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.
Client’s Occupational Profile
Client Information
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 won’t 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 hasn’t 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
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OCCT 506: Clinical Reasoning about Occupation
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Referral Information
Activity Description
Describe the goal of the activity and
most of her time looking for a job and exercising. Sam’s 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
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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 client’s 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
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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 client’s
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
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Long-Term Goal
Short Term Goal
Intervention Goals
Practitioners role
Activity Preparation
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
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Personnel required to complete the
preparation
Required preparation steps and time
for each step
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 Sam’s 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
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OCCT 506: Clinical Reasoning about Occupation
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Required place and space
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 practitioner’s 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
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OCCT 506: Clinical Reasoning about Occupation
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Required materials
Required equipment
Safety precautions
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
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Personnel required
Setting and location
Activity
Implementation
Space required
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
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OCCT 506: Clinical Reasoning about Occupation
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Required materials
Required equipment
Required steps and time for each
step
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
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OCCT 506: Clinical Reasoning about Occupation
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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
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OCCT 506: Clinical Reasoning about Occupation
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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 client’s 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
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OCCT 506: Clinical Reasoning about Occupation
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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
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OCCT 506: Clinical Reasoning about Occupation
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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
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OCCT 506: Clinical Reasoning about Occupation
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 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
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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
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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
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Domain
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 client’s 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. Sam’s 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
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OCCT 506: Clinical Reasoning about Occupation
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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
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OCCT 506: Clinical Reasoning about Occupation
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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
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OCCT 506: Clinical Reasoning about Occupation
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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
client’s 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
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OCCT 506: Clinical Reasoning about Occupation
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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
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OCCT 506: Clinical Reasoning about Occupation
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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,
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OCCT 506: Clinical Reasoning about Occupation
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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
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OCCT 506: Clinical Reasoning about Occupation
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Discuss how you have utilized the
occupational profile, activity
preparation, and activity
implementation to achieve
occupational therapy outcomes.
Process
SOAP Note
Subjective
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 client’s 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 won’t 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. Sam’s
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
Sam’s visit is to learn how to tie her shoelaces with one hand.
Client wants to be able to participate in running competitions after
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OCCT 506: Clinical Reasoning about Occupation
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Objective
Assessment
Plan
having difficulties with the dressing component of donning a shoe.
Client’s 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
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OCCT 506: Clinical Reasoning about Occupation
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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
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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)