Friday, June 22, 2012

4 weeks down - a little about evals

I just finished my 4th week at the rehab center! I'm still really enjoying it and learning a lot. I have now gotten into doing evaluations on the new patients which I really like! I have done 2 this week! At the facility we only get 15 min for each evaluation and here is how we go about them for most of the pts I have seen thus far

1. Intro self and purpose of Occupational Therapy
2. Assess their cognitive status: judgement, insight, safety awareness, orientation (x4), problem solving, memory etc..  Do this by asking questions (address, what happened to bring them to the facility, their bday, where they are, what day of the week it is etc..).
3. Pain- rate it on a scale of 1-10
4.  Endurance- note any shortness of breath after activity
3. UE ROM and Strength.
4. Functional Mobility: bed mobility, transfers sit-stand onto/off the toilet, into/out of w/c, whether they walk indep, use a walker or w/c. sitting/standing tolerance and balance.  Include level of assistance with transfers,
5. ADLs: UB dressing/bathing, LB dressing/bathing, toileting, eating/feeding,  include level of assistance for each ADL
6. IADLs: meal prep, shopping, cleaning.... most of our pts are dependent for IADLs at eval status..

After the evaluation portion is over, the pt is taken to the rehab gym for their first session- which is usually pretty short just to ease them into it.

This is just one what to organize an eval....of course there will be many other components for more complex patients such as sensation (2 point, pain, temperature, touch), vision, trunk control, reflexes etc..

I find this outline really helpful to go by when evaluating patients (esp ortho and cardiac pts like I have been seeing).

Thursday, June 14, 2012


Because not everyone that reads this knows the terms that I use pretty often, I thought I would have this little 'glossary' post for the abbreviations! Sorry these aren't in any particular order and I will prob add to this as I use them or think of them-and feel free to ask me about any terms or abbreviations!

UB- upper body
LB- lower body
UE- upper extremity
LE- lower extremity
R- right
L- left
B- both (i.e. B UE= both upper extremities)
ADL- Activities of Daily Living (incl dressing, bathing, toileting, grooming etc..)
IADL- Instrumental Activities of Daily Living (incl shopping, meal prep, pet care, child care etc..)
AE- adaptive equipment (ie reacher, sock aid..)
d/c- discharge
ROM- range of motion
MMT- manual muscle testing
max A- pt needs maximum assistance (pt does less that 25-49% of task)
mod A- pt needs moderate assistance (pt does about 50-74% of task)
min A- pt needs minimal assistance (pt does 75% or more of task)
mod I- modified independence- pt is independent with task but uses adaptive equipment
dep- dependent
SBA- stand by assistance
CGA- contact guard assistance
EOB- edge of bed
SOB- shortness of breath
HEP- home exercise plan
tx- treatment
NWB- non weight bearing
WBAT- weight bearing as tolerated by pt
TTWB- toe-touch weight bearing
PWB- partial weight bearing
fx- fracture
CABG- coronary artery bypass graft
CVA- cerebrovascular accident (aka stroke)
TBI- traumatic brain injury
SCI- spinal cord injury
THA- total hip arthroplasty
TSA- total shoulder arthroplasty
FM- fine motor
GM- gross motor
Ther ex- therapeutic exercise
Ther act- therapeutic activity

Tuesday, June 12, 2012

Here we are in week three

Wow, its my third week already and even though it has only been 2 days, its been one of the busiest!! Yesterday I had two clients scheduled but I found out (about an hour before my tx session) that one was being d/c'd... I didn't have a chance to say buy to her because she has already left for a doctor's appointment. I was kinda sad because she was my first client that I was treating there. My other client is doing really well, she has not been complaining of pain as much lately (she had an acute flare up of arthritis in both upper extremities). I am having such difficulty writing her daily notes though, I feel like she is so high functioning right now that I'm not really doing that much and I have to put what skilled intervention I DO in my note.
I just hate the whole business i said in my last post and because even though my client is basically independent in her ADL's and we have cooked and she did fine with that, she can clean her house and has been demonstrating normal ROM in her UE and not complaining of seems that I'm not allowed to put in my notes that she is independent...because they want to keep her in the facility to make money (since Medicare will pay for 21 days they want her to stay those 21 days). It really irks me because I feel like she has the tools and skills necessary to be independent at home again..but I can't say that. it is sooo annoying. makes me wonder if it is like this every where? if not, I must find that exception!

Yesterday, I participated in my first evaluation. I feel so bad for this client, she makes me sad! She is in her 70's and fell last week and broke her left distal radius (one of the bones in your forearm) and has severe bruising on her left hip. Also she had torn her rotator cuff in her right arm a couple years ago and she has decreased range of motion and strength in that arm. AND on top of that, she has had back surgery and has severe pain from that. Its just sad bc I feel like she is in pain all of the time!
Anyways, I was responsible for filling out the eval and writing her eval note and daily tx note yesterday. And today, I saw her this morning for bathing at the sink, grooming and dressing. I was sweating so bad bc her room was hot and she is max A for pretty much everything from getting out of bed to the wheel chair, to washing her back and legs to transferring from her wheel chair to the its a lot of work to get her up, bathed and dressed. I have my work cut out with her that's for sure!

Today I just did not have that great of a day though. Last night we had to sign the papers to officially sell my grandparents house (since my Nana died in December and it just now sold). I have been sad ever since and just holding back the tears and keeping myself from really thinking about the fact that I will never go to their house again. so I was a little emotional inside today and then when I started getting 'constructive criticism' on my daily notes I almost started crying but I held it back thankfully. I just wasn't in the mood today bc my mind was flooded with other emotions. Luckily we finished the day around 3 so I didn't have to stay a full work day.

  I've decided that tomorrow will be better!

Tuesday, June 5, 2012

the 'bottom line'. a rant.

I hate hate hate how everything is about the 'bottom line'  ...aka dollars and cents.
Throughout my past two years of OT school, I can't tell you how much it was drilled into us about getting the patient's occupational profile and taking time to interview them and really learn what occupations are meaningful to each individual. That is the basis of occupational therapy- being client centered and using the occupations that the client finds meaningful as the means and ends in treatment.

I'm getting frustrated already with how the whole payment system works and what is considered 'billable' and whats not, productivity demands yada yada yada...

Between all of the paperwork and stuff dealing w/ the $$, there just is no time to really get to know the patient. No time to spend more than 10-15 minutes on an Eval (apparently OTs in my facility can't bill for time spent doing evals so it doesn't count as 'productive time'), no time to develop an occupation profile- and the eval form they use don't even include a spot for the occupational profile anyways! I want to spend time with the patient before beginning treatment so that I can really tailor the sessions to what THEY want to do, not what I think they would want to do.

I find that the OT I am with pretty much has the same goals for every patient..and while self care and IADLs are VERY important..there are other things that the patient may really want to work on that she doesn't include in the goals (short or long term)....I don't feel like we ask the patient what they want to focus on enough.

Now, I know that as the OT's we are the 'experts' and are the ones who set up and grade activities for the patients needs, but I just feel like the patient should have a say in their goals and what the tx sessions focus on in general.

So basically, I just wish there was a balance between the business aspect of OT and the foundational quality of OT as being client-centered.

// end rant.

Hello, week 2

Well I'm not almost halfway through week number two. I have gotten my second patient who has arthritis in both upper extremities, every joint except her elbows.
Yesterday we did a quick eval and then I got to wrap her fingers in coband because of the edema (it is similar to an ace bandage but is thinner and more porous. You wrap it tight at the finger tips and then make the wrapping more loose as you move proximal to 'squeeze' the fluid out of her fingers. White the fingers were wrapped we had her hands on a wedge to allow gravity to help move the fluid and we also worked on some fine motor activities (peg board, putty..) to get her fingers moving to help move the fluid.
She is such a great lady, SO motivated, I think she would stay in the rehab gym alll day if we would let her. She seems to want to push her self too hard thought, esp being in the acute phase of inflammation and pain.
Today we did the shoulder arc (see pic for a similar one) to work on shoulder flexion, abduction and horizontal adduction. Then I got to do ultrasounds on both of her shoulders for the pain and then we did the shoulder arc again to see if there was a difference in pain level before/after the ultrasound. She loved the ultrasounds and said it really helped so that was great.

I also saw my other client this morning, who had a CABG and we worked on sorting and stapling packets of paper for the department, to work on hand strength and FM and then stood at the counter to make a sandwich and wash the dishes. I'm kindof getting stuck with her though because she is doing so well but still gets OT every day.

As far as documentation goes today, I had to write a daily note for my two patients and a weekly note was due today for one of them so I had to do that as well. I struggled a little with the weekly but I think my next one will be easier!

Friday, June 1, 2012

Week One: complete

Well I have officially completed my first week of fieldwork :) I feel really great about how the first week went and I'm starting to get a hand of the schedule there and get to know the other therapists too :) They are all so nice and willing to help me out so I def appreciate that!

I saw my patient today and we were going to do a ADL session in her room so she could get a shower today and I could try out the long handled sponge, and teach her about using a reacher for LB dressing but she was already dressed and didn't feel like getting a shower...which is totally understandable bc I see her at 1:00! So we headed on down to the rehab gym and did some strengthening exercises and worked on standing at a table to fold laundry. My supervisor did her eval and wrote the goals for her with are: to perform all UB dressing and bathing independently, LB dressing and bathing, using AE as needed, adhering to sternal precautions, performing simple meal prep while standing and perform laundry tasks while standing. On Monday I think I'm goin to try and get her to make something in the kitchen and try to stand for a few minutes at a time, she was complaining about her foot being swollen and numb today so the doctor was going to look at it this afternoon- hopefully its okay! Also we are going to staple papers for the department, I think she will really like doing that because its something 'productive' and useful, instead of doing hand weights, the stapler will help strengthen her hands even if she doesn't realize it!
Please let me know if you have worked with a pt with a CABG and what types of treatment activities you have done!
I think she is doing really well and I'm not sure how much longer I will be seeing her- we set goals for 4 and 8 weeks but I'm not sure she will be there for that long. 
I was glad to get more good feedback on my daily note today too- its good to know that I'm doing it right when I seemed to have difficulty in class with my notes and getting all the right info in it. Notes in 'real life' are different, we don't write SOAP notes at the facility, we just write a narrative that includes 1. what activity we did 2. why we did it (relate to d/c, goals, occupation...) 3. What the OT did (level of A, client education, family education, verbal cues...etc) and 4. How the treatment you did affected the client's performance, did they improve their skills from the beginning of the tx to the end, did they respond to your education, were they successful with the level of A provided...)
I think its a pretty easy way to write a note and not worry about what goes into each section..I still find myself jotting down quotes from the patient to put in the note (like the S part of a SOAP note).

We also saw the lady that had a CVA and she was looking much better today, I can tell such a difference in her head control in just the past couple of days. She seems to be in the 'anger' stage of recovery and she has every right to feel that way- I know I would if I were in her situation...I just hope she can work through it and face whats going on so she can really work on getting better. While she can't speak to us, she really knows what we are saying and can follow simple commands. Today we took her out on the porch to look at the flowers and then put her in the stander so she can engage her trunk muscles. She did really well with that and did well holding her head up on her own and looking out the window. I can't wait to see how much progress she makes in the next couple months.

Next week my supervisor said that I will get more exposure and practice doing the evaluations on new patients. I feel like there is a new patient admitted to the facility everyday, well multiple patients admitted every supervisor did 2 evals today! The evals they do at the facility seem pretty straight forward, they don't seem to use any standardized assessments like we had used in classes. They have a form they fill out and rate the patient in areas like self care, mobility etc..and then you rate them again at time of discharge and hopefully their scores are higher at d/c than during the evaluation. I'm looking forward to doing one but I DEF need to review manual muscle testing and the rating scale.

I'm super glad its the weekend, its taking a bit to get used to this 'real world' working schedule and the weekends now have a whole new meaning! :)