On my last prac I was looking after a older lady (90+) who was initially admitted for a laparotomy. In most cases the patient is discharged anywhere between 4-10 days. This patient had her operation at the beginning of my second week and was still not discharged by the time I finished the prac. She had no chest issues that were keeping her in hospital and after consultation with her surgical team I found no medical reason to keep her in hospital.
The reason she was still at hospital was because her carer had informed the social worker that the patient was not coping at home. This was revealed to us at a team meeting. The patient lived at home pre-admission and had services for cleaning and cooking and family help for shopping. She was still home alone for large amounts of time with no help. It was reported that her mobility was impaired to such a level that there were hygiene and toileting issue beginning to emerge. She was also found many times asleep in her lounge chair because she was not able to make it to her bedroom.
Consequently the patient's main physiotherapy concern was mobility. This patient was a typical candidate for low-level care and a request for the DCGM (Department of Community and Geriatric Medicine) team to review her was promptly sent with the aim of an ACAT (Aged Care Assessment Team) assessment.
When I discussed this with the patient I recieved quite a negative response from her and was promptly told that the only place she was going to would be back home. The treatment session I had planned was refused and the patient would not talk to me. Even though the medical and allied health team, together with the family, decided that the patient was not coping at home, the patient was still adamant that she was going home.
Now I don't believe I was being dishonest, but to be able to perform any rehab with this patient it was necessary for me to not mention low-level care again. The patient repeatedely commented during the rest of our treatment sessions how she was going home. I didn't say anything contrary but neither did I agree with her. In the end I believed that the best course of action was to maintain a rehab program while she was still on the surgical ward. Maybe later on in her rehab process the issue could be raised again but in order to provide the most effective rehab while she was still on my ward I chose to not disucss low-level care again.
Sunday, November 16, 2008
Monday, November 10, 2008
Rapport building
Whilst treating a patient this week I learnt the benefit of being polite but firm with patients. I was seeing an older lady who was day 4 post routine TKR. She was only getting about 20 degrees of active knee flexion but should have had around 50 or 60 by then. She was complaining of severe pain however refused pain medication as she preferred more natural remedies. My supervisor had warned me that she was difficult and very particular about her treatment and not to bring up some of her PMHx as she would argue that none of it was true. If things weren’t done her way then they weren’t done at all – hence the lacking ROM.
So the first time I went to take her down to the gym, I tried extra hard to be nice and build some rapport with her so that she would be compliant. Which meant that I let her brush her hair, put on some hand cream, helped her walk very slowly to the toilet etc. However this meant that I had already spent 25 minutes with her by the time she got into the wheel chair to go down to the gym. She was extremely friendly with me and did as I asked and increased her AROM, albeit very slowly. By the time I got her back to her room, a treatment that should have taken a maximum of 30 minutes had taken just over 1 hour. I still had so many patients to see and therefore was rushed the rest of the day.
From this I learnt that whilst building rapport with the patient is essential, we still have to be in control of the treatment session because our time is very precious, especially next year when it would have been just me on the ward. The next time I went to see her I popped in 15 minutes earlier to say she had to be completely ready by a certain time and we had to be back to the room in 20 minutes. This worked effectively and taught me that yes you need to build rapport with the patient but this should not mean using up all our time just to keep ‘fussy’ patients happy.
So the first time I went to take her down to the gym, I tried extra hard to be nice and build some rapport with her so that she would be compliant. Which meant that I let her brush her hair, put on some hand cream, helped her walk very slowly to the toilet etc. However this meant that I had already spent 25 minutes with her by the time she got into the wheel chair to go down to the gym. She was extremely friendly with me and did as I asked and increased her AROM, albeit very slowly. By the time I got her back to her room, a treatment that should have taken a maximum of 30 minutes had taken just over 1 hour. I still had so many patients to see and therefore was rushed the rest of the day.
From this I learnt that whilst building rapport with the patient is essential, we still have to be in control of the treatment session because our time is very precious, especially next year when it would have been just me on the ward. The next time I went to see her I popped in 15 minutes earlier to say she had to be completely ready by a certain time and we had to be back to the room in 20 minutes. This worked effectively and taught me that yes you need to build rapport with the patient but this should not mean using up all our time just to keep ‘fussy’ patients happy.
Diagnosis and treatment
On my current prac I work on the wards each morning, mainly with post-op and respiratory patients. Last week I was asked to see a young girl with 'left lower lobe pneumonia'. She had quite frank haemoptasis, and was in a great deal of pain, which was localised to the left side of her chest. She was short of breath, fluctuated between febrile and afebrile an back to febrile in the blink of an eye. For the first few days of her stay, she was quite uncooperative with breathing exercises ue to pain, and was refusing to get out of bed. Wary of her pain and blood stained sputum, I approached her with caution. Her sats were VERY low and she was in serious need of some treatment. The first treatment conisisted of teaching thoracic expansion exercises within pain limits, and bed exercises (ankle pumps, static quads and gluts), and instructing the patient to perform these at least every hour. I documented each treatment in great detail, and saw her everyday. Gradually she was able to get out of bed, and walk on the ward, but she was not getting better no matter what we tried. Each chest xray came back the same. After 10 days, the doctor finally ordered a CT scan and other investigations that had not yet been done. These picked up that my pneumonia patient actually had a PE and a DVT!!! No wonder she wasn't improving. On reviewing the notes, it was evident that we had done all we could to treat her, and had done our best to prevent the subsequently developing DVT. After being treated for the actual problem, the patient was back to health in just a few days. If I have taken anything away from this experience, it is to be conservative and cautious, and never underestimate simple bed exercises and good documentation. Even if you think a word of advice or basic exercises are not that important to document thoroughly, you never know when your documentation will be reviewed. My documentation in this case is evidence that we did everything within our power to offer the patient the best possible treatment.
Sunday, November 9, 2008
Age Care Assessments
I was on my rural prac doing aged care assessment for permanent residents at the hospital. This assessment is done by a physio either six monthly or yearly and involves an in depth look at the patient mobility, balance, ROM, strength and coordination. It is documented in the patient notes and can be reference to monitor the patient through out there residency at the hospital.
This particular patient I was required to assess had been admitted due to dementia and varies co morbidities. More recently her mental status had declined and the nursing staff where finding her more and more difficult.
I had been warned that she was most likely going to be uncooperative, but I thought I could lay down a bit of the physio student charm and get her onside and happily participating in the assessment.
I strolled into her room confident as can be, quickly built some rapport with her, then wrongly asked her if she would like to participate in the assessment. She quickly changed tunes from being a nice old lady to promptly telling to where to stick it. I was shocked; I had been bitterly shut down by an old lady giving the nurse looking after her quiet chuckle and slightly denting my ego.
I walked away with my head down preparing for round two. It was extra important for me to win round two as she and her stubborn ways was the only thing stopping me from going home nice and early.
I thought I would change tacts a little and instead of asking participation in the assessment I would DEMAND it. I went in for round two, not mentioning the word assessment but rather asking the patient to do various tasks involved in the assessment. This change in communication strategy work quite well and left the nursing staff amazed I had got so much out of the patient. In the end I finished the assessment thoroughly completing the assessment. What I learnt from this was don’t give up when a patient is difficult go in for round two changing communication strategies.
This particular patient I was required to assess had been admitted due to dementia and varies co morbidities. More recently her mental status had declined and the nursing staff where finding her more and more difficult.
I had been warned that she was most likely going to be uncooperative, but I thought I could lay down a bit of the physio student charm and get her onside and happily participating in the assessment.
I strolled into her room confident as can be, quickly built some rapport with her, then wrongly asked her if she would like to participate in the assessment. She quickly changed tunes from being a nice old lady to promptly telling to where to stick it. I was shocked; I had been bitterly shut down by an old lady giving the nurse looking after her quiet chuckle and slightly denting my ego.
I walked away with my head down preparing for round two. It was extra important for me to win round two as she and her stubborn ways was the only thing stopping me from going home nice and early.
I thought I would change tacts a little and instead of asking participation in the assessment I would DEMAND it. I went in for round two, not mentioning the word assessment but rather asking the patient to do various tasks involved in the assessment. This change in communication strategy work quite well and left the nursing staff amazed I had got so much out of the patient. In the end I finished the assessment thoroughly completing the assessment. What I learnt from this was don’t give up when a patient is difficult go in for round two changing communication strategies.
Staying motivated for Self directed placement
Looking back on the 4 years of my physiotherapy degree it seems that I have been subjected to an amazing amount of work. Why now with less than 10 weeks to go do I find it ever so hard to stay motivated with this ridiculous self directed placement?
I know this blog is not under the typical contents of reflections, but I think is fits nicely within the professional practice and ethics theme of blogs.
The self directed practicum may be as challenging as any other pracs undertaken in the 4th year clinical experience. For some like me it seems to be extremely challenging in regards to motivating my self.
I believe the self directed prac is included in the 4th year clinical experience as it duelly reflects a task that may be required whilst working as a physiotherapist. It is beneficial to now realise the troubles of motivating ones self when completing a teadious (at time seemly pointless) task.
In terms of overcoming my limited self motivation, I have no magic answer. Personally I have found treating it like a job useful. (If you can trick yourself and not sleep in) I have found the most benefit by going into Uni finding a computer and pretending I’m getting paid to complete my self directed assignment (I wish). The deadline also helps, breaking up the big tasks into smaller tasks and putting achievable deadline on them may also prove useful for some.
Well best of luck for anyone else going through this similar conundrum.
I know this blog is not under the typical contents of reflections, but I think is fits nicely within the professional practice and ethics theme of blogs.
The self directed practicum may be as challenging as any other pracs undertaken in the 4th year clinical experience. For some like me it seems to be extremely challenging in regards to motivating my self.
I believe the self directed prac is included in the 4th year clinical experience as it duelly reflects a task that may be required whilst working as a physiotherapist. It is beneficial to now realise the troubles of motivating ones self when completing a teadious (at time seemly pointless) task.
In terms of overcoming my limited self motivation, I have no magic answer. Personally I have found treating it like a job useful. (If you can trick yourself and not sleep in) I have found the most benefit by going into Uni finding a computer and pretending I’m getting paid to complete my self directed assignment (I wish). The deadline also helps, breaking up the big tasks into smaller tasks and putting achievable deadline on them may also prove useful for some.
Well best of luck for anyone else going through this similar conundrum.
Patient not managing at home
Recently on my Neurological outpatient’s prac, I was treating this gentleman with degenerative neurological condition. He had been diagnosed with this condition for 10 year but was still able to live at home independently. He presented to outpatients, this time been the first time I had seen him reporting a severe pain in his left hip. He reported having this pain for a number of weeks with it becoming unbearable in the last few days.
With further questioning he reported that he wasn’t managing at home due to the severe pain. The pain was made worse when he suffered a spasm in his left leg. It was a negative support reaction or flexor withdraw response associated with his neurological condition.
Straight away I realised it was my duty to organise further referral to get to the bottom of this patients pain. Collaborating with my supervisor we had a medical team reviewed this patient within 30 mins and offer him an inpatient bed for further investigation.
The patient ended up on a rehabilitation ward for 2 weeks and had his pain thoroughly investigated and treated. It improved vastly and the patient was heading towards pre hospitalisation function. My prac ended, but it was assumed the patient was adequately rehabilitated to again function independently at home.
The time physiotherapists spend with patients in the rehabilitation setting, places them in a good position to understand there needs and basic requirements. The time spent with a client often reveals information that otherwise wouldn’t have been revealed if time was rushed. The example above highlights this; the physiotherapist initiated other services which benefited the patient. If this information wasn’t obtained the patient may have continued living at home not coping well.
With further questioning he reported that he wasn’t managing at home due to the severe pain. The pain was made worse when he suffered a spasm in his left leg. It was a negative support reaction or flexor withdraw response associated with his neurological condition.
Straight away I realised it was my duty to organise further referral to get to the bottom of this patients pain. Collaborating with my supervisor we had a medical team reviewed this patient within 30 mins and offer him an inpatient bed for further investigation.
The patient ended up on a rehabilitation ward for 2 weeks and had his pain thoroughly investigated and treated. It improved vastly and the patient was heading towards pre hospitalisation function. My prac ended, but it was assumed the patient was adequately rehabilitated to again function independently at home.
The time physiotherapists spend with patients in the rehabilitation setting, places them in a good position to understand there needs and basic requirements. The time spent with a client often reveals information that otherwise wouldn’t have been revealed if time was rushed. The example above highlights this; the physiotherapist initiated other services which benefited the patient. If this information wasn’t obtained the patient may have continued living at home not coping well.
Monday, November 3, 2008
observe
I am currently doing my cardio placement on a surgical ward. As most of you would know this involves mainly chest physiotherapy and mobilising the patient (amb, SOOB in chair etc). When it comes to getting the patient up from a bed for the first time post surgery, it is imperative that we monitor their SpO2 and make sure it does not drop dramatically. We should also check the pt's charts prior to any treatment to make sure their blood pressure is stable.
Even though monitoring the patient is quite important, I have been made aware of the fact that I seem to rely too heavily on a SATS monitor and not enough on my observational skills. This was pointed out to me a number of times by my CCT, who is encouraging me not to underestimate the reliability of these observational skills. It seems that I have been using the monitor as a security blanket. As a result I am not questioning the pt throughout the treatment about any changes in their symptoms.
The two pt's I have seen with my CCT have both displayed low SpO2's of below 94% but have been consistently asymptomatic. If this is the case what is the point of me fumbling constantly with a monitor when I know the patient is not suffering from any ill effects. In fact, there have been some instances where the added piece of equipment may potentially compromise the pt's safety.
After all this was pointed out to me I realised that a major area of improvement within my skill set was my observational skills. It is just as important if not more to monitor the pt's appearance and note any signs that they are not coping with ambulating or moving out of bed. In order to effectively learn this, we sometimes have to go easy on the SATS monitors and develop our observational skills, especially while we are still students for only 2 more weeks.
Even though monitoring the patient is quite important, I have been made aware of the fact that I seem to rely too heavily on a SATS monitor and not enough on my observational skills. This was pointed out to me a number of times by my CCT, who is encouraging me not to underestimate the reliability of these observational skills. It seems that I have been using the monitor as a security blanket. As a result I am not questioning the pt throughout the treatment about any changes in their symptoms.
The two pt's I have seen with my CCT have both displayed low SpO2's of below 94% but have been consistently asymptomatic. If this is the case what is the point of me fumbling constantly with a monitor when I know the patient is not suffering from any ill effects. In fact, there have been some instances where the added piece of equipment may potentially compromise the pt's safety.
After all this was pointed out to me I realised that a major area of improvement within my skill set was my observational skills. It is just as important if not more to monitor the pt's appearance and note any signs that they are not coping with ambulating or moving out of bed. In order to effectively learn this, we sometimes have to go easy on the SATS monitors and develop our observational skills, especially while we are still students for only 2 more weeks.
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