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.
Saturday, May 29, 2010
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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