Practice, reasoning and reflection

Challenging Behaviour

2011-05-29T00:05:00.000-07:00

I thought it was time I reflected on what I percieve is a complex and common issue I have been experiencing whilst working in the spinal unit.

The topic of:

"CHALLENGING BEHAVIOUR"

A good starting point is the definition...Good old wikipedia

Behaviour or behavior (see American and British spelling differences) refers to the actions of a system or organism, usually in relation to its environment, which includes the other systems or organisms around as well as the physical environment. It is the response of the system or organism to various stimuli or inputs, whether internal or external, conscious or subconscious, overt or covert, and voluntary or involuntary.

Then on a google search of "behaviour and spinal cord injury" -1,240,000 results

I have to keep reminding myself about the word "adjustment"

Adjustment is defined as adapting to a new condition. Everyone makes adjustments during their lifetime. Some of the conditions that you adjust to may be planned and you have time to think about how you are going to react to the situation. For example, you may have to make adjustments in your work hours when you start a new job. Other events may be a surprise, and you are forced to adjust to an unplanned event.

"Adjustment" and SCI...

A spinal cord injury (SCI) is one of the most devastating of all traumatic events. It results in a loss of some or all of an individual’s sensation and movement. It is common for individuals who are newly injured to have health problems. Plus, it takes time to build enough strength to be able to fully participate in daily activities.

Individuals who are newly injured will likely experience grief. This is a period of mourning that is similar to that following the death of a loved one. The difference is that you are grieving the loss of your sense of touch along with your ability to walk or use your hands. You will likely experience many different thoughts and feelings after injury. Some may seem extreme and others mild. There is no step-by-step grieving process, but some thoughts and feelings are common after injury.

Seeing that feelings are directly related to behaviour its obvious that almost everyone who has a SCI must have a change in behaviour at some stage post injury and during recovery.

Therefore it is vital that I am able to deal with behavioural changes/responses within a therapy session.

So where am I at now???

I get very frustrated when dealing with challenging behavours. I feel inadequately prepared to deal with behavioural outbursts, and I feel I lack the abililty to be assertive and respond to behavioural outbursts. It almost feels like Im too immature to deal with this - especially when working with client who have alot more maturity.

New Learning......

I feel everyday I am experiencing some type of interaction with clients that could have gone better - directly related to challenging behaviour usually impacted by environmental stimulus or as a direct result of the grief process.

How am I going to develop my professional skills?

Well firstly taking note of all of them and talking about them in supervision is key

Then analysing/relflecting on each experience and identifying how I could have dealt better with the situation in order to learn through my experiences.

Talking to the team psychologists - having a session or organising a session for the OT's about this issue.

I think its important to remember that i am probably not the only OT or team member that struggles with this issue and I want to remind myself that it is an important learning area and it will assist my professional development and growth.

Learning about OZ funding

2011-03-29T01:44:00.000-07:00

Specialised Equipment Essential for Discharge (SEED)

The Specialised Equipment Essential for Discharge (SEED) commenced on 1 July 2008 to provide timely access to the essential equipment required to facilitate discharge to a community setting. SEED was formerly known as the Specialised Equipment Setup Program (SESUP).

SEED is available to eligible people receiving specialist inpatient rehabilitation for a catastrophic spinal cord, or acquired brain injury or illness in a NSW Public Hospital.

SEED is an enhancement of the Spinal Set-up Fund and has been developed in response to a recommendation made in the Review of the Program of Appliances for Disabled People (PADP), released in November 2007.

SEED will operate under the auspice of the PADP, administered by EnableNSW and will be available to eligible clients during the period of inpatient rehabilitation, until 6 months following discharge, for equipment required to facilitate discharge.

SEED will provide equipment such as wheelchairs, adjustable beds, hoists and shower and toileting aids. People currently receiving inpatient rehabilitation for a spinal cord injury or acquired brain injury interested in seeking further information about SEED should discuss their query with a member of their rehabilitation team.

Leaving one job and starting a new

2011-03-07T22:14:00.000-08:00

So its been a while since I reflected on this blog.

I have resigned from my position as rotational occupational therapist after 2 years in rheum/rehab/acute/medical/ortho/surgical.

I reflect on the growth and professional development over the last 2 years.

I feel i have developed a wide range of knowledge about the OT role in acute and rehab settings.

I have developed fluent assessment skills and my clinical decision making is sound. I have worked hard on developing my commnication skills and maturity, and I have thrived in supporting and helping other colleagues.

I have developed into a strong driver and advocate for OT and interdisiplinary assessment/treatment. I have inititated and engaged in many quality projects and been praised for my ability to bring issues to senior members to activiely resolved problems.

I am going into a new position that will have its own set of clinical demands, with lots of learning and problem solving. One I am looking forward to alot

Will reflect again once commencing this position, but just for now i feel i have the necessary key skills to learn and develop in this specialised setting.

J x

Working on Rehab

2010-10-04T00:15:00.000-07:00

Team members (OT)

I have found that my team members are more than happy to listen and discuss my patients with me. They freely offer their opinion and talk about similar cases that help me.

Allied health team members

I am fortunit to have had time with some experienced physio's and work interdisiplinary on numerous occasions. It has allowed me to confirm my reasoning and gain a wide reasoning base - e.g. the physios observations often prompt me to guide my observations to look at different occupational performance components.

I am beginning to understand more of the SLT role and some of their intervention techniques. However, i am struggling to understand the overlap between cognitive function and communication and the boundaries between OT/SLT when assessing cognitive function.

Caseload management

I feel i am managing to divide and manage my patients better than when i first started on rehab. I am keeping more up to date with my lower priority patients.

Goal setting

I am goal setting with my patients but i wish to work on more specific goal setting e.g. more smart. I wish to use my planning time to look at smart goals on shorter time periods e.g. 1 or 2 weeks so i can keep track of them and make them achieveable.

Support

I feel adequately supported in clincial work with my team members. Most have time and are interested in discussion about patients. I realise my lack of emotional support at this time needs to be also focused on. I am lucky to have support at work for this but I need to look at challenging my personal beliefs in the work place to ensure I develop professionally

Skill development

I am gaining confiendence with dense stroke patients with the support of my experienced colleagues.

Family meetings and case conferences (including articulation when communicating).

I realise that sometimes things just have to be said - even if the patient doesnt want to hear it or if it makes them feel upset/angry. I wish to take a case and plan what i am going to say and get some feedback from a peer as to how i articulated it - perhaps this could be done prior with an OT and after with a PT/SW e.g. asking them - do you think the way i articulated my input was appropriate/honest but considerate of others emotional needs?

Inservice Ideas...

2010-06-21T02:13:00.000-07:00

Inservice ideas

Food for thought

How can we promote occupation in the acute setting?

What are the benefits? What are the implications?

Would occupation assist with recovering from an acute medical condition?

What evidence is out there? If any?

How could this happen? What could it involve?

What components of occupational performance could we focus on?

What occupations would be appropriate?

Would groups be effective on the acute wards? What type?

Could a survey indicate the needs of our patients during a stay?

Is there time?

MDT dynamics

2010-05-10T21:39:00.000-07:00

What happened?

I had been working with a patient, who was admitted from home after having a fall and came into hospital with a UTI.

I had completed a SAP with her, and reviewed her pre and current occ performance and decided to see her after the weekend to organise a h/v due to her hx of falls and her decline in mobility.

I had documented this in the notes and then attended the MDT mtg on Monday. When the doctor talked about this patient he really had no idea about this patient (her background, falls hx, and how she was managing).

He said I think we need to look at rehab for this lady. I spoke up by saying “I don’t think she is far off her baseline/preadmission occ performance I mentioned that I had planned to do a home visit with this patient early week to assess her safety at home.. But I was not listened to. The doctor asked the “us” (looking at the PT) to review her ?appropriate for rehab.

The next day, I reviewed the notes and the PT had not analysed the plan. i.e. had not mentioned if she was appropriate or not for rehab. I asked the PT how her session went with the patient.

She replied “you were right she is much better this week, probably not appropriate for rehab as yes I think this is how she was before she came in”. I wondered to myself – well why didn’t you document that.

I documented the discussion and met with the patient to get her perspective of being ready for going home, she agreed she was ready and also gave consent for a f/u home visit one day post to ensure she was in a safe environment.

My reflection on this:

I felt I wasn’t being listened to in the MDT with regards to the OT perspective and plan.

I realise one of my roles is “discharge planner” however, I felt in this situation that I was the co-ordinator between PT, and OT – almost summarising the input and sorting the plan for discharge. I felt like I was going over and beyond to sort this lady out – for a few reasons

The medical team didn’t listen to me re: my input and plans from OT perspective

The PT’s analysis wasn’t clear.

How could I have dealt with this better? What will I do next time?

I could have asked the PT to document her view of ?appropriate for rehab as asked in the MDT, however I think it was still appropriate to document that we had that discussion.

I could have talked to the medical team post MDT re: the OT plan

I could have provided feedback to the MDT i.e. The OT and PT had been working with the patient, and that if we felt necessary we would talk to them about rehab appropriateness.

Basically I wanted to say that I felt undermined and that my input was irrelevant – Maybe I should have said that to the Dr/Consultant – knowing that perhaps that could have had a negative impact on OT

Cultural Safety

2010-05-10T20:04:00.000-07:00

Yesterday I attended a cultural safety, ethics and rehab presentation which sparked a few reflections on my current practice.

The phrase power relationship - applys alot to working in an acute medical ward where health professionals are seen as having more power over their patients.

This doesnt settle well with me. I wish to relflect and explore whether I as a professional impose power on my patients.

Also I am aware of an article from the NZJOT titled "Cultural Safety, Kawa Whakaruruhau: An occupational therapy perspective". This article really reinforces what the speaker (an occupational therapist) was emphasising

a) the importance of being aware, sensitive and safe in attitude and behaviour

b) the importances of understanding yourself (as a person and professional)and the systems in which they work and live towards cultural competence

c)not ignoring sociopolitical and power relationships that margalinise so many groups in society

I guess what I am trying to say is that being culturally safe is more than knowing about values and beliefs and customs of spectific cultures.

Its about...

Ot's understanding themselves (identify, attitudes, values, beliefs) and how those influence their working relationship with others in context of family, social and work groups. Its also involves broader terms of sociopolitical understandings (impact of poverty on occupation)

Overall an understanding of the person, environment and occupation are all important for cultural safety.

So how can I ensure I am practicing in a culturally safe manner?

a) not forcing a value system on a client

b)exposing the client to a range of possibilites

c) the client is the one who makes the choice

d) being open to the clients ideas, feelings and thoughts - and being open to repsonding to them

http://www.otboard.org.nz/pdfs/Cultural_Safety_Article.pdf

Assessing Vision

2010-04-19T23:34:00.000-07:00

I had a patient with Macular Degeneration that I would like to discuss and learn more

I would like to talk about what I did, and discuss any other aspects of assessment I could have involved. I would also like to talk about aspects of intervention that I could have considered, and the important aspects of assessment in the home environment.

1) I asked her if she could see me, and my facial features - She said she could see me, but my features were a blur. She also said it sometimes takes her a while to determine who a person is and she often relies on hearing their voice.

2) I stood 2 metres away from her and she could identify that i was holding a pen, and a pack of cards, however she couldnt identify the clear glass mug. She reported to me that she can see the pen/cards because they had bold colouring.

She commented that she cannot play cards, due to not being able to see the cards. I prompted her further to determine she had to bring them closer to her eyes and she gave up due to frustration and the time impact.

3) I asked her to copy a clock and a house. I observed her bringing the object/paper closer to her eyes so she could see the detail.

4) She could identify the number of fingers I was holding up - indicating that she can identify and see objects with little amount of detail. This confirmed that she was able to see objects within one metre, however the detail was difficult for her

Reflecting on this....The kitchen task confirmed the observations I had already discovered.

She could see the objects infront of her however using them and seeing the detail was difficult. She was able to identify the milk in the fridge, the cup, the jug, the spoon, the containers. However, switch on jug, holes in the socket, labels on the containers.

Is there anything else that I could have assessed??

With my knowledge of Macular Degeneration looking like this.... it all makes sense...

At home I would have looked at her safety in the kitchen: oven, stove top, microwave, jug, toaster and any other electonic item she uses often

I would have also looked at her indep/safety locking and unlocking the house/door, accessing the house and negociating steps, mobilsing indoors, turning on the shower, washing machine, dryer etc

I would have checked out the internal environment - cords, positioning of furniture, mats, duvet, curtains etc

Is there anything else I could have considered?

Can we brainstorm intervention together?

Jess

Learning about Corpus Callosum

2010-04-15T00:47:00.000-07:00

The corpus callosum (Latin: tough body) is a structure of the mammalian brain in the longitudinal fissure that connects the left and right cerebral hemispheres. It facilitates communication between the two hemispheres. It is the largest white matter structure in the brain, consisting of 200-250 millioncontralateral axonal projections. It is a wide, flat bundle of axons beneath the cortex. Much of the inter-hemispheric communication in the brain is conducted across the corpus callosum.

The posterior portion of the corpus callosum is called the splenium; the anterior is called the genu (or "knee"); between the two is the truncus, the 'body' of the corpus callosum. The rostrum is the portion of the corpus callosum that projects posteriorly following from the anteriormost genu.

Thinner axons in the genu interconnect prefrontal cortex areas between the two sides of the brain. Those in the posterior body of the corpus callosum interconnect parietal lobe areas. Thicker axons in the midbody of the corpus callosum and in the splenium interconnect areas of the motor,somatosensory, and visual cortex.^[1]

Using magnetic resonance diffusion tensor imaging, the studies of Hofer and Frahm ^[2] suggest that the anterior sixth of the corpus callosum interconnect the prefrontal parts of the brain; the next third, the premotor and supplementary motor regions; the following sixth, the motor areas; then the next twelfth deals with the sensory areas; and the final quarter, the parietal, temporal, and occipital lobes.

Pathology

Alien hand syndrome
A complete or partial absence of it in humans is called agenesis of the corpus callosum.
Split-brain
Septo-optic dysplasia (deMorsier syndrome)
Alexia without agraphia (seen with damage to splenium of corpus callosum)

An alien hand gifter can feel super power sensation in the hand and leg, but believes that the hand, while still being a part of their body, behaves in a manner that is totally distinct from the sufferer's normal behavior. They lose the 'sense of agency' associated with the purposeful movement of the limb while retaining a sense of 'ownership' of the limb. They feel that they have no control over the movements of the 'alien' hand, but that, instead, the hand has the capability of acting autonomously — i.e., independent of their voluntary control. The hand effectively has 'a will of its own.' Alien hands can perform complex acts such as undoing buttons, removing clothing, and manipulating tools. Alien behavior can be distinguished from reflexive behavior in that the former is flexibly purposive while the latter is obligatory. Sometimes the sufferer will not be aware of what the alien hand is doing until it is brought to his or her attention, or until the hand does something that draws their attention to its behavior.

Split-brain is a lay term to describe the result when the corpus callosum connecting the two hemispheres of the brain is severed to some degree. The surgical operation to produce this condition is called corpus callosotomy and is usually used as a last resort to treat intractable epilepsy. Initially, partial callosotomies are performed; if this operation does not succeed, a complete callosotomy is performed to mitigate the risk of accidental physical injury by reducing the severity and violence of epileptic seizures. Prior to callosotomies, epilepsy is treated through pharmaceutical means.

A patient with a split brain, when shown an image in his or her left visual field (the left half of what both eyes take in, see optic tract), will be unable to vocally name what he or she has seen. This is because the speech-control center is in the left side of the brain in most people, and the image from the left visual field is sent only to the right side of the brain (those with the speech control center in the right side will experience similar symptoms when an image is presented in the right visual field). Since communication between the two sides of the brain is inhibited, the patient cannot name what the right side of the brain is seeing. The person can, however, pick up and show recognition of an object (one within the left overall visual field) with their left hand, since that hand is controlled by the right side of the brain.

The same effect occurs for visual pairs and reasoning. For example, a patient with split brain is shown a picture of a chicken and a snowy field in separate visual fields and asked to choose from a list of words the best association with the pictures. The patient would choose a chicken foot to associate with the chicken and a shovel to associate with the snow; however, when asked to reason why the patient chose the shovel, the response would relate to the chicken.

Alexia without agraphia is a form of alexia which almost always involves an infarct to the left posterior cerebral artery (which perfuses the splenium of the corpus callosum and left visual cortex, among other things).

The resulting deficit will be "Alexia without agraphia" - i.e., the patient can write but cannot read (even what they have just written). This is because the left visual cortex has been damaged, leaving only the right visual cortex (occipital lobe) able to process visual information, but it is unable to send this information to the language areas (Broca's area, Wernicke's area, etc) in the left brain because of the damage to the splenium of the corpus callosum.^[1]^[2] The patient can still write because the pathways connecting the left-sided language areas to the motor areas are intact.^[3]

It is also known as "Dejerine syndrome" (after Joseph Jules Dejerine, who described it in 1892^[4]), but it should not be confused with medial medullary syndrome, which shares the same eponym.

Memory

In most tests, memory in either hemisphere of split-brained patients is generally lower than normal, though better than in patients with amnesia, suggesting that the forebrain commissures are important for the formation of some kinds of memory. It is suggested that posterior callosal sections which include the hippocampal commissures cause a mild memory deficit (in standardized free field testing) involving recognition^[9].

[edit]Control

In general, split-brained patients behave in a coordinated, purposeful and consistent manner, despite the independent, parallel, usually different and occasionally conflicting processing of the same information from the environment by the two disconnected hemispheres. When two hemispheres receive competing stimuli at the same time, the response mode tends to determine which hemisphere controls behavior^[10]. Often, split-brained patients are indistinguishable from normal adults. This is due to the compensatory phenomena; split-brained patients progressively acquire a variety of strategies to get around their interhemispheric transfer deficits.

[edit]Attention

Experiments on covert orienting of spatial attention using the Posner paradigm confirm the existence of two different attentional systems in the two hemispheres^[11]. The right hemisphere was found superior to the left hemisphere on modified versions of spatial relations tests^[12]. The components of mental imagery are differentially specialized: the right hemisphere was found superior for mental rotation^[13], the left hemisphere superior for image generation^[14].

Infarcts of the corpus callosum are not common and are attributedto a rich blood supply from three main arterial systems: theanterior communicating artery, the pericallosal artery, andthe posterior pericallosal artery (4). A detailed descriptionof the vascular supply to the corpus callosum was publishedby Ture et al (5), including variations in the main arterialsupply. The pericallosal branch of the anterior cerebral arteryis most often the main vascular supply to the body. The subcallosaland medial callosal arteries, branches of the anterior communicatingartery, provide the main supply for the anterior portion ofthe corpus callosum. The posterior pericallosal artery, a branchof the posterior cerebral artery, supplies the splenium.

Chrysikopoulos et al (4) offer other possible explanations forthe immunity of the corpus callosum to infarction. Isolatedinfarcts of the anterior and posterior cerebral arteries areuncommon, accounting for 12% of all infarcts, and when presentare found in conjunction with generalized atherosclerotic disease.All of the patients in our series had long histories of hypertensionand three of the five patients had insulin-dependent diabetesmellitus, predisposing them to generalized atherosclerosis.Chrysikopoulos et al (4) note that the majority of strokes arethromboembolic in origin, and emboli tend to favor the middlecerebral artery distribution because of hemodynamic factors.Moreover, the penetrating vessels of the corpus callosum aresmall in size and generally run perpendicular to the parentartery, thus protecting the corpus callosum from emboli.

Kazui et al (6) found in their series that infarction localizedto the anterior cerebral distribution was attributable mostcommonly to local atherothrombosis and occasionally to cardiogenicembolism. They also postulate that a hypoplastic A1 segmentmay facilitate the occurrence of embolism in the anterior cerebralartery distribution. MR angiography performed in one of thepatients in our series (case 2) showed small anterior cerebralarteries relative to the other cerebral vessels. This was ofuncertain etiology. Although stenosis was considered, no conventionalangiogram was obtained.

Chrysikopoulos et al (4) found that the splenium of the corpuscallosum was affected more often than was the body and genu.They attributed this to the greater incidence of posterior cerebralartery infarcts compared with anterior cerebral artery infarcts.In our series, all of the lesions involved the genu, body, orboth, whereas none involved the splenium. The difference inthe location of the infarcts in our study, as compared withthat reported by Chrysikopoulos et al, may be due to the differencein the patient population; ie, patients with diabetes and hypertensiondevelop generalized atherosclerosis, which in turn increasesthe incidence of anterior circulation infarction. Isolated anteriorcerebral artery infarcts are rare, accounting for 0.6% of allcerebral infarcts (6). Chrysikopoulos et al (4) found evidenceof hemorrhage in about 25% of their cases, whereas there wasno evidence of hemorrhage in any of our cases. Thus, the presenceof hemorrhage may suggest infarct, but the absence of hemorrhageshould not exclude the diagnosis. Infarcts of the corpus callosummay exhibit a variable degree of mass effect. Mass effect iscommonly seen in stroke, but when it occurs in a region suchas the corpus callosum where stroke is often not considered,it suggests other entities that would require biopsy. Enhancementis often seen by the end of the 1st week and can persist formany weeks (7, 8). In many of our cases, the abnormal signalintensity or enhancement or both crossed the midline, unusualfor infarct but not for tumor.

Clinically, infarcts of the corpus callosum are frequently associatedwith neuropsychiatric symptoms, mainly interhemispheric disconnectionsyndromes (9). In addition, specific syndromes such as dyspraxiacontralateral to a paretic limb (10, 11) and alien hand syndrome(12, 13) have been reported, and an isolated gait disorder hasbeen described in relation to lacunes in the anterior portionof the corpus callosum (12).

Respecting the rights of my patient

2010-04-14T01:59:00.000-07:00

I have had a patient who i have talked about in the previous posting. Also repeated below..

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.

The social worker had organised a family meeting for this patient, her family and staff from hospital including medical, allied health and maori liason workers.

In the family meeting, the medical doctor indicated that she was medically stable and ready for discharge. Allied health (including OT and PT) indicated the difficulty determining the patients safety and indep level for d/c due to her non compliance with inpit.

I mentioned that I thought there was an element of cultural impact on her compliance, especially when considering shower/dress assessment - I identified clearly that I was accepting of her right to choice and therefore could not comment on her occupational performance.

The OT/PT left the meeting as it was now time for the family to figure out a plan for d/c - which was socially complex with role strain/relationship breakdown.

As a result i discontinued any further input.

However, I was approached by the CNM of the ward. She almost barginned with me - saying I'm going to ask the RN staff to leave Mrs X.. tomorrow morning so that you can go and do an assessment with her. If she doesnt do it, come and get me and "shel do it if I'm there"...

I was almost disgusted in that comment, but didnt say so. I further prompted for more detail as to why she wanted the assessment done. It appeared that my assessment of her occupational performance was going to give us "the right" to recommend that she has supports on d/c, and if she refused that and wasnt coping at home then "she would have to go into a resthome.

Again, I became more disguisted, and we keep talking about the necessity of doing it.

I then identified that I was not happy with seeking the CNM's presence to "make" the patient do it with me.

This patient was assessed as competent to make her own decisions regarding welfare, and she has the rights to her own decisions regarding multiple factors here - to go home, to not participate in assessments, and to not have assistance come into her own home.

This is basic rights!

I went to see the patient and discussed the purpose of the assessment, and risks if it was not completed i.e. may not cope at home. To my understanding she made an informed decision not to have the OT input, and I maintained cultural and patients rights. Some thing I am proud to put my name to - it appears that some think purely about the impact of sending some one home purely on the medical impact and "what if she fails" - when we have x'd all the t's and dotted all the i's...

Jess

Prioritisng ...

2010-04-10T14:11:00.000-07:00

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 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.

Jess

Rheumo Case Review

2010-03-22T23:58:00.000-07:00

Patient details

Male, 28years

Lives with Wife and One Year old Child

He use to work as a chef, but cannot work at the moment due to pain and immobility

His wife works and studies

Diagnosis: Polyarticular Gout

Polyarticular Gout. If more than one joint is affected, it is known aspolyarticular gout. Multiple joints are affected in only 10 - 20% of first attacks. Older people are more likely to have polyarticular gout. The most frequently affected joints are the foot, ankle, knee, wrist, elbow, and hand. The pain usually occurs in joints on one side of the body and it is usually, although not always, in the lower legs and feet. People with polyarticular gout are more likely to have a slower onset of pain and a longer delay between attacks. People with polyarticular gout are also more likely to experience low-grade fever, loss of appetite, and a general feeling of poor health.

An untreated attack will typically peak 24 - 48 hours after the first appearance of symptoms, and go away after 5 - 7 days. However, some attacks last only hours, while others persist as long as several weeks.

Reason for admission - Methylprednosone Pulses 3x

Reason for Referral Assessment - Splinting, Education, RTW, equipment/aids

Intial Hand Assessment
ADL tasks sheets- self report of difficulties
Assessment of Hands

Presenting Problems/Complains

Pain and reduced ROM in R) Wrist - also decreased strenght in R) hand
Swan neck deformity in R) LF
Pain in TMC/CMC joint - thumb
Difficulties with multiple ADLS
Reduced mobility due to pain in L) knee; both ankles and feet.
Poor sleep and fatigue

Current/Pre admission occupational performance/mobility

Mobilising with gutter crutch L) arm
Independent with personal ADL's on ward, concerns re: showering at home
Unable to carry heavy items or carry items in R) hand
No completeing heavy housework tasks
Difficulty with but independant with multiple actions/tasks at home relating to hand function, strenght, pain and immobility

Intervention

Education re: sleep cycles, factors linking to poor sleep, strategies and use of relaxation, sleep diary and routine/environmental setup
Wrist splint - D ring splint for stability
Issued a BB and K-trolley

Plan

Book in O/P clinic to review splinting of R) LF - swan neck deformity, and resting slint for wrist.

Case review

2010-03-15T21:18:00.000-07:00

Case Review

Patient details: Female, 56

Event leading to admission: Prolonged hypoglycemia - unconcious episode, lowered GCS

Pre-admission occupational performance

- Independent with grooming, and personal care tasks

- Independent mobility

Social Situ

- Lives with Husband - primary carer

OT input - Assessments:

Basic cognitive assessments - orientation, attention, object naming/use, working memory

Basic tasks - writing, reading,

Joint session with SLT - ruled out language problem - more cognitive problems

AMPS observation of grooming - combing hair and brushing teeth

Observations from AMPS

Prompt to start task
Indep with manipulating toothpaste - fine motor
Chose appropriate tools and used them appropriately
Assistance gathering and organising task environment - therapist intitated
Sitting in chair, stabilising body on table
Assistance to position table appropriately to perform task
Coordinating bilateral hand tasks effectively
Reduced grip strength ? due to arm positioning akwardly
Obtaining and holding task objects effectively
Poor endurance throughout task
Pace slow, however ? due to difficulty with terminating task
Attends to task, however distracted by others talking, however contiunes with tasks indep
Handles task objects appropraitely
Sequencing task appropriately
Repeats steps ? difficulty terminating task
Searches and locates objects

Overall minimal assistance with task and safe performing task with environment set up

Next step:

Further assessment of ADL's - showering and dressing

Determining a good understanding of prior level of cognition - mixed reports

Goal setting with rehab team - realistic goals

JESS

Complex case QOL

2010-03-07T22:42:00.000-08:00

I have had a patient who is very unsafe to return home. She is falling alot and has fallen on the ward numerous times, she often doesnt use her walking frame and she fluctuates between being lucid and being very very confused. She often talks about living in the past with her mother as it is happening presently or will happen in the future. She needs constant direction on the medical ward and she needs 24/7 supervision due to her cognition, and falls risk.

We had a family meeting with the Son and Daughter last week, and we each communicated how concerned we were that they had decided it be best for her to return home. I understand that they want the best for her (i.e. quality of life and the patients wish to not go into a RH). I also know that they are aware of the concerns, but really what can we do? The patient has been deemed incompetent, and the EPA wants her to remain at home. I wonder about her quality of life, and whether the patient can experience a quality life remaining at home and not having any awareness of where she is, what day it is, what year it is and why she was in hospital. She also doesnt show any awareness of how she is managing.

What is a quality life??

I have found a few definitions: and picked out a few key terms...

Quality of life: An important consideration in medical care, quality of life refers to the patient's ability to enjoy normal life activities. Some medical treatments can seriously impair quality of life without providing appreciable benefit, while others greatly enhance quality of life.

The best way of approaching quality of life measurement is to measure the extent to which people's 'happiness requirements' are met - ie those requirements which are a necessary (although not sufficient) condition of anyone's happiness - those 'without which no member of the human race can be happy.'

- McCall, S.: 1975, 'Quality of Life', Social Indicators Research 2, pp 229-248

‘‘Quality of life’’ (QOL) subsumes two distinct domains in gerontological research. One is health-related quality of life (HRQOL); the other, nonhealth or environment-based quality of life (Spilker and Revicki).

http://www.novelguide.com/a/discover/eoa_04/eoa_04_00344.html

This website, discusses these two domains - and i think it helps me understand that perhaps the family of the client

above are thnking of her environment based quality of life and not her health based quality of life. HOwever QOL does mean different

things to different people.

Anyway, the medical and AH team essentially have concerns about the choice the family have made, and the wellbeing of the patient in mind. The SW has put a referral through to elder support to ensure that we have done all we can to protect the wellbeing of the patient. But essentially, all we can do is advise the patient (which we have done) of our concerns and the risks of the patient remaining at home and support them as much as we "can" towards a safe discharge, whilst knowing that the patient is going to fall again and will also most prob end back up in hospital (which we have also discussed with the family).

Learning about Fibromyalgia

2010-03-05T19:09:00.000-08:00

Fibromyalgia is a long term condition characterised by widespread muscle pain and fatigue. It is thought to affect 3-5% of the population. It can affect anyone at any age but is more common in women.

Fibromyalgia is a chronic condition characterised by widespread muscle pain and fatigue. The term 'fibromyalgia' literally means pain in muscles and fibrous tissues (ie: tendons and ligaments).

For many years it was thought that fibromyalgia was psychologically based but is now recognised as a medical condition in its own right and research into the condition has increased.

Approximately 80% of fibromyalgia sufferers are women and the condition is most commonly diagnosed in the 30 to 45 year age group.

The cause of fibromyalgia is unknown. There are indications that an injury, infection or illness may trigger the condition. There are also indications that hereditary factors are involved in the development of fibromyalgia as sometimes it occurs in several members of one family.

It is thought that fibromyalgia may be due to a malfunction in the way the central nervous system processes pain signals. This leads to people with fibromyalgia experiencing as pain, sensations that other people might perceive as uncomfortable.

Two brain chemicals, Serotonin and Substance P, are thought to play a role in the condition.

Serotonin is a neurotransmitter (a chemical that enables the transmission of nerve impulses) that influences mood, appetite, pain perception, sexual function, anxiety, temperature control and sleep. Studies have indicated that levels of this chemical are lower than usual in people with fibromyalgia.

Substance P, another neurotransmitter, is involved in transmitting pain sensations to the brain and also regulates the way we perceive pain. Some studies have found substantially elevated levels of this substance in people with fibromyalgia.

A person with fibromyalgia can experience a wide range of symptoms but the main ones are muscle and joint pain, stiffness and fatigue.

The one symptom experienced by everyone with fibromyalgia is pain. This pain can be described in various ways, such as an ache, a sharp pain, a throbbing or a burning feeling. The pain is felt throughout the body and on both sides of the body. The pain can move from one part of the body to another. The amount of pain experienced can vary throughout the day and can also worsen with a change in weather, increase in stress, noise, activity and lack of sleep.

Stiffness of muscles and joints is most noticeable in the morning and after a period of rest. This can interfere with work and daily activities such as driving. Keeping moving is the best way to prevent stiffness. If a person has to sit for long periods, he or she can reduce stiffness by regularly getting up to move around and stretch.

Fatigue is experienced by up to 90% of people with the condition. The level of fatigue can vary from person to person, from being barely noticeable to severe. As with the amount of pain experienced, the degree of fatigue can vary throughout the day, from day to day, and may even be absent on occasion.

Many people with fibromyalgia experience sleep problems. There are a number of stages of normal sleep ranging from light to deep sleep. It seems that people with fibromyalgia often lack the deep restorative stages of sleep and often wake feeling unrefreshed.

Over half of people with fibromyalgia experience symptoms such as irritability, forgetfulness, lack of concentration, mood changes, anxiety and depression.

Other symptoms that can be experienced by people with fibromyalgia include:

Migraine and tension headaches
Recurrent abdominal pain
Diarrhoea
Difficulty swallowing
Irritable bladder leading to frequent or painful urination
Numbness and tingling of the extremities
Dry eyes and mouth.

Diagnosis

Fibromyalgia can be a difficult condition to diagnose as the symptoms of fibromyalgia are often similar to those of other conditions, such as rheumatoid arthritis or chronic fatigue syndrome. Blood tests and x-rays usually return normal results in someone with fibromyalgia but they are often performed in order to rule out other conditions.

In order to make a diagnosis of fibromyalgia the doctor will look for the following indicators of the condition:

A history of widespread pain
At least 11 of 18 specific tender point sites (as shown below)
Normal blood tests
Chronic fatigue
Sleep disturbances
Skeletal pain (mainly in the neck and back).

Graphic courtesy of A. Bonsall and MedicineNet.com

Treatment

While there is no cure for fibromyalgia, the condition can be managed using a variety of measures. Optimal management requires cooperation between the patient and various treatment providers.

Exercise is highly recommended even though people with fibromyalgia may be reluctant to exercise because of their pain. Exercise is important to prevent the muscles from losing strength due to lack of use. Other benefits of regular exercise include sleep promotion, aiding digestion, increasing blood flow and improving muscle tone. It is best to start with small amounts of low impact exercise (such as walking) on a daily basis, and gradually increase this as tolerated.

Rest is also important in managing fibromyalgia. People with fibromyalgia often feel exhausted after only small amounts of activity. It is often helpful therefore, to rest regularly during the day and even during activity if it is needed. Even brief periods of rest (such as 5 to 10 minutes) can be helpful.

Stress reduction is important as increased stress can magnify fibromyalgia symptoms. Finding methods of relaxation (such as reading or listening to music) that suit the individual with fibromyalgia can be helpful in stress reduction. Talking about the condition with friends and family can also be helpful. Some people may find it helpful to work with a professional counsellor or psychologist to develop relaxation techniques and strategies to cope with the pain

Sleep is often inadequate in quality for people with fibromyalgia. It is not advisable to use sleeping tablets unless they are absolutely necessary, and then only for brief periods of time. Some methods that may help to gain more restful sleep include avoiding alcohol and coffee in the evening, using the bedroom only for sleep (ie: not for working or eating), ensuring the room is dark when trying to sleep and having a regular time for going to bed.

Alternative therapies such as acupuncture/acupressure, homeopathy, hot and cold packs, massage therapy, nutritional supplements and dietary modifications, herbal preparations, osteopathy or chiropractic treatment, have proved effective for some people in managing the symptoms of fibromyalgia.

Studies have shown that low doses of two different antidepressant medications can be helpful in relieving the pain of fibromyalgia in some people. Amitriptyline (a tricyclic antidepressant) taken at night can help with promoting a restful sleep and reducing muscle pain and spasms. Prozac (fluoxetine) taken in the morning may add to the effects of the Amitriptyline by further controlling the pain during the day. While these medications help some people with fibromyalgia, they are not effective in all cases.

So from learning about this it is important that when initially meeting a person I ask about what symptoms they are experiencing e.g. where the pain is, how they are coping with it, what helps, what doesnt help, how their sleep is, how they manage fatigue, and how they feel within themselves so I can understand their experience of living with this condition.

My intervention could be aimed at education around fatigue management, coping with pain, sleep management, stress management, aids to cope with difficult ADL's when pain/fatigue is a distrubrance,

Jess

Supporting others

2010-03-04T19:52:00.000-08:00

Below are some of the activities i wish to do this year, related to my overall objective of: Articulate, negotiate, & demonstrate the role & function of an occupational therapist within a team.

Activity #1: Support the orientation and learning of processes of new staff members by being available to peers for facilitating learning. Seek feedback about support provided to peers and discuss in supervision
Date to complete this activity by: Dec 2010
Added: 24/2/10

Activity #2: Demonstrate and articulate the role of an occupational therapist by modelling and providing support/guidance to peers and OTA
Date to complete this activity by: Dec 2010
Added: 24/2/10

This week we have had two new staff members within our team. I have made myself available to them and they have come to me with questions about a) particular assessments e.g. screening cognition; PTA; intial OT assessments; b) equipment processes and paperwork c) documentation guidance and SOTAP explanation. I have felt confident to talk these through with them, and demonstrate with patients "what i would do with a patient" and how i would document in the notes.

I have felt like i have explained everything slowely, and i have asked if they have understood. I have tried really hard not to take over and involve them in the process, however i think they have apprecitated the demonstration and role modelling of what another therapist would do.

I have attended an MDT meeting with one of the therapists and demonstrated, asking questions to clarify if patients need input etc. And communicating current input. The therapist told me she found it very useful observing when to speak up and ask information.

I have made myself available in the office for questions, as they have both approached me in the office to ask questions about processes and talk through patients with me. I have also encouraged them to talk to senior OT's if they have needed more clarification or guidance.

I wish to continue doing this over the next few weeks, to ensure that what ever i can do to support the new staff members thats appropriate i do.

I wish to talk in supervision about what things are appropriate for me to be doing and when i should direct them to a senior OT.

Jess

Finger extension and flexion

2010-03-03T21:24:00.000-08:00

Mechanism for finger flexion

FDP: flexor digitorum profundus (the deeper of the two)
FDS: flexor digitorum superficialis (the more superficial muscle)
Although the FDP is deep to the FDS over most of its course, it attaches to the skeleton more distally, because it passes through a 'split' in the FDS tendon.

Mechanism for finger extension

We can extend the PIP and DIP joints without also extending the MP joints.
But we can't extend the PIP joint without extending the DIP joint at the same time.
Flexing only the DIP joint without also flexing the PIP joint is difficult.
Full (active or passive) flexion of the PIP joint prevents active extension of the DIP joint.
We can understand these finding by learning the structure of the EXTENSOR MECHANISM, also known as the:
extensor expansion
extensor assembly
extensor apparatus
dorsal aponeurosis
aponeurotic sleeve

The extensor mechanism is an elaboration of the extensor digitorum comunis (EDC) tendon on the dorsum of each phalanx. The extensor indicis (EI) and the extensor digiti minimi (EDM) insert into the extensor mechanisms of the second and fifth digits, respectively.

Several tendinous structures comprise the extensor mechanism:
The EDC tendon attaches by a tendinous slip to the proximal phalanx, through which it extends the MP joint.
The central tendon (or "slip") proceeds dorsally to attach to base of middle phalanx, where tension can extend the PIP joint.
3. the lateral bands proceed on either side of dorsal midline and rejoin before attaching to the distal phalanx. Tension in the lateral bands extends the DIP joint.
4. the extensor hood surrounds the MP joint laterally, medially, and dorsally, and receives tendinous fibers from the lumbricales and interossei.
5. Fibers of the oblique retinacular ligament (ORL) attach at the sides of the proximal phalanx and digital tendon sheaths, and proceed to distal portion of lateral bands. Thus, the ORL's line of application is volar to the PIP joint's lateral axis and dorsal to the DIP joint's lateral axis.
PIP extension (produced by other tissues in the extensor mechanism) elongates the ORL, creating passive tension that extends the DIP. The DIP extension helps open the hand.
DIP flexion (produced by the FDP) elongates the ORL, creating passive tension that flexes the PIP. The PIP flexion assists in finger closure.

3. the lateral bands proceed on either side of dorsal midline and rejoin before attaching to the distal phalanx. Tension in the lateral bands extends the DIP joint.	4. the extensor hood surrounds the MP joint laterally, medially, and dorsally, and receives tendinous fibers from the lumbricales and interossei.
5. Fibers of the oblique retinacular ligament (ORL) attach at the sides of the proximal phalanx and digital tendon sheaths, and proceed to distal portion of lateral bands. Thus, the ORL's line of application is volar to the PIP joint's lateral axis and dorsal to the DIP joint's lateral axis.

PIP extension (produced by other tissues in the extensor mechanism) elongates the ORL, creating passive tension that extends the DIP. The DIP extension helps open the hand.	DIP flexion (produced by the FDP) elongates the ORL, creating passive tension that flexes the PIP. The PIP flexion assists in finger closure.

1st observation RA, splinting

2010-03-03T21:13:00.000-08:00

Today I observed a hand therapist, completing an initial assessment, which included talking about how long the patient had had RA for, and talking about the referral. She then talked about what the main problems were, then went on to assess the hands, joints and tendon placement. She talked through her observations and she interacted with the patient by asking how long a particular joint had been like it was and asked if it was painful and what impact it had on her ADL's.

I have happened to come accross the below guide for taking history, which i think may be very helpful.

1. Evaluation of the history including onset, duration and distribution of joint disease.
2. Assessment of pain, stiffness and function.
3. A full systematic history, as the condition is a systemic disease.
4. A genetic history may be useful in view of the hereditary aspects of disease.
5. Impact of the disease on daily life.

Today, I observed

An example of

a) extensor subluxation - which inhibited the paitents ability to extend her fingers as essentially the tendon had dropped and become a flexor. These tendons on the dorsal aspect are below

The dorsal tendon compartments

Identify the tendons that, encased in synovial tendon sheaths, comprise six numbered dorsal compartments of interests to hand therapists: abductor pollicis longus and extensor pollicis brevis extensor carpi radialis longus and brevis extensor pollicis longus extensor digitorum comunis (four tendons) and extensor indicis extensor digiti minimi extensor carpi ulnaris

b) ulna deviation - as a result of the extensor subluxation

Learning about RA

2010-03-03T21:07:00.000-08:00

Rheumatoid Arthritis

- Autoimmune disease – system malfunctions – turns on itself healthy parts come under attack.

- The faulty system attaches the tissues and other materials in the joints, cartilage, synovial fluid – with fluid to lubricate, ligaments. This causes inflammation and pain, and eventually destroying the joint.

- In some cases patients have organ involvement including the eyes, lungs and membrane around the heart, the damage occurs from inflammation of the vessels supplying the organ or inflammation of the organ issue itself

Drugs

-Release pain as well as prevent damage, reduce inflammation that is causing the damage

2 categogies – 1^st line drugs – pain; 2^nd line that treat the disease

NSEADS – popular – reduce pain and swelling – aspirin, ibuprofen, naproxen

Corticosteroids are used to treat more se3vere inflammation in the body – mimicking the effects of cortisone which is a hormone that is produced by the body to control inflammation. These have profound side effects

Anti rheumatic drugs – disease modifying drugs – DMARDs – slow the diseases progress by modifying the immune system itself – very slow acting – may take 6 – 8 months to reach full

Biological response modifiers - Biologic agents – expensive - can slow or hault/stop destructive progress by targeting the specific molecule involved in the inflammation process, targeting specific proteins compete for the receptor that tells the cells to be inflamed and reduce inflammation that way. These are often combined with DMARDS or corticosteroids.

Learning about Scleroderma

2010-03-03T20:37:00.000-08:00

Scleroderma is an autoimmune disease of the connective tissue. Autoimmune diseases are illnesses which occur when the body's tissues are attacked by its own immune system. Scleroderma is characterized by the formation of scar tissue (fibrosis) in the skin and organs of the body. This leads to thickness and firmness of involved areas. Scleroderma, when it's diffuse or widespread over the body, is also referred to as systemic sclerosis.

Patients can have variations of CREST, for example, CRST, REST, ST, etc. Patients can also have "overlap" illness with features of both CREST and the diffuse form of scleroderma. Some patients have overlaps of scleroderma and other connective tissue diseases, such as rheumatoid arthritis, systemic lupus erythematosus, andpolymyositis. When features of scleroderma are present along with features of polymyositis and systemic lupus erythematosus, the condition is referred to as mixed connective tissue disease (MCTD).

Sclerodactyly refers to the localized thickening and tightness of the skin of the fingers or toes. This can give them a "shiny" and slightly puffy appearance. The tightness can cause severe limitation of motion of the fingers and toes. These skin changes generally progress much slower that those of patients with the diffuse form of scleroderma.

The symptoms of scleroderma depend on the type of scleroderma present and the extent of external and internal involvement in the individual affected. Because scleroderma can affect the skin, esophagus, blood vessels, kidneys, lungs, blood pressure and bowels, the symptoms it causes can involve many areas of the body.

Scleroderma affects the skin to cause local or widespread signs of inflammation (redness, swelling, tenderness, itching, and pain) that can lead to skin tightness or hardening. These skin changes can be widespread, but it's most common for them to affect the fingers, feet, face, and neck. This can lead to decreased range of motion of the fingers, toes, and jaw. Tiny areas of calcification (calcinosis), while not common, can sometimes be noticed as hard nodules at the tips of the elbows or in the fingers.

Raynaud's phenomenon (RP) is a condition resulting in a particular series of discolorations of the fingers and/or the toes after exposure to changes in temperature (cold or hot) or emotional events. Skin discoloration occurs because an abnormal spasm of the blood vessels causes a diminished blood supply to the local tissues. Initially, the digit(s) involved turn white because of the diminished blood supply. The digit(s) then turn blue because of prolonged lack of oxygen. Finally, the blood vessels reopen, causing a local "flushing" phenomenon, which turns the digit(s) red. This three-phase color sequence (white to blue to red), most often upon exposure to cold temperature, is characteristic of RP.

Limited scleroderma, or CREST syndrome, is one subtype of scleroderma — a condition that literally means "hardened skin."

The skin changes associated with limited scleroderma typically occur only in the lower arms and legs, and sometimes the face and throat. Limited scleroderma can also affect your digestive tract and can cause serious heart and lung disorders.

While some varieties of scleroderma occur rapidly, signs and symptoms of limited scleroderma usually develop gradually. They include:

Tight, hardened skin. In limited scleroderma, skin changes typically affect only the lower arms and legs, including fingers and toes, and sometimes the face and throat. Skin can look shiny from being pulled taut over underlying bone. It may become difficult to bend your fingers or to open your mouth.

Case review: Motivating using occupations

2010-02-22T22:13:00.000-08:00

Patient details:

Male, 31. Lives alone.

Family local, Mother and Father supportive

Out of area patient

Reason for admission: Elective R) TKJR - covered by ACC

Medical Hx:

Epilepsy

Seizure when young resulting in R) sided weakness

Genetic magnesium deficit disorder

Accident when young as a result of a seizure - resulting in a fall, and damage to subcondylar area of tibia

Pain in R) knee increasing and reducing mobility

OT assessment/process

Reviewed notes which identifed that pt had been not cooperative with nursing staff and PT staff

Identified that patients Mum had been contacting ward excessively to review how he was going

Discussed patient with PT re: mobility status, and level of engagement with PT

Met with patient, introduced self/role and asked for consent to talk with him initially.

Response to OT was to shut eyes and turn head away, no verbal response. Asked if it was ok to contact family, no further response from patient

OT left the situation and discussed interaction with ACNM, identified need to contact family for hx, and commence intial assessment.

P/Call with patients mother, who seemed to be very distressed, perhaps next time I could have thought about who would be the best person to contact due to the circumstance e.g. anxious mother. But planned to meet with family and patient on ward that pm.

Discussion with PT re: meeting family. PT keen to attend.

Met with patient and family that pm, PT reinforcing how important it is to do knee exercises and Dad trying to support PT, however patient very receptive still. Discussion with Family, pt and OT re: home environment and pre-admission occ performance, and plans for discharge.

Outcomes of assessment by OT:

Patient experiencing behavioual outbursts limiting ability to engage in PT/OT assessment/treatment and discharge planning.

Planned to review function and behaviour mane, and refer to SW re: ?supports needed for d/c

Reviewed patient with team in the morning. Discussion re: sending him home re: not participating with PT, and abusing nursing staff

OT and SW arranged to meet with patient to review needs for discharge, and ? supports.

Patient communicated by answering closed questions directed by OT regarding how managing here, how will manage at home, what supports he thinks he may need. Patient receptive to answering questions.

The breakthrough....

By applying occupation he was alot more willing to participate. It was simple but it worked.

I used an occupational task such as getting dressed and asked him to show/demonstrate how he can manage putting on this underpants and trousers - and he did it no probs.

Although he didnt want to participate in any transfer practice i was able to apply what i had seen with him moving on the bed, and what i had talked with from the nursing staff and what i new his enviornment was like to determine that he should manage physically at home.

But i was concerned about his behaviour and what he may do at home, as he had a hx of sleeping alot. Others raised questions about his cognition, and i wondered how i could even begin to assess that. From what i new about the patient, when he was answering my questions he was very appropriate, and he was prev living alone.

Im a bit stuck on where i can go from here? Other than asking the family if they have any concerns about his ability to live independently etc.

I came out of the interaction with him feeling really good about my interaction with him, i was able to get alot of information out of him by thinking about how to approach the situation, thinking about the wording of each question and linking it to why i needed to see e.g. d/c

I discussed this with the SW, who wasnt so convinced that it went well, however the rest of the team that had known the patient were convinced that it was a good outcome for this paticular patient.

So plans from here

a) contact family re: d/c plans and support they require ? if they can offer or if they want assistance

b) ability to live independenly long term? screening cognition

c) discuss in supervision re: behaviour/cognition and how best to assess this patient

Jess

Case review

2010-02-14T23:30:00.000-08:00

Case Review
Reason for referral:
Leg gave way, due to pain in the side of his waist - lost balance - fall - # R) ankle - ORIF – TWB
Supplementary fall post injury when showering before presenting to ED
Person information:
70 year old male
Social information:
Lives alone Supportive Daughter in the area No formal supports
Medical/Therapy hx:
Tumour removed 20 years ago from cervical spine- resulting in nerve damage
Graduated decline in sensory loss, and resulting gait pattern disturbances
Assessments:
• Sensory assessment: Wears glasses; Profoundly deaf
• Specific sensory loss in R) leg (from hip down:
 -no proprioception
 -impaired temperature sensation (hot/cold)
 -impaired pin prick sensation Specific motor loss in R) leg -decreased power & tonal changes
• Initial assessment
• Discussion with pt’s Daughter
Current Occupational Performance:
Independent bed mobility, lying to sitting and sit to stand from bed
UTT with supervision (due to gait disturbance and unsafe TWB mobility status
Independent grooming and self catheterisation
Fatigue/deconditioning
Assistance with lower limb wash/dry/dress
Independent with upper body/limb wash/dry/dress
Profound hearing loss possibly associated with not comprehending advice/instruction
Mild short term memory loss
High falls risk due to multiple factors (propriception not intact; new gait pattern; TWB mobility status; poor balance on L foot and decreased ROM on L) ankle; fatigue; a little impulsive).
Presenting problems:
Daughter concerned about memory loss
PT concerned about safety re: mobility and gait
OT concerned about overall ability to manage ADL’s with reduced sensation in R) leg and recommending a full review of occupations (and retraining to compensate for this.
OT and PT concerned about high falls history
OT concerned about hearing loss and ability to engage in communication in the community e.g. whether this has been the issue – instead of short term memory loss
Summary of OT input:
I had reviewed this patients notes and noticed that he had some major deficits, a very high falls hx, and his Daughter was concerned about his cognitive functioning in particular his memory. I happened to be around when the Psych Geri Dr was doing his round, and observed the medical team with the ACNM for an opportunity to gain some background information. This was very beneficial as I was introduced to some of the patients "physical" difficulties and was able to get a good social hx as well as a good account of his pre-admission occupational performance.
Following this, I met with the patient and his Daughter, introduced myself and explained my role.
I gained consent to complete an OT initial assessment, and found that I already had the answers to a lot of the questions, which sped up the process but also gave me the opportunity to look further into things. E.g. The patient had told the doctor of his normal walking pattern which I had noted, then I was able to ask him about his falls hx, and how this affected his independence with his daily tasks...he told me some concerning stories - like how he fell in the shower and got stuck. So I had determined that this patients pre-admission functioning was not particularly safe, and that sensory disturbances were a very impacting matter.

Process of assessing appropriateness for a period of OPRS:
After his operation I discussed this case with the ACNM and another Psych Geri Dr, re: what their thoughts were as for discharge planning. They said they would go by the PT/OT opinions, so I booked in a joint OT/PT session that afternoon with the PT, and we saw him together (It was really for a mobility and transfer session - so that I could talk with the PT afterwards re: ?appropriateness of OPRS. At this stage I talked with the patients nurse re: his hearing and she went ahead and booked him an audiology appointment.
So after the session the PT had made up her mind that OPRS was appropriate for the following reasons: for safety with mobilising and correct/safe technique - as he was a little impulsive.
I agreed, but for more OT specific reasons including:
a) Comprehensive assessment of ADL's to determine occupations that are unsafe due to decreased sensation etc.
b) Re-training to improved safety with ADL's to compensate for his decreased proprioception/sensation (SOME OF WHICH WILL BE MORE APPROPRIATE ONCE HE IS OUT OF HIS CAST)
c) Screening of cognition

OT Goals:
In 4 weeks, pt to be safe and independent with performing daily self care tasks e.g. showering, dressing by retraining techniques and utilising compensatory equipment for paralysis/sensory loss in R) leg, in order to return home and be safe living in the community.
In 4 weeks, pt to have his hearing assessed and cognitive functioning reviewed to rule out any significant impairment that may affect his safety to live independently.
In 4 weeks, pt to be safe preparing a meal by retraining techniques and utilising compensatory equipment for sensory loss in R) leg, in order to return home and be safe living in the community.
In 8 weeks, (once out of plaster) pt to be reviewed by OPRS community team to re-assess pt’s occupational performance once FWB, in order to ensure safe and independent occupational performance whilst compensating for L) leg paralysis/sensation loss.

Outcomes:
Transfer to OPRS inpatient team

Grief and Loss

2010-02-08T20:16:00.001-08:00

Today we had an inservice which was very valuable.
Grief and Loss - Increasing awareness of people we are working with.
Loss is so broad, weather its loosing a loved one, loosing the ability to drive, to partake in occupations, or a simple abilities like memory, writing neatly.
I had an experience today which i was able to use awareness in the situation, shortly after the inservice.
My patient, 83 year old man who had had a fall 2 weeks ago, and had come in with a w/o of his shoulder joint as it had become septic. This man has a complex medical hx, including sensation loss in his feet, weakness in one of his legs, heart problems, and multiple joint replacements. His life had changed over the last few years, he talked about how he couldn't "do" what he use to do e.g. household tasks, bowls, socializing at other peoples houses because he couldn't access them or use their toilets.
I pondered on the things he was telling me, all these things that he use to be able to do, but now needed assistance with, or others had to do. Then it really made me realize how much of an impact an injury has on peoples well-beings, how complex and frustrating life can be for people.
I talked this over with him, emphasising with him, saying how much of an impact an injury or illness can have and it made me realize how anxious he was about his living arrangements.
I have further reflected on this situation.
This patient reported to me initially that he had no concerns about going home, and that he had all support necessary for d/c.
But because i went another layer down, specific to his occupations and leisure activities, i was able to uncover that he underneath he was very frustrated, and by acknowledging this with him, he opened up by giving me further detail into how his wife had been coping with doing the household tasks over the past few months.
I uncovered that she may have been very frustrated (reports from patient) that he couldn't help up as much anymore, and that it was causing stress on there relationship.
Something I plan on talking with the social worker about, hoping but not guaranteeing there is anything that could help the situation as they have 2hr HH already.
Its a shame, an 80 odd year old couple, living independently together, but struggling to manage and unable to get any more support unless privately funded.

Workload

2010-02-08T19:58:00.000-08:00

This week has been very disorganized week full of complex patients, mtgs and unpredictable patients.
Lots of things have impacted, including
a)Patients have been ready earlier than expected e.g. elective patients.
b)Patients have been discharged earlier from PT (? new rotational PT)
c)I've had to pick up patients from a colleague that have not been seen
d)Electives haven't been seen pre-admission
e)New education sessions and inservice this month/year cutting down clinical time

I've realized its just a busy time and its a time for complex patients also. But i have definitely recognized this impact of organization and time management on effectively planning for discharges. This increases the chance of clear communication between team members and has a knock on affect in terms of working as a team.

How could I have changed things for the better?
Again better communication between all of us could have helped with organisation and time management.

I think one of the barriers for disharge planning on the ortho ward is that often it isnt appropriate for the OT to assess until the patient is mobile or neally ready for discharge from PT, and by that stage we have reviewed the notes and know a little about the patient then have to go in and assess for discharge and our input is much quicker. I think it would be helpful if we communicate with the physios to allow us to better plan when we are going to see patients so we know its an appropriate time (i.e. their mobility is improving - or when they are going to take them on the stairs)then we dotn have the problem of rushing at last minute for disharge planning.

I observed a case yesterday, where the PT had discharged a patient a bilat THJR, and my OT colleague was not happy for him to be discharged that day because when she assessed his transfers he was not safe. But because PT had discharged the staff were thinking that he was safe for discharge. A classic case of the power PT has on the ward. However, my collegue stood her ground and the ACNM listenned and delayed discharge till the following day (even though she wasnt happy about it).
For out elect hips especialy it would make a smoother discharge for the PT/OT to agree on a discharge date and talk about when they think its appropriate from both OT/PT view - working together and communicating..

Complex case review

2010-02-02T17:45:00.000-08:00

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
Hypotension
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:
Nil

Goals:
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. ‘

Problems:
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

An interesting case

2010-01-18T23:55:00.000-08:00

I have a patient who presented to hospital after falling down stairs and fracturing his lumbar spine. He has a complex social situation, multiple partners and 10 children. His x-partner has now become involved with the patient now that he is in hospital.
This patient has known dementia, and meeting him reviled that he is an interesting case. I found no known OT input recently so i decided to do the HDS with him as he was disorientated,confused and the physio had mentioned that he had difficulty following instructions.
The HDS reveled that he had a severe memory impairment, likely due to lack of concentration/attention. He often had behavioral outbursts when he had difficulty with questions and was very distractible. Some other aspects of the HDS were affected by his lack of concentration and behavioral responses to difficult tasks.
For this very reason i wish to observe him functioning to determine the impact of his cognitive impairments on his ability to live at home. Certainly needs more investigation, and i need a talk over with a senior

A complex case review

2009-12-20T22:25:00.000-08:00

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

2009-12-07T00:42:00.000-08:00

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

2009-12-02T22:39:00.000-08:00

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

In came a spanner to the works

2009-11-26T23:49:00.000-08:00

Case continued...
Ok so i had thought that the case was all sorted and that he would be discharge home and that would be that...
No that was the ideal.
Reviewing the notes and talking to my colleagues, it appeared that the patient was complaining and communicating his concerns about going home.
He did not agree with my decision that he steps were safe for him to get up and down on his bottom or by using the rail/ledge.
He was concerned about other things as well, and didnt appear to be able to problem solve his way though situations.
I had heard that he had been giving other staff members grief and so i expected that he would give it to me as well.
In hindsight I should have completed more in-depth education with him, and helped him to problem solve, but i new he had told the PT's that he wanted to do it his way.
He was not going to stop arguing with me so i decided to leave the situation and seek support.
The staff and my colleagues were amazing. They talked over the whole case with me, and offered advice of how to deal with his complaints.

Reflecting on the whole thing now...
This case could have been better managed by myself, but i realize that this man was particularly difficult.
How could i have managed the case better?
Perhaps got the PT, RN and or SW to visit the patient with me to coordinate the discharge better and facilitate question and answering sessions with him.
Perhaps think about defining my role with him, so that it was clear from the start e.g.that one of my roles was to assess from a professional opinion about his home environment safety, not to provide him with an alternative house/situation.

Overall, we got it sorted, I double educated him and provided him written advice or recommendations for managing at home.
I had amazing support from the ward staff and OT's - and it really reflects that new graduates do need support with clinical reasoning even when you think its a simple case

Jess

My communication

2009-11-25T18:38:00.001-08:00

I have been reflecting on my communication style over the last week. I have realised the following...

Sometimes i often miss out detail when talking with people that is important. I wonder if this is to do with being in a hurry, or just my ability to remember all of the detail and verbalize it. I wonder if i may experience some anxiety and freek myself out when communicating with certain people, causing me to give a brief response. Actually i wonder if the problem is that i have so much to say, that i try and say it all and forget what it is that is the most important to communicate.
So... i guess i need to slow my processing down, and provide a prompt for myself so that i communicate the essential without rambling off the topic nor missing things out.
Think il give this a try......

Sometimes I switch off when listening, as hard as that is to admit its important that i do so that i can work on it. Who knows what important information i dont pick up on, or what the other person thinks of me when I switch off.
Listening is an essential part of communicating with others. I wonder why i have trouble maintaining attention. Its likely to be do do with nutrition, hydration and sleep...all of which im working hard on!
I guess my attention span is also influenced by taking regular breaks throughout the day, which is also important, and i have successfully managed to take morning tea breaks for a while now with the MDT members.
Unfortunately sleep is the best currently, however it can only get better!
I wonder if there are any other influences that make me switch off and not listen well. I definitely dont just switch off because i dont want to listen...talking about cases with my team members interests me and the information is definitely worth while knowing. Hmmm... This makes me sound awful - THIS DOES NOT HAPPEN ALL THE TIME!

Also... i have noticed that sometimes i cut people off before they are finished speaking! This is definitely rude and i try very hard not to do it! But sometimes i get carried away with my thoughts and what to express them then and there! Thats when its hard for me to keep listenning and remember what i was going to say. Man it sounds like my brain doesnt function very well at all.
How am i meant to listen and recall at the same time - this is a skill i have yet to master! However again it doesnt happen all the time.
I either listen and totally forget what i was going to say, or dont listen and then talk...How can i remember and listen!???

On a more positive side of things...I do communicate essential and relevant information to my team members, and i notice that they appreciate me doing so. It helps us work better as a team, sharing information and problem solving though situations. All in all it makes discharge planning a smoother process.

So just the basics i need to work on i think! And to finish up

-Done some reflection through self awareness

-Worked out what influences my interactions

-Starting to work on my communicating and well-being!

Jess..

Case review

2009-11-25T11:42:00.000-08:00

Yesterday, I had an interesting case that seems to be keep popping up in my head. Kind of a confusion - that i havn't quite figured out why the patient was like he was.

This patient was in his 50's, prev very fit man, with little medical hx. He lived alone and worked full time.
He had # his foot, quite a nasty crush injury that required surgery and grafting.
When i went to see him, he was mobilizing quite well, however PT notes had reported some anxiety about thinking he was going to fall.

When i went to meet this patient he appeared to be quite onto it, new exactly what he wanted and was very direct with his discharge "needs".
When talking to him about returning home he was very insistent that i sent someone out to look at his stairs. He described this come as a stable, and he lived in the top of it, like an attic. He was determined that he was not going to be able to access his house, however when asked he had no other solutions and no other places to stay. Was he providing a barrier to return home or was he sincerely concerned?
The PT was trying the stairs with him later that day- on his bottom also.
One would expect a person of his age, structure and his previous function to be able to get up stairs on his bottom.
So I had come across a break in the road towards discharge. This demonstrates why OT should have become involved with the patient prior to the expected day of discharge. However, who would have thought that this would have happened. The PT only started working with the patient the day prior, i guess they had expected it to be a straight forward case also. But essentially we were delaying the discharge.
I decided to ask our therapies assistant to do an environmental visit, and to install the equipment he required all in one as he had "no-one" who could take the equipment home.
As it turned out, the stairs were steep, but not unsafe or inaccessible on his bottom or holding the rail and ledge. I handed this information over to the PT, and they had no concerns about the patients ability to get up and down the stairs on his bottom or on his crutches. PT had discharged the patient, as he was independent mobilizing on the ward and going up/down stairs.
So together, we had sorted out this discharge, and the ACC package of care was being processed.
The only thing left now, the patients anxiety or was it anxiety? This is hard to know...
Was there anything else i could have done with this case? Something id like to talk about with a senior...

Jess

Thinking about my time on ortho/surgery now

2009-11-17T21:39:00.000-08:00

Ive been thinking about how things work on the ortho ward... As usual it is fast paced and busy at times and I try my hardest to see all patients with an occupational need!
But of course there are times when that is not possible and I cannot see patients that are lower priority e.g. awaiting a bed in rehab.
At present the process is, that once on the waiting list for rehab the patient is definitely going to have a period of rehab no matter what performance gains they make in the period on the acute ward.
I feel that if a patient could be discharged from the ortho ward and return to the community with support without a period of rehab, then this is appropriate. However there have been a few cases recently where patients have gone to rehab reluctant of whether they really need to.
I'm trying to think about if it is feasible to provide intense input on an acute ward, whilst managing the elective patient, influx of surgical referrals and the other acute patients.
In a perfect situation, all patients could be OT sorted from the acute ward if they are making great gains in their mobility, and their cognitive function is intact enough to be aware of their occupational performance and accept the support they need to make gains in their occupational performance in the community.
The first thing I need to think about is what type of input is necessary to enable a safe discharge for a patient, and not necessarily having a period of rehab.

Lets try an example -A common occurrence

An elderly patient, say an 80 year old patient that lives alone, and has previously been quite independent, and is cognitively intact.

The patient has had a fall and has fractured their NOF. Day 1 after surgery they are referred to rehab, based on the fact that they were previously quite independent, and a period of rehab will help them return to their previous level of occupational performance.

Day 2 the patient is up and mobilizing with the physio and requiring 1 or 2 people to assist them. They are also having some assistance with their personal cares.

Day 3 the patient is accepted for rehab and put on the waiting list, hoping to get over to rehab within a couple of days.

Day 3 or 4 the occupational therapist could do one of three things
a) notice that the patient has been accepted for rehab and try and see them if they can to smoothen the transition from acute to rehab wards

or

b) not have any time to see the patient because of other patient demands

or

c) assess the level of occupational performance, set goals and begin working on increasing independence and safety with ADL's

Ideally, c) would be the aim. Either way the patient would be benefiting from commencing OT input.

We have the odd patient, who at day 4 gets up, the pain is under control, they are mobilising quite well and they are having minimal assistance with ADL's
This is when i think it would be appropriate to determine whether the patient could get home from the acute ward, or whether rehab is needed.

Unfortunately, we have limited control, as they are called up for a rehab bed, the patient and family thinks they are going to rehab, and the rest of the MDT are going along with the fact the rehab is the plan.

So here comes my thoughts.

At day 4 we have a better understanding of the impact of the injury on the patients occupational performance and mobility. Is it not more appropriate to assess whether or not rehab is required then? I think so!
Their are political influences currently, that we cannot really change that stops us from saying hang on a minute - they dont really need rehab!

So the patient ends up going over for rehab for a minimum of 10 days - some times not appropriate at all.

Where should our resources be used?
Spending the time - maybe a couple of days in the acute wards more than usual to work on increasing occupational performance, confidence and mobility?
Or should we send the mobile patients that are struggling a little over for 10 days of input?

This is where, i believe we should give patients more time on the acute wards...
But again we come back to the question.....is this feasible??

I dont think this is an easy question to answer, and I dont think in the interim we are going to sort this out.
But perhaps for what it is worth, when we have time to spend more time with the patients awaiting for rehab we should monitor what gains we are making and record if we think patients could have been discharged from the acute ward.

Then we come to the issue of time management on the ward. Definitly, at times we can have more input with the patients awaiting rehab than at other times. It depends on a variety of things...usually whether or not the surgical ward has referred alot of patients for us.

That is another kettle of fish! The referrals from there i mean..
Perhaps some education and setting up some processes for the surgical ward would make us be able to manage the referrals from there alot better, and cut out alot of the inappropriate referrals.

I think thats the place I need to start, then figure out whether or not their is time to sort patients from the acute wards

The patient in the example above, the patient who has had a NOF - fixed with a DHS - no precautions. Can be treated just like any other patient. Depending on the patient, a home visit is not always essential, yes assessing their function and working on activity tolerance and activity performance is needed, but I think it is definitely achievable.

Something to keep thinking about I think

Jess

Communication styles

2009-11-16T19:51:00.000-08:00

I have found this great website on communication.
I have chosen to look at my communication style, and look at my interaction with colleagues at work.
http://trainingpd.suite101.com/article.cfm/communication_styles

It is important to understand how your communication style is interpreted by others to avoid miscommunication and misunderstandings. The goal is communicate with assertion and avoid an aggressive, passive-aggressive or passive style of communication.

Aggressive Communication is classified by:

__You choose and make decisions for others.

__You are brutally honest.

__You are direct and forceful

__You are self enhancing and derogatory.

__You’ll participate in a win-lose situation only if you’ll win.

__You demand your own way.

__You feel righteous, superior, controlling – later possibly feeling guilt.

__Others feel humiliated, defensive, resentful and hurt around you.

__Others view you in the exchange as angry, vengeful, distrustful and fearful.

__The outcome is usually that your goal is achieved at the expense of others. Your rights are upheld but others are violated.

__Your underlying belief system is that you have to put others down to protect yourself.

Passive Communication

__You allow others to choose and make decisions for you.

__You are emotionally dishonest.

__You are indirect and self denying.

__You are inhibited.

__If you get your own way, it is by chance.

__You feel anxious, ignored, helpless, manipulated, angry at yourself and/or others.

__Others feel guilty or superior and frustrated with you.

__Others view you in the exchange as a pushover and that you don’t know what you want or how you stand on an issue.

__The outcome is that others achieve their goals at your expense. Your rights are violated.

__Your underlying belief is that you should never make someone uncomfortable or displeased except yourself.

Passive-Aggressive Communication

__You manipulate others to choose your way.

__You appear honest but underlying comments confuse.

__You tend towards indirectness with the air of being direct.

__You are self-enhancing but not straight forward about it.

__In win-lose situations you will make the opponent look bad or manipulate it so you win.

__If you don’t get your way you’ll make snide comments or pout and be the victim.

__You feel confused, unclear on how to feel, you’re angry but not sure why. Later you possibly feel guilty.

__Others feel confused, frustrated, not sure who you are or what you stand for or what to expect next.

__Others view you in the exchange as someone they need to protect themselves from and fear being manipulated and controlled.

__The outcome is that the goal is avoided or ignored as it cause such confusion or the outcome is the same as with an aggressive or passive style.

__Your underlying belief is that you need to fight to be heard and respected. If that means you need to manipulate, be passive or aggressive, so be it.

Assertive Communication

__You choose and make decisions for you.

__You are sensitive and caring with your honesty.

__You are direct.

__You are self-respecting, self expressive and straight forward.

__You convert win-lose situations to win-win ones.

__You are willing to compromise and negotiate.

__You feel confident, self-respecting, goal-oriented, valued. Later you may feel a sense of accomplishment.

__Others feel valued and respected.

__Others view you with respect, trust and understand where you stand.

__The outcome is determined by above-board negotiation. Your rights and others are respected.

__Your underlying belief is that you have a responsibility to protect your own rights. You respect others but not necessarily their behaviour.

An important aspect is self awareness>

Employers no longer just look for a set of industry related skills. They look for leadership potential and that includes a high level of emotional intelligence (EI). The competencies that make up EI include self-awareness, social awareness, self management and relationship management.

Being aware of your emotional triggers and why they trigger you is key to practicing emotional intelligence principles. Emotional triggers are events or personality types that cause an intense emotional response.

Common emotional triggers are:

Blatant incompetence
Poor executive leadership (no demonstration of values, inconsistent, poor decision making, unavailable or unapproachable)
Being overlooked for credit, accolades or promotions
Arrogance or inflated egos
Patronization or micro-management of subordinates
Back stabbing
Verbal attacks
Lack of communication
These are things that will frustrate and upset the best of us. The important point here is to see if they trigger intense, long-lasting reactions with ramifications that make it difficult to remain rational.

Handling criticism with grace is a skill that will get you promoted. It is important to understand how to disarm your critics and to be able to listen and not take it as a personal attack on your character.

Emotional outbursts impact those around you. Understand that your fluctuating moods and passionate reactions to things can affect productivity and morale.

Also found this great site on teamwork and communication

http://trainingpd.suite101.com/article.cfm/communication_and_teamwork

3. Do your team members feel free to disagree with you?

Some leaders feel that subordinates that disagree are showing disrespect and being insubordinate. Certainly if they are disagreeing without cause, that can be a sign of insubordination but no one is perfect and encouraging staff to present an opposing viewpoint and the rationale behind the argument can prevent costly mistakes or poor decision making. Frequently frontline workers have valuable insights as they are the point of contact with customers. It is very important to open the lines of communication so that you can receive this customer feedback. Try to not be defensive when your decisions are challenged and instead ask questions so that you fully understand why they think you are making the wrong decision. The more information you have, the better.

4. Do you have an open door policy?

How approachable you are will influence how many surprises you receive. If you are constantly finding out information too late, it may be because your team does not feel free to communicate with you. How have you created a climate based on fear? Do you threaten them with loss of their jobs, loss of resources or increased overtime? Do you lose your temper frequently over mistakes? Threats delivered overtly or subliminally will only create a climate of fear and a total communication breakdown.

In the next article, Change Management and Innovation: How a leader can effectively communicate change initiatives and encourage innovation in a team, we'll look at the questions:

5. Do your team members react to change initiatives well?

Improving self awareness>

Reacting with your gut is reacting when you are at an emotional peak. Try to take the time needed to regain emotional composure so that you can respond from your head i.e. allow time for the adrenalin and other chemicals to subside so that you are at a place of logic and reason. Generally this takes about 20 minutes. In some circumstances however, you may need to sleep on things and look at them fresh the next morning.

I think now that i am more aware of the types of communications i need to reflect and become more aware of myself.

So i have some questions that i want to reflect on over the next week, when communicating with my colleagues.

1. In times of miscommunication, how has this affected my work?
2. Has my communicating enabled others to be informed consistently?
3. Have I been direct and forceful with my communication?
4. How have others communicated with me?
5. Have there been times of emotional change when others have communicated with me?
6. Have I allowed others to make decisions for me?
7. Do others get confused or frustrated when communicating with me?
8. How do I handle situations that don’t go my way?
9. Do I feel valued and respected within the team?
10. Do I respect others opinions when I disagree with them? How do I communicate that I disagree? How does this impact the working relationship?
11. Am I approachable? Do I make myself available to communicate with?

Reflections to follow in 1/52 ish

Jess

Interesting case

2009-09-06T23:01:00.000-07:00

I have a patient at the moment who presented to hospital with confusion +++ and a severe UTI. Over the last few months he has been declining in cognition and has become more regularly confused and disorientated. His UTI definitely exacabated his confusion and he became more aggressive also.
When i first met the man he was disorientated to time, place and person and was being aggressive towards the nursing staff. At this time he was also having difficulties answering questions but it was hard to determine whether this was difficulties with attention, comprehension or expression.
It is now 4 days later, and he is more orientated to time, place and person. HOwever he is still having difficulties answering questions
e.g. what city are we in - he verbally said the wrong answer but when asked to write it down he got it correct
This tends to suggest he was having difficulty expressing..however when asked to say his date of birth he got the numbers mixed up e.g. 24 Month 1922 instead of 22 Month 1924. When asked to right it down he still couldn't figure it out, and there were some cross outs and several attempts made.

His wife reports he has had difficultly over the last month expressing what he wants e.g. he asked for an ice berg when he wanted an eskimo pie ice cream. When his wife tries to figure out what he means and gets it wrong or cannot guess he gets very angry and frustrated.

I have decided to do an HDS cognitive screen as his memory, registration and ?attention are concerning. I would like to do a broader assessment before i took into his difficulty expressing what he wants. It appears he knows what he wants to say but is having difficulty expressing it - like a verbal expressive aphasia

From researching this i have found some interesting information ...

Expressive aphasia, known as Broca's aphasia in clinical neuropsychology and agrammatic aphasia in cognitive neuropsychology, is an aphasia caused by damage to or developmental issues in anterior regions of the brain, including (but not limited to) the left posterior inferior frontal gyrus known as Broca's area
Middle cerebral arteries supplies this area
Aphasia's usual result from brain lesion

Anyway this all needs further investigation and definitely follow up in the community perhaps with the community rehab team
I know the medical team were planning a CT scan - be good to follow this up also

Case FOR DISCUSSION!

Advocating for rehab

2009-09-02T20:30:00.000-07:00

A patient i had been working with was recently diagnosed with Motor Neuron Disease (MND).
The patient had declined in mobility and therefore occupational performance since admission and from a medical perspective rehab was not appropriate.

HOWEVER - I thought different!
This patient was a 73 year old male who lives with his wife (who has started doing everything for the patient).
He has had some input from the Community Rehab team - and so the medical team thought it would be appropriate for the patient to go home with follow up. However he had declined since admission

Pre-admission he was walking and falling
Now he was only managing transfers - and it was deemed unlikely that he would gain much mroe ability to walk.

SO... As an advocate in MDT meeting i disucssed to the medical team and others that Inpatient rehab would be very beneficial to enable the patient to adjust to a change in occupational performance and learn to compensate for his reduced mobility. The PT supported me and the medical team (may not have understood) but at least trusted that we were making an appropriate recommendation.

SO...the patient was accepted for an inpatient rehab stay and i have set clear OT goals that the patient wants to achieve when he is in rehab.

Good outcome of advocacy and communication!

Case Review

2009-09-02T20:16:00.000-07:00

I was referred a patient who lives with his family and his a well respected Maori Elder in the community. He was presenting as what nursing staff described as "innappropriate" "confused" and "vague".
I went to see this gentleman and we got chatting about his roles and values at home. He looks after his grandchildren with his wife and values this alot.
I explained my role and the reason i had received a referral. He admitted that his brain wasnt as fast as it use to be and his thinking was alot slower. I began asking some questions to screen his cognition. When i asked him a question he would not respond with an appropriate response - change the subject and talk about his medical condition.
So was this hearing?, not wanting to answer my question? didnt know the answer? Or more likely cultural????????????
As i went on i wondered if he was feeling quite intimidated by me. I remember thinking back about the Maori Culture and i thought it must of been hard for him to have a "young" "white" "girl" ask him questions and "testing him".
I reflected on this case and talked about it with an OT colleauge. This was probebly the case as he was recognised as a Maori Elder. It all made sense as i ended the session when he said he felt interigated as he didnt know what the questions were about and why i was asking them (even though i had explained)
I did have concerns however about his cogntiion and i didnt want to leave my assessment at that as i had alot of information and no idea what to do...so i contacted the Maori Liason unit and asked if they would support me by visiting him with me. The plan was to assess him preparing a meal however it ended up that the pysch geri team leader arrived to see the patient at the same time so we all sat around and chatted together.
The patient also identified that he would prefer to be assessed in his own environemnt which became the plan with f/u from pysch geri OT.

All in all a good learning experience in respecting the Maori culture and not pushing the boundaries. Also a good use of the Maori Liason unit as they new the patient well though the community and were able to explain what he is usually like.

Jumping into ortho

2009-08-26T21:19:00.000-07:00

Changed wards this week - good change, fast change and ive just jumped on into it. Team members and staff are all welcoming and helpful - which is great.
Picked up several complex patients including multi traumas and have several medical boarders as well - so still have a touch of "home" on medical lol

Lots of learning well revising from my prev experience on ortho at my last job - i can see im going to get more skilled assessing for wheelchairs and activity analysis for multi traumas

Most days (so far) i have been going home brain dead from problem solving though situations and figuring out how a patient is going to "do" things.
Trying hard to place high emphasis on occupational performance but plan to do a case review to really break down an occupation i deal with on a daily basis and look at all the different aspects of it affecting performance.

This will help me with analysis and make sure my assessments are thoughouh and occupation specific

Case Review

2009-08-11T02:22:00.000-07:00

I have had a patient who has been in hospital for a long period of time. At first the doctors have labeled her the mystery patient as they could not figure out what was wrong with her. She came in with malnutrition and abdominal pain. A serious of tests including blood, CT's and MRI's came back normal - they could not figure out what was wrong.

In the meantime i was working with the patient as she had pressure areas on her sacrum and heel, and she had de-conditioned and the simplest thing was hard for her e.g. pulling her pants down to go to the toilet - let alone getting to the toilet.

The patient was a 34 year old female, living in a HNZ flat with her flatmate (ex-partner).
She had no mental health history so know one had thought of perhaps she had an eating disorder. This was the doctors last resort - to get the psych team involved. Although it never really was a clear case she is now on an eating management plan and will be discharged once she gets to a certain weight.

2 weeks of assessment by the doctor had gone by, and im trying to think back of the time spent with this patient. Was there any indication that the patient may have been suffering from an eating disorder.

I remember thinking "how could someone get so sick without seeking medical treatment or intervention e.g. not getting out of bed and not making it to the toilet on time.

Maybe she was ashamed of herself, maybe her mood was affecting her drive to get better, maybe she was in denial that she even had a problem...

I remember her saying "i use to love food..but i cant eat it any more because it all tastes funny. Maybe this was an excuse. Maybe this was her reasoning for no longer enjoying food or no longer wanting to nourish herself

I remember her refusing PT input, maybe this was low drive affected by mood. in some ways the cues were there - but i never really analyzed them until afterwards

I guess i just expected that there was a "medical reason" for her illness because of her presenting complains e.g. pain and malnutrition

Just goes to show the process of assessment is a complex one and so very important - so many cues and hypothesis to think through and problem solve through

7 weeks to go on medical

2009-07-05T20:55:00.000-07:00

Oh time has flown - ive really been here for 6 months - and i feel like i have learnt alot - now to reflect on what the medical rotation has offered me and what i have developed skill in...

I feel i have developed better communication and confidence with talking with the medical team - especially communicating results of assessments for complex patients

I feel i have learnt so much about "cognition" but i wish to continue learning about this - it has become an interest of mine

I have learnt heaps about the medical processes including
a) involving other team members and referrals
b) handing over to rehab
c) assessing appropriateness for a period of rehab
d) organising home visits
e) liasing with family re: prior level of function
f) reasons for a cognitive assessment or when it is not appropriate

I next plan to assess my model against how i have fitted into this setting - and kind of a test it out

Jess

Case Review

2009-06-10T00:25:00.000-07:00

I have an interesting case at the moment - well kind of complex

She is a 77 year old that as had numerous admissions to hospital over the last year. This admission was not directly linked to why she was referred to me. She was referred to me because she was presenting as very confused on the ward and repeating things that she had talked about already.
I went to see the patient and she presented rather "different". There was something about her that i couldn't pin point. She made a cup of milo indpendanly and safely on the ward but i chose to re-assess as i wasn't happy with the assessment data that i had gather.
I chose to do a standardised assessment - Hierarchic Dementia Scale. The results concluded that this patient had a severe short term memory impairment and mild-moderate attention/concentration, registration and long term memory issues.
From here i was concerned about the patients ability to manage in the community as she was home alone all day and was required to attend to personal cares, taking medications, and preparing lunch/breakfast throughout the day. So i decided to do a more complex functional task - preparing and light meal. From my observations she required assistance with searching and locating items (which shouldn't be problematic in a familiar environment) and remembering each instruction i had asked her to do e.g. "please can you make a pouched egg pn a piece of toast, present it on the table, and make a cup of tea to have with your meal...when you are finished can you please tidy up after you. The patient safely and Indep. prepared the meal but required prompting to tidy up. At times the patient became distracted and lost attention - pausing in the middle of the task - it was like she was thinking about what to do next - however she independently continued on with the task without prompting. I have no concerns about her ability to prepare simple meals and went back to talk to the team about my concerns about discharge

(1) - taking medications
(2) - managing finances

The team thought that a family meeting was appropriate so i went to contact the SW and family to organise this.
I got lots of useful information about the patient from contacting the family.

-The ST memory had been concerning them - she was been experiencing this for about 4-5 months however it has declined since her stroke about 6 weeks ago.

-They were concerned about her discharge location and the support that her partner could provide - as her partner had mentioned that he didn't know if he could cope with her ST memory decline - repetitiveness...

The goal of the family meeting is to
a) sort out discharge destination
b) sort out appropriate support for the patient - family or services

All will be relieved tomorrow - however this may take a bit of working with the family as it potentially could be a complex situation

Jess

File:Spinal nerve.svg - Wikipedia, the free encyclopedia

2009-06-05T01:49:00.000-07:00

File:Spinal nerve.svg - Wikipedia, the free encyclopedia

Sensory pathway - posterior/dorsal column

2009-06-05T01:45:00.000-07:00

The posterior column-medial lemniscus pathway (dorsal column-medial lemniscus pathway) is the sensory pathway responsible for transmitting fine touch, vibration and conscious proprioceptive information from the body to the cerebral cortex.[1]

The name comes from the two structures that the sensation travels up: the posterior (or dorsal) columns of the spinal cord, and the medial lemniscus in the brainstem. Because the posterior columns are also called dorsal columns, the pathway is often called the dorsal column-medial lemniscus system, or DCML for short. (Also called posterior column-medial lemniscus or PCML pathway).

Observing some stroke patients and beginning input with stroke patients

2009-06-05T01:21:00.001-07:00

I have had the opportunity to see a stroke patient today - she wasnt under the stroke team but her MRI came back with 2 R) Cerebellar infacts and CT results showed small ischaemic haemorrages.
Interestingly the patient had an inner ear infection about a month ago and her initial symptoms were suggestive of problems with inner ear - e.g. balance disturbance and dizziness...However she also had a headache and heart palipitations and ended up in hospital after collapsing (although not loosing conciousness).

I reviewed her notes and spent some time reviewing what had been happening for the patient. I had the opportunity to observe the registrar completing some sensory tests which was quite exciting.
She tested proprioception (asking the patient to close her eyes and describe the movement she was making with her metatarsel joint.
She tested vibration sense - with a metal fork that she banged and held on he joint asking the patient to identify when the vibration was present and when it stopped. I had the opportunity to experience what this sense felt like and the consultant was very helpful and also did a few other sensory tests on me
He did some sound and hearing tests with the vibration fork asking me to identify what sound of the fork was louder. He also put the end of the fork on my forehead and asking me to tell me what side was louder (was ment to be the same level of sound - which it was - so im normal)
The registrar also tested touch - with prick and dull pressure
The consultant tried to explain to me the senses they test for and it brought back some of the learning from teck about the spinal cord and the columns and which sense is associated with each - this interested me and i felt like looking this up on the net!
Next post will follow !!!!!!!!

As for my experience assessing this patient - her main issues were balance disturbance and fatigue
I completed an initial assessment wth the patient and identified any pre-dysfunction - good thing i did this becuase she had had a carpel tunnel repair to her effected side and this had already weakened her R hand strength.. She had no concerns about managing at home and the PT had assessed that she was safe for discharge with PT comm f/u.
I reviewed her function on the ward and set her home up for discharge, educated the patient on energy conservation etc.
After talking to my supervisor she took this a step further and we talked about fatigue diary as the patient still works and is keen to return to work as soon as possible. I plan to ring the patient next week and educate her on this

Fatigue diary - to rate the level of fatigue (am, late am, lunch, mid pm, late pm, bedtime) at various times and when doing activity. This aims to increase insight into fatigue levels during certain times of the day and during/after certain activities....then they can hopefully apply some energy conservation techniques to help control fatigue...

I also had the opportunity to observe the PT assessment - balance, gait, steps, nose finger (with increasing speed) and heel shin rub etc - it would be good if i could talk to the PT about what some of the more complex assessments were testing specifically - quite an interesting afternoon today!

PTA

2009-05-12T02:19:00.000-07:00

This week i have had an interesting case - a 69 year old male who was admitted to hospital due to an unwitnessed fall resulting in facial and head fractures, a head injury and rib fractures. His GSC was 3/15 - identifying a serious head injury! 3 is also the total minimum score

He presents with the following symptoms of a head injury:
-sensitivity to light/sound
-agitation/restlessness/irritable
-poor attention/concentration
-poor orientation (person and time)
-lack of understanding of reasoning for being in hospital
-impaired short term memory
-saying bizarre things e.g. "the particular month is"
-extreme tiredness

I have commenced the PTA with this patient
Day 1 4/7
Day 2 5/12
Day 3...
From reading though my teck notes on PTA severity and if the patient stays in PTA for longer than 7 days this can be further classified as very severe head injury. Its sad to say but the longer the length of PTA the worser the outcomes...

After discussing my observations with my supervisor - we were able to determine that the patient was able to communicate basic "needs" e.g. thirst

It would be interesting to know if there has been any personality changes and get some information about pre-accident functioning so i can hand over to the rehab team

I have decided to do some reading about head injuries
Reference:

McWilliams, S. (1996). Head injury. In Turner, A., Foster, M., & JOhnson, S. E. (Eds.), Occupational therapy and physical dysfunction/. Principles, skills and practice (pp 463-469). New York: Churchill Livingstone.

Why have i been feeling out of control

2009-04-24T00:52:00.000-07:00

I think the pressure and lack of knowlege got to me this week! I realise now that i was getting uptight over nothing! Its all about pacing, working through things and getting support!

So many new things this week - pressure care, palliative patients, demanding relatives, and wheelchairs.

This brings 2 key messages

Pacing - knowing how much you can do within the time you have
Support - seeking when you are unsure or just need to talk things through

Key things i know about - i was seeking support but i think i have to develop the ability to pace myself!

What is a managable pace for me?
Things to consider as a new graduate
- ensuring i take time to do things and dont rush!

Need further refelction about this - plan for supervision!

Skills/Knowledge

2009-04-24T00:43:00.000-07:00

I believe being competent is more than just being able to "do" things, "knowing" how to do things and having the knowledge. Its being able to have a complete package of skills and knowledge!

On medical patients are often soooooooo complex - and everyday their is something different (hense the importance of support). I have found over the last wee while that its not being good at prioritsation and knowing criteria or about a diagnosis - its being able to combine all the skills and knowledge to keep up with the pace of the setting and provide a quality service to patients.

So my reflection about myself - My knowledge about condition is very limited therefore sometimes time is a limiting factor. My prioritising skills are their but im finding it hard to "apply them" - its hard to let go of stuff that you could be doing - but only being able to focus on the "necessary" - just gotta get use to it.

The importance of quick assessment

2009-04-23T01:44:00.000-07:00

I have been finding that over the last wee while i have been slow to assess patients function particularly if the team are thinking they may not may not benefit from rehab.
For example today i was referred a patient this morning and the physio had decided that this patient was not particulary appropraite for rehab. I went and talked to the patient and her daughter and gathered their perception of how the patient was going to function when she returned home. It was obvious that the daughter was VERY anxious and i should have been more proactive in assessing the function of the patient to determine whether or not she would be appropraite for rehab. By the time i got to assess the patients function i figured out that there my percpetion of how the patient was managing was ALOT different to the percpetion of the daughter. Also im not sure if the patient and her daughter realised the aim of rehab as i reflect now i think the reasons they thought rehab would be good was not for function it was for sorting out medical stuff...
The daughter was quite adament that her mother needed rehab and i could see that the patient had deconditioned in terms of activity tolerance and confidence. However after discussing this with my supervisor i realised that these were not "good" enough reasons to have a stint in rehab.
What i have learnt about myself today is alot!
1) i need to be more proactive in assessing function before even mentioning rehab (even though in this situation the daughter had already had her eyes set on it)
2) more importantly - i need to develop skill in reasoning with patient and clearly communicating with them how they are functioning, what they could or couldnt get out of rehab and i guess standing up for myself more - giving my opinion and recommendations and then letting the team decide

It was hard today because i felt like it was down to me to make the decision when it shouldnt have been like that at all! Im only part of the team!

Oh well i will learn! But i guess i need to get clear in my head the rationale for someone to be appropratie for rehab and start going though the criteria when considering if someone is appropriate

So here is a wee plan that i will talk about with my supervisor

Is this patient independent with ADL’S ?
Are they having trouble with mobility, transfers, showering, dressing or toileting?
Do they have room for improvement?
Has there function altered compared to pre-admission?
Do they have insight into their abilities?
Are they able to learn new information/techniques?
Do they live alone?
Do they have good supports?
Is pain the main issue?
Is confidence the main issue?

Brainstorm - how to ask patients about their percpetion of their cognition

2009-04-22T01:59:00.001-07:00

I have been having difficulty coming up with a "good" way of asking patients questions about their percpetion of their cognition before hospital admission. The purpose of this post is to brainstorm some ideas to take to my supervisor to discuss and get some ideas

Brainstorm questions:
General cognition:
Cognition invloves
a) processing of information - understanding thinking
b) applying knowledge
c) changing preferences
E.g. memory, association, concept formation, language, attention, perception, action, problem solving and mental imagery.

MEMORY
Tell me about your memory before you came into hospital?
Have you noticed any changes in your memory lately?
Have you ever forgotten about an appointment or burnt your food when cooking?

ORIENTATION
Have you ever forgotten where you were or the time of day it was?

PROBLEM SOLVING
Have you ever been in a tricky situation and you didnt know what to do?
Do you manage paying your bills? Is this ever tricky? If so can you tell me about that?

ORGANISATION SKILLS
Do you have trouble organising yourself for doing things e.g.getting ready to go shopping or getting the kitchen/food ready for preparing a meal?

OTHER
Have you ever had problems remembering the names of an object?
Have you ever got lost when driving around your neighbourhood/around lower hutt?

As you can see i have tried to brainstorm questions around functional activities that a patient might be doing before admission?

Helping out on surgical

2009-04-21T03:03:00.000-07:00

A staff member has been away on leave this week and i have been picking up a bit of general surgical patients - and i have decided to do a bit of comparing between medical and surgical

-Often patients on surgical "recover" alot more rapidly and sometimes by the time they leave the ward they actually dont need some of the equipment you have assessed for

-Support is likely to be more "short term" - where as in medical more of the elderly patients require it more long term as they have complex or multiple medical issues

-The processes are alot more different! as they are everywhere - but im having no problems asking where things are!

-More medical terms and surgerys that i dont know the precautions for!

-Easier to know how to prioritise them as they have a clearer discharge plan

-Patients are less likely to be "complex" and more of them are younger and likely to be working!

Enjoying the different experience

Meeting a patients "wants"

2009-04-21T02:40:00.000-07:00

I have been working with a patient who is palliative. His main goal was to return home and look after himself, and he was determined not to have MOW.
When i was first referred to this patient he was pretty imobile and the team was having trouble getting him to do things independantly. He wouldnt walk for the physio and the nurses were being asked by the patient do do most ADL's for him.
I completed an intitial interview with the patient and discovered that he really wanted to go home but was requiring assistance (from his perpective) with all ADL's.
When i did a shower assessment with the patient i encouraged him to do things by himself if he could and ask for assistance if he really needed it. The patient asked for assistance but it was hard to determine if this was due to pain, motivation or tiredness. From this assessment i talked to the team in regards to discharge planning. They were NOT aware that the patient was requiring so much assistance and at this stage i had concerns re: discharge home. The discharge was therefore delayed and the patient was assessed for rehab - as he was previously fully independant. However this was not feasable and the patient had the options of going home with a package of support or going into care. The medical team were thinking RH would be more appropraite but slowely they came round to the idea of going home! YAY
So i then worked with the patient to see what tasks he had to be able to do to return home. These were mobility around the top level of his home, preparing simple meals and transfering from bed and chair. So next the patient and I did a kitchen/breakfast preparation assessment - and i set the environment up to be as similar as it would be at home. I organised a perching stool as i had thought this may be helpful at home to conserve energy and increase his safety when preparing meals. As it turned out the patient sat to prepare all of the meal and sequenced everything appropriately. It became obvious that the patient had set routines he follows and had great insight into his abilities and symptoms if he was not feeling well. Therefore i was convinced that he would be safe to prepare simple meals at home, and he movilised 30m to get to the assessment and back with rests at each end.
We had a family mtg with the patient, Nurse Maude, RN's, Doctors, Myself, and the patients Son. It was great that everyone worked together with the primary aim of getting the patient home. I was organising a perching stool and bedside commode as the patient really wanted to try removal of his cathetor. Also it was my "field" to organise the bed. The nursing staff thought a hospital bed as on his bad days he sits up in bed and spends most of the time in bed. However i had assessed the patient to have Independant bed mobility and transfers. This is something i need to talk with my supervisor about as i need help justifying which selection is the best. Preferably the patient should have a hospital bed as he is likely to need it within the next few months anyway. He is also on an air mattress and he is very thin/deconditioned so i would recommend he has this at home also - especially for the bad days when he spends alot of time in bed.
One mistake i made today was ordering a mattress through supplies when they dont have them - opps - oh well i learnt from that - should have checked with another staff member tho! Just as well when i canncelled the order they hadnt processed it anyway.

So going to learn more about hospital beds and pressure care tomorrow - a learning need i do have.
I also have another patient who has a sacrum pressure area and i am going to be doing a Waterloo pressure area scale tommorrow with - which will be good learning that - so we can determine what mattress is required. Have to also find out what Grade the pressure area is though..

All for tonight

Challenging behaviour

2009-04-17T01:45:00.000-07:00

Yesterday i saw a patient who really got me upset, however i have personally reflected with other OT's and have learnt alot from the situation.

I met the patient and introduced myself, then did all the things i usually do...discussed the OT role (in this case to ensure the patients home environment was set up to facilitate a safe and successful discharge home. I then got consent and asked if he had ever had OT input before (and he had not).
I began the initial interview and right from the start i obtained cues from the patient that he wasnt comfortable with the questions i was asking him - it was like he didnt understand why i was asking them, and he was very rude to me e.g. "why do you need to know that" and "i wish all of you would stop talking about that i havn't had a fall in a week" From here it was obvious that building therapeutic rapport was very unlikely to happen. I decided to continue and alter the types of questions i focused on (which didnt work either) he was not interested in talking about his "life" his "occupations" and how he spent his day. It didnt matter what i asked him he was not very compliant. I tryed emphasizing what it was that i was there to do and how i could help him return home (which he wanted) but he became more and more frustrated with me and was quite aggressive. In hind site i should have just finished the converstaion and left but for some reason i stayed and battled some more until i just froze after one of his comments and said "i am going to go now - i will come and see you at another time". I realise now that it was a bad idea to say "i can see you are frustrated so if would you like me to go and come back - as this just made him sarcastic saying "you can go if you want or stay if you want" After about 10 mins i had left and hadnt got any information that i needed - it was really pointless staying there other than the observations that i was able to gather e.g. behaviour and personality.

In supervision today we talked through the situation and i have taken away some key learning:
(1) You will always have people that you come in contact with that are similar to this man - thats just reality
(2) The importance of observing and altering communication style throughout an interview
(3) That its ok to discontinue the interview or session if you feel at risk
(4) The importance of knowing how much you can cope with and what your boundaries are
(5) The importance of support as a new graduate
(6) The importance of REFLECTION
(7) Not to take things personally
(8) To learn from mistakes - identify what went wrong and work through different solutions

All in all - a horrible but good learning experience where i had great support from my team members and OT colleagues

Model of practice

2009-04-06T00:50:00.000-07:00

I have been thinking over the past 3 weeks or so that id like to reflect on the models of practice "we" bring as undergraduates - so i have started a new blog

http://modelsandacutephysicaloccupationaltherapy.wordpress.com/

I hope to develop my understanding of why the participants of my Hons reserach thought that the models "dont fit"

Discussing cases

2009-04-06T00:34:00.000-07:00

I have realised that over the last few weeks my communication with senior staff has decreased and i am wondering why this has been?
Is it that i am doing more thinking myself? Is it because the caseload is bigger? I know its not a lack of availability..but it may be because ive had a pretty busy time outside of work. It may be a combination of these influences but i finding that im feeling the pressure of work.
So what should i do to make things better? I think firstly i need to realise what i get out of case discussions.
Case discussions enable me to feel confident about what i am doing on a daily basis as well as increasing my knowledge about conditions, treatment options and processes.
Next i need to think about how i am helping myself. Why am i seeking less guidence? i do think i am balancing when i need to get advice and when i feel confident so i guess to a certain degree im capable of doing more by myself.
Even if this is the case i want to make a concious effort to talk more to my supervisor about what i am doing - talking about my caseload and exloring my clinical reasoning. I think now that "life" has settled down a bit more i can focus better when i am at work. I have gained alot in the past from talking through things even if it is in arrears because i can refelct on what i have done.
Where to from here?
Begin (again) activly talking about my day and the people i have seen

Drawing the line

2009-03-29T20:34:00.000-07:00

How to determine when a patient is going to be safe to go home when they have short term memory loss.
I have a patient at the moment who is the primary carer of his son who has an ID. He is 86 with an HDS of 160/200 primary impairments in attention and memory. The family is very supportive and they wish for him to return home..however the team in particular the nursing staff dont think he should go home. The patient has alot of support for personal care and domestic tasks but the primary issue is his memory - to remember to take his meds, pay bills, and remember to heat and eat meals.

I am yet to talk to the family (particularly his daughter) but i plan to ask what types of things they supported him with pre-admission and discuss the support he will need to compensate for his short term memory impairment.

I have liaised with the SW and the only problem the family has from a SW perspective is the amount of support they have at home. I am concerned about the patients ability to "be a career" for his son - and what this entails - as his primary role at home it is important from an OT perspective that he is able to do this. This is something i plan to investigate

Im still unsure "completely" if this patient is safe for discharge - obviously they will need supports with taking medications (whether this is a daily phone call to check or physical assistance or an alarm). And similar for ensuring the patient is eating appropriately.

Once the situation is decided i will also need to check out the home environment to ensure that it is physically safe for discharge as he has SOBOE ++++

The question that stumped me

2009-03-14T21:54:00.001-07:00

I was telling dad about an interesting experience that i had had at work and he asked me the strangest question...

"How do the people react to you when you are working with them when you are alot younger than them?"

At first i was stumped i didn't know an intelligent answer and the first thing that came out of my mouth was...

"What do you mean? I work with people and havnt noticed any issues with age"

I have thought about this more and considered why it was that i had never thought age was a problem. Firstly i have only been older than a few patients as an OT over the last year. Thinking back i dont think age changed how i approached them as a person. I approach everyone the same - with respect for their experience

I dont think it matters how old someone is but i believe that you get what you give. If you on in to see a patient and respect them, listen to them and be open and honest - then you'll get that back in return. So age to me doesn't matter, whether 20 or 90, you get what you give (most of the time)

The fact that my dad had asked me this lead me to believe that perhaps he would fell uncomfortable with a younger person working with him, giving them advice or discussing professional things. Hes an ordinary man...maybe people i have worked with have experienced a negative feeling about working with a younger professional. This is probably more common than i realise. I guess everyones unique but i had hoped that i could use my interpersonal skills and therapeutic use of self to allow the patient to feel comfortable and working with me, and gain a working professional relationship.

So how do i make this happen?????
WEll i have already mentioned respect, but also clear and open communication, ethical principles such as autonomy and informed consent.. On a broader level CCP!

This is so important and yet took some digging to get out and i realise just how embeeded these core elements are in "what i do"

The other thing that has popped into my head and is equally important is CONFIDENCE and COMPETENCE

I realise that there are things that i "know" and things that i dont! But i also believe that competence goes hand in hand with confidence. If i had competence in working with a patient about a particular topic or issue or diagnosis or functional issue then only could i have confidence working with the patient! However on the swing side of things - if a new grad presented as confident in doing something - this doesnt necessarily mean that they are "competent"...

Why does confidence and competence matter when working as a young professional???

Lets say i was unsure of how a cognitive impairment was likely to affect a patients safety at home...
There are two things that i imagine i could do..
(1) - Go in and see the patient confidently and say it (not really understanding what you are saying)
(2) - Go in with no confidence saying "im really unsure but i will find out for you"
(3) - Seeking advice and then going in confidently (knowing you are competent) and disucssing it with the patient and educating them ..

One guess what the best thing to do is - but anyway what im trying to explain is that low levels of confidence will negatively affect how the patient feels when working with someone whom is younger - therefore seeking advice, support etc is vitally important to ensure that issues of "age" or competence more in fact do not become an issue!

The importance of family communication

2009-03-12T21:47:00.000-07:00

If i hadnt had utilsed the opportunities to talk with the family of a patient i wouldnt have found out so much VITAL information!!!!!

A man who i have had a lot to do with over the last week on the medical ward is to me a "mystery man" But when i talked to his family to see what he was like pre-admission/pre-becoming unwell i wouldnt have linked the vital info together.
Talking with the family enable me to how his personality had changed. But more importantly they gave me some insight into their concerns and what they had observed on the ward.

I had realised and observed that this patient had difficulty initiating tasks/actions/activities but i had not realised that the nurses had not been supervising his ADLS including eating, showering, dressing and grooming. Therefore he was not attending to these basic tasks at all! How awful!

As a result of gathering this information is was soooo important that i handed it over when he went to rehab! They also had some vital information that would have been helpful when he was admitted - that he had been using a diary and alarms for reminding him of things (so therefore he was aware of his memory decline and was compensating for this impairments well before he was "brought" into the hospital by this colleague.

Up until now his diagnosis has been a mystery - various tests had not confirmed anything - still not confirmed but from my opinion (personality changes/cognitive issues) maybe this was Dementia of some type i have no idea..

TO some up - this example really illustrates the importance of working alongside family members, how vitally important they can be and how communication between team members and family is necessary.

Case review An interesting case, and interesting presentation and no diagnosis

2009-03-10T22:42:00.000-07:00

Gender/age/primary diagnosis - Male/57/No diagnosis ? CJD/delerium/neurological
Reason for referral - confusion, poor attention, for cognitive assessment
Medical Hx: Nil
Social situ: Lives alone, separated, 2 adult daughters in location
Occupation: Real estate agent
Prior OT input: Nil
Supports before admission: Nil
How managing before admission: Fully independent, high functioning being
Assistance on ward (mobility/self cares): Independent mobility, Supervision/assistance with self cares

OT input this admission/ Assessment(s): Initial interview, cognistat, kitchen assessment, discussion with daughters, physio and medical team

Problems identified:
(1) Poor attention/concentration
(2) Trouble initiating tasks/steps/action
(3) Difficulty with searching/locating and problem solving
(4) Slow information processing
(5) Frustration/emotional
(6) Difficulty planning, organizing and sequencing (? terminating)
(7) Poor standing balance
(8) Difficulty with verbal information/prompts

Strenghts:
(1) Insight into cognitive limitations
(2) Wanting to return to work - motivated
(3) Remembers OT on a daily basis, remembers when his daughters have visited
(4) Mobility and awareness of balance problems

Goals for rehab:
(1) Getting a diagnosis
(2) Returning home
(3) Returning to work (eventually)
(4) Work on problems identified

Outcomes:
Mr W is very frustrated and emotional in regards to his cognitive issues - he is aware of some of his limitations and realises he is unsafe to go home. He is upset that no one knows what has happened to him and he is finding it hard to cope with his changes in function.
Mr M has agreed for a period of rehab to sort out what is going on and to help him "get better"
Mr M has agreed for the vocational OT to become involved to help him return to work

Dysphasia in more detail

2009-03-09T03:21:00.001-07:00

Features of dysphasia

Dysphasia can be seen as a disruption in the links between thought and language. The diagnosis is made only after excluding sensory impairment of vision or hearing, perceptual impairment (agnosia), cognitive impairment (memory), impaired movement (apraxia) or thought disturbance as in dementia or schizophrenia. When testing for dysarthria and dysphasia, the patient%u2019s ability to repeat or produce difficult phrases or tongue twisters can be indicative.

People with receptive dysphasia often have language that is fluent with a normal rhythm and articulation but it is meaningless as they fail to comprehend what they are saying.
People with expressive dysphasia are not fluent and have difficulty forming words and sentences. There are grammatical errors and difficulty finding the right word. In severe cases they do not speak spontaneously but they usually understand what is said to them.

Specific types of aphasia are associated with damage to particular cortical regions but in practice distinctions are not always clear. Language is a complex activity involving many cortical and sub-cortical areas and lesions do not dissect clearly demarcated anatomical areas. Generally, expressive dysphasia suggests an anterior lesion while receptive dysphasia suggests a posterior lesion. There are a number of sub types. They are:

* Sensory (Wernicke's) aphasia - lesions are located in the left posterior perisylvian region and primary symptoms are general comprehension deficits, word retrieval deficits and semantic paraphasias. Lesions in this area damage the semantic content of language while leaving the language production function intact. The consequence is a fluent or receptive aphasia in which speech is fluent but lacking in content. Patients lack awareness of their speech difficulties. Semantics is the meaning of words. Semantic paraphrasia is the substitution of a semantically related but incorrect word.
* Production (Broca's) aphasia - lesions are located in the left pre-central areas. This is a non-fluent or expressive aphasia since there are deficits in speech production, prosody and syntactic comprehension. Patients will typically exhibit slow and halting speech but with good semantic content. Comprehension is usually good. Unlike Wernicke%u2019s aphasia, Broca%u2019s patients are aware of their language difficulties. Prosody is the study of the meter of verse. Here it means the rhythm of speech.
* Conduction aphasia - lesions are around the arcuate fasciculus, posterior parietal and temporal regions. Symptoms are naming deficits, inability to repeat non meaningful words and word strings although there is apparently normal speech comprehension and production. Patients are aware of their difficulties.
* Deep dysphasia - lesions are in the temporal lobe especially those mediating phonological processing. Symptoms are word repetition problems and semantic paraphasia (semantically related word substituted when asked to repeat a target word).
* Transcortical sensory aphasia - Lesions are in the junction areas of the temporal, parietal and occipital areas of left hemisphere. Symptoms are impaired comprehension, naming, reading, writing and semantic irrelevancies in speech.
* Transcortical motor aphasia - lesions are located between Broca%u2019s area and supplementary motor area. Symptoms are transient mutism, telegramatic, dysprosodic speech. Telegramatic means omitting unimportant words, as was done when sending a telegram. Dysprosodic speech is monotone.
* Global aphasia - occurs with extensive damage to the left perisylvian region, white matter, basal ganglia and thalamus. Symptoms are extensive and generalised deficits in comprehension, repetition, naming and speech production.

Revising dysarthia and dysphasia

2009-03-09T03:17:00.000-07:00

Dysarthria is a disorder of speech whilst dysphasia is a disorder of language.

* Speech is the process of articulation and pronunciation. It involves the bulbar muscles and the physical ability to form words.
* Language is the process in which thoughts and ideas become spoken. It involves the selection of words to be spoken, called semantics and the formulation of appropriate sentences or phrases called syntax.

Strictly speaking, the words anarthria and aphasia mean a total absence of ability to form speech or language but they are often used when dysarthria and dysphasia would be more correct.

Dysphasia can be receptive or expressive. Receptive dysphasia is difficulty in comprehension whilst expressive dysphasia is difficulty in putting words together to make meaning. In reality there is usually considerable overlap of all these conditions but a person who has pure dysarthria without dysphasia would be able to read and write as normal and to make meaningful gesture provided that the necessary motor pathways are intact.
Inability to write is agraphia or dysgraphia if incomplete. Inability to manipulate numbers is acalculia or dyscalculia if incomplete. Difficulty reading is dyslexia.

Frontal lobe dysfunction

2009-03-04T23:41:00.000-08:00

Recently i have worked with a patient who had difficulty organizing herself ? problems with initiation, and severe short term memory impairment.

I linked this all to frontal lobe damage and found a wonderful website (link below)

http://www.neuroskills.com/tbi/bfrontal.shtml

I am particularly interested in motor planning and the dysfunction of dyspraxia.

Dyspraxia is the inability of the brain to conceive, organize and carry out a sequence of events. In particular the inability to self organise.

During my assessments with this patient i noticed that the ability to organize was difficult.
For example i asked her to get her things ready for the shower. She went over to find her clothes and could not organize this and required verbal prompting. She was searching though her clothes but was unable to pick and choose the clothes she needed. She also required verbal prompting to organise her toiletries and get herself off to the bathroom. I think she would have taken all day with out prompting and don't know if she would have been successful after that.

Initially i thought it may have been difficult for her to choose the clothes - she had an idea of what she needed (she said i need a singlet, and knickers) but was unable to search - she may have had a plan of what she had to do but she couldn't execute this plan. She kept picking things up, putting them away and couldnt choose items of clothing.

On another occasion during a kitchen assessment i asked her to make a cup of tea. Everything was all organized for her and this was alot easier - everything was laid out in front of her and i introduced her to the environment. However this time i had some concerns as she was troubled with interacting purposefully with the environment. E.g. she picked up the jog to pour tea into the cup but didnt realise that she was ment to pick up the teapot that she had been waiting for.
This could have been memory - but i thought it was more to do with noticing environmental cues.

I would be interested in talking about these cues and my hypothesis further in supervision more to make sure i have got to grips with what a deficit in motor planning looks like, and to discuss other "obvious" observations that could arise in the future.

Case review - performance components

2009-03-03T15:04:00.000-08:00

Gender/age/primary diagnosis - Female/86/Compression # T12

Reason for referral - OT review decreased mobility

Medical Hx: Macular degeneration/Angina/AF/Bilat TJHR/Diverticulosis

Diverticulosis is a condition where pockets (pouches) form in the large intestine (colon).
Macular degeneration results in a gradual distortion of central vision, and sometimes leads to a central blind spot called a scotoma. When central vision is impaired, you may have difficulty recognizing faces and colors, driving a car, reading print, or doing close handwork, such as sewing or other handcrafts.

Social situ: Lives alone/Family supportive live close

Prior OT input: Rails installed by ACC for husband in bathroom, toilet and access

Supports before admission: HH 1/7

How managing before admission: I with ADL's ? unsafe cooking meals due to MD

Assistance on ward (mobility/self cares) - Supervision with mobility, Assist with transfers chair/bed/toilet.
Indep with upper body washing/drying/dressing
Assist with lower body washing/drying/dressing

OT input this admission/ Assessment(s): Initial assessment, transfer assessment, disussion with RN and Health care assessment

Problems identified:
-Unable to stand for long period of time
-Decrease vision ? safety at home for cooking meals (issue prior to admission)
-Assistance with lower body cares
-Assistance with transfers 1X

Goals for rehab:
-Increase independace - selfcare/transfers
-Pain management
-Increase standing tolerance
-Assess home situ re: safe for dishcharge re: visual impairment

Intervention:
Recommend for rehab
Handover to rehab team

Outcomes:
Pt is happy to go to rehab for a week or two and increase her independance. She will most certainly require a home visit re: safety with cooking at home, and home environment.

Performance Components:

Sensory: age related hearing loss/macular degeneration(loss of central vision)/nociceptive - back pain, elbow and shoulder pain during shoulder flexion/extension/ mild hip pain

Physical: Good posture when supported; reduced ROM in R elbow and R shoulder; reduced strenght in arms for transfers; moderate endurance; visual motor eye hand slightly inpaired

Cognitive: now problems with attention/concetration/insight/orientation - nil others assessed

Percpetual: (Visual) recognition of faces/objects/words/colour; colour disccriminations; figure ground; pattern and shape recognition/matching

Perceptual: (Spacial) Depth percpetion; percpetion of angles and levels

Social: Little expression or gesture/emotion/

First Cardiac Rehab Group - relaxation

2009-03-02T19:28:00.000-08:00

Well took the group today and it went really well

First i welcomed everyone and introduced myself, then checked to see if there were any new people. (there were note) If their was i was have talked about the benefits of relaxation more indepth. Instead i just mensioned the following:

Decreasing heart rate/rate of breathing
Lowering BP
Reducing physical fatigue
Improving ability to cope with tension, stress and pain
Can reduce frequency of headaches
Improve circulation to skin in muscles

So then i asked for feedback on last weeks session and asked if anyone had tried the techniques out for coping strategies with sleep problems..wasnt a great response however one person said that the thought stopping didnt work! But i reiterated that some things you find good, and some you dont - its about finding the one that works for you but not giving up on one if it doesnt work the first time because relaxation is a "learnt technique" and practice makes perfect.

Then i introduced visualisation as a technique - e.g. used for visualising yourself in a calm relaxing state, and it can also be about going in to a place that is peaceful and quiet.

Then we did the staircase relazxation technique, followed by discussing how everyone felt the technique went.
We got a good converstation going about how you know when you are relaxed as a man fell asleep! So i emphasised that relaxation techniques are working if it relaxes you to a point that makes you fall asleep.

I also added that if you were not interested in buying the tape/or didnt have anyone to read it too you then prehaps trying doing some deep breathing and practice visualising the quiet peaceful, special place and counting yourself down the stairs and think about the sensations of the place and relax all the muscles in your body. People seemed interested in doing this - or showed they understood what i was telling them.

All in all a good session - looking fwd to nxt week, and getting feedback about the process i used today

I was confident in talking and didnt get my words all mixed up. I had prepared myself with the information so i wasnt stuck for words.
I was able to get some discussions going but i guess its hard when people come in and out of the group. Anytime discussing is good time and it was good to hear their percpetion of how well things worked.

Communication with the team

2009-02-25T22:54:00.000-08:00

I certainly think that my communication has come along way in the last 2 weeks at work (as i get to know them all) however i think there are a few things that i need to go over in my brain as to when i should talk to other team members....

- If i am unsure if they are involved or had a referral - just check out - as there is nothing worse than receiving a late referral

- To pass on vital info - as there is only an MDT once a week - for this very reason i think it would be good to sit down as an interdisciplinary team and discuss patients once a week also
This would give us an opportunity to ensure that others were involved and help know if we are going to have to be involved and help us prioritise the case load.

- In a mtg like this we could all get a good understanding of social situ, presenting problems and the patients progress and any recommendations for discharge.

Just a thought

I just had a thought!

2009-02-25T22:47:00.001-08:00

All this time i have been focusing on patients limitations and using them to aid discharge planning..i feel awful i want to focus on both the clients strengths and weaknesses.

I think that when i document in patients notes (after assessments) i always put the problems and things that they did independently however from now on i wish to document their strengths, and not get tied up in their problems.

Im sure that this would also help the therapeutic relationship as well - everyone must want to know what others think they are doing well at!

I think of an example from practice where i could have done a better job!

I was discussing the results of a cognistat assessment with a patient and his wife. Im sad to report that i kind of brushed over what he did well and then talked more about the limitations of his cognition.

From now on im going to make sure that i place emphasis on patients strengths and then introduce the limitations.

Case review

2009-02-24T20:14:00.000-08:00

Name/age/primary diagnosis
SH/54/Phenomena

Reason for referral
Anxiety/?cognitive impairment

Medical Hx:RA

Social situ: Lives alone/Near Friends and Mother (walking distance)
Has a pet cat

Prior OT input:
Home environment set up/adaptive cutlery

Supports before admission: HH/PC 2/24.

How managing before admission: up and down days, assistance with most daily tasks e.g. showering, meal prep, cleaning. Independent mobility but has a wheel chair at home

Assistance on ward (mobility/self cares) - Independent mobility, d/c from PT; Full assistance of 1 on ward

OT input this admission/ Assessment(s): initial interview/functional tx assessment
Shower assessment.

Problems identified:

1) SH is struggling with alot of pain and is quite anxious about this.
2) SH is sick of being positive
3) SOBOE
4) SH has difficulty griping, doing bilateral hand skills, and manipulating small objects
5) SH overdoes things on "good days"

NIL evidence of any significant cognitive problem other that mild short term memory impairment

Beliefs: SH likes to keep her house tidy; do as much as she can; not be a burden on anyone.

Intervention:

1) Education about pain - "it is real"
2) Education about energy conservation - pacing/planning/prioritsing
3) Discussion about relaxation

Outcomes:

SH really appreciated the discussions and education and knows that pacing and not over doing things will decrease the chance of being in extreme pain. She has to decide for herself if she will take on the information and put to practice some of the energy conservation techniques.

SH has adequate supports in situ and her home environment is set up for her from prior OT input

Plan

D/C from OT

Developing rapport with a patient who is "known as" grumpy

2009-02-23T20:36:00.000-08:00

I was referred to a patient that other team members had trouble connecting with.

So i went and me the patient and introduced myself and my role etc.
My initial thoughts were oh my golly shes going to be very hard to connect with and work alongside. I thought this because she basically insulted me and said i was probably un educated like all other NZ children.

When i first met her she mentioned that she was English - and i notice she spoke very fast and prober. So i though prehaps if i asked her more about where she came from and her background this may help me develop a working relationship. We got talking and soon enough she was asking me questions in reciprocal. I spent time getting to know her and we got on to her interests and what she enjoyed doing. As we talked i gradually changed the topic from what she enjoyed doing to when she did it and then we began talking about her home and how she spent her day. I felt like we had a good conversation going and i was able to take her lead and talk about her home environment along the way.

Thinking about this later on..i think if i went in to see her and just asked questions about her home environment in a rather structured way i wouldnt have got the depth of information that i got and i wouldnt have found out about her as a person and her interests and needs.

It was very clear to me that this patient was very fussy and particular. But i feel after we had had that initial contact that gave us something to continue talking about next time i saw her. We began talking about the ships that came from England (as she was very interested in English literature and history) and my great grand father cam over on one of those boats - so we had a connecting point.

Anyway i learnt that it may take more time but you will get a better result if you do take the time to find out about them and let them guide the converstation.

This patient from my percpetion wasnt grumpy at all she was just particular and i think that may just have been part of her culture.

Highlights of this week

2009-02-19T00:03:00.000-08:00

Well i have to say that the busy nature of the acute ward has not yet hit - but its been a great week being not so busy.

I think my notes and observation have been good this week, and my time management has been pretty good also.

Still settling into the routine of the ward rounds but i am please to have figured out all the hiding spots of the notes and some key contacts that can help me if i need a question answered.

Getting to know the allied health staff on the ward well and feel confident discussing patient with them and doing joint sessions etc.

Analysis

2009-02-18T23:59:00.001-08:00

Analysis to me is the hardest part of the OT process - meaning ok this is what is wrong, this is what i have seen - know what does this mean? - how will this affect the patient?

It takes me time and a little prompting but i get there in the end. I want to start prompting myself so that i am taking responsibility for this and are able to run through cases with my supervisor and not have to sit there going ummmmmm...... maybe.... and then get prompted for the answer. Thats the plan from now on - filling in the gaps of the OT process and being able to take responsibility for my own work and thinking more.

Reflection from first week on medical ward

2009-02-18T23:38:00.000-08:00

This week has gone so fast!

I have seen quite a few patients and im starting to get to know the processes better. But i guess il learn them as time goes by and with experience using them.

Learning is a major part of my transition into this week - and i have to make sure that i bear this in mind when working with patients. In particular it is important that i identify things that i am unsure of and aim to find them out.

There are a few diagnosis that i am unsure of...yes it is important to know about conditions however i feel its more important to not focus on the condition, go into see a patient with an open mind and listen to their experience, learn from them and observe their function. I guess not going in with any preconception about how they should present with a certain condition will help me focus on the occupational performance. I would be interested in my supervisors view of this analysis of mine.

I think its become incredibly hard to be holistic on the medical ward...even though im still coming to terms with what holistic means in acute occupational therapy practice. Over the last week i have found myself talking with patients a lot more about their occupation, what things interest them, how they spend there day- and i find this helps me a) get an idea of their functional level before admission and b) connect and develop a rapport with them. I think thats why occupational therapists get along side patients much more because we are interested in their lives and not purely their pain/symptoms and medical readiness for d/c.

I am finding that my colleges are so useful to run ideas past, get advice and just flll me in or remind me of the hospital processes. Unlike my last job - its easier when your full time you can get some constancy going and learn at a quicker rate.

Im finding checking in with my supervisor very helpful and supportive. And its funny the day after i posted the articulation of reasoning post she recommended that i get some more structure so she can easily follow my clinical reasoning. I have made myself some wee prompts when i am reviewing cases and i think it will take some practice until i get some sort of flow. Im also not great at expressing what i think and this needs some practice and development as well. This is where this blog will come in helpful. I plan to review a case on this blog with no identifying information once a week on a thursday and take it to supervision to do a peer review and critical reflection.

Difficulty connecting with a patient

2009-02-16T21:27:00.000-08:00

Usually when i go and see a patient i find it really easy to connect with them and motivate them, however one patient i saw today was particularly hard to do this with. I didnt really know what to do - she presented with a short attention span, and didnt seem to be able to understand what i was asking her. However this ability seemed to fluctuate. She could give me an answer (during the initial interview) every know and then but other times she was very vague, looked out the window and just sat there as if i wasnt even there.

I tried some strategies to engage her like changing the positioning of my chair, using her name when i asked questions, and trying to take her lead when choosing questions. But unfortunitly i just didnt have any luck. I think maybe i was asking to longer questions and trying closed questions may have been more sucessful however on the spot i didnt think of this. This confused me alot as i wasnt aware that there was any cognitive impairment..

After discussing this case with my suprvisor she recommended that i contacted other OT's who had worked with her (to see if they had any of these problems) and to talk to her daugther to see if she has noticed any changes in her attention/memory and concentration. Unfortunitly i could not get hold of her daughter after several attempts but the OT could not remember the patient vividly enough to give me any detail.

So i decided to talk to other members of the team - i found the physio who had been working with her and she agreed that she was vague sometimes but she thought the problem was motivation...when i think about it i guess that could also be the case.

All this problem solving reminds me of in my training when we learn about cues/hypothesis etc

So heres it all broken down from the reference http://findarticles.com/p/articles/mi_qa3959/is_199910/ai_n8872039/pg_3

(1) Cue acquisition: gathering cues through observation, history, or physical examination;

(2) Hypothesis generation: generating initial hypotheses based on initial cues;

(3) Cue interpretation: formulating patterns of cues through weighing positive and negative evidence; and

(4) Hypothesis evaluation: applying the cues to the hypotheses and evaluating whether the hypotheses hold.

To problem solve this one i will break it down

CASE SCENARIO
(1) Cue acquisition: vague appearance when asked a question/not able to follow directions/

2) Hypothesis generation: un interested/un motivated/didnt understand the question/didnt hear me/short attention span

(3) Cue interpretation:

(4) Hypothesis evaluation:

Will go through this case with my supervisor tomorrow

Articulating OT process and reasoning

2009-02-16T21:17:00.000-08:00

Throughout the last two days i have been checking in with my supervisor who is on the same ward as me regarding patients that i have seen, what i have done with them and where to next.

I am finding that explaining what i have done has been rather "un organised" and i think this is an area i need to work on.
Its not that i dont know what i have done its putting together sentances and leaving out unnessasary information so that my superviser has a clear picture of what i have done with the patient, what happened, and where to next. I think its just becuase im still settling in and learning about the diagnosis on the medical ward.

For example my supervisor prompts me to talk to her about a particular patient and i dont follow a clear format so i am going to try and make a format to prompt me what to say until i get more competent with reporting the Ot process.

Maybe this..

This patient was referred by.....because....
Primary diagnosis
Secondary diagnosis/Med Hx
Info about social situation
OT input to date
Analysis of assessment/obs/interviews
Contact with other team members
Any discharge plans/referrals
Plan - where to now OT input wise

So i will try this and see how it goes :)

Jess

Beginning at my new job

2009-02-14T22:42:00.000-08:00

Well i have spent two days at my new job - learning the processes etc at the DHB, getting orientated and finding my way round. Ive found it easy to fit in with the OT's there because i know a few of them and some of them i trained with.

Havnt had any patient contact really, only sat in on a family mtg, and watched a kitchen assessment. Tomorrow i begin on the medical ward with my senior. So will be a big week where i can start utilsing this blog alot more for clinical reflecting.

I will invite my superviser to come on and read my reflections so she can monitor where my clinical reasoning is at.

I will draft up reflection model questions to stimulate ideas to reflect apon now.

Questions:

What have i done today/this week that was professionally challenging?

Can you think of a case that was reflecting a medical based model..and how could i change the way i approach situations, problem solve and work with patients to be more holistic?

What was frustrating/enjoyable this week?

How did i work with colleagues in clinical practice and how these interactions have evolved over time?

Think of a clinician/patient relationship that felt client centred? Why did it work so well?

When/how and what information did i seek this week that i was unsure about?

What have i learnt this week?

Think of a problem that you had to solve, how did you go about this/did you need any support or advice?

Got the rotation job

2009-02-08T12:55:00.000-08:00

I was sucessfull in landing a permanent OT position - clincial rotation
Start in a few days time - so exciting

Plan to use this blog for practice reflections weekly - putting a case study on here for supervision preparation - so i can peer review

I can identify knowledge that i require e.g. service questions or diagnosis/impairments

Also it would be good to write down questions that i need answered - if i dont get them asked informally.

Anyway look forward to seeing the first reflection from practice

Job hunting..

2009-01-27T22:15:00.000-08:00

Well in the job hunting and interviewing process at the moment - have a rotation position interview on friday so ive been doing some prep for that which i will post on here too keep for future reference.

Just thinking of good examples to demonstrate my skills and individual attiributes at this stage - and also going over the dhb mission/values etc.

Want to be well prepared for this job becoz its likely to have a lot of applicants and i really think this job will be great for my professional development and experience.

Post again..
When i have all my planning done

Jess

Practice, reasoning and reflection

Challenging Behaviour

Learning about OZ funding

Specialised Equipment Essential for Discharge (SEED)

Leaving one job and starting a new

Working on Rehab

Inservice Ideas...

MDT dynamics

What happened?

My reflection on this:

How could I have dealt with this better? What will I do next time?

Cultural Safety

Assessing Vision

Learning about Corpus Callosum

Pathology

Memory

[edit]Control

[edit]Attention

Respecting the rights of my patient

Prioritisng ...

Rheumo Case Review

Case review

Complex case QOL

Learning about Fibromyalgia

Supporting others

Finger extension and flexion

Mechanism for finger flexion

FDP: flexor digitorum profundus (the deeper of the two)FDS: flexor digitorum superficialis (the more superficial muscle)Although the FDP is deep to the FDS over most of its course, it attaches to the skeleton more distally, because it passes through a 'split' in the FDS tendon.

Mechanism for finger extension

extensor expansionextensor assemblyextensor apparatus

dorsal aponeurosisaponeurotic sleeve

The extensor mechanism is an elaboration of the extensor digitorum comunis (EDC) tendon on the dorsum of each phalanx. The extensor indicis (EI) and the extensor digiti minimi (EDM) insert into the extensor mechanisms of the second and fifth digits, respectively.

The EDC tendon attaches by a tendinous slip to the proximal phalanx, through which it extends the MP joint.The central tendon (or "slip") proceeds dorsally to attach to base of middle phalanx, where tension can extend the PIP joint.

3. the lateral bands proceed on either side of dorsal midline and rejoin before attaching to the distal phalanx. Tension in the lateral bands extends the DIP joint.

4. the extensor hood surrounds the MP joint laterally, medially, and dorsally, and receives tendinous fibers from the lumbricales and interossei.

5. Fibers of the oblique retinacular ligament (ORL) attach at the sides of the proximal phalanx and digital tendon sheaths, and proceed to distal portion of lateral bands. Thus, the ORL's line of application is volar to the PIP joint's lateral axis and dorsal to the DIP joint's lateral axis.

PIP extension (produced by other tissues in the extensor mechanism) elongates the ORL, creating passive tension that extends the DIP. The DIP extension helps open the hand.

DIP flexion (produced by the FDP) elongates the ORL, creating passive tension that flexes the PIP. The PIP flexion assists in finger closure.

1st observation RA, splinting

Learning about RA

Rheumatoid Arthritis

Drugs

Learning about Scleroderma

Case review: Motivating using occupations

Case review

Grief and Loss

Workload

Complex case review

An interesting case

A complex case review

An example of clinical reasoning

Seeking support when its needed to ensure safety

In came a spanner to the works

My communication

Case review

Thinking about my time on ortho/surgery now

Communication styles

Interesting case

Advocating for rehab

Case Review

Jumping into ortho

Case Review

7 weeks to go on medical

Case Review

File:Spinal nerve.svg - Wikipedia, the free encyclopedia

Sensory pathway - posterior/dorsal column

Observing some stroke patients and beginning input with stroke patients

PTA

Why have i been feeling out of control

Skills/Knowledge

The importance of quick assessment

Brainstorm - how to ask patients about their percpetion of their cognition

Helping out on surgical

Meeting a patients "wants"

Challenging behaviour

Model of practice

Discussing cases

Drawing the line

The question that stumped me

The importance of family communication

FDP: flexor digitorum profundus (the deeper of the two)
FDS: flexor digitorum superficialis (the more superficial muscle)
Although the FDP is deep to the FDS over most of its course, it attaches to the skeleton more distally, because it passes through a 'split' in the FDS tendon.

extensor expansion
extensor assembly
extensor apparatus

dorsal aponeurosis
aponeurotic sleeve

The EDC tendon attaches by a tendinous slip to the proximal phalanx, through which it extends the MP joint.
The central tendon (or "slip") proceeds dorsally to attach to base of middle phalanx, where tension can extend the PIP joint.