OCCT 506: Clinical Reasoning about Occupation Form #5 Student: Yara Bezgina Activity: http://www.youtube.com/watch?

v=UTPpfHKfP_8 Date: 10/17/2012

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 Rick Lightcap is a 61 year male who has suffered from blockage of carotid artery followed by a stroke of the right side of his brain that resulted in hemiplegia of his left dominant side. Mr.Lightcap lives with his spouse in one story house and is a retired accountant. However, his wife has a full time job and also likes to have two of their grandchildren over for the weekends. Mr. Lightcaps greatest pleasure in life is spending time with his grandkids and he enjoys reading books, playing puzzles and making up puppet shows with them. He also has a best friend Bill whom he knows since college and they frequently dine together, and play chess tournaments or card games. Strength: Rick has a very supportive wife who has been taking care of him and his children who have been taking him to the doctors appointments and providing rides. Rick shows strong motivation and drive to recover, and has been consistent with the exercises and regimen provided by other healthcare professionals. Client has been able to re-establish neural pathways and can partially bend his fingers and move the wrist, as well, as perform functional range of motion in movement of the shoulder and wrist. Rick is cognitively

Client Information

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

OCCT 506: Clinical Reasoning about Occupation Form #5 aware, understands the directions and explanations and displays good learning skills. Rick shows minimal spatial neglect and is aware of the objects on his left side; does not alienate his left side of the body. Client suffers from mouth drooping, yet no dysphasia is observed and participant is able to swallow Weaknesses: Ricks shows difficulty in performing ADLs and IADLs due to paralysis of upper extremity. Client shows hemiplegic gait and displays moderate degree of incoordination. Client shows reduced endurance due the weakness and loss of neurons of the muscles on the affected side. Client shows some loss of proprioception in his left hand but reports recovery of tactile sensation. Rick has difficulty forming a grasp or a fist and tires quickly when exercising his affected hand. Client shows limited range of motion of the shoulder, elbow, wrist and carpal/metacarpal joints. Rick shows disappointment when he doesnt perform as well as he wants, and be discouraged quickly, however he makes up for it with optimistic outlook. Referral Information After the patient had suffered from stroke and hemiplegia on his left dominant side he was referred to inpatient rehabilitation facility by his neurologist Thomas J.Grobelny, MD of Chris Medical. The reason for referral is to work on regaining functional levels needed for activities ADLs (dressing, bathing, feeding and cooking ) and IADLs (play, leisure, work). Thomas J.Grobelny, MD Chris Medical Center, Sherman Oaks, CA Tel: (818) 456-8970

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

OCCT 506: Clinical Reasoning about Occupation Form #5 Activity Description Describe the goal of the activity and why the client is completing it Long-Term Goal The main goal of the client is achieving independence by feeding himself without relying on help of others. Within 2 months , Mr. Lightcap will show functional range of motion of his wrist and PIP/DIP joints and will be able to feed himself by holding normal spoon and fork Within 3 weeks, Mr. Lightcap will improve his range of motion of the wrist and PIP/DIP joints to be able to form & maintain the tenodesis grasp with adapted handle spoon or fork during feeding. The practitioners role is to educate and guide the client how to utilize safe and energy preserving techniques. The practitioner will assist and teach how to perform an activity in efficient and comfortable way. The practitioner will support and provide educational materials on the condition and precautions. The practitioner will provide counseling and training to family members, and will discuss realistic expectations and goals. Practioner need to prepare the room or station for activity and know what tools and materials are needed beforehand. Therapist should have clear instructions and have mental sequence of steps of how the activity will be conducted. Step 1: Acquire food (potato soup) from the fridge.(3min) Step 2: Choose the soup bowl from the cupboard. (2 min) Step 3: Pour the soup into the bowl (do not fill to the edge). (1 min) Step 4: Set the soup into microwave and heat up to medium warmth. (2 minutes) Step 5: Bring soup to the table .(1 minute) Step 6: Take non slip mat and place the soup bowl on it.(3 min) Step 7: Acquire utensils such as adapted handle spoon or fork and set it on the table.(2 min) Step 8: Set napkins or tissue on the side of the table for the client to use in case any spilling occurs.(2 minutes) Step 9: Adjust table height to be accessible for the wheelchair if needed.(1 minute)

Intervention Goals

Short Term Goal

Practitioners role

Personnel required to complete the preparation

Activity Preparation

Required preparation steps and time for each step

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

OCCT 506: Clinical Reasoning about Occupation Form #5 Required place and space ADL room in inpatient rehab with the kitchen large enough to have fridge and dining room table and still be able to move around comfortably. Room has to be wheelchair accessible and free of clutter. Required materials include food that participant will be feeding to himself, and napkins for cleaning. The choice of materials should depend on clients preference for specific foods and textures. Client states that he likes soups especially potato and French onion. Tools: Soup bowl, adapted spoon, nonslip mat, food tray Equipment: microwave, fridge, table, chair or wheelchair The main precaution is following basic infection control protocols, and using clean and sanitized equipment; therapist should wear gloves. Therapist will need to make sure that the soup is not too hot Therapist should make sure that there are no sharp objects such as knives or forks laying around unorganized and can potentially hurt the client, and adjust the table to correct height to promote posture and elbow placement on the table. The only personnel required is a therapist which will be supervising the client during the activity and will guide and give feedback. The activity will take place in inpatient rehabilitation center at ADL room preferably with minimal to moderate distractions and noise, and good lighting. Table big enough for the patient to sit comfortable and place both of his elbows without feeling constricted. Enough space for leg room and possibly wheelchair accessible table. Comfortable chair with cushions if needed for good postural balance. Tools: Adapted spoon with built up handle, soup bowl , napkin, nonslip mat, food tray Table- rectangular and hard, Wheelchair- soft and tall to serve as a chair or specialized chair Once everything is set on the table for the activity the first step for the client is to check if he is properly seated position and to check if

Required materials

Required tools & equipment Safety precautions

Personnel required Setting and location

Space required Activity Implementation Required materials & tools Required equipment Required steps and time for each step

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

OCCT 506: Clinical Reasoning about Occupation Form #5 his wheelchair breaks are on (3 minutes). This step fits into functional mobility as the patient need to understand safety of how to use wheelchair and operate it (ADLs). The step will also promote functional mobility and awareness of hazardous situations which will help to reduce threat to health (IADLs) Second step will be instructing the patient on how perform the steps in the most advantageous way and avoid spilling (5 minutes). This step will promote education on how to use appropriate body mechanics and will also promote social participation skills as the client will be able to engage in communication process with the therapist (IADLs) The client then will proceed to take the spoon and adjust his fingers around the handle creating a grasp (2 minutes) This step is important for ADLs because a lot of activities of daily living such as brushing, feeding, bathing and etc. require functional grasp and working on forming and maintaining this grasp is crucial for building independence. This step will work on increasing patients range of motion and on rebuilding neural pathways to the specific muscles. It will also work on maintaining the joints of PIP/DIP by providing necessary blood flow and supply. For his IADLs such as playing chess and performing puppet show participant will also need functional grasp. Perform an activity trying to get the spoon all the way to his mouth (1minute). This activity will work on clients range of motion for shoulder and elbow as the functional range of motion is needed for a lot of ADLs such as dressing, transferring, cooking. It will also be beneficial for client as it will work on his eye/hand coordination and spatial

Step 1:

Step 2:

Step 3:

Step 4:

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

OCCT 506: Clinical Reasoning about Occupation Form #5 recognition that are important for ADLs, during social interactions, and for many activities of independent living (house maintenance, shopping, etc.) The client will repeat step 3 over and over until he has finished his meal (10 minutes). This step will work on clients endurance and sequencing. By repeating step over and over again it will increase clients awareness of an activity, and will promote neural system to start rebuilding connections to the affected muscles through secondary pathways. This step will also improve coordination as well as promote muscle strength of the affected hand. It is important to work on endurance and strength to increase performance in the ADLs and IADLs. The client will acquire a napkin and wipe his mouth and hands (1 minute). This activity will promote self-awareness and social etiquette as the client will have to determine if the affected and unaffected sides of his face need cleaning. It will work on proprioceptive feedback on the affected side as the client will need to identify and cognitively think about touching his face and it will improve spatial recognition of his affected side. This step will also work on ADLs and IADLs as participant will need to do similar steps in his grooming, hygiene routines. Make sure that the client is sitting in upright position in a chair with good back and arm support to promote safe swallowing & feeding Make sure the unaffected arm is placed on the table to stabilize during the feeding activity. Confirm that client is aware and alert and has no problems with swallowing, and can follow instructions. Client needs to be present and cognitively aware and oriented in time and space.

Step 5:

Step 6:

Safety precautions

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

OCCT 506: Clinical Reasoning about Occupation Form #5 Describe how the activity overall fits into the domain(s) of occupational therapy in detail. Consider: Areas of Occupation Client Factors Performance Skills Performance Patterns Context & Environment Activity Demands Values Areas of Occupation Self feeding fits into activities of daily living (the client needs to be able to feed himself on a regular basis). It could be also a part of IADLs as a part of the leisure activity such as client can plan and schedule dinners with specific foods he enjoys and will need to be able to feed himself. Feeding can also fall into social participation as the client will have dinners or meals with his family and grandchildren Client Factors The values of the client are value and regard for the family and in being a good grandparent and role model. Mr.Lightcap also values his independence and wants to return to his prior levels of functioning as soon as possible. Client believes that by following prescribed routines for exercise he will get better and that hard work will pay off. Client believes in social support that he will receive from his grandchildren and wife. Clients spirituality consists of him finding new purpose in life after suffering debilitating stoke that almost took his life. Mental functions: Overall clients level of mental functioning is working properly and he shows appropriate judgment formation, short term and long-term intact memory. Client is able to maintain his attention and categorize objects and be aware of reality. Client knows how to execute learned movements and shows good coping skills. Client shows minimal degree of decrease in self-image related to his disability. Mr.Lightcap shows appropriate level of consciousness and is oriented to person and place, as well, as shows good motivation to improve and participate in activities. Sensory functions and pain: Participant show partial loss of his sensory functions on his affected side and has reduced sensation to

Domain

Body Functions

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

OCCT 506: Clinical Reasoning about Occupation Form #5 touch, pain and heat in his elbow and posterior arm region, however patient is able to feel pain, touch and thermal changes around his wrist and hand region. Patient is visually aware of the environment and shows minimal spatial neglect as evident by, pt recognized and tracks objects on his left side, but reports a reduction in depth perception. Patient is able to follow directions and move his limb up and down. Participant is able to distinguish between various textures of food, taste and is able to distinguish different types of smell. Participant shows intact awareness of the body in space and is able to sense if his body is moving against gravity. Neuromuscoskeletal & movement related functions: Due to the left side hemiplegia and motor neuron loss client shows reduced range of motion in his arm with functional range of motion in the elbow, and shoulder. Client shows limited range of motion in his radiocarpal joints and can only achieve around 10 degrees of flexion and extension. Client shows limited range of motion in his PIP and DIP joints and CMC joint of the thumb. Client shows impaired postural alignment due to weakness of the erector spinae of the left side and difficulty to maintain stability when bending laterally to the left. Participant shows reduced balance/supporting and coordination due to reduced muscle tone of the left side and uses walker to shift his center of gravity. The degree of muscle tone of the affected side is generally weak/flaccid Client shows functional bilateral coordination, yet the overall fine and gross motor endurance is weakened. Walking pattern (hemiplegic gait) is impaired due to muscle flaccidity and inability of postural muscles to adjust and maintain COG as evidenced by the participant using a wheelchair; however client is able to walk with a walker for limited amount of time.

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

OCCT 506: Clinical Reasoning about Occupation Form #5 Cardiovascular/hematological/immunological and respiratory system: Due to carotid artery blockage patient has impaired cardiovascular functions such as POTENTIALLY weakened blood flow. Respiratory system functions are appropriate and no breathing reducing functions has been observed, however aerobic functions may be reduced post stroke which will affect endurance and increase fatigue. Client does not show any inflammation of tissues Voice and speech functions: problems with speech due to weakness of the facial muscles related to paralysis as evident by drooping mouth Digestive , metabolic and endocrine system functions: no problems have been observed or reported by the patient Genourinary and reproductive functions: no bladder/bowl incontinence has been observed as per patient report and chart review. Skin related structural functions: skin is intact with no lesions and abrasions observed. Body Structures Body structures are : affected nervous system (motor neuron loss and cutaneous innervations). Intact joints with partial/functional range of motion. Weak upper and lower extremity, postural muscles and facial muscles on the affected side. Potentially affected arteries and heart due to post stroke condition. Normal functioning of the eyes and ear, stomach and lungs. Normal functioning of the urinary bladder. No impairment of larynx is observed the speech function is impaired by flaccid facial muscle and mouth droop. The client shows intact skin (maybe scar tissue due to recent surgery).

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

OCCT 506: Clinical Reasoning about Occupation Form #5 Activity Demands. Objects and their properties: for the activity the client needs to use tools to feed himself such adapted handle spoon (round and hard). He will also need soup bowl (round and wooden) or a plate on which to place food. The equipment needed for the activity is table (hard and rectangular) to place the food on, the nonstick mat (small and texturized) to prevent bowl of soup slipping from the table surface or a food tray for the same purpose. Adapted chair or wheelchair that client will be sitting on during the activity (cushioned and soft). The materials required are preferred choice of food such as potato soup (warm), and napkins (light and soft) that client will need to clean himself up after completing an activity. Space demands: For the activity the client needs relatively spacious and clutter free space where he can navigate. Good lighting has to be present for the patient to see what he is eating and to see kitchen utensils. Moderate to minimal amount of noise is preferred so the client can concentrate on the task. Table has to be large and tall enough to accommodate wheelchair and for the client to be able to place his elbow on for support. Room temperature and good air conditioning for the client to be comfortable and not to be distracted by temperature or stuffy air. Social demands: Client needs to understand the expectations from activity and be able to receive and act accordingly to feedback. Client will need to listen and give time to therapist to speak and explain, and will also need to take turn in socializing and describing his sensation and concerns during the activity. Client has to be aware of his eating habits (etiquette) and be able to control his impulses if activity is more difficult than expecting.

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

OCCT 506: Clinical Reasoning about Occupation Form #5 Sequence and timing: Step 1: The client will check if he is properly seated position and will check if his wheelchair breaks are on (3 minutes). Step 2: Second step will be listening and receiving tips and instructions from the therapist (5 minutes) Step 3: The client then will proceed to take the spoon and adjust his fingers around the handle creating a grasp (2 minutes) Step 4: Perform an activity trying to get the spoon all the way to his mouth (1minute). Step 5: The client will repeat step 3 over and over until he has finished his meal (10 minutes). Step 6: The client will acquire a napkin and wipe his mouth. The client will have to establish what he wants to achieve during this activity and have sufficient time given to him to complete the activity in a way that is comfortable to him. Required actions and performance skills: The client will need to be able to maintain the tenodesis grip while holding the spoon and will need to be able to process proprioceptive feedback such as feeling the texture of the handle and how tight his fingers are around it. The client will need to orient himself in time and space, and coordinate his movement according to change of position in space. The client will need to determine the most comfortable postural position for him to sit while eating that will promote safe swallowing. The client will need to be able to chew, and swallow food, and able to taste the food. The client will need to be able to know if the food is too hot or too cold for him, as well as to determine if smells appetizing or not. The client will need to determine how place his unaffected hand to gain the best base of support , and will need to process amount of sensory feedback from the affected hand while moving the spoon towards his mouth (muscle control and coordination). The client will need to answer

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

OCCT 506: Clinical Reasoning about Occupation Form #5 the questions and engage in conversation with the therapist and maintain his emotional control if activity is too difficult. The client will need to determine and feel if he needs to clean his face after eating and be able to maintain social etiquette rules while eating. The client needs to be able to visually track objects on the table and be able to reach for the napkins on his left side. Required body functions: To complete an activity client requires functional joint mobility of his upper extremity and needs to form and maintain tenodesis grasp Client requires visual and perceptual functioning to track objects and coordinate his movements in space, and proprioceptive function to distinguish between inherent properties of the tools and surrounding environment. Client needs to maintain attention and appropriate level of consciousness to follow the steps and understand instructions. Client will need to maintain good postural alignment and endurance while siting. Client has to have appropriate muscle grade to be able to lift up his affected extremity and move it to his mouth. Client has to be able to chew and swallow food in a proper manner and be aware of not too swallow too much and too fast to prevent suffocation. Client needs to maintain urinary control and be able to suppress urges or be able to tell if he needs to use a bathroom. Client will need appropriate endurance and respiratory function to breathe normally and not be fatigued during the activity. Client will have to be able to know the sequence of learned movements and be able to execute them, as well as be aware of his left side of the body to perform an activity. Client has to be able to have normal functioning digestive system and organs to swallow and process food. Client will need functioning speech functions to vocalize his feelings, concerns and feedback. Neck tone is required to be straight and aligned in a manner that will promote safe swallowing.

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

OCCT 506: Clinical Reasoning about Occupation Form #5 Required body structures: Clients nervous system is affected by stroke and client displays partial loss of motor neurons and cutaneous innervations. Client needs eyes and ear for coordinating himself and space and adjusting to environment, as well as, normal mental functions to process information coming from the environment. Client requires two arms and postural muscles to be able to sit while feeding self. Client requires normal breathing and lungs, as well, as properly functioning heart and arteries to participate in activity without fatiguing. Clients need to have normally functioning, trachea, and esophagus to be able to feed, swallow and breathe. Client requires normal stomach and intestinal metabolic functions to digest food consumed during feeding activity. Client requires normally functioning bladder and colon to be able to control urges. Client requires functional joints (some degree of range of motion), and muscles (grade) to complete the feeding activity with his affected hand. Client requires intact skin with no lesions to be able to move and navigate his hand in space without risk for infections. Client requires straight neck to maintain sitting posture during feeding activity. Performance Skills: Motor and praxis skills: Participant shows limited ability to bend laterally and maintain good balance d/t hemiplegia. Participant shows hemiplegic gait while walking and is having difficulty with adjusting posture and body position while standing, however pt shows better posture while sitting and displays better coordination and body adjustment. Client shows difficulty manipulating objects in his hands or maintaining normal grasp, yet is able to produce 10 degrees of extension needed for tenodesis grasp. Client is able to produce functional range of motion of his shoulder and is able to flex his elbow, yet shows problems with supination and pronation

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

OCCT 506: Clinical Reasoning about Occupation Form #5 and can only produce slight movement. Overall client shows slower pacing time for coordinating movements and body positioning, but is able to carry out sequence of movements just in a slower pace. Sensory perceptual skills: Client is able to locate kitchen utensils by touch and visually identify the on the table. Client is able to adjust his posture when leaning over and reaching for spoons or napkins. Client is able to hear and respond to practitioners voice and instructions, and is able to distinguish the flavor and temperature of the soup. Client is able to position himself in front of the food in a way that is comfortable for reaching and seeing objects on the table. Emotional regulation skills: Client responds well to feedback and explains his feelings and sensations to the therapist. Client is able to control his frustration when the activity is taking too long or too hard to perform. Client shows discouragement when having difficulty forming a grasp around the handle of the spoon, yet is able to control and persist with activity Cognitive skills: Client is able to judge the appropriate utensils to use for eating soup and attire to wear such as having napkin and comfortable clothes that do not limit his movement. Client is able to proceed with sequence of tasks required for activity and shows good ability to tell if he needs to readjust his posture or put the right hand to stabilize. Client is able to concentrate on activity and tune out distractions. Communication and social skills: Client is able to follow with therapists instruction and visually follow when instructor shows how to use a spoon. Client maintains physical space and personal boundaries, and is taking turns in dialogue with the therapist.

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

OCCT 506: Clinical Reasoning about Occupation Form #5 Performance Patterns Habits: Client checks the cleanliness of the utensils and glassware before eating. Routines: Client always drinks milk and takes his vitamins first thing in the morning and then brushes his teeth and shaves. Rituals: Spends time with his grandchildren every Thanksgiving and prepares pumpkin spice milkshake using old family recipe. Roles: a husband, a father and grandfather, a retired worker, housekeeper Contexts and Environments Cultural: Important male figure in the house and is expected to be inspiring and motivating person that his grandchildren look up to. Rick values his relationships with the family and is main decision maker in the household Personal: Client is 61 year old male who is a retired accountant and suffered from stroke Temporal: Client has been married for 40 years and has been retired for past 5 years, who also suffered from stroke 3 weeks ago. Virtual: Client communicates with his family and grandchildren via phone and sometimes uses his wifes Ipad for skyping with his colleagues. Physical: One story house with spacious kitchen and garden outside. Good and wide hallways and bright lighting throughout the house wit even floors and grass in the backyard. Social: Client has good family support that is provided by his spouse along with children, and grandchildren. Client also keeps in touch with his coworkers and his best friend Bill that he knows since college.

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

OCCT 506: Clinical Reasoning about Occupation Form #5 Process Discuss how you have utilized the occupational profile, activity preparation, and activity implementation to achieve occupational therapy outcomes. The process of gathering information on occupational profile of the client helped to point out clients weaknesses and strength, as well as, to define priorities and main goals to work on. This knowledge guided intervention process as the client was able to point areas on which he wants to improve and therapist then was able to set up and engage client in activity that was interesting and functional. The communication and constant feedback between therapist and the client were important in knowing how activity could be graded up or down, and what potential barriers interfered with clients motivation. By building rapport with the client and by establishing trusting and therapeutic relationship the therapist was able to set appropriate goals to help the client move from continuum of dysfunction to function, as smoothly, and with as much support as possible. Client is looking forward to participate in therapy sessions and is excited about trying all the new adaptive equipment. Mr.Lightcap has been moved to a private room in inpatient rehab and had his best friend Bill visiting his over the weekend. Client is in a good mood, and is motivated to work on improving his hand movement. Client expressed that he wants to impress his grandchildren that are visiting over next few weeks by eating independently and finishing all the meals they bring. Client also continues to work with a speech therapist. Mr. Lightcap engaged in 30 minutes of self-feeding activity with feedback and instructions provided. Mr.Lightcap was able to form and maintain tenodesis grasp with 10 degrees of wrist extension and was able to maintain function elbow and shoulder flexion. Client was able to perform and activity without breaks yet the pace was slow and client was guarded when using his hand. Encouragement and visual demonstration improved patients confidence and reducing guarding.

Subjective

SOAP Note Objective

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

OCCT 506: Clinical Reasoning about Occupation Form #5

Assessment

Plan

Mr.Lightcap was able to complete an activity using an adapted handle spoon and showed overall a good performance. Client had trouble in the beginning of the activity as he struggled to grasp the handle, but with direction and few trials the client was able to achieve tenodesis grasp and hold the spoon, and completed an activity slightly over the expected time. After performing the sequence of steps Mr.Lightcap was more confident in moving his affected arm, and also showed less restriction and guarding when moving his finger. Mr.Lightcap also stated that activity made him feel tired. Mr.Lightcap demonstrates potential to improve his functional range of motion and grasp of the upper extremity to successfully engage in activities of daily living as well as leisure and play activities that are important for him. Client will meet with the occupational therapist at inpatient rehab twice a week on Tuesday and Friday for 30 minutes. The treatment session will include: engaging in self- feeding activity with different meals every time. During the activity client will be working on holding different utensils spoons, forks, operating a knife to work on increasing muscle strength, grasp and endurance of affected upper extremity. Within first 3 weeks Mr. Lightcap will be supplied with adapted handle spoons and forks, and as patients range of motion and grasp improve he will gradually start using normal forks and spoons during the activity. The client will be able to complete his feeding activity without fatigue and within appropriate time frame. By the end of the 2 month treatment client will be able to feed himself during three course dinner and appropriately clean and operate all of the needed utensils. Clients family will be educated on how to perform exercises that will work on clients functional levels in home setting that will help the client to increase his independence and self-efficacy even further.

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