Posts filed under ‘phys dys’

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

Ethical Dilemma with Treating Unethical Patients

I have been struggling with an ethical dilemma ever since my Level I fieldwork assignment, where I was doing my clinical at an outpatient facility within a hospital located near one of the local jails.

Since this hospital was affiliated with the city, we often got the prisoners that needed occupational therapy at this facility.  If a prisoner is scheduled to come in for an appointment, they are accompanied by two police officers and their hands and feet are both shackled.

As part of our assessments, we typically ask our patients what their own goals are for therapy.   Unfortunately, I had one patient (who had had an ulnar nerve and tendon injury from a knife fight) tell me that his goal for therapy was “to be able to close my hand into a fist so that I can fight again.”

When I hear something like that, I think to myself, “Why do I want to treat this person?  Why do I want to help this person meet his goals?”

This question bothered my enough that I knew right away that I would never want to work with forensic patients.  As an occupational therapist, I know that we have to work with patients to meet their goals and increase their occupational well-being.  But if that involves beating up other people and doing illegal things, how can I, in good faith, treat this type of patient?

March 3, 2008 at 11:51 pm 10 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

Educating Patients with Amputations

Aside from educating an amputee about phantom limb pain, what else do occupational therapists have to teach patients?  The things I can think of are: skin checks, wound care, ace wrapping, and splint education.  Anything else?

(My question refers to on top of the usual ADL training that we would do)

February 13, 2008 at 9:28 pm 11 comments

Acute Care is Intense

I started working in acute care as a student on my Level II fieldwork, so I never realized just how intensive it can be. I recently had a friend of mine who is an OT express interest in working in acute care. She wanted to follow me for a few hours to see how my day was.

Here is how I do a typical chart review before seeing a patient for the first time:

  • Go on the computer
    • Check out the therapy orders, as well as their activity orders (out of bed, ambulate with assistive device, etc.) I also check what other services have been consulted. Is physical therapy on board? Social work? Rehabilitation? etc.
    • See what diagnostic tests have been ordered. A CT scan of the thorax may be ordered to rule out pulmonary emboli, ultrasound may be ordered to rule out DVT, x-ray to rule out fracture, etc.
    • Check on specific patient care orders – do they need a brace when out of bed? how many liters of oxygen should they be on?
    • Patient alerts – What kind of precautions are they on? Contact isolation? Are they on aspiration, neutropenic, or seizure precautions?
    • Diet – Are they NPO?  Stage I, II, III, or IV diet?  Knowing a patient’s diet can help with the education part of what they can and cannot do in the hospital
    • Code status – Are they DNR? Some patients have specific instructions as to whether or not they can be intubated
    • Lab values – The most common things I look for are hematocrit, hemoglobin, potassium, sodium, creatinine, PT/INR. Are the lab values high? low? Which way are they trending? All these are factors into whether or not a patient should be on hold. For example, if a patient has a hemoglobin of 7.5 and a hematocrit of 22.6, I would probably not see the patient, since they are below critical and are probably going to be too weak to see me anyway.
    • Vital signs – Check the latest blood pressure readings, heart rate, temperature, and sometimes the respiratory rate.
  • Next, I check the physical chart:
    • I first go through the History of Present Illness section to see what led up to the hospitalization. Often times, I’ll find most of the patient’s past medical history.
    • Then, I check the consultation section to see what medical services have looked at the patient. This can include Medicine, Neurology, Orthopedics, Nephrology, Infectious Disease, Oncology, Cardiology, Pulmonary, and more. This section helps give a nice, complete picture of what is going on with the patient.
    • Next, I look throughout all the notes that everyone wrote. This includes mostly nursing notes, but also notes from doctors and from any of the above mentioned services giving updates. You see a progression of status as you read the notes.

I am only comfortable going into a patients room when I’m done looking up everything mentioned above. And now that I typed it all up, I can see why my friend who was shadowing for a few hours was so overwhelmed when she left! Working in acute care is intense; there is no question about it. But since I was brought in as a student and learned things slowly at a pace that a student would learn, I have no problem doing it today.

One of the great things with acute care (which others may specifically not like) is the fast pace. Going in to work, you never know who your new patients will be, making each and every day very unique. Often times, there are lots of new evaluations that need to be completed, so just the rush of trying to get everyone done makes the day go by very fast.

Acute care is definitely not for everyone, but if you can handle some of the minor stresses and be willing to learn a LOT about anything medical related, then it is for you!

February 11, 2008 at 4:29 pm 53 comments

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