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.

Stares 2 rotation 3

Stares 2 rotation 3

Situation:

Mr J was my first patient from admission, during my first week at Carinya. He was an 81 yo male, three months post CVA (stroke). He had extensive left sided involvement. His main problems were impulsivity, left neglect, poor coordination and timing, as well as poor balance. He was functioning independently, despite looking a little unsafe. To achieve his goal of returning home, I decided the main areas of therapy focus should be improving safe, functional, independent mobility and ambulation. In this reflection will review my treatment planning and execution over the first two weeks of Mr J’s rehab.

Task:

Rehab this patient aiming for the optimal goal of returning home. As this was my patient from his admission this would involve laying the foundations of his rehab program at Carinya.

Action:

Rather than form a comprehensive treatment plan, the document I filled out on assessment was more of an overall look at what I planned to address. As I had no clear frame work to follow, I tended to formulate treatment plans daily. Although I feel I had many fresh ideas, they would usually come to me sporadically and I would try them out for something different as I went along. This meant Id often changed treatment aims from one day to the next or even within the one session. One day I might be doing some strength work, followed by some balance work, the next day Id focus the whole session on something functional such as a transfer or ambulation.

Result:

By the start of the third week I started to feel as though I was running out of new Ideas and I had to go back and revisit some of the old activities I had done. I also began to feel that the patient did not have much of a sense of achievement or progression.

Evaluation:

As Mr J was very impulsive and was always excited to try anything new, I feel I was spurred on to try new things all the time for fear of the sessions becoming boring. In hind-sight, this may have been to the determent of the patient. The sessions lacked direction and flow. Now, although I feel the patient has progressed, I feel he has a decreased sense of just how far he has come.

Strategies:

· Formulate long term and short term goals in the initial treatment plan, rather than general goals.

· Further refine this in your own notes breaking down goals into daily, weekly and monthly aims. -Perhaps using a grid style document to achieve this.

· Have one particular focus for each session.

· Make some aspects of the program documentable on a daily basis, some sort of quick test such as distance cycled in a certain time on stationary bike or distance of functional reach test.

Stares 1 rotation 3

Stares 1 rotation 3

Situation:

I had been given a patient who was in her last three weeks of rehab. I was told to follow on from the previous therapist who had been in looking after Mrs R. According to her program plan Mrs R’s main problems were independent mobility and endurance with ambulation. The aim was to address these problems with the aim of discharge home. I had seen this patient twice at this stage, with her husband present. Mrs R was fairly obliging during these sessions although did complain of pain. Her husband was very supportive, providing Mrs R allot of encouragement.

Task:

Continue rehab of Mrs R with the goals of increasing independent mobility and ambulation.

Action:

Third day of therapy: Went into see Mrs R, her husband was not present as he had renovations to attend to at their house which would last two weeks. Mrs R she flatly refused to move from her room, saying she was in far too much pain to do anything. I accepted this planning to come back the next day.

Fourth day of therapy: I received much the same response as the third day. I sought advice from my supervisor who told me that Mrs R was very hard to get motivated at times, particularly when her husband was not present. She also told me that there was nothing physically wrong with her that could explain her reluctance to engage in rehab.

Fifth day of therapy: Mrs R refused again when asked if she would come to the gym for exercise or go for a walk, however after much encouragement agreed to do some work within her room. Once I was able to get Mrs R started on her exercises in her room, she then agreed to come for a walk and we were able to do a full session of rehab.

Result:

Two days of rehab had been wasted. It is more than likely that all the mobility Mrs R had done in the two days she was not seen was walk 10 m to the dining room and back for her meals. Though I do not think the patient regressed, she certainly didn’t progress in the two days with no therapy. On top of this, once she became engaged in the therapy she actually enjoyed it, asking if I could come by tomorrow.

Evaluation:

It is my opinion that I perhaps did not know enough about this patient in the first place to know how hard to push her. However, I should have sought advice from the start, rather than letting the patient go for two days without therapy. Reflecting on the type of patients the facility takes on, I think this will not be the only time I will come across this type of patient on this rotation. I think I need to be more firm with these types of patients in the future. In the end this lady actually enjoyed her session in the end, as well as bringing her a little closer to her goal of returning home.

Strategies:

· Invest more time communicating the importance behind the therapy.

· Tap into the goals of patients and use to engage them.

· Develop a clear plan with goals. Present the plan to the patient so that they can see what needs to be achieved to reach their goals.

· Invest in stakeholders – In this case I could have contacted the husband.

Initial entry rotation 3

Initial Entry

Having gone to a placement in an acute setting in a tertiary hospital, and a community setting I am excited to see what things I will learn from a transitional care facility such as Cariniya.

From what I understand so far, Carinya provides permanent high care beds as well as transitional care service (TCS) beds to frail and elderly people. The Physiotherapy department has an ongoing (group based?)program in place as well as individual programs for residents. I suspect the main aims of these programs would be to optimise and maintain the residents’ physical mobility and fitness.

I only have one main concern at this stage. That is some of my peers and one supervisor at my last prac have given me some negative impressions about the prospect of going to a ‘nursing home’ for this rotation, however I am still optimistic about the placement. As a prospective new graduate it is my thinking that, with our aging population, it is likely that these types of positions will become very important in the future for physiotherapists. Therefore it is important for me to have a good understanding of how these facilities are run. This rotation will provide me with that opportunity.

In addition to this, I believe this placement will give me the opportunity to cement some of the important knowledge I have already gained this year. In particular, communication with older adults, making exercise fun and engaging, confidently running group situations and liaising with HCPs from other disciplines.

In my time at Carinya, I would like to further develop my specialist gerontology skills. I imagine as a base line, I will be expected to know how to professionally and successfully conduct both subjective and objective gerontology assessments, as well as some basic treatments. I hope to build on these expectations on this rotation by achieving the following skills: Accurately prioritising gerontology assessment (S and O), detailed analysis of patients’ impairments, activity limitations and participation restrictions, a well as taking a more holistic approach to treatment planning.

I hope that in going on a rotation at Carinya, where the patients are not acute, I will get the opportunity to do allot of my work independently as I know that I work best when I am forced to problem solve through situations as they arise, and am sometimes put off by having a supervisor looking over my shoulder. (Although I am aware this is a necessary part of assessment on occasion).

Overall, I am optimistic that if I have the right attitude towards the placement I hope I can get allot out of it. I am looking forward to Monday to see exactly what type of case load and responsibility I will have at Carinya.

Final Entry Rotation 2

Final Entry Rotation 2

This placement had given me a good taste of the role of physiotherapists in acute settings. I did not think I would enjoy this rotation at first, but I have been pleasantly surprised. My placement at Fremantle hospital (FH) was in the cardiothoracic ward, as well as some time spent in ICU. This provided an interesting mix for my clinical experience. Most of the patents had a fairly short stay. It was nice to see so many patients able to go home as I am aware that this was not always the case on some of the wards the other students were working on. This also provided me with some good opportunities to take part in discharge planning. I was able to appreciate the patents experience from beginning to end, even getting to help out in some cardiac rehab classed where the patient were at the very end of their rehab.

For the most part, the patients were happy to have me treating them as a student. By addressing their problems and questions confidently I was able to gain their confidence. This was very difficult in the first few weeks as I was finding my feet in a new facility and had never been around really sick people before. Being confident in what I was doing and saying to the patients was a skill I further developed at this clinical experience.

I found the peer learning structure at FH quite difficult at times, especially since we did not often see patients together. Our supervisor would often spend all of her time organising our day so that my peer and I could see our own patients and she would be popping in-between the two rooms we were in on the ward. This did not run very smoothly in the first few weeks when our clinical skills were not the best. This did improve however, to the point where we would always finish all of the patients on the ward early. Although I found the large student – supervisor ration difficult, the other students at the facility did provide good support. It was useful being able to ask another student any questions you felt were to silly or obvious to ask your supervisor.

Initially, I never thought cardio is an area I would consider working in. This placement had changed many of the preconceived ideas I had about the role of a physio in acute settings. To be honest, before going on this placement I was of the opinion that cardio physios did not have much scope to improve patents acutely and that their problems could be best handled through a medical perspective. I have seen firsthand through the fast turnover of patients on the cardiothoracic ward, the rapid improvements seen in patients after a little physio input, advice, and help to get going.

Stares entry three rotation 2

Stares entry 3 rotation 2 2010

Situation

Mrs T had initially presented to ED after a fall. After a diagnosis of a hip fracture and subsequent proximal femoral nail insertion (PFN), she had to be transferred to the cardiothoracic ward as she was in fast AF post-op. She was now day 3 post op and had not been out of bed due to complications with BP and AF. She had stabilised somewhat and the medical team had given the all clear for gentle ambulation. She was high priority for physio intervention as the nursing staff were having great difficulty mobilising this patient. After a fairly superficial investigation of the patient notes, I found out 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 T was very chatty when I initially went o 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 T was not completely orientated, she seemed compliant.

There were no signs in the Hx or on subjective questioning of chest related complications, so I proceeded to a mobility review in bed. In particular I was most interested in quad strength (– 4/4 L and R), ability to do a bridge, and DF/PF strength. I deemed this patient safe for a sit to stand transfer using a frame for assistance.

After organising Mrs T attachments and helping her to the edge of the bed with minimal assistance, I asked Mrs T to stand up. All of a sudden she became very frightened. I suspect as she tried to move to a weight bearing position she felt a great deal of pain. 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 T into a full stand. She was still very frightened and confused. I asked Mrs T to take some steps to the side and the forward 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 T 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, arguing with my instruction and shouting ‘I just want to get in my car and go home!’I ended up having to give her max assist to get back into bed.

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 patient had deviated from a normal path way, I should have further investigated this rather than accepting what I had been told about the patient’s medical instability.

· Communicate more readily with other HCPs from other disciplines. I am often reluctant to talk to nurses as they often seem too busy to talk to you. I will certainly change my attitude toward asking them questions after this experience.

· 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.

Stares 2 rotation 2:

Situation

Mr S was day 4 post mitral valve repair and coronary artery bypass graft x 1. I had been asked to AX and RX this patient. He had been seen by the weekend physio, who was only able to do breathing exercises with this patient as there were some problems with pain management. Since this, Mr S had mobilised with assistance from the nursing staff to the toilet, (about 10 m total).

PMHx: Bronchiectasis – normally productive of about 3 – 4 Tbs creamy sputum daily.

Task

Safe and effective AX and RX of this patient, ideally aiming to increase this patient’s mobilisation, given the delay in this patient’s rehab.

Action

I checked all necessary notes and obs to be adequately prepared for the patient. I then conducted a subjective and objective focusing on respiratory components of Ax.

I found the problem list was as follows:

· Pain

· Reduced airway clearance

· Reduced lung volumes

· Dyspnoea

As there was no reason for treatment to be contraindicated, I decided this patent was physiotherapy appropriate. I began to run into problems when I started my Rx of this patient. As I was trying to explain my plan to this patient, he would not make eye contact with me. I even changed my position to be directly in front Mr S, with no success. I tried to combat this by using my cheeriest voice and speaking loudly, however this made little difference.

After convincing the patient that a walk might be a good idea, I was able to mobilise the patient on the ward. Once back at the bed, I attempted to teach a supported ACBT to help with airway clearance, reduced lung volumes, dyspnoea and pain. Again the patient looked very glum and did the bare minimum possible participation.

On realisation that the patient was not really listening to me at all, I stopped doing my treatment, instructed Mr S to do these exercises hourly, reassessed and left the room.

Evaluation:

Afterwards I felt as though I had written the patient off because I had so readily abandoned the Rx when things weren’t going as planned. This was a patient who was very slow to get going, who had a HX off bronchiectasis and was normally productive. A prime candidate for physiotherapy, and a patient I should have probably spent some quality time addressing airway clearance with. This experience has shown me that my communication and patience needs work.

Strategies

· Invest some time seriously talking to the patient about the rationale behind the Rx, so that they can understand and feel involved in the process.

· Think ahead when seeing patients you know have had trouble with pain management. If this patient had had pain cover prior to Rx, perhaps he would have been less reluctant move and speak to me.

· Make an effort to stay positive and persist with difficult patients.

· Find out more about the patients goals and then link it into my persuasion and motivation of the patient.

· Realise that some patients are simply feel to unwell to fully engage in treatment all of the time.

stares 1 rotation 2 2010

Stares Entry One – Placement 2 2010

Situation:

I was asked to see a Mr H was day 2 post CABG. He had been transferred from ICU the previous day. PMHx: smoker, HTN, previous MI. Today he had not yet been mobilised on the ward. Mr H had only sat out of bed with the nursing staff.

Task:

Ax & Rx of patient. I was aiming to mobilise according to day 2 post CABG path way.

Action:

After doing a thorough Ax (- chest screen and checking obs, pain , SOB, ecetera) and giving this patient breathing exercises to help airway clearance and decreased lung volumes, I deemed this him suitable to mobilise. I told the patient I was going to get him out of bed as I was on one side of the bed preparing the attachments. Before I had a given clear instructions, the patient began to get out on the opposite side to the one I was on. He had on support from me and I was not able to probperly monitor him as he sat up out of bed. After checking he was ok to get up and mobilise, I told him we will be going for a walk soon. As I went to place the trolley in front of Mr H and hook up all of his attachments, he stood up on his own without any support. Once again he was ok, however it was not good practice that I hadn’t been there ready to give full support if necessary. Once the patient was ready, we walked 70m up and down the ward. Mr H had quite a fast walking pace and I had to keep asking him to stop to get his heart rate down as it was rising above 100 BPM. When the walk was finished Mr H felt fine, although a little tired. After a reassessment and some patient education, our session was finished.

Result

Patient was able to ambulate a good distance. I achieved my goals for the patient on that day. Although nothing negative happened to myself or the patient, the session did not run very smoothly and because of this the session was not optimally safe for the patient.

Evaluation

My Rx was not very safe because my instructions to the patient were not clear enough. This patient was very eager to do everything all at once. If you are not there on standby when the patient is mobilising for the first times after major surgery, there is a high possibility the patient could have an accident and undo all the hard work of the surgical team. After trying to run an Rx session with a patient when I was not familiar with the attachments and not clear enough with my instructions, I know this is something I need to improve.

Strategies

• Practice verbal communication on someone who is not a patient – making sure I am absolutely clear about when they are to move.
  
• Get more practice with supervision setting up trolleys with attachments ready for the patient to mobilise.
• Always give the acute surgical patients more assistance than necessary for the first few times you see them until you are familiar with the patient.

Rotation 2 Initial Entry

Initial entry

At the moment I am both nervous and excited about my next clinical rotation. I am excited that I have successfully completed rotation 1 and that I am moving onto something new. I think one of the best things about this year will be an opportunity to sample everything before making a decision about which area I would like to start working in. I hope this placement will give me the chance to broaden my understanding about the role of physiotherapists in acute settings. (I was in a community health setting on my previous rotation.)

At the same time I am nervous because I am aware that my patients will probably be sicker than any patients I have had in the past. Not only might this make them harder to motivate and treat, they might be less reluctant than your average person to place their health in the hands of a student. Though this is understandable, I anticipate it to be very frustrating. To combat this I will have to be very well prepared to treat these acute patients. By developing a rapport quickly and showing my supervisor that I am competent and confident hopefully this problem will be overcome.

I am also nervous because I know that Fremantle is such a large teaching hospital. There will be 6 students from Notre Dame doing cardio rotations alone! I am worried that it will be difficult to get guidance from my supervisor because this clinical setting is likely to be very busy. In previous practical experiences, although I have had the opportunity to be independent, there was always someone on hand if I was really unsure. Again, I think being very well prepared and confident will help with this problem..Thank goodness for clinical prep week.

I have not had a chance to speak to any other students about a cardio placement at Fremantle Hospital. I am not sure how independent I will be expected to be, however I expect to be supervised/observing for the first few days at least. After that, depending on which ward I get placed on, perhaps I will start getting my own patients and as I progress, work up to a full patient load.

This is my cardio prac, however I could be working in any on the following areas: General Medical, General Surgical, Cardiothoracics, Intensive Care Unit, Ambulatory Care (Including Pulmonary, Cardiac and Functional Rehabilitation), Haematology or Oncology. I am not going to get my hopes up about with one I would prefer to go to, they all have their positives and negatives. I anticipate that my preparation will need to be broad. I hope to expand my knowledge of cardiorespriatory physiotherapy assessment and treatment in one of those areas during my time at Fremantle Hospital.

Final Entry

Final Entry

Looking back at my initial entry I realise how clueless I was about the type of facility I was going to! It was my understanding initially that Mandurah Community Health Centre would be connected to Peel Health Campus as they were right next door to one another, In fact MCHC is a multidisciplinary facility. There is a wait list for patients seeking the services of the centre. GP’s as well as Dr’s and surgeons from hospitals are able to refer patients to the centre. The physios’ see between 8 and 10 patients per day on average, with group exercise classes run every day.

My Time at MCHC was structured the same as the other physiotherapists working at the centre, roughly 70% one on one patient time, 30% class work. My case load at MCHC was not that varied. I saw many people with neck, back and shoulder problems. This was good as it has provided me with a strong foundation to treat these types of problems in the future.

I saw my own patients independently from week two. This provided me with a great opportunity to learn independently. I found myself really having to reason, rather than just go to my supervisor straight away. This was challenging but I think it brought out the best in me.

Though I was a little uncomfortable with the sudden responsibility I was given I believe it was necessary. This placement provided a good chance for me to build on my clinical reasoning, assessment and treatment capabilities. Some examples of these opportunities are listed in my previous stares entries.

Perhaps the most important thing I gained was confidence with treating real, live patients. Looking back, one of the main skills I think I was missing was confidence. Much of this confidence I feel was gained from the large number of patients I was able to treat while on placement as well as running group classes, in particular hydrotherapy. I have learned that you can be well versed on all the theory in the world, but if you aren’t good at selling that knowledge it’s hard to get patients on your side. To sum up, confidence in what I know and what I tell patients is the best and most important thing I have taken from this placement.

Stares entry three

Stares Entry Three

Situation:

Mrs H is a woman in her early 50’s. She attended physiotherapy for her first appointment last week, 4 weeks post rotator cuff repair. The post op orders stated there is to be no glenohumoral joint movement for 6 weeks. I asked Mrs H about this, according to her she was told not to so take the arm out of the abduction sling or move the arm at all during this time. At this stage she had not even had an appointment to see her surgeon since discharge from hospital.
I am thinking there are a few problems with this situation. This seems a very odd protocol to me. I had thought that most post op treatment protocols called for at least passive range of motion in the first 1-2 weeks of rehab, but was not confident with my knowledge.
I felt conflicted because I got the distinct sense that this lady had been lost in the surgeons system, she had told me that she was meant to have an appointment at two weeks, however when she went to make the appointment she was told she would be contacted to make an appointment when she needed to be. There was no reason I could think of in this lady’s history for such a restrictive post op protocol.
What was my role to be if the only exercises I could give this lady, she had already had on a sheet of paper given to her at discharge.

Task:

1. Try and provide this patient with the best possible treatment given the surgeons restrictions.
2. Find out more about the usual rehabilitation protocol post rotator cuff repair and any possible reasons for this surgeon’s post op orders.

Action:

I spent great deal of time of time talking to this patient regarding her ongoing management, what she needed to do and what would likely happen in the future. She was very distressed at how long the whole process was taking and how she seemed to have been lost in the system.
After reassuring the patient and setting a plan in place, I checked her elbow and wrist stretches as well as adding in a scapula stetting exercise.
After this I went home and did a search on rotator cuff rehabilitation protocols. I did a quick scan of PEDRO and ebsco. I found that in most of the control groups in studies testing various rotator cuff rehab protocols had the patients doing at least passive range of motion from day 2 or so. The experimental groups often had accelerated progression to static contractions and active assisted. Most of the evidence seemed to suggest that there was no difference in approach, also that a generic exercise approach was as good as a specific one.
Some reasons for adhering to a more limited post op program of exercise were specific problems with instability, poor bone strength or repair integrity. To my patients knowledge she had none of these. Perhaps this lady should have received a more accelerated program.

Result:

Hopefully the overall result for the patient will be good. Although her path to full function has been delayed, I convinced Mrs H to take a more active role in ensuring that she was receiving the best care possible. She will see her Dr as soon as possible, hopefully when he sees her he will give her the all clear to go ahead with physio as he was the person who referred her in the first place. Hopefully the surgeon had strong reason for the delay in GHJ ROM.
Seeing this patient has been a positive experience for me as seeing this patient prompted me to do some research. I have acknowledged that there are some holes in my understanding of standard rehabilitation protocols.

Evaluation:

It is important to keep up to date with the latest EBP. One of the positive things about musculoskeletal physiotherapy is that this is one area of physio where there is usually ample resources to keep up to date on the latest research. This experience has brought to my attention that I am not 100% confident with post op protocols of many orthopaedic procedures, (including rotator cuff repair). In order to understand why a surgeon may have given certain orders, or when someone needs further follow up I think it is important for me to have a better understanding of what the surgeon has done in each procedure and the standard path of rehabilitation. Because I wasn’t really sure of the norm compared with what this surgeon had asked, I was not confident with what I was doing.

Strategies:

• 
  Set myself the goal of revising general rehab protocols from orthopaedics.
  
• Keep up to date on EBP. Set the goal of choosing at least one case from my patient list each week and research the most up to date information about relevant treatment techniques and prognosis.
  
• If unsure, in the future try and call the surgeon. I might not get an answer straight away but at least I might get some more understanding about the patient from a surgical perspective.

Blog two (week 3)

Stares Entry two

Situation:

Mrs T presents to MCHC with low back pain. When I begin my subjective assessment I quickly realise that Mrs T’s English is not that well developed. She answers most questions with yes or no and is unable to describe her pain, only outlining where she can feel it.

I am thinking that understanding this woman’s problem is going to be extremely challenging, given that so much of what we learn about a person’s problem is gained through good communication. This will likely effect both my assessment and treatment of Mrs T.

After trying to understand this pain though the subjective questioning process with little success I began the objective assessment. Mrs T was unable to describe what she was feeling as I carried out my assessment. I attempted to use other methods of communication besides verbal. I payed particular attention to her face, the way she moved etcetera. Even this did not reveal much. The only piece of information I really gained was that she had a pain down the side of her thigh. Flexion and extension seemed vaguely uncomfortable. However to my understanding, I was unable to make a significant change to her pain on active movements. I then moved onto PPs, checked nerves and cleared SIJ. I didn’t have much to go on, having found nothing, I moved onto PA’s. A PA on L5 was the * sign. I thought because the lady seemed to have a large ROM on all active movements, particularly extension, it was likely that his may be an extension control dysfunction.

Task:

Treat this patient, aiming to make a positive difference to her back pain.

Action:

After mobbing L4/5 into flexion and then getting the patient up to reassess, there seemed to be little or no change in the pain. I then thought perhaps this is a stiffness problem because the lady was in her late 60’s. So I mobilised the joint into extension, I then got her up to re asses again. Once again there was not really a distinguishable change that I could note. Felling very confused, I thought I should do at least something to make this woman feel good before the end of the session. I had noticed some increased tension and development of the lumbar para-vertebral muscles so I decided to do some soft tissue techniques to this area and put a heat pack on Mrs T. I had just done two treatments and had no idea if either of them had done any good.

Result:

There was not a clear result in this situation. From observing Mrs Ts movements and trying to decipher what Mrs T meant when she was trying to describe the way she was feeling, I suspect there may have been no change in this lady’s pain. This is a poor result because if there was a change it may have been altered by the treatment/s done before / after the first treatment. This lack of results is what tells me there was probably a problem with the treatment I chose to use with this patient.


Evaluation:

Reflecting on what I did with this patient, I can see that it may have been better to stick to one treatment aim per session. I understand that in reality you may not get crystal clear clarity about the patient’s problem in the first time you meet them, especially when you have such severe language barriers to deal with. However I think there are ways to make life easier. If you are able to stick to one treatment aim, you can get the patient back and review if there was any change over a short amount of time. If this patient comes back with a positive effect, your treatment is then easy. If they have a negative effect you have a clue where to look. I do think it is worth noting however, this is not a luxury you would have if you were working in the private sector.

Strategies:

• 
  Write a list of evidence for the problems you suspect the patient should have. At the end of assessment, make a strong decision on what you are going to treat for.
• Try different things that treat the same problem and stick to this plan as long as you are not making the patient worse.
  
• Reassess frequently and note any minor change in the patient’s problem.
  
• Utilise additional services if they are available to you e.g. – interpreter.
  
• If you don’t quite get a clear response keep asking questions even if you feel like you are repeating yourself.

Week One – Journal Entry

Week One - Journal Entry

Situation:

Mr J presented with a referral stating he had a constant deep ache in his low back with intermittent pulling in his lateral thigh. Before I had even said anything to Mr J regarding his pain, he had given me a 15 minute run down on every injury he had had as a child, everything he could think of in his current history, including details of his recent divorce, problems with his children and work. Each time I would try and interject Mr J would go off on a completely new tangent. Even when prompted to clarify it was difficult to make allot of sense of the symptoms he described because he might say one word and then use that as a segway to talk about something else. After 30 minutes of attempting to clarify this patient’s pain I decided to cut my losses and move onto the physical. Through the physical Mr J also had allot to say and carried on in much the same way as he did in the physical. Nothing seemed to be particularly painful except for a twinge of pain into extension in mid range. After going through everything in the examination book I had very little to go on for my treatment plan, not to mention I only had about 15 minutes left to do my treatment.

The main problems I was presented with / anticipated were:

· Lack of clarity about which treatment option to take.

· Lack of time to do anything useful with this patient.

· Difficulty communicating with this patent.

· Difficulty keeping the patient on task with any Rx I choose to do. – particularly neutral spine and core muscle training as that would require communication back and forth between therapist and patient.

· Difficulty making an accurate assessment of any Rx preformed – I felt the patient was having trouble describing what he felt in his back.

Task:

My task was to treat this patient in 15 minutes. The information I had obtained from the assessment was questionable because of the difficulty I was encountering getting this patient to stay on task.

Action:

I quickly nipped out to my supervisor who told me that the clinical world isn’t always going to be like how assessment and treatment of a patient is described at uni. Sometimes you won’t have much to go on but you have to go with a treatment plan that you have the most evidence for. In my case it was an extension control dysfunction of L3/4. My treatment was as follows:

· PP flexion Gd 4

· Flexion exercise for home – knees to chest (+ prescription for home).

· Education and advice on neural posture and activation of TA, multifidous and pelvic floor (+prescription for home).

Result:

Unclear how this treatment affected the patient at his stage as I placed most of the focus of this Rx on things he could do at home. I had allot of trouble communicating with this patient. Each time I would try and explain something he would talk so consistently and for so long that I felt rude constantly interjecting. It was my feeling that although I did the best I could have done with my treatment plan given what had happened in the assessment; I felt the patient did not really soak in anything I had to say about muscle activation for neutral spine or advice for his home program. I would not be surprised if this patient comes in next week and cannot demonstrate a good neural spine with correct co contraction.

Evaluation:

The desired outcome was not reached with this patient. The reasons I can see for this were primarily due to communication. I was trying to build a patient rapport by allowing the patient to tell me his story; however this came at a cost of getting little useful treatment into the hour long session he was allotted.

From the problem of poor communication between the patient and myself came many other problems. Because of time constraints and lack of clarity in assessment, my treatment plan was limited. My ability to follow up and reassess my treatment was also limited. Because of this I am unsure of my results, however due to the way the patient continued to talk over the top of me during the education and advise part of his treatment I am almost certain that poor communication and time management rendered my treatment ineffective.

Strategies:

Find a balance between building a rapport with the patient and getting the job done. In the future if I find myself in a similar situation I will aim to take better control of the situation. This will help to make Ax and Rx flow more easily and hopefully will avoid many of the problems I encountered with this patient.

Be positive with this patent even though the last session did not run smoothly. Perhaps change tact from open to closed questions in this case.

Better prioritise the parts of subjective and objective that I absolutely need and try and fill in the gaps in my knowledge as I go along. I think this will also come with experience.

Make one definite goal. In cases such as this have limited goals and make an effort to get that done well. Rather that coming to the end having attempt a few things with a poor result.

Review this patent’s notes before next visit and have a clear plan of the most important goals for the session. Make a real effort to stick to this unless I find it is no longer relevant.

Initial entry

INITIAL ENTRY

I am excited to finally be starting fourth year. Although my supervisors expectations of what I will be doing day 1 - week 1 are at this stage unclear, I have formulated a few expectations about what this placement will be like for me.

I am expecting this placement to be more challenging than any other prac I have been on. This is not only because it is the first rotation in fourth year when the supervisors expectations often jump significantly. I will also be expected to use a great deal more clinical reasoning than in past rotations and take on allot more individual responsibility for my patients.

I expect the prac to be interesting as I have heard that there will be a vary varied case load. I am looking forward to this as I have not yet had great exposure to a wide array of musculoskeletal problems (mainly only backs and necks so far).

I am expecting to learn allot very quickly. Being in musculoskeletal outpatients and working somewhat independently will be a bit of dive into the deep end for me, however I am looking forward to this opportunity as I feel it is a great way for me to learn.

After speaking to one of the supervising physiotherapists at Mandurah Community Health I have a better idea (although still not sure) of how my time will be structured on placement. It is going to be a mix of seeing outpatients individually and taking group classes. I am unsure of how quickly I will be expected to take on a full case load, and have allot of reservations about what tasks might be waiting for me Monday morning. However by the end of placement I expect I will be confidently and independently taking the group classes, as well as seeing my own load of outpatients individually with limited guidance from my supervisor.

I am looking forward to this placement as I have never had an opportunity to have this level of independence and responsibility before. Although it is a little daunting right now I am hoping it will work out to be a rewarding learning opportunity.