“The Sometimes Disparity Between Goals and Reality”

“The Sometimes Disparity Between Goals and Reality”

and a “United MDT Approach”

Situation

A 79 year old female had a R CVA 3 months previously. She was admitted to the facility for further rehab, with the aim of returning home (at the passionate insistence of the patient and her family). She previously lived with her husband and both were fully independent. The patients husband also suffered a stroke ~ 14 months ago. His recovery though has been a near full return to premorbid levels and he and the family appear bewildered that the patients recovery has not been of a similar path (her stroke had more significant physical effects, and she has shown limited recovery of those functions).

 

The elderly couple had been greatly involved in their family’s lives (with grandchildren and family events) and were quite active physically and socially before the stroke occurred. The patient rehab has often at times fluctuated with her walking quality, and often states she is tired and doesn’t feel like walking to the gym. She also appears to possibly be in denial about her physical state, expecting the same recovery as her husband, though not appearing motivated to completing therapy, and complying with our recommendations that she walk to the dining room and gym as able. I often see the patient wheeled in her wheelchair, even though it’s been taken off her care plan (to promote her walking ability). The care plan for the patient is a detailed description of the caring requirements for the patient and is located in the patients room for all to access. The wheel chair I believe is used as a result of convenience (for the often short-staffed and rushed nursing team) and the lack of motivation from the patient herself.

 

Task

My task has been to see the patient daily for physical therapy. This involves walking the patient from her room to the physio gym, using the WZF, and conducting exercises in the gym to physically prepare her for her return home.

 

Action

Walking the patient to the gym is often timed around the nursing staffs commitments, which is of course normal and expected. I find the patient is often in a flat mood. This is perhaps expected given the physical stroke effects, and the effect it has had on her life as she knew it. Our walking to the physio gym takes a little time, as she has L side effects from her stroke, and that of course affects her gait. She is 1 x assist, mainly keeping her balanced if her foot placement is not quite right, and keeping her left thumb and fingers hooked onto the frame for better balance also. I have placed a chair halfway to the gym for her to have a seat and rest if she needs it. While she is a little hard to encourage initially, she often walks the whole distance without a rest, and overall her walking has improved over my time at the facility.

 

Result

I will walk the patient to the gym (often without a rest), complete the other exercises focussing on her needs for getting home, and find that she once again is being wheeled to the dining room for lunch or to the shower in the morning when I’m not seeing her. There appears to be this tug of war between rehab recommendations, the patient herself (and her motivations) and the nursing staff. The patient has come to the facility for rehab specifically, yet we are only able to see the patient realistically once a day. Which is why it’s so important that 24hr physio occurs throughout the day, via other means such as optimising walking opportunities etc.

 

 

Evaluation

The goals clearly differ between the patient and the physiotherapist. Upon chatting with the patient, she seems to believe that everything will just fall in place, and routines will resume once she returns home. She was the primary cook of the house and believes she will have no problems undertaking this role again (along with all others such as showering unassisted, transfers etc). Given she was such an active and motivated individual beforehand, I would have thought that she would be more driven regarding her rehab, but it is unfortunately not the case. I discussed with my supervisor the situation, and that I can’t realistically see the patient returning home successfully. She informed me that indeed yes, because of the stubbornness of the patient (and her family), her return home is somewhat expected to fail, and that it is only then that the patient and her family will realise that she is not suitable for living at home again. She will in fact more likely require low to high-level care in a designated facility.

 

Strategies

My first thought was to accompany the OT’s home visit with the patient, to see how she manages with ADL’s and other tasks. This unfortunately was not an option as the home visit was conducted early on in the patient’s placement due to a high number of home modifications needing to be done. I would think that another home visit would be an idea, as the patient would be more likely to see if her ambitions and expectations match them physically at home, though I’m told this wont be happening.

 

Regarding the wheelchair use, I discussed this with my supervisor and the nursing staff. Communicating with the senior nurse and informing all staff of not using the wheelchair was done, yet it seemed to make little difference. The only time the nurses walk the patient with the WZF is when either my supervisor or myself are in the patients room also. My supervisor will apparently be taking this up with senior management, as there are some agency staff that may be contributing to this disparity due to miscommunication. Having all staff be aware of and adhering to the care plan will help address this.

 

I also decided I’d walk the patient with one of the nursing staff. Even though the patient was 1 x assist, there seemed to be a reluctance to do this and the insisted use of a second nurse and someone to push the wheelchair was used on this particular occasion. This no doubt reinforces the reluctance to walk the patient due to time and staff restrictions. I aimed to educate the nursing staff at this particular time that in fact only one nurse was required, and proceeded to show exactly where the assist should come from (her L hand on the frame, and one across to her right hip). I checked with the nurse after the ambulation and she informed me yes, she does in fact walk reasonably well, just quite slow. Since this practical approach with a couple of the staff, the patient does seemed to be walked more often, though I’m sure to the disappointment of the patient herself!

 

 

 

I can only hope that the patients return home is successful. It appears that this is one of those grey area cases that I’ll learn from. That goals sometimes don’t meet reality, and that working in any facility always requires a comprehensive and united multidisciplinary approach is what I’ve taken from this.