S: I was treating a 63 year old male with idiopathic Parkinson's disease (PD). The main tasks he was having difficulty with/main impairments identified were turning in confined spaces and walking (poor step length, arm swing and heel strike). His walking had improved over the past few sessions and I had begun to address turning. I had taught him a 'clock turn' the week before in different contexts i.e. open space initally then smaller spaces i.e. toilet. The clock turn is one technique or strategy that can be used to help people with PD to turn in smaller spaces. The week before, the patient had reported and it was observed that he was twisting on his knee (which had a history of being painful secondary to cartilage damage) or pivoting on his foot and tended to cross his feet over to turn. During the session last week he performed the clock turn relatively well with verbal prompts and feedback and was encouraged to practice this at home. I also gave him a handout about turning i.e. not crossing feet over, picking the feet up, etc and had drawn a diagram to assist with the turn.
T: to re-evaluate the patient's clock turn/ effectiveness of this technique in improving the patient's ability to turn and modify it if it was not found to be effective
A: In my subjective assessment, I enquired whether the patient had been practicing turning using the clock turn strategy at home. He had, therefore I asked him to demonstrate it. It turned out he had been practicing the turn wrong. I went through the clock turn as I had the week before with him however he seemed to find it very difficult and continued to twist his knee which aggravated his knee pain. Therefore, I taught him another strategy to turn by getting him to march on the spot/shift weight side to side first then step around ("step, step"). I taught this in varying contexts. I also gave him a cue card to take home to remind him of these steps and reminded him to refer to the handout on turning. I also told him to not worry about the clock turn technique but the diagram I had drawn for him previously would still help assist the turning in smaller spaces. I also recounted what we had gone through in the session to help consolidate what he had learnt and ensure when he went home and practiced he was clear on what to do.
R: The patient was able to turn using the new strategy fairly independently i.e. with mental rehearsal of the steps himself and twisted on the knee only occassionally. He only required occassional prompts to pick his feet up during the turn. He turned with more 'fluidity' than he did using the clock turn. He found the marching before commencing the turn to be very helpful and reported this was much easier to concentrate on than the steps involved in a clock turn.
E: I thought I did well in changing the strategy used to assist the patients turn and didn't try persist with something that wasn't working well for him. I also thought it was good that I recounted what we had covered in the session. It would have been ideal to practice the new strategy for a longer period of time to ensure there was carry over however this is not necessarily something I could have had full control of as the session was only for 45 minutes. The patient had potentially been practicing the clock turn wrong and misunderstood the technique taught in the previous session for a number of reasons such as:
- I could have not explained it simply or clearly
- I overloaded him with too much information
-practice of the technique wasn't sufficient or consistent enough to ensure the patient understood the technique
- the diagram needed to be backed up with more or more concise written instructions to ensure it made sense
- a combination of the above or the patient had simply forgot or had not practiced what we went through
S: Strategies I could use to prevent the above happening would be to make my communication more clear and consistent. For example, using short and simple instructions and making sure I repeat these and not add more prompts or instructions along the way and therefore make them more wordy. This would prevent any confusion or overloading the patient with information. In terms of communication and intervention, I also need to make sure I match my verbal instructions to what I write on the patient's cue card and make sure they are consistent with each other especially if I were to change one or the other. I could also manage my time a little better and allow for time for the patient to perform the task more independently or say the steps of the strategy out loud. Therefore 'weaning' the level of verbal support I give to ensure that the patient has in fact understood what I have taught in the session. I also need to be more considerate that as part of PD and/or older age the patient could potentially have a poor memory or poor cognition which influences the learning of a new task.
Sunday, July 25, 2010
Final entry - placement 4
Upon finishing this final placement, I feel much more confident with my skills in regards to physiotherapy. I do think that I still need to work on my clinical reasoning and treatment but I am hoping this will come with more time and experience. I did feel quite nervous throughout this placement which I think was due to knowing that this was the final one and after being through three previous placements there is more expected of us. There was also the thought that graduation is coming up and even though this is exciting it is also terrifying!
I did make the assumption initially that working in Parkinson's would be simple which was the wrong assumption to make! I think the simple part is knowing which strategies to use but these may not work for an individual patient and if so you need to take the principle behind these strategies and be creative to ensure the individuals needs are met and you are demonstrating best practice. It was also challenging to treat a Parkinson's patient who presented with say a non-Parkinson's specific problem because not only did you have to manage this problem but take into consideration the features of Parkinson's disease (PD) that would impact on your management. For example, I had a patient who came into the clinic for treatment of acute on chronic ankle pain. One of the strengthening excercises I gave him was sit to stand which is commonly a difficult task for people with Parkinson's! However it was very suitable to treat his remote mechanical contributing factors that would assist in treating his ankle pain.
I dealt with more elderly patients during the placement which I wasn't concerned about to begin with. However one factor I didn't take into account which I have actually been told before was remembering to speak slowly, simply, clearly and loudly in communicating with older patients. This was even more significant in dealing with Parkinson's patients as some had cognitive and memory deficits. I did work on this as the placement continued although I could definitely continue to work on this.
I was expecting to have to use various outcome measures. I think the placement taught me the value of these measures. For example, instead of just looking at the numbers, I learnt to ask myself what these numbers meant and how they represented a patient's functional status and what they meant for their treatment path. As an example, whenever I performed the 20mwt my supervisor encouraged me to calculate the person's gait speed and step length from this which helped make the person's results much more meaningful to me and assisted in my clinical reasoning. I was a little worried about knowing the effects of medications and being able to time them with my treatment however I learnt that patient's appointments were made to be for the same time on the same day each week which took the pressure out of this! I did come to learn things such as the names of various medications and at what stages of PD they were given and their side effects. I found this aspect of the placement very interesting.
One thing I did not consider or comment on prior to commencing the placement was that I would obviously be working with other members of the multi-disciplinary team. Throughout the placement I had the most contact with occupational therapists (OT's). This was great in that I learnt a lot more about their role and this helped me to know when it was appropriate to refer a patient for OT. I also learnt a lot more about the role of social workers which was particularly important for people with Parkinson's.
To conclude, I feel I am much more knowledgeable about Parkinson's disease and can appropriately and soundly manage people with PD which I will most defnitely come across when working in a clinical setting in the future considering it is a common disease. This last placement really helped consolidate in my mind aspects which I need to improve on in regards to becoming a physiotherapist but also helped me to realise what I have achieved this year and how much I've grown especially in terms of my confidence. Specifically, I have learnt that the real world is never as simple as what we learn from the books and that one can learn a lot from being continuously challenged by different situations. These experiences help to shape how you will choose to manage your patients and experiences as a physiotherapist.
I did make the assumption initially that working in Parkinson's would be simple which was the wrong assumption to make! I think the simple part is knowing which strategies to use but these may not work for an individual patient and if so you need to take the principle behind these strategies and be creative to ensure the individuals needs are met and you are demonstrating best practice. It was also challenging to treat a Parkinson's patient who presented with say a non-Parkinson's specific problem because not only did you have to manage this problem but take into consideration the features of Parkinson's disease (PD) that would impact on your management. For example, I had a patient who came into the clinic for treatment of acute on chronic ankle pain. One of the strengthening excercises I gave him was sit to stand which is commonly a difficult task for people with Parkinson's! However it was very suitable to treat his remote mechanical contributing factors that would assist in treating his ankle pain.
I dealt with more elderly patients during the placement which I wasn't concerned about to begin with. However one factor I didn't take into account which I have actually been told before was remembering to speak slowly, simply, clearly and loudly in communicating with older patients. This was even more significant in dealing with Parkinson's patients as some had cognitive and memory deficits. I did work on this as the placement continued although I could definitely continue to work on this.
I was expecting to have to use various outcome measures. I think the placement taught me the value of these measures. For example, instead of just looking at the numbers, I learnt to ask myself what these numbers meant and how they represented a patient's functional status and what they meant for their treatment path. As an example, whenever I performed the 20mwt my supervisor encouraged me to calculate the person's gait speed and step length from this which helped make the person's results much more meaningful to me and assisted in my clinical reasoning. I was a little worried about knowing the effects of medications and being able to time them with my treatment however I learnt that patient's appointments were made to be for the same time on the same day each week which took the pressure out of this! I did come to learn things such as the names of various medications and at what stages of PD they were given and their side effects. I found this aspect of the placement very interesting.
One thing I did not consider or comment on prior to commencing the placement was that I would obviously be working with other members of the multi-disciplinary team. Throughout the placement I had the most contact with occupational therapists (OT's). This was great in that I learnt a lot more about their role and this helped me to know when it was appropriate to refer a patient for OT. I also learnt a lot more about the role of social workers which was particularly important for people with Parkinson's.
To conclude, I feel I am much more knowledgeable about Parkinson's disease and can appropriately and soundly manage people with PD which I will most defnitely come across when working in a clinical setting in the future considering it is a common disease. This last placement really helped consolidate in my mind aspects which I need to improve on in regards to becoming a physiotherapist but also helped me to realise what I have achieved this year and how much I've grown especially in terms of my confidence. Specifically, I have learnt that the real world is never as simple as what we learn from the books and that one can learn a lot from being continuously challenged by different situations. These experiences help to shape how you will choose to manage your patients and experiences as a physiotherapist.
Sunday, July 11, 2010
week 3 post, prac 4 : evidence based-practice
S: I took over one of my supervisors parkinson's patients. The patient was a 73 year old female who had been diagnosed with parkinson's approximately 6 years ago. Her main presenting problem was with walking. Variations that could be identified from her notes in regards to her walking included reduced thoracic rotation/ rigid trunk; nil arm swing bilaterally; poor foot clearance and a tendency to shuffle. Her most recent intervention addressing these problems was a home exercise programme (HEP)involved an arm swing exercise to be done prior to walking (this involved standing on the spot and swinging each arm alternately with a chair in front to assist in reaching); heel- toe exercise to improve her heel strike; strategies to manage her shuffling e.g. written cue cards to remind the patient to place her heels down first and to think long steps. On subjective assessment, the patient reported she had tried to swing her arms more during walking but was forgetting to practice doing this. She found that the cue cards were helping her to take slightly longer steps when she could refer to them.
T: to assess the patient's gait for myself as well as carry out my supervisors planned aims for the session which included re-evaluating her HEP and progress with her walking.
A: I analysed the patients gait which confirmed the findings from her notes and reviewed her home exercise programme. I modified her arm swing exercise by prompting her to reach for the corners of the chair i.e. left arm to right side or chair to further encourage thoracic rotation as there was little rotation occurring when she reached just generally for the back of the chair. I progressed the exercise by including leg lifts (marching). After 5 mins of doing this exercise I got the patient to practice walking for 10-15 mins along the corridor using the cues she already had as well as a new cue: "imagine reaching for the sides of the chair". I said the cues out loud to assist the patient, then encouraged her to say these to herself either out loud or in her head. I then got the patient to transfer what she had learnt and got her to walk outside on pavement for 5 minutes. I also encouraged her to mentally rehearse walking with long steps, arm swing, etc before going for a walk at home. Lastly, I gave her a copy of the modified arm swing exercise and of a new cue card and advised her to place this in her pocket/bag or take it with her for a walk as a reminder.
R: The patient understood the progressed arm swing exercise and responded well to the cues in regards to the chair during the exercise and while walking. Her gait appeared to improve when I repeated the cues verbally as she walked. It remained improved when I got her to say the cues to herself however this was only temporary as she found it difficult to think about the cues and perform them at the same time. She did have some difficulty thinking about her arm swing and long steps, etc when walking outside and shuffled occassionally.
E: I thought I did well in choosing to modify her arm swing exercise and in how I modified it. Evidence-based practice in relation to neurology suggests that task-specific practice, practicing functional tasks, mental rehearsal and repetition are amongst some of the key principles of rehabilitation. Most studies performed I believe have been mostly based on stroke patients however I think they could be applicable to other neurological conditions. I tried to use this to guide the session by modifying the arm swing exercise to make it slightly more functional i.e. to mimic a more normal gait pattern and by getting the patient to repeat the arm swing exercise then repeat walking using the cues/ strategies. I encouraged the use of mental rehearsal however it was difficult to evaluate how much this helped her as I didn't give her much time to do it during the session and asked her to do it more when at home. I think I utilised the common treatment approaches typically used for parkinsons e.g. breaking tasks down. I thought it was a good idea to get her to practice walking on a different surface (outside) to make the skills she had learnt transferrable to a new environment which is an integral part to learning and consolidating new skills. However, it may have been more effective to focus on improving her walking indoors in that single session then progressing this at a later stage by doing it outdoors. I did give her a lot to think about by doing this as well and could say that she was having to multi-task a fair bit which is difficult for a person with parkinsons disease. It is discouraged in later stages of the disease so I thought it may be alright for this particular patient. It is questionable how much "carry over" there would have been from the session that would really make a difference to her walking as it was a complex task and it is likely she will need a few sessions and lots of practice to see any significant change to her gait. Ideally it would be great to spend hours with the patient to ensure there is some carry over. Finally, it would be hard to the patient to read her cue card and for example walk along a busy street and talk to her husband all at once. It is a lot to think about so it is difficult to establish how transferrable or practical what was learnt in the session is to her everyday life.
S: Strategies I could use would mainly be to focus more on one task during the session instead of getting the patient to try perfrom multiple tasks. Learning may be consolidated better this way. This also means slowing down the process of progressing the patient especially in treating parkinsons patients. It might be beneficial to research if the above principles for rehabilitation are that applicable to parkinsons patients.
T: to assess the patient's gait for myself as well as carry out my supervisors planned aims for the session which included re-evaluating her HEP and progress with her walking.
A: I analysed the patients gait which confirmed the findings from her notes and reviewed her home exercise programme. I modified her arm swing exercise by prompting her to reach for the corners of the chair i.e. left arm to right side or chair to further encourage thoracic rotation as there was little rotation occurring when she reached just generally for the back of the chair. I progressed the exercise by including leg lifts (marching). After 5 mins of doing this exercise I got the patient to practice walking for 10-15 mins along the corridor using the cues she already had as well as a new cue: "imagine reaching for the sides of the chair". I said the cues out loud to assist the patient, then encouraged her to say these to herself either out loud or in her head. I then got the patient to transfer what she had learnt and got her to walk outside on pavement for 5 minutes. I also encouraged her to mentally rehearse walking with long steps, arm swing, etc before going for a walk at home. Lastly, I gave her a copy of the modified arm swing exercise and of a new cue card and advised her to place this in her pocket/bag or take it with her for a walk as a reminder.
R: The patient understood the progressed arm swing exercise and responded well to the cues in regards to the chair during the exercise and while walking. Her gait appeared to improve when I repeated the cues verbally as she walked. It remained improved when I got her to say the cues to herself however this was only temporary as she found it difficult to think about the cues and perform them at the same time. She did have some difficulty thinking about her arm swing and long steps, etc when walking outside and shuffled occassionally.
E: I thought I did well in choosing to modify her arm swing exercise and in how I modified it. Evidence-based practice in relation to neurology suggests that task-specific practice, practicing functional tasks, mental rehearsal and repetition are amongst some of the key principles of rehabilitation. Most studies performed I believe have been mostly based on stroke patients however I think they could be applicable to other neurological conditions. I tried to use this to guide the session by modifying the arm swing exercise to make it slightly more functional i.e. to mimic a more normal gait pattern and by getting the patient to repeat the arm swing exercise then repeat walking using the cues/ strategies. I encouraged the use of mental rehearsal however it was difficult to evaluate how much this helped her as I didn't give her much time to do it during the session and asked her to do it more when at home. I think I utilised the common treatment approaches typically used for parkinsons e.g. breaking tasks down. I thought it was a good idea to get her to practice walking on a different surface (outside) to make the skills she had learnt transferrable to a new environment which is an integral part to learning and consolidating new skills. However, it may have been more effective to focus on improving her walking indoors in that single session then progressing this at a later stage by doing it outdoors. I did give her a lot to think about by doing this as well and could say that she was having to multi-task a fair bit which is difficult for a person with parkinsons disease. It is discouraged in later stages of the disease so I thought it may be alright for this particular patient. It is questionable how much "carry over" there would have been from the session that would really make a difference to her walking as it was a complex task and it is likely she will need a few sessions and lots of practice to see any significant change to her gait. Ideally it would be great to spend hours with the patient to ensure there is some carry over. Finally, it would be hard to the patient to read her cue card and for example walk along a busy street and talk to her husband all at once. It is a lot to think about so it is difficult to establish how transferrable or practical what was learnt in the session is to her everyday life.
S: Strategies I could use would mainly be to focus more on one task during the session instead of getting the patient to try perfrom multiple tasks. Learning may be consolidated better this way. This also means slowing down the process of progressing the patient especially in treating parkinsons patients. It might be beneficial to research if the above principles for rehabilitation are that applicable to parkinsons patients.
Tuesday, June 29, 2010
week 1 post prac 4: planning/intervention
S: Every week as part of the Parkinson's Clinic an exercise class is run at SCGH. I was asked to run most of the class that day. Five patients all diagnosed with Parkinsons at different stages attended the class. The class involves aerobic exercises as well 'voice' exercises and education and/or exercises on a chosen topic relevant to Parkinsons disease. The topic for the day was posture. My supervisor and myself planned some new aerobic exercises to do to make the session more interesting while also making it therapeutic.
T: To run an parkinsons specific exercise class
A: My supervisor ended up providing most of the education in regards to posture. Now and again while I tried to add in a few ideas along the way. I took the class through the voice exercises which were fairly straight forward. Lastly I took the class through the exercises we had planned out previously. Most of the exerices only required simple instructions, some of which involved sit to stands; calf stretches; regular walking; walking with high knees and side stepping around a circle made with chairs (with direction changes) and step ups. Another exercise done was clock turns on the spot.
R and E: Overall the class ran fairly smoothly and I finished going through the exercises in good time. I tried to appeared confident and speak clearly which I thought I achieved quite well (even though I was a little nervous). Planning the exercises prior to the class helped a lot as I was able to discretely refer to the list during the class which helped it run a bit smoother and made me seem more confident too! I did struggle a bit with a basic exercise on 'clock turning' in terms of wording my instructions well and I wasn't entirely accurate with my instructions either. I was informed during the class that part of the instructions consist of using numbers from the clock to help with the steps of the turn which I stupidly enough did not realise despite them being called clock turns! There were a few instances where I would be busy helping one of the patients in the class and forgot to continue instructing the rest of the class on what to continue with or do next which occassionally disrupted the flow of the class. My supervisor did step in at times due to this however if I was running the class by myself (which I may well have to in future) I would have to make sure I'm more in control. I did find it awkard when I asked the class a question and no one replied - there was only silence in the room!
S: In future I think I could make sure I research anything which I may not know much about e.g. clock turns! This means I'll be more confident with running a class. This will also allow me to be more consistent with what I'm teaching patients without possibly having to re-teach an exercise or let them practice it incorrectly at home until the next class! To avoid awkward silences it might help to ask each person individually about a certain question or topic if appropriate. Learning the patients names would also help with this as I forgot a couple of names during the class so I avoided questioning anyone individually in front of the class! I think a useful strategy I could use to ensure I don't get caught up with assisting an individual patient and forget to continue instructing the class would be for example, to give an instruction to do step ups with the left foot first ten times, then to go onto the right foot instead of just saying step ups starting with the left foot. So, giving a few short, specific and easy instructions means others can continue to do an exercise without having to wait for me to instruct them further.
T: To run an parkinsons specific exercise class
A: My supervisor ended up providing most of the education in regards to posture. Now and again while I tried to add in a few ideas along the way. I took the class through the voice exercises which were fairly straight forward. Lastly I took the class through the exercises we had planned out previously. Most of the exerices only required simple instructions, some of which involved sit to stands; calf stretches; regular walking; walking with high knees and side stepping around a circle made with chairs (with direction changes) and step ups. Another exercise done was clock turns on the spot.
R and E: Overall the class ran fairly smoothly and I finished going through the exercises in good time. I tried to appeared confident and speak clearly which I thought I achieved quite well (even though I was a little nervous). Planning the exercises prior to the class helped a lot as I was able to discretely refer to the list during the class which helped it run a bit smoother and made me seem more confident too! I did struggle a bit with a basic exercise on 'clock turning' in terms of wording my instructions well and I wasn't entirely accurate with my instructions either. I was informed during the class that part of the instructions consist of using numbers from the clock to help with the steps of the turn which I stupidly enough did not realise despite them being called clock turns! There were a few instances where I would be busy helping one of the patients in the class and forgot to continue instructing the rest of the class on what to continue with or do next which occassionally disrupted the flow of the class. My supervisor did step in at times due to this however if I was running the class by myself (which I may well have to in future) I would have to make sure I'm more in control. I did find it awkard when I asked the class a question and no one replied - there was only silence in the room!
S: In future I think I could make sure I research anything which I may not know much about e.g. clock turns! This means I'll be more confident with running a class. This will also allow me to be more consistent with what I'm teaching patients without possibly having to re-teach an exercise or let them practice it incorrectly at home until the next class! To avoid awkward silences it might help to ask each person individually about a certain question or topic if appropriate. Learning the patients names would also help with this as I forgot a couple of names during the class so I avoided questioning anyone individually in front of the class! I think a useful strategy I could use to ensure I don't get caught up with assisting an individual patient and forget to continue instructing the class would be for example, to give an instruction to do step ups with the left foot first ten times, then to go onto the right foot instead of just saying step ups starting with the left foot. So, giving a few short, specific and easy instructions means others can continue to do an exercise without having to wait for me to instruct them further.
Saturday, June 19, 2010
Initial entry: placement 4
Prior to commencing this last placement, I still have the same nerves as I have had prior to starting my other placements for many of the same reasons! However, I do feel as though I have a little more confidence in myself and my abilities. I am looking forward to working in a more specialised area of neurology in that I will be mainly dealing with Parkinson's patients. The fact that it is a specialised area initially made me assume that it will not be too difficult to get through or prepare for however I am sure there is a lot more to it than I expect and I have come to learn there are always challenges in the real clinical setting which books cannot prepare you for. I don't think the particular setting I will be going into will be as fast paced or stressful as some of my previous placements and I may have more time to plan and reflect on my performance day by day. I expect I will be dealing with an older age group of patient's which I have had experience with already and I am therefore not feeling too concerned about coping with this aspect of the placement.
I am expecting to have to take a few outpatient exercise classes as well as possibly design individual exercise programmes to be done in these classes. I will have to be quite creative and confident in doing the above as well as learn to give patients strategies and education for Parkinson's specific problems such as freezing and an altered gait pattern. I am a little anxious about not being able to do this effectively or on the spot! I am expecting to have to use a few outcome measures such as the timed up and go test. The placement will provide a good opportunity for me to gain some experience in regards to what outcome measures are appropriate to use and when and also about how to carry these assessments out effectively. I am fairly comfortable with the idea of having to do this frequently during the placement. In relation to Parkinson's patients, I will have to be aware of timing my treatment with their medications and will have to know the effects of these medications which I am hoping I will learn to be confident with and will have to continue to research over the course of the 5 weeks. I am nervous about potentially coming across patients who not only have Parkinson's disease but who may also have another co-exisiting disease which I will have to consider in my management (and I'm sure I will come across this!). In regards to this I think knowing how to modify my management while ensuring it is still effective will be the challenge.
Overall, I am anxious but at the same time eager to work in a new environment. Hopefully by the end of the placement I will be a full bottle on Parkinson's patients and many of my concerns will be eased as I go!
I am expecting to have to take a few outpatient exercise classes as well as possibly design individual exercise programmes to be done in these classes. I will have to be quite creative and confident in doing the above as well as learn to give patients strategies and education for Parkinson's specific problems such as freezing and an altered gait pattern. I am a little anxious about not being able to do this effectively or on the spot! I am expecting to have to use a few outcome measures such as the timed up and go test. The placement will provide a good opportunity for me to gain some experience in regards to what outcome measures are appropriate to use and when and also about how to carry these assessments out effectively. I am fairly comfortable with the idea of having to do this frequently during the placement. In relation to Parkinson's patients, I will have to be aware of timing my treatment with their medications and will have to know the effects of these medications which I am hoping I will learn to be confident with and will have to continue to research over the course of the 5 weeks. I am nervous about potentially coming across patients who not only have Parkinson's disease but who may also have another co-exisiting disease which I will have to consider in my management (and I'm sure I will come across this!). In regards to this I think knowing how to modify my management while ensuring it is still effective will be the challenge.
Overall, I am anxious but at the same time eager to work in a new environment. Hopefully by the end of the placement I will be a full bottle on Parkinson's patients and many of my concerns will be eased as I go!
Sunday, June 13, 2010
final entry- placement 3
After finishing this third placement I find I can confidently reflect on most of my concerns and expectations written in my initial entry. I was initially anxious about working in a tertiary hospital. This was certainly daunting and I found myself lost on many occassions however once I found my feet I felt more confident like you would in any other working environment. I found it a lot easier than I thought to apply the theory in cardiorespiratory physiotherapy. Overtime I learnt to apply this quickly in situations which inevitably you have to be able to do! For example, I had a patient who was too nauseous and her blood pressure was too low for me to get her out of bed, so I corrected her position in bed by correcting her slump and increasing the head tilt to the bed which improved the position of her lungs and therefore optimised their ventilation which improved her oxygen saturations and general comfort and ease of breathing. I learnt simple interventions like this could be used and be effective enough in situations where there is only so much you can do at the time. I was concerned about the pressure of working in an acute setting and managing patients safely. I found that I gradually was less and less worried about this as the placement went on as one gets into the habit of checking medical files and bedside notes which give a lot of information to help guide your thoughts on the appropriateness of assessments and treatments. I came to learn that the nursing staff are also very helpful in reassuring you about attachments and how to manage them as well as how a patient is progressing and often have a comment on what they can or can't do with you. Attachments were another big concern of mine! As mentioned the nurses were helpful and obviously very knowledgeable in regards to these. I did make some mistakes with these, for example I forgot a patient had an IDC in-situ and their other attachments which were on a mobile pole were still plugged into the wall. However I learnt from these mistakes and was much more aware of and confident in managing these towards the end of the placement.
I was hoping to improve on my time management over the course of the 5 weeks. I feel as though I did improve on this and adopt strategies to help me do this especially with the help of feedback from my supervisor and tutor. Although this still needs further improvement. This will be very important for me to work on as I would not successfully run a ward on my own with such time management which I may have to do once graduated! This realisation really helped motivate me to work on my time management. I am aware of the factors that contribute to my poor management so will strive to work on these during my next placement.
I knew I would be expected to have at least a basic understanding of common medications while on this placement which I feel I know have. I was looking forward to analysing chest xrays and applying the information they gave to my management of patients. I did really enjoy this aspect of the placement and became a lot quicker with analysing these and identifying abnormalities. I was also keen to get the chance to practice the many techniques we have learnt at university. I did find towards the end of the placement that I felt like I was doing the same interventions with most patients however after discussion with my supervisor I was reassured that on a general surgery ward (where I was placed), this is fairly common as long as one knew when to use an alternate, less 'common' intervention. The placement was great in that I was allowed to practice some hands on techniques which have conflicting evidence behind them and evaluate their effects for myself, for example rib springing. The placement did make me think about the evidence out there and how to apply it to my patients. For example, the evidence about incentive spirometry suggests it is not that effective nor more effective than other hands on techniques such as thoracic expansion exercises (TEE's). I found that a lot of patient's responded better to TEE's than to using an incentive spirometer for many reasons.
Finally, I was looking forward to working within the multi-disciplinary team and gained experience and a bit more confidence in liaising with doctors and other members of the team. I learnt when it was and what was important to report to the other members and how to go about handing over information while considering the fact that they were very busy too.
I feel as though my confidence has definitely grown and I am really proud to be becoming a physiotherapist! My knowledge base in regards to cardiorespiratory physiotherapy has been consolidated really well and I think I am more experienced at the end of these 5 weeks in dealing with other members of the team and with interesting individuals and situations that I will no doubt come across when out there working! I have established a fairly clear idea in my head about the differences between working in a private practice compared to a hospital setting and this will hopefully eventually guide me into making a decision with my likely career path.
I was hoping to improve on my time management over the course of the 5 weeks. I feel as though I did improve on this and adopt strategies to help me do this especially with the help of feedback from my supervisor and tutor. Although this still needs further improvement. This will be very important for me to work on as I would not successfully run a ward on my own with such time management which I may have to do once graduated! This realisation really helped motivate me to work on my time management. I am aware of the factors that contribute to my poor management so will strive to work on these during my next placement.
I knew I would be expected to have at least a basic understanding of common medications while on this placement which I feel I know have. I was looking forward to analysing chest xrays and applying the information they gave to my management of patients. I did really enjoy this aspect of the placement and became a lot quicker with analysing these and identifying abnormalities. I was also keen to get the chance to practice the many techniques we have learnt at university. I did find towards the end of the placement that I felt like I was doing the same interventions with most patients however after discussion with my supervisor I was reassured that on a general surgery ward (where I was placed), this is fairly common as long as one knew when to use an alternate, less 'common' intervention. The placement was great in that I was allowed to practice some hands on techniques which have conflicting evidence behind them and evaluate their effects for myself, for example rib springing. The placement did make me think about the evidence out there and how to apply it to my patients. For example, the evidence about incentive spirometry suggests it is not that effective nor more effective than other hands on techniques such as thoracic expansion exercises (TEE's). I found that a lot of patient's responded better to TEE's than to using an incentive spirometer for many reasons.
Finally, I was looking forward to working within the multi-disciplinary team and gained experience and a bit more confidence in liaising with doctors and other members of the team. I learnt when it was and what was important to report to the other members and how to go about handing over information while considering the fact that they were very busy too.
I feel as though my confidence has definitely grown and I am really proud to be becoming a physiotherapist! My knowledge base in regards to cardiorespiratory physiotherapy has been consolidated really well and I think I am more experienced at the end of these 5 weeks in dealing with other members of the team and with interesting individuals and situations that I will no doubt come across when out there working! I have established a fairly clear idea in my head about the differences between working in a private practice compared to a hospital setting and this will hopefully eventually guide me into making a decision with my likely career path.
week 5 post - prac 3
S: 49 year old female day 1 post- right hemicolectomy with a past medical history of diverticulitis; recent diagnosis of lung cancer (being treated with chemotherapy); hypertension; and a hysterectomy. The patient was a non-smoker with no history of smoking which she stated to me after saying she had been diagnosed with lung cancer. She was previously independent with all ADL's and ambulant with no aid. She currently lived with her husband and reported they were in the middle of moving houses prior to the surgery. She will be staying at her sister-in laws upon discharge as her husband and herself were meant to be staying in their small caravan in between moving houses. The patient had already gotten out of bed with the nurse to have a shower (approx. 15metres away) and was sitting out of bed with her husband present when I walked in to see her. The nurse informed me she had just been switched to oral pain relief from a PCA and had just been given some pain relief. The surgeon's orders were to do 'chest physio.'
T: to perform a routine post-operative assessment on the patient and provide appropriate treatment
A: I checked the patient's obs chart and all her obs were stable and she was afebrile. The patient did not report any dizziness, shortness of breath or nausea/vomiting. She reported coughing earlier which was productive of small amounts of pale yellow sputum. She reported pain as 4/10 at rest and 8/10 with a cough (unsupported cough) and transfers. Pain was 3/10 with ambulation. When I asked how she coped with getting out of bed she reported it was very painful. I assessed her cough, chest expansion, auscultated her chest, checked her oxygen saturation and heart rate and re-measured her blood pressure (hereafter BP) again as it had been taken many hours before. On the physical assessment I found that her oxygen saturations were within normal limits on room air (97%) as were her heart rate and BP. On auscultation I heard fair-good breath sounds bi-basally with the left base being better than the right. Mid. fine inspiratory crackles were audible on the right lower lobe posteriorly. Breath sounds were good elsewhere. Her cough was moderately strong, effective, non-productive and slightly moist. Pain was 6/10 with the cough being supported. Chest expansion was fair on the right and good on the left basally. I also assessed her mobility:her transfer from sit to stand from a high backed chair as well as her ambulation. The sit to stand transfer was independent but very painful. She was safe to ambulate independently however during the walk she turned pale and reported her pain went from a 3/10 to a 5/10 and required a quick rest. Upon arriving back to her room from the walk which was approximately 120m on the ward the patient had nil complaints apart from pain 5-6/10 and felt tired. Her oxygen saturations were normal (98% on RA) and her cough was strong; dry and non-productive and the crackles were almost inaudible in the base of her right lung and both chest expansion and breath sounds had improved here. She was happy to sit out in her chair. I realised I hadn't had a chance to assess her bed mobility or transfer out of bed so asked if I could assess it quickly. The patient consented. I also educated the patient on a supported cough, transfer skills, deep breathing exercises and regular ambulation as tolerated.
R: From my assessment and re-evaluation of my intervention I obtained a good picture about the patient's function and the 'state' of her chest. The patient was thankful for the education I had given her and reported feeling reassured that she had been told how to get out of bed in a way that wouldn't aggravate her pain as much; her pain was less with the cough being supported (6/10) and her cough was stronger. Her 'chest' had improved. However, after getting the patient to try getting in and out of bed (with my assistance) she complained of pain 8/10 and became quite anxious. Her husband did not seem impressed at all either!
E: I thought I was fairly thorough in my assessment of the patient and monitored the effects of my intervention well up until I realized while the patient was trying to get in and out of bed that it wasn't necessary for me to get her to do that again. The reasons being were that pain appeared to be her overwhelming complaint and I had identified it has the priority out of the 'problem list.' Features from my subjective and objective had demonstrated this, for example, high pain scores, her being switched to oral analgesia which provides less immediate relief from pain compared to a PCA and her having to take a rest during ambulation secondary to pain. Also, pain is very psychological and in this patient's case possibly even more so as she has had previous pain experiences in the past (surgeries) and has had to go through the psychological stress of being diagnosed and treated for cancer. Socially, she would also have been going through a stressful time with moving house and then unexpectedly needing the surgery. This all impacts on the pain experience. I think I should have taken this into account at the time much more as pain can impact hugely on patient outcome and psychological state. I could have prevented aggravating her pain as much by not assessing her transfers in and out of bed.
S: Strategies which I could use to improve on a similar situation would be to take in and consider the bigger picture with a patient and from this decide how I can better modify and in a way accomodate my approach to assessing and treating the patient. This way I won't build up a rapport with a patient (and their family) and then ruin it slightly by doing something unecessary that may make the patient lose confidence in me. I could have explained why I was getting her to try get in/out of bed better but ultimately it would have been a better decision to leave that part of the mobility assessment out. I could easily have assessed it the next day if required and documented this in my plan. Instead I was worried I would not be able to put it in my notes for the nursing staff to see and they might have questioned this. I could have trusted my judgement better and not assessed this. I could even become more confident with being prepared to stand up for my clinical decision making instead of making one that negatively affects my management of a patient.
T: to perform a routine post-operative assessment on the patient and provide appropriate treatment
A: I checked the patient's obs chart and all her obs were stable and she was afebrile. The patient did not report any dizziness, shortness of breath or nausea/vomiting. She reported coughing earlier which was productive of small amounts of pale yellow sputum. She reported pain as 4/10 at rest and 8/10 with a cough (unsupported cough) and transfers. Pain was 3/10 with ambulation. When I asked how she coped with getting out of bed she reported it was very painful. I assessed her cough, chest expansion, auscultated her chest, checked her oxygen saturation and heart rate and re-measured her blood pressure (hereafter BP) again as it had been taken many hours before. On the physical assessment I found that her oxygen saturations were within normal limits on room air (97%) as were her heart rate and BP. On auscultation I heard fair-good breath sounds bi-basally with the left base being better than the right. Mid. fine inspiratory crackles were audible on the right lower lobe posteriorly. Breath sounds were good elsewhere. Her cough was moderately strong, effective, non-productive and slightly moist. Pain was 6/10 with the cough being supported. Chest expansion was fair on the right and good on the left basally. I also assessed her mobility:her transfer from sit to stand from a high backed chair as well as her ambulation. The sit to stand transfer was independent but very painful. She was safe to ambulate independently however during the walk she turned pale and reported her pain went from a 3/10 to a 5/10 and required a quick rest. Upon arriving back to her room from the walk which was approximately 120m on the ward the patient had nil complaints apart from pain 5-6/10 and felt tired. Her oxygen saturations were normal (98% on RA) and her cough was strong; dry and non-productive and the crackles were almost inaudible in the base of her right lung and both chest expansion and breath sounds had improved here. She was happy to sit out in her chair. I realised I hadn't had a chance to assess her bed mobility or transfer out of bed so asked if I could assess it quickly. The patient consented. I also educated the patient on a supported cough, transfer skills, deep breathing exercises and regular ambulation as tolerated.
R: From my assessment and re-evaluation of my intervention I obtained a good picture about the patient's function and the 'state' of her chest. The patient was thankful for the education I had given her and reported feeling reassured that she had been told how to get out of bed in a way that wouldn't aggravate her pain as much; her pain was less with the cough being supported (6/10) and her cough was stronger. Her 'chest' had improved. However, after getting the patient to try getting in and out of bed (with my assistance) she complained of pain 8/10 and became quite anxious. Her husband did not seem impressed at all either!
E: I thought I was fairly thorough in my assessment of the patient and monitored the effects of my intervention well up until I realized while the patient was trying to get in and out of bed that it wasn't necessary for me to get her to do that again. The reasons being were that pain appeared to be her overwhelming complaint and I had identified it has the priority out of the 'problem list.' Features from my subjective and objective had demonstrated this, for example, high pain scores, her being switched to oral analgesia which provides less immediate relief from pain compared to a PCA and her having to take a rest during ambulation secondary to pain. Also, pain is very psychological and in this patient's case possibly even more so as she has had previous pain experiences in the past (surgeries) and has had to go through the psychological stress of being diagnosed and treated for cancer. Socially, she would also have been going through a stressful time with moving house and then unexpectedly needing the surgery. This all impacts on the pain experience. I think I should have taken this into account at the time much more as pain can impact hugely on patient outcome and psychological state. I could have prevented aggravating her pain as much by not assessing her transfers in and out of bed.
S: Strategies which I could use to improve on a similar situation would be to take in and consider the bigger picture with a patient and from this decide how I can better modify and in a way accomodate my approach to assessing and treating the patient. This way I won't build up a rapport with a patient (and their family) and then ruin it slightly by doing something unecessary that may make the patient lose confidence in me. I could have explained why I was getting her to try get in/out of bed better but ultimately it would have been a better decision to leave that part of the mobility assessment out. I could easily have assessed it the next day if required and documented this in my plan. Instead I was worried I would not be able to put it in my notes for the nursing staff to see and they might have questioned this. I could have trusted my judgement better and not assessed this. I could even become more confident with being prepared to stand up for my clinical decision making instead of making one that negatively affects my management of a patient.
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