; more specifically tying shoes which the client has stated as her concern Diagnosis: Amputation of left arm Physician name: Dr. Oz Title: Doctor of Osteopathic Medicine Contact Information: (863) 282-1111 Dr_oz@sunshine.com Sunshine Hospital The goals of the activity are to have the client successfully tie her

Referral Information

Activity Description

Describe the goal of the activity and

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 why the client is completing it shoelaces. She will be able to put on her shoes in a seated position. Being seated will simplify the task so that she does not have to maintain balance while standing. Also, the task requires that she uses her free foot to assist in tightening the knot. She will be relying mostly on her 3 extremities which are her left foot, right foot, and her right arm/hand. She will also be able to memorize the steps without having to refer to an instruction sheet and will be competent in performing the activity independently. The client is completing this activity because she has stated that her main concern is to be able to participate in running again and in order to do so, she needs to wear shoes and be able to tie the shoelaces. She does not want to be any different from other runners so has ruled out using running shoes that have Velcro and she also wants to be fully independent without using adaptive equipment. With the successful completion of one-handed shoe tying, the client will be confident in being able to participate in running again. The activity will use a right shoe with shoelaces already attached into the designated holes. It is assumed that if Sam will be able to successfully tie her shoelaces, she will be able to apply it regardless of whether it is a left or right shoe. The therapist will run through the activity just explaining the steps, then walk through the activity with Sam (a couple steps at a time), then allow Sam to complete the activity on her own. Before the activity can occur, the therapist must communicate with the client and let her know to bring a shoe that has shoelaces already attached. If the client is unable to bring it, the therapist must ask for the clients shoe size and bring a shoe for the client to use. The therapist must also bring a shoe for him/her to be able to use as a model during the session. The therapist must also ensure that there is an available room for the treatment session to take place in. Once there is a room, the therapist must set up the area to have two chairs (one for the client and one for the therapist) to sit in and have

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 them facing each other. There must also be a platform for the shoes to be propped on during the activity. A table must also be set up to set the paperwork on and for note taking regarding the activity. The therapist must disinfect these equipment to safeguard the clients health. There should be nothing obstructing the area where the activity is taking place. Major steps: 1. Call the client and ask whether she needs a shoe or will provide her own for treatment (2 minutes) 2. Disinfect and set up room with chairs, table, platform and no obstructions (10 minutes) 3. Introduce/obtain client history and explain activity to the client (2 minutes) 4. Therapist completes activity to give an overview of all the steps (~3 minutes) a. Ensure the shoelaces are loose and slip foot into the shoe (1 minute) b. Tighten the shoelaces from the bottom to the top and cross strings over and make a loop with one side (45 seconds) c. Use the free foot to hold one side of the shoelace down and pull the other shoelace with your hand to make the loop tight and snug (15 seconds) d. With the foot still on one side of the shoelace, make a loop with the shoelace in the hand and put the loop under the lace that is held down by the foot (25 seconds) e. Grab the end of the shoelace under the foot and slide it through the first loop to make a knot (15 seconds) f. Hold the new loop with your foot and pull the old loop with your hand (10 seconds) 5. Therapist walks the client through the same activity as

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 above (5 minutes and 40 seconds; time is doubled since both therapist and client will be completing the activity simultaneously) 6. Client completes activity on her own (3 minutes) 7. Therapist asks for feedback regarding the activity and hands Sam instructions to refer to at home (2 minutes) 8. Clean up the area (5 minutes) Overall time: ~33 minutes (12 minutes: Set up, 16 minutes: Treatment, 5 minutes: Clean up) Within 8 weeks, Sam will be able to independently use her right hand to insert laces on both shoes and tie the shoelaces while in a seated or standing position, at her training site, without losing balance within 7 minutes, 3 out of 4 opportunities, without fatigue. Within 2 weeks, Sam will be able to independently loosen her shoelaces using her right hand while in a seated position inside a treatment room, within 3 minutes, 3 out of 4 opportunities, without fatigue. Within 2 weeks, Sam will be able to independently tie a shoe using her right hand while in a seated position inside a treatment room within 5 minutes, 3 out of 4 opportunities, without fatigue. Performing the activity of tying a shoe with one hand correlates to the goals I have written because both of the short term goals deal with specific checkpoints to be able to properly don a shoe. In addition, these two short term goals lead into the long term goal of being able to function in the component of dressing, so that the client can participate in her hobby of running. With enough practice of the short term goal, the client will hopefully be able to don a shoe with ease. She will be able to transfer the activity into different contexts such as tying her shoes in the actual environment where she will be running incase her shoelaces come untied during her competition. Being versatile in regard to where she is able to tie her

Long-Term Goal

Short Term Goal Intervention Goals

Practitioners role

Activity Preparation

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 shoes will prevent her from panicking when a situation arises that she may not be accustomed to. The practitioner is involved with the preparation of the activity because he/she will consider possible goals beforehand that are outside the box and introduce/ collaborate more with the client during treatment. The practitioner will set up the activity by getting in touch with the client and making sure that a shoe is available. If no shoe is available, the practitioner will ask for Sams shoe size and purchase a shoe with shoelaces for the client and bring it to therapy. The practitioner will also wear shoes during that treatment session so that the client is able to mimic the steps during the session. Lastly, the practitioner is involved with the preparation of the activity by setting up the treatment room with 2 chairs, a table, and a platform. The area must also be disinfected and free of any obstructions that may distract the client and it would be beneficial to have a room where no other individuals are occupying the space so that the client can have a distraction free environment and an atmosphere to focus. Only the practitioner is needed to complete the preparation for the activity. Seeing that the practitioner is an able-bodied individual who is capable of moving the chairs, table, and a platform and can legally drive a vehicle to obtain the shoe, then the practitioner does not need any outside assistance for preparation. However, if the client states that she can provide her own shoe, then the client will be responsible for the preparatory work of remembering to bring the shoe to treatment and making sure that it is laced and the correct size for her foot. Seeing that the client is already an experienced runner, it is likely that she will have a shoe that she prefers to use during treatment. For preparation of the environment of the activity (which includes the set-up of the treatment room), it will take approximately 10 minutes to move the 2 chairs, table and platform as well as

Personnel required to complete the preparation

Required preparation steps and time for each step

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 disinfecting/tidying the area of the room. The telephone call made to Sam will take approximately 2 minutes. Obtaining a shoe if Sam is not able to provide one for herself will take approximately 30 minutes to 1 hour, which includes driving time, and is dependent on how far the store is from the point of origin. Prepping for the brainstorming component of the goal will take approximately 10 minutes depending on the level of experience that the practitioner has. Lastly, the client will take approximately 2 minutes to find a shoe that she would like to bring to use during her therapy session. Activity preparation will mostly take place at the clinical site, more specifically the actual room where the activity will occur. The room is about 20x25 feet and has 4 walls. There are windows on one side of the wall, a door to enter on the opposing side, and other objects within the room such as chairs, tables, benches, therapy balls and cabinets. There is a lot of open space for the client and practitioner to move around. It is relatively quiet when no one is in the room other than the sound of the air conditioning system running. There is bright lighting and the temperature is often cool. There is proper ventilation with the windows being open, if necessary. The preparatory steps for brainstorming and calling the patient will occur in the practitioners office which is a smaller room than the therapy room. It is about 13x13 feet and has 4 walls. There is one door and no windows. There is also a table and chairs as well as a bookshelf. On the table there is a computer and paperwork. There is proper lighting to complete work. It remains relatively cool and quiet, and there is adequate ventilation from opening the door and the air conditioning system. The store that the shoe may be purchased at is a large store with rows of shelves containing shoes. There is a register in front of the store as well as surveillance cameras. It remains relatively cool and has proper lighting. It can get noisy when a large amount of customers occupy the space. The ventilation system is mainly acquired from the air conditioning

Required place and space

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 system. The apartment that Sam lives in (if she were to bring the shoe) is a studio that is located on the first floor of the complex. Her kitchen, bathroom and rest area are all within one room and are not divided by walls. It is about 900 square feet with adequate lighting and ventilation. It is very quiet because Sam is the only person who lives in the studio. It can get chilly and Sam responds to temperature changes by adjusting her air conditioning system. A required material for the preparation would be Clorox Disinfecting Wipes that the practitioner will use to disinfect the equipment. It is a cylindrical object that is made of plastic and encloses wet wipes inside. There are 35 wipes and have a lemon fragrance to it. An indirect material to the preparation of the activity that could be considered is the gas that is needed for the car to move and work. Gas is a liquid, strong smell, dangerous to ingest, and dark. A phone is needed to make the call to the client. Chairs, table, and a platform are going to be set up in the therapy room to be used during the activity. A computer is needed to get information regarding the patient, research, and brainstorm goals. A car is needed to get from the point of origin to the shoe store. Tool Phone; black, rectangular, smooth, lightweight, bright screen Equipment Chairs; about 2 feet off of the ground, heavy, hard, metal feet base Table; large, hard, flat surface, brown, heavy, metal feet base Platform; rectangular block, brown, heavy, flat surface, length: 2 feet, width: 2 feet, height: 1 foot Computer; hard, smooth, black, bright colors Car; large, very heavy, 4 doors, windows, smooth Potential hazards that could arise from preparation of this activity are that the practitioner may get into an accident while driving to

Required materials

Required equipment

Safety precautions

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 the store to purchase the shoes. Therefore, caution must be taken to drive safely to the store. Another safety precaution during preparation is that the practitioner may injure or strain their body while moving the chairs, table and platform. Proper body mechanics must be followed in order to prevent this from occurring. A potential hazard that may arise for the client is that if the shoes are in a difficult to reach location at her house, she may either trip, fall or cause injury to her body when obtaining the shoes. Therefore, if the shoes are on a ledge, or underneath her bed, Sam must be cautious in ensuring that she is not endangering herself just to get the shoes. The practitioner and Sam will be involved with completion of this activity. The practitioner is responsible for instructing, guiding and facilitating the completion of the activity. She will also ensure that the environment is safe at all times for the client. The client has the duty of having the shoe at the treatment session and being engaged and participating in the activity. She is also responsible for asking questions if she is having difficulty with a specific step. The activity will take place inside the therapy room. It is located inside of a clinic that is geared toward rehabilitation of adult clients. There are multiple therapy rooms within the clinic (about 7). There is also an administrative side on the other half of the clinic which has about 5 offices to handle aspects such as billing and scheduling. There are offices for the practitioners (about 10) which are generally smaller than the therapy rooms. The clinic is conveniently located next to the freeway. The room is about 20x25 feet and has 4 walls. There are windows on one side of the wall, a door to enter on the opposing side, and other objects within the room such as chairs, tables, benches, therapy balls and cabinets. There is a lot of open space for the client and practitioner to move around. It is relatively quiet when no one is in the room other than the sound of the air conditioning system

Personnel required

Setting and location Activity Implementation

Space required

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 running. There is bright lighting and the temperature is often cool. There is proper ventilation with the windows being open if necessary. The materials required for the activity are a pen and paper for the practitioner to make notes as well as the paper with instructions for when the client is at home. Materials Pen; about 5 inches long, cylindrical, thin, lightweight, black ink inside, smooth, unbendable Paper; 8.5x11 inches, white, thin, lightweight, and smooth The tools required for the activity is a shoelace and shoe for each the client and practitioner. The equipment necessary are 2 chairs, a table and a platform for the client and practitioner to sit on and set their objects on. Tools Shoelace; cylindrical, about 2 feet long, white, soft, lightweight, made out of cotton Shoe; rubber sole, black (Sam) and white (practitioner), lightweight and various textures including cotton and leather Equipment Chairs; about 2 feet off of the ground, heavy, hard, metal feet base Table; large, hard, flat surface, brown, heavy, metal feet base Platform; rectangular block, brown, heavy, flat surface, length: 2 feet, width: 2 feet, height: 1 foot For the entire activity to be completed, about 12 minutes is required due to the repetitive nature. The practitioner must allow the client to practice in order for the client to understand and have the activity engrained in her memory. The activity will be implemented by the practitioner doing the activity first (3 minutes), then guiding the client step by step as the client completes the activity (6 minutes), and finally having the client complete the activity on her own (3

Required materials

Required equipment

Required steps and time for each step

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 minutes). However, for one attempt of the actual activity (of tying shoelaces with one hand), the duration is approximately 3 minutes. Activity of tying shoelaces with one hand a. Ensure the shoelaces are loose and slip foot into the shoe (1 minute) Areas of Occupation ADL- Dressing is addressed because the action of putting on a shoe is a component of dressing. Client Factors Values and spirituality are addressed because Sam values performing activities independently and her going to therapy is a spiritual outlet for her to release her stress from the week. Body Functions are addressed through multiple components. Mental functions are addressed because the client must be able to use higher-level cognitive functions to pay attention during the step. Memory is needed to recall what the instructor just stated with this particular step. Mental functions of sequencing complex movement are needed to be able to execute the newly learned pattern of movement. Emotional function is needed so that the client can regulate and cope if she is having trouble with this step. Energy and drive is needed for the client to push through this step. Sensory functions and pain components are also addressed during this step. Seeing and related functions are needed for the client to be able to see what she is

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 doing and to watch the practitioner. Hearing functions are needed for the client to listen to what the practitioner is saying. Proprioceptive functions are needed so that she is aware of how her body is positioned during this step. Touch functions are needed for the client to be able to feel the shoe and shoelace. Pain function is needed so that the client can vocalize if she is feeling discomfort. Temperature awareness is needed so that the client can vocalize if the room is too hot or cold and if it is preventing her from completing the step. Neuromusculoskeletal and movement-related function components are addressed in this step. Joint mobility of the clients extremities is needed as well as joint stability in order to maintain proper postural alignment during this step. Muscle power, tone and endurance are needed to complete the step multiple times without fatigue. Cardiovascular, hematological, immunological, and respiratory system function are addressed because the client must have normal blood pressure and respiration in order to complete this step. Voice and speech functions are addressed because the client must be able to vocalize her needs or any questions to the practitioner. Skin and related-structure functions are needed because any open wounds must be protected to complete the step without any pain. The Body Structures

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 that are needed for this step are 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 1 foot. Performance Skills Motor and praxis skills are addressed in this step. Client must bend and reach for the shoe and shoelace. Client must coordinate body movements to complete the task. Client must maintain balance while flexed at the hip to perform the step. Client must manipulate the shoelaces as needed. Sensory-perceptual skills are addressed in this step. Client must position the body so that she does not cause strain and has proper body mechanics. Client must listen to the practitioner giving instructions. Client must visually determine if she is following the exact instructions that the practitioner has relayed. Emotional regulation skills are addressed in this step. Client must persist through the activity if she is having difficulty. Client must control her frustration if she is having trouble with the step. Client must be aware of her feelings and realize if she is getting frustrated so she is able to utilize a coping strategy. Cognitive skills are addressed in this step. Client must select which tool the practitioner has told her to pick up. The client must multitask by watching, listening and performing the step. Communication and social skills are addressed because the client must look to see what the practitioner is doing. Maintain appropriate space with the practitioner during

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 the step. Initiate any questions she may have regarding the step. Performance Patterns A role that Sam assumes with this step is a runner who participates in competitions. A ritual that is associated for this step is that Sam will wear a specific pair of shoes when she competes, so she is currently using that shoe during treatment. A routine that is associated with this step is that Sam runs 3 times a week. A habit that is associated with this step is that Sam always puts on her right shoe first. Context and Environment Cultural context: Being able to complete this step to putting on a shoe is consistent with the cultural expectation to wear shoes. Personal context: A 29 year old female runner who would like to use this step to be able to put on a shoe with one upper extremity. Temporal context: An individual who had a recent upper limb amputation at an occupational therapy clinic. Physical: Occupational therapy clinic, more specifically in a therapy room Social: Occupational therapist is present during this step and holds expectations for the completion of this step Activity Demands Objects and their properties Tools

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 Shoelace; cylindrical, about 2 feet long, white, soft, lightweight, made out of cotton Shoe; rubber sole, black (Sam) and white (practitioner), lightweight and various textures including cotton and leather Equipment Chairs; about 2 feet off of the ground, heavy, hard, metal feet base Table; large, hard, flat surface, brown, heavy, metal feet base Platform; rectangular block, brown, heavy, flat surface, length: 2 feet, width: 2 feet, height: 1 foot A space demand for this step is a medium size area for the client to be able to freely move her body. Proper lighting is needed to see what she is doing and the temperature must be set at a comfortable setting for the client to complete the step. A social demand would be the expectation of the practitioner for the client to complete this step. Sequence and timing is needed because client must loosen the shoelaces before slipping her foot into the shoe. Required actions and performance skills is needed for client to grip the shoe and shoelace. Also, client must ask and answer any questions related to the step. Required body functions of the step are the mobility of her joints such as her digits, as well as her extremities. Required body

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 structures are 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 1 foot. b. Tighten the shoelaces from the bottom to the top and cross strings over and make a loop with one side (45 seconds) Areas of Occupation- See above Client Factors- See above The Body Structures that are needed for this step are 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 1 foot. Performance Skills- See above Performance Patterns- See above Context and Environment- See above Activity Demands- See above Sequence and Timing: Client must tighten shoelaces before crossing strings over and making the loop Required Body Structures: 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 1 foot. c. Use the free foot to hold one side of the shoelace down and pull the other shoelace with your hand to make the loop tight and snug (15 seconds) Areas of Occupation- See above Client Factors- See above The Body Structures that are needed for this step are 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 2 feet. Performance Skills- See above Performance Patterns- See above Context and Environment- See above Activity Demands- See above Sequence and Timing: Client must hold

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 down the shoelace before pulling and making a loop with the other lace. Required Body Structures: 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 2 feet. d. With the foot still on one side of the shoelace, make a loop with the shoelace in the hand and put the loop under the lace that is held down by the foot (25 seconds) Areas of Occupation- See above Client Factors- See above The Body Structures that are needed for this step are 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 2 feet. Performance Skills- See above Performance Patterns- See above Context and Environment- See above Activity Demands- See above Sequence and Timing: Client must make a loop with the shoelace in her hand before putting the loop under the opposite lace. Required Body Structures: 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 2 feet. e. Grab the end of the shoelace under the foot and slide it through the first loop to make a knot (15 seconds) Areas of Occupation- See above Client Factors- See above The Body Structures that are needed for this step are 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 2 feet. Performance Skills- See above Performance Patterns- See above Context and Environment- See above

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 Activity Demands- See above Sequence and Timing: Client must grab the lace under the foot before sliding it through and making a knot. Required Body Structures: 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 2 feet. f. Hold the new loop with your foot and pull the old loop with your hand (10 seconds) Areas of Occupation- See above Client Factors- See above The Body Structures that are needed for this step are 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 2 feet. Performance Skills- See above Performance Patterns- See above Context and Environment- See above Activity Demands- See above Sequence and Timing: Client must hold the new loop before pulling the old loop to tighten the knot. Required Body Structures: 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 2 feet. Overall time: ~3 minutes Safety precautions A potential hazard during the implementation of the activity is extreme fatigue or strain to the clients body. Continually having to bend over and tie a shoelace may cause stress to the body if proper body mechanics are not followed or taken into consideration. Another site of potential fatigue is of the digits. Sams fingers may cramp if she overuses them and does not rest in between attempts. Describe how the activity overall fits Activity overall into the domain(s) of occupational Areas of Occupation therapy in detail. Consider: ADL- Dressing is addressed because the action of

Domain

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 Areas of Occupation Client Factors Performance Skills Performance Patterns Context & Environment Activity Demands putting on a shoe is a component of dressing. Personal hygiene and grooming is also addressed because the client must wear shoes in order to remain hygienic when walking outdoors to protect her feet from bacteria and dangerous objects that can cut her feet. IADL- Community mobility is addressed because Sam must wear shoes in order to move around in the community. If Sam desires to take a walk around her neighborhood, she must wear shoes. Health management and maintenance is addressed because she has stated that she has a routine of running and in order to do so, she must wear shoes. Home establishment and management are addressed because if she would like to take out the trash or do some cleaning outside of the apartment, she must wear shoes. Safety and emergency maintenance are addressed because if there is ever a sudden danger such as an evacuation at her apartment structure, she must be able to safely and quickly put on her shoes. Shopping is addressed because some establishments require shoes to be worn if the individual would like to enter. Work- Employment seeking and acquisition is addressed because Sam is currently looking for a job so while she visits various establishments, she must be able to put on a shoe. Job performance is addressed because when she does find a job, depending on the type of shoe she wears, she will have to manipulate shoelaces. Volunteer participation is addressed because if her company requires volunteer participation or if Sam chooses to

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 do it during her spare time, she must wear close toed shoes. Play- Play exploration and participation is addressed because if she decides to spontaneously play a sport like basketball, she must wear running shoes which deal with shoelaces. Leisure- Leisure participation is addressed because if she would like to go running, which she has stated as her hobby, she will need to be able to tie her shoelaces. Social participation- When going out with her family or friends, she will eventually need to wear shoes that have shoelaces so Sam must be proficient in being independent and tying her own shoes. Client Factors Values, beliefs and spirituality are addressed because Sam values her health and believes that it is important for a person to take care of their own body through exercise and proper diet. Therefore, she has a sense of purpose and meaning to her life whenever she goes running because it allows her to de-stress which is essential for her spirituality. These are related to this activity because this particular step will eventually lead to Sam being able to function in her hobby of running. Body Functions are addressed through multiple components. Mental functions are addressed because the client must be able to use higher-level cognitive functions to pay attention during the entire activity. Memory is needed to recall what the instructor just stated with the activity. Mental functions of sequencing complex movement are needed to be

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 able to execute the newly learned pattern of movement. Emotional function is needed so that the client can regulate and cope if she is having trouble with the activity. Energy and drive is needed for the client to push through the activity. Sensory functions and pain components are also addressed during the activity. Seeing and related functions are needed for the client to be able to see what she is doing and to watch the practitioner. Hearing functions are needed for the client to listen to what the practitioner is saying. Proprioceptive functions are needed so that she is aware of how her body is positioned during the activity. Touch functions are needed for the client to be able to feel the shoe and shoelace. Pain function is needed so that the client can vocalize if she is feeling discomfort. Temperature awareness is needed so that the client can vocalize if the room is too hot or cold and if it is preventing her from completing the activity. Neuromusculoskeletal and movement-related function components are addressed in the activity. Joint mobility of the clients extremities is needed as well as joint stability in order to maintain proper postural alignment during the activity. Muscle power, tone and endurance are needed to complete the activity multiple times without fatigue. Cardiovascular, hematological, immunological, and respiratory system function are addressed because the client must have normal blood pressure and respiration in order to complete the activity. Voice and speech functions are addressed because the client must be able to vocalize her needs or any questions to the

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 practitioner. Skin and related-structure functions are needed because any open wounds must be protected to complete the activity without any pain. The Body Structures that are needed for this activity are 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 2 feet. Performance Skills Motor and praxis skills are addressed in this activity. Client must bend and reach for the shoe and shoelace. Client must coordinate body movements to complete the task. Client must maintain balance while flexed at the hip to perform the activity. Client must manipulate the shoelaces as needed. Sensoryperceptual skills are addressed in this activity. Client must position the body so that she does not cause strain and has proper body mechanics. Client must listen to the practitioner giving instructions. Client must visually determine if she is following the exact instructions that the practitioner has relayed. Emotional regulation skills are addressed in this activity. Client must persist through the activity if she is having difficulty. Client must control her frustration if she is having trouble with the activity. Client must be aware of her feelings and realize if she is getting frustrated so she is able to utilize a coping strategy. Cognitive skills are addressed in this activity. Client must select which tool the practitioner has told her to pick up. The client must multitask by watching, listening and performing the activity. Communication and social skills are addressed because the client must look to see what the practitioner is doing. Maintain appropriate space with the practitioner during the activity. Initiate any

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 questions she may have regarding the activity. Performance Patterns A role that Sam assumes with this activity is a runner who participates in competitions. Sam also is a client in an occupational therapy clinic. A ritual that is associated for this activity is that Sam will wear a specific pair of shoes when she competes. A routine that is associated with this activity is that Sam runs 3 times a week. A habit that is associated with this activity is that Sam always puts on her right shoe first. Context and Environment Cultural context: Being able to complete this activity is consistent with the cultural expectation to wear shoes. Wearing shoes in public is expected. Being barefoot is considered to be unhygienic and unsanitary. Personal context: A 29 year old female runner who would like to complete this activity to be able to put on a shoe with one upper extremity. Temporal context: An individual who had a recent upper limb amputation at an occupational therapy clinic. Physical: Occupational therapy clinic, more specifically in a therapy room Social: Occupational therapist is present during this step and holds expectations for the completion of this step Activity Demands Objects and their properties Tools Shoelace; cylindrical, about 2 feet long,

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 white, soft, lightweight, made out of cotton Shoe; rubber sole, black (Sam) and white (practitioner), lightweight and various textures including cotton and leather Equipment Chairs; about 2 feet off of the ground, heavy, hard, metal feet base Table; large, hard, flat surface, brown, heavy, metal feet base Platform; rectangular block, brown, heavy, flat surface, length: 2 feet, width: 2 feet, height: 1 foot Materials Pen; about 5 inches long, cylindrical, thin, lightweight, black ink inside, smooth, unbendable Paper; 8.5x11 inches, white, thin, lightweight, and smooth A space demand for this activity is a medium size area for the client to be able to freely move her body. Proper lighting is needed to see what she is doing and the temperature must be set at a comfortable setting for the client to complete the activity. A social demand would be the expectation of the practitioner for the client to complete this activity independently. Sequence and timing is needed because client must complete specific steps in order such as putting on the shoe before tying the shoelaces. Required actions and performance skills is needed for client to grip the shoe and shoelace. Also, client must ask and answer any questions related to the activity. Required body functions of

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 the step are the mobility of her joints such as her digits, as well as her extremities. Required body structures are 2 eyes, 2 ears, 10 fingers, 1 hand, 1 arm, and 2 feet. I was able to utilize the occupational profile, activity preparation, and activity implementation to achieve occupational therapy outcomes because Sam is able to adapt to her amputation and is able to engage and participate in her hobby of running. Since her hobby is running, it also ties into her overall health and wellness because through physical exercise, she is able to promote a healthy lifestyle and body. Understanding the client through her occupational profile allowed me to gauge what the clients goals were for herself and to help her establish other goals that she may not have considered but would also like to address. The activity preparation allowed me to brainstorm and process the information regarding the client beforehand in order to maximize the time that the client was in therapy, so that she is able to get quality care. The activity implementation allowed the facilitation of the overall activity in order for the client to learn and hopefully retain the information that she acquired during therapy. These factors that go into the therapy session all will improve the quality of life for Sam because she will get back to what she enjoyed doing before the accident and she wont feel alienated or different from other runners during the competition. She will establish role competence by being able to meet the demands of being a runner. Sams occupational performance on tying a shoe with one hand has improved through treatment. This has enhanced other areas in her life because now she is able to see that seemingly difficult activities can still be accomplished with one upper extremity. Sam was willing and enthusiastic to start treatment. Reason for Sams visit is to learn how to tie her shoelaces with one hand. Client wants to be able to participate in running competitions after

Discuss how you have utilized the occupational profile, activity preparation, and activity implementation to achieve occupational therapy outcomes.

Process

SOAP Note

Subjective

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 having difficulties with the dressing component of donning a shoe. Clients left upper extremity was amputated after an accident one month ago. She is not experiencing any pain other than the inconvenience of having to complete activities with one upper extremity. Patient was relatively healthy prior to the accident and is not currently taking any medications. Diet consists heavily of fruits and vegetables, minimum meat and water. Patient is allergic to Aspirin. Client has an amputated left upper extremity. Relies on the use of her two lower extremities and right upper extremity. Client is able to successfully put on a shoe and tie the shoelace after one attempt. Client needs guidance and cueing for next steps. Client is able to follow directions. Client participated for 13 minutes in tying a shoe with one hand with only 1 minute of rest between attempts. Activity requires continual flexion at the hip to reach for and tie the shoe. Also requires flexion of the leg to prop the lower extremity onto the platform. Tying the shoelaces requires finger dexterity and the digits form a pinch grip to hold onto the laces. Forearm interchange from pronation to supination. Foot dorsi flexes and plantar flexes in order to hold onto the lace and apply pressure. Client is seeking services to be able to tie a shoelace with one hand after her left upper extremity was amputated. Left upper extremity was severed due to an accident. Client needs treatment to facilitate a method to tie a shoelace with one hand. Client progressed with first appointment and is now aware of a method to perform onehanded shoelace tying. There is a potential that the client will plateau. She may show improvement with performance at treatments but may not practice at home which will delay progression of skill and remain at her current capacity. A problem to be addressed is that the client is unable to insert laces onto a shoe when changing laces or buying a new pair of shoes. Continue training on how to dress, more specifically, with donning

Objective

Assessment

Plan

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 her shoes so that she can be independent and perform the activity without guidance or cueing, in the real setting of where she runs. Continue to teach client how to deal with obstacles that may arise when wearing a shoe such as balancing on uneven surfaces.

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 References American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62; 625-683 Clifford, J. O. & Hussey, S. M. (2012). Introduction to Occupational Therapy (4th ed.). St. Louis, Missouri: Elsevier Mosby. Crepeau, E. C. (2009). Willard & Spackman's Occupational Therapy (11th ed.). Baltimore, Maryland: Lippincott Williams & Wilkins. Garcia, V. & Kang, S. (Producer). (2012). Tying shoes. Podcast retrieved from http://www.youtube.com/watch?v=prlaMRpbkJA&feature=channel&list=UL

(Modified from Hersch, Lamport, & Coffey, 2005)