Week 4: Weighing up

Week 4: 24-27 March 2015...

After a month of fieldwork, a life-jacket has been thrown to us in the form of a mid-term break. We've been given the chance to halt amidst the bobbing waves of prac and take a look back at how far we've come, and how far we still need to travel.

 

 

 

Over the last four weeks, I've seen my confidence grow as I've become used to the hospital routine and the therapy process. I have a better understanding of what's expected so that it no longer feels like I'm blindly feeling my way around treatment anymore, but am moving according to some sort of logical progression.

 

I've become more adept at building rapport with my clients, and slowly getting used to the knack of extracting maximum information within minimal interview time. I've begun to realise the importance of observation skills, which can confirm or invalidate information from interviews and provide quick, accurate assessment findings.

 

One of the most important principles of ensuring that the session is maximally therapeutic is the structuring of the work environment. Through practice, I find it easier to visualise where the client, myself and the required items should be placed to allow for development of necessary skills or improvement of the required performance components. It has also become easier to adapt as needed, moving things around as the client's position changes or fatigue sets in.

 

 

There are many aspects of treatment that I still need to work hard on before the end of fieldwork. One of my biggest challenges is time management: ensuring that there is enough time allocated to direct treatment, record-keeping and doing the necessary follow-up with other health care professionals.

Often, I find that I spend hours of time with the client only to realise that I have just a few minutes to document my findings in a logical manner within the patient file before having to rush down to catch the bus back to campus.

I still have some way to go, but over the past few weeks, my records have improved from the blue-ink randomly scribbled observations and assessment findings to the black-ink notes in slightly neater handwriting jotted down in an attempted SOAP pattern.

It's important that I spend sufficient time recording my treatment, so that it follows the correct sequence, is legible and gives a concise, comprehensive picture of what I accomplished with the client. Especially within an acute hospital, where patients are discharged or transferred within  a few days or weeks, it's important that whichever therapist takes over treatment from me is able to continue exactly where I left off.   

 

Another factor that I need to work on, and one that will also affect how much time I am required to spend with a particular client, is assertiveness.

It's important that I establish a balance between respecting the client's fatigue or pain, and being firm about what's expected of the client within the session so that no unnecessary time is wasted in trying to coerce the client through therapy. Within the activity session, it's important that I am clear about what constitutes acceptable standards of task completion, so that the client exerts the necessary effort.

 

Another aspect of fieldwork that requires attention is building professional links with other health care professionals working with my client, so that I can get an idea of the sort of therapy they are already receiving, and decide whether any additional referral should be made. I need to structure my schedule so that there is time to find each relevant department and make the necessary enquiries.

 

 

 

From where  I am, I can see the changes in myself from the beginning of fieldwork. As I look forward to the next few weeks of fieldwork, the horizon is bright with opportunities, and I can only hope I am able to make the best of each one. 

Week 3: Chasing Time

Week 3: 17-20 March...

 

As the third week of prac rolled in, it was as though some errant hospital worker had inadvertently pressed the fast forward switch. Patients were here one day, and gone the next.

 

 

 

Arriving on Tuesday, I was allocated two new clients, one inpatient and one out. This meant that I had to return all the way back to assessment once again. 

Having never encountered neuropathy before, it was a great experience to work on my first neuropathy client with a visiting medical student, who had an good theoretical knowledge of CNS dysfunction.

For the first time, I realised the value of working within an interdisciplinary team, with each member bringing in the expertise of their profession. I had more experience doing sensation and ROM assessments, while she was well versed in reflex and special sense testing.  

 

Working through assessments of ROM, muscle strength, sensation and balance, I realised that functionally, the client was presenting as a T10 paraplegic, event though the sensation findings were inconsistent. This assisted me in determining what would most likely need to be focused on during treatment.  

 

OT stresses the importance of client-centeredness: ensuring that therapy is relevant to the client. Therapy must be focused on return of function that the client views as important in the achievement of her life roles.

Upon asking the client what she felt was impacting on her most, she replied that it was her inability to get out of bed and move around that was preventing her from fulfilling her daily roles. I decided that mobility would therefore form the largest part of the therapeutic programme, as self-care and home management dysfunction would automatically be lessened if the client was able to move around her environment independently, with the use of mobility aids.

 

I began a functional assessment of bed mobility, realising, as the client was unable to roll over or sit up by herself, that this would be a good treatment session to begin with. However, the high hospital bed made structuring of the session slightly difficult as it was difficult for me to reach over the entire bed. I lowered the cot sides so that the client could be brought up to sitting on the side of the bed. However, I should have ensured that the client was closer to the edge of the bed before rolling her over, as she was too far back when brought to sitting, resulting in her needing to be shuffled forward.

 

My handling also required some adjustment, particularly the principle of using key points of control to facilitate movement of the client into sitting. Instead of pushing downwards over the left hip joint and pushing up on the right shoulder to bring the client into sitting, I had pushed on the right hip joint and pulled on the left shoulder, making my facilitation inefficient, requiring much more energy on the part of both myself and the client.

As I was rushing in order to complete the session in time for the CP group, I had focused too much on the end result of the session, instead of the therapeutic process. In future, even when moving straight from assessment to treatment in the same session, a little bit of time must be taken to quickly mentally run through the handling and structuring principles before commencing the activity, so that every action is controlled and therapeutic.

 

After Tuesday's fieldwork session, I drew up a bed mobility programme, with carefully considered principles to ensure a well-structured and fully therapeutic session. However, I arrived on Friday to find that the client had been discharged already...

 

 

 

On both Tuesday and Friday, I received clients with radial nerve palsy. For both clients, lack of grip was a major problem, as the first client found it hard to board public transport, and the second was employed in a job that required a lot of writing. Hence the aim for both was the combatting of wrist drop through wrist extension splints, and the increase of muscle strength of the finger flexors.

 

With both clients, wrist drop was evident, accompanied by the sensory deficits and muscle weakness associated with radial nerve damage. The first client had already been seen previously and issued with a wrist extension splint, which needed to be remoulded to accommodate muscle atrophy.

 

 

 

For the second client, I had to manufacture my first wrist extension splint from scratch. I worked at a 90 degree angle to the client, as the chairs and towel had already been placed in that position near the water heater. However, the structuring may not have been ideal, as the angle made it difficult to see whether the hand was in the correct alignment. Seating directly opposite the client, as we do when practicing splint-making on campus, may have been a better idea for this client. It may have also been better structuring for me to sit when moulding the splint, as I would have been at the same level of the client, and therefore have a better view of how the splint was turning out.

 

As time was running out, manufacture of the splint became very hurried towards the end, which may have been overwhelming for the client, having two people (Chantal and I) hovering over him and trying to ensure the splint was moulded correctly. I hope that as I gain experience, my splint-making skills will become faster and more efficient, resulting in neater splints in a shorter space of time.

 

 

On Friday, my distal radius and ulnar fracture client returned from re-debridement surgery. However, due to non-union of the fracture, she was now in a cast, with a sling to prevent mobilisation. The doctor advised that the arm should not be mobilised at all.

 

Hence, my aim of treatment had to be changed entirely, from preserving AROM in the unaffected joints of the injured arm, to a more generalised aim of maintaining AROM in unaffected limbs, maintaining physical endurance, increasing mental endurance and promoting engagement in constructive leisure pursuits.

 

Having prepared a knitting activity, structuring had to changed as well, as the client was now only able to use one arm functionally. Hence, I had to hold the frame steady, while she wound the string. However, after only a few seconds, the client's attention would waver as she heard the doctor's voice approaching or saw someone in the corridor outside. She would express that she was tired and put down the activity.

 

Another aim, therefore, would be to increase volition, as the client, due to prolonged hospitalisation, has become increasingly withdrawn, anxious and fatigued. To prevent deconditioning due to pain and lack of activity, sessions should be active, appealing and highly satisfactory. Using the client-centred approach, it will be important to use activities that are meaningful to the client, and that will assist her in returning to her chosen roles.

 

Having observed the client performing self-care tasks one-handed, I realised there is a need to incorporate hygiene principles, as well as more efficient methods of performing self-care into the treatment schedule, as it appears that due to complications in healing, the client may not have bilateral function for a longer period than anticipated.

 

 

With 3 weeks of fieldwork over, the clock is ticking faster. The rhythm of assessment and treatment is slowly becoming more familiar, but a lot of work still remains as we inch our way from theory to practice within the rapid timeframes of the acute setting.

  

Week 2: Piecing the Puzzle Together

Week 2: 10-13 March...

 

Activity is both the medium and endpoint of Occupational Therapy treatment. The key is choosing an activity that hits all the performance skills that need to be improved, but is at the same time enjoyable and relevant to the client.

When it came to my first activity session, I had it all planned out in my head: I would put a clay pot on an elevated surface, and would assist the client to reach up with her oedematous arm to stick pebbles onto the pot. By doing this, I hoped to maintain AROM of the unaffected shoulder and finger joints and reduce oedema.

However, two problems arose:

 

1. My client found it painful to flex her shoulder beyond 45 degrees. due to the weight of her cast, and due to the pain of her forearm. Hence, she refused to lift her affected arm up onto the elevated surface, or allow me to lift it for her.

 

2. Due to the oedema and tight bandaging, the client was not able to close her affected hand without severe pain, therefore she could not pick up the pebbles, even with hand-over-hand assistance.

 

We reached a compromise by which she would keep her arm as elevated as possible, and use it to hold the clay pot in place, while the other arm would be used to stick the pebbles onto the pot. This way, part of the aim would be achieved in that some shoulder flexion and elevation was maintained.

 

From this session, I grasped the importance of doing a thorough analysis of what the client can and cannot do so that correct structuring can be put into place. Even though the client should not have had problems with her shoulder and finger movements given that her diagnosis was a distal radial and ulna fracture, the other complications of sepsis, oedema and muscle atrophy due to prolonged hospitalisation must be taken into consideration as well.

 

For my next session with this client, I decided to use slings and a universal cuff to combat the problems I had experienced in the first session. The aim was to stick a large paper 'canvas' to the wall of the client's hospital room and engage the client in a painting activity through use of the slings to elevate the client's arm, and a universal cuff to hold the paintbrush. 

 

I entered the client's hospital room early the morning of the session, as I'd noticed she is significantly more active and cheerful earlier in the day. However, she had just had the dressings removed on her affected arm and was waiting for them to be reapplied. For infection control reasons, it was necessary to wait until the dressings had been replaced before applying the slings and commencing the treatment. I decided to complete my interview in this time, and demonstrated a one-handed knitting technique using a knitting frame to see whether she would be interested in doing a knitting activity in the next session.

 

2 hours later, the nurse arrived to redress the arm.

 

 

 

By this time, I had left the client to rest for a bit while I visited my new client, an ankle debridement client who was being prepared for discharge. After determining that she was independent in all ADL's with the use of crutches, was due to make a full recovery after a few weeks of bed rest, and had already been taught elevation techniques by her doctor to relieve oedema, I thanked her and returned to my first client. 

 

Now just after 11am, my client was already starting to tire and was not interested in doing an activity. I decided to set up anyway in the hope of arousing her curiosity. A few minutes later, she walked over to see what I had laid out and decided to participate. As she was slightly tired, we decided to downgrade by using a chair sit and paint instead of standing.

 

The slings, attached to a metal stand used to hold drips, worked perfectly. Using the slings, the client was able to maintain her arm in an elevated position for around 45 minutes with ease. However, the new bandage had been applied very thickly around the client's hand. As a result, the universal cuff holding the paintbrush could not fit over the client's hand. The client suggested using her other hand to paint, while leaving the affected hand in elevation.

This achieved the aim of elevation to decrease oedema, as well the aim of promoting shoulder flexion to maintain ROM of the shoulder joint. However, the aim of promoting mobilisation of the affected limb to maintain shoulder ROM and decrease oedema was not entirely met, because although the client moved her affected arm slightly to hold the paper as she painted, the horizontal ab- and adduction movements I'd been hoping for were not achieved.

 

Reflecting back on the structuring, it would have been possible to slide the paintbrush into one of the outer layers of the bandage to hold it in place, which would have allowed the client to paint using the affected hand, and thereby achieve the required mobilisation. However, dipping the paintbrush into the paint and water at this angle would have to be facilitated by me, or would require very specific structuring, e.g. sticking the watercolour palette in a vertical position on the wall next to the canvas.

 

 

 

 

The client thoroughly enjoyed the activity, and was reluctant to conclude painting once 12 o'clock arrived. I found that being engaged in an activity took her mind away from the pain of her arm, as she did not complain about the pain throughout the session, even though lifting her arm into the same position without an activity caused her to grimace with pain.

 

 

Not every client required as much careful planning and structuring. On Tuesday, it was refreshing to receive a finger debridement client, with whom I could conduct the full standard hand assessment, identify clear problems and immediately give him strengthening exercises which he could do on his return home that afternoon.

 

With more complex clients, such as my CVA client, there are still fairly standard assessment and treatment schedules to follow, with some variations for each client. For me, determining the schedule of treatment still needs some work, as I go about improving performance components in a slightly haphazard manner, for example, mixing fine and gross motor co-ordination activities instead of working from fine motor to gross motor. My structuring of therapy sessions also requires more thought, as there are many NDT principles, such as weight-bearing, crossing the midline and elongation of the affected limb that I can use to influence tone and activate muscle groups. How much physical handling I provide in the form of hand-over-hand facilitation must be modified depending on the activity and the client's progress.

 

I have also realised that when working in an acute hospital, where patients are discharged before therapy is complete, or even started, it is important to keep a file of home programmes or handouts of each of the common conditions or performance component deficits I am likely to experience, so that the clients can continue their treatment at home.

 

 

 

With 2 weeks complete, I find I'm staring to get a clearer idea of what OT in an acute setting entails, as well as where I as a student fall short. The level of thought that must go into each session to ensure it is entirely therapeutic feels immense to me, but through practice will become a natural second nature (I hope!)