Final entry rotation 4

Stares final entry rotation 4

I have come to the end of the practical component of my course. I have found this year quite stressful and I will be happy to move onto the next step leading to completion of my physio degree.

Looking back on the initial reflection for this rotation, I my role was pretty much what I expected it to be. I worked in conjunction with another junior therapist. This was challenging initially as I had to democratically ask my supervisor to back away slightly from the decision making role on the ward to give me a chance to show her my skills as a junior therapist. This conflict was resolved easily through good communication. It also helped that my supervisor was a very accommodating and open professional.

All in all the practical experience flowed very easily and I was able to assimilate very without difficulty into the work environment at PHC. Perhaps the only main negative I could see on this prac rotation was the lack of neurology patients I was able to see for what was meant to be my main neurology experience as an undergrad. Despite this, my time at PHC did give me many opportunities to see a wide variety of patients, which I enjoyed.

Although it has been a long year, I am finally seeing the pay off from all of my hard work. Looking back on the first rotation I did this year, I was shy, non confident and reluctant to tackle problems independently for fear of making mistakes. This is a stark contrast to the student I feel I am today. However I could not have grown in such a way as a professional without the consistent practical experience I have had over the past 7 months. By having to adapt to a diverse array of clinical situations, and a diverse array of work places I now feel I could take any situation, in my stride. I stated that the most important thing I learned in my first rotation this year was confidence in my abilities. This statement still rings true in my last rotation as I feel that my confidence and ability to adapt only continued to grow.

Stares entry three rotation 4

Stares entry 3 rotation 4

Situation
Today I received a referral on the ward to see an 80 year old lady who was admitted to PHC due to delirium and decreased mobility resulting from a UTI. The referral stated that the patient was ready for a discharge mobility review and could go home once able to transfer independently.

Task
Evaluate the patient’s suitability for discharge home.

Action
I observed the patient’s mobility watching her transfer on and off the bed, did a quick balance screen and watched the patient walk a few metres to her chair. The patient seemed quite confident on her feet.
I then documented my findings in the patient notes, evaluating that the patient would be safe to go home with some support such as a care package. Soon after documenting this in the notes the nurse responsible for this patient came up to me and said “Are you sure she is ok to go home? How far can she even walk? It’s going to come back to us is she goes home and falls.”I began to doubt myself because I hadn’t actually measured the patients walking distance. I had only met this woman once and had only done a quick screen of her mobility. I got the feeling that she would be able to cope at home because the referral only stated that she needed to be able to transfer independently.
I went back to the patient’s room to recheck her mobility. She was able to walk 30 metres with ease using a WZF and her mobility was definitely adequate to go back to her retirement home. I presented this information to the nurse who was still not entirely happy with my decision. After speaking to the coordinator and checking that the patient would be having care support over the weekend, the nurse acknowledged that perhaps the patient should go home.

Result
The patient was to be transferred home with a 7 day per week home support package. This was a good outcome, however I did appear slightly incompetent to some members of the ward’s nursing staff. As well as this, what started as a quick mobility assessment ended up consuming allot of my time a bit unnecessarily.

Evaluation
I had attempted to shorten my assessment by quickly observing the patient and making conclusions based on what I had seen. I was then unable to provide other members of the MDT with objective information, therefore they did not take me seriously, doubting my abilities.

Strategies
Improve my presentation of the evidence – provide team members a systematic, well planned argument.
Learn to tailor my assessment, while keeping in mind the need for objective measures to back up any decisions I make.
Prioritise outcome measures in assessment.
Be confident when talking to other members of the team.

Stares 2 rotation 4

Stares 2 Rotation 4

Situation

Although I am on a neurology placement, I am really on a restorative unit at a relatively small hospital. This means I am often called up to the ward to treat chests and carry out complex mobility reviews. I received a referral to see Mrs M, an 80 year old lady who had suffered a fall and subsequent radial fracture. As the fracture was complicated, she received an ORIF. Post surgery she was suffering from delirium and the nursing staff were having difficulty mobilising her, reporting she was impulsive and very unsteady on her feet. On this particular day I had received 10 new physiotherapy referrals, this is a great deal considering on a usual day I would be likely to see around five patients on the ward in one afternoon. After carrying out a fairly superficial investigation of the patient notes, my main findings were that this patient was previously independent with mobility, living in a hostel. She also had a PMHx of dementure.

Task

Complete safe Ax and Rx of patient - aiming for mobilisation.

Action

Mrs M was very chatty when I initially went to asses her. TPP revealed orientation to place and person but not time. She was also unaware of her recent fall and subsequent surgery. Although it was clear Mrs M was not completely orientated, she seemed compliant.

I proceeded to a mobility review in bed. She was able to bridge, plantar flex and dorsiflex with 5/5 strength left and right and her quad strength was – 4/5 left and right. For the reasons outlined above, I deemed this patient safe to mobilise.

After organising Mrs M’s attachments and helping her to the edge of the bed with minimal assistance, I asked Mrs M to stand up. Half way through the stand she began to push back against my support. I had to hold her upright using my bodyweight and arm strength. While in this position, after allot of coaching I managed to get Mrs M into a full stand. She was still very frightened and confused. I asked Mrs M to take some steps on the spot, which she did with great difficulty. She wasn’t really following my commands, pushing her frame away from herself instead of walking with the frame. She was very unsteady on her feet. After realising that Mrs M was near the end of her tether, her confusion and resistance to instruction increasing, I tried to return her to bed. Again she was not responding to commands, she began arguing with my instructions and shouting obscenities at the top of her lungs.

Result

My physical wellbeing as well as the physical well being of the patient had been put at risk because I did not have enough support for the treatment. Although I was able to get the patient back in bed, I would say the result was quite unsafe.

Evaluation

In planning this treatment session I had not assessed to risk of the transfer thoroughly enough. This resulted in an unsafe treatment session. I could have minimised the risk of injury to myself and the patient by more closely assessing the patient’s cognitive state and further investigating what had happened on previous occasions when the nursing staff had attempted to get her out of bed. I think if I had better forward planning and a more thorough prior assessment of past interventions with this patient I could have better managed the risks of treating such a patient.

Strategies

I need to more thoroughly assess the patient’s notes. In this case the nursing staff were having particular trouble mobilising this patent, so I should have further investigated this in person with the staff.

Communicate more readily with other HCPs from other disciplines.

If in doubt I will not hesitate to ask for assistance.

I need to improve forward planning. I need to visualise what I need to do and what the patient might be like before seeing the patient. I think this will improve, the more experience I get.

Stares Entry 1 rotation 4 2010

Stares Entry 1 Rotation 4 2010

Situation

Day one of the placement and first task of the day, my supervisor asked me to do an initial assessment of an orthopaedic patient. This patient was a day 2 post ORIF for a L fractured humerus. She was very mobile and was fully independent with mobility, using only a stick for ambulation. I felt quite nervous because I had never had to see a patient in front of my supervisor on the first week, let alone the first day before.

Task

Initial geriatric assessment of a new patient.

Action:

I began my assessment asking subjective questions regarding the patient’s pre-morbid status, home situation and social history. This part of the assessment went reasonably well but when it came to the objective testing I became a bit flustered. Although I knew how I would do a geriatric assessment, I wasn’t sure how much detail to go into in front of my supervisor. I decided to do a very thorough examination. After completing COVS, muscle strength and ROM testing, my supervisor told me I was being a little too thorough and that I needed to move onto some balance testing. At this point I got a little flustered. For sitting balance I had a very brief look at the patient’s ability to reach out of their base of support. After the patient demonstrated this with ease I go them into standing. For standing balance I looked at wide stance, stance with feet together and realising the patient was finding this easy decided to move onto dynamic standing balance. I asked, Mrs H to march on the spot, not holding onto anything. She was able to do this; however she did wobble around while doing about 5 steps. The task was certainly challenging for her.

Result:

My supervisor was not too impressed by my assessment of standing balance. She was not happy that I had jumped straight from static standing balance tasks to a fairly challenging dynamic standing balance task. In hind-sight I know this was probably not the best way to asses a patient.

Evaluation:

I had rationalised that marching on the spot would take my assessment up to a level where it would be challenging. It did do this but it was borderline unsafe. I did not properly asses the tasks that should precede that level of balance activity for me to make an informed decision about what I should ask the patient to do next. I think my performance would have been far better if my supervisor had been able to show me the way she would asses a new client initially.

Strategies:
Have a better formulated ideas of what your assessment will entail before commencing.

- For example, next time I am asked to do a systematic assessment of balance I will do static sitting balance- internal perturbations – external perturbations – static standing balance (including variations on foot position and eyes open vs eyes closed) – internal perturbations in standing (such as look behind and march on the spot)– external perturbations in standing.

Try to keep my cool even I am under pressure.

Try to communicate more efficiently with my supervisor. Perhaps I should have asked for the opportunity to see how she would like the assessment to run, this way I wouldn’t have been guessing what she wanted me to do, while getting increasingly flustered.

Initial journal entry -Rotation 4

Initial journal entry -Rotation 4

If I was to be honest about my opinion on doing another prac rotation, I can’t wait to get this last one over and done with. Although I know I still have a great deal to learn, I am starting to feel I am more of a physiotherapist and less of a physiotherapy student. I’m looking forward to finally being able to take the last few steps towards getting the degree I’ve been working towards for what seems like forever. I hope this rotation will give me the chance to widen my knowledge about the role of physiotherapists in treating neuro patients in sub-acute settings. I hope I will be able to help the patients I see make real functional improvements. I am a little nervous because neurology was not my strongest subject when we studied the theory side of things at uni, but I am hoping by being able to apply theoretical knowledge into practical situations my skills in this area will grow.

From speaking to another fourth year student who has been on this placement earlier in the year, I am expecting to be doing quite allot of group work with mostly older patients effected by neurological conditions. I understand that I will be doing some one-on-one therapy with those patients who are not yet up to the level of function needed to participate in the group sessions.

Initially, I expect that I will be doing some observation and some hands on work. As I this is my last placement I would not be surprised if the introduction/ observation period was as much as one day. Once I am familiar with the setting, I expect I will be assessing new patients, taking the group classes and working with individual clients just as another physiotherapist at the facility would work. Although I expect to be taking on a similar role to a junior physiotherapist, as a student, I will still be working under the guidance of my supervisor.

As I am now well used to the process of going on prac, I don’t have any major concerns about this rotation. From the sounds of things this rotation will be a good learning opportunity and I am looking forward to getting this one checked off, to move a bit closer to graduation.

Final entry rotation 3

Final Entry Rotation 3

Carinya on Bristol is a 41 bed facility that caters for those older people who may need some further rehabilitation before they go to a place of permanent residence. From my previous 4P experience of gerontology, working in a high care facility, I had reservations about what this placement would be like and how much improvement I would see from my patients at Carinya. Geriatric rehab is an area of physiotherapy I would not have considered working prior to this experience. I was pleasantly surprised at how much my patients progressed, and just how fun and rewarding this role was.

My role at Carinya was primarily to asses new clients as they came to the facility and work with those clients who needed one-on-one therapy. There were group programs at the facility run by the therapy assistants which formed a great adjunct to individual therapy. Perhaps the most important part of my role was developing a rapport with my patients and tapping into their goals. Although this part of the job came relatively easily to me, in order to use the relationships, developed with the patients, to engage them in rehab I had to build on my assessment and treatment skills. This is something I feel I succeeded in. I turned my assessments from a ritual into a systematic, tailored routine. I also learned along the way the importance of goal setting in treatment plans, these became more structured. I think this made the therapy more rewarding for the patients as they could see their achievements more clearly.

In addition to these fairly basic skills, at Carinya I got many opportunities to do higher level administrative tasks. I was frequently liaising with the nursing and care staff, the social worker and OT, as well as the Drs at the weekly team meetings. On a number of occasions I was able to advocate for patients and provide evidence to the team about why they should have what they were asking for. I was not only able to see the day to day improvements of some of the patents, but understand what it takes from all aspects of care to get patients back home. It was this level of involvement with the patients that made the placement so rewarding.

Although gerontology is not always glamorous, I have found most of these patients a pleasure to work with. You would be surprised how grateful people are when you help them to achieve what might seem like a simple goal, for instance to be able to make it to the toilet to preserve your continence. Being able to help people achieve the simple things we all take for granted is very rewarding. It is this aspect of this placement that had made me realise gerontology/rehab is an area I may like to work in some time in the future.

Stares3 rotation3

Stares 3 rotation 3

Situation:

We had received a new admission at Carinya, since my supervisor was tied up in meetings all day, I was asked to conduct an initial assessment of this patient. Mrs K was an 81 year old lady who had been run over by a car, resulting in a significant brain injury and cervical spine fractures. She had loss of motor control, cognitive function and very poor communication. Mrs K was previously very high functioning, living on her own independently with no assistance and no aids. I was aware that this lady was a 2 person assist transfer from reading her transfer summary. To conduct the initial assessment, I had to get the help of one of the carers at the facility.

Task:

Asses Mrs K’s mobility in order to liaise with the staff at Carinya in regard to independence and assistance requirements.

Action:

The carer who was available to help me with the transfer happened to be one of the more experienced carers. As soon as she entered the room, she was very assertive. As I was a student and a guest in the facility, I automatically took the subordinate role. The carer suggested we do a one-step transfer, based on the handover, I agreed. When trying to communicate to the patient what we would be doing, the carer was pulling the patient forward in the chair. With the carer leading the commands, we began the transfer. Once we had this lady up, she did not seem to understand our commands. Without much warning, the carer quickly pivoted the patient around, sitting her on the bed. I could see this was very painful for the patient as her neck was still very sore from the fractures. Once the patient was on the edge of the bed, I began asking her to move to lie down on the bed. Mrs K began to move slowly, again the carer jumped in and pivoted the patient into bed. I could see this was also painful for the patient. Once the patient was in bed, the carer, who was clearly in a hurry, asked me if I was ok and promptly left me to it.

Result:

Although I was able to asses Mrs K’s mobility, achieving my task, the transfers were not done safely or comfortably for the patient. By taking a subordinate role, I was not acting as a soon to be graduate, because of this; the patient did not have an optimal assessment.

Evaluation:

I did not take control of the situation where I needed to. As a guest in the facility, I was trying get along with everyone by allowing the carer to feel as though I respected her, letting her tell me what to do. However, this was probably not a wise decision as the result was pain and discomfort for the patient as well as less than optimal safety. This situation has made me realise that I am the one with the skills and training to do the most appropriate transfer and assessment of the patient. Therefore I should be assertive and take the role of leader, especially with these types of high dependency patients.

Strategies:

Don’t be shy; take on the role of the physio because you will be one soon!

Be assertive but open to suggestions.

Plan ahead so you are confident about what you want to do and. -Portray this confidence to anyone you are working with including the patient.

Make others feel important by asking their opinion, but ultimately deciding how to deal with the patient and explaining why you have made that decision.

Be sure to communicate with the person you are working with throughout the task and give them feedback. – Also be open to feedback.