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.
Sunday, February 28, 2010
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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