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.
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