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