I always end up with the patients who have some kind of virus that requires contact isolation precautions -meaning I treat them in their room, doors shut, fully gowned and gloved and masked and dying of heat. On Monday I evaled a new patient, who I will call Kate, who had these same precautions. Kate is in her late thirties, morbidly obese, and was diagnosed with Clostridium difficile, otherwise known as C. diff. C. diff is an infection of the colon that occurs primarily with people who have been using antibiotics.
Typically when we get a new admit, they are scheduled for a 15-min occupational therapy and physical therapy evaluation, followed by 60 minutes of treatment for each discipline. Sometimes if admits arrive later in the day, we do the 15-min eval and treat the following day. But I like to do the whole 75 minutes because I feel that the 15-min eval time does not give me a clear picture of what my patient can do in terms of their daily tasks. With the 60-min treatment following the eval, I get to see their bed mobility, how they transfer out of their wheelchair with their walker, on and off the toilet, toilet hygiene, how they manage and don their clothes, how they transfer in and out of the shower, can they reach their feet and lower back to wash, can they locate their grooming materials while standing at the sink, can they balance well when reaching for things at the sink, put their pants on over their toes, pull them up in standing, how is their safety awareness?, are they impulsive, distractible, inattentive... At the same time, I get to converse with them and build rapport for a whole 75 minutes. I leave the eval having a pretty good sense of what they can accomplish. With a 15-min eval, I am in and out and my documentation sucks for whoever has to read it the following day.
So with Kate, I did the whole 75-min treatment, which was definitely needed. Because, due to Kate's generalized muscle weakness, she needed a bed bath. And half the time she was crying so we had to stop and give her room to breathe. Kate was, for the most part, max assist x2 -me and the CNA (my new bestfriend). I gave her a washcloth and had her do what she could on her own, which was wiping her face and chest. With what seems like the simplest task, Kate needed rest breaks. In the middle of it all, Kate needed to use the bed pan. I thought to myself how I'd feel if I were laying flat in a bed, unable to move my legs more than an inch, with two people completely gowned and masked hovering over me, helping me with the most intimate of tasks. Oh how we take things for granted. I told Kate that I hated being fully gowned. She told me she didn't blame me and that her son even refuses to visit her because it's such a pain to get all gowned up. I said, "That's not what I meant. I feel very impersonal in this. Like I'm here to conduct experients on my patients". We laughed.
Despite Kate's situation, she was a very pleasant lady. Our long-term goal was to get her in the shower. But first we had to get her to transfer safely into her wheelchair. The physical therapy assistant (PTA) and I did a lot of collarborating this week. Whenever she'd come back to the gym from her room, I'd chase after her and ask her how Kate did. There was always progress being made. She was able to get Kate up in a static standing position for one minute. Her main problem was pushing herself up from the bed with her arms. Her triceps were so weak and she had so much weight to carry. So we started with tricep exercises with her semi-reclined in bed. Then we progressed to her holding herself up in bed with her elbows locked and pumping herself up and down as best she could (even if it was just a centimeter) during bed mobility tasks. Kate broke down once during that session because she said her son came in to celebrate his birthday with her but she couldn't do anything for him. She couldn't be a mom. But that motivated her even more to continue with her exercises.
When I walked by her room the other day, one of the CNAs was getting all gowned up to go in. Kate's door was slightly open and I could see her sitting in her wheelchair, watching tv -her hair braided back. I stopped in the hall and called her name. She had a BIG smile on her face and we waved at eachother. She said in her cute, nasally voice, "Hello world! ..I'm suppose to say that to everyone who sees me today sitting in my chair". I loved it. And I told her I liked her hair. She stayed in that chair for 5 and a half hours, which I think was a little too much after being in supine for so long, because the next day she was worn out.
She had the energy the next day to go from supine to sitting on the edge of the bed. But when I got the CNA to help me assist her to do a partial-stand-pivot transfer, Kate freaked out. With time, we attempted it twice, but there was no way I was going to risk her falling on her face and going back to square one. So we decided to do a bed bath with her sitting on the edge of the bed. I gave her a couple washcloths and told her to go to work, and I'd be there to help with what she couldn't do. She was able to wash down to the top of her feet, part of her peri area, her chest and armpits, and her face. She was doing great. She combed her hair and I braided it. She put her gown on and rolled back in bed, lifting her legs up with just a few verbal cues on hand placement. I raised the head of her bed and then, out of nowhere, Kate started crying. I asked what she was so sad about. And she said, "I feel like I disappointed you. We were so excited to get in the shower today and I thought today was the day that I could do it". I told her, "Kate! I am going to tell you FIVE things that you did GREAT today". Here was my list that I pointed out to her (literally):
1. You got yourself up to the edge of the bed, where you sat with no assistance for about 30 minutes.
2. You washed your own legs and feet! Remember how I had to do that for you with you laying flat in bed the other day?
3. You washed part of your privates! How awesome is that?! (We laughed)
4. You got yourself back in bed with NO help from me to get your feet up.
5. Your hair's all combed! Granted I did the braiding. But I couldn't have done it if you hadn't have combed it! (We laughed again).
I told her that yes, she may not have gotten in the shower today, but to put her focus on what she COULD do today that she COULDN'T do yesterday. It all brings her one step closer to reaching her goal of getting in the shower. Baby steps. She was getting there.
I am hoping that once she is able to safely transfer to her wheelchair and her C. diff sample comes back negative, I can take her on an outing to the store. That was her long-long-LONG term goal. And I really want to make it happen to lift up her spirits. I told her yesterday how proud I was of her and that I was looking forward to seeing what we could do Monday. She was all smiles.
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