Situation
Follow-up Gowland
Assessment on an 83 year old male requiring discharge from rehab hospital post
CVA 4/52 with complications of previous Progressive Supranuclear Palsy (PSP)
with expressive dysphasia. The patient was previously a doctor.
Task
Conduct an updated Gowland Assessment on
the patient and complete all discharge documentation including Rehab in the
Home (RITH) referral. The patient had been discharged early at the request of
the family. Discharge was scheduled for early the following week but needed to
be prior to the weekend. It was Friday at 14:30 when the consultant agreed to
the discharge.
Action
I had been through the discharge procedures
the day before with another patient and knew where to find the discharge
checklist and documentation forms. My supervisor informs me that most of the
documentation can be completed next week but to focus on conducting the Gowland
Assessment, issuing the walking aids (stick and wheeled zimmer frame) and
getting the consent signature for RITH. As the patient has expressive dysphasia
and only able to write his communication, all discharge procedures will take
awhile. I start with the Gowland Assessment and explain to the patient that it
is a similar test to one he had done before but we were going to look at
slightly harder tasks.
It was the first time I had looked at the
Gowland since my Neuro labs but it is part of the CMII that I had used at my
previous Neuro placement. I looked over the assessment and realized that the
patient would not greatly improve on his original attempts, having worked with
him for the past three weeks and seen his capabilities. We had worked well on
his balance and ambulation but this would not translate well when broken down
into “Hand, Arm, Leg, Foot and Postural control”. The patient seemed keen to
try and I was also interested in seeing the outcome so we progressed with the
assessment. The patient had improved on some of his scores for hand and foot
control but not done very well in the other areas. This seemed to distress the
patient and he communicated that he had not slept very well the night before. I
explained that it was just a measure of progress to pass on the RITH team but
he seemed very down and requested to speak with the doctors about increasing
his medication.
I accompanied the patient from the gym to
the registrars office and left the to discuss medications. I explained to the
doctor the assessment we had conducted and how the patient had felt he could
have done better with rest and a boost in medication. There would not be any
time to redo the assessment and I informed the doctor of this. He understood
the dilemma and knew the patient well. He agreed to the medication boost but
instructed me to just continue with the discharge.
Occupational and speech therapy as well as
the pharmacy needs to spend some time to get their discharges in order. I write
up the equipment and RITH form and liaise with OT and the speech pathologist in
regards to their RITH needs. I am able to get the patient to sign the required
documents before the other health professionals begin to move in to finalise
the discharge.
Result
On reflection I realized how important it
was to the patient to feel like he had improved on his scores. He had been a
medical professional and realized that all rehab support would stem from
objective measures. If he was not improving, he would be left to make
compensations, and he had felt he could do more. I could have structured my
assessment better to allow him to complete the tasks he was capable of first
and then progressed to the harder stages. As their were time constraints this
was not and option but worth remembering in future.
Evaluation
The Gowland Assessment is not a quick
process especially when a patient has any difficulty in understanding
instructions or in communicating with the therapist. I should have taken the
time to review my plan and take consideration of the patient. A few easier
tasks would not have increased the assessment time greatly and may have lifted
the confidence of the patient and he may have not been left feeling so
despondent. The patient had overcome many obstacles in the last few years of
his life and shouldn’t have left feeling that he had failed a task.
Strategies
- · Good assessment structure that is flexible
- · Forward planning (Gowland could have been completed in an earlier session).
- · Clear assessment purpose and instructions
- · Timely feedback to the patient and positive encouragement if required.
- · Know the limitations of your patients from other Co-morbidities.
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