STARES 1

SITUATION:

A patient was transferred from the ED department to the neurology ward for further treatment. She had presented to the ED department complaining of a severe headache behind her right eye and a sense of vagueness and confusion. This was later diagnosed on CT scan as a haemorrhagic stroke in her right frontal lobe. On initial admission, the patient was medically unstable, therefore only the necessary mobility screen could be carried out on day one. Initially she required two people to assist transfers and could only step stand transfer over the right side. Her sitting balance was poor, standing balance almost non-existent and she was not ambulating. By day two, there was lingering drowsiness, though she was now medically stable and her headache had eased. A neuro assessment was commenced and it was found that she had a low affect, significant rigidity throughout her right side, lower and upper limb, mild problem with initiation of movement, reduced ROM in her right shoulder secondary to a rotator cuff repair a few months prior, poor postural control and poor pelvic, lower limb and trunk dissociation. On the Gowland assessment she scored level 6 on most parts. Day three her presentation had changed again. She was now requiring one assist to transfer and ambulating in physiotherapy only with maximal assist of one.

TASK

My task in this situation was to conduct the initial mobility screen of this patient, complete a full initial neuro assessment and plan and carry out daily physiotherapy sessions.

ACTION

After I had conducted the initial assessment and developed a problem list for this patient, I developed some ideas for treatment and presented this to my supervisor. We were in disagreement in the approach to this patient as I was adopting a more functional approach, where as my supervisor wanted to address the impairments specifically. I carried out a fairly standard treatment session addressing impairments, which incorporated bridging and trunk control activities in supine, encouraging glute activation. I then finished this session with a facilitated walk. As she had a haemorrhagic stroke, her presentation was highly variable and by day four, Friday, she was requiring moderate assist of one for transfers and ambulation. My treatment focus then turned to addressing her pelvic control in standing and her confidence towards the forward space to bring her centre of mass in front of her base of support, making sit to stand transfers and walking easier.

RESULTS

My supervisor didn’t encourage walking this patient, though after seeing me walk her in my treatment session with the tutor, she identified that with appropriate facilitation, her gait pattern was near normal. I was able to show my supervisor that my observation of this patient’s ability was good and the treatments I had chosen were suitable. Focusing treatment on a functional task involved the patient more as she understood the relevance of the activity. This also boosted her confidence in recovery and physiotherapy.

EVALUATION

It has been difficult to build rapport with my supervisor on this placement as I feel a functional approach in some cases is more appropriate than addressing impairments specifically. When the functional ability of a patient is high, I feel that the impairments can be addressed through fine-tuning of the functional tasks rather than taking the patient to a non-specific task that addresses the impairment in isolation. In this particular situation I had this difficulty. Though I was able to see this patient with my tutor who agreed with my decision to walk this patient, which was fairly successful. Something I could perhaps improve on is my confidence in my ideas and ability to translate this to my supervisor.

Also my neuro assessment wasn’t systematic and it was obvious that this was my first experience with this. This is something I will need to work on and practice to improve my efficiency in assessment.

My communication to my patient was appropriate and effective. I found it easy to develop rapport and engage the patient in treatment. Another element I need to work on is facilitation. This again comes with experience.

STRATEGIES

- Relate all treatments to tasks that the patient find relevant to their goals. This helps with engagement of the patient in treatment sessions

- Confidence in observations and treatment ideas to relay this to my supervisor.

- Planning assessment in order of position eg. Supine tests, sitting tests, standing etc. This improves the flow and efficiency of the assessment process.