Situation
I was asked to continue the rehabilitation of a 37 year old female patient who last week experienced multiple seizures and developed expressive dysphasia. She was bought into the hospital via an ambulance after an episode and was found to have a left frontal glioma. She underwent a craniotomy and excision of the frontal tumor on the 24/05/10. This woman has only recently moved here from China and does not speak or understand any English. Her supportive husband has become a boarder on the ward but unfortunately speaks and understands limited English also. The medical team have also been struggling with communication but have organised an interpreter to be available during their visits and meetings when interpretations are required and are also using the bilingual skills of one of the student doctors. This patient has been seen previously by another physio whose assessment revealed the patient requires work on her high level balance as she tends to veer to the right when ambulating and walks with a ‘floppy gait’. She also has a slightly weaker right side strength in her upper and lower limbs but does not seem to notice a difference between the two sides herself. It was documented in the patient’s notes that she “responds well to actions”.
Task
To continue this patient’s rehabilitation.
Perform a treatment session with a patient with complex communication problems.
Action
After checking the patient’s integrated notes and checking her obs chart (BP=115/70, SpO2=97% on room air, afebrile) I went to visit her room where I found her resting in bed with her husband. I knew I had to keep my language simple and use as many actions as I could. I indicated “Hello! I’m Dorianne, one of the physios” while pointing at myself and “that we would be going for a walk and do exercises” while acting out marching on the spot, doing bicep curls and pointing down the corridor to the gym. These actions were met by a blank stare from both the patient and the husband. I felt like an idiot and a clown but I persisted and pointed to the patient and myself, made a ‘rise up’ actions with both my hands and pretended to march out of the room. That seemed to work as the patient began getting up and the husband got her a dress robe and shoes to wear. Usually with all patients I would ask them about symptoms and complaints they had like pain, headaches, nausea and dizziness. With this patient I tried grimacing my face and rubbing my temples/head, my stomach, indicating throwing up and dizzy/fainting. The patient responded with rubbing the left side of her face and stomach. According to her integrated notes she is having period pains at the moment so I assumed that this is what she was indicating. I got her down to the gym and proceeded with her exercise rehabilitation by first demonstrating the exercises and she was able to copy and follow them all. I realise that most patient’s don’t tell you symptoms they are experiencing during treatment unless constantly questioned so I was taking extra care in monitoring her non-verbal expressions and body reactions. It was through this that I noticed the colour in her face suddenly fade and her eyes shut but the patient remained standing. Her husband did not seem to realise but was able to grab one of the high back chairs in the room when I pointed at it while I held onto the patient who was still standing but not opening her eyes on command or when I applied a sternal rub to her chest with my hand. We sat the patient who then opened her eyes and I was able to get another physio in the room to find me a sats monitor. Her obs were BP=113/66 and SpO2=96% on room air. This was similar to her most recent obs so I was not too worried except I did not know what happened at the patient indicated that she felt fine. I was unwilling to continue treatment and returned her to her room via a wheelchair and informed her nurse of what happened.
Result
The inability to properly communicate really affected my ability to treat this patient. Everything seemed to take triple the amount of time and I was never sure if she fully understood the exercise or reason for treatment. The treatment session was poor as I was unable to determine if I was challenging her balance enough and there little work done. Having her husband around was more useful than a distraction as I assume that he was explaining exercises in Chinese and encouraging her to perform them. Unfortunately it also seemed as if he did not understand anything I was saying as they both looked confused for most of the session. It was only with demonstration and pointing that I was able to communicate exercises or actions properly. Even then, getting her to march on thick foam without upper limb support and walking heel-toe on a straight line I felt as though she did not understand the benefits of these exercises and why she was with me.
Evaluation
Before walking into this patient’s room I didn’t realise how much communication is just verbal! The majority of the time I spent with this patient I felt like an idiot with my over the top actions and had to remind myself to not get frustrated with the lack of communication between the husband, the patient and myself. I think my strengths with this patient would be with my demonstration abilities and how I was able to correct the patient. For example when the patient was marching on the foam, I was able to indicate to her to lift her knees higher by pointing to her legs and then demonstrating little steps and then pointing to my own legs and demonstrating big steps. I was also impressed with my ability to notice her non-verbal reactions like her eyes shutting and face draining during the treatment session. My weakness would be how I dismissed the stomach and head gestures the patient made at the beginning of the session – maybe there was something worse going on then period pain and post head surgery pain. I thought I dealt with this patient well by staying close to her throughout the treatment but it would have been better to organise a better way of communicating before or during the session.
Strategies
This was very different from all other cases of communication/language barriers I have had with other patients. After seeing this patient, I had a talk to my supervisor who said I had acted in the best possible way for this situation. Using different actions to get my point across is important even though you may feel silly sometimes. I think it is vital to not just second guess what the patient may be indicating, especially for this one who had expressive dysphagia. I had to try read the patient’s facial and body expressions and act accordingly to the reactions I saw.
I went home and printed out a list of Mandarin medical terms from http://mandarin.about.com/od/vocabularylists/tp/medical_terms.htm incase this can help me with the treatment or question of the patient in the future.
Getting an interpreter would be ideal but it is not possible in this environment for an interpreter to be around 24/7. If I know when the interpreter will be around maybe I could tee up treatment times accordingly.
Don’t get angry at the patient as it is not your fault or their fault!
Don’t just give up! They need rehab and should be treated like every other patient.
Friday, May 28, 2010
Saturday, May 15, 2010
Fourth Year - Rotation 3 - Assessment STARES
Situation:
The other physio student and myself were asked to perform an assessment on a 75 year old female who was transferred to this hospital following a fall. When presented to the hospital, she was found to have a NSTEMI and further developed left sided weakness, confusion and a transient fever. Scans revealed a right frontal lobe lesion which was surgically drained four weeks ago. Since then the patient had been recovering well but was suspected of having a minor stroke or acute pulmonary oedema over the weekend and was moved back into the High Dependency Unit (HDU) for close observation. She just been transferred back onto the ward where we have been asked to take over the physio management of this patient - starting with an assessment. Previously this patient lived at home alone but has a son in Perth. She is usually independent with all activities of daily living including ambulation and requires no aids.
Task:
To perform an initial assessment on this patient taking into consideration her recent surgery, current condition and past medical history. This assessment is key for deciding what her current limitations are, establishing a baseline for outcome measures which will ultimately aid in choosing her appropriate intervention during her stay in this hospital.
Action:
The day before the assessment, we met the patient in the HDU where she appeared highly distractible and seemed to not attend to her left side when our supervising physio was trying to treat her. These are aspects we considered and discussed before entering her room for the assessment. After reading the patient's integrated notes, the other student and I decided to enter the room and approach the patient's bed from the left side - aiming to draw attention to this side. After re-introducing ourselves and explaining our aim of today's session, we checked her 'obs' which were stable and the patient appeared alert and was able to identify the correct time, person and place. As the patient was already positioned high sitting in bed with a C cushion supporting her left arm, indwelling catheter, a PICC line and IV antibiotic treatment insitu, we were limited in our ability to move the patient around. We were also requested by her nurse to not get her out of bed. Just watching the patient, we did not see any spontaneous movement of her left lower and upper limbs, increased upper chest movement and effort for breathing and still the patient seemed to avoid turning her head to the left past midline.
We auscultated the patient's chest next which revealed atelectasis in her right and left lower lobes but otherwise good air entry throughout. She had decreased but equal lateral expansion when breathing but with facilitation and encouragement was able to increase this. The patient had a weak, moist but productive cough which was followed by a swallow.
The other student and I then took turns with the rest of the assessment. We asked the patient to move her left upper limb but there was no visual or palpable activation of any muscles in her left upper and lower limbs. Although when we resisted the movement, there was evidence of the patient initiating left hip flexion and extension. The patient had no increased tone in either limbs at rest or with velocity applied and her strength was weak but normal for a woman of her age on her right. Sensation was tested next and the patient had decreased light touch sensation all the way up her left upper and lower limb but normal sharp/blunt sensation. She also had very good joint position and motion proprioception in her thumb and big toe which meant that we didn't have to waste time testing the remainder of the joints.
The patient at this time was getting very fatigued and started losing concentration easily so we decided to wrap up the assessment here and see the patient the next day for treatment.
Result:
This assessment highlighted to us that the main impairments for this patient is the decreased voluntary movement of the left limbs followed by her decreased air entry to the lower lobes of her chest. The patient's fatigue at the end of the session may have impaired some of the testing as well as she started to just say "Same. Same. Same." instead of saying "up" or "down" during the proprioception tests which may have given a false negative. Our tactic of addressing the patient from the left may have also influenced some results and possibly tired her out more.
Evaluation:
I think that the other student and I performed this assessment well but occasionally had to alter our hand positions especially when doing the proprioception tests. As this was our first assessment of a neuro patient, the assessment was very stop/start while we checked with our supervisor about the best position to be in and discussing the meaning to the results of the tests performed. This meant that a lot of time was wasted as we re-performed tests so that both us students were able to feel the patient's 'abnormalities'. I realised my auscultation skills are not very good for these neuro patients as I tend to take too much time listening to one area and this tires out the patient or they get distracted and need continuous prompting to deep breathe. Also as there were two students in the room trying to take control of the assessment, we may have been bombarding the patient with too many questions and information. Next time we need to discuss who is going to take lead before going into the room.
Strategies:
The best thing to do is to practice on a variety of patients to improve handling techniques, time management and choosing the appropriate tests to perform.
One main thing picked up with this assessment is that we don't have to perform every single neuro assessment out there in the first session! Just choose the most appropriate ones for the patient at the time.
Be aware of the patient's fatigue and emotional state as this can influence the test results and how you perform the tests.
I can definitely benefit from reviewing how to handle and move neuro patients as well as looking over my auscultation techniques again!
Our supervisor has pointed out a neuro revision file in the office for us to go over in our own time and we have also started practicing assessments with our tutor.
The other physio student and myself were asked to perform an assessment on a 75 year old female who was transferred to this hospital following a fall. When presented to the hospital, she was found to have a NSTEMI and further developed left sided weakness, confusion and a transient fever. Scans revealed a right frontal lobe lesion which was surgically drained four weeks ago. Since then the patient had been recovering well but was suspected of having a minor stroke or acute pulmonary oedema over the weekend and was moved back into the High Dependency Unit (HDU) for close observation. She just been transferred back onto the ward where we have been asked to take over the physio management of this patient - starting with an assessment. Previously this patient lived at home alone but has a son in Perth. She is usually independent with all activities of daily living including ambulation and requires no aids.
Task:
To perform an initial assessment on this patient taking into consideration her recent surgery, current condition and past medical history. This assessment is key for deciding what her current limitations are, establishing a baseline for outcome measures which will ultimately aid in choosing her appropriate intervention during her stay in this hospital.
Action:
The day before the assessment, we met the patient in the HDU where she appeared highly distractible and seemed to not attend to her left side when our supervising physio was trying to treat her. These are aspects we considered and discussed before entering her room for the assessment. After reading the patient's integrated notes, the other student and I decided to enter the room and approach the patient's bed from the left side - aiming to draw attention to this side. After re-introducing ourselves and explaining our aim of today's session, we checked her 'obs' which were stable and the patient appeared alert and was able to identify the correct time, person and place. As the patient was already positioned high sitting in bed with a C cushion supporting her left arm, indwelling catheter, a PICC line and IV antibiotic treatment insitu, we were limited in our ability to move the patient around. We were also requested by her nurse to not get her out of bed. Just watching the patient, we did not see any spontaneous movement of her left lower and upper limbs, increased upper chest movement and effort for breathing and still the patient seemed to avoid turning her head to the left past midline.
We auscultated the patient's chest next which revealed atelectasis in her right and left lower lobes but otherwise good air entry throughout. She had decreased but equal lateral expansion when breathing but with facilitation and encouragement was able to increase this. The patient had a weak, moist but productive cough which was followed by a swallow.
The other student and I then took turns with the rest of the assessment. We asked the patient to move her left upper limb but there was no visual or palpable activation of any muscles in her left upper and lower limbs. Although when we resisted the movement, there was evidence of the patient initiating left hip flexion and extension. The patient had no increased tone in either limbs at rest or with velocity applied and her strength was weak but normal for a woman of her age on her right. Sensation was tested next and the patient had decreased light touch sensation all the way up her left upper and lower limb but normal sharp/blunt sensation. She also had very good joint position and motion proprioception in her thumb and big toe which meant that we didn't have to waste time testing the remainder of the joints.
The patient at this time was getting very fatigued and started losing concentration easily so we decided to wrap up the assessment here and see the patient the next day for treatment.
Result:
This assessment highlighted to us that the main impairments for this patient is the decreased voluntary movement of the left limbs followed by her decreased air entry to the lower lobes of her chest. The patient's fatigue at the end of the session may have impaired some of the testing as well as she started to just say "Same. Same. Same." instead of saying "up" or "down" during the proprioception tests which may have given a false negative. Our tactic of addressing the patient from the left may have also influenced some results and possibly tired her out more.
Evaluation:
I think that the other student and I performed this assessment well but occasionally had to alter our hand positions especially when doing the proprioception tests. As this was our first assessment of a neuro patient, the assessment was very stop/start while we checked with our supervisor about the best position to be in and discussing the meaning to the results of the tests performed. This meant that a lot of time was wasted as we re-performed tests so that both us students were able to feel the patient's 'abnormalities'. I realised my auscultation skills are not very good for these neuro patients as I tend to take too much time listening to one area and this tires out the patient or they get distracted and need continuous prompting to deep breathe. Also as there were two students in the room trying to take control of the assessment, we may have been bombarding the patient with too many questions and information. Next time we need to discuss who is going to take lead before going into the room.
Strategies:
The best thing to do is to practice on a variety of patients to improve handling techniques, time management and choosing the appropriate tests to perform.
One main thing picked up with this assessment is that we don't have to perform every single neuro assessment out there in the first session! Just choose the most appropriate ones for the patient at the time.
Be aware of the patient's fatigue and emotional state as this can influence the test results and how you perform the tests.
I can definitely benefit from reviewing how to handle and move neuro patients as well as looking over my auscultation techniques again!
Our supervisor has pointed out a neuro revision file in the office for us to go over in our own time and we have also started practicing assessments with our tutor.
Saturday, May 8, 2010
Fourth Year - Rotation 3 - Neuro Initial Entry
After my musculoskeletal placement, I thought I had faced my scariest prac for this year. Fortunately, my last placement felt so comfortable working in the outpatient department that over this past week I have started to become slightly anxious about starting my neurosurg prac on Monday.
This anxiety is not so much about not knowing how to act in a hospital setting but it is stemmed by actually working with patients who are in such an acute stage of rehabilitation and that every action I take may be critical to their overall recovery. I expect the patients will have many co-morbidities which will need to be addressed or made aware of prior to treatment. They will possibly be unable to communicate or participate in treatment 100% secondary to their injury or post surgery anaesthetic which means the timing of treatments will be important and also finding other ways to communicate with the patient. This probably involves a lot of work within the multidisciplinary team, like the speech therapist, to determine the best way to communicate. The patients will most likely be surrounded by family members who are very concerned about the patients condition and may not like the treatment be are putting the patient through so communicating with the family and having a family orientated approach will be important. I am also expecting there to be many different protocols regarding the management of the patient I will need to know depending on the surgeon and type of surgery undergone.
Another aspect I am concerned about is the neurological examination. There is just so much to know and it can be quite complex! I think that working on perfecting my speed and technique of testing the cranial nerves, muscle strength, tone, motor control, vestibular function and analysing movements for patients with their various disabilities will be important and hopefully I come out of this prac feeling as though this aspect of my assessment has improved greatly!
I have been told that I will be seeing a wide variety of patients including patients with acute/traumatic brain injuries, cerebral haemorrhaging, cerebral tumours, spinal cord/nerve root compressions and hydrocephalus who have received shunts. I have not worked with this group of patients before and I’m worried if I will be confronted by how young the patients are and if this will affect my ability to treat them. I am also expected to make a 10 minute presentation during these 5 weeks so learning from last time I’d better get on top of that early!
I am no stranger to working within a tertiary hospital, but this one will be the largest hospital I will be attending so far. I think this will mean that I probably won’t get to know the staff as well as I have done in previous placements but hopefully they will be just as approachable and helpful as other hospital staff have been – especially in the first few weeks where I’ll more than likely get lost!
I will be receiving help from a tutor during this placement, which I think will be very helpful. I really enjoyed and appreciated the help I got from my last tutor last year at Joondalup hospital so I know that this one will be very beneficial for neuro.
This placement should be very interesting and it will give me the opportunity to experience life in a big tertiary hospital. Fingers crossed it all goes well!
This anxiety is not so much about not knowing how to act in a hospital setting but it is stemmed by actually working with patients who are in such an acute stage of rehabilitation and that every action I take may be critical to their overall recovery. I expect the patients will have many co-morbidities which will need to be addressed or made aware of prior to treatment. They will possibly be unable to communicate or participate in treatment 100% secondary to their injury or post surgery anaesthetic which means the timing of treatments will be important and also finding other ways to communicate with the patient. This probably involves a lot of work within the multidisciplinary team, like the speech therapist, to determine the best way to communicate. The patients will most likely be surrounded by family members who are very concerned about the patients condition and may not like the treatment be are putting the patient through so communicating with the family and having a family orientated approach will be important. I am also expecting there to be many different protocols regarding the management of the patient I will need to know depending on the surgeon and type of surgery undergone.
Another aspect I am concerned about is the neurological examination. There is just so much to know and it can be quite complex! I think that working on perfecting my speed and technique of testing the cranial nerves, muscle strength, tone, motor control, vestibular function and analysing movements for patients with their various disabilities will be important and hopefully I come out of this prac feeling as though this aspect of my assessment has improved greatly!
I have been told that I will be seeing a wide variety of patients including patients with acute/traumatic brain injuries, cerebral haemorrhaging, cerebral tumours, spinal cord/nerve root compressions and hydrocephalus who have received shunts. I have not worked with this group of patients before and I’m worried if I will be confronted by how young the patients are and if this will affect my ability to treat them. I am also expected to make a 10 minute presentation during these 5 weeks so learning from last time I’d better get on top of that early!
I am no stranger to working within a tertiary hospital, but this one will be the largest hospital I will be attending so far. I think this will mean that I probably won’t get to know the staff as well as I have done in previous placements but hopefully they will be just as approachable and helpful as other hospital staff have been – especially in the first few weeks where I’ll more than likely get lost!
I will be receiving help from a tutor during this placement, which I think will be very helpful. I really enjoyed and appreciated the help I got from my last tutor last year at Joondalup hospital so I know that this one will be very beneficial for neuro.
This placement should be very interesting and it will give me the opportunity to experience life in a big tertiary hospital. Fingers crossed it all goes well!
Subscribe to:
Posts (Atom)
