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.