Situation: Day one of placement at Neurology Stroke Unit. Supervisor has
arranged meeting with university tutor. Patient to be organised to help
introduce the 3rd year neurology physiotherapy students to
conducting an initial assessment.
Task: Assess mobility and give treatment to 90 yo female with Right MCA
infarct. Patient presents with left side neglect, dysphagia and mild confusion. Guidance given from
university tutor and main assessment role shared with 3rd year physiotherapy
student.
Action: We had been given a brief account of the presenting condition with
the major obstacle being the strong contralateral push when transferring the
patient. We introduced ourselves and our tutor to the patient and her daughter,
who was present. The patient was sitting in her wheelchair but was slumped in
an uncomfortable position. A nasal gastric tube was in place as the patient had
been aspirating her food due to dysphagia. Patient had a mild cough and
complained of the tube irritating her throat. The tape securing the tube had
lifted and there was some discussion as to whether the tube was still correctly
fitted. We assisted the tutor in repositioning the patient and transporting to
the physiotherapy gym via wheelchair. On arrival at the gym my student colleague
conducted the chest auscultation to clear the airways as a possible cause of
the cough. The airways sounded clear and the cough noted as being due to the
feeding tube. We prepared to transfer the patient to the plinth to begin our
assessment. We removed footplates and the patient’s socks and compression
bandages. The brakes were checked and the patients support table was removed.
Our tutor took the lead role as she had been warned about the patient’s
tendency to push. The other student and I positioned ourselves to give
assistance from the plinth and from the left side of the patient. The patient
was assisted to shuffle forward in the chair until her feet touched the ground.
Instructions were given to lean forward and hold the therapist for support. As
soon as the transfer started the patient tried to get her right hand to the
plinth for support. This created a strong push from the right side that the
therapist found difficult to control. Attempts were made to straighten the
patient up but the very strong push made it difficult and the frail condition
of the patient made it difficult to return the force to stabilise the patient. The patient began to
slide toward the floor and the therapist gave instruction for a 3 x max assist
to get her back to the wheelchair. We all lifted on “GO” and returned the
patient to her chair. The pushing ceased and the patient was safe.
Result: The initial attempt to transfer the patient was unsuccessful and
dangerous for the patient and the therapists. A second attempt ensured the
patient was unable to get her arm in a position to push by placing a pillow on
her right side. A mirror and strong verbal prompts throughout the transfer
assisted to get the patient upright and transferred to the plinth.
Evaluation: Even though there was a clear plan, and the senior therapist was
prepared for the problem, the patient was able to get into a position that extenuated
the pushing and created an unsafe situation for all. However, because we had
cleared our area, revised some basic communication and handling techniques, we
were able to return the patient to a safe position and make a new plan.
Strategies: Being more familiar with the techniques to reduce the effects of
pushing would have made me more prepared and confident to suggest some ideas
prior to the transfer. All the literature and lab work seemed to go out the
window when a real patient demonstrated the real effects of the condition. It
was a rapid learning curve and one that kept me up most of the night. The
importance of preparatory techniques and planning for the worst were the main
strategies that came to the fore and were utilized successfully on future
transfers of this patient.
