Second Stares Entry

SITUATION
I have a female client who is recovering from a right sided CVA. Her left side is affected (upper limb more so than the lower limb). The stroke occurred approximately 4 months ago. Her left arm has no functional movement and is supported by a sling, however her left leg has had some recovery and she is able to ambulate with a quad-stick approximately 50 metres. This client is not safe to ambulate by herself, and must have somebody to walk with her and assist. She has decreased control of her left foot, creating a high falls risk situation as she cannot always place it in the correct spot on the floor. This client has been slowly improving using the quad-stick and one of my supervisors suggested we try a pulpit frame instead.

TASK
I had to assist this client to transfer from her bed into a wheelchair. Once we were out in the main corridor there was another transfer to perform as the client stood up and held onto the pulpit frame. I then had the task of assisting her to walk with the pulpit frame. This required two people (one each side of the client).

ACTION
I used verbal cues and minimal hands on assistance to help the client transfer from the bed to the wheelchair. I was more a “stand-by assist” in case she needed it. While the client is capable of performing this transfer, it is not always performed correctly and can be unsafe if nobody is there to help. Once in the wheelchair we went out into the main corridor. This was chosen so we had a long, straight distance to practice walking with the pulpit frame. I helped her stand up from the chair (with minimal hands-on assistance) and hold onto the frame. I then went through where the brakes were and how to use them. As this client’s left arm has no movement, I had to help steer from my side. I was also trying to help her place her left foot in the correct spot.


RESULT
Ambulating with the pulpit frame was difficult for this client as she could not see where her left foot was being placed. As she has decreased awareness of where this foot is in space she normally relies on her vision to know where to place it while walking. When she could not see her foot she had difficulty putting it in the right spot, and it was often placed too close to the midline. This was unsafe as it could cause her to trip, resulting in a fall. There were a few times her right foot was caught behind her left foot. The client managed to walk approximately 20 metres with the frame.

EVALUATION
I didn’t think this was particularly successful as it did not feel safe for the client. While there were two people there to assist her there was only very small risk she would fall. It would not be possible for her to do this by herself. Due to this, I do not believe it was a functional task. It may have improved her gait pattern (particularly the swing-through of her right left) but when the client returns to the quad-stick I don’t think it would have made much of a difference to her gait. There is more of a chance of this client walking independently with a quad-stick than a pulpit frame so I think it would be better to spend time practicing with the stick. My other supervisor agreed the pulpit frame may not the best option as the client has difficulty when she cannot see her foot. This supervisor suggested sticking to the quad-stick. My other supervisor (who suggested trying the pulpit frame) thought it would be worth pursuing this option and spending time practicing. As this lady is my client it was ultimately up to me, however I found it confusing with my supervisors saying different things. Both had good reasons for what they said, however I spent time thinking of my own reasons (both for and against) each mobility aid. In the end I decided to stick with the quadstick. Some of my reasons were as follows:
1. It is likely to be more functional for the client in the long-term (important for her discharge)
2. Often I am working with the client by myself and it could be difficult to find someone else to help (as it needed one person on each side)
3. The client said she didn’t like the pulpit frame as she couldn’t see where to put her foot (and the client’s opinion is very important)
4. The pulpit frame did not seem like the safest option


STRATEGIES
In the future when I have supervisors suggesting different ideas there are a few strategies I can utilize to help me make my own decision. I think these strategies also apply in situations where a supervisor suggests a treatment idea and I have a different idea of how to treat the client. The strategies are:
1. Research: I can research the topic and see what evidence there is. I would feel more confident with my choice if I have evidence to back it up.
2. Pros and Cons: I think making a list of reasons for and against all the options or choices is a good idea. It certainly helped me make my decision in this situation.
3. Client: Asking the client what they would prefer. It is also important to find out why the client chose a particular option (as their reasoning may be very different from yours!)