12 weeks goes by even faster the second go around!!
My final occupational therapy Level II fieldwork was at an inpatient rehab/long term care facility just 15 minutes from Auburn University >>>war eagle, hey<<<.
With a patient caseload pretty much 3-4x older than me –they basically thought I was about 16 years old–, this was a complete contrast (or so I initially thought) to my prior fulltime Level II fieldwork in outpatient pediatrics where the majority of my caseload was younger than 8 years old. The experiences of working separately with the two populations on opposite ends of the spectrum was truly invaluable for growing my clinical competence and personal development.
>>>>>BASICALLY, LEVEL 2 FIELDWORK IS THE BEST (and in some ways the most challenging) PART OF OT SCHOOL<<<<<
In this post, you will find my stream of consciousness thought process as a student in addition to a broad overview of the process of OT in this specific setting!!
In outpatient peds (see previous blog post) my full attention was given to an individual kiddo in an isolated treatment room (with my stellar supervisor) away from other therapists and distractions from outside those four walls.
However, an OT who works in an inpatient rehab/skilled nursing facility/long term care whichever way you refer to this site does not operate like this at all. A nursing home is in essence an extension of a hospital; thus, it provides medical care/supervision in addition to rehabilitative or restorative services — so therapists must be cognizant of the patient’s medical needs.
Moreover, in an outpatient setting- yes you must understand the medical history of the patient- but these individuals are considered to be “medically stable” and are living in community/home environments. When I was in the very fast-paced OP pediatric world I felt like I was rrrruuunnnnnnning 90 miles an hour every hour, but I was able to attend to the occupational (primarily areas of occupation including ADL, education/school, play) needs of the child without really worrying about how my intervention plan would affect the medical status of the child.
Fast forward three months later on my first day as an OTS in the inpatient rehab/LTC setting— and these five thoughts piddled through my brain.
- Cute old people!! I just love them. Second thought-eeeeeek at all of this medical equipment to navigate around during therapy hmmmmm foley catheters, IVs, nasal cannulas and oxygen tanks, wheelchairs, walkers, the works. Brain immediately and silently freaks out because although I can tell these patients are resilient-they are also fragile and need a med terms refresher.
- Slower paced than outpatient peds. Between ensuring adequate rest breaks to checking O2 sats to asking a nurse for a snack for a patient with low blood sugar to stopping briefly for medication administration, there are multiple brief interruptions in this setting and that is okay!
- Less documentation. Whattttt???? I don’t have daily detailed (loooovved my kiddos but pediatrics or outpatient in general equals a lot of documentation) soap notes and reassessments to write. #score
- Holy crap there are a ton of people in multiple professional healthcare disciplines needed to work (with goal being collaborative care) together for the health and well-being of these patients. (Also on that first day I asked myself how in the world would I learn every individual name…)
- Physicians to nurse practitioners to physician assistants to rehab-occupational, physical, speech- to audiologists, to RNs, LPNs, and CNAs, to restorative care to social services to janitorial services, to cafeteria staff and more–each job duty with its own unique contribution and need.
- I have an utmost appreciation for physical therapists and speech therapists after countless awesome cotreat sessions with them.
- Woot woot I get my own desk. feelin da love. Really though. My coffee cup enjoyed having a place for it everyday.
PSA***MDs and DOs worked as the attending physicians over the plan of care at this facility-what a concept that there are 2 and only 2 real types of physicians in America-please for the love if you know a DO (Doctor of Osteopathic Medicine) or a DO student give them a hug because for some reason the world hasn’t caught on to them yet-admittedly, I didn’t know how awesome osteopathic physicians were either until about 3 years ago*** and click here to learn more.
Where to begin-
Nursing homes get a bad rap- let me just start out with that. But this misleading perception can change if we become the change (which is undeniably difficult to do when you have the pressures of Medicare billing and productivity). ~~~~Think person-centered. Be person-centered.~~~
Patients are people first.
It’s just as important to remember this as a student therapist as it will be years (many years) down the road as an advanced occupational therapy practitioner-as well as in any healthcare fields.
Their occupational identity (how the individual describes himself/herself):
Teachers, Engineers, Nurses, Salesmen, Carpenters, Administrators, Counselors, Realtors, Secretaries, Welders, Church leaders, Janitors, Retail workers, Police officers, Volunteers, Grandfathers, Grandmothers, Fathers, Mothers, Sons, Daughters, you name it.
Their medical history (how the chart describes him/her):
COPD, Parkinson’s disease, Alzheimer’s disease, Peripheral neuropathy, Diabetes, Hip replacement, Knee replacement, Cognitive decline, Low vision, OA, RA, history of cancer, Myocardial infarction, Cervical spine survey, Rotator cuff repair, Amputations, Cardiac disease, Anxiety, Depression, Schizophrenia… to name a few.
***note- I am not saying that the medical chart/patient history isn’t important!! It is extremely important!! I am just emphasizing that it is also imperative to retrieve enough info on a patient’s occupational/work/life history in addition to their medical history. This extra effort is demanded from OTs in order to develop an occupational profile that will promote client centeredness from the beginning (initial evaluation) through the end (discharge).
Gathering an occupational profile in this setting will enable the occupational therapist and/or occupational therapy assistant to choose treatment interventions that not only address underlying problems or weakness areas, but also are of some meaning to the patient.***
The OT PROCESS
(at least this is how it was at my site):
Evaluation Write Up and Goals
Intervention Plan and Implementation
Progress Reports with Updated Intervention Plan and Goals
Family Meeting to discuss progress
#1. Initial Evaluation
- READ and comprehend the patient’s medical chart. Physician notes, nurse notes, therapy history, precautions, etc. Reason for referral. Length of prior hospital stay. Find out treatment and diagnosis code.
- Patient/caregiver interview and general observation. What is the patient’s occupational identity? What is the patient’s prior level of function? Any falls in the last 6 months? Behavior changes? Where does the family/patient hope to discharge to after rehab? Using your clinical competence–is this potential D/C location feasible and safe? EXPLAIN IN PATIENT FRIENDLY LANGUAGE WHAT OT IS IN REFERENCE TO THAT PATIENT’S NEEDS.
- Have the patient rate his/her/their pain verbally or nonverbally depending on cognitive status.
- What can the patient do now? Includes bed mobility, assessment of ADLs-toileting, feeding, grooming, bathing-, use of an assistive device, range of motion/manual muscle testing, sensory testing, visual processing, and more.
- What does the person want to get back to doing? What brings them joy? In what ways are illness/injury/disease/environmental factors/socioeconomic factors/confidence/insert many other combinations here –impeding occupational participation and performance?
#2. Eval Write Up and Goals
- Varies by facility and electronic documentation system
- Along with the initial evaluation, the Evaluation write up and goals must be written by the registered therapist
- Short term and long term goals
- Probably should make it a habit to make a long term bathing goal for most patients because it addresses a jillion things (functional mobility, safety, activity tolerance, dynamic sitting or standing ability, visual perceptual skills, sequencing…)
#3. Intervention Plan and Implementation
- Be creative, client-centered, and occupation-based
- Improve strength, endurance, and coordination in effort to reach PLOF
- Treat underlying impairments that are hindering occupational participation
- Think >>>>occupation as means, occupation as ends<<<
- ADL training, ADL training, ADL training!!!! In the patient’s room, in the ADL kitchen, in the rehab gym–so important
- Co treat!!! PT and ST bring awesome cards to the table!
- Teach modifications to activities -change the task, completely eliminate a portion of the task, provide adaptive equipment as needed
- Compensatory strategies are always a win -joint protection, task segmentation, energy conservation…)
- OT is all-encompassing which is probably why it is so hard to explain at times, hmmm.
A few interventions – Social Jenga; Reach, Retrieve, Practice Precautions, Matching and Sorting Sock Activity; Adaptive Equipment Training
#4/5. Progress Reports and Family meeting
- Discuss the patient’s progress, activity tolerance, medical concerns, insurance/ Medicare days (mehhh), plans for D/C, and any needed AE fr home.
- PT, OT, ST and other disciplines collaborate with the patient’s D/C goal in mind to determine the safest environment that is the least restrictive
- discover supports and barriers
- establish and address “the what comes next“
- discharge planning begins on admission — aka you are always planning and modifying your plan of care to match the needs of discharge
Death and Dying–For me the most difficult part of working in this setting can be summed up in one experience I had at mass one Sunday. “We pray for those who have died this week including…” And that’s when I broke down in tears because one of the names read was one of my patients whom I did not expect to pass so soon. It is this experience and a few others that will remain with me and remind me to be kind and compassionate to even the most irritable patients because when it comes down to it-they are someone’s mom, dad, sister, brother, friend before they are patients.
Halloween ———————————Rehab Style
Since Halloween was on a Monday this year, we brought the holiday spirit to the residents. As an OT to be, it’s important for me to be able to adapt to multiple contexts… so I altered my Statue of Liberty costume in order to be in appropriate attire necessary to treat patients. Summer, the speech therapy student, brightened up many patients’ days as a strawberry. The rest of the rehabilitation team -speech, occupational, and physical therapists and assistants- dressed as deviled eggs, which was quite a sight. Also, creating a caramel apple pumpkin was pretty sweet as well.
I am without a doubt grateful for my 12 weeks spent collaboratively working with my clinical instructor, speech, occupational, physical therapists and assistants, nurses, CNAs, social workers, physicians, and other disciplines. I am most thankful for the patients who have deepened my passion for the profession, increased my insight, and allowed me to be a small part of their lives-they are the reason this field continues to grow and enables us to have fulfillment in our role of being advocates, listeners, encouragers, adapters, and lifelong learners through our professional identity of occupational therapists.
As much as I love kids, my heart belongs to the patients with the old souls, the wisest stories, and the most loving hugs. I am so excited to begin my career as an occupational therapist and am so stoked to graduate December 10th!!! Cheers to the Class of 2016!!
Let all you do
Be done in L O V E.
1 Corinthians 16:14