Situation
An 85 year old male inpatient was referred to physio for his chest and mobilisation. He was admitted into hospital after a fall for further assessment of a suspected pulmonary embolism and/or cancer. This patient lives with his wife in a unit with no stairs and usually mobilises around the house with a 4 wheeled walker or with a gofer when outdoors. 4 months ago he suffered from an unknown skin condition that caused him to develop rashes and sores all over his body and since then his health and physical abilities have rapidly decreased secondary to lower limb weakness, shortness of breath and general lethargy. His main goals are to be able to become independent in transfers and activities of daily living as his wife has been struggling to cope looking after him at home over the last 4 months. This patient occasionally becomes confused and disorientated and is not keen to exercise as he constantly feels weak and tired and reports he is having trouble sleeping. His wife is keen for physio and pushes him to exercise as she realises this is the only way he is going to improve his strength and become independent and safe at home.
Task
I was asked to perform an initial objective assessment for this patient, identify his problem list and create a plan accordingly. No x-rays were available to be viewed at this point in time. A thorough examination was required to indicate what areas we could focus on and produce outcome measures we could reassess at a later point in time.
Action
My assessment began with a brief but clear explanation of who I was, what my role is and what I planned to do. I educated the patient on why he was referred to me and the benefits he will receive from physio input. This consisted of discussing his symptoms of shortness of breath and relating it to his recent sedentary lifestyle and the possible complications of him staying in bed for the majority of the day (ie. developing infections in the lungs). We discussed his new difficulty in walking due to the weakness in his legs, dyspnoea and discussed his goals and requirements for discharge. After checking his obs were stable within normal limits, I took his SpO2 which was sitting at 90% on room air. I explained to the patient that we needed to start with an assessment in order to have a baseline to refer back to observe any changes that are taking place. I started with listening to his cough which was moist, weak and produced frank haemoptysis. With further questioning I was able to discover that he doesn't cough often, has no pain when coughing but does cough up blood occasionally. He repeated the cough but it was unproductive. Next I auscultated him in his long sitting position on the bed. I observed a decrease in breath sounds in his left lower lobes. Chest expansion was decreased overall, more so on the left. His SpO2 was constantly monitored throughout the assessment and after his chest assessment, it was sitting at 96% on room air. Lower limb muscle strength testing came next while the patient was still on the bed in supine. I tested his static quads, static hamstrings, static gluteals, active knee flexion, inner range quads, abductors, adductors and his ability to do a straight leg raise. The assessment showed the lower limbs considerably weak but the left slightly worse than the right. I then observed the patient's ability to transfer himself into sitting on the edge of the bed where he needed 1 X minimal assist and in this position I finished his posterior lobes auscultation. At this time his SpO2 had risen to 98% on room air. I assessed his ability of sit to stand (1 X stand-by assist) and we went for a walk to his door with his 4 wheeled walker so I could observe his gait and distance he was able to ambulate. The patient reported shortness of breath 5 metres into the walk and his SpO2 dropped to 87% on room air. He was able to recover with 30 seconds of relaxed breathing while sitting on his 4 wheeled walker and his SpO2 rose to 97% on room air. He agreed to finish the walk back to his high back chair where he denied any feelings of shortness of breath, weakness or pain.
Result
After performing my assessments I was able to construct an exercise program to target his chest, lower limb muscle strength and could compare any improvements or changes to his initial presenting condition. I was able to learn that his shortness of breath related to a drop in his SpO2 but was easily recoverable with relaxed breathing. I noticed that he needed re-training in his transfers as I believe that he has the strength and is capable of performing them but has been relying on the support of others surrounding him to perform these tasks independently. His gait looks good but his leg weakness and dyspnoea was a limiting factor.
Evaluation
Overall I felt as though my assessment was very thorough in the areas that I checked. My performance of the above mentioned assessments were at a good standard also. On the other hand I believe my time management in this assessment should be reconsidered as it took quite a long time and I also could have looked at his seated and standing balance. I was able to explain to the patient how to perform the tasks well and also I was constantly monitoring his obs for his main complaint of shortness of breath. I was able to show him that by moving around and doing his exercises, he was able to increase his oxygen uptake compared to if he just lay in bed all day. I was conscious of the patients safety during the assessment and questioned him about if he needed a break or was feeling ill.
Strategies
For future assessments I need to consider the order of my assessments for example doing the lower limb strength test before sitting him up and doing all the auscultation in the upright position. I will realise from now on how hard it is for a person to do so many deep breaths while I'm auscultating and getting him to breathe normally with an open mouth will produce similar results without getting the patient dizzy from too much oxygen. Also I will discuss coughing with the patient first before getting them to perform the action as I was very surprised when he produced blood which concerned the patient as I myself was concerned. Further practice on different patients will improve my timing for assessments but my supervisors say that it's better to have a thorough assessment than a quick one.
Thursday, February 25, 2010
Friday, February 12, 2010
Fourth Year - Rotation One - Intervention STARES
Situation
71 year old male, day one post op left knee replacement. Besides having a previous medical history of medicated controlled hypertension and depression, he was generally a healthy fit man for his age. Unfortunately he also suffers from claustrophobia. My job was to do a routine day one physio post op assessment and treatment for him. This should usually consist of deep breathing exercises, bed exercises (to improve circulation and strengthen the operated limb) and also apply the CPM to the affected limb to help improve ROM.
Task
Altering my intervention so I am able to conduct a day one post op assessment and treatment session while taking into account the patient claustrophobia.
Action
By reading the patients notes previously before entering his room, I was able to note his fear of enclosed spaces. I also saw that he had identified in his own previous medical history that before he has an 'attack' he begins to perspire profusely and gets 'nervous' asthma. His claustrophobic condition was further evident from when I entered his room to find him already sitting out of bed without being prompted (a very rare case for day 1 post op patients). I decided to conduct the initial introduction to the role I'll be playing in his rehabilitation, his assessment and basic exercises in his comfortable seated position. I explained that being positioned out of bed and moving around is one of the best things he could be doing at this stage. Instead of making him return to his bed and going through the set bed exercises, I adapted them to a seated position (which is normally a progression usually done day 3-4 post op). I also explained the bed exercises to this patient while he was seated and only once they were explained fully did we return him to his bed to practice them. At this stage he started looking anxious and beads of sweat were dripping from his forehead. I concluded this part of the treatment and returned him to his chair.
About an hour later I returned to his room to apply the CPM machine. This was a requirement/order from his orthopaedic surgeon. Unfortunately this intervention requires the patient to lay in bed for an hour literally strapped to a machine constricting his leg. After I'd measured the patient, set up the machine and explained the use, I left him with the instructions on how to adjust the settings and stop the machine for emergencies. At this point in time he commented on the foot strap which I took off to ease him. I said I'd return in an hour to remove the CPM and apply an cryocuff to ease the pain.
Twenty minutes later, a nurse reported to me that my patient had turned off the CPM and jumped off the bed and back into his chair. I went to check on this patient and discussed with him his feelings of claustrophobia and he stated he couldn't tolerate the CPM for more than 10 minutes.
I told him to continue the previous seated exercise/stretches while I went to discuss this patient with my supervisor. Unfortunately my supervisor was treating an outpatient at the time so I returned to the patient with a skateboard and demonstrated how he could use that similarly to a CPM while in the seat.
My supervisor contacted the surgeon and discussed alternatives to the CPM and decided that he thought the skateboard was a good idea as long as my patient was able to achieve around 90 degrees of active knee flexion preferably by day 2 post op or he will have to be forced onto the CPM. We passed these details onto the patient who agreed to the terms.
Result
This patient was able to achieve 80 degrees active knee flexion by day 2 and his surgeon was happy to allow him to remain using the skateboard and seated exercises/stretches as an alternative to the CPM. This was great as it was a win from the patients perspective as he didn't need to suffer from the constriction of the machine to increase his range of motion in order to be discharged.
Evaluation
I felt pretty bad that I didn't consider the effect that the CPM would have on this patients condition. It seems so obvious in hindsight! I shouldn't have put my patient through that emotional situation as I was previously aware of his severe claustrophobia. Although I didn't totally dismiss his condition as I did respond to his signs of distress during the first time I saw him and took the action of stopping the session and restarting it after a break. I also went into the patients room with adapted exercises planned out ahead of time. Unfortunately I believe I still didn't consider the patient as an individual but continued with the routine knee intervention protocol and assumed that a CPM would be fine. Lesson learnt! At least I was able to sort out an alternative to the CPM problem on my own with a simple prop like a skateboard!
Strategies
I believe that initially I did the right thing of checking the patients notes and planning his treatment with claustrophobia in mind. Unfortunately his condition was more severe than I thought.
I have to be more aware of treating patients as individuals and not always follow routine exercises or protocol because they would always apply to everyone the same way.
Being aware of conditions is very important and luckily this time there were no lasting detrimental affects on the patient. Also not assuming the severity of a condition is important!
Look out of signs of discomfort especially if the patient has already indicated to you what those signs may be!
71 year old male, day one post op left knee replacement. Besides having a previous medical history of medicated controlled hypertension and depression, he was generally a healthy fit man for his age. Unfortunately he also suffers from claustrophobia. My job was to do a routine day one physio post op assessment and treatment for him. This should usually consist of deep breathing exercises, bed exercises (to improve circulation and strengthen the operated limb) and also apply the CPM to the affected limb to help improve ROM.
Task
Altering my intervention so I am able to conduct a day one post op assessment and treatment session while taking into account the patient claustrophobia.
Action
By reading the patients notes previously before entering his room, I was able to note his fear of enclosed spaces. I also saw that he had identified in his own previous medical history that before he has an 'attack' he begins to perspire profusely and gets 'nervous' asthma. His claustrophobic condition was further evident from when I entered his room to find him already sitting out of bed without being prompted (a very rare case for day 1 post op patients). I decided to conduct the initial introduction to the role I'll be playing in his rehabilitation, his assessment and basic exercises in his comfortable seated position. I explained that being positioned out of bed and moving around is one of the best things he could be doing at this stage. Instead of making him return to his bed and going through the set bed exercises, I adapted them to a seated position (which is normally a progression usually done day 3-4 post op). I also explained the bed exercises to this patient while he was seated and only once they were explained fully did we return him to his bed to practice them. At this stage he started looking anxious and beads of sweat were dripping from his forehead. I concluded this part of the treatment and returned him to his chair.
About an hour later I returned to his room to apply the CPM machine. This was a requirement/order from his orthopaedic surgeon. Unfortunately this intervention requires the patient to lay in bed for an hour literally strapped to a machine constricting his leg. After I'd measured the patient, set up the machine and explained the use, I left him with the instructions on how to adjust the settings and stop the machine for emergencies. At this point in time he commented on the foot strap which I took off to ease him. I said I'd return in an hour to remove the CPM and apply an cryocuff to ease the pain.
Twenty minutes later, a nurse reported to me that my patient had turned off the CPM and jumped off the bed and back into his chair. I went to check on this patient and discussed with him his feelings of claustrophobia and he stated he couldn't tolerate the CPM for more than 10 minutes.
I told him to continue the previous seated exercise/stretches while I went to discuss this patient with my supervisor. Unfortunately my supervisor was treating an outpatient at the time so I returned to the patient with a skateboard and demonstrated how he could use that similarly to a CPM while in the seat.
My supervisor contacted the surgeon and discussed alternatives to the CPM and decided that he thought the skateboard was a good idea as long as my patient was able to achieve around 90 degrees of active knee flexion preferably by day 2 post op or he will have to be forced onto the CPM. We passed these details onto the patient who agreed to the terms.
Result
This patient was able to achieve 80 degrees active knee flexion by day 2 and his surgeon was happy to allow him to remain using the skateboard and seated exercises/stretches as an alternative to the CPM. This was great as it was a win from the patients perspective as he didn't need to suffer from the constriction of the machine to increase his range of motion in order to be discharged.
Evaluation
I felt pretty bad that I didn't consider the effect that the CPM would have on this patients condition. It seems so obvious in hindsight! I shouldn't have put my patient through that emotional situation as I was previously aware of his severe claustrophobia. Although I didn't totally dismiss his condition as I did respond to his signs of distress during the first time I saw him and took the action of stopping the session and restarting it after a break. I also went into the patients room with adapted exercises planned out ahead of time. Unfortunately I believe I still didn't consider the patient as an individual but continued with the routine knee intervention protocol and assumed that a CPM would be fine. Lesson learnt! At least I was able to sort out an alternative to the CPM problem on my own with a simple prop like a skateboard!
Strategies
I believe that initially I did the right thing of checking the patients notes and planning his treatment with claustrophobia in mind. Unfortunately his condition was more severe than I thought.
I have to be more aware of treating patients as individuals and not always follow routine exercises or protocol because they would always apply to everyone the same way.
Being aware of conditions is very important and luckily this time there were no lasting detrimental affects on the patient. Also not assuming the severity of a condition is important!
Look out of signs of discomfort especially if the patient has already indicated to you what those signs may be!
Wednesday, February 3, 2010
Fourth Year - Rotation One - Initial Entry
Finally entering fourth year and what better way to start than going rural!
I'm excited to be back on prac again except this time I'm experiencing a tingling of nervousness of living away from home without the support of close relatives and friends - especially if I experience one of 'those days' on prac.
I've got my bag packed, uniform washed/ironed, shoes shined and namebadge tucked away safely - let's hope I don't forget to pack my toothbrush!
I just had a chat to my supervisor yesterday about my placement and she's calmed my nerves somewhat and given me some direction on what to look at prior to commencing on Monday. We've discussed and I've organised transportation/parking so that's one stressful situation out of the way. When I arrive in Bunbury on Sunday, I'm planning to drive from my residence to the hospital to minimise getting lost on the first day!
I've been told to expect plenty of THR and TKR which is great because I spent lots of time doing acute rehab treatments with these sort of patients last year! Hopefully I've retained some knowledge! I think I'll be working in a variety of wards as well as seeing patients in the outpatient department, rehab classes, hydro pool and possibly some home visits.
With this placement I'm keen on seeing the whole spectrum of patients in the hospital before I'm sent off to my next round of pracs where the patients will be generally more specific to either neuro, musculoskeletal or cardio. This has made studying prior to this prac difficult though as there is A LOT to cover! I've been told to do gero-cardio revision as well as musculo and ortho.
This year I expect to be less spoonfed by my supervisors/co-workers as I'm a big grown up fourth year student now! So from day 1 I may be seeing patients as their physio and not just observing initially like I have every other year. This scares me a little as I learn a lot more by first observing and then having a go. I'm crossing my fingers that i won't just be chucked straight into the deep end... although if I am I'm sure it'll be a great -and fast- learning experience.
I know there are two previous Notre Dame graduates currently working at the hospital so it'll be awesome to see some old friendly faces. On the other hand, I'm a bit apprehensive of the expectations these graduates and my supervisors will have on me. I know I've learnt all my techniques/tests/theories/exercises over the last three years but will I be able to put my knowledge actually into action when confronted by the patient/supervisor? Performance anxiety is one of my biggest concerns!
As this is my rural placement, I'm wondering how this facility will run differently to my last hospital placement. Will I need to act or treat patients differently? I'm guessing that their goals/aims are going to be slightly different to those patients who live in a busy city but my location isn't actually country/desert rural so maybe there will be much more similarities with the 'big city' patients and these 'little city' ones.
I'm keen to try out the home visits lined up as this will definitely be a new experience for me! Also, speaking to other students who have been to this placement, I may have to oppurtunity to observe more operations!
Other concerns for me are my ability to take subjectives/objectives, give accurate and fast handovers and see patients on my own. These will be my personal goals for self improvement for this year/placement.
I'll looking forward to heading down south and experienceing life working as a physio away from home. This prac is going to be the starting block for a great year of learning and developing myself into an ace physio!
I'm REALLY PUMPED AND EXCITED!
xx Dori
I'm excited to be back on prac again except this time I'm experiencing a tingling of nervousness of living away from home without the support of close relatives and friends - especially if I experience one of 'those days' on prac.
I've got my bag packed, uniform washed/ironed, shoes shined and namebadge tucked away safely - let's hope I don't forget to pack my toothbrush!
I just had a chat to my supervisor yesterday about my placement and she's calmed my nerves somewhat and given me some direction on what to look at prior to commencing on Monday. We've discussed and I've organised transportation/parking so that's one stressful situation out of the way. When I arrive in Bunbury on Sunday, I'm planning to drive from my residence to the hospital to minimise getting lost on the first day!
I've been told to expect plenty of THR and TKR which is great because I spent lots of time doing acute rehab treatments with these sort of patients last year! Hopefully I've retained some knowledge! I think I'll be working in a variety of wards as well as seeing patients in the outpatient department, rehab classes, hydro pool and possibly some home visits.
With this placement I'm keen on seeing the whole spectrum of patients in the hospital before I'm sent off to my next round of pracs where the patients will be generally more specific to either neuro, musculoskeletal or cardio. This has made studying prior to this prac difficult though as there is A LOT to cover! I've been told to do gero-cardio revision as well as musculo and ortho.
This year I expect to be less spoonfed by my supervisors/co-workers as I'm a big grown up fourth year student now! So from day 1 I may be seeing patients as their physio and not just observing initially like I have every other year. This scares me a little as I learn a lot more by first observing and then having a go. I'm crossing my fingers that i won't just be chucked straight into the deep end... although if I am I'm sure it'll be a great -and fast- learning experience.
I know there are two previous Notre Dame graduates currently working at the hospital so it'll be awesome to see some old friendly faces. On the other hand, I'm a bit apprehensive of the expectations these graduates and my supervisors will have on me. I know I've learnt all my techniques/tests/theories/exercises over the last three years but will I be able to put my knowledge actually into action when confronted by the patient/supervisor? Performance anxiety is one of my biggest concerns!
As this is my rural placement, I'm wondering how this facility will run differently to my last hospital placement. Will I need to act or treat patients differently? I'm guessing that their goals/aims are going to be slightly different to those patients who live in a busy city but my location isn't actually country/desert rural so maybe there will be much more similarities with the 'big city' patients and these 'little city' ones.
I'm keen to try out the home visits lined up as this will definitely be a new experience for me! Also, speaking to other students who have been to this placement, I may have to oppurtunity to observe more operations!
Other concerns for me are my ability to take subjectives/objectives, give accurate and fast handovers and see patients on my own. These will be my personal goals for self improvement for this year/placement.
I'll looking forward to heading down south and experienceing life working as a physio away from home. This prac is going to be the starting block for a great year of learning and developing myself into an ace physio!
I'm REALLY PUMPED AND EXCITED!
xx Dori
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