Mental Health Rotation in Occupational Therapy as a Fieldwork Student

I write this at sunset with my cat howling outside for love. 🙂 And I’m bored but not in a “I’m going to be productive” kinda way, more in a ‘Nothing appeals to me” kinda way, so I guess I’ll write about showers, haha.

So let me start off by saying that I’m actually quite a private person when it comes to things like showering and toileting…but as it turns out depending on what area you work in OT, you have to get pretty Un private…at least being around other people. In my case, we used the shower for one of our assessments on their cognitive level using Claudia Allen’s levels…so all new admits had a shower at one point or another. (Backtrack – only if their initial evaluation showed them to be at an ACLS score of 3.0 or higher if I recall correctly…below this level I believe it meant they required more than max A and were not appropriate for me to shower them). This was a behavioral health ward, locked, for geriatric people with behavioral problems severe enough to warrant going inpatient. This could be something like depression or dementia or schizophrenia, etc. Some were higher level – I basically offered them the chance then held back to see if they could cognitively figure out the planning of it all, like “Okay I need my towel and a change of clothing and some shampoo etc”….and I was scoring them based on this. Because some would say “Oh yes! I need a towel!” and then that would be it….no other cognition on what else would be necessary, and I’d have to cue them. Others would be lower level and need complete cuing and/or me doing most of the work….

Our shower room had a large shower with a hand-held shower attachment plus tub bench. Almost EVERYONE used the tub bench, minus a few really high level pts (usually the ones with just depression). The tub bench was actually also a commode bench meaning there was a hole in the middle. What THIS meant was that some of the patients with severe dementia associated being placed on a hole in a bench as a toilet, and would either urinate or defecate in the shower. Urination was not so bad but dealing with defecation in the shower wasn’t fun. 🙁 I was wearing my normal clothes and depending on their level of asistance I’d be standing by their side…sometimes having to help (either for physical or mental reasons) shower them, other times just being nearby. Most of them required at least a little assistance, like with their backs and feet, although if I recall correctly as this was years ago, they weren’t necessarily losing points for that. Hmm. I forget.

Anyway – some of them were quite docile and just a little confused or passive, needing me to start the process of putting soap on a washcloth and then typically if i put it in their hands, even if they weren’t really “with it”, muscle memory would kick in and they’d start rubbing….although they would maybe just rub the same spot over and over again with verbal or physical cues needed to move to other spots. It always was a little awkward if for example a man needed me to help clean his privates or something. I can’t remember if a male aide would be in the room with me for that…we didn’t really have many male employees in that area. It was rarely necessary though since usually I could hand them a washcloth with soap on it, put their hand on it and put it in that area….and usually if they were that low level they weren’t getting a shower from me anyway….blah blah blah can’t remember the details now!

A few would be agitated or manic and that would mean that for the sake of independence, they needed to be able to hold onto the shower attachment themselves, but that always put me at risk in terms of getting soaking wet since they’d let the water fly everywhere, lol. But if I held onto it was less independence, so I really wasn’t supposed to do that unless they were going really extra wild. I definitely got wet a lot…and sometimes ridiculously hot. I always tried to give them as much dignity as possible – most were old enough and hospitalized enough to be beyond caring, but for the younger depressed ones who were cognitively intact (at least more or less) I did my best to give them privacy while being safe. I didn’t want to lose my license having a pt fall and break their hip while my back was turned but I also didn’t want to stare at them…so tried to keep a balance of being safe while giving dignity/privacy as needed.

Remember I was on a fieldwork so I didn’t always make the best decisions…one time I showered a man who was aphasic (I think due to dementia) and easily agitated…he kept saying “G_damnit” and other curse words with increasing agitation as the shower dragged on. I tried desperately to figure out the problem but couldn’t….he was also physically disabled so that didn’t help matters. I actually successfully got him through the shower but felt like a failure, although I found out that actually the nurses had been unable to give him a shower at all, so it was actually impressive. I think a lot of staff occasionally overlooked him since he was aphasic with dementia but his curse words usually seemed to have different expressions and so I tried to make it clear I was listening and trying to understand….like he might say a curse word in a nice tone of voice versus an angry tone of voice depending on the situation. It was SEMI- only slightly – amusing at times but mostly I felt sorry for his struggle. That was definitely the hardest shower, I’m not even getting into all the details!

I dreaded the showers because of the dignity/privacy issue + the heat + water….luckily I don’t think I ever had to do more than twice in a day. They could be long ordeals especially since I wasn’t supposed to cue unless necessary (ie wait patiently for them to get to next step of logic until clear it’s not going to happen, based on scoring the cognitive levels). I remember one time I was about to take a lady down the hall to the shower when another patient started screaming and throwing chairs in the hallway, so I closed the door to her room and we sat there (me losing productivity units but it was worth it to not put her or me in danger!) until the person was calmed down enough for it to be safe.

One of my patients had the same pair of red heart underwear as me!!! She was picking out her clothes and grabbed that pair of underwear and I was like “I have that same pair!!” and we both laughed. 🙂 I have to say I had my favorites…some based on their family members or their level of sweetness or vulnerability. Like obviously I was not thrilled with the agitated ones who threw things (like cups of water in someone’s face, or chairs etc) since they scared me. But I liked the ones with dementia who were sweet, just not cognitively intact…I was supposed to leave the unit at a certain time to do notes etc but I very, very frequently stayed at the unit later than planned just to sit with some of them or get them a glass of water or something, if all the nurses/aides were busy at the time…I always felt sorry for them. One of my favorites used to sing. We had activity groups twice a day (which I dreaded more than showers – leading groups is HARD for me) and sometimes as a little break I’d ask her to sing us something. She actually sent a CD to the office after she was discharged, for me. 🙂 Some of them I would think were with it, and then as we went through the MMSE or SLUMS, I’d realize were only superficially with it.

Keeping track of days was a hard one for these patients. When you are in a hospital, especially for behavioral ones, it’s easy to lose track of time…..we tried to always keep updated calendars and stuff in each room “Today is X”….seeing as how that’s a common question. Honestly considering I had to always look at my watch which has the date on it, it didn’t seem like a fair question…if I can’t answer it why should they be able to. haha. I liked it when they said it was like…the year 1930 ….or that they had to go get the milk out from the spring….it was heartbreaking when they would FREAK out and
scream and bang at the locked door wanting to go get their children from school or something…they’d argue piteously “My child is only 3, what kind of monster are you, let me go” – of course these were like 90 year olds with dementia who were confused- we’d do our best to distract them in kind ways so that they would forget, which they usually would.

I had to go to a self-defense class when I started using HELP principles – basically it’s to help you extract yourself from a physical situation using body leverage while NOT hurting them. You know how most self-defense is like kicking someone in the crotch or nose….this was opposite. We tried to preserve ourselves AND them. Like if someone grabs you tightly around your wrist as you are walking by…how to get out of it using leverage and not just punching them in the face, for example.

I occasionally, but luckily rarely, had to visit a different ward that had younger, more psychotic patients, that were also more violent. This always made me very nervous. Even with my new training (which I have now totally forgotten), I never liked knowing that I was potentially at the mercy of a patient. And you always had to be careful about getting out of the ward – since it’s locked, patients would try to slip behind you…you’d sometimes have to ask a nurse to distract the patient long enough to get out!

I got to really like the nurses and doctors….they ran the place well. They really cared about the patients. I wish their had been a higher staff to patient ratio but with funding, that’s impossible just about everywhere. I told one of the psychiatrists about the SLUMS test which is similar to the MMSE and he liked it a lot….he liked me a lot actually which made me proud! I used the COPM with one depressed patient to make some shared goals and put it in her chart and he looooved that. ahahaha.

I guess I should clarify that this was a mental health rotation – OTs are not seen in mental health settings nearly as often these days but we can certainly work in those arenas. While I was in that ward the point was to figure out the cognitive levels of the patient in order to determine how much they would benefit from my activity groups (ie if they were a candidate) and how much assistance they may be needing in basic self-care, and then to work with patients individually as needed to work on improving certain life skills….this was rare considering most had dementia. Also, by regularly assessing their cognition using a variety of methods, I could help contribute to decisions as to whether the patient was safe to go home or needed a nursing home, etc…..I’m probably forgetting some things. That’s a start.

That was a hard rotation for me in that each day my heart raced as I entered the ward….and each day my heart raced as I had to give a shower…or if I heard an agitated patient start up…or as I started each activity group…..but I learned a lot and worked very hard and I like to think I helped make a positive difference, even if temporary, in some of their lives!

I could share sooooooo much more….and maybe I will one of these days…..but for now I guess I’ll stop. This started out about showers and became a looong post huh. If anything I says scares, offends, disturbs, you….please ask for clarification or something. It’s always possible I said something incorrectly or inadvertently …I dunno. Just ASK me if anything seems wrong…I always welcome comments. Remember I’m talking about an experience I had as a STUDENT and that it was YEARS ago so I may be remembering some things wrong…and if any of it scares you….don’t let one person’s experience scare you! Sooooo many diverse places out there…you will probably never be in that kind of position unless you seek it out. But mental health is a cool area for OT….wish there were more options (and that it paid better, lol). I think adult physical dysfunction, especially in nursing homes and skilled nursing facilities, pays the best…but not sure. Pediatrics usually pays least.

Well my cat is still crying…so I am going to go give it some love. ASK ME QUESTIONS IF YOU NEED TO! It kind of makes me nervous to post things like this in case anything comes across wrong!!
PS: I realized I kind of posted more of the negative highlights…because obviously that’s what stays in my mind the strongest…but there were a LOT of positive things too…must write more about those next! 🙂

Jan 21, 2011 | Category: Occupational Therapy | Comments: 4

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