I had a mentally disabled patient last week and he had orders to get out of bed. However, he was combative everytime we tried to even roll him over in the bed. I tried to assess his ROM but he kept saying it hurt and he wouldn't move his legs. He could definitely move his arms. Would you label this limited range of motion? Because I'm pretty sure he was ABLE to move all 4 limbs, but just refused to do so. I'm not sure what to document it as.
Nov 1, '09
Was he showing non-verbal signs of pain? (grimacing, flinching, etc) You could document that, or a lack of that. Did you do a pain assessment (PQRST)?
Did you speak with the Pt.'s RN or CNA? (to find out if this was a common pattern...ie did the PT have a routine in the morning that wasn't being followed, etc) Did the Pt just want to work with someone they knew? What was the patient's complaint? Did he say why he was refusing?
I've worked with developmentally delayed adults as a caregiver. Lots of times, my clients were just tired of being told what to do. I found if I chatted with them and figured out what THEY wanted, sometimes I could combine what I needed them to do and what they wanted to do.....then everyone's happy.