S-We work on the Gen Med ward in the mornings, seeing patients with a variety of conditions. On Thursday we were to see a lady, Mrs A, admitted for increased SOBOE. From reading her notes we were able to ascertain that she had a history of COPD (despite never smoking) and a severe thoracic scoliosis. The doctors impressions on admission were ? exacerbation of COPD, ? worsening thoracic scoliosis. We then had a look at her x-ray and saw that her scoliosis certainly was severe, and was causing a marked reduction in her lung volumes, and could well be the reason for her dyspnoea. Looking at her blood results, she had no signs of infection, making an exacerbation of COPD less likely in my mind.
On further reading, we discovered that english was her second language and communication was difficult. She also lives alone on home oxygen (plus she is a CO2 retainer, meaning we had to be careful with oxygen levels), is short of hearing (wears bilateral hearing aids) and has 2 very supportive children.
T- Mrs A was flagged for chest physio, and our task was to conduct an initial respiratory assessment and come up with an appropriate treatment plan.
A-We entered Mrs A's room not really knowing what to expect. It soon became clear she had much difficulty understanding more complex sentences and questions. Luckily her daughter was in the room and I looked to her to help answer my questions. We went through a very thorough subjective and objective assessment, utilising Mrs A's daughter to answer questions.
We gathered very good information, and on putting the 2 assessments together we soon realised that her chest was not the main issue at play. Mrs A's scoliosis was severely restricting her ability to take deep breaths and was almost completely closing down on the right lung. This is a structural problem and something that Chris and I realised we can have little effect on. Rather than leaving it there however, we decide to follow up on the other concerns voiced by Mrs A and her daughter.
1.Mrs A mentioned she has just started choking when she drinks water, thus we decided to refer her to the speech pathologist with the thought she may need to be on thickened fluids?
2.Secondly, Mrs A's daughter mentioned that she and her brother were taking it in turn to stay the night at Mrs A's house. They felt she couldn't be alone because she couldn't hear the alarm on her oxygen tank when it signalled it was empty. This had been going on for 5 months at the expense of their own families! They were also currently doing all house-work, cooking, gardening etc and were finding it too much to integrate with their own lives. Their mother did not want to go to a nursing home, and they loved and respected her wishes, but they also identified that they needed some form of help. Chris and I referred Mrs A and her family to the wards social worker, to have a family meeting and discuss the services and options available to them.
3.Lastly, Mrs A previously walked with no aid, no more than 10 steps before she need to rest. Chris and I decided to test her out on a 4WW. This had so many benefits! She could fix her UL making her shoulder girdle available to be an accessory for breathing, she could sit on the walker if she needed to rest, and she could attach her O2 bottle to the frame for any outside trips! With the 4WW she was able to walk 3 times as far as her pre-morbid distance!
R-As a result of our extensive and thorough subjective questioning, Mrs A was referred to the correct departments and proper discharge planning could begin. I think we highlighted the crux of her problems and were able to get appropriately managed. I feel her diagnosis became more acopia, and we were the ones who were able to pick this up!
E-I was so happy with the result of our assessment. I think that as a first or second year student, I would have left the assessment thinking there was little I could do from a respiratory point of view-and felt that thus my job was done. Now, (as an almost graduate!!) I realise that there are so many aspects that go in to someone's discharge, not just physio. Our questioning flowed really well and as a result we could highlight the gaps in her care and refer her down the appropriate path. We were the first people to identify these gaps and I really feel it was because we built a rapport with her daughter and asked the right questions in the right order. For me, this case really highlighted the importance of the MDT and I feel that now it is something that will be in mind for every patient I see. Just because I can't do too many things to help there and then doesn't mean I don't know of people who can!
The weakness I identified, was that once I knew who she needed to see, I didn't really know how to go about it. I think that this is something that will come with experience and learning the certain procedures and protocol on my ward. I shouldn't be afraid to ask, because once we found out how to contact the speechy ad SW, they were more than happy to see Mrs A that day!
S-The strategies we used were
COMMUNICATION
-Involvement of Mrs A's daughter who could help translate
-Clear and slow voice when speaking to Mrs A, for ease of understanding and in recognition of her hearing loss
-If instruction were given to Mrs A, we asked for confirmation of understanding from her and her daughter
-Much use of body language and demonstration, particularly with using the 4WW (brakes, sitting to rest etc)
INVOLVEMENT OF THE MDT TEAM!!
-recognition of issues that can't be addressed by physio and appropriate referral to combat these.
Saturday, May 15, 2010
Sunday, May 9, 2010
week 1 cardio
Tomorrow I start my cardio prac at Fremantle hospital. Im really nervous as it will be my first experience in an inpatient setting in a large hospital! But I am also feeling excited as cardio is a subject I thoroughly enjoyed! I think it will be intense, challenging, and most of all, exciting!
NATURE: I'm not too sure about the nature of the setting. There wasn't much in depth information to go by under facility information so I spoke to some students who had been previously. From what I gathered, students are situated on particular wards, ranging from general medical, general surgical, cardiothoracics, ICU, ambulatory care and hematology and oncology. Either way, I'll be seeing very sick patients and must brush up on all attachments/ surgical approaches/ medications etc. Previous students also mentioned that Fremantle use a 'peer-coaching' model, where you work with another student initially and learn from one another. I think this is a great idea and I'm really looking forward to it. Having another opinion and point of view can only further my own knowledge! And I don't think my supervisor will be with me 100% of the time so it will be extra nice having someone else there! I think that as time passes and our skills improve, we will be seeing patients alone and almost running our own ward!!
STRUCTURE: From speaking to previous students I was able to gather a general idea of how my day will be structured. In the morning, you print off a patient list for that day, corresponding to your ward. From here, you can flag patients who you think will be appropriate, based on underlying chest conditions, pre-morbid status, long ICU stays/surgeries etc. Once you have a list, you must make time during the day to see them. I can imagine most of these wards will be bustling, with patients being constantly seen by members of the allied health and medical team, so fitting patients in and working around (and with) others may be tricky.
ROLE: I feel like my role will expand on this placement, and we may become more like colleagues rather than just students. Hospitals are very busy places and I can imagine supervisors enjoying an extra set of hands. Previous students mentioned almost staffing an entire ward by themselves! (Of course though, getting approval of the prioritised problem list before treating) I'm so looking forward to this responsibility! I think I will need to step-up and take this role head on. I imagine though that initially I will work closely with my partner and supervisor and that as time goes by I can up my patient load. All in all I am SO looking forward to the challenge! And lastly, as always, my role will be to learn as much as possible!
CONCERNS: I have quite a few concerns about this placement. Firstly, this is a brand new experience for me, working in a large hospital in an inpatient setting. I really hope that being surrounded by many sick and sad people will not be too overwhelming for me. I felt that during on prac at Shenton Park, I spent a lot of time being sad for patients. This doesn't really help anyone, and makes the day quite tough! Hopefully, I can distance myself (within reason) so that I can perform assessments and treatments to the best of my ability.
Secondly, I feel like I can understand cardio in theory, but until you've seen things in real life, you don't really have a handle on everything. For example, I understand attachments, their use and the fact that you need to move them while mobilising patients. But in real life, when I see someone with attachments galore I can imagine myself freezing and becoming flustered! I have to remember that people walk everyday and not to be put off by such a confronting sight!
Lastly, my 2 weeks off didn't feel like 2 weeks off! I think I was actually busier than when I was on prac! Consequently, I'm feeling quite under-prepared for tomorrow. I always feel like I don't know enough...but I do wish I put aside more time for study.
NATURE: I'm not too sure about the nature of the setting. There wasn't much in depth information to go by under facility information so I spoke to some students who had been previously. From what I gathered, students are situated on particular wards, ranging from general medical, general surgical, cardiothoracics, ICU, ambulatory care and hematology and oncology. Either way, I'll be seeing very sick patients and must brush up on all attachments/ surgical approaches/ medications etc. Previous students also mentioned that Fremantle use a 'peer-coaching' model, where you work with another student initially and learn from one another. I think this is a great idea and I'm really looking forward to it. Having another opinion and point of view can only further my own knowledge! And I don't think my supervisor will be with me 100% of the time so it will be extra nice having someone else there! I think that as time passes and our skills improve, we will be seeing patients alone and almost running our own ward!!
STRUCTURE: From speaking to previous students I was able to gather a general idea of how my day will be structured. In the morning, you print off a patient list for that day, corresponding to your ward. From here, you can flag patients who you think will be appropriate, based on underlying chest conditions, pre-morbid status, long ICU stays/surgeries etc. Once you have a list, you must make time during the day to see them. I can imagine most of these wards will be bustling, with patients being constantly seen by members of the allied health and medical team, so fitting patients in and working around (and with) others may be tricky.
ROLE: I feel like my role will expand on this placement, and we may become more like colleagues rather than just students. Hospitals are very busy places and I can imagine supervisors enjoying an extra set of hands. Previous students mentioned almost staffing an entire ward by themselves! (Of course though, getting approval of the prioritised problem list before treating) I'm so looking forward to this responsibility! I think I will need to step-up and take this role head on. I imagine though that initially I will work closely with my partner and supervisor and that as time goes by I can up my patient load. All in all I am SO looking forward to the challenge! And lastly, as always, my role will be to learn as much as possible!
CONCERNS: I have quite a few concerns about this placement. Firstly, this is a brand new experience for me, working in a large hospital in an inpatient setting. I really hope that being surrounded by many sick and sad people will not be too overwhelming for me. I felt that during on prac at Shenton Park, I spent a lot of time being sad for patients. This doesn't really help anyone, and makes the day quite tough! Hopefully, I can distance myself (within reason) so that I can perform assessments and treatments to the best of my ability.
Secondly, I feel like I can understand cardio in theory, but until you've seen things in real life, you don't really have a handle on everything. For example, I understand attachments, their use and the fact that you need to move them while mobilising patients. But in real life, when I see someone with attachments galore I can imagine myself freezing and becoming flustered! I have to remember that people walk everyday and not to be put off by such a confronting sight!
Lastly, my 2 weeks off didn't feel like 2 weeks off! I think I was actually busier than when I was on prac! Consequently, I'm feeling quite under-prepared for tomorrow. I always feel like I don't know enough...but I do wish I put aside more time for study.
Thursday, April 22, 2010
FINAL ENTRY NEURO
Most of my assumptions about the Wel-Tell centre were correct. Well-Tel is a play on ho-tel, ie: a hotel for well people! It is there for those people who need an intensive burst of physiotherapy but are independent enough that they don't need to stay on the ward. Not only is this better for the patients, but it saves a whole heap of tax payer money!
Patient's were generally well versed in self care, and I found that my role was supervisory, but not the extent I had guessed. I did have to ensure patients could perform their exercise programs well enough that they could do it at home. However, it was also a great time to utilise treatments techniques that could not be done at home, things like the tilt table, hydrotherapy, hands on mobilisations and stretches and normal movement facilitation etc. So not only did I supervise, I was a hands on therapist! I was correct in saying that patients were no longer in an acute phase of rehab, but this did not necessarily mean that that they needed higher level training. Some patients did require this type of therapy as they had been admitted straight after an inpatient stay on the ward, ie: were in the final stages of motor recovery post stroke or GBS. Most of the patients however had degenerative or genetic conditions like MS or HSP (hereditary spastic paraparesis.) They did not require high level training, rather treatment to maintain or improve their current functional status.
The structure of the of the program was that patients came to the gym for 2 and half hours in the morning. Here they had one on one time with a physio, doing all those things they miss out on at home, and also work independently on their tailored programs. The rest of the day is for themselve. They can book in with the OT, speech therapist, social worker, podiatrist, attend hydrotherapy or even come back to the gym in the afternoon. It is a really well-rounded program that includes every aspect of the multi-disciplinary team!! And as I had thought, patients did make some really good friends and it was definitely a motivation to work. We were all in the gym together and it made for such a nice and supportive environment!
Aside from Wel-Tell, I was also assigned to the ward 2 gym, which sees neurological inpatients. Here I dealt with stroke patients in their acute phases of recovery. This meant my role was very hands on. I felt that my afternoon patients were much more dependent and my role was to facilitate and re-educate normal movement patterns. I felt that this gave me a really huge opportunity to see such a range of conditions throughout all phases of recovery!!
Concerns:
I did feel that I was a bit behind in my neuro, but I learnt so much! I really realised that it is all related to normal movement, and as the weeks went on I was able to more effectively not the deviations from normal and why. I may have been less confident initially, but with time it became much easier. Once you develop a rapport with the patient confidence really just comes. My supervisor did expect a lot of me, but only what was within my knowledge base. She didn't expect me to have a million different treatment techniques up my sleeve. She was aware that you only learn a few at uni and the rest comes with experience. And I did learn HEAPS of different techniques, but I think I would be still learning 20 years into a neuro career...the scope of what you can do is enormous.
I did enjoy my placement, but I also found it very confronting and overwhelming. I think experience is also needed in how to detach yourself emotionally (although I also think emotion is what can make you a great physio!) It was really hard and challenged me in more ways than I imagined. I'm not sure that it's the career path I'm cut out for, but it's an experience I'll definitely remember! I think if you can master neuro you can probably master most things...having a normal movement base is what most physio is about!!
My take home message: To be really honest I felt that neuro physio was initially quite subjective, everyone seems to do everything differently and you have different feedback coming from every angle!! (I'm also aware that it is less evidence based because it's unethical to withhold treatments from these patient groups.) But I've come to realise that it doesn't overly matter if everyone does things a different way. Nothing is really 'wrong' as such...as long as you're achieving your aim of normal movement an exercise is appropriate! You need to experiment with techniques and constantly monitor and progress. This drives home the importance of assessment. If you get your neuro impairment list 100%, you can work a treatment to suit your aim! Lastly, I wasn't expected to know everything there is to know about neuro, so don't be afraid to ask! I became aware of my own limitations and as such I knew when to ask for help and advice.
Patient's were generally well versed in self care, and I found that my role was supervisory, but not the extent I had guessed. I did have to ensure patients could perform their exercise programs well enough that they could do it at home. However, it was also a great time to utilise treatments techniques that could not be done at home, things like the tilt table, hydrotherapy, hands on mobilisations and stretches and normal movement facilitation etc. So not only did I supervise, I was a hands on therapist! I was correct in saying that patients were no longer in an acute phase of rehab, but this did not necessarily mean that that they needed higher level training. Some patients did require this type of therapy as they had been admitted straight after an inpatient stay on the ward, ie: were in the final stages of motor recovery post stroke or GBS. Most of the patients however had degenerative or genetic conditions like MS or HSP (hereditary spastic paraparesis.) They did not require high level training, rather treatment to maintain or improve their current functional status.
The structure of the of the program was that patients came to the gym for 2 and half hours in the morning. Here they had one on one time with a physio, doing all those things they miss out on at home, and also work independently on their tailored programs. The rest of the day is for themselve. They can book in with the OT, speech therapist, social worker, podiatrist, attend hydrotherapy or even come back to the gym in the afternoon. It is a really well-rounded program that includes every aspect of the multi-disciplinary team!! And as I had thought, patients did make some really good friends and it was definitely a motivation to work. We were all in the gym together and it made for such a nice and supportive environment!
Aside from Wel-Tell, I was also assigned to the ward 2 gym, which sees neurological inpatients. Here I dealt with stroke patients in their acute phases of recovery. This meant my role was very hands on. I felt that my afternoon patients were much more dependent and my role was to facilitate and re-educate normal movement patterns. I felt that this gave me a really huge opportunity to see such a range of conditions throughout all phases of recovery!!
Concerns:
I did feel that I was a bit behind in my neuro, but I learnt so much! I really realised that it is all related to normal movement, and as the weeks went on I was able to more effectively not the deviations from normal and why. I may have been less confident initially, but with time it became much easier. Once you develop a rapport with the patient confidence really just comes. My supervisor did expect a lot of me, but only what was within my knowledge base. She didn't expect me to have a million different treatment techniques up my sleeve. She was aware that you only learn a few at uni and the rest comes with experience. And I did learn HEAPS of different techniques, but I think I would be still learning 20 years into a neuro career...the scope of what you can do is enormous.
I did enjoy my placement, but I also found it very confronting and overwhelming. I think experience is also needed in how to detach yourself emotionally (although I also think emotion is what can make you a great physio!) It was really hard and challenged me in more ways than I imagined. I'm not sure that it's the career path I'm cut out for, but it's an experience I'll definitely remember! I think if you can master neuro you can probably master most things...having a normal movement base is what most physio is about!!
My take home message: To be really honest I felt that neuro physio was initially quite subjective, everyone seems to do everything differently and you have different feedback coming from every angle!! (I'm also aware that it is less evidence based because it's unethical to withhold treatments from these patient groups.) But I've come to realise that it doesn't overly matter if everyone does things a different way. Nothing is really 'wrong' as such...as long as you're achieving your aim of normal movement an exercise is appropriate! You need to experiment with techniques and constantly monitor and progress. This drives home the importance of assessment. If you get your neuro impairment list 100%, you can work a treatment to suit your aim! Lastly, I wasn't expected to know everything there is to know about neuro, so don't be afraid to ask! I became aware of my own limitations and as such I knew when to ask for help and advice.
week 5 neuro
S- I have been continuing my treatment with Mr B in the neurological inpatient gym every afternoon. Mr B suffered a L pontine stroke on the 12/03/2010 and consequently is experiencing R hemiparesis and hemisensory loss, as well as decreased arousal, mild expressive dysphasia and moderate dysarthria. Mr B is displaying excellent movement return and we have minimised the amount of tone coming in. All in all he is displaying excellent potential for a good recovery!!
However, on Monday and Tuesday we experienced 2 set-backs in therapy. On Monday he had a fall in the PT gym. My supervisor and I were practicing 2 mod A STS with Mr B as this is major goal, he is VERY focussed on achieving this as he wants to be able to transfer without the hoist. Mr B is determined, but if something is too hard he will sit down without any warning to the PT, you just have to be ready. During STS from the W/C, Mr B made it about half way, then just could not straighten his legs any further. He slipped in front of the W/C, and as he weighs 97kg my supervisor and I just could not save him, so we began a controlled lowering to the floor. He then required a 3 max A to get back into the W/C. It turned out fine, but it shattered Mr B's confidence.
The next day, shortly after Mr B's arrival he needed to go to the bathroom. He has suffered some urge incontinence since his stroke so I quickly rushed him up to the ward. Once here, I offered my assistance but as he is a standing hoist t/f the nursing staff declined, they would just have to teach me to use the hoist and he was in a rush. I decided to wait for Mr B so I could take him back to the gym and save the PCA. I was waiting in the office and heard the nursing staff talking about me. It was very unprofessional. They suggested that PT never offer to help, they were run off their feet and I was just sitting down! (Meanwhile, they couldn't have been that busy if 6 people had the time to and around and talk about me.) It really upset me as I try my hardest to be polite and helpful, I would never intentionally not offer my assistance. So, I stood up and joined their conversation...with the end result being me bullied into getting Mr B off the toilet. This was really awkward for him. After the experience, he said he was too embarrassed to come back to phsyio and absolutely dreaded it!!
T-My task was to reinstate some of Mr B's confidence and reassure him about physio generally!
A-I wheeled Mr B back to his room for the day. Once here I shut the curtains to give us some privacy. I sincerely apologised for his experience in the bathroom. I let him know that I wasn't embarrassed and had taken many patients to the bathroom before. He explained that he felt physio's were for therapy only and he was mortified that I had to see him in another light. I empathised with this and understood exactly where he was coming from. We decided to put a few strategies in place to ensure that physio WAS only therapy time. They offer patients drinks while they're in the gym. Mr B felt his drink had upset his stomach, so we opted for water only while exercising. We also pushed back his start time till 2:30. This allowed his lunch to go down (he has just started to eat normal meals so he felt he needed some time getting used to it again.) This also worked well for me, as I had a higher level patient who could come and take Mr B's earlier time slot.
We then talked about his fall. Mr B was so nervous it would happen again, and it was such a struggle for him and us to get him off the floor. I let him know that he shouldn't view the fall as a set-back. If anything, it proves he can transfer from the floor without a hoist. I told him that falls were to be expected ( I had already seen 2 in that gym!) and now hopefully he's had his and that's it! I then really emphasised his great potential for recovery! I related hard-work to his goals and hopefully inspired him not to give up. Only with therapy time will he achieve a stand-step transfer and he has already come so far! I tried not to play into his nervousness and let him know that sometimes these things happen, it is not a reason to stop. I told him that he had to be in control of his rehab, and if he feels tired he has to let us know.
R-I feel that my talk with Mr B went really well. When I left, he was no longer embarrassed and was willing and excited to continue his therapy. He felt happy with the strategies we put in place and felt more in control of his own recovery. I feel that I built on our rapport and our professional relationship had grown. I was really excited to have him back on board, he has to want to be in the gym for us to make any type of improvements!
E-I really feel I handled the situation well. I was just as embarrassed as Mr B and I could have left without talking to him. I was really proud that I was professional enough to sit down with him and analyse the events. I really learnt the importance of listening. I felt Mr B's concerns were valid, and we worked through them appropriately and professionally. I left knowing that Mr B was reassured and had regained some confidence in his abilities (and some more confidence in me!!)
However, I did not handle the situation with the nurses very well!! I felt so worried and flustered when I heard them talking about me so I just stood up and did whatever they said. Looking back, it was definitely bullying, and it was not professional. I did not need to be rude, but I could have been more assertive. I should have reminded them that I did offer assistance and I am more than happy to help out whenever required, especially as I am a student and have more time on my hands, all they needed to do was ask. But I also should have reminded them to listen to the patients wishes, it was clear that he did not want me there and as such I shouldn't have been. In those situations I need to politely point out the facts and not fall into the trap of workplace bullying! I also need to find my voice sometimes and stand up for myself. I am not rude or lazy and shouldn't let people say that about me.
S-When Mr B next comes into the gym I am going to use the following strategies
1. Relate STS practice to his goals
2.Positive feedback to boost his confidence
3.Bolster him in so he feels really safe
4.Have confidence in myself, and let him see that! I can't let him know I'm nervous too because that won't help anyone.
In regards to the situation on the ward, I let my supervisor know what happened so she was informed. We then talked through strategies together on how to deal with anything like that in the future.
However, on Monday and Tuesday we experienced 2 set-backs in therapy. On Monday he had a fall in the PT gym. My supervisor and I were practicing 2 mod A STS with Mr B as this is major goal, he is VERY focussed on achieving this as he wants to be able to transfer without the hoist. Mr B is determined, but if something is too hard he will sit down without any warning to the PT, you just have to be ready. During STS from the W/C, Mr B made it about half way, then just could not straighten his legs any further. He slipped in front of the W/C, and as he weighs 97kg my supervisor and I just could not save him, so we began a controlled lowering to the floor. He then required a 3 max A to get back into the W/C. It turned out fine, but it shattered Mr B's confidence.
The next day, shortly after Mr B's arrival he needed to go to the bathroom. He has suffered some urge incontinence since his stroke so I quickly rushed him up to the ward. Once here, I offered my assistance but as he is a standing hoist t/f the nursing staff declined, they would just have to teach me to use the hoist and he was in a rush. I decided to wait for Mr B so I could take him back to the gym and save the PCA. I was waiting in the office and heard the nursing staff talking about me. It was very unprofessional. They suggested that PT never offer to help, they were run off their feet and I was just sitting down! (Meanwhile, they couldn't have been that busy if 6 people had the time to and around and talk about me.) It really upset me as I try my hardest to be polite and helpful, I would never intentionally not offer my assistance. So, I stood up and joined their conversation...with the end result being me bullied into getting Mr B off the toilet. This was really awkward for him. After the experience, he said he was too embarrassed to come back to phsyio and absolutely dreaded it!!
T-My task was to reinstate some of Mr B's confidence and reassure him about physio generally!
A-I wheeled Mr B back to his room for the day. Once here I shut the curtains to give us some privacy. I sincerely apologised for his experience in the bathroom. I let him know that I wasn't embarrassed and had taken many patients to the bathroom before. He explained that he felt physio's were for therapy only and he was mortified that I had to see him in another light. I empathised with this and understood exactly where he was coming from. We decided to put a few strategies in place to ensure that physio WAS only therapy time. They offer patients drinks while they're in the gym. Mr B felt his drink had upset his stomach, so we opted for water only while exercising. We also pushed back his start time till 2:30. This allowed his lunch to go down (he has just started to eat normal meals so he felt he needed some time getting used to it again.) This also worked well for me, as I had a higher level patient who could come and take Mr B's earlier time slot.
We then talked about his fall. Mr B was so nervous it would happen again, and it was such a struggle for him and us to get him off the floor. I let him know that he shouldn't view the fall as a set-back. If anything, it proves he can transfer from the floor without a hoist. I told him that falls were to be expected ( I had already seen 2 in that gym!) and now hopefully he's had his and that's it! I then really emphasised his great potential for recovery! I related hard-work to his goals and hopefully inspired him not to give up. Only with therapy time will he achieve a stand-step transfer and he has already come so far! I tried not to play into his nervousness and let him know that sometimes these things happen, it is not a reason to stop. I told him that he had to be in control of his rehab, and if he feels tired he has to let us know.
R-I feel that my talk with Mr B went really well. When I left, he was no longer embarrassed and was willing and excited to continue his therapy. He felt happy with the strategies we put in place and felt more in control of his own recovery. I feel that I built on our rapport and our professional relationship had grown. I was really excited to have him back on board, he has to want to be in the gym for us to make any type of improvements!
E-I really feel I handled the situation well. I was just as embarrassed as Mr B and I could have left without talking to him. I was really proud that I was professional enough to sit down with him and analyse the events. I really learnt the importance of listening. I felt Mr B's concerns were valid, and we worked through them appropriately and professionally. I left knowing that Mr B was reassured and had regained some confidence in his abilities (and some more confidence in me!!)
However, I did not handle the situation with the nurses very well!! I felt so worried and flustered when I heard them talking about me so I just stood up and did whatever they said. Looking back, it was definitely bullying, and it was not professional. I did not need to be rude, but I could have been more assertive. I should have reminded them that I did offer assistance and I am more than happy to help out whenever required, especially as I am a student and have more time on my hands, all they needed to do was ask. But I also should have reminded them to listen to the patients wishes, it was clear that he did not want me there and as such I shouldn't have been. In those situations I need to politely point out the facts and not fall into the trap of workplace bullying! I also need to find my voice sometimes and stand up for myself. I am not rude or lazy and shouldn't let people say that about me.
S-When Mr B next comes into the gym I am going to use the following strategies
1. Relate STS practice to his goals
2.Positive feedback to boost his confidence
3.Bolster him in so he feels really safe
4.Have confidence in myself, and let him see that! I can't let him know I'm nervous too because that won't help anyone.
In regards to the situation on the ward, I let my supervisor know what happened so she was informed. We then talked through strategies together on how to deal with anything like that in the future.
Saturday, April 10, 2010
week 3 neuro
S- Today I was to perform my first treatment of Mr B in the neurological inpatients gym after assessing him the day before. Mr B suffered a L pontine stroke on the 12/03/2010 and is now experiencing R sided hemiparesis and hemisensory loss. He also has moderate dysarthria and expressive dysphasia, and since the stroke he has noticed a decrease in motivation, increase tiredness and a general flat affect. Mr B is displaying great movement return, with his number one impairments being a decrease in postural tone and stability, decrease R sided voluntary control and decrease in static and dynamic sitting balance. He doesn't seem to have the abdominal strength to save himself once outside his base of support. Mr B's main goal for now is to be able to stand up and transfer without the use of a hoist.
T-My task was to perform an initial treatment of Mr B targeting his main impairments . As he is quite difficult to transfer (due not only to his lack of voluntary control but also the fact that he is over 6 foot tall and over 90kg) I had to structure the session so that it flowed well (none of my usual sit up, lie down sit up again). I also had to maintain Mr B's interest in order to keep him focussed and motivated.
A-I decided to treat Mr B in supine first and work on his abdominal strength. I thought it was important to get this firing before he was in sitting to prepare his abs for balance work. We worked on sit-ups with a wedge behind Mr B. This made the sit-up easier for him as he didn't need to start from a fully lengthened position. We also worked on posterior pelvic tilt in crook lying, progressing to a bridge. Once we completed these, we moved to sitting. Here we worked on reaching out of his base of support with the left and right hand. We emphasised lateral tilt of the pelvis and trunk righting. Rather than growing on the reaching side Mr B seems to slump or pull down. We practiced component work when reaching with the right working first at the shoulder and breaking the movement into parts. After this, we came into standing and practiced finding the centre (Mr B pushes to the R). To end the session, I gave Mr B a list of exercises for his hand that he can do on the ward. (Previously he was squeezing a stress ball which only works to reinforce the flexor pattern of the arm.)
R-Mr B was happy with the treatment session, particularly coming up to standing. This is his short-term goal and he was so proud to be making the first steps. I was happy that he could prove this to himself, as he was feeling like the situation was hopeless prior to treatment. I also felt that the exercises we did in sitting were very successful at firing up his trunkal tone, as I could see good extensor activity happening in his back after reaching.
E-All in all I think our first treatment session together worked well. I think that the flow of the exercises worked well from a transfer perspective as well as preparing him for each new and more challenging exercise. However, I feel the work we did in supine didn't achieve the desired effect. Mr B seems to take whatever support is given him, thus in supine, he completely switches off and does very little work, which isn't really achieving anything... aside from making me work more! I also found that Mr B led his sit-ups through global extension, particularly leading with his head, so I need to think of some strategies to improve this. In sitting, reaching was very effective at firing up postural tone and preparing him for standing. On the left I made this interesting by incorporating coits, but on the right, he cannot hold coits. As such, Mr B found this a bit boring and lost interest. He is quite hard to motivate, and I became slightly disheartened as he starting yawning a lot! I also felt that reaching to the R is particularly problematic because he hinges from his trunk rather than switching it on to provide a stable base for the scapula. I feel that it would thus be best to reach to the R in standing while his trunk has max input, but his being so tall may not make this possible with only 1 assist. I do however think that we made a great start and I developed a good rapport with Mr B. I really feel that the best thing to come out of the session was proving to Mr B that there is hope and a point in trying, and that with continued work he can only get better!
S-For our next session I have decided to eliminate supine all together. I think for now it is important for Mr B to be doing most of the work and reminding his brain that he can! I do think it is so important for him to work on his abdominal strength, but I will try this in reclined sitting. I will not let him fully rest or let go in the reclined position, forcing him to do the work for himself. I will also get him to do this ab work with his chin on chest, hopefully this prevents global extension and leading with the head. To make the reaching to the R more interesting and in order to involve Mr B more in his own treatment I'm going to try and relate it to something that interests him. He previously worked full time as a bus driver and loved this job, so maybe we can look at holding a steering wheel or flicking indicators. I can also use my voice here to fire him up. Lastly, I think I will give him generally less support. He is capable of working on his own, but takes whatever you give him. I need to make sure that I give him every opportunity to do this, within reason and staying safe. Plus, this will go towards helping him see that he is indeed capable and there is much hope of being functional again.
T-My task was to perform an initial treatment of Mr B targeting his main impairments . As he is quite difficult to transfer (due not only to his lack of voluntary control but also the fact that he is over 6 foot tall and over 90kg) I had to structure the session so that it flowed well (none of my usual sit up, lie down sit up again). I also had to maintain Mr B's interest in order to keep him focussed and motivated.
A-I decided to treat Mr B in supine first and work on his abdominal strength. I thought it was important to get this firing before he was in sitting to prepare his abs for balance work. We worked on sit-ups with a wedge behind Mr B. This made the sit-up easier for him as he didn't need to start from a fully lengthened position. We also worked on posterior pelvic tilt in crook lying, progressing to a bridge. Once we completed these, we moved to sitting. Here we worked on reaching out of his base of support with the left and right hand. We emphasised lateral tilt of the pelvis and trunk righting. Rather than growing on the reaching side Mr B seems to slump or pull down. We practiced component work when reaching with the right working first at the shoulder and breaking the movement into parts. After this, we came into standing and practiced finding the centre (Mr B pushes to the R). To end the session, I gave Mr B a list of exercises for his hand that he can do on the ward. (Previously he was squeezing a stress ball which only works to reinforce the flexor pattern of the arm.)
R-Mr B was happy with the treatment session, particularly coming up to standing. This is his short-term goal and he was so proud to be making the first steps. I was happy that he could prove this to himself, as he was feeling like the situation was hopeless prior to treatment. I also felt that the exercises we did in sitting were very successful at firing up his trunkal tone, as I could see good extensor activity happening in his back after reaching.
E-All in all I think our first treatment session together worked well. I think that the flow of the exercises worked well from a transfer perspective as well as preparing him for each new and more challenging exercise. However, I feel the work we did in supine didn't achieve the desired effect. Mr B seems to take whatever support is given him, thus in supine, he completely switches off and does very little work, which isn't really achieving anything... aside from making me work more! I also found that Mr B led his sit-ups through global extension, particularly leading with his head, so I need to think of some strategies to improve this. In sitting, reaching was very effective at firing up postural tone and preparing him for standing. On the left I made this interesting by incorporating coits, but on the right, he cannot hold coits. As such, Mr B found this a bit boring and lost interest. He is quite hard to motivate, and I became slightly disheartened as he starting yawning a lot! I also felt that reaching to the R is particularly problematic because he hinges from his trunk rather than switching it on to provide a stable base for the scapula. I feel that it would thus be best to reach to the R in standing while his trunk has max input, but his being so tall may not make this possible with only 1 assist. I do however think that we made a great start and I developed a good rapport with Mr B. I really feel that the best thing to come out of the session was proving to Mr B that there is hope and a point in trying, and that with continued work he can only get better!
S-For our next session I have decided to eliminate supine all together. I think for now it is important for Mr B to be doing most of the work and reminding his brain that he can! I do think it is so important for him to work on his abdominal strength, but I will try this in reclined sitting. I will not let him fully rest or let go in the reclined position, forcing him to do the work for himself. I will also get him to do this ab work with his chin on chest, hopefully this prevents global extension and leading with the head. To make the reaching to the R more interesting and in order to involve Mr B more in his own treatment I'm going to try and relate it to something that interests him. He previously worked full time as a bus driver and loved this job, so maybe we can look at holding a steering wheel or flicking indicators. I can also use my voice here to fire him up. Lastly, I think I will give him generally less support. He is capable of working on his own, but takes whatever you give him. I need to make sure that I give him every opportunity to do this, within reason and staying safe. Plus, this will go towards helping him see that he is indeed capable and there is much hope of being functional again.
Saturday, March 27, 2010
week 1 neuro
WEEK 1
S-In the afternoons we work in the neurological inpatients gym. Here we mainly see stroke and brain injury patients in their last month or so of rehab before discharge. Patients on the ward make appointments with the physios here and can spend up to three hours in the gym! It is a real team orientated environment. All the physios work in one large room asking each other for help when required. (i.e.: if they’re having difficultly pinpointing the patient’s impairments or need extra assistance walking a patient.)
I was to see a new patient on my very first day. Ms A has multiple sclerosis and was admitted to Shenton Park that morning experiencing her 2nd relapse since her diagnosis (2003). She became aware of her condition deteriorating as she could no longer transfer with a slide board independently; she felt her balance was too poor. Ms A is fiercely independent and her ability to transfer is thus very important.
T-My task was to make the initial assessment of Ms A. Seeing as Ms A experiences most of her fatigue in the afternoon, we decided to just complete an assessment that day. We felt it may be too exhausting to include treatment in the one session as well.
A-I completed a thorough subjective examination whilst Ms A was in her chair. I tried to elicit as much information as possible about her condition, so that our objective examination could be specific from the outset to minimise her fatigue levels. While she was still in her chair we quickly ran thorough cranial nerves and sensation. We then transferred her onto the plinth to assess her motor status and tone. I quickly realised that muscle testing muscle testing was not clear-cut with Ms A. She had almost no movement in her lower limbs and I didn’t want to overly fatigue her by getting her in and out of numerous ‘gravity eliminated’ positions. I found the best way to elicit movement was to perform active assisted LL movements and document as such. It showed me the importance of palpating the muscle whilst moving it so I could feel for any muscle flickers. After these assessments Ms A came into sitting for a postural and balance assessment. She was not safe to be sitting unassisted and I noticed that her trunk was very ataxic. Because of this I decided to test her coordination looking for signs of potential new cerebellar involvement.
R- From this assessment I produced a concise impairment list, and thankfully I didn’t tire my patient out too much. She did in fact have positive results on cerebellar testing, including a new (3 week old) intention tremor. These findings will cause us to go down a different treatment path, focussing more on core stability and target type training.
E- I felt that my assessment went well. It was very important to be well organised as Ms A said asthenia really hinders her ability to participate in any kind of therapy. I thought that my subjective examination really helped to direct me to what was important, namely her new found LL worsening weakness and balance issues. I didn’t spend too much time on other aspects, such as cranial nerves as I had already asked about visual and swallowing difficulties etc. I also thought I did well in not making her moving around too much, as that is something I am usually terrible at! I’m always asking patients to sit down, stand up and sit down again!
The problem list that I came up with was reflective of her impairments but probably not prioritised well enough. I needed to remember that Ms A came in wanting to fix a specific problem, her transfers. So number one on our list should be to work on her core stability and practice transfers, and things like spasticity and LL weakness should be lower priorities. This is something I think I should do more every time I see a patient. I need to remember why they are here, what they want to achieve, and look more globally at the person.
S- The main strategy I used was preparation! Knowing that she fatigues easily meant I needed to be really well organised, focussed and specific. Before I saw the patient I wrote down what was essential to find out in my subjective examination. From here I worked out was most important to assess and tried to put that at the start of our objective examination. I also thought hard about testing positions and what would flow best. I think being well prepared was really the most important thing in making this a successful assessment.
S-In the afternoons we work in the neurological inpatients gym. Here we mainly see stroke and brain injury patients in their last month or so of rehab before discharge. Patients on the ward make appointments with the physios here and can spend up to three hours in the gym! It is a real team orientated environment. All the physios work in one large room asking each other for help when required. (i.e.: if they’re having difficultly pinpointing the patient’s impairments or need extra assistance walking a patient.)
I was to see a new patient on my very first day. Ms A has multiple sclerosis and was admitted to Shenton Park that morning experiencing her 2nd relapse since her diagnosis (2003). She became aware of her condition deteriorating as she could no longer transfer with a slide board independently; she felt her balance was too poor. Ms A is fiercely independent and her ability to transfer is thus very important.
T-My task was to make the initial assessment of Ms A. Seeing as Ms A experiences most of her fatigue in the afternoon, we decided to just complete an assessment that day. We felt it may be too exhausting to include treatment in the one session as well.
A-I completed a thorough subjective examination whilst Ms A was in her chair. I tried to elicit as much information as possible about her condition, so that our objective examination could be specific from the outset to minimise her fatigue levels. While she was still in her chair we quickly ran thorough cranial nerves and sensation. We then transferred her onto the plinth to assess her motor status and tone. I quickly realised that muscle testing muscle testing was not clear-cut with Ms A. She had almost no movement in her lower limbs and I didn’t want to overly fatigue her by getting her in and out of numerous ‘gravity eliminated’ positions. I found the best way to elicit movement was to perform active assisted LL movements and document as such. It showed me the importance of palpating the muscle whilst moving it so I could feel for any muscle flickers. After these assessments Ms A came into sitting for a postural and balance assessment. She was not safe to be sitting unassisted and I noticed that her trunk was very ataxic. Because of this I decided to test her coordination looking for signs of potential new cerebellar involvement.
R- From this assessment I produced a concise impairment list, and thankfully I didn’t tire my patient out too much. She did in fact have positive results on cerebellar testing, including a new (3 week old) intention tremor. These findings will cause us to go down a different treatment path, focussing more on core stability and target type training.
E- I felt that my assessment went well. It was very important to be well organised as Ms A said asthenia really hinders her ability to participate in any kind of therapy. I thought that my subjective examination really helped to direct me to what was important, namely her new found LL worsening weakness and balance issues. I didn’t spend too much time on other aspects, such as cranial nerves as I had already asked about visual and swallowing difficulties etc. I also thought I did well in not making her moving around too much, as that is something I am usually terrible at! I’m always asking patients to sit down, stand up and sit down again!
The problem list that I came up with was reflective of her impairments but probably not prioritised well enough. I needed to remember that Ms A came in wanting to fix a specific problem, her transfers. So number one on our list should be to work on her core stability and practice transfers, and things like spasticity and LL weakness should be lower priorities. This is something I think I should do more every time I see a patient. I need to remember why they are here, what they want to achieve, and look more globally at the person.
S- The main strategy I used was preparation! Knowing that she fatigues easily meant I needed to be really well organised, focussed and specific. Before I saw the patient I wrote down what was essential to find out in my subjective examination. From here I worked out was most important to assess and tried to put that at the start of our objective examination. I also thought hard about testing positions and what would flow best. I think being well prepared was really the most important thing in making this a successful assessment.
Sunday, March 21, 2010
INITIAL ENTRY (NEURO)
Tomorrow I start my Neuro placement at the Well-Tel Centre (part of Shenton Park Hospital). From what I can gather, it is a place that provides accommodation for people undergoing rehab or other services, but do not necessarily need to be admitted as an inpatient, in a ward environment. This will mean that the patients have much more independence and are in a less acute phase of their illness/recovery. For me, I think this means that the patients will be well versed in self care and will require more high level rehabilitation.
NATURE
I found it quite difficult to find much information on the Centre, but speaking to students who went previously confirmed my above ideas. The Centre is almost like a 'halfway house' for those who don't really need to be in hospital. Thus, PT sessions can be much more intensive, up to an hour of one on one work. As the patients are no longer acute, I think I will need to be prepared for 'later stage' training, ie: the final stages of motor recovery/high level balance work/coordination and power etc, all those things that make up a more 'normal' movement (as opposed to initial periods of flaccidity immediately following stroke for example.)
STRUCTURE
I have only been in outpatient and hospital settings, so as far as the structure of the Well-tel centre is concerned, I think I may be in for a whole new experience!! I imagine it will be similar to an outpatient setting, with patients seeing you at previously booked times, but then they can go back to their rooms! Similar to a hotel or boarding house! I am also curious to see if they run any group sessions. I think it would be a great way to exercise as patients there for a week or more would most likely make friends (if it's similar to a hotel environment?) -this could be a great motivation!!
ROLE
I also found out I will be dealing mostly with disorders like multiple sclerosis, acquired brain injuries, spinal cord injuries and potentially some amputees. I think my role as a student will be to perform one on one rehab sessions with these patients, involving more high level and independent activities. I think I will become more of a 'supervisor' and less of an 'assistant' as patients at this Centre are independent, and will need more supervision of programs to ensure they're doing it correctly at home. I think I will also become an educator. I can only imagine how difficult it would be to live with MS, and I think I will need to be on the ball with advice, encouragement and support. I think my role is also going to be to learn as much as I can. As I understand from Ali, there are many different ways to approach neuro rehab, and I am hoping to learn many new skills, as well as consolidate those I already have.
CONCERNS
I have SO many concerns about this placement! I feel like my past 2 placements were very MSK based, and thus I have a much better idea about the MSK subjective and objective assessments and treatment techniques. (Not to mention more confidence!) I also missed the first placement as I was doing my project. We were told that now supervisors are less lenient and expect more because it is placement number two...but I am behind. I literally haven't seen any patients since Collie last year! I don't know if I trust myself. Plus, I have my usual worry about not living up to my own expectations or those of my supervisors...but that is nothing new:)
But, if it's anything like my previous 2 placements, I will love every second of it!!
NATURE
I found it quite difficult to find much information on the Centre, but speaking to students who went previously confirmed my above ideas. The Centre is almost like a 'halfway house' for those who don't really need to be in hospital. Thus, PT sessions can be much more intensive, up to an hour of one on one work. As the patients are no longer acute, I think I will need to be prepared for 'later stage' training, ie: the final stages of motor recovery/high level balance work/coordination and power etc, all those things that make up a more 'normal' movement (as opposed to initial periods of flaccidity immediately following stroke for example.)
STRUCTURE
I have only been in outpatient and hospital settings, so as far as the structure of the Well-tel centre is concerned, I think I may be in for a whole new experience!! I imagine it will be similar to an outpatient setting, with patients seeing you at previously booked times, but then they can go back to their rooms! Similar to a hotel or boarding house! I am also curious to see if they run any group sessions. I think it would be a great way to exercise as patients there for a week or more would most likely make friends (if it's similar to a hotel environment?) -this could be a great motivation!!
ROLE
I also found out I will be dealing mostly with disorders like multiple sclerosis, acquired brain injuries, spinal cord injuries and potentially some amputees. I think my role as a student will be to perform one on one rehab sessions with these patients, involving more high level and independent activities. I think I will become more of a 'supervisor' and less of an 'assistant' as patients at this Centre are independent, and will need more supervision of programs to ensure they're doing it correctly at home. I think I will also become an educator. I can only imagine how difficult it would be to live with MS, and I think I will need to be on the ball with advice, encouragement and support. I think my role is also going to be to learn as much as I can. As I understand from Ali, there are many different ways to approach neuro rehab, and I am hoping to learn many new skills, as well as consolidate those I already have.
CONCERNS
I have SO many concerns about this placement! I feel like my past 2 placements were very MSK based, and thus I have a much better idea about the MSK subjective and objective assessments and treatment techniques. (Not to mention more confidence!) I also missed the first placement as I was doing my project. We were told that now supervisors are less lenient and expect more because it is placement number two...but I am behind. I literally haven't seen any patients since Collie last year! I don't know if I trust myself. Plus, I have my usual worry about not living up to my own expectations or those of my supervisors...but that is nothing new:)
But, if it's anything like my previous 2 placements, I will love every second of it!!
Subscribe to:
Posts (Atom)