RT5-LTC reflection paper

End of rotation reflection- Margaret Tietz-Long term care

Jinjin Lin

 

During 5 weeks rotation at long term care at Margaret Tietz, the most important thing I learned is to deal with subacute issues and restorative rehabilitation. Patients are usually suffering from an illness or injury, and being transferred to long term care facility with the purpose of improving functioning. Long term care focus on increasing patient’s strength and functioning by providing physical, occupational and speech therapy. For example, s/p stroke patients, they need to increase their balance, improve safety when walking, and help to move their legs again after stroke, improve their independence with ADLs and improve their cardio fitness. Besides patient’s chronic issues and comorbidities, there are other complications and issues should be managed at the same time, such as wound care, pain management, and respiratory care. The most important thing to know is patient’s progress, see if patent is improving their status under current care plan, which the goal of the long term care.

For H&P, it is different from what I learned from OB/GYN rotation. In the OB/GYN, I learned that HPI should include obstetric history, with the outcome of all previous pregnancies, and during the subsequent visits, questions will focus on interim developments and changes in frequency or intensity of fetal movement. In the long-term care, the HPI is a little different, past medical history should be described in detail, and it should include the reasons why patient is admitted to the hospital, the stay in the hospital, course in the hospital, treatments received in the hospital. After addressing the major issues, HPI should also include patient’s current status after being transferred to the facility and any acute medical complaints as well. In addition, it is important to have advanced directives documented in the patient’s chart, including DNR, living will or health care proxy. Furthermore, in the assessment and plan part, it should include the justification for placement requiring skilled nursing facility, like restorative rehabilitation, gait training, and endurance.

Dealing with elderly patients are not easy. As people age, new concerns arise. Sometimes, it becomes very difficult to talk with patients and discuss their needs in a constructive manner. Patients may lose their physical and mental capacity, and then the anger, sadness, confusion, and fear come along, which all lead to aggressive speech and behaviors. Then, there are some patients who suffer from mental and physical illnesses, which makes the situation even worse. Their behaviors are understandable due to their condition, but it is not easy to handle. Elderly patients will require some special consideration, and it’s important to figure out ways to cope. During this rotation, I have learned some strategies to interview elderly patients. For examples, make elderly patients comfortable when interview them; take a few minutes to establish rapport by introducing myself clearly and speak slowly; try not to push the patients, because older people may have trouble following questioning or processing too much information, and time spent discussing concerns will allow me to get important information which leads to better treatments and patient care; try not to interrupt when elderly patient is talking, because they will be less likely to reveal all of their concerns if being interrupted; and teach-back method is very helpful when I need to make sure patients understand their main health issues, and the care plan for them.

In this long-term care rotation, there is one case that I still remember. The patient is 87 years old male with PMHx of HLD, AFib, Hypothyroidism, dementia, GERD was admitted to NYPQ for AMS. After stabilized patient, he is transferred to Margaret Tietz for rehabilization. Patient’s sister leaves the facility around 4pm, and the dinner of the facility serves at 6pm. The nurse puts the patient in the wheelchair and locates him to the table in dining room. When the patient is placed in his spot, he holds a sharp knife in his hand, and yelling at nurses and social workers who are trying to talk to him and get close to him. The patient thinks he is being accused and he is the hostage. The patient holds the knife and asks us to contact his wife, who passed away years ago. The head of nurse comes, and tells everyone to go away, and leave them alone. The head of nurse talks really nicely and saying she will give his wife a call, and then gives him a pen, and tells him to write down everything his wife says. The patient hold phone in one hand, and the pen the other hand, and gives the knife to nurse. I learned a lot how to deal with this situation. We need to calm the patient down, say yes to all his requests, and need to distract the patient, and get the sharp.

For my next internal medicine rotation, I will try to practice on obtaining arterial blood gas, IV access, male and female catheterization, and interpretation of imaging studies, like xrays, CTs, and EKG. If I have chances, I also want to assist in CPR, put in NG tube, and assist lumbar puncture. In the long-term care rotation, I saw a lot of elderly patients come for rehabilitations. But I will learn more about chronic managements and post-op care. For the following rotation, I will observe how clinicians interact with patients on the floor, how they deal with issues like multiple comorbidities, and how they do physical examination and monitor the patients progression, then practice on these.

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