Week 3

Situation:
Pt A had a Left MCA CVA on the 21/05/2010 and was found on the floor by her husband. She was transferred to SCGH with right-sided weakness. Patient A has a pacemaker and a previous medical history of paroxysmal atrial fibrillation and mitral regurgitation. The progress notes handed over from SCGH indicated that patient A had been non ambulant on the ward and was a two assist step transfer. When I entered the room, the patient was alert and sitting out of bed.

Task:
My task was to perform an initial objective assessment of patient A. I needed to assess gowlands, Covs the motor assessment and Berg balance. I then needed to create a mobility chart for the patient’s room to direct the nurses as to the appropriate transfer and aids.

Actions:
I got consent and then took patient A down to the gym in her wheel chair to commence the assessment. I did a two assist step transfer from the chair to the plinth, as was previously recorded in her notes from SCGH. Once lying on her back I commenced the gowlands assessment. On completion of gowlands I assessed Covs and MAS. I did not have time to assess patient A’s berg balance, proprioception, sensation or vision.

Results:
Patient A had expressive dysphasia. This made it very difficult to interpret her response to questions. Patient A would often muddle up her ‘yes’ and ‘no’ response. I needed to repeat myself numerous times throughout the assessment. It was also very difficult to determine the limiting factors in each assessment. For example when I asked patient A to perform a task I did not know if the limited performance was due to pain, weakness or confusion. I did not get the opportunity to discuss goals with my patient. When I assessed Gowlands, I had to constantly transfer my patient from supine to sitting for the different starting positions. This caused my patient to fatigue very quickly, resulting in deterioration in the performance level during the second half of the assessment.

Evaluation:
Due to patient A’s dysphasia, it was very difficult to determine the accuracy of her verbal responses. For example patient A would often say ‘yes’ when she actually meant ‘no’. When analysing my problem list, I found it very difficult to interpret the cause of her impairments. For example during the assessment of patient A’s shoulder, it was hard to tell if her limited range of motion was due to pain or weakness. I felt that my Gowlands assessment was very inefficient and poorly structured. As I was unfamiliar with the outcome measure I did not choose an appropriate order of assessment.

Strategies:
1: Find alternative means of communication e.g. facial expressions, body language, hand gestures, Draw or write, I could ask the husband to assist in interpretation during the sessions.

2: Plan my assessment better. If my patient is likely to fatigue quickly, I need to think about the sort of things I will assess in each different position (supine/ sitting/ standing For example, assessing Gowlands). This will enable me to structure my session more efficiently with less transfers.

3: I will plan a shorter session, so that my patient does not fatigue so much. (Split the initial assessment over two days)