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.

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.

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.

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.

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.