Because my last internship was at an outpatient neuro rehab facility, I have developed great interest in neuro rehab. Which is why everytime we get a new-admit slip placed on the rehab desk at work that reads "CVA", I ask to have that patient put on my schedule. My patient, who I'll call Kelly, got admitted last Friday, having had what the doctor believes was a stroke to the occipital portion of her brain. According to her chart, nothing has been accurately diagnosed yet. In this case, and in any other case, you treat whatever you see. My ex-fieldwork supervisor in neuro rehab told me on my internship that, because the symptoms patients present vary with every CVA, it is important to not just rely on what the book tells you the symptoms are, but to explore the patient in depth, and treat what you discover during the evaluation and throughout treatment.
So here's what I discovered about Kelly. She was very weak. She could perform a toilet and shower transfer with me simply guiding her at her hips, but at any given moment, may need maximum assistance from two people because she can have muscle spasms in her legs in a split second. She can be in the middle of drying herself while sitting on her shower chair, and then collapse onto you because everything around her starts to spin. That was a little scary. She wears a black eye patch with a garter strapped around her head because she has double vision, and in order to focus on something and see it accurately, she has to have one eye closed. She has difficulty and fatigues easily with circular and vertical eye movements. She has poor short-term memory and divided attention. She will be walking to get clean clothes out of her drawer, get there, and forget what she walked over there for. Or she'll attempt to don her jeans in the morning and forget to take her pajama bottoms off.
With every limitation Kelly has, she has a million strengths. She is highly motivated. She is willing to try anything and everything I ask her to. One morning she was so nauseated after breakfast and kept apologizing for having to re-schedule, almost in tears, because she really wanted to do therapy. She goes to the afternoon recreational activities in our facility -attempting to play Bingo and Keno even though she tells me it's frustrating at times. Kelly also has a lot of hobbies and a thirst for learning new ones. She loves brain-teaser activities that are perfect for working on improving short-term memory. She has amazing family support. The posters, cards, flowers, pirate hat to match her eye patch, Winnie the Pooh and Snoopie stuffed animal in her room say it all. And whenever I recommend getting a portable grab bar or a vision stick or large-print playing cards, her daughter, parents, or husband will have it for her the next day to show me in therapy.
I look forward to working with Kelly every day because she makes me do treatments that are different from the typical ones I do with our more common patients with orthopedic injuries. It allows me to pull from what I've learned on my internship and be creative to find ways for her to re-learn new things or compensate for skills that may be difficult to regain. I've done visuomotor exercises with Kelly with her vision stick from the home exercise program she was given upon discharge from the hospital. But then I thought of ways to vary the exercises and make them more functional. We've scanned and read through the grocery newspaper which I really liked not only because Kelly loves grocery shopping, but because it has a lot of contrasting color and bigger font that make it easier for Kelly to read and maintain visual focus. I've taped a vertical and horizontal list of letters and numbers to the wall and had Kelly read them up and down, side to side, with her head facing the front and only moving her eyes(alternating the patch). I explained to Kelly that when she is discharged, she will have to be able to read signs being out and about in the community. At times I'd take out the middle portion of the list so she would have to jump back and forth to the first letter/number on one side and then to the first letter/number on the other side. Not only is she again working on her eye movement, but she is also working on her short-term memory and divided attention, because as she is going from one letter/number, she has to remember where her placement was and where she left off. I've played the memory game with Kelly and emphasized the importance of repetition, repetition, repetition. The more she reminded herself over and over again of what picture was beneathe the cards, the easier it was for her to finish the game. I printed an article on activities for short-term memory (http://www.livestrong.com/article/187149-activities-for-short-term-memory/) in large font and had Kelly read it during one of our sessions while, at the same time, teaching her how to use a rular to mark her place or use her finger to jump from one word to the next. It's amazing how one simple compensatory strategy can help.
In the meantime, we've also worked together to build Kelly's strength for safe transfers and shower tasks. On Thursday, almost a week after she was admitted, she asked if she could attempt shaving her legs because she hadn't for three weeks now. Why not! She was in the shower for, not kidding, a good 30 minutes. Hunched down, reaching for her ankles with her razor, she started laughing. When I asked her what was funny, she said to me, "I'm just laughing at the little things that are making me so happy right now". I grabbed my clip board and wrote that special quote down, thinking to myself, "That's what OT is all about". After her shower, she pulled out a pair of new jeans out of her drawer. She told me they were new and she couldn't fit into them when she bought them. She told me she lost 20+ lbs since before the hospital and wanted to try them on. She pulled them up over her legs all on her own, saying, "They feel so nice against my smooth skin! Amazing the things we take for granted." She layed supine, sucked her stomach in, and buttoned them shut. They fit. She sat on the edge of her bed and said to me, "I will never take things for granted ever again. Never."
On Friday, she mentioned she couldn't continue reading her novels on the kindle application on her iPad because the font was so small. So I saved the last 10 minutes in our therapy session to mess around with it. Surprisingly, my technologically-retarded self, discovered how to maximize the font. Kelly sighed and said wtih a big smile, "I can read now!" Next week, I'm going to print out large Sudoku sheets for her to work on since she told me she misses doing them. Then we are going to visit her home to give Kelly ideas on how to make her environment safer and more accessible. That should be a good session. And one to motivate her even more towards discharge.
Saturday, October 29, 2011
Friday, October 7, 2011
Room 104
I can't help but feel a sense of failure (even if it's slight) when a former patient of mine returns to our facility after a fall. I felt that for the first time on Wednesday morning. I was in room 104, doing a room treatment, when my patient's phone rang. It was not long until I realized that the person calling was someone my patient did not know. She said, "Here. Talk to my therapist" and handed me the phone. To my surprise, it was my ex-patient's daughter. That patient used to be in room 104 and was discharged a couple weeks ago. What her daughter told me broke my heart.
My patient fell on Saturday in the middle of the night, tripping over the wheel of her four-wheel walker as she was getting out of bed to go to the bathroom. She had not gotten out of bed since. It was already Wednesday. And according to her daughter, home health never arrived. First thing I asked was, "Did you take her to the hospital?" No. I was so confused. So I told her I'd see what I could do, never having this situation happen before, and that I was glad she called when she did. I talked to the physical therapist who also worked with this patient and our social worker, who was in charge of getting home health services set up prior to discharge. She took it from there and sent a home health nurse over to the house.
At 4:30, as I was getting ready to leave and was walking down the hall, I saw my patient's name outside one of the rooms. I stared at it for a second to make sure I was reading it correctly. Then I knocked, opened the door, and peeked inside. My patient (let's call her Connie) was attempting to sit up in bed with a big, gasping smile on her face. She opened her arms up to me. I made my way past her daughter, who was on the phone and ended up taking her call in the bathroom, and gave Connie a big hug. "What happened?!" I asked her. She told me how she fell and that she feels she has declined and has been depressed since she's been home and does not understand why. Then she hugged me again. I told her I was glad she was back under the circumstances and that we'll talk tomorrow and figure out what's been going on and how we can fix it. I told her, "You were READY to go home, Connie. In fact, you were more than ready." And she knew that.
When I first met Connie, she became very special to me right away. Connie used to be on hospice care, which was shocking to me. Because even though she fatigued easily when bending over to put her socks on and needed me guiding her into the shower, she had so much potential. With Connie's Rheumatoid Arthritis (RA), we adapted her writing utensils and found easier ways to allow her to open packages in the kitchen. With her Chronic Obstructive Pulmonary Disorder (COPD), we went over energy conservation strategies and did endurance training. With her decreased strength, we did bilateral upper extremity exercises and functional activities, keeping her RA precautions in mind. And with her depression, we talked. Mostly about family and baking and what she wishes she COULD do.
When her endurance finally picked up and her physical therapist gave me the go-ahead with walking long distances with her front-wheel walker, I planned a trip to the dollar store. When the facility driver and I went into her room to get her ready, she was sitting on the edge of the bed, with a big smile on her face, and a list of almost 20 items she wanted to purchase -all listed in her squiggly handwriting, that she told me she did with her adapted pen. Here's what she came up with:
3 birthday cards - one for my grandson, one for my sister, and one for my brother (this one has to be extra special).
Hairbrush
Hair color
Hair curlers (2 packs)
Hair spray
Mirror
Floss (2 packs)
Hot tamales
Pantyliners
Non-slip mat (The main reason we were going to the dollar store in the first place)
Mascara
Shades
Reading glasses
Small notebook
I wasn't sure if we could find all this stuff at the dollar store, but Connie reassured me we would. We got there and she looked like a kid in a candy store. On top of getting all the items on her list, she found more things she wanted. She demonstrated good endurance in walking for a long period of time, good safety with positioning her walker when reaching for items, and good fine motor skills as she manipulated her wallet and money. As we walked out, Connie said to me, "I haven't been taken to the store in 8 years". I felt happy and sorry for her all at the same time, I almost cried.
That same week we baked sugar cookies in the kitchen in the rehab gym. Connie told me she used to bake all the time but that she stopped because it became too difficult for her with her RA and COPD. But there she was! In control. Opening packages with minimal assistance and adaptive strategies, obtaining everything she needed, stirring ingredients in standing, managing the oven, and washing dishes. We stood there and ate a cookie (or two) before I walked her back to her room.
The following week, Connie told me she needed a smaller pair of black sweat pants because she had lost a lot of weight. She wanted to go to Ross for their Senior-20%-off-Tuesday. I scheduled it with the driver, which almost became a disaster because I wrote it on the Wednesday calendar by accident. Connie said if we couldn't go, she would've cried. Connie would've hated me (well, not really). The driver, by luck, showed up to her room at the perfect time to replace her oxygen tank and was greeted with Connie asking, "Ready to take me?" Luckily, he had no appointments scheduled and we were able to make it to Ross for our therapy session. She bought a pair of black sweats, a bunch of socks, and a cute turqoise blouse that I picked out for her. The only thing that she didn't find that was on her list was a wallet. She did amazingly well considering how huge Ross was. The only little scare we ran into was when we were in the dressing room and she told me that she was having BM accidents lately. Luckily, she did not have one under my watch, on a community outing nonetheless!
And now here she was. Back in transitional rehab because of falling at home. In a way I felt responsible because she was my patient and my job was to keep her safe. But when I told the physical therapist the situation and how I randomly, but thankfully, received a phone call in room 104 that morning, he told me we did our part. She was more than ready to go home. Among all the patients I've had, she's been able to do the most -bake, go on outings, walk through an entire store and try on clothing.. There was nothing more we could've done as a team.
I missed Connie so much when she left. In fact, I considered doing PRN work in home health to possibly be her home health therapist. But that was just a thought. I know I say this a lot in my posts, but I had a true bond with Connie. I am not happy of course about the circumstances, but I am glad that she is back in an environment where she can get the skilled service and support she needs to get back to where she was the day she left. It seemed as if Connie was excited to be back. She hugged me again for a third time before I told her I had to go clock out because I was done working for the day and that I would see her tomorrow. As I walked out the door, Connie called out, "I love you, hun".
Today, I saw her for a 70-minute treatment session. She was in the gym, just finishing up her physical therapy session, when she whispered that she'd like to start our session in her room because she wanted to talk to me. In her room, she told me she wanted to get out of bed since Saturday but her daughter told her not to because she didn't want her to fall. She told me all her frustrations and hurtful feelings towards her family. All I could do was listen. Then, as she sat on the toilet, she broke down into tears and said, "I just wish somebody wanted me". My heart broke once again and I felt for her. There I was, hugging my patient who was sitting on the toilet thinking, "I don't know how sanitary this is but I don't give a crap" (no pun intended).
My patient fell on Saturday in the middle of the night, tripping over the wheel of her four-wheel walker as she was getting out of bed to go to the bathroom. She had not gotten out of bed since. It was already Wednesday. And according to her daughter, home health never arrived. First thing I asked was, "Did you take her to the hospital?" No. I was so confused. So I told her I'd see what I could do, never having this situation happen before, and that I was glad she called when she did. I talked to the physical therapist who also worked with this patient and our social worker, who was in charge of getting home health services set up prior to discharge. She took it from there and sent a home health nurse over to the house.
At 4:30, as I was getting ready to leave and was walking down the hall, I saw my patient's name outside one of the rooms. I stared at it for a second to make sure I was reading it correctly. Then I knocked, opened the door, and peeked inside. My patient (let's call her Connie) was attempting to sit up in bed with a big, gasping smile on her face. She opened her arms up to me. I made my way past her daughter, who was on the phone and ended up taking her call in the bathroom, and gave Connie a big hug. "What happened?!" I asked her. She told me how she fell and that she feels she has declined and has been depressed since she's been home and does not understand why. Then she hugged me again. I told her I was glad she was back under the circumstances and that we'll talk tomorrow and figure out what's been going on and how we can fix it. I told her, "You were READY to go home, Connie. In fact, you were more than ready." And she knew that.
When I first met Connie, she became very special to me right away. Connie used to be on hospice care, which was shocking to me. Because even though she fatigued easily when bending over to put her socks on and needed me guiding her into the shower, she had so much potential. With Connie's Rheumatoid Arthritis (RA), we adapted her writing utensils and found easier ways to allow her to open packages in the kitchen. With her Chronic Obstructive Pulmonary Disorder (COPD), we went over energy conservation strategies and did endurance training. With her decreased strength, we did bilateral upper extremity exercises and functional activities, keeping her RA precautions in mind. And with her depression, we talked. Mostly about family and baking and what she wishes she COULD do.
When her endurance finally picked up and her physical therapist gave me the go-ahead with walking long distances with her front-wheel walker, I planned a trip to the dollar store. When the facility driver and I went into her room to get her ready, she was sitting on the edge of the bed, with a big smile on her face, and a list of almost 20 items she wanted to purchase -all listed in her squiggly handwriting, that she told me she did with her adapted pen. Here's what she came up with:
3 birthday cards - one for my grandson, one for my sister, and one for my brother (this one has to be extra special).
Hairbrush
Hair color
Hair curlers (2 packs)
Hair spray
Mirror
Floss (2 packs)
Hot tamales
Pantyliners
Non-slip mat (The main reason we were going to the dollar store in the first place)
Mascara
Shades
Reading glasses
Small notebook
I wasn't sure if we could find all this stuff at the dollar store, but Connie reassured me we would. We got there and she looked like a kid in a candy store. On top of getting all the items on her list, she found more things she wanted. She demonstrated good endurance in walking for a long period of time, good safety with positioning her walker when reaching for items, and good fine motor skills as she manipulated her wallet and money. As we walked out, Connie said to me, "I haven't been taken to the store in 8 years". I felt happy and sorry for her all at the same time, I almost cried.
That same week we baked sugar cookies in the kitchen in the rehab gym. Connie told me she used to bake all the time but that she stopped because it became too difficult for her with her RA and COPD. But there she was! In control. Opening packages with minimal assistance and adaptive strategies, obtaining everything she needed, stirring ingredients in standing, managing the oven, and washing dishes. We stood there and ate a cookie (or two) before I walked her back to her room.
The following week, Connie told me she needed a smaller pair of black sweat pants because she had lost a lot of weight. She wanted to go to Ross for their Senior-20%-off-Tuesday. I scheduled it with the driver, which almost became a disaster because I wrote it on the Wednesday calendar by accident. Connie said if we couldn't go, she would've cried. Connie would've hated me (well, not really). The driver, by luck, showed up to her room at the perfect time to replace her oxygen tank and was greeted with Connie asking, "Ready to take me?" Luckily, he had no appointments scheduled and we were able to make it to Ross for our therapy session. She bought a pair of black sweats, a bunch of socks, and a cute turqoise blouse that I picked out for her. The only thing that she didn't find that was on her list was a wallet. She did amazingly well considering how huge Ross was. The only little scare we ran into was when we were in the dressing room and she told me that she was having BM accidents lately. Luckily, she did not have one under my watch, on a community outing nonetheless!
And now here she was. Back in transitional rehab because of falling at home. In a way I felt responsible because she was my patient and my job was to keep her safe. But when I told the physical therapist the situation and how I randomly, but thankfully, received a phone call in room 104 that morning, he told me we did our part. She was more than ready to go home. Among all the patients I've had, she's been able to do the most -bake, go on outings, walk through an entire store and try on clothing.. There was nothing more we could've done as a team.
I missed Connie so much when she left. In fact, I considered doing PRN work in home health to possibly be her home health therapist. But that was just a thought. I know I say this a lot in my posts, but I had a true bond with Connie. I am not happy of course about the circumstances, but I am glad that she is back in an environment where she can get the skilled service and support she needs to get back to where she was the day she left. It seemed as if Connie was excited to be back. She hugged me again for a third time before I told her I had to go clock out because I was done working for the day and that I would see her tomorrow. As I walked out the door, Connie called out, "I love you, hun".
Today, I saw her for a 70-minute treatment session. She was in the gym, just finishing up her physical therapy session, when she whispered that she'd like to start our session in her room because she wanted to talk to me. In her room, she told me she wanted to get out of bed since Saturday but her daughter told her not to because she didn't want her to fall. She told me all her frustrations and hurtful feelings towards her family. All I could do was listen. Then, as she sat on the toilet, she broke down into tears and said, "I just wish somebody wanted me". My heart broke once again and I felt for her. There I was, hugging my patient who was sitting on the toilet thinking, "I don't know how sanitary this is but I don't give a crap" (no pun intended).
Thursday, October 6, 2011
I Can Use a Wrench!
Yesterday, I decided to play the role of handyman. Considering the only tools I know how to use are crochet and knitting needles, I think I did a pretty good job and I am proud enough to write a post entirely on my experience fixing my patient's wheelchair brakes!
I was working with one of my patients, doing a room treatment, when I noticed her wheelchair moved as she performed a sit-to-stand transfer. This surprised me at first because for one, I did not want her to fall, and second, she has always been my A-patient when it came to safety during functional transfers. Lord help me if I had to document that she all of a sudden had poor safety awareness. I checked her brakes and they were locked. But they were loose and just barely touched the wheel. She told me the PRN physical therapy assistant noticed it yesterday and that someone would tighten them today. I had her sit on the edge of the bed and looked at the clock. We had 10 minutes left. Now in 10 minutes, could I really figure out how to fix this thing? Why not. The physical therapist taught me how to do it my second week on the job when my patient's brakes were loose. But it took me a good 20 minutes to get it done because saying "yes, I can do that" after being shown how, does not necessarily mean, "yes I can do that" once you try it yourself. But I figured I had to figure it out eventually. And my patient cannot go through the rest of the day with loose brakes.
So I went to the gym, grabbed the toolbox, went back to my patient's room, gave her some theraband to do her exercises with in the meantime as she watched me.. layed out the tools on her floor, tipped her wheelchair on it's side, and crouched down. I told my patient, "So here's the thing. I know what I'm SUPPOSED to do-", as I pointed to the nut and bolt I was suppose to take apart, "-I just don't know if I remember what I'm suppose to do it WITH", as I held up the different little hollow cylindrical silver thingys. "I REALLY don't wanna have to call Jason" (her PT). But after a couple minutes of being unproductive, I had to give in.
Jason was sitting at the computer. I grabbed him and off we went back to her room. He laughed at all the tools on the floor. Once he picked out the tools I was suppose to use, I was good to go. I fixed the first wheel and clapped once it locked tightly into the wheel. Then I flipped the chair over and started unscrewing the other. When I was close to finishing, the nut got stuck in the cylindrical silver thingy. Panic. My patient laughed. I was glad to provide entertainment as she was doing her exercises on the edge of the bed. "I am NOT calling Jason back here. You cannot tell him this happened." We laughed. I figured out that if I attached it back onto the chair, it stabilized the nut well enough for me to unscrew it from the other side. I got it! Done! I was so excited and proud of myself. There's a first time for everything.
I was working with one of my patients, doing a room treatment, when I noticed her wheelchair moved as she performed a sit-to-stand transfer. This surprised me at first because for one, I did not want her to fall, and second, she has always been my A-patient when it came to safety during functional transfers. Lord help me if I had to document that she all of a sudden had poor safety awareness. I checked her brakes and they were locked. But they were loose and just barely touched the wheel. She told me the PRN physical therapy assistant noticed it yesterday and that someone would tighten them today. I had her sit on the edge of the bed and looked at the clock. We had 10 minutes left. Now in 10 minutes, could I really figure out how to fix this thing? Why not. The physical therapist taught me how to do it my second week on the job when my patient's brakes were loose. But it took me a good 20 minutes to get it done because saying "yes, I can do that" after being shown how, does not necessarily mean, "yes I can do that" once you try it yourself. But I figured I had to figure it out eventually. And my patient cannot go through the rest of the day with loose brakes.
So I went to the gym, grabbed the toolbox, went back to my patient's room, gave her some theraband to do her exercises with in the meantime as she watched me.. layed out the tools on her floor, tipped her wheelchair on it's side, and crouched down. I told my patient, "So here's the thing. I know what I'm SUPPOSED to do-", as I pointed to the nut and bolt I was suppose to take apart, "-I just don't know if I remember what I'm suppose to do it WITH", as I held up the different little hollow cylindrical silver thingys. "I REALLY don't wanna have to call Jason" (her PT). But after a couple minutes of being unproductive, I had to give in.
Jason was sitting at the computer. I grabbed him and off we went back to her room. He laughed at all the tools on the floor. Once he picked out the tools I was suppose to use, I was good to go. I fixed the first wheel and clapped once it locked tightly into the wheel. Then I flipped the chair over and started unscrewing the other. When I was close to finishing, the nut got stuck in the cylindrical silver thingy. Panic. My patient laughed. I was glad to provide entertainment as she was doing her exercises on the edge of the bed. "I am NOT calling Jason back here. You cannot tell him this happened." We laughed. I figured out that if I attached it back onto the chair, it stabilized the nut well enough for me to unscrew it from the other side. I got it! Done! I was so excited and proud of myself. There's a first time for everything.
Subscribe to:
Posts (Atom)