ABC’s of OT 2018 Recap

I completely failed at keeping up with shannenmarie_ot’s ABCs of OT advocacy challenge for OT Month. Clearly I’m not good at sticking with daily scheduled programming. But I still wanted to participate and finish out what I started. So below, I’ve highlighted some of what I’ve shared over the course of the month, plus the stuff I missed.

Allen’s Cognitive Assessment – In school this assessment haunted me. I hated learning it and hoped to never encounter it again after passing my ACL Practical Exam. But life is funny, and now that I’m a practicing therapist, I find myself WILLINGLY choosing to select this assessment with our higher-functioning patients. Now that I’ve found my groove with its administration process, the whole thing just flows. Plus the information I get from it is so helpful in identifying appropriate intervention strategies. So if you’re in school and you’re learning how to administer this assessment, keep you head up. It will get easier the more you use it with real patients.

Baseline – In any setting, it’s always important to know your patient’s functional baseline to know what your working towards. If someone never had full shoulder ROM, it would be foolish to make that your treatment priority when the treatment diagnosis is something like a UTI. But one thing I’m learning since working with older adults is that functional baseline often changes. Sometimes our patients don’t always achieve their previous functional baseline, maybe because of a stroke or progressed dementia. But the great thing about OT in this setting is we can help them find and achieve a new baseline that is perfectly functional for them and still enables independence.

Client-Centered Care – This might be an obvious one, but keeping our clients at the focal point of care can actually become harder than it sounds when you’re juggling patients, their families, communication with other staff, and your productivity standards. The more I work with older adults, the more I learn how often our society can treat them like children, especially those older folks who are not fully alert and oriented. It’s as if the aging process strips people of their ability to advocate for themselves. And sure, there are certainly times in which an 82 year old patient with significant visual deficits and poor motor planning might be hard pressed to stop driving, needing some firm encouragement to make safe decisions. But even with progressed dementia, people still have preferences and interests that can and should be accounted for when providing care. One of my favorite things about OT is how easy it is to make therapeutic exercises and activities relevant and unique to a specific patient. Card games, baking, knitting, light carpentry work, painting, dancing, fishing… these are all BILLABLE therapeutic tasks when placed in the proper context. Patients aren’t their diagnoses, they are people. People with loves and interests and opinions. We as OTs should certainly advocate for that.

Documentation – Such a fun part of the job, amiright?! Honestly, this was my least favorite topic to discuss in school. But since beginning my clinical practice, I’ve finally found my ‘writing style’ when it comes to documentation. And I’m learning it’s all about being creative in how you choose to concisely summarize what you did and why you did it. I’ve also learned the importance of incorporating my patients into the documentation process. It’s so important to ensure that your goals are also their goals and vice versa. So get those patients involved in the therapeutic discussion. Let them give their input and work together to write those goals!

Exercise – By the end of a typical day at the SNF, I’ve probably written “…to increase functional strength and endurance needed for successful participation in daily occupations” at least once per daily note. Usually, when I hand a patient a weight and instruct them on an exercise I usually hear “I’m in my 90s, I don’t need to be doing this”. But even in just my 7 months of practice I have seen how much light-weight exercises and endurance training can positively impact ADL/IADL task performance. And while OT’s Scope of Practice is more in the realm of ADL routines, some patients and some situations just respond better to repetitive exercise. So never underestimate the power of both task performance and strength training. Together they can work in perfect harmony, enabling patients to experience greater independence in all areas of living.

Family Units – In school we talked a lot about how family members are part of the patient unit. And in the long term care setting, they are often a part of the treatment session. {In fact just this week I eval’ed one of our LTC residents based on family concern/request}. And while sometimes family members can be challenging to deal with, I often remind myself that the family is going through just as much of a transition as the patient is, especially when it comes to patients who are admitted for care because of diagnoses like progressed dementia or Parkinson’s. But again, the great thing about OT is how well we are trained to look at the patient beyond the diagnosis. These patients are parents, spouses, siblings, friends. They have people in their lives who {hopefully} care about them and want what’s best for them. We as OTs have the unique ability to teach and train patients and their families on ways to maximize safety and quality of life. And oh how rewarding that can be.

Gait Belts – “These are all the rage in New York right now” – me when patients ask me why they have to wear this belt. But seriously, gait belts are such an essential part of safe treatment. They keep you and the patient safe and enable you to provide appropriate guidance and stability during transfer and ambulation training.

Holistic Care – I’m certain I’m biased, and of course I know that other professions can achieve a fully holistic approach, but to me OT is known for its holistic quality {at least among those of us who actually know what OT is}. OTs are trained to look at the whole person first, then the individual parts. So for example, if you break your knee I’m not necessarily looking at the knee first. I’m looking at how well you can get bathed and dressed on your own. How the injury might limit your ability to do your favorite things. What your environment looks like. Who in your life is available to help you if needed. And how you’re feeling about the injury from an emotional standpoint (#topdownapproach). This is what separates OT from other healthcare professions. We are all about that function and who our patients are as whole humans.

Identity and Independence – When I interviewed for my current OT position, my {now} boss asked me “How would you define independence?”. And it actually took me off guard. Independence is independence, right? Independence is the ability to do things independently. But you can’t define a word with the word. Independence = Independence didn’t seem like a professional answer. In a stroke of Divine Intervention, my thoughts came together and a more appropriate answer emerged. “Patient independence is the ability to safely perform the tasks he/she wants to do on his/her own. And if he/she can’t safely do those things on his/her own safely, then he/she must know when and how to independently ask for help.” Apparently that was the right answer because I {obviously} got the job. And now that I’m working as a full time therapist, that definition could not be more true. Independence might not always come in the forms we think it will. But it should always be the priority. Keep your eye on the prize and help your patient’s to do the same. Because the reward will certainly be worth it.

Just-Right Challenge – As clinicians, achieving a just-right-challenge during our treatment sessions is so important. We want the intervention to push the patient to new limits. We don’t want it to be too easy, but we also don’t want it to be unattainable. We’re looking for that perfect level of ‘challenging but achievable’. While the execution will be different for each patient, the concept is the same. And our ability to find that sweet spot of ‘perfectly challenging’ is part of what makes us skilled clinicians.

Kitchen Tasks – Meal prep is not only a great IADL to work on (with tons of different patient populations), it is also a dynamic task. Through a simple meal prep task, you can work on sequencing, direction-following, fine motor control, standing tolerance, time management – there are so many ways to make meal prep a BILLABLE activity.

Lovewell – My absolute FAVORITE thing about being an OT is the ability to come alongside someone when they’re in a physically {and let’s be honest often emotionally} vulnerable state and love them. Often by the time a patient meets me, they’ve been through a long ER visit, an acute hospitalization, a transport to the SNF, and they’re tired and burnt out. Then I come in with my gait belt and dynamometer and start asking them to recap everything they’ve been through in the last 7-14 days. But in these moments, I’m given the ability to learn their likes and interests and assure them that I’m on their side. No matter what you’re job is, every day is an opportunity to love your people well. And for me, that starts with first loving my God by surrendering to His Guidance.

Memory – I assess memory with every single one of my patients. We all know that aging and memory loss are often closely correlated. But as OTs we are equipped with the skill set to not only improve memory/cognitive functioning, but also appropriately compensate and adapt for the areas that we cannot fix. There is always room to maximize safety and independence, no matter what stage of memory loss a patient is in. And it is up to us as OTs to ensure that this philosophy is heeded.

Nutrition – Fun fact: ‘sweet’ is the last taste bud to go during the aging process. Because of this, appropriate nutrition can often be difficult to achieve in the aging population. Add arthritic hands, poor motor planning, and dementia that limit the ability to hold a fork and you’ve got malnutrition. But OT is all about adaptation, and when it comes to meals we can use positioning, adaptive equipment, environmental changes, and staff/caregiver education to maximize safety and independence during meals.

Oral Care – I recently read in an AOTA magazine that poor oral care is the leading cause of malnutrition in older adults. I’ve noticed within the SNF setting that oral care can often go overlooked. And I have seen proper nutrition decrease as a result. So make sure those patients are brushing their teeth, soaking their dentures, and rinsing their gums. It’s just as important as the rest of the ADL routine.

Pain Management – I’m learning first hand that it can be difficult to manage pain in the aging population because people either down-play the pain, exaggerate the pain, or are unable to communicate the presence of pain secondary to the progressive nature of their disease. And usually when we find out that someone is in pain, the solution is to give them some medicine. But in OT, we like to use more conservative means of pain management, such as moist heat, massage, cryotherapy, stretching, energy conservation, etc. We can also sometimes notice the silent signs of pain faster than other professions might notice them, which only further proves the importance of patient advocacy.

Quiet Environments – At about 3pm every afternoon, some of our LTC residents make their way down to the therapy gym to sit in front of our big windows, soak in the sunlight, and enjoy the peace and quiet. Which I sometimes find funny because most of our LTC residents are basically deaf, so we constantly have to shout at them. But when the craziness of shift-change and sun-downing starts up every afternoon at 3, people seek refuge in our calm and quiet gym. Patients can so easily become overstimulated; especially dementia patients. It is our job as OTs to not only help to create these quiet environments, but to also assist in educating the staff on why calm quiet spaces are so important for our older adults.

Respiration – At the SNF, we often receive skilled patients after an acute hospitalization for either pneumonia or a COPD exacerbation. So our intervention plans often focus on increasing pulmonary endurance. But just because a patient’s medical record is clear of COPD and/or pneumonia doesn’t mean you shouldn’t check their O2 levels. Every older adult should understand the importance of pursed-lip breathing and energy conservation to maintain endurance and independence as long as possible. And a lot can change quickly, so always keep a pulse-oxymeter in your pocket (just in case).

Sensory Integration – When a dementia patient is expressing emotional distress, it can often be due to either too much sensory stimulation, or not enough stimulation. This is why it is so important for us as OTs to understand appropriate sensory integration. We are trained to interpret sensory processing and how to improve it in order to maximize calm affect and appropriate environmental interaction. I’m learning that sensory integration is something a bit more specific to OT than any other factor we’ve discussed thus far. Which makes it crucial for us to appropriately educate staff and caregivers on the role of sensory processing as it relates to emotional regulation.

Transfer Training – A few week ago, I was chatting with an LNA about one of our LTC residents and during our discussion she said, “I don’t know why, but So-And-So has gotten so much better at transferring out of her w/c and into bed”. And I replied, “Yes, because she’s been standing for up to 2 minutes with me during our therapy sessions”. Transfer training is so crucial in maximizing not only patient safety, but staff safety as well. The more a patient can participate in the transfer, the less the staff have to pull and push to get a patient safely into bed. And their’s nothing quite like the feeling of upgrading a patient from a Hoyer transfer to a stand-pivot transfer, to a supervised transfer.

Ulcers – Imagine sitting in the exact same position for 10 hours a day. How uncomfortable! And yet this is often what we end up doing to our patients when we transfer them into a wheelchair in the morning and keep them there until they go do bed a night. A constant seated position can be incredibly unhealthy for anyone at any age. But our older adults are especially susceptible to skin breakdown. If left unchecked, a simple red area can turn into a deep wound with the potential to result in lethal infection. So always check for new red areas when assisting with ADL routines. A quick skin-check can prevent future damage.

Vision – In school, we had a prof who was/is OBSESSED with vision/low vision/interventions to compensate for low vision. So in every. single. class. she talked about the top three ways to compensate for decreased vision: 1. increase light, 2. increase contrast, 3. decrease clutter. And of course my friends and I would kind of joke about how often we got the same lecture. But now I’m really laughing because I’ve given the same lecture (in an abbreviated form) to some of our staff members at the SNF. {like, what?} It’s just so true, doing these three things will in fact make a big difference in the lives of our older adults. So I guess that lecture on repeat wasn’t that bad after all.

Wheelchairs and Walkers – I’m going to admit right now that identifying an appropriate wheelchair style and cushion option is not my strong-suit. But fit is so key here! Earlier this month, we actually had a really incredible on-site seating and positioning training, during which we were actually able to perform part of the training with some of our current patient. And through it, I learned how crucial appropriate wheelchair and walker administration is. A poor fitting wheelchair can lead to permanent skin, joint, and muscle damage, not to mention decreased functional performance. I’m thinking about maybe making a specific post all about seating and positioning so stay tuned for that. But in the meantime,just know that it is within OT’s scope of practice to prescribe wheelchairs and walkers. So it is so important that we know all the pieces and parts of what we can and do provide.

‘X-Files’ – I’ve never actually seen this show, but I thought the phrase was fitting for what I want to talk about. A lot of times (at least where I work), we in the therapy department sometimes have to hunt around and rule things out in order to figure out what’s really going on with a patient. And in conjunction with the nursing staff, we dig around and sort through the symptoms and the behaviors that the patient is experiencing until we figure out “Oh this patient has a UTI”, or “Oh maybe this patient fractured their wrist when they fell at home and it didn’t show up on the initial x-rays at the hospital”. New problems and diagnoses can always come up during the course of therapy, especially in the geriatric population. So we as OTs need to constantly be looking beyond the surface to make sure we advocate for and treat our patients in all the best ways.

Youth – They say youth is wasted on the young. But honestly, I’ve encountered some 90-something-year-old residents who are so full of life and youth and vitality, simply because they choose to be that way. Of course, I’ve also encountered some 40-something-year-old residents who choose to act like they are old and decrepit and unable to function. But seriously, youth can be a choice. Even if the body shows signs of aging, the mind and soul doesn’t always have to. And sure, this may sound fruity and ‘out-there’, but it is so true. So use your therapy sessions to remind people that youthfulness can be a choice. Play games. Sing songs. Dance. Laugh. Be joyful. Find those fun things that your patients love to do and do them. Life may be short, but it’s always worth celebrating.

Zeal – Pretty much what everyone else picked for the letter ‘Z’. But let’s be honest, there aren’t that many ‘z words’ in the world of OT. That being said, I’m glad this one fits so perfectly. Passion and enthusiasm and joy in your work is something that patients can and will notice. Older adults aren’t afraid to say what’s on their mind (I’ve quickly learned). And they can tell when you actually care about what you’re doing. So be the OT and the healthcare provider that stands out as someone who is known for loving their job. Be the person who is always smiling because you’re genuinely happy to be here. Sure the tough days will come, but when the hard days come remember why you chose to be an OT in the first place. Remember those people and those moments that drew you into this profession, and use them to further fuel your passion.



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