Case review: Motivating using occupations

Patient details:

Male, 31. Lives alone.

Family local, Mother and Father supportive

Out of area patient

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

Medical Hx:

Epilepsy

Seizure when young resulting in R) sided weakness

Genetic magnesium deficit disorder

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

Pain in R) knee increasing and reducing mobility

OT assessment/process

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

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

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

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

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

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

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

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

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

Outcomes of assessment by OT:

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

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

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

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

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

The breakthrough....

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

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

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

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

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

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

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

So plans from here

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

b) ability to live independenly long term? screening cognition

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

Jess

Case review

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

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

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

Outcomes:
Transfer to OPRS inpatient team

Grief and Loss

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

Workload

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

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

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

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

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

Complex case review

Personal information:
Male, 48 years
Elective admission – Bilateral TKJR

Social Hx:
Lives with wife and children/grandchildren
Has had to quit his job, due to immobility caused by bilateral knee OA
He was a representative rugby league player and when he stopped playing at the age of 33 started to put on weight.
He lives in a Maori Whanau with the associated dietary habits.

Reason for referral:
Advised at pre-admission, as patient for bilateral TKJR

Presenting problems as stated by patient/family/whanau:
Decreased mobility, fatigue, and pain.

Relevant medical and therapy history:
Bilateral medial compartment osteoarthritis of knees
He is morbidly obese with a weight of 205kg
Sleep apnoea
Hypotension
Mild Asthma

Statement of patient goals:
Short term: He wishes to regain his mobility, and return home with assistance from his family for personal ADL’s.
Long term: Regain independence in personal ADL’s and return to work (paper deliveries).

All assessments completed:
Environmental visit
Initial interview

Agencies involved prior to admission:
Nil



Goals:
In one week, Mr C to be independent with transfers (bed, chair, commode) using Barriatric compensatory equipment (bed lever/monkey bar, shower commode chair, lazy boy platform).

In one week, Mr C to be independent with mobility around home using barriatric walking frame/elbow crutches

In one week, Mr C to have adequate equipment in his home environment to enable independent toileting (urinal bottle, shower commode) in his bedroom.

In one week, Mr C to have a sponge wash with assistance from his Wife/Daughter using shower commode in his bedroom. ‘

Problems:
Ø No short-term hospital equipment suited to patients weight and size requirements
Ø No ward based hospital equipment suited to patients weight and size requirements
Ø Poor planning for admission – equipment needs on ward

Clinical/theoretical justifications for treatment:
Ø Based on enabling and maximising occupation within size and weight limits

Cultural needs:
Ø Family involvement in discharge planning e.g. supports, wishes re: attending to personal cares, what family have been assisting with.
Ø Housing and lifestyle - Problem solving with family re: recommendations for discharge as shower and toilet facilities inaccessible for patient

Advice provided:
Ø Safety aspects – accessing shower over bath, narrow doorways to bathroom and toilet.
Ø Enabling occupation – being cautious and discussing implications with patient when he requests compensatory equipment for home and its affect on rehabilitation at home


Ethical Issues:
Type of operation performed – Bilateral TKJR
Ø Poor mobility status pre-op/leg muscle weakness
Ø Safety risks for ward staff post operative
Ø Wearing out of prosthesis
Ø Implications on quality of life
Ø Weight gain/loss
Ø Pain control on ward

A member of the IDT – future father in law
Ø Impacting discussions in the team

Organisation of ward for admission:
Ø Better planning could have been initiated much earlier to organise necessary equipment e.g. walking frame, arm chair, shower commode, barriatric bed
Ø Pre-admission PT and OT input would have been beneficial to initiate patients needs on the ward, and get a better baseline occupational performance/mobility status.

Advice for OT’s in this situation: (Prior to patient admission)
Ø Get together with or talk about the patient to sort out a plan of attack e.g. ward equipment required to allow optimal treatment/input on the ward.
Ø Discuss in IDT meeting
Ø Complete pre-admission assessment/home visit
Ø Research barriatric equipment needs