How one Ax can have such an impact....

Recently on a neuro prac I was asked to go and Ax a patient who had just been moved from another ward. After reading her notes I found out she had had a L MCA, mild R sided weakness and severe speech dyspraxia. She had been Ax briefly by the ED Physio’s, but had not yet received any rehab PT Rx. Her mobility status had not yet been Ax.

As she had just been transferred from another ward, I was asked to go and do her initial Ax to determine her mobility status and complete the mobility chart for her bedside. This patient was 11 days post stroke, and up until now had been hoisted for all transfers. Due to this mentioned in her notes, I assumed she was going to be a ‘heavier’ stroke patient, in terms of more severe abnormal tone symptoms.

I was quite nervous before going in to see the patient, because I had never done an initial Ax and only seen patients who had been handed over by other PT’s – therefore they had mentioned any specific issues regarding the particular patient.

The patient was sitting in her wheelchair beside the bed. I had discussed with my supervisor (who had come in with me) prior to the session how I was going to structure the Ax. After beginning the subjective, it became apparent at how severe the speech dyspraxia was. The patient did not appear to have any receptive or expressive aphasia, as her body language and nodding/shaking her head was all very appropriate to the questions being asked. Her frustration at not being able to physically form the words she wanted to say became increasingly evident as the session went on.

I had come across patients with types of aphasia before, but none had seemed as frustrated as this patient, as she knew exactly what she wanted to say. She was also very insightful towards her condition and symptoms. She could follow the conversation and 2 stage requests easily.

I Ax her PROM then voluntary control, and she had very very mild weakness in her R UL and LL, but good voluntary control. She did not have any abnormal tone evident and had good strength in all her limbs.

Positioned on her R side (and supervisor standing close by aswell), I asked if she could stand up. She did very easily, the only assistance needed was to hold her R hand so she could steady herself, as this had been the first time she stood in 11 days. She was able to transfer with min assist from wheelchair to bed, and had independent bed mobility – rolling and supine to sitting on the edge.

After we had done this Ax and I told her about the mobility chart for the nurses, she burst into tears. At first I was shocked, as I thought she had done really well and I thought she would of too. After sitting and consoling her for a little while, and her using hand signals to communicate with me, I realised that one of the reasons she was crying was that she was so grateful that she could now move more independently and not have to be hoisted. I realised how vulnerable you must feel being unable to express how you are feeling, and being in a hospital environment where lots of people talk about you and make decisions for and about you, and not being able to say anything. This patient probably knew how strong she felt and how well she could move, but without being able to say anything, and with the policy that patients are hoisted until Ax, she had had no control over that aspect.

I also gave her a pad of paper and pen so that she could write things down if she needed.

The things I learnt from this experience is to not assume symptoms, especially as neuro patients with the same diagnosis can present SO differently. I assumed she would be a max assist due to the need for being hoisted, whereas she only needed minimal assistance, and it was hospital policy to hoist until Ax. I also realised how upsetting it must be to not be able to talk when being assessed, and I concentrated on how I was communicating around this patient. I tried to ask closed questions so she could answer yes/no as anything that needed explanation would frustrate her.
It also made me aware that a mobility Ax should never be ‘put off’ as it can have such an impact on the patient’s mental state. It was my first experience at having such an impact on a patients stay in hospital, as she no longer needed hoisting and was so grateful. I will keep this in mind for all types of patients in the future.