Fourth Year - Rotation 4 - Communication STARES

Situation:
I was asked to review and mobilise a 70 year old male patient who was admitted to hospital 2 days ago with an acute exacerbation of chronic COPD and also for an ACAT review. This patient currently lives in a shared 22 stepped boarding house with nine other males, uses 2 litres home oxygen constantly throughout the day and previously refused moving to low-level care after his previous hospital admission 4 weeks ago for another acute exacerbation of COPD. This patient recently could not move for 4 days secondary to increased pain and shortness of breath and decided to succumb to moving into a low-level or high-level facility.

Task:
After an initial subjective history had been taken and relevant observations were made, I had to check this patient’s mobility. In order to qualify for a low-level care facility, the patient is required to ambulate independently 50 metres at least.

Action:
The patient complained of being too tired and refused to go for a walk after the subjective interview and chest examination. When asked if he felt short of breath in his seated resting position he answered “Yes” and when asked to rate his shortness of breath out of 10 with 0 being where your breathing is causing you no difficulty at all and 10 being where your breathing difficulty is maximal, he replied with “Seven”. This patient was not heavily breathing nor showing any signs of respiratory distress. His SpO2 was being maintained at 97% on 2LO2 via NP and when questioned, he stated that this level of breathing for him was ‘normal’. I explained to him that 7/10 on this particular scale would be equivalent to saying his breathing was “very severe” and he said, “No, it is not that bad” but would not give me another numerical value for his own perceived breathlessness. We eventually got up for the walk and whenever questioned about his shortness of breath on the Borg Scale he would always say “seven”. During the walk, his SpO2 did decrease, his breathing became heavier and he increased the use of his accessory muscles and upper limb support when breathing. He did not want to take a rest through the walk and was extremely short of breathe and physically drained after the 30 metre walk.

Result:
Due to a miscommunication of the Modified Borg Scale, I was unable to properly determine the patient’s dyspnoea changes during the walk. He was in a rush the whole time and did not understand the importance of this ambulation assessment. He was more interested in going too the toilet and returning to bed as fast as possible. This made it very difficult to get him to slow down and monitor how far he could walk before his dyspnoea started affecting him too much and thus made the walk assessment useless and it needed to be repeated the following day after the patient had adequate rest.

Evaluation:
My explanation of the Modified Borg Scale was not too poor but I don’t think I highlighted the importance of the mobility assessment adequately for the patient to take it seriously. I believe that without a visual guideline of the scale, this patient was unable to break the scale down into 10 and just said 7 every time as he wanted me to either leave him alone and/or though that 7 was what I wanted to hear. As a result, the mobility assessment was useless for this day as I know that he had the capability to walk a lot further and qualify for low-level care. I had to use other visual and non-verbal feedback to determine how hard the walk was for him.
The next time I visited him I knew I would have to repeat the assessment but firstly explain to him in why we needed to see how far he could walk and at the same time monitor his dyspnoea. I planned to print out a copy of the Borg scale so he would be able to have a visual guide of what each number stood for.
This situation taught me the importance of explaining to a patient why we need to do these assessments and also that some patients find it difficult to understand how to use a 0 to 10 scale.

Strategies:
Use a print out of the Borg Scale (like this one - http://www.pulmonaryrehab.com.au/pdfs/resourcesPatient%20Assessment_BorgScale.doc)
Explain that the assessment is not just for the physio but also important for planning their discharge out of the hospital.
I discussed this problem with my supervisor and she agreed that the best option was to provide a handout sheet of the scale and also reminded me that this scale is very subjective to the patient so he may only be getting to 7/10.

Fourth Year - Rotation 4 - Cardiorespiratory Initial Entry

So we’ve hit the home stretch! I’m starting my final placement tomorrow but I’m not as nervous going out on prac this time around. I think this may be because I really enjoyed studying cardio during the last few years so hopefully it will be just as enjoyable practically! In my last placement, I was lucky enough to experience some cardio-respiratory jobs such as suctioning through a trachy and neuro tactile stimulation techniques and I have to admit that clearing airways was one of my highlights at SCGH. I do not think that Cardio in Fremantle Hospital will be easy though. There are so many aspects to cover in cardio and I don’t know if I will be seeing ICU patients or post surgery patients or general medical cardio/thoracic patients. Will I be dealing with acute cases where monitoring blood gases will be very important or will I be helping maintain airways with breathing cycles and sputum clearing techniques? I’m very keen to use the techniques we’ve learnt over the last 3 years at uni and increase my knowledge on this subject which I have a lot of interest in.

My expectations for this placement include doing a lot of auscultating and being able to interpret the results and choose the correct treatment. I’m not too sure on what patients I will be seeing so I could be expected to perform a variety of treatments including mobilising the patient, teaching deep breathing exercises, suctioning, drainage/ventilation positioning, vibes/percussion, ‘bagging’ a patient or even just monitoring a patient’s O2 sats.

This hospital is another tertiary hospital like SCGH so I’m expecting the same busyness of a big hospital. I’m glad to be working again in a multidisciplinary team as I enjoy the interaction between the allied health teams and also going on ward rounds. Maybe I’ll even get to see some cardio surgery!

Concerns I’m having at the moment are my auscultation skills and interpretation of specific tests such as ECGs and ABGs. From previous placements, I’m fairly happy with my interpretation of thoracic X-Rays but I think on this placement I’ll be seeing a lot more complex cases. This will be interesting to listen to and then compare what I hear to the X-Rays. Improving my timing of assessments and treatments has been a person goal for myself for this whole year and I will continue aiming towards developing a speedy yet thorough examination of my patients on this prac. Other concerns include remembering precautions for specific surgeries and diseases, being safe when ambulating a patient for the first time post op, being able to explain exercises in simple terms and clearly for the patient and also just having enough treatment and general knowledge for this placement.

Over the last three placements I have found I’ve learnt best when someone’s demonstrated the task first then watched me perform it. I’ll be informing my supervisor of this so hopefully they’ll take it into account so I can get the best learning experience I can from this prac!

I’m really excited about starting tomorrow and having a blast over the next 5 weeks!
Let’s hope this last prac is just fun and challenging as the last 3!

Rotation 3 - Neuro - Final Entry

Wow! Another 5 weeks already!

 

This prac has probably been the most difficult prac to get ‘into the swing of things’. Whether or not this was due to my sickness during weeks 2 and 3 or if every student finds neurosurgery hard to get their head around in the first couple of weeks, I don’t know.  It was only after my head cleared from the virus at the beginning of week 4 that I really started enjoying this prac and everything started to smooth out. By the end of this prac though, I can honestly say I really had a great time in neurosurgery! It was a lot different than I imagined 5 weeks ago.

Dealing with patients in this acute state was a bit daunting – especially those whose GCS wasn’t 15/15. However, I found the most rewarding and inspiring cases to my physio career so far – getting people to move again. One specific case was working with a patient who had a very complicated SAH and various failed surgeries to deal with it. When I first met her, she had no movement anywhere, had a trachy insitu and struggled to keep eyes open during treatment let alone actively participate. By the end of this prac we were in the process of weaning her off her trachy, she had active movement in the right upper and lower limbs, I had heard her voice through a speaking valve and we were planning to decannulate her on Monday. This may seem not much to some people, especially coming from a musculoskeletal placement, but seeing the little yet functional improvement and joy in the patient’s eyes really made me appreciate my work as a physio.

Dealing with patient’s co-morbidities were slightly more complex than any other placement I have been on as with the risk of vasospasm and other acute surgical issues, we had to tread carefully around some patients and outright not see them for the first few days until they had the all clear.

Communication was something I worked on a great deal as I was presented with a couple of dysphasic patients. Using tactics from each case I dealt with helped me from getting frustrated with the inability to communicate properly.

Working within a multidisciplinary team again was lovely! Let me just say I have a new appreciation for speech therapists with this whole trachy business! During this prac, I was able to observe one of the SP work with one of my patients and I found out that they’re not only about correcting a stutter or lisp!

Another one of my concerns was my assessment abilities but after going over it with my tutor, supervisor and also practicing it on various patients I think I am confident with my technique and timing! – this was a personal goal for myself and every placement I’ve been on this year.

 

Working in this big tertiary hospital was a bit scary and I felt so lost so many times! Also as the hospital was so big and there were so many physios and students I never felt at home there like I have in other placements. This is what I expected anyway but I do prefer smaller hospitals and the ‘closeness’ of it all.

 

My tutor was possibly the most useful person in the last 5 weeks! I got so much out of her and the techniques I learnt I will be putting into practice forever! Although this placement and my tutor was very Bobath purest and this was slightly frustrating as at uni we have been taught if they can do the movement with compensatory techniques then let them do it! Unlike the Bobath theory where they have to be able to perform the movement with perfect technique before being allowed to do the task.

 

I learnt a great deal from this placement and wish I could’ve spent another few weeks there just to fine tune everything. It’s a shame it took until week 4 to really get into the prac but I’ve had amazing experiences here which have made me appreciate our profession a lot more! Suctioning a patient was a highlight of this placement and I look forward to using this technique a lot more in my cardio placement next!

Fourth Year - Rotation 3 - Analysis and Planning STARES

Situation

On the 03/06/10, a 71 yr old male presented to this hospital with an intramedullary cervical spine lesion. On the 02/06/10, he had a C5-C7 laminectomy and subtotal resection of the intramedullary tumor. Day 1 post-op, the patient currently presents with signs of Brown-Séquard Syndrome – left sided weakness in both upper and lower limbs, decreased sensation in the right lower limb, decreased proprioception in the left lower limb – as well as having allodynia in the left lower limb and jerky spontaneous movements in the right lower limb.

This patient experienced a fall 6 months ago and several falls thereafter. The falls were due to being unsteady during gait. He also reported pins and needles on bilateral upper limbs and unable to feel his left thigh. He attended falls classes in another hospital and was given a walking stick to assist with his ambulation. He was then referred for a MRI that revealed the intramedullary tumor.

The patient currently lives with his wife in a level house with 1-2 steps internally and 6 steps outside with nil rails or equipment. Prior to the falls 6 months ago, this patient was independent with ambulation but now ambulates independently with a walking stick. Previously the patient was independent with all activities of daily living and personal care but recently began having difficulty with these tasks secondary to deteriorating function in his limbs. He also used to run his own clock fixing/making business and occasionally still helps son who has now taken over the trade.

 

Task

To complete an analysis and treatment plan for this patient post assessment.

 

Action

After my thorough assessment:

 

“ OBJECTIVE:

                General: obs stable. PCA, IDC, flowtrons, drain and nasal prongs insitu. Pt appears alert, found in RIB.

                Conscious State: GCS 15/15. Pt able to identify correct TÖ PÖ PÖ

                Chest: Ausc à good AE t/o. Cough à strong, dry, non-productive

                ROM: full PROM (L) and ® UL and LL

                Voluntary movement/strength: nil movement of (L) LL, UL shoulder flexion and abduction (L) = ®, elbow flexion (L) = ®, decreased (L) wrist extension and flexion strength, decreased (L) AROM finger flexion/extension and decreased grip strength on (L). ® LL and UL NAD AROM and strength.

                Tone/Abnormal posture: 3 second fatigable clonus in (L) calf. Increased resistance into hip and knee flexion which eases with repetitive movements. Nil increased tone in limbs at rest.

                Sensation/Proprioception: Hypersensitive and allodynia in (L) LL. Decreased sensation on ® LL to light touch and sharp/blunt. Decreased proprioception jt motion and jt position on (L) LL. ® UL decreased light touch sensation in fingers 3&4.

                Function: Bed mobility with 1 X min assist. Lie to sit with 1 X min assist. STS with 2 X max assist to wzf. Transfer bed to w/c with 1 X mod assist with pivot t/f. Ambulation unable.

                Balance: Sitting à pt fixes on ® side and has decreased wt shift on ®. Balance is also compromised with ® LL’s jerky spontaneous movements. Pt is unable to sit upright without 2 X assist support for ® LL and trunk support      ”

 

I put together an analysis of this patient’s impairments, activity limitations and possible participation restrictions he might experience.

 

ANALYSIS:

            Impairments:

1.      altered sensation bilateral lower limb

2.      decreased proprioception left lower limb

3.      decreased strength left side

4.      decreased voluntary movement left side

            Activity Limitation:

1.      manipulation of objects/gripping objects with upper limb secondary to decreased voluntary movement and strength

2.      independent bed mobility secondary to decreased left lower limb strength, decreased voluntary movement left lower limb, decreased proprioception left lower limb and decreased sensation of the right lower limb

3.      independent sitting secondary to decreased left trunk strength, reduced sensation to the right lower limb and decreased proprioception to the left lower limb

4.      independent sit to stand secondary to reduced lower limb sensation on the right, reduced proprioception on the left lower limb, reduced left lower limb strength, reduced left trunk side strength and reduced voluntary movement left lower limb

5.      independent standing secondary to reduced lower limb sensation on the  right, reduced proprioception on the left lower limb, reduced left lower limb strength, reduced left trunk side strength and reduced voluntary movement of the left lower limb

6.      transferring wheelchair to bed independently secondary to reduced lower limb sensation on the right, reduced left lower limb proprioception, reduced left lower and upper limb strength, reduced left trunk side strength and reduced voluntary movement to the left lower limb

7.      independent ambulation secondary to reduced right lower limb sensation, reduced left lower limb proprioception, reduced left lower limb strength, reduced left trunk side strength and reduced voluntary movement of the left lower limb

            Participation Restriction:

1.      doing up buttons to get dressed independently

2.      shopping for groceries independently

3.      walking a dog

 

To work out the patient’s goals, I approached the patient and we discussed short term and long term goals which we could work on through rehabilitation. His main goals was to become independent in activities again as he was quite annoyed about the fact that prior to 6 months ago he was fully independent and supporting his family. With his treatment sessions, my interventions therefore tailored to the short term and long term plans discussed below. The plans identified are directed to getting this patient more independent with all activities with functional exercises or strengthening up and activating the muscles required for these tasks.

 

PLAN:

            Short term goal:

1.      Independent sitting balance on plinth for 1 min in 1/52

·        In sitting, practice weight shift to right, reaching up to the right with approximation through the right pelvis to elongate right side, going down onto right elbow and return to midline, compression through bilateral lower limbs knee/ankle to feel for ground, dissociate trunk/pelvis movements with facilitation while relaxing the right side and then combining the movement with reaching to right.

2.      Independent pivot transfer bed to wheelchair in 1/52

·        Mini raises off plinth à reach with right upper limb. Practice guided pivot transfer in 2 steps à 1 step à reduce assistance

3.      Have active hip and knee extension in 2/52

·        Left lower limb facilitation into extension in supine and sitting, closed chain exercises in crook lying with physiotherapist providing compression onto left knee and right lower limb positioned further down. Sit to stand practice and mini squats in standing with 3 assist à decrease assist

            Long term goal:

1.      Independent static standing balance for 30 seconds in 3/52

·        Bilateral foot mobilisations. Hip/knee extension as above and left sided trunk facilitation as above also. Patient in supported standing with bolster in front for upper limb support and 3 assist – 1 for left lower limb alignment and hip facilitation, one for right lower limb approximation and to encourage weight to the right, and one for trunk support. Weight shift side to side in standing. Reduce assist but make sure the patient has the correct alignment hip and knee. Decrease the base of support of the upper limb on the bolster and finally remove the bolster.

2.      Ambulate with 1 X assist with pulpit frame for 10m in 3/52

·        As above for standing. With weight shift practice taking one step forward and backwards with weight shift side to side and followed by forward and backwards weight shift. Assist needed for left lower limb movement and to encourage weight shift. Start with 3 assist à reduce assist.

 

Result

With the impairments and plan identified, I was able to easily target every treatment session appropriately with a goal in mind. With each exercise I was able to explain to the patient why we were doing these exercises and this gave the patient extra enthusiasm for the treatments.

 

Evaluation

I believe I identified all main impairments and suitable activity limitations which aided with planning treatments and exercises for this patient. Also working in collaboration with the patient we were able to come up with goals that not only helped myself with planning treatments but also got the patient involved with the sessions. Although we have been told numerous times throughout our uni course to make all treatments patient orientated, I now appreciate how explaining to the patient why we are doing each exercise to target specific goals influences their willingness to take time out of their day for rehabilitation. By taking this tactic with all patients who had enough cognitive skills and communication abilities to discuss goals, I found this very useful in getting patients to participate in treatments.

 

Strategies

Establish early on that you are there to help the patient with their own goals.

With every exercise, direct them towards why they are doing the exercise.

Always refer to their goals and the improvements they make towards the goals.

Keep goals SMART! Simple measurable achievable realistic and timely.