After having a dissatisfying Prac day on Monday, I am feeling
a lot more content after today’s intervention implemented. I was feeling
quite down when leaving the hospital on Monday, as I had decreased availability of time with my clients to perform
more assessments and average to poor intervention sessions implemented. One of
which needed to be adapted by my supervisor (Passive mobility exercises being
turned into more of an activity) and a feeding session which ended up with me
feeding the client. This client did not have the PROM for wrist flexion needed
for feeding. I had not affectively assessed PROM and I have since realised
its importance through this mistake.
My AFR I have used for Mr Udairaj was the biomechanical AFR including
the following approaches.
Graded approach:
· Repetition, intensity and duration would be
graded.
I used this approach by, for example, requiring the client to
repeat the steps of the normal movement patterns which were taught to him. I would give him step by step instruction for bed
mobility and then ask him to repeat the movement using the new method. This
reassured me he was comprehending the movements. I determined the number of
breaks I’d give the client based on his signs of fatigue.
Compensatory/ Rehab approach:
·
Relying on assistive devices and the unaffected
hand to enable increased independence. As well as teaching him to plan ahead for
energy conservation. E.g. getting the towel prepared before showering or placing
the shorts in front of him to enable placing them on correctly the first-time round.
I have been showing the client compensatory methods to perform tasks with the
unaffected hand such as using the unaffected elbow to get into long sitting for
bed mobility etc. I have also been suggesting many assistive devices during
sessions, for him to buy post discharge. E.g. bath-mitt, toilet handle
bars, non-slip mats, shower chair etc.
Activity as a means:
To improve MS and JROM of the affected side. Performed an activity requiring interlocked fingers to reach forward and knock a water bottle off the table. I also performed a hand-over-hand activity to wipe a table in figures of eight which improved JROM of the affected UL too.
·
Activity as an end:
Client should be able to dress UL and LL as well as perform
bed mobility with modified independence. Client should be able to toilet with minimal
assistance and shower with minimal assistance. The client will be given a
pamphlet with the steps and some pictures of the methods taught to him.
·
Preventative approach:
Provide right UL and LL AROM and PROM exercises to prevent
muscle stiffening and contractures. This was implemented with the client and
the client will be given a pamphlet with pictures of the exercises taught to
him. Education on his diagnosis, including his Subluxated shoulder, through
teaching him techniques of how to position the arm to support the shoulder and
prevent it from being damaged further. E.g. Support it with pillows when lying
in bed or support it on the wheelchair armrest when seated in the wheelchair.
Mr De Grey had a TBI at age 20. This was 40 years ago and
since having his incomplete C3/4 SCI Mr De Gray has become a tetraplegic patient.
As the client had the TBI 40 years ago and recently had the SCI, my AFR being
used is focused more on the Biomechanical framework, rather than the
Neurodevelopmental. This is because remedial aspects are a lot more important
to improve, at this stage, to regain MS and JROM in all areas.
The approaches used for MR De Gray include activity as a
means with grading approach to improve MS of the UL from a general overall
2 to a 2+ and improve A&PROM of the UL in general, mainly the Left UL (dominant
since he was 20 and less affected). This will be graded through duration, repetition
and intensity. As well as the preventative approach (PROM by staff or
caregiver daily to prevent further muscle stiffening and use of a functional resting
splint of the R UL to prevent permanent contracture in finger flexion) and
compensatory approach (Use of an assistive device e.g. a w/c with a raised back
and has an angle which requires more of a posterior pelvic tilt to prevent
sliding and improve client posture). I
need to speak to Erin regarding the splint as it is causing redness on
the skin over the thenar muscles, which could lead to a pressure sore if not adapted. As well
as educate the client on how often to wear his splint.
Through speaking to my supervisor, I have also realised the
importance of education on the use of the affected hand for CVA clients and
incorporating the affected hand more into activities (This is an area which I feel
I could improve more in). As well as education on assistive devices for
discharge. I will be including a list of assistive devices in my Discharge programme
and where to possibly buy them from.
In general, I have focused on Mr Udairaj’s ADL’s to make him
as independent as possible and reduce demands for the caregiver, when he is
discharged next week Tuesday. This includes Dressing, Toileting, showering
(Done with his OT), Bed mobility and UL exercises. I also perform NDT warm up techniques
with him before each treatment session, including: hoovering, bridging
and trunk rotation as well as incorporating weight bearing on the affected UL.
Mr Udairaj also complained about not being able to read anymore
and I therefore included a reading assistive device to meet the clients needs
and include client centeredness into therapy. Reading is an activity he has really
missed being able to do for leisure. However, this was not implemented as a
treatment session and rather an additional task performed for 5-10 minutes at the
end of the last two treatment sessions, to ensure client independence in using the
new device.
Today I performed a blow painting activity with Mr De Gray, which
aimed to improve static sitting balance. It also incorporated trunk flexion
through blowing and deep breathing exercises. I saw an improvement in the beginning
of the session from static sitting balance of 10 seconds to static sitting
balance of 100 seconds by the end of the session, by him following verbal promptings for postural change to maintain his balance. I have been so directed towards focusing on Activity as an end, as a therapist, in these first few weeks of
learning to treat and have only recently learnt the importance of implementing Activity as a means with my clients.
I am going to end off my blog with an OT on Instagram, named Courtney's, Instagram photo and caption as it impacted my passion for this career even further.
Refernces:
2) Mc Millian, I. (2016). The biomechanical frame of
reference in occupational therapy. https://musculoskeletalkey.com/the-biomechanical-frame-of-reference-in-occupational-therapy/
3) Mullersdorf,
M. (2016). What, Why, How – Creative Activities in Occupational Therapy
Practice in Sweden. https://onlinelibrary.wiley.com/doi/full/10.1002/oti.1438
4) Schmidler,
C. (2018). Spinal cord Injury: Functions, nerves, surgery. https://www.healthpages.org/health-a-z/spinal-cord-injury-function/
Lovely creative activities! Beware of naming clients.
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