I am wondering why you don't take goniometric measurements? I work in homecare and OT's get all of the referrals for UE dysfunction. For an orthopedic I always take measurements and write goals based on improving ROM. Why wouldn't you work on doffing/donning a bra or clothing management with toileting? Couldn't you ask the women to donn a bra over her shirt so that you could observe any difficulty that she is having and then take that opportunity to explain to her what functional goal you could work on? You could also simulate clothing management with a piece of theraband. Tie it into a circle and have her put it over her feet and pull it up to her waist. With that you can assess dressing, sitting and standing balance, B/L UE integration, functional use of that broken elbow. As far as pain management you could write a goal such as: pt will be independent with use of modalities and positioning to decrease pain to 3/10. You could also write caregiver goals: Caregiver will be independent assisting pt with PROM HEP. Our patients are not always aware of how we can help them to improve thier functional status. An older person may just accept that they have limited abilities and not be aware that there are compensatory techniques, adaptive devices, ect. They may really want to be able to donn that bra themselves and every pt that I have had always wanted to improve independence with toileting. It's our job to help them to understand that they have options. If we try and are unable to achieve the goal. Then at least the pt can have a better understanding of why they can't do it. Then I just write: Goal set too high, unable to achieve secondary to the following limitations....Sorry this is so long winded. Debbie Schwartz, OTR/L Cape May, NJ
[EMAIL PROTECTED] wrote: Send OTlist mailing list submissions to [email protected] To subscribe or unsubscribe via the World Wide Web, visit http://otnow.com/mailman/listinfo/otlist_otnow.com or, via email, send a message with subject or body 'help' to [EMAIL PROTECTED] You can reach the person managing the list at [EMAIL PROTECTED] When replying, please edit your Subject line so it is more specific than "Re: Contents of OTlist digest..." Today's Topics: 1. Re: Elbow Break, Referral... (Ron Carson) 2. Re: Elbow Break, Referral... ([EMAIL PROTECTED]) 3. Re: Elbow Break, Referral... (Ron Carson) 4. Re: Elbow Break, Referral... ([EMAIL PROTECTED]) 5. Re: Elbow Break, Referral... (L Sloan) ---------------------------------------------------------------------- Message: 1 Date: Sat, 30 Aug 2008 19:54:38 -0400 From: Ron Carson Subject: Re: [OTlist] Elbow Break, Referral... To: Kari Rogozinski Message-ID: <[EMAIL PROTECTED]> Content-Type: text/plain; charset=iso-8859-1 Call me think-headed, but I don't see how those goals are any different than PT. When I read the goals I see the primary focus on decreasing pain and increasing ROM and the "functional" stuff is just thrown in. And that's primarily what PT does. OT knows there's a lot more to dressing than just physical dysfunction. There's the environment, cognition, motivation, family issues, etc. With your goals, what happens if ROM is increase so the patient SHOULD be able to dress but they still can't because the family doesn't feel they are safe? According to your goals, the patient is d/c. Either that or you'll need some new goals! I will also suggest that goals should not be written unless it has been assessed. In other words, I don't write ROM goals, because I don't take ROM measurements. I do assess occupation and those are the goals that I write. Again, what the therapists assess should be the goals. And conversely, if it's not assessed then it shouldn't be a goal. Also, goals must be measurable and progress must be made. How can a therapist measure progress towards a goal that is not initially measured? And, what measure is going to be used? I will say the "increase functional performance with bilateral UE tasks" is not exactly a measurable goal? Now, if you assessed that the patient required mod assist to donn her bra and the goal was "Pt will independently donn/doff bra", then that's an OT assessment and goal. However, can you see this ladies face when I ask her about how much assistance she need to put on her bra, or pull up her underwear? She's going to think I'm nuts because she wants me to fix her arm, not worry about teaching her to get dressed! Gosh, I hate long messages..... Ron -- Ron Carson MHS, OT ----- Original Message ----- From: Kari Rogozinski Sent: Saturday, August 30, 2008 To: [email protected] Subj: [OTlist] Elbow Break, Referral... KR> I agree with Chris, I would take this patient and right all 4 KR> goals.? The only exception is i would state why i was going to KR> decrease the pain or increase ROM.? I would probably say something KR> like: ? Pt. will increase active elbow extension to -20 degrees to KR> allow for increased independence with upper body dressing or KR> decrease reports or pain to increase functional performance with KR> bilateral upper extremity tasks (grooming, bathing, dressing, etc.)? KR> ? KR> Ron, you have now given us examples of 2 patients you would not KR> treat, I too am wondering what kind of patient would you see?? KR> ? KR> ? KR> Kari, MOT, OTR/L KR> Hollywood, Florida KR> --- On Sat, 8/30/08, [EMAIL PROTECTED] wrote: KR> From: [EMAIL PROTECTED] KR> Subject: Re: [OTlist] Elbow Break, Referral... KR> To: [email protected] KR> Date: Saturday, August 30, 2008, 5:21 PM KR> I would write all 4 goals.? Why in the world would you not take this patient?? KR> "I shouldn't have taken it but I did."? What patient's do you KR> take? KR> Chris Nahrwold MS, OTR KR> St. John's Hospital KR> Anderson, Indiana KR> -----Original Message----- KR> From: Ron Carson KR> To: OTlist KR> Sent: Sat, 30 Aug 2008 2:48 pm KR> Subject: [OTlist] Elbow Break, Referral... KR> Received a new referral for a elbow fracture. I shouldn't have taken KR> it but I did. KR> And here is the dilemma facing our profession. The patient is 95, KR> previously living independently. Fractured elbow in a fall. Now living KR> with daughter. She is in a large amount of pain. Obviously, she is KR> dependent for most of her occupations. She currently uses a cane but KR> is not safe. KR> The patient's immediate concerns are her elbow. When pressed, she of KR> course wants to go back home, but that is not an immediate goal. KR> So what do I write for goals? For example should I write: KR> Patient will self-report pain as 3 out of 10 KR> Patient's will increase active elbow extension to -20 degrees KR> These goals seem to direct the patients and doctor's concerns but are KR> not occupationally oriented. So, should I write: KR> Patient will safely and independently dress lower body KR> Patient will safely and independently ambulate to the bathroom KR> using the least restrictive mobility aid KR> I like these goals but they don't address the immediate concerns. KR> Ron KR> -- KR> Ron Carson MHS, OT KR> -- KR> Options? KR> www.otnow.com/mailman/options/otlist_otnow.com KR> Archive? KR> www.mail-archive.com/[email protected] KR> -- KR> Options? KR> www.otnow.com/mailman/options/otlist_otnow.com KR> Archive? KR> www.mail-archive.com/[email protected] KR> ------------------------------ Message: 2 Date: Sat, 30 Aug 2008 19:59:50 -0400 From: [EMAIL PROTECTED] Subject: Re: [OTlist] Elbow Break, Referral... To: [email protected] Message-ID: <[EMAIL PROTECTED]> Content-Type: text/plain; charset="us-ascii" I don't thing the separation is artificial at all.? Just look at what we learned in school during our orthopedic classes.? Not saying it is right, it is just the experience of the professors at my class?and in the profession from what I can tell. -----Original Message----- From: Ron Carson To: LRappap765 Sent: Sat, 30 Aug 2008 6:23 pm Subject: Re: [OTlist] Elbow Break, Referral... To follow the below logic, doesn't a patient need to increase ROM to sit on the toilet? Doesn't the patient need to reduce pain to get into the shower? My point is that there is this artificially created separation where OT expertise is ONLY above the waist. I think we either need to expand our musculoskeltal expertise to include the whole body, or stop focusing on the UE. And it is up to the patient to understand what we are doing. For one, it allows the patient to be part of the process, not a bystander. Regarding need to increase elbow function to "hook a bra" or "reach for a kettle", I don't know that the patient wears a bra or reaches for a kettle. I understand that you don't mean these specific things, but in a patient-centered approach to OT, when possible, the patient drives the goal-making process, not the therapist. IF this patient said, you know I really want put on my bra but this dang elbow just won't let me, then I'd say 100% OT is the correct profession. But if I say, "I'm going to increase your elbow function so you can put on your bra", isn't that PT? If I had an elbow fracture, and I did about 7 years ago, the VERY LAST thing on my mind was fastening my bra (joke). Really though, it was hard for me to zip my pants but that wasn't my concern. My concern was the pain and the loss of ROM. If I went to a therapist and he said what's your goals, I would say; 1. decrease my pain and 2. increase my ROM. If they came out with questions about dressing I'd say, "yeah, you meet the above goals and I'll be able to dress myself" Making occupational goals when patients are not concerned about occupation makes very little sense. What does make sense is fixing the problem causing the occupational issues. And I believe that if that's the case, and that's the focus and it's musculoskeltal issue, it should go to the PT. And, do you know of situations where is the ONLY provider when a patient has a recent hip fracture or hip replacement? Or, wha t about a TKR, I've never seen OT being the only therapist. So, why is OT often the only provider when an UE is injured? These are all situations where a musculoskeltal issue impacts occupation, so why isn't OT involved in the remediation of these issues? Gosh, I hate long messages.......................... Ron -- Ron Carson MHS, OT ----- Original Message ----- From: LRappap765 Sent: Saturday, August 30, 2008 To: [email protected] Subj: [OTlist] Elbow Break, Referral... L> Hi, L> I don't think it's so unusual for a patient to focus on L> eliminating pain. I don't think it means they are not interested L> in occupations. Aren't we doing both things? Doesn't she need to L> increase active elbow extension to hook her bra on, or L> reach for the kettle to make tea. Just because she doesn't L> articulate these things doesn't mean that' L> s not the goal, does it? Isn't it really up to the OT to see the L> link and make the connection and Maybe impart an understanding to L> the patient. It's really up to us to understand what we do and L> why, not the patient. Also, Using a cane safely also seems like L> it falls in our domain. Just my 2 cents... L> Linda Rappaport, MS, OTR/L L> In a message dated 08/30/08 15:49:07 Eastern Daylight Time, [EMAIL PROTECTED] writes: L> Received a new referral for a elbow fracture. I shouldn't have taken L> it but I did. L> And here is the dilemma facing our profession. The patient is 95, L> previously living independently. Fractured elbow in a fall. Now living L> with daughter. She is in a large amount of pain. Obviously, she is L> dependent for most of her occupations. She currently uses a cane but L> is not safe. L> The patient's immediate concerns are her elbow. When pressed, she of L> course wants to go back home, but that is not an immediate goal. L> So what do I write for goals? For example should I write: L> Patient will self-report pain as 3 out of 10 L> Patient's will increase active elbow extension to -20 degrees L> These goals seem to direct the patients and doctor's concerns but are L> not occupationally oriented. So, should I write: L> Patient will safely and independently dress lower body L> Patient will safely and independently ambulate to the bathroom L> using the least restrictive mobility aid L> I like these goals but they don't address the immediate concerns. L> Ron L> -- L> Ron Carson MHS, OT L> -- L> Options? L> www.otnow.com/mailman/options/otlist_otnow.com L> Archive? L> www.mail-archive.com/[email protected] -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/[email protected] ------------------------------ Message: 3 Date: Sat, 30 Aug 2008 20:03:18 -0400 From: Ron Carson Subject: Re: [OTlist] Elbow Break, Referral... To: "[EMAIL PROTECTED]" Message-ID: <[EMAIL PROTECTED]> Content-Type: text/plain; charset=windows-1252 Well, it's artificial in the sense the occupation doesn't start and stop above the waist.... Finally, a short message... <<>> Ron -- Ron Carson MHS, OT ----- Original Message ----- From: [EMAIL PROTECTED] Sent: Saturday, August 30, 2008 To: [email protected] Subj: [OTlist] Elbow Break, Referral... cac> I don't thing the separation is artificial at all.? Just look at what we cac> learned in school during our orthopedic classes.? Not saying it is right, it is cac> just the experience of the professors at my class?and in the profession from what cac> I can tell. cac> -----Original Message----- cac> From: Ron Carson cac> To: LRappap765 cac> Sent: Sat, 30 Aug 2008 6:23 pm cac> Subject: Re: [OTlist] Elbow Break, Referral... cac> To follow the below logic, doesn't a patient need to increase ROM to cac> sit on the toilet? Doesn't the patient need to reduce pain to get into cac> the shower? cac> My point is that there is this artificially created separation where cac> OT expertise is ONLY above the waist. I think we either need to expand cac> our musculoskeltal expertise to include the whole body, or stop cac> focusing on the UE. cac> And it is up to the patient to understand what we are doing. For one, cac> it allows the patient to be part of the process, not a bystander. cac> Regarding need to increase elbow function to "hook a bra" or "reach cac> for a kettle", I don't know that the patient wears a bra or reaches cac> for a kettle. I understand that you don't mean these specific things, cac> but in a patient-centered approach to OT, when possible, the patient cac> drives the goal-making process, not the therapist. cac> IF this patient said, you know I really want put on my bra but this cac> dang elbow just won't let me, then I'd say 100% OT is the correct cac> profession. But if I say, "I'm going to increase your elbow function cac> so you can put on your bra", isn't that PT? cac> If I had an elbow fracture, and I did about 7 years ago, the VERY LAST cac> thing on my mind was fastening my bra (joke). Really though, it was cac> hard for me to zip my pants but that wasn't my concern. My concern was cac> the pain and the loss of ROM. If I went to a therapist and he said cac> what's your goals, I would say; 1. decrease my pain and 2. increase my cac> ROM. If they came out with questions about dressing I'd say, "yeah, cac> you meet the above goals and I'll be able to dress myself" cac> Making occupational goals when patients are not concerned about cac> occupation makes very little sense. What does make sense is fixing the cac> problem causing the occupational issues. And I believe that if that's cac> the case, and that's the focus and it's musculoskeltal issue, it cac> should go to the PT. cac> And, do you know of situations where is the ONLY provider when a cac> patient has a recent hip fracture or hip replacement? Or, wha cac> t about a cac> TKR, I've never seen OT being the only therapist. So, why is OT often cac> the only provider when an UE is injured? These are all situations cac> where a musculoskeltal issue impacts occupation, so why isn't OT cac> involved in the remediation of these issues? cac> Gosh, I hate long messages.......................... cac> Ron cac> -- cac> Ron Carson MHS, OT cac> ----- Original Message ----- cac> From: LRappap765 cac> Sent: Saturday, August 30, 2008 cac> To: [email protected] cac> Subj: [OTlist] Elbow Break, Referral... L>> Hi, L>> I don't think it's so unusual for a patient to focus on L>> eliminating pain. I don't think it means they are not interested L>> in occupations. Aren't we doing both things? Doesn't she need to L>> increase active elbow extension to hook her bra on, or L>> reach for the kettle to make tea. Just because she doesn't L>> articulate these things doesn't mean that' L>> s not the goal, does it? Isn't it really up to the OT to see the L>> link and make the connection and Maybe impart an understanding to L>> the patient. It's really up to us to understand what we do and L>> why, not the patient. Also, Using a cane safely also seems like L>> it falls in our domain. Just my 2 cents... L>> Linda Rappaport, MS, OTR/L L>> In a message dated 08/30/08 15:49:07 Eastern Daylight Time, cac> [EMAIL PROTECTED] writes: L>> Received a new referral for a elbow fracture. I shouldn't have taken L>> it but I did. L>> And here is the dilemma facing our profession. The patient is 95, L>> previously living independently. Fractured elbow in a fall. Now living L>> with daughter. She is in a large amount of pain. Obviously, she is L>> dependent for most of her occupations. She currently uses a cane but L>> is not safe. L>> The patient's immediate concerns are her elbow. When pressed, she of L>> course wants to go back home, but that is not an immediate goal. L>> So what do I write for goals? For example should I write: L>> Patient will self-report pain as 3 out of 10 L>> Patient's will cac> increase active elbow extension to -20 degrees L>> These goals seem to direct the patients and doctor's concerns but are L>> not occupationally oriented. So, should I write: L>> Patient will safely and independently dress lower body L>> Patient will safely and independently ambulate to the bathroom L>> using the least restrictive mobility aid L>> I like these goals but they don't address the immediate concerns. L>> Ron L>> -- L>> Ron Carson MHS, OT L>> -- L>> Options? L>> www.otnow.com/mailman/options/otlist_otnow.com L>> Archive? L>> www.mail-archive.com/[email protected] cac> -- cac> Options? cac> www.otnow.com/mailman/options/otlist_otnow.com cac> Archive? cac> www.mail-archive.com/[email protected] ------------------------------ Message: 4 Date: Sat, 30 Aug 2008 20:12:55 -0400 From: [EMAIL PROTECTED] Subject: Re: [OTlist] Elbow Break, Referral... To: [email protected] Message-ID: <[EMAIL PROTECTED]> Content-Type: text/plain; charset="us-ascii" I can totally see Ron's point now.? I work in acute rehab and we actually have them undress and dress,?so it is easy for me.? To make things more functionally based in outpatient or home health I think I would trial the DASH.? This is an upper extremity assessment tool that is a pre and post treatment?survey of what functional problems the patient is encountering.? This will give the therapist a better idea of what to focus on based on the patients survey results.? Check it out on Google.? Based on a good description of what we do in OT?for the patient, I don't think they will have a problem talking about their occupational dysfunctions.? I would use both a therapeutic exercise/splinting/ and ADL practice/compensation approach. Chris Nahrwold MS, OTR St. John's Hospital Anderson, Indiana -----Original Message----- From: Ron Carson To: Kari Rogozinski Sent: Sat, 30 Aug 2008 6:54 pm Subject: Re: [OTlist] Elbow Break, Referral... Call me think-headed, but I don't see how those goals are any different than PT. When I read the goals I see the primary focus on decreasing pain and increasing ROM and the "functional" stuff is just thrown in. And that's primarily what PT does. OT knows there's a lot more to dressing than just physical dysfunction. There's the environment, cognition, motivation, family issues, etc. With your goals, what happens if ROM is increase so the patient SHOULD be able to dress but they still can't because the family doesn't feel they are safe? According to your goals, the patient is d/c. Either that or you'll need some new goals! I will also suggest that goals should not be written unless it has been assessed. In other words, I don't write ROM goals, because I don't take ROM measurements. I do assess occupation and those are the goals that I write. Again, what the therapists assess should be the goals. And conversely, if it's not assessed then it shouldn't be a goal. Also, goals must be measurable and progress must be made. How can a therapist measure progress towards a goal that is not initially measured? And, what measure is going to be used? I will say the "increase functional performance with bilateral UE tasks" is not exactly a measurable goal? Now, if you assessed that the patient required mod assist to donn === message truncated === -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/[email protected]
