Capstone Case #6 Psychological

PT616 Comprehensive Capstone

Case Study 6/ Homework 6A
Physical Therapy Psychological Considerations Cases
Carol Tubbs, OTR/L

Instructions: Review the following cases and answer the questions associated with each case.
Please submit the homework assignment through the Canvas portal by 8.30AM on Tuesday, October
11. Be prepared to discuss these cases in class.

Case 1: Marvin:
Marvin is a 42 year old mentally ill man who was recently assaulted in a local park. He was
transported to the hospital where he underwent surgery for a humeral fracture and was given a brace
for a stable vertebral fracture. Marvin lives in a board and care home and has limited contact with
family. He is sometimes delusional and usually paranoid. Although he has legitimate injuries, he is
also somewhat of a hypochondriac and is fairly certain that he has a heart condition that his doctors
are ignoring. Marvin has received mental health services at various times in the past, but has
difficulty staying on his medication.
Questions:
1. What are the signs and symptoms Marvin may display during periods when he is
a. Delusional? Irritable, angry, or low mood, and hallucinations-hear or feel things not
really there
b. Paranoid? Intense and irrational mistrust or suspicion, rigid behavior, difficulty with
forgiveness, defensive attitude, inability to relax, stubborn, argumentative, fearful being
taken advantage of

2. Based on the above, what are some strategies for communicating with Marvin effectively?
 Slow speech, calm and quiet use of simple and concrete language or instructions
 Wait patiently for a response and repeat during communication if needed
 Calling the person’s name while entering the patient’s room so they are aware that you
are there
 Explain who you are, what you are going to doing, and why you are there
 Reassurance - make sure that the patient knows that you are there to help them by
explaining who you are, what you are doing, and why you are there all while making eye
contact with the patient
 All the patient time to process the information and the instructions that you are giving
them

3. How will you address his noncompliance due to his belief that exercise will damage his heart?
 Explain to the patient that you are trying to help his heart and not damage it
 Communication is key - explain what you do as a PT and how you are going to help him
 Reassure the patient that you have talked to their doctor and that their heart is okay for
exercise but that we will take it slowly and at a comfortable pace for them

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 Let the patient know that you want to know how they are feeling and if at any point they
need to stop to let you know and you will do whatever it takes to help them get back to
their prior level of functioning as best you can
4.
What factors will complicate home programming and how might you manage them?
 Medication and any side effects that may play a factor in the PT treatment sessions -
these need to be made aware of and talking to the nurse can always be beneficial to
see if there is a certain time in the day that is best to see this patient due to their
medications
 All of the interdisciplinary staff members need to be in communication about how best to
approach this patient and come up with a consistent daily schedule and make sure that
he is provided with proper care
 The mental illness may complicate things as well - patience will be very important with
this patient but as long as the staff members are in communication with one another,
the patient’s delusional and paranoia shouldn’t affect PT all of the time if the staff is
educated properly

Case 2 Rita:
Rita is a 53 year old attorney who has just undergone a total hip arthroplasty. Due to various medical
complications, Rita has had to be off her medication for her bipolar disorder and is now in a
hypomanic state. The physician is aware and they are attempting to re-introduce her meds, but in
the meantime, you are concerned about post-op compliance. Rita is married and has two children,
both of whom are in college. Her husband is involved, but is feeling somewhat overwhelmed with his
responsibilities and trying to manage her behavior as well.
Questions:
1. Briefly describe the characteristics of bipolar disorder.
 Alternating mood swings between depression and mania
 Overly elevated and expansive mood, inflated self-esteem, excessive involvement in
pleasurable activities, flight of ideas, pressured speech, decreased need for sleep, increase
in goal-directed activity, and highly distractible

2. What would you observe if the patient is in a hypomanic state?

 Euphoria or irritability
 Increased energy
 Increased activity
 Excessive talking
 Racing thoughts
 Inflated self-esteem
 Unusual energy or less need for sleep
 Impulsiveness

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3. How might these hypomanic behaviors negatively impact a treatment session?

 Difficulty following through with tasks to completion - distracted easily
 Attention is fragmented (repeating yourself)
 Grossly lacking judgement (don’t make good choices)
 Will often test limits (do opposite of what you ask just to see what happens)
 Blames others or shifts responsibility on others (like “you aren’t a good therapist”)

4. What strategies might help Rita adhere to her hip precautions?

 Discuss with the patient about what is and what isn’t appropriate behavior while recovering
from the hip surgery. Explaining to her how inappropriate behaviors could lead to negative
outcomes on her hip and explaining to the patient what that type of behavior would lead to
and the consequences she would be facing.

Case 3 George:
George is a 79 year old man who has been hospitalized for several weeks following a complex
surgery for colon cancer. He is now medically stable but severely deconditioned. He also exhibits
many depressive symptoms and it has been hard to motivate him to participate in therapy. George’s
wife and children visit frequently and have been very encouraging, but with little effect. Prior to this
hospitalization, he was fully independent in all daily activities and led a fairly active life.
Questions:
1. Briefly describe 4 symptoms of depression.
 Feeling of saddness
 Difficulty concentrating, remembering details, and making decisions
 Fatigue and decreased energy
 Insomnia - early wakefulness or excessive sleeping
 Physical aches and pains

2. How will George’s depression affect therapy sessions?

 Difficult to initiate tasks or express that ‘he can’t do it’
 Very fatigued or lack energy due to decreased appetite and cause a decrease in
participation
 Difficulty paying attention to a specific task and may require constant redirection back to
task at hand
 Slow progression through a task and obsess over errors that were made

3. What should you communicate to George’s primary physician?

 Any lack of progression or participation in therapy that made but due to some psychological
disturbance or medication that he may be currently taking
 Symptoms or signs of a psychological disorder that may a referral for a screening
 Any red flags that may lead to the PT to think the pt. is experiencing thoughts or suicide or
wanting to harm themselves in any way

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4. How might you motivate George to participate?

 Provide positive thoughts and let the pt. know you are there to help him get stronger and to
listen if he needs to talk about anything by making the pt. feel comfortable and make sure
to stay positive and that to the patient knows that small steps are good!
 Continuously offer to the patient help and encourage him to participate in therapy and
reassure him that you will help get him back to daily activities as best as you can.
 Provide compliments and stay positive with the patient while always reminding him of the
positive things in life.

Case 4 Celeste:
Celeste is a 73 year old woman who suffered a CVA resulting in right hemiparesis. She has had
several previous, less severe strokes, and shows signs of vascular dementia. She also has a history
of alcoholism which may have impacted her physical health as well as her cognitive state. She is
widowed and has a grown daughter who seems frustrated in dealing with her mother. During
activities, Celeste displays poor attention to task, poor short term memory, and lack of insight into her
limitations.
Questions:
1. What are the signs and symptoms of vascular dementia?
 Confusion
 Trouble paying attention and concentrating
 Reduced ability to organize thoughts or actions
 Decline in ability to analyze a situations
 Decline in development of an effective plan and communication of their plan to others,
 Problems with memory loss
 Restlessness and agitation

2. How might dementia affect Marie’s ability to learn new information?

 Multiple small strokes that affect the blood vessels and nerve fibers deep inside the
brain that may cause gradual thinking or memory changes and decreased ability to
organize thoughts and learn new information as damage accumulates and progresses.

3. How would a history of alcoholism affect Marie’s care?

 Alcoholism has an increased risk for developing Dementia and the patient may continue
drink alcohol due to the confusion. This also has effects on the patient’s brain, which
does not help the dementia signs and symptoms.

4. What might you recommend in terms of discharge planning.

 I would recommend SNF placement for continued rehabilitation therapy to work on gait
training with a hemi-walker (although not sure if she would be accepted due to STM loss
and if she was not being compliant in therapy), refer for psychological screen, and OT
referral to work on self-care for improved independence if has to go to an ALF or NH.
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