Assessment

Situation – An elderly man was transfer to Peel Health Campus requiring rehabilitation following a fall at home which caused a subdural haematoma on the right due to him being on warfarin for his atrial fibrillation. This was operated on a week post fall due to symptoms not arising until that point. He underwent a craniotomy and evacuation. The patient has a past medical history of alzheimers, atrial fibrillation, hypertension and hypercholesterolemia, decreased hearing with no aids present due to being lost. Pt previously was independent with all activities and lives at home with his wife. Currently presents confused and disorientated with stand by assist for ambulation with a wheeled zimmer frame. The confusion limits the ability for a smooth assessment.
Task – Pt was seen for mobility assessment and full elderly assessment. This included assessment of orientation, communication, vision, joint ROM, muscle strength, tone, co-ordination, sitting and standing balance (static and dynamic), functional ability’s within bed and ambulation and a COVS.
Action – I began my assessment in the patient’s room where he was resting in bed. I then asked him to roll over to both side, sit up over the edge of the bed and to stand with his frame. I then asked him to walk with his frame to the physio plinths for further examination. I observed his gait pattern while my supervisor walked alongside the patient for safety. His gait consisted of short steps, decreased weight transfer and decreased cadence.
In the physio gym I began my assessment by doing all the tasks required in sitting for example- orientation (time, place, person), sitting balance (internal and external perturbations), upper limb ROM and muscle strength, co-ordination tests and vision. Then asked the patient to lay down where I checked tone, lower limb ROM and strength, sensation and proprioception. Then asked the patient to sit up again and then to stand where I did a standing balance assessment (internal and external perturbations).
This was all completed yet took longer than it normally would due to patient’s confusion, lack of hearing and not being able to understand what I was asking him to do for each test.
Result – Results were as follows; orientation to time and person but not place, communication indicted mild dysphasia, vision indicated visual inattention to the left, full ROM, muscle strength was resited against gravity for all muscle groups and left equals right, tone was nothing abnormal, as was co-ordination, sensation, proprioception, sitting and standing balance. Standing balance at a high level is what needs further investigation and treatment.
Evaluation – Overall I think that my assessment was thorough and I now know my activity limitations and impairments that I can use to create my treatment plan. I think I did my assessment well in the sense that I moved easily between each position (sitting, supine, standing) rather than just making the patient sit up, lie down sit up throughout the assessment. However I took longer than I should to complete it but I think that with time and with the more I do I will improve on this. It didn’t help that I had to change the way I would normally explain each task due to the patients confusion and the fact the patient was unable to completely grasp the idea of what we were doing. This made me feel as if I wasn’t doing it or explaining it right which made me worried and starting to doubt myself.
Strategies – I think the main thing I can do is to just immerse myself in everything that is happening at the hospital, get to see as many patients as possible to see how they all respond differently to the same thing being said. I also want to be able to do more of these assessments because I think the more I do the better I will get.