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.
Monday, August 31, 2009
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.
Sunday, July 26, 2009
Initial Entry
I will be on placement at the Gerontology Evaluation & Management Unit at RPH Wellington St.
I am looking forward to being more heavily involved in Gero assessment, management and treatment and putting to use the skills that i have learnt during the gero units. My previous placement allowed me some exposure to certain aspects but not the entire process and being able to track the progress of individual patients which will be a great learning experience.
I expect the placement to essentially involve the thorough assessment of each patient and the development of goals and aims through a treatment program created by myself. As the placement progresses I see my role becoming more independent and this will give myself an opportunity to use my initiative and draw on information I have gathered during gerontology units and uni.
I am looking forward to being able to assist with the rehabilitation of patients and hopefully the improvement of their quality of life with simple treatments and adjustments to their daily living practices. We all know someone who does or will be suffering from ailments typical to geriatric patients so there is a personal desire to learn and develop my skills to assist with patient recovery and their state of health. I predict that at times there will be many cases of conditions being repeated but I see this as a good opportunity to hone my basic skills and develop my abilities to target more of a holistic approach by acknowledging the complexity and individual nature of every patient’s situation.
I am looking forward to being more heavily involved in Gero assessment, management and treatment and putting to use the skills that i have learnt during the gero units. My previous placement allowed me some exposure to certain aspects but not the entire process and being able to track the progress of individual patients which will be a great learning experience.
I expect the placement to essentially involve the thorough assessment of each patient and the development of goals and aims through a treatment program created by myself. As the placement progresses I see my role becoming more independent and this will give myself an opportunity to use my initiative and draw on information I have gathered during gerontology units and uni.
I am looking forward to being able to assist with the rehabilitation of patients and hopefully the improvement of their quality of life with simple treatments and adjustments to their daily living practices. We all know someone who does or will be suffering from ailments typical to geriatric patients so there is a personal desire to learn and develop my skills to assist with patient recovery and their state of health. I predict that at times there will be many cases of conditions being repeated but I see this as a good opportunity to hone my basic skills and develop my abilities to target more of a holistic approach by acknowledging the complexity and individual nature of every patient’s situation.
Tuesday, November 11, 2008
Week 5.1 Entry
The patient we saw today was progressing very well since we had seen 2/52 ago. She had had a TKR and we were dealing with her return to normal function and reporting back to her surgeon when the time came. She did not believe that she was moving along well at all but we reassured her that she is going very well and on track to having a great recovery from such an invasive operation. In the first week we may not have been able to make this call but with treating 6 patients and dealing with another 10 people in a class designed for those people who have undergone TKRs we felt we were in a good position to offer our opinion on how she was progressing. The patient had also been ill the last few weeks and showed some concern for possible complications such as infection. Our supervisor was able to offer his thoughts on the situation and suggested that the patient mention this to her doctor when she visited him in the next couple of days.
This made me think about all the questions we ask that are designed to clear the possibility of more severe conditions such as infection, cauda equina issues and vertebral artery insufficiencies. At what point does an answer warrant more investigation. For instance we have had many patients who have mentioned losing 5kgs in 2 weeks, dizziness with certain movements or increased frequency of urination. Ultimately most people will lose some weight following surgery thru decreased exercise and food intake, many people get small dizzy spells when moving suddenly etc. Since most of the time the question can appear odd in the context of a musculoskeletal examination, (as we discovered when we asked a 16yo girl about her bowel/bladder function) a patient may begin to worry that there may be something more severe wrong with them. Therefore having a thorough knowledge of the specifics of the question is vital so the patient can be assured that it is simply a routine question. The prevalence of such circumstances may be very low but I’m guessing that at some point in all of our careers we will be faced with dealing with such a situation and it is not something we should disregard at this stage.
At this point in the placement I am feeling very comfortable and confident with treating patients, more so the communication side of things and just making the patient feel comfortable to discuss and trust the treatments which we are applying. I have found that I have developed my ability to explain to patients clearly what is occurring and make them understand what my intention is and how they will progress with time. Also I see that it is very important to build a complete and smooth assessment and treatment process so that the patient can have total confidence in the physiotherapist, as I increase my knowledge base about all the different conditions I imagine this will become second nature to me.
If possible the best option is to plan the process ahead of time and anticipate numerous different scenarios and then deal with the situation as it presents itself. We have learnt this many times with expecting simple situations but been suprised when a patient has many more complicating factors than we could have imagined.
This made me think about all the questions we ask that are designed to clear the possibility of more severe conditions such as infection, cauda equina issues and vertebral artery insufficiencies. At what point does an answer warrant more investigation. For instance we have had many patients who have mentioned losing 5kgs in 2 weeks, dizziness with certain movements or increased frequency of urination. Ultimately most people will lose some weight following surgery thru decreased exercise and food intake, many people get small dizzy spells when moving suddenly etc. Since most of the time the question can appear odd in the context of a musculoskeletal examination, (as we discovered when we asked a 16yo girl about her bowel/bladder function) a patient may begin to worry that there may be something more severe wrong with them. Therefore having a thorough knowledge of the specifics of the question is vital so the patient can be assured that it is simply a routine question. The prevalence of such circumstances may be very low but I’m guessing that at some point in all of our careers we will be faced with dealing with such a situation and it is not something we should disregard at this stage.
At this point in the placement I am feeling very comfortable and confident with treating patients, more so the communication side of things and just making the patient feel comfortable to discuss and trust the treatments which we are applying. I have found that I have developed my ability to explain to patients clearly what is occurring and make them understand what my intention is and how they will progress with time. Also I see that it is very important to build a complete and smooth assessment and treatment process so that the patient can have total confidence in the physiotherapist, as I increase my knowledge base about all the different conditions I imagine this will become second nature to me.
If possible the best option is to plan the process ahead of time and anticipate numerous different scenarios and then deal with the situation as it presents itself. We have learnt this many times with expecting simple situations but been suprised when a patient has many more complicating factors than we could have imagined.
Friday, November 7, 2008
Week 4.3 Entry
Today we saw the disappointment that can occur when a patient’s return is not as quick as they would have hoped or that they were promised.
I have spoken about the patient with bilateral calcaneal fractures after falling from a height several weeks ago. His progress has been steady but as expected slow which he understands to a certain extent but is very keen to get back to work since he is not receiving any workers compensation and is self employed. His work involves him working at height and at some points he needs to jump down from scaffolding that is up to 1m off the ground. He thought that this may be possible sooner rather than later but with an injury such as a fracture and particularly on a constantly weight bearing structure as the calcaneus this is not going to be happening in a hurry. As well the soft tissue damage may not be sufficiently strong and stable enough to allow him to land from such a height. He controls his emotions very well and but it was obvious that he was annoyed that his return would be delayed. To make the matter even worse we made a comment that he should stop drinking everyday….well before midday anyway. This seemed ridiculous to him but when we told him that alcohol is not helpful for improving his injury he seemed to realize that he may need to make the change.
Another patient of ours was recovering from a TKR approximately 8/52 ago and was doing really well when we first saw him and had only improved from there. He could walk well and was affected more by pain in his other knee. Last week we had progressed him to low grade WB ex’s which he was managing very well and was expecting to move him onto some higher grade ex’s and include some more functional ex’s. This session was to be after his visit to the surgeon to see how his knee was going and also decide if he was able to return to work (just gardening and maintenance at a primary school). All 3 of us had expected for him to be able to return to work and were anticipating this by organizing a more extensive exercise list for him to leave us with. Unfortunately the surgeon rejected his request to return to work! This was after the surgeon said originally that he should be able to return to work. His reasoning was….wait for it….the prothesis he had put in was not designed for work such as his!! Bec and I were as amazed as the patient (our supervisor couldn’t believe it as well) and decided that we would keep seeing him but 2/52 apart from now on. The patient is needing to get the other knee done in the near future so was not as forceful with getting an explanation out of him but we expect him to get pretty fired up after the second operation. It was important that we assured him that he was doing really well and to look on the brightside that he gets a permanent holiday on retirement but he really wanted to keep busy.
I realized that it is important to not promise too much to patients and give them false hope on where they will end up by the end of their rehabilitation. Giving a conservative opinion is the best option and possibly avoiding giving a stead fast answer is even better. Everything health professionals say is often taken as gospel by patients and people will base their life around the predictions we have made.
I have spoken about the patient with bilateral calcaneal fractures after falling from a height several weeks ago. His progress has been steady but as expected slow which he understands to a certain extent but is very keen to get back to work since he is not receiving any workers compensation and is self employed. His work involves him working at height and at some points he needs to jump down from scaffolding that is up to 1m off the ground. He thought that this may be possible sooner rather than later but with an injury such as a fracture and particularly on a constantly weight bearing structure as the calcaneus this is not going to be happening in a hurry. As well the soft tissue damage may not be sufficiently strong and stable enough to allow him to land from such a height. He controls his emotions very well and but it was obvious that he was annoyed that his return would be delayed. To make the matter even worse we made a comment that he should stop drinking everyday….well before midday anyway. This seemed ridiculous to him but when we told him that alcohol is not helpful for improving his injury he seemed to realize that he may need to make the change.
Another patient of ours was recovering from a TKR approximately 8/52 ago and was doing really well when we first saw him and had only improved from there. He could walk well and was affected more by pain in his other knee. Last week we had progressed him to low grade WB ex’s which he was managing very well and was expecting to move him onto some higher grade ex’s and include some more functional ex’s. This session was to be after his visit to the surgeon to see how his knee was going and also decide if he was able to return to work (just gardening and maintenance at a primary school). All 3 of us had expected for him to be able to return to work and were anticipating this by organizing a more extensive exercise list for him to leave us with. Unfortunately the surgeon rejected his request to return to work! This was after the surgeon said originally that he should be able to return to work. His reasoning was….wait for it….the prothesis he had put in was not designed for work such as his!! Bec and I were as amazed as the patient (our supervisor couldn’t believe it as well) and decided that we would keep seeing him but 2/52 apart from now on. The patient is needing to get the other knee done in the near future so was not as forceful with getting an explanation out of him but we expect him to get pretty fired up after the second operation. It was important that we assured him that he was doing really well and to look on the brightside that he gets a permanent holiday on retirement but he really wanted to keep busy.
I realized that it is important to not promise too much to patients and give them false hope on where they will end up by the end of their rehabilitation. Giving a conservative opinion is the best option and possibly avoiding giving a stead fast answer is even better. Everything health professionals say is often taken as gospel by patients and people will base their life around the predictions we have made.
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