I think most of the information I received about the placement was accurate regarding the structure, expectations and level of Independence so I was well prepared in that aspect. It was good that we started seeing patients on our own straight away as it pushed me to develop a lot faster, increased my confidence sooner and developed my communication, assessment and treatment skills more rapidly too. It also highlighted areas that I needed to work at home.
The expectations were made clear by the supervisor regarding a sound knowledge of anatomy, assessment and treatment techniques. They also encouraged me to clinically reason with each patient and to also keep an open mind to new concepts and ideas.
Being able to see our patients referral the previous day was a big help for me as it allowed me to brush up on that area and any techniques I was uncertain with. This then allowed me to be more confident when discussing the patient in the morning tutorials and later when I was actually seeing the patient.
My concern prior to the placement (re not knowing what exactly was wrong with the patient) was eliminated early on as our supervisor explained that you don't always need a diagnosis to be able to treat the patient well and see results. I then learned to use the following tips; 1) the simplest answer as to the reason of someones pain is often the right one 2) treat what you see 3) work from the outside in. These three guidelines helped me to simplify the problem and treat the most necessary things.
Saturday, July 24, 2010
Friday, July 23, 2010
Week Five Entry- Professional Behaviour/Communication
Situation:
49yr old female was referred to physio for low back pain. She presented to clinic with a very antalgic gait and posture. After the subjective history, it became clear that this lady had complex psychosocial issues going on. Her LBP started just after the death of her husband whom she had been a carer for the previous 4yrs. His care involved lots of heavy lifting and she reported having to lift him off the floor numerous times. She also has two sons. She has a 19yr old who has been diagnosed with mild autism. She also has a 13yr old who she suspects as ADHD and he is currently undergoing testing. The 13yr old has recently been skipping school. The patient has been contacted by the school and they have threatened to take her to court unless his attendance improves. The patient is also illiterate and has received no formal education (both her parents died when she was 2). She is incontinent of urine (urgency, stress and urge incontinence), has regular falls due to her knees giving way and she cannot get up off the floor so has to call for someone to help. She has recently noticed an increase in memory loss, she does not drive and she has no family in Australia.
Task:To provide an assessment and treat this patient, taking into consideration her psychosocial issues and her culture.
Action:
After the subjective assessment I continued with the objective, firstly looking at her posture. During the assessment I was able to place my hands on her with no complaint of pain and place a reasonable amount of pressure while palpating her thoracic and lumbar spine. I then went onto active movements. Every direction caused her pain and she was gasping, wincing, and jerking out of every movement. There was no difference in the type or intensity of the pain between the different movements. To have a closer look at her lower back I asked if she would move over to the plinth. She was then able to bend forward to pick up her bag from the floor and move it without any complaint of pain. She reported she could not lie prone so I did the assessment with the patient in sitting. This time when I placed my hand on her she again displayed non-organic pain behaviours and was wincing, gasping and jerking with only light touch. As I was not able to do any further testing I used this time to consult with my supervisor. He also agreed that this patient had huge psychological component contributing to her pain and that it too would need to be addressed. He also agreed that she should not be transferred to another student as this type of patient would benefit from consistency and would probably feel more comfortable with a senior staff member.
Result:
I returned to the patient and provided her with some reassurance and education about her back pain and the process involved to try and decrease the intensity of the pain. As no “hands on” treatment was appropriate in that session, I provided her with education regarding the use of heat over the area to help relax the muscles and reduce pain. I also explained to her that movement is good for the back and I encouraged her to increase the amount of movement she was doing with general, gentle exercises and stretches.
After this explanation the patient showed good understanding and her mood also seemed to improve. Her pain postures and abnormal gait pattern also was less obvious.
Evaluation:
I think I handled this complex patient well. I listened to what the patient had to say and documented important things but ensured I did not dramatise/catastrophise as this would only heighten the patients’ perception of pain. I maintained a holistic approach by discussing the involvement of social work/psychology with my supervisor. I also was culturally sensitive to the patient.
Strategies:
To continue managing complex patients well, I think I need to be confident in the information and education I am providing them. Also remembering to avoid over complicating the situation and initially just providing education and treating what I see in front of me.
49yr old female was referred to physio for low back pain. She presented to clinic with a very antalgic gait and posture. After the subjective history, it became clear that this lady had complex psychosocial issues going on. Her LBP started just after the death of her husband whom she had been a carer for the previous 4yrs. His care involved lots of heavy lifting and she reported having to lift him off the floor numerous times. She also has two sons. She has a 19yr old who has been diagnosed with mild autism. She also has a 13yr old who she suspects as ADHD and he is currently undergoing testing. The 13yr old has recently been skipping school. The patient has been contacted by the school and they have threatened to take her to court unless his attendance improves. The patient is also illiterate and has received no formal education (both her parents died when she was 2). She is incontinent of urine (urgency, stress and urge incontinence), has regular falls due to her knees giving way and she cannot get up off the floor so has to call for someone to help. She has recently noticed an increase in memory loss, she does not drive and she has no family in Australia.
Task:To provide an assessment and treat this patient, taking into consideration her psychosocial issues and her culture.
Action:
After the subjective assessment I continued with the objective, firstly looking at her posture. During the assessment I was able to place my hands on her with no complaint of pain and place a reasonable amount of pressure while palpating her thoracic and lumbar spine. I then went onto active movements. Every direction caused her pain and she was gasping, wincing, and jerking out of every movement. There was no difference in the type or intensity of the pain between the different movements. To have a closer look at her lower back I asked if she would move over to the plinth. She was then able to bend forward to pick up her bag from the floor and move it without any complaint of pain. She reported she could not lie prone so I did the assessment with the patient in sitting. This time when I placed my hand on her she again displayed non-organic pain behaviours and was wincing, gasping and jerking with only light touch. As I was not able to do any further testing I used this time to consult with my supervisor. He also agreed that this patient had huge psychological component contributing to her pain and that it too would need to be addressed. He also agreed that she should not be transferred to another student as this type of patient would benefit from consistency and would probably feel more comfortable with a senior staff member.
Result:
I returned to the patient and provided her with some reassurance and education about her back pain and the process involved to try and decrease the intensity of the pain. As no “hands on” treatment was appropriate in that session, I provided her with education regarding the use of heat over the area to help relax the muscles and reduce pain. I also explained to her that movement is good for the back and I encouraged her to increase the amount of movement she was doing with general, gentle exercises and stretches.
After this explanation the patient showed good understanding and her mood also seemed to improve. Her pain postures and abnormal gait pattern also was less obvious.
Evaluation:
I think I handled this complex patient well. I listened to what the patient had to say and documented important things but ensured I did not dramatise/catastrophise as this would only heighten the patients’ perception of pain. I maintained a holistic approach by discussing the involvement of social work/psychology with my supervisor. I also was culturally sensitive to the patient.
Strategies:
To continue managing complex patients well, I think I need to be confident in the information and education I am providing them. Also remembering to avoid over complicating the situation and initially just providing education and treating what I see in front of me.
Sunday, July 4, 2010
Week Three Entry- Intervention
Situation:
79 year old male presented with right shoulder pain which was anterior and lateral in its distribution. Onset was insidious starting approximately 6 weeks ago with no identified cause. Aggravating factors included his right arm resting on an armchair/table and also lying on his left side at night. The problem was mildly irritable. On objective examination, the patient had full range of motion in all directions with no pain. Speed's test and Neer's test provoked a small amount of pain. Palpation of the long head of biceps and the insertion of deltoid was tender and reproduced his pain.
Task:
To provide the patient with appropriate information and education regarding his condition and ways he can manage it at home. Also to provide effective, hands on treatment during this session with the patient.
Action:
I provided the patient with education regarding the possible inflammatory process going on. I also gave him a home exercise program consisting of the use of heat/ice as well as some general range of motion and postural exercises. I also treated his tender areas with ultrasound with settings of continuous, 1MHz, 6mins, 0.5-1.0Wcm.
79 year old male presented with right shoulder pain which was anterior and lateral in its distribution. Onset was insidious starting approximately 6 weeks ago with no identified cause. Aggravating factors included his right arm resting on an armchair/table and also lying on his left side at night. The problem was mildly irritable. On objective examination, the patient had full range of motion in all directions with no pain. Speed's test and Neer's test provoked a small amount of pain. Palpation of the long head of biceps and the insertion of deltoid was tender and reproduced his pain.
Task:
To provide the patient with appropriate information and education regarding his condition and ways he can manage it at home. Also to provide effective, hands on treatment during this session with the patient.
Action:
I provided the patient with education regarding the possible inflammatory process going on. I also gave him a home exercise program consisting of the use of heat/ice as well as some general range of motion and postural exercises. I also treated his tender areas with ultrasound with settings of continuous, 1MHz, 6mins, 0.5-1.0Wcm.
Friday, June 25, 2010
Week One Entry- Assessment
Situation:
I was transferred a patient from another student to continue the care of an 82 year old male who recently had a fall. He had slipped and fallen directly onto his right knee. On initial assessment by the previous student, he had 0-8/10 intermittent pain at the right posterior knee and 0-6/10 intermittent pain at the anterior knee. Aggravating factors included getting into and out of the car, getting out of bed, prolonged sitting >15 mins and putting on shoes. Easing factors included walking, movement of the knee, lying down and self massage. It was also observed that at his last visit he had bilateral swelling at both of his ankles.
Task:
To continue to provide a thorough and holistic assessment of this patient and to then provide appropriate treatment for what his current presentation is.
Action:
After subjective questioning, it became clear that the patient thought his overall pain levels had decreased. He had been compliant with his home exercise program and also noticed improvements in his knee flexion range. The patient also raised some concern about the swelling in his lower limbs. On observation, it was evident that his entire lower limb (up to his knee) was swollen. The patient described his leg as painful, tight and heavy. To look at the skin was very shiny and tight and on palpation it was slightly warmer than the left leg and there was obvious pitting oedema. I then assessed pain levels of calf palpation as well as passive dorsiflexion. After a few other muscle length/strength tests I went to consult with my supervisor of my findings.
Result:
Due to my objective assessment, I was able to identify to my supervisor potential red flags this patient might have. First of all I thought about some kind of inflammation (hot and swollen areas) process occuring. I then thought about the possibility of a DVT. This was a potential cause but the testing I had already done had reduced the likelihood of that ie: no tenderness of gastroc/soleus and no pain on passive dorsiflexion (therefore -ve Homan's sign). Cellulitis was another possible differential diagnosis. My supervisor decided to come and have a look with me. To help manage the swelling I suggested using some tubigrip which my supervisor agreed that it could be of help. He also recommended that the patient go and see his doctor about this sudden increase in swelling. I then also suggested that I could take circumferential measurements of the foot, ankle and calf as an objective measure to use as a comparison when the patient returned in a weeks time. My supervisor also agreed that the measures would be beneficial.
Evaluation:
I think I did well in this assessment as I listened to the patients current concerns and then examined the area very closely. Also knowing the signs and sypmtoms of potentially more serious problems allowed me to do a thorough examination of the area. This previous knowledge of the signs and symptoms of DVT and the tests to assess (Homan's sign) came mainly from my previous cardio and neuro placements. Also, knowing how to do sa tandardised measure of the calf circumference was from doing lymphoedema measurements at my women's health placement. I think this really shows that you can't divide physio into certain categories (cardio, neuro, WH etc) as there will always be a case where crossover occurs and you will need to know various assessments from all the specialties.
Strategies:
From this I have learned that you aren't providing the best care for your patients if you have "tunnel vision" and are too musculo focussed. To try and avoid this happening in the future I will endevour to keep an open mind when doing assessments and be sure to integrate all aspects of physio in my assessments.
I was transferred a patient from another student to continue the care of an 82 year old male who recently had a fall. He had slipped and fallen directly onto his right knee. On initial assessment by the previous student, he had 0-8/10 intermittent pain at the right posterior knee and 0-6/10 intermittent pain at the anterior knee. Aggravating factors included getting into and out of the car, getting out of bed, prolonged sitting >15 mins and putting on shoes. Easing factors included walking, movement of the knee, lying down and self massage. It was also observed that at his last visit he had bilateral swelling at both of his ankles.
Task:
To continue to provide a thorough and holistic assessment of this patient and to then provide appropriate treatment for what his current presentation is.
Action:
After subjective questioning, it became clear that the patient thought his overall pain levels had decreased. He had been compliant with his home exercise program and also noticed improvements in his knee flexion range. The patient also raised some concern about the swelling in his lower limbs. On observation, it was evident that his entire lower limb (up to his knee) was swollen. The patient described his leg as painful, tight and heavy. To look at the skin was very shiny and tight and on palpation it was slightly warmer than the left leg and there was obvious pitting oedema. I then assessed pain levels of calf palpation as well as passive dorsiflexion. After a few other muscle length/strength tests I went to consult with my supervisor of my findings.
Result:
Due to my objective assessment, I was able to identify to my supervisor potential red flags this patient might have. First of all I thought about some kind of inflammation (hot and swollen areas) process occuring. I then thought about the possibility of a DVT. This was a potential cause but the testing I had already done had reduced the likelihood of that ie: no tenderness of gastroc/soleus and no pain on passive dorsiflexion (therefore -ve Homan's sign). Cellulitis was another possible differential diagnosis. My supervisor decided to come and have a look with me. To help manage the swelling I suggested using some tubigrip which my supervisor agreed that it could be of help. He also recommended that the patient go and see his doctor about this sudden increase in swelling. I then also suggested that I could take circumferential measurements of the foot, ankle and calf as an objective measure to use as a comparison when the patient returned in a weeks time. My supervisor also agreed that the measures would be beneficial.
Evaluation:
I think I did well in this assessment as I listened to the patients current concerns and then examined the area very closely. Also knowing the signs and sypmtoms of potentially more serious problems allowed me to do a thorough examination of the area. This previous knowledge of the signs and symptoms of DVT and the tests to assess (Homan's sign) came mainly from my previous cardio and neuro placements. Also, knowing how to do sa tandardised measure of the calf circumference was from doing lymphoedema measurements at my women's health placement. I think this really shows that you can't divide physio into certain categories (cardio, neuro, WH etc) as there will always be a case where crossover occurs and you will need to know various assessments from all the specialties.
Strategies:
From this I have learned that you aren't providing the best care for your patients if you have "tunnel vision" and are too musculo focussed. To try and avoid this happening in the future I will endevour to keep an open mind when doing assessments and be sure to integrate all aspects of physio in my assessments.
Sunday, June 20, 2010
Initial Entry- 4th Placement 2010
I'm quite excited about starting this placement tomorrow. I'm not sure if it's because of the musculo-skeletal outpatients facility or the fact that it is the start of our last rotation for the year!
I think the structure of this placement will be slightly different to my previous 3, in that there is much more independence expected from students from day 1. After speaking to other students and the facility supervisor, I know I will be seeing patients on my own tomorrow morning, whereas in all my other placements the first day was more orientation and we may have sat in on a treatment session to observe. This is a little bit daunting but I feel as though my previous placements have helped me build confidence in communicating with patients and other staff. So I don't think I'm as nervous now as what I might have been if this was my first rotation back in February.
From the information package that this facility had sent out, it appears they have set expectations of students to be well prepared for this placement in the way of theory, assessment and treatment techniques. I think this is an essential request as it will also facilitate us to get the most out of the placement and enable us to progress beyond the basics which we have learnt at university. I'm sure it will become obvious in the first few days if I have met the expectation and prepared well enough!
Another advantage of this placement (and all outpatient departments) is that I will know what patients I am seeing the day before their appointment. I think this will suit my style of learning really well because I can go home the night before and cover anything may be unsure of and I can also plan various possible treatments. This is just another aspect of being prepared which I feel will help give me more confidence when I'm actually with the patient.
If I had to pick out a concern I have, it would probably be coming out of a subjective history and not knowing what is happening with the patient. What reassures this concern is that the facility has already said that there may be some conditions that pop up which may be new to us and we won't know the answers. It's in that situation where the senior physio will be able to provide that extra bit of guidance and assistance in helping me work out the problems.
Overall, I'm ready excited to get this placement started... the countdown has begun!
I think the structure of this placement will be slightly different to my previous 3, in that there is much more independence expected from students from day 1. After speaking to other students and the facility supervisor, I know I will be seeing patients on my own tomorrow morning, whereas in all my other placements the first day was more orientation and we may have sat in on a treatment session to observe. This is a little bit daunting but I feel as though my previous placements have helped me build confidence in communicating with patients and other staff. So I don't think I'm as nervous now as what I might have been if this was my first rotation back in February.
From the information package that this facility had sent out, it appears they have set expectations of students to be well prepared for this placement in the way of theory, assessment and treatment techniques. I think this is an essential request as it will also facilitate us to get the most out of the placement and enable us to progress beyond the basics which we have learnt at university. I'm sure it will become obvious in the first few days if I have met the expectation and prepared well enough!
Another advantage of this placement (and all outpatient departments) is that I will know what patients I am seeing the day before their appointment. I think this will suit my style of learning really well because I can go home the night before and cover anything may be unsure of and I can also plan various possible treatments. This is just another aspect of being prepared which I feel will help give me more confidence when I'm actually with the patient.
If I had to pick out a concern I have, it would probably be coming out of a subjective history and not knowing what is happening with the patient. What reassures this concern is that the facility has already said that there may be some conditions that pop up which may be new to us and we won't know the answers. It's in that situation where the senior physio will be able to provide that extra bit of guidance and assistance in helping me work out the problems.
Overall, I'm ready excited to get this placement started... the countdown has begun!
Sunday, June 13, 2010
Final Entry- 3rd Placement
This placement definitely lived up to my expectations. I was exposed to a whole variety of things which has allowed me to get a good grasp of all the things women's health incorporates as well as some aspects of what the paediatric physios do too.
The lecture material from uni was a good basis to start from, but as I expected most of the information was taught at KEMH and picked up along the way. I got so much out of the tutorials and really valued the time that I had with the tutors. I was especially grateful for the time I spent with the uro-gynae consultants. I sat in on their appointments in the clinic as well as watching multiple surgeries and also observing urodynamics. Having this extra exposure really helped me develop the bigger picture for these patients we were seeing on the ward and in outpatients.
A basic level of understanding was expected from my supervisors but it was obvious that a lot of this information was new to us. In that respect they were always willing to explain or elaborate on anything which was new to me or that I may not have fully understood.
Overall, I feel that I have learnt a lot on this placement and that this experience may have steered me in the direction of wanting to pursue a career in the women's health field!
The lecture material from uni was a good basis to start from, but as I expected most of the information was taught at KEMH and picked up along the way. I got so much out of the tutorials and really valued the time that I had with the tutors. I was especially grateful for the time I spent with the uro-gynae consultants. I sat in on their appointments in the clinic as well as watching multiple surgeries and also observing urodynamics. Having this extra exposure really helped me develop the bigger picture for these patients we were seeing on the ward and in outpatients.
A basic level of understanding was expected from my supervisors but it was obvious that a lot of this information was new to us. In that respect they were always willing to explain or elaborate on anything which was new to me or that I may not have fully understood.
Overall, I feel that I have learnt a lot on this placement and that this experience may have steered me in the direction of wanting to pursue a career in the women's health field!
Week 5 Entry- Professional Behaviour
Situation:
63 year old female patient was booked to undergo urodynamic tests. Her history included urgency, urge incontinence, recurrent UTI's and dysuria. This patient was very anxious about having the tests done and also was very emotional about her current symptoms. She was clearly distressed about the whole situation and she was overwhelmed with the number/size of machines in the room as well as the number of people in the room. Throughout the process (catheters being inserted, bladder inflated) she became more and more emotional and distressed. She also found it extremely difficult to hold in large volumes during the testing so leakage was also occurring.
Task:
To maintain professional behaviour during the testing while also demonstrating sympathy and understanding for the patient.
Action:
After the testing was complete, I was asked to escort the patient to the uro-gynae clinic where she would wait for the consultant to discuss with her what the test results showed. The patient was still quite emotional at this time so I tried to explain some of the mechanisms behind what was actually causing her bladder to "misbehave". This gave the patient a better understanding of the reasons of why she was experiencing her symptoms. I tried to reassure her in that it is quite a common problem amongst older females and that many people are going through the same thing she is. The last thing I talked about before the consultant arrived was some simple strategies (bladder calming techniques) which she could use to help control her symptoms and hopefully avoid any accidents occurring in public places.
Results:
I think that I was able to use my position as a student to show this patient extra sympathy and understanding which helped her calm down. Once she had settled and was telling me more information I was also able to provide her with some education about her problems which she didn't seem to have received previously. She seemed very grateful for the time I had spent with her and the information I had provided.
Evaluation:
I think that I showed a good level of professionalism throughout the situation as well as demonstrating good communication skills in dealing with this complex patient. I was able to sympathise with her, which aided in calming her down, which allowed her to take in some extra information which could potentially improve her symptoms in the community.
Strategies:
To improve in the future, I could possibly be more specific about the facts related to the situation ie have a better idea of the proportion of women this can affect, the percentage of woman whose symptoms improve etc. This would just provide a little bit more reassurance and possibly some hope for the patient in that many people do improve and they too can improve and live a normal life.
63 year old female patient was booked to undergo urodynamic tests. Her history included urgency, urge incontinence, recurrent UTI's and dysuria. This patient was very anxious about having the tests done and also was very emotional about her current symptoms. She was clearly distressed about the whole situation and she was overwhelmed with the number/size of machines in the room as well as the number of people in the room. Throughout the process (catheters being inserted, bladder inflated) she became more and more emotional and distressed. She also found it extremely difficult to hold in large volumes during the testing so leakage was also occurring.
Task:
To maintain professional behaviour during the testing while also demonstrating sympathy and understanding for the patient.
Action:
After the testing was complete, I was asked to escort the patient to the uro-gynae clinic where she would wait for the consultant to discuss with her what the test results showed. The patient was still quite emotional at this time so I tried to explain some of the mechanisms behind what was actually causing her bladder to "misbehave". This gave the patient a better understanding of the reasons of why she was experiencing her symptoms. I tried to reassure her in that it is quite a common problem amongst older females and that many people are going through the same thing she is. The last thing I talked about before the consultant arrived was some simple strategies (bladder calming techniques) which she could use to help control her symptoms and hopefully avoid any accidents occurring in public places.
Results:
I think that I was able to use my position as a student to show this patient extra sympathy and understanding which helped her calm down. Once she had settled and was telling me more information I was also able to provide her with some education about her problems which she didn't seem to have received previously. She seemed very grateful for the time I had spent with her and the information I had provided.
Evaluation:
I think that I showed a good level of professionalism throughout the situation as well as demonstrating good communication skills in dealing with this complex patient. I was able to sympathise with her, which aided in calming her down, which allowed her to take in some extra information which could potentially improve her symptoms in the community.
Strategies:
To improve in the future, I could possibly be more specific about the facts related to the situation ie have a better idea of the proportion of women this can affect, the percentage of woman whose symptoms improve etc. This would just provide a little bit more reassurance and possibly some hope for the patient in that many people do improve and they too can improve and live a normal life.
Saturday, May 29, 2010
Week Two Entry- Treatment
Situation:
We had been referred to see a 25year old lady who had given birth to a 3.5kg baby the day before. Her 2nd stage of labour was 1.5hrs and her only form of pain relief during the labour was nitrous oxide. She had a medio-lateral episiotomy which extended into a 3rd degree tear. The patient reports the area is a little uncomfortable but has had no pain. However she has also been given regular analgesics. On examination, the area appeared very red and bruised. She also had huge amounts of swelling on the left side more than the right. The area was quite moist and she had been using ice on the area regularly.
Task:
To provide the patient with indicated and appropriate treatment as well as provide her with some basic education and advice for the next couple of days.
Action:
The decided form of treatment was therapeutic ultrasound in the attempt to reduce swelling and reduce any pain/discomfort. Written and verbal consent was gained from the patient. First we set up the parameters on the ultrasound machine, Intensity: 0.8W/cm, Frequency: 3MHz Time:15mins. Gloves were then applied before touching the ultrasound head. A small amount of gel was placed in the tip of the condom, which was then placed over the ultrasound head. More gel was then applied on top of the condom. The treatment was started firstly with the patient in crook lying. As she also had a 3rd degree tear, we treated the patient in side lying to allow better access to the more posterior areas. In this position it became evident that she had 3 large haemorrhoid's which also indicated treatment. We added an extra 10mins to the treatment time to account for the extra area covered. Once were had started treating the posterior areas, we made sure we didn't go back to the front regions to prevent any infections.
Results:
It is difficult to determine the results of my treatment as ultrasound doesn't produce immediate effects. It would be good to see the patient again the following day to reassess the amount of swelling, redness and if her pain levels had altered from the day before. Also by asking the patient what they feel about the effectiveness of the ultrasound could be a good indicator of the percieved benefits for the patient.
Evaluation:
I think the infection control and hygiene was well managed throughout, ensuring there was no cross contamination of the equipment which had been in contact with the patient. Good time management was also demonstrated as we were providing the patient with post-natal education and advice while we were treating the perineum. Information and advice (such as RICE) was also provided so the patient can be doing things regularly herself to help with the healing process. This encourages a more active approach to treatment rather than solely the passive ultrasound treatment. In the future I think I need to improve the time it take to set up the machine and the parameters. I need to do this while continuing to maintain a clean and hygienic area.
Strategies:
The main way I'm going to improve on my handling skils and timing of the technique is through practise. The more familiar I am with the order of processing, the quicker I will be able to set up and start the treatment.
Sunday, May 16, 2010
Week One Entry- Communication
Situation:
My patient was a 45 year old female who was day 2 post-op. She had an Anterior Vaginal Repair to fix a cystocele. This particular lady was overweight and also suffered from arthritis and chronic low back pain. She has a husband and two sons who live with her in the Helena Valley. She works as an Avon Sales Representative but has leave for 6 weeks.
Task:
My task was to provide this lady with comprehensive post-op education and advice before she returns home.
Action:
As this was the first time I had seen this lady I introduced myself and my supervisor and let her know why we were there to see her. I also had a handout sheet to give to her which had on it all the information that I was going to talk to her about. This included information on rest, posture, driving, returning to work and safe activities she can complete when she goes home. I then briefly discussed with her the pelvic floor muscles and when she should be starting those exercises. Next was about general exercise and fitness and some early post-op exercises she could be doing if she had any lower back discomfort. Finally I talked about normal/good bladder and bowel habits. This included some information about fluid intake and diet also.
Results:
The patient seemed to take in all the information I was giving and appeared to already have a good understanding on some of the topics of education. As there was so much information to get through I had to make sure that I spent most time on the most important information relevant to her ie specifically tailoring the information to her and to the surgery she had. This meant spending more time on the 'rest' section and really emphasising and explaining the reason why she should and shouldn't do certain things. This is where good communication was required to provide the patient with clear information and place most importance/emphasis on the most critical things.
Evaluation:
I think I did fairly well in providing the patient with comprehensive education and advice. This patient proved to be more difficult as she tended to talk as much as I was talking. This made it distracting and more complicated to stick to a formatted, succinct structure. One thing I think I can improve on is providing the patient with the reason why we say do/don't do certain things. For example, instead of just saying 'you need to sit tall and walk tall' I can explain to them why this is important post an abdominal incision and discuss scarring, the healing process and the general benefits of good posture. By providing the patients with the reason behind the rule, I think they will be more likely to do what you are saying as they can see/understand the thought process
Strategies:
Try to individualise the information as much as possible to the person, their lifestyle and to the surgery they've had. And to also practise giving the patient reasons as to why we say to do certain things. This could be the key to them actually following the advice you are giving.
My patient was a 45 year old female who was day 2 post-op. She had an Anterior Vaginal Repair to fix a cystocele. This particular lady was overweight and also suffered from arthritis and chronic low back pain. She has a husband and two sons who live with her in the Helena Valley. She works as an Avon Sales Representative but has leave for 6 weeks.
Task:
My task was to provide this lady with comprehensive post-op education and advice before she returns home.
Action:
As this was the first time I had seen this lady I introduced myself and my supervisor and let her know why we were there to see her. I also had a handout sheet to give to her which had on it all the information that I was going to talk to her about. This included information on rest, posture, driving, returning to work and safe activities she can complete when she goes home. I then briefly discussed with her the pelvic floor muscles and when she should be starting those exercises. Next was about general exercise and fitness and some early post-op exercises she could be doing if she had any lower back discomfort. Finally I talked about normal/good bladder and bowel habits. This included some information about fluid intake and diet also.
Results:
The patient seemed to take in all the information I was giving and appeared to already have a good understanding on some of the topics of education. As there was so much information to get through I had to make sure that I spent most time on the most important information relevant to her ie specifically tailoring the information to her and to the surgery she had. This meant spending more time on the 'rest' section and really emphasising and explaining the reason why she should and shouldn't do certain things. This is where good communication was required to provide the patient with clear information and place most importance/emphasis on the most critical things.
Evaluation:
I think I did fairly well in providing the patient with comprehensive education and advice. This patient proved to be more difficult as she tended to talk as much as I was talking. This made it distracting and more complicated to stick to a formatted, succinct structure. One thing I think I can improve on is providing the patient with the reason why we say do/don't do certain things. For example, instead of just saying 'you need to sit tall and walk tall' I can explain to them why this is important post an abdominal incision and discuss scarring, the healing process and the general benefits of good posture. By providing the patients with the reason behind the rule, I think they will be more likely to do what you are saying as they can see/understand the thought process
Strategies:
Try to individualise the information as much as possible to the person, their lifestyle and to the surgery they've had. And to also practise giving the patient reasons as to why we say to do certain things. This could be the key to them actually following the advice you are giving.
Sunday, May 9, 2010
Initial Entry 3rd Placement 2010
I'm really looking forward to starting tomorrow at King Edward Memorial Hospital. I've heard only good things about the whole experience from previous students which has really settled any of the nerves I might of had. After speaking to the physio there, I was looking forward to it even more as she was able to give me a more structured overview of what we will be doing and what to expect in the first week. This also allowed me to prioritise my study throughout the preparation week which has again improved my confidence in starting the placement and settled my nerves.
I expect this placement to be very interesting and rewarding as a lot of the material will be of a post graduate level. I will gain as much information as I can from my supervisors, tutors and any other professions we are exposed to (doctors, specialists and surgeons). I think this will be the kind of placement where the more effort and interest I express, the more I will get out of the placement. I also expect that some of the time I will only be observing the physio/doctor with the patients as a lot of the techniques/examinations require post graduate education which is above what we are expected to know.
I think our supervisors would expect us to know the basics in women's health and revise the lecture material provided through the uni. I also think that most of the education will happen on the placement through observation and with spending time with our tutors. I am also looking forward to this aspect as I think our tutors will be able to provide us with a wealth of knowledge and other important information which might not necessarily be in a text book.
Overall I am really excited to be starting this placement tomorrow. I definitely don't feel as nervous as I have previously on the night before my first day. At the moment I'm most concerned about catching the right train/bus to get there (and be early)!
Sunday, April 25, 2010
Final Entry- Placement 2
Reflecting on my initial entry, I think I was probably stressing more than I needed to prior to my first day. Although I felt unprepared, our supervisors were actually quite impressed with how much we had covered before starting the placement. I also was able to remember a lot of other things I hadn't studied recently which helped with my confidence in the first week. As we got further into the placement, other area's did come up which needed revision but this was to be expected.
I was right to think this placement would be a confronting one. The majority of patients were in car/motor bike accidents or victims of assault. Some of the histories behind the accidents were also very confronting. Communication was an essential part between the allied health professionals as well as between medical and nursing staff. I thought there would be a lot more communication between family members, but there was only a few patients whose families visited daily. Safety issues also played a big part with this head injured population as their condition can change daily and can have a great impact as to what the medical staff want the patient to be doing and what they shouldn't be doing. Preparing the environment also became an important aspect after we had to make a MET call while treating one of our patients. This highlighted how you must expect the unexpected.
Our supervisors were very supportive throughout the placement and I was able to appreciate their individual styles and ways they approached various patients. Although I personally felt I had not met student expectations in the way of preparation, I was actually able to draw on previous knowledge for many of the "on the spot" questions. I was able to verbalise the theory with a lot of the assessment and treatment techniques but I think initially my handling skills were not of the best standard. This obviously improved over the placement with more and more practise on different patients. Documentation was also an area which required high standards and by the 3rd-4th week I think all my documentation was of a good standard and was very thorough.
Overall I think my main concern prior to the placement was the lack of theory preparation. I also think I underestimated how much I had actually covered in the clinical prep week and how much I was able to recall when prompted. I may have been a little harsh on myself on the initial entry as I was probably stressing out out at the time and putting pressure on myself to make a good first impression!
I was right to think this placement would be a confronting one. The majority of patients were in car/motor bike accidents or victims of assault. Some of the histories behind the accidents were also very confronting. Communication was an essential part between the allied health professionals as well as between medical and nursing staff. I thought there would be a lot more communication between family members, but there was only a few patients whose families visited daily. Safety issues also played a big part with this head injured population as their condition can change daily and can have a great impact as to what the medical staff want the patient to be doing and what they shouldn't be doing. Preparing the environment also became an important aspect after we had to make a MET call while treating one of our patients. This highlighted how you must expect the unexpected.
Our supervisors were very supportive throughout the placement and I was able to appreciate their individual styles and ways they approached various patients. Although I personally felt I had not met student expectations in the way of preparation, I was actually able to draw on previous knowledge for many of the "on the spot" questions. I was able to verbalise the theory with a lot of the assessment and treatment techniques but I think initially my handling skills were not of the best standard. This obviously improved over the placement with more and more practise on different patients. Documentation was also an area which required high standards and by the 3rd-4th week I think all my documentation was of a good standard and was very thorough.
Overall I think my main concern prior to the placement was the lack of theory preparation. I also think I underestimated how much I had actually covered in the clinical prep week and how much I was able to recall when prompted. I may have been a little harsh on myself on the initial entry as I was probably stressing out out at the time and putting pressure on myself to make a good first impression!
Week Five Entry- Communication
Situation:
This patient was a 49yo male who had been injured in a MBA, scooter vs car. He had a GCS of 10 at the scene and was moving all four limbs. A thoracotomy was also performed at the scene as the patient had a flail segment and multiple broken ribs. At the time we were treating him he had developed right sided weakness and pain at most joints. Xrays cleared both shoulders and his right elbow, hip and knee of any fractures. The patients first language is Mandarin and from what we could gather from his wife he was able to understand English. However it was uncertain how much English the patient actually understood and how well he was able to follow commands. The patient also has a trachy insitu and his decuffing regime has just commenced. During this most recent treatment session the cuff was down so he did have the physical capacity to communicate verbally. It had also recently been identified by the speech pathologist that this patient had elements of dyspraxia and dysphasia.
Task:
To understand and establish some form of communication with this patient when English is his second language and he is also currently suffering from dyspraxia and possibly dysphasia.
Action:
The patient was taken around to the gym for his daily rehab. I asked the patients wife to also come along as she too speaks Mandarin as her first language so can assist in translating for for husband. When trying to establish where the pain was, the patient was not able to communicate with us verbally. He continued to only use head movements (nod/shake) and hand gestures. With encouragement to use his voice he was still only able to use simple one word responses and even then required promts/choices of which words he meant. Even with this non-verbal from of communication, his responses were variable and inconsistent. Also with his wife present and able to translate, the pain location and intensity also continued to change.
Results:
A reasonable amount of communication was able to be established with the patient, some verbally but mainly through gestures and body language. As both forms were quite inconsistent in determining pain levels, the most accurate way I could determine this was though facial expressions. This was the most consistent way to determine area and intensity of pain and it did not require any kind of verbal communication therefore neither his language, dysphasia or dyspraxia could impact on the information needed to get across.
Evaluation:
I think I did a lot of things to try and account for the communication barrier. For the language difference I was able to utilise his partner to help translate in an attempt to bridge any gap in what the patient was trying to tell us. I also tried to encourage the patient to verbalise as much as possible. This would also address more of a time efficient aspect in getting the information directly from the patient rather than going through different people to get the same info. To help with the patients dyspraxia I tried to keep commands simple and keep the tasks functional. This did prove effective as the patient was able to do tasks automatically with functional tasks but unable to do the same thing when asked to do the movements separately.
Strategies:
When treating patients with these communication barriers I will establish a basic form of communication first. If the patient then develops more enhanced forms of communication we can work on these but still have the basics to fall back on. Keeping commands simple and functional will also make treatment sessions much more productive for the patient.
This patient was a 49yo male who had been injured in a MBA, scooter vs car. He had a GCS of 10 at the scene and was moving all four limbs. A thoracotomy was also performed at the scene as the patient had a flail segment and multiple broken ribs. At the time we were treating him he had developed right sided weakness and pain at most joints. Xrays cleared both shoulders and his right elbow, hip and knee of any fractures. The patients first language is Mandarin and from what we could gather from his wife he was able to understand English. However it was uncertain how much English the patient actually understood and how well he was able to follow commands. The patient also has a trachy insitu and his decuffing regime has just commenced. During this most recent treatment session the cuff was down so he did have the physical capacity to communicate verbally. It had also recently been identified by the speech pathologist that this patient had elements of dyspraxia and dysphasia.
Task:
To understand and establish some form of communication with this patient when English is his second language and he is also currently suffering from dyspraxia and possibly dysphasia.
Action:
The patient was taken around to the gym for his daily rehab. I asked the patients wife to also come along as she too speaks Mandarin as her first language so can assist in translating for for husband. When trying to establish where the pain was, the patient was not able to communicate with us verbally. He continued to only use head movements (nod/shake) and hand gestures. With encouragement to use his voice he was still only able to use simple one word responses and even then required promts/choices of which words he meant. Even with this non-verbal from of communication, his responses were variable and inconsistent. Also with his wife present and able to translate, the pain location and intensity also continued to change.
Results:
A reasonable amount of communication was able to be established with the patient, some verbally but mainly through gestures and body language. As both forms were quite inconsistent in determining pain levels, the most accurate way I could determine this was though facial expressions. This was the most consistent way to determine area and intensity of pain and it did not require any kind of verbal communication therefore neither his language, dysphasia or dyspraxia could impact on the information needed to get across.
Evaluation:
I think I did a lot of things to try and account for the communication barrier. For the language difference I was able to utilise his partner to help translate in an attempt to bridge any gap in what the patient was trying to tell us. I also tried to encourage the patient to verbalise as much as possible. This would also address more of a time efficient aspect in getting the information directly from the patient rather than going through different people to get the same info. To help with the patients dyspraxia I tried to keep commands simple and keep the tasks functional. This did prove effective as the patient was able to do tasks automatically with functional tasks but unable to do the same thing when asked to do the movements separately.
Strategies:
When treating patients with these communication barriers I will establish a basic form of communication first. If the patient then develops more enhanced forms of communication we can work on these but still have the basics to fall back on. Keeping commands simple and functional will also make treatment sessions much more productive for the patient.
Saturday, April 10, 2010
Week 3 Entry- Risk Management
Situation:
We were treating a 47 year old male who had suffered a spontaneous bleed as a result of an atrioventricular malformation. The patient currently presented with right sided weakness, Pushers syndrome, expressive dysphasia and dyspraxia. We had been seeing this patient every day for 2 weeks so this day we were continuing our daily rehab. All of the patients obs were stable. There was three of us treating the patient, myself, a second Notre Dame student and our ND tutor. This day we were focusing on sit to stand practise and weight transfer in standing. We were treating in the physio gym and had one Bobath plinth behind the patient and one in front for upper limb support. While the patient was in standing our ND tutor noticed the patients hands were very sweaty. On closer examination of his face, we saw his eyes were glazed over and his head then slumped forward.
Task:
To safely lower the patient without injury to him or ourselves and to get medical assistance as soon as possible.
Action:
When the patient started to collapse, we were able to control his descent to the plinth that was already behind him. It was during this lowering that the patient also had some convulsions/twitching which lasted approximately 3 seconds. He was positioned in supine and his legs were then elevated. The emergency bell was raised by our supervisor who was in the adjacent office and had overheard what had been happened. We removed the patients shirt which showed a large amount of perspiration. As the MET team arrived we tried to clear away from the patient as much as possible. I was at the patients head which was in the corner of the room so i was unable to move away from the patients direct area. I was however able to help assist in trying to calm the patient and answer some of the questions the doctors had about what just occurred.
Results:
The patient was successfully lowered onto the plinth x2 assist and all medical emergency procedures were followed appropriately. The doctors diagnosed the events to be a vasovagal attack. An ECG and the patients bloods were taken on the spot with the ECG being clear. The patient became more alert and started looking around after about 10mins.
Evaluation:
I think that in this situation we did everything possible in the way of creating a safe environment for our treatment session. What made this situation more unique is that the patient wasn't able to communicate to us that he was getting dizzy/or that he needed to sit down. This meant we needed to take closer note of his physical signs. The positioning of the patient in front of the plinth proved crucial in enabling us to lower him safely. Also our close proximity to the patient during treatment was important as it took two of us to lower him down. It was good that we had one person either side of the patient which in some cases would seem unnecessary. Also having the awareness of the location of the call bell was an essential part in raising the alarm as quick as possible. This aspect also brings in the importance of a team approach in this situation (we all had different roles) and effective communication which also was essential throughout.
We were treating a 47 year old male who had suffered a spontaneous bleed as a result of an atrioventricular malformation. The patient currently presented with right sided weakness, Pushers syndrome, expressive dysphasia and dyspraxia. We had been seeing this patient every day for 2 weeks so this day we were continuing our daily rehab. All of the patients obs were stable. There was three of us treating the patient, myself, a second Notre Dame student and our ND tutor. This day we were focusing on sit to stand practise and weight transfer in standing. We were treating in the physio gym and had one Bobath plinth behind the patient and one in front for upper limb support. While the patient was in standing our ND tutor noticed the patients hands were very sweaty. On closer examination of his face, we saw his eyes were glazed over and his head then slumped forward.
Task:
To safely lower the patient without injury to him or ourselves and to get medical assistance as soon as possible.
Action:
When the patient started to collapse, we were able to control his descent to the plinth that was already behind him. It was during this lowering that the patient also had some convulsions/twitching which lasted approximately 3 seconds. He was positioned in supine and his legs were then elevated. The emergency bell was raised by our supervisor who was in the adjacent office and had overheard what had been happened. We removed the patients shirt which showed a large amount of perspiration. As the MET team arrived we tried to clear away from the patient as much as possible. I was at the patients head which was in the corner of the room so i was unable to move away from the patients direct area. I was however able to help assist in trying to calm the patient and answer some of the questions the doctors had about what just occurred.
Results:
The patient was successfully lowered onto the plinth x2 assist and all medical emergency procedures were followed appropriately. The doctors diagnosed the events to be a vasovagal attack. An ECG and the patients bloods were taken on the spot with the ECG being clear. The patient became more alert and started looking around after about 10mins.
Evaluation:
I think that in this situation we did everything possible in the way of creating a safe environment for our treatment session. What made this situation more unique is that the patient wasn't able to communicate to us that he was getting dizzy/or that he needed to sit down. This meant we needed to take closer note of his physical signs. The positioning of the patient in front of the plinth proved crucial in enabling us to lower him safely. Also our close proximity to the patient during treatment was important as it took two of us to lower him down. It was good that we had one person either side of the patient which in some cases would seem unnecessary. Also having the awareness of the location of the call bell was an essential part in raising the alarm as quick as possible. This aspect also brings in the importance of a team approach in this situation (we all had different roles) and effective communication which also was essential throughout.
Strategies:
To continue safe practise, I will continue to check patients obs chart and medications prior to getting the patient up. Monitoring the patient throughout assessment/treatment is also an extra measure which can be taken if in any doubt about change in BP/HR. Also checking up on the patients blood results if available to note any change in Hb. Positioning the patient safely is also essential, having either a chair or plinth close by is a simple thing to do which can make a lot of difference in an emergency situation. Another important safety measure to take is knowing where the call bell is in each and every room. You never know when you might need it!
Sunday, March 28, 2010
Week One Entry- Assessment
Situation:
I was asked to carry out a neurological assessment of a 47 year old male. He had an atrioventricular malformation (AVM), which may have been a contributing factor to the spontaneous bleed which he presented with. Although he had a brain injury, his presentation was much like a stroke. He had right sided weakness of upper and lower limbs and he also had a dysphasic presentation and was unable to communicate verbally (3 in verbal section of GCS). My supervisor chose this patient as it would also be a good opportunity to be able to feel tone and get a better understanding of what is normal/abnormal tone. The focus of this first assessment was therefore looking mainly and tone and motor control.
Task:
To conduct a thorough neurological assessment with specific emphasis on the assessment of tone and motor control.
Action:
To start the assessment I introduced myself to the patient. I then checked the obs chart and medications list. I first asked the patient to do some gross movements with both arms and legs to get a general idea of his level of understanding as well as his ability to follow commands. This also gave me a good indication of the level of impairment of his right side. I then proceeded to assess the patients tone. I looked at his unaffected side first and started distally, looking at his fingers, wrist, elbow then shoulder. I then compared this to his affected side again starting distally. The last part of the assessment included a quick chest check and a look at his current mobility.
Results:
All obs were within normal limits. The patient had voluntary control and full range of motion with the left upper and lower limb. Looking at the tone of the unaffected side, all joints had a certain level of resting tone/ slight resistance with movement. The affected side however had no resistance with passive movement. The upper limb was completely flaccid and there was no real end feel at the end of range. No voluntary movement of the upper limb was observed on the right side. The right leg also had low tone but slight dorsiflexion was achieved.
I was asked to carry out a neurological assessment of a 47 year old male. He had an atrioventricular malformation (AVM), which may have been a contributing factor to the spontaneous bleed which he presented with. Although he had a brain injury, his presentation was much like a stroke. He had right sided weakness of upper and lower limbs and he also had a dysphasic presentation and was unable to communicate verbally (3 in verbal section of GCS). My supervisor chose this patient as it would also be a good opportunity to be able to feel tone and get a better understanding of what is normal/abnormal tone. The focus of this first assessment was therefore looking mainly and tone and motor control.
Task:
To conduct a thorough neurological assessment with specific emphasis on the assessment of tone and motor control.
Action:
To start the assessment I introduced myself to the patient. I then checked the obs chart and medications list. I first asked the patient to do some gross movements with both arms and legs to get a general idea of his level of understanding as well as his ability to follow commands. This also gave me a good indication of the level of impairment of his right side. I then proceeded to assess the patients tone. I looked at his unaffected side first and started distally, looking at his fingers, wrist, elbow then shoulder. I then compared this to his affected side again starting distally. The last part of the assessment included a quick chest check and a look at his current mobility.
Results:
All obs were within normal limits. The patient had voluntary control and full range of motion with the left upper and lower limb. Looking at the tone of the unaffected side, all joints had a certain level of resting tone/ slight resistance with movement. The affected side however had no resistance with passive movement. The upper limb was completely flaccid and there was no real end feel at the end of range. No voluntary movement of the upper limb was observed on the right side. The right leg also had low tone but slight dorsiflexion was achieved.
Evaluation:
I think to improve my assessment of tone, I need to address my hand positioning skills. This is crucial in being able to perform the technique correctly and to feel any abnormalities. It also is important in terms of safety especially when doing quick stretches. As this patient has low tone, hand positioning and safety would be especially important as his joints are at risk of damage if inappropriate forces are applied to these areas of risk.
Strategies:
To improve my assessment of tone, I need to practise handling on family and friends. By practising on people with normal tone, I will be able to perfect my hand position for both the slow stretch and the quick stretch. Another strategy would be to try and continue assessing this patients tone to see if I can pick up any change in the level of tone.
Sunday, March 21, 2010
Initial Entry- 2
Right now I feel very unprepared for this placement. I haven't covered the theory that I would have liked to at this stage which is making me very nervous, anxious and not really wanting to go tomorrow. I don't think I have covered enough of the theory and neuroanatomy to be confident in starting the placement tomorrow. I think I will therefore find this first week a very stressful and tiresome one with minimal sleep!
As to the nature of the placement, I think it will be very confronting, as it is an acute setting and the majority of injuries are a result of car accidents. I think my communication and professionalism skills will also play a large part on this placement as I suspect we will be interacting a lot with the patients families and close friends. Dealing with the families might also bring up issues as the family members may not be as willing to let a student be involved with the care of their loved ones. I also think safety issues will play a large role in this setting as these patients will have many medical issues to take into consideration.
I think this placement will be well structured and will provide a great learning experience. The previous students had mainly three supervisors who they said were all very supportive and they provided them with lots of knowledge, guidance, hands on experience and constructive criticism/feedback.
Expectations of me will be to know the basics of neuroanatomy from day one (I don't think I have currently met this expectation). Also we would be expected to know the specific strategies of treating neurological impairments. As the placement progresses we would be expected to have improved our clinical reasoning skills, time management skills and to be providing a thorough neurological assessment and treatment session within a reasonable amount of time. Our documentation will also be expected to be of a high standard.
My main concern currently is that I have let myself down by not having the theoretical knowledge behind me to make a good first impression. I will however, endeavor to change/improve on this starting as soon as I finish this entry.
As to the nature of the placement, I think it will be very confronting, as it is an acute setting and the majority of injuries are a result of car accidents. I think my communication and professionalism skills will also play a large part on this placement as I suspect we will be interacting a lot with the patients families and close friends. Dealing with the families might also bring up issues as the family members may not be as willing to let a student be involved with the care of their loved ones. I also think safety issues will play a large role in this setting as these patients will have many medical issues to take into consideration.
I think this placement will be well structured and will provide a great learning experience. The previous students had mainly three supervisors who they said were all very supportive and they provided them with lots of knowledge, guidance, hands on experience and constructive criticism/feedback.
Expectations of me will be to know the basics of neuroanatomy from day one (I don't think I have currently met this expectation). Also we would be expected to know the specific strategies of treating neurological impairments. As the placement progresses we would be expected to have improved our clinical reasoning skills, time management skills and to be providing a thorough neurological assessment and treatment session within a reasonable amount of time. Our documentation will also be expected to be of a high standard.
My main concern currently is that I have let myself down by not having the theoretical knowledge behind me to make a good first impression. I will however, endeavor to change/improve on this starting as soon as I finish this entry.
Sunday, March 14, 2010
Final Entry
After the completion of my placement, I think I have really developed as a physio, especially in the cardio area. My background of already working in a hospital was a big advantage which mainly assisted with my communication both with the patients and with other health professionals on the ward. Looking back I didn't need to be worried about the cardio side of things. My assessment and treatment skills really developed over the 5 weeks along with getting a greater understanding of the pathophysiology behind the conditions we were presented with.
My supervisors definitely met my expectations in the way they assisted with my learning experience. Both of my supervisors were very knowledgeable especially with the pathophysiology which really made me think about the reason why we use certain techniques on certain patients. I definitely needed that prior knowledge of the physiology, cardiorespiratory problem list, normative values and medications as they were all part of everyday care and part of my daily routine.
The application of cardio techniques was a lot less daunting than I expected. There were not that many acute cases to see so the general management was often mobilising patients which I had a lot of experience with. And as the placement went on I was able to refine my assessment and treatment techniques, as well as my time management skills in order to see my 8 patients each day. Patient prioritisation was also a key element in this setting as there was potential for a lot of variation in a patients condition.
Overall I have found this placement a valuable one which has further developed my skills in the cardiorespiratory area. It has especially developed my analysis and planning with the emphasis on the pathophsyiology of the presenting condition.
My supervisors definitely met my expectations in the way they assisted with my learning experience. Both of my supervisors were very knowledgeable especially with the pathophysiology which really made me think about the reason why we use certain techniques on certain patients. I definitely needed that prior knowledge of the physiology, cardiorespiratory problem list, normative values and medications as they were all part of everyday care and part of my daily routine.
The application of cardio techniques was a lot less daunting than I expected. There were not that many acute cases to see so the general management was often mobilising patients which I had a lot of experience with. And as the placement went on I was able to refine my assessment and treatment techniques, as well as my time management skills in order to see my 8 patients each day. Patient prioritisation was also a key element in this setting as there was potential for a lot of variation in a patients condition.
Overall I have found this placement a valuable one which has further developed my skills in the cardiorespiratory area. It has especially developed my analysis and planning with the emphasis on the pathophsyiology of the presenting condition.
Thursday, March 11, 2010
Week Five Entry- Evidence Based Practice
Situation:
I was asked to present a case study to my supervisors on a patient that I have assessed and treated. I was also asked to include some research findings in my presentation on either the condition that the patient has or evidence backing the treatment I decided to use with them. I chose to do my case study on a patient with Hereditary Hemorrhagic Telangiectasia (HHT), who was admitted for a liver transplant. Therefore, the evidence I searched for was was based on studies of people with HHT who have also undergone a liver transplant.
Task:
To find relevant, current, peer reviewed, full text articles on the pathophysiology of HHT and the outcomes of these patients post liver transplant.
Action:
Through the University of Notre Dame Library Link, I used Ebsco database. I searched the keywords "liver transplant" AND "Hereditary Hemorrhagic Telangiectasia". "Peer reviewed" and "full text articles" were also selected. This search yielded 26 articles.
Results:
Two of the 26 articles were most relevant to my topic as they involved information on the pathophysiology as well as information on the long-term outcomes of patients with Hereditary Hemorrhagic Telangiectasia and severe hepatic involvement after orthotopic liver transplantation.
Evaluation:
In regards to the actual searching of the evidence, I find that it takes me quite a long time to find the right articles. Once I've got the article it is then easy to extract the relevant information. I think the content of my case study presentation was good. I started with a handover of the patient and then further discussed her condition. I was a little nervous during the presentation which is probably the main thing that let me down. The research I found and used was specific and directly applicable to my patient, making it especially relevant for my supervisor who has also dealt with this patient and will be taking over her care when I leave. I received good feedback from my supervisors and one in particular found it especially interesting and asked for copies of the 2 articles I referenced.
Strategies:
I need to improve my searching techniques when looking for specific articles. To do this I think I need to practice identifying all the important keywords to narrow the search down from the start. In regards to the delivery of my evidence, I think I need to be more confident in the information I am presenting. To do this I need to know the material I am talking about and go over my talk a few times out loud to help remember the content.
I was asked to present a case study to my supervisors on a patient that I have assessed and treated. I was also asked to include some research findings in my presentation on either the condition that the patient has or evidence backing the treatment I decided to use with them. I chose to do my case study on a patient with Hereditary Hemorrhagic Telangiectasia (HHT), who was admitted for a liver transplant. Therefore, the evidence I searched for was was based on studies of people with HHT who have also undergone a liver transplant.
Task:
To find relevant, current, peer reviewed, full text articles on the pathophysiology of HHT and the outcomes of these patients post liver transplant.
Action:
Through the University of Notre Dame Library Link, I used Ebsco database. I searched the keywords "liver transplant" AND "Hereditary Hemorrhagic Telangiectasia". "Peer reviewed" and "full text articles" were also selected. This search yielded 26 articles.
Results:
Two of the 26 articles were most relevant to my topic as they involved information on the pathophysiology as well as information on the long-term outcomes of patients with Hereditary Hemorrhagic Telangiectasia and severe hepatic involvement after orthotopic liver transplantation.
Evaluation:
In regards to the actual searching of the evidence, I find that it takes me quite a long time to find the right articles. Once I've got the article it is then easy to extract the relevant information. I think the content of my case study presentation was good. I started with a handover of the patient and then further discussed her condition. I was a little nervous during the presentation which is probably the main thing that let me down. The research I found and used was specific and directly applicable to my patient, making it especially relevant for my supervisor who has also dealt with this patient and will be taking over her care when I leave. I received good feedback from my supervisors and one in particular found it especially interesting and asked for copies of the 2 articles I referenced.
Strategies:
I need to improve my searching techniques when looking for specific articles. To do this I think I need to practice identifying all the important keywords to narrow the search down from the start. In regards to the delivery of my evidence, I think I need to be more confident in the information I am presenting. To do this I need to know the material I am talking about and go over my talk a few times out loud to help remember the content.
Sunday, February 28, 2010
Week Three Entry- Intervention
Situation
I was asked to see a 65yr old male admitted for chemotherapy to treat acute myeloid leukaemia. His past medical history included hypertension (HTN), high cholesterol and he is an ex-smoker (of 30years, 15/day, quit 6 yrs ago). He lives at home with his wife on a large property, currently has no support at home and his wife completes household duties. Before this admission he was previously independant with ambulation using a walking stick. His maximum walking distance was 50m and he played golf x2/week.
From the subjective assessment, relevant information included that he has developed a cough since being in hospital and is currently bringing up approximately 2 teaspoons of thick, white, creamy sputum. He also found it painful to cough due to abdominal muscle pain and fatigue. On auscultation he had breath sounds throughout with decreased breath sounds and fine inspiratory crackles bibasally, left worse than right. Exercise tolerance and mobility has also decreased as the patient now requires x1 minimum assistance and is using a wheeled zimmer frame (WZF). Patient currently on saline nebulizers 4 times a day (QID) with good effects.
Task
To provide an appropriate treatment in 30mins to address the patients most prevalent respiratory problems of decreased gas exchange, impaired sputum clearance and decreased exercise tolerance.
Action
My intervention included mobilty to improve exercise tolerance. Patient used a WZF with x1 min assist. Portable oxygen was also taken as a precaution for the patient desaturating as well as a pulse oximeter to measure oxygen saturations. On return to sitting out of bed, I taught the patient an Active Cycle Breathing Technique (ACBT) as well as a supported cough to help with the pain during forced expiration.
Result
Patient able to ambulate 30m with WZF which was double distance of the previous day. His saturations remained within 96-98% on room air and he did not require the use of oxygen therapy. On return to sitting out of bed and after the completion of the ACBT, a strong, effective, moist cough was achieved but it was not productive. Also during and after ACBT, oxygen saturations remained at 98-99% on room air.
Evaluation
I think I covered many treatment aspects with this patient. By mobilising this patient I addressed his decreased exercise tolerance and sputum retention. Having the portable oxygen there was an extra measure to address his gas exchange if required. After mobilising, I positioned the patient out of bed in an upright position which has many benefits for the cardiorespiratory system. This is also the optimal position for this patient to do the ACBT. To further assist in his sputum retention problem, I gave a clear explanation and demonstration of a supported cough which will hopefully allow for a less painful and more productive cough. To improve on my treatment session I could have further addressed the sputum retention problem by administering a nebulizer 20mins before the treatment session. This would hopefully allow for more sputum to be loosened prior to mobilisation which would then make it easier for the patient to cough up at the end of the ACBT.
Strategies
Integrate treatments known to be effective from the subjective history with all other appropriate physio techniques.
I was asked to see a 65yr old male admitted for chemotherapy to treat acute myeloid leukaemia. His past medical history included hypertension (HTN), high cholesterol and he is an ex-smoker (of 30years, 15/day, quit 6 yrs ago). He lives at home with his wife on a large property, currently has no support at home and his wife completes household duties. Before this admission he was previously independant with ambulation using a walking stick. His maximum walking distance was 50m and he played golf x2/week.
From the subjective assessment, relevant information included that he has developed a cough since being in hospital and is currently bringing up approximately 2 teaspoons of thick, white, creamy sputum. He also found it painful to cough due to abdominal muscle pain and fatigue. On auscultation he had breath sounds throughout with decreased breath sounds and fine inspiratory crackles bibasally, left worse than right. Exercise tolerance and mobility has also decreased as the patient now requires x1 minimum assistance and is using a wheeled zimmer frame (WZF). Patient currently on saline nebulizers 4 times a day (QID) with good effects.
Task
To provide an appropriate treatment in 30mins to address the patients most prevalent respiratory problems of decreased gas exchange, impaired sputum clearance and decreased exercise tolerance.
Action
My intervention included mobilty to improve exercise tolerance. Patient used a WZF with x1 min assist. Portable oxygen was also taken as a precaution for the patient desaturating as well as a pulse oximeter to measure oxygen saturations. On return to sitting out of bed, I taught the patient an Active Cycle Breathing Technique (ACBT) as well as a supported cough to help with the pain during forced expiration.
Result
Patient able to ambulate 30m with WZF which was double distance of the previous day. His saturations remained within 96-98% on room air and he did not require the use of oxygen therapy. On return to sitting out of bed and after the completion of the ACBT, a strong, effective, moist cough was achieved but it was not productive. Also during and after ACBT, oxygen saturations remained at 98-99% on room air.
Evaluation
I think I covered many treatment aspects with this patient. By mobilising this patient I addressed his decreased exercise tolerance and sputum retention. Having the portable oxygen there was an extra measure to address his gas exchange if required. After mobilising, I positioned the patient out of bed in an upright position which has many benefits for the cardiorespiratory system. This is also the optimal position for this patient to do the ACBT. To further assist in his sputum retention problem, I gave a clear explanation and demonstration of a supported cough which will hopefully allow for a less painful and more productive cough. To improve on my treatment session I could have further addressed the sputum retention problem by administering a nebulizer 20mins before the treatment session. This would hopefully allow for more sputum to be loosened prior to mobilisation which would then make it easier for the patient to cough up at the end of the ACBT.
Strategies
Integrate treatments known to be effective from the subjective history with all other appropriate physio techniques.
Sunday, February 14, 2010
Week One Entry- Communication
Situation:
I was asked to see a young female patient, who was admitted to hospital with abdominal pains following a liver transplant 4 weeks ago. The previous day she was ambulating x1 min assist approximately 15m. Since that time she had progressed to ambulating independently with her IV pole 10m, but other aspects of her condition were not going so well. She gave her pain score a 4/10 at rest and said it can get up to an 8/10 on movement. Her chest x-ray (CXR) showed a large pleural effusion spanning 2/3's of her right lung. Her haemoglobin (Hb) was down to 76 and her general mood was also down. To get a holistic picture of her current condition and the most up to date information of her medical management, it was necessary to consult other members of the team before continuing with any physiotherapy management.
Task:
My task was to liaise with the other members of the multidisciplinary team in order to gain the relevant information required to devise a physio treatment strategy.
Action:
1) First of all I approached the intern to see what the medical team's plan was for the management of this patient.
2) I was approached by the OT who had just been in with the patient.
3) I approached the nurse looking after the patient
4) I was approached by the pain team about to assess the patient
Results:
1) medical team- the two main area's of physio concern was in regards to the pleural effusion and the low Hb. No management was planned for the effusion as the patient was not de-saturating at rest. If this did happen, only then would the medical management be reviewed. As for the low Hb, a transfusion had not been planned.
2) OT- she was able to give me some insight on how the patient was feeling. The patient was feeling frustrated and couldn't get comfy. She also was able to give me info on the patients transfer which was x1 min assist from the bed to a high backed chair.
3) Nursing- the nurse gave me information of the patients overnight condition. She had quite a restless night with back pain and she had also been vomiting. The nurse said the patient was ambulating independently with the IV stand to and from the toilet.
4) This was the time where I had to do a more formal handover. I was introduced to all 3 members of the team and all 3 were present during my handover. I was able to give the pain team information on her current pain levels at rest and with movement. I also handed over information about her mobility status both today and yesterday and how her pain was during those different times.
Evaluation:
On my last placement, some of the feedback for me included being more confident in approaching other staff members. So this was an area I was already aware of and wanted to improve on. For this situation to happen in my first week and all within an hour, I was quite pleased with how I dealt with the different staff members, all of which were older and more experienced than me. I think I spoke with confidence and asked relevant questions specific to physio. Each staff member/team was happy to spend the time answering my questions and were grateful for the information that I passed on to them too. One thing I think I could improve on is cutting down the time it takes to do the handover. I also want to make sure I tailor the information specifically to who the handover is for, I don't want to waste time by telling them things which are not of their concern.
Strategies:
To cut down the time of a handover I think I need to practise giving verbal handovers, focusing the majority of my time on providing the specific information that the team member would find most relevant/important.
I was asked to see a young female patient, who was admitted to hospital with abdominal pains following a liver transplant 4 weeks ago. The previous day she was ambulating x1 min assist approximately 15m. Since that time she had progressed to ambulating independently with her IV pole 10m, but other aspects of her condition were not going so well. She gave her pain score a 4/10 at rest and said it can get up to an 8/10 on movement. Her chest x-ray (CXR) showed a large pleural effusion spanning 2/3's of her right lung. Her haemoglobin (Hb) was down to 76 and her general mood was also down. To get a holistic picture of her current condition and the most up to date information of her medical management, it was necessary to consult other members of the team before continuing with any physiotherapy management.
Task:
My task was to liaise with the other members of the multidisciplinary team in order to gain the relevant information required to devise a physio treatment strategy.
Action:
1) First of all I approached the intern to see what the medical team's plan was for the management of this patient.
2) I was approached by the OT who had just been in with the patient.
3) I approached the nurse looking after the patient
4) I was approached by the pain team about to assess the patient
Results:
1) medical team- the two main area's of physio concern was in regards to the pleural effusion and the low Hb. No management was planned for the effusion as the patient was not de-saturating at rest. If this did happen, only then would the medical management be reviewed. As for the low Hb, a transfusion had not been planned.
2) OT- she was able to give me some insight on how the patient was feeling. The patient was feeling frustrated and couldn't get comfy. She also was able to give me info on the patients transfer which was x1 min assist from the bed to a high backed chair.
3) Nursing- the nurse gave me information of the patients overnight condition. She had quite a restless night with back pain and she had also been vomiting. The nurse said the patient was ambulating independently with the IV stand to and from the toilet.
4) This was the time where I had to do a more formal handover. I was introduced to all 3 members of the team and all 3 were present during my handover. I was able to give the pain team information on her current pain levels at rest and with movement. I also handed over information about her mobility status both today and yesterday and how her pain was during those different times.
Evaluation:
On my last placement, some of the feedback for me included being more confident in approaching other staff members. So this was an area I was already aware of and wanted to improve on. For this situation to happen in my first week and all within an hour, I was quite pleased with how I dealt with the different staff members, all of which were older and more experienced than me. I think I spoke with confidence and asked relevant questions specific to physio. Each staff member/team was happy to spend the time answering my questions and were grateful for the information that I passed on to them too. One thing I think I could improve on is cutting down the time it takes to do the handover. I also want to make sure I tailor the information specifically to who the handover is for, I don't want to waste time by telling them things which are not of their concern.
Strategies:
To cut down the time of a handover I think I need to practise giving verbal handovers, focusing the majority of my time on providing the specific information that the team member would find most relevant/important.
Sunday, February 7, 2010
Initial Entry
On the eve of starting this placement, I think my level of excitement is slightly outweighed by fear. I feel this is because it's my cardio rotation and applying the assessment and treatment techniques in the hospital setting can be quite different when compared to our labs. One aspect which is easing my fears is that I have already had experience in an acute hospital setting. I therefore have had practise at managing attachments and being an active member of the Multidisciplinary Team (MDT).
From talking to students who have previously been to SCGH, it seems as though the physio department is one which offers students a great learning experience. I intend to really make use of this and try to learn as much as I can especially in the first 2 weeks. I am prepared to begin assessing and treating from day one (which did happen at my last hospital placement!), but I hope that I will be able to observe my supervisor on the first day just to see how they organise attachments, interact with patients and to pick up any other tips on how they run their physio department.
As for my role as a student, I expect the first few days to be ones full of questions mainly to do with admin, paperwork and procedures of the hospital. This will also be the time to absorb as much information as possible from not only my supervisor but from other members of the MDT (transfers, discharge planning/considerations etc). I will be expected to know the basics necessary for cardio management from day one including surface anatomy, physiology, the cardiorespiratory problem list, normative values for vital signs/assessments, medications and specific cardio techniques. I would then expect my role to expand and develop as I gain more experience and confidence in the management of my patients. By week 4-5 I hope to be working at the level of a new graduate.
My main concern is that I feel I have a lack of experience in applying treatment techniques to real patients with real conditions. I would like to be as productive and efficient as possible from day one but in reality these things take a little more time and practise. That also leads on to my second concern in that some patients might not be keen on having an inexperienced student looking after them. This is totally understandable and I would probably have a similar opinion. I will aim to be as professional and confident as possible to help reassure the patient and hopefully alleviate any doubts they may have.
Overall I am looking forward to starting tomorrow and I think my fears will ease over the week!
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