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.