Lester the Lion Kitty: Prairie dog at heart

Centennial Vision Moment, Dum Dum Dum

Pt = patient, shorthand, in documentation. I keep forgetting to write out patient. Sorry.

Today was a relatively normal day, plus an extra special Centennial moment.

A friend jogged my memory about the COPM, which reminded me of the Occupational Performance Process Model (OPPM)…I remembered a case study in our book “Individuals in Context” that I really liked, as it detailed the steps of the OPPM used to help a lady with major depression after the birth of her second child, and ended up inpatient. I have a patient with severe depression so I decided to use that case study to help me use the steps. I had to do my own modified version because I have a much shorter timeline and limited resources, but it still was AWESOME, and I really felt like it was therapeutic and functional.

Today I wrote myself a skeleton of OPPM, then met with the pt. The pt and I came up with occupational performance issues (OPIs), based on me asking pointed questions about typical days, both before depression and during depression. (People with severe depression can have a hard time coming up with own ideas, concentrating, etc) We discussed importance, performance, satisfaction, of these performance issues, with some trouble, so I did not use that part, even though I know it's key if the OPPM is used properly. Since there isn't a way to follow up with pt after discharge,  I didn't worry.

We discussed patient's strengths, pt's resources, and came up with targeted outcomes and an action plan, with very simple, basic goals, that she agreed were reasonable…after lunch I put it all into the computer and typed the goals/all of it up, with extra spaces for pt to add more strengths/goals. I put one copy into the chart and gave the pt a copy. The psychiatrist showed up right as I was putting it in her chart and I showed it to him and he was like “This is GREAT! This is what OT is all about! Does OT work on the other units?” I said yes, if the doctor orders it….I forget his exact response, but it was along the lines of “You may regret telling me that”, ie he was going to start using us more often on other units.

It turns out this is a reimbursement problem for various reasons I don't fully understand, but if a doctor orders it, we do it regardless of reimbursement? I guess if we get this huge deluge of orders we'll have to narrow it down, but it was clear the psychiatrist was enthusiastic and pleased with the specific, detailed functional goals made to promote pt's success in participating in activities of daily life, after discharge.

I enjoyed the process – I spend most of my day doing things I don't find very therapeutic, as it is mostly cognitive assessments. This was one of the first times I felt like a real OT (student). I've said I don't particularly care for the rotation in general as I don't like the unpredictability…but working with people with depression/anxiety for mental health OT, is kinda cool. Too bad it's hard to find a job that lets you only work with that specific population.  ANYWAY….it was an awesome CentenniallyVisionish moment and I'm proud. Considering I didn't even use the model properly (mostly used its skeleton, missing a few ribs and a leg bone) and it was still powerful, I can only imagine its power when used right!!

Random “Stand out” moments of day:

1) Rescuing a lady in a wheelchair being pushed unwillingly by a pt wandering aimlessly. I've noticed patients with Alzheimers at the stage of wandering in the hall, will push wheelchairs, whether people are in them or not. Of course typically the pt in a wheelchair doesn't appreciate this, especially if the pt is pushing them into closed doors. Luckily typically the staff catch this early and stop it.

2) Patients being extra demanding/needy/restless/fidgety all at once – which started around my group time, lol. I didn't do anything special or different, but by 1035ish I had only 2 of my own patients left, so I stopped there at the end of the first group (on self-esteem), instead of doing another one. If this had happened earlier on in my rotation I might have felt like I did something wrong, but now I know that some days are better than others, and sometimes it seems like patients feed off each other and all end up wanting things at the same time…either they're all calm or all upset.

The rec therapy student had a flop group this afternoon too…she was frustrated and asked me advice…I told her not to feel bad because that's just the nature of it…some groups work, some don't…it might not work one day, but work a few days later…

3) A nurse and I did a rather complicated toileting ADL for a woman who requires a lot of assistance…I was proud because I did a good job with the transfer helping, yay…and also, that nurse afterward, who doesn't normally work the floor and doesn't know me, told me randomly, “You're sweet. You have a good heart, I can tell.” and then walked off.

4) Did an ADM placemat task (copying shapes/colors of a placemat, onto a blank one, using felt pieces) with a lady who did it slowly and steadily and perfectly – except for the upper right quadrant. Probably a visual impairment rather than a cognitive one.

One last thing…

an achievement…I saw on the nursing/social worker notes that often accompany a chart, that the social worker had mentioned to a particular patient's family that OT would be assessing patient for safety returning back to living alone.

Six weeks ago, the social worker didn't use OT at ALL for anything, and now she comes to me for any patient that may be making a change of living situation, asking me to do the Cognitive Performance test, etc. We talk almost daily for a few brief minutes about patient statuses…

I hadn't really thought about it because it's become a norm, but when talking to my friend tonight, I realized what a change that is from when I first started there, and I'm proud to say it's 100% because of me going to her and letting her know we can assist her. She hadn't realized. It helps her a lot to not have to make the decisions quite as blindly so she is happy to utilize OT now, and it's just become commonplace.

Talk about Centennial Vision! Woot! Alright, no more bragging…just realized how things have changed.

Week 7, Day 3…

Today was a catch-up day. A few people had been discharged, and no evals. So I made a list of all the assessments I needed to catch up on. Mostly a ton of ADM placemat tasks (a task where you have a patterned placemat and a blank placemat with felt shapes, and have them make their placemat match yours. Helps you gauge cognitive level up to a certain level…many of my patients are around a 4.4 level…don't have the form to remember what that corresponds to, but they definitely require quite a bit of cognitive assistance).

Also caught up on the geriatric depression scale and mini mental state.

My depression scale lady scored off the charts for depression 🙁 I gave her a Tangle to hold while she answered questions because she was restless. I think she liked it.

I don't tend to push patients who do poorly on placemat…like I give them a chance or two to see if they can make theirs like mine, but if it is clear they can't, I'll be like “That's a pretty pattern you're making, I like it”…no point in frustrating them in my opinion, if they are nursing home level anyway especially. One man today made a beautiful design that looked like a big flower made of hearts. Very artistic. It surprised me. I wish we had more supplies so the patients could keep what they make instead of it being taken back part – which I know isn't how it's supposed to happen, it's supposed to be used therapeutically and fully, but with this economy and understaffing, that's not possible. Let's say it's been 8 minutes and it's clear what their score is. Technically I could be like “Okay that's it and move on, since I've gotten the billable unit. But if they're enjoying the task, I'll give them the extra 5 minutes or so to play with it, before I stop them, so that it's at least SLIGHTLY therapeutic in the sense they are immersed in the activity.

I get frustrated with lack of supplies in unit – again, economy, short-staffed, and tendency of patients to destroy/lose things, makes it hard. But still – some magazines, a bunch of playing cards, a bunch of crayons and adult coloring book pages – not that hard. Anything. They have NOTHING besides TV and a few groups a day. Lucky ones get magazines or books brought to them. Some of them get restless and bored and cause nurses/techs issues because they have NOTHING TO DO.

I wonder if foam dominoes exist, so they can play without it being dangerous if someone gets angry.

Today I did one group on orientation in multiple planes – a little easy for most of them. Can I be embarassed to admit that one of the questions asked what century we are in, and none of them knew, and I was like…ummm….I THINK 21st? It's one of those things you hear but don't think about it until an embarassing moment like that where it's like I AM TOO IGNORANT TO LIVE! EGGPLANTS ARE SMARTER THAN ME! None of them were too perturbed though, lol. If they don't know the answer, they don't seem to think it shocking that I don't either…thank goodness, lol.

This one lady who wanders around really agitates some of the other patients – apparently she has smacked some of them. One patient in particular, who is my patient, gets really restless and slightly agitated when she is around him. She got really close to him several times and one time started to really get in his face. I had to PHYSICALLY maneuver my body in between hers and him, and with gentle pressure got her to move back. I didn't hurt her or be physically aggressive at all – just needed to get between them as I was worried either or both of them would hit each other.

Hmmm what else. I got my windshield replaced today – it had a massive crack – which is structurally dangerous, who knew. They came to my work, phew.

Oh…we have a patient who was very demanding and needy and needed a lot of physical assistance. I spent a long time helping her with various unrelated things before we finally got the ADM placemat task done. She got really mad at another pt in the room who was just sitting there quietly. She mentioned her higher degree and told the other pt accusingly “I bet you never even finished high school”. This was quite offensive to this other lady, who prides herself on learning, even though her learning opportunities have been limited by socioeconomic status and other issues. I told my lady that the pt was allowed to be in there and that that wasn't very nice, etc. I think she was mad about the other pt because she likes all the attention.

Some of our needier patients have left…I don't feel like I'm going to be ambushed every time I leave the nurse's station or enter the unit…although of course every time we loose a few needy patients, we quickly gain some new ones. I hope the census stays slightly lower for a while so I can catch up and breathe and do some ADLs and such. I'd love if it got REALLY low so I could do a lot more one-on-work, but the nurses/techs like it busy so they can make money, of course, lol.

I stopped and spoke to one of my patients who has been not feeling well lately. Sat with her about 5 minutes and held her hand and helped her rinse out her mouth and stuff. I try really hard to look them in the eyes, show them I'm paying attention, sit with them a few minutes, just show them I care. Sometimes I'm so busy I have to just flit around, but when I get a chance, I like to spend a minute here, a minute there, interacting with a patient, just for fun. I do like that pretty much ALL of our groups involve some laughter – no matter what it is about – I especially like it when patients make each other laugh (because of humor, not the mean kind).

Today in group a pt was describing a picture that involved a little child peering into a birds nest with eggs. The pt elaborated, saying “And then the momma bird pops up and says DONT EAT MY BABIES!” and another pt thought that was funny and went with it further. I love stuff like that. I'm trying to figure out how to do a group entirely on humor – jokes of varoius types – and relate it to life skills. Like, maybe focusing on laughter/humor as a coping skill for stress/depression. Hmm. Wonder if that would fly.

I am trying to come up with new groups and not just do old ones – most of them are too dry in my opinion. I end up feeling nervous because I know the topics are boring, and that never flies well because the patients can sense it.

Recently, a patient described a war memory. He has lost most of his words so he is rather Alice in Wonderland like when he describes things in vague terms, but it was clear in the line of duty he had seen some horrible things. He described a story and it was possible to get the gist of it. He wiped tears away. The poor man…some memories never go away.

Alright, this is way too long as normal…

Week 7, Day 2…over

Today was a day of assessments.

Started with watching my OT do the KELS on a patient in adult acute who can't leave the unit (hence no CPT), I didn't much like the assessment. The pt decided to pull up her shirt/down her pants to show us fire burns.

I did two groups – very small groups today – one on “Noodle Boosters” and one on Healthy Lifestyle Habits.

Then I went to Dual Diagnosis and brought the patient to the rehab area, did the CPT on the patient.

After lunch I did an eval on a very confused lady who said her dad could hear the sound of a “pea dropping off a dog”….she later changed it to flea. LOL.

I have a HUGE list of patients to do ADMs on, I'm only a little behind on LACLS, and a tiny bit behind on MMSEs and GDS.

Gotta think about groups tomorrow, hmm. Hmmmmmmmmmmmm. Hmmmmmmmmmmmmmmmmmmmmmm.

Went to gym after work….took a “nap” which was mostly me lying there thinking about patients and who needs what in the unit.

I need to try and remember to stop at a Dollar General or something and get some cheap cards. I'm tired of patients asking for them and there not being any. I'm sure they've had cards on and off and they always get destroyed or something, but still. Costco, sell giant things of cheap playing cards, all with different color backs to keep decks separate, to stock up rehab units and stuff.

Wow, this was an almost short post, how is that possible.

Didn't get anything helpful done this afternoon, but tomorrow is a new day with new opportunities, right?

The Healthcare Cake

My recipe for “Best Patient Care”

1 cup enthusiasm
3/4th cup compassion
1/2 cup respect and dignity
1/4 cup sweetness
3 tablespoons creativity
2 tablespoons patience
4 tablespoons teamwork
2 teaspoons empathy
1 dash of passion
2 pinches of hope

Gather ingredients. Stir together in one large bowl until well-blended. Bake for 30 minutes at 350 degrees. Let cool. Share with others. Enjoy.

Week SEVEN

Did a group on stress (identification of symptoms, stress reduction) and one on relaxation. The tables in the day room – typically in one long arrangement like a feast – have been changed to more cafe style, so instead of sitting at head of table, I walked around the room. One of my patients asked if I used to be a schoolteacher and said I'd be good at it. That was really sweet I thought, since I definitely don't feel like I have any group skills.

One of my patients was in rare form today – bright and bushy tailed – one of her ideas for stress reduction was doing something fun – like catching a fish with your bare hands. And then she told us about how she did that once, lol.

I attempted two more times to do an evaluation on a man with serious aggression, but I didn't try too hard to rouse him because he gets aggressive quickly. I just needed to be able to document the attempt. I'm sure he won't get picked up, but have to keep documenting that I've tried.

I have two patients in another unit that need the KELS done – neither can or should be taken off the units for various reasons such as elopement risk so the CPT is out…so my OT suggested the KELS. She has a free spot in the morning so she'll do the first one and I can go off and do the second after…I'm sure I saw it done once in an OT school lab but it's been a long time, I've forgotten. I've now been in the Mood & Stress, Acute Adult, and Dual Diagnosis, beyond just the geriatric psych unit…so branching out, woot.

I have about 16 patients right now…not enough hours in the day to get all their short term goals met, let alone long term goals. I am hoping a few got discharged or will be discharged asap…about 5 of them apparently are all waiting placement but are otherwise stable.

Alright….tomorrow…two KELS…attempt eval again…hope there are no other evals lol…and then try to catch up on LACLS and MMSEs and ADMs….ADLs would be nice but take a lot of time so unlikely. And of course groups…..as a friend pointed out, only 58 to go….

Ummmmmmm………..maybe I'll do one on an AARP article about boosting “noodle” (brain) power…haven't done that one in a long time. And maybe a lifestyle habit one using bingo chips…asking wellness questions and if they answer yes they get a bingo chip…ie accumulation…….something along those lines. I don't hardly prepare for my groups anymore – most of them are repeats. I remember when I first started there I could not fathom just grabbing something in 2 seconds and then doing a group…but it's not that hard.

Rereading that paragraph it sounds like I don't try. I do spend a LOT of time looking up ideas/topics for groups…but in terms of sitting down and plotting it out, that hasn't been necessary…once I have the topic in mind – that is the hardest part – the rest is not hard. I've gotten books from the library on art therapy, spent hours searching the Internet, used some guided meditations, brought in my own relaxation CDs, etc. So I do try to think outside the box.

I saw the doctor today and changed medications. I'm weaning off one and starting two others…a little bit (okay a lot) more medication than I'd like. I think that when I swallowed my new pills this afternoon, I also swallowed some hope. This evening for the first time in a long time, I felt some mild energy/motivation. I got some paperwork done and cleaned out about 70+ emails…although of course have 220 to go. Not counting being about 100 Facebook msgs behind (many of which have to do with OT).  If this feeling of hope and motivation continues, I may actually get those Christmas thank you cards done this month…wow. lol.

Hey I had my midterm today. A lot of 2-s for need improvement, some 3s for good work, lol. I passed, that's all that matters. I don't think I've done any worse on this rotation than my others, this OT is just a tougher scorer!

Apparently there is an OT blogging carnival coming up…read about it today after seeing a comment about it. Will post on it later. And other stuff.

All y'all need to keep your fingers crossed that my hope, energy, and motivation, stay strong, so that I can get through this next 6 weeks with courage and grace, giving my best to my patients, my best to myself, my best to family and friends.

BLAH!!! BLAH!! BLAH!!!

Um….I've been hit by a little old lady, watched the smearing of feces, watched the spontaneous public disrobings of patients, dealt with auditory and visual hallucinations, and delusions, and aggression,
etc. I don't think I've written up my day for a while, I forget when I last did it. Seems the last few days haven't had massively big issues – just more typical stuff. Seems like there were a few things I wanted to share but my mind is blank right now. Just wanted to post so that people knew I didn't fall off the face of the earth.

Have a doc appt tomorrow afternoon – need a medication adjustment I think – feeling very zombie-ish. Makes work very very challenging as its very VERY busy – much higher census than normal – so there is VERY RARELY downtime. If you feel like a zombie, running around all day long is a very daunting task. I need to do my midterm questions by the end of this week. And start working on professional development evaluation stuff. And register for class on taking the boards/get review book. And deal with the over 300+ emails and such. And start planning trips/what happens after this final six weeks are up. I'm on month 8 of 9 months of fieldwork – my fieldwork baby is about to be born, ha ha ha. I crack me up. Anyway, it's pretty freaky to try and figure out what is next….ooooh.

Lester the Lion Kitty is soooo cute/sweet….

If anyone I see regularly has some extra decks of cards, please donate to me…..I'd like to take them to my geri unit.

Ok…hmm tomorrow's groups….maybe one on relaxation and one on boring nutrition. boo. lol. Hmm…

I guess I'm going to try and go to bed…if you've emailed me asking me to answer questions re OT school….I promise I ALWAYS answer….its just sometimes a very, very delayed answer. Like I'll probably send out my Christmas thank you cards in March….seriously. :X

Week Six.

Today was neutral. Not great, not bad. I admit every weekday morning I wake up feeling slightly nauseated and anxious as I realize I have a full workday ahead of me. I try and give myself pep thoughts, think positive, breathe deeply, try to relax, etc. But it's a yucky feeling. I know it's going to stick around probably the rest of this fieldwork as well as a while longer, as I figure out where I'm going to be settling down for work…I steel myself each time I enter the unit because I never know what to expect…

I heard my first Code 100 today….which means combative patient…..it was around 4pm and my supervisor had just left (early for the first time in like forever), so I couldn't go as a student without a supervisor around, but my heart still raced!! (Technically anyone with training who can go, should go…I've had the training…although I'm forgetting it!). It's probably my fault it happened, lol, because I saw the HELP training guy today and we chatted briefly and he mentioned there hadn't been a code in a few months. Tempted fate, oops.

Today the chaplain came in and over-ran my time….I couldn't exactly hover over her shoulder while she sang about Jesus but I did lose quite a bit of productivity. But I just hovered in another room and didn't disturb – I think the patients need that time for praise and reflection and relaxation and song and I wish she came every day. I was glad she was there, just wish her time didn't affect mine! I lost about 8-9 units because I could only run one group instead of two…I made an executive decision to run one longer group instead of two overly
short groups. Especially because the rec group had involved exercise and one of mine involved some exercise, so I crossed that one out…I did one on self-awareness…using advice…ie, what advice would you give someone younger/less experienced than you, regarding various themes like friendship, relationships, education…one person said “Don't get married at age 14 like I did”…yep, good advice. We discussed briefly at the start the importance of reflecting on the past, good and bad, and thinking about own experiences and satisfaction, and what you've learned from your experiences you'd want to share with others. There were 11 patients in the room + 1 who wandered in and out. 9/11 were my patients – two I had discharged due to lower levels and/or refusals, but they were there today. Two others slept the entire time and didn't participate so although they were at the table of my group, I didn't charge for them obviously.  I think some of the techs think of my group time as a “break” which frustrates me – if there are 16 people on the unit and 11-12 of them are in a single room with me doing a group, how about one of y'all techs stick around in the room in case a pt needs something, which is inevitable?

I guess I've come a long way that 12 people in a room with me the leader, wasn't too stressful.

One lady kept wandering around dropping her pants…not sexually, just randomly… I was in a room with a more or less bed-bound man, and this lady wandered by, and he hollered YOU KEEP YOUR CLOTHES ON! I DON'T WANT TO GO BLIND! And he explained to me she walked into his room the other day and got buck naked. AHAHAHAHAHAHA Yikes. I bet he was like noooooooooooooo!!!!!!! noooooooooooooooo!!!!! Poor lady….

Ummmmmm…….I'm way behind on lather lacing. I really don't like the LACLS….and I'm still not so hot at the single cordovan stitch. 😡 But it's a goal for pretty much all my patients so I better get crackalackin. I think my OT would have a heart attack if she realized that I have like eight more people to do it on…:X I'm pretty caught up on ADM/MMSEs….need to try and deal with some ADLs. Have two people on another unit to deal with. I'm just thinking out loud here, lol

I got a really nice e-mail from a guy from India who is also switching to OT from a computer-tech-ie oriented career. He was interested in thoughts on OT as a second career as well as cultural differences in OT…I'll have to think about what to write about it. My last supervisor was British and my current one is Australian….wow so cosmopolitan…lol. Gotta think about who else.

Ummmmmmmmmmmmmmmmm…………..ummmmmmmm……….gotta think about tomorrow's groups…..

Lester the Lion Kitty and Roger the Cowardly Kitty are messing with each other….Lester has Asperger's I'm pretty sure. No real social skills, but the desire to be social. He needs social skills training.

Ummmmmmm UMMMMMMMMMMMMMMMMMMMMM I feel like there is more to say……what what what……….oh…….an ethical thing………let's just say I'm doing an eval with a guy in his room..and then at 917 another patient comes in and tries to get into his bed and generally causes a mini ruckus that takes, oh, 5ish minutes to resolve…and then he and I finish up. And then when it's time to bill…do I count that time? Technically I was in the middle of an eval, didn't leave the room, was still with him, but was forced to deal with another patient. Do I try and glance at my watch and subtract the few minutes of chaos? If I can even remember to do so in the midst of chaos? Do I just bill for the time from start to finish and ignore a 3-5 minute interruption, even if it makes the difference between billing for one unit or two? What's most ethical/fair/feasible/realistic? These are the days of our OT lives.

Ok I'm going to stop my vegetable typing…I'm practically comatose. Hmmmmmmmmm, what does tomorrow's groups bring with probably 10ish patients and most of them with dementia? Hmmmmmmmmmmm

RIP Orange Kitty

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Orange kitty/black kitty aka cat, my beloved La Jolla kitties….enjoying a rare inside visit while I’m home for Christmas. RIP Orange kitty!!