OCCT 506: Clinical Reasoning about Occupation Form #5 Student: Nicole Quisao Activity: Tying Shoes Date: 10/4/12

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 Charisse is an 18 year old female who was born in Littleton, CO. Her mother had an emergency C-section because the umbilical cord had a knot around Charisses neck. For the first seven minutes of her life, Charisse did not have oxygen. She was required to be on oxygen during her first two weeks at home. Her mother noticed at a young age that Charisse was not developing in the way that her three older brothers developed when they were younger. At two years old, Charisse was diagnosed with low tone cerebral palsy and ataxia. She was referred for an occupational therapy evaluation by her nurses at the hospital regarding voluntary upper extremity motor control and trunk control Charisse is able to care for herself in many ways, however, needs help and assistance with many activities. Charisse is able to enjoy certain activities such as decorating for hallowing, using the internet or playing wii. However, for some of these activities, she has trouble with the necessary fine and gross motor control. This is a result of the cerebral palsy and ataxia. Gait patterns, trunk stability, knee stability and overall mobility are impacted. It is often difficult for her to climb the stairs. Often, Charisse uses a brace which helps her with knee and lower extremity stability. Charisse is mainly concerned with control of her upper extremity motor control, specifically with her hand, wrist, and forearm.

Client Information

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

OCCT 506: Clinical Reasoning about Occupation Form #5

Despite her impairments, Charisse is very outgoing and enjoys spending time with her family and friends. She enjoys activities that individuals in her age range enjoy and she believes that she can do anything that the other students can do. She just does it in her own unique way. Charisse would like to be able to participate in school events and activities such as art class, prom, cheerleading, and yearbook club. She has expressed the desire to be able to paint and draw pictures, go to prom, learn and perform the cheer routines, as well as help make her schools yearbook. She would also like to be able to independently tie her shoes, as she is already able to dress herself independently. Strengths that Charisse has include that she is: motivated to participate in therapeutic activities, determined to be as independent as possible, and already independent in certain ADLs and IADLs. Weaknesses that Charisse has included: a decreased range of motion in upper extremities, this causes certain movements to be restricted. She has difficulty flexing and extending shoulder and elbow joints. Charisse has poor motor control in relation to ataxia which results in diminished fine and gross motor activities. Charisse also has difficulty in maintaining normal gait patterns. Particularly when Charisse walks up the stairs, she has much difficulty and often requires a leg or knee brace to aid in stability. In addition, Charisse has weak trunk stability and posture as well as weak muscle coordination. Charisse was referred by her nurse at her doctors office after her mother noticed that she had physical delay. She continues to receive outpatient therapy to work on upper extremity fine motor control, gait patterns, muscle coordination and trunk stability.

Referral Information

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

OCCT 506: Clinical Reasoning about Occupation Form #5

Jennifer L Armstrong-Wells, M.D. Children's Hospital Colorado 13123 E. 16th Avenue B155 Aurora, CO 80045-7106 Ph: 720-777-6895 Fax: 720-777-7285 The goal of the activity that Charisse is completing is tying her shoes independently. This activity is to be completed using her upper extremities. Charisse is tying her shoes to improve her fine motor coordination of her upper extremities, specifically her hands. She would like to be able to control her hand movements in order to grasp the shoelaces and perform this activity independently. She does not want anyone else to have to tie them for her. Currently she receives help from other individuals when tying her shoes. In two months, Charisse will be able to complete the activity of grasping shoelaces and tying her shoes using fine motor control and muscle coordination independently while seated in a chair. In one to two weeks, Charisse will be able to use her upper extremities with improved motor and muscle control to tie a ribbon on a large cube shaped box or present while seated at a table. The practitioners physical role in preparation is minimal. Most of the physical preparatory work will be completed by Charisse. The practitioner will work on guiding Charisse to improve motor skills in order to be able to tie her shoes independently. Focus will be on upper extremity motor control, specifically with the wrist in hand in order to tie gym shoes as well as muscle coordination. By practicing tying a ribbon around a large cube shaped box, Charisse will begin to understand the movements required to tie her shoes.

Describe the goal of the activity and why the client is completing it

Activity Description

Long-Term Goal Intervention Goals

Short Term Goal

Practitioners role

Activity Preparation

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

OCCT 506: Clinical Reasoning about Occupation Form #5 The practitioner will guide and provide Charisse with appropriate directions regarding sequencing and techniques related to appropriately tying shoes. For preparation of tying shoes, Charisse will perform the required work. Charisses responsibilities would include retrieving socks from the dresser drawer, retrieving the shoes from the shoe rack, and ensuring that there is an appropriate seating area that is structurally stable for her to sit on as well as free of hazards. No additional personnel would be required for the activity. 1. Locate and identify a safe and stable surface appropriate to perform the activity. (2 minutes) 2. Gather and retrieve required materials from various locations around the house. a. The gym shoes and shoelaces can be found in the downstairs hallway closet. (5 minutes) b. The socks can be retrieved from the dresser drawer located in Charisses bedroom, which is upstairs. (10 minutes) 3. Set the materials out on the work surface and sit down with hands and feet ready. (3 minutes) This activity preparation does not have to take place in any particular place or space. For example, it can be performed in a home or school setting. Charisse will likely be required to tie her shoes at home prior to leaving her house for planned activities. In regards to the space requirements, Charisse usually sits on the floor in when tying her shoes, but she can also tie her shoes on a surface such as a couch. The main requirement for this particular activity is that it should be performed on a surface which provides stability and ample space. She may be able to tie her shoe while seated in a chair, but this may require an additional amount of coordination, which may be addressed in the future. For Charisse to retrieve the require materials; she needs to walk down a hallway which is about

Personnel required to complete the preparation

Required preparation steps and time for each step

Required place and space

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

OCCT 506: Clinical Reasoning about Occupation Form #5 14 feet long. This particular space is normally clear and free of obstructions. Charisse will also need to climb up and down her wooden staircase, which has 20 steps. To get to her bedroom dresser drawer, Charisse will need to walk down the hallway for about 8 feet. In order to successfully tie a pair of shoes there are certain required materials. Charisse would need a pair of gym shoes, a set of shoelaces, and a pair of socks. Charisses gym shoes are made of firm rubber, which is flexible and bendable. The body of the shoe is soft and breathable. Charisses shoes are womens size seven. The shoelaces are made of rough and bumpy cloth and are thin, stringy, flimsy, and have an inch of plastic on each end. The socks are made of cotton and are stretchable. The equipment required in preparation for tying shoes includes the floor. This is the preferred surface for the Charisse. The floor is a flat, sturdy and stable surface. The floor in Charisses home is of wooden material, it is cool to touch, and is slick and slippery. Some potential hazards that may cause harm during preparation for Charisse include; clutter on her work surface. Since she will tie her shoes while seated on the floor, it would be imperative to ensure that the floor is cleared of all obstacles and hazards. In addition, the slick and slippery nature of her wood floor at home may be dangerous, potentially causing her to slip and fall. The shoelaces may also cause injury or harm to Charisse if the material is bumpy, or if the plastic ends become broken. This may potentially cause skin breakdown. If Charisse had difficulty with emotional regulation or impaired judgment, the shoelaces may potentially be used for harm. In addition, moving across the floor as well as climbing the stairs are challenging for Charisse. It would be important for Charisse to use her leg and knee brace especially when climbing the stairs. Completion of this activity can be solely performed by Charisse.

Required materials

Required equipment

Safety precautions

Activity

Personnel required

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

OCCT 506: Clinical Reasoning about Occupation Form #5 Implementation While some of her motor control may inhibit her performance of this occupation, causing it to take an extended amount of time, no other individuals will be required to complete it. The practitioners duties during this activity are to guide, instruct, and encourage Charisse through the steps by verbally assisting. In addition, if Charisse has difficulty understanding the activity sequence, the therapist may be able to prompt with statements to encourage problem solving skills. The only personnel required to be present throughout the activity are Charisse and the therapist. For implementation, Charisse will complete the activity at home during therapy. She may complete this activity during some therapy sessions at her outpatient clinic. However, her home will be the natural setting where she will initially learn to tie her shoes comfortably. The setting for tying shoes should be spacious, comfortable, free of hazards, adequate lighting, appropriate internal temperature, with minimal noise. The space requirements for tying shoes include; ample space for In order to successfully tie a pair of shoes there are certain required materials. Charisse would need a pair of gym shoes, a set of shoelaces, and a pair of socks. Charisses gym shoes are made of firm rubber, which is flexible and bendable. The body of the shoe is soft and breathable. Charisses shoes are womens size seven. The shoelaces are made of rough and bumpy cloth and are thin, stringy, flimsy, and have an inch of plastic on each end. The socks are made of cotton and are stretchable. The equipment required for tying shoes includes the floor. This is the preferred surface for the Charisse. The floor is a flat, sturdy and stable surface. The floor in Charisses home is of wooden material, it is cool to touch, and is slick and slippery. Major steps to complete the activity of tying shoes: 1. First, Charisse will need to choose and retrieve which pair shoes

Setting and location

Space required 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 and socks she will wear. The shoes will have laces. (5 minutes). a. Areas of Occupation Selecting the pair of shoes and socks to wear and utilize for this activity allows for Charisse to be introduced to the ADL of dressing. Selecting appropriate socks and shoes could be important for time of day, weather or occasions. In addition, the ADL of functional movement is addressed in this part of the activity because in order to select and retrieve the socks and shoes, she is required to move from one position or place to another. This also includes transporting the shoes and socks from her dresser drawer to the space and place of the activity. Also, in preparing for the activity, Charisse had to consider the safety of the environment when performing the activity. No IADLs are addressed. b. Client Factors Mental functions are required in order to select which shoes and socks she wants to wear in relation to the weather. She would need to decide to select thicker socks if it was going to be a cold temperature. Also, following verbal directions given by the therapist would be important to be successful. Sensory functions related to seeing, vestibular, touch, and pressure would be related to this particular step. Touch and pressure would be required when picking up the shoes and transporting them to the required space. In addition, she would need to visually see where she was when walking up and down the stairs, as well as to see if she selected the appropriate materials. Joint mobility, stability, muscle tone, endurance and coordination, as well as gait patterns are all required body functions related to selecting the materials.

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

OCCT 506: Clinical Reasoning about Occupation Form #5 Charisse would need appropriate function of her cardiovascular system especially when climbing the stairs, as well as intact skin to ensure safety. The structures necessary for this step include her nervous system, eyes, heart, bones and muscles, as well as her skin. c. Performance Skills Choosing and retrieving the pair of shoes and socks to utilize requires use of coordinating body movements as well as maintaining balance in order to travel to and from her bedroom. In addition, bending and reaching into the dresser drawer is necessary. For sensory-perceptual skills, Charisse would need to visually determine where she is walking, as well as whether or not she is retrieving the appropriate materials from her bedroom. Positioning of her body is also important when retrieving the materials. Emotion regulation in regards to being aware that it may take time to be able to walk up the stairs in a timely manner. She would need to display appropriate behavior and persist despite difficulties with her stability and coordination. Cognitively, Charisse would be required to judge the importance of selecting and retrieving the appropriate socks and shoes for a particular occasion or for weather. Multitasking by walking and holding materials would be important. d. Performance Patterns When selecting and retrieving the appropriate socks and shoes for this activity, Charisse would need to make use of the appropriate routine of walking up the stairs and making a right as she enters the hallways. Also, she would need to be familiar with her own habit of placing socks in the wrong drawer. In addition, she should recognize her

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

OCCT 506: Clinical Reasoning about Occupation Form #5 role as a female with cerebral palsy and impairments. e. Context and Environment the physical environment is the most important aspect of this particular step of typing her shoes. The physical environment is that of her home. It is generally clean and free of hazards. f. Activity Demands Selecting and retrieving the socks and shoes from her bedroom will require Charisse to move across her house by climbing stairs and 2. Next, Charisse will need to put a sock onto her right foot, and then onto her left foot. To complete this step, she will first position the sock so that the foot will fit into the opening, then slip the foot into the opening of the socks (3 minutes). a. Areas of Occupation position the sock and slipping the sock onto her foot addresses the importance of being able to dress oneself. Charisse is able to complete many dressing activities independently and she is able to know how to sequentially place the socks on prior to the shoes. This particular step of the activity does not fit into any IADLs. b. Client Factors- Regarding values, the fact that Charisse can complete this step independently with ease is very important to Charisse. In addition, she needs to use her mental functions as well as sensory functions in order to properly place the socks onto her feet. Though is required when deciding whether or not the socks are matching. Mobility of her upper extremity is required and again, skin as well as cardiovascular system is required. Muscle endurance and strength would also be useful when place socks onto feet appropriately. c. Performance Skills Charisse would need to bend her trunk and extend by reaching her upper extremities in order to get to her feet. She would need to be able to

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

OCCT 506: Clinical Reasoning about Occupation Form #5 judge and select the socks in order to complete the activity of tying shoes and she would also need to visually locate as well as position her body in the appropriate location to place the socks on. d. Performance Patterns Charisse often has the habit of placing the socks inside out, so being aware of this may aid in her ability to place the socks on correctly. Placing her socks on is part of Charisses routine. It generally comes after selection of materials is made. Since Charisse was a young girl, she has a particular pair of socks that she believes to be lucky. She has a ritual of using these socks during therapy. e. Context and Environment For this activity, the physical environment is on a wood floor in her home. This floor is hard and smooth, with no obvious hazards or difficult terrain. f. Activity Demands The socks for this activity are rough and made cloth material. They are elastic, which aid in the process of placing the sock onto the foot. Charisse would use touch and sensation to determine if the sock is inside out. In addition, metal function and sensory function are important for this activity because Charisse would need to put thought into the execution of these learned movement. Discriminating tactile sensations is especially important for this step in relation to the sock texture. 3. After that, she will place a shoe onto each foot, ensuring that the tongue portion of the shoe is properly positioned (6 minutes). a. Areas of Occupation Proper placement of her shoes onto her foot aids in Charisses ability to independently dress herself. In addition, this could potentially aid in her ability to care for others. For example, she may be

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

OCCT 506: Clinical Reasoning about Occupation Form #5 able to translate her own skill set in tying shoes to potentially help her younger brother to tie his shoes. Also, it may promote safety in regards to avoiding small hazards or challenging terrain. b. Client Factors Attention needs to be utilized when placing the shoe on her foot in order to ensure the correct placement or right versus left shoe. Charisse would need to recognize also whether or not the shoelaces are tied or untied. Touch function when manipulating the shoe should be recognized since different shoes have differing textures. In addition, pain is related to this step if Charisse places the incorrect size shoe on causing her foot to be squeezed into a tight and uncomfortable space. Use of her joints of her fingers and wrist are most important in order to ease the action of place the shoe onto her foot. Also, she would need to ensure that her skin is intact, and no bumps, bruises, or wounds would impede her ability to place the shoe onto the foot. c. Performance Skills These skills are similar to that of the action of placing the socks on her foot. Charisse would need to bend her trunk and extend by reaching her upper extremities in order to get to her feet. She would need to be able to judge and select the shoes in order to complete the activity of tying shoes and she would also need to visually locate as well as position her body in the appropriate location to place the socks on. d. Performance Patterns - Charisse has a habit of placing the left shoe onto the right foot. This often frustrates Charisse, so addressing this issue may increase her satisfaction in completing the activity. Charisses routine when placing the shoe on includes her routine of

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

OCCT 506: Clinical Reasoning about Occupation Form #5 putting her shoes on in the same place in her house every day. e. Context and Environment As mentioned above in regards to placing socks on, the physical environment is on a wood floor in her home. This floor is hard and smooth, with no obvious hazards or difficult terrain. f. Activity Demands - The shoes for this activity are rough, rubbery, and bendable. The shoes are made of rubber and cloth. They are bendable, which aid in the process of placing the shoe onto the foot. Charisse would use touch and sensation to determine if the shoes were of adequate temperature. In addition, metal function and sensory function are important for this activity because Charisse would need to put thought into the execution of these learned movement. Similarly to placing the sock on, discriminating tactile sensations is especially important for this step in relation to the shoe texture. 4. She will then tip-to-tip pinch each of the laces and cross them over the top to form an X. (2 minutes) a. Areas of Occupation This particular step of the activity is not directly related to an ADL or IADL. It may be addressed in relation to dressing as preparation to complete the activity of tying her shoes. b. Client Factors Mental functions are necessary for this portion of the activity in order for Charisse to know how to cross the shoelaces over one another. Also, attention has to be present so that she does not incorrectly carry out this step. Regarding the pinching of the shoelaces, Charisse needs to have appropriate touch and pain function as well as pressure. These functions are all important when discerning textures. As with most other

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

OCCT 506: Clinical Reasoning about Occupation Form #5 steps of this activity, it is important to have appropriate joint mobility and stability. This is especially true when crossing the shoelaces to being the actual tying process. Voluntary movement is absolutely important during the step because the dexterity needed to manipulate the thin shoelaces it high. c. Performance Skills The most important element related to performance skills in relation to crossing the shoelaces over one another is the ability to manipulate the thin shoelaces. Again, bending and reaching are all important aspects in order to be able to reach the shoe on the foot. Locating the shoelaces visually and by touch would be helpful if multitasking. Responding to the situation positively regardless of the struggle to complete the task would be essential for Charisse. Additionally, cognitive skills related to properly crossing the shoelaces over the other would be essential. For a difficult task such as crossing the shoelaces over on another, it may also be important to communicate with the therapist and initiate help and direction when confused or lost. d. Performance Patterns When crossing the shoelaces one over the other, it remains a habit for Charisse to automatically place the right side shoelace over the left side shoelace. In regards to routine, crossing the shoelaces on over the other is part of the sequence. e. Context and Environment The aspect of context and environment that can be applied to this step is the physical environment. This will be the same as the previous step. As mentioned above, in regards to crossing the laces over each other in preparation the physical environment is on a wood floor in her home.

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

OCCT 506: Clinical Reasoning about Occupation Form #5 This floor is hard and smooth, with no obvious hazards or difficult terrain. f. Activity Demands - The shoes for this activity are rough, rubbery, and bendable. The shoes are made of rubber and cloth. They are bendable, which aid in the process of placing the shoe onto the foot. In addition, it is important to Charisse would use touch and sensation to determine if the shoes were of adequate temperature. In addition, metal function and sensory function are important for this activity because Charisse would need to put thought into the execution of these learned movement. Similarly to placing the sock on, discriminating tactile sensations is especially important for this step in relation to the shoe texture. 5. Next, she will draw the top shoelace through the bottom to tighten the shoe and form a knot. (3 minutes) a. Areas of Occupation Regarding drawing the shoelaces through the other with the use of the upper extremities, areas of occupational therapy can be loosely related to the ADL of dressing. Areas of occupation would not really fit into any other IADLs. b. Client Factors - For this step of the activity, mental function, and sensory functions would be important to sustain attention and judge the appropriate steps as well as touch, feel, may be required for this movement of drawing the shoelaces through the bottom to tighten the shoe. c. Performance Skills These are similar to the previous step. Charisse would need to bend her trunk and extend by reaching her upper extremities in order to get to her feet. She would need to be able to retrieve and grasp the shoelaces in order to complete the activity of tying shoes

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

OCCT 506: Clinical Reasoning about Occupation Form #5 and she would also need to visually locate as well as position her body in the appropriate location to place the tie the knot. d. Performance Patterns The habits regarding this step may be that Charisse automatically tightens the shoelaces following the drawing of the shoelace between the other. Also, a routine for the part of the activity is that she follows a sequence for each of the steps e. Context and Environment Similar to the previous step, the aspect of context and environment that can be applied to this step is the physical environment. This will be the same as the previous step. As mentioned above, in regards to crossing the laces over each other in preparation the physical environment is on a wood floor in her home. This floor is hard and smooth, with no obvious hazards or difficult terrain. f. Activity Demands The same as the previous step, the shoes for this activity are rough, rubbery, and bendable. The shoes are made of rubber and cloth. They are bendable, which aid in the process of placing the shoe onto the foot. In addition, it is important to Charisse would use touch and sensation to determine if the shoes were of adequate temperature. In addition, metal function and sensory function are important for this activity because Charisse would need to put thought into the execution of these learned movement. Similarly to placing the sock on, discriminating tactile sensations is especially important for this step in relation to the shoe texture 6. Charisse will then make bunny ear-shaped loops on both sides of the shoelaces. (3 minutes) a. Areas of Occupation Similar to several of the previous

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

OCCT 506: Clinical Reasoning about Occupation Form #5 steps, this particular step of the activity is not directly related to an ADL or IADL. However it may be addressed in relation to dressing as preparation to complete the activity of tying her shoes. b. Client Factors The importance of this step in regards to beliefs is that for many individuals who are just learning how to tie shoes, the bunny ear-shaped loop technique is chosen. This is simply because it is an easier concept to grasp. This impacts Charisse because she may be able to more easily learn to be independent is shoe tying using this. Also, Charisse will need to use her mental functions to be able to think about and understand the idea of executing this task. Sensory function is required to touch and feel the shoelaces between her fingers. Also, joint mobility, joint stability, as well as muscle endurance are important especially for this step because grasping both bunny ear loops can be considered multitasking. Cardiovascular system as well as skin structures would impair Charisses ability to function if impaired. The structures used would be the same as the previous step. c. Performance Skills Again, these are similar to the previous step. Charisse would need to bend her trunk and extend by reaching her upper extremities in order to get to her feet. She would need to be able to judge and grasp the shoelaces to complete the activity of tying shoes and she would also need to visually locate as well as position her body in the appropriate location to place the bunny ear loops in the proper placement. d. Performance Patterns - The habits regarding this step may be that Charisse tightens the shoelaces following the drawing of the shoelace between the other with the

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

OCCT 506: Clinical Reasoning about Occupation Form #5 bunny ear loops. Also, a routine for the part of the activity is that she follows a sequence for each of the steps e. Context and Environment - Similar to the previous step, the aspect of context and environment that can be applied to this step is the physical environment. This will be the same as the previous step. As mentioned above, the physical environment is on a wood floor in her home. This floor is hard and smooth, with no obvious hazards or difficult terrain. f. Activity Demands The activity demands are same as the previous step, the shoes for this activity are rough, rubbery, and bendable. The shoes are made of rubber and cloth. They are bendable, which aid in the process of placing the shoe onto the foot. In addition, it is important to Charisse would use touch and sensation to determine if the shoes were of adequate temperature. In addition, metal function and sensory function are important for this activity because Charisse would need to put thought into the execution of these learned movement. Discriminating tactile sensations is especially important for this step in relation to the shoe texture. Also, the space require should be large enough to allow the appropriate space for Charisse to complete the activity. The sequence of tying shoes is relatively specific, requiring certain steps to be completed prior to other steps. Mobility of upper extremities is required. 7. Next, she will need to cross the bunny ear-shaped loops and draw them through to form a knot, and tighten the knot. (4 minutes) a. Areas of Occupation - Like the previous step, this particular step of the activity is not directly related to an

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

OCCT 506: Clinical Reasoning about Occupation Form #5 ADL or IADL. However it may be addressed in relation to dressing as preparation to complete the activity of tying her shoes. b. Client Factors As mentioned above, the importance of this step in regards to beliefs is that for many individuals who are just learning how to tie shoes. The bunny earshaped loop technique is chosen. This is simply because it is an easier concept to grasp. This impacts Charisse because she may be able to more easily learn to be independent is shoe tying using this. Also, Charisse will need to use her mental functions to be able to think about and understand the idea of executing this task. Sensory function is required to touch and feel the shoelaces between her fingers. Also, joint mobility, joint stability, as well as muscle endurance are important especially for this step because grasping both bunny ear loops can be considered multitasking. Cardiovascular system as well as skin structures would impair Charisses ability to function if impaired. The structures used would be the same as the previous step. c. Performance Skills - Again, these are similar to the previous step. Charisse would need to bend her trunk and extend by reaching her upper extremities in order to get to her feet. She would need to be able to judge and grasp the shoelaces to complete the activity of tying shoes and she would also need to visually locate as well as position her body in the appropriate location to place the bunny ear loops in the proper placement. d. Performance Patterns - The habits regarding this step are that Charisse tightens the shoelaces following the drawing of the shoelace between the other with the bunny ear loops. Also, a routine for the part of the

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

OCCT 506: Clinical Reasoning about Occupation Form #5 activity is that she follows a sequence for each of the steps. e. Context and Environment - This is the same as the previous step. The aspect of context and environment that can be applied to this step is the physical environment. The physical environment is on a wood floor in her home. This floor is hard and smooth, with no obvious hazards or difficult terrain. f. Activity Demands These activity demands are the same as the previous step. Safety precautions Some potential hazards that may cause harm to Charisse during activity implementation include clutter on her work surface. Since she will tie her shoes while seated on the floor, it would be imperative to ensure that the floor is cleared of all obstacles and hazards. In addition, the slick and slippery nature of her wood floor at home may be dangerous, potentially causing her to slip and fall. The shoelaces may also cause injury or harm to Charisse if the material is bumpy, or if the plastic ends become broken. This may potentially cause skin breakdown. If Charisse had difficulty with emotional regulation or impaired judgment, the shoelaces may potentially be used for harm. Describe how the activity overall fits The activity of tying shoes fits into the domain of areas of into the domain(s) of occupational occupation mostly through certain ADLs and not IADLs. For the therapy in detail. Consider: ADLs, tying shoes is related to dressing oneself. Specifically, selecting the socks and shoes, and obtaining them from designated Areas of Occupation storage areas. In addition, placing the shoes on as well as selecting Client Factors the materials in relation to weather should be considered. Performance Skills Performance Patterns Tying shoes in relation to client factors includes certain values, Context & Environment beliefs. Mental functions, sensory functions, neuromusculoskeletal Activity Demands functions and cardiovascular functions are important throughout the duration of the activity. Specifically, attention, safety, joint

Domain

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

OCCT 506: Clinical Reasoning about Occupation Form #5 mobility and stability, muscle coordination and endurance, as well as voluntary movements are required to use and manipulate the shoelaces during the activity. Each of these aids in the efficiency of completing the activity of tying shoes. Performance skills for the activity of tying shoes include certain motor and praxis skills. The performance skills include; bending and reaching, coordinating movements, maintaining balance, and manipulating the shoes, socks and, shoelaces. The sensoryperceptual skills include positioning the body in the proper location, visually locating and, determining the appropriate materials. For emotional regulation, persisting, controlling anger, and recovering from mistakes as a result of impairments may be necessary when tying shoes. It is often difficult for Charisse to complete the activity due to poor fine motor control. Displaying the appropriate emotions in difficult situations can be used when performing this activity. Cognitive skills such as judging materials, selecting materials, sequencing tasks, multitasking and, prioritizing steps is important for identifying solutions and planning of tying shoes. Performance patterns for the activity of tying shoes include certain habits, routines and rituals. For example, certain routines habits help Charisse to perform this activity in the most efficient way possible. For context and environment, the physical environment impacts this activity the most. When tying shoes, Charisse generally completes this activity on the hard, wood, smooth floor surface in her home. While it may be performed in other environments and contexts, it is important to note that whenever Charisse exits her home, she needs to put shoes on. So this surface and environment is the most frequent.

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

OCCT 506: Clinical Reasoning about Occupation Form #5

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

Process

The activity demands in the activity of tying shoes include shoes, shoelaces, and socks. The space for this activity required is on a floor surface with ample surface area to allow Charisse to be seated on the floor while performing the activity. Also, ample space, mobility of upper extremity joints, muscle coordination and endurance, and use of mental and sensory functions will allow Charisse to efficiently complete the activity. This activity requires the eyes, bones and joints of the upper extremity, related muscles, skin, nervous system structures as well as cardiovascular structures overall. When planning goals and striving to achieve occupational therapy outcomes, it is important to consider the occupational profile, activity preparation, and activity implementation. In the case of Charisse, considering the occupational profile allowed me to be knowledgeable about her specific impairments, strengths, weaknesses, desires, and goals. For example, I know that Charisse is an outgoing 18 year old girl who, despite her impairments, would like to be able to be independent throughout her life. She wants to be in cheerleading and different activities in school, and knowing this information can guide therapy. It also gave me the opportunity to understand how she understood her impairments. Most importantly, considering the occupational profile helped to guide in the process of planning and devising the appropriate interventions for therapy. Considering activity preparation is important especially because it is a large portion of completion of the activity. Many components of the preparation would physically still be a part of the therapy process. For example, Charisse is required to go up the stairs in order to retrieve her socks from her bedroom dresser drawer. This part of preparation allows for Charisse to work on her trunk

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

OCCT 506: Clinical Reasoning about Occupation Form #5 stability, gait patterns, and functional mobility. Also, looking at activity preparation addresses the aspects of safety, sequencing, as well as required materials and equipment. Utilizing the activity implementation and addressing the requirements and details also contribute to the overall process of achieving occupational therapy outcomes. This is because it allows you to consider details regarding the safety, required materials and equipment, required steps, the roles of those involved. Being able to identify all of those factors will ensure that an organized and thoughtful plan can be carried out. For example, it was imperative to note that Charisse would usually prefer to tie her shoes on floor type of surface. In addition, precautions and details regarding safety hazards ensure that Charisse will be kept safe and away from harm. Overall, C. was enthusiastic and willing to participate in therapy sessions following her referral. C. just transferred to a new high school about one year ago due to difficulty in socializing and is transitioning well to her new school. C. has made new friends and would like to become more involved in school. As a result of cerebral palsy and ataxia, motor control and muscle coordination are weak. C. experiences difficulty with most ADLs and IADLs. There is increased anxiety in relation to becoming independent in ADLs and IADLs. Specifically, she becomes stressed when tying shoes. C. is not on medication, does not have allergies, and exhibits normal eating patterns. C. opened the door to her house and displayed ability to supinate forearm, flex elbow, and extend shoulder joint. C. displayed abnormal gait patterns without a brace. With brace, C. showed improved gait patterns. C. displayed abnormal gait patterns while climbing the staircase. Trunk stability appeared to wane as activity progressed at around 15 minutes into it. C. was able to pinch grasp

Subjective

SOAP Note

Objective

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

OCCT 506: Clinical Reasoning about Occupation Form #5 shoelaces for approximately 5 seconds at a time throughout the shoe tying activity. C. showed involuntary arm movements every few seconds throughout the activity. C. followed direction and steps with 85% accuracy. C. actively participated in the shoe tying activity throughout the duration of the activity. She was able to complete the activity 1 and a half times with verbal direction taking small breaks in between. C. is alert and engaged throughout the duration of the session. C. is demonstrating progress with fine motor control skills of both hands. She demonstrates potential for improvement in regards to gait patterns as well as trunk stability. She continues to have difficulty with control to complete the activity of shoe tying without assistance. C. also continues to demonstrate poor ability related to pinch grasp. With continued occupational therapy intervention, C. demonstrates the potential to improve each area of impairment in order to reach her goal of being independent in ADLs and IADLs. The plan for C. is to address motor control of fine motor skills of both upper extremities as well as muscle coordination. In addition, therapy will address trunk stability and gait patterns in order for C. to be successful the activity of tying her shoes independently.

Assessment

Plan

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

OCCT 506: Clinical Reasoning about Occupation Form #5 References Anderson, S. (2012) Occt 506: Clinical reasoning about occupation occupational analysis form #5 [PowerPoint slides]. Retrieved from https://bbtun.touro.edu/webapps/portal/frameset.jsp?tab_group=courses&url=%2Fwebapps%2Fblackboard%2Fexecute %2Fcontent%2Ffile%3Fcmd%3Dview%26content_id%3D_1472616_1%26course_id%3D_104887_1%26framesetWrapped% 3Dtrue Jazzygirl585 (2012, February 5). Tying my shoes with cerebral palsy [Video file]. Retrieved from http://www.youtube.com/user/jazzygirl585?feature=CAQQwRs%3D

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