Jimmy is already walking independently around the house; working on his confidence, stamina and balance.
As he improves he progresses to walking outside with the therapists. His rehabilitation programme includes using his external steps, kerbs and walking on uneven pavements. His family are keen to support him and walk with him most days.
Gradually he is able to walk further and is confident enough to walk to the local shops safely and independently. He is keen to use public transport and in particular Jimmy would like to use a bus.
Jimmy is now at home. He can walk independently indoors but finds walking outside difficult. He is anxious about falling, feels that he lacks stamina and, as a result, doesn’t venture outside.
The CRT have visited Jimmy at home. Jimmy wishes to improve his indoor and outdoor mobility and increase his fitness levels. He reports having difficulty with fine motor skills e.g. writing and fastening clothing. The CRT plan to support Jimmy with his on-going rehabilitation.
There may be a number of ways to improve Jimmy’s fitness level. Consider the quiz below.
Q. Which of the following activities might Jimmy consider as appropriate to improve his fitness levels? Select true or false for each of the options listed below.
Scenario
Mr Jimmy Yu is a 51 year old self employed financial advisor who has built up his business over the last few years. He regularly looks after his two young children whilst his wife is working.
Jimmy’s symptoms began while driving his car and he was stopped by the police. Initially the policemen thought he was under the influence of alcohol but they quickly realised that he was unwell and called an ambulance. On admission to hospital Jimmy was classified as having a posterior circulation stroke (POCS) affecting the cerebellum.
Following two weeks of in-patient rehabilitation he was discharged home with follow up from the community rehabilitation team (CRT).
NB: Please be advised that during the Covid-19 pandemic due to social distancing, meeting others and entry to venues, access to exercise programmes/classes may be restricted or provided in a different format (e.g. virtual). Please refer to your local Health Board for further guidance and information.
- Patient centred goal setting ensures patients are actively involved in their rehabilitation
- The key worker can be any member of the team and has identified responsibilities for managing the goal setting process for that patient
- Goal setting can be used as a tool to manage patients’ expectations
- A wheelchair is an alternative way of mobilising and can be used early on in rehabilitation
To learn more about self-management and the strategies which may be used in the process of self management visit STARs AM 15: Self Management.
Alice has accepted that walking is something she may never manage. However, she has achieved her self propelling goal and is now wheelchair independent in the ward. She has had a successful home visit and her discharge is planned for 2 weeks time. Alice continues to set personal goals and is planning to return to Lanzarote in about 6 months time. She plans to access the Self Help4 Stroke self management resource and Mr Rowan has found the stroke for carers website very helpful.
Prior to your goal review meeting with Alice you had discussed self propelling wheelchair with your colleagues and had a review of the evidence.
Q. What did you find out about self propelling? Select Yes, No or Maybe for each of the statements below.
You explain to Alice that it has been suggested that the effort required to self propel a wheelchair may cause an increase in arm and leg stiffness but there is no clear evidence to support this. You have discussed this with the physiotherapist and she has agreed that she will closely monitor Alice for this. You feel that self propelling would allow Alice to be more independent, reduce the work load for her husband and allow her to go out socially. Additionally as she is doing other functional tasks throughout the day such as transferring and standing you do not believe that self propelling at this stage should negatively impact on her long term recovery.
After careful consideration and following your discussion with Alice, Alice agrees to have wheelchair self propulsion as a goal.
Alice has been working toward her goals for the last 2 weeks. She is about to have another review meeting with her key worker. Have a look at her goal sheet to see how she has got on.
Alice’s goal sheet [.pdf, 30KB]
Two weeks later Alice and the keyworker have another goal review meeting. Go through the slides to move from scene to scene.
Following her review Alice was asked if her priorities were the same.
Alice told you – ‘I am happy with cooking because I know I can make a meal. I know I will be slower and will need some help from my husband but with the adaptive equipment I feel I can quite happily manage the cooking. My husband has already bought the one handed tin opener I think he bought it for himself, he likes his gadgets. The others I’d like to keep as the same but one thing I really would like to be able to do and I’m not sure how easy it would be, is to go out with my husband in the car. It would be great to be able to go for a drive, especially as it’s our daughter’s birthday in a few weeks and I’d really like to go and buy her a present’.
| Alice’s priorities and current status |
| Alice’s priorities |
Alice’s current abilities/status |
| 1. To walk around the house |
When walking Alice needs help to get up from a chair to standing and needs help of two therapists to walk as she finds keeping her balance and moving her left leg difficult. She feels that if she had a higher chair to get up from and a walking aid she would be able to walk by herself. |
| 2. To be able to dress myself |
Alice is able to put on her t-shirt and jumper getting help with her bra only. She needs total help with her lower clothes from one person. |
| 3. To be able to go to the toilet by myself (including getting to and on/off the toilet; adjusting clothes) |
Alice transfers onto and off the toilet with the help of one person. She can stand with a rail but is anxious about letting go fearing she will fall. She requires help from one person to pull up and adjust her clothes. |
| 4. To be able to go out with my husband for a drive |
Alice would like to be able to go out for a drive with her husband. She recognises she will need a wheelchair to go out but is concerned about accessing one and how to use it. |
Q. From the information given above which are the appropriately written patient centred goals? Answer yes or no to each of the parts below.
One common method of implementing goal setting is to have a member of the multi-disciplinary team nominated as a key worker who works closely with the patient to identify their goals. Go through the slides to find out more about the headings.
An example of a patient centred goal setting sheet [.pdf, 18KB]
What is goal setting?
‘Goal setting can be defined as a behavioural target that is central to rehabilitation, but is also effective in
secondary risk factor reduction such as weight loss, smoking cessation or alcohol reduction.’ ‘Goals are worked towards over a specified period of time, both short and long term.’ (RCP 2016).
What is patient centred goal setting?
These are goals that are led by the patient. The clinical team and the patient identify the patient’s primary rehabilitation aims with respect to their recovery and functional ability and from this patient relevant goals are identified and documented in a narrative patient friendly style. The goals are determined by the patient. Whilst the team can guide the patient if a patient does not identify areas as areas they need to work on then they cannot/ should not be documented as the patient’s goals.
What are therapeutic/intervention goals?
These are goals that are totally identified and set by the clinical team. The patient may be aware of the goals but does not directly contribute. The goals reflect what the professional team anticipates will be the patient’s potential level of functional ability. They relate to activities that the team deems to be important for the patient’s rehabilitation and are documented in a more clinical/medical intervention style. By setting and documenting therapeutic goals it ensures that tasks happen in a timely manner. Therapeutic/intervention goals can often occur alongside patient- centred goals e.g. the team has identified that they need to get Mr Rowan more involved in Alice’s care. Whilst this is not Alice’s specific goal in order to make sure that this occurs the team will need to co-ordinate and manage this. The therapeutic goal set for two weeks time could therefore be:-
‘Mr. Rowan will have attended therapy and nursing sessions and be competent transferring his wife in and out of a chair and will have begun assisting her in the toilet with supervision of one staff’.
What if a patient cannot do patient centred goal setting?
For some patients with marked cognition and comprehension problems patient centred goal setting is not appropriate. In this situation intervention/therapeutic goals are more appropriate. It is important to constantly review if the patient’s abilities have changed so that should they become capable of patient centred goal setting that they get offered that opportunity. Patients with expressive difficulties with the correct assistance can still set goals.
The theory is all very well but how can I put into clinical practice?
