A complex case review

I have a patient at the moment who is severely underweight. She was admitted to the ward with a fractured neck of femur or # NOF. She was intoxicated when she presented to ED, and was admitted to my ward. She underwent surgery having a DHS (dynamic hip screw) procedure.
I had known this patient from a prior admission. She is 39 years old and has a history of drug and alcohol abuse, and depression. Last admission she had a pressure ulcer, had lost endless amounts of weight and was very de-conditioned. She was and still is a high pressure area risk. She "lives alone" however has a partner who is very supportive. She also has a supportive sister living in the area.
Pain has been a major issue for this patient, so from the very start it was hard for the physiotherapist to work with this patient. I decided to not have any involvement on the ward until she was actively participating and the medical team had sorted a plan for her.
I visited the patient to check in with her every few days, and i liaised with the physiotherapist often also. The nursing staff and medical team kept me in touch with what the plans were.
Last MDT we were up to the stage of figuring out a plan for her, as she was becoming more actively involved with physio. In the MDT we decided it was best that we organized a daily routine for her to help facilitate progress and get her more involved in therapy. The following day the physio and I met with the patient and discussed a daily routine, including physio sessions, rest times, self care tasks, leisure activities, and eating periods. I liaised with the dietitian re: meals.
I completed a daily planner, provided the patient with some sudoku's which she loves to do and sat down to look at some goals.
The concern i have now is that she has developed a broken area on her sacrum and will not remove the pillows from under her so that the air mattress can do what it is designed to do. She has great bed mobility, but this doesn't solve the problem of sleeping at night.
So hopefully over the next few days i will convince her to remove the pillows, wish me luck...the RN staff have had none...
I look forward to working with this patient every 2 days working on her activity tolerance and her independence with self care tasks.

Jess

An example of clinical reasoning

I have a patient (male, 86 years) at the moment who was admitted to the ward with a fractured humerus. He is known to the community rehab team, and there have been safety concerns voiced by various team members over recent months.
He has poor vision, postural HTN and Parkinson's disease. He lives in a two storied home and before he fell he was basically living in bed, and taking himself to the toilet.
The medical/surgical team were talking to the patient about considering RH level care. However, this NOK was very much against this. When i talked to the patient he wanted to return home if at all possible.
I want to encourage the patient to make his own decision, as well as providing some sort of recommendation as to if he would be safe at home. So due to his poor vision, decline in occ performance and postural HTN I decided the best way he can make an informed decision is to take him home, assess how he would manage and make my recommendations.
So the home visit is booked and il reflect on my recommendations and decisions post visit.

Jess

Seeking support when its needed to ensure safety

I have learnt that sometimes I take comments from patients too personal. I have realized that identifying when my emotion changes towards a situation that i need to seek support and talk over the situation with a senior OT as soon as possible, in order to reflect on what has happened and deal with it appropriately. At times throughout this year i have become upset in situations with patients, and this has stressed me out. I am aiming to be more self aware in these situations so that i don't over react, don't internalize thoughts and begin to analyze the comment or situation. On one particular occasion this year i have realised that it was not purely my wrong doing that caused a patient to act the way he did, which made me react negatively causing me to become upset by the situation. It is a team approach on the ward, and really the best thing to do when a patient has been "difficult" is to get together as a team and sort out the best approach to apply when working with the particular patient. E.g. with discharge planning, expectations, ways of dealing with questions/complaints/concerns. Over all, I have learnt the importance of ensuring the safety of myself by seeking support from my seniors

Jess