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.