Tuesday, February 2, 2010

Complex case review

Personal information:
Male, 48 years
Elective admission – Bilateral TKJR

Social Hx:
Lives with wife and children/grandchildren
Has had to quit his job, due to immobility caused by bilateral knee OA
He was a representative rugby league player and when he stopped playing at the age of 33 started to put on weight.
He lives in a Maori Whanau with the associated dietary habits.

Reason for referral:
Advised at pre-admission, as patient for bilateral TKJR

Presenting problems as stated by patient/family/whanau:
Decreased mobility, fatigue, and pain.

Relevant medical and therapy history:
Bilateral medial compartment osteoarthritis of knees
He is morbidly obese with a weight of 205kg
Sleep apnoea
Mild Asthma

Statement of patient goals:
Short term: He wishes to regain his mobility, and return home with assistance from his family for personal ADL’s.
Long term: Regain independence in personal ADL’s and return to work (paper deliveries).

All assessments completed:
Environmental visit
Initial interview

Agencies involved prior to admission:

In one week, Mr C to be independent with transfers (bed, chair, commode) using Barriatric compensatory equipment (bed lever/monkey bar, shower commode chair, lazy boy platform).

In one week, Mr C to be independent with mobility around home using barriatric walking frame/elbow crutches

In one week, Mr C to have adequate equipment in his home environment to enable independent toileting (urinal bottle, shower commode) in his bedroom.

In one week, Mr C to have a sponge wash with assistance from his Wife/Daughter using shower commode in his bedroom. ‘

Ø No short-term hospital equipment suited to patients weight and size requirements
Ø No ward based hospital equipment suited to patients weight and size requirements
Ø Poor planning for admission – equipment needs on ward

Clinical/theoretical justifications for treatment:
Ø Based on enabling and maximising occupation within size and weight limits

Cultural needs:
Ø Family involvement in discharge planning e.g. supports, wishes re: attending to personal cares, what family have been assisting with.
Ø Housing and lifestyle - Problem solving with family re: recommendations for discharge as shower and toilet facilities inaccessible for patient

Advice provided:
Ø Safety aspects – accessing shower over bath, narrow doorways to bathroom and toilet.
Ø Enabling occupation – being cautious and discussing implications with patient when he requests compensatory equipment for home and its affect on rehabilitation at home

Ethical Issues:
Type of operation performed – Bilateral TKJR
Ø Poor mobility status pre-op/leg muscle weakness
Ø Safety risks for ward staff post operative
Ø Wearing out of prosthesis
Ø Implications on quality of life
Ø Weight gain/loss
Ø Pain control on ward

A member of the IDT – future father in law
Ø Impacting discussions in the team

Organisation of ward for admission:
Ø Better planning could have been initiated much earlier to organise necessary equipment e.g. walking frame, arm chair, shower commode, barriatric bed
Ø Pre-admission PT and OT input would have been beneficial to initiate patients needs on the ward, and get a better baseline occupational performance/mobility status.

Advice for OT’s in this situation: (Prior to patient admission)
Ø Get together with or talk about the patient to sort out a plan of attack e.g. ward equipment required to allow optimal treatment/input on the ward.
Ø Discuss in IDT meeting
Ø Complete pre-admission assessment/home visit
Ø Research barriatric equipment needs

No comments: