My 5 weeks of clinical placement at Rocky Bay are over and my clinical requirements for the year are now complete. I thoroughly enjoyed my time at Rocky Bay, having learnt many new skills and feel that I finished the year off on a good note. Some of my pre-placement expectations turned out to be spot on the mark, while others weren’t so accurate.
My predictions about the nature of the placement were pretty much correct, in that the focus was very much on detailed assessments and I certainly saw less clients per day than on previous placements. I think being there during school holidays may have made things a little different for me compared to others because so many of the clients are booked in for their annual physiotherapy assessments. As I mentioned in my entries throughout the placement, these assessments are detailed and time consuming, so I was always busy, despite not always seeing many clients per day. Some days I might have only seen 1 person for the day, but the rest of my time was spent writing up the reports of the previous assessments I had conducted. My preparation of specific conditions such as Duchenne Muscular Dystrophy (DMD), Spinal Muscle Atrophy and Friedreich’s Ataxia proved to be very useful as these certainly formed the majority of the conditions that I was exposed to.
The structure of the placement was quite different to those I’d had previously in the year. From the first day there was tasks that I was performing unsupervised, but there were some that I always had supervision for through the entire placement. For example, after I had performed a treatment of passive movements and stretches on a client with DMD, I was then able to perform this treatment independently on all my other DMD clients for the rest of the placement. Compared to the annual physio assessments for which I always had supervision. This was understandable though, as the different physios that I was conducting the assessments with knew more about the particular clients than I could gather from just reading the previous assessments and were able to ask client specific questions for greater accuracy with the history than I could have. Rocky Bay’s perception and expectations of students was very close to my expectations in that I was there to learn and enhance my skills working with a population of clients that I wouldn’t otherwise get very much experience working with. This meant that it was an environment very conducive to learning, which I was very appreciative of and managed to improve my skills remarkably from start to finish. I feel that I was an integrated member of the clinical services team at Rocky Bay by my 3rd week, regularly liaising with the OT’s and social workers and making phone calls to other members of the client’s care team that may not have been on site. I believe I was able to work independently and schedule effectively from an early stage in the placement and just had my supervisors present for the tasks that were required.
My knowledge about the specific conditions, which I was initially concerned about, wasn’t really an issue. On my first day I was shown the information sheets on the computer system about the various conditions and after reading these to consolidate my knowledge I was confident that I was well prepared. When questioned by my supervisors at any stage I was able to respond with the appropriate answers, which was pleasing. Apart from this knowledge base, many of the treatments themselves were very individualised to the specific client. For example, the DMD boys had a very regular and similar set of treatments, mainly consisting of passive movements and stretches to maintain muscle length and joint range of motion when they were lacking the strength to move their limbs independently. Many of the other conditions though, such as Friedreich’s Ataxia had very different presentations and treatment aims depending on the individual, so I had to think quite laterally at times. I had 2 different boys, of similar age, 1 was able to walk independently, while the other was using a wheelchair for mobility because of his balance deficits. It meant that their goals and consequently their treatment programs very different. I had to modify 1 boy’s exercise program and create one for the other and they both turned out to be very different because of the different circumstances and individual abilities.
My other concern was my ability to conduct assessments correctly, which I really need not have worried about. My skills and knowledge were adequate and the assessment templates that Rocky Bay had were very easy to follow. When I started I was definitely a bit slow and my first couple of annual assessments would have taken me between 2 and 2 and half hours to complete. With practise I was able to improve my technique and time efficiency to the point where I was able to complete an assessment in less than 1 and half hours on my final day of placement. It was good to see this personal improvement and I certainly noticed that I learnt the appropriate questions to ask in the subjective assessment and the appropriate instructions to give during the objective examinations. I was pleased with my growth in this particular aspect of the placement.
Finally, I didn’t really find I had any difficulties communicating with the clients. The majority of the DMD clients were about my age, so it was easy strike conversations with them, (especially with the soccer world cup in full swing!). Most of the annual assessments I performed were on younger boys, between the ages of 6 and 12, which I found fun, rather than difficult. I don’t think I had any real difficulties to start off with, but definitely picked up more tricks as time went on. Instead of “bend your elbow” for elbow flexion, the instruction was “hand to your shoulder” or something similar to this. When conducting the respiratory assessment with the vitalograph for VC and FVC everyone found it much easier when I told them it was like blowing the candles out on a birthday cake through a big straw. Just little things like these really helped, especially with the younger clients and helped to further improve my time efficiency. I was certainly able to give instructions to the different clients that would give me the particular movement or action that I was trying to assess.
Overall, I thoroughly enjoyed my 5 weeks at Rocky Bay. I found that I was busy, but not too busy that I couldn’t stop to think in detail about things or have a have a good conversation with the other physios. As I previously mentioned, the environment was very conducive to learning and everyone there was willing to teach and impart their own personal knowledge or experience. The other thing that was really great about clinical services at Rocky Bay was that they were a very close and well organised team. Because of this, they were able to provide excellent care for their clients and in short amounts of time too, which I thought was excellent and really encouraged me to participate as actively as possible in the team environment. I couldn’t speak highly enough of my supervisors and the facility and can only hope that the real world of work will be as enjoyable as this placement.
Sunday, July 25, 2010
Entry 3
Situation: In my previous journal entry I spoke in detail about the annual physiotherapy assessments that Rocky Bay clients receive. Equally as important as the assessment itself is the report that accompanies it. The report must include a subjective section detailing things such as mobility and transfers, school and physical activities. It must also include a respiratory, postural, gait, functional ability, muscle strength and joint range of motion assessment along with a detailed analysis of the assessment itself and a plan for the future. With all these requirements it makes for quite a lengthy report and is a time consuming process as well. Last week I had a young man with Friederich’s Ataxia come into Rocky Bay with his mother and I was booked in to perform his annual physiotherapy assessment.
Task: My task was to perform the assessment that afternoon and although I didn’t have a set time frame, I set myself a goal to have the assessment report completed by the end of the following day. The reason I wanted to do this, was so that the assessment was still fresh in my mind and I could give myself every opportunity to write a good quality report.
Action: I conducted the assessment without any dramas that afternoon and because I’d had a bit more practise and developed some better techniques I was able to complete it in under an hour and a half, which I was pleased with. This meant I had a bit of extra time up my sleeve to get started on my documentation that afternoon. The following afternoon after having a pretty busy day I had almost finished my report. I had entered all the necessary numerical data such as muscle strengths and lengths, and done postural and functional ability descriptions so just needed to complete my analysis and I was done. Despite having done a few before, I was finding this one a bit more difficult because there wasn’t many major or significant changes compared to the previous assessment findings.
Result: The result was that I ended up viewing the analysis from the previous report to give me some ideas on how I could get started. I managed to get some good points that I was able to modify to suit my current assessment findings, but at the same time noticed that it was quite a detailed analysis in the previous report. It was certainly more detailed than those I’d done in the past, so I adopted this method and made my dot points more detailed before finishing off the report. I then notified my supervisor that I’d finished the report and asked her to have a read before I submitted it into the system. My supervisor said I’d done an excellent job with the report, but did give me a few pointers on things to improve for next time. One was that I don’t need to go into such detail in the analysis and that some points weren’t really necessary, which I was a little shocked to hear considering it was what I’d read in the previous one. I responded by telling her that it was last year’s document that I had read and had given me the impression that it was how I should be doing it, and subsequently thought I should do the same. Her response was that she could see I had done my own analysis, she just didn’t want me to write as much in the summary section of the report and that in the future I shouldn’t copy what I see on previous reports. She also gave me a few additional tips for the future.
Evaluation: In evaluating this process I feel that everything went really well except for the analysis in my report. I conducted an effective and efficient assessment and wrote a detailed and accurate document and was quite proud of my work. I don’t even feel that my analysis was really that bad. If I was going to be criticised for something, I’d prefer it to be for being too detailed and thorough than too brief. I feel that my supervisor brought the point up more because of the principle of the situation in stopping me from getting into bad habits by always reading the previous reports and potentially not thinking about things for myself. I know that I didn’t blatantly copy the previous analysis, rather I used it as a template to guide my own efforts, but I could see exactly what my supervisor was saying. I also understood that the analysis of the assessment didn’t need to be so detailed, as it was almost repeating my findings from the assessment, it should be used more as a summary section in this situation.
Strategies: My supervisor’s suggestion was that in the instance where I’m having trouble with an analysis, I should write some brief notes that I want to include and then once I’ve done this view reports from previous years. In doing this, I have my own opinion and have some additional information with which to make further judgements as to how I want to write the final edit of the analysis. Another strategy that I used regularly after this event was simply to write down the main headings from the report and then write a note about the most significant finding under this heading. For example under the heading of muscle strength I could input the information that overall hip strength findings decreased from grade 4’s in the previous assessment to grade 3’s currently. By using this system I never had any further problems with formulating the analysis section in my reports. The other thing that immediately came into my mind after this scenario was the importance of making your own clinical judgements and not simply relying on you what have been told by another source. This may come into play when receiving a referral from another health care professional who may have made a diagnosis on an individual you are about to see. It’s important you make your own diagnostic decision in regards to the individual because the previous person may have got it wrong and it is you who has to treat them. Consequently it would be you who would pay the penalty for providing treatment for the wrong condition or case, so it’s always important to formulate your own clinical judgements about the current situation confronting you.
Task: My task was to perform the assessment that afternoon and although I didn’t have a set time frame, I set myself a goal to have the assessment report completed by the end of the following day. The reason I wanted to do this, was so that the assessment was still fresh in my mind and I could give myself every opportunity to write a good quality report.
Action: I conducted the assessment without any dramas that afternoon and because I’d had a bit more practise and developed some better techniques I was able to complete it in under an hour and a half, which I was pleased with. This meant I had a bit of extra time up my sleeve to get started on my documentation that afternoon. The following afternoon after having a pretty busy day I had almost finished my report. I had entered all the necessary numerical data such as muscle strengths and lengths, and done postural and functional ability descriptions so just needed to complete my analysis and I was done. Despite having done a few before, I was finding this one a bit more difficult because there wasn’t many major or significant changes compared to the previous assessment findings.
Result: The result was that I ended up viewing the analysis from the previous report to give me some ideas on how I could get started. I managed to get some good points that I was able to modify to suit my current assessment findings, but at the same time noticed that it was quite a detailed analysis in the previous report. It was certainly more detailed than those I’d done in the past, so I adopted this method and made my dot points more detailed before finishing off the report. I then notified my supervisor that I’d finished the report and asked her to have a read before I submitted it into the system. My supervisor said I’d done an excellent job with the report, but did give me a few pointers on things to improve for next time. One was that I don’t need to go into such detail in the analysis and that some points weren’t really necessary, which I was a little shocked to hear considering it was what I’d read in the previous one. I responded by telling her that it was last year’s document that I had read and had given me the impression that it was how I should be doing it, and subsequently thought I should do the same. Her response was that she could see I had done my own analysis, she just didn’t want me to write as much in the summary section of the report and that in the future I shouldn’t copy what I see on previous reports. She also gave me a few additional tips for the future.
Evaluation: In evaluating this process I feel that everything went really well except for the analysis in my report. I conducted an effective and efficient assessment and wrote a detailed and accurate document and was quite proud of my work. I don’t even feel that my analysis was really that bad. If I was going to be criticised for something, I’d prefer it to be for being too detailed and thorough than too brief. I feel that my supervisor brought the point up more because of the principle of the situation in stopping me from getting into bad habits by always reading the previous reports and potentially not thinking about things for myself. I know that I didn’t blatantly copy the previous analysis, rather I used it as a template to guide my own efforts, but I could see exactly what my supervisor was saying. I also understood that the analysis of the assessment didn’t need to be so detailed, as it was almost repeating my findings from the assessment, it should be used more as a summary section in this situation.
Strategies: My supervisor’s suggestion was that in the instance where I’m having trouble with an analysis, I should write some brief notes that I want to include and then once I’ve done this view reports from previous years. In doing this, I have my own opinion and have some additional information with which to make further judgements as to how I want to write the final edit of the analysis. Another strategy that I used regularly after this event was simply to write down the main headings from the report and then write a note about the most significant finding under this heading. For example under the heading of muscle strength I could input the information that overall hip strength findings decreased from grade 4’s in the previous assessment to grade 3’s currently. By using this system I never had any further problems with formulating the analysis section in my reports. The other thing that immediately came into my mind after this scenario was the importance of making your own clinical judgements and not simply relying on you what have been told by another source. This may come into play when receiving a referral from another health care professional who may have made a diagnosis on an individual you are about to see. It’s important you make your own diagnostic decision in regards to the individual because the previous person may have got it wrong and it is you who has to treat them. Consequently it would be you who would pay the penalty for providing treatment for the wrong condition or case, so it’s always important to formulate your own clinical judgements about the current situation confronting you.
Sunday, July 11, 2010
Entry 2 – Assessment
Situation: School holidays are the busiest times of the year at Rocky Bay as it is when all the school-aged clients are booked in for their annual assessments. The annual assessment is conducted to determine how the individual is progressing or regressing with their condition from the previous year. It involves a detailed subjective questioning on things such as mobility and transfers, school, physical activities, general comfort and goals. The objective assessment includes photographs of sitting and standing postures, functional assessments, respiratory assessment, joint ranges and muscle strength assessment. It’s a lengthy process that usually takes about one and half hours to complete in its entirety.
Last week I was scheduled to perform my second annual assessment with one of my supervisors and it was actually a double assessment on 2 brothers, both with Friederich’s Ataxia. From previous assessments I was able to ascertain that the younger brother was more severely affected and was wheelchair bound, only standing out of his chair to transfer, while the older brother had maintained his ability to walk, unless severely fatigued. Both boys had recently been for their regular check-ups at the PMH spinal clinic and the feedback from this was that there was no noteworthy change with the younger brother, but that the older brother would soon be fitted with a spinal brace but first needed his physio assessment including gait analysis. Because of this, my supervisor and I decided that we would make the older brother the priority in this session if we began to run short on time.
Task: My task was to perform the annual physio assessment on the 2 brothers with the assistance of my supervisor. I only had 2 hours to perform both assessments and after a quick discussion with my supervisor prior to starting she told me that she wasn’t expecting me to get through both in the allotted time slot. We agreed that realistically it would be a good effort on my behalf to get through both boys subjective assessments and the objective assessment on the older brother. This became my modified task and goal for the session.
Action: As it turned out the whole family came into Rocky Bay for the assessments, being the 2 boys and their younger brother, plus their mother and father. When I was initially introduced to the family the boy’s father seemed very nice and friendly, however I didn’t get the same response from the mother, who didn’t seem too happy that I would be performing the assessment. When we had all made our way into the private assessment room in the therapy area I got started with the assessment. I began with subjective questioning by asking the younger brother, who seemed the quieter of the 2, if he was enjoying the start of his holidays and this quickly lead to his school life. From this platform I was able to ask about physical activities in and out of school, mobility and his ability to transfer. It was at this point I realised that the older brother had been sitting patiently, but hadn’t actually been involved for close to 15 minutes. I quickly swapped over and began asking him a few questions. I again found that one topic of questions easily flowed into the next and this time got carried away with the older brother. From this point I was able to complete my subjective questioning, switching from brother to brother fairly frequently.
With the subjective assessment over I decided to perform the respiratory assessments on the boys one after the other. This involved measurements of vital capacity and forced vital capacity using a vitalograph. Once completed, I took the photographs of the boys sitting and standing postures, again one after the other. As time was beginning to run short, I turned the individual focus onto the older brother as previously discussed. We went outside to begin his functional assessment and returned back to the assessment room to complete it. I was then able to perform a full range of motion assessment of the upper and lower limbs before time was unfortunately up.
Result: The result was that I didn’t really have a full subjective assessment for either boy when I reviewed my notes after the session had ended. I attributed this to the swapping over between each brother during my questioning. This aside, I was nearly able to complete the entire assessment for the older brother, having only needed to assess muscle strength for it to be complete. I was also able to begin the objective assessment on the younger brother and finish taking his posture photographs, which is one of the more time consuming aspects of the assessment. As I wasn’t able to finish both assessments, we were able to book a return appointment for after the school holidays so that they can be completed. After the session my supervisor and I both took a file and the notes so that we could begin writing up one set of assessments each.
Evaluation: Even though I initially felt a bit uncomfortable because of the mother’s attitude towards me, I feel that overall I performed well during this double assessment. I believe that in my attempts to make my subjective questions flow from one topic to the next, it actually made the initial part of the assessment not flow so well. By asking long series of questions to each boy when I started it actually got me out of place a bit and I feel that this was the reason there was some parts missing to my subjective assessment. Despite this, I feel that the questions that I did manage to ask were appropriate and worked well, which also helped with the boy’s mother who became much more cooperative as the assessment progressed. I feel that doing the respiratory and posture photograph aspects of the objective assessment on each of the boys at the same time also worked well. It meant that I didn’t have to explain the process to each boy individually which saved me time in the end. I also feel that I was able to complete the other parts of the assessment in an effective, but time efficient manner. Although the session turned out different to what we had initially planned, I believe that I was actually able to accomplish more than originally anticipated, which was a positive. The problem with the actual outcome was that I wasn’t able to complete the full assessment for either boy, but they are booked in to return soon, so they should both be completed in the next few weeks.
Strategies: One thing I have learnt from this experience is that in the future it would be advisable not to conduct double assessments where possible, especially when under time constraints. By doing the double assessment it unfortunately meant that neither boy’s assessment was able to be completed in the time available. If performing both is unavoidable, I learnt that it works best if each part of the subjective assessment is asked individually and in turn. When I adopted this method at the end of the subjective questioning I didn’t miss any sections or important parts. This is definitely a strategy I would use in the future to ensure I got a thorough and complete subjective history. The other thing I learnt from both my supervisor and my own actions in this scenario was the importance of planning a session before you begin. By having the plan in place to make the older brother the priority in this assessment, it meant that even though we strayed from this plan, I was still well prepared with how the session would run. Also the planning involved with having all the relevant equipment and resources available, such as cameras, stopwatches, goniometers and stickers for spinal assessment in the photographs. It wasn’t a big issue in this instance because there was 2 of us and 1 could just leave the room to gather the forgotten equipment while the other continued, but if you were on your own this would be a time wasting action at a point where time is of the essence. The other thing that was further cemented in my mind was the importance of time efficient positioning and testing everything possible when the client is in their current position, which I was glad to be commended on by my supervisor at the end of the session.
Last week I was scheduled to perform my second annual assessment with one of my supervisors and it was actually a double assessment on 2 brothers, both with Friederich’s Ataxia. From previous assessments I was able to ascertain that the younger brother was more severely affected and was wheelchair bound, only standing out of his chair to transfer, while the older brother had maintained his ability to walk, unless severely fatigued. Both boys had recently been for their regular check-ups at the PMH spinal clinic and the feedback from this was that there was no noteworthy change with the younger brother, but that the older brother would soon be fitted with a spinal brace but first needed his physio assessment including gait analysis. Because of this, my supervisor and I decided that we would make the older brother the priority in this session if we began to run short on time.
Task: My task was to perform the annual physio assessment on the 2 brothers with the assistance of my supervisor. I only had 2 hours to perform both assessments and after a quick discussion with my supervisor prior to starting she told me that she wasn’t expecting me to get through both in the allotted time slot. We agreed that realistically it would be a good effort on my behalf to get through both boys subjective assessments and the objective assessment on the older brother. This became my modified task and goal for the session.
Action: As it turned out the whole family came into Rocky Bay for the assessments, being the 2 boys and their younger brother, plus their mother and father. When I was initially introduced to the family the boy’s father seemed very nice and friendly, however I didn’t get the same response from the mother, who didn’t seem too happy that I would be performing the assessment. When we had all made our way into the private assessment room in the therapy area I got started with the assessment. I began with subjective questioning by asking the younger brother, who seemed the quieter of the 2, if he was enjoying the start of his holidays and this quickly lead to his school life. From this platform I was able to ask about physical activities in and out of school, mobility and his ability to transfer. It was at this point I realised that the older brother had been sitting patiently, but hadn’t actually been involved for close to 15 minutes. I quickly swapped over and began asking him a few questions. I again found that one topic of questions easily flowed into the next and this time got carried away with the older brother. From this point I was able to complete my subjective questioning, switching from brother to brother fairly frequently.
With the subjective assessment over I decided to perform the respiratory assessments on the boys one after the other. This involved measurements of vital capacity and forced vital capacity using a vitalograph. Once completed, I took the photographs of the boys sitting and standing postures, again one after the other. As time was beginning to run short, I turned the individual focus onto the older brother as previously discussed. We went outside to begin his functional assessment and returned back to the assessment room to complete it. I was then able to perform a full range of motion assessment of the upper and lower limbs before time was unfortunately up.
Result: The result was that I didn’t really have a full subjective assessment for either boy when I reviewed my notes after the session had ended. I attributed this to the swapping over between each brother during my questioning. This aside, I was nearly able to complete the entire assessment for the older brother, having only needed to assess muscle strength for it to be complete. I was also able to begin the objective assessment on the younger brother and finish taking his posture photographs, which is one of the more time consuming aspects of the assessment. As I wasn’t able to finish both assessments, we were able to book a return appointment for after the school holidays so that they can be completed. After the session my supervisor and I both took a file and the notes so that we could begin writing up one set of assessments each.
Evaluation: Even though I initially felt a bit uncomfortable because of the mother’s attitude towards me, I feel that overall I performed well during this double assessment. I believe that in my attempts to make my subjective questions flow from one topic to the next, it actually made the initial part of the assessment not flow so well. By asking long series of questions to each boy when I started it actually got me out of place a bit and I feel that this was the reason there was some parts missing to my subjective assessment. Despite this, I feel that the questions that I did manage to ask were appropriate and worked well, which also helped with the boy’s mother who became much more cooperative as the assessment progressed. I feel that doing the respiratory and posture photograph aspects of the objective assessment on each of the boys at the same time also worked well. It meant that I didn’t have to explain the process to each boy individually which saved me time in the end. I also feel that I was able to complete the other parts of the assessment in an effective, but time efficient manner. Although the session turned out different to what we had initially planned, I believe that I was actually able to accomplish more than originally anticipated, which was a positive. The problem with the actual outcome was that I wasn’t able to complete the full assessment for either boy, but they are booked in to return soon, so they should both be completed in the next few weeks.
Strategies: One thing I have learnt from this experience is that in the future it would be advisable not to conduct double assessments where possible, especially when under time constraints. By doing the double assessment it unfortunately meant that neither boy’s assessment was able to be completed in the time available. If performing both is unavoidable, I learnt that it works best if each part of the subjective assessment is asked individually and in turn. When I adopted this method at the end of the subjective questioning I didn’t miss any sections or important parts. This is definitely a strategy I would use in the future to ensure I got a thorough and complete subjective history. The other thing I learnt from both my supervisor and my own actions in this scenario was the importance of planning a session before you begin. By having the plan in place to make the older brother the priority in this assessment, it meant that even though we strayed from this plan, I was still well prepared with how the session would run. Also the planning involved with having all the relevant equipment and resources available, such as cameras, stopwatches, goniometers and stickers for spinal assessment in the photographs. It wasn’t a big issue in this instance because there was 2 of us and 1 could just leave the room to gather the forgotten equipment while the other continued, but if you were on your own this would be a time wasting action at a point where time is of the essence. The other thing that was further cemented in my mind was the importance of time efficient positioning and testing everything possible when the client is in their current position, which I was glad to be commended on by my supervisor at the end of the session.
Sunday, June 27, 2010
Entry 1: Intervention
Situation: I was preparing to see a long term Duchenne Muscular Dystrophy patient for the first time on the Wednesday of my first week at Rocky Bay. I was going to see the young man with my supervisor for his regular stretching and passive movement program, designed to maintain joint range of movement because he had lost his inability to perform the movements actively. I decided I would view his program before the session so that I would be better prepared for my intervention. The client comes to the Rocky Bay site twice per week for his program, but on a Wednesday does not get out of his electric wheelchair, so the program is performed while he is sitting. The program involved a warm up with general passive movements of the upper and lower limbs, followed by stretches into all directions at every joint in the upper and lower limbs.
Task: My task was to perform the client’s regular stretching and passive movement program, under the supervision of my supervisor, who would make sure I was performing things correctly so that I could do the treatments on my own in the future.
Action: After an introduction my supervisor and I started on the passive movements of the upper limb. He was performing them on one side to start off with and then I was copying on the other side once he had finished. After this I began with the upper limb stretches. At the shoulder, I performed flexion, abduction, horizontal adduction and external rotation as per the program. At the elbow I performed flexion and extension and forearm supination and pronation, again as per the program. At this point my supervisor told me I was doing well. In his wheelchair, the client rested one upper limb on each of the arm rests, with his wrists and fingers in slight flexion, which is how he stayed as he did not have the capability to actively move out of this position. At the wrist, I firstly did a passive stretch into extension and then went on to start flexion, as was written up in his program.
Result: After stretching into wrist flexion for less than 5 seconds I was told to stop the stretch by the client as he didn’t need it. I stopped and queried this with my supervisor who told me that he doesn’t usually stretch into wrist flexion as the client rests in wrist flexion anyway, so there is no need to stretch into this direction and that it is extension that we really need to be maintaining at the wrist. After this I continued on with the rest of the program on that side, then progressed to the other upper limb and then to both lower limbs without any problems. When I had finished my intervention and had a quick discussion with my supervisor I went and edited the exercise program and removed the wrist flexion stretch.
Evaluation: I feel that I performed my task well in this situation, particularly my preparation, but there was just the small part of my intervention where I fell down a bit. My supervisor commended me on the fact that I had taken the time to view the client’s program prior to treating him, saying that it would have been very easy for me just to check each part of the treatment with him as I went. He said it was actually this enthusiasm and initiative that caused the problem with the wrist flexion stretch in this instance because I had viewed the most recent exercise program on the computer, however this document had not been updated for some time. He said this was not my fault, as I was not to know it was an outdated program that I had viewed. I felt that it was a good move on my behalf to stop the stretch immediately when I was asked and then to check things over with my supervisor because he was able to point me in the right direction. However, I was still disappointed in myself for not being switched on to the fact that there really was no point in performing a stretch into the direction that the wrist is positioned in for the majority of the day anyway. The rest of the intervention went really well though and updating the exercise program was also the right thing to do as it should save people from making the same mistake as I did in the future.
Strategies: Despite what I honestly felt was a pretty good first up performance on my behalf there is a few things that I learnt from the experience that I will endeavour to incorporate into my clinical performance in the future. Firstly, I will continue to prepare for all people that I see as best as I possibly can, to try give them the best possible care. Secondly, I will know to check the publication date of all documents that I view in the future to try and give me an idea of how up to date and relevant the material contained in it really is. Thirdly, I believe this experience was a reminder that often it is the patient or in this case client who knows best. The young man knew that he didn’t usually receive the wrist flexion stretch that I was performing and was able to tell me and hence get me to stop. By listening to the client I was able to provide the usual treatment that he receives. I believe that listening to the patient/client’s thoughts and beliefs is important in any situation or setting, but also something that has to be interpreted appropriately as I’m sure people’s belief about what needs to be done in terms of treatment is often well off the mark. In this case though, it was spot on and therapeutically it was the correct move to listen to the client and act as he suggested.
Task: My task was to perform the client’s regular stretching and passive movement program, under the supervision of my supervisor, who would make sure I was performing things correctly so that I could do the treatments on my own in the future.
Action: After an introduction my supervisor and I started on the passive movements of the upper limb. He was performing them on one side to start off with and then I was copying on the other side once he had finished. After this I began with the upper limb stretches. At the shoulder, I performed flexion, abduction, horizontal adduction and external rotation as per the program. At the elbow I performed flexion and extension and forearm supination and pronation, again as per the program. At this point my supervisor told me I was doing well. In his wheelchair, the client rested one upper limb on each of the arm rests, with his wrists and fingers in slight flexion, which is how he stayed as he did not have the capability to actively move out of this position. At the wrist, I firstly did a passive stretch into extension and then went on to start flexion, as was written up in his program.
Result: After stretching into wrist flexion for less than 5 seconds I was told to stop the stretch by the client as he didn’t need it. I stopped and queried this with my supervisor who told me that he doesn’t usually stretch into wrist flexion as the client rests in wrist flexion anyway, so there is no need to stretch into this direction and that it is extension that we really need to be maintaining at the wrist. After this I continued on with the rest of the program on that side, then progressed to the other upper limb and then to both lower limbs without any problems. When I had finished my intervention and had a quick discussion with my supervisor I went and edited the exercise program and removed the wrist flexion stretch.
Evaluation: I feel that I performed my task well in this situation, particularly my preparation, but there was just the small part of my intervention where I fell down a bit. My supervisor commended me on the fact that I had taken the time to view the client’s program prior to treating him, saying that it would have been very easy for me just to check each part of the treatment with him as I went. He said it was actually this enthusiasm and initiative that caused the problem with the wrist flexion stretch in this instance because I had viewed the most recent exercise program on the computer, however this document had not been updated for some time. He said this was not my fault, as I was not to know it was an outdated program that I had viewed. I felt that it was a good move on my behalf to stop the stretch immediately when I was asked and then to check things over with my supervisor because he was able to point me in the right direction. However, I was still disappointed in myself for not being switched on to the fact that there really was no point in performing a stretch into the direction that the wrist is positioned in for the majority of the day anyway. The rest of the intervention went really well though and updating the exercise program was also the right thing to do as it should save people from making the same mistake as I did in the future.
Strategies: Despite what I honestly felt was a pretty good first up performance on my behalf there is a few things that I learnt from the experience that I will endeavour to incorporate into my clinical performance in the future. Firstly, I will continue to prepare for all people that I see as best as I possibly can, to try give them the best possible care. Secondly, I will know to check the publication date of all documents that I view in the future to try and give me an idea of how up to date and relevant the material contained in it really is. Thirdly, I believe this experience was a reminder that often it is the patient or in this case client who knows best. The young man knew that he didn’t usually receive the wrist flexion stretch that I was performing and was able to tell me and hence get me to stop. By listening to the client I was able to provide the usual treatment that he receives. I believe that listening to the patient/client’s thoughts and beliefs is important in any situation or setting, but also something that has to be interpreted appropriately as I’m sure people’s belief about what needs to be done in terms of treatment is often well off the mark. In this case though, it was spot on and therapeutically it was the correct move to listen to the client and act as he suggested.
Sunday, June 20, 2010
Initial Entry
It’s 3 down and 1 to go for my final year clinical placements and I am looking forward to my final 1 for the year. This will be my paediatrics placement for the course and I will be in the physio department at Rocky Bay in Mosman Park. I have had some really good experiences at Rocky Bay, having spent time helping with the Getabout program with Matt Webb in 1st year and also having completed my aquatic hour requirements helping in the pool for 4P in 2nd year. It is these experiences that have me looking forward to the next 5 weeks at Rocky Bay, although I’ll admit I am still a little unsure of what the placement will hold for me.
Having been involved with Rocky Bay in the past, checking the university sources, speaking with other students and having been in contact with my supervisor, I feel I have a pretty good idea about the nature of the placement. Rocky Bay mainly caters for children with neuromuscular conditions and as such my preparation has been centred around brushing up on these and in particular Duchenne Muscular Dystrophy, Spinal Muscular Atrophy and Friedreich’s Ataxia as suggested by my supervisor. Dealing with young people with these conditions leads me to believe the nature of this placement will have a large focus on detailed assessments to monitor the progression/regression of the child’s condition state. With this, I believe a lot of my focus will be on maintenance of function with the people I see. From reports I believe there is a smaller case load per day than my previous placements where I was seeing in excess of 10 people per day at times. Despite this I know there will be a lot of time and detail required for correct and accurate assessment and documentation this time around.
The structure of the placement is something I am particularly unsure about. I expect that as with my previous placements I will start off heavily supervised and a spectator, but as time progresses I expect more hands-on roles and more independent work. Not having had much experience in this exact field of work I do expect plenty of supervision initially which is definitely preferable to me. I also expect to be spending time in the pool as I have been told to bring my bathers daily, so I’m looking forward to some hydrotherapy treatments. As I mentioned, I feel my role as a student at this facility will be to improve my skills working with the younger population. Initially by observing how the therapists there go about their work and then progressing to perform these roles on my own. I believe I will be expected to be a fully integrated member of the team by my final week and I intend on demonstrating that I do have the capabilities to fulfil this expectation.
Despite my preparation for the placement, I do still have concerns about my specific knowledge of the conditions I will encounter on this placement. I have been doing plenty of reading through my own resources and also on the internet, but I am worried that there may be information I have missed. I just hope that I will be aware of all the major and essential points to helping the individuals with their conditions and that I can learn the rest as I go and identify any gaps in my knowledge and do my best to fill them in.
Another concern is my ability to correctly perform the thorough and detailed assessments that are required for identifying condition state changes and also the documentation associated with this. It’s another point associated with my inexperience in this field, as I am not sure how proficient I will be with these skills at the initial point of the placement. It’s because of these potential weaknesses though that I intend on capitalising on having supervision around and making sure that I do improve and progress as the placement goes on. This is just another one of those things where I can’t be sure how I’ll fair until I give it a go, but I can only hope that I manage okay and as I mentioned, improve on this if I need to.
Thirdly, I do have some concern over my ability to communicate effectively with kids. Although I have never had a problem with this in the past and I know I enjoy kids, I feel that my limited experience in completing a straight out assessment or doing a treatment with the kids could prove to be a problem. I am just worried that I won’t be able communicate well enough to get them to do what I want them to try and do so that I can accurately assess them. Hopefully this doesn’t turn out to be too much of a problem, but again it’s just one of those things that as a student you have to practice and improve on throughout clinical placement. There are a few concerns, but overall I’m looking forward to the next 5 weeks at Rocky Bay.
Having been involved with Rocky Bay in the past, checking the university sources, speaking with other students and having been in contact with my supervisor, I feel I have a pretty good idea about the nature of the placement. Rocky Bay mainly caters for children with neuromuscular conditions and as such my preparation has been centred around brushing up on these and in particular Duchenne Muscular Dystrophy, Spinal Muscular Atrophy and Friedreich’s Ataxia as suggested by my supervisor. Dealing with young people with these conditions leads me to believe the nature of this placement will have a large focus on detailed assessments to monitor the progression/regression of the child’s condition state. With this, I believe a lot of my focus will be on maintenance of function with the people I see. From reports I believe there is a smaller case load per day than my previous placements where I was seeing in excess of 10 people per day at times. Despite this I know there will be a lot of time and detail required for correct and accurate assessment and documentation this time around.
The structure of the placement is something I am particularly unsure about. I expect that as with my previous placements I will start off heavily supervised and a spectator, but as time progresses I expect more hands-on roles and more independent work. Not having had much experience in this exact field of work I do expect plenty of supervision initially which is definitely preferable to me. I also expect to be spending time in the pool as I have been told to bring my bathers daily, so I’m looking forward to some hydrotherapy treatments. As I mentioned, I feel my role as a student at this facility will be to improve my skills working with the younger population. Initially by observing how the therapists there go about their work and then progressing to perform these roles on my own. I believe I will be expected to be a fully integrated member of the team by my final week and I intend on demonstrating that I do have the capabilities to fulfil this expectation.
Despite my preparation for the placement, I do still have concerns about my specific knowledge of the conditions I will encounter on this placement. I have been doing plenty of reading through my own resources and also on the internet, but I am worried that there may be information I have missed. I just hope that I will be aware of all the major and essential points to helping the individuals with their conditions and that I can learn the rest as I go and identify any gaps in my knowledge and do my best to fill them in.
Another concern is my ability to correctly perform the thorough and detailed assessments that are required for identifying condition state changes and also the documentation associated with this. It’s another point associated with my inexperience in this field, as I am not sure how proficient I will be with these skills at the initial point of the placement. It’s because of these potential weaknesses though that I intend on capitalising on having supervision around and making sure that I do improve and progress as the placement goes on. This is just another one of those things where I can’t be sure how I’ll fair until I give it a go, but I can only hope that I manage okay and as I mentioned, improve on this if I need to.
Thirdly, I do have some concern over my ability to communicate effectively with kids. Although I have never had a problem with this in the past and I know I enjoy kids, I feel that my limited experience in completing a straight out assessment or doing a treatment with the kids could prove to be a problem. I am just worried that I won’t be able communicate well enough to get them to do what I want them to try and do so that I can accurately assess them. Hopefully this doesn’t turn out to be too much of a problem, but again it’s just one of those things that as a student you have to practice and improve on throughout clinical placement. There are a few concerns, but overall I’m looking forward to the next 5 weeks at Rocky Bay.
Sunday, June 13, 2010
Final Entry
My 5 weeks at Fremantle Hospital were tiring, but a great learning experience for me. As with all my previous placements I started off pretty nervously and tended to stand back initially, but as time progressed I became more confident and took on more and varied roles and duties. I had one main supervisor for the placement, however I got to spend time on many different wards and subsequently spent time with a number of different physios working on the wards, which was great to learn and get varied opinions and treatment styles from the different people I was working with.
My initial comments about a more thorough preparation for this placement compared to others turned out to be spot on and I feel that because I did have a good grasp on the theory component I was able to make better clinical reasoning judgements. My solid preparation this time around empowered me to show my supervisors my full potential both from a practical and theoretical standpoint. A nice gesture from my supervisor was being complimented a number of times on my sound theoretical knowledge of the cardiorespiratory system that is applicable to this domain of physiotherapy, which was pleasing and rewarding to hear.
I ended up working in a number of the different areas that were listed in the orientation outline. The majority of my time was spent on the general medical ward, but I also saw at least one patient from each of general surgical, cardiothoracics, intensive care unit and haematology and oncology. I had to approach my patients on these different wards all the same way, it was just that the scope of patients varied from ward to ward with exactly what they were presenting with. As I predicted in my initial entry, things did start off slowly with more supervision and progress to less supervision and more patients under my case load. I was also introduced to the “peer-coaching model,” in which I was paired with Monique and for most of the first week we saw all the patients together. This worked really well I believe, because it enabled us to develop our own styles but also observe how the other was going about things. Monique and I were a good team, constantly encouraging each other but also offering constructive criticism when it was due. One of our strengths while we were working together was that after assessing each patient we decided we would leave the room to discuss a prioritised problem list and treatment goals before actually providing the treatment. I found that this thinking out loud, discussion and planning worked really well and we were able to provide the appropriate management for each of our patients and provide good quality treatments.
After the first week where we were paired together, Monique and I were split up and given our own patients. Initially we were seeing around 4 patients a day, but as time progressed and we became more efficient with our patients, we were able to see 9-10 patients per day by the end of the placement. As the placement went on I also feel that I was contributing more to the multidisciplinary team. For example liaising with the medical team about how a patient was progressing towards their pre-admission level of mobility and nearing discharge, which was something I developed during the placement, whether it was by phone or in person. Towards the end of the placement I was also attending more team meetings and giving input to the team about my patients, where I initially was not doing this as much as I wasn’t too sure about where I stood as a member of the team. This was something I’m very glad I developed from this placement, as I wrote about in my third entry.
I wrote in my initial entry that I was concerned about my time management skills in a clinical situation and how I would cope with a large case load and initially I did struggle with this. I found myself leaving late at the end of the day and having less time for lunch. When this happened a few days in a row I went to my supervisor to tell him about my problem and asked if he had any suggestions that would help me. He was really helpful and we had a pretty long discussion about a lot of it just being an experience factor and it would be something that I would just pick up, but he still offered me some solutions. He suggested that when I get my patient list in the morning that I prioritise it and then plan my day on a time sheet. In doing this, he suggested that I should allocate certain amounts of time for each patient and then not run over this time. That night I created a blank timetable on the computer and made copies to use. From this point on I immediately saw a difference in the number of patients I was seeing when using my timetable and I didn’t have too many more late finishes either, which was good. I was very pleased with my own growth and development in terms of my ability to manage a large case load and do it effectively, but also efficiently over the course of my placement at Fremantle Hospital.
My other pre-placement concern about the practical application of some techniques didn’t end up posing a problem. I was exposed to all the examples that I mentioned (percs and vibes, suctioning, mechanical ventilators and patient lines and attachments) initially either with my supervisor or with Monique, so I was quickly able to get a good grasp on how to do those sorts of things. Monique and I had a patient with bronchiectasis, who had lots of difficulty clearing her secretions independently. We decided on percussion for a treatment technique. The woman informed us that her husband had performed it on her for the past 30 years and she knew what worked well for her and she was able to tell us so that we were able to emulate this and subsequently were able to clear large amounts of sputum daily with this patient. The point I took from this is that often patients know what works well for them and what doesn’t and that within reason it’s always worth listening to and considering the patient’s response when ask them what they do want. After seeing this patient I tried to ask all my future patients if they had previously received treatment and if so what and how was it performed? I found this worked well, particularly with things such as percs and vibes which can tend to administered very differently from patient to patient.
Finally, I was pretty quickly able to develop a tolerance to constantly seeing sputum. Although I will admit that there were a few uneasy moments early on in the placement when getting patients to clear their sputum and then inspecting it to classify it, but it was nothing that a few deep breaths couldn’t resolve.
All in all I found this placement to be very beneficial to my development as a therapist, although it did prove to be quite tiring work running around the wards all day. Amongst many things, I believe the main thing I will take from this placement is the importance of having a good sound knowledge base to work from and knowing your assessment techniques. Effective assessment technique is not only efficient in terms of time but it enables you to clearly identify what treatments you need to perform with the person in front of you because your assessment has just provided you with the information to know what their problems are. The beauty of this as well is that it applies to all domains of physiotherapy and it is something I will take with me into the future no matter where I end up.
My initial comments about a more thorough preparation for this placement compared to others turned out to be spot on and I feel that because I did have a good grasp on the theory component I was able to make better clinical reasoning judgements. My solid preparation this time around empowered me to show my supervisors my full potential both from a practical and theoretical standpoint. A nice gesture from my supervisor was being complimented a number of times on my sound theoretical knowledge of the cardiorespiratory system that is applicable to this domain of physiotherapy, which was pleasing and rewarding to hear.
I ended up working in a number of the different areas that were listed in the orientation outline. The majority of my time was spent on the general medical ward, but I also saw at least one patient from each of general surgical, cardiothoracics, intensive care unit and haematology and oncology. I had to approach my patients on these different wards all the same way, it was just that the scope of patients varied from ward to ward with exactly what they were presenting with. As I predicted in my initial entry, things did start off slowly with more supervision and progress to less supervision and more patients under my case load. I was also introduced to the “peer-coaching model,” in which I was paired with Monique and for most of the first week we saw all the patients together. This worked really well I believe, because it enabled us to develop our own styles but also observe how the other was going about things. Monique and I were a good team, constantly encouraging each other but also offering constructive criticism when it was due. One of our strengths while we were working together was that after assessing each patient we decided we would leave the room to discuss a prioritised problem list and treatment goals before actually providing the treatment. I found that this thinking out loud, discussion and planning worked really well and we were able to provide the appropriate management for each of our patients and provide good quality treatments.
After the first week where we were paired together, Monique and I were split up and given our own patients. Initially we were seeing around 4 patients a day, but as time progressed and we became more efficient with our patients, we were able to see 9-10 patients per day by the end of the placement. As the placement went on I also feel that I was contributing more to the multidisciplinary team. For example liaising with the medical team about how a patient was progressing towards their pre-admission level of mobility and nearing discharge, which was something I developed during the placement, whether it was by phone or in person. Towards the end of the placement I was also attending more team meetings and giving input to the team about my patients, where I initially was not doing this as much as I wasn’t too sure about where I stood as a member of the team. This was something I’m very glad I developed from this placement, as I wrote about in my third entry.
I wrote in my initial entry that I was concerned about my time management skills in a clinical situation and how I would cope with a large case load and initially I did struggle with this. I found myself leaving late at the end of the day and having less time for lunch. When this happened a few days in a row I went to my supervisor to tell him about my problem and asked if he had any suggestions that would help me. He was really helpful and we had a pretty long discussion about a lot of it just being an experience factor and it would be something that I would just pick up, but he still offered me some solutions. He suggested that when I get my patient list in the morning that I prioritise it and then plan my day on a time sheet. In doing this, he suggested that I should allocate certain amounts of time for each patient and then not run over this time. That night I created a blank timetable on the computer and made copies to use. From this point on I immediately saw a difference in the number of patients I was seeing when using my timetable and I didn’t have too many more late finishes either, which was good. I was very pleased with my own growth and development in terms of my ability to manage a large case load and do it effectively, but also efficiently over the course of my placement at Fremantle Hospital.
My other pre-placement concern about the practical application of some techniques didn’t end up posing a problem. I was exposed to all the examples that I mentioned (percs and vibes, suctioning, mechanical ventilators and patient lines and attachments) initially either with my supervisor or with Monique, so I was quickly able to get a good grasp on how to do those sorts of things. Monique and I had a patient with bronchiectasis, who had lots of difficulty clearing her secretions independently. We decided on percussion for a treatment technique. The woman informed us that her husband had performed it on her for the past 30 years and she knew what worked well for her and she was able to tell us so that we were able to emulate this and subsequently were able to clear large amounts of sputum daily with this patient. The point I took from this is that often patients know what works well for them and what doesn’t and that within reason it’s always worth listening to and considering the patient’s response when ask them what they do want. After seeing this patient I tried to ask all my future patients if they had previously received treatment and if so what and how was it performed? I found this worked well, particularly with things such as percs and vibes which can tend to administered very differently from patient to patient.
Finally, I was pretty quickly able to develop a tolerance to constantly seeing sputum. Although I will admit that there were a few uneasy moments early on in the placement when getting patients to clear their sputum and then inspecting it to classify it, but it was nothing that a few deep breaths couldn’t resolve.
All in all I found this placement to be very beneficial to my development as a therapist, although it did prove to be quite tiring work running around the wards all day. Amongst many things, I believe the main thing I will take from this placement is the importance of having a good sound knowledge base to work from and knowing your assessment techniques. Effective assessment technique is not only efficient in terms of time but it enables you to clearly identify what treatments you need to perform with the person in front of you because your assessment has just provided you with the information to know what their problems are. The beauty of this as well is that it applies to all domains of physiotherapy and it is something I will take with me into the future no matter where I end up.
Entry 3
Situation: I had been referred to see a patient, who had just been transferred to the ward and was waiting to be cleared for discharge. The man was initially admitted to the hospital following a Myocardial Infarction (MI) and had been recovering well, but was still waiting to be cleared by the medical team. I had been referred to conduct a mobility review on the man as he had not been seen by physio for a while. According to most recent physio admission in the notes, the man was ambulating with a standby assist with a wheeled zimmer frame (WZF) and independent with all transfers. From the social history I discovered that the man previously walked without aids, but did have a walking stick (WS) at home from a previous admission to hospital where he required it upon discharge. I also noted that he had 5 unavoidable steps at the front entrance of his home.
Task: My task was to assess the man’s current mobility and determine whether he was appropriate for discharge from a physio point of view. As he had unavoidable steps to enter his home, I had to see him walk safely with a WS or without an aid and ensure he was safe going up and down stairs in order to deem his mobility as being at a level appropriate for discharge.
Action: I went into the patient’s room hoping that he already had a WS in there, but took one in with me to save time just in case he didn’t. I ran through my usual routine of checking bloods, nursing observations and meds before eventually starting my subjective assessment. During this questioning I learnt that the man had been using his WZF a lot since last being assessed by a physio and he was confident whilst using it. Unfortunately he hadn’t used a WS since being in hospital and was slightly nervous at the thought of using one.
I started my objective mobility assessment by reviewing the man’s transfers and balance. He was safe and independent with his transfers and was able to stand with his feet together and eyes closed for 20 seconds, although showing a bit of sway and he was able to reach out of his base of support for internal perturbation and was able to demonstrate good righting reactions, but poor protective reactions with external perturbation. I then assessed his ambulation with the WZF, which I could quickly see was safe and competent enough to be made independent. I then wanted to trial the man walking with a WS as his balance assessment showed he should have been capable of using one and he needed to be using one for discharge home with his stairs. The man agreed to this and he walked about 60m with me as a standby assist as he was certainly more wobbly on his feet compared to the WZF, particularly when he tried to turn around (180° turn) to head back to his room. I explained to the man that because I wasn’t completely confident to have him walking with a WS on his own and as of then I had not seen him walking on stairs that I’d have to see him at least once more before I could say his mobility was at a level suitable for discharge home. He was a bit upset, however when I explained that he could not safely use his WZF to go up the steps out the front of his home, but he wasn’t yet safe with the WS, he was able to understand the rationale behind what I was telling him. I told him that I would come back in the afternoon, so that I could see him on some steps and give him every opportunity to show me he was safe and capable with the WS because I knew he was so keen to go home. When I left his room I went straight to the integrated notes to document my assessment findings and note that I did not currently feel the man was safe for discharge from a physio mobility point of view.
Result: I went back to see the man immediately after lunch to continue practising with the walking stick and assess him on some stairs. When I got to his room though, he wasn’t there. I saw a nurse come out of the patient toilet after helping someone and I asked her if my patient was in the toilet, she told me that it wasn’t and that my patient had been discharged earlier. I was shocked! I had clearly documented in the notes that the man wasn’t yet appropriate for discharge, but he had still been discharged from the hospital, so I went straight to my supervisor. When I told him about the situation he was very unhappy that the team had discharged the patient against my recommendations and he contacted the team after he told me to go see my next patient. He fed back to me that the team had not even read my notes from that morning and that he had suggested that the team pay more attention to the physio entries in the notes and especially to those concerning patients with reduced mobility. I think the same thing must have happened to my supervisor in the past, but I was happy that he was willing to fly the flag on my and the whole physio teams behalf.
He went on to tell me that my actions were fine and that it was what he would have done under the same circumstances. He explained that the fact the patient had been discharged was by no means my fault, but he said that to be absolutely certain next time with a patient who is close to being sent home that I could contact the team in person to inform them of my recommendations.
Evaluation: On evaluation I feel that I acted appropriately under the circumstances that were presented to me. I deemed that my patient was not yet safe for discharge home and I believe I clearly documented that in the integrated notes. The fact that I did feel this way led me to be very concerned that he had been discharged and so I went straight to my supervisor and I feel that telling my supervisor what had happened was also a good move on my behalf. The situation didn’t turn out to be ideal, with the patient being discharged without any aids and he will be using one that he will initially be unsafe with at home, but the medical team were made to be aware of the situation and personally I feel I did just about all that I could to look out for the welfare of the patient.
Strategies: Despite believing that I acted appropriately in this situation there is still some strategies that I will take from it to improve my clinical performances in the future. Firstly that it is always ideal to let other members of the multidisciplinary team know about your assessment or treatment findings and recommendations. Whether this is the medical team, nursing staff, other physios or other allied health members, you need to let them know, because you may have information that is crucial to the patient receiving the care they require. It again comes down to recognising that you’re an important member of the team and that you do have important information to contribute. Secondly, to continue making the most of having a supervisor around while the opportunity is still there. There is only one supervised rotation remaining, so I definitely intend on using the knowledge and experience that each of our supervisors have to maximise the potential benefits of my final placement. Thirdly, one of the things my supervisor commended me on was the safety behind the logic of my decision making. Although the outcome wasn’t ideal in this instance, to err on the side of caution when you are unsure about a patient is always the safest option to take. To say that this man wasn’t appropriate for discharge was the safe and correct option and to continue to do this while I am still gaining experience is a good mindset and will benefit the safety of the people under my care.
Task: My task was to assess the man’s current mobility and determine whether he was appropriate for discharge from a physio point of view. As he had unavoidable steps to enter his home, I had to see him walk safely with a WS or without an aid and ensure he was safe going up and down stairs in order to deem his mobility as being at a level appropriate for discharge.
Action: I went into the patient’s room hoping that he already had a WS in there, but took one in with me to save time just in case he didn’t. I ran through my usual routine of checking bloods, nursing observations and meds before eventually starting my subjective assessment. During this questioning I learnt that the man had been using his WZF a lot since last being assessed by a physio and he was confident whilst using it. Unfortunately he hadn’t used a WS since being in hospital and was slightly nervous at the thought of using one.
I started my objective mobility assessment by reviewing the man’s transfers and balance. He was safe and independent with his transfers and was able to stand with his feet together and eyes closed for 20 seconds, although showing a bit of sway and he was able to reach out of his base of support for internal perturbation and was able to demonstrate good righting reactions, but poor protective reactions with external perturbation. I then assessed his ambulation with the WZF, which I could quickly see was safe and competent enough to be made independent. I then wanted to trial the man walking with a WS as his balance assessment showed he should have been capable of using one and he needed to be using one for discharge home with his stairs. The man agreed to this and he walked about 60m with me as a standby assist as he was certainly more wobbly on his feet compared to the WZF, particularly when he tried to turn around (180° turn) to head back to his room. I explained to the man that because I wasn’t completely confident to have him walking with a WS on his own and as of then I had not seen him walking on stairs that I’d have to see him at least once more before I could say his mobility was at a level suitable for discharge home. He was a bit upset, however when I explained that he could not safely use his WZF to go up the steps out the front of his home, but he wasn’t yet safe with the WS, he was able to understand the rationale behind what I was telling him. I told him that I would come back in the afternoon, so that I could see him on some steps and give him every opportunity to show me he was safe and capable with the WS because I knew he was so keen to go home. When I left his room I went straight to the integrated notes to document my assessment findings and note that I did not currently feel the man was safe for discharge from a physio mobility point of view.
Result: I went back to see the man immediately after lunch to continue practising with the walking stick and assess him on some stairs. When I got to his room though, he wasn’t there. I saw a nurse come out of the patient toilet after helping someone and I asked her if my patient was in the toilet, she told me that it wasn’t and that my patient had been discharged earlier. I was shocked! I had clearly documented in the notes that the man wasn’t yet appropriate for discharge, but he had still been discharged from the hospital, so I went straight to my supervisor. When I told him about the situation he was very unhappy that the team had discharged the patient against my recommendations and he contacted the team after he told me to go see my next patient. He fed back to me that the team had not even read my notes from that morning and that he had suggested that the team pay more attention to the physio entries in the notes and especially to those concerning patients with reduced mobility. I think the same thing must have happened to my supervisor in the past, but I was happy that he was willing to fly the flag on my and the whole physio teams behalf.
He went on to tell me that my actions were fine and that it was what he would have done under the same circumstances. He explained that the fact the patient had been discharged was by no means my fault, but he said that to be absolutely certain next time with a patient who is close to being sent home that I could contact the team in person to inform them of my recommendations.
Evaluation: On evaluation I feel that I acted appropriately under the circumstances that were presented to me. I deemed that my patient was not yet safe for discharge home and I believe I clearly documented that in the integrated notes. The fact that I did feel this way led me to be very concerned that he had been discharged and so I went straight to my supervisor and I feel that telling my supervisor what had happened was also a good move on my behalf. The situation didn’t turn out to be ideal, with the patient being discharged without any aids and he will be using one that he will initially be unsafe with at home, but the medical team were made to be aware of the situation and personally I feel I did just about all that I could to look out for the welfare of the patient.
Strategies: Despite believing that I acted appropriately in this situation there is still some strategies that I will take from it to improve my clinical performances in the future. Firstly that it is always ideal to let other members of the multidisciplinary team know about your assessment or treatment findings and recommendations. Whether this is the medical team, nursing staff, other physios or other allied health members, you need to let them know, because you may have information that is crucial to the patient receiving the care they require. It again comes down to recognising that you’re an important member of the team and that you do have important information to contribute. Secondly, to continue making the most of having a supervisor around while the opportunity is still there. There is only one supervised rotation remaining, so I definitely intend on using the knowledge and experience that each of our supervisors have to maximise the potential benefits of my final placement. Thirdly, one of the things my supervisor commended me on was the safety behind the logic of my decision making. Although the outcome wasn’t ideal in this instance, to err on the side of caution when you are unsure about a patient is always the safest option to take. To say that this man wasn’t appropriate for discharge was the safe and correct option and to continue to do this while I am still gaining experience is a good mindset and will benefit the safety of the people under my care.
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