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.


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.


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


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


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!


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...


Tuesday, November 17, 2009

Thinking about my time on ortho/surgery now

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


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


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 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


Monday, November 16, 2009

Communication styles

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.

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

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


Sunday, September 6, 2009

Interesting case

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


Wednesday, September 2, 2009

Advocating for rehab

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

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 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.

Wednesday, August 26, 2009

Jumping into ortho

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

Tuesday, August 11, 2009

Case Review

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

Sunday, July 5, 2009

7 weeks to go on medical

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


Wednesday, June 10, 2009

Case Review

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


Friday, June 5, 2009

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

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

Sensory pathway - posterior/dorsal column

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

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!

Tuesday, May 12, 2009


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
-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

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.

Friday, April 24, 2009

Why have i been feeling out of control

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!


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.

Thursday, April 23, 2009

The importance of quick assessment

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?

Wednesday, April 22, 2009

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

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.

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?

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

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?

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?

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?

Tuesday, April 21, 2009

Helping out on surgical

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"

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

Friday, April 17, 2009

Challenging behaviour

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

Monday, April 6, 2009

Model of practice

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

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

Discussing cases

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

Sunday, March 29, 2009

Drawing the line

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 ++++

Saturday, March 14, 2009

The question that stumped me

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!

Thursday, March 12, 2009

The importance of family communication

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.

Tuesday, March 10, 2009

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

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

(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

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

Monday, March 9, 2009

Dysphasia in more detail

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

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.

Wednesday, March 4, 2009

Frontal lobe dysfunction

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)

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.

Tuesday, March 3, 2009

Case review - performance components

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

Recommend for rehab
Handover to rehab team

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/

Monday, March 2, 2009

First Cardiac Rehab Group - relaxation

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.

Wednesday, February 25, 2009

Communication with the team

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!

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.

Tuesday, February 24, 2009

Case review

Name/age/primary diagnosis

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
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.


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


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


D/C from OT

Monday, February 23, 2009

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

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.

Thursday, February 19, 2009

Highlights of this week

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.

Wednesday, February 18, 2009


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

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.

Monday, February 16, 2009

Difficulty connecting with a patient

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

(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

(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

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 :)


Saturday, February 14, 2009

Beginning at my new job

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.


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?

Sunday, February 8, 2009

Got the rotation job

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

Tuesday, January 27, 2009

Job hunting..

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