OT in Hospital Settings Test Notes PDF

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Summary

These notes contain the basics of OT and have thorough information on clinical conditions, SOAP notes, clinical reasoning and other essential OT knowledge....

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OT IN HOSPITAL SETTINGS TEST NOTES Multidisciplinary = team members working side by side, each with specific responsibilities Interdisciplinary = team members share responsibilities to support each other’s goals, e.g. physio + OT working together if client isn’t balanced/stable Transdisciplinary = client receives services from one professional who consults other team members about their recommendations but then does the intervention for the entire team

OT ASSESSMENTS •

An assessment is an info-gathering process OTs use to identify occupations & ADLs/IADLs that are problematic

Purpose: 1. To understand the occupations that are important in the client’s life 2. To identify the client’s occupational performance 3. To identify environmental factors which impact on the client’s occupations

4. To inform clinical reasoning about the factors which facilitate or constrain OP for the client 5. To inform collaborative goal setting and planning for intervention 6. Assessment may be used later in the OT process to monitor progress What does a hospital OT need to understand about a client’s OP?  Before admission to hospital: o Their usual routines o Areas of OP important in the client’s life (valued, occupations, responsibilities) o Any areas of OP client found difficult (self-care, IADL, work, leisure, social participation) o Any strategies / supports which facilitated OP  During hospital stay: o How is the client managing OP within the hospital setting? (eg. Feeding, grooming, bathing, dressing if attempting, moving around environment, interacting with others) o Has the client’s capacity or OP changed significantly from before admission? o What factors might be limiting OP or underlying capacity? o What are the client’s / carers expectations / concerns for OP on discharge?  After discharge from hospital: o Where will the client go after DC? o Requirements for OP (routines, responsibilities) o Environmental barriers to successful OP

What is the focus of the assessment?  Acute hospital – focus on ensuring safe and successful discharge  Sub-acute or rehab – focus on developing initial plan of intervention. OT will have longer to work with client to strengthen OP before discharge. Subsequent assessment to review progress.  Outpatient – focus on planning next stages of intervention and monitoring progress Example: Jim is a chef admitted to hospital after having burnt his arm. The OT might make a splint, help mobilise his hand or provide education about self-care, showering etc. He may need referral as an outpatient to a physio, community OT or plastic surgeon What does an OT need to know about their client’s OP in hospital? INFO BEFORE: age, occupation, family, interests, usual routines, difficulties in OP INFO DURING: how are they managing with ADLs? has their capacity changed? Do they have opportunities for OP? INFO AFTER: where will client go after D/C? requirements for OP (routines, equipment), environmental barriers for successful OP (e.g. stairs), resources available, experiences after previous D/C How does OT develop an understanding of current + potential OP issues? • Conduct interview before and after admission • During hospital stay, they will do a review of referral + medical record, initial interview, observation, info from team + others, additional assessment to explore areas of difficulty *Environment in hospital is different, therefore need to create opportunities for observing OP in hospital setting

SOAP NOTES S SUBJECTIVE

O OBJECTIVE

A ASSESSMEN T

P PLAN

The patient’s emotions or attitudes Verbal response about treatment client goals Any information reported by the patient and/or family. Goals expressed by patient What therapy/treatment was offered and frequency this week Your clinical observations and any education given Details of home environment and previous home modifications Services used to assist with ADL tasks Results of cognitive, physical and sensory assessments eg. ROM, strength, patterns of sensory loss Length and purpose of session Client's response to treatment Justifications for goals/plan Opportunity to identify inconsistencies and draw conclusions between S and O Where you comment on progress in therapy and potential for further intervention Short term and Long-term goal setting Clinical reasoning about patient’s condition and situation What treatment the patient will receive Plans for further assessment or re-assessment, and plans for discharge Equipment needs and equipment to be ordered and / or supplied Therapy and home assessment recommendations Referral to other services

SMART GOALS S M A R T

specific  who, what, where, when, why measurable  have goals been achieved? achievable  does person have capacity to achieve it? realistic  based on skill, movement capacity etc. timed  set a goal, e.g. before discharge

CLINICAL REASONING • •

Refers to the thinking and processes associated with the clinical practice of health care providers Is a goal-directed process that involves the therapist in making sense of the patient’s condition while establishing a collaborative relationship with the patient

Aspect of Reasoning Scientific Diagnostic Procedural

Narrative

Pragmatic

Ethical

Description and Focus Using applied logical and scientific methods e.g. hypothesis testing, statistical evidence, what typically happens with these clients Analysing the cause or nature of conditions using personal and impersonal information OT considers and uses intervention routines + frameworks for identified conditions Is more impersonal and diagnostically driven Used to make sense of client’s circumstances to imagine the effect of illness, disability or OP problems on their lives and create a collaborative story that is shared with clients and families through intervention Relates to the ‘so what’ of the condition for the person’s life Considers current realities like service delivery, payment for services, equipment availability, therapist’s skills and client’s personal situation to get intervention OT must weigh & balance these factors when we try meets client’s needs within the boundaries of a particular delivery system Analyses an ethical dilemma and generates alternative solutions.

Interactive

Conditional

OT determines what the ‘right’ thing to do is Helps to gain an understanding of what the illness or disability means to the client by developing interpersonal interactions using empathetic comments and encouragement Allows for collaborative problem solving A blending of all forms of reasoning to respond to changing conditions or predicting a client’s future Involves reflection and imagination by OT

ADLs are: • Activities oriented toward taking care of one’s own body (Rogers & Holm, 1994). • Also referred to as basic activities of daily living (BADLs) and personal activities of daily living (PADLs). • Are “fundamental to living in a social world; they enable basic survival and well-being” (Christiansen 2001) IADLs are: • Activities to support daily life within the home and community that often require more complex interactions than those used in ADLs.

OPPM 1. Name, agree & prioritise issues Does the client need occupational therapy services? What are the client’s areas of difficulty or OPIs? What might be some of the underlying causes for the OPIs? How will you gather the information needed to determine the client’s OPIs? Patient with Alzheimer’s has pneumonia, is easily confused, has urinary incontinence, is not engaging in meaningful occupations 2. Select theoretical approach Which theory will you use to guide the assessment process? How are you going to assess this client? What needs to be assessed? What is the purpose of the assessment(s)? What does the evidence from the literature suggest about dealing with this issue? What is your clinical practice model? How often will you see the client? Cognitive disability as it addresses cognitive limitations and helps to alter environment and educate carers (patient’s wife). 3. Identify OP components and environmental conditions What person factors are contributing to the OPIs ‐ physical, cognitive, affective? Which personal and environmental factors should be targeted for change? Patient has shortness of breath, increased fatigue, affected role performance, difficulties with iADLs Clinical reasoning used: scientific (Alzheimer’s is well researched), procedural (in a shower Ax, must look at whole procedure) 4. Identify strengths and resources What are his/her personal strengths and environmental resources? What are the OTs strengths and resources? Strengths: good relationship with wife, determined to recover/ease situation, physically competent in grasping and walking Resources: wife, OT, nurses, CNC, access to hospital staff, ACAT service Clinical reasoning used: interactive (is a personal topic so rapport is needed), narrative (requires problem solving) 5. Negotiate desired outcomes and develop plan Do you/your client have the strengths/resources needed to accomplish the plan? Have you developed action plans based on the client’s OP, the selected theoretical approaches and EBP? Goal = to be able to get dressed independently in casual clothes (tshirt, trackies) with verbal prompts if required by discharge) S = being able to put on full outfit in correct sequence with verbal prompts M = observe to see if it was sequenced correctly A = yes, given the clothing is basic and doesn’t require much attention R = yes, as it is an ADL and something he will do everyday T = before he is discharged, must be able to complete competently

Strategies to assist ADLS  buttonless shirts, visual cues in shower, hide complicated clothes 6. Implement therapy plans via appropriate well-designed occupation-based activity & programs What strategies are you going to use to facilitate client engagement in treatment? Is the occupational intervention meaningful to your client? Will the activities accomplish the targeted outcomes? Do the activities need to be graded? Are environmental modifications required? Community/social groups to encourage engagement Whether a home assessment is necessary to replicate hospital environment where he learnt the steps of showering ACAT and community OT referral / OT to organise equipment and whether long-term equipment is required 7. Evaluate process and outcomes Have OPIs been resolved? Have you achieved the targeted outcomes? Does the client still require occupational therapy services or other services? If he can dress and shower correctly without prompts Follow up meeting or perform reassessments Get Doris to document his progress and report to OT or GP IF UNRESOLVED: reassess, revaluate, replan and find new strategy suited to client’s personality

SELF CARE Considerations when assessing self-care • Clients needs, interests and perceived difficulties. • Clearly define (operationally define) the nature and meaning of the activity for the client. • Identify contextual features which may affect the assessment (physical/social context) Why assess self-care? • To describe self-care status, to measure change + monitor progress, to facilitate communication + decision making Types of tests a) Standardised  therapist has standard procedure to follow and specific norms b) Non-standardised  therapist decides on structure e.g. Interview to gather information, direct observation of client carrying out the self-care task Intervention Strategies for self-care Adaptation: an internal process within a person – a response to change, through repetition and practice Compensation:

changing the activity and the environment to match client by using adaptive techniques, routines or equipment, family members to assist with or carry out the self-care activities

Remediation: changing a person’s capabilities by impacting upon body functions Prevention: identify and reduce risk factors, anticipatory action Health promotion: enable person to identify resources (time, energy) Education: Consultation:

ways to manage occupation providing expert advice and information

EDUCATION Teaching strategies from behavioural approaches Building Chains of Behaviour breaking complex tasks into steps and then reinforcing each step e.g. planting a seedling  buy plant, collect tools, dig hole, put seedling in hole, cover up roots, pat down soil, water plant Backward chaining – complete last step, eg plant watering. Grade by gradually increasing component steps,

Reinforcement: Anything that increases the likelihood that a behaviour will occur. Types of reinforcer: extrinsic (consumable, social, activity) intrinsic (sense of achievement) Reinforcement is done

Shaping: reinforcing behaviours which are similar to the desired behaviour. Gradually shift to reinforcing only closer and closer approximations to

good for teaching complex skills which need steps performed correctly, in sequence. Used to teach many ADL and social skills (eg. Transport training)

to establish a new behaviour and accomplishments in the task

the desired behaviour. (May need to have analysed or planned the steps).

Modelling: by watching the behaviour of someone else. Eg imitation –OTs use demonstration and videos to provide opportunities for client to learn from observing others Modelling is more successful when verbal labels or descriptions are given to the behaviour.

Cueing: using something eg visual aid, presence of certain equipment to prompt the person with what behaviour is required

Plan for transfer / generalisation transfer the skill to another environment. Generalise the principles learnt.

Techniques to Increase Recall of Instructions Primacy information first.

we remember best what we have heard first, so put the most vital

Repetition

information is more likely to be retained if it is repeated. This can be achieved by combining verbal input with a handout.

Simplification

use short sentences.

Stressed importance stress material you particularly want the person to remember. Link it with primacy eg. I would like you to particularly remember what I am about to tell you Explicit categorisation Specific statement

if there is lots of info (especially >6 items) categorise it before starting

Developing a graded program (for someone with heart

GRADING Characteristic to be graded

Pace and intensity

Sequence/complexity

What could Liam do to reduce the demands of the activity? Could spread food preparation over the day- ie. prepare vegetables earlier so that this does not have to be done in the eveningCould take regular rest breaks by sitting rather than standing. Could use microwave to cook the vegetables – takes less time, requires less monitoring. Could reduce steps/complexity by cooking a less complex meal, such as heating a can of soup, or a frozen meal/ready-made meal in the microwave/oven.

Could cook chicken in oven – decrease the need to stand at stove top. Could someone else do all or some of the steps? Some steps could be removed by buying vegetables already chopped or frozen vegetables. Arrangement of objects in relation to each other Have frequently used utensils, pots pans, plates, cutlery, etc within easy reach Could sit (using kitchen stool) for some activities instead of standing Working position/postures Gather all ingredients at once to reduce frequency of walking back/forth to fridge/cupboards. Use kitchen trolley to assist with transporting items to the table Equipment/ Tools used use kitchen stool at bench. Lighter pots/pans. Consider efficient work practices such as gathering all items at once so that you are Method/technique used not going back and forward to the cupboard/fridge. Initially having no distractions while he is preparing the meal may be easier for him to concentrate Nature and extent of If distractions are not an issue, then his Daughter /grandchildren could assist with interpersonal contact part of the meal Is he happy to have ready-made meals such as heating can of soup or frozen meals in the microwave initially? Quality of the result Making sure his daughter and grandchildren do not expect him to prepare a 3 required course meal when he returns home. Discuss with them what their expectations are. Ensuring the activity is carried out in an environment which is familiar Having the Aspects of environment environment as uncluttered as possible (physical features, Having limited noise or visual distractions. demands, social or Also consider temperature and lighting (if temperature is too hot or cold it can cultural aspects): affect energy levels, good lighting makes tasks requiring vision easier Characteristics of a good adaptation: • Accomplishes the specific goal • Not dangerous to client • Does not demean the patient or embarrass them

ETHICAL ISSUES Types of ethical issues 1. Ethical uncertainty unsure what moral principles apply or if the situation is a moral problem 2. Ethical distress knowing the right course of action to take but feeling scared to act due to organisation rules 3. Ethical dilemmas facing two or more equally pleasant/unpleasant situations that are mutually exclusive e.g. can’t come up with best-care scenario (patient wants to leave but worried about safety) Situations that can lead to ethical issues - Resource and system issues o Inadequate time/staff/funding  reduced quality of service o Excessive caseloads  not dedicating enough time to clients o Pressure to discharge client  unthorough assessment / service - Upholding values + ethical principles o Telling cleints the truth when it causes more harm (e.g. prognosis) o In multidisciplinary team and disagreeing with co-worker - Client safety / vulnerability o Knowing unsafe client behaviour (e.g. drugs) versus confidentiality o Client wanting to go home but it being unsafe versus client-centredness o OT makes error in treatement  do you tell the client? Principles of biomedical ethics that guide our practice 1. Autonomy  respect client’s ability to decide for themselves 2. Beneficience  should be in best interests of client 3. Non-maleficience  do no harm 4. Justice  being fair * must also be introspective and engage in reflective practice (this helps to identify our values + beliefs as these may interfere with our practice Model/FoR Biomechanical Motor control Sensory integration Cognitiveperceptual Cognitive disability Model of Human Occupation Canadian Model of Occupational Performance

Problem addresses Limited range of motion, strength, endurance Problems of motor coordination Problems with sensory processing & adaptive movement Perceptual and cognitive impairments Cognitive limitations Personal & environmental problems influencing choice, organisation & performance Mismatch between person, environment & occupation that restrict occupation

FRAMES OF REFERENCE MATCH M– A–

modify task alter expectations

Representative concepts Positioning, exercise & conditioning. Adaptive equipment Sensory input & goal directed action. Modification of task/ environment to elicit effective movement Support person to engage in adaptive movement Educate carers and adapt environment Train in cognitive & perceptual capacities Adapt task/ environment Alter task/ environment Teach client to accommodate limitations. Educate carers Support clients occupational engagement and modifying environment to enhance motivation adaptive patterning and occupations. Collaborate and involve clients in decision making to change personal, occupational or environmental factors restricting performance. Looks at mismatch of P, E & O

T– teach strategies about movement C– change environment (sound level, space) H– help by understanding THR Quiz Answers 1. What are the medical/surgical management options for a hip fracture? • Internal fixation- securing the # site with pins, rods, plates and...