Topic Two - Assessment

Situation
This week I had the opportunity to do an initial assessment on a day 1 post op patient who had a right total knee replacement. After reading this patient's medical notes including pre and post op notes, surgery procedure, OT notes and looking at their x-ray, I had to go and see the patient and conduct my own subjective and objective assessment followed by their treatment.

Task
My task was to conduct a good subjective assessment and get enough information to direct my treatment plan.

Action
I went into the patient's room (after reading their notes) with all my main questions in mind such as finding out their past medical history, what their home environment is like, any hobbies, previous function and history of their knee problem.

Result
As a result of all the questions I wanted answered, the interview did not flow very smoothly. I was able to get out all the information I wanted from the patient but I found that I felt awkward and the whole process was very 'stop-start'.

Evaluation
I need to be able to not make my subjective so structured and just let it flow like a conversation letting one topic lead onto the next. It's easy to say that but only with lots of practice will I be able to develop those skills. A strength I noted throughout the initial assessment was my ability to give great explanations to the patient on what my role is, the questions they asked and why I needed to ask these specific questions. I also had great compromising skills to get the patient to perform certain tasks during the objective (get patient sitting up on the edge of the bed when they didn't want to do anything at all). I was also able to gather all the relevant information needed to develop this patient’s treatment and goals to discharge them safely from the hospital.

Strategies
I believe I need to develop rapport with my patient quicker than I have been doing recently. This will help with keeping the subjective more 'flow-y' and less like a questionnaire. I attempted this with the next day 1 post op patient I interviewed and found this strategy seemed to work well. I also believe that I shouldn't ask questions like I’m going down a page and ticking off every question asked but let one topic say about their PMHx lead onto previous surgeries and their previous experience of using crutches then using crutches in their home environment and so on and so forth.