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
Saturday, June 26, 2010
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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