Posts filed under ‘acute care’

Would a splint be contraindicated in this case?

We all know that one of the purposes of splinting by occupational therapists is for joint protection and to preserve function and range of motion.  I have blogged before about my experience with fabricating below knee amputation (BKA) splints, used to preserve knee extension for being able to fit orthoses at a later date.

Sometimes, however, I wonder if a patient really needs the splint.  For example, I once had a 85 year old patient who had severe Alzheimer’s dementia, was completely bedbound at a nursing home at baseline and had a BKA due to gangrene.  While normally I would make a splint, I wasn’t sure that it was indicated in this case.

First, the patient was bedbound at baseline, and therefore an unlikely canditate for a prosthetic.  Second, a patient is very likely to develop skin breakdown and sores from a splint if the splint schedule isn’t adhered to, or frequently monitored.  Third, splints aren’t generally the most comfortable things.

Providing a splint would not increase or improve quality of life, and so it would seem to me that a splint would not be indicated in this case for the reasons listed above.  What are your thoughts?

November 17, 2008 at 8:09 pm 22 comments

Quote of the day

While working with a patient who had cerebral palsy:
ME: “Can you try to relax your muscles?”

Patient: “You should know better than asking a spastic CP to relax!  The only way to get me to relax is with alcohol!”

September 12, 2008 at 3:24 pm 2 comments

Can a family be too involved?

One thing that I have always observed while working in the hospital setting is that the patients who have family and friends that come to visit tend to fare better when it comes to physical rehabilitation and overall attitude towards the outcome.  They are better able to laugh through their hospital stay and they have a strong support system.  The patients who are alone during their entire hospital stay tend to be more depressed, less motivated to participate in therapy, and have a poorer affect.

As a result, I have always advocated that when possible, patients should encourage family and friends to visit.  I recently had a situation where I questioned this for the first time.  The patient was an older person who was completely independent with all her activities of daily living and participating in the community.  She suffered a fall, fracturing some bones and having aches all over.

Once stable, therapy was called in to see the patient.  On a typical patient, we would normally ask if the patient would be willing to get up, and work towards getting her out of bed and to a chair, at least for the first time in therapy.  Patients usually complain of pain, but we try to coordinate with the nursing staff so that the patients can be fully medicated and ready to go.  Usually, this is enough, and we can proceed with therapy.

However, with this patient, we saw that there would be problems from the start.  Upon arrival, the patient’s son was in the room.  Right away, he told us that she was sleeping and that he doesn’t think she should have therapy so that she could rest.  If a patient is alert and oriented, I like to at least ask the patient their opinion on participating in therapy, which is what I did.  The patient was quick to say that she would welcome sitting at the edge of the bed, so I’m happy I asked.

Then, when approaching the bed and reaching out to shake her hand and introduce myself, the son audibly gasped, worried that my touch would cause more pain.  This went on throughout the entire 40-minute long evaluation.  Any time I touched the patient in any way, the son could be seen and heard wincing and gasping, as if my touching the patient was actually hurting him!

Now as an aside, I completely empathize with the son, and I fully understand that his mom is in pain.  I could not even begin to imagine what it would be like if that were my own mother.  However, the son took this to an extreme that I had never seen before.

In moving the head of the bed upwards, the son demanded that we be “gentle” several times.  Unfortunately, there is no gentle button, just an up and down button, but I managed to get the head of the bed situated in a way that was agreeable to everyone.  Before removing the patients waffle boots (used to prevent heel sores), the son made us wait and ask the patient to make sure that it was ok to remove them, as her legs were very sore.

With literally every single movement, the son was involved, asking his mom to tell us to stop when it became too much.  To get to the edge of the bed, we have to move one leg, then the other, adjust the shoulders and hips, move both legs again, adjust the shoulders and hips, sit her forward, etc. until she can sit at the edge of bed appropriately.  Even then, we had to manage her sitting balance and control her dangling legs.  Imagine for a moment getting stopped by the family member for each and every single one of those movements!  I’m honestly quite surprised that we completed the evaluation in only 40 minutes.  We had to reassure the son over and over again that we were being as gentle as possible, explaining exactly what we were doing, and why we were doing it.

Take note that I have spent most of this post discussing the son, and not the patient.  When a family member gets so involved that we can barely pay attention to the patient, I think that there is something wrong.  When the son asks the patient repeatedly to tell therapy to stop if it becomes too painful is absolutely detrimental to the patients ability to recuperate.  Patients need to be encouraged to do more so that they can get stronger and healthier.

Once again, I empathize with the son and I think he is the greatest son a mother could have for his ability to be at her bedside throughout the day and worry about her.  But there comes a time when it can be too much.  I had actually heard rumors that when the patient was in the ICU (where they have very specific visiting hours), the patients heart rate and blood pressure was noted to be higher when family members were present!  So, while I normally advoate for patients to welcome family members and friends to visit, I also think that there is a time when they need to step back and let the patient get therapy so that they can get well and go back to being independent.

July 17, 2008 at 10:31 pm 11 comments

Fundamentals of Clinical Instruction

One of the great things about the place I work is the fact that we have a vast amount of opportunities to attend inservices and continuing education classes.  A class I recently attended that was put together by therapists at the hospitals was regarding clinical instruction, and how to be a fieldwork educator.

The class was broken up into two parts.  The first part was just with the occupational therapists, and laws and regulations related specifically to occupational therapy were discussed.  The second part went over how students learn, various learning methods, and how to handle the problem and exceptional student.

Hearing about ways of handling the problem student was especially interesting, as we got to hear stories about various students who did all sorts of things that I could never imagine doing myself as a student.  But we also got to hear about some creative ways of working with students who have a hard time with certain skill sets.

For example, if the clinical instructor (CI) sees that the student has a hard time managing the patient and the IV pole at the same time, the CI should attach a blood pressure cuff to his arm, and use the vitals machine as the IV pole.  A clean chest tube drain can be used a Foley catheter.

Overall, it was a great class, and it was nice to see that my hospital takes teaching students so seriously.  At any given time, there are always at least two students somewhere in the hospital, whether it is a phsyical therapy student, occupational therapy student, or a speech-language pathology student.  While I did already have a Level I student, I hope to soon be able to take a Level II student and use some of the principles I learned in this class.

June 19, 2008 at 11:09 pm Leave a comment

Celebrating Occupational Therapy month

This year, I joined the OT Month Committee at my hospital to see what kind of ideas we could come up with to spread the word about OT. In past years, we had a booth set up near the cafeteria, but few people stopped to look at what was being presented at the booth. Since we wanted to reach out to a larger group of people, we decided to send out an all-user email.

In the email, we talked about how April is occupational therapy month and we had a link to an online quiz inviting people to test their knowledge about occupational therapy. Additionally, we offered a $20 giftcard as an incentive for people to take the quiz.

I was pleasantly surprised to see that a total of 67 people had successfully completed the quiz! There were plenty of wrong answers, but the fact that people took the time to try the quiz shows that we helped spread the word. As an added fun tidbit, one of the questions we asked was for people to name an occupational therapist that they knew. Many people left that last question blank, but it was interesting to see which therapists got mentioned.

Here are the questions from the quiz: (more…)

April 27, 2008 at 11:04 pm 6 comments

Getting my First Student

In a few weeks, I’ll be getting my first student, guiding her through her Level I fieldwork.  I like to help others (isn’t that why I became an OT?), and I think that assisting other students going through school is a great way of helping them.  I’m looking forward to the experience and was also looking for guidance.

If you have had students or you are a student yourself, what kind of things are you looking for in your Level I experience?  What worked for you and what didn’t work for you?  What kind of supervision did you enjoy?  Let me know!

March 16, 2008 at 8:36 pm 7 comments

Splints I have Fabricated

Here’s a list of some of the splints I have either fabricated myself or got assistance in fabricating:

  • Several below knee amputation splints
  • Resting hand splints (actually, these are pre-fabricated)
  • Humeral fracture brace (two pieces; protects the humerus from getting bumped by others; limits some shoulder range of motion if the doctor chooses)
  • Several posterior gutter splints (usually for protection of an elbow status post ORIF; often, the splint starts along the forearm and extends down to the carpals)
  • Yesterday, I helped with two splints (both on the same person, one for each hand): Ulnar gutter splint that involved providing slight MCP flexion for the 4th and 5th digits; and a resting hand splint that only provided ‘rest’ for the index finger through the MCP, but allowed for free range of motion of the PIP and DIP, and the rest of the fingers.

Sometimes the orders can be very complicated and specific, such as the ones highlighted in the last bullet above.  But I really enjoy making the splints, and am more and more strongly considering to specialize in splinting.

February 21, 2008 at 10:05 pm 6 comments

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