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
Monday, January 18, 2010
Sunday, December 20, 2009
A complex case review
I have a patient at the moment who is severely underweight. She was admitted to the ward with a fractured neck of femur or # NOF. She was intoxicated when she presented to ED, and was admitted to my ward. She underwent surgery having a DHS (dynamic hip screw) procedure.
I had known this patient from a prior admission. She is 39 years old and has a history of drug and alcohol abuse, and depression. Last admission she had a pressure ulcer, had lost endless amounts of weight and was very de-conditioned. She was and still is a high pressure area risk. She "lives alone" however has a partner who is very supportive. She also has a supportive sister living in the area.
Pain has been a major issue for this patient, so from the very start it was hard for the physiotherapist to work with this patient. I decided to not have any involvement on the ward until she was actively participating and the medical team had sorted a plan for her.
I visited the patient to check in with her every few days, and i liaised with the physiotherapist often also. The nursing staff and medical team kept me in touch with what the plans were.
Last MDT we were up to the stage of figuring out a plan for her, as she was becoming more actively involved with physio. In the MDT we decided it was best that we organized a daily routine for her to help facilitate progress and get her more involved in therapy. The following day the physio and I met with the patient and discussed a daily routine, including physio sessions, rest times, self care tasks, leisure activities, and eating periods. I liaised with the dietitian re: meals.
I completed a daily planner, provided the patient with some sudoku's which she loves to do and sat down to look at some goals.
The concern i have now is that she has developed a broken area on her sacrum and will not remove the pillows from under her so that the air mattress can do what it is designed to do. She has great bed mobility, but this doesn't solve the problem of sleeping at night.
So hopefully over the next few days i will convince her to remove the pillows, wish me luck...the RN staff have had none...
I look forward to working with this patient every 2 days working on her activity tolerance and her independence with self care tasks.
Jess
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
Monday, December 7, 2009
An example of clinical reasoning
I have a patient (male, 86 years) at the moment who was admitted to the ward with a fractured humerus. He is known to the community rehab team, and there have been safety concerns voiced by various team members over recent months.
He has poor vision, postural HTN and Parkinson's disease. He lives in a two storied home and before he fell he was basically living in bed, and taking himself to the toilet.
The medical/surgical team were talking to the patient about considering RH level care. However, this NOK was very much against this. When i talked to the patient he wanted to return home if at all possible.
I want to encourage the patient to make his own decision, as well as providing some sort of recommendation as to if he would be safe at home. So due to his poor vision, decline in occ performance and postural HTN I decided the best way he can make an informed decision is to take him home, assess how he would manage and make my recommendations.
So the home visit is booked and il reflect on my recommendations and decisions post visit.
Jess
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
Wednesday, December 2, 2009
Seeking support when its needed to ensure safety
I have learnt that sometimes I take comments from patients too personal. I have realized that identifying when my emotion changes towards a situation that i need to seek support and talk over the situation with a senior OT as soon as possible, in order to reflect on what has happened and deal with it appropriately. At times throughout this year i have become upset in situations with patients, and this has stressed me out. I am aiming to be more self aware in these situations so that i don't over react, don't internalize thoughts and begin to analyze the comment or situation. On one particular occasion this year i have realised that it was not purely my wrong doing that caused a patient to act the way he did, which made me react negatively causing me to become upset by the situation. It is a team approach on the ward, and really the best thing to do when a patient has been "difficult" is to get together as a team and sort out the best approach to apply when working with the particular patient. E.g. with discharge planning, expectations, ways of dealing with questions/complaints/concerns. Over all, I have learnt the importance of ensuring the safety of myself by seeking support from my seniors
Jess
Jess
Thursday, November 26, 2009
In came a spanner to the works
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
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
Wednesday, November 25, 2009
My communication
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..
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
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
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
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