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.
Sunday, May 30, 2010
Entry 2: Intervention
Situation: I had been treating a middle aged gentleman who had come onto the ward with an acute exacerbation of COPD for about a week and was not really seeing any improvements in his function. The man was a CO2 retainer, usually had home oxygen (O2) and had severely decreased exercise tolerance, walking a maximum of about 30m with a wheeled zimmer frame (WZF) at home before he had to have a rest because of shortness of breath. Since being in hospital it hadn’t purely been his exercise tolerance that was the problem as he could still walk about 30m, but he was just much more short of breath after doing so. He was also having difficulty clearing his increased amount of secretions. Whilst being in hospital he had also developed gout in his foot, which was very painful and subsequently we abandoned the plan to walk on consecutive days because of this pain. When this pain was being controlled better, we were able to walk 30m with a WZF on 2L of O2/min with a 2 minute break at 15m because of the shortness of breath (Rated at 8/10 on a Borg Scale by the man.) Other interventions in my treatment sessions included deep breathing exercises, active cycle of breathing techniques (ACBT), supported cough, expiratory vibes and breathlessness relieving positions. After this session, I had a particularly long think about what I could differently next time I treated the man and identified that I could try ambulation with a 4 wheeled walker (4WW) as it would have a seat and may help the man with his shortness of breath recovery time if he were to sit down if he did become more short of breath.
Task: My task was to perform my daily respiratory and mobility treatment for the man, with the plan of trialling ambulation with a 4WW and oxygen rather than WZF.
Action: I started my session with subjective questioning about how the man had been since I saw him previously and then took his obs so that that I had up to date figures that I could use as outcome measures. The patient reported his shortness of breath at rest was 6/10 on the Borg scale, his gout pain was negligible, but feet pain secondary to his usual peripheral oedema was 2/10 on a pain scale, his blood pressure was 117/81 and oxygen saturation was 92% on 2L of O2 per minute. Being a CO2 retainer, I was to expect that his sats would be around 88-92%, so this was an acceptable level to be walking with him, so that was definitely the plan for my first intervention of the session. He told me he was very keen to try the 4WW as he thought it would be a great aid for him to use upon discharge if it was beneficial for him. I switched his oxygen source over to a portable bottle and turned it onto 2L/min and I kept the pulse oximeter on, so that I could monitor his sats as we walked as he did have a history of de-satting. I would look after the portable oxygen and pulse oximeter and just follow the patient as he walked. I knew he was independent with his walking, so we were ready to go.
After walking about 10 metres outside his room the man quickly became short of breath and his sats began to fall quite rapidly. 5 metres further and the man complained of 9/10 breathlessness and his sats were 88%, the oximeter showed a good pulse so I was confident I was getting an accurate reading but I made the man have a sit down on the 4WW’s seat because of his symptoms. In the breathlessness relieving position of forward lean sitting and performing some deep breathing the man was still not recovering and his sats dropped to 86%. It was then that my supervisor walked past after seeing a patient of his own and checked to see if everything was alright with me and my patient. When I told him that the man was in a bit of distress after the short walk the first thing he did was check the portable oxygen bottle. To my surprise there was no oxygen coming out of the bottle and after being questioned as to whether I had turned it on, which my patient and I were both certain that I had, and after altering the flow dials to no avail, we came to the conclusion that the bottle had run out of oxygen, so I quickly got a new bottle and swapped it over. After making the switch the man quickly recovered to a SOB of 6/10 and sats of 91% and was happy to continue on with the walk, which we did.
Result: The result was that he was able to walk a total of 30m in returning to his room without needing to take a break. On completion his sats were 89% and SOB 7/10, so he had deteriorated a little, but not significantly like the previous day or initial walk. After 2 mins of forward lean sitting and deep breathing the man had returned to his baseline sats of 92% and 6/10 shortness of breath, which was a much more rapid recovery than previous efforts. I felt that the increased distance walked, smaller sats and SOB deterioration and quicker recovery were a significant enough result to warrant switching the patient to ambulation with a 4WW as opposed to a WZF. The man was also very pleased with his efforts.
Evaluation: I feel that my rationale and thinking about this patient’s intervention were pretty good, as demonstrated by the eventual improved ambulation performance with the 4WW. However, I believe my initial execution of the intervention showed a lot of inexperience as I did not execute it very well, which showed with the man’s first attempt to walk with the 4WW. After a discussion with my supervisor he said that despite the fact it wasn’t my fault that the oxygen bottle had run out oxygen, it’s still my job to be aware of the possibility and check and prevent it from occurring with a patient. As I said, it was just an inexperience factor, but I did not check to see how much oxygen was still in the bottle when I turned it on, I was only concerned that it was initially producing 2L per minute, something that I now know to look out for in the future. Despite this, I feel most of this particular intervention was done well on my behalf, mainly in reference to the outcome measures and other safety precautions that I had in place. Taking the pulse oximeter with us and having a Borg scale shortness of breath rating was a good decision, because although the man had de-satted more on previous occasions than the 86-88%, it was the rapid fall combined with the symptomatic shortness of breath response that alerted me to the need for the man to stop and recover. Leaving the 4WW in the patient’s room was also a good idea because it means he can become more familiar with it prior to his discharge, which will help facilitate a safe return to home for the man.
Strategies: The obvious strategy that I will take out of this situation is the need to always check the working order of portable oxygen bottles before walking a patient with them. I now know to always check the gauge to make sure the bottle is not nearly empty. This does not just have to apply to portable oxygen though, it’s alerted me to the fact that all devices or equipment should be regularly checked to ensure they are in correct working order, so as not to put the wellbeing of our patients under scrutiny. One of the aspects I felt I did well in this scenario was evaluate the situation to see what else I could do to further improve the outcome for my patient. It certainly was not the first time I have done this and I feel that I am pretty good at reflecting and evaluating after seeing all of my patients, however it was just a good example of why I should continue to do this, as the result of changing the man’s ambulation aid to a 4WW produced significant performance improvement compared to previous sessions. The benefit of a 4WW’s seat for people who get short of breath on exertion is also something I will remember, because it means they have an effective walking aid plus the bonus of a mobile place to sit to recover when they do become short of breath. One final thing which my university tutor helped me to identify was the need to make treatment session plans and then stick to them. In this case, I decided I wanted the man to trial walking with a 4WW and despite the initial events with the oxygen bottle I still carried through with this plan so that I could assess the benefit of this particular ambulation aid for the man. By completing what I had planned to achieve, I was able to identify that the man did indeed perform better with the 4WW compared to the WZF and thus was able to leave it in his room for him to continue using in the future.
Task: My task was to perform my daily respiratory and mobility treatment for the man, with the plan of trialling ambulation with a 4WW and oxygen rather than WZF.
Action: I started my session with subjective questioning about how the man had been since I saw him previously and then took his obs so that that I had up to date figures that I could use as outcome measures. The patient reported his shortness of breath at rest was 6/10 on the Borg scale, his gout pain was negligible, but feet pain secondary to his usual peripheral oedema was 2/10 on a pain scale, his blood pressure was 117/81 and oxygen saturation was 92% on 2L of O2 per minute. Being a CO2 retainer, I was to expect that his sats would be around 88-92%, so this was an acceptable level to be walking with him, so that was definitely the plan for my first intervention of the session. He told me he was very keen to try the 4WW as he thought it would be a great aid for him to use upon discharge if it was beneficial for him. I switched his oxygen source over to a portable bottle and turned it onto 2L/min and I kept the pulse oximeter on, so that I could monitor his sats as we walked as he did have a history of de-satting. I would look after the portable oxygen and pulse oximeter and just follow the patient as he walked. I knew he was independent with his walking, so we were ready to go.
After walking about 10 metres outside his room the man quickly became short of breath and his sats began to fall quite rapidly. 5 metres further and the man complained of 9/10 breathlessness and his sats were 88%, the oximeter showed a good pulse so I was confident I was getting an accurate reading but I made the man have a sit down on the 4WW’s seat because of his symptoms. In the breathlessness relieving position of forward lean sitting and performing some deep breathing the man was still not recovering and his sats dropped to 86%. It was then that my supervisor walked past after seeing a patient of his own and checked to see if everything was alright with me and my patient. When I told him that the man was in a bit of distress after the short walk the first thing he did was check the portable oxygen bottle. To my surprise there was no oxygen coming out of the bottle and after being questioned as to whether I had turned it on, which my patient and I were both certain that I had, and after altering the flow dials to no avail, we came to the conclusion that the bottle had run out of oxygen, so I quickly got a new bottle and swapped it over. After making the switch the man quickly recovered to a SOB of 6/10 and sats of 91% and was happy to continue on with the walk, which we did.
Result: The result was that he was able to walk a total of 30m in returning to his room without needing to take a break. On completion his sats were 89% and SOB 7/10, so he had deteriorated a little, but not significantly like the previous day or initial walk. After 2 mins of forward lean sitting and deep breathing the man had returned to his baseline sats of 92% and 6/10 shortness of breath, which was a much more rapid recovery than previous efforts. I felt that the increased distance walked, smaller sats and SOB deterioration and quicker recovery were a significant enough result to warrant switching the patient to ambulation with a 4WW as opposed to a WZF. The man was also very pleased with his efforts.
Evaluation: I feel that my rationale and thinking about this patient’s intervention were pretty good, as demonstrated by the eventual improved ambulation performance with the 4WW. However, I believe my initial execution of the intervention showed a lot of inexperience as I did not execute it very well, which showed with the man’s first attempt to walk with the 4WW. After a discussion with my supervisor he said that despite the fact it wasn’t my fault that the oxygen bottle had run out oxygen, it’s still my job to be aware of the possibility and check and prevent it from occurring with a patient. As I said, it was just an inexperience factor, but I did not check to see how much oxygen was still in the bottle when I turned it on, I was only concerned that it was initially producing 2L per minute, something that I now know to look out for in the future. Despite this, I feel most of this particular intervention was done well on my behalf, mainly in reference to the outcome measures and other safety precautions that I had in place. Taking the pulse oximeter with us and having a Borg scale shortness of breath rating was a good decision, because although the man had de-satted more on previous occasions than the 86-88%, it was the rapid fall combined with the symptomatic shortness of breath response that alerted me to the need for the man to stop and recover. Leaving the 4WW in the patient’s room was also a good idea because it means he can become more familiar with it prior to his discharge, which will help facilitate a safe return to home for the man.
Strategies: The obvious strategy that I will take out of this situation is the need to always check the working order of portable oxygen bottles before walking a patient with them. I now know to always check the gauge to make sure the bottle is not nearly empty. This does not just have to apply to portable oxygen though, it’s alerted me to the fact that all devices or equipment should be regularly checked to ensure they are in correct working order, so as not to put the wellbeing of our patients under scrutiny. One of the aspects I felt I did well in this scenario was evaluate the situation to see what else I could do to further improve the outcome for my patient. It certainly was not the first time I have done this and I feel that I am pretty good at reflecting and evaluating after seeing all of my patients, however it was just a good example of why I should continue to do this, as the result of changing the man’s ambulation aid to a 4WW produced significant performance improvement compared to previous sessions. The benefit of a 4WW’s seat for people who get short of breath on exertion is also something I will remember, because it means they have an effective walking aid plus the bonus of a mobile place to sit to recover when they do become short of breath. One final thing which my university tutor helped me to identify was the need to make treatment session plans and then stick to them. In this case, I decided I wanted the man to trial walking with a 4WW and despite the initial events with the oxygen bottle I still carried through with this plan so that I could assess the benefit of this particular ambulation aid for the man. By completing what I had planned to achieve, I was able to identify that the man did indeed perform better with the 4WW compared to the WZF and thus was able to leave it in his room for him to continue using in the future.
Sunday, May 16, 2010
Entry 1: Professional Behaviour
Situation: On my second day at Fremantle Hospital, my clinical tutor was spending time with both Monique and myself for the entire day. For the first part of the morning we discussed expectations and had a bit of a generalised tutorial about what to expect and how to get the most out of a cardiorespiratory placement. After this we went on to the ward to prepare for our first patient of the placement. We were shown how to analyse patient notes for relevant information to get an idea as to what the patient will look like and their capabilities before we initially see them. Our tutor also showed us how to review all the relevant investigations that have been performed on the patient, such as chest x-rays and bloods, all so that we could see the correct process that should be followed before seeing a patient. Once this preparation process was complete, our tutor went to the patient just to check she was happy to be seen by students and when we got the okay we took a lunch break knowing we were ready to see the patient immediately after lunch. During our lunch break, Monique and I decided that she would perform the subjective assessment, then I would be objectively assessing the patient.
When we met up with our tutor after lunch we went straight in to see the patient. She was an elderly woman who had pneumonia, with a productive cough and very decreased exercise tolerance. She was also being investigated for another infection, subsequently she was in a single room and we all had to wear precautionary gown and gloves before entering the room. Once inside the room, our tutor introduced us and then handed control over to Monique, who was ready to start her subjective questioning. Monique was conducting an initial assessment as she had been instructed to do by our tutor and was about 6 questions into it when we began to see that this was not going to be the easiest patient. The patient began questioning Monique and what she was doing and when this was initially happening I thought it was a bit of a joke, but when she continued to do it I realised that the patient actually meant what she was saying. Right now I’d like to make it be known that I thought Monique was doing a great job with her assessment and there was absolutely nothing wrong with her questioning, she was being clear and asking appropriate things and I wouldn’t have faulted her at all. She continued with her questions, but the patient continued with her ‘treatment’ on Monique as well. The patient kept telling her that she was doing things wrong and then started mimicking her and actually verbally insulting her, then told her to go away. After this our tutor stepped in to relieve a slightly upset Monique by continuing with a partly modified subjective assessment. Then she finished and handed control over to me.
Task: My task was to perform the objective assessment on the patient. This was to include an initial respiratory assessment, which would consist of a cough, chest expansion and auscultation assessment. In addition I was to perform a mobility assessment of things such as bed mobility, transfers and ambulation.
Action: When I was starting I was just praying that the patient would be a bit more friendly and cooperative with me than she had been with Monique. I was able to get her to cough so that I could assess it without much difficulty. Then I wanted to auscultate to listen to her breath sounds, but first asked for consent to do this. The woman got very annoyed that I had asked for her permission to do this as she felt everything was already taking too long and thought I should have just done it anyway. I explained that I would not do the auscultation if she did not approve and then she began explaining her extensive thoughts about how stupid it was that I had to get her consent before performing the assessment, before finally allowing me to do it. During this assessment, I unfortunately forgot that you can’t hear yourself as loudly when you speak with stethoscope ear pieces in and proceeded to speak at an increased volume right next to the patient’s ear as I was listening to her chest. She was very quick to let me know that she was not deaf and there was “no need for me to shout,” which was quite embarrassing. When I finished auscultating I explained that the final thing I had to do was assess her current level of mobility. This also turned out to be a very long and difficult process, but I was eventually able to get her to walk approx 2 metres with a wheeled zimmer frame before she needed to sit down and rest on a chair. After a few minutes she felt able to walk back to her original bed side chair and this is what we did. Once back in the chair, the woman immediately cleared some sputum into her tissue, but refused to let myself or anyone else look at what she had cleared. We were then unable to persuade the patient to perform any further mobility assessments or even clearance exercises such as the ACBT despite there clearly being a need for it. I finished by auscultating the lungs again and we finished and left the room.
Result: The result was that my respiratory assessment did not include a chest expansion assessment and the mobility assessment only comprised of sit to stands and ambulation. Despite it not being one of my individual set tasks, Monique and I still would have liked to perform some form of treatment, which did not eventuate either, meaning the woman was left with uncleared secretions remaining in her airways when we finished with her. This certainly was not a desirable outcome and in addition to this, both Monique and I left the patient’s room feeling a bit lower and more dejected than when we had entered over 45 minutes earlier.
Evaluation: On evaluation I feel I let the way the patient treated Monique initially affect my part of the assessment a lot more than it should have. I feel that I forgot to feel the patient’s chest expansion because I was so concerned with what she was thinking about me and what she was going to say to me. Despite this being the first patient I had assessed on this placement, I feel it was a poor effort to forget one of only three things from my assessment because of nerves and because of this action particularly I was disappointed with myself. In regards to the mobility assessment, there’s not much more you can do when a patient is refusing to cooperate with you like this patient was. I couldn’t assess her mobility if she wasn’t willing to move around for me, perhaps the only thing I could have done was persuade her further, but apart from this, my attempt at a mobility assessment was about as good as it could have been under the circumstances. When we finished, Monique and I had a very long discussion with our tutor about how things had gone with the patient. She told both of us that she felt we handled the situation pretty well and again that under the circumstances, being quite a difficult patient, we both performed well. She also gave us a few tips and strategies to use if we find ourselves in a similar situation again.
Strategies: Our tutor told us that when we have difficult patients one of the best things you can do is to give them what they want. She used the example of when Monique was asking her initial subjective questions and said that the patient had most likely been asked those questions (eg. Are you a smoker? Do you have a cough?) many times before and that she would have been wanting more questions relating to her current state. The tutor said the better questions to ask would have been about how she was coping that day, if there was any pain that day and if she had been coughing a lot recently? This, rather than the more initial subjective history questions that were asked by Monique as she was performing her set task. Another thing the tutor said to do was have checklists made up that we could either think of or refer to when we are treating our patients. By having a checklist or set routine that you follow, then you are much less likely to miss something important, such as part of your assessment process. One of the things that I noticed the tutor do when she was speaking to the patient was identify that she really wanted to go back to her hostel as soon as possible. She then said the quicker she lets us perform our assessments the quicker we could tell the rest of the team when we felt she was ready to be discharged. This immediately made the patient more cooperative than she initially was with the assessment process. I believe this was an appropriate action to take with this particular patient and I feel that depending on the person sitting in front of me, I also may decide that a method like this could be employed to help with patient persuasion into cooperation with you and your efforts. I also learnt that you can’t let yourself get flustered by difficult patients because it impairs your normal thought processes and interferes with your work. This one however, is probably easier said than done, but something that I intend to try my very best to adhere to. Finally, I learnt that you must speak softly to a patient while you have stethoscope ear pieces in.
When we met up with our tutor after lunch we went straight in to see the patient. She was an elderly woman who had pneumonia, with a productive cough and very decreased exercise tolerance. She was also being investigated for another infection, subsequently she was in a single room and we all had to wear precautionary gown and gloves before entering the room. Once inside the room, our tutor introduced us and then handed control over to Monique, who was ready to start her subjective questioning. Monique was conducting an initial assessment as she had been instructed to do by our tutor and was about 6 questions into it when we began to see that this was not going to be the easiest patient. The patient began questioning Monique and what she was doing and when this was initially happening I thought it was a bit of a joke, but when she continued to do it I realised that the patient actually meant what she was saying. Right now I’d like to make it be known that I thought Monique was doing a great job with her assessment and there was absolutely nothing wrong with her questioning, she was being clear and asking appropriate things and I wouldn’t have faulted her at all. She continued with her questions, but the patient continued with her ‘treatment’ on Monique as well. The patient kept telling her that she was doing things wrong and then started mimicking her and actually verbally insulting her, then told her to go away. After this our tutor stepped in to relieve a slightly upset Monique by continuing with a partly modified subjective assessment. Then she finished and handed control over to me.
Task: My task was to perform the objective assessment on the patient. This was to include an initial respiratory assessment, which would consist of a cough, chest expansion and auscultation assessment. In addition I was to perform a mobility assessment of things such as bed mobility, transfers and ambulation.
Action: When I was starting I was just praying that the patient would be a bit more friendly and cooperative with me than she had been with Monique. I was able to get her to cough so that I could assess it without much difficulty. Then I wanted to auscultate to listen to her breath sounds, but first asked for consent to do this. The woman got very annoyed that I had asked for her permission to do this as she felt everything was already taking too long and thought I should have just done it anyway. I explained that I would not do the auscultation if she did not approve and then she began explaining her extensive thoughts about how stupid it was that I had to get her consent before performing the assessment, before finally allowing me to do it. During this assessment, I unfortunately forgot that you can’t hear yourself as loudly when you speak with stethoscope ear pieces in and proceeded to speak at an increased volume right next to the patient’s ear as I was listening to her chest. She was very quick to let me know that she was not deaf and there was “no need for me to shout,” which was quite embarrassing. When I finished auscultating I explained that the final thing I had to do was assess her current level of mobility. This also turned out to be a very long and difficult process, but I was eventually able to get her to walk approx 2 metres with a wheeled zimmer frame before she needed to sit down and rest on a chair. After a few minutes she felt able to walk back to her original bed side chair and this is what we did. Once back in the chair, the woman immediately cleared some sputum into her tissue, but refused to let myself or anyone else look at what she had cleared. We were then unable to persuade the patient to perform any further mobility assessments or even clearance exercises such as the ACBT despite there clearly being a need for it. I finished by auscultating the lungs again and we finished and left the room.
Result: The result was that my respiratory assessment did not include a chest expansion assessment and the mobility assessment only comprised of sit to stands and ambulation. Despite it not being one of my individual set tasks, Monique and I still would have liked to perform some form of treatment, which did not eventuate either, meaning the woman was left with uncleared secretions remaining in her airways when we finished with her. This certainly was not a desirable outcome and in addition to this, both Monique and I left the patient’s room feeling a bit lower and more dejected than when we had entered over 45 minutes earlier.
Evaluation: On evaluation I feel I let the way the patient treated Monique initially affect my part of the assessment a lot more than it should have. I feel that I forgot to feel the patient’s chest expansion because I was so concerned with what she was thinking about me and what she was going to say to me. Despite this being the first patient I had assessed on this placement, I feel it was a poor effort to forget one of only three things from my assessment because of nerves and because of this action particularly I was disappointed with myself. In regards to the mobility assessment, there’s not much more you can do when a patient is refusing to cooperate with you like this patient was. I couldn’t assess her mobility if she wasn’t willing to move around for me, perhaps the only thing I could have done was persuade her further, but apart from this, my attempt at a mobility assessment was about as good as it could have been under the circumstances. When we finished, Monique and I had a very long discussion with our tutor about how things had gone with the patient. She told both of us that she felt we handled the situation pretty well and again that under the circumstances, being quite a difficult patient, we both performed well. She also gave us a few tips and strategies to use if we find ourselves in a similar situation again.
Strategies: Our tutor told us that when we have difficult patients one of the best things you can do is to give them what they want. She used the example of when Monique was asking her initial subjective questions and said that the patient had most likely been asked those questions (eg. Are you a smoker? Do you have a cough?) many times before and that she would have been wanting more questions relating to her current state. The tutor said the better questions to ask would have been about how she was coping that day, if there was any pain that day and if she had been coughing a lot recently? This, rather than the more initial subjective history questions that were asked by Monique as she was performing her set task. Another thing the tutor said to do was have checklists made up that we could either think of or refer to when we are treating our patients. By having a checklist or set routine that you follow, then you are much less likely to miss something important, such as part of your assessment process. One of the things that I noticed the tutor do when she was speaking to the patient was identify that she really wanted to go back to her hostel as soon as possible. She then said the quicker she lets us perform our assessments the quicker we could tell the rest of the team when we felt she was ready to be discharged. This immediately made the patient more cooperative than she initially was with the assessment process. I believe this was an appropriate action to take with this particular patient and I feel that depending on the person sitting in front of me, I also may decide that a method like this could be employed to help with patient persuasion into cooperation with you and your efforts. I also learnt that you can’t let yourself get flustered by difficult patients because it impairs your normal thought processes and interferes with your work. This one however, is probably easier said than done, but something that I intend to try my very best to adhere to. Finally, I learnt that you must speak softly to a patient while you have stethoscope ear pieces in.
Sunday, May 9, 2010
Initial Entry
My third clinical placement for the year is cardiorespiratory at Fremantle Hospital and I am looking forward to it. I am half way through my four placements for the year and the finishing line is getting closer and closer, which is very exciting. I feel my preparation for this placement has been much better than the previous two, which I am hoping will serve me well through the five weeks. After the two previous efforts I feel that I was able to prepare more effectively and thoroughly this time round and made use of past student, university and facility revision recommendations to aid in my study endeavours. Having said this though, I am still very nervous about what the next five weeks will hold, because I think this placement will be very different again to what I have encountered previously.
I am not entirely sure about the nature of this placement, because the orientation outline provided by the facility has suggested six different areas that I could possibly be involved with while on my cardiorespiratory placement. These are General Medical, General Surgical, Cardiothoracics, Intensive Care Unit, Ambulatory Care and Haematology and Oncology, certainly a wide variety of possibilities. No matter which area I am working in, I do expect it to be fast paced and at times hectic with the number of duties I will be expected to fulfil. In terms of placement structure, I have read from the orientation outline that Fremantle Hospital placements use a “peer-coaching model,” which I am assuming involves working pretty closely with another or other students that are also on placement. I am expecting that initially I will be working alongside another student and a supervisor, but as the placement progresses the degree of supervision will decrease as we become more familiar with the facility, then to the point where I will be operating without a partner. I expect that as time goes by my case load will increase as I become more proficient with my duties. I feel that there will also be greater expectations on me to be able to perform these duties effectively and efficiently and that despite being a student I should be a contributing member of the multidisciplinary team. I believe my role as a student will be to learn and progress my skills, knowledge and capabilities as much as possible, but also to be an effective team member and contribute as much as possible as I previously mentioned.
I mentioned at the beginning of my previous placement that I was concerned about my time management skills and I would have to admit I still feel the same way now. At Osborne Park Hospital I was given my daily timetable which had my patients sorted into allocated time slots and I just stuck to this as best as possible. Despite the convenience of this system, it didn’t really challenge my time management skills, which is why I am still a bit concerned about it heading to Fremantle Hospital. Particularly the patient prioritisation aspect of time management, which Shane has told us can be very difficult in this area, especially with a large case load, is something that I would like to discuss with my supervisor pretty early on in the placement, so that I am able to cope with the demands placed on me and be as efficient as possible.
Another concern of mine is my ability to perform some techniques and treatments that we have learnt about and practiced at uni but I have never performed on a patient. I am nervous about things such as percussion and vibrations, suctioning, mechanical ventilators and just the management and awareness of attachments like ICCs and different lines. I hope that with these treatments and other aspects that I will get some guidance from my supervisor when I am initially performing or administering them, but if not I will just have to rely on my previous teachings and readings to get me through. I am hoping that after five weeks of these sorts of treatments I will have the techniques all sorted out, but the practical performance on a patient is something that is a bit of a concern to me currently.
Finally, I am very much hoping that I quickly develop a tolerance to the sputum, vomit and other bodily fluids/contents that I am sure I’ll be seeing quite a bit of on this placement. I’m fine with blood and have seen surgeries in the past and been fine, but I realised on my last placement that I’m not the best with some of the other secretions that we as physiotherapists are exposed to. It sounds pretty silly, but it is something I’m genuinely concerned about at this point in time. I’m going to have to train myself to toughen up and deal with it pretty quick, otherwise it’s going to be a long five weeks!
Despite these concerns, I am looking forward to getting this placement underway. From the information I have read from the facility and feedback from others this does seem like a good environment to be in as a student. I realise there is added expectations surrounding me as this is one of my final placements, but I’m sure I will be able to handle it and will perform well. I definitely intend to get as much as I possibly can out of this placement and hope I can enjoy it too.
Ready, Set, Go!
I am not entirely sure about the nature of this placement, because the orientation outline provided by the facility has suggested six different areas that I could possibly be involved with while on my cardiorespiratory placement. These are General Medical, General Surgical, Cardiothoracics, Intensive Care Unit, Ambulatory Care and Haematology and Oncology, certainly a wide variety of possibilities. No matter which area I am working in, I do expect it to be fast paced and at times hectic with the number of duties I will be expected to fulfil. In terms of placement structure, I have read from the orientation outline that Fremantle Hospital placements use a “peer-coaching model,” which I am assuming involves working pretty closely with another or other students that are also on placement. I am expecting that initially I will be working alongside another student and a supervisor, but as the placement progresses the degree of supervision will decrease as we become more familiar with the facility, then to the point where I will be operating without a partner. I expect that as time goes by my case load will increase as I become more proficient with my duties. I feel that there will also be greater expectations on me to be able to perform these duties effectively and efficiently and that despite being a student I should be a contributing member of the multidisciplinary team. I believe my role as a student will be to learn and progress my skills, knowledge and capabilities as much as possible, but also to be an effective team member and contribute as much as possible as I previously mentioned.
I mentioned at the beginning of my previous placement that I was concerned about my time management skills and I would have to admit I still feel the same way now. At Osborne Park Hospital I was given my daily timetable which had my patients sorted into allocated time slots and I just stuck to this as best as possible. Despite the convenience of this system, it didn’t really challenge my time management skills, which is why I am still a bit concerned about it heading to Fremantle Hospital. Particularly the patient prioritisation aspect of time management, which Shane has told us can be very difficult in this area, especially with a large case load, is something that I would like to discuss with my supervisor pretty early on in the placement, so that I am able to cope with the demands placed on me and be as efficient as possible.
Another concern of mine is my ability to perform some techniques and treatments that we have learnt about and practiced at uni but I have never performed on a patient. I am nervous about things such as percussion and vibrations, suctioning, mechanical ventilators and just the management and awareness of attachments like ICCs and different lines. I hope that with these treatments and other aspects that I will get some guidance from my supervisor when I am initially performing or administering them, but if not I will just have to rely on my previous teachings and readings to get me through. I am hoping that after five weeks of these sorts of treatments I will have the techniques all sorted out, but the practical performance on a patient is something that is a bit of a concern to me currently.
Finally, I am very much hoping that I quickly develop a tolerance to the sputum, vomit and other bodily fluids/contents that I am sure I’ll be seeing quite a bit of on this placement. I’m fine with blood and have seen surgeries in the past and been fine, but I realised on my last placement that I’m not the best with some of the other secretions that we as physiotherapists are exposed to. It sounds pretty silly, but it is something I’m genuinely concerned about at this point in time. I’m going to have to train myself to toughen up and deal with it pretty quick, otherwise it’s going to be a long five weeks!
Despite these concerns, I am looking forward to getting this placement underway. From the information I have read from the facility and feedback from others this does seem like a good environment to be in as a student. I realise there is added expectations surrounding me as this is one of my final placements, but I’m sure I will be able to handle it and will perform well. I definitely intend to get as much as I possibly can out of this placement and hope I can enjoy it too.
Ready, Set, Go!
Monday, April 26, 2010
Final Entry
Five weeks at Osborne Park Hospital on the stroke and general rehab ward are over and I’m pleased with my efforts over this time, but glad that it’s over. I found this placement to be a very beneficial one, as I predicted in my initial entry and feel that I’d be performing at a graduate level for working with stroke patients. I believe that most of my initial entry predictions were fairly true and I definitely started off pretty nervously, but I certainly grew into the position as time progressed and become more and more confident that I could handle the different scenarios that were thrown my way. I found I was able to call on my knowledge from PHTY 314 pretty well, although at times I was able to call on the knowledge but not able to put it to good use with my treatment, which I was disappointed in. My supervisor identified this as well, so I will definitely be making a greater effort in the future to know clinical implications or relevant treatment techniques for situations where I am able to identify specific abnormalities about a patient. Overall though, I was very pleased with how I performed on this placement.
My predictions about the nature of the placement were close to spot on, where I started off with a smaller case load and more supervision and progressed in the final weeks to a larger more complex case load with minimal supervision. For example, in my first week, I would see on average around 4 patients per day, consisting of 2 stroke unit and 2 general rehab patients. My stroke patients had all been on the ward for quite a while, but my tasks in the first week were to conduct initial assessments on them as if they were new admissions. This was also done with my supervisor present. By the end of the placement, I was generally seeing 3 or 4 stroke patients and 3 or 4 general rehab patients a day, plus attending up to 2 meetings a day, so my case load increased significantly, meaning that my time management skills had to improve as well, which they certainly did. In my final weeks, I was entrusted to perform initial assessments independently, which was a good indicator for me of my growth over the placement.
I had 2 supervisors for this placement, 1 for my stroke patients and 1 for my general rehab ones. Both made sure that my progress was tracked well along the guide for the placement that has been provided on blackboard. It was very well set out and focussed initially on assessment techniques, then on treatment techniques in the 2nd week and on improving and progressing these areas in the final weeks. This was shown by the SOAPIERs that I had to hand in at the completion of my first 2 weeks. The first was quite short and focussed more on the objective assessment and then analysis sections. While the second that I handed in was almost 3 times as long as it was much more detailed in the O and A, but also included a comprehensive plan, intervention and evaluation. My supervisors told me at this point that my growth and improvement were fitting in well with the placement guide and their expectations of me. One of the things that was very much consolidated in my mind during this placement was the importance of accurate assessment. I learnt that through a thorough and effective assessment you can easily identify what the patient needs help with, consequently making your treatment objectives very easy to identify. This is definitely something I will take forward with me into the future.
My prediction that I would feel like a part of the team as time progressed also turned out to be correct, which was demonstrated well in my final journal entry. It wasn’t just because I knew people’s name or that they knew mine by the end of the placement, it was the fact that I was able to make valuable contributions to the team, enabling better patient care for both my stroke and general rehab patients. The example I used in my third journal entry was a good one, where it was my confidence to feed my findings back to the medical team that enabled them to get a better understanding a patient’s thoughts and feelings and subsequently help manage her treatment the way she wished for it to be handled. Although on this occasion it wasn’t really a favourable outcome, as the patient essentially had decided to decline any further treatment, it was still a good lesson for the positives of an effective multidisciplinary team.
My initial concerns about starting a neuro placement were not a great issue in the end. As I previously mentioned, I felt I did well when recalling on required knowledge, but at times it was just the application of this knowledge that let me down. I didn’t really have any problems with my neuroanatomy because I found that an accurate assessment will outline your treatment goals irrespective of the anatomical site of damage in stroke patients. I also learnt that in a neuro setting, the patient will often have impairments that you as the physiotherapist cannot treat directly, but that we do have strategies that can help to reduce the implications of these impairments. For example, visual field defects, inattention, dysphasia and dyspraxia are all impairments that have considerable implications for providing treatment, but by identifying them, you can incorporate strategies into your general treatment to try reduce the impact of them. By being aware of them, you can use single commands for dyspraxia or encourage the patient to turn their head and be aware of the side where they may have visual defects or inattention. All of these things can be identified through simple assessment techniques, but play large parts in the structure and methods you use during treatment.
My final concerns about case load and time management, weren’t large issues in the end either. They both increased and improved pretty naturally as I became more confident and familiar in the environment and developed good routines. For example, many of my general rehab patients would be in pain before physio treatment, so if they were written up for pain relief medication then I would advise them to get some to enable rehab effective time with me. I learnt that by checking on the patient and their pain levels 20-30 minutes prior to your scheduled session time with them, you can get them to have the required relief and come back when it has begun to act. This minimises the amount of wasted time spent waiting for the patient’s pain levels to be manageable. In the time in between I could either see another patient or write up my notes. It was little things like this that I picked up over the duration of the placement that improved my time management.
The initial concern of supervision also proved to be something I need not have worried about. Both of my supervisors were always there to lend support whenever I needed it, but at the same time left me to be quite independent as soon as they felt I was capable. I mentioned previously that the level of supervision was initially very high, which was good while I found my feet, but then as time progressed I saw more and more patients on my own. I felt I handled these situations well, but was also able to call on assistance whenever I felt I needed it, which was good for my development as a student therapist.
At the end of the 5 weeks at Osborne Park Hospital I am pleased with my performance on the stroke ward, but I am also glad that it is over. I found it to be pretty challenging and a different environment and certainly different patients to what I was used to. At times I found it hard when I was seeing such little progress with my patients because of the extent of their impairments. I found it even harder when patients that had worked so well for an extended period of time, only to move backwards in terms of their rehab status. This was the case with one of my patients who was almost ready for discharge, when they had another stroke in my final week and subsequently were set back a long way. I suppose I just have to get used to difficulties such as this being present in areas of the physiotherapy and general health care line of work. It also continues to surprise me how tired I am at the end of a working week, but I am slowly getting used it. I will certainly enjoy some quieter time this week plus extra time to prepare for my next placement.
My predictions about the nature of the placement were close to spot on, where I started off with a smaller case load and more supervision and progressed in the final weeks to a larger more complex case load with minimal supervision. For example, in my first week, I would see on average around 4 patients per day, consisting of 2 stroke unit and 2 general rehab patients. My stroke patients had all been on the ward for quite a while, but my tasks in the first week were to conduct initial assessments on them as if they were new admissions. This was also done with my supervisor present. By the end of the placement, I was generally seeing 3 or 4 stroke patients and 3 or 4 general rehab patients a day, plus attending up to 2 meetings a day, so my case load increased significantly, meaning that my time management skills had to improve as well, which they certainly did. In my final weeks, I was entrusted to perform initial assessments independently, which was a good indicator for me of my growth over the placement.
I had 2 supervisors for this placement, 1 for my stroke patients and 1 for my general rehab ones. Both made sure that my progress was tracked well along the guide for the placement that has been provided on blackboard. It was very well set out and focussed initially on assessment techniques, then on treatment techniques in the 2nd week and on improving and progressing these areas in the final weeks. This was shown by the SOAPIERs that I had to hand in at the completion of my first 2 weeks. The first was quite short and focussed more on the objective assessment and then analysis sections. While the second that I handed in was almost 3 times as long as it was much more detailed in the O and A, but also included a comprehensive plan, intervention and evaluation. My supervisors told me at this point that my growth and improvement were fitting in well with the placement guide and their expectations of me. One of the things that was very much consolidated in my mind during this placement was the importance of accurate assessment. I learnt that through a thorough and effective assessment you can easily identify what the patient needs help with, consequently making your treatment objectives very easy to identify. This is definitely something I will take forward with me into the future.
My prediction that I would feel like a part of the team as time progressed also turned out to be correct, which was demonstrated well in my final journal entry. It wasn’t just because I knew people’s name or that they knew mine by the end of the placement, it was the fact that I was able to make valuable contributions to the team, enabling better patient care for both my stroke and general rehab patients. The example I used in my third journal entry was a good one, where it was my confidence to feed my findings back to the medical team that enabled them to get a better understanding a patient’s thoughts and feelings and subsequently help manage her treatment the way she wished for it to be handled. Although on this occasion it wasn’t really a favourable outcome, as the patient essentially had decided to decline any further treatment, it was still a good lesson for the positives of an effective multidisciplinary team.
My initial concerns about starting a neuro placement were not a great issue in the end. As I previously mentioned, I felt I did well when recalling on required knowledge, but at times it was just the application of this knowledge that let me down. I didn’t really have any problems with my neuroanatomy because I found that an accurate assessment will outline your treatment goals irrespective of the anatomical site of damage in stroke patients. I also learnt that in a neuro setting, the patient will often have impairments that you as the physiotherapist cannot treat directly, but that we do have strategies that can help to reduce the implications of these impairments. For example, visual field defects, inattention, dysphasia and dyspraxia are all impairments that have considerable implications for providing treatment, but by identifying them, you can incorporate strategies into your general treatment to try reduce the impact of them. By being aware of them, you can use single commands for dyspraxia or encourage the patient to turn their head and be aware of the side where they may have visual defects or inattention. All of these things can be identified through simple assessment techniques, but play large parts in the structure and methods you use during treatment.
My final concerns about case load and time management, weren’t large issues in the end either. They both increased and improved pretty naturally as I became more confident and familiar in the environment and developed good routines. For example, many of my general rehab patients would be in pain before physio treatment, so if they were written up for pain relief medication then I would advise them to get some to enable rehab effective time with me. I learnt that by checking on the patient and their pain levels 20-30 minutes prior to your scheduled session time with them, you can get them to have the required relief and come back when it has begun to act. This minimises the amount of wasted time spent waiting for the patient’s pain levels to be manageable. In the time in between I could either see another patient or write up my notes. It was little things like this that I picked up over the duration of the placement that improved my time management.
The initial concern of supervision also proved to be something I need not have worried about. Both of my supervisors were always there to lend support whenever I needed it, but at the same time left me to be quite independent as soon as they felt I was capable. I mentioned previously that the level of supervision was initially very high, which was good while I found my feet, but then as time progressed I saw more and more patients on my own. I felt I handled these situations well, but was also able to call on assistance whenever I felt I needed it, which was good for my development as a student therapist.
At the end of the 5 weeks at Osborne Park Hospital I am pleased with my performance on the stroke ward, but I am also glad that it is over. I found it to be pretty challenging and a different environment and certainly different patients to what I was used to. At times I found it hard when I was seeing such little progress with my patients because of the extent of their impairments. I found it even harder when patients that had worked so well for an extended period of time, only to move backwards in terms of their rehab status. This was the case with one of my patients who was almost ready for discharge, when they had another stroke in my final week and subsequently were set back a long way. I suppose I just have to get used to difficulties such as this being present in areas of the physiotherapy and general health care line of work. It also continues to surprise me how tired I am at the end of a working week, but I am slowly getting used it. I will certainly enjoy some quieter time this week plus extra time to prepare for my next placement.
Sunday, April 25, 2010
Entry 3 - Intervention (25/04/2010)
Situation: I had been treating a very elderly woman for about a week and a half, when out of no-where she refused physio treatment 2 days in a row. I thought this to be very strange as she was a very pleasant woman who had previously been so enthusiastic and always enjoyed her rehab physio sessions with me. The woman was at Osborne Park Hospital for ongoing rehabilitation following a left hemiarthroplasty, performed because of a fractured neck of femur (NOF) suffered from a fall outside her home. The first 2 days that the woman refused treatment I didn’t really think too much of it. On those days she reported feeling very tired which I didn’t feel was unreasonable as she’d had multiple investigations such as CT’s and X-rays on each of the days and told me she had slept poorly on each of the previous nights. After the second day I did have a quick chat with one of the members of the medical team regarding the investigations that were being performed, his response was that some of the patient’s symptoms such as her abdominal pain could have been linked to cancer, so they were investigating this further.
When I went to continue with the rehab the following day and the patient refused again, I wanted to look into this more, so asked some additional questions to ones from the previous days. During a lengthy discussion with the patient I discovered that the she had basically had enough, did not want any further treatment and just wanted to go home. She told me that she felt her “time was up,” referring to her life, suggesting that she didn’t feel she had much longer to live. She told me multiple times that she had “lived a good life” and as such was “happy to go.” She also explained to me that she felt she may go unconscious soon and if she did, she did not wish to be resuscitated. After the events of this conversation I knew I had to relay my findings back to the medical team.
Task: My ongoing task for this patient was to provide rehabilitation for her hemiarthroplasty to get her a point where she would be able and safe for discharge home from the hospital. She was living with her son at home and this was to be her planned discharge destination, so I had to get her to a state where she was independent with transfers and mobility so she could go home.
Action: After becoming aware of my patient’s thoughts and feelings, I was quick to assure her that the doctors and the whole team were doing their best to try and help with her pain and recovery. I explained that the tests that had been performed were necessary to try and ascertain what was causing her problems. I also reminded the patient of her sons and all the stories she had told me about them and asked her if they knew about her current state of mind and if so what they thought about it. She responded by saying that they were fully supportive of her decision, a response that I was not utterly convinced about, but nonetheless took on board. Apart from what I had already said and explained to the woman, I felt that I was out of my depth to say much more on the subject to her, so I headed straight to the doctor’s office to let them know about my conversation.
I explained to the team that was present all the events that had occurred prior to the conversation and exactly what was said during the conversation itself. The registrar said that they were aware of the patient’s low mood over the previous few days, but were not aware that the patient did not wish to be resuscitated in the event of an emergency. They thanked me for my findings and went straight in to have a further discussion with the patient about the matter.
When they had finished with the woman, they came back to me, thanked me again for my efforts and we had another lengthy discussion concerning the patient. In summary, the patient informed the team that she’d decided not to have any further investigations performed and that she wanted it officially put on the record that she was not to be resuscitated if it came down to it. They explained to me that their goal was to get the patient medically stable to enable her to be discharged home as she wished. Until then she was to remain in the hospital and I would still continue to be her treating physiotherapist. I was told, that I could try my absolute best to get her to do some rehabilitation exercises, but if she refused, then I had to respect this decision and there was nothing that they or I could do about it. I made sure that I documented precisely and thoroughly the events that had transpired, so that there was clear records of exactly what had happened over the previous few days.
Result: In my final week, I managed to get the woman to go for a short walk on just 2 occasions, but there was no additional rehabilitative therapy to go with these. She was still in a fair bit of pain and having bowel problems on my final day at the hospital and it had not been confirmed as to exactly why her symptoms were present. During the week I was trying most mornings and afternoons to get her to go for a walk or do some exercises and tried many different approaches, most to no avail. I tried saying that she may feel better after a walk, referred to the doctors saying they felt she may feel better, said that she could relax for the rest of the day after a walk or that she could sleep better if she does a bit of exercise. When it did come time for me to finish at the hospital she was still medically unstable and consequently was waiting to be discharged home.
Evaluation: I feel I did really good, learnt the importance of liasing with the whole team, although in this incidence it wasn’t the best outcome, I still learnt that its good to do it, coz u don’t know what u might get out of it, I strongly encouraged her to at least go for a walk with me if she wouldn’t go to the gym, but at the end of the day it was her decision and there wasn’t much that I could do about it
On reflection, I feel I acted appropriately under the circumstances and actually performed pretty well. The unfortunate part of the situation was that I couldn’t get the patient to attend physio treatment sessions as often as I would have hoped, but I feel that I did as well as I could to try and make this goal of rehab a reality. I learnt the importance of effective liaison with other members of the multidisciplinary team, which in this case were the doctors. I felt I showed I could be a responsible member of the team who had vital information to present and this was fully understood and acted upon by the doctors. I also felt that by going to them after the second day, to try get an understanding of the situation was a wise move as it prepared me well for the conversation that I had with the patient the following day, that resulted in me being able to abstract so much important information from the patient for the first time. By attending to the patient twice a day where possible it gave her every opportunity to come with me for her physical rehabilitation, which is why she was initially transferred to Osborne Park Hospital. At the end of the day, I left it up to the patient to decide if she wanted to participate or not, as per the medical team’s advice, however I felt I did all that I personally could to make this achievable. I was pleased with my performance, despite a less than desirable outcome for the patient personally.
Strategies: Above all, this situation taught me that I personally can contribute and be a valuable member of the multidisciplinary team, despite my status as a relatively inexperienced student therapist. I realise that I should have known I still play an important role in the team despite being a student, but this experience just proved to me more than anything that I do belong and do have worth in that environment, which was encouraging. By liaising with other members of the team so much, it also showed that I can learn a lot of important information from others, which will help me when treating my patients, but also that I can in turn provide information that can help others. In the future I will definitely be trying harder to get more out of the others members of the team, plus contribute by passing on what I know. I was also reminded of the fact that you can’t force a patient to engage in the treatment routine. It’s ultimately their choice and if they are refusing treatment, then you have to respect this decision and move on. I feel that giving my patient two opportunities per day was appropriate as it was important that she try to participate in rehab, however, spending any more time than this probably would have been a waste of my time. It really is important not to dwell on a patient who has refused treatment because you invariably have plenty of others who would appreciate your time and efforts much more. Finally, I discovered some new ways of trying to get a difficult patient to agree to treatment, both from my own accord and from my supervisor. These include the ones mentioned previously such as feeling better, doctors, sleeping better plus movement helping if needing to go to the toilet and multiple attempts in a day. None of which were particularly successful with this patient, but were on others that I treated during this placement and that I could see myself using in the future when encountering difficult patients.
When I went to continue with the rehab the following day and the patient refused again, I wanted to look into this more, so asked some additional questions to ones from the previous days. During a lengthy discussion with the patient I discovered that the she had basically had enough, did not want any further treatment and just wanted to go home. She told me that she felt her “time was up,” referring to her life, suggesting that she didn’t feel she had much longer to live. She told me multiple times that she had “lived a good life” and as such was “happy to go.” She also explained to me that she felt she may go unconscious soon and if she did, she did not wish to be resuscitated. After the events of this conversation I knew I had to relay my findings back to the medical team.
Task: My ongoing task for this patient was to provide rehabilitation for her hemiarthroplasty to get her a point where she would be able and safe for discharge home from the hospital. She was living with her son at home and this was to be her planned discharge destination, so I had to get her to a state where she was independent with transfers and mobility so she could go home.
Action: After becoming aware of my patient’s thoughts and feelings, I was quick to assure her that the doctors and the whole team were doing their best to try and help with her pain and recovery. I explained that the tests that had been performed were necessary to try and ascertain what was causing her problems. I also reminded the patient of her sons and all the stories she had told me about them and asked her if they knew about her current state of mind and if so what they thought about it. She responded by saying that they were fully supportive of her decision, a response that I was not utterly convinced about, but nonetheless took on board. Apart from what I had already said and explained to the woman, I felt that I was out of my depth to say much more on the subject to her, so I headed straight to the doctor’s office to let them know about my conversation.
I explained to the team that was present all the events that had occurred prior to the conversation and exactly what was said during the conversation itself. The registrar said that they were aware of the patient’s low mood over the previous few days, but were not aware that the patient did not wish to be resuscitated in the event of an emergency. They thanked me for my findings and went straight in to have a further discussion with the patient about the matter.
When they had finished with the woman, they came back to me, thanked me again for my efforts and we had another lengthy discussion concerning the patient. In summary, the patient informed the team that she’d decided not to have any further investigations performed and that she wanted it officially put on the record that she was not to be resuscitated if it came down to it. They explained to me that their goal was to get the patient medically stable to enable her to be discharged home as she wished. Until then she was to remain in the hospital and I would still continue to be her treating physiotherapist. I was told, that I could try my absolute best to get her to do some rehabilitation exercises, but if she refused, then I had to respect this decision and there was nothing that they or I could do about it. I made sure that I documented precisely and thoroughly the events that had transpired, so that there was clear records of exactly what had happened over the previous few days.
Result: In my final week, I managed to get the woman to go for a short walk on just 2 occasions, but there was no additional rehabilitative therapy to go with these. She was still in a fair bit of pain and having bowel problems on my final day at the hospital and it had not been confirmed as to exactly why her symptoms were present. During the week I was trying most mornings and afternoons to get her to go for a walk or do some exercises and tried many different approaches, most to no avail. I tried saying that she may feel better after a walk, referred to the doctors saying they felt she may feel better, said that she could relax for the rest of the day after a walk or that she could sleep better if she does a bit of exercise. When it did come time for me to finish at the hospital she was still medically unstable and consequently was waiting to be discharged home.
Evaluation: I feel I did really good, learnt the importance of liasing with the whole team, although in this incidence it wasn’t the best outcome, I still learnt that its good to do it, coz u don’t know what u might get out of it, I strongly encouraged her to at least go for a walk with me if she wouldn’t go to the gym, but at the end of the day it was her decision and there wasn’t much that I could do about it
On reflection, I feel I acted appropriately under the circumstances and actually performed pretty well. The unfortunate part of the situation was that I couldn’t get the patient to attend physio treatment sessions as often as I would have hoped, but I feel that I did as well as I could to try and make this goal of rehab a reality. I learnt the importance of effective liaison with other members of the multidisciplinary team, which in this case were the doctors. I felt I showed I could be a responsible member of the team who had vital information to present and this was fully understood and acted upon by the doctors. I also felt that by going to them after the second day, to try get an understanding of the situation was a wise move as it prepared me well for the conversation that I had with the patient the following day, that resulted in me being able to abstract so much important information from the patient for the first time. By attending to the patient twice a day where possible it gave her every opportunity to come with me for her physical rehabilitation, which is why she was initially transferred to Osborne Park Hospital. At the end of the day, I left it up to the patient to decide if she wanted to participate or not, as per the medical team’s advice, however I felt I did all that I personally could to make this achievable. I was pleased with my performance, despite a less than desirable outcome for the patient personally.
Strategies: Above all, this situation taught me that I personally can contribute and be a valuable member of the multidisciplinary team, despite my status as a relatively inexperienced student therapist. I realise that I should have known I still play an important role in the team despite being a student, but this experience just proved to me more than anything that I do belong and do have worth in that environment, which was encouraging. By liaising with other members of the team so much, it also showed that I can learn a lot of important information from others, which will help me when treating my patients, but also that I can in turn provide information that can help others. In the future I will definitely be trying harder to get more out of the others members of the team, plus contribute by passing on what I know. I was also reminded of the fact that you can’t force a patient to engage in the treatment routine. It’s ultimately their choice and if they are refusing treatment, then you have to respect this decision and move on. I feel that giving my patient two opportunities per day was appropriate as it was important that she try to participate in rehab, however, spending any more time than this probably would have been a waste of my time. It really is important not to dwell on a patient who has refused treatment because you invariably have plenty of others who would appreciate your time and efforts much more. Finally, I discovered some new ways of trying to get a difficult patient to agree to treatment, both from my own accord and from my supervisor. These include the ones mentioned previously such as feeling better, doctors, sleeping better plus movement helping if needing to go to the toilet and multiple attempts in a day. None of which were particularly successful with this patient, but were on others that I treated during this placement and that I could see myself using in the future when encountering difficult patients.
Sunday, April 11, 2010
Entry 2: Assessment (11/04/2010)
Situation: On Monday afternoon I was told by my supervisor that there was a new patient on the stroke ward. She told me I was to be his treating therapist and to start with an initial assessment. I had 2 hours until I would be seeing the new patient and I had two of my other patients that I had to see before then as well, which would leave me very little time to prepare. In the very brief amount of time that I did have to review the patient’s history, I found out that he had been transferred from Sir Charles Gardiner Hospital (SCGH) to Osborne Park Hospital over the weekend but had not yet received any physio treatment. I did have the patient’s SCGH notes that came over with the discharge, however it was missing many relevant and important sections, such as discharge documents and investigation results. I basically had the progress notes to skim over within a few minutes. From them, my main findings were that the man was very dysphasic, both receptive and expressive, and was dyspraxic too. I knew immediately that these would play a large part in how I went about conducting the assessment, because it becomes very difficult to conduct an assessment on someone with whom it is difficult communicating. This was to be my first initial stroke patient assessment and with the limited preparation time and a communication barrier looming, the lead up wasn’t ideal, however I still approached the situation with confidence and wanted to do a good job.
Task: My task was to perform the initial neurological assessment on this man with the aim of completing it in one session, and then to complete the necessary initial stroke outcome measures the following day. My supervisor would be present for the session, however I was told to conduct the assessment as if she was not there and that she would only have input if she felt I required it.
Action: When I arrived at the man’s room I was surprised to find that his mobility chart had already been filled out. As it turned out the weekend physio had completed this when the man was admitted over the weekend. He was written as ambulating without aids with a standby assist, so I introduced myself, explained what my plan was for the session and walked with him to the physio gym. Having been with the man for less than 5 minutes at this point, it was already evident to me the extent of the dysphasia and dyspraxia. The man’s only response to my questions was a yes or no answer and even these did not correlate appropriately with what the man was doing. This lack of response to many of my initial questions was a sign of the breakdown in communication ability. I very quickly learned that there was going to be no point in trying to get any kind of subjective history out of this man, because he simply could not communicate effectively. I began objectively assessing the man, with things such as his vision and cranial nerves. This again proved to be very difficult, but also time consuming and I had large questions over the validity of the results I was obtaining from the man. I began assessing things such as his volitional movement and range of motion using methods such as demonstrations and beginning the movements passively for the man, who could not comprehend what I wanted him to do. It got to the point where I had about 10 minutes to go of my 45 minute session and I was still looking at these same kinds of range of motion assessments. I then decided to turn to my supervisor to ask for her thoughts about the situation and how I should finish off. Her response was that I was doing well with what I had done thus far, especially with the use of demonstrations and passively moving the man to initiate movements to perform the assessment. She then went on to say that if I was to continue as I was then we would both be there until Friday afternoon trying to complete this initial assessment and advised me just to do what I could easily assess for now and then finish up. I took this on board and looked at tone, which is more of a therapist guided assessment, but then went onto functional abilities of rolling, supine to sit, transfers and eventually gait, all of which required demonstrations and heavy hands on guidance and facilitation to achieve the desired movements. This worked well and was much quicker as it was not relying on the man’s comprehension of the spoken word. It was for this reason that I abandoned testing things such as sensation, strength, cerebellar signs and balance, as I would not have obtained true results due to the patient not being able to understand my instructions for the testing. I was now out of time, and hoped that the man would be a bit better the following day when I would continue my neurological assessment.
Result: The result of my actions was that I had a very patchy-looking initial neurological assessment sheet when I had finished the session. I documented all that I had found, as best as I could in the notes, which again was difficult with the subjective history due to lack of transfer notes and the state of the patient himself. I did the best that I could with my documentation though, and left the assessment ready to come back to it the next day.
My session the following day with the man did turn out to be much better than the first. I was able to complete the majority of the assessments I had left from the previous day and also began with some outcome measures such as the Gowland and motor assessment scale. It was still very difficult however, to verbally communicate with the man, but I persevered as best I could. One thing that I did observe was a difference in many of the findings from the previous day, for example active and passive range of movements and some differences in posture. What this meant was that I had to alter some of my findings from the previous day in the notes, which I did under the objective heading in my SOAPIER. Although it took me about twice as long as it was supposed to, I achieved my task of performing the initial neurological assessment.
Evaluation: On reflection, I was quite dissatisfied with my performance, even under the circumstances. I felt that I was far too slow, which was both a product of having a difficult patient, but also a reflection of my ability to perform the different assessments. I found myself constantly having to stop and think about exactly what I wanted to do next with the assessment procedure, which proved to be costly in terms of time management. I felt that if I had have known some of the assessment techniques better, then it would not have taken me as long to complete the process. Despite this, I was happy with my decision to turn to my supervisor at the point when I did because it guided me in the right direction to finish off. I knew in my own mind that this was not a plea for help from my supervisor, but more a quick comment on how I was actually going and what I could do to be better. I hope that it came across this way and not as me struggling to cope with the situation. My thoughts about the performance were eased a little when my supervisor explained to me that it was a very hard patient to perform my first initial assessment on and complimented me on the effort that I did put in. However, I was still disappointed in myself as I felt it could have been done much better and more effectively, particularly on the first day, when things seemed to go so slow. I was glad to have the practice though and hopefully after having a difficult case first up, it will put me in good stead for my next new patient and if it is a difficult case again, then I will be all the more prepared.
Strategies: On reflection, I became aware of many new strategies from this experience. Strategies that were identified by both myself and my supervisor, but all of which I intend to utilise when assessing and treating in the future. The first of which is very important when assessing any population, but particularly stroke patients, is that of being very observant and in this case, the more informal observations. My supervisor and I had a lengthy discussion about this after my initial session, where she felt that many of the things that I was attempting to assess, but was having difficulty with due to dysphasia and other impairments, had actually been demonstrated by the man whilst he was doing other activities. She advised me that with good observational skills you can mark the patient down as having the ability to perform a certain skill or movement because you have seen them do it elsewhere, even if you have not formally assessed it. From this, I definitely intend to become more observant, and improve this very important skill of an effective therapist.
The next strategy was easy to identify because I had a fair bit of trouble with it initially and that is, knowing the tests, assessments and outcome measures well enough to execute them effectively and efficiently. I have found that knowing these well can increase your efficiency dramatically, as it means you can chop and change the assessment you are performing, according to the position that you currently have the patient in, minimising time wastage from constantly changing position.
Thirdly, I learnt that to get the desired response from the patient may require using a number of different communication methods. Due to this particular patient’s difficulty in comprehending what I was saying to him, I had to resort to demonstrations and hands on guidance and facilitation to initiate movements. For most people I will obviously have to use more verbal communication, but it is important to know that there are alternative methods such as the ones afore mentioned, as well as sensory, written, including written words and pictures plus videos or photos and sometimes more. Having these different methods of communicating and showing the patient what you want them to try and do means that you will be able to conduct a more comprehensive and effective assessment and get correct results.
Finally, from this particular situation, I learnt you can only ever do so much under particular circumstances. With this patient, there were still some parts of the assessment that my supervisor and I discussed and decided were not even worth doing due to the patient’s comprehension difficulty. In this instance, I was experiencing difficulty during the initial session, but I did what I could in the allotted time frame and then came back to continue the following day and thankfully things were slightly improved. I found that there was no point in getting flustered and worked up over the situation, because as I later discovered, you may be able to be more effective in future endeavours.
Task: My task was to perform the initial neurological assessment on this man with the aim of completing it in one session, and then to complete the necessary initial stroke outcome measures the following day. My supervisor would be present for the session, however I was told to conduct the assessment as if she was not there and that she would only have input if she felt I required it.
Action: When I arrived at the man’s room I was surprised to find that his mobility chart had already been filled out. As it turned out the weekend physio had completed this when the man was admitted over the weekend. He was written as ambulating without aids with a standby assist, so I introduced myself, explained what my plan was for the session and walked with him to the physio gym. Having been with the man for less than 5 minutes at this point, it was already evident to me the extent of the dysphasia and dyspraxia. The man’s only response to my questions was a yes or no answer and even these did not correlate appropriately with what the man was doing. This lack of response to many of my initial questions was a sign of the breakdown in communication ability. I very quickly learned that there was going to be no point in trying to get any kind of subjective history out of this man, because he simply could not communicate effectively. I began objectively assessing the man, with things such as his vision and cranial nerves. This again proved to be very difficult, but also time consuming and I had large questions over the validity of the results I was obtaining from the man. I began assessing things such as his volitional movement and range of motion using methods such as demonstrations and beginning the movements passively for the man, who could not comprehend what I wanted him to do. It got to the point where I had about 10 minutes to go of my 45 minute session and I was still looking at these same kinds of range of motion assessments. I then decided to turn to my supervisor to ask for her thoughts about the situation and how I should finish off. Her response was that I was doing well with what I had done thus far, especially with the use of demonstrations and passively moving the man to initiate movements to perform the assessment. She then went on to say that if I was to continue as I was then we would both be there until Friday afternoon trying to complete this initial assessment and advised me just to do what I could easily assess for now and then finish up. I took this on board and looked at tone, which is more of a therapist guided assessment, but then went onto functional abilities of rolling, supine to sit, transfers and eventually gait, all of which required demonstrations and heavy hands on guidance and facilitation to achieve the desired movements. This worked well and was much quicker as it was not relying on the man’s comprehension of the spoken word. It was for this reason that I abandoned testing things such as sensation, strength, cerebellar signs and balance, as I would not have obtained true results due to the patient not being able to understand my instructions for the testing. I was now out of time, and hoped that the man would be a bit better the following day when I would continue my neurological assessment.
Result: The result of my actions was that I had a very patchy-looking initial neurological assessment sheet when I had finished the session. I documented all that I had found, as best as I could in the notes, which again was difficult with the subjective history due to lack of transfer notes and the state of the patient himself. I did the best that I could with my documentation though, and left the assessment ready to come back to it the next day.
My session the following day with the man did turn out to be much better than the first. I was able to complete the majority of the assessments I had left from the previous day and also began with some outcome measures such as the Gowland and motor assessment scale. It was still very difficult however, to verbally communicate with the man, but I persevered as best I could. One thing that I did observe was a difference in many of the findings from the previous day, for example active and passive range of movements and some differences in posture. What this meant was that I had to alter some of my findings from the previous day in the notes, which I did under the objective heading in my SOAPIER. Although it took me about twice as long as it was supposed to, I achieved my task of performing the initial neurological assessment.
Evaluation: On reflection, I was quite dissatisfied with my performance, even under the circumstances. I felt that I was far too slow, which was both a product of having a difficult patient, but also a reflection of my ability to perform the different assessments. I found myself constantly having to stop and think about exactly what I wanted to do next with the assessment procedure, which proved to be costly in terms of time management. I felt that if I had have known some of the assessment techniques better, then it would not have taken me as long to complete the process. Despite this, I was happy with my decision to turn to my supervisor at the point when I did because it guided me in the right direction to finish off. I knew in my own mind that this was not a plea for help from my supervisor, but more a quick comment on how I was actually going and what I could do to be better. I hope that it came across this way and not as me struggling to cope with the situation. My thoughts about the performance were eased a little when my supervisor explained to me that it was a very hard patient to perform my first initial assessment on and complimented me on the effort that I did put in. However, I was still disappointed in myself as I felt it could have been done much better and more effectively, particularly on the first day, when things seemed to go so slow. I was glad to have the practice though and hopefully after having a difficult case first up, it will put me in good stead for my next new patient and if it is a difficult case again, then I will be all the more prepared.
Strategies: On reflection, I became aware of many new strategies from this experience. Strategies that were identified by both myself and my supervisor, but all of which I intend to utilise when assessing and treating in the future. The first of which is very important when assessing any population, but particularly stroke patients, is that of being very observant and in this case, the more informal observations. My supervisor and I had a lengthy discussion about this after my initial session, where she felt that many of the things that I was attempting to assess, but was having difficulty with due to dysphasia and other impairments, had actually been demonstrated by the man whilst he was doing other activities. She advised me that with good observational skills you can mark the patient down as having the ability to perform a certain skill or movement because you have seen them do it elsewhere, even if you have not formally assessed it. From this, I definitely intend to become more observant, and improve this very important skill of an effective therapist.
The next strategy was easy to identify because I had a fair bit of trouble with it initially and that is, knowing the tests, assessments and outcome measures well enough to execute them effectively and efficiently. I have found that knowing these well can increase your efficiency dramatically, as it means you can chop and change the assessment you are performing, according to the position that you currently have the patient in, minimising time wastage from constantly changing position.
Thirdly, I learnt that to get the desired response from the patient may require using a number of different communication methods. Due to this particular patient’s difficulty in comprehending what I was saying to him, I had to resort to demonstrations and hands on guidance and facilitation to initiate movements. For most people I will obviously have to use more verbal communication, but it is important to know that there are alternative methods such as the ones afore mentioned, as well as sensory, written, including written words and pictures plus videos or photos and sometimes more. Having these different methods of communicating and showing the patient what you want them to try and do means that you will be able to conduct a more comprehensive and effective assessment and get correct results.
Finally, from this particular situation, I learnt you can only ever do so much under particular circumstances. With this patient, there were still some parts of the assessment that my supervisor and I discussed and decided were not even worth doing due to the patient’s comprehension difficulty. In this instance, I was experiencing difficulty during the initial session, but I did what I could in the allotted time frame and then came back to continue the following day and thankfully things were slightly improved. I found that there was no point in getting flustered and worked up over the situation, because as I later discovered, you may be able to be more effective in future endeavours.
Sunday, March 28, 2010
Entry 1: Analysis and Planning
Situation: For this placement at Osborne Park Hospital I am on a stroke and general rehabilitation ward and have a mixture of both stroke patients and other rehabilitation type patients under my case load. On Monday I was given a handover sheet for the general rehab patients that I would be seeing that day and continuing on with their physiotherapy treatment. One of the patients was an elderly male who had a high anterior resection surgery performed approximately 3 weeks previous and had been on the ward at Osborne Park for about a week. From the handover and reading the notes I deduced that the man lived at home with his supportive wife, in a home with 2 sets of stairs, both with rails and that previously he was independent with all ADL’s and ambulating with a walking stick. Currently he was independent with all transfers and ambulating on the ward with a standby assist for both a wheeled zimmer frame (WZF) and with a walking stick for up to 60m. His treatment plan was to manage his chest, increase ambulation endurance, improve balance, be safe and independent with transfers and to increase strength. These were previously being targeted through deep breathing exercises, ambulation with both the WZF and walking stick, static and dynamic balance exercises, transfer education and practice and strength exercises including sit to stands and squats.
Task: My task was to take over the physiotherapy care of this patient and progress his treatment to get him to a functional level where he was confident and safe to be discharged back home.
Action: For the first day of the week I continued the treatment in a very similar fashion to what had previously been done, particularly with the ambulation practice, which consisted of a half and half mix of walking with the WZF and the walking stick. On reflection, I agreed with the standby assist status for ambulation with both aids as the man was having trouble with the steering and direction of the WZF and was generally a bit unsteady with his use of the walking stick. It wasn’t until a quick chat with the man after that first session that I realised that the current course of treatment was a bit odd, in terms of progressing to independent ambulation status by doing equal amounts of practice with each aid. This method was clearly showing some progress with both aids, but certainly very slowly for each and for a man who was crying out to be independent as he told me he was at home, this wasn’t targeting his immediate goals. I decided to change my plan of attack for this man’s ambulation, to focus more heavily on the WZF, whilst still practising with the walking stick, just not to the same degree. I ran this idea past my supervisor to get her thoughts first before implementing this plan and she agreed that it was a much better way of going about things for this man. In the subsequent sessions this week, I had the man walking to and from the physio gym with his WZF, each day taking a different route to get there to get him walking further and for longer. Once in the gym, the ambulation practice focused more on the walking stick along with his other exercises, but the spotlight was now definitely more focused on the WZF for ambulation.
Result: The result was a dramatic increase in the man’s ability to manoeuvre and manage ambulation with his WZF, whilst still maintaining progression and carry over with the walking stick. On Wednesday after our treatment session I granted the man independent status for going to and from his bed to the bathroom using his WZF, which he was very pleased about. I felt this was a good place to start by making him independent to the bathroom, but kept him with a standby assist for ambulation on the ward as I wasn’t yet confident he could handle longer distances on his own. By Friday however, after 2 extra days of practice with me, with even more focus on the longer distances I was confident that the man was now safe and capable of independent ambulation on the ward with the WZF. The patient was also more confident in his ability to manage on his own with the WZF, so I granted him full independent status for ambulation with the WZF.
Now that the man has achieved independent ambulation status with the WZF which was his short term goal, I can now focus more on progressing to the longer term goal of becoming independent with the walking stick and preparing for discharge. I had a discussion with my supervisor and the ward OT about a home visit for the man to prepare for discharge and the OT explained to me that now he has achieved this independent status with his WZF, that a home visit can now be arranged, whereas it previously could not because of his ambulation. This was another great positive to come out of the situation.
Evaluation: I feel I analysed the situation well and consequently a favourable outcome followed. I believe it was important to get the man who was previously so independent with all his daily activities back to a level where he at least had some level of independency and progressing his use of the WZF has enabled that. I hope that now the man has seen the excellent result he has achieved with the WZF, that he will be motivated to do the same with his ambulation with the walking stick. I also feel that it was a good idea to check with my supervisor at the time about my idea to progress the work with the WZF because I was only new to the facility and didn’t know what kind of protocols they had for ambulation aids. I believe that checking with my different supervisors throughout the year before acting is very important because of the fact that we know different facilities have different beliefs and systems in place for all sorts of treatment and assessment methods, so this is definitely something I will continue to do for the rest of the year and for years to come when I am at a new facility. After I had the discussion with my supervisor and got the all clear then the rest of the treatment progression seemed to fall into place very nicely, to the point where the man in now independent with all ambulation with the WZF.
Strategies: I feel the biggest things that I have learnt from this situation are the importance of viewing the patient holistically and of appropriate goal setting. By having the different goals in place to work towards, it meant that there was a logical progression and treatment outline for this man’s ambulation. In this instance it was the short term goal of independent ambulation, which was modified to purely relate to ambulation with the WZF which was identified and subsequently worked towards and achieved with effective treatment and practice of ambulation with this aid. Now that the short term ambulation goal has been achieved, we can begin working towards the longer term goals of independent ambulation with the walking stick and also towards getting this man home again, where he will be safe and manage on his own. The other point I make about viewing the person holistically was important in this case because I could see how desperate the man was to restore some independent function back to his life and by fast-tracking the use of the WZF we were able to achieve this. Thirdly, another point I have learnt about goals is that you can be working on and towards multiple goals at the same time. In this situation I had prioritised the time more towards the WZF ambulation, but didn’t completely discard the use of the walking stick, as it was used around the gym. In doing this, the short term goal was at the forefront of the treatment session aims, but I was still very much working towards the ultimate goal of home discharge, which could be achieved when the man is deemed safe and independent ambulating with his walking stick.
Task: My task was to take over the physiotherapy care of this patient and progress his treatment to get him to a functional level where he was confident and safe to be discharged back home.
Action: For the first day of the week I continued the treatment in a very similar fashion to what had previously been done, particularly with the ambulation practice, which consisted of a half and half mix of walking with the WZF and the walking stick. On reflection, I agreed with the standby assist status for ambulation with both aids as the man was having trouble with the steering and direction of the WZF and was generally a bit unsteady with his use of the walking stick. It wasn’t until a quick chat with the man after that first session that I realised that the current course of treatment was a bit odd, in terms of progressing to independent ambulation status by doing equal amounts of practice with each aid. This method was clearly showing some progress with both aids, but certainly very slowly for each and for a man who was crying out to be independent as he told me he was at home, this wasn’t targeting his immediate goals. I decided to change my plan of attack for this man’s ambulation, to focus more heavily on the WZF, whilst still practising with the walking stick, just not to the same degree. I ran this idea past my supervisor to get her thoughts first before implementing this plan and she agreed that it was a much better way of going about things for this man. In the subsequent sessions this week, I had the man walking to and from the physio gym with his WZF, each day taking a different route to get there to get him walking further and for longer. Once in the gym, the ambulation practice focused more on the walking stick along with his other exercises, but the spotlight was now definitely more focused on the WZF for ambulation.
Result: The result was a dramatic increase in the man’s ability to manoeuvre and manage ambulation with his WZF, whilst still maintaining progression and carry over with the walking stick. On Wednesday after our treatment session I granted the man independent status for going to and from his bed to the bathroom using his WZF, which he was very pleased about. I felt this was a good place to start by making him independent to the bathroom, but kept him with a standby assist for ambulation on the ward as I wasn’t yet confident he could handle longer distances on his own. By Friday however, after 2 extra days of practice with me, with even more focus on the longer distances I was confident that the man was now safe and capable of independent ambulation on the ward with the WZF. The patient was also more confident in his ability to manage on his own with the WZF, so I granted him full independent status for ambulation with the WZF.
Now that the man has achieved independent ambulation status with the WZF which was his short term goal, I can now focus more on progressing to the longer term goal of becoming independent with the walking stick and preparing for discharge. I had a discussion with my supervisor and the ward OT about a home visit for the man to prepare for discharge and the OT explained to me that now he has achieved this independent status with his WZF, that a home visit can now be arranged, whereas it previously could not because of his ambulation. This was another great positive to come out of the situation.
Evaluation: I feel I analysed the situation well and consequently a favourable outcome followed. I believe it was important to get the man who was previously so independent with all his daily activities back to a level where he at least had some level of independency and progressing his use of the WZF has enabled that. I hope that now the man has seen the excellent result he has achieved with the WZF, that he will be motivated to do the same with his ambulation with the walking stick. I also feel that it was a good idea to check with my supervisor at the time about my idea to progress the work with the WZF because I was only new to the facility and didn’t know what kind of protocols they had for ambulation aids. I believe that checking with my different supervisors throughout the year before acting is very important because of the fact that we know different facilities have different beliefs and systems in place for all sorts of treatment and assessment methods, so this is definitely something I will continue to do for the rest of the year and for years to come when I am at a new facility. After I had the discussion with my supervisor and got the all clear then the rest of the treatment progression seemed to fall into place very nicely, to the point where the man in now independent with all ambulation with the WZF.
Strategies: I feel the biggest things that I have learnt from this situation are the importance of viewing the patient holistically and of appropriate goal setting. By having the different goals in place to work towards, it meant that there was a logical progression and treatment outline for this man’s ambulation. In this instance it was the short term goal of independent ambulation, which was modified to purely relate to ambulation with the WZF which was identified and subsequently worked towards and achieved with effective treatment and practice of ambulation with this aid. Now that the short term ambulation goal has been achieved, we can begin working towards the longer term goals of independent ambulation with the walking stick and also towards getting this man home again, where he will be safe and manage on his own. The other point I make about viewing the person holistically was important in this case because I could see how desperate the man was to restore some independent function back to his life and by fast-tracking the use of the WZF we were able to achieve this. Thirdly, another point I have learnt about goals is that you can be working on and towards multiple goals at the same time. In this situation I had prioritised the time more towards the WZF ambulation, but didn’t completely discard the use of the walking stick, as it was used around the gym. In doing this, the short term goal was at the forefront of the treatment session aims, but I was still very much working towards the ultimate goal of home discharge, which could be achieved when the man is deemed safe and independent ambulating with his walking stick.
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