I have finished my gerentology placement, and on my last day, knowing that my next placement was in neurology, my supervisor arranged a neuro patient for me to assess. The patient was 97 years old, had a stroke a few years ago, and had been in a nursing home since then, until recently moving back to her home!! The patient is wheelchair bound and her home is in a retirment village, having good wheel chair access and all other modifications and assistive equipment in place. The patient also has a carer 24/7. The patient is able to pull to stand , and can stand for a long while and do squats while holding on, and also walks, with a gutter frame 3 x a week, with the physio (~50m).
After assessing this patient I established that she is reliant on 24/7 care, and will be for the remainder of her life. However, this patient had no cognitive impairments, and her determination to continue to live at home and continue rebab was truly inspirational. She insisted that she could increase her walking indurance, and would like to improve her standing, a she beleives that she is getting stronger.
I have seen patients in nursing homes that have reached a plateau, but are still cognitively there and have an extrodinary will to live. It is unfortunate that they no longer receive rehab, as in the long term they may still improve, and at least improve their quality of life. I understand though that there are limited resources, but I beleive that if someone is determined enough, it is possible (look at this amazing 97 patient of mine).
This experience has made me realise that with particular patients, you shouldn't just have an end goal to work towards, one which when the patient reaches, results in the patient being discharged. Some patients will need ongoing rehab, for years, so explaining this to the patient and fighting for them to recieve ongoing physio is what I will endeavour to do.
Monday, June 23, 2008
Monday, June 16, 2008
Playing it safe
I'm approaching the end of my Ortho prac, and have been taking on a more varied patient load, partly due to my supervisors request and also due to the lack of straight forward patients. As such I received a male who had sustained some fractures to his vertebrae, and I was asked to conduct a S and O on the patients (who had reported no Neurological deficit). He had been taken by ambulance to another hospital, then transferred to the hospital were I am completing my placement. Previously today he had had a number of images taken of his upper and lower limbs, as well as his upper thoracic and cervical vertebrae. When I went to see the patient he was reporting pain in his lower back, which he had not experienced before the imaging. This pain was reported by the patient as worse then any pain that he had experienced following his accident. On further assessment there was no motor deficit noted, although he did have some altered sensation. Based on what I had seen on the assessment, I discussed the patients comments with my supervisor, who in turn advised me not to attempt to mobilise the patient, and instead to confer with the medical officer managing the patient. I did so, and it appeared that the medical team were also questioning his presenting complaint, I was advised to cease treatment and informed that further investigations would be made on his lower back. In addition to this it was found that xrays had been taken at the initial hospital, but they were unavailable on the pacs system.
During all of this I was unsure whether or not I was being too cautious with the patient, as I have had limited experience with patients who have received a spinal injury. I feel that I made the right call by being as cautious as I could, even though I also felt that it could make me look less than confident in my final week of my placement. However I also decided that I would rather have looked less confident and then had to justify it, as opposed to mistreating a patient.
It should be noted that I don't know what the results of the xrays were, I'll find out tomorrow. However, I think that if I encountered a similar problem next time, I would still be cautious, although due to my lack of significant experience with spinal patients, my cautiousness may have been exaggerated. I don't think cautiousness is actually a word...
During all of this I was unsure whether or not I was being too cautious with the patient, as I have had limited experience with patients who have received a spinal injury. I feel that I made the right call by being as cautious as I could, even though I also felt that it could make me look less than confident in my final week of my placement. However I also decided that I would rather have looked less confident and then had to justify it, as opposed to mistreating a patient.
It should be noted that I don't know what the results of the xrays were, I'll find out tomorrow. However, I think that if I encountered a similar problem next time, I would still be cautious, although due to my lack of significant experience with spinal patients, my cautiousness may have been exaggerated. I don't think cautiousness is actually a word...
Verbal Handovers
This week on prac, I was about to see a new patient and was required to provide a handover to my supervisor prior to seeing the patient. The Patient had only been in hospital for 2 nights but had already accumilated a rather extensive set of notes, since following his stroke he had a number of other complicating matters. I had been trying to read the rather difficult to read writing in the notes for while, and then my supervisor asked me to provide a handover. At this point i really hadnt gotten some vital pieces of information about the patient, let alone the full picture. But i endevoured to give the handover.
Subsequently the handover came over as a bunch of squabble and with incredibly poor articulation, with 'ums' and 'ahs' scattered densely throughout. I was well aware of this poor performance.
I have since performed a number of verbal handovers that are not perfect, but are certainly better than that performance. One thing that I learnt from the poor performance, is that if you do not have the information you cannot provide a decent handover, no matter how much you speak with confidence. And if you dont have this information, you are better off stating this to the person you are giving the handover to and asking for more time, or assistance with reading messy writing or difficult to interpret notes. ie. you cannot give a good handover without the required information (obvious but true).
Subsequently the handover came over as a bunch of squabble and with incredibly poor articulation, with 'ums' and 'ahs' scattered densely throughout. I was well aware of this poor performance.
I have since performed a number of verbal handovers that are not perfect, but are certainly better than that performance. One thing that I learnt from the poor performance, is that if you do not have the information you cannot provide a decent handover, no matter how much you speak with confidence. And if you dont have this information, you are better off stating this to the person you are giving the handover to and asking for more time, or assistance with reading messy writing or difficult to interpret notes. ie. you cannot give a good handover without the required information (obvious but true).
nosy patients
I am currrently on my musculo outpatient placement at curtin clinic. Most of the patients are nice and I don't have a problem talking to them and making chit chat etc. However one of my patients is a priest and the other day he was asking me questions like "why aren't you married" and I replied that I was only 21. he told me he was married when he was 22 and implied that I was getting old and should be looking at people to get married. He then went on to say that I had to work hard at getting married by making things work with someone. I found this very intrusive into my personal life and rude on his behalf. If this was a social setting I would have told him where to go but as this was a professional setting I could not do this. I think he shouldn't ask me personal questions in a professional setting where I am required to be professional and I am not allowed to be rude back to him as I have to be on my best behaviour as I am being assessed.
I did not know what to say to him and I was wondering what to say to a patient when you are trying to stay professional and want to keep the topic of conversation as such. Does anyone have any suggestions on what to say to a patient who has clearly crossed the line and you want to steer the conversation back to more appropriate subjects?
I did not know what to say to him and I was wondering what to say to a patient when you are trying to stay professional and want to keep the topic of conversation as such. Does anyone have any suggestions on what to say to a patient who has clearly crossed the line and you want to steer the conversation back to more appropriate subjects?
Patient Notes
For every client I have seen this placement I have first read a discharged patient physio referral from the ward physio (including some from fellow students!). Certain instances have given me reasons to consider more carefully the notes I have read and consequently the notes I then write.
For instance - every client I have seen has been reported as being independent in bed mobility. Yet some of the clients cannot get their legs up onto the bed without assistance and many of the clients have demonstrated that once in bed they are unable to roll onto their side and are uncomfortable lying on their back but they just put up with it. There are obviously some valid reasons for this discrepancy between what is reported and what I am seeing at the client's home such as - hospital beds being height adjustable which makes it easier to get in/out of bed, and having side rails to help a client turn over while many clients do not have these options at home.
However this is just one example off the patients referrals, there are many more I could give.
This placement has made me re-evaluate how I read/interpret patient notes, and I now take a little more time with the client to help confirm and clarify information on the referral. In addition it has made me think more about the information I write in my patient notes. I find myself asking 'what information would I have liked to have known about this client, prior to seeing the client, that the previous physio would have already known but hasn't given me that would have helped me provide a better service to the client'.
Students are sometimes advised not to write so much in their notes (I was told on this placement- "if you write too much - no-one will bother reading it") but i think we need to be mindful not to go to the other extreme of writing too little.
For instance - every client I have seen has been reported as being independent in bed mobility. Yet some of the clients cannot get their legs up onto the bed without assistance and many of the clients have demonstrated that once in bed they are unable to roll onto their side and are uncomfortable lying on their back but they just put up with it. There are obviously some valid reasons for this discrepancy between what is reported and what I am seeing at the client's home such as - hospital beds being height adjustable which makes it easier to get in/out of bed, and having side rails to help a client turn over while many clients do not have these options at home.
However this is just one example off the patients referrals, there are many more I could give.
This placement has made me re-evaluate how I read/interpret patient notes, and I now take a little more time with the client to help confirm and clarify information on the referral. In addition it has made me think more about the information I write in my patient notes. I find myself asking 'what information would I have liked to have known about this client, prior to seeing the client, that the previous physio would have already known but hasn't given me that would have helped me provide a better service to the client'.
Students are sometimes advised not to write so much in their notes (I was told on this placement- "if you write too much - no-one will bother reading it") but i think we need to be mindful not to go to the other extreme of writing too little.
Palliative care patient
I had a patient who was very deconditioned and had a history of cancer and current history of Pneumonia. Throughout my prac , I was treating him as a ‘cardio’ patient – doing all the airway clearance techniques etc. Later on in the prac, the Dr has classified him as a patient for palliative care because his cancer has matastasised to other parts of his body. This patient has a very supportive wife and the patient’s mood depends very much on his wife. The wife was sick for a while when I was treating him and she didn’t come in to visit for a few days. During those few days, the patient became very agitated and non compliant with all the staff on the ward. It was very difficult to get the patient to do anything, I tried very hard to explain to the patient that it is important to clear out his secretions and it will make him feel better. I also re-ensured him that his wife will be fine and she will be coming to visit soon. I liaised with the nursing staff so that I can walk him to showers instead of taking him to the shower in a commode – to make the task more functional for him and it will benefit him as well. I also learnt that we have to be forceful to patients sometimes when they are not compliant as long as we know that the task we are trying to do will benefit the patient. There was one treatment session where I asked my supervisor to come along and we had to do a fully dependent transfer to get the patient sitting out of bed. That session ended well and the patient was able to clear out his sputum (quite a large amount as well!). From this experience, I have built my confidence with treating difficult patients and learnt to modify treatment sessions to get the result I want. At the same time, I also learnt to treat the patient with empathy and be understanding to his psychosocial /emotional behaviours. If I was to encounter the same situation again, I will do the same thing and try harder to liaise with nursing staff to get the most effective treatment out of the patient before they get annoyed.
Limited English
At my current placement (cardio), I have been learning the importance of asking concise and specific subjective questions. This was highlighted especially in patients who have limited English and patients who tend to go off on a tangent.
After consulting my tutor, and applying what she suggested, here are some examples of specific subjective questions I found effective.
- Do you feel SOB now? When you are well, do you feel SOB?
- When you are well, how far can you walk? What stops you?
Over the course of the placement, I had a couple of patients who have limited English. Initially, I found difficulty with this category of patients. This was due to the fact that the subjective exam was usually limited to how much they can understand me and vice versa.
In particular, I had a 76 y/o Chinese male patient, who not only had very limited English, but was also hearing impaired. On the first treatment session, I planned to run through the usual cardio questions. However, found this challenging as the patient could not understand most of what I said. On realizing this, I started using only key words and changing the tone of my voice to make the words sound like a question. For example, cough? Phlegm? When the patient did not understand, I added hand gestures or actions. With coughing, I said cough? Then if needed, I coughed in addition to my question. This proved effective as the patient was able to understand and answered appropriately. With his hearing problem, I found that standing or sitting on his side when talking, allowed him to hear me.
On top of that, I also liaised frequently with his family to gain information, updating them on the patient’s status, and educating them about the different aspects of his physio treatment.
In future, when encountering patients with limited English, I will be patient when discovering what style of communication suits them best. I will also use simple words and shorter sentences when asking questions. Lastly, if able, I could get family members to be present at treatment sessions. This will facilitate a more effective treatment session.
After consulting my tutor, and applying what she suggested, here are some examples of specific subjective questions I found effective.
- Do you feel SOB now? When you are well, do you feel SOB?
- When you are well, how far can you walk? What stops you?
Over the course of the placement, I had a couple of patients who have limited English. Initially, I found difficulty with this category of patients. This was due to the fact that the subjective exam was usually limited to how much they can understand me and vice versa.
In particular, I had a 76 y/o Chinese male patient, who not only had very limited English, but was also hearing impaired. On the first treatment session, I planned to run through the usual cardio questions. However, found this challenging as the patient could not understand most of what I said. On realizing this, I started using only key words and changing the tone of my voice to make the words sound like a question. For example, cough? Phlegm? When the patient did not understand, I added hand gestures or actions. With coughing, I said cough? Then if needed, I coughed in addition to my question. This proved effective as the patient was able to understand and answered appropriately. With his hearing problem, I found that standing or sitting on his side when talking, allowed him to hear me.
On top of that, I also liaised frequently with his family to gain information, updating them on the patient’s status, and educating them about the different aspects of his physio treatment.
In future, when encountering patients with limited English, I will be patient when discovering what style of communication suits them best. I will also use simple words and shorter sentences when asking questions. Lastly, if able, I could get family members to be present at treatment sessions. This will facilitate a more effective treatment session.
Liaising with Other Health Professionals
Since beginning the practical component of this course, I am constantly learning the importance of working with the other allied health professionals and the value of developing a good relationship with them. Until my current neuro practical, I have had a positive experience with nursing staff, OT’s and the doctors and realise the benefit of working with them as a team for the patient’s optimal outcome. At the beginning of this placement, the other students and I were introduced to all the staff on the ward and over time have built a respect for each other, with the one exception being an occupational therapist.
There are a few OT’s that currently work on this ward, and a majority have been so helpful in my learning of the overall rehabilitation required post stroke. Unfortunately I have had repeated incidents with one OT with regards to a particular patient and scheduling our respective treatment sessions. On the ward there is a board with patient’s names and room numbers on, and there is a column for allied health professionals to write in appointment times. Over all this board has been a great help in organising my day and treatment times with patients. This particular OT is the only staff member that does not utilise this board consistently, and it has resulted in them returning a patient to ward repeatedly late for my treatment sessions- with me waiting up to an hour for them to return.
Initially I just accepted that not all treatment session times can be predicted, but after several of these incidents I decided to approach them about the issue. Before addressing this concern with the OT, I was nervous as she was a qualified professional and I have never had previous conflict with hospital staff before. In the end I decided the best approach was to acknowledge the issue: that by repeatedly showing up late, it was impacting on my treatment sessions and then offer an easy solution: Ask her to utilise this board to avoid future situations. I attempted to discuss this with her in the most respectful way, and was relieved when she apologised for her actions as she didn’t realise I had booked appointments with that patient. She accepted the solution, and has since used this board to avoid future miscommunications.
My learning from this experience was that although daunting at times, if you approach other staff with respect and a reasonable solution, issues can be resolved quickly and can usually be a simple result of misunderstanding. If any one has any other possible solutions or alternative ways I could have better approached this situation I would appreciate it. Thanks.
There are a few OT’s that currently work on this ward, and a majority have been so helpful in my learning of the overall rehabilitation required post stroke. Unfortunately I have had repeated incidents with one OT with regards to a particular patient and scheduling our respective treatment sessions. On the ward there is a board with patient’s names and room numbers on, and there is a column for allied health professionals to write in appointment times. Over all this board has been a great help in organising my day and treatment times with patients. This particular OT is the only staff member that does not utilise this board consistently, and it has resulted in them returning a patient to ward repeatedly late for my treatment sessions- with me waiting up to an hour for them to return.
Initially I just accepted that not all treatment session times can be predicted, but after several of these incidents I decided to approach them about the issue. Before addressing this concern with the OT, I was nervous as she was a qualified professional and I have never had previous conflict with hospital staff before. In the end I decided the best approach was to acknowledge the issue: that by repeatedly showing up late, it was impacting on my treatment sessions and then offer an easy solution: Ask her to utilise this board to avoid future situations. I attempted to discuss this with her in the most respectful way, and was relieved when she apologised for her actions as she didn’t realise I had booked appointments with that patient. She accepted the solution, and has since used this board to avoid future miscommunications.
My learning from this experience was that although daunting at times, if you approach other staff with respect and a reasonable solution, issues can be resolved quickly and can usually be a simple result of misunderstanding. If any one has any other possible solutions or alternative ways I could have better approached this situation I would appreciate it. Thanks.
Sunday, June 15, 2008
Knowing when to dischrage a patient
On my current prac, a patient was admitted with severe hip pain, which was due to his hip replacement prostheses becoming loose (it was 10 years old). The patient had too many co-morbidity's to undergo surgery, so the doctor's decided to treat it conservatively: appropriate pain management and walking with a frame to unload the hip joint. The patient lived alone, had no family, with a cleaner coming in to see him weekly. The doctors were ready to discharge him, from a pure physio point of view he was also ready for discharge, and the OT was happy to discharge him as well (with a few additional services).
My supervisor, who is very experienced and caring (she always asks herself if her own family was in the same position as a patient of hers, how would she want them to be treated), was concerned that the patient may not take his new pain medications a s needed (he had some memory issues), and that he may become so overcome with pain that he may collapse and not be able to get up. She believed that he needed to have someone come to see him daily, at least for the first week or so, to monitor that he is coping. She told the OT about his, the discharge was delayed, and the OT contacted the social worker, who organised this. If my supervisor had not thought about this the patient may have ended up back in hospital, possibly with a new injury.
This made me realise that even though there is a pressure to discharge patients asap, sometimes it is better in the long term to delay discharge until all aspect of the patients welfare are organised. It is now also more clear to me why, even though each health professional has a distinct role in the health care setting, you are a better health professional if you think 'outside the square'. If you really care about your patient you do not just think of discharging and caring about the patient from a physio point of view, you must consider their social circumstances, their cognitive function, how the condition that brought them into hospital may effect them when they go home (will they cope?), etc. Like my supervisor said, think of your patient as a member of your family, or, at the risk of sounding preachy, treat your patients as you would want to be treated yourself.
My supervisor, who is very experienced and caring (she always asks herself if her own family was in the same position as a patient of hers, how would she want them to be treated), was concerned that the patient may not take his new pain medications a s needed (he had some memory issues), and that he may become so overcome with pain that he may collapse and not be able to get up. She believed that he needed to have someone come to see him daily, at least for the first week or so, to monitor that he is coping. She told the OT about his, the discharge was delayed, and the OT contacted the social worker, who organised this. If my supervisor had not thought about this the patient may have ended up back in hospital, possibly with a new injury.
This made me realise that even though there is a pressure to discharge patients asap, sometimes it is better in the long term to delay discharge until all aspect of the patients welfare are organised. It is now also more clear to me why, even though each health professional has a distinct role in the health care setting, you are a better health professional if you think 'outside the square'. If you really care about your patient you do not just think of discharging and caring about the patient from a physio point of view, you must consider their social circumstances, their cognitive function, how the condition that brought them into hospital may effect them when they go home (will they cope?), etc. Like my supervisor said, think of your patient as a member of your family, or, at the risk of sounding preachy, treat your patients as you would want to be treated yourself.
Time Management
During my orthopaedic inpatients placement when I had to see 12-14 patients a day, there were a couple of times when I told my patients that I would come back to see them in half an hour after they had their painkiller prior to treatment (which takes about 30 minutes to kick in), I would then end up doing something else that take longer than that which made two of my patients unhappy. I would either have to see other patients during this period of time when my supervisor was ready to stand a patient up with me or when the nursing staff was ready to wash them or get them to shower. When this occurred, most patients were able to put up with it as they understood that I had to see many other patients especially in the morning, however throughout my placement, two patients were not happy with my unpunctuality and walked down the corridor to look for me. One of them complained to me that I should have seen her on time for treatment as she was having painkiller that she normally would refuse to have. Another patient could not wait for me and started doing his exercises on his own. I explained to the patient that painkiller only takes 30 minutes to have their pain covered maximally, however will normally last for 4 hours and therefore it would not be necessary to perform treatment 30 minutes right after having the painkiller. I also apologized to both patients and suggested that I would come and see them last in the next morning so that our treatment would not be hindered by other patients. I consulted my supervisor and she suggested trying not to see too many patients at a time, for example not having them to have painkiller at the same time and also increase liaison with nursing staff and continue to improve my effectiveness in planning and management of time. She also suggested that this will usually come with practice when I become more familiar with the patients and the nursing staff. On reflection, even though many other patients did not complain about this problem, I will need to continue to improve in managing the variable demands of time and to see my patients as punctual as possible. It is also worth taking each patient’s characteristics into account when managing my time.
Monday, June 9, 2008
Patient safety vs quality of life
During this first semester I have managed to see patients in both an orthopaedic and neuro based clinical setting and have begun to gain an appreciation of when and why supervising physios make the call regarding whether a patient is appropriate for discharge and to where.
While the patients who are inpatients on an orthopaedic ward will differ significantly in functionality to those in a neuro rehabilitation setting, the criteria for discharge can be similar from a safety perspective, in that the patients need to be able to ambulate and transfer safely and independently ideally. For an orthopaedic patient the main barriers to discharge are being able to ambulate safely given their post op precautions or walking aids (such as being TWB or PWB, or ambulating with Elbow crutches when previously in dependant, or having to be able to fit a Richards splint). In the case of a neurological inpatient the barriers to DC would depend on what level of recovery they have made with regards to impairments of function or balance as well as ambulating with / without aids as needed. I know that when planning for discharge on either ward they have been the criteria that I have roughly assessed patients with. From here the pathways for Ortho patients is ideally home and for neuro patients the same is ideal, although it has not been uncommon for patients from either ward to be sent to a low care facility, or a facility more appropriate to their current needs from my understanding.
However I have noticed over the year that for elderly patients especially they have been discharged home when their status at discharge does not correlate with what I would have called safe. In these cases however it was seen as appropriate by all staff for the patient to go home, and when asking my supervisor why this was the case, it was a decision based on quality of life. For some patients, they would have a much higher quality of life in their home environment then they would in a nursing home, and they had enough support at home to cope. Its worth noting that all of the patients i am referring to were not grossly unsafe, but I would have definitely sought consultation before sending them home. I believe that this sort of decision making is one that comes with experience, which I am only just developing. I can understand and appreciate that for an elderly patient, staying in their home environment would be their desired situation if they thought they were able to continue to care for themselves. I feel more aware that a patients wellbeing involves more then just their physical ability to be independent, but I also believe that being able to make such a decision is something that will come with experience. This is also an example of how patients can be greatly different despite a similar length of hospital stay or diagnosis.
While the patients who are inpatients on an orthopaedic ward will differ significantly in functionality to those in a neuro rehabilitation setting, the criteria for discharge can be similar from a safety perspective, in that the patients need to be able to ambulate and transfer safely and independently ideally. For an orthopaedic patient the main barriers to discharge are being able to ambulate safely given their post op precautions or walking aids (such as being TWB or PWB, or ambulating with Elbow crutches when previously in dependant, or having to be able to fit a Richards splint). In the case of a neurological inpatient the barriers to DC would depend on what level of recovery they have made with regards to impairments of function or balance as well as ambulating with / without aids as needed. I know that when planning for discharge on either ward they have been the criteria that I have roughly assessed patients with. From here the pathways for Ortho patients is ideally home and for neuro patients the same is ideal, although it has not been uncommon for patients from either ward to be sent to a low care facility, or a facility more appropriate to their current needs from my understanding.
However I have noticed over the year that for elderly patients especially they have been discharged home when their status at discharge does not correlate with what I would have called safe. In these cases however it was seen as appropriate by all staff for the patient to go home, and when asking my supervisor why this was the case, it was a decision based on quality of life. For some patients, they would have a much higher quality of life in their home environment then they would in a nursing home, and they had enough support at home to cope. Its worth noting that all of the patients i am referring to were not grossly unsafe, but I would have definitely sought consultation before sending them home. I believe that this sort of decision making is one that comes with experience, which I am only just developing. I can understand and appreciate that for an elderly patient, staying in their home environment would be their desired situation if they thought they were able to continue to care for themselves. I feel more aware that a patients wellbeing involves more then just their physical ability to be independent, but I also believe that being able to make such a decision is something that will come with experience. This is also an example of how patients can be greatly different despite a similar length of hospital stay or diagnosis.
Lack of Suitable Patients and absent supervisor
When I was on my orthopaedic inpatients placement earlier in the semester, there was a severe shortage of strictly orthopaedic patients on the ward that my facility supervisor was in charge of. The ward was being filled up with cardio, neuro and outlier patients. For the 1st 2-3 weeks of the practicum I was not seeing many patients at all, since my supervisor was only allocating me patients who were more strictly orthopaedic patients. I was keen to follow my supervisor to see the other patients with her, but she was rarely on the ward, and was usually too busy to spend any time with me when she was on the ward.
Therefore I tried to see more patients with the junior physiotherapist on the ward, and this was a good learning experience. However, it did not really test my ability to assess patients from beginning to end in the detail that I would later find my supervisor was after. Neither did it help me gain a better understanding of orthopaedic patients, when I was just seeing outlier patients being treated by the physio.
It was only in the last couple of weeks that it came to my attention that I could take patients from the adjacent ward, since this ward was more strictly orthopaedics. And even though my supervisor was not on this ward, it gave me greater opportunities to develop my assessment and treatment skills of orthopaedic patients.
The lesson I learnt was to take the initiative to seek whether it is appropriate to see patients from another ward if your own is inadequate. And to seek as much information from other physios if your supervisor has no time for you.
Therefore I tried to see more patients with the junior physiotherapist on the ward, and this was a good learning experience. However, it did not really test my ability to assess patients from beginning to end in the detail that I would later find my supervisor was after. Neither did it help me gain a better understanding of orthopaedic patients, when I was just seeing outlier patients being treated by the physio.
It was only in the last couple of weeks that it came to my attention that I could take patients from the adjacent ward, since this ward was more strictly orthopaedics. And even though my supervisor was not on this ward, it gave me greater opportunities to develop my assessment and treatment skills of orthopaedic patients.
The lesson I learnt was to take the initiative to seek whether it is appropriate to see patients from another ward if your own is inadequate. And to seek as much information from other physios if your supervisor has no time for you.
Complicated Social History
When I was doing my gerontology placement, I had an interesting 78 year old male patient, Mr. O, who presented with fall and past medical history of bipolar affective disorder and cardiac diseases. The usual expected length of stay in the ward was around 10 days and patients who need more rehab were usually sent to transitional care or restorative unit. However, Mr. O exceptionally spent more than 3 weeks in the ward due to his difficult social history.
He normally lives at home with his wife and is highly dependent on his wife who does everything for him at home. He has a supportive daughter too. However, during his stay in the hospital, her wife was diagnosed with breast cancer and admitted to the same hospital in oncology ward for chemotherapy which delayed Mr. O’s discharge from hospital. His daughter at that time was also too busy taking care of her husband who was diabetic and was undergoing a leg amputation. The patient knew nothing neither about his wife’s nor daughter’s situations as the wife requested the doctors and all staff not to inform the patient. After having a team meeting, we discussed with the wife that it would be best for Mr O to transfer to Bentley’s restorative unit for longer rehab until she was discharged from hospital. However, Mrs. O strongly disagreed and warned that she would discharge herself from hospital and take her husband home if we did so. As there was a high possibility that she might not be able to take care of her husband as before, we offered a variety of discharge options including low-level care or home services but Mrs O strongly refused. She insisted that she would get better and continue to take care of her husband once she completed her chemotherapy treatment. Fortunately, Mrs O reacted well to her treatment and her doctor agreed that it might be possible for her to continue to provide assistance for her husband when they go home.
I attended the family meeting which involved two patients and two teams. Mr. O discovered his difficult situation however told us that he would do what his wife wanted to do. Finally, we discharged both of the patients with home physio and no other services. Obviously, care was the sole reason for the delay of Mr. O’s discharge from hospital and his difficult social history further hindered the process. Although we tried to suggest and provide what we thought were best for our patients, at the end of the day, it was still up to the patients to make the decision even though the discharge plan was not ideal for them. On reflection, I thought that the team should have put more effort in explaining to the patients in details regarding different kind of home services. Most importantly, Mr. O should be informed regarding his family situations from the beginning and treated fairly in making decision regarding his own discharge plan.
awkward situation
I am currently on my musculo outpatient prac and so far everything is going well. The other day however I had a new patient who I happened to be friends with. He presented to physio with groin and lower abdominal pain. I outlined my objective assessment to my supervisor and she told me that the palpation assessment would be very important and that I would need to palpate the pubic symphysis and ramus. This is awkward enough when you don't know the patient but as I actually new him and was friends with him I found this extremely embarrassing. During my assessment I didn't actually palpate those regions specified by the supervisor because I didn't want to embarrass the patient or myself. Luckily the supervisor came in the treatment room at this point and did the palpation for me.
I think in the future if I know the patient who is coming to physio for a reason such as this I will ask for another male physio to take them.
My supervisor also told me that a test for a type of hernia that may have been the cause of the patients groin pain requires the physio to push their finger up into the male patients scrotum and get the patient to cough. If it is positive there should be a bulging in the scrotum felt on your finger.
I as a female physio would never feel comfortable doing this and was wondering if it was necessary and if there is another way around this? Not only that but I don't think a male patient would be entirely comfortable allowing a female physio to do this test. I was never taught this test and I don't know if it is really a physio thing or more something we can refer on to a GP to assess?
I think in the future if I know the patient who is coming to physio for a reason such as this I will ask for another male physio to take them.
My supervisor also told me that a test for a type of hernia that may have been the cause of the patients groin pain requires the physio to push their finger up into the male patients scrotum and get the patient to cough. If it is positive there should be a bulging in the scrotum felt on your finger.
I as a female physio would never feel comfortable doing this and was wondering if it was necessary and if there is another way around this? Not only that but I don't think a male patient would be entirely comfortable allowing a female physio to do this test. I was never taught this test and I don't know if it is really a physio thing or more something we can refer on to a GP to assess?
Different opinions
I was on a neurology placement at a stroke unit and I had this issue with the FCE and CCT having different opinions on treatment techniques. Something as basic as a transfer for a hemiplegic patient, the FCE suggested to do a 2xA front/back slideboard transfer and the CCT had strong opinion on doing an “angel” transfer (1xA patient fully passive). The FCE’s explanation was that the patient should be encouraged to as active as possible in the transfer – to use their quads to stand and 2xA to help pivot and support. However, the CCT had different opinion! The CCT explained that you shouldn’t encourage hemiplegic patients to participate in the transfer because that will increase tone, encourage pushing effect etc. Later in that prac I was told that different hospitals had different protocols in the stroke unit. In the hospital I was doing the prac in, the hospital’s protocol was to encourage the patient to be functional as early as possible – ie get them to stand early which differs to another hospital which will hoist transfer the patient for a prolonged period of time (even if they have the ability to stand with assistance). This made me think which “protocol” was better.
I would think functional tasks was more important and this should be encourage and retrained at an early stage. This will also allow the patient to see their improvement functionally and will enhance rehab and increase compliance, but I also understand that with the hoisting issue (I was thinking maybe due to lack of staff and for convenience?)
I would think functional tasks was more important and this should be encourage and retrained at an early stage. This will also allow the patient to see their improvement functionally and will enhance rehab and increase compliance, but I also understand that with the hoisting issue (I was thinking maybe due to lack of staff and for convenience?)
I thought if I had a good rationale of how I did the treatment, then the supervisors will understand where I’m coming from and if I’m comfortable with the technique, then the supervisors should be happy with what I did. I also asked the FCE how I should have dealt with the problem with FCE and CCT doing different techniques for one task. The FCE suggested that if the CCT didn’t accept how things were done at the facility even after I explained to her, then I should do it the CCT’s way when the CCT was at the facility “just to make her happy”. The CCT understood my explanation after a long discussion but I did it the CCT’s way in the end anyway just so I can practice the technique while she was there but I told her that I would have done it the other way because I was more comfortable with it and the CCT was fine with it!
Sunday, June 8, 2008
Discovering the Importance of Rapport
We are continually reminded of the importance of building patient rapport through out the theory component of our course, but I have only developed a real appreciation of its value since beginning practical work this year.
Although it is only one line on our blue assessment sheet at mid and end placement, all of my tutors have placed great emphasis on developing rapport with our patients, one tutor even referencing a research article stating 40% of an effective treatment is based on the relationship you build with your patient before you even place your hands on them. Yes- this shocked me too.
A 46 yo female MS patient I am currently treating as an inpatient at SCGH has revealed the significance of a good relationship between therapist and patient over this past week. She was first admitted for a trial of intrathecal baclofen to treat her lower limb muscle spasms and chronic pain. This trial was unsuccessful, so the surgeons decided to trial a spinal electrical stimulation device without fully describing this procedure to the patient. Prior to the surgery she expressed her confusion as to the exact procedure and her consequent anxiety for the surgery scheduled for the next day. She broke down in tears during our treatment session, so I ceased the trunk stability exercises to allow her to discuss her emotions. After listening to her situation, I put my rather basic empathetic skills to the test to console her, then resumed the exercises. On completion of the session, I took her back to her room then liaised with the medical team to discuss the possibility of further educating the patient on the procedure of the surgery. They agreed and explained to the patient what was to be done.
Two days later I had my mid placement assessment, and the tutor chose this particular patient to observe. Prior to the treatment session I read in her inpatient notes that she had been in extreme pain the since the surgery and was quite emotional. As I took her down to the gym, I was thinking of the best way to deal with the situation as to how her emotional state could possibly affect the treatment session. I was very surprised when she gave me a big hug and thanked me for all my help, stating that I made her feel like it was possible to keep going when she felt like giving up. Needless to say, my tutor was quite impressed (as was I!)
I learned a great deal from this situation on the importance of developing listening skills and building a relationship with a patient, as physios are the members of the health team that spend a majority of time with inpatients on some wards. In the future I hope to further develop these skills in a variety of clinical settings as they do impact on the success of a treatment.
Although it is only one line on our blue assessment sheet at mid and end placement, all of my tutors have placed great emphasis on developing rapport with our patients, one tutor even referencing a research article stating 40% of an effective treatment is based on the relationship you build with your patient before you even place your hands on them. Yes- this shocked me too.
A 46 yo female MS patient I am currently treating as an inpatient at SCGH has revealed the significance of a good relationship between therapist and patient over this past week. She was first admitted for a trial of intrathecal baclofen to treat her lower limb muscle spasms and chronic pain. This trial was unsuccessful, so the surgeons decided to trial a spinal electrical stimulation device without fully describing this procedure to the patient. Prior to the surgery she expressed her confusion as to the exact procedure and her consequent anxiety for the surgery scheduled for the next day. She broke down in tears during our treatment session, so I ceased the trunk stability exercises to allow her to discuss her emotions. After listening to her situation, I put my rather basic empathetic skills to the test to console her, then resumed the exercises. On completion of the session, I took her back to her room then liaised with the medical team to discuss the possibility of further educating the patient on the procedure of the surgery. They agreed and explained to the patient what was to be done.
Two days later I had my mid placement assessment, and the tutor chose this particular patient to observe. Prior to the treatment session I read in her inpatient notes that she had been in extreme pain the since the surgery and was quite emotional. As I took her down to the gym, I was thinking of the best way to deal with the situation as to how her emotional state could possibly affect the treatment session. I was very surprised when she gave me a big hug and thanked me for all my help, stating that I made her feel like it was possible to keep going when she felt like giving up. Needless to say, my tutor was quite impressed (as was I!)
I learned a great deal from this situation on the importance of developing listening skills and building a relationship with a patient, as physios are the members of the health team that spend a majority of time with inpatients on some wards. In the future I hope to further develop these skills in a variety of clinical settings as they do impact on the success of a treatment.
Giving your patient a choice
I am still on my geriatric placement at SCGH. I was treating my patient with alcohol induced 'MS' (symptoms similar to multiple sclerosis). He is not the most enthusiatic of patients and he does not talk much, which has made it hard for me to build repoire with him. It was his second treatment session and his carer had mentioned that he had not want to attend today, but felt obliged. During the treatment he did not say much, and alluded that he did not see the point to his treatment.
I decided to explain to him what our aims of treatment are and that he has a choice with regrads to his treatment. I told him that if there is anything that he does not like or want to do, to tell me and we can discontinue it or think of something else to do. The patient seemed to become more complient from then on, and agreed to come back for another session next week.
My supervisor had overheard this and told me that I had handled the situation very well, but that his carer did not think so. The carer beleived that he should not be given the choice because he will use it as an excuse not to attend physio, and that he should be attending physio because it is doing him good, even though he doesn't want to come. I beleive I did the right thing, that the patient always has the right to decline treatment. But it got me thinking: what if you had, for example, a stroke patient, that you knew had a lot of potential, but they had no motivation or interest in their treatment or recovery. Would you keep treating them if their carer/family wanted you to, as it would make the patients's and the carer/families life easier?
I decided to explain to him what our aims of treatment are and that he has a choice with regrads to his treatment. I told him that if there is anything that he does not like or want to do, to tell me and we can discontinue it or think of something else to do. The patient seemed to become more complient from then on, and agreed to come back for another session next week.
My supervisor had overheard this and told me that I had handled the situation very well, but that his carer did not think so. The carer beleived that he should not be given the choice because he will use it as an excuse not to attend physio, and that he should be attending physio because it is doing him good, even though he doesn't want to come. I beleive I did the right thing, that the patient always has the right to decline treatment. But it got me thinking: what if you had, for example, a stroke patient, that you knew had a lot of potential, but they had no motivation or interest in their treatment or recovery. Would you keep treating them if their carer/family wanted you to, as it would make the patients's and the carer/families life easier?
Being Assertive
This week, I learnt the importance of being more assertive with patients.
The patient was a 70 y/o male admitted due to an exacerbation of COPD. His main problems were dyspnoea and decreased exercise tolerance. Treatment included breathing strategies to decrease dyspnoea and ambulation.
The patient had limited English (but was able to understand the bulk of what I said) and was reluctant to comply with physiotherapy treatment.
On the first treatment session, the patient only ambulated 20 metres and refused to go further despite plenty of encouragement, as he was SOB. His exercise tolerance pre-admission was about 20-30 minutes of slow walking in the shops. In subsequent sessions, the patient only ambulated to a maximum of 50 metres. To deal with this, I had to continually state the importance of ambulation. I also made it a point to come in the mornings when the patient was resting in bed and finishing off his breakfast. This was because, I realized that the patient did not want to ambulate after he had been to the toilet or had a shave, as he was feeling SOB. To facilitate the effectiveness of the treatment, I liased with the patient’s daughter, explained the importance of physio and requested that she was there during one of the sessions to assist with translation. That treatment session was very successful, as the patient was able to understand the finer details. The daughter gave further support and encouragement, and the patient ambulated more without complaints.
In addition to his reluctance to ambulate, he absolutely refused to allow me to turn down the oxygen flow. He required only 1L/min at rest. However, he has been insisting that the doctor said he needed 2L/min at all times. On each treatment session, I had to explain clearly the effects of having too much oxygen. After much persuasion, the patient gave in and allowed me to turn down his oxygen to the required amount.
In future, I will be more assertive and persuasive when dealing with more difficult patients. I will explain the benefits and importance of doing physiotherapy (eg: ambulation, deep breathing exercises etc.) Last, I will strive to make the treatments more relevant in the patient’s life so that they will be motivated to do the activities.
The patient was a 70 y/o male admitted due to an exacerbation of COPD. His main problems were dyspnoea and decreased exercise tolerance. Treatment included breathing strategies to decrease dyspnoea and ambulation.
The patient had limited English (but was able to understand the bulk of what I said) and was reluctant to comply with physiotherapy treatment.
On the first treatment session, the patient only ambulated 20 metres and refused to go further despite plenty of encouragement, as he was SOB. His exercise tolerance pre-admission was about 20-30 minutes of slow walking in the shops. In subsequent sessions, the patient only ambulated to a maximum of 50 metres. To deal with this, I had to continually state the importance of ambulation. I also made it a point to come in the mornings when the patient was resting in bed and finishing off his breakfast. This was because, I realized that the patient did not want to ambulate after he had been to the toilet or had a shave, as he was feeling SOB. To facilitate the effectiveness of the treatment, I liased with the patient’s daughter, explained the importance of physio and requested that she was there during one of the sessions to assist with translation. That treatment session was very successful, as the patient was able to understand the finer details. The daughter gave further support and encouragement, and the patient ambulated more without complaints.
In addition to his reluctance to ambulate, he absolutely refused to allow me to turn down the oxygen flow. He required only 1L/min at rest. However, he has been insisting that the doctor said he needed 2L/min at all times. On each treatment session, I had to explain clearly the effects of having too much oxygen. After much persuasion, the patient gave in and allowed me to turn down his oxygen to the required amount.
In future, I will be more assertive and persuasive when dealing with more difficult patients. I will explain the benefits and importance of doing physiotherapy (eg: ambulation, deep breathing exercises etc.) Last, I will strive to make the treatments more relevant in the patient’s life so that they will be motivated to do the activities.
Wednesday, June 4, 2008
Miscommunication
I was on a placement and my supervisor was great: she always tried to make us think by asking us a lot of clinical reasoning questions. This, however was a bit overwhelming during the first week; I (and one other student) needed to get used to her way of wording questions, and we found that at times, we wern't exactly sure what exactly she was asking. She has a different style of tutoring to what we have experienced previously. The tutor picked up on this, except she interpreted our confusion as aggression!!!
During a discussion about planning a treatment for a patient, the other student and me were not sure what exactly she wanted us to change in our treatment plan, so we questioned her about it. Her explanation still did not make sense to us, so we questioned her further. At this point the supervisor stated that she was sensing agressive body language from us, and that she felt that we thought that she was not an adequate tutor. We were shocked! This was so far from the truth! We explained to her that, at times, like now, we get confused by the way that she words her questions and explainations, and are not always sure what she wants us to say or do. We aplogised if we made her feel uncomfortable with our questions, and that we in no way meant to be aggressive or think she is an inadequate tutor. The supervisor understood and was happy that we had cleared the air. Now that she understood that our body language and our questioning was a result of confusion, she felt at ease and stated that she would endevour to try and explain things differently and welcome our questioning.
Before I started my clinics, I was worried that I may come across a tutor that I may not get along with (I have heard some horror stories). This experience highlighted why this may occur: misinterpretation of 'behaviour'. I was lucky that this supervisor decided to openly disscuss her potenial issue with me as soon as they came up, otherwise the rest of my placement would have been quite unpleasant, and my marks may have suffered. It has made me realise that if something is unclear to you, you must address it asap. In this example, I probably should have said to my supervisor that I do not always understand what she is asking of me rather than repeating my questions and standing there looking confused.
A Difficult Patient
During my current placement (orthopaedic inpatients), I had a very difficult 36 year old lady who undergone a right total knee replacement. On day 1 and 2 post-op, she complained of severe pain when bending her right knee (8/10) and she could only perform 2-3 repetitions of each knee exercises. The patient obviously appeared to be highly unmotivated and incompliant due to her severe pain. In this case, I focused on liaising with the nursing staff to ensure appropriate and regular pain relief prior to each treatment session. I educated the patient and emphasized the importance of doing the bed exercises as well as the importance of mobilizing from day 1 post-op to make sure that her pain did not stop her from doing her exercises and SOOB. I also negotiated with the patient to discuss her preferred time for physio treatment and to divide one treatment session into a few shorter sessions hoping to improve her compliance with the exercises. After discussing with my supervisor for the first time regarding her situation, given that I could not do much with her active exercises, my supervisor suggested me to put the patient on a CPM machine, hoping to at least improve her knee PROM; however it did not help much at all. The worst part was she would start crying and swearing after each treatment. At that time, I did not feel that this patient had improved much at all after her surgery which greatly reduced my confidence in persuading and encouraging her to continue with her exercises. I also became suspicious of my treatment decisions and strategies.
On day 3 post-op, an active ROM of 70° knee flexion was expected in her operated knee according to her surgeon’s protocol; however she could only flex her operated knee to an active-assisted ROM of 30° using pulleys and slings. I consulted my supervisor again and she was willing to see the patient with me this time. My supervisor attempted to push her with her exercises by putting her on CPM and flexing her knee from 0 to 40°. As expected, the patient started crying and swearing again. It took us for a while to comfort her. After this treatment, my supervisor advised me not to take what the patient had said personally and not to let this patient affect my confidence in treating other patients. She commented that this lady was just a difficult patient to treat. She suggested me to let her have the patient back and that she would give me a new patient to see. I agreed and felt much relieved. On reflection, I learnt that successful treatments should not be expected at all times and constant evaluation of the effectiveness of each treatment is essential to ensure a good outcome for the next treatment. Given that the outcomes of my first few treatments with this patient were not optimistic, I should have discussed more with my supervisor or other senior therapists to seek for other professional opinions. I also found that my gentleness with this difficult patient and her exercises during the treatment might have caused her to overstress her pain that stopped her from doing the exercises, I learnt that pushing the patients harder with their exercises in a good way may be helpful to achieve a good treatment outcome.
Tuesday, June 3, 2008
patients with poor english
I am currently on my musculo prac at Curtin clinic. One of my new patients speaks limited English which can be difficult when educating her about her condition and trying to get a detailed subjective picture of her pain (especially when she doesn’t know what “ache” and “burning” in regards to pain means). She presented with cervical pain which was later diagnosed as irritation of the C3/4 facets and C5/6 facets due to the protracted neck position she has adopted from having generalized hypermobility of all joints.
I found it very difficult to tell her what was happening to cause her pain, as her basic English was limited. She told me she would look up any words she didn’t understand in her English translation dictionary. With this in mind I wrote down a bit about her disorder and underlined the words she didn’t understand. I wrote: you have hypermobility (lots of movement) in all your joints because your ligaments are too stretchy. I didn’t think they would have diagrams of ligaments and joints in the English dictionary so I showed her a good picture of the skeletal system with ligaments intact and also used a model to show her how ligaments let our joints move/restrict movement.
She was very grateful for me dedicating time to allow her to understand her condition, as she was very confused initially as she had seen a doctor who probably didn’t take the time to explain it to her. In the future I will use shorter words and rely heavily on models and diagrams to make sure people with limited English skills understand their condition fully, as they will be more likely to comply with self-management.
I found it very difficult to tell her what was happening to cause her pain, as her basic English was limited. She told me she would look up any words she didn’t understand in her English translation dictionary. With this in mind I wrote down a bit about her disorder and underlined the words she didn’t understand. I wrote: you have hypermobility (lots of movement) in all your joints because your ligaments are too stretchy. I didn’t think they would have diagrams of ligaments and joints in the English dictionary so I showed her a good picture of the skeletal system with ligaments intact and also used a model to show her how ligaments let our joints move/restrict movement.
She was very grateful for me dedicating time to allow her to understand her condition, as she was very confused initially as she had seen a doctor who probably didn’t take the time to explain it to her. In the future I will use shorter words and rely heavily on models and diagrams to make sure people with limited English skills understand their condition fully, as they will be more likely to comply with self-management.
Monday, June 2, 2008
Team work
I earlier this year completed a prac at an Intensive Care Unit at one of the major teaching hospitals for my cardio placement. I found this to be an extremely interesting prac in which I was faced with challenges that I do not think I would have encountered on other cardio wards.
In dealing with Intubated and Extubated patients who were at times quite medically unstable it helped me a lot in developing some sort of clinical judgement and due to the support from staff learned to appreciate the individual presentation of different patients even if they were to have the same diagnosis.
I found this to be a great environment to work in and I think I learnt a lot from not only the physiotherapists, but also the nursing staff, doctors and other allied health team members (such as Speech therapists and occupational therapists).
I think that the reason that the ward seemed to operate so well was because of the exceptional team work and experience of all members of staff. The interaction between staff and patients was extremely high, with a nurse allocated to each room and the doctors were always on the ward. As a result the members of staff seemed ready to rely on each other in most situations, wether it be transfering patients or assisting in treating a patient / teaching students. As a result, my interaction with members of staff was much more enjoyable then on other placements, and I had no significant problems in treating patients that I can remember. If i was unable to see a patient at a certain time, the member of staff always explained why rather then just saying the patient was unavailable.
However I do not think that it is likely that other areas of the hospital would be like this;
having a ratio of 1:1 with the patient to nursing staff would be unheard of in other wards, with a ratio of 4:1 sounding more reasonable. In addition to this, the fact that patients in ICU do not have allocated meal times in most cases, or commitments off the ward (with the exception of certain investigations and operating theatre) meant that the patients were available for treatment most of the time they were on the ward. It would be very unlikely for any of us to have the luxury of a patient would be available for treatment at all times.
I suppose that the reason I decided to write on this was to reflect on how different things are on different wards. In an area like ICU where the patient is still too unstable for the ward, the main aim is to get the patient stable and then send them for further therapy, and staff are provided with the time and resources to achieve this. However once on the ward the patients time becomes more divided between the different facets of their rehab and their impending discharge. This in turn results in less available time for treating the patients and the possible conflicts that may arise when trying to utilise time for treatment while other staff may have demands for te patients time as well.
In dealing with Intubated and Extubated patients who were at times quite medically unstable it helped me a lot in developing some sort of clinical judgement and due to the support from staff learned to appreciate the individual presentation of different patients even if they were to have the same diagnosis.
I found this to be a great environment to work in and I think I learnt a lot from not only the physiotherapists, but also the nursing staff, doctors and other allied health team members (such as Speech therapists and occupational therapists).
I think that the reason that the ward seemed to operate so well was because of the exceptional team work and experience of all members of staff. The interaction between staff and patients was extremely high, with a nurse allocated to each room and the doctors were always on the ward. As a result the members of staff seemed ready to rely on each other in most situations, wether it be transfering patients or assisting in treating a patient / teaching students. As a result, my interaction with members of staff was much more enjoyable then on other placements, and I had no significant problems in treating patients that I can remember. If i was unable to see a patient at a certain time, the member of staff always explained why rather then just saying the patient was unavailable.
However I do not think that it is likely that other areas of the hospital would be like this;
having a ratio of 1:1 with the patient to nursing staff would be unheard of in other wards, with a ratio of 4:1 sounding more reasonable. In addition to this, the fact that patients in ICU do not have allocated meal times in most cases, or commitments off the ward (with the exception of certain investigations and operating theatre) meant that the patients were available for treatment most of the time they were on the ward. It would be very unlikely for any of us to have the luxury of a patient would be available for treatment at all times.
I suppose that the reason I decided to write on this was to reflect on how different things are on different wards. In an area like ICU where the patient is still too unstable for the ward, the main aim is to get the patient stable and then send them for further therapy, and staff are provided with the time and resources to achieve this. However once on the ward the patients time becomes more divided between the different facets of their rehab and their impending discharge. This in turn results in less available time for treating the patients and the possible conflicts that may arise when trying to utilise time for treatment while other staff may have demands for te patients time as well.
Patient Confidentiality
In my 1st week of my Neurology Prac, I was sharing a patient with a fellow physio student. This patient had been admitted to hospital after inducing nitric oxide recreationally and had subsequently suffered myelinonopathy of her peripheral nerves and hence weakness in her limbs. She was a very pleasantly spoken patient, however was trying very hard to keep any information concerning substance abuse away from those other than health professionals and friends.
On her last couple of days at the hospital, we had written up a referral, in order to provide her with assistance where necessary, just to get her used to having to look after herself again. We entered her room intending to tell her of this referral and were holding the form which she needed to sign to gain consent. When we entered there was another lady in the room, who appeared to be a friend or relative. We discussed with her the referral and that she had to sign the form. When we showed her the form, she noticed that the words “nitric oxide” has been written under the headings: diagnosis/condition. We explained that we needed to have to form back, but she was trying to hold onto the form.
When the visitor in the room left she told us that the lady was her boss and was desperately trying to avoid her know that she had been inducing nitric oxide recreationally, and that she preferred us not to be bringing around pieces of paper that had such “confidential information” written on it.
The other student and myself were later discussing, that we did not understand how her boss could come to visit her in hospital and not know why she was in there for. However, even though we had not verbalized the words “nitric oxide” while the boss was in the room, the patient had seen the information on the form as a threat to confidentiality.
The lesson that can be learned from a situation like this is that we cannot presume that visitors in the room know the details of the patient’s admission. Or that the patient intends to tell the visitor the reasons for their admission. We felt that since we had not actually discussed the reasons for her condition while we were in the room, we had acted appropriately. However, perhaps, if the patient does not say who the visitor is in the room, it may help to enquire their relationship with the patient (which needs to be done with sensitivity also).
Inpatient gerontology
When I was on my gerontology placement (inpatient setting), I found that they had a very quick turnover rate (around 5 days for the majority of the cases). The patients were in and out in less than a week !! During the patient’s stay on the ward, I had to assess the patient, treat the patient as appropriate, and prepare their discharge. At first it was quite a handful as I found that it was quite difficult to assess the patient in one go as they fatigue easily or their cognitive state limits their ability to be assessed. So by the time I get around to treating them properly they will be out to another ward. This placement gave me the opportunity to learn to modify assessments to assess the most appropriate and manage my time effectively. I also had lots of chances to do handovers !
In addition to that, I found that in an inpatient gerontology setting, most of the patients were confused or deconditioned which limits the treatment choices. Sometimes, the only treatment I do with them is ambulation (for a very short distance) because that is all they can manage and it was very difficult to convince them to do more.
As the placement progressed, I learnt that some patients had better compliance at a specific time of the day (am Vs pm), or they had a better mood when their family was around so I try to plan my day around that so I can get the most effective treatment out of the patient.
Managing A Case Load
Although as students we are generally given a fairly low case load in order to develop our clinical skills in as pressure free environment as possible, this placement has challenged my ability to effectively manage the number of patients I have been allocated. Currently on my neuro inpatient placement, we are given an average of three patients to see in the am and pm, which doesn’t sound like a lot but as a developing student with only basic clinical skills in this area, I am quickly learning the value of preparation and organisation.
This week I learned the value of time management and organisation at the expense of one of the patients I am currently treating. The patient is a 51 y.o L MCA with right sided weakness and expressive aphasia who has been quite emotional since her admission, with regular episodes of crying and swearing out of frustration at her current functional level. Another student and I notified her we were coming to see her for a gym session at 10 am, then went to treat another stroke patient from 9 am. With the first patient, I was fortunate enough to experience the gratification of walking a patient for the first time post stroke who cried with happiness. Unfortunately this achievement took longer then the estimated hour we had allocated and when the other student and I showed up to our second patients room 20 mins late, we found her crying out of frustration.
We apologised for our lateness and attempted to explain why we weren’t there on time, yet she refused to attend physio that morning saying she was too distraught. The other student and I decided not to persist and came back later that afternoon. When we came back she explained the reason she was so upset was because she has difficulty communicating and non of the nursing staff understood what she was waiting for. She also expressed frustration at waiting and not being told what was happening, making her feel useless and confused. After this explanation I felt terrible and realised either the other student or I should have taken two minutes to let her know we would be running late.
From this experience I learned the importance of communication and preparing myself for situations like these which may occur in the future. I understand that in the future my case load will increase and I have to develop strategies to manage that increase with the patients bet interests. If any one has any suggestions on how the situation could have been handled better I would be very appreciative. Thanks.
This week I learned the value of time management and organisation at the expense of one of the patients I am currently treating. The patient is a 51 y.o L MCA with right sided weakness and expressive aphasia who has been quite emotional since her admission, with regular episodes of crying and swearing out of frustration at her current functional level. Another student and I notified her we were coming to see her for a gym session at 10 am, then went to treat another stroke patient from 9 am. With the first patient, I was fortunate enough to experience the gratification of walking a patient for the first time post stroke who cried with happiness. Unfortunately this achievement took longer then the estimated hour we had allocated and when the other student and I showed up to our second patients room 20 mins late, we found her crying out of frustration.
We apologised for our lateness and attempted to explain why we weren’t there on time, yet she refused to attend physio that morning saying she was too distraught. The other student and I decided not to persist and came back later that afternoon. When we came back she explained the reason she was so upset was because she has difficulty communicating and non of the nursing staff understood what she was waiting for. She also expressed frustration at waiting and not being told what was happening, making her feel useless and confused. After this explanation I felt terrible and realised either the other student or I should have taken two minutes to let her know we would be running late.
From this experience I learned the importance of communication and preparing myself for situations like these which may occur in the future. I understand that in the future my case load will increase and I have to develop strategies to manage that increase with the patients bet interests. If any one has any suggestions on how the situation could have been handled better I would be very appreciative. Thanks.
Almost successful treatment session
This week, I was treating a 72 y/o male admitted onto the respiratory ward due to an exacerbation of COPD. He has a PMH of motor neuron disease (diagnosed in 2001, very slow progression, no bulbar signs), IHD, GORD and gout. His exercise tolerance is limited by SOB, pain/ache in both knees and weakness in both legs, and therefore is able to ambulate independently for about 5 m with a 4WW. The problem list included, 1) dyspnoea, 2) decreased exercise tolerance 3) Impaired gas exchange 4) impaired airway clearance. The considerations for treatment included musculoskeletal problems (pain in both knees, and weakness in the lower limb).
On the Friday before the 3 day long weekend, I did a follow up treatment session. The plan was to ambulate the patient for about 5-10m with 1x rest, then do ACBT (TEE with BC). I went to see the patient in the morning, but he was resting in bed refusing treatment due to complaints of increased pain and general fatigue. I said I’d come back in the afternoon which I did.
In the afternoon, I spoke to the nurse, who said that the patient has not gotten out of bed for the whole day. It was going to be a 3 day long weekend and there were no indications for the patient to be put on the weekend list. And it was highly likely that the patient would stay in bed for the 3 days. For these reasons, I was quite determined to get the patient out of bed. However the patient again refused to get out of bed to ambulate. Frustrating!
First, I told the patient the plan and its importance (get him out of bed and amb), to which he was very reluctant. I then proceeded to ask if I could just have a listen to his chest and to check his SpO2. He agreed to that, and I completed my usual subjective questions (SOB, cough, sputum) while he was resting in bed. During which, also listened to his complains about pain/feeling tired. After that, I asked if he could sit up over the edge of the bed to finish up the auscultation. He agreed. At the same time, I was also listening to his complains about his frustration at the doctors about being treating like a “specimen” instead of a real person.
Since he was already sitting up in bed, I thought it would be good if he could t/f to the high back chair using a step t/f with the 4 WW. I then explained how sitting up would be good for lung function. And assured the patient that he could stop if he wanted to and all he needed to do was to sit in the chair for ½ hour. To my surprise, he was willing to give it a shot. The t/f went well, with some c/o increased pain in the knees due to weight bearing. While in the chair, I finished off with some ACBT.
After the session, I asked if the patient preferred to remain sitting or be t/f back into bed. He said that he wanted to stay in the chair for a while longer. I then went and got the patient a foot stool as he mentioned earlier that he was more comfortable with his legs stretched out.
Through this experience, I realized that building a rapport with the patient is very important as the patient will trust you and it will enable a treatment session to be successful. With this patient, persistence, lots of encouragement and compromise/flexibility is the key to a successful treatment session. Good listening skills and plenty of patience is vital with every patient you come across.
On the Friday before the 3 day long weekend, I did a follow up treatment session. The plan was to ambulate the patient for about 5-10m with 1x rest, then do ACBT (TEE with BC). I went to see the patient in the morning, but he was resting in bed refusing treatment due to complaints of increased pain and general fatigue. I said I’d come back in the afternoon which I did.
In the afternoon, I spoke to the nurse, who said that the patient has not gotten out of bed for the whole day. It was going to be a 3 day long weekend and there were no indications for the patient to be put on the weekend list. And it was highly likely that the patient would stay in bed for the 3 days. For these reasons, I was quite determined to get the patient out of bed. However the patient again refused to get out of bed to ambulate. Frustrating!
First, I told the patient the plan and its importance (get him out of bed and amb), to which he was very reluctant. I then proceeded to ask if I could just have a listen to his chest and to check his SpO2. He agreed to that, and I completed my usual subjective questions (SOB, cough, sputum) while he was resting in bed. During which, also listened to his complains about pain/feeling tired. After that, I asked if he could sit up over the edge of the bed to finish up the auscultation. He agreed. At the same time, I was also listening to his complains about his frustration at the doctors about being treating like a “specimen” instead of a real person.
Since he was already sitting up in bed, I thought it would be good if he could t/f to the high back chair using a step t/f with the 4 WW. I then explained how sitting up would be good for lung function. And assured the patient that he could stop if he wanted to and all he needed to do was to sit in the chair for ½ hour. To my surprise, he was willing to give it a shot. The t/f went well, with some c/o increased pain in the knees due to weight bearing. While in the chair, I finished off with some ACBT.
After the session, I asked if the patient preferred to remain sitting or be t/f back into bed. He said that he wanted to stay in the chair for a while longer. I then went and got the patient a foot stool as he mentioned earlier that he was more comfortable with his legs stretched out.
Through this experience, I realized that building a rapport with the patient is very important as the patient will trust you and it will enable a treatment session to be successful. With this patient, persistence, lots of encouragement and compromise/flexibility is the key to a successful treatment session. Good listening skills and plenty of patience is vital with every patient you come across.
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