STARES - 3

Situation

I have a client with an extensive medical history. She is 70 years old and is recovering from a stroke. There are many complications as she is PEG fed and has general deconditioning as a result of immobility. She also suffers from aspiration pneumonia and has a poor cough and swallow. Her chest is compromised as a result of this. She has speech trouble (primarily expressive). This client requires a standing hoist from transfers and has very limited use of her right upper limb.

Task

I am required to provide rehab for this client. As she is PEG fed I must organise treatment around feeding times. This client requires a lot of encouragement and motivation. She often becomes depressed and refuses to do physio sessions. The goal of physio is to improve overall conditioning, increase the strength of upper and lower limbs and improve transfers (so a standing hoist is not necessary).
At one particular session the client did not want to do physio. I had to get her to participate in a rehab session without forcing her (as she has the right to say no and not give consent).

Action

I started by asking the client to come to a physio session. She frowned at me and said “no”. I explained to her that she had to do some form of exercise today and went on to say how it would help her (i.e. it would make her stronger, she would be able to stand up etc.). She still wasn’t convinced and was getting upset. I took a different approach. I tried bargaining with her. I said to her we wouldn’t do the strength exercises that we normally did, we would only do some standing practice. She considered this and with a little more prompting she agreed (albeit rather grumpily!). I took the client down to the gym in her wheelchair. By positioning the wheelchair in front of the parallel bars the client could practice standing and sitting without transferring first (we would normally transfer onto the plinth first).

Result

The client stood three times, holding each stand for 30-45 seconds. The fourth attempt was not successful as the client was exhausted. This was the end of the session and I returned the client to her room.

Evaluation

The client can normally stand three to four times after completing all the other strength exercises. In this case she had not done any other exercises so it was not one of the best sessions. The client gave it her best effort and was exhausted by the end of it, so it was better than nothing. The client was happier by the end of the session an was glad she had come to physio.

Strategies

It can be difficult when you have a client who does not want to do physio. Some ways of dealing with this include:
• Come back later (although in this case the client is PEG fed and there are only two specific times each day I can see her to fit in with her feeds).
• Compromise – at least the client will end up doing something (even if it’s not everything you had planned for them) which is better than nothing.
• Find something to motivate them and set a specific goal – for example, going home or being able to walk independently. Aim to reach this specific goal that is important to them, and remind them that this is what physio sessions will do. It it to encourage them to attend physio.
• Set a specific time each day with the client to they know when you will be coming and can psych themselves up for exercise!
• Bring in reinforcements – for example, your supervisor or another physio. Also get the family onboard so they can encourage the client to do physio as well.