Entry 2: Assessment (11/04/2010)

Situation: On Monday afternoon I was told by my supervisor that there was a new patient on the stroke ward. She told me I was to be his treating therapist and to start with an initial assessment. I had 2 hours until I would be seeing the new patient and I had two of my other patients that I had to see before then as well, which would leave me very little time to prepare. In the very brief amount of time that I did have to review the patient’s history, I found out that he had been transferred from Sir Charles Gardiner Hospital (SCGH) to Osborne Park Hospital over the weekend but had not yet received any physio treatment. I did have the patient’s SCGH notes that came over with the discharge, however it was missing many relevant and important sections, such as discharge documents and investigation results. I basically had the progress notes to skim over within a few minutes. From them, my main findings were that the man was very dysphasic, both receptive and expressive, and was dyspraxic too. I knew immediately that these would play a large part in how I went about conducting the assessment, because it becomes very difficult to conduct an assessment on someone with whom it is difficult communicating. This was to be my first initial stroke patient assessment and with the limited preparation time and a communication barrier looming, the lead up wasn’t ideal, however I still approached the situation with confidence and wanted to do a good job.

Task: My task was to perform the initial neurological assessment on this man with the aim of completing it in one session, and then to complete the necessary initial stroke outcome measures the following day. My supervisor would be present for the session, however I was told to conduct the assessment as if she was not there and that she would only have input if she felt I required it.

Action: When I arrived at the man’s room I was surprised to find that his mobility chart had already been filled out. As it turned out the weekend physio had completed this when the man was admitted over the weekend. He was written as ambulating without aids with a standby assist, so I introduced myself, explained what my plan was for the session and walked with him to the physio gym. Having been with the man for less than 5 minutes at this point, it was already evident to me the extent of the dysphasia and dyspraxia. The man’s only response to my questions was a yes or no answer and even these did not correlate appropriately with what the man was doing. This lack of response to many of my initial questions was a sign of the breakdown in communication ability. I very quickly learned that there was going to be no point in trying to get any kind of subjective history out of this man, because he simply could not communicate effectively. I began objectively assessing the man, with things such as his vision and cranial nerves. This again proved to be very difficult, but also time consuming and I had large questions over the validity of the results I was obtaining from the man. I began assessing things such as his volitional movement and range of motion using methods such as demonstrations and beginning the movements passively for the man, who could not comprehend what I wanted him to do. It got to the point where I had about 10 minutes to go of my 45 minute session and I was still looking at these same kinds of range of motion assessments. I then decided to turn to my supervisor to ask for her thoughts about the situation and how I should finish off. Her response was that I was doing well with what I had done thus far, especially with the use of demonstrations and passively moving the man to initiate movements to perform the assessment. She then went on to say that if I was to continue as I was then we would both be there until Friday afternoon trying to complete this initial assessment and advised me just to do what I could easily assess for now and then finish up. I took this on board and looked at tone, which is more of a therapist guided assessment, but then went onto functional abilities of rolling, supine to sit, transfers and eventually gait, all of which required demonstrations and heavy hands on guidance and facilitation to achieve the desired movements. This worked well and was much quicker as it was not relying on the man’s comprehension of the spoken word. It was for this reason that I abandoned testing things such as sensation, strength, cerebellar signs and balance, as I would not have obtained true results due to the patient not being able to understand my instructions for the testing. I was now out of time, and hoped that the man would be a bit better the following day when I would continue my neurological assessment.

Result: The result of my actions was that I had a very patchy-looking initial neurological assessment sheet when I had finished the session. I documented all that I had found, as best as I could in the notes, which again was difficult with the subjective history due to lack of transfer notes and the state of the patient himself. I did the best that I could with my documentation though, and left the assessment ready to come back to it the next day.
My session the following day with the man did turn out to be much better than the first. I was able to complete the majority of the assessments I had left from the previous day and also began with some outcome measures such as the Gowland and motor assessment scale. It was still very difficult however, to verbally communicate with the man, but I persevered as best I could. One thing that I did observe was a difference in many of the findings from the previous day, for example active and passive range of movements and some differences in posture. What this meant was that I had to alter some of my findings from the previous day in the notes, which I did under the objective heading in my SOAPIER. Although it took me about twice as long as it was supposed to, I achieved my task of performing the initial neurological assessment.

Evaluation: On reflection, I was quite dissatisfied with my performance, even under the circumstances. I felt that I was far too slow, which was both a product of having a difficult patient, but also a reflection of my ability to perform the different assessments. I found myself constantly having to stop and think about exactly what I wanted to do next with the assessment procedure, which proved to be costly in terms of time management. I felt that if I had have known some of the assessment techniques better, then it would not have taken me as long to complete the process. Despite this, I was happy with my decision to turn to my supervisor at the point when I did because it guided me in the right direction to finish off. I knew in my own mind that this was not a plea for help from my supervisor, but more a quick comment on how I was actually going and what I could do to be better. I hope that it came across this way and not as me struggling to cope with the situation. My thoughts about the performance were eased a little when my supervisor explained to me that it was a very hard patient to perform my first initial assessment on and complimented me on the effort that I did put in. However, I was still disappointed in myself as I felt it could have been done much better and more effectively, particularly on the first day, when things seemed to go so slow. I was glad to have the practice though and hopefully after having a difficult case first up, it will put me in good stead for my next new patient and if it is a difficult case again, then I will be all the more prepared.

Strategies: On reflection, I became aware of many new strategies from this experience. Strategies that were identified by both myself and my supervisor, but all of which I intend to utilise when assessing and treating in the future. The first of which is very important when assessing any population, but particularly stroke patients, is that of being very observant and in this case, the more informal observations. My supervisor and I had a lengthy discussion about this after my initial session, where she felt that many of the things that I was attempting to assess, but was having difficulty with due to dysphasia and other impairments, had actually been demonstrated by the man whilst he was doing other activities. She advised me that with good observational skills you can mark the patient down as having the ability to perform a certain skill or movement because you have seen them do it elsewhere, even if you have not formally assessed it. From this, I definitely intend to become more observant, and improve this very important skill of an effective therapist.
The next strategy was easy to identify because I had a fair bit of trouble with it initially and that is, knowing the tests, assessments and outcome measures well enough to execute them effectively and efficiently. I have found that knowing these well can increase your efficiency dramatically, as it means you can chop and change the assessment you are performing, according to the position that you currently have the patient in, minimising time wastage from constantly changing position.
Thirdly, I learnt that to get the desired response from the patient may require using a number of different communication methods. Due to this particular patient’s difficulty in comprehending what I was saying to him, I had to resort to demonstrations and hands on guidance and facilitation to initiate movements. For most people I will obviously have to use more verbal communication, but it is important to know that there are alternative methods such as the ones afore mentioned, as well as sensory, written, including written words and pictures plus videos or photos and sometimes more. Having these different methods of communicating and showing the patient what you want them to try and do means that you will be able to conduct a more comprehensive and effective assessment and get correct results.
Finally, from this particular situation, I learnt you can only ever do so much under particular circumstances. With this patient, there were still some parts of the assessment that my supervisor and I discussed and decided were not even worth doing due to the patient’s comprehension difficulty. In this instance, I was experiencing difficulty during the initial session, but I did what I could in the allotted time frame and then came back to continue the following day and thankfully things were slightly improved. I found that there was no point in getting flustered and worked up over the situation, because as I later discovered, you may be able to be more effective in future endeavours.