Final Entry

Even though this possibly wasn't the best place to be sent out to and initially i wasn't too enthusiastic about this placement, the experience of actual hands on physio was so much better than just learning all the theory all semester. I wish that I had more oppurtunities to do more patient assessments and see the supervisor doing physio work but this prac was good in the sense that it has consolidated lots of information we learnt this semester. Going on prac and having this practical experience really suits my learning type as actually seeing patients with diseases such as parkinsons and stroke is so different than just reading about them.

From this prac i've really learnt a lot about patient communication and i believe this was an excellent first prac to go on to rather than go out somewhere where i would be more challenged with difficult cases but instead i've established the basic building block of being a physio; communcation. From the people at UCH, i've learnt the importance of getting to know your patient as an individual not a disease or problem which needs to be fixed.

day 24

I believe i've really gained experience with my communication over the last few weeks. In today's 'Men's Group' and even yesterday's 'No-Falls Group', i've noticed myself communicating with the residents on a different level. Everything was very chillaxed and the classes ran smoothly. I believe by having more confidence in myself while taking these classes, the residents can feel a difference and are willing to challenge themselves more and listen to my directions. I approach people in different ways depending on their personality and character which seems to work well. I also take notice of how they react to exercises and offer them easier or harder options. Some residents require more attention then others and I need to make an effort to talk to them about random things (the weather, lunch, the weekend, family) and others like getting the instructions and following it exactly and wait for the next cue. So to some this learning experience up, it is importnat to get the know the patients as individuals and play off their personalities to achieve optimum results. We always hear lecturers talking about 'building rapport' this and 'building rapport' that but to actually spend that little extra amount of time with your patients and learning that they are actual real people not 'a weak quad' or 'poor balance patient number 3' really make a difference in the long term picture to the patient and yourself.

day 22

Today i recieved an email from Jo reminding me about the only three reasons to break confidentiality – pt at risk of harming self or others, threat to the wider community or in case of court order.

Back to the discussion on confidentuality a few days ago, I believe i did act in the best way due to the fact in the first case the patient had injured herself and I could see her bleeding through a tissue and it didn't look like it was going to stop and she wasn't going to report it herself as she felt like she was going to hassle people. In the second case, I realluy think i acted well as what the resident told me made me believe she had the intention of harming herself physically. If i was to turn back time i would have done the same thing.

Jo also told me to reflect more on my performance and skills.
So i'd like to bring forth a case of a lady in the nursing home. This client (Mrs V) is in her late 90's and bed bound. Tim and I do passives to her daily. Since the second week, Tim and I have started taking cases separtely mainly to optimise our own learning experience here and also to cover more patients in a day.

When I have Mrs V on my own she doesn't respond to me well as she would if i was with the other PTAs or Tim. She moans and only yells NO! when i talk to her.
For example:
Me: Hello Mrs V!
Mrs V: Nooooooooooo!

Me: How are you feeling this morning Mrs V?
Mrs V: Noooo!

Me: You look pretty in pink!
Mrs V:...mmm.

I'm fairly sure I've always been polite and never hurt her or ignored her in anyway. These passive movements are very important for the residents in the nursing home as they don't move around at all except to be repositioned to prevent pressure sores. So it wasn't like i could just not do her or only give her to Tim. Instead I decided to watch how other carers talked to Mrs V and approached her. I talked to the supervisor who just said that it could be anything from the colour of my hair to the sound of my voice. One thing i did pick up on was that Mrs V was rather religious in her youth and enjoys singing... so i said to myself, "You know many songs and you have a gorgeous voice" so yes i did sing to Mrs V the next day. I also approached her differently. Rather than approaching her first and saying hello, I walked confidently into the room and said loundly and enthusiastically "Good Morning Mrs V!". I received a positive response from her (Mrs V: Yes...) and even a sentence (Why is there a couch on the wall?). This was amazing as she was talking! (incoherently yes, but still talking!). This case taught me a lot abount communication and figuring out different ways to approach people. It also showed me that if something doesn't work one way, don't give up instead try again. By just doing some little research and observing other people, I was able to find common ground on which I could build rapport with Mrs V.

day 21

Last week!

After running exercise classes for 4 weeks now i have really learnt and improved my communication skills and group leading skills i believe. For example today during house 3 group exercises I paid attention to how the residents were feeling that day. One resident (who suffers from Parkinsons) had just taken her meds so i knew i had to keep an eye out on her progress during the session. I always gave two options when doing the exercises. The initial one (easy) and a progression for the residents who were more abled. (Eg bouncing the ball in front and catching it or if you want to, try clapping before catching the ball!) Also another client (Mr A) was looking very tired and kept nodding off during the warm up. He also has shoulder pains past 90 degrees flexion. I made sure when i did arm exercises to say "take it as far as YOU can without any pain". This made him give the exercises a go whereas a couple of weeks ago when I last took this group, he just sat and watched all the upper arm exercises. I also accomodated with different size/weight/colour balls depending on the groups capability that day. I've also learnt that this group doesn't respond well to making team games to compete against ewach other while house 2 (which i do on fridays) really enjoy. I cater for this by just keeping the exercises to whole group exercises in a circle. This includes individual (bouncing own ball) and group (bouncing ball to each other) but NOT splitting the groups (lederball).

day 19

I'm feeling very easy and at home here now on prac. I know the majority of every residents name in this facility so walking down the hallways i'm greeted with a lot of very friendly hellos!

The residents are getting use to seeing me day to day so there's no more struggles to get them to walk with me any more. Some people in particular i may have to sit and talk to them for 5-10 mins before bring up the subject of walking but I enjoy the little chats!

The cold weather really affects the residents and they experience all sorts of pains and won't get out of bed or their homes due to the coldness. Mr W was my only walker who declined today and I let it pass due to fact that I have to apprently go easy on him as he just got out of hospital but mainly because he said the following to me. "Tomorrow after our walk, could you please leave the walker behind so I can walk on the weekend?" This is a huge development for Mr W as he never ever gets out of bed and rarely leaves his room. I've spent a lot of time building rapport with this patient and it feels awesome when he actually gets out of bed for me or even thinks about it! We'll see how he goes tomorrow!

Hopefully this weather clears up again as the effects weather has on the older patients could be quite detrimental in the long run. I guess thats why so many residents die during winter.

Yesterday i forgot to mention that we got to practise using the hoists! April set up situations and the PTA's, Tim and I had to safely get the patient back into their chair. My situation was that the patient had fallen within the parrallel bars. We first couldn't decide the best way of how to manuver the hosit around the bars then with April's hints, we decided to slide sheet the patient across onto the floor (open space) and proceed per usual from there. It was a very useful learning X and I hope to use the hoist again soon! (without sounding like I want a resident to fall over and not get up)

day 18

Today I experienced some complicated confidentuality issues. There were two cases where I saw/was told something by residents and then further told to "not tell anyone" where I thought attention was required. This put me in an akward situation which I discussed what to do with one of the PTA's who told me to talk to my supervisor. In the first case the issue was resolved when another PTA saw the same injury (one resident hurt herself and was unwilling to get medical attention or notify anyone) and went to find the hostel nurse but by the time they both got back another staff member was treating the injury. The second case was more complicated as I recieved some information from a resident after I walked her. This information made me feel uncomfortable as the resident specifically told me to not tell the head nurse or anyone else. I felt very uneasy but thought it was best to discuss it with my supervisor incase anything further was to happen. I couldn't locate my supervisor so after I explained my uneasyness to the PTA she advised that if I felt really uneasy about this predicament I was best to speak to the head nurse and break the confidentuality of the resident. I did do this and was told by the nurse that I did the right thing and that this resident quite commonly became depressed but she'll keep a closer eye on her.

So this was not a situation I really thought I'd come across in this placement and I still don't like the feeling of breaking the confidentuality pact between professional and patient but I still feel I acted in the best way possible.

day 17

Melbourne Cup Day! (No lady luck for me. Tim got 1st and 2nd place!)

It was very very busy at UCH today with everyone running around for the lucheon event. Everyone dressed up in their bests today and all staff brought in hats to wear! 

Yesterday, Tim and I recieved our mid-prac assessments from April and I was pleased with how I am going. Although April believes I communicate very well with the residents and that I am able to build a good rapport with everyone I meet, I apparently need to work on slowing down when speaking and also bring up more topics that the residents like to talk about (ie their family).

I am suprisingly really enjoying this placement so far. The staff are all very friendly and most of the residents are really sweet (I do have my favourites though). It is really good how we've been given alot more responsibilty lately as we've been running all the exercises by ourselves (taking turns). Every X group i take i find i'm becoming more confident and learning more about the things these older people can and can't do and what they enjoy/dislike doing.

day 16

just a quick post.

Mr D fell on the w/e. I believe this just shows how an older patient can be improving so much and just suddenly crash. The ups and downs of the older generation. It seems we'll have to work extra hard on his balance when he returns from hospital and especially look at how and why he fell.

This makes me feel pretty bad as i thought we had made really good progress with Mr D and I hope his falling wasn't our fault from working him too hard or not progressing his X's so they weren't hard enough or functional enough.

day 15

Happy Halloween!

This week i believe i've had a really good taste of the politics of this facility. Some nurses believe they are the top of the world and it is obvious that some carers believe that physios don't do any good and we should leave the residents alone and let them just lay around and die. I just don't think some of the carers realise that if older people don't walk/join X classes/do anything they will decondition a lot quicker. It was very annoying to hear snide comments by some people today who believed they knew what was right when they bearly have any qualifications. 

But i guess you do get the good with the bad so it was really nice to see one bed bound patient (Mrs C) being wheeled around today in a Princess chair. This is the first time she has been up for a year! Tim and I do daily passive mvmts with Mrs C as she has an awful flexion fetal posture which she is very tight in. Today was the first time i've heard Mrs C say anything bar "Yeeeeeeeaaahhh" and "Nooooooooo".  She seemed really happy to be out of her room and breathing fresh air next to the bird cage and in the sun room. She even complied with her passives easier today as one of the conditions Liz the carer told her if she was going to get out of bed was that she had to keep her legs straight. And you could tell she really tried!

Also as Tim was off sick today, it was only Trudy and me in. Trudy's really good with letting Tim and I do the physio work and listens to what we have to say about the patients and our ideas about improving their X's or anything/everything. Today I took over house 2 (my fav house) X's which I enjoyed having that responsibility. There was a bit that concerned me at the end of the session when they all wanted tea but I had to leave to go back and do paper work before my day was over. This made me feel uneasy as I had to leave the residents unattended when I felt I really wanted to be supervising them until they got back into their rooms. I discussed my feelings with Trudy and an OTA and they told me that I just have to judge the situation for myslef and reminded me that those residents in low care should be independant themselves as they are not expected to be watched 24/7 and that they walk around making tea for themselves all the time. In hindsight i still wish i had stayed there and especially watched Mr D get back to his room safely especially with his history of falls.

day 12

We've been assigned a new patient today in the nursing home from the carers down there.

Mrs B suffered from a stroke years and years ago. She recently was put into hospital due to a shaft of femur # and since coming back has had really really bad adduction in her legs. This is apparently problematic for the nursing staff when they try washing her or dressing her. They told April that when they get her up in the morning, both legs are fully adducted over each other. Tim and I have now been assigned to do passive abduction and leg passives daily.
On seeing her for the first time I doubt that she has no abduction as the nursing home staff report. I (as well as the PTA) recon that they NH staff are too rough with her and speak so loudly that she tightens up due to their forceful tones and actions. On examination today, Mrs B was able to have AROM and PROM in abduction and flexion of the hip. Not too good mind you but enough to be suffcient to be able to wash and dress her. We'll continue the passives and observe her improvement.

Day 11

I'd like to discuss some of the various types of Parkinson's disease i've noticed here at UCH. Previously, i've had experience with a few Parkinson patients at the Osbourne Park Hospital Parkinson's clinic but here i've discovered even more about the disease.
Firstly there's Mr W: He's one of the younger men in the facility. Mr W has the typical characterics of Parkinsons. He's quite slow (bradykinesia) and has a quite voice. He recently has had an increased amount of falls. He lacks the typical shuffling of feet i expected in PWP (people with parkinsons) and he is very determined to get around to the shops and doesn't realise the danger he puts himself into.
Next there's Mrs G: She's recently been put into the nursing home for increased supervision. When working with her, she demonstates the typical shuffling of feet and very very quite voice. She also has very slow movements and increased muscle weakness.
On the other side there's Mr L: He is an outpatient who we see once a week. He is affected a lot by his medications and we are able to observe him coming to the end of his medication at the end of treatment. With Mr L, his movements become stiffer and stiffer as the medication runs out. This is where i see a huge difference between him and Mr W and Mrs G. Mr L lives at home with his wife but i believe they are talking about moving him into the nursing home of this facility for extra monitoring.
Then there's Mrs H: When she takes her medication it make she arms and legs move around like mad. She can not literally keep them still. This fact is important to note when we are running exercise groups in her house and have to time it with her meds.
This is just a glimpse into the different things i'm learning here at UCH and the modifications we have to make for each client indiciually and how it effects our scheduals and timing of the groups we have.

Day 10

Again there was no one physio related present today.

Tim and I started off the morning with individual X's. The two patients that came were regulars so Tim worked with the female and did lots of balancing work while I worked with the male. As my patient has been attending these hour long X classes everyday, I decided to give him an 'easy' day where he started off with lying on the plinth for 10 min to stretch out him flexors with the use of gravity and he also did some neck rotations as his neck had been hurting recently. We supplied him with a warm heat pack. After lying there for a while I took him over to the X bike where he road for 4Km in around 12 mins. Normally he rides 7Km in 23.5 mins. After his bike ride i took this patient back to the plinth and continued with passive flexor stretches followed by bridges. He found bridging without bending his knees a bit difficult so i simplified it down to knees bent. This made it a lot easier by next week i think we should progress it back to straight knees. After this exercise I sent him on his way.

At 9:30, Tim and I met an OTA to do walking in the NH with the female patient who has been having the buckling knee. She was able to walk further on Thursday and was very disappointed with her distance she made today. She seems to suffer SoB and this changes day to day. Hopefully after the weekend she will perform better as she gets so down when she thinks she's done a bad job. I think next week April is going to walk her herself and see if there is anything significantly wrong with her. Our goal for this lady is to maintain her ability to walk as she is whellchair bound all day and this helps with her fitness and self esteem. Also I think by able to stand she is able to help in toileting and showering. This makes a huge difference in the nursing home!

Day 9

Walks and passives in NH. We were seeing if 1 patient walked better in the AM. With this patient we have been having difficulities with consistant distances with her walking. Our supervisors seem to believe it because of how we are holding positioning our hands on her as she keeps buckling at her knees. This patient is usually wheel-chair bound with the exception of us doing daily walks with her. It is very dissapointing when she doesn't make it to her set walking goal (to the butterflys or fire box) as she blames herself and believes she is a nuisance to us. I think the problem lies with the fact that she use to be a 2 assist walker but the physio has now changed her to be a 3 assist walker and this is throwing her off.
assessed a female parkinson patient from nursing home. Good ROM in all joints except dorsiflexion of ankles and active hip flexion.
did x's with another resident from NH which i assessed on monday who i decided had weaker hip flexors and abductors than u'd expect from an aging patient. While doing X's and I was count to 10 while she was maintaining IQR X;s, she taught me how to count to five in german. Well in fact initially 10 but seeing as i suffer from short term memory loss i could barely remember up to 5. 5 stars for Dori for building rapport.
The afternoon consisted of hostel walks of which we did only a few as most people were out/had visitors/too sick/too tired/out right refused to walk. This has been problematic as it is hard to organise walks with these conditions. It really shows how we as physios have to fit around other peoples timetables.
At 2 we had the men's X group (aka the men's club) where some of the few male resisdents we have (4) come and do individual x's to suit their conditions. These are usually strengthening X's and X's to promote maintain ROM. I worked on the male parkinson patient i memntioned yesterday who has had the falls. We did lots of balancing work as yesterday but slightly progressed. He was pretty exhausted by the end on the 35 min session even though we didn't do much. He suffered SoB at one stage and had to use his puffer (blue ventilator).

I really wish we had more time with our supervisor as it seems we hardly ever log time with her.

Day 8

Worked on a patient (Mr D) who suffers from Parkinsons. Lately readmitted into hospital due to increased amount of falls to relook over his meds and has come back without much improvement. I thought it was best to assess and work on his balance. 
sitting balance was suprisingly good! For this session I worked on Mr D's balance reactions with him sitting on a wobble cushion and reaching OOBOS to touch my hand then place a mediball into a basket. We then preceeded to the vertical bars to do some functional reaching in standing where I called out numbers which we designated to a particular bar and he had to reach and touch it. We first did it with his left and touching the left numbers and right to right then progressed it to a crossover with his left hand touching the right numbers. 
Next session i think we need to work on sit to stand as this is when he usually falls and also progressing his balance exercises to the next level.

Day 4

April usually doesn't come in on a Thursday or Friday. So in the morning it was just Tim and I all alone. We were instructed previously to do walks in the Nursing Home with a list of patients. 

Tim and I then proceeded to do passive movements in the nursing home until Trudy (a PTA) came to help us with the more difficult 2 assist walks. 

After lunch, we went to do walks in the hostel. One interesting patient is a man i'll call mr W. Mr W is an alcoholic who likes to stay in bed all day. Apprently he stayed in bed for 5 weeks previously while April was on holiday. No showers. No walking. My job was to walk this difficult patient. As we had only met in passing once before he wasn't very compliant. I spent 15mins just talking to him and at the end of it he promised to walk with me tomorrow. A victory? apparently.

Big news fellow bloggers! I got to use a hoist today!!!!!! When Tim, Trudy and I were doing walking rounds, we walked in a patients (Mr D) room, to find him on the floor with his head on the corner of a table next to his chair. Now this is where I got pretty frustrated as this facility has a no lift policy so we were not allowed to assist Mr D to a comfortable position. He was lying on his back all embarressed while Trudy went to find the head nurse to examine him before we were allow to touch him. When Trudy and Chris (the nurse) arrived, we got to assist in using the hoist machine to lift Mr D into his chair but you should have seen the shocking manutention of the nurse! They didn't know how to get the hoist out from under mr D after hoisting and Tim had to talk them throught it. Also as Mr D wasn't quite in his chair properly, Chris tried moving Mr D back my grabbing under his armpits. I think that I could have handled that whole situation better if given the chance and if that no lift policy wasn't there. 

The day finished with the weekly's men's group which Tim and I will possibly be given the oppurtunity to take by ourselves in the following weeks. About 5 men participate and the objective is to just get them exercising for fitness or working on strength or balance. Each exercise Rx plan in catered for their specific needs.

Day 2

An interesting thing that happened today was that I got to do a six minute walk test on a new resident. Firstly I took her HR and BP (initially by hand and manual BP pump + stethoscope and then with the battery BP machine to compare results - I was pretty much spot on!). This patient's BP was always at 66 due to her pacemaker.

The 6mwt was only a test we talked about during gero lectures this sem so it was pretty awesome to be actually doing it. I explained to the patient that we were doing a test to monitor her fitness by seeing how far she could walk in 6 minutes. She was allowed to sit down or stop walking during this time but the clock would still be ticking. I explained that after her Rx plan was organised and had commenced we would be doing this test again to see if her fitness was improving during and after weeks of Rx. 

She began her test at one end of the corridor with myself walking next to her measuring how far she walked with a measuring tool that i pushed and it recorded distance. She walked quite slowly that I believe the average patient would and completed 150m in 6 minutes. This score is not comparable to a norm as its the patients own PB which will be compared to later results.

April and I then started doing a Berg Balance test with her which we didn't complete as April thinks its best to break it up into parts as to not tire the patients out too much and therefore get optimum results.

I really enjoyed actually doing this test today as it feels like actual physio. Stupid as that sounds. But I would like to do more hands on work like that again.

Day 1

Dear Diary,

Today was rather an exciting experience as i embarked on a my 5 week long journey of discovery and enlightenment.

The staff and residents at UCH are sooo friendly and everyone knows everyone! We stopped many a times to chat to gardeners, maintence men and residents of which our supervisor (April) knew by name! This amazed me and boy i hope there is no spot quiz on that tomorrow! (There were one too many jokes of that being the case.)

One thing I would like to share with u today, my dedicated reader, is a case about a resident I helped exercise. This 85 y/o male was a lovely fellow who was suffering from T2DM and had significant sensory loss in his lower left leg. This impairment mainly impacted his static & dynamic balance. But his main impairment was his posture while ambulating. As he was using a WZF, his posture had become quite flexed at the hips.

1) Tim and I were able to diagnose this patient by asking questions while observing his old exercise programme. We then reported to April what we thought was wrong and what we should/would work on if making up an exercise programme. We established that there was significant extensor muscle weakness/flexor tightness and this is what i planned my Rx on. So in addtion to April's adduction/abduction X's, stepping X's and laying flat on his back to stretch his flexors, i introduced this patient to squeezing a ball while in side lying (3 sets of 5, holding for 10 seconds) to work on his gluteal strength and also stretching his abductors and flexors in sidelying. The patient reported a positive reaction to the Rx initially but i'll be waiting to see what he reports back tomorrow morning!(ouch)

2a) I believe i built up a good rapport with this gentleman as he himself was awfully friendly and loved a good chat! On the plus side he also was very good at following instructions and didn't mind doing anything I asked him to do. b) I possibly should have considered my X's a little better as i may have done to much for someone of his age as he would never say no and never reported any pain when now i think about it he probably was being too much of a man about it. c) i suspect tomorrow he will be in a bit of pain because even when i do those x's myself the next day i pull up a bit rough! so tomorrow i think we'll take it a tad easier and i'll monitor other things (fascial expressions) as well next time. d) I actually felt really confident while looking after this patient today due to previous experience in 4P and our gero pracs from this semester.

3) covered above.

4) I'm feeling very comfortable in this facility so far. I'm pretty happy about having Tim there with me as well to bounce ideas off and share client experiences with. Even though today was mostly an orientation I was pleased that we were able to help out in both low/high care exercise classes, ambulating residents (one lady was 99yrs old turning 100 next month!) and help Rx the outpatients.

5)REMEMBER THEY ARN'T SPRING CHICKENS! and need to have appropriate X's set out for their age!

6) In UCH they use a different manutention style which involes no lifting! I've been given a booklet to read up on it tonight!

Well my very dedicated readers i have a lot to read tonight so i'll catchya on the flip side tomorrow!

xoxo dori

Initial Entry 12/10/2008

Dear diary,

Today is my birthday. Hip hip hooray!

1) I'm so excited about going out on placement and have been since the beginning of this semester. The nerves havn't kicked in yet but we'll see how I'm feeling tomorrow morning!

For the next 5 weeks I'm going to be working 8:30-3:30 at Crystal Halliday (a high and low residential care facility) with my soon to be besty Tim Sacks. This semester I've really enjoyed gero with Anne-Marie and Jacqui so when we we initially found out about our placements I couldn't wait to put eveything we've been learning into practice. NB. I'm especially excited about using hoists! Keep an eye out for that day my fellow bloggers.

Concerns range from the daily spot quizzes on anatomy, writing SOAPIERS and also what the physio's expectations of us will be. I've also heard that the physio will not be there every single day so hopefully this will not be detrimental to my learning. At least it will give me experience in taking charge of exercises and working with the PTA's. I really hope this placement is very hands on!

2) I believe that physios who work in aged care facilities mostly check up and aid in maintaining the wellbeing of their patients. I believe this may involve doing various balance and mobility tests, teaching them exercises help to improve their lives functionally and also teach them functional movements such as tranfers and ambulation. These interventions will heavily revolve around other health care professionals such as PTA's, nurses, doctors and OT's. It will be awesome to see how they all fit together to provide the optimum treatment for our patients.