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!