Situation
Every day the first port of call for the physiotherapist on each ward is to check the list of patients to see if new patients have been admitted, the status of all patients and if physiotherapy is indicated according to the medical team. There are usually 4 or 5 new patients every day but not all are for the physio to see. On one particular day a 62yr old gentleman had been admitted to the ward after a mechanical fall that morning which had resulted in him hitting his forearm and causing a distal fracture to the ulnar. This had been treated by the medical team with a plaster cast and pain relief….his stay in hospital was not expected to be long. Since it was a simple broken bone physiotherapy was not requested by the medical team
Task
On the ward I am currently on it is normal practice to check up quickly on each new patient no matter what the recommendation and then re-assess the situation from there. This is not intended to undermine the medical team but is simply put in place so that no at risk patients miss out on physio intervention that they may need.
Action
As with all patients the medical notes are analysed to determine the patient’s situation and if any important factors need to be taken into account when treating. This is usually a quick process but with patients that have a complex medical history it can take sometime to fit all the pieces together and determine the overall picture for the patient. As mentioned the notes of all new people are quickly scanned just to be sure that nothing had been missed by other health professionals.
Result
Following the analysis of the notes of the individual in question (62yr old man) my supervisor and I realised that the man had been admitted previously for exacerbation of COPD on 2 separate occasions. Even though this patient was not in hospital for any respiratory compromise we delved a bit further and discovered he was a smoker of some 40+ yrs. We then consulted the medcial team to see if we could see him with reference to managing his COPD, which they had no issue with at all. After speaking with the gentleman we discovered his exercise tolerance was very low secondary to SOB, he lived alone, didn’t leave his home very often and importantly had had 2 recent near miss falls as a result of SOB and fatigue (nearby furniture was used to support himself)
Evaluation
As a result we decided that physiotherapy intervention from a cardio-respiratory point of view was warranted even though it did not appear to be the underlying cause of this current hospitalization. The patient had clearly not had sufficient help regarding maintenance of a healthy lifestyle and no opportunities to regularly check up on his status. In terms of assessing whether this patient was appropriate for physio the correct and standard process was used whereby the notes were analysed, the medical team was consulted and the patient himself was spoken to with regards to the management of his COPD. My supervisor and I then determined that it was necessary to assess and treat this patient to post-pone but hopefully prevent another very likely admission for exacerbation of COPD as well as improving his lifestyle through education and increasing his independence once he got back home.
Strategies
In a hospital a physio is positioned to listen to doctors orders and take them at face value, either treat or don’t treat. As physio students most of time we would follow this protocol strictly but as I learnt from my supervisor we have to be proactive and assess things for ourselves since we shouldn’t let the orders of a medical team restrict us from seeing a patient since the patient’s health is always the main consideration. I learnt that spending a little extra time looking through the notes of a patient to see if physio should really be indicated can pay huge dividends in the future.
Monday, March 1, 2010
Wednesday, February 17, 2010
Week 1 STARES - Joondalup Cardio
Situation
Mrs X is a 39 yr female admitted 2 days prior with suspected panceatitis. Following hospitalization she suffered from significant SOB and decreased exercise tolerance with no known cause for the condition. Chest physiotherapy was requested to assess her cardiorespriratory limitations and intervene with appropriate treatment.
Task
Chest physiotherapy was requested to improve her SOB and exercise tolerance so that she may be able to cope with surgery to treat her pancreatitis and the expected post-op deconditioning / complications more effectively. This involved assessment to determine her current status from a cardiorespiratory point of view and then determining a treatment regime to address these concerns.
Action
Initially subjective questioning was used to gain an insight into the patient’s history. ie. any Hx of SOB, previous exercise tolerance, cough, sputum production, pain, dizziness, home environment & other Social History questioning. I then assessed the patient’s vitals and carried out auscultation posteriorly and assessed the movement of the chest. I had the patient cough & noted if it was productive, moist and it’s strength.
Based on the assessment results and the patient’s previous activity levels I determined that mobilization and deep breathing exercises would be the best intervention based on her presentation and assessment results.
Result
Prior to physiotherapy intervention the patient was significantly SOB so with mobilization this increased. The patient was noticeably shakey and required very close assistance to provide support and reassurance. Re-auscultation did not show any changes.
Evaluation
The desired outcome was mobilization of the patient which was achieved but there were a couple of things that could be worked on. The patient had a number of attachments; IDC, PCA, IV line and O2 supply. I found myself trying to figure out on the spot quickly how to organise things. It is a very simple thing but if one gets it wrong the patient can quickly lose confidence in what the therapist is doing for them.
Also during auscultation I was measuring posteriorly and during the process the patient predictably became SOB. I had warned the patient to let me know if she did feel SOB but I should have constantly been checking on her. Because I had to wait for the patient to recover the session was extended thus lengthening an already long process for the patient.
Strategies
In the next situation I will be prepared to know how to arrange the attachments effectively and efficiently without putting the patient in harms way. I will look at the notes to identify likely scenarios and also upon entering a room I will immediately identify the equipment and how to organize it
With the auscultation, a patient that is markedly SOB there should be planned rest periods so either break the assessment in halves or even thirds so that effect and similar depth breathing occurs throughout to achieve an accurate assessment of the lungs.
Mrs X is a 39 yr female admitted 2 days prior with suspected panceatitis. Following hospitalization she suffered from significant SOB and decreased exercise tolerance with no known cause for the condition. Chest physiotherapy was requested to assess her cardiorespriratory limitations and intervene with appropriate treatment.
Task
Chest physiotherapy was requested to improve her SOB and exercise tolerance so that she may be able to cope with surgery to treat her pancreatitis and the expected post-op deconditioning / complications more effectively. This involved assessment to determine her current status from a cardiorespiratory point of view and then determining a treatment regime to address these concerns.
Action
Initially subjective questioning was used to gain an insight into the patient’s history. ie. any Hx of SOB, previous exercise tolerance, cough, sputum production, pain, dizziness, home environment & other Social History questioning. I then assessed the patient’s vitals and carried out auscultation posteriorly and assessed the movement of the chest. I had the patient cough & noted if it was productive, moist and it’s strength.
Based on the assessment results and the patient’s previous activity levels I determined that mobilization and deep breathing exercises would be the best intervention based on her presentation and assessment results.
Result
Prior to physiotherapy intervention the patient was significantly SOB so with mobilization this increased. The patient was noticeably shakey and required very close assistance to provide support and reassurance. Re-auscultation did not show any changes.
Evaluation
The desired outcome was mobilization of the patient which was achieved but there were a couple of things that could be worked on. The patient had a number of attachments; IDC, PCA, IV line and O2 supply. I found myself trying to figure out on the spot quickly how to organise things. It is a very simple thing but if one gets it wrong the patient can quickly lose confidence in what the therapist is doing for them.
Also during auscultation I was measuring posteriorly and during the process the patient predictably became SOB. I had warned the patient to let me know if she did feel SOB but I should have constantly been checking on her. Because I had to wait for the patient to recover the session was extended thus lengthening an already long process for the patient.
Strategies
In the next situation I will be prepared to know how to arrange the attachments effectively and efficiently without putting the patient in harms way. I will look at the notes to identify likely scenarios and also upon entering a room I will immediately identify the equipment and how to organize it
With the auscultation, a patient that is markedly SOB there should be planned rest periods so either break the assessment in halves or even thirds so that effect and similar depth breathing occurs throughout to achieve an accurate assessment of the lungs.
Sunday, February 7, 2010
Initial Entry - Rotation 1
My first placement for the year will be at Joondalup working on one of the medical wards with a bit of a cardiorespiratory twist. From what I’ve been able to gather so far it is not strictly people with cardio conditions so I will have to draw on my powers from all the other disciplines to make it through in one piece.
At this stage my impression of treating people on a medical ward with cardio problems is that my supervisor will simply determine if they have any cardio issues then decide if they are able to be seen by me. Having only just finished the cardio unit last semester a lot of the information is relatively fresh in my mind but there is certainly going to be a lot of recapping on things covered in university. But in saying that we have learnt a lot from the theory side of things with some prac, but actually putting it into practice with real patients is going to be a whole different ball game.
One of the major factors that makes me slightly anxious is the fact that being on a medical ward means a high percentage of patients will likely have a co-morbidity of some description. This can significantly affecting the treatment given and restrict what intervention strategies I can use. I’m half expecting there to be situation where I assess a patient, decide what the problem list, look in my tool box of possible treatments & slowly cross them off the list due to contraindications as a result of co-morbidities. Despite this I imagine that with time I’ll see that there is always something that a physio can do, it’s just a matter of finding it.
Having been on a placement last year with a small amount of cardio exposure I see my role involving initial & ongoing assessment and treatment of issues determined during these, all under the watchful eye of my supervisor. Initially I would hope there would be a considerable amount of observation to see how experienced clinicians carry out the duties of a cardio physio. I would imagine that there would be a large amount of interaction with the other allied health professionals working on the ward to discuss and determine what the patient’s best course of action is. This will allow me to clearly understand each of their roles within the patient care structure and how to approach things for this placement and prepare me for other hospital situations.
Despite my nervousness ahead of this placement I am looking forward to developing my physiotherapy skills from a clinical point of view as well as professionally. I am also very eager to fine tune my communication and documentation skills so that I may spend more time focusing on aspects that directly benefit the patient such as treatment options and interventions. This will benefit me both now and when I encounter similar scenarios in future.
At this stage my impression of treating people on a medical ward with cardio problems is that my supervisor will simply determine if they have any cardio issues then decide if they are able to be seen by me. Having only just finished the cardio unit last semester a lot of the information is relatively fresh in my mind but there is certainly going to be a lot of recapping on things covered in university. But in saying that we have learnt a lot from the theory side of things with some prac, but actually putting it into practice with real patients is going to be a whole different ball game.
One of the major factors that makes me slightly anxious is the fact that being on a medical ward means a high percentage of patients will likely have a co-morbidity of some description. This can significantly affecting the treatment given and restrict what intervention strategies I can use. I’m half expecting there to be situation where I assess a patient, decide what the problem list, look in my tool box of possible treatments & slowly cross them off the list due to contraindications as a result of co-morbidities. Despite this I imagine that with time I’ll see that there is always something that a physio can do, it’s just a matter of finding it.
Having been on a placement last year with a small amount of cardio exposure I see my role involving initial & ongoing assessment and treatment of issues determined during these, all under the watchful eye of my supervisor. Initially I would hope there would be a considerable amount of observation to see how experienced clinicians carry out the duties of a cardio physio. I would imagine that there would be a large amount of interaction with the other allied health professionals working on the ward to discuss and determine what the patient’s best course of action is. This will allow me to clearly understand each of their roles within the patient care structure and how to approach things for this placement and prepare me for other hospital situations.
Despite my nervousness ahead of this placement I am looking forward to developing my physiotherapy skills from a clinical point of view as well as professionally. I am also very eager to fine tune my communication and documentation skills so that I may spend more time focusing on aspects that directly benefit the patient such as treatment options and interventions. This will benefit me both now and when I encounter similar scenarios in future.
Monday, August 31, 2009
Final Entry
Final Entry
The placement proved to be much like I expected but not having completed a gerontology placement previously the depth and complexity of a lot of the cases was well beyond how I expected it to be. The ward contained patients who had reported to the main RPH hospital (often ED) in serious conditions on some occasions but had recovered sufficiently to be considered for discharge to their previous living environment but prior to this they required some rehabilitation to prepare them for this transition.
Despite each patient having been admitted and assessed at least twice it was still vital to view the notes in depth and also answer those questions which still needed answering. Clear development of a problem list and possible issues with treatment was vital and constant reflection upon these factors as the patient’s condition changed (for good or worse) was necessary. It was necessary to know where the patient was ultimately headed and barriers in the way to this. Consultation with doctors, nurses, social workers and OT’s was important to understand the patient’s situation fully.
I enjoyed the exercise prescription and seeing the patient improve over time and modifying the treatment as this happened. I noticed an improvement in most of the patients but one particular patient who was there for almost 4 weeks made me constantly rethink the intervention I was applying. The priority list changed from balance to conditioning to strength to balance and then finally an underlying leg pathology that popped up that nobody was really sure what it was. When I left the placement the patient was still in the same condition that she was admitted in.
Despite this incident the fact that I constantly re-analysed the patient’s status and modified treatment accordingly made me content that I had done all I could. I believe that I will be in a good position if I maintain this approach to placements in future.
The placement proved to be much like I expected but not having completed a gerontology placement previously the depth and complexity of a lot of the cases was well beyond how I expected it to be. The ward contained patients who had reported to the main RPH hospital (often ED) in serious conditions on some occasions but had recovered sufficiently to be considered for discharge to their previous living environment but prior to this they required some rehabilitation to prepare them for this transition.
Despite each patient having been admitted and assessed at least twice it was still vital to view the notes in depth and also answer those questions which still needed answering. Clear development of a problem list and possible issues with treatment was vital and constant reflection upon these factors as the patient’s condition changed (for good or worse) was necessary. It was necessary to know where the patient was ultimately headed and barriers in the way to this. Consultation with doctors, nurses, social workers and OT’s was important to understand the patient’s situation fully.
I enjoyed the exercise prescription and seeing the patient improve over time and modifying the treatment as this happened. I noticed an improvement in most of the patients but one particular patient who was there for almost 4 weeks made me constantly rethink the intervention I was applying. The priority list changed from balance to conditioning to strength to balance and then finally an underlying leg pathology that popped up that nobody was really sure what it was. When I left the placement the patient was still in the same condition that she was admitted in.
Despite this incident the fact that I constantly re-analysed the patient’s status and modified treatment accordingly made me content that I had done all I could. I believe that I will be in a good position if I maintain this approach to placements in future.
Monday, August 24, 2009
TOPIC 3 - PROFESSIONAL BEHAVIOUR
S – I given a patient who had reported to ward following admission for SOB and recurrent falls in the previous 2/52. Her condition had improved but her cognitive state was still impaired significantly. Upon initial assessment she was very drowsy and required a lot of prompting to wake up and become involved in the assessment process. Once I explained to her what I was there for she asked me to “kindly leave the area” (paraphrasing since the language was a little bit more colourful). After some time I had her sitting in her chair at which point she indicated she could hurt me with her elbow and also by kicking me which she did, lightly hitting me in the thigh. No harm done at all but this changed my tactics a lot.
T – I had to determine the best way to get this patient on side and involved in the process without aggravating the situation more and potentially being detrimental to the overall to the patients situation.
A – I made my instructions very basic and explained that this was all for her benefit to get better and return home sooner which is the frame of mind of the majority of the people on this ward. The requests were made step by step instead of explaining the whole process which would only confuse and most likely aggravate the patient.
R – The patient responded positively with some of the more basic commands but when it came to balance assessments and ambulation the patient did not respond well to since she was very tired and just wanted to be left alone by the end of the session. (she once again asked me to “leave the room”)
E – The session should have been broken up into more components over the course of the day instead of trying to get it all done in one go. I should have also notified the nurses about the patient’s potential to become violent, even though when she hit me it was nothing but next time it could have been with more force. I felt that I communicated with the patient as best as I could by not reacting to her comments and highlighting the benefits for her.
S – Next time I would create a priority list for the patient to know the most important items that need to be addressed such as ambulation. If I was to do nothing else for the whole session getting the patient up and moving would be a very important goal to focus on and then assess the remaining aspects in due course. Also limiting the time I spent with the patient because even though she needs more time it should not affect the time I spend with the other patients who need equal attention.
T – I had to determine the best way to get this patient on side and involved in the process without aggravating the situation more and potentially being detrimental to the overall to the patients situation.
A – I made my instructions very basic and explained that this was all for her benefit to get better and return home sooner which is the frame of mind of the majority of the people on this ward. The requests were made step by step instead of explaining the whole process which would only confuse and most likely aggravate the patient.
R – The patient responded positively with some of the more basic commands but when it came to balance assessments and ambulation the patient did not respond well to since she was very tired and just wanted to be left alone by the end of the session. (she once again asked me to “leave the room”)
E – The session should have been broken up into more components over the course of the day instead of trying to get it all done in one go. I should have also notified the nurses about the patient’s potential to become violent, even though when she hit me it was nothing but next time it could have been with more force. I felt that I communicated with the patient as best as I could by not reacting to her comments and highlighting the benefits for her.
S – Next time I would create a priority list for the patient to know the most important items that need to be addressed such as ambulation. If I was to do nothing else for the whole session getting the patient up and moving would be a very important goal to focus on and then assess the remaining aspects in due course. Also limiting the time I spent with the patient because even though she needs more time it should not affect the time I spend with the other patients who need equal attention.
Friday, August 21, 2009
Topic 2 -Assessment
S – My patient was a 88yo female who was admitted with decreased mobility & functional decline. She had a long history of falls with no significant injuries but the frequency of falls had increased markedly in the 2/52 prior to admission. Upon initial Ax she was noted to have very poor balance, hypotension and rapidly fatigued.
T – From this it was determined that her treatment should focus on improvement of her balance and fitness whilst still keeping in mind her poor tolerance to exercise.
A – Treatment involved balance exercises to improve her standing balance and ability to adjust to internal & external perturbations. Her protective reactions, especially stepping, would need to be refined for occasions when she cannot maintain her CoG within her BoS. Her tolerance to exercise was also a focus as this would enable her to be more functionally capable upon discharge.
R – Initially the patient showed improvement but after only 3 days her condition began fluctuating and her tolerance to activity decreased. Simply getting up for the shower in the am meant she was unable to complete a physio session for the rest of the am. The quality of her balance had actually improved from a subjective point of view but it appeared that other factors were at play.
E – After approximately 7 days of Rx I noticed that she would lean to the right and almost collapse in the same direction (which she did during one session). This could possibly have been the cause for her decreased exercise tolerance throughout but as I recognized early on this patient tends to under-report symptoms since she just wanted to get home. I pushed her for a reason for the collapsing and she then told me that her right leg just gives way. Upon a repeated investigation it was found that her R leg (mainly hip flexors) were much weaker than the L.
S – In future I will learn to interpret what a patient is telling me and determine if it is in fact the truth and if they may be concealing something in an effort to escape from the hospital sooner. I learnt how valuable Re-Ax can be since during the initial Ax this irregularity was not picked up. Not only for physio purposes but for other health professionals as well since it could suggest more complex medical issues…which luckily in this case it didn’t.
T – From this it was determined that her treatment should focus on improvement of her balance and fitness whilst still keeping in mind her poor tolerance to exercise.
A – Treatment involved balance exercises to improve her standing balance and ability to adjust to internal & external perturbations. Her protective reactions, especially stepping, would need to be refined for occasions when she cannot maintain her CoG within her BoS. Her tolerance to exercise was also a focus as this would enable her to be more functionally capable upon discharge.
R – Initially the patient showed improvement but after only 3 days her condition began fluctuating and her tolerance to activity decreased. Simply getting up for the shower in the am meant she was unable to complete a physio session for the rest of the am. The quality of her balance had actually improved from a subjective point of view but it appeared that other factors were at play.
E – After approximately 7 days of Rx I noticed that she would lean to the right and almost collapse in the same direction (which she did during one session). This could possibly have been the cause for her decreased exercise tolerance throughout but as I recognized early on this patient tends to under-report symptoms since she just wanted to get home. I pushed her for a reason for the collapsing and she then told me that her right leg just gives way. Upon a repeated investigation it was found that her R leg (mainly hip flexors) were much weaker than the L.
S – In future I will learn to interpret what a patient is telling me and determine if it is in fact the truth and if they may be concealing something in an effort to escape from the hospital sooner. I learnt how valuable Re-Ax can be since during the initial Ax this irregularity was not picked up. Not only for physio purposes but for other health professionals as well since it could suggest more complex medical issues…which luckily in this case it didn’t.
Tuesday, August 11, 2009
Topic One - Communication
S – Prior to visiting Mr X I had checked out his notes to give me an insight into the pt prior to seeing him. It proved to potentially be quite a challenging situation with the pt speaking minimal English, being partially deaf and also having a ‘Do Not Resuscitate’ form filled out by the family which indicated he may not be the most communicable pt. He did not have severe cognitive problems but did score a 7.5/10 on the AMTS.
T – To successfully assess & treat the pt clarity of communication was essential and not confusing the pt was key. At the initial assessment discussions had to follow a logical path and also show the pt that PT intervention would improve his situation.
A – From the start constant eye contact and clear succinct communication was used. This ensured the pt was focused on me and also that the discussion was to the point and didn’t confuse him. I lowered myself down to his level and ensured that I was not speaking in a condescending tone during our session.
R – At times it was not so much the pt understanding me that was the issue but me understanding him. It turned out his ability to understand English was much better than his ability to speak it. The pt did understand what I was saying most of the time but it was not always that easy. At times he would just simply say yes which didn’t make sense with the question asked and I then had to rephrase and simplify it.
E – The session took a lot longer than any other assessment I had carried out but after this furthering questioning would be a lot simpler. I was challenged to think on my feet at times when he couldn’t understand and in couple of instances I had no way of asking him the question I was after without potentially doing a 10minute short course in Italian. Avoiding complicating questions and making them simple yes or no answers and definitely avoiding the dreaded leading questions….a tired pt will say whatever you want them to say to get you out of their space.
S - With a pt that is easy to communicate with asking all the additional questions that are relevant is so much of an issue but if I can avoid them with other pts like this gentleman the session would be a lot quicker and put the pt more at ease, thus making for a much more enjoyable session.
T – To successfully assess & treat the pt clarity of communication was essential and not confusing the pt was key. At the initial assessment discussions had to follow a logical path and also show the pt that PT intervention would improve his situation.
A – From the start constant eye contact and clear succinct communication was used. This ensured the pt was focused on me and also that the discussion was to the point and didn’t confuse him. I lowered myself down to his level and ensured that I was not speaking in a condescending tone during our session.
R – At times it was not so much the pt understanding me that was the issue but me understanding him. It turned out his ability to understand English was much better than his ability to speak it. The pt did understand what I was saying most of the time but it was not always that easy. At times he would just simply say yes which didn’t make sense with the question asked and I then had to rephrase and simplify it.
E – The session took a lot longer than any other assessment I had carried out but after this furthering questioning would be a lot simpler. I was challenged to think on my feet at times when he couldn’t understand and in couple of instances I had no way of asking him the question I was after without potentially doing a 10minute short course in Italian. Avoiding complicating questions and making them simple yes or no answers and definitely avoiding the dreaded leading questions….a tired pt will say whatever you want them to say to get you out of their space.
S - With a pt that is easy to communicate with asking all the additional questions that are relevant is so much of an issue but if I can avoid them with other pts like this gentleman the session would be a lot quicker and put the pt more at ease, thus making for a much more enjoyable session.
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