RECTH 4320

Recreational Therapy Assessment of an Individual with a Physical Disability

Identifying Data
Name (use alias for confidentiality) John Smith
Age 65
Gender Male
Date of Admission to Facility/Program November 30, 2023
Primary Diagnosis The family reports, “He does not officially have a diagnosis.”
(The dx/s that caused the admission or referral of the client) Meningitis
Secondary Diagnoses N/A
(Other dx/s that are still active – the person is still experiencing – that are
not the primary reason for admission/referral of the client)
Past medical history Previous injuries from a horse falling on him have affected his hips.
(Other dx/s that the client had in the past that are no longer active)
Precautions Wear a face mask, wash your hands, and remove gloves, gown, mask, and
eye protection when leaving the patients room.
Diet Fruits and vegetables, whole grains and lean proteins.
Medications Penicillin, rifampin, quinolones, and ceftriaxone.
Education (highest level achieved) High school diploma
City & state of residence; characteristics of home & living situation Salt Lake City, Utah; great home support system and home is where he is
most comfortable
Employment status & occupation Not employed currently but previous profession of farmer
Social roles/social support Wife and daughter
Religious and cultural values Believes in a higher power, does not attend church services
Life habits Caregiver to farm animals such as horses, cows, and pigs. Judge at local and
professional rodeos.
Client goals (What does he/she hope to accomplish?) His goals are to leave the hospital and hang out with those he loves more.
Reasons for admission Increased weakness and fatigue in everyday living, cognitive impairments,
(What is the main reason the person is at your particular facility or and decreased independence in functioning. Diagnosis of Meningitis.
participating in this program; e.g., respite, decreased independence in
functioning, rehabilitation)
Reason for referral to RT The reason for the recreational therapy referral is his physical and cognitive
(Reason for referral will vary by setting/program, please be sure to talk with impairments. Through recreational therapy services, he hopes to accomplish
your supervisor to find out the specific reason for RT treatment/services; an increase in strength memory, and problem-solving skills.
what is hoped to be accomplished through Rec Therapy services at this
facility/program?)

Using the facility RT assessment tool, secondary sources (e.g. chart, family, staff, etc.), and/or a standardized RT assessment tool, conduct a functional skills
assessment of your client and list your assessment findings in the chart below. This section should be reflective of skills of a 2nd year RT Student.
Assessment Methods
Instructions: What assessment
tool/source/method did you utilize
(e.g., medical chart review,
observation within activity,
discussion with a specific team
member/team/physician, client or
family interview, standardized
assessment tool, etc)? What
specifically did you look for/do?
Why did you do this (how does it
relate to the client’s diagnoses)?
A client and family interview
assessment were conducted. During
the client and family interview, the
focus was on looking for past and
present functioning levels in all the
five domains of health. These
domains include physical, cognitive,
emotional, social and spiritual.
Questions regarding client’s leisure
Functional Skills Assessment
Assessment Domains
Do not write anything in this
column.
Note: While all domains are
important, since this course
focuses on clients with physical
disabilities, be certain you have
comprehensively assessed physical
functioning.
Physical functioning
Assessment Findings
Instructions: Report measureable
assessment findings. After each
finding, indicate the source where you
obtained the information using the
below codes: (e.g. Hard of Hearing –
O,MC; Loneliness – SR; R Hemiparesis
– O, MC, P)
O Observation
MC Medical Chart
T Standardized Assessment Tool
(administered by you)
P Pt hx (anything told you to by
the family, other team
members, etc.)
SR Self Report (items told you to
you by the client)
Walking – P; Lack of Balance – P
Interpretation of Findings
Instructions: After reviewing your
assessment findings, what
preliminary conclusions can you
draw from the assessment data?
How do you foresee the client’s
strengths/weaknesses impacting
his/her recreation/leisure
engagement, health, and quality of
life (RT scope of practice)?
*Pay careful attention to when it is
appropriate to use absolute (e.g.,
will) verses flexible (e.g., could,
might, may) terms.
The client's challenges with walking
and lack of balance may limit their
engagement in various physical
activities, potentially impacting their
overall health and quality of life.
These limitations could hinder
participation in activities requiring
mobility and stability, potentially
increasing the risk of falls and
and recreation interests were also
asked during interview. Conducting
a client interview assessment helps
gather crucial information about the
onset of symptoms, medical history,
and understanding the
circumstances surrounding the
diagnosis of meningitis.
Cognitive functioning
Speech/language/communication
functioning
Difficulties Concentrating – O, P;
Memory Deficits – P, SR
Ability to verbalize thoughts – O;
Anxious when speaking to large
groups - SR
reducing their confidence in
engaging in recreational activities
that involve movement and
coordination.
The client's difficulties with
concentration could impact their
engagement in activities that require
sustained focus, potentially affecting
their recreational involvement and
ability to fully participate. Memory
deficits might hinder their ability to
recall instructions or sequences
during activities, affecting their
confidence in performing tasks and
potentially limiting their enjoyment
and success in recreational activities
that rely on remembering steps or
details.
The client's challenges with
verbalizing thoughts may impact
their participation in activities
requiring effective communication,
potentially limiting their engagement
in certain social or group-based
recreational activities. Additionally,
 their anxiety when speaking to large
groups could deter them from
participating in events or activities
involving public speaking or larger
gatherings, potentially affecting their
confidence and enjoyment in such
situations.
Psychological/emotional Decrease in Mood – P; Sadness – P, SR The client's decrease in mood and
functioning feelings of sadness may impact their
motivation and interest in engaging
in recreational activities. These
emotional struggles might decrease
their overall enjoyment in activities
they previously found enjoyable,
potentially affecting their willingness
to participate and increase
satisfaction from recreational
activities. Additionally, these
emotions might limit their social
interactions during recreational
activities, impacting their overall
experience and sense of connection.
Sensory functioning Hard of hearing – O; Numbness - P The client's challenges with hearing
might affect their participation in
recreational activities involving

Social functioning Maintaining social connections – O, P;
Withdrawal from previously enjoyed
activities – O, P, SR
verbal communication or sound-
dependent interactions, potentially
limiting their engagement in certain
events or group activities.
Additionally, the sensation of
numbness might impact their ability
to fully experience aspects of
recreational activities, potentially
reducing their enjoyment and
participation in sensory-based
pursuits such as art, cooking, or
outdoor activities that rely on tactile
sensations for engagement and
pleasure.
The client's ability to maintain social
connections might be impacted,
potentially affecting their
involvement in group-based
recreational activities and
diminishing their enjoyment derived
from social interactions during such
events. Moreover, their withdrawal
from previously enjoyed activities
may lead to a decline in participation
in recreational pursuits, limiting their

Self-care functioning Lack of daily grooming – P; Challenges
in managing medication - P
Play/leisure/recreation/ Limitations in participating in
community functioning previously enjoyed leisure activities –
engagement and potentially affecting
their overall satisfaction and sense of
belonging within recreational
settings. This withdrawal may also
impact their social interactions and
relationships within recreational
contexts, potentially reducing their
sense of community and
connectedness.
The client's lack of daily grooming
might impact their confidence in
participating in recreational activities
that involve social interactions,
potentially affecting their overall
engagement and enjoyment.
Additionally, challenges in managing
medication might lead to concerns or
interruptions during recreational
activities, affecting their ability to
fully participate or causing potential
health-related issues that could limit
their involvement in certain
recreational activities.
The client's limitations in
participating in previously enjoyed
 SR; Withdrawal from community leisure activities might diminish their
events - P overall satisfaction and engagement
in recreational pursuits, potentially
reducing their enthusiasm for these
activities and affecting their overall
well-being. Additionally, their
withdrawal from community events
might decrease their sense of
connection and involvement within
the community, potentially
impacting their social relationships
and reducing opportunities for
participation in community-based
recreational activities, leading to a
decrease in overall engagement and
enjoyment.
Leisure Lifestyle Review
Identify leisure interests and activity patterns for your client. Each activity should be coded as a current, past and/or future interest.
Add additional rows if needed.
Current (C), Activity How often With who Where Other Notations (possible information to include):
Past (P), & 1) Provide other specific notations about the activity that does
Future (F) not fit in the previous columns.
interests 2) Explain the barriers (or foreseeable barriers/challenges) to
performing the activity.
*List in this 3) Explain the facilitators that could enhance the client’s ability
order to participate in the activity.
4) Explain any reasons to be concerned about the activity (e.g.,
unhealthy, could cause harm to self or others).
5) Explain reasons (if known) about why past activities are not
being done any more.
 6) Explain motivation for participating in this activity.
F Trying new food Once a Family Hospital, At Motivation for participating in this activity includes expanding
week home their exposure to different foods.
P Judge rodeos Once a Friends Rodeo Health impacts are a big reason why this activity is not being
week done anymore. Meningitis has led to physical limitations, making
it unsafe or physically challenging for the individual to actively
participate in judging rodeos.
C Cook/Smoke meat 2-3 Times a Family Home Physical Limitations are a big barrier to preforming this activity.
week The individual faces physical weakness and mobility issues due
to their health condition. They might find it challenging to stand
for long periods, lift heavy objects, or perform intricate tasks
involved in cooking.
P Feed cattle Everyday Family Home The reason this activity is not being done anymore is because of
the physical demands feeding cattle requires. Feeding cattle
involves physical labor such as carrying feed, walking across
uneven ground, and often lifting heavy items.
P Hunting 3-4 Times a Friends Mountains Ways to enhance participation and bring this activity back into
month the life of the individual could be through adaptive hunting.
Exploring adaptive hunting techniques or tools that cater to the
individuals physical limitations, such as using assistive devices or
modified equipment, could enable their involvement.
P Wrestling 4-5 Times a Friends High School The reason this activity is not being done anymore is because
week gym wrestling requires high physical demands. Wrestling involves
high amounts of physical activity, including intense movements,
strength, agility, and flexibility.
P Welding Everyday Friends Out in the The reason this activity is not being done anymore is because of
shop the health and safety risks welding holds. Engaging in welding
activities while experiencing a health condition could pose risks
of injury or health complications due to exposure to hazardous
materials or physical strain.

Major Concerns

Given your assessment findings, what are three priorities for Why is this a priority? Explain how it relates to participation in healthy
treatment/service? List one overarching area in each box. leisure activities (especially those that are meaningful to the client), as well
Make sure at least one of these relates to physical functioning. as how it relates to health promotion, rehabilitation, and/or quality of life.
Increase balance while standing
Increase social participation within the community
Increase physical strength
Focusing on improving balance is crucial because it helps the client stay
steady on their feet, making it safer to enjoy their favorite activities like
cooking, caring for farm animals and welding. Better balance means fewer
chances of falling. When the client can stand and move without feeling
unsteady, it helps them feel stronger, more independent, and able to do the
things they love, which makes life happier and more enjoyable.
Encouraging more social involvement within the community is essential for
this client because it will help them feel connected and involved. When they
participate more in community events or gatherings, it gives them a chance
to meet people, make friends, and feel like they belong. This social
connection can make them feel happier and less lonely, which is important
for their recovery. Being part of community activities also helps them get
back into their regular routine and feel more confident. Overall, being active
in the community can boost their mood, make them feel supported, and
improve their overall well-being.
Increasing physical strength is crucial for this client because it will help
rebuild their bodies endurance levels and ability to move. When they work
on getting stronger, it helps them do daily activities more easily, like walking
and lifting things. Since the client interests are physically demanding
increasing their strength can help the client get back to the activities they
enjoy. Building physical strength also helps to regain their confidence.