Final Entry

After completing this unit I feel great. I learned so much over the 5 weeks and I saw and experienced many new things. I got a much better understanding of dementia especially and how to handle people with moderate to severe dementia. I also got so much info and feedback from our supervisor who was very supportive and approachable over the whole time. My confidence also grew in meeting and interacting with new residents and also in the level of my patient handling skills.

I have leaned that in aged care, time limits and restrictions are not possible as each resident takes a different amount of time to do certain things. Ive also learned that in places like BF, it is actually the residents home and no matter how much you want them to give something a try, or know how much they need to do exercise, you cannot make them do exercise, it is their choice. I think it is this concept that the families of the residents also may not get.

Week Five- Case 3

Week Five- Thurday 13th November

We were on our final bus outing with 12 residents and during a tea and cakes a lady had a TIA. It was quite scary at the time as I had never actually seen one happen before. The 2 PTA's were there trying to get her attention and get her out of it. The main thing to avoid was her choking or blocking her airway so they held her head up from being stooped over while I tried to jeep her upright in her chair. She was breathing/gasping quite deeply and her hand/legs did tremor.

After about 10mins she finally came out of it which was when the RN from BF was on the phone. We got her standing up then back down, raising both arms up and gripping onto my hands as a base check to see if we still needed to get an ambulance. She was well enough to go back on the bus home.

I think the situation was handled well for what we were able to do. We protected her from further injury by stabiling her and removing any potential hazards (ie teeth). We were also able to stay relatively clam while we got the neccessary information from the RN over the phone. In a similar situation, I think they will now have a wheelchair on the bus just in case something similar or worse happens.

Week Five- Client 2

Week Five- Tuesday 11th November

This patient suffers from painful arthritis in her left hand. She gets pain all the time but especially inthe mornings. The physio department bought a wax bath while we were there and we thought that this lady should benefit from using the wax. She also was keen to come down and try it. After all the tests, warnings, explanations etc were given, she put her hand in and had a very exaggerated reaction to the heat, but as soon as her mind was taken off her hand she showed no symptoms of it being too hot.

I think that by distracting her from the hand we were able to see that it was just her mind that was causing her pain and that if was safe to continue treatment. In a similar case, we would probably do the same thing in trying to divert their attention away from the area being treated. The next day the same lady wanted to come back do it again saying that it wasnt that hot, her reaction the next time was defiently more appropriate and she had also just watched another resident have it done to them without any complaints!

Week 5- Client 1

Week Five- Monday 10th November

This patient is one who we have been seeing over our whole time at Bethanie. She suffered from a right side hemi-paresis, which has resulted in left side paralysis and also left side neglect. We noticed this becasue she would never respnd or look at the person who was standing on her left side.

We do stretches with the left arm of this patient. I think we do it well and always encourage her to do other exercises with her right hand to try and distract her from the stretch. To improve this treatment we could massage her left arm before doing the streches to try and improve the available ROM. When she looks particularly tight we do massage lightly.

Overall things have gone well today, we also did our end of unit assessment of a resident with Kate looking on and marking us. I think I did pretty well!

Week Four- Case 3

Week Four- Thursday 6^th November

Case 3

In the activity centre, there is a large plasma TV and a Nintendo Wii. The Wii is available for the residents to use but it is not used very often. The OT department are responsible for the machine and even they don’t know how to work all the parts of it. We went to our supervisor and asked what she thought about us trying to get it going in the group activity classes. She and the physio department really wanted to see it get up and going so we had full support from them to learn how to use it and then teach the residents.

I think we showed initiative in bringing up the idea and trying to get the residents to learn something new and fun. We spoke to the right people to make sure we weren’t stepping on anyone’s toes and organised appropriate times to practise. We then set up the game during an activity/games group and brought people over who we thought would be interested. By the end of the session we had 6 men around the TV who all had a go at playing one or all of the games.

The most successful sport was the boxing, this was because they didn’t have to press any buttons and the movements needed to box were fairly straight forward. Golf and tennis were the next easy to play and the hardest was ten pin bowling as it required timing while pressing/releasing buttons. To improve the group next time, we could try and get more people to come and even just watch other residents play. There is the social aspect as well in encouraging the people who are playing and congratulating and reacting to good or bad shots.

Week Four- Client 2

Week Four- Wednesday 5^th November

Client Two

I was a little concerned with the presentation of this patient. She was attending the open gym session and was on a circulation booster for her feet. Her left foot became very discoloured and was a deep purple colour. Her left side is also her affected side of her right hemi-paresis. Communication with this patient was also a little more difficult as she suffers from expressive aphasia. But she did indicate it was painful over her toes and around the heel.

I think I palpated the area well, I was very gentle and was really only seeing if the areas was hot which it wasn’t. I then suggested we just elevate the foot until the physio came and had a look. When we did this the colour went back to almost normal within 10seconds. As I hadn’t seen anything like this before, I was a little unsure of what to do next. The physio and registered nurse then came in and had a look, they too were unsure but just took her back to her room to elevate it. Later I saw the resident with a pressure stocking on but she still indicated it was sore and hadn’t got any better since we first noticed it in the morning.

In a similar case I would know to elevate the limb straight away to try and reduce the discolouration. I would then continue to manage the pain based on what the resident prefers ie heat/ice. This day has again been an interesting one. Seeing the resident with an unusual condition just makes you think a little more about what could possibly be the problem and how you can reduce the symptoms.

Week Four- Client 1

Week Four- Monday 3^rd November

Client One

This client was another resident who suffered from lymph oedema of her arm. As I had previously done a lymph oedema massage on a different patient I knew the technique which was required for it to be effective. I was fairly confident about meeting the resident but I knew her condition would be slightly different to the one I’d seen previously and would need to adjust my technique accordingly.

I think that I approached the resident well as I was told prior to seeing her that she doesn’t always respond well to change/new people. I made sure I knocked on her door, introduced myself clearly, asked her if she wouldn’t mind if I did her massage and reassured her that I had done this type of massage before. The PTA was also present to give me any feedback.

To possibly improve the session would be to put the residents arm in a more relaxed position ie use more pillows to prop it up or take her to a more comfortable chair so she can really relax during the treatment. I would also continue to check if the technique I was doing was one that she preferred.

Overall I think the day has gone well as I again got to see a different resident with an interesting condition. I can continue to practise and improve the massage technique for lymphatic drainage.

Week Three- Client 3

Week Three- Wednesday 29^th October

Client Three

This involved an assessment of a new patient who suffers from dementia and was very confused and anxious. We were with our supervisor as she hadn’t fully assessed this patient either. It took a lot of encouragement and reassurance to even get the patient to try and stand up. She had it in her mind that she couldn’t weight bare when in fact, when she was distracted in what she was doing, she walked approx 30m. We then attempted to do some of the Physical Mobility Scale with her. This proved very difficult as the resident had no idea how to initiate the movement.

In this situation I think we did well in facilitating the resident to do as much as she could. We explained as clearly as possible what we wanted her to do and how she could do it. We also provided her with the physical support if she needed it. To improve the performance, it would have been good to show her a demonstration of the desired movements, although this still may not have helped her to actually initiate the movement herself.

In a similar case we could break down the task even further or almost ‘trick’ them into doing the desired movement ie for the rolling, ‘can you reach for this with that hand’. Overall I think it was a successful day, even just to see her walking was good as usually she will refuse to stand let alone walk. Although it took a long time to do the assessment, in the end we were able to complete the full assessment form using her medical notes, the PMS scale and some ROM function tasks.

Week Three- Case 2

Week Three- Tuesday 28^th October

Case Two

Nicolle and I were asked to run the weekly “Stretch it Out” exercise class. I did the warm up and a fast song to get the blood pumping and Nicolle did deep breathing and read a relaxation story. I was fairly confident in the content and structure of the class as the movements and stretches were fairly common as easy for the residents to follow. I thought it was only one song for the warm up and one for the fitness but it was actually 2 for the warm up so I had rushed the exercises a little bit in the first song and then had to think on the spot a little for the second song. By the end of the 3 songs I had covered all movements that had been done in previous classes which was good!

I think I kept the class interested by changing the order of doing things, this meant they needed to watch and copy the movements I was doing. I also added different movements that they hadn’t done before so that would also have been good for them. I kept the class moving too because I know how doing too much of one thing can get boring.

To do better I could have checked before the class how many songs there were and how long they go for so I could evenly spread the workload and do even amounts on each part of the body (ie head and neck, upper limb, trunk, lower limb). Again I thought the day went well, we again were exposed to something new in taking the class by ourselves and I think we did pretty well and the group enjoyed it (we got a round of applause at the end)!

To improve my performance in future classes I can think of some extra relevant moves to add to the class. They would need to be easy to follow, functional but still need to be made fun and enjoyable and able to be applied to music.

Week Three- Client 1

Week Three- Monday 27^th October

Client One

I was looking forward to seeing this patient as she has lymph oedema of her left arm. This was a condition that I hadn’t seen before, so I was grateful to her for letting me watch the massage first and then let me have a go. After talking to her, she said that after the massage, she really notices a decrease in the swelling of her arm. I think this is proof that this lymph oedema massage is a beneficial form of intervention for her.

I think my massage technique was good, I used very light effleurage with lots of circular movements and worked more on the more swollen areas. I took on the suggestions from the PTA like starting to first break it down from the shoulder to the hand then really working all the fluid up from the fingers to the axilla. If I were to see this patient again I would need to make sure I use my time effectively ie spread the 30mins out evenly across the whole arm and don’t do one area too much or too little. I felt quite comfortable, mainly due to the resident being quite encouraging and also my previous experience in massage techniques.

In a similar case I would alternate more often between circular massage and gentle stroking massage. I could also ask the patient what kind of massage they prefer or what they think is most beneficial.

Today has gone quite well, we got through 8 of our 12 patients before 12noon! It’s good now that we know the residents routine as well as the physio program so we can work around both and know who will be free at certain times in the day. This allows us to cover more patients each day and still have time to see extra/interesting residents. To improve my performance I could do more practise of the lymph oedema massage to perfect my technique.

Week Two- Client 3

Week Two- Thursday 23^rd October

Client 3

This is patient we do regular gait practise with. She is very frail, always leans right over her frame and her voice is hardly a whisper! She is a good one to take for walks because although she doesn’t walk very far, we are maintaining the strength in her legs as well as preventing her functional mobility from declining.

When managing this patient we have to think a lot about our manutention training as she is much shorter than us plus she loves to lean over. We really have to think about where our bodies are and make sure that we too aren’t leaning over with her. What we do well is maintain our neutral spine while transferring and walking her but we also are trying to prompt her to stand tall and keep her neutral spine. Our hearing must also be in tip top shape to be able to hear what she is saying.

To improve this and other cases, before we stand the patient up, I could show her the posture that she has when she walks and demonstrate to her how to correct it. This will just make her a little bit more aware of what she is doing as she may not even realise how bad her back position actually is.

This was another good day, we are well into our routine and having to plan our day so we see all of our regular patients. Most of our patients need walking 3 times per week and there are a couple who need walking every day. We also help with all the groups run on different days.

To continue to improve I can focus on patient positioning during transfers and gait practise as well as the position of my body in relation to the patient.

Week Two- Client 2

Week Two- Tuesday 21^st October

Client 2

This situation was quite a slow and time consuming process. It involved a new resident who has dementia and she was telling the care staff that she couldn’t stand when in fact there was no sign or incidences that she couldn’t weight bear. It took a lot of chatting, a lot of encouragement and a relocation outside on the grass to get this lady to try to stand up. The physio was running the assessment as she was a new resident but from observing, it was very obvious that communication and compromise is the key when dealing with dementia patients.

This situation was managed very well. There was good, encouraging and communication between the PT and the resident and through that communication we were able to make adjustments to the environment to make the resident more at ease and comfortable with the situation. The main goal of this assessment was to see if in fact there was anything which was preventing her to stand. Once we got her outside we were able to easily confirm that there were no real problems once we adjusted her surroundings to suit her and she stood up with assistance and walked 3metres.

For a similar situation I would again spend the time talking to the resident first and getting as much information as possible about why they don’t think they can walk. I can then make any necessary adjustments to suite that individual. I would also give lots more encouragement to the resident about what they are able to achieve if they try.

Again this was a beneficial day in the way of seeing how an experienced physio deals with patients with dementia. I could see how much patience is required by the physio even to get the person to try and do what you need them to do. I can use this example to help improve my performance with other residents, especially in the way of the amount of time I may need to spend to get them to have a go.

Week Two- Client1

Week Two- Monday 20^th October

Client One

We were doing our routine visit to one of the residents who suffers from Parkinson’s disease. He does conditioning exercises in the chair, peddling with the foot pedals and sit to stand practice trying to incorporate weight shift. It seemed that he may have been getting a little bored with the exercises and I feel that he thinks he is more able than he actually is. He always asks to go walking in the parallel bars but he can only sometimes weight transfer efficiently. Communication with this resident is also quite difficult as he talks very softly and it’s very difficult to make out exactly what he is saying.

I think we managed the resident well, we tried to encourage him while making the exercises more fun. We also tried to challenge him a little bit when he was in standing to try and facilitate the shifting of his centre of mass from one foot to the other. One improvement I could make is to try and think of different kinds of conditioning exercises that he can do in his chair to prevent him from being bored. I can also try alternative ways to work on his lower limb strength. I can also improve on my listening skills when working with this resident.

In a similar case I would try to change the conditioning exercises every week, work on many aspects of fitness for the patient, (not just lower limb activities) and I would always finish with a functional task ie sit to stand, taking a couple of steps on the spot or moving if they’re able.

Overall I think the day went well. Our patients are always grateful for the time we spend with them and they really do try their hardest with a bit of encouragement. The main thing I can improve on in this situation is effective communication with the resident even if it means getting very close to hear what they are trying to say. I will also try to ‘change it up’ with all residents to keep them motivated and interested in exercising.

Week One- Client 3

Week One- Friday 17th October
1. This situation involved us going to take a lady for a walk, but once at her room, we found that she was busy so we said we'd come back later. When we did return she didnt want to come because she felt like she was made to do things that she didnt want to. I felt bad for assuming that she wanted to come for a walk with us. It was posssibly a lack of communication which meant that in the end this lady didnt go for a walk that day.

2. Things we did well was showing her general courtesy when first coming to her room we knocked on her door, and then only came into her room once we heard a reply. When we knew she was busy we said we can just come back later. Then when we returned we let her make the decision of what she wanted to do and accepted her decision.

3. Next time I would apoligise for catching her at a bad time and ask her if she wanted us to come back later in the day.

4. Overall the morning was quite productive, we got through our list of patients (10)with success/improvement in most of them.

5. I can continue to work on my communication skills and ways to really encourage the patients to want to walk for themselves, not just us because we are telling them to!

Week One- Client 2

Week One- Tuesday 14^th October

Client Two

1. 1. This patient is a double lower leg amputee

· Was initially walking with prosthesis, then gave up, but recently has decided he would like to walk again, this was the 3rd time he’d tried standing/walking with the PT in the past couple of weeks

· Decided to start him in the parallel bars, was a little wobbly but very confident

· Did 12 laps in parallel bars which was double what he had done the previous time

· Decided to progress further and he was also willing to have a go at the pulpit frame

· Gave clear instructions and a demo before he got up and gave it a go

· He walked out the physio room and to the front door (~20m) which he hadn’t done for approx 12 months

· If we started him on the frame earlier, he would most probably have walked a lot further (he was getting tired toward the end of the pulpit frame walk)

2. 2. Management of the patient was good, she possibly underestimated was he could actually achieve. We can now set more goals, most likely distance goals ie 30-40m etc. Eventually may progress to walking with a less supportive frame. Can also aid in building strength in the quads and hamstrings.

3. 3. I felt very comfortable again, there was 3 of us there to help with the frame and wheelchair and we were all there to reassure him. It was also good for the resident to have so much physical and verbal support around him

4. 4. To change this session, i would probably have challenged the resident from the start. I would still have started him in the parallel bars but probably have progressed him sooner to the pulpit frame to minimise fatigue while using the more unstable walking aid. I think it’s also important to believe in what the patient can do and show this belief through what you are asking them to do and how you are challenging them

5. 5. To improve from this situation, I could ask them resident first what they think they can do, and if it’s realistic, safe and if they want to try it, then progress them as soon as you can. I think I also have seen that challenging the patient will lead to better results, faster.

6. 6. Today was a more active and interesting day, we saw more patients and was also a little bit more hands on. Looking forward to when we get our own case load and can talk to and treat patients individually.

Week One- Client 1

Week One- Monday 13^th October

Client One

1. 1. This experience involved a client who was in an exercise class

· Class was about to start, we were collecting patients for the exercise class when a carer approached asking if one particular resident could join in , he suffers from Parkinsons Disease and apparently has been very bored and hardly has come out of his room. When he was taken for a walk the previous day, he dug his heels in when they returned because he didn’t want to go back into his room. She said he probably won’t do anything but the social interaction would be good for him

· He joined the class and was trying to do absolutely everything, the warm-up, theraband exercises, ball games and also kicking the ball

· I felt as though he wasn’t really given the opportunity to participate and it was only when someone else forced him in the room that we actually saw what he was able to do

· We now know we need to get this patient more involved, he clearly wanted to join in but may not have been given the opportunity previously

· In the future we now know we should always ask him if he would like to come and join in

2. 2. The first good thing was that we said to bring him in and let him sit in on the class and see what he wants to do. Once he started joining in, we were all applauding his efforts and encouraging him to do more. To improve his situation in this regard, we can invite him to all those exercises classes seeing as he enjoyed it so much. We could also be more personalised to him and see what other things he might be interested in doing. The main complication with this is that there is a communication barrier due to his condition.

3. 3. I felt very comfortable and confident in this group setting. Everyone was very friendly and I was able to participate in the exercises too. I was also able to give the residents encouragement as well as have a laugh and a joke and a chat with them. My background as a dance teacher also meant I was very comfortable in the group environment.

4. 4. In the group situation I could be more encouraging and active within the group. I could also speak up a little more and help the residents participate the best they can. Eventually I will probably either run the whole or part of the class

5. 5. To improve my performance, I could probably aim to have a chat with all the group members, help out with any extra things when needed and continue to encourage and praise the residents for coming out and doing some exercises.

6. 6. I think this first day has been very good as an overview of how this facility runs. We had a good orientation, tour and experienced some classes as well as watching a couple of individual treatments

Initial Entry

2. There is a very friendly environment between the physio, PTA's and other health professionals. They integrate all their knowledge so they dont double up and they get a very good overview of the resident in all areas. The communication between the PTA's and the physio is also very good, they have lists of people to get through, and they always report back to Kate with any changes and updates.

Pre-placement Entry

1. Thoughts and feelings before starting placement
At the moment, I am really exicted about starting my placement tomorrow. I've got all my bags packed and the pile of things to fit into my car is growing rapidly! After talking to one of the PTA's on Friday, I really started looking forward to going. She sounded really pleased to have us coming and was reassuring me on how much fun it will be! I think this gerontology based placement will also be good as a first placement for me, I find it relatively easy to understand and apply all our knowledge from Anne-Marie's labs. There will also hopefully be some interesting cases with the gero like orthopaedics and neuro. Now all I have to do is get down there!