During this year across placements in the hospitals and my personal experiences I have been disheartened to observe the attitude of many nurses and allied health professionals to the nursing home residents in the hospital setting. What was most apparent was the view that all we needed to do was get them back to a level of function so the nursing home would take them back and do that as quickly as possible with as little input as possible. With respect part of this attitude has developed because of the shortage of nursing and allied health staff within the hospital system and the large caseload they have to cover.
I believe that physiotherapist have the training to offer the elderly population a great deal that would improve their quality of life as they enter the twilight years. Yet these skills that we have are not being utilised by the nursing homes or low care facilities and those that do employ a physiotherapist are using them basically to do mobility assessments for the clients care plan.
Obviously there are multiple factors surrounding this issue, the pay scales in the care facilities do not encourage physiotherapist to work in this area, the allocation of funding within the nursing home - carer v physiotherapist to suggest just a few.
I hope that if I work in the hospital environment I will be able to manage my time efficiently to enable quality time to be spent with some of these elderly clients.
Wednesday, December 17, 2008
Tuesday, December 9, 2008
confused patients
My last placement was a gerontology placement where a lot of my patients had dementia and were confused. I found this hard initially as it is important with demented patients to make the exercises very functional so they comply and do them correctly.
One lady I had loved sitting in a chair. So instead of doing ten sit to stands (which she didnt understand the point of) I would set up 2 chairs (10m apart) and get her to walk to the chair and sit down, then she would see another chair 10m away and I'd ask her to go sit on that chair. She didn't remember that we had just sat down on one chair so she would be happy to do this exercise up to 20 times in one session.
Making an exercise functional for the specific patient is very useful in dealing with demented patients I have found. Otherwise if they don't understand what you want from them they are likely to by uncompliant or even aggressive.
One lady I had loved sitting in a chair. So instead of doing ten sit to stands (which she didnt understand the point of) I would set up 2 chairs (10m apart) and get her to walk to the chair and sit down, then she would see another chair 10m away and I'd ask her to go sit on that chair. She didn't remember that we had just sat down on one chair so she would be happy to do this exercise up to 20 times in one session.
Making an exercise functional for the specific patient is very useful in dealing with demented patients I have found. Otherwise if they don't understand what you want from them they are likely to by uncompliant or even aggressive.
the boring part of physio
on my last prac I was doing gerontology. I found that all I was doing was walking patients and doing basic exercise programs for them. As they were very elderly there was no high level exercise or anything too challanging. after the second week I found this to be be very mundane and boring. most of the patients didn't like exercising and as a result hated coming to physio, making my job vey hard. They would often be very difficult with me come physio time, and I would spend a good part of the session persuading them to come down and exercise and the benifits of exercise. After a while this became wearing on my enthusiasm for physio as a profession. I feel that we are too over qualified for a lot of the things that we do in the hospital system, and that we receive little respect from patients themselves.
I voiced this opinion to some of my peers and many were in aggreeance with this belief. I also spoke to my friend who is a physio and she said that it is just one field of physio, and that it is important to try other parts of physio before making a judgement based on my experience on prac as a whole.
I think it is important to ensure we don't become disheartened by the profession if we have one bad experience on prac, and to continue to stive to find an area that you find exciting and challanging. In the future I will remember this advice and try to maintian my positive attitude in all situations.
I voiced this opinion to some of my peers and many were in aggreeance with this belief. I also spoke to my friend who is a physio and she said that it is just one field of physio, and that it is important to try other parts of physio before making a judgement based on my experience on prac as a whole.
I think it is important to ensure we don't become disheartened by the profession if we have one bad experience on prac, and to continue to stive to find an area that you find exciting and challanging. In the future I will remember this advice and try to maintian my positive attitude in all situations.
Wednesday, November 26, 2008
Paediatrics
On a paediatric placement earlier this semester under the supervision of my CCT I was assessing a 18 month year old boy who had been referred by a Child Health Nurse for delayed motor development. The mother indicated that she was aware something was not right but appeared to be looking to us for reassurance that this was not serious. Unfortunately as I progressed with my assessment it became more and more apparent to me that this child had a significant motor delay and was probably diplegic. At this stage the mother had not had any input from a paediatrician. At the conclusion on my assessment the CCT checked a few things and then asked the mother to excuse us while we discussed my findings in private. I voiced my concerns to the tutor and she concurred with my diagnosis and offered to explain to the parent. I accepted her offer and was interested to watch her approach to the parent. She confirmed with the parent that the mother was correct to be concerned about the child's problems and that she would like to refer the child to a paediatrician for further assessment. She did not jump in and tell the parent that she suspected the child had cerebral palsy. She addressed a number of areas where the child was having difficulties and offered therapy for these. She indicated to the parent that it was likely that the child would require ongoing therapy. Having the opportunity to listen to an experienced clinician deliver such news was a valuable learning experience. It clearly defined the role of the physio in these circumstances and I feel that if I am placed in a similar situation I will feel more comfortable and able to deliver such news in an caring and considered manner.
Friday, November 21, 2008
Consent is important!
Recently on my cardipumonary placement I was treating a patient in NSU (nursing specialty unit) with my supivisor. The patient had been admitted followig exacerbation of COPD, but had mets and lung ca, with the doctors deeming him pallitive. They had requested chest physio to decrease his WOB and anxiety.
I began to explain breathing startegies when the patient became quite distressed explaining he had not slept well and just had a sleeping med so would prefer to comply with physio in the afternoon. I agreed, though my supivisor interrupted and insisted- due to her heavy case load that we would treat him now. The patient declined treatment due to fatigue and resp distress, yet my supivisor persisted. I was hestitant as a student to interrupt, yet I felt she had breached the pts rights.
I looked on the treatment sessio with the pt becoming increasingly distressed, and finally left the room feeling the supiviso had crossed the line.
On reflection I should have interrupted for the pts sake, but as a student felt I was in no position to do so. In the future I will always remember that above all- the patients consent is important as well as a legality.
I began to explain breathing startegies when the patient became quite distressed explaining he had not slept well and just had a sleeping med so would prefer to comply with physio in the afternoon. I agreed, though my supivisor interrupted and insisted- due to her heavy case load that we would treat him now. The patient declined treatment due to fatigue and resp distress, yet my supivisor persisted. I was hestitant as a student to interrupt, yet I felt she had breached the pts rights.
I looked on the treatment sessio with the pt becoming increasingly distressed, and finally left the room feeling the supiviso had crossed the line.
On reflection I should have interrupted for the pts sake, but as a student felt I was in no position to do so. In the future I will always remember that above all- the patients consent is important as well as a legality.
Sunday, November 16, 2008
Treating the foot to cure the knee
I was treating a patient on my rural placement with chronic lateral knee pain (~ 6mths). The patient had hurt their knee going down some stairs and, being a fit person, decided to leave the injury to get better on its own. When the patient had finally decided to see the physio, they had a lot of wasting of their VMO and calf’s and his main complaint was pain when sitting with their knee flexed for long periods of time.
The patient had been seeing the previous PT student for 3 weeks, who had prescribed VMO strengthening exercises and applied McOnnells (med glide) taping, as well as STM of the ITB. The patient said that these treatments had offered him relief so for the first session with him I continued with the same treatments, and progressed his VMO exercise. Each week I concentrated on his VMO exercises (my theory was that his VMO had become so decondisioned that he needed some time to build its strength before his pain would improve). By the second time I saw the patient they had good length of ITB, good VMO activation, but their symptoms had not improved one bit. I was stumped and asked my supervisor for some guidance.
I explained to my supervisor all that I had done and was asked if I had checked what the patient’s hip and foot posture is like. I had analysed it when the patient was standing still and it looked normal. The supervisor advised me to have a look at those joints while the patient is walking. I did so and realised that the patient had poor control of pronation of the affected side foot. I then looked at his gasrtoc-soleus length and found that it was decreased significantly, and he mentioned that he had a Achilles rupture then surgical repair year ago. I addressed this by taping the foot to prevent over pronation and giving the patient a calf stretch program and the patient said instantly he no longer felt a pull in his knee.
The patient had not reported walking as causing his pain, and only once I had put the tape on his foot that he realise that he had a ‘pull’ of his knee when walking. Hence why I did not look at his walking. This taught me how important it is to analyse motor control during walking in a patient who has lower limb symptoms, even though that may not be the aggravating symptom. The body is a kinetic chain and an alteration in motor control at one point can effect other parts in the chain, particularly if it is injured. This experience made more observant of all my other patient’s movement patterns and actually helped me find things that were not obvious to the condition/symptoms the patient had presented with.
The patient had been seeing the previous PT student for 3 weeks, who had prescribed VMO strengthening exercises and applied McOnnells (med glide) taping, as well as STM of the ITB. The patient said that these treatments had offered him relief so for the first session with him I continued with the same treatments, and progressed his VMO exercise. Each week I concentrated on his VMO exercises (my theory was that his VMO had become so decondisioned that he needed some time to build its strength before his pain would improve). By the second time I saw the patient they had good length of ITB, good VMO activation, but their symptoms had not improved one bit. I was stumped and asked my supervisor for some guidance.
I explained to my supervisor all that I had done and was asked if I had checked what the patient’s hip and foot posture is like. I had analysed it when the patient was standing still and it looked normal. The supervisor advised me to have a look at those joints while the patient is walking. I did so and realised that the patient had poor control of pronation of the affected side foot. I then looked at his gasrtoc-soleus length and found that it was decreased significantly, and he mentioned that he had a Achilles rupture then surgical repair year ago. I addressed this by taping the foot to prevent over pronation and giving the patient a calf stretch program and the patient said instantly he no longer felt a pull in his knee.
The patient had not reported walking as causing his pain, and only once I had put the tape on his foot that he realise that he had a ‘pull’ of his knee when walking. Hence why I did not look at his walking. This taught me how important it is to analyse motor control during walking in a patient who has lower limb symptoms, even though that may not be the aggravating symptom. The body is a kinetic chain and an alteration in motor control at one point can effect other parts in the chain, particularly if it is injured. This experience made more observant of all my other patient’s movement patterns and actually helped me find things that were not obvious to the condition/symptoms the patient had presented with.
Cerebellar impairment following alcoholism
On my rural placement I was treating an alcoholic patient with moderate cerebellar impairment. I have realised that rehabilitating a patient with a cerebellar impairment is challenging in itself and is even more challenging when the patient is an alcoholic.
The patient was relatively young, early 50s and was admitted to hospital for frequent falls due to impaired balance, ataxia and peripheral sensory loss. This patient denied that they drank too much and was keen to get home as soon as they were ‘better’. It was obvious that this patient also had some cognitive deficits, with their denial of their drinking problem and also memory loss and they were also in alcohol withdrawal.
I had come up with a treatment plan, for his ataxia and impaired balance, but found it very difficult to implement due to these cognitive impairments. During the treatment sessions the patient was very agitated and verbally aggressive, and I became quite impatient with him and each time I went back to my supervisor and told him that the patient was not cooperating and that I felt I was not getting anywhere with them. My supervisor joined me for the next treatment session and managed to actually get an effective treatment session out of the patient.
I realised after watching my supervisor treat the patient were I was going wrong. My supervisor’s demeanour was sympathetic to the patient and my supervisor also attempted to make everyday conversation. I realised that I did not, I was in fact just telling the patient what to do and not building repoire. The next time I was due to treat this patient I read his notes and there was a new social worker entry, highlighting the events that had lead to the patient’s drinking problem. These events were extremely sad and I immediately realised I was judging this patient for being an alcoholic. When I went to treat the patient I changed my demeanour to being sympathetic, to explaining what and why they were receiving physio and during treatment I spoke to the patient about thing other then the treatment session and we even managed to have a laugh together.
This experience has taught me that I still have preconceived stereotypes that I need to deal with, and how much these can actually effect patient progress. I have learnt to leave my preconceived judgements out of my treatment sessions and have learnt how to build repoire with a type of patient that I have never had the experience to do so with. This will make me a better physio as I can be confident that I can help different types of patients even if I may not support or accept their personal decisions.
The patient was relatively young, early 50s and was admitted to hospital for frequent falls due to impaired balance, ataxia and peripheral sensory loss. This patient denied that they drank too much and was keen to get home as soon as they were ‘better’. It was obvious that this patient also had some cognitive deficits, with their denial of their drinking problem and also memory loss and they were also in alcohol withdrawal.
I had come up with a treatment plan, for his ataxia and impaired balance, but found it very difficult to implement due to these cognitive impairments. During the treatment sessions the patient was very agitated and verbally aggressive, and I became quite impatient with him and each time I went back to my supervisor and told him that the patient was not cooperating and that I felt I was not getting anywhere with them. My supervisor joined me for the next treatment session and managed to actually get an effective treatment session out of the patient.
I realised after watching my supervisor treat the patient were I was going wrong. My supervisor’s demeanour was sympathetic to the patient and my supervisor also attempted to make everyday conversation. I realised that I did not, I was in fact just telling the patient what to do and not building repoire. The next time I was due to treat this patient I read his notes and there was a new social worker entry, highlighting the events that had lead to the patient’s drinking problem. These events were extremely sad and I immediately realised I was judging this patient for being an alcoholic. When I went to treat the patient I changed my demeanour to being sympathetic, to explaining what and why they were receiving physio and during treatment I spoke to the patient about thing other then the treatment session and we even managed to have a laugh together.
This experience has taught me that I still have preconceived stereotypes that I need to deal with, and how much these can actually effect patient progress. I have learnt to leave my preconceived judgements out of my treatment sessions and have learnt how to build repoire with a type of patient that I have never had the experience to do so with. This will make me a better physio as I can be confident that I can help different types of patients even if I may not support or accept their personal decisions.
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