I can’t believe prac is completely over! The year has gone by too fast.
Mandurah was a fantastic note to end on, I feel that I really experienced true working life, and I loved it!
NATURE: I saw outpatient MSK referrals (as well as a few cardio and stroke patients!!). My supervisor was correct, I think I saw 90% back, neck and shoulder complaints, and about 95% of these were chronic complaints. (It showed me how well versed you need to be in chronic pain management in a community setting). I was involved in many classes, up to 3 a day. It was nice, almost a bit of down time before your next patient.
STRUCTURE: I was very independent!! I even had my own treatment room! My supervisor really left me to do my own thing, but I knew he was just in the next room. If I had a complex patient, needed advice or just wanted to talk through my reasoning he was very approachable.
ROLE: I did see a full caseload, and I feel I worked as if I was a new graduate. Sometimes we saw 9 patients/day including classes. If was great to know I could do it!! And it did involve good time management. The classes were very ‘client run’, we just supervised. The patients attend 8 weeks of class work and running it themselves gives them the confidence and skill to continue to do so independently.
CONCERNS: It was really hard to clinically reason in such a short time frame, but I’m glad I had to do it. It became easier and easier as the weeks went on, and now I have the confidence to do it in the workforce. Generally, as I was writing my patient notes, I had time to clinically reason and reflect on my chosen treatment. If I had missed something I would immediately put it in my plan for the patients next appointment.
All in all, I had a truly fantastic time. This last prac gave me the confidence to know that I can work independently and as part of an allied health team.
Friday, July 23, 2010
MSK week 5
S-I was referred a patient, Miss B, with an acute exacerbation of chronic low back pain. She was in a car crash in 1988 and from that time onwards she has been in constant pain, at the neck, shoulder and low back. She was initially involved in a compensation claim and has been off work since that time receiving a disability pension.
From the first moment I met her I knew she would be a tough patient. Miss B is only 44 years old, yet she walked into the treatment room with a WZF! I think now that this is in an attempt to display her sickness, especially seeing as she didn’t use it correctly. My first question to Miss B was ‘can you show me exactly where your pain is’…her response was ‘L4/L5.’ I couldn’t believe it! Throughout the assessment, many more yellow flags became apparent. She had underlined x-ray findings for me (degeneration at L4/L5, arthritic changes), she was on such a cocktail of pain meds she was unable to drive and had had numerous hospitalizations with CLBP.
In my first treatment session I tried a bit of everything. No movements of the back were relieving whatsoever, even gravity eliminated PT induced. I then tried IFT therapy with a heat pack but even this was aggravating. TENS also had the same effect. I then tried some grade II mobilizations to achieve a pain gate effect. Miss B had to sit in a special pregnancy chair as prone lying was out of the question. Doing these gentle mobilizations turned out to be disastrous. Miss B became so sweaty and was in so much pain she almost threw up. This shook me a fair bit, so I decided to leave her with just gentle pelvic floor contractions. (Even these tugged at her low back). It seemed hopeless.
T-my task was to provide appropriate treatment at her next session.
A-I realized that the above treatments I tried were not the right things for her. I had already recognized that Miss B’s pain was dominated/maintained by psychological factors and so my treatment really should have been directed at her thoughts/feelings and beliefs. So I decided to research pain in an effort to best describe it to her and decrease its threat value.
I re-read the book ‘explain pain’ and summarized what I thought was most important on 2 A4 pages. I booked an hour appointment for her next session and the first half of that we spent just talking about chronic pain and explaining her x-rays. The next half of the session we brainstormed a graduated exercise program. Miss B’s goal is to get back into pilates. Thus we made an 8 day program that encouraged gently re-entry into some basic moves…starting in sitting, moving to side-lie and then on day 7-8, into crook lying (to perform Miss B’s goal of leg slides). On day 8, she made another appointment to see me, and assuming everything goes to plan, we are aiming to start a graduated walking program.
R- Initially Miss B didn’t seem too won over by me. I think I was bit nervous because I didn’t want her to think I was suggesting she was making the pain. (Which she wasn’t…she was DEFINITELY in pain, it almost made her throw up! It’s just that the way she thinks and feels is sustaining this pain). After a while though I eased into it. Miss B seemed to be particularly open to the idea of increased sensitivity. (Having more ‘sensors’ in her low back and a lower threshold for them to fire). She understood the analogy of a car alarm that used to go off normally, and that now goes off when just a bird lands on it. This means that hurting doesn’t mean you are causing re-injury; rather it’s just a throwback to a state of heightened sensitivity.
Miss B left feeling quite excited and ready to take part in her graduated program.
E- I’m beginning to realize that with many patients, what you say can be SO MUCH more valuable to the person than what you do with your hands. It’s amazing, and probably the best tool we have.
STRENGTHS:
-Good preparation. The session would not have been successful otherwise!
-Incorporating Miss B’s goal into the graduated program. This enabled her to get on board with the idea…which I’m sure seemed very foreign to start with.
-Building a good rapport with Miss B, which was essential in order to get her to believe in what I was saying.
-Picking up on what Miss B responded to (pain hypersensitivity), I could then use this throughout the session to keep her on track.
WEAKNESSES:
-I was nervous to start with. I didn’t want Miss B to think I was saying she was making her pain up. My nervousness probably made it even worse to start with! I think next time I’ll practice my spiel on someone first so that I’m more comfortable with how to word things.
-Until I got into the flow of things, my talking may have seemed a bit rehearsed (I had written down all my important points on paper). Hopefully it becomes more natural with practice!
S- Good preparation
- Practice first on somebody I know
- Build a good rapport
- When describing complex concepts, create simple analogy’s to aid understanding
- Find out patient goals and use them to create a meaningful treatment
- Remember to treat what you identify as the cause of the problem
From the first moment I met her I knew she would be a tough patient. Miss B is only 44 years old, yet she walked into the treatment room with a WZF! I think now that this is in an attempt to display her sickness, especially seeing as she didn’t use it correctly. My first question to Miss B was ‘can you show me exactly where your pain is’…her response was ‘L4/L5.’ I couldn’t believe it! Throughout the assessment, many more yellow flags became apparent. She had underlined x-ray findings for me (degeneration at L4/L5, arthritic changes), she was on such a cocktail of pain meds she was unable to drive and had had numerous hospitalizations with CLBP.
In my first treatment session I tried a bit of everything. No movements of the back were relieving whatsoever, even gravity eliminated PT induced. I then tried IFT therapy with a heat pack but even this was aggravating. TENS also had the same effect. I then tried some grade II mobilizations to achieve a pain gate effect. Miss B had to sit in a special pregnancy chair as prone lying was out of the question. Doing these gentle mobilizations turned out to be disastrous. Miss B became so sweaty and was in so much pain she almost threw up. This shook me a fair bit, so I decided to leave her with just gentle pelvic floor contractions. (Even these tugged at her low back). It seemed hopeless.
T-my task was to provide appropriate treatment at her next session.
A-I realized that the above treatments I tried were not the right things for her. I had already recognized that Miss B’s pain was dominated/maintained by psychological factors and so my treatment really should have been directed at her thoughts/feelings and beliefs. So I decided to research pain in an effort to best describe it to her and decrease its threat value.
I re-read the book ‘explain pain’ and summarized what I thought was most important on 2 A4 pages. I booked an hour appointment for her next session and the first half of that we spent just talking about chronic pain and explaining her x-rays. The next half of the session we brainstormed a graduated exercise program. Miss B’s goal is to get back into pilates. Thus we made an 8 day program that encouraged gently re-entry into some basic moves…starting in sitting, moving to side-lie and then on day 7-8, into crook lying (to perform Miss B’s goal of leg slides). On day 8, she made another appointment to see me, and assuming everything goes to plan, we are aiming to start a graduated walking program.
R- Initially Miss B didn’t seem too won over by me. I think I was bit nervous because I didn’t want her to think I was suggesting she was making the pain. (Which she wasn’t…she was DEFINITELY in pain, it almost made her throw up! It’s just that the way she thinks and feels is sustaining this pain). After a while though I eased into it. Miss B seemed to be particularly open to the idea of increased sensitivity. (Having more ‘sensors’ in her low back and a lower threshold for them to fire). She understood the analogy of a car alarm that used to go off normally, and that now goes off when just a bird lands on it. This means that hurting doesn’t mean you are causing re-injury; rather it’s just a throwback to a state of heightened sensitivity.
Miss B left feeling quite excited and ready to take part in her graduated program.
E- I’m beginning to realize that with many patients, what you say can be SO MUCH more valuable to the person than what you do with your hands. It’s amazing, and probably the best tool we have.
STRENGTHS:
-Good preparation. The session would not have been successful otherwise!
-Incorporating Miss B’s goal into the graduated program. This enabled her to get on board with the idea…which I’m sure seemed very foreign to start with.
-Building a good rapport with Miss B, which was essential in order to get her to believe in what I was saying.
-Picking up on what Miss B responded to (pain hypersensitivity), I could then use this throughout the session to keep her on track.
WEAKNESSES:
-I was nervous to start with. I didn’t want Miss B to think I was saying she was making her pain up. My nervousness probably made it even worse to start with! I think next time I’ll practice my spiel on someone first so that I’m more comfortable with how to word things.
-Until I got into the flow of things, my talking may have seemed a bit rehearsed (I had written down all my important points on paper). Hopefully it becomes more natural with practice!
S- Good preparation
- Practice first on somebody I know
- Build a good rapport
- When describing complex concepts, create simple analogy’s to aid understanding
- Find out patient goals and use them to create a meaningful treatment
- Remember to treat what you identify as the cause of the problem
Saturday, July 10, 2010
MSK week 3
S- Mrs A was referred to me with R shoulder pain. After a thorough examination, I concluded she had a R shoulder impingement secondary to poor posture, namely a stiff and stuck thoracic spine (into flexion), protracted and ante-tilted scapulae, and an anteriorly sitting and internally rotated humeral head.
Taking her history, I began to realise she was also very dejected about her shoulder and the treatment she had received. The initial injury occurred 19 years ago (a SS tear). She was put on the waitlist for surgery. After being on the list for so long the surgeon told her it had gone beyond repair, and due to her age etc surgery was no longer an option. She was under the care of GP following this, and seemed to get lost in the system. She said she had been waiting two years to see a physio. She really felt like no one took her problem seriously. She knew it wasn’t going to miraculously recover, but she desperately wanted guidance in things she could do!!
T- Provide appropriate treatment and create a meaningful home exercise program.
A- I spent so long with the assessment I actually had to re-book Mrs A the following day for a treatment session. At this session I decided that my best tool was communication. I needed her to understand how posture causes shoulder pain to have any hope of her getting on board and performing her HEP. Most importantly though, I needed to reassure that her problem was important to me and that I was going to go out of my way to treat her as best I could. If I could get her feeling more positive about the care she received I felt we could make a real difference to her problem.
We spent 20 mins going over shoulder impingement and I made use of skeleton to demonstrate. I then performed a passive physiological in thoracic extension, provided an individualised HEP and referred Mrs A to the upper limb hydro classes.
R- Mrs A was extremely happy to have been listened to, taken seriously and be given the tools to start to take control of her life. At her follow-up appointment, 2 weeks later, she stated that her pain had reduced by up to 80%! And that she had regained function of the arm.
E- I was really amazed at the success Mrs A experienced! I’m not so sure she would experience benefits that rapidly from exercise, but I do think having an understanding of your problem and being given the ability to self-manage would make a huge difference….the power of the mind!! No one had explained any reason for her shoulder pain. Once she had an understanding she could start to control it. She no longer viewed her problem as completely unfixable and ruining her life. I’m sure that positivity changes your pain experience.
I was really proud that I could do that for her. I think it helped that I booked an hour appointment for her following our assessment. I feel that she benefited most from the time I put into education and demonstration and I feel that I communicated this really well.
However, my assessment time management DEFINITELY needs some improvement. I spent so long with her assessment that I needed to re-book her for a treatment session. She did benefit from the extra time I was able to put into her treatment, but I can’t be doing that for every patient I see! What would make everything flow faster and smoother, would be not to perform every single test I know. I need to be more streamlined, right from my initial observations. For example, I only really need to test what I see. Looking at Mrs A’s posture (as described above) the key muscles to test the length of probably would be pecs, infraspinatus and lats. Whereas I tested every muscle around the shoulder/neck. In retrospect this definitely was a time waster, and had no impact on my treatment. I need to know what tests to omit rather than doing every single test I know! I’m hoping this improves with experience.
S- listening!
-education
-communication
These 3 things are, I think, what made my treatment successful, more so than any hands on treatment I could offer. I'm realising how important this is with every patient. You need them to be confident in you in order for them to do any home exercise/self management.
TIME MANAGEMENT! omit those things that are unnecessary to test in order to make my assessment smoother and faster!
Taking her history, I began to realise she was also very dejected about her shoulder and the treatment she had received. The initial injury occurred 19 years ago (a SS tear). She was put on the waitlist for surgery. After being on the list for so long the surgeon told her it had gone beyond repair, and due to her age etc surgery was no longer an option. She was under the care of GP following this, and seemed to get lost in the system. She said she had been waiting two years to see a physio. She really felt like no one took her problem seriously. She knew it wasn’t going to miraculously recover, but she desperately wanted guidance in things she could do!!
T- Provide appropriate treatment and create a meaningful home exercise program.
A- I spent so long with the assessment I actually had to re-book Mrs A the following day for a treatment session. At this session I decided that my best tool was communication. I needed her to understand how posture causes shoulder pain to have any hope of her getting on board and performing her HEP. Most importantly though, I needed to reassure that her problem was important to me and that I was going to go out of my way to treat her as best I could. If I could get her feeling more positive about the care she received I felt we could make a real difference to her problem.
We spent 20 mins going over shoulder impingement and I made use of skeleton to demonstrate. I then performed a passive physiological in thoracic extension, provided an individualised HEP and referred Mrs A to the upper limb hydro classes.
R- Mrs A was extremely happy to have been listened to, taken seriously and be given the tools to start to take control of her life. At her follow-up appointment, 2 weeks later, she stated that her pain had reduced by up to 80%! And that she had regained function of the arm.
E- I was really amazed at the success Mrs A experienced! I’m not so sure she would experience benefits that rapidly from exercise, but I do think having an understanding of your problem and being given the ability to self-manage would make a huge difference….the power of the mind!! No one had explained any reason for her shoulder pain. Once she had an understanding she could start to control it. She no longer viewed her problem as completely unfixable and ruining her life. I’m sure that positivity changes your pain experience.
I was really proud that I could do that for her. I think it helped that I booked an hour appointment for her following our assessment. I feel that she benefited most from the time I put into education and demonstration and I feel that I communicated this really well.
However, my assessment time management DEFINITELY needs some improvement. I spent so long with her assessment that I needed to re-book her for a treatment session. She did benefit from the extra time I was able to put into her treatment, but I can’t be doing that for every patient I see! What would make everything flow faster and smoother, would be not to perform every single test I know. I need to be more streamlined, right from my initial observations. For example, I only really need to test what I see. Looking at Mrs A’s posture (as described above) the key muscles to test the length of probably would be pecs, infraspinatus and lats. Whereas I tested every muscle around the shoulder/neck. In retrospect this definitely was a time waster, and had no impact on my treatment. I need to know what tests to omit rather than doing every single test I know! I’m hoping this improves with experience.
S- listening!
-education
-communication
These 3 things are, I think, what made my treatment successful, more so than any hands on treatment I could offer. I'm realising how important this is with every patient. You need them to be confident in you in order for them to do any home exercise/self management.
TIME MANAGEMENT! omit those things that are unnecessary to test in order to make my assessment smoother and faster!
Saturday, June 26, 2010
week 1 MSK- EBP
S- We are able to access our new patient referrals for the next working day. Checking through Tuesday’s referrals, I noticed I was referred a patient with Achilles Tendinopathy. Her doctor had recommended the ‘Alfredson Eccentric Protocol’ as a potential treatment strategy.
T- I like to prepare for the new patients I see, thus my task was to
a) find out what the Alfredson Eccentric Protocol involves, and;
b) find out if it is beneficial when compared with other treatments for Achilles Tendinopathy.
A- Searching Pedro, I found a systemic review of 8 articles, 4 RCTs and 4 cohort studies. 6/8 articles used the alfredson eccentric protocol, and 2/8 articles used a variation of the alfredson eccentric protocol. The various control groups used the following conventional treatment:
- Surgery
- Pain free concentric exercises
- Pain free stretching
- Night splint
- Night splint with eccentric exercises
R- Alfredson et al. (1998) developed the eccentric traning protocol as follows:
- 3 sets of 15 reps eccentric heel drops 2x/day, 7days/week for 12 weeks
- Work through non- disabling pain
- Progressively add weight
The benefits of the alfredson program above and beyond those of the control groups were as follows:
PAIN:
-In 5/8 studies improvements were seen in both the eccentric and control groups
-Results were on average 34% better the eccentric groups
FUNCTION:
-At 12 weeks function improved an average of 42% from baseline in the eccentric
groups
-The control groups also improved an average of 33% from baseline
As a result, I decided to use the Alfredson eccentric protocol with my patient the following day.
E- Some of the evidence I found was of questionable quality. There were varied ‘control’ groups, most of the studies were not randomized, various different outcome measures were used and various methods of diagnosis were employed.
However, the results were fairly persuasive suggesting that pain enduring eccentric exercise is superior to conventional therapy. From my own knowledge base, I would choose to use eccentric exercise anyway; regardless of what protocol I would be following. Thus, I decided to use the Alfredson protocol.
I feel that preparing for my patient and researching the protocol was a valuable task. It means I am continually learning, staying up to date with research, am able to write back to the doctor letting them know I was on top of what they asked of me and I was able to deliver better quality, evidence based care.
S- Electronic search of databases
-quality checking of articles
T- I like to prepare for the new patients I see, thus my task was to
a) find out what the Alfredson Eccentric Protocol involves, and;
b) find out if it is beneficial when compared with other treatments for Achilles Tendinopathy.
A- Searching Pedro, I found a systemic review of 8 articles, 4 RCTs and 4 cohort studies. 6/8 articles used the alfredson eccentric protocol, and 2/8 articles used a variation of the alfredson eccentric protocol. The various control groups used the following conventional treatment:
- Surgery
- Pain free concentric exercises
- Pain free stretching
- Night splint
- Night splint with eccentric exercises
R- Alfredson et al. (1998) developed the eccentric traning protocol as follows:
- 3 sets of 15 reps eccentric heel drops 2x/day, 7days/week for 12 weeks
- Work through non- disabling pain
- Progressively add weight
The benefits of the alfredson program above and beyond those of the control groups were as follows:
PAIN:
-In 5/8 studies improvements were seen in both the eccentric and control groups
-Results were on average 34% better the eccentric groups
FUNCTION:
-At 12 weeks function improved an average of 42% from baseline in the eccentric
groups
-The control groups also improved an average of 33% from baseline
As a result, I decided to use the Alfredson eccentric protocol with my patient the following day.
E- Some of the evidence I found was of questionable quality. There were varied ‘control’ groups, most of the studies were not randomized, various different outcome measures were used and various methods of diagnosis were employed.
However, the results were fairly persuasive suggesting that pain enduring eccentric exercise is superior to conventional therapy. From my own knowledge base, I would choose to use eccentric exercise anyway; regardless of what protocol I would be following. Thus, I decided to use the Alfredson protocol.
I feel that preparing for my patient and researching the protocol was a valuable task. It means I am continually learning, staying up to date with research, am able to write back to the doctor letting them know I was on top of what they asked of me and I was able to deliver better quality, evidence based care.
S- Electronic search of databases
-quality checking of articles
Friday, June 18, 2010
MSK initial entry
Tomorrow I start my MSK prac at the Community Health Centre in Mandurah.
NATURE: From what I understand I will be seeing MSK patients in an outpatient setting. I spoke with my supervisor yesterday who mentioned that the clientele are generally older and the most common complaints are back and neck pain and shoulder problems. I will also be involved in numerous exercise classes, including; hydro, pulmonary rehab, cardiac classes, tai chi, no falls and diabetes education. From speaking to other students, I may also be required to travel to Pinjarra hospital. I’m not too sure what I would be doing here. Perhaps seeing inpatients and utilizing my experience from previous placements?
STUCTURE: I gather that I will be fairly independent on this placement. I think my day will involve seeing patients who I have booked in, either new referrals or follow up treatments. I will also be involved in the classes and potentially travelling to Pinjarra Hospital.
ROLE: I believe that I will be expected to see a full patient caseload and work as if I am a new graduate given it is our final prac. I’m going to have to prioritize my time very effectively!! I will also be involved in a number of classes. My supervisor mentioned that I am not there to partake in the classes or run them as such; the emphasis is on patients running the class for themselves (so they have the power to continue independently). Thus I will be more of a supervisor during class time.
CONCERNS: I am really excited about this placement; so far MSK is something I’ve enjoyed from the outset. I have had 2 previous MSK based placements and I am looking forward to consolidating my knowledge from these experiences (mainly upper and lower limb type things). I am quite nervous about seeing back and neck pain patients, as it will be new to me. It’s obviously something you need to get right from the beginning, as there is a higher potential for these things to become chronic. Thus I’m going to need to clinically reason appropriately!
I’m also worried about clinically reasoning within a short time frame if I’m expected to see a full caseload. Often it is helpful for me to step outside the room and gather my thoughts in relation to the clinical reasoning outline, this way I can be much more confident of my treatments. If say, I only have half an hour to see a patient I’m going to have to do this as I go…which will be difficult, but also a good challenge!
NATURE: From what I understand I will be seeing MSK patients in an outpatient setting. I spoke with my supervisor yesterday who mentioned that the clientele are generally older and the most common complaints are back and neck pain and shoulder problems. I will also be involved in numerous exercise classes, including; hydro, pulmonary rehab, cardiac classes, tai chi, no falls and diabetes education. From speaking to other students, I may also be required to travel to Pinjarra hospital. I’m not too sure what I would be doing here. Perhaps seeing inpatients and utilizing my experience from previous placements?
STUCTURE: I gather that I will be fairly independent on this placement. I think my day will involve seeing patients who I have booked in, either new referrals or follow up treatments. I will also be involved in the classes and potentially travelling to Pinjarra Hospital.
ROLE: I believe that I will be expected to see a full patient caseload and work as if I am a new graduate given it is our final prac. I’m going to have to prioritize my time very effectively!! I will also be involved in a number of classes. My supervisor mentioned that I am not there to partake in the classes or run them as such; the emphasis is on patients running the class for themselves (so they have the power to continue independently). Thus I will be more of a supervisor during class time.
CONCERNS: I am really excited about this placement; so far MSK is something I’ve enjoyed from the outset. I have had 2 previous MSK based placements and I am looking forward to consolidating my knowledge from these experiences (mainly upper and lower limb type things). I am quite nervous about seeing back and neck pain patients, as it will be new to me. It’s obviously something you need to get right from the beginning, as there is a higher potential for these things to become chronic. Thus I’m going to need to clinically reason appropriately!
I’m also worried about clinically reasoning within a short time frame if I’m expected to see a full caseload. Often it is helpful for me to step outside the room and gather my thoughts in relation to the clinical reasoning outline, this way I can be much more confident of my treatments. If say, I only have half an hour to see a patient I’m going to have to do this as I go…which will be difficult, but also a good challenge!
Saturday, June 12, 2010
final entry cardio
NATURE: The nature of our placement ended up being a bit all over the place! We were actually situated on MANY wards as during our 5 weeks as so many of the staff were either sick or on holidays...so Chris and I had to fill the gaps. It meant that we saw patients from gen med wards, hematology and oncology, ICU, Cariothoracics and rehab wards!! Even though going up and down the stairs so often was frustrating (and hard work on the legs!!), it meant we got to experience such a wide variety of patients and situations. I would now feel confident in any situation on a ward!
The peer-coaching model worked really well. Working with Chris in the first week really put me at ease. It meant I wasn't as nervous as I could have been seeing our first ever ward patients. We broke it down well, with one of us doing the subjective assessment and the other doing the objective assessment. This way the patient only had to listen to one person, and the other student could watch and then give very valuable feedback. This is great, because your supervisor can't be with you all the time, and getting feedback from a third party is often what you need to improve. In the second week, Chris and I saw our own patients and I felt much more confident after a week of peer work. And, we DID run the ward in our last week. It was flat out, exciting and a great learning curve. Your time management has to be PERFECT!
STRUCTURE: The structure was as I initially thought. Seeing patients on the ward daily who are flagged as needing physio reviews/treatments. It was difficult to fit in around the other health professionals. Patients constantly have procedures to go to etc. But having so many patients meant there was always someone else you could see. As long as I prioritised my patient list and didn't miss any urgent priorities, my day ran fairly smoothly.
ROLE: My role really was as a colleague to my supervisor. With all the staffing issues Chris and I were running a ward by the end of our placement. Without us there I think many patients would have missed and I feel like our help was really appreciated!
CONCERNS: There were many sick people on prac, and it was overwhelming. But I think I managed it well. In the acute stages of illness/recovery you do see rapid improvements, so there was a lot of hope involved with many of the patients. Also, knowing I was on such a strict time schedule helped. At Shenton Park I sometimes had up to 3 hours with people, which was emotionally draining. I think that at Freo, I managed my patient list well and didn't let myself become too emotionally involved.
Oh my god. The attachments were so daunting! I was right to be concerned! I couldn't believe how many tubes and lines could be in one person! We were very lucky in seeing some surgery patients with our tutor. She talked us through all the attachments, and when you have done it once, it is much less scary the next time! Also, if I was ever unsure, I just asked the nursing staff. They mobilise people to the bathroom etc daily and probably have the BEST understanding of attachments and what can be moved/unplugged etc. I've decided no question is too silly!
My take home message: I thoroughly enjoyed working at Freo, but I don’t know if it’s something I would want to do forever. I found that in ICU my time was really warranted and people really needed chest physio. However, up on the general med wards, I constantly found myself taking people for walks and going through deep breathing cycles. For all that we need to learn at uni, I was a bit disappointed at our limited scope in practice.
BUT…for the people that did really need me, it was very rewarding. I think that as a student you should take every opportunity in the hospital. I always jumped at any chance to go down to ICU/cardiothoraics and try and experience every facet of hospital life. It meant that I was exposed to suction, MHI/VHI and other techniques that are used less frequently on the ward. It also meant that I could really fine-tune my cardio assessment skills to every type of patient. It really is so important to have your assessment skills down pat. You use the same assessment for every patient and having it together perfectly means you can best come up with a problem list and justify your reasons for specific treatments. (Also, the same recipe won’t work for every one. Assessing correctly allows you to cater to the individual.)
Lastly, from the moment a patient is admitted, hospital becomes all about when they can leave and how we can best prepare them for this. I realized that discharge planning is often the most important aspect of our treatments, and it should be on your mind from the first assessment with your patient. It is so important, and good discharge planning should keep patients from being re-admitted. Thus, we should all do our best to familiarize ourselves with the services out there so as to provide the optimal care for our patients.
The peer-coaching model worked really well. Working with Chris in the first week really put me at ease. It meant I wasn't as nervous as I could have been seeing our first ever ward patients. We broke it down well, with one of us doing the subjective assessment and the other doing the objective assessment. This way the patient only had to listen to one person, and the other student could watch and then give very valuable feedback. This is great, because your supervisor can't be with you all the time, and getting feedback from a third party is often what you need to improve. In the second week, Chris and I saw our own patients and I felt much more confident after a week of peer work. And, we DID run the ward in our last week. It was flat out, exciting and a great learning curve. Your time management has to be PERFECT!
STRUCTURE: The structure was as I initially thought. Seeing patients on the ward daily who are flagged as needing physio reviews/treatments. It was difficult to fit in around the other health professionals. Patients constantly have procedures to go to etc. But having so many patients meant there was always someone else you could see. As long as I prioritised my patient list and didn't miss any urgent priorities, my day ran fairly smoothly.
ROLE: My role really was as a colleague to my supervisor. With all the staffing issues Chris and I were running a ward by the end of our placement. Without us there I think many patients would have missed and I feel like our help was really appreciated!
CONCERNS: There were many sick people on prac, and it was overwhelming. But I think I managed it well. In the acute stages of illness/recovery you do see rapid improvements, so there was a lot of hope involved with many of the patients. Also, knowing I was on such a strict time schedule helped. At Shenton Park I sometimes had up to 3 hours with people, which was emotionally draining. I think that at Freo, I managed my patient list well and didn't let myself become too emotionally involved.
Oh my god. The attachments were so daunting! I was right to be concerned! I couldn't believe how many tubes and lines could be in one person! We were very lucky in seeing some surgery patients with our tutor. She talked us through all the attachments, and when you have done it once, it is much less scary the next time! Also, if I was ever unsure, I just asked the nursing staff. They mobilise people to the bathroom etc daily and probably have the BEST understanding of attachments and what can be moved/unplugged etc. I've decided no question is too silly!
My take home message: I thoroughly enjoyed working at Freo, but I don’t know if it’s something I would want to do forever. I found that in ICU my time was really warranted and people really needed chest physio. However, up on the general med wards, I constantly found myself taking people for walks and going through deep breathing cycles. For all that we need to learn at uni, I was a bit disappointed at our limited scope in practice.
BUT…for the people that did really need me, it was very rewarding. I think that as a student you should take every opportunity in the hospital. I always jumped at any chance to go down to ICU/cardiothoraics and try and experience every facet of hospital life. It meant that I was exposed to suction, MHI/VHI and other techniques that are used less frequently on the ward. It also meant that I could really fine-tune my cardio assessment skills to every type of patient. It really is so important to have your assessment skills down pat. You use the same assessment for every patient and having it together perfectly means you can best come up with a problem list and justify your reasons for specific treatments. (Also, the same recipe won’t work for every one. Assessing correctly allows you to cater to the individual.)
Lastly, from the moment a patient is admitted, hospital becomes all about when they can leave and how we can best prepare them for this. I realized that discharge planning is often the most important aspect of our treatments, and it should be on your mind from the first assessment with your patient. It is so important, and good discharge planning should keep patients from being re-admitted. Thus, we should all do our best to familiarize ourselves with the services out there so as to provide the optimal care for our patients.
Thursday, June 10, 2010
week 5 cardio-treatment
STARES
S- Mrs C is a 63 year old lady admitted to the ward with ?pneumonia. She also has a 30-year history of bronchiectasis, which she has managed well throughout her life. Her husband passed away 2 years ago and she admits he played a large role in her care. He built a makeshift tilt table and percussed her chest daily to help her secretion removal. Since being in hospital, Mrs C’s secretions have increased. She feels that being out of her daily rhythm fatigues her and decreases her ability to self manage.
My assessment found the following asterisk signs, moist cough++, widespread scattered wheeze (low pitched) throughout lung field R>L, coarse expiratory crackles R LL. So, I concluded impaired airway clearance to be her major problem.
T- I had to plan an appropriate treatment session to best cater to Mrs C.
A-Firstly, I decided to ask Mrs C how she would usually manage her secretions…with a 30-year history of bronchiectasis I assumed she was fairly well versed in self-management.
Mrs C informed me that her husband percussed her chest daily on a tilt table they had made together. She stated this was the best thing for her and related her husband’s death to her now more frequent hospital admissions. She said she was most productive in prone lying with two pillows under her chest.
With this information on board I developed the following treatment plan.
1. Ambulation to encourage deep breathing (via demand ventilation principal) to hopefully begin to mobilise secretions in the lower lobes.
2. Percussions in L side lying, 2 pillows under chest and 30 degrees of head down tilt.
3. Mrs C performed ACBT cycles throughout (I had taught her previous to ambulating)
4. Percussions in prone lying, 2 pillows under chest with 30 degrees of head down tilt and ACT cycles.
-Throughout the treatment I continually asked Mrs C how she was going, if I was doing it correctly/with enough pressure, and when she felt she had had enough.
R-I feel that our first treatment session went really well. Mrs C was productive of about 10x M2P2 sputum plugs and stated that, although tired, she felt much better afterwards.
E- STRENGTHS:
-By asking Mrs C what she usually did enabled us to build a strong rapport. She instantly knew that I wanted to listen to what she had to say in regards to what has been successful for her in the past.
-I incorporated what Mrs C suggested as well as some new ideas (walking first to mobilise secretions, L side-lying as position 1 ad utilising the ACBT throughout treatment). I feel that my choice of treatments were very effective because I had clinically reasoned to justify them.
-I was safe in all treatments, ensuring to ask all relevant C/I and precautions for percussion and GADP. Mrs C was clear of anything that may have contraindicated the treatments. She had had an abscess removed from her brain over a year ago, which I felt was not recent enough to exclude head down tilt as a treatment option.
WEAKNESS
-I used auscultation as my asterisk sign and re-measured this after treatment. However, I also think monitoring her sats throughout treatment would have been wise. I could have monitored for improvement as well as ensuring she could cope from a respiratory sense with the treatments.
-I think my hands-on treatment was appropriate as an inpatient, but I needed to think to d/c planning from the moment I met her. Obviously she can’t continue percussions at home (and her husband passed away 2 years ago meaning he can no longer help her out). My supervisor suggested calling silver chain. They can go to her home 3x/week for hands-on chest physio. All I had to do then was think of something she could do independently. (We decided upon walking first, then performing ACBTs, using bubble pep during the TEE’s.)
S- LISTENING! I think the biggest help in my treatment was asking my patient what worked for her. People have to manage their own chronic disease and so obviously know the best strategies.
-Think to discharge planning from the first meeting. This makes their whole hospital stay smooth and ensures they can cope when they return home.
-Create a good problem list! From this, it is very easy to clinically reason appropriate treatment.
-Check all C/I’s and precautions.
S- Mrs C is a 63 year old lady admitted to the ward with ?pneumonia. She also has a 30-year history of bronchiectasis, which she has managed well throughout her life. Her husband passed away 2 years ago and she admits he played a large role in her care. He built a makeshift tilt table and percussed her chest daily to help her secretion removal. Since being in hospital, Mrs C’s secretions have increased. She feels that being out of her daily rhythm fatigues her and decreases her ability to self manage.
My assessment found the following asterisk signs, moist cough++, widespread scattered wheeze (low pitched) throughout lung field R>L, coarse expiratory crackles R LL. So, I concluded impaired airway clearance to be her major problem.
T- I had to plan an appropriate treatment session to best cater to Mrs C.
A-Firstly, I decided to ask Mrs C how she would usually manage her secretions…with a 30-year history of bronchiectasis I assumed she was fairly well versed in self-management.
Mrs C informed me that her husband percussed her chest daily on a tilt table they had made together. She stated this was the best thing for her and related her husband’s death to her now more frequent hospital admissions. She said she was most productive in prone lying with two pillows under her chest.
With this information on board I developed the following treatment plan.
1. Ambulation to encourage deep breathing (via demand ventilation principal) to hopefully begin to mobilise secretions in the lower lobes.
2. Percussions in L side lying, 2 pillows under chest and 30 degrees of head down tilt.
3. Mrs C performed ACBT cycles throughout (I had taught her previous to ambulating)
4. Percussions in prone lying, 2 pillows under chest with 30 degrees of head down tilt and ACT cycles.
-Throughout the treatment I continually asked Mrs C how she was going, if I was doing it correctly/with enough pressure, and when she felt she had had enough.
R-I feel that our first treatment session went really well. Mrs C was productive of about 10x M2P2 sputum plugs and stated that, although tired, she felt much better afterwards.
E- STRENGTHS:
-By asking Mrs C what she usually did enabled us to build a strong rapport. She instantly knew that I wanted to listen to what she had to say in regards to what has been successful for her in the past.
-I incorporated what Mrs C suggested as well as some new ideas (walking first to mobilise secretions, L side-lying as position 1 ad utilising the ACBT throughout treatment). I feel that my choice of treatments were very effective because I had clinically reasoned to justify them.
-I was safe in all treatments, ensuring to ask all relevant C/I and precautions for percussion and GADP. Mrs C was clear of anything that may have contraindicated the treatments. She had had an abscess removed from her brain over a year ago, which I felt was not recent enough to exclude head down tilt as a treatment option.
WEAKNESS
-I used auscultation as my asterisk sign and re-measured this after treatment. However, I also think monitoring her sats throughout treatment would have been wise. I could have monitored for improvement as well as ensuring she could cope from a respiratory sense with the treatments.
-I think my hands-on treatment was appropriate as an inpatient, but I needed to think to d/c planning from the moment I met her. Obviously she can’t continue percussions at home (and her husband passed away 2 years ago meaning he can no longer help her out). My supervisor suggested calling silver chain. They can go to her home 3x/week for hands-on chest physio. All I had to do then was think of something she could do independently. (We decided upon walking first, then performing ACBTs, using bubble pep during the TEE’s.)
S- LISTENING! I think the biggest help in my treatment was asking my patient what worked for her. People have to manage their own chronic disease and so obviously know the best strategies.
-Think to discharge planning from the first meeting. This makes their whole hospital stay smooth and ensures they can cope when they return home.
-Create a good problem list! From this, it is very easy to clinically reason appropriate treatment.
-Check all C/I’s and precautions.
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