week five post

Situation:
Pt A had a left MCA CVA six weeks ago. She has a right hemiplegia and dysphasia. Pt A attends daily physio for gait re education, balance training and lower limb strengthening. Patient A is a stand by transfer with the nurses and ambulates using a walking stick with moderate assistance from one person. During the family meeting it was discussed that the goal is for patient A to return home with her husband as the primary care giver. I had not previously met patient A’s husband, or observed their interaction during his visits.

Task:
It was discussed during the meeting that in the preparation for discharge, we would need to teach patient A’s husband how to safely assist her to transfer into and out of the car. I booked a session with patient A and her husband to teach him the transfer and assess his appropriateness as the primary care giver.

Actions:
I took patient A down to the car in her wheel chair. First I explained to the husband that patient A needed constant assistance on her weak side. I demonstrated correct use of the wheel chair, indicating where the brakes and the tilt option were. I then showed the husband how to put her supportive sling on her right arm correctly. After this I explained that we wanted patient A to always lead with her strong side, so her approach to the car seat was very important. I suggested that as the car seat was low, she was likely to need assistance getting her legs into the car. To finish off I demonstrated the full transfer into the car. I then asked the husband to perform the same task as I had done.

Results:
Patient A’s husband attempted to put the sling on the wrong arm, when I corrected the sling; he explained ‘that he had got confused’. He then tried to get patient A into standing without putting the wheel chair brakes on. Once in standing, the husband stood at over a meters distance from his wife, and tried to control her movement by holding onto her right arm that was in the sling. He directed her into the car leading with her weak side, and did not assist to get her right leg into the car. When I asked patient A’s husband about his current health, he informed me that he had bilateral ongoing rotator cuff problems and had just recently been back to hospital for a scan and ultrasound. The husband told me that he often has sleepless nights due to pain and has next to no overhead shoulder movement.

Evaluation:
It was very clear from the husbands attempt at assisting a car transfer; he would not currently be a safe primary care giver for her. He appeared disengaged and disinterested in the advice provided. He also did not demonstrate any understanding of providing support or assistance for her right hemiplegia. I was unsure whether the husband’s lack of involvement was indicative of disinterest or of fear of responsibility. We have not had any previous interaction or discussion with him, so it is difficult to gage how he feels about being a full time carer. The husband’s health will also need to be discussed, as his shoulder pain is likely to impede on his capabilities as a carer.

Strategies:
1: Document the events of the session and reflect on my current thoughts about the husband ‘s potential as a full time carer
2: Liaise with the Occupational Therapist
- Discuss home visits, a repeat session with the OT on car transfers + slings + night splints
3: Liaise with the social worker
- Discuss organising a family meeting so we can do some realistic goal setting with the husband and their kids.
4: Liaise with my physio supervisor about getting the husband to come in for physio sessions so that he can start to learn how we help patient A transfer and ambulate.