Saturday, April 10, 2010

Prioritisng ...

This week I have had some very complex cases. I felt as if i had nothing urgent to do on the medical ward but as usual had to prioritise between all of the complex cases

My caseload...

Patient A: A lady with a delusional disorder, not agreeable to OT "assessments" or a home visit. However quite happy to come and "have a cup of tea" with the OT - enabling myself to see her in the kitchen, which demonstrated her delusional disorder impacted her in several ways - her distractability caused her to stop and start, she got items mixed up in the kitchen (OT's cup mixed up with hers). At times she verbalised "now what am I doing here" indicating that she had got distracted and needed to orientate herself back to where she was up to in the task.
However, she also had alot of difficulty working out how much water she needed, and solving the problem of "how much water do i need in this jug to make 2 cups of tea. She was unable to determine if 1L was enough (? knowing what 1L was or not - so the OT said it was one litre). She wasnt sure so she filled the jug right up. Even though she usually used a pot on the stove - one would assume that someone should be able to use a basic jug and have knowledge of basic metric to solve this problem. Also we presume that this patient is well educated as she had been through several court cases in regards to money - part of her delsuional disorder.
As she was often distracted by people around her, and by her own thoughts - i.e. wanting to talk she often didnt notice and respond appropriately to environmental cues - which is a concern. For example she didnt notice the jug wasnt working, that she hadnt turned it on, that it had finished boiling. When she got confused between what cup was hers she just chose one, and didnt intiate to perhaps taste or smell one of them to figure our what one was hers.
All in all, she was in a hospital environment - and all of these observations are not particularly valid until I have the opportunity to observe her in her own environment - but the difficult even with this is that a) she doesnt give consent to having an assessment at home b) she may not be giving consent as she may not see any problems c) her home environment is likely to distract her further with the OT there - i.e. boxes of files regarding her delusional disorder.
So all I can do now is await a review from a member of the psych geri team that knows this patient well - as 6 months ago it was demmed that she was coping "ok" at home -even with a history of burning pots on the stove. Unfortunitly I dont see any other OT involvement on this admission unless she agrees to a follow up home visit which is unlikely.

Patient B: A man who was admitted from a prison very unwell with double incontience. He has vascular/alziemers mixed dementia and over the last 4 months has been very forgetful and needing assistance with personal cares, medication management and eating. I attended a meeting with the prison authoroties and ward staff to sort out where to next for this patient.
He is independently mobile with no walking aid, and is indep with transfers. However, he scored 136/200 on the HDS and on the ward was requiring prompting to eat,shower,dress, shave and brush his teeth. He was also occasionally incont of urine and faeces.
The case complicates further, as the patient has restrictions as to where he can be placed due to his prison sentance. Basically this patient doesnt fit anywhere. He cannot go back to any prison in NZ as they do not provide assistance with personal cares. However, we are stuck as he needs to be in prison for an extended period of time. The process has to begin to get him released from prison through the protrol board with certain conditions - ? if there is anywhere in NZ that will take him also.
My role with this case is providing a functional report to the custodian manager so he can use it to prove what level of care the patient requires.

Patient C: A lady who has been verbally agressive and non compliant since admission has finaly agreed to participating in OT asessments. As this was identified to me on Friday, I de-prioritised after discussing the case with the medical team who agreed.

Patient D: A lady who has been living with her Son. It was identified 1 week prior that the Son would take the patient home if she was independently mobile. On Friday she was d/c'd from the PT as safe for mobilising at home. I had d/c'd the patient prior as her home environment was well set up for her, i didnt think she was appropriate for a period of rehab due to her vision (80% in R and 100% in L - loss) Basically, she was ready for discharge from PT but the Son was concerned about her mobilising to the toilet at night. The RN came to talk to me and asked me to meet with the son. I attempted to solve the problem, but it seemed that she was not as mobile as the PT had assessed the day prior. I unforntunitly was the wrong person to becoming involved in the case, however the RN couldnt get in touch with the PT and the patient was ready to leave the ward. I talked to Suzanne about the case. She was suprised that the patient couldnt mobilise with me to practice a transfer. From my observations i was not willing to clear the patient for d/c but the Son ended up deciding to take her home. I guess this just shows the fluctuating function of our patients and how difficult it is to assess if a patient is safe for d.c based on little observation.

Patient E: A lady who was admitted to the ward with confusion, decreased mobility and a headache. She had a NSTEMI on the ward and then a fall. She also began having visual hallucinations. I met with the patient 5 days after admission and she was aware of the hallucinations but was orientated to time place and person. She was able to accurately recall all of the details of her admission. I determined her prior level of functioning with her and her son confirming and will see her next week to review her functioning.

Patient F: A man who was admitted ?having another stroke. He has had a hx of 6 strokes in the past with residual R sided UL and LL weakness. I reviewed the patients medical hx, and noted he had had various OT's involved in the past, with housing mods etc. I noted he was indep mobile on the ward, but wasnt liekly to be d/c over the weekend so i decided to leave reviewing his occ performance on Monday.

Patient G: Rheum patient with a new diagnosis. A 40 year old lady with a new diagnosis - unclassified inflammatory disease ? reactive arthritis, ankylosing spond, or RA. She lives with her Husband and 6 children aged 6-16. She is a body builder and power lifter. She was experiencing fatigue and pain. As she was not yet provided with a definite diagnosis, I decided to do alot of education with her - around pacing, energy conservation, and fatigue management. She was very receptive to the information and began to realies how all of it would impact on her quality of life. We talked about her priorities and she aimed to incorporate the prinicples of pacing/pain management into her life. She also agreed to some compensatory methods e.g. shower stool and perching stool to enable her to conserve her energy in those activities that she rated lower on her priority list that those on her high priority list e.g. power lifting. We discussed how she could plan the principles into her power lifting training also.


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