Week 9 down

Wow, I can't believe I only have three weeks left!!! I am starting to realize how much I will miss everyone I have met at the facility.
I'm seeing 5 patients now but this week was kind of weird because the case loads were a little low so we had to pass some of our patients to the COTA's so I had 3-4 patients all week.

I did 2 evaluations by myself this past week. One was a man that has stage 4 melanoma and the other had abdominal surgery (very confusing PMH).
The man who had abdominal surgery is now on my caseload. During the evaluation he was so inappropriate and his son/his sons friend were in the room/hallway just laughing at everything he was saying. I was a little hesitant to take him on as a pt for my caseload but he has been completely different than that first day. My supervisor and I think that his son probably liquored him up (he has a hx of drug/alcohol abuse) before they brought him it. Because of that his notes show a drastic improvement in just the week he has been there and I think he will be d/c'ed next week. I just really do not feel he is appropriate for OT now. This week he refused me 3x in one day and 2x the next day but he finally came down after speaking with the doctor and my supervisor. I just don't know what to do with him anymore so I am crossing my fingers he gets to go home soon.

The man with stage 4 melanoma that I eval'ed just reading his background info made me sad. He noticed a lump under his arm and then let it grow bigger and bigger for 6 months before getting it checked. He was taking care of his mother who was dying and said he just put his own health on the back burner. Makes me so sad because they could have prob caught it before it spread to his spine and sternum.  He said he is real hopeful and has a lot of people praying for him.

My pt with the TKA finallllly got an upgrade in her weight bearing status thank goodness!! She was an independent as possible at w/c level so I really needed her to get weight bearing as tolerated (WBAT) when she went to her appointment this past week. She has been doing so good standing =) She is prob my favorite patients right now because we have really formed the therapeutic relationship and she trusts me and lets me push her a little more than she is comfortable with because I just know she can do it! I'm going to be sad when she leaves next week (that's the plan at least).

My pt who had a stroke is still doing really well. I'm concerned he may be getting depressed though. This week we started working more on his L neglect. He is always looking straight ahead and doesn't really acknowledge anything to the L or R really. I attached a timer to his L forearm and set it to beep every 10 minutes to get him to turn his head to the L side. The first time it took him 11 seconds to find and turn off the timer.  By the end of the session it only took him 3 seconds so that showed a good improvement!

Anyways, that pretty much sums up whats been going on so far... Can't wait to see what these next three weeks bring!

week 7

Wow, how is it already week 7?? I'm over halfway through with this placement now.
Things have been going really great. I had my midterm review last week and got really great feedback. My supervisor gave me all 3's (out of a possible 4)- and said I already had enough points to be passing at the end if I just keep on doing what I'm doing. She said that she feels I'm just about at the level of an entry-level practitioner which is amazing because I'm only in my first fieldwork placement!
Today she basically said I would definitely be able to get a job with one of the facilities under the same company as my placement. That is really exciting because right now I am looking to move to Arlington, Va or Charlotte, NC and this company has facilities in both of those cities!

I'm treating 4 patients right now and will probably add a 5th next week. My patients right now are 1. CVA with L hemianopia (meaning he has vision loss in the L side of each eye),  2. R foot fx and R wrist fx, 3. TKA, 4. CABG.

My favorite patient is the guy with the CVA just because he is so interesting and he is the first stroke pt that I have been able to treat on my own. Its fun getting to do some tx for the vision loss. Here are a few things that I have done with him:
1. Put numbers 1-10 on post-its and taped them to the wall - 5 on R and 5 on L but with the numbers mixed up. I had him stand up in front of the numbers and I stood behind him. Then I would call out a number and he had to visually scan through the post-its to find the number I said. This worked on visual scanning and learning to compensate for the loss of vision by turning the whole head to look to the L
2. I set out two rows of playing cards and asked him to scan through all the cards and flip over all the black cards. He left ones on the L side so I had to cue him to look to the left to find them.
3. There is a US quarter map in the dept so I got that out and set it on the table. The quarters are in little slots at each state (i'm sure you have seen them). I instructed him to find 5 quarters with his left hand and hold them in his hand. He was then supposed to keep them in his hand and set them back in their slots one at a night. He had decreased strength and some sensation deficits in his L hand. This worked on in-hand manipulation, visual scanning and fine motor skills.
4. To work on item retrieval- such as gathering clothing in room or items in the kitchen- i placed about 8 colored cones in the room and asked pt to walk about and find each cone.  If cones were to pt's left side, he really didn't see them and so he needed cuing to look to the left side.
5. Ball toss- when i toss the ball to the L of midline he just totally loses sight of it and it just kind of bounces off of his hands because he isn't anticipating it coming at him but its good to cue him to turn to the left and try to focus on the ball the whole time.
6. He has decreased strength in this L UE so we have done some simple strengthening using hand weights

He's really fun to work with and had a great sense of humor. He said that if he needs to look to the left I should just sing The Cupid Shuffle part where they say "to the left to the left to the left the left the left..." if you have heard it you know what I'm talking about it.  We have a fun time in therapy and he keeps me laughing!

Anyways, that's just a little update on what's been going on with my fieldwork since I last posted!

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).

Abbreviations

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

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 side...like 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 pain....it 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 toilet..so 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!

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!