I have had an excellent final placement in both a musculoskeletal and rural capacity. As usual my initial concerns regarding my supervisor’s expectations of me on day one were quickly laid to rest. Once I was in the clinical environment I realised that I knew more than I thought I did and the further through my placement I got the more specific information I thought I'd forgotten came back to me. Although I did initially struggle with the finer details of assessment and functional anatomy in the upper and lower limb, I was able to learn on the job and study as I went to cement my knowledge.
My assessments weren’t perfect, as I had expected, but improved dramatically with clinical experience and as I felt more confident with the processes. As well as revising my musculoskeletal notes, I believe it was the hands on practice and clinical experience that really propelled the improvements in my clnical skills and knowledge base. I now feel able to perform a thorough and client specific assessment and develop an appropriate treatment plan from that.
In addition to the musculoskeletal patients I saw I was also able to gain experience with women’s health patients, treating many pregnant women and being involved in ante and post-natal classes. This was really beneficial for me as I hadn’t previously had any experience in this field and it is an area that I feel is important to understand as it required a varied approach to assessments and treatments and different handling skills.
The other class I took part in whilst away were for older adults to improve balance and mobility. Unlike similar classes I’d been involved with in the city, these classes often only had two people in them and at most had five or six patients. This meant you were able to be more specific in exercises used and use more equipment, such as weights and fitballs.
As I had hoped, I got the opportunity to visit two of the three local communities serviced by Tom Price Hospital. The communities I saw were a lot smaller than I had expected but it was great to see another aspect of working in rural Australia and the different approaches to working as a physio in these communities.
Although I was nervous about living so far from home, I loved my rural experience and found it very refreshing to have a good break from my ordinarily hectic city lifestyle. I also found that I excelled and enjoyed the musculoskeletal component more than I had anticipated, getting to experience such a wide variety of conditions that constantly challenged me and inspired me to continue learning more and more right to the end of the placement.
Sunday, July 25, 2010
STARES #3: EBP
Evidence Based Practice
SITUATION
My placement for this rotation is in the outpatient physiotherapy at Tom Price Hospital with the majority of patients falling under the musculoskeletal category with a small number of women’s health, paediatric and neurology patients. Tom Price is a small, rural mining town with the majority of the patients we see being mine workers and partners of those employed by the mine. Due to the demographics and occupational hazards there are many people with chronic low back pain and other persistent pain problems. Often these conditions are self limiting but in a small portion, usually with multiple yellow flags, pain becomes chronic and is very detrimental to the patient in regards to physical, social and work issues.
TASK
As a part of my placement in Tom Price my supervisor asked me to design a brochure on the central sensitisation of pain and an introduction to chronic pain management that can be given to chronic pain patients.
ACTION
Once told of this project I immediately got to work on finding appropriate resources to gather information from. I decided that I was going to use the book Explain Pain by David Butler and Lorimer Moseley as the foundation for this project as it nicely summarises essential information on pain in terms able to be understood by both patients and therapists. Obviously I was not going to be able to include all the information portrayed by the book in an A4 sized pamphlet so it was important me to have a good understanding of the book in order to decide which aspects were most relevant to my patient population and hence what I wanted to included in my brochure. I chose to start with a brief explanation of pain and reassurance that it is normal. I also briefly summarised the mechanisms of pain production in the initial phases of a pain experience and then discussed how pain can be maintain by other factors than purely tissue damage. I concluded the main body of information with an overview of key strategies for taking control of pain – education, knowledge, understanding and movement, with emphasis on active coping strategies. As well as the facts about the pain experience I also gave a couple of examples of patients who had extreme injuries such as amputation in war time, but felt little or no pain because of the context of the pain experience.
RESULT
The result of this task is an informative but not overwhelming resource that can be given to patients as an introduction into understanding about pain and how to best manage it. This task has also resulted in me having a greater understanding of central sensitisation of pain and ways to incorporate pain management into a treatment plan for chronic pain patients.
EVALUATION
I think that this brochure was a very good resource for a first attempt at designing a brochure for patient in a clinical setting. I felt that my prior understanding of the pain experience provided a solid base of knowledge for me to build on and develop into something able to be understood by someone with no prior knowledge or understanding of the pain experience. One area that I believe could have been improved was the number of resources I used to get information from for this project. As I was in a rural environment I was limited in my access to relevant texts however I could have searched for relevant information in the form of e-Books or e-Journals. Even if they could not explain the facts as well as Explain Pain does, I could have developed my own understanding even further and developed my own terminology and analogy’s to describe the pain experience. Instead I predominantly used the descriptions as worded by Lorimer Moseley and David Butler.
STRATEGIES
Strategies that I would employ if I was required to produce another brochure under similar circumstances I would use a wider variety of sources. I also feel that the brochure may be to ‘wordy’ to engage all patients. In hindsight the inclusion of more flowcharts or diagrams to explain key ideas would probably have been better. Specific strategies I have employed since producing this brochure were to examine a wide variety of the other brochures at the hospital to see what designs/layouts really appealed to me and which ones I felt best delivered the various messages. Other methods I used to improve this area were to get a wide scope of feedback on the brochure I produced from other health professionals, nursing students, my supervisor and a chronic pain patient. This was very beneficial and confirmed that some people did find there to be too much text and not enough information provided that would entice visual learners to take in the key messages.
SITUATION
My placement for this rotation is in the outpatient physiotherapy at Tom Price Hospital with the majority of patients falling under the musculoskeletal category with a small number of women’s health, paediatric and neurology patients. Tom Price is a small, rural mining town with the majority of the patients we see being mine workers and partners of those employed by the mine. Due to the demographics and occupational hazards there are many people with chronic low back pain and other persistent pain problems. Often these conditions are self limiting but in a small portion, usually with multiple yellow flags, pain becomes chronic and is very detrimental to the patient in regards to physical, social and work issues.
TASK
As a part of my placement in Tom Price my supervisor asked me to design a brochure on the central sensitisation of pain and an introduction to chronic pain management that can be given to chronic pain patients.
ACTION
Once told of this project I immediately got to work on finding appropriate resources to gather information from. I decided that I was going to use the book Explain Pain by David Butler and Lorimer Moseley as the foundation for this project as it nicely summarises essential information on pain in terms able to be understood by both patients and therapists. Obviously I was not going to be able to include all the information portrayed by the book in an A4 sized pamphlet so it was important me to have a good understanding of the book in order to decide which aspects were most relevant to my patient population and hence what I wanted to included in my brochure. I chose to start with a brief explanation of pain and reassurance that it is normal. I also briefly summarised the mechanisms of pain production in the initial phases of a pain experience and then discussed how pain can be maintain by other factors than purely tissue damage. I concluded the main body of information with an overview of key strategies for taking control of pain – education, knowledge, understanding and movement, with emphasis on active coping strategies. As well as the facts about the pain experience I also gave a couple of examples of patients who had extreme injuries such as amputation in war time, but felt little or no pain because of the context of the pain experience.
RESULT
The result of this task is an informative but not overwhelming resource that can be given to patients as an introduction into understanding about pain and how to best manage it. This task has also resulted in me having a greater understanding of central sensitisation of pain and ways to incorporate pain management into a treatment plan for chronic pain patients.
EVALUATION
I think that this brochure was a very good resource for a first attempt at designing a brochure for patient in a clinical setting. I felt that my prior understanding of the pain experience provided a solid base of knowledge for me to build on and develop into something able to be understood by someone with no prior knowledge or understanding of the pain experience. One area that I believe could have been improved was the number of resources I used to get information from for this project. As I was in a rural environment I was limited in my access to relevant texts however I could have searched for relevant information in the form of e-Books or e-Journals. Even if they could not explain the facts as well as Explain Pain does, I could have developed my own understanding even further and developed my own terminology and analogy’s to describe the pain experience. Instead I predominantly used the descriptions as worded by Lorimer Moseley and David Butler.
STRATEGIES
Strategies that I would employ if I was required to produce another brochure under similar circumstances I would use a wider variety of sources. I also feel that the brochure may be to ‘wordy’ to engage all patients. In hindsight the inclusion of more flowcharts or diagrams to explain key ideas would probably have been better. Specific strategies I have employed since producing this brochure were to examine a wide variety of the other brochures at the hospital to see what designs/layouts really appealed to me and which ones I felt best delivered the various messages. Other methods I used to improve this area were to get a wide scope of feedback on the brochure I produced from other health professionals, nursing students, my supervisor and a chronic pain patient. This was very beneficial and confirmed that some people did find there to be too much text and not enough information provided that would entice visual learners to take in the key messages.
Friday, July 9, 2010
STARES #2: Assessment
Situation
My patient, Miss R, was a seventeen year old female with a three month history of severe, intermittent right sided hip pain. She reported that if felt like a stiffness and stinging pain and was associated with clicking and occasionally felt as if it would give way. There were no pins and needles or numbness associated with her hip pain. The pain developed gradually and no history of trauma or precipitating events could be attributed to the onset of the increased intensity. Relevant past medical history included being treated by a physiotherapist for incontinence in 2005 at the age of twelve. Miss R noted that her pain was aggravated by moving from a long sitting or crossed legged sitting position into standing with a sudden onset of pain that took around ten minutes to ease.
Task
My task was to perform an objective examination of this patient following my subjective assessment to identify the source of her symptoms and possible factors contributing to her pain.
Action
I initially looked at the patient’s active range of motion at her hip joint in supine, palpated along the joint line anteriorly and around the greater trochanter to assess for any obvious tenderness on palpation. Whilst still in supine I began performing muscle strength assessment for each direction of movement at the hip. I then performed the hip quadrant and FABERs tests in an attempt to reproduce my patient’s pain. Following this I assessed the muscle length of key muscles acting on the hip including Thomas test, Ober’s and hamstrings (90/90). I then got Miss R to move into prone lying to finish assessing range of motion and strength. Key findings from this assessment were tenderness on palpation around the right anterior hip joint; pain at end of range hip flexion and external rotation, positive FABERs on the right, and reproduction of her worst pain in this position, and reduced muscle length of rectus femoris on the right side. Miss R had full range of movement into all directions and normal muscle strength bilaterally.
Result
The result of this examination was that I was able to reproduce the patient’s pain and identify potential contributing factors; however, I failed to include some key aspects involved in this process. As a result of this I did not have a clear understanding of all factors relating to her pain and had my supervisor not been there to guide me, I would have provided a sub-optimal treatment for this patient.
Evaluation
Although I did include most parts of an objective examination in my assessment of this patient, on reflection there were some obvious areas that required improvement. First and foremost I did not disrobe the patient to expose the area I was assessing. This meant that I was unable to specific when palpating as key landmarks and prominences were not visible. I also did not initially perform quick tests such as looking at gait or her moving from sitting to standing prior to the rest of my assessment. Another area I did not assess was muscle function of key stabilising muscles around the hip. This was even more essential in assessment of this patient due to her history of incontinence secondary to poor pelvic floor and proximal muscle function. Finally I was not confident with the hip special tests and therefore did not include them in my initial assessment. I had intended to revise this area and assess it in my nest session with the patient however it would have been preferable if I knew them well enough to include them in my initial assessment.
Strategies
Following this very average objective assessment I immediately revised key aspects of a physical examination of the hip and went through the hip assessment preform that we had used in our lower limb musculoskeletal unit. I made sure that I was familiar with all aspects of the assessment including optimal positioning and special tests and then practiced the assessment again on another student. As well as this I reviewed anatomy of the hip and hip joint as I did not feel confident in knowing which muscles and ligaments I was palpating where which is essential knowledge to have to perform a thorough assessment. As well as this I wrote up an impairment list and possible treatment options for Miss R and discussed this in depth with my supervisor. I have since done another hip assessment on a patient and felt far more confident in my clinical skills following the revision I did which was prompted by seeing Miss R.
My patient, Miss R, was a seventeen year old female with a three month history of severe, intermittent right sided hip pain. She reported that if felt like a stiffness and stinging pain and was associated with clicking and occasionally felt as if it would give way. There were no pins and needles or numbness associated with her hip pain. The pain developed gradually and no history of trauma or precipitating events could be attributed to the onset of the increased intensity. Relevant past medical history included being treated by a physiotherapist for incontinence in 2005 at the age of twelve. Miss R noted that her pain was aggravated by moving from a long sitting or crossed legged sitting position into standing with a sudden onset of pain that took around ten minutes to ease.
Task
My task was to perform an objective examination of this patient following my subjective assessment to identify the source of her symptoms and possible factors contributing to her pain.
Action
I initially looked at the patient’s active range of motion at her hip joint in supine, palpated along the joint line anteriorly and around the greater trochanter to assess for any obvious tenderness on palpation. Whilst still in supine I began performing muscle strength assessment for each direction of movement at the hip. I then performed the hip quadrant and FABERs tests in an attempt to reproduce my patient’s pain. Following this I assessed the muscle length of key muscles acting on the hip including Thomas test, Ober’s and hamstrings (90/90). I then got Miss R to move into prone lying to finish assessing range of motion and strength. Key findings from this assessment were tenderness on palpation around the right anterior hip joint; pain at end of range hip flexion and external rotation, positive FABERs on the right, and reproduction of her worst pain in this position, and reduced muscle length of rectus femoris on the right side. Miss R had full range of movement into all directions and normal muscle strength bilaterally.
Result
The result of this examination was that I was able to reproduce the patient’s pain and identify potential contributing factors; however, I failed to include some key aspects involved in this process. As a result of this I did not have a clear understanding of all factors relating to her pain and had my supervisor not been there to guide me, I would have provided a sub-optimal treatment for this patient.
Evaluation
Although I did include most parts of an objective examination in my assessment of this patient, on reflection there were some obvious areas that required improvement. First and foremost I did not disrobe the patient to expose the area I was assessing. This meant that I was unable to specific when palpating as key landmarks and prominences were not visible. I also did not initially perform quick tests such as looking at gait or her moving from sitting to standing prior to the rest of my assessment. Another area I did not assess was muscle function of key stabilising muscles around the hip. This was even more essential in assessment of this patient due to her history of incontinence secondary to poor pelvic floor and proximal muscle function. Finally I was not confident with the hip special tests and therefore did not include them in my initial assessment. I had intended to revise this area and assess it in my nest session with the patient however it would have been preferable if I knew them well enough to include them in my initial assessment.
Strategies
Following this very average objective assessment I immediately revised key aspects of a physical examination of the hip and went through the hip assessment preform that we had used in our lower limb musculoskeletal unit. I made sure that I was familiar with all aspects of the assessment including optimal positioning and special tests and then practiced the assessment again on another student. As well as this I reviewed anatomy of the hip and hip joint as I did not feel confident in knowing which muscles and ligaments I was palpating where which is essential knowledge to have to perform a thorough assessment. As well as this I wrote up an impairment list and possible treatment options for Miss R and discussed this in depth with my supervisor. I have since done another hip assessment on a patient and felt far more confident in my clinical skills following the revision I did which was prompted by seeing Miss R.
Friday, June 25, 2010
STARES #1: Treatment
SITUATION:
My patient was a 28yr female who 30 weeks pregnant with her 2nd child. She self presented from the community with bilateral low back pain (LBP) with the left side greater than right and also experienced numbness and tingling into L buttock on occasions. Her symptoms were aggravated by prolonged standing at end of long day and eased with rest. No other abnormal sensations or muscle weakness were associated with her symptoms.
This patient had similar pain with previous pregnancy but at later stage which was effectively managed with physiotherapy a back brace for extra support.
There was no history of trauma or any change in activities that were related to the onset of her latest episode of LBP.
On physical examination, her LBP but not buttock symptoms was reproduced with extension and left side flexion and the symptoms in her left buttock provoked with a left unilateral PA on L5/S1. Sacro-iliac joint (SIJ) tests were negative, and the patient in fact felt relief with SIJ compression. Neurodynamic tests (SLR) were also negative.
My PPIVM assessment found increased movement on the left side L3-S1 into extension and left side flexion, but no reproduction of pain.
TASK:
My task was to treat this patient who I had performed the subjective and objective examination on who presented with what appeared to be a L5/S1 control dysfunction into the direction of extension/left side flexion.
ACTION:
My baseline assessment prior to treatment was the level of pain into extension and L side flexion.
As a treatment I then performed a grade III unilateral PA glide on L5/S1 transverse process for 30s and then reassessed.
Re-assessment of combined extension/left side flexion movement showed an increase of pain and worsening of symptoms into the buttock. Immediately I realised that I had not treated it as a control dysfunction bur as a mobility restriction and as a result made the patients symptoms worse.
Following this re-assessment my supervisor stepped in and completed the rest of the treatment session with the patient with me observing.
Her treatment consisted of lumbo-pelvic muscles stabilisation exercises, targeting the pelvic floor and transverse abdominus and gluteus medius.
The patient was also given these exercises as a home exercise program.
RESULT:
The final result for the patient was no dramatic reduction in pain following her physiotherapy session, but the pain that I flared up initially had settled. The stabilisation exercises were effective but will require the patient to continue with them independently for maximal benefit. I have booked the patient in for a follow-up treatment in one week’s time to reassess lumbo-pelvic control
EVALUATION
On reflection, I performed a sub-optimal treatment technique for this patient choosing to perform an incorrect manual therapy technique. Luckily for my patient however my supervisor intervened and the pain did ease following the stabilisation exercises.
I now realise that I should have picked up key features from the subjective & objective examinations as to whether it was a control or mobility problem in this patient. For example, pregnancy, relief with SIJ compression, increased movement on PPIVMs into direction of dysfunction all suggests control dysfunction.
Even though I knew which direction to treat into for a control dysfunction, when put on the spot I treated as mobility and am not sure why. I think because I was not 100%confident in my diagnosis and then where to go with treatment techniques, I fell back on manual therapies, which I got mixed up with. As a result of my confusion and being unsure of the optimal treatment for this patient, I treated her incorrectly and subsequently worsened her symptoms.
STRATEGIES
To improve on my performance with LBP patients, I revised key features of both control and mobility dysfunctions and LBP treatment algorithms.
I also went over our lab manuals and lecture notes in what were the best techniques for improving lumbo-pelvic muscle control, especially for pregnant patients.
In addition to these strategies, at the time of the situation I documented and then asked to go over with my supervisor the exercises she had done with the patient and the best way to progress those (as the patient improved.
I also reviewed my anatomy of the lumbar spine and handling during a PPIVM assessment as I feel that a lot of my uncertainties stemmed from not being confident in what I was feeling in regards to whether there was too much or not enough movement.
Furthermore, I have asked my supervisor to, when possible, feel a variety of lumbar spine patients (especially PPIVMs) to be able to appreciate the difference between normal’s and increased or decreased movement.
My patient was a 28yr female who 30 weeks pregnant with her 2nd child. She self presented from the community with bilateral low back pain (LBP) with the left side greater than right and also experienced numbness and tingling into L buttock on occasions. Her symptoms were aggravated by prolonged standing at end of long day and eased with rest. No other abnormal sensations or muscle weakness were associated with her symptoms.
This patient had similar pain with previous pregnancy but at later stage which was effectively managed with physiotherapy a back brace for extra support.
There was no history of trauma or any change in activities that were related to the onset of her latest episode of LBP.
On physical examination, her LBP but not buttock symptoms was reproduced with extension and left side flexion and the symptoms in her left buttock provoked with a left unilateral PA on L5/S1. Sacro-iliac joint (SIJ) tests were negative, and the patient in fact felt relief with SIJ compression. Neurodynamic tests (SLR) were also negative.
My PPIVM assessment found increased movement on the left side L3-S1 into extension and left side flexion, but no reproduction of pain.
TASK:
My task was to treat this patient who I had performed the subjective and objective examination on who presented with what appeared to be a L5/S1 control dysfunction into the direction of extension/left side flexion.
ACTION:
My baseline assessment prior to treatment was the level of pain into extension and L side flexion.
As a treatment I then performed a grade III unilateral PA glide on L5/S1 transverse process for 30s and then reassessed.
Re-assessment of combined extension/left side flexion movement showed an increase of pain and worsening of symptoms into the buttock. Immediately I realised that I had not treated it as a control dysfunction bur as a mobility restriction and as a result made the patients symptoms worse.
Following this re-assessment my supervisor stepped in and completed the rest of the treatment session with the patient with me observing.
Her treatment consisted of lumbo-pelvic muscles stabilisation exercises, targeting the pelvic floor and transverse abdominus and gluteus medius.
The patient was also given these exercises as a home exercise program.
RESULT:
The final result for the patient was no dramatic reduction in pain following her physiotherapy session, but the pain that I flared up initially had settled. The stabilisation exercises were effective but will require the patient to continue with them independently for maximal benefit. I have booked the patient in for a follow-up treatment in one week’s time to reassess lumbo-pelvic control
EVALUATION
On reflection, I performed a sub-optimal treatment technique for this patient choosing to perform an incorrect manual therapy technique. Luckily for my patient however my supervisor intervened and the pain did ease following the stabilisation exercises.
I now realise that I should have picked up key features from the subjective & objective examinations as to whether it was a control or mobility problem in this patient. For example, pregnancy, relief with SIJ compression, increased movement on PPIVMs into direction of dysfunction all suggests control dysfunction.
Even though I knew which direction to treat into for a control dysfunction, when put on the spot I treated as mobility and am not sure why. I think because I was not 100%confident in my diagnosis and then where to go with treatment techniques, I fell back on manual therapies, which I got mixed up with. As a result of my confusion and being unsure of the optimal treatment for this patient, I treated her incorrectly and subsequently worsened her symptoms.
STRATEGIES
To improve on my performance with LBP patients, I revised key features of both control and mobility dysfunctions and LBP treatment algorithms.
I also went over our lab manuals and lecture notes in what were the best techniques for improving lumbo-pelvic muscle control, especially for pregnant patients.
In addition to these strategies, at the time of the situation I documented and then asked to go over with my supervisor the exercises she had done with the patient and the best way to progress those (as the patient improved.
I also reviewed my anatomy of the lumbar spine and handling during a PPIVM assessment as I feel that a lot of my uncertainties stemmed from not being confident in what I was feeling in regards to whether there was too much or not enough movement.
Furthermore, I have asked my supervisor to, when possible, feel a variety of lumbar spine patients (especially PPIVMs) to be able to appreciate the difference between normal’s and increased or decreased movement.
Friday, June 18, 2010
Inital entry - Tom Price
I’m looking forward to my time in Tom Price but expecting my musculoskeletal placement to be very challenging. I feel very under prepared and am concerned that my lack of previous experience in the musculoskeletal field will make the transition into the area more difficult. I am especially anxious about my knowledge of the lower limb and upper limb as they were very complex units we did in second year and so I’ve forgotten a lot of the specific details regarding assessment and special tests. Being able to conduct a thorough and correct physical examination will be essential to forming the best treatment plan for each individual patient and I hope that I will be given adequate time to prepare for each patient in the initial stages of this prac.
As this will be our final rotation I also expect that my supervisor will expect more from me in terms of my clinical knowledge but more so in terms of professionalism and communication with patients. I feel confident that I will be able to perform and effective and efficient subjective examination with clients due to the multitude of practice we have had in this area with clinical reasoning exams and thorough information provided to us.
Although I will be primarily based at the Tom Price Hospital I do to travel to Paraburdoo once a week to work and hopefully I will get an opportunity at some stage over the five weeks to visit local indigenous communities. This may be confronting at first but I have travelled to remote Aboriginal communities before and would really like to experience working as a health professional in these areas.
I am hoping that a lot of my skills in this area will come back to me as I get more patients but I believe my understanding of the basic principles of musculoskeletal physiotherapy will allow me to provide a good explanation of the processes to my patients and provide an acceptable initial consultation/treatment. As well as revising my notes on the area, it will be with further practice and clinical experience that my skills and knowledge base will expand.
My main role on this placement will be treatment of musculoskeletal conditions but I have been informed that I am also likely to see paediatric and women’s health patients as well as run exercise classes for older adults. A significant aspect of treatment in these areas will be active patient involvement and motivation to improve, rather than promoting passive approaches to recovery. I feel well equipped to educate patients on the importance of this and provide them with a mixture of passive treatment techniques and home exercises.
I am nervous about being so far from home and on placement in the area which I feel least confident about. However I am motivated to embrace this challenge and make the most of my musculoskeletal experience as well as my time living and working in rural Western Australia.
As this will be our final rotation I also expect that my supervisor will expect more from me in terms of my clinical knowledge but more so in terms of professionalism and communication with patients. I feel confident that I will be able to perform and effective and efficient subjective examination with clients due to the multitude of practice we have had in this area with clinical reasoning exams and thorough information provided to us.
Although I will be primarily based at the Tom Price Hospital I do to travel to Paraburdoo once a week to work and hopefully I will get an opportunity at some stage over the five weeks to visit local indigenous communities. This may be confronting at first but I have travelled to remote Aboriginal communities before and would really like to experience working as a health professional in these areas.
I am hoping that a lot of my skills in this area will come back to me as I get more patients but I believe my understanding of the basic principles of musculoskeletal physiotherapy will allow me to provide a good explanation of the processes to my patients and provide an acceptable initial consultation/treatment. As well as revising my notes on the area, it will be with further practice and clinical experience that my skills and knowledge base will expand.
My main role on this placement will be treatment of musculoskeletal conditions but I have been informed that I am also likely to see paediatric and women’s health patients as well as run exercise classes for older adults. A significant aspect of treatment in these areas will be active patient involvement and motivation to improve, rather than promoting passive approaches to recovery. I feel well equipped to educate patients on the importance of this and provide them with a mixture of passive treatment techniques and home exercises.
I am nervous about being so far from home and on placement in the area which I feel least confident about. However I am motivated to embrace this challenge and make the most of my musculoskeletal experience as well as my time living and working in rural Western Australia.
Sunday, June 13, 2010
Final Entry (NEURO)
FINAL ENTRY
Overall, I had an amazing time at Shenton Park and feel so lucky to have had such a positive neuro clinical placement. My initial anxieties were certainly unnecessary as I immediately realised, with my supervisor, tutor and other clinicians all very supportive and keen to assist my learning.
The placement was challenging. It was very confronting at first working with patients who had suffered severe strokes but I was able to not become overwhelmed and embrace this when it was obvious how much you could help these patients and there families in the recovery process.
I was also challenged theoretically by all the therapists who would often quiz me on neuroanatomy and my clinical reasoning behind a certain treatment. I had expected this and so had thoroughly revised these areas which allowed me to answer promptly and correctly as well as effectively reason with them. Having a sound background knowledge from day 1 meant that my supervisor was able to trust me with a variety of patients early on and didn’t feel the need to prompt me and question me as often in the later weeks. I enjoyed this autonomy and feel that it really enhanced my learning and enabled me to feel comfortable with trying different approaches to treatments.
Prior to starting this placement I did not feel completely confident in performing neurological assessments. Luckily, my I had expected more of myself than my supervisor and tutor who saw the placement as an opportunity to gain that experience and improve the efficiency of an assessment. It did take me the majority of the placement to feel I could perform a thorough and accurate assessment but now feel confident in this area.
I also doubted my ability to perform correct transfers before commencing this placement. As most of the patients I saw were very heavy, it was a great opportunity for me to practice dependent transfers and be the second pair of hands to learn how more experienced professionals performed transfers. Due to patients being so dependent I had to be certain of my postures as it was immediately apparent if I had not been in the best position. One factor that I had not previously considered was the positioning of the affected upper limb in stroke patients and how important this was. All patients were constantly reminded to protect their upper limb with their unaffected arm to reduce risk of any damage or pain at the shoulder joint.
One of the roles of therapists in this setting which I identified before commencing at Shenton Park, was that of patient motivation. Although I do still believe this is important and communication with family as well as the patient essential, this was not an area which I was exposed to and had any direct experience with on this prac. I also witnessed patients who lacked motivation and although his clinician tried to be encouraging, his lack of motivation made her job far more difficult and created tension between the patient and therapist. This is not ideal but I now realise there is only so much you can do to motivate and there must be active involvement by both parties.
Although I did not attend family meetings and goal setting meetings with my patients, I did my best to motivate my patients on a day to day basis, always maintaining a positive outlook and setting different short term goals with my patients week by week.
I feel that I am now possess the skills to develop efficient and thorough assessments, set timely and relevant patient goals as well as am confident in developing treatment plans for individual patient. I believe I’ll continue to improve my treatment and handling skills with further experience in this field.
Despite my uncertainties about this placement initially, I had a fantastic experience and learnt more than I ever could have imagined. I loved that I still felt challenged and was learning new skills up until my very last day. I certainly believe that my previous clinical experiences provided a good foundation for me to start building specific neuro skills on.
Overall, I had an amazing time at Shenton Park and feel so lucky to have had such a positive neuro clinical placement. My initial anxieties were certainly unnecessary as I immediately realised, with my supervisor, tutor and other clinicians all very supportive and keen to assist my learning.
The placement was challenging. It was very confronting at first working with patients who had suffered severe strokes but I was able to not become overwhelmed and embrace this when it was obvious how much you could help these patients and there families in the recovery process.
I was also challenged theoretically by all the therapists who would often quiz me on neuroanatomy and my clinical reasoning behind a certain treatment. I had expected this and so had thoroughly revised these areas which allowed me to answer promptly and correctly as well as effectively reason with them. Having a sound background knowledge from day 1 meant that my supervisor was able to trust me with a variety of patients early on and didn’t feel the need to prompt me and question me as often in the later weeks. I enjoyed this autonomy and feel that it really enhanced my learning and enabled me to feel comfortable with trying different approaches to treatments.
Prior to starting this placement I did not feel completely confident in performing neurological assessments. Luckily, my I had expected more of myself than my supervisor and tutor who saw the placement as an opportunity to gain that experience and improve the efficiency of an assessment. It did take me the majority of the placement to feel I could perform a thorough and accurate assessment but now feel confident in this area.
I also doubted my ability to perform correct transfers before commencing this placement. As most of the patients I saw were very heavy, it was a great opportunity for me to practice dependent transfers and be the second pair of hands to learn how more experienced professionals performed transfers. Due to patients being so dependent I had to be certain of my postures as it was immediately apparent if I had not been in the best position. One factor that I had not previously considered was the positioning of the affected upper limb in stroke patients and how important this was. All patients were constantly reminded to protect their upper limb with their unaffected arm to reduce risk of any damage or pain at the shoulder joint.
One of the roles of therapists in this setting which I identified before commencing at Shenton Park, was that of patient motivation. Although I do still believe this is important and communication with family as well as the patient essential, this was not an area which I was exposed to and had any direct experience with on this prac. I also witnessed patients who lacked motivation and although his clinician tried to be encouraging, his lack of motivation made her job far more difficult and created tension between the patient and therapist. This is not ideal but I now realise there is only so much you can do to motivate and there must be active involvement by both parties.
Although I did not attend family meetings and goal setting meetings with my patients, I did my best to motivate my patients on a day to day basis, always maintaining a positive outlook and setting different short term goals with my patients week by week.
I feel that I am now possess the skills to develop efficient and thorough assessments, set timely and relevant patient goals as well as am confident in developing treatment plans for individual patient. I believe I’ll continue to improve my treatment and handling skills with further experience in this field.
Despite my uncertainties about this placement initially, I had a fantastic experience and learnt more than I ever could have imagined. I loved that I still felt challenged and was learning new skills up until my very last day. I certainly believe that my previous clinical experiences provided a good foundation for me to start building specific neuro skills on.
STARES #3: Treatment
STARES #3
Treatment
SITUATION
My patient, Miss A, was a 36year old lady admitted to Shenton Park Hospital for rehabilitation following a decline in function associated with an undiagnosed neurodegenerative condition. Her condition predominantly manifests in cerebellar ataxia and cognitive dysfunction. Miss A previously lived at home alone but it is likely that because of her recent functional deterioration she may have to return to living with her parents.
The main findings from the initial objective examination were that Miss A was severely ataxic bilaterally in her upper limbs, lower limbs, head and trunk (left worse than right), presented with an intention tremor, had increased neural tone in both plantar flexors (left worse than right), slowed and ineffective balance reactions, moderate dysarthria and was very impulsive. She also has very poor sitting and standing posture as a result of compensatory over-activity in her scapula retractors, trunk extensors and neck extensors. Furthermore, she severely fixes her upper limbs against her trunk and clenches her fingers when her balance is challenged.
She is independent with bed mobility, transferring from supine to sitting, sitting over the edge of bed and sit to stand. She requires 1x minimal assistance for standing balance and 1x moderate assistance for a step-stand transfer. She is currently non-ambulant on the ward but ambulates 20m with 2x moderate assistance in physiotherapy. Miss A’s goal is to be able to walk 10m independently and return home to her unit (rather than living with her parents).
TASK
My task with Miss A was to devise an initial treatment plan for this patient who’s primary impairment was cerebellar ataxia taking into account the other results of her objective assessment and her reduced cognitive function.
ACTION
Following a brief subjective examination I began implementing my treatment program for Miss A. My main focus for the treatment was to improve proximal stability of the trunk and pelvis, to allow a more stable base for movement of the limbs to occur from. Drawing on my prior knowledge of important features of exercises for ataxic patients I tried to ensure exercises were closed chain and incorporated specific targets and reference points, as well as continually emphasising the importance of slow and controlled movement.
I started the patient in crook lying, doing various abdominal and trunk strengthening exercises and then progressed to 4 point kneeling, and reaching in 4 point kneeling then maintain balance and correct alignment in 2 point kneeling. From 2 point kneeling I chose to include more functional exercises of sit to stand and standing balance, again emphasising the need for slow movement. The session was concluded with 2x assisted ambulation of roughly 40m.
Due to Miss A’s cognitive impairment and impulsiveness she required continual verbal prompting to minimise her rushing the exercises and using incorrect movement patterns.
RESULT
The result of this treatment for Miss A was that she did appear to have improved trunk control and was aware that she needed to concentrate on slow and controlled movement, requiring less verbal cues as the session progressed.
Although she may have had improved trunk control and subsequently better gait pattern, she definitely did still require 2x moderate assistance.
EVALUATION
On reflection, I think that overall my treatment plan was good however my implementation lacked a few essential clinical skills. In hindsight I realised that Miss A was fixing a lot through her scapula retractors and cervical extensors, which I didn’t pick up on at first as I expected to see her fixing via weight bearing with her upper limbs. She also fixed with her ULs against her trunk in every position she was in despite me changing her UL placement in an attempt to minimise this.
As a result of this I allowed the patient to move and perform exercises with incorrect movements, rather than enforcing error-free practice with correct timing as should be a priorty when treating ataxic patients. The incorrect movements were also influenced by her impulsiveness and tendency to rush movements and exercises.
I now realise that I should have started with my own formal postural assessment and included techniques aimed at relaxing the overactive muscles through her neck, thorax and upper limbs. Once that was completed I then should have started with the simplest postural control exercises in crook lying until she could perform them satisfactorily and then progress, rather than continuing to progress exercises with poor and incorrect recruitment.
STRATEGIES
Strategies I used to improve my subsequent treatment sessions with Miss A were revising my musculoskeletal lab manuals and text books to gain ideas about different muscle relaxation techniques. I also asked my supervisor whether she could direct me to any good references on reducing muscle overactivity or give me any techniques she used and found effective.
I also reviewed my neurorehabilitation texts and course material to get further insight into management techniques of ataxic and impulsive/cognitively impaired patients.
From this research I came across methods to minimize fixations in ataxic patients which included making the patient feel safe, using reference points and targets to improve quality of movement as well as emphasising error-free practice with correct timing.
Treatment
SITUATION
My patient, Miss A, was a 36year old lady admitted to Shenton Park Hospital for rehabilitation following a decline in function associated with an undiagnosed neurodegenerative condition. Her condition predominantly manifests in cerebellar ataxia and cognitive dysfunction. Miss A previously lived at home alone but it is likely that because of her recent functional deterioration she may have to return to living with her parents.
The main findings from the initial objective examination were that Miss A was severely ataxic bilaterally in her upper limbs, lower limbs, head and trunk (left worse than right), presented with an intention tremor, had increased neural tone in both plantar flexors (left worse than right), slowed and ineffective balance reactions, moderate dysarthria and was very impulsive. She also has very poor sitting and standing posture as a result of compensatory over-activity in her scapula retractors, trunk extensors and neck extensors. Furthermore, she severely fixes her upper limbs against her trunk and clenches her fingers when her balance is challenged.
She is independent with bed mobility, transferring from supine to sitting, sitting over the edge of bed and sit to stand. She requires 1x minimal assistance for standing balance and 1x moderate assistance for a step-stand transfer. She is currently non-ambulant on the ward but ambulates 20m with 2x moderate assistance in physiotherapy. Miss A’s goal is to be able to walk 10m independently and return home to her unit (rather than living with her parents).
TASK
My task with Miss A was to devise an initial treatment plan for this patient who’s primary impairment was cerebellar ataxia taking into account the other results of her objective assessment and her reduced cognitive function.
ACTION
Following a brief subjective examination I began implementing my treatment program for Miss A. My main focus for the treatment was to improve proximal stability of the trunk and pelvis, to allow a more stable base for movement of the limbs to occur from. Drawing on my prior knowledge of important features of exercises for ataxic patients I tried to ensure exercises were closed chain and incorporated specific targets and reference points, as well as continually emphasising the importance of slow and controlled movement.
I started the patient in crook lying, doing various abdominal and trunk strengthening exercises and then progressed to 4 point kneeling, and reaching in 4 point kneeling then maintain balance and correct alignment in 2 point kneeling. From 2 point kneeling I chose to include more functional exercises of sit to stand and standing balance, again emphasising the need for slow movement. The session was concluded with 2x assisted ambulation of roughly 40m.
Due to Miss A’s cognitive impairment and impulsiveness she required continual verbal prompting to minimise her rushing the exercises and using incorrect movement patterns.
RESULT
The result of this treatment for Miss A was that she did appear to have improved trunk control and was aware that she needed to concentrate on slow and controlled movement, requiring less verbal cues as the session progressed.
Although she may have had improved trunk control and subsequently better gait pattern, she definitely did still require 2x moderate assistance.
EVALUATION
On reflection, I think that overall my treatment plan was good however my implementation lacked a few essential clinical skills. In hindsight I realised that Miss A was fixing a lot through her scapula retractors and cervical extensors, which I didn’t pick up on at first as I expected to see her fixing via weight bearing with her upper limbs. She also fixed with her ULs against her trunk in every position she was in despite me changing her UL placement in an attempt to minimise this.
As a result of this I allowed the patient to move and perform exercises with incorrect movements, rather than enforcing error-free practice with correct timing as should be a priorty when treating ataxic patients. The incorrect movements were also influenced by her impulsiveness and tendency to rush movements and exercises.
I now realise that I should have started with my own formal postural assessment and included techniques aimed at relaxing the overactive muscles through her neck, thorax and upper limbs. Once that was completed I then should have started with the simplest postural control exercises in crook lying until she could perform them satisfactorily and then progress, rather than continuing to progress exercises with poor and incorrect recruitment.
STRATEGIES
Strategies I used to improve my subsequent treatment sessions with Miss A were revising my musculoskeletal lab manuals and text books to gain ideas about different muscle relaxation techniques. I also asked my supervisor whether she could direct me to any good references on reducing muscle overactivity or give me any techniques she used and found effective.
I also reviewed my neurorehabilitation texts and course material to get further insight into management techniques of ataxic and impulsive/cognitively impaired patients.
From this research I came across methods to minimize fixations in ataxic patients which included making the patient feel safe, using reference points and targets to improve quality of movement as well as emphasising error-free practice with correct timing.
Saturday, May 29, 2010
STARES #2: Communication
SITUATION:
My patient, Mr M, was 58 year old male who suffered a left sided MCA infarct three months ago. He has been undergoing intensive rehabilitation at Shenton Park Hospital since then with great success. At present his main impairments are in speech, as he has severe expressive dysphasia and mild receptive dysphasia, reduced joint range of motion into shoulder flexion, extension and abduction (with pain at end of range) and decreased muscle length of pectoralis major and latissimus dorsi on his right side. He is currently independent in all functional mobility tasks, using a step-stand transfer to transfer from chair to bed and ambulating independently without an aid over 15m but for longer distances requires a walking stick.
Before seeing this patient I was given a brief handover regarding his limited ability to communicate effectively. Mr M has extreme difficulty communicating verbally as he can only say ‘no’, and does so repetitively, with minimal ability to vary his tone of voice. His main method of communication is via hand gestures, predominantly a ‘thumbs up’, and facial expressions, always greeting people with a smile and ‘thumbs up’ combination.
TASK:
My task in this situation was to treat Mr M’s lack of range at his shoulder with mobilisation and muscle lengthening techniques. More important than this though was that I also had to establish an effective method of communication with this dysphasic patient as it was known he had pain in his shoulder and so I needed to closely monitor this throughout my treatment.
ACTIONS:
After introducing myself, my initial thought was that I needed to confirm what signals/gesture he used to say ‘yes’ and ‘no’. For Mr M, he was able to say ‘no’ and used a ‘thumbs up’ sign as ‘yes’.
After instructing the patient with verbal cues to move into supine lying, I assessed his shoulder joint range and muscle length as a baseline assessment, also noting any pain.
Mr M did get pain in his shoulder which I monitored by continually through by asking about pain to gain a yes or no response, I closely observed his facial expressions too looking for any wincing or watery eyes. Although it was difficult communicating with this patient I wanted to try and gain rapport with him and speak to him as I would other patients. To do this I used clear and concise closed questions and pointed to objects I was referring too. This was effective until he wanted to answer with more than yes/no and tried to explain things to me. I did not know what to do in this situation and it was very unclear to me what the message was he was trying to get across despite many unsuccessful guesses. At this point I had to discard what he was saying and continue with my treatment.
Mr M obviously had something that we wanted to say to me as he kept pointing to things and saying ‘no’, ‘no’, ‘no’, which got confusing as he was not using the word no in the appropriate context, making me question his use of the word previously in the session. In an attempt to understand Mr M, I brought out paper and a thick marker for him to write down what he was talking about. I thought this method was going to work well until I realised his handwriting was basically illegible and he was only able to write very simple words. Unfortunately, after multiple attempts and asking my supervisor if she could understand what he was trying to say, we were again unable to work out what he wanted. At this point I re-assessed his shoulder and concluded my treatment with him as my supervisor required my assistance with another patient.
RESULTS
Despite a successful treatment on his shoulder with the re-assessment indicating an improved range of motion my ability to communicate well with this patient was questionable. The result of my inability to find appropriate methods of communication with this patient meant that I was unable to have longer, more meaningful conversations with the patient which led to me not able to develop as good a rapport with this patient as I’ve been fortunate enough to gain with other patients. At times, Mr M also became slightly frustrated at his inability to explain himself and gave up trying to communicate with more than the signalled yes/no response.
EVALUATION
This was the first time I had been exposed to this speech impairment in the clinical setting and had not been given an opportunity to prepare for this prior to seeing the patient and I definitely believe that my communication skills were sub-optimal in this setting. In regards to my communication with this patient I felt quite disappointed in myself following this session as I thought I knew more strategies and tools I could implement to communicate with dysphasic patients. The disappointment was predominantly due to the fact that Mr M obviously had something he really wanted to be able to tell me, based on his multiple attempts, but I could not decipher what that was. On a more positive note, I do believe that I effectively established signals for yes and no which allowed me to monitor his level of pain throughout the treatment and stop when the pain got too much.
STRATEGIES
I explored a number of avenues to get more ideas on methods of effective communication with dysphasic patients. Initially I asked my supervisor (who has been treating Mr M since his admission) what methods she has found to be most effective with this patient. She suggested using pen and paper for him to try and write words, which I had tried with him, and also instead of him writing, you write words or draw images that he can recognise and say yes/no as to whether that’s what he is trying to say, for example drawing family members. I also asked my supervisor if there were any resources/handouts that she was aware of that I could read for other possible strategies I could try with this patient and for future patients.
Additionally I reviewed our university course materials on methods of communication with speech and/or cognitive impairments which I found to be very beneficial in directing me to further readings specific to dysphasic patients.
My patient, Mr M, was 58 year old male who suffered a left sided MCA infarct three months ago. He has been undergoing intensive rehabilitation at Shenton Park Hospital since then with great success. At present his main impairments are in speech, as he has severe expressive dysphasia and mild receptive dysphasia, reduced joint range of motion into shoulder flexion, extension and abduction (with pain at end of range) and decreased muscle length of pectoralis major and latissimus dorsi on his right side. He is currently independent in all functional mobility tasks, using a step-stand transfer to transfer from chair to bed and ambulating independently without an aid over 15m but for longer distances requires a walking stick.
Before seeing this patient I was given a brief handover regarding his limited ability to communicate effectively. Mr M has extreme difficulty communicating verbally as he can only say ‘no’, and does so repetitively, with minimal ability to vary his tone of voice. His main method of communication is via hand gestures, predominantly a ‘thumbs up’, and facial expressions, always greeting people with a smile and ‘thumbs up’ combination.
TASK:
My task in this situation was to treat Mr M’s lack of range at his shoulder with mobilisation and muscle lengthening techniques. More important than this though was that I also had to establish an effective method of communication with this dysphasic patient as it was known he had pain in his shoulder and so I needed to closely monitor this throughout my treatment.
ACTIONS:
After introducing myself, my initial thought was that I needed to confirm what signals/gesture he used to say ‘yes’ and ‘no’. For Mr M, he was able to say ‘no’ and used a ‘thumbs up’ sign as ‘yes’.
After instructing the patient with verbal cues to move into supine lying, I assessed his shoulder joint range and muscle length as a baseline assessment, also noting any pain.
Mr M did get pain in his shoulder which I monitored by continually through by asking about pain to gain a yes or no response, I closely observed his facial expressions too looking for any wincing or watery eyes. Although it was difficult communicating with this patient I wanted to try and gain rapport with him and speak to him as I would other patients. To do this I used clear and concise closed questions and pointed to objects I was referring too. This was effective until he wanted to answer with more than yes/no and tried to explain things to me. I did not know what to do in this situation and it was very unclear to me what the message was he was trying to get across despite many unsuccessful guesses. At this point I had to discard what he was saying and continue with my treatment.
Mr M obviously had something that we wanted to say to me as he kept pointing to things and saying ‘no’, ‘no’, ‘no’, which got confusing as he was not using the word no in the appropriate context, making me question his use of the word previously in the session. In an attempt to understand Mr M, I brought out paper and a thick marker for him to write down what he was talking about. I thought this method was going to work well until I realised his handwriting was basically illegible and he was only able to write very simple words. Unfortunately, after multiple attempts and asking my supervisor if she could understand what he was trying to say, we were again unable to work out what he wanted. At this point I re-assessed his shoulder and concluded my treatment with him as my supervisor required my assistance with another patient.
RESULTS
Despite a successful treatment on his shoulder with the re-assessment indicating an improved range of motion my ability to communicate well with this patient was questionable. The result of my inability to find appropriate methods of communication with this patient meant that I was unable to have longer, more meaningful conversations with the patient which led to me not able to develop as good a rapport with this patient as I’ve been fortunate enough to gain with other patients. At times, Mr M also became slightly frustrated at his inability to explain himself and gave up trying to communicate with more than the signalled yes/no response.
EVALUATION
This was the first time I had been exposed to this speech impairment in the clinical setting and had not been given an opportunity to prepare for this prior to seeing the patient and I definitely believe that my communication skills were sub-optimal in this setting. In regards to my communication with this patient I felt quite disappointed in myself following this session as I thought I knew more strategies and tools I could implement to communicate with dysphasic patients. The disappointment was predominantly due to the fact that Mr M obviously had something he really wanted to be able to tell me, based on his multiple attempts, but I could not decipher what that was. On a more positive note, I do believe that I effectively established signals for yes and no which allowed me to monitor his level of pain throughout the treatment and stop when the pain got too much.
STRATEGIES
I explored a number of avenues to get more ideas on methods of effective communication with dysphasic patients. Initially I asked my supervisor (who has been treating Mr M since his admission) what methods she has found to be most effective with this patient. She suggested using pen and paper for him to try and write words, which I had tried with him, and also instead of him writing, you write words or draw images that he can recognise and say yes/no as to whether that’s what he is trying to say, for example drawing family members. I also asked my supervisor if there were any resources/handouts that she was aware of that I could read for other possible strategies I could try with this patient and for future patients.
Additionally I reviewed our university course materials on methods of communication with speech and/or cognitive impairments which I found to be very beneficial in directing me to further readings specific to dysphasic patients.
Saturday, May 15, 2010
STARES 1; Neuro Assessment
SITUATION
My patient, Mr S, is a 63yr male who has been attending rehabilitation at Shenton Park hospital for the past 2 months following a left LACS (from an internal capsule infarct in the area of the L anterior choroidal artery), presenting with right sided ataxic hemiparesis symptoms.
From his history I expected his main impairments to be co-ordination deficits in his right upper and lower limbs possibly combined with altered tone (likely hyperreflexia) and hemianopia. Consequently, a reduced functional capacity and an inability to ambulate were also aspects I considered prior to meeting the patient.
Mr S is a very positive and motivated patient with an extremely supportive family.
Prior to his stroke he worked full time as a farmer and is very keen to get back to work and return to playing golf. From reading his progress notes, he appears to have progressed well so far with his rehab.
No discharge date has been set for the patient as yet.
TASK
Prioritised re-assessment of the patient in a 60 minute time frame identifying key measures most important to determine an initial impairment list based on my findings so that I could begin to build a treatment plan for this patient. As neuro examinations are timely I was not expected to complete the full assessment in the one session but prioritise so that the rest of the tasks could be completed in later sessions.
ACTION
After introducing myself to the patient, performing a brief subjective assessment and explaining what I was going to be doing, I began the re-assessment process.
I chose to objectively assess, time permitting, vision, co-ordination, tone, joint ROM and Gowlands motor recovery scale in my initial examination.
In an attempt to use my time effectively, I began with the vision and coordination tests with the patient sitting over the edge of the bed with their feet supported, and then I moved onto the tone and joint ROM assessments in supine and concluded with Gowlands.
Vision was an essential inclusion to ensure patient is able to see what you as therapist are doing as well as identifying any hemianopias/quadrantopias that may be present increasing the likelihood of neglect/inattention. I assessed visual field, visual acuity, eye follow, convergence and divergence to thoroughly examine if any of the cranial nerves involved in vision were affected. These tests were all negative.
The ataxic presentation required a thorough assessment of co-ordination to determine the extent of any cerebellar signs and as this was a re-assessment, whether there had been any improvements made since the initial assessment. The tests I included were rebound phenomenon, finger-thumb/heel-knee, rapid supination-pronation/toe-tap, finger-nose/heel-shin, pendular reflexes and bridging. I examined the unaffected side first to have a reference point as to what was probably normal for the patient. I then moved to the affected signs where Mr S demonstrated a mild level of co-ordination difficulties with the right upper limb and a moderate level in his right lower limb.
As patients with ataxia often fix their limbs to feel safe and supported, assessing tone and joint ROM to determine if any specific areas were becoming stiff and sore, potentially limiting function, had arisen I believed was very important. I was most concerned with the shoulder and hip joints as they are most at risk of developing further musculoskeletal complications if tone is increased and joint ROM is lost.
Due to the time limitations I only assessed tone, using the Tardieu scale, in key muscles which in the upper limb were biceps, triceps and wrist and finger flexors; and in the lower limb, hip adductors, hamstrings, quadriceps and gastrocnemius/soleus. The patient had increased tone in his right hip adductors (Tardieu = 2) and right plantarflexors (Tardieu = 3). I found no abnormalities in tone on the left side.
I assessed ROM in were the shoulder giving the number of degrees of flexion, abduction and external rotation and then the elbow, wrist, hip, knee and ankle stating whether the patient had full, ¾, ½, ¼, or no range in that joint. These were all assessed in supine, except for hip extension range which I assessed in prone. Reduced range into abduction and external rotation were noted on the right side but the patient did not report any pain with these movements. Reduced range was also apparent in the right ankle into dorsiflexion and hip into adduction and flexion. No loss of range was evident on the left side.
The Gowlands motor recovery scale is a measure of voluntary control which has been validated within the stroke population. This assessment also allowed me to have a general look at the patient performing functional movements as well as aspects of a balance assessment. The patient was positioned according to the standard starting instructions and although ideally I would have assessed his unaffected side first, I was running short of time so just documented that it wasn’t tested. The patient scored a 4 – postural control, 4 – leg, 2 – foot, 5 – arm, 4 – hand.
RESULTS
Although I managed to complete all the essential components (except for Gowlands on the left side) it took me 75 minutes, 15 minutes longer than the time frame I was given. Luckily the patient didn’t have any other appointments to go to so I was able to take the extra time required to finish.
My supervisor agreed with the assessment tasks I had chosen however said that for next time I should include a better assessment of functional tasks and mobility level for reassessment as his mobility status on the ward may be able to be changed.
EVALUATION
Although the assessment was completed to an adequate standard for my first attempt, there are a few things I will be able to work on and improve. Firstly, my time management skills were not the greatest, however I think the reason it took me longer than anticipated was due to the fact my handling was not ideal and I was not familiar with all the tests so lacked a degree of confidence. As a result of this I performed some tests, for example tone, a number of times to be sure I was certain of my result.
When I realised that I was running short of time, I got nervous and flustered, losing my place in the Gowlands and getting mixed up with the scoring on a couple of occasions. Although it probably didn’t contribute excessively to time, my handling was not optimal in terms of patient comfort and providing good, firm sensory input to the affected limbs.
STRATEGIES
I believe that the best strategy for me to improve my assessment skills is practice, practice, practice! Not only will this help to improve my confidence, but also have better handling skills and feel like I only need to perform an assessment once to have a definite result. With an improvement in all of these factors I think my assessment will be more efficient and not so time consuming.
Another way I plan to improve my time management is to make a list of which Gowland stages are performed in each position so the patient doesn’t have to change position all the time. I also plan to watch video of the Gowlands assessment do improve that specific aspect of my assessment.
Furthermore, I asked my supervisor if there were any resources I could revise on assessment protocols and how to be as efficient as possible, she said she would have a look and get back to me but went through specific aspects of my assessment with me which she believed could be improved.
My patient, Mr S, is a 63yr male who has been attending rehabilitation at Shenton Park hospital for the past 2 months following a left LACS (from an internal capsule infarct in the area of the L anterior choroidal artery), presenting with right sided ataxic hemiparesis symptoms.
From his history I expected his main impairments to be co-ordination deficits in his right upper and lower limbs possibly combined with altered tone (likely hyperreflexia) and hemianopia. Consequently, a reduced functional capacity and an inability to ambulate were also aspects I considered prior to meeting the patient.
Mr S is a very positive and motivated patient with an extremely supportive family.
Prior to his stroke he worked full time as a farmer and is very keen to get back to work and return to playing golf. From reading his progress notes, he appears to have progressed well so far with his rehab.
No discharge date has been set for the patient as yet.
TASK
Prioritised re-assessment of the patient in a 60 minute time frame identifying key measures most important to determine an initial impairment list based on my findings so that I could begin to build a treatment plan for this patient. As neuro examinations are timely I was not expected to complete the full assessment in the one session but prioritise so that the rest of the tasks could be completed in later sessions.
ACTION
After introducing myself to the patient, performing a brief subjective assessment and explaining what I was going to be doing, I began the re-assessment process.
I chose to objectively assess, time permitting, vision, co-ordination, tone, joint ROM and Gowlands motor recovery scale in my initial examination.
In an attempt to use my time effectively, I began with the vision and coordination tests with the patient sitting over the edge of the bed with their feet supported, and then I moved onto the tone and joint ROM assessments in supine and concluded with Gowlands.
Vision was an essential inclusion to ensure patient is able to see what you as therapist are doing as well as identifying any hemianopias/quadrantopias that may be present increasing the likelihood of neglect/inattention. I assessed visual field, visual acuity, eye follow, convergence and divergence to thoroughly examine if any of the cranial nerves involved in vision were affected. These tests were all negative.
The ataxic presentation required a thorough assessment of co-ordination to determine the extent of any cerebellar signs and as this was a re-assessment, whether there had been any improvements made since the initial assessment. The tests I included were rebound phenomenon, finger-thumb/heel-knee, rapid supination-pronation/toe-tap, finger-nose/heel-shin, pendular reflexes and bridging. I examined the unaffected side first to have a reference point as to what was probably normal for the patient. I then moved to the affected signs where Mr S demonstrated a mild level of co-ordination difficulties with the right upper limb and a moderate level in his right lower limb.
As patients with ataxia often fix their limbs to feel safe and supported, assessing tone and joint ROM to determine if any specific areas were becoming stiff and sore, potentially limiting function, had arisen I believed was very important. I was most concerned with the shoulder and hip joints as they are most at risk of developing further musculoskeletal complications if tone is increased and joint ROM is lost.
Due to the time limitations I only assessed tone, using the Tardieu scale, in key muscles which in the upper limb were biceps, triceps and wrist and finger flexors; and in the lower limb, hip adductors, hamstrings, quadriceps and gastrocnemius/soleus. The patient had increased tone in his right hip adductors (Tardieu = 2) and right plantarflexors (Tardieu = 3). I found no abnormalities in tone on the left side.
I assessed ROM in were the shoulder giving the number of degrees of flexion, abduction and external rotation and then the elbow, wrist, hip, knee and ankle stating whether the patient had full, ¾, ½, ¼, or no range in that joint. These were all assessed in supine, except for hip extension range which I assessed in prone. Reduced range into abduction and external rotation were noted on the right side but the patient did not report any pain with these movements. Reduced range was also apparent in the right ankle into dorsiflexion and hip into adduction and flexion. No loss of range was evident on the left side.
The Gowlands motor recovery scale is a measure of voluntary control which has been validated within the stroke population. This assessment also allowed me to have a general look at the patient performing functional movements as well as aspects of a balance assessment. The patient was positioned according to the standard starting instructions and although ideally I would have assessed his unaffected side first, I was running short of time so just documented that it wasn’t tested. The patient scored a 4 – postural control, 4 – leg, 2 – foot, 5 – arm, 4 – hand.
RESULTS
Although I managed to complete all the essential components (except for Gowlands on the left side) it took me 75 minutes, 15 minutes longer than the time frame I was given. Luckily the patient didn’t have any other appointments to go to so I was able to take the extra time required to finish.
My supervisor agreed with the assessment tasks I had chosen however said that for next time I should include a better assessment of functional tasks and mobility level for reassessment as his mobility status on the ward may be able to be changed.
EVALUATION
Although the assessment was completed to an adequate standard for my first attempt, there are a few things I will be able to work on and improve. Firstly, my time management skills were not the greatest, however I think the reason it took me longer than anticipated was due to the fact my handling was not ideal and I was not familiar with all the tests so lacked a degree of confidence. As a result of this I performed some tests, for example tone, a number of times to be sure I was certain of my result.
When I realised that I was running short of time, I got nervous and flustered, losing my place in the Gowlands and getting mixed up with the scoring on a couple of occasions. Although it probably didn’t contribute excessively to time, my handling was not optimal in terms of patient comfort and providing good, firm sensory input to the affected limbs.
STRATEGIES
I believe that the best strategy for me to improve my assessment skills is practice, practice, practice! Not only will this help to improve my confidence, but also have better handling skills and feel like I only need to perform an assessment once to have a definite result. With an improvement in all of these factors I think my assessment will be more efficient and not so time consuming.
Another way I plan to improve my time management is to make a list of which Gowland stages are performed in each position so the patient doesn’t have to change position all the time. I also plan to watch video of the Gowlands assessment do improve that specific aspect of my assessment.
Furthermore, I asked my supervisor if there were any resources I could revise on assessment protocols and how to be as efficient as possible, she said she would have a look and get back to me but went through specific aspects of my assessment with me which she believed could be improved.
Saturday, May 8, 2010
Neuro prac: Initial entry
After having the last five weeks off to do my Honours project I am anxious but very much looking forward to getting back to the clinical side of things. When I found out that my Neuro placement was going to be on Ward 2 at Shenton Park I was really pleased. I have heard that although this placement is challenging it is also very rewarding.
In what will be the third round of rotations I believe that my clinical supervisors will have higher expectations in terms of professionalism, communication, time management and other transferable clinical skills. I think that these attributes are essential to demonstrate from day 1 to make a good first impression. Having a thorough knowledge of neuroanatomy will be also a key to knowing what type of deficits to expect in a patient before seeing them.
I am aware that I will be expected to be competent with neurological assessments, which is probably the area I feel least confident about. This is mainly due to the fact that I have never worked with stroke patients before and despite the practice I have done on 'normals', I know it's going to be a extremely different on the ward and will require the ability to prioritise assessments and make modifications for each individual.
As well as assessment, another area which I feel that I may lack some practice in is transfers of Neuro patients. Similarly, despite the extensive practice of transfers we have had in various labs over the years, I have found that when I’m put into the situation I am focused on the patient and often forget basic manual handling postures. I think this will be vital to remember in this prac due to the safety aspect involved for not only the patient but also myself.
One area which I think physios working in this field have a key role in is motivating the patient. This will involve me communicating with the patient and their family, as well as other staff members to form goals that are achievable and relevant to the patient. I see goal setting as a key aspect of management in this patient group as the progress is often very slow and treatment sessions long, up to three hours I’m told! As a result of this it’s important to have something the patient can focus on and aim towards plus see the improvements they are making. I think this is especially relevant at Shenton Park as the patients are relatively very young and most often have great rehabilitation potential. I am hoping that my previous experiences in working in multidisciplinary teams and involving families in patient care will assist me in this area.
On the whole, I don’t feel entirely confident with my abilities in a Neuro field but I think my previous clinical experiences will provide a good foundation for me to start from and improve when I am placed into the specific environment and have a better understanding the area. From this prac I hope to develop efficient and thorough assessment skills, improve my skills of patient goal setting and motivation as well as by the end of the placement feel confident in developing comprehensive treatment plans for any individual patient.
In what will be the third round of rotations I believe that my clinical supervisors will have higher expectations in terms of professionalism, communication, time management and other transferable clinical skills. I think that these attributes are essential to demonstrate from day 1 to make a good first impression. Having a thorough knowledge of neuroanatomy will be also a key to knowing what type of deficits to expect in a patient before seeing them.
I am aware that I will be expected to be competent with neurological assessments, which is probably the area I feel least confident about. This is mainly due to the fact that I have never worked with stroke patients before and despite the practice I have done on 'normals', I know it's going to be a extremely different on the ward and will require the ability to prioritise assessments and make modifications for each individual.
As well as assessment, another area which I feel that I may lack some practice in is transfers of Neuro patients. Similarly, despite the extensive practice of transfers we have had in various labs over the years, I have found that when I’m put into the situation I am focused on the patient and often forget basic manual handling postures. I think this will be vital to remember in this prac due to the safety aspect involved for not only the patient but also myself.
One area which I think physios working in this field have a key role in is motivating the patient. This will involve me communicating with the patient and their family, as well as other staff members to form goals that are achievable and relevant to the patient. I see goal setting as a key aspect of management in this patient group as the progress is often very slow and treatment sessions long, up to three hours I’m told! As a result of this it’s important to have something the patient can focus on and aim towards plus see the improvements they are making. I think this is especially relevant at Shenton Park as the patients are relatively very young and most often have great rehabilitation potential. I am hoping that my previous experiences in working in multidisciplinary teams and involving families in patient care will assist me in this area.
On the whole, I don’t feel entirely confident with my abilities in a Neuro field but I think my previous clinical experiences will provide a good foundation for me to start from and improve when I am placed into the specific environment and have a better understanding the area. From this prac I hope to develop efficient and thorough assessment skills, improve my skills of patient goal setting and motivation as well as by the end of the placement feel confident in developing comprehensive treatment plans for any individual patient.
Sunday, March 14, 2010
Final Entry
Looking back over the last five weeks, I really enjoyed the experiences I have had on my cardio prac a lot more than I thought I would have. I now am aware that although in the acute phase cardio physio is predominantly about chest physio techniques, as patient’s progress the dominant treatment is mobilising a patient back to their pre-morbid level as this is a treatment patients can easily do themselves.
As I had anticipated, professionalism and time management skills were essential and especially professional behaviour was expected from day one. The time management practice developed as my patient load increased over the five weeks until I was finally running the ward when my supervisor was away for a day.
Developing a prioritised cardiorespiratory problem list was another area that I knew would be tested with this prac and it certainly was. I hadn’t quite expected the amount of detail my supervisor expected from me in my full SOAPIERs each week. Another aspect of this was also being able to adapt the problem list as the patient progressed, which is an area I hadn’t thought about that much prior to this placement but since gaining the clinical experience am aware of how important a consideration this is.
In terms of patient populations, I did not see as many COPD patients as I had expected, most likely because I was on a general medical ward, however I did get a lot of experience with pneumonia patients. These patients often had a lot of co-morbidities which led to their condition being severe enough for hospitalisation. I did gain some exposure to post surgical patients, especially abdominal and cardiac, although as I was not on the surgical ward it was only a small proportion of all the patients I saw. I did need to be aware of the effects of anaesthesia on the respiratory system, the effect of pain and side effects of narcotics often used to manage post-op pain, but my main role with these patients was mobilising them and giving them post-operative education which is an area I had not considered as a physio’s role previously but now I know that it is in fact a key element, especially in heart surgery patients.
With all patients, safety was a priority. I had some challenging situations early on in my placement with patients who had multiple attachments however as I became more aware of the environment I was much more equipped to safely manage this.
Unlike my last hospital placement where I was very vocal in team meetings with doctors and all allied health staff, on this prac, most meetings I was involved with were with only nurses and allied health. In these meetings I did have an important role in discussing patient’s mobility level and what my thoughts were on their options for discharge. Discharge planning was a major part of my role on this prac as very often patients were coming in from home but were not coping and so were requiring an increased level of services or residential placement. I was often having to discuss with medical staff which destination I thought was appropriate and why which I found initially daunting but an excellent way to improve communication skills with medical professionals.
I thoroughly enjoyed the variety of experiences I had on this prac from pneumonia patients to cardiothoracic surgery patients as well as ICU patients. I felt this was most beneficial for my learning as there were limited chest patients on my home ward. The most important thing that I think I gained from this prac was the ability to discuss a patient and their progress with medical professionals and also gaining the knowledge about the many options for patients on discharge to have continuing care.
As I had anticipated, professionalism and time management skills were essential and especially professional behaviour was expected from day one. The time management practice developed as my patient load increased over the five weeks until I was finally running the ward when my supervisor was away for a day.
Developing a prioritised cardiorespiratory problem list was another area that I knew would be tested with this prac and it certainly was. I hadn’t quite expected the amount of detail my supervisor expected from me in my full SOAPIERs each week. Another aspect of this was also being able to adapt the problem list as the patient progressed, which is an area I hadn’t thought about that much prior to this placement but since gaining the clinical experience am aware of how important a consideration this is.
In terms of patient populations, I did not see as many COPD patients as I had expected, most likely because I was on a general medical ward, however I did get a lot of experience with pneumonia patients. These patients often had a lot of co-morbidities which led to their condition being severe enough for hospitalisation. I did gain some exposure to post surgical patients, especially abdominal and cardiac, although as I was not on the surgical ward it was only a small proportion of all the patients I saw. I did need to be aware of the effects of anaesthesia on the respiratory system, the effect of pain and side effects of narcotics often used to manage post-op pain, but my main role with these patients was mobilising them and giving them post-operative education which is an area I had not considered as a physio’s role previously but now I know that it is in fact a key element, especially in heart surgery patients.
With all patients, safety was a priority. I had some challenging situations early on in my placement with patients who had multiple attachments however as I became more aware of the environment I was much more equipped to safely manage this.
Unlike my last hospital placement where I was very vocal in team meetings with doctors and all allied health staff, on this prac, most meetings I was involved with were with only nurses and allied health. In these meetings I did have an important role in discussing patient’s mobility level and what my thoughts were on their options for discharge. Discharge planning was a major part of my role on this prac as very often patients were coming in from home but were not coping and so were requiring an increased level of services or residential placement. I was often having to discuss with medical staff which destination I thought was appropriate and why which I found initially daunting but an excellent way to improve communication skills with medical professionals.
I thoroughly enjoyed the variety of experiences I had on this prac from pneumonia patients to cardiothoracic surgery patients as well as ICU patients. I felt this was most beneficial for my learning as there were limited chest patients on my home ward. The most important thing that I think I gained from this prac was the ability to discuss a patient and their progress with medical professionals and also gaining the knowledge about the many options for patients on discharge to have continuing care.
Saturday, March 13, 2010
STARES #3, Topic: Intervention
SITUATION:
My patient was a 39 year old male diagnosed with severe diabetic ketoacidosis and a subsequent pneumonia after a night of binge drinking combined with Type 1 DM, currently in ICU, sedated and mechanically ventilated on BiPAP. He required physiotherapy intervention to gain a sputum sample and minimise further respiratory complications as well as treating his suspected pneumonia. I saw the patient with my supervisor for a chest assessment and treatment indicated as his CXR showed bilateral infiltrates. Following the assessment we decided the patient would be likely to benefit from manual hyperinflation (MHI), to simulate sustained maximal inspirations (SMIs), and oropharyngeal suctioning.
TASK:
My role in the intervention was to do the MHI prior to suctioning (which my supervisor did) to pre-oxygenate the patient and afterwards as SMIs. It was the first time I had performed the technique on a patient so I was given plenty of practice prior to the treatment.
ACTION:
Initially I practiced 'bagging the bag', that is performing MHI to the bag attached to would to the end which would usually be connected into the circuit to get air into the lungs. This was to practice the action and well as the timing of the technique. Following that, I watched my supervisor MHI the patient for the first few cycles and she also showed me how to connect it into the ventilator circuit as quickly as possible. When I started to perform the technique on the patient my supervisor initially did the timing for me as I got the hang of the action and then I progressed to timing it myself. This was when I began to have a few difficulties. On a couple of occasions I gave the patient to great an inspiration and he began to make a gurgling type noise. Although my supervisor was not concerned and I continued 'bagging' the patient, it made me nervous to know that it was very easy to injure his lungs by giving to large a breath.
RESULT:
The result of my intervention was not harmful or unsafe for the patient as I only held the breath slightly too long and I was under close supervision the whole time, it was more so a good learning experience for me. The treatment did achieve the goal of improved gas exchange as oxygen saturations went up and the patient had greater tidal volumes during the MHI, however these were both only short term changes. There were no detrimental effects to the patient or changes to cardiodynamic stability.
EVALUTATION
As it was the first time I performed MHI on a patient I was not expecting to have perfect technique and timing. From my experience I have learnt a new skill and also learnt a lot more about potential complication of MHI such as barotrauma and volutrauma. As I continued to practice on that patient I was able to adjust my hand positioning to be more efficient and effective as well as improving my timing by getting immediate feedback from my supervisor. I think that my strength was in the position and handling of the equipment where as my weakness was definitely in timing the technique. The aim is for the patient to take deeper breaths than normal however maintain a normal respiratory rate, that is, aiming for 12-16 breaths a minute. By giving my patient too great an inspiratory volume continuously it could have reduced his respiratory rate and reduced his oxygen saturations or a more severe consequence would be permanently damaging his lung tissue. As I only made this mistake a couple of times the intervention was still effective.
Strategies that I implemented at the time included gaining direct feedback from my supervisor and asking questions as I performed the technique to adapt my treatment as I went along. I also used the method of 'bagging the bag' the bag again to improve my positioning and timing which was helpful despite the bag having far more resistance than normal lungs. Another method I used was to count in my head as my supervisor was performing MHI on the patient to cement the rhythm in my mind. After I had finished treating the patient, that night I went home and revised my notes on MHI as well as ventilator hyperinflation (VHI), especially taking note of the signs and symptoms that suggest adverse effects. Furthermore I revisited my information on the complications of the technique and when it is indicated to perform it. For my few days left on placement, whenever I was given the chance to go down to ICU, I asked my supervisor if she had any patients appropriate for MHI as I wanted gain as much experience with this technique as I could and hoped to be able to feel a variety of different lung compliance on various patients. I was able to perform MHI again, however only a couple more times but I felt that when compared to my first attempts, my technique had definitely improved.
Thursday, February 25, 2010
STARES #2, Topic: Risk Management
Situation:
I was asked to do a chest review a 69yr old female just transferred out of ICU, following a Hartmann's procedure for a perforated bowel and diverticulitis complicated by multiple washouts of the wound as the patient was also septic and the wound infected. However, at day 8 post-op the main challenge for me during my assessment was the number of attachments this lady had. These included an IDC, CVC, NGT, IV line (for fluids and ABs), stoma bag, vac dressing on the wound, a wound drain and O2 via HM. Not only was it important for me to understand what each was for but also where they entered the body and which side of the bed they were on. This was my first experience with multiple attachments and an excellent learning curve in the principles of risk management.
Task:
My task in this situation was to safely assess this patient’s chest and bed mobility taking into account all of her attachments and also pain levels. This was necessary to best direct treatment but also important for me to develop the skills of organisation, awareness and planning ahead when it comes to attachments.
Action:
The patient was resting in bed when I arrived and after checking her observations chart and assessing the environment, I continued with my assessment. I began with the subjective which was relatively straightforward as I was able to raise the bed head up so the patient was more upright and better eye contact could be made. Following from the subjective, I began my specific chest assessment. To my surprise, even just getting the patient to use a pillow for a supported cough proved challenging. This was due to the increased pain levels at the incision during this and the fact that with the cough, the stoma bag began to leak slightly. After informing the nurse and getting her to empty the bag I continued with the assessment. I went on to auscultate, anteriorly, as asking the patient to lean forward to get behind placed a lot more pressure on the wound. The next part of the assessment was bed mobility. This included rolling, bridging and then transferring from supine to sit over the edge of the bed. Rolling and bridging were ok as the attachments were able to stay as they were as they were long enough to withstand the movement. Before assisting the patient to sit up over the edge of the bed, I move all of the attachments around to the side we were getting up on and then instructed the patient on the movement. However, I had moved all but one attachment over. Her IDC, which was tucked under a sheet, remained on the other side and with movement pulled slightly on the patient, although luckily didn’t dislodge. After moving the patient into sitting, she was very fatigued and didn’t tolerate the position for very long and so it was decided to continue the mobility assessment the next day.
Result:
The result was a less than perfect assessment of this patient as a result of ineffective risk management. Not only did the patient experience unnecessary increased levels of discomfort but also if anything had been dislodged there would have been a high risk of infection to the patient as well as staff with body fluids exposed. Despite the poor risk management and sub-optimal safety aspects, the assessment was completed and a good rapport still established with the patient who was very understanding that this was one of my first complicated patients, luckily!
Evaluation:
As a first attempt of dealing with multiple attachments although there are many areas for improvement, in terms of assessment skills, I believe they have improved immensely since the start of my placement. On reflection however the main areas I need to improve are, checking IDCs and stoma bags prior to assessment to make sure they aren’t overly full, ensuring that all attachments are on the side of the bed that I am moving the patient towards and being careful not to compromise IV lines and catheters with movements. This all requires a high level of planning ahead and assessing the environment prior to commencing a session.
Had I checked the stoma bag prior to assessment I would have noted it was very full and could have got the nurse to empty it before I commenced, avoiding patient’s discomfort and embarrassment as well as an awkward situation for myself.
Similarly, I increased patient discomfort and also risked dislodging the catheter because I didn’t check thoroughly that all the attachments were moved. If it had dislodged it would have meant a lot more work for nursing staff, patient discomfort and also risk of infection with urine exposed.
Strategies:
Strategies I have used sine this incident to improve my knowledge and handling of patients with many attachments have included familiarising myself with the attachments and any specific precautions relevant to each. I have also discussed with my supervisor the possibility of having more exposure to these types of patients. Furthermore, I have now adopted a systematic approach to entering a patient’s environment and managing ant potential risks, being extra cautious with complicated patients. Another method I have employed has been to enlist the assistance of nursing staff. Communication with the nursing staff has been an excellent help as they are aware of the specific patient and their individual attachments. They also have been more than happy to help with attachments when mobilising patients. Since the above occasion I am pleased to say I have greatly improved in my organisational skills in terms of setting up the environment as well as managing a wide variety of patients.
I was asked to do a chest review a 69yr old female just transferred out of ICU, following a Hartmann's procedure for a perforated bowel and diverticulitis complicated by multiple washouts of the wound as the patient was also septic and the wound infected. However, at day 8 post-op the main challenge for me during my assessment was the number of attachments this lady had. These included an IDC, CVC, NGT, IV line (for fluids and ABs), stoma bag, vac dressing on the wound, a wound drain and O2 via HM. Not only was it important for me to understand what each was for but also where they entered the body and which side of the bed they were on. This was my first experience with multiple attachments and an excellent learning curve in the principles of risk management.
Task:
My task in this situation was to safely assess this patient’s chest and bed mobility taking into account all of her attachments and also pain levels. This was necessary to best direct treatment but also important for me to develop the skills of organisation, awareness and planning ahead when it comes to attachments.
Action:
The patient was resting in bed when I arrived and after checking her observations chart and assessing the environment, I continued with my assessment. I began with the subjective which was relatively straightforward as I was able to raise the bed head up so the patient was more upright and better eye contact could be made. Following from the subjective, I began my specific chest assessment. To my surprise, even just getting the patient to use a pillow for a supported cough proved challenging. This was due to the increased pain levels at the incision during this and the fact that with the cough, the stoma bag began to leak slightly. After informing the nurse and getting her to empty the bag I continued with the assessment. I went on to auscultate, anteriorly, as asking the patient to lean forward to get behind placed a lot more pressure on the wound. The next part of the assessment was bed mobility. This included rolling, bridging and then transferring from supine to sit over the edge of the bed. Rolling and bridging were ok as the attachments were able to stay as they were as they were long enough to withstand the movement. Before assisting the patient to sit up over the edge of the bed, I move all of the attachments around to the side we were getting up on and then instructed the patient on the movement. However, I had moved all but one attachment over. Her IDC, which was tucked under a sheet, remained on the other side and with movement pulled slightly on the patient, although luckily didn’t dislodge. After moving the patient into sitting, she was very fatigued and didn’t tolerate the position for very long and so it was decided to continue the mobility assessment the next day.
Result:
The result was a less than perfect assessment of this patient as a result of ineffective risk management. Not only did the patient experience unnecessary increased levels of discomfort but also if anything had been dislodged there would have been a high risk of infection to the patient as well as staff with body fluids exposed. Despite the poor risk management and sub-optimal safety aspects, the assessment was completed and a good rapport still established with the patient who was very understanding that this was one of my first complicated patients, luckily!
Evaluation:
As a first attempt of dealing with multiple attachments although there are many areas for improvement, in terms of assessment skills, I believe they have improved immensely since the start of my placement. On reflection however the main areas I need to improve are, checking IDCs and stoma bags prior to assessment to make sure they aren’t overly full, ensuring that all attachments are on the side of the bed that I am moving the patient towards and being careful not to compromise IV lines and catheters with movements. This all requires a high level of planning ahead and assessing the environment prior to commencing a session.
Had I checked the stoma bag prior to assessment I would have noted it was very full and could have got the nurse to empty it before I commenced, avoiding patient’s discomfort and embarrassment as well as an awkward situation for myself.
Similarly, I increased patient discomfort and also risked dislodging the catheter because I didn’t check thoroughly that all the attachments were moved. If it had dislodged it would have meant a lot more work for nursing staff, patient discomfort and also risk of infection with urine exposed.
Strategies:
Strategies I have used sine this incident to improve my knowledge and handling of patients with many attachments have included familiarising myself with the attachments and any specific precautions relevant to each. I have also discussed with my supervisor the possibility of having more exposure to these types of patients. Furthermore, I have now adopted a systematic approach to entering a patient’s environment and managing ant potential risks, being extra cautious with complicated patients. Another method I have employed has been to enlist the assistance of nursing staff. Communication with the nursing staff has been an excellent help as they are aware of the specific patient and their individual attachments. They also have been more than happy to help with attachments when mobilising patients. Since the above occasion I am pleased to say I have greatly improved in my organisational skills in terms of setting up the environment as well as managing a wide variety of patients.
Sunday, February 14, 2010
STARES #1, TOPIC: ASSESSMENT
SITUATION
Auscultation is an assessment technique that I quickly realised needs to be finely tuned on a cardio practical. Auscultation has been used for every patient I have seen this past week with a variety of conditions, from pneumonia and post-surgical patients to suspected pulmonary embolism. It is essential that this technique is effective to determine the severity of a patient's condition, how best to focus a treatment as well as whether the treatment has been effective or not.
TASK
Prior to this placement my auscultation skills were probably not as good as they should have been and on my first day when I was asked to auscultate a 66yr old male with left lower lobe pneumonia patient I didn't feel adequately prepared. It was used in this circumstance as part of my initial objective assessment to then determine the most appropriate treatment technique.
ACTION
I began by instructing the patient to cough and clear any secretions and then disrobed the patient appropriately so I wasn't auscultating through clothing. As the patient was slightly short of breath I chose to auscultate posteriorly as it was more accessible with less soft tissue that may obstruct the technique in case the patient wasn't able to tolerate all of the deeper breaths. I began at the bases posteriorly as this is where he was likely to have abnormal sounds. I instructed the patient not to talk during the auscultation and to take slightly deeper breaths in than normal. I compared the left side to the right systematically as I went along, segment by segment to determine if there was any differences between sides, listening to two breaths at each point. As I had thought, my patient became increasingly short of breath with the auscultation so I completed the posterior assessment but felt it was unsafe and also would be uncomfortable for the patient to continue.
RESULTS
My patient had fair breath sounds and bilateral crackles at the bases with the left worse than the right. This suggested that there was some sputum retained within the lungs especially at the left base, confirming the results of the CXR and the diagnosis.
EVALUATION
My technique was certainly far from perfect. Although I had remembered and implemented most of the theoretical knowledge, my practical skills were lacking. I auscultated too many points posteriorly, which probably contributed to my patient becoming quite SOB. As well as this, I began my auscultation too inferior and so my interpretation was less accurate as what I thought was reduced breath sounds was as a result of no lung tissue being where I was auscultating. Despite a few mistakes I was able to auscultate and gain the correct findings when compared to what my supervisor had heard, apart from the breath sounds. Another area where I was unsure about was what the different sounds actually reflected. I knew that crackles could be from sputum or the reopening of collapsed lung tissue but I didn't know how to clearly differentiate between the two. I now am aware that it is the quality of the crackles, coarse or fine, as well as whether they were heard on inspiration or expiration that determines this. That is, despite reaching the desired outcome, my technique was inefficient, with much room for improvement.
STRATEGIES
With feedback from my supervisor on board I went home and revised surface anatomy of the chest, listing key landmarks to assist in orientating me to exactly which lobe I'm auscultating. I also re-read the information regarding interpretation of findings and what the different abnormal sounds. I have since gained more practice in auscultating and feel far more confident in my ability to assess and interpret the results. I have also asked my supervisor to watch me auscultate again and give me feedback which was very helpful and positive with great improvement after only a few days. I will continue to practice my auscultation daily to further develop and fine tune my ability and hopefully get to listen to some interesting chests with more than just a little consolidation!
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