PRAC 1: Initial entry

My initial thoughts on finding out that my first placement was to be cardio based were that it would be great to be able to put into practice all the things that we learnt only last semester into practice while they were still fresh in my head. However, coming back after such a long break and after revising our cardio material this week I am getting more and more nervous about the placement and what the expectations of me are going to be as it's not as clear in my head as I thought it would have been.

Furthermore, I don't know what ward I will be on yet so have been fairly general with my revision which I hope will keep me in good stead, but if I get quizzed on the specifics of ICU patients day 1 I would be feeling quite unprepared.


In regards to expectations of myself on placement I am certain that professionalism and time management skills will be expected from day 1. In terms of knowledge I know that I must be confident in applying and reasoning a cardiorespiratory problem list as well as taking into consideration cardiac and respiratory conditions as well as other co-morbidities such as diabetes, when assessing and treating patients.

I have some great feedback from the clinical mix forms from other students who have been at my same facility which has been really beneficial in my preparation. From this information I have gathered that I will definitely be exposed to a lot of COPD and pneumonia patients, plenty of patients with chest infections on top of other co-morbidities and potentially post-op patients whether that is cardiac surgery, abdominal surgery or head and neck surgery. It will be essential for me to therefore 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.

On top of this, working in a hospital with potentially very unwell patients it will be crucial to be aware of all the safety aspects that will be necessary to monitor and check when assessing, mobilising and treating a patient. This includes things such as checking a patients obs chart, noting medical results, e.g. haemoglobin levels as well as checking all attachments are functioning and are not interrupted by physio treatments.

I thoroughly enjoyed working in the private hospital setting on my last prac and it will be interesting to compare and contrast that with working in the public sector. I also am looking forward to again being a part of a MDT which I found a very useful tool last year to gain further insight into a patient's problems as well as expressing my own ideas and opinions in a forum of other health professionals and getting feedback from people with expertise in a different field.

Although I’m nervous at the moment I feel that I am well equipped to take on my cardio prac on Monday and all the challenges that come with it and can't wait to apply the many principles and techniques I’ve learnt so much about.

Final entry - review

I have thouroughly enjoyed this placement and now realise that although initially 'thrown in to the deep end', it made me become more confident in my own ablilities in the long run and develop much better skills in assessing and treating patients than if I had been only observing my supervisor.

I feel that I have improved my time management skills and ability to communicate my opinions and views with other members of the multidisciplinary team. My role in discharge planning has also made me far more aware of the team work that is required in planning when a patient can be discharged.

I learnt far more from this prac than I had imagined I would as in the rehab setting you are able to see a real variety of cases from orthopaedic to cardiorespiratory and musculoskeletal on top of the relevant gerontology issues.

Topic 3

Situation
The situation was such that I had a patient who was needing to be weaned off oxygen therapy in the rehab environment to assess whether or not he would be required to have oxygen therapy in his home following respiratory failure from AAA repair. The patient was 78yr old man who was previously completely independent in ADLs, ambulating without aids and still driving.

Task
The task was to measure his O2 saturation levels during physio sessions with decreased oxygen therapy (cont via NP) than prior to his rehab admission. As he was able to maintain his O2 sats above 90 during exertion the oxygen was to be removed.

Action
I completed a 6mwt with this patient initially, with him on 2L continuous O2 via NP, and after 3mins his saturation levels decreased to 88 so he was unable to continue walking the finally 3 minutes. A week later, after daily PT of ambulating, seated cycling and LL strength exercises, I re-assessed the 6mwt. The patient had been of O2 therapy during the day for the 3 days prior and off oxygen at night for 1 night.

Result
The result of this test was a much improved total distance at the conclusion of the test and on RA the patient's SpO2 levels remained between 92-93 on exertion. These were measured using pulse oximetry. He also had a lower maximum HR and a lower BORG rating of shortness of breath.

Evaluation
This reflects a positive outcome and suggests that my intervention of a PT program aiming to improve CR fitness and endurance assisted this patient in being able to maintain adequate O2 levels during physical exercise. However, this result can not simply be attributed to physio input but also nursing and medical management of the patient. During this process I realised the necessity of communication with nurses and doctors about the change in oxygen therapy the patient was to receive.


Strategies
Next time I feel that I may have been able to acheive the desired outcome earlier by using a gradual decline in O2 therapy rather than dropping the patient straight from 2L cont O2 throughout the day and on exertion to just RA. Perhaps it would have been more beneficial to the patient to have had periods during the day when he was at rest where the oxygen could have been removed, ensuring that SpO2 levels were regularly assessed.

Entry 2:

Situation:
I had a patient today who is a 97yr old man, admitted into the rehab unit 2 days ago after being in an acute ward following a postural collapse. He was mobilising with a wzf but at home was using a 4ww over a distance of 30m. His goal was to go back home and to do this he needed to be able to walk I with a 4ww over the required distance. His BBS was 33/56.

Task:
The task for me has been to improve his mobility so that he is ready for discharge when all other allied health and medical goals have been met. To achieve this I needed to make sure he was safe and independent on the wzf and then progress to a 4ww, ensuring that he was safe on that with stand-by assistance initially and then independently.

Action:
Day 1 treatment included assessing his ambulation on the wzf and also aiming to improve his dynamic balance reactions. Day 2, the patient was loaned a 4ww to ambulate with on the ward and reminded of extra safety precuations involved with having 4 wheels. Since the patient is so old it is expected his balance will improve sigificantly and the fact that the reason for his admission was not related to his poor balance, the main goal prior to discharge is to return the patient to his previous functional mobility level.
Communication was also another important aspect of this intervention as when a patients mobility status on the ward is changed it must be documented in the progress notes, changed on his bedside chart and the nurses need to be made aware of the change.

Result:
The result of my intervention has meant that the patient is now ready for discharge from a physio perspective and is mobilising at the level he was prior to his hospital admission.

Evaluation:
My actions in this situation were very effective and met the desired outcome of the patient being ok for discharge in terms of mobility. Ensuring good communication with the nursing staff is also essential and I made certain all the requirements of a mobility status change were met so all staff were aware.


Strategies:
I used the strategies of goal setting, communication with patient and staff and effective assessment and planning to ensure this patient was ready for discharge as soon as possible.

Week 1 Entry: INTERVENTION

Today I had a great learning experience as a result of doing the wrong thing. We had done an initial assessment on an 82yr old lady who was recovering from pneumonia, was deconditioned and as well as had severe swelling of her lower limbs and especially around her left knee as a result of a fall. Our first treatment priority for the day was do decrease some of the swelling as it was severely affecting her mobility and comfort. However, as a result of a misunderstanding with our supervisor we performed RICE techniques and gentle massage to both lower limbs when we should have only been applying these treatments to the area around her knee injured in her fall. The error in this situation was that we didn't have a thorough understanding about what was causing the bilateral lower limb oedema and hadn't considered that this may be secondary to and infection or cardiac complications, in which case RICE and massage would be very inappropriate. I now am aware that is essential to be able to explain why you are doing a treatment before jumping in and doing it as well as the importance of liasing with the medical staff to discover if a sign is symptom is in fact caused be a medical imbalance and therefore not suitable for physiotherapy. That is, basic clinical reasoning about why you are doing something is vital before beginning any intervention.

3rd Year Prac - Initial Entry

I am excited to start my placement at Hollywood hospital and am more relaxed about prac second time round as I have a better idea of what to expect. I am certain that this placement in neurology/gerontology will be a very different and im sure rewarding experience than my last placement in paeds. I am slightly apprehensive about being in a hospital for the first time but am looking forward to working as part of a larger multidisciplinary team. Working with the elderly is something very new to me but I'm sure that all my skills learnt at uni will assist me in adapting and being an active team member at Hollywood Hospital.

Week 5: Entry 3

Today I met lovely little 11mth boy who is in the care of a foster mum as he waits to be placed for adoption. He is seen by many othe medical professionals and is waiting on an MRI to be confirmed with hyrocephallus. This is where there is too much fluid in his ventricles that is unable to move in or out of the brain causing compression from the inside out. He is most likely globally delayed and has great difficulty in planning movements. At 11mth he is functioning at a 7-8 month gross motor level and similar level in fine motor skills. It is also likely that his speech is delayed and he is waiting to be seen by an opthamologist because 0f a nystagmus query in one eye. For this baby as well as all the stresses of many different appointments and tests being done to him, his medical issues also have meant that an adoption that was lined up has fallen through.

I was given the task of an objective assessment with this boy in the session. This consisted of playing with toys in various positions and seeing how much he would tolerate. In prone he was pivoting and rolling but often found himself stuck in sidelying. In supine he would also roll but wasn't trying to play with his knees or feet and quickly moved into prone. He could sit well without support and was weight bearing on his legs. He was also low toned and probably on the borderline of being classed as hypotonic. He had significantly reduced strength and endurance in his trunk, upper limbs and lower limbs and was not showing any lateral head righting responses. I didn't have much structure to my examination but did feel that I covered most of the essential elements and was able to understand and transfer other knowledge.