Problem solving

During my neurology prac I went to see a new patient who had been screened the day before in ED before being admitted to the ward. The handover had stated the patient had a right sided stroke and was ambulating and transferring with one minimal assistance.

When I arrived to see the patient I launched into my usual introduction and set about getting the patient ready to go to the gym. Given the reported level of function I expected to be able to walk the patient to the gym to complete my assessment. However I found the patient required significant assistance to transfer from supine and after a couple of attempted sit to stands the patient was not able to stand with minimal assistance.

At this point I returned the patient to bed and I was seriously doubting my ability to record a handover. I went and reviewed the notes which confirmed that the patient was minimal assist yesterday, so either the patient had suddenly got worse and no one had noticed or I was doing something wrong.

I decided to review the latter option first and after some more detailed attention to the notes I found that the patient had a significant hearing difficulty and required hearing aids as well as glasses for decreased vision. When I returned to the patient I was able to get the hearing aids and glasses organised and the improvement in response from the patient was noticeable. However I did not feel comfortable walking the patient to the gym and chose to use a wheelchair instead.

I completed part of my assessment in the gym and found that the patient had quite high Gowland scores with good range of motion and minimal perceptual deficits. When I explained the situation to my supervisor she simply walked over to the patient and asked her to walk to the door. To my surprise the patient stood up with minimal support and proceeded to walk comfortable to the door.

After reviewing what had occurred I realised that I had bombarded the patient with instructions that were poorly understood due to hearing loss. When the patient was not performing the task as I expected I reverted to breaking the task into obscure instructions from the patients point of view, rather focusing on a task the patient knew.

I have realised from this experience the need to make our intentions really clear with our patients and this is even truer in a patient population, such as a stroke, that has sensory and cognitive deficits. If we are able to focus on simple tasks that the patient knows initially then it will be much easier to give them into tasks that are less familiar.