Hi,
I just wanted to write about what I felt last Thursday at my placement. As it was the last week of this placement, my supervisor wanted to check on my caseload and gave me 10 patients to see. So I started to see the first three patients who were in high priority.
The first patient was 64yo male patient who has oesophagocarcinoma which my grandma died of two years ago and the survival rate after op is only 15-20%. I met this patient in my first week and has seen him twice a day to improve his lung function and walking tolerance. Although he seemed doing well with physio, he has had two re-operation due to gastric fistula. After repeated operations, he seemed losing confidence and anxious about his future. He reminds me of my grandma and it's hard for me to see him going through all that. Anyways he was very anxious and his voice was shaking during physio session with me.
Then I saw this BKA patient to ambulate him on zimmer frame and do some bed exercises. He didn't look well and finally threw up in front of me as soon as I applied compression bandage on his stump.
Hoo..Next patient is a very fragile 91yo lady, who admitted with abdominal distention and docs suspect that she has a cancer, and I met her for the first time. By accident, while I was sitting in physio gym behind the board, I heard when the doc and her family were having a meeting about sending her to the palliative care department.
All of these accumulated and I got very emotional and was in tears. I think I was never exposed to the environment where there are so many sick patients, and I couldn't stay in hospital any longer on that day and my supervisor sent me home early. Sometimes it's hard to control my emotions and don't know how to deal with it even though I know it's not professional to show tears in front of patients.
In Sun
Sunday, March 30, 2008
Thursday, March 27, 2008
Reflection on my cardiopulmonary placement
Hi All,
This is my last week of cardiopulmonary placement so I have decided to reflect what I have learnt throughout last 4 weeks.
I have had an opportunity to treat post CABG and valves repair surgery. I have assessed patients with respiratory problems and when appropriate enrolled them to pulmonary rehab classes. Being on medical/surgical ward, I had some straightforward patients as well as some more complex patients such for example male with bilateral ankles fracture managed with external fixation, female with flap (thumb-thigh) plus external fixation. I was helping in supervising pulmonary rehab classes twice a week. I found that most of people participating in these classes are highly motivated and eager to exercise despite having some limitations. It was great experience-“living evidence base physiotherapy” when these patients were telling about how much difference pulmonary rehab program made in their lives, how their quality of life improved and exercise tolerance increased as well as management of breathless/fear.
I had opportunity to observe and learnt some things we had not been exposed to at Uni such as teamwork, interpersonal skills. My supervisor has been bombarding me with questions in unstressed manner, which was great! He has been willing to share his experience and always encouraging me to look “outside box”.
Daria
This is my last week of cardiopulmonary placement so I have decided to reflect what I have learnt throughout last 4 weeks.
I have had an opportunity to treat post CABG and valves repair surgery. I have assessed patients with respiratory problems and when appropriate enrolled them to pulmonary rehab classes. Being on medical/surgical ward, I had some straightforward patients as well as some more complex patients such for example male with bilateral ankles fracture managed with external fixation, female with flap (thumb-thigh) plus external fixation. I was helping in supervising pulmonary rehab classes twice a week. I found that most of people participating in these classes are highly motivated and eager to exercise despite having some limitations. It was great experience-“living evidence base physiotherapy” when these patients were telling about how much difference pulmonary rehab program made in their lives, how their quality of life improved and exercise tolerance increased as well as management of breathless/fear.
I had opportunity to observe and learnt some things we had not been exposed to at Uni such as teamwork, interpersonal skills. My supervisor has been bombarding me with questions in unstressed manner, which was great! He has been willing to share his experience and always encouraging me to look “outside box”.
Daria
Monday, March 24, 2008
Anxious patient
Hi All,
I am on my Cardio placement and this week I have learnt how important non-verbal communication is.
My patient is 75 years old after CABGx3 and MVR (nil complications). When I came first time the patient reported to me how well she was after surgery, how diligently she was performing her exercises and that doctors and nursing staff were saying to others patients that they should take example by Mrs.SK. Later during the same visit patient told me that she is excepting to stay at hospital for 8-12 weeks! Additionally, patient mentioned that is scared to stay at home on her own during night. In patient’s notes, I found that Mrs.SK had pharmacological treatment for depression. She is 7 days post CABG, independent with self-caring and ambulation around ward (including stairs), able to perform her HEP independently and correctly, no chest problems. However, patient complained that her (R) hand and leg shaking. At the beginning, I worried about this shaking so I reported to my supervisor. My supervisor made me aware that it does not need be “serious neurological sign” but just anxiety++. Each time when I have been treating this patient, I was trying to match evidence for example auscultation, SpO2/HR/BP) with what patient was saying. I was looking as well for any discrepancy between patient’s performance, verbal and non-verbal communication. During team meeting, other AHS members bring anxiety issue out, too. From the physio point patient is safe for discharge but I think patient would benefit from psychological/counselling referral. As this particular patient is from non-English background with limited English skills, it makes this situation even more complicated.
I would like to know if you have treated similar patient and how you dealt with anxious++ patient from non-English background. Thanks for any suggestions.
Daria
I am on my Cardio placement and this week I have learnt how important non-verbal communication is.
My patient is 75 years old after CABGx3 and MVR (nil complications). When I came first time the patient reported to me how well she was after surgery, how diligently she was performing her exercises and that doctors and nursing staff were saying to others patients that they should take example by Mrs.SK. Later during the same visit patient told me that she is excepting to stay at hospital for 8-12 weeks! Additionally, patient mentioned that is scared to stay at home on her own during night. In patient’s notes, I found that Mrs.SK had pharmacological treatment for depression. She is 7 days post CABG, independent with self-caring and ambulation around ward (including stairs), able to perform her HEP independently and correctly, no chest problems. However, patient complained that her (R) hand and leg shaking. At the beginning, I worried about this shaking so I reported to my supervisor. My supervisor made me aware that it does not need be “serious neurological sign” but just anxiety++. Each time when I have been treating this patient, I was trying to match evidence for example auscultation, SpO2/HR/BP) with what patient was saying. I was looking as well for any discrepancy between patient’s performance, verbal and non-verbal communication. During team meeting, other AHS members bring anxiety issue out, too. From the physio point patient is safe for discharge but I think patient would benefit from psychological/counselling referral. As this particular patient is from non-English background with limited English skills, it makes this situation even more complicated.
I would like to know if you have treated similar patient and how you dealt with anxious++ patient from non-English background. Thanks for any suggestions.
Daria
Friday, March 21, 2008
hypothyroidism and heart conditions
It was my second last week on my cardio placement this week. I've met a number of patients who has undergone cardiac surgery such as CABG and also has hypothyroidism in the past medical history. So, I was wondering what it is and what's the relationship between hypothyroidism and heart conditions.
As background information, the thyroid gland is located at the base of the neck, just below Adam's apple and releases hormones such as thyroxine, triiodothyronine and calcitonin, which regulate all aspects of metabolism in our body. they maintain the rate at which the body uses fats and carbohydrates, control body temperature, influence heart rate and regulate the production of protein.
Causes of hypothyroidism are autoimmune disease, treatment for hyperthyroidism, radiation therapy used to treat cancers of the head and neck, thyroid surgery removing all or a large portion of thyroid, meds such as lithium, congenital disease, pituitary disorder, pregnancy and iodine deficiency.
Person with this disease presents with fatigue, depression, mod weight gain, cold intolerance, sleepiness, muscle cramps, vague aches and pains, etc. Mostly it's well controlled by medication though untreated hypothyroidism can lead to cardiomyopathy, worsening heart failure and pleural effusion.
Heart problems are common complication of hypothyroidism primarily because high levels of LDL cholesterol, an increase in total cholesterol levels and impaired the contractility of the heart leading to an enlarged heart and heart failure.
Thus, it's important to screen the condition by blood test and also control by the synthetic thyroid hormone levothyroxine (for instance, you can find Levothyroid in patient's med chart).
Hope it's useful information if you were wondering about hypothyroidism:)
As background information, the thyroid gland is located at the base of the neck, just below Adam's apple and releases hormones such as thyroxine, triiodothyronine and calcitonin, which regulate all aspects of metabolism in our body. they maintain the rate at which the body uses fats and carbohydrates, control body temperature, influence heart rate and regulate the production of protein.
Causes of hypothyroidism are autoimmune disease, treatment for hyperthyroidism, radiation therapy used to treat cancers of the head and neck, thyroid surgery removing all or a large portion of thyroid, meds such as lithium, congenital disease, pituitary disorder, pregnancy and iodine deficiency.
Person with this disease presents with fatigue, depression, mod weight gain, cold intolerance, sleepiness, muscle cramps, vague aches and pains, etc. Mostly it's well controlled by medication though untreated hypothyroidism can lead to cardiomyopathy, worsening heart failure and pleural effusion.
Heart problems are common complication of hypothyroidism primarily because high levels of LDL cholesterol, an increase in total cholesterol levels and impaired the contractility of the heart leading to an enlarged heart and heart failure.
Thus, it's important to screen the condition by blood test and also control by the synthetic thyroid hormone levothyroxine (for instance, you can find Levothyroid in patient's med chart).
Hope it's useful information if you were wondering about hypothyroidism:)
Monday, March 17, 2008
listen to the patients
I'm in cardiothoracic ward on my cardio prac and got the mid-placement assessment last week. I had 2 sessions with this patient who underwent Ivor Lewis oesophagectomy due to adenocarcinoma 6 days ago.
Subjectively he was quite well and keen on mobilising in the morning, so he ambulated about 100m with only one rest and did DBXs with supportive coughs. When I saw him second time in the afternoon though his face looked quite flushed and anxious. When I was ambulating him, I thought he could at least walk the similar distance which he made in the morning. He sat down in a chair for a short rest after about 25m walk and told me he couldn't do anymore and refused further treatment. I think there is very fine line; when I have to listen to the patient and modify my treatment, and when I push the patient a bit so that he can achieve more than what he is actually capable of. On top of that, he is quite impulsive and anxious. Because he has so many drains and IV lines, I always have to make sure that everything is sorted out on the trolley before he actually gets up, though he tends to stand up too quickly. I should, therefore, make clear instructions and assure him throughout the treatment.
So my point is that I always have to listen to what the patient tells me and be flexible depending on patient's personality and behaviour type. You cannot expect that the patient's condition would be same even on the same day, and every patient is different and individual.
Hope you all are enjoying your prac:)
Subjectively he was quite well and keen on mobilising in the morning, so he ambulated about 100m with only one rest and did DBXs with supportive coughs. When I saw him second time in the afternoon though his face looked quite flushed and anxious. When I was ambulating him, I thought he could at least walk the similar distance which he made in the morning. He sat down in a chair for a short rest after about 25m walk and told me he couldn't do anymore and refused further treatment. I think there is very fine line; when I have to listen to the patient and modify my treatment, and when I push the patient a bit so that he can achieve more than what he is actually capable of. On top of that, he is quite impulsive and anxious. Because he has so many drains and IV lines, I always have to make sure that everything is sorted out on the trolley before he actually gets up, though he tends to stand up too quickly. I should, therefore, make clear instructions and assure him throughout the treatment.
So my point is that I always have to listen to what the patient tells me and be flexible depending on patient's personality and behaviour type. You cannot expect that the patient's condition would be same even on the same day, and every patient is different and individual.
Hope you all are enjoying your prac:)
Sunday, March 16, 2008
Supportive supervision (Daria's Post)
Hi All,
I am on my Cardio placement and on Wednesday, I had experienced hard time from one of my new patients.
Mr.NT is 65 years old male after CABGx5 with pulmonary complication. I checked the patient’s X- ray and blood results. I found that the patient has ¯Hb (below 90).When I came to perform cardiopulmonary subjective and objective assessment and gather missing SHx information I could felt that patient is not in “good mood” however; the patient let me do assessment. I found some very “interesting information” such for example patient was using puffer (Ventolin) 2 puffs every 2 hours. I went to my clinical supervisor to present my findings and discuss my treatment plan( DBExs, supported huff ect). Additionally, I was going to provide some information to the patient about Ventolin and reviewed his technique. When I came back, the patient was standing at doorframe and he stated that either I take him outside or I can go away. I did not wanted be bossy and tell that I in charge so first, I tried to explain to the patient what is treatment plan and why. I mentioned as well that I would like to have a look how he is using his puffer. Automatically, patient commented this that I am saying he is using wrongly his puffer. I kept trying to clarified and explained, however in vain. Finally, I decided to clarify whether the patient refusing treatment. The answer was yes. I went to my clinical supervisor and I reported this situation and documented in patient’s notes.
My supervisor was supportive and said I should treat this as a good experience and do not take personally. Later afternoon my supervisor asked me again if I am OK and added that this patient was grumpy to other medical staff too. He refused blood transfusion and was unpleasant to nursing staff. He said that not all patients are compliant.
It is hard especially at the beginning do not take this sort of situation personally but it was good lesson. I am glad I had this lesson now.
Daria
I am on my Cardio placement and on Wednesday, I had experienced hard time from one of my new patients.
Mr.NT is 65 years old male after CABGx5 with pulmonary complication. I checked the patient’s X- ray and blood results. I found that the patient has ¯Hb (below 90).When I came to perform cardiopulmonary subjective and objective assessment and gather missing SHx information I could felt that patient is not in “good mood” however; the patient let me do assessment. I found some very “interesting information” such for example patient was using puffer (Ventolin) 2 puffs every 2 hours. I went to my clinical supervisor to present my findings and discuss my treatment plan( DBExs, supported huff ect). Additionally, I was going to provide some information to the patient about Ventolin and reviewed his technique. When I came back, the patient was standing at doorframe and he stated that either I take him outside or I can go away. I did not wanted be bossy and tell that I in charge so first, I tried to explain to the patient what is treatment plan and why. I mentioned as well that I would like to have a look how he is using his puffer. Automatically, patient commented this that I am saying he is using wrongly his puffer. I kept trying to clarified and explained, however in vain. Finally, I decided to clarify whether the patient refusing treatment. The answer was yes. I went to my clinical supervisor and I reported this situation and documented in patient’s notes.
My supervisor was supportive and said I should treat this as a good experience and do not take personally. Later afternoon my supervisor asked me again if I am OK and added that this patient was grumpy to other medical staff too. He refused blood transfusion and was unpleasant to nursing staff. He said that not all patients are compliant.
It is hard especially at the beginning do not take this sort of situation personally but it was good lesson. I am glad I had this lesson now.
Daria
Thursday, March 13, 2008
how do you treat that?
Here I am down in Surfton (anme changed to protect the innocent... eat yer hearts out, Brent, Shadi & Nick) doing the rural thing.
Patient with a sub-archnoid L parietal haemorrhage was referred to us for a mobility review. Notes said she was mobilising independently, "but probably shouldn't be". So I go see the pt. do the sujective routine, then a mobility review. Bed mob, STS to sit again, Amb all perfectly safe & indep. I have 10 min. before I have to cruise over to senior's centre for Stay on Your Feet, so I go back to physio gym and grab a step to make sure pt can negotiate her 1 step FE. She does it no prob, even when I get fussy on her and ask her to do the step without touching the WZF (she used the door frame: safe, fast and steady). No sign of ataxia, synergistic movement, weakness or other motor defects... So I write up the notes and head off to SOYF.
Later that day, I cop an earful from one of the staff physios who says I need to treat and not just assess. Of course, I listened and accpeted the feedback without question.
After reflection, I wasn't sure if I should do anything different. I mean, I couldn't see any impairments, so what should I treat? I fulfilled the request at the heart of the referral and no other impairments were evident... Ironically, I would have had to do more Ax to find something to Rx!
So my questions is: should I try to ask the physio what he/she would have done (to learn from the situation - but hard to do without making it sound like I am questioning his / her call) or just forget about i?
Patient with a sub-archnoid L parietal haemorrhage was referred to us for a mobility review. Notes said she was mobilising independently, "but probably shouldn't be". So I go see the pt. do the sujective routine, then a mobility review. Bed mob, STS to sit again, Amb all perfectly safe & indep. I have 10 min. before I have to cruise over to senior's centre for Stay on Your Feet, so I go back to physio gym and grab a step to make sure pt can negotiate her 1 step FE. She does it no prob, even when I get fussy on her and ask her to do the step without touching the WZF (she used the door frame: safe, fast and steady). No sign of ataxia, synergistic movement, weakness or other motor defects... So I write up the notes and head off to SOYF.
Later that day, I cop an earful from one of the staff physios who says I need to treat and not just assess. Of course, I listened and accpeted the feedback without question.
After reflection, I wasn't sure if I should do anything different. I mean, I couldn't see any impairments, so what should I treat? I fulfilled the request at the heart of the referral and no other impairments were evident... Ironically, I would have had to do more Ax to find something to Rx!
So my questions is: should I try to ask the physio what he/she would have done (to learn from the situation - but hard to do without making it sound like I am questioning his / her call) or just forget about i?
Sunday, March 9, 2008
Open Heart Surgery outcomes (Daria's Post)
I am currently on my cardio placement. I am treating the patients who have undergone cardiothoracic surgery such as CABG as well as I have opportunity to conduct pulmonary rehabilitation classes. That is great experience to observe how patients attitudes toward lifestyle are changing.
Hi Guys,
I has treated patient that had CABGx3 performed 2 weeks ago. The patient had presented in ED with chest pain and SOB. PMHx included Ca throat, IHD, high cholesterol, DM, #jaw, ETOH abused. When I asked the patient about smoking history, the patient reported that he had been smoking for 50 years about 40 cigarettes per day before admission. He did not quit smoking after diagnosis of throat Ca but this time the patient said he had his lesson. The patient reported he has not been participated in any regular physical activities or structured exercises. However, because of education about his disease and effects of physical activity, the patient was more than happy to take part in Cardiac Rehabilitation after being discharge.
It is great to treat this very compliant patient with very good outcomes, immediate release of symptoms, good posture, full UL ROM, ability to walk independently and frequently including 2 flights of stairs.
Thanks
Daria
Hi Guys,
I has treated patient that had CABGx3 performed 2 weeks ago. The patient had presented in ED with chest pain and SOB. PMHx included Ca throat, IHD, high cholesterol, DM, #jaw, ETOH abused. When I asked the patient about smoking history, the patient reported that he had been smoking for 50 years about 40 cigarettes per day before admission. He did not quit smoking after diagnosis of throat Ca but this time the patient said he had his lesson. The patient reported he has not been participated in any regular physical activities or structured exercises. However, because of education about his disease and effects of physical activity, the patient was more than happy to take part in Cardiac Rehabilitation after being discharge.
It is great to treat this very compliant patient with very good outcomes, immediate release of symptoms, good posture, full UL ROM, ability to walk independently and frequently including 2 flights of stairs.
Thanks
Daria
getting results from Rx
Hi Everyone.
On my musculo prac I had a lovely 78yr old lady who came in with her main initial Ax findings including: hypomobility of her Lx spine L2-L5 with referral of pins and needles in her buttock and down her posterior thigh. Her aggravating factors were bending over forward and also having to push her grocery trolley. I treated her for the full 4 weeks of my placement- treatment initial included mobilizations to her lower Lx spine and STM to her erector spinae muscle group. In the final couple of sessions with her we started doing some lumbopelvic stability exercises as well. Throughout the course of treatment with her she was able to get increasing more movement in her Lx spine as well as her referred pins and needles and pain subsiding down her leg. For me, it was really great to see progress as a direct result of my treatment.
Thanks- Hope everyone enjoys there rural placements :)
On my musculo prac I had a lovely 78yr old lady who came in with her main initial Ax findings including: hypomobility of her Lx spine L2-L5 with referral of pins and needles in her buttock and down her posterior thigh. Her aggravating factors were bending over forward and also having to push her grocery trolley. I treated her for the full 4 weeks of my placement- treatment initial included mobilizations to her lower Lx spine and STM to her erector spinae muscle group. In the final couple of sessions with her we started doing some lumbopelvic stability exercises as well. Throughout the course of treatment with her she was able to get increasing more movement in her Lx spine as well as her referred pins and needles and pain subsiding down her leg. For me, it was really great to see progress as a direct result of my treatment.
Thanks- Hope everyone enjoys there rural placements :)
Depression after surgery
Hi guys,
I had the first week of my cardio placement this week and it has been very interesting.
I’m treating patients who have undergone cardiothoracic surgery such as CABGs and MVR. I’m teaching them DBXs + supported cough, helping with ambulation and exercises for ULs and LLs. Cause it is a major surgery on the heart, most patients have some sort of depression and aggression (according to research, 30% of patients who have cardiac surgery has depression).
I met this patient who came up to the ward after being ICU for one day. She is 67yo lady with a history of metastatic adenocardinoma in her (R) lung diagnosed in 2007 and recurrent pleural effusion in both lower lobes. She admitted to hospital to get pleuridesis for recurrent pleural effusion as pleural fluid drainage in January has failed.
The operation was for one hour and her obs were stable throughout eg 99% on 6L O2. Also, she does not have major complications after the operation.
When I saw her for the first time, she looked very tired. I ambulated her 100ms on 3L O2 and taught her DBXs and arm exercises. She was compliant to the treatment session with me though whenever I pass by her room, she was slouched and lying in bed most of the day. So I encouraged her to sit in chair and keep doing exercises and also gave her positive feedback on her condition every day.
She progressed pretty well and ambulated 500ms on RA last Friday when she was discharged. She was happy with her progression, however I was worried about her as lung cancer is still the issue for her and she needs more positivity on how she is coping well.
Just wonder if you guys have any strategies to deal with depressed patients.
Thanks
I had the first week of my cardio placement this week and it has been very interesting.
I’m treating patients who have undergone cardiothoracic surgery such as CABGs and MVR. I’m teaching them DBXs + supported cough, helping with ambulation and exercises for ULs and LLs. Cause it is a major surgery on the heart, most patients have some sort of depression and aggression (according to research, 30% of patients who have cardiac surgery has depression).
I met this patient who came up to the ward after being ICU for one day. She is 67yo lady with a history of metastatic adenocardinoma in her (R) lung diagnosed in 2007 and recurrent pleural effusion in both lower lobes. She admitted to hospital to get pleuridesis for recurrent pleural effusion as pleural fluid drainage in January has failed.
The operation was for one hour and her obs were stable throughout eg 99% on 6L O2. Also, she does not have major complications after the operation.
When I saw her for the first time, she looked very tired. I ambulated her 100ms on 3L O2 and taught her DBXs and arm exercises. She was compliant to the treatment session with me though whenever I pass by her room, she was slouched and lying in bed most of the day. So I encouraged her to sit in chair and keep doing exercises and also gave her positive feedback on her condition every day.
She progressed pretty well and ambulated 500ms on RA last Friday when she was discharged. She was happy with her progression, however I was worried about her as lung cancer is still the issue for her and she needs more positivity on how she is coping well.
Just wonder if you guys have any strategies to deal with depressed patients.
Thanks
Tuesday, March 4, 2008
difficult subjective assessment
just a little question. i had a patient in my last week of musculo placement that was referred after a fall with an MRI showing a meniscal tear. As a result, i had the expectation that it would be a fairly straightforward case. However, upon subjective questioning, i realised that she had pain in 3 different regions of her knee which radiated up and down her thigh and shin and also pain in her ankle, 2nd toe and pins and needles which were related to her knee pain. she had 2 different falls which predisposed her to different structures in her knee being injured. besides, she also presented with wrist and elbow pain as well as occasional stiffness in her neck, shoulder and even back. the entire subjective assessment took me about 35 minutes to complete even though i just focussed on the lower limbs! my question is then how do we balance getting a comprehensive subjective and making sure we don't eat up too much of the patients time? what a dilemma...
Monday, March 3, 2008
a reminder to all
Just a quick reminder to all to look after yourselves and take care in your positioning when handling patients. Last week while doing passive mvmts on a pt's leg i flet a little twinge in my back as i reached across the bed to put the leg back down. At the time i didn't think much of it as i'd just finished anyway, and i felt ok. Later in the day i leaned over to open a draw in the nurses station and my little twinge got a little biggerand got slowly bigger throughout the day...
I'm sure there's no serious damage done but its been niggling me all weekend and when i'm in certain positions i am aware that its not right.
Just thought i'd take this opportunity to remind us all of how important it is that we look after ourselves as a damaged physio is no good to anyone... and seeing as we've just spent all these $$$ to become physios it would be nice to be able to earn some of it back before we wear ourslves out too much!!
Good luck to everyone this week. Study hard, and then drink even harder when its all over!!!
Tara
I'm sure there's no serious damage done but its been niggling me all weekend and when i'm in certain positions i am aware that its not right.
Just thought i'd take this opportunity to remind us all of how important it is that we look after ourselves as a damaged physio is no good to anyone... and seeing as we've just spent all these $$$ to become physios it would be nice to be able to earn some of it back before we wear ourslves out too much!!
Good luck to everyone this week. Study hard, and then drink even harder when its all over!!!
Tara
"crazy" patient
I have been seeing a 77 yo lady for the last two or so weeks who has just recently been diagnosed with terminal lung cancer. She comes across as a really sweet old lady at most of the time but then other times she was really agressive and confrontational with some of the nursing staff in particular. She was also quite confused at times, not knowing whether she was dreaming or awake. Because of her sudden changes in moods and he diagnosis of cancer the doctors thought that she may have some brain tumours in the frontal lobe. She refused for a few days to have the head CT but then finally changed her mind and nothing abnormal was found.
A few days later before the team meeting, the doctor was in talking to the patient and she was acting completely "normal" and having an appropriate conversation. As soon as the nurses came in she changed her manner completely and acted as if she didn't know where she was or who she was. As soon as they left she turned to the doctor and said "See, i'm completely fine. I just do that when those stupid nurses come in to get rid of them faster. Its just easier that way so they leave me alone."
This shocked me completely as she'd done this to me as well. She wasn't very compliant with physio because she thought she was fine to just sit there in bed all day and have ppl do whatever she asked them to, so she really didn't like it when i asked her to go for a walk and do some breathing exercises.
After the doctors told us what she was doing tho we all had a lot less sympathy for her, and the nurses refused to do things for that she could do for herself and i certainly didn't put up with her fake craziness anymore!
A few days later before the team meeting, the doctor was in talking to the patient and she was acting completely "normal" and having an appropriate conversation. As soon as the nurses came in she changed her manner completely and acted as if she didn't know where she was or who she was. As soon as they left she turned to the doctor and said "See, i'm completely fine. I just do that when those stupid nurses come in to get rid of them faster. Its just easier that way so they leave me alone."
This shocked me completely as she'd done this to me as well. She wasn't very compliant with physio because she thought she was fine to just sit there in bed all day and have ppl do whatever she asked them to, so she really didn't like it when i asked her to go for a walk and do some breathing exercises.
After the doctors told us what she was doing tho we all had a lot less sympathy for her, and the nurses refused to do things for that she could do for herself and i certainly didn't put up with her fake craziness anymore!
Sunday, March 2, 2008
Another lesson learned
Hello Everyone,
This week I learned probably my most important lesson of all. I did my first assessment of a lady who’s showed up to the outpatient client. During the assessment she said she was referred to physiotherapy because she has been experiencing bilateral paraesthesia and numbness in her arms. She has had 7 episodes over the past 6 years. These episodes mostly occur at night and some during the day. When I initially questioned her about the episodes she was very vague and did not really know the details to any of the questions I asked. She kept repeating how her last episode was 6 months ago. So from that point on of the subjective I moved onto the other parts of the body chart and questioned her about other areas of pain. She reported she did have stiff neck and I knew she had x-rays taken with evidence of degeneration at C5C6. Therefore I started to go into the necessary detail into the neck stiffness/ pain. She was a lot more aware of this and was able to describe it in a lot more detail then the bilateral numbness and paraesthesia. But I also think I am more skilled at questioning issue of pain/ stiffness then other problems. When I went and discussed my subjective findings with my supervisor he asked me what her main complaint/ concern was. I said "the numbness and paraesthesia" he said "yes and what do you have the most information on"? He was right I had transformed the subjective assessment into dealing with her neck pain because is was a more concrete problem that she was able to confidently and directly answer questions about as appose to the vagueness which she used with the neural symptoms. It reinforced that based on the questions we ask we are in control of the direction of the subjective exam. But the subjective exam is so important and inorder to have an effective assessment it should be centered around the patients primary complaint. You have to be careful not to enter with any presumption ( ie X-ray results) so that you don’t narrow your focus to early in the examination. I returned and with more firm questioning and investigation I was able to get more detail on the primary complaint of bilateral numbness and paraesthesia. It was a really important lesson to learn in a clinical situation one that I will remember for a long time to come.
Good luck with PCR studying!
PS- Yes I know its a red flag and I referred her on for further neurological investigation.
This week I learned probably my most important lesson of all. I did my first assessment of a lady who’s showed up to the outpatient client. During the assessment she said she was referred to physiotherapy because she has been experiencing bilateral paraesthesia and numbness in her arms. She has had 7 episodes over the past 6 years. These episodes mostly occur at night and some during the day. When I initially questioned her about the episodes she was very vague and did not really know the details to any of the questions I asked. She kept repeating how her last episode was 6 months ago. So from that point on of the subjective I moved onto the other parts of the body chart and questioned her about other areas of pain. She reported she did have stiff neck and I knew she had x-rays taken with evidence of degeneration at C5C6. Therefore I started to go into the necessary detail into the neck stiffness/ pain. She was a lot more aware of this and was able to describe it in a lot more detail then the bilateral numbness and paraesthesia. But I also think I am more skilled at questioning issue of pain/ stiffness then other problems. When I went and discussed my subjective findings with my supervisor he asked me what her main complaint/ concern was. I said "the numbness and paraesthesia" he said "yes and what do you have the most information on"? He was right I had transformed the subjective assessment into dealing with her neck pain because is was a more concrete problem that she was able to confidently and directly answer questions about as appose to the vagueness which she used with the neural symptoms. It reinforced that based on the questions we ask we are in control of the direction of the subjective exam. But the subjective exam is so important and inorder to have an effective assessment it should be centered around the patients primary complaint. You have to be careful not to enter with any presumption ( ie X-ray results) so that you don’t narrow your focus to early in the examination. I returned and with more firm questioning and investigation I was able to get more detail on the primary complaint of bilateral numbness and paraesthesia. It was a really important lesson to learn in a clinical situation one that I will remember for a long time to come.
Good luck with PCR studying!
PS- Yes I know its a red flag and I referred her on for further neurological investigation.
Successful COPD pt
Hey guys,
The last week of my cardio placement has been really good in tying together all the pt’s seen so far on placement. This week a 67 y.o. female presented to the ED with increasing SOB, excess sputum production (green-yellow) and decreased exercise tolerance.
PMHx: End stage COPD with numerous exacerbations, last being Dec. ’07, hypertension, hypercholestermia.
SHx: retired, married, lives in a single story home on a large property. Has a 4WW for around the house and a scooter for outdoors. Smoker- 10 a day
Exercise tolerance: usually 60-80 meters before requiring a rest
After the subjective & objective examination the problem list in order of priority was:
Dyspnoea
Impaired airway clearance
Impaired gas exchange
¯ exercise tolerance
Airflow limitation
Initial Rx for this pt involved ACBT to help clear secretions and positioning to ¯WOB. The pt was too breathless to stand and ambulate. Over the next couple of days Rx was given 2 times a day with improvements in the pt evident after each intervention. Ambulation was the main intervention employed with excellent results. This increased Vt and FRC- increasing airflow and shearing secretions thus improving V/Q matching. Upper limb exercises were also prescribed increasing the efficiency of accessory muscles used for ventilation. Lower limb strengthening exercises incl. STS & ¼ squats were also employed to improve exercise tolerance and increase the requirements of the respiratory system.
The pt progressed quite quickly and just prior to D/C could ambulate ≈140-160 meters with 1 rest. A HEP was given with the exercises performed on the ward being prescribed. The pt was also r/f to pulmonary rehabilitation for further intervention and continuing education for self mx of her COPD. It was good to see a pt through from admission to almost D/C.
Thanks
The last week of my cardio placement has been really good in tying together all the pt’s seen so far on placement. This week a 67 y.o. female presented to the ED with increasing SOB, excess sputum production (green-yellow) and decreased exercise tolerance.
PMHx: End stage COPD with numerous exacerbations, last being Dec. ’07, hypertension, hypercholestermia.
SHx: retired, married, lives in a single story home on a large property. Has a 4WW for around the house and a scooter for outdoors. Smoker- 10 a day
Exercise tolerance: usually 60-80 meters before requiring a rest
After the subjective & objective examination the problem list in order of priority was:
Dyspnoea
Impaired airway clearance
Impaired gas exchange
¯ exercise tolerance
Airflow limitation
Initial Rx for this pt involved ACBT to help clear secretions and positioning to ¯WOB. The pt was too breathless to stand and ambulate. Over the next couple of days Rx was given 2 times a day with improvements in the pt evident after each intervention. Ambulation was the main intervention employed with excellent results. This increased Vt and FRC- increasing airflow and shearing secretions thus improving V/Q matching. Upper limb exercises were also prescribed increasing the efficiency of accessory muscles used for ventilation. Lower limb strengthening exercises incl. STS & ¼ squats were also employed to improve exercise tolerance and increase the requirements of the respiratory system.
The pt progressed quite quickly and just prior to D/C could ambulate ≈140-160 meters with 1 rest. A HEP was given with the exercises performed on the ward being prescribed. The pt was also r/f to pulmonary rehabilitation for further intervention and continuing education for self mx of her COPD. It was good to see a pt through from admission to almost D/C.
Thanks
Non compliant COPD pt
Hey guys,
This week in my cardio placement I have been able to return to the medical ward as it has reopened after being closed by a norovirus outbreak. A patient I was treating approx. 10-12 days before the outbreak was still on the ward and was awaiting placement in a rehabilitation ward.
Initially she presented to hospital with increasing SOB, increased sputum production and reduced exercise tolerance. The pt was diagnosed with an infective exacerbation of her COPD. The chest infection has since resolved and her main problem now is reduced exercise tolerance.
The patient was quite reluctant to ambulate on the ward and would even refuse physiotherapy at times; thus further contributing to the cycle of deconditioning. A number of strategies were tried to convince this patient about the importance of ambulation including:
- earlier D/C
- education RE: immunity thus ¯ risk of future exacerbations & hospital admissions
- maintenance of independence & therefore maintenance/improvement of her quality of life.
To gain optimal benefits it would have been ideal to treat this pt 2 times a day; however she was only compliant with 1 session a day. I was wondering if anyone experienced non-compliant pt’s and what strategies they used to overcome this
Thanks guys
This week in my cardio placement I have been able to return to the medical ward as it has reopened after being closed by a norovirus outbreak. A patient I was treating approx. 10-12 days before the outbreak was still on the ward and was awaiting placement in a rehabilitation ward.
Initially she presented to hospital with increasing SOB, increased sputum production and reduced exercise tolerance. The pt was diagnosed with an infective exacerbation of her COPD. The chest infection has since resolved and her main problem now is reduced exercise tolerance.
The patient was quite reluctant to ambulate on the ward and would even refuse physiotherapy at times; thus further contributing to the cycle of deconditioning. A number of strategies were tried to convince this patient about the importance of ambulation including:
- earlier D/C
- education RE: immunity thus ¯ risk of future exacerbations & hospital admissions
- maintenance of independence & therefore maintenance/improvement of her quality of life.
To gain optimal benefits it would have been ideal to treat this pt 2 times a day; however she was only compliant with 1 session a day. I was wondering if anyone experienced non-compliant pt’s and what strategies they used to overcome this
Thanks guys
Hydro for GB
Hi all,
During the last placement I have come to the conclusion that hydro is great way of treating patients with neuromuscular disorders especially Guillain Barre Disease. I have been treating a couple of patients with this disease and both are able to complete tasks in the pool that seem impossible in the clinic. Hydro is especially effective when dealing with the impairments of decreased strength, decreased balance and hypotonia. My sessions usually begin with trunk exercises including seaweeding, alternate shoulder protractions keeping trunk level on the surface of water, and assisted ab curls. Then my session moves on to LL strengthening exercises utlising kicking and swimming activities, buoyancy resisted work, squatting and steps exercise. After this the session moves on to high level balance activities that can be progressed in difficulty by reducing water depth and/or adding trubulence. Finally the session ends with some running, and bounding work followed by some stretching.
The two patients have made the comment that they are often less fatigued after the sessions (which is a huge problem with GB) and recover faster for subsequent sessions. I guess the thing to remember is that they must be able to transfer the impairment improvements into every day functional activities so I think the best mix is to have one session in the pool and one in the clinic/gym. It would be interesting to hear from anyone else about their hydro experiences during their various placements. It is certainely one area where I feel there is much still to learn.
Finally I just would like to say thanks everyone for the interesting and informative blogs over the last couple of months. Good luck this week and have fantastic rural placements.
Cheers
Nico
During the last placement I have come to the conclusion that hydro is great way of treating patients with neuromuscular disorders especially Guillain Barre Disease. I have been treating a couple of patients with this disease and both are able to complete tasks in the pool that seem impossible in the clinic. Hydro is especially effective when dealing with the impairments of decreased strength, decreased balance and hypotonia. My sessions usually begin with trunk exercises including seaweeding, alternate shoulder protractions keeping trunk level on the surface of water, and assisted ab curls. Then my session moves on to LL strengthening exercises utlising kicking and swimming activities, buoyancy resisted work, squatting and steps exercise. After this the session moves on to high level balance activities that can be progressed in difficulty by reducing water depth and/or adding trubulence. Finally the session ends with some running, and bounding work followed by some stretching.
The two patients have made the comment that they are often less fatigued after the sessions (which is a huge problem with GB) and recover faster for subsequent sessions. I guess the thing to remember is that they must be able to transfer the impairment improvements into every day functional activities so I think the best mix is to have one session in the pool and one in the clinic/gym. It would be interesting to hear from anyone else about their hydro experiences during their various placements. It is certainely one area where I feel there is much still to learn.
Finally I just would like to say thanks everyone for the interesting and informative blogs over the last couple of months. Good luck this week and have fantastic rural placements.
Cheers
Nico
Proper Patient Positioning and Handling is Essential
If there is one key point that I’ll take away from my neurology placement, that would be the importance of maintaining a high standard in our positioning of patients and the way in which we handle patients during transfers and therapy sessions.
First to the topic regarding the positioning of a patient who has suffered a stroke, whether in bed or a wheelchair. Over the past weeks, I’ve witnessed the effect poor positioning has on the level of upper/lower limb tone and the de-activation of postural tone. Having an upper limb positioned in a not so optimal position in bed on a repeated basis will increase the potential for a loss of ROM and function. This should be addressed with nursing staff and OT as soon as possible as the patient’s functional outcome is the priority.
Additional information that can be relayed to the nursing staff is the positioning in a wheelchair as many patients will be transferred when a therapist is not present. A great strategy that was pointed out to me was when working with a patient in a wheelchair, ensure that the patient has neutral pelvic tilt by having them lean forward and if their pelvis remains in contact with back of the chair then a good position has been achieved. Also ensuring that the pelvis is centered in the chair is a priority. As the patient will be spending a significant amount of time in the chair it’s important that they have every opportunity to increase their postural tone when not having physiotherapy.
To the topic of our handling of patients’ limbs and during transfers, I believe we must look at this from the patient’s perspective. I’ve had a couple of patients mention the difference when they’ve been handled by individuals who take a bit of care and those who don’t. Guess which way was better? I think patients will be much more receptive to our treatment sessions if they feel like they are being handle with care and respect, thus making our sessions that more effective.
Anyway I hope that everybody has enjoyed their placements and good luck this week.
Gareth
First to the topic regarding the positioning of a patient who has suffered a stroke, whether in bed or a wheelchair. Over the past weeks, I’ve witnessed the effect poor positioning has on the level of upper/lower limb tone and the de-activation of postural tone. Having an upper limb positioned in a not so optimal position in bed on a repeated basis will increase the potential for a loss of ROM and function. This should be addressed with nursing staff and OT as soon as possible as the patient’s functional outcome is the priority.
Additional information that can be relayed to the nursing staff is the positioning in a wheelchair as many patients will be transferred when a therapist is not present. A great strategy that was pointed out to me was when working with a patient in a wheelchair, ensure that the patient has neutral pelvic tilt by having them lean forward and if their pelvis remains in contact with back of the chair then a good position has been achieved. Also ensuring that the pelvis is centered in the chair is a priority. As the patient will be spending a significant amount of time in the chair it’s important that they have every opportunity to increase their postural tone when not having physiotherapy.
To the topic of our handling of patients’ limbs and during transfers, I believe we must look at this from the patient’s perspective. I’ve had a couple of patients mention the difference when they’ve been handled by individuals who take a bit of care and those who don’t. Guess which way was better? I think patients will be much more receptive to our treatment sessions if they feel like they are being handle with care and respect, thus making our sessions that more effective.
Anyway I hope that everybody has enjoyed their placements and good luck this week.
Gareth
Saturday, March 1, 2008
Compassion and COPD
Hey folks
My final assessment yesterday was with a middle aged man currently having an infective exacerbation of his COPD. I had not seen him before, but from his notes gathered that his history of increasing shortness of breath and reduced exercise tolerance co-incided with an exacerbation of his haemorrhoids, with were very painful.
Upone some subjective questioning it came out that his haemorrhoids were preventing him from being comfortable in any position, particulary sitting and standing. A modified high side-lying positiong was the most easing of his pain. On top of this he had not opened his bowels for a few days, and when he does it is obviouslety painful. These facts alone were making this guy quite distressed and anxious, and it he was still waiting for a decisiong as to best manage his problem, as the surgeon would not operate and medical management had been unsuccessful as yet.
The anxiety and worry this man had over his pain and discomfort were reulting in him becoming more and more short of breath, and in general worsening his COPD symptoms. It had been my plan to re-assess some important signs then begin my treatment of techniques to reduce SOB, a walk with his O2 and some UL exercises, while assessing his mobility. We did manage a walk, which was interrupted by a sudden desire to defecate (false alarm). This in turn made him more upset. He bacme quite teary and upset after this, expressing his concern over his haemorrhoids, which to him were his primary problem, but it seemed as if others were just brushing over it. And he felt, as did we, that his COPD symptoms were as bad as they are because of this primary problem. I instinctively tried to comfort him, but was glad my supervisor was thereas she knew exactly what to say. These people with chronic lung disease have a very specific set of problems and associated anxiety and depression and I learnt a lot from my supervisor with regard to what to say to ease these feelings and make them feel more comfortable.
My final assessment yesterday was with a middle aged man currently having an infective exacerbation of his COPD. I had not seen him before, but from his notes gathered that his history of increasing shortness of breath and reduced exercise tolerance co-incided with an exacerbation of his haemorrhoids, with were very painful.
Upone some subjective questioning it came out that his haemorrhoids were preventing him from being comfortable in any position, particulary sitting and standing. A modified high side-lying positiong was the most easing of his pain. On top of this he had not opened his bowels for a few days, and when he does it is obviouslety painful. These facts alone were making this guy quite distressed and anxious, and it he was still waiting for a decisiong as to best manage his problem, as the surgeon would not operate and medical management had been unsuccessful as yet.
The anxiety and worry this man had over his pain and discomfort were reulting in him becoming more and more short of breath, and in general worsening his COPD symptoms. It had been my plan to re-assess some important signs then begin my treatment of techniques to reduce SOB, a walk with his O2 and some UL exercises, while assessing his mobility. We did manage a walk, which was interrupted by a sudden desire to defecate (false alarm). This in turn made him more upset. He bacme quite teary and upset after this, expressing his concern over his haemorrhoids, which to him were his primary problem, but it seemed as if others were just brushing over it. And he felt, as did we, that his COPD symptoms were as bad as they are because of this primary problem. I instinctively tried to comfort him, but was glad my supervisor was thereas she knew exactly what to say. These people with chronic lung disease have a very specific set of problems and associated anxiety and depression and I learnt a lot from my supervisor with regard to what to say to ease these feelings and make them feel more comfortable.
The importance of being thorough
So this week was our last week of clinic and I had a great start to the week on Tuesday with three of my patients being invloved in an 'incident' with me or immediately after I had seen them. The first incicent was unavoidable so I wont go into that here. The second, however, could have been prevented or at least handled a lot better on my behalf.
I was told to take a patient to the exercise class we hold daily on the ward (medical specialties ward at RPH, cardio placement), with the intention of doing some leg exercises with him as he wasnt moving his legs very well and to get him to walk for some distance without his WZF. So with this in mind we walked to the class (roughly 70m) with the frame, doing some UL and LL exercies in the class with a focus on some active-assisted knee extension in sitting, then walking back to his room without the frame, just me putting it a few metres in front, then us both walking up to it. His knee collapsed about 40m into the walk back, so I gave him the frame and he happily walked on back to his room. When he was safely in his chair, ready for lunch, I left him, but not until I had questioned him on any pain/dizziness, which I had been doing throughourt the treatment.
I was informed later that day by a nurse that a short time later, on doing her routine obs, this patient was found to have a blood pressure reading of 85/35 and instruced to lay in bed with the head tilited down until this resolved. At this stage he was also looking out of sorts, and apparently feeling pretty crap, none of which was reported to me or present when I was with the patient. I felt pretty guilty at this stage and was thinking how this could have been avoided.
As it turned out, the reason this guy couldnt move his legs was because they had been burnt, quite serverly, so of course he was in a lot of pain and had restriced ROM which I should not have pushed as far as I did in the exercise class had I know. This was not presented to me in my 1 mintue handover of the patient, but I should have taken the time to read his notes, find out why he was in hospital and his current problems.
On top of this I should have checked his obs after the treatment. In my defence I had checked his chart before treatment, his obs were stable and there was no indication that he would have any adverse affect to the treatment. But this was the most amount of exercise he had done in a while and I really should have monitored him more closely and it was just lucky that his nurse did this for me!
I wont go into the third patient but lets just say it was a very draining day and one that reinforced to me the importance of being thorough with my monitoring of patients and keeping in mind other complicating factors/co-morbidities thart may impact on their treatment and how they will respond.
I was told to take a patient to the exercise class we hold daily on the ward (medical specialties ward at RPH, cardio placement), with the intention of doing some leg exercises with him as he wasnt moving his legs very well and to get him to walk for some distance without his WZF. So with this in mind we walked to the class (roughly 70m) with the frame, doing some UL and LL exercies in the class with a focus on some active-assisted knee extension in sitting, then walking back to his room without the frame, just me putting it a few metres in front, then us both walking up to it. His knee collapsed about 40m into the walk back, so I gave him the frame and he happily walked on back to his room. When he was safely in his chair, ready for lunch, I left him, but not until I had questioned him on any pain/dizziness, which I had been doing throughourt the treatment.
I was informed later that day by a nurse that a short time later, on doing her routine obs, this patient was found to have a blood pressure reading of 85/35 and instruced to lay in bed with the head tilited down until this resolved. At this stage he was also looking out of sorts, and apparently feeling pretty crap, none of which was reported to me or present when I was with the patient. I felt pretty guilty at this stage and was thinking how this could have been avoided.
As it turned out, the reason this guy couldnt move his legs was because they had been burnt, quite serverly, so of course he was in a lot of pain and had restriced ROM which I should not have pushed as far as I did in the exercise class had I know. This was not presented to me in my 1 mintue handover of the patient, but I should have taken the time to read his notes, find out why he was in hospital and his current problems.
On top of this I should have checked his obs after the treatment. In my defence I had checked his chart before treatment, his obs were stable and there was no indication that he would have any adverse affect to the treatment. But this was the most amount of exercise he had done in a while and I really should have monitored him more closely and it was just lucky that his nurse did this for me!
I wont go into the third patient but lets just say it was a very draining day and one that reinforced to me the importance of being thorough with my monitoring of patients and keeping in mind other complicating factors/co-morbidities thart may impact on their treatment and how they will respond.
Thursday, February 28, 2008
Thinking about the 'core'
Hi all,
Currently on my Musculo placement and have been treating a lovely 78 yr old lady who first presented with sharp back pain, with referral of pain down her posterior leg, she also had a +ve SLR. She had good global ROM in all directions, however, her inter-segmental movement was hypomobile in the lower segments.
Rx consisted of PAIVMs & STM to the Lx region and muscle stretching & STM to her piriformis as this was often the site of her buttock symptoms. For the initial first treatments with her I focused on the above- both times when she returned she would state how for the first 2-3days after the Rx she felt great however after this until her next session she would slowly deteriorate with the pain intensifying. So, last week I decided to add in some lumbopelvic stability exercises as an adjunct to the manual hands on techniques I had been using. This included pelvic tilts in sitting and some TA work in crook lying. When she came back this week she stated how those exercises had really helped her and the treatment had had a longer lasting effect then the previous treatments.
Again, as many other posts have brought up, it highlights the importance of core stability work in patients and how manual treatments shouldn’t only be used as you need to empower the patient and get them highly involved in their rehabilitation process.
Currently on my Musculo placement and have been treating a lovely 78 yr old lady who first presented with sharp back pain, with referral of pain down her posterior leg, she also had a +ve SLR. She had good global ROM in all directions, however, her inter-segmental movement was hypomobile in the lower segments.
Rx consisted of PAIVMs & STM to the Lx region and muscle stretching & STM to her piriformis as this was often the site of her buttock symptoms. For the initial first treatments with her I focused on the above- both times when she returned she would state how for the first 2-3days after the Rx she felt great however after this until her next session she would slowly deteriorate with the pain intensifying. So, last week I decided to add in some lumbopelvic stability exercises as an adjunct to the manual hands on techniques I had been using. This included pelvic tilts in sitting and some TA work in crook lying. When she came back this week she stated how those exercises had really helped her and the treatment had had a longer lasting effect then the previous treatments.
Again, as many other posts have brought up, it highlights the importance of core stability work in patients and how manual treatments shouldn’t only be used as you need to empower the patient and get them highly involved in their rehabilitation process.
Tuesday, February 26, 2008
suctioning
Hi all,
Throughout my cardio placement i've had to do suctioning on an unconcious pt with a trachy in. The first time i did this was during the first week of my placement. My supervisor went through a quick refresher on how to suction and did a demonstration on the pt and then it was my turn. I was pretty grossed out by the noise of the suctioning and the fact that when the saline was put into the trachy to help with clearance a cough reflex was elicited and the saline along with a bit of sputum can shooting back out the trachy, but i had to give it a go. Although my first suctioning experience was a bit rushed, it was fairly effective and got a good amount of sputum out... and luckily nothing came spewing out the trachy all over me! (Thank god!) Over the next couple of suctioning episodes i became a lot more comfortable with the whole thing and eventually got over the grossness and it actually became quite satisfying to get the sputum out!
For those who didn't get the chance to do any suctioning on their cardio placement, the number one tip i can give when you do give it a go is preparation. If you set everything up before you start and make sure that everything you need is within reaching distance then it makes things so much easier... there's nothing more annoying than getting halfway through the suctioning process and realising that you left the clean gloves on the other side of the room!!
Throughout my cardio placement i've had to do suctioning on an unconcious pt with a trachy in. The first time i did this was during the first week of my placement. My supervisor went through a quick refresher on how to suction and did a demonstration on the pt and then it was my turn. I was pretty grossed out by the noise of the suctioning and the fact that when the saline was put into the trachy to help with clearance a cough reflex was elicited and the saline along with a bit of sputum can shooting back out the trachy, but i had to give it a go. Although my first suctioning experience was a bit rushed, it was fairly effective and got a good amount of sputum out... and luckily nothing came spewing out the trachy all over me! (Thank god!) Over the next couple of suctioning episodes i became a lot more comfortable with the whole thing and eventually got over the grossness and it actually became quite satisfying to get the sputum out!
For those who didn't get the chance to do any suctioning on their cardio placement, the number one tip i can give when you do give it a go is preparation. If you set everything up before you start and make sure that everything you need is within reaching distance then it makes things so much easier... there's nothing more annoying than getting halfway through the suctioning process and realising that you left the clean gloves on the other side of the room!!
Monday, February 25, 2008
Should we 'fire' patients?
On my present placement, an interesting case has come up regarding compliance w HEP. It has led time to wonder whether we should 'fire' some patients?
In reading the pt.'s first and second transfer summary, it became apparent that this patient never did her HEP X.s; and, aside from some initial progress, her status had plateau’d. Her disorder is a low back postural / loading disorder, so her X.s and behaviour modification re key to resolving the problem.
The obvious thoughts occurred to me: perhaps she did not understand the PT approach (i.e. that pt. involvement is a key part of Mx) or that she did not know that she would have to stick with her X.s for 5-6 weeks to see strength gains and longer to see permanent assimilation of new motor patterns necessary for modified posture to become 'first nature'. Or maybe she was too busy to do her X.s - or they hurt?
So I gently asked her why she didn't do her X.s and she didn't have a reason. I went over the aforementioned concepts and she replied that this was very much what the previous student physios had said. Period.
Admittedly, some of this pt.'s issues are emotional / psychological. I also couldn't help wondering if some of the poor oldies on the waiting list couldn't benefit more from clinic time than this pt. was... So I came to the questions? Should we fire pt.s? My heart says yes, but I am not sure if we have the authority to do this. What are other people's thoughts?
In the end, I asked her if she would be interested in a X rehab class and when she expressed an interest, I signed her up. Perhaps the structure and context will give her some motivation, but in the end I am not sure if 1-2x /week will make enough difference...
In reading the pt.'s first and second transfer summary, it became apparent that this patient never did her HEP X.s; and, aside from some initial progress, her status had plateau’d. Her disorder is a low back postural / loading disorder, so her X.s and behaviour modification re key to resolving the problem.
The obvious thoughts occurred to me: perhaps she did not understand the PT approach (i.e. that pt. involvement is a key part of Mx) or that she did not know that she would have to stick with her X.s for 5-6 weeks to see strength gains and longer to see permanent assimilation of new motor patterns necessary for modified posture to become 'first nature'. Or maybe she was too busy to do her X.s - or they hurt?
So I gently asked her why she didn't do her X.s and she didn't have a reason. I went over the aforementioned concepts and she replied that this was very much what the previous student physios had said. Period.
Admittedly, some of this pt.'s issues are emotional / psychological. I also couldn't help wondering if some of the poor oldies on the waiting list couldn't benefit more from clinic time than this pt. was... So I came to the questions? Should we fire pt.s? My heart says yes, but I am not sure if we have the authority to do this. What are other people's thoughts?
In the end, I asked her if she would be interested in a X rehab class and when she expressed an interest, I signed her up. Perhaps the structure and context will give her some motivation, but in the end I am not sure if 1-2x /week will make enough difference...
Assessment shortcuts
On the musculo placement, it has become clear that rapid assessment is key, especially in more complex cases (e.g. where there are multiple different pains, sensory loss, sensitisation, etc.). What I am wondering is, how do physios decide to narrow down what things to assess?
Also, how thorough an Ax should we do for hand-over pt.s? In an initial assessment, there is usually enough time to do a thorough assessment, especially for things like a knee or ankle problems. But if we have a hand-over pt, should we just accept the previous student physio's evaluation of what the major problem is or key comparable signs are? At my present placement, the faculty supervisor and the Curtin tutor don't agree on this...
Has anyone found a good way of narrowing down what to assess? I guess we are taught that a good subjective and observation of functional tasks should help, but I have watched someone with Gr.III quads; and someone else with Gr.IV- H.Abdr.s walking without spotting a gait anomaly! Perhaps it just comes with experience?
Also, how thorough an Ax should we do for hand-over pt.s? In an initial assessment, there is usually enough time to do a thorough assessment, especially for things like a knee or ankle problems. But if we have a hand-over pt, should we just accept the previous student physio's evaluation of what the major problem is or key comparable signs are? At my present placement, the faculty supervisor and the Curtin tutor don't agree on this...
Has anyone found a good way of narrowing down what to assess? I guess we are taught that a good subjective and observation of functional tasks should help, but I have watched someone with Gr.III quads; and someone else with Gr.IV- H.Abdr.s walking without spotting a gait anomaly! Perhaps it just comes with experience?
Pelvis as a Base of Support
This past week ended with an exciting outcome as one of my patients on my neurology placement achieved an important goal that he had set for himself. This patient was diagnosed with Guillain-Barre Syndrome three weeks ago and after deteriorating for approximately one week, has started to experience gradual recovery of his upper and lower muscle groups over the past two weeks. It has been a privilege to work with this patient from the beginning and watch his progression of recovery. The patient had the goal of taking his first steps by the end of last week, however at the beginning of the week the patient was still quite wobbly in standing. This was partly due to the weakness in his lower limbs but, as my supervisor pointed out to me, he still didn’t have the stability around the pelvis to stand, let alone take a few steps.
So we focused our sessions around improving the activation of his lower abdominal wall and thus improving lumbopelvic stability. The exercises progressed from crooklying, 4pt and then 2pt kneeling. We worked on contraction of the lower abdominal wall with lower and upper limb movement, then dissociation of the lumbar and pelvis in both the 4pt and 2 pt positions. The improvement was quite noticeable as his ability to perform ¼ squats in 2pt and standing progressed even though his muscle strength in the hip and knee extensors remained constant.
The importance of having good activation of the trunk and pelvic muscles as well as good stability around the hips and pelvis was a frequent theme in our labs and was highlighted to me in this experience. And as was pointed out to me, with ambulation the pelvis is the base of support of importance. So as a result of his hard work this week, the patient was able to walk two laps in the parallel bars independently. It was great to able to share in his excitement for being able to achieve such an important goal for the patient.
Gareth
So we focused our sessions around improving the activation of his lower abdominal wall and thus improving lumbopelvic stability. The exercises progressed from crooklying, 4pt and then 2pt kneeling. We worked on contraction of the lower abdominal wall with lower and upper limb movement, then dissociation of the lumbar and pelvis in both the 4pt and 2 pt positions. The improvement was quite noticeable as his ability to perform ¼ squats in 2pt and standing progressed even though his muscle strength in the hip and knee extensors remained constant.
The importance of having good activation of the trunk and pelvic muscles as well as good stability around the hips and pelvis was a frequent theme in our labs and was highlighted to me in this experience. And as was pointed out to me, with ambulation the pelvis is the base of support of importance. So as a result of his hard work this week, the patient was able to walk two laps in the parallel bars independently. It was great to able to share in his excitement for being able to achieve such an important goal for the patient.
Gareth
Sunday, February 24, 2008
Cardio placement turned Musculo (only for 1 pt though)
Hey guys,
Currently I am completing my cardiopulmonary placement with the majority of my time being spent on the medical ward. That was up until last Wednesday when there was an outbreak of the norovirus. This resulted in the ward being closed; staff who work on this ward are not allowed to any other areas of the hospital. Unfortunately for me the policy of the hospital is that students are not allowed into wards that have been closed due to norovirus outbreak.
Therefore I was very limited to the number of patients I could treat. The surgical ward has very few patients and the majority of the surgery is lower abdominal, it is very rare that any patients here have a PPC. With my supervisor struggling to find patients for me to see cardio wise, I was able to attend emergency with him in relation to a patient who presented with severe acute LBP.
“Steve”, 46 y.o. male presented with severe pain, and unable to stand or walk; previously he was independent with everything. He was t/f to hospital via ambulance. Steve has had 3 previous episodes of acute LBP that resolved spontaneously within 3-5 days in the past. On this occasion Steve hurt his back at work two days earlier shovelling gravel. He went home immediately and had been mainly resting in bed and doing some light walking around the house. The back was improving over the next day and a half until he started to get the severe pain again and was unable to move.
Due to the irritability Ax was limited to Steve moving from supine to SOEB. With attempting to stand he slumped back down to the bed. Steve displayed a large list towards his painful side and unable to sit vertical due to the pain. His greatest relieving position was right side lying.
Our intervention was to apply a heat pack for 20min in right side lie. This had a good effect and relieved the pain so my supervisor told me. Unluckily for me I was unable to follow up with Steve. But I was told that in conjunction with some very strong pain med’s Steve was able to walk out of the emergency department after a couple of hours.
Even though I was unable to access my cardio patients I was still able to learn something in another area. Having to think on my feet in a completely different area to the placement I am completing was a great challenge and gave me good variety.
Currently I am completing my cardiopulmonary placement with the majority of my time being spent on the medical ward. That was up until last Wednesday when there was an outbreak of the norovirus. This resulted in the ward being closed; staff who work on this ward are not allowed to any other areas of the hospital. Unfortunately for me the policy of the hospital is that students are not allowed into wards that have been closed due to norovirus outbreak.
Therefore I was very limited to the number of patients I could treat. The surgical ward has very few patients and the majority of the surgery is lower abdominal, it is very rare that any patients here have a PPC. With my supervisor struggling to find patients for me to see cardio wise, I was able to attend emergency with him in relation to a patient who presented with severe acute LBP.
“Steve”, 46 y.o. male presented with severe pain, and unable to stand or walk; previously he was independent with everything. He was t/f to hospital via ambulance. Steve has had 3 previous episodes of acute LBP that resolved spontaneously within 3-5 days in the past. On this occasion Steve hurt his back at work two days earlier shovelling gravel. He went home immediately and had been mainly resting in bed and doing some light walking around the house. The back was improving over the next day and a half until he started to get the severe pain again and was unable to move.
Due to the irritability Ax was limited to Steve moving from supine to SOEB. With attempting to stand he slumped back down to the bed. Steve displayed a large list towards his painful side and unable to sit vertical due to the pain. His greatest relieving position was right side lying.
Our intervention was to apply a heat pack for 20min in right side lie. This had a good effect and relieved the pain so my supervisor told me. Unluckily for me I was unable to follow up with Steve. But I was told that in conjunction with some very strong pain med’s Steve was able to walk out of the emergency department after a couple of hours.
Even though I was unable to access my cardio patients I was still able to learn something in another area. Having to think on my feet in a completely different area to the placement I am completing was a great challenge and gave me good variety.
Bilateral Knee Replacement.
Hello Everyone,
This week the importance of physiotherapy rehabilitation post knee, hip, and shoulder replacement was highlighted. This week I had a new patient who had bilateral total knee replacements in 2001 and 2002. She reports not having had physiotherapy at any stage post surgery. She presented to the clinic with an abnormal gait pattern using a walking stick for assistance. After having a closer look at her gait I noticed it was actually a bilateral compensated Trendelenberg gait pattern. The reason this lady presented to the clinic was due to bilateral leg weakness and increased incidence of falls. After my assessment I discovered she had 72 degrees of knee flexion in her left knee and 80 degrees of flexion in her right knee. Post knee replacement we would want at least 100 degrees of flexion for most functional tasks. MMT showed she has grade 2; hamstrings glut med, glut max, grade 3 quads and grade 4 gastrocs. As you can see her major problem is weakness in her lower limbs which is also affecting her ROM at her knee as well. This was the first time I have seen an example of such massive de-conditioning. It surprised me that a 63 year old lady who use to square dance for 25 years prior to knee replacement could have ended up with grade 2 muscle strength. I was surprised to see this type of weakness in the outpatient clinic I would have expected this on a neurological ward but not with someone walking into the outpatient clinic. It was a good learning lesson for me and will be a great challenge to strengthen this lady. It’s a shame it is my last week I would have enjoyed being able to monitor her progression through an extensive strengthening program. Being able to use the skills we were taught for muscle strengthening use of eccentric and concentric, gravity eliminated positions as well as isometric resistance to aid this ladies rehabilitation. I would have learned a lot with regards to time frame for muscle strengthening as I don't feel confident with estimating these times. It would have been very rewarding to see her walk with out her current pattern. My question is how long do you think it would take for her to regain a normal gait pattern or do you even think this is possible with her present de-conditioning?
This week the importance of physiotherapy rehabilitation post knee, hip, and shoulder replacement was highlighted. This week I had a new patient who had bilateral total knee replacements in 2001 and 2002. She reports not having had physiotherapy at any stage post surgery. She presented to the clinic with an abnormal gait pattern using a walking stick for assistance. After having a closer look at her gait I noticed it was actually a bilateral compensated Trendelenberg gait pattern. The reason this lady presented to the clinic was due to bilateral leg weakness and increased incidence of falls. After my assessment I discovered she had 72 degrees of knee flexion in her left knee and 80 degrees of flexion in her right knee. Post knee replacement we would want at least 100 degrees of flexion for most functional tasks. MMT showed she has grade 2; hamstrings glut med, glut max, grade 3 quads and grade 4 gastrocs. As you can see her major problem is weakness in her lower limbs which is also affecting her ROM at her knee as well. This was the first time I have seen an example of such massive de-conditioning. It surprised me that a 63 year old lady who use to square dance for 25 years prior to knee replacement could have ended up with grade 2 muscle strength. I was surprised to see this type of weakness in the outpatient clinic I would have expected this on a neurological ward but not with someone walking into the outpatient clinic. It was a good learning lesson for me and will be a great challenge to strengthen this lady. It’s a shame it is my last week I would have enjoyed being able to monitor her progression through an extensive strengthening program. Being able to use the skills we were taught for muscle strengthening use of eccentric and concentric, gravity eliminated positions as well as isometric resistance to aid this ladies rehabilitation. I would have learned a lot with regards to time frame for muscle strengthening as I don't feel confident with estimating these times. It would have been very rewarding to see her walk with out her current pattern. My question is how long do you think it would take for her to regain a normal gait pattern or do you even think this is possible with her present de-conditioning?
Saturday, February 23, 2008
The Running Group
Hi all,
Some of you that have already completed my neuro placement will know about the running group clinic on Thursday afternoons, but I just thought I would share the experience with the rest of the crew.
The running group was the brainchild of our supervisor and is run by the students. The group consists of 4/5 stroke patients of a younger age (25-50) that have recovered sufficiently to allow them to begin to run again. The clinic is run in the gym. The clinic provides a way of facilitating a return to sport or allows a client to achieve a goal that is not possible in the neuro outpatient setting. Each client is given a targeted set of exercises which consists of stretching, LL strength work, bounding and running drills, facilitated running, and eventually a timed run. Focus is on quality and style of running, not only time. It also provides a way of improving the client's cardio respiratory fitness.
I have enjoyed being part of the group and I think it is really beneficial in helping a client to achieve their goals. There is always great atmosphere amongst the group and the support and camaraderie of the fellow participants makes the participants achieve results that I am continually amazed with. I think sometimes in neuro we think that once a person can transfer, walk and reach, then this is the end of the rehabilitation process, when in fact (especially for the younger poulation) there are many more activities that these people would like to be involved with again. The guy I was looking after last session was once a high level soccer player in his former country and would like to become a soccer coach.
It would be interesting to know whether any of the crew has had similar experiences with group activity/special interest classes that we as Physios could possible implement into our workplace once we graduate.
Cheers
Nico
Some of you that have already completed my neuro placement will know about the running group clinic on Thursday afternoons, but I just thought I would share the experience with the rest of the crew.
The running group was the brainchild of our supervisor and is run by the students. The group consists of 4/5 stroke patients of a younger age (25-50) that have recovered sufficiently to allow them to begin to run again. The clinic is run in the gym. The clinic provides a way of facilitating a return to sport or allows a client to achieve a goal that is not possible in the neuro outpatient setting. Each client is given a targeted set of exercises which consists of stretching, LL strength work, bounding and running drills, facilitated running, and eventually a timed run. Focus is on quality and style of running, not only time. It also provides a way of improving the client's cardio respiratory fitness.
I have enjoyed being part of the group and I think it is really beneficial in helping a client to achieve their goals. There is always great atmosphere amongst the group and the support and camaraderie of the fellow participants makes the participants achieve results that I am continually amazed with. I think sometimes in neuro we think that once a person can transfer, walk and reach, then this is the end of the rehabilitation process, when in fact (especially for the younger poulation) there are many more activities that these people would like to be involved with again. The guy I was looking after last session was once a high level soccer player in his former country and would like to become a soccer coach.
It would be interesting to know whether any of the crew has had similar experiences with group activity/special interest classes that we as Physios could possible implement into our workplace once we graduate.
Cheers
Nico
Monday, February 18, 2008
MACI
hey guys, have you heard of MACI? Well, i didn't and so i thought i'd share some basic information with you guys.
MACI stands for matrix-induced autologous chondrocyte implantation. Basically, it's a type of articular cartilage repair. These repair procedures can be generally classified into 4 broad categories. They are
1) Arthroscopic lavage and debridement
2) Marrow stimulating techniques
3) Osteochondral autografts and allografts
4) Cell-based repair including autologous chondrocyte implantation
MACI involves obtaining a small amount of the patient's cartilage ( via a biopsy usually via an arthroscopy) and then culturing the cells and seeding them on a membrane. Once this process is complete, the cells are returned to the surgeon . The surgeon than clears any damaged tissue in the knee and fixes the membrane of cultured cells into the defect. Over several months, these cells create a matrix that covers the articular surface, in effect replacing the lost cartilage in the knee.
Key benefits of the MACI include a shortened recovery time, a shortened intervention time due to a smaller incision, earlier return to work and sport, excellent clinical outcomes and application to multiple joints (now available in the knee and ankle).
Post MACI, the patient will have to undergo months of physiotherapy to regain mobility and strength. Much like any cartilage repair, the physiotherapy sessions will include progressive weight-bearing and mobility and strengthening for the affected muscles and joints. The program should also be guided by pain responses and cartilage repair but the patient should achieve full weight-bearing by week 12. There are some protocols available online and here are 2 useful websites:
http://www.kneeclinic.info/download/Carticel_ACI_Rehabilitation_Guide.pdf
http://www.genzyme.nl/thera/joint/MACI%20product%20information.pdf
Hope it is useful especially for those who are also on their musculo-prac.
MACI stands for matrix-induced autologous chondrocyte implantation. Basically, it's a type of articular cartilage repair. These repair procedures can be generally classified into 4 broad categories. They are
1) Arthroscopic lavage and debridement
2) Marrow stimulating techniques
3) Osteochondral autografts and allografts
4) Cell-based repair including autologous chondrocyte implantation
MACI involves obtaining a small amount of the patient's cartilage ( via a biopsy usually via an arthroscopy) and then culturing the cells and seeding them on a membrane. Once this process is complete, the cells are returned to the surgeon . The surgeon than clears any damaged tissue in the knee and fixes the membrane of cultured cells into the defect. Over several months, these cells create a matrix that covers the articular surface, in effect replacing the lost cartilage in the knee.
Key benefits of the MACI include a shortened recovery time, a shortened intervention time due to a smaller incision, earlier return to work and sport, excellent clinical outcomes and application to multiple joints (now available in the knee and ankle).
Post MACI, the patient will have to undergo months of physiotherapy to regain mobility and strength. Much like any cartilage repair, the physiotherapy sessions will include progressive weight-bearing and mobility and strengthening for the affected muscles and joints. The program should also be guided by pain responses and cartilage repair but the patient should achieve full weight-bearing by week 12. There are some protocols available online and here are 2 useful websites:
http://www.kneeclinic.info/download/Carticel_ACI_Rehabilitation_Guide.pdf
http://www.genzyme.nl/thera/joint/MACI%20product%20information.pdf
Hope it is useful especially for those who are also on their musculo-prac.
written communication
i've always read about the importance of communication but i never realised that how it actually impacted the patient. My patient had a full thickness rotator cuff tear in 2006 and now has outstanding issues with hypomobility in the GH joint and decreased strength. Today was the first time he came for a physiotherapy session with me.
Subjectively, he said he was improving but upon objective assessment, i discovered that his range and strength was much worse than it was 3 weeks ago (the last time he came for physio). Intrigued, i had a look at his home exercises and discovered that even though he said he had been doing them at least once a day, he did not know how to most of them.
After a little more investigation, i realised that even with the exercise sheet, he did not understand what most of the exercises were referring to and thus was unable to follow them. The exercise sheet had stick figures but single word instructions eg "elevation" which he did not understand.
I then went through all his exercises again and wrote the exercises in "layman terms" and with the same cues for the same directions (eg sideways for abduction and turning outwards for external rotation so he wouldn't get confused). This proved to be really useful as he felt a lot more confident with the exercises and were able to do them without any prompts.
It also helped me to understand that even in the outpatient setting, communication is key- both written and verbal. Also, it's just a good reminder that we should not take for granted that the patients necessarily know what we are referring to even with pretty stick figures and that we should always check that they understand and are able to interpret the program written up for them.
Subjectively, he said he was improving but upon objective assessment, i discovered that his range and strength was much worse than it was 3 weeks ago (the last time he came for physio). Intrigued, i had a look at his home exercises and discovered that even though he said he had been doing them at least once a day, he did not know how to most of them.
After a little more investigation, i realised that even with the exercise sheet, he did not understand what most of the exercises were referring to and thus was unable to follow them. The exercise sheet had stick figures but single word instructions eg "elevation" which he did not understand.
I then went through all his exercises again and wrote the exercises in "layman terms" and with the same cues for the same directions (eg sideways for abduction and turning outwards for external rotation so he wouldn't get confused). This proved to be really useful as he felt a lot more confident with the exercises and were able to do them without any prompts.
It also helped me to understand that even in the outpatient setting, communication is key- both written and verbal. Also, it's just a good reminder that we should not take for granted that the patients necessarily know what we are referring to even with pretty stick figures and that we should always check that they understand and are able to interpret the program written up for them.
Sputum Clearance
Hey there
My cardio placement is on a medical ward (actually an infectious diseases ward!) and I am currently seeing a middle aged woman who was brought in 3 months ago with R sided pneumonia and R upper lobe abcess. I have seen her every day since being on this ward (for a week) and her main respiratory problem is impaired airway clearance. She was in ICU on and off for a couple of months and still has an open trachy wound. This is having a big impact on her ability to cough and clear her secretions and she needs constant reminders (like every couple of minutes) to cover the site in order to get an effective cough, and even to talk.
I have been concentrating on breathing techniques (ACBT) to mobilise her secretions and then huffing/coughing to bring them up. If needed a neb of normal saline is given prior to treatment The patient is very weark and deconditioned (her second prominent cardio problem) and can mobilise roughly 5m with a WZF before her legs give up. We have been doing some standing with marching on the spot to try and mobilise her secretions as well, but sometimes she is too weak for this (such as today, her legs just gave way, luckily we were at her bed!). She tires very easily and somtimes the effort of huffing/coughing is too much and the ACBT is just ineffective.
What I wanted from you guys was some advice from your clinical experience as to what other techniques you have found that are successful in helping with airway clearance in such a patient. We have done a whole lot of stuff at uni, and I am in the middle of revising it, but there does seem to be a bit of a gap in what we are taught and what is actually used clinically or what people have found that works for them. Any suggestions would be much appreciated.
Cheers
Bini
My cardio placement is on a medical ward (actually an infectious diseases ward!) and I am currently seeing a middle aged woman who was brought in 3 months ago with R sided pneumonia and R upper lobe abcess. I have seen her every day since being on this ward (for a week) and her main respiratory problem is impaired airway clearance. She was in ICU on and off for a couple of months and still has an open trachy wound. This is having a big impact on her ability to cough and clear her secretions and she needs constant reminders (like every couple of minutes) to cover the site in order to get an effective cough, and even to talk.
I have been concentrating on breathing techniques (ACBT) to mobilise her secretions and then huffing/coughing to bring them up. If needed a neb of normal saline is given prior to treatment The patient is very weark and deconditioned (her second prominent cardio problem) and can mobilise roughly 5m with a WZF before her legs give up. We have been doing some standing with marching on the spot to try and mobilise her secretions as well, but sometimes she is too weak for this (such as today, her legs just gave way, luckily we were at her bed!). She tires very easily and somtimes the effort of huffing/coughing is too much and the ACBT is just ineffective.
What I wanted from you guys was some advice from your clinical experience as to what other techniques you have found that are successful in helping with airway clearance in such a patient. We have done a whole lot of stuff at uni, and I am in the middle of revising it, but there does seem to be a bit of a gap in what we are taught and what is actually used clinically or what people have found that works for them. Any suggestions would be much appreciated.
Cheers
Bini
Treating patients without the clear "pain picture"
Hi everyone,
I am currently on my Musculoskeletal prac and had a interesting situation in which I wasn’t sure how best to deal with.
A gentleman presented to the clinic with a history of lower back pain and hypomobility of the Lx spine. He had also been diagnosed as having delusional psychosis which is a mental illness characterized by radical change in personality and a distorted or diminished sense of objective reality.
In doing my objective Ax on this gentleman, namely his PPIVM and PAIVM it was very difficult to get a clear idea of his “pain picture” as everything I seemed to touch or do caused him pain. Even with the lightest of touch he was complaining on pain- however, his responses were very inconsistent as I could be doing the testing without asking him a response and he didn’t complain of any pain but as soon as I asked him how something felt he complained of pain. The problem I had was determining what the best treatment was for this gentleman as I didn’t have much of an idea what his main limiting problems were. In the end I went with my main findings however I wasn’t sure exactly how accurate they were such that I felt that my Rx was rather pointless…
Just wondering how other people would deal with a situation in which you can’t get a clear picture of the individuals problem due to the inconsistent pain responses.
Hope everyone enjoys their final 2 weeks on prac!!
Debs
I am currently on my Musculoskeletal prac and had a interesting situation in which I wasn’t sure how best to deal with.
A gentleman presented to the clinic with a history of lower back pain and hypomobility of the Lx spine. He had also been diagnosed as having delusional psychosis which is a mental illness characterized by radical change in personality and a distorted or diminished sense of objective reality.
In doing my objective Ax on this gentleman, namely his PPIVM and PAIVM it was very difficult to get a clear idea of his “pain picture” as everything I seemed to touch or do caused him pain. Even with the lightest of touch he was complaining on pain- however, his responses were very inconsistent as I could be doing the testing without asking him a response and he didn’t complain of any pain but as soon as I asked him how something felt he complained of pain. The problem I had was determining what the best treatment was for this gentleman as I didn’t have much of an idea what his main limiting problems were. In the end I went with my main findings however I wasn’t sure exactly how accurate they were such that I felt that my Rx was rather pointless…
Just wondering how other people would deal with a situation in which you can’t get a clear picture of the individuals problem due to the inconsistent pain responses.
Hope everyone enjoys their final 2 weeks on prac!!
Debs
Desaturation
Hi all,
I’m currently on placement on an acute respiratory ward. This week, I think what has surprised me the most has been just how quickly patients desaturate with any kind of effort. A good example of this was a 75 yo lady I was seeing with an acute infective exacerbation of COPD complaining almost exclusively of SOB. Her O2 sats were to be maintained between 88 and 92% and O2 could be adjusted between 0-4L depending on what she required at the time. At rest her sats were maintained in this range on 0.5L O2. On exertion, the standard 85% was when she had to stop and rest.
When it was time to go for a walk, I turned to O2 up to 2L/min (which was the recommended amount) and off we went. We had probably walked about 20m before her sats dropped to 85% so I asked my pt to sit down and have a rest. She assured me that she wasn’t too breathless, felt fine and didn’t need a rest but with a little persuasion she did. While she was sitting, her sats stayed around the 84-85% range but then she started randomly telling me a story about her family. Just from the increased effort from talking, her sats dropped rather quickly to 78%. I turned her O2 up and tried to encourage her to stop talking which was quite difficult, so in the end I had to be rather blunt with her. It took a good 3-4 min for her sats to come back up again before we could try the walk back to her room.
I know we are told at uni how quickly sats can drop, but even so, I was still amazed at just how quickly it can happen and how the pts don’t even know anything is wrong. It really makes you wonder what their sats levels are when they’re at home during their everyday activities.
Tara
I’m currently on placement on an acute respiratory ward. This week, I think what has surprised me the most has been just how quickly patients desaturate with any kind of effort. A good example of this was a 75 yo lady I was seeing with an acute infective exacerbation of COPD complaining almost exclusively of SOB. Her O2 sats were to be maintained between 88 and 92% and O2 could be adjusted between 0-4L depending on what she required at the time. At rest her sats were maintained in this range on 0.5L O2. On exertion, the standard 85% was when she had to stop and rest.
When it was time to go for a walk, I turned to O2 up to 2L/min (which was the recommended amount) and off we went. We had probably walked about 20m before her sats dropped to 85% so I asked my pt to sit down and have a rest. She assured me that she wasn’t too breathless, felt fine and didn’t need a rest but with a little persuasion she did. While she was sitting, her sats stayed around the 84-85% range but then she started randomly telling me a story about her family. Just from the increased effort from talking, her sats dropped rather quickly to 78%. I turned her O2 up and tried to encourage her to stop talking which was quite difficult, so in the end I had to be rather blunt with her. It took a good 3-4 min for her sats to come back up again before we could try the walk back to her room.
I know we are told at uni how quickly sats can drop, but even so, I was still amazed at just how quickly it can happen and how the pts don’t even know anything is wrong. It really makes you wonder what their sats levels are when they’re at home during their everyday activities.
Tara
Sunday, February 17, 2008
Progressing from Voluntary Control Stage 1/7
Hey there crew,
This past week I had the opportunity to work with a sub-acute stroke patient on my placement. The patient was admitted to hospital after a fall and suffered a right MCA infarct the following day. After almost a month of rest in bed and no time spent sitting out bed, the patient slowly improved and was moved to the ward. I had the privilege of being there the first day this patient was transferred to the wheelchair and taken to the physiotherapy gym.
Initial assessment findings revealed Gowland Postural Control stage 1/7, Arm stage 1/7 and Leg stage 1/7 in addition to perceptual deficits leading to the patient having left unilateral neglect. As the stages of recovery suggest, the patient has flaccid paralysis of both the upper and lower limb as well as decreased tone of the trunk and pelvic muscles. The patient has left side diminished light touch and intact JMS but mod-severe left side sensory inattention. Our initial goals are to improve static sitting endurance, bed mobility and transfer ability. However, my knowledge of how to progress recovery of voluntary control from stage 1 is rather limited. Our teachings have been mostly around re-training balance, whether in sitting or standing, and activating muscles through active assisted exercises.
My clinic tutor was able to provide a few ideas that I think would be helpful to share with the crew. The theories of adding proprioceptive and vestibular stimuli become handy in this situation. Such as having the patient in crooklying and then the therapist oscillating weight through the patient’s knees so that approximation of the hip joints occur as well as stirring up the vestibular system. Then doing active assisted lower limbs movements after adding that stimuli.
Additionally due to the left sided neglect, time spent during the session having the patient attend to sensory stimuli along the trunk, left upper and lower limb is effective. Providing stimuli such as heavier pressure than light touch and having the patient attend visually to the limb prior to facilitating movement in the limbs will be an intervention that will be used this week.
If any of the crew have further ideas to help make my treatment sessions effective I would really appreciate some feedback.
Thanks
Gareth
This past week I had the opportunity to work with a sub-acute stroke patient on my placement. The patient was admitted to hospital after a fall and suffered a right MCA infarct the following day. After almost a month of rest in bed and no time spent sitting out bed, the patient slowly improved and was moved to the ward. I had the privilege of being there the first day this patient was transferred to the wheelchair and taken to the physiotherapy gym.
Initial assessment findings revealed Gowland Postural Control stage 1/7, Arm stage 1/7 and Leg stage 1/7 in addition to perceptual deficits leading to the patient having left unilateral neglect. As the stages of recovery suggest, the patient has flaccid paralysis of both the upper and lower limb as well as decreased tone of the trunk and pelvic muscles. The patient has left side diminished light touch and intact JMS but mod-severe left side sensory inattention. Our initial goals are to improve static sitting endurance, bed mobility and transfer ability. However, my knowledge of how to progress recovery of voluntary control from stage 1 is rather limited. Our teachings have been mostly around re-training balance, whether in sitting or standing, and activating muscles through active assisted exercises.
My clinic tutor was able to provide a few ideas that I think would be helpful to share with the crew. The theories of adding proprioceptive and vestibular stimuli become handy in this situation. Such as having the patient in crooklying and then the therapist oscillating weight through the patient’s knees so that approximation of the hip joints occur as well as stirring up the vestibular system. Then doing active assisted lower limbs movements after adding that stimuli.
Additionally due to the left sided neglect, time spent during the session having the patient attend to sensory stimuli along the trunk, left upper and lower limb is effective. Providing stimuli such as heavier pressure than light touch and having the patient attend visually to the limb prior to facilitating movement in the limbs will be an intervention that will be used this week.
If any of the crew have further ideas to help make my treatment sessions effective I would really appreciate some feedback.
Thanks
Gareth
Anyone interested in a challenge?
Hey Everyone,
I just wanted to share an interesting patient with you. I am on my musculoskeletal outpatients at the moment. I have been seeing a lady who had a right total shoulder replacement 12 weeks ago. Her relevant past medical history is that her left shoulder is fused and therefore limited range on top of this she has RA and therefore she has deformities and loss of function in both hands. This lady is wonderfully keen and optimistic to regain ROM in her right shoulder. I have become very motivated working with this lady due to her keen attitude and due to how important function is in that remaining shoulder. Her goal is to be able to wash her hair.
She only has 110 degrees of active abduction, and 130 degrees of shoulder flexion. She needs active assisted exercises in her HEP to help her gain range at her shoulder. Currently she uses the stick for assisted abduction, a home made pulley system for flexion. The current challenge of increasing range has become limited by her right fussed shoulder and she lives at home alone and therefore has no one else to help. My question is for any other useful active assisted exercises that might help increase her range but that do not require the other arm assisting and full hand function. So far I have come up with hydro therapy to help, the use of a longer stick, and rolling a ball in side flexion. I tried the finger walking up the wall however her deformities in her hands made it difficult. Finally we have started anchoring her arm and lowering her body to increase the elevation at her shoulder. I will see this week how effective that was.
It has been a fun challenge to think of how to increase her ROM keeping in mind her impairments. I will be seeing her again on Monday prior to her review to see if any of the new suggestions were successful or not. If anyone has any other innovative ideas that you think might work for this lady she is very keen and will take any of your suggestions on board. Thanks for the help ladies and gentlemen.
I just wanted to share an interesting patient with you. I am on my musculoskeletal outpatients at the moment. I have been seeing a lady who had a right total shoulder replacement 12 weeks ago. Her relevant past medical history is that her left shoulder is fused and therefore limited range on top of this she has RA and therefore she has deformities and loss of function in both hands. This lady is wonderfully keen and optimistic to regain ROM in her right shoulder. I have become very motivated working with this lady due to her keen attitude and due to how important function is in that remaining shoulder. Her goal is to be able to wash her hair.
She only has 110 degrees of active abduction, and 130 degrees of shoulder flexion. She needs active assisted exercises in her HEP to help her gain range at her shoulder. Currently she uses the stick for assisted abduction, a home made pulley system for flexion. The current challenge of increasing range has become limited by her right fussed shoulder and she lives at home alone and therefore has no one else to help. My question is for any other useful active assisted exercises that might help increase her range but that do not require the other arm assisting and full hand function. So far I have come up with hydro therapy to help, the use of a longer stick, and rolling a ball in side flexion. I tried the finger walking up the wall however her deformities in her hands made it difficult. Finally we have started anchoring her arm and lowering her body to increase the elevation at her shoulder. I will see this week how effective that was.
It has been a fun challenge to think of how to increase her ROM keeping in mind her impairments. I will be seeing her again on Monday prior to her review to see if any of the new suggestions were successful or not. If anyone has any other innovative ideas that you think might work for this lady she is very keen and will take any of your suggestions on board. Thanks for the help ladies and gentlemen.
Saturday, February 16, 2008
Using the appropriate type of language
Hi all,
One of my patients that I find very inspiring is a young guy struck down with Guillain Barre disease 18 months ago. My supervisor really wanted me during my 4 weeks to push ahead with strengthening and balance work. So most of my treatment has taken part outside, in the hydro pool, and at the large facility gym. During a gym session the other day whilst on the leg press machine, he praised the way that I was speaking with him. Curiously, I asked him what he was talking about. He said that during his experience on the wards many of the hospital staff (including PTs) spoke to him like he was a stupid or could not understand English well. At that very moment he told me just to stop and listen to the other staff members speaking with their patients in the gym. Unfortunately, I recognized at once what he was taliking about. Some of the staff were shouting at their patients or using very simple patronising language. Although he never said it, I could tell that this was something that had affected him deeply over his lengthy treatment.
Granted there may some type of neuro patients that need this type of communication but on the whole I think it is very important to talk to them like you would to any other 'normal' person in the community. I think it is very easy to get into a rut and start using this condescending type of language with all your patients, especially if you think they are not getting what you are saying. I think it is important to be clear with your directions but also not sound patronising at the same time. This experience will certainely made me aware of my future communication with my neuro patients. It was great to get the patient perspective and find that this is a very important aspect of any successful PT session. It would be great to find out what the crew thinks about this.
Have a good weekend!
Cheers
Nico
One of my patients that I find very inspiring is a young guy struck down with Guillain Barre disease 18 months ago. My supervisor really wanted me during my 4 weeks to push ahead with strengthening and balance work. So most of my treatment has taken part outside, in the hydro pool, and at the large facility gym. During a gym session the other day whilst on the leg press machine, he praised the way that I was speaking with him. Curiously, I asked him what he was talking about. He said that during his experience on the wards many of the hospital staff (including PTs) spoke to him like he was a stupid or could not understand English well. At that very moment he told me just to stop and listen to the other staff members speaking with their patients in the gym. Unfortunately, I recognized at once what he was taliking about. Some of the staff were shouting at their patients or using very simple patronising language. Although he never said it, I could tell that this was something that had affected him deeply over his lengthy treatment.
Granted there may some type of neuro patients that need this type of communication but on the whole I think it is very important to talk to them like you would to any other 'normal' person in the community. I think it is very easy to get into a rut and start using this condescending type of language with all your patients, especially if you think they are not getting what you are saying. I think it is important to be clear with your directions but also not sound patronising at the same time. This experience will certainely made me aware of my future communication with my neuro patients. It was great to get the patient perspective and find that this is a very important aspect of any successful PT session. It would be great to find out what the crew thinks about this.
Have a good weekend!
Cheers
Nico
Monday, February 11, 2008
the written Word
over the last three placements, I have often though about what we - and other health professionals - write.
Most of what I have been thinking of is the utility (usefulness) of our writing for those who read it. Legibility is a big issue, of course, but there is also the key content. I notice some physios make themselves much more effective through a few key habits:
Most of what I have been thinking of is the utility (usefulness) of our writing for those who read it. Legibility is a big issue, of course, but there is also the key content. I notice some physios make themselves much more effective through a few key habits:
- writing 'E/' items that that give a quick picture of where pt. is instead of just showing that their 'I/' was effective e.g. instead of "I/ STM HS || increased KE" one could write "I/ STM HS || decreased QL 12 degrees to 3" - the second one tells how much effect the Rx had, where the pt should be if the Rx had a lasting effect / gives basis for deciding whether HEP has maintained gains, etc.)
- writing 'R/' items that point the way for next time. When we finish an Rx session and are writing up the notes, this is the time when we best understand how to continue next time. E.g. instead of writing "R/ progress HEP" or "continue Rx, we can write items like: "Check Gl Med. strength, add Gl Max X.s", we will save ourselves & others the time to needed to plough through the O/, I/ & E/ to hopefully remember / figure out where pt is at.
Sunday, February 10, 2008
Troponin & Communication
Hey guys,
Currently I am completing my cardiorespiratory placement; with time being spent between the medical and surgical wards. A new patient presented to the medical ward with a query of pneumonia. Therefore it was indicated for physiotherapy to perform a respiratory assessment and a mobility assessment. Both my supervisor and I read the patients notes and proceeded with our assessment as usual. After checking the patient’s chest expansion, cough, auscultating and completing the patients subjective it was time to assess their mobility. The patient was asked to stand and nothing was contraindicated to walking, therefore a short walk on the ward was carried out with continual monitoring taking place. The patient was returned to bed without any events or nothing abnormal.
The patients nurse then came up to us and said that the patient was supposed to be on bed rest as the patients had an elevation in troponin levels. Neither my supervisor or I had seen this in the patient notes. Reading them again it was with great difficulty that there was some writing that resembled the word troponin- 0.15. There was nothing else in the notes that might have indicated the patient be on bed rest as the doctors did not write this in the notes. It is not routine for the physiotherapist to talk to the doctor in what appeared to be a straight forward case. For those who may not know troponin is an enzyme that is released by the heart when there has been a MI or death of some of the cells of the heart.
During the physiotherapy intervention the patient did not report any chest pain, increased WOB, dizziness or nausea. With monitoring by a pulse oximeter the SpO2 and HR stayed within acceptable limits. The key point here was that a lack of communication could have resulted in an adverse outcome for the patient, and it wasn’t just verbal. Written notes were difficult to read. Fortunately the patient was fine and didn’t have any effects from getting out of bed. The bottom line is that if in doubt than consult with the other health professionals. I didn’t feel very good about the situation upon reflection and have tried to analyse what I could have done differently to prevent this happening again.
Thanks
Currently I am completing my cardiorespiratory placement; with time being spent between the medical and surgical wards. A new patient presented to the medical ward with a query of pneumonia. Therefore it was indicated for physiotherapy to perform a respiratory assessment and a mobility assessment. Both my supervisor and I read the patients notes and proceeded with our assessment as usual. After checking the patient’s chest expansion, cough, auscultating and completing the patients subjective it was time to assess their mobility. The patient was asked to stand and nothing was contraindicated to walking, therefore a short walk on the ward was carried out with continual monitoring taking place. The patient was returned to bed without any events or nothing abnormal.
The patients nurse then came up to us and said that the patient was supposed to be on bed rest as the patients had an elevation in troponin levels. Neither my supervisor or I had seen this in the patient notes. Reading them again it was with great difficulty that there was some writing that resembled the word troponin- 0.15. There was nothing else in the notes that might have indicated the patient be on bed rest as the doctors did not write this in the notes. It is not routine for the physiotherapist to talk to the doctor in what appeared to be a straight forward case. For those who may not know troponin is an enzyme that is released by the heart when there has been a MI or death of some of the cells of the heart.
During the physiotherapy intervention the patient did not report any chest pain, increased WOB, dizziness or nausea. With monitoring by a pulse oximeter the SpO2 and HR stayed within acceptable limits. The key point here was that a lack of communication could have resulted in an adverse outcome for the patient, and it wasn’t just verbal. Written notes were difficult to read. Fortunately the patient was fine and didn’t have any effects from getting out of bed. The bottom line is that if in doubt than consult with the other health professionals. I didn’t feel very good about the situation upon reflection and have tried to analyse what I could have done differently to prevent this happening again.
Thanks
Irritability
Irritability = pain severity + how long it takes for pain to appear + how long it takes to ease. We are taught that irritability will guide the amount of assessment we are able to do during the session. I am on my musculoskeletal placement and when we have a new patient we carry out our subjective then speak to our supervisor then return to do our objective.
My new patient has had an annoying shoulder pain for 3.5 years and has recently found out he tore his supraspinatous tendon. When questioning him on pain his levels they were relatively low 1/10 at rest and 3/10 with some movements like reaching for his wallet. The pain decreased immediately once he changed out of the movement. As the subjective continued I realized he has modified a lot of his daily activities so he just no longer uses his left arm. He just ‘puts up with it’ as he would say.
After I reported my subjective my supervisor asked me what objective assessment I planned on doing. I felt the patient had low irritability and therefore I was prepared to complete the entire shoulder assessment as indicated. My supervisor told me to continue and felt this was the appropriate thing to do.
As I began the examination asking him to move his shoulder the pain levels began to increase. The resting pain levels also started to increase. I could tell that this man was in more and more pain. He also complained of muscle spasm showing the body was trying to protect his shoulder. I had performed very little examination and it became more and more obvious that this man avoided using his shoulder over the last 3 years. Now that his shoulder was moving again it was very painful and irritated. I automatically gave him a rest and prioritized my examination into what tests/ assessment would give me the most information and him the least pain. My supervisor was happy with this adjustment and said this can be very common and that the remainder of the assessment can be collaborated over the following sessions.
From this situation I learned to be flexible and that is it important to be able to alter your treatment/ assessment plan as needed. Also your patient might not always paint a perfectly accurate picture of what is going on and so in depth questions in the subjective are needed to pin point the truth.
My new patient has had an annoying shoulder pain for 3.5 years and has recently found out he tore his supraspinatous tendon. When questioning him on pain his levels they were relatively low 1/10 at rest and 3/10 with some movements like reaching for his wallet. The pain decreased immediately once he changed out of the movement. As the subjective continued I realized he has modified a lot of his daily activities so he just no longer uses his left arm. He just ‘puts up with it’ as he would say.
After I reported my subjective my supervisor asked me what objective assessment I planned on doing. I felt the patient had low irritability and therefore I was prepared to complete the entire shoulder assessment as indicated. My supervisor told me to continue and felt this was the appropriate thing to do.
As I began the examination asking him to move his shoulder the pain levels began to increase. The resting pain levels also started to increase. I could tell that this man was in more and more pain. He also complained of muscle spasm showing the body was trying to protect his shoulder. I had performed very little examination and it became more and more obvious that this man avoided using his shoulder over the last 3 years. Now that his shoulder was moving again it was very painful and irritated. I automatically gave him a rest and prioritized my examination into what tests/ assessment would give me the most information and him the least pain. My supervisor was happy with this adjustment and said this can be very common and that the remainder of the assessment can be collaborated over the following sessions.
From this situation I learned to be flexible and that is it important to be able to alter your treatment/ assessment plan as needed. Also your patient might not always paint a perfectly accurate picture of what is going on and so in depth questions in the subjective are needed to pin point the truth.
Effectiveness of Functional Training
Hi crew,
Well my first week on my neurology placement was something that I was looking forward to as I haven’t yet had the chance to work with patients with neurological disorders. Conversely my lack of exposure also meant that I had some anxiety during the first couple of days. My main concern was the way in which I would handle communicating with patients with perceptual deficits during assessment and treatment. And to reinforce my concerns, I was allocated a patient who had been on the ward for a few months with a demyelinating disease of unknown origin to the medical team.
The patient presented with decreased limits of stability bilaterally and required the assistance of two therapists for ambulation in addition to cognitive and behavioural disturbances. After assessing the patient’s postural control, my partner and I decided to focus on retraining sitting and standing dynamic balance. Our first goal was to improve the anterior pelvic tilt in sitting and back extension. Being the therapist behind the patient on the plinth, my responsibility was to keep the patient sitting with good posture. However I was not being very successful as the patient kept returning to a slumped position despite verbal instructions and my handling of the central key points in addition to the patient becoming distracted. I needed another strategy.
Then my partner suggested that we change our tack and use functional upper limb tasks to facilitate improve sitting posture. The suggestion was to have the patient reach for quoits in both directions slightly above shoulder height. This immediately had the desired result as the patient responded by sitting with improved thoracic extension and anterior pelvic tilt.
After the treatment session, we discussed the reasons why the patient responded well to the change from specific treatment strategies to a more functionally based treatment session. The evaluation concluded that the patient most likely did not understand the point of the treatment. The patient needed more relevance to the session than just sitting in an improved posture, which was provided by reaching for an object. The irrelevance of the initial strategy resulted in the patient becoming bored and disinterested to the stimuli we were providing. This was an important learning experience as I most likely knew that using functional tasks would be effective but I need to be reminded about this key treatment strategy.
Gareth
Well my first week on my neurology placement was something that I was looking forward to as I haven’t yet had the chance to work with patients with neurological disorders. Conversely my lack of exposure also meant that I had some anxiety during the first couple of days. My main concern was the way in which I would handle communicating with patients with perceptual deficits during assessment and treatment. And to reinforce my concerns, I was allocated a patient who had been on the ward for a few months with a demyelinating disease of unknown origin to the medical team.
The patient presented with decreased limits of stability bilaterally and required the assistance of two therapists for ambulation in addition to cognitive and behavioural disturbances. After assessing the patient’s postural control, my partner and I decided to focus on retraining sitting and standing dynamic balance. Our first goal was to improve the anterior pelvic tilt in sitting and back extension. Being the therapist behind the patient on the plinth, my responsibility was to keep the patient sitting with good posture. However I was not being very successful as the patient kept returning to a slumped position despite verbal instructions and my handling of the central key points in addition to the patient becoming distracted. I needed another strategy.
Then my partner suggested that we change our tack and use functional upper limb tasks to facilitate improve sitting posture. The suggestion was to have the patient reach for quoits in both directions slightly above shoulder height. This immediately had the desired result as the patient responded by sitting with improved thoracic extension and anterior pelvic tilt.
After the treatment session, we discussed the reasons why the patient responded well to the change from specific treatment strategies to a more functionally based treatment session. The evaluation concluded that the patient most likely did not understand the point of the treatment. The patient needed more relevance to the session than just sitting in an improved posture, which was provided by reaching for an object. The irrelevance of the initial strategy resulted in the patient becoming bored and disinterested to the stimuli we were providing. This was an important learning experience as I most likely knew that using functional tasks would be effective but I need to be reminded about this key treatment strategy.
Gareth
musculo o/p
hey guys, i just started my musculoskeletal placement and it's been a really fun and enriching experience so far. i felt that it was quite a fair difference though moving from cardiopulmonary inpatients to musculo-o/p though and i suppose one of the main things is just that in cardio i/p we manage our time and arrange to see the patients whenever we please (of course taking into consideration things like lunch/investigations) but with musculo o/p we're more dependent on the patients coming to us.
just in the last week, i think the total 'no-show' and cancellations were more than 10 at the clinic i am doing my prac at. as a result, i was just thinking what we could do to decrease those numbers? for example, the patients are all given an appointment card in the first session but many fail to bring it or use it thus leading to them forgetting their appointment times for example. as a result, the number of 'do not attend' and cancellations increase. i was thinking then in the future if it would be feasible to maybe send alerts/messages to their mobiles to remind them of their appointment the day before? (perhaps through an automated program if there are any?) or if anyone has any ideas, please do share. thanks
just in the last week, i think the total 'no-show' and cancellations were more than 10 at the clinic i am doing my prac at. as a result, i was just thinking what we could do to decrease those numbers? for example, the patients are all given an appointment card in the first session but many fail to bring it or use it thus leading to them forgetting their appointment times for example. as a result, the number of 'do not attend' and cancellations increase. i was thinking then in the future if it would be feasible to maybe send alerts/messages to their mobiles to remind them of their appointment the day before? (perhaps through an automated program if there are any?) or if anyone has any ideas, please do share. thanks
Another blog on importance of communication...
Hi everyone,
This week I have started my placement in Musculoskeletal. It has been a really interesting week with various different patient conditions coming up. My blog this week is on a patient who stood out to me and I learnt something from.
This patient was a 69 yr old male who presented with “excruciating pain” 9/10 at the lower buttock with referred pins and needles down his entire posterior leg. His aggravating factors were any loading positions such as walking or standing- his pain increased to 9/10 within ~2mins. At rest, he had a constant ache which was 2/10 pain levels. On Ax he had slight reduced ROM with significant hinging at L2-3- his pain symptoms were reduced with flexion & lateral flexion away from painful side (i.e. opening up the spine reduced symptoms), very hypomobile Lx spine (L1-L5) on PAIVM findings, normal neurological signs (power, sensation & reflexes) and +ve NTPTs.
After consulting my supervisor about his symptoms we diagnosed him as having an inflamed nerve at possibly L3/4 L4/5 which was causing his referred pins and needles as well as his severe levels of pain. This patient has been seen by various other health professionals prior to coming to us- including Doctors, various Chiropractors and an Occupational Therapist all which did not have any affect. The Dr however, had diagnosed him with possible sciata and booked him in to have injections into his facet joints 4 days later to help reduce his inflamed nerve. I wasn’t sure what the best way to treat this gentleman was, as I knew that his symptoms could change significantly after his injections. I decided that physical therapy would not help him at this stage so I decided to go with the management option and not actually treat him as such. I educated him about why he was getting the pain and strategies he can use to help relieve the pain (i.e. flexion to open up the area where the inflamed nerve exited). We spent awhile discussing this and he was so thankful that he finally understood what was going on with his symptoms and why he was getting the pain. He stated that of all the therapists he had seen no one had bothered to explain why he was getting the pain.
This experience showed me that communication with patients is so very important in explaining to them the causes of their symptoms. This post supports Bini’s post earlier and again highlights the importance that we as physiotherapists have in educating patients about their conditions and our role in helping them to regain function.
Hope everyone enjoys their next wk of prac- not long to go now :)
Debs
This week I have started my placement in Musculoskeletal. It has been a really interesting week with various different patient conditions coming up. My blog this week is on a patient who stood out to me and I learnt something from.
This patient was a 69 yr old male who presented with “excruciating pain” 9/10 at the lower buttock with referred pins and needles down his entire posterior leg. His aggravating factors were any loading positions such as walking or standing- his pain increased to 9/10 within ~2mins. At rest, he had a constant ache which was 2/10 pain levels. On Ax he had slight reduced ROM with significant hinging at L2-3- his pain symptoms were reduced with flexion & lateral flexion away from painful side (i.e. opening up the spine reduced symptoms), very hypomobile Lx spine (L1-L5) on PAIVM findings, normal neurological signs (power, sensation & reflexes) and +ve NTPTs.
After consulting my supervisor about his symptoms we diagnosed him as having an inflamed nerve at possibly L3/4 L4/5 which was causing his referred pins and needles as well as his severe levels of pain. This patient has been seen by various other health professionals prior to coming to us- including Doctors, various Chiropractors and an Occupational Therapist all which did not have any affect. The Dr however, had diagnosed him with possible sciata and booked him in to have injections into his facet joints 4 days later to help reduce his inflamed nerve. I wasn’t sure what the best way to treat this gentleman was, as I knew that his symptoms could change significantly after his injections. I decided that physical therapy would not help him at this stage so I decided to go with the management option and not actually treat him as such. I educated him about why he was getting the pain and strategies he can use to help relieve the pain (i.e. flexion to open up the area where the inflamed nerve exited). We spent awhile discussing this and he was so thankful that he finally understood what was going on with his symptoms and why he was getting the pain. He stated that of all the therapists he had seen no one had bothered to explain why he was getting the pain.
This experience showed me that communication with patients is so very important in explaining to them the causes of their symptoms. This post supports Bini’s post earlier and again highlights the importance that we as physiotherapists have in educating patients about their conditions and our role in helping them to regain function.
Hope everyone enjoys their next wk of prac- not long to go now :)
Debs
Saturday, February 9, 2008
Patient Education
Hello there :)
On recurring theme I have found in all my pracs, and brought to my attention by my last couple of supervisors is the importance of clear and consice education for patients on a number of issues. This message has been brought home again in my third placement, cardio inpatients on a medical ward. I have found that many paitents are interested in the assessments you are conducting, the treatments carried out and why, what exactly if wrong with them and what impact what you are doing will have on their condition. I have found that a lack of education on the physio's behalf can result in a flat-out decline of physio treatment from the patient, only for them to come around and be much more open when a simple explanation of the aforementioned topics is offered.
We have all learnt to include our patients in their treatment and to provide education and explanations as to what we are doing, and I really thought I was doing this adequately, and it was only after being specifically questioned by a couple of patients, both who were quite upset, that I realised I should be putting in some more effort. So I am now trying to make a concentrated effort to fully explain what the purpose of our physio sessions are and how this was benefit the patient, at least on the very first treatment session as I believe this builds rapport and increases patient compliance.
Cheers
Bini
On recurring theme I have found in all my pracs, and brought to my attention by my last couple of supervisors is the importance of clear and consice education for patients on a number of issues. This message has been brought home again in my third placement, cardio inpatients on a medical ward. I have found that many paitents are interested in the assessments you are conducting, the treatments carried out and why, what exactly if wrong with them and what impact what you are doing will have on their condition. I have found that a lack of education on the physio's behalf can result in a flat-out decline of physio treatment from the patient, only for them to come around and be much more open when a simple explanation of the aforementioned topics is offered.
We have all learnt to include our patients in their treatment and to provide education and explanations as to what we are doing, and I really thought I was doing this adequately, and it was only after being specifically questioned by a couple of patients, both who were quite upset, that I realised I should be putting in some more effort. So I am now trying to make a concentrated effort to fully explain what the purpose of our physio sessions are and how this was benefit the patient, at least on the very first treatment session as I believe this builds rapport and increases patient compliance.
Cheers
Bini
Patients with aphasia.
Hi all,
I begun a neuro outpatient clinic this week and just wanted to share some experiences to date with aphasic patients and maybe seek some solutions to communication difficulties.
A couple of my patients have suffered (L) TACIs with one of the impairments being aphasia (both receptive and expressive). Being the first session with the patients I have found it very difficult to communicate and establish that rapport that you need in the beginning. One 44 year old gentleman in particular was very frustrating. He had been coming to the clinic for 6 months and had established a long file of notes. In the file it mentioned his aphasia (mainly expressive) but did not mention his communication book that helps him to communicate. In the first session whilst he was on the tilt table, I attempted to start up some conversation and I could see that he was keen to communicate. I could understand much of what he was saying but I could also tell that there was much more that he wanted to say but just couldn't. I could see he was getting frustrated and often resorted to the loud expletive 'f#*k' every 10 sec or so. He kept on pointing to another room where he had left his bag, but I didn't think anything of this. Eventually I went and got his bag and he pulled out a communication book with pictures of varous aspects of his life. This immediately broke down much of the communciation barrier, and I started posing many questions related to his favourite football teams, family, former occupation etc. He became less frustrated and we had a great session with plenty of laughing.
On detailed examination of the notes it did mention the book earlier on but this was not really highlighted. So, what I learnt from this was experience was how important it is to thoroughly read the notes and put this information regarding the book in future transfer summaries. Also from my experience to date with these patients, I have often found that if you give them time to respond they can usually communicate what they want to say. I know one of the solutions to effectively communicating with these patients is to pose only closed questions to them, but are we as Physios denying them a chance of developing their communication skills?. If you have the time (such as when the pt is on a tilt table) then just be patient. It would be interesting to get some more ideas from a 'speechie' on this, so if anyone has sat in on a session with a 'speechie' and an aphasic patient please let us know.
Cheers
Nico
I begun a neuro outpatient clinic this week and just wanted to share some experiences to date with aphasic patients and maybe seek some solutions to communication difficulties.
A couple of my patients have suffered (L) TACIs with one of the impairments being aphasia (both receptive and expressive). Being the first session with the patients I have found it very difficult to communicate and establish that rapport that you need in the beginning. One 44 year old gentleman in particular was very frustrating. He had been coming to the clinic for 6 months and had established a long file of notes. In the file it mentioned his aphasia (mainly expressive) but did not mention his communication book that helps him to communicate. In the first session whilst he was on the tilt table, I attempted to start up some conversation and I could see that he was keen to communicate. I could understand much of what he was saying but I could also tell that there was much more that he wanted to say but just couldn't. I could see he was getting frustrated and often resorted to the loud expletive 'f#*k' every 10 sec or so. He kept on pointing to another room where he had left his bag, but I didn't think anything of this. Eventually I went and got his bag and he pulled out a communication book with pictures of varous aspects of his life. This immediately broke down much of the communciation barrier, and I started posing many questions related to his favourite football teams, family, former occupation etc. He became less frustrated and we had a great session with plenty of laughing.
On detailed examination of the notes it did mention the book earlier on but this was not really highlighted. So, what I learnt from this was experience was how important it is to thoroughly read the notes and put this information regarding the book in future transfer summaries. Also from my experience to date with these patients, I have often found that if you give them time to respond they can usually communicate what they want to say. I know one of the solutions to effectively communicating with these patients is to pose only closed questions to them, but are we as Physios denying them a chance of developing their communication skills?. If you have the time (such as when the pt is on a tilt table) then just be patient. It would be interesting to get some more ideas from a 'speechie' on this, so if anyone has sat in on a session with a 'speechie' and an aphasic patient please let us know.
Cheers
Nico
Wednesday, February 6, 2008
creepy patient
Hi all,
Throughout my four weeks in neuro OP I was treating a pt (~50 yo male) who had a R LACI approx 12 months ago. For the first few treatments there was the general chit chat that we have with most pt we see and he seemed like a really nice guy… after I’d seen him a few times he started with some offhand comments like “I’m really glad you’re my physio, your hands are so soft…” or “ you’re very nice to look at” and things like that, which I just kinda let go with a thankyou and didn’t think much more about it. Those sorts of comments kept coming over the next few sessions and I’d find that he’d stare at me while I was treating him, and I’d really have to try hard to make him concentrate on what he was doing instead of what I was doing and it started to creep me out.
He never said or did anything that was really inappropriate but it was just a feeling that I got about him and made me very conscious of how I was with him during treatments. I never felt unsafe or anything around him, and because the gym was open with no curtains or anything it was fine, but I guess because physio is very hands on and there is a lot of close contact that we have with patients sometimes, we just have to be careful about some patients like this who are a bit “friendlier” than most. Especially when we’re treating pts of the opposite sex we have to be very careful that they don’t get the wrong idea, and that there’s always someone else around that can see what’s going on if needed. I hope no one else has had a pt like mine!
Tara
Throughout my four weeks in neuro OP I was treating a pt (~50 yo male) who had a R LACI approx 12 months ago. For the first few treatments there was the general chit chat that we have with most pt we see and he seemed like a really nice guy… after I’d seen him a few times he started with some offhand comments like “I’m really glad you’re my physio, your hands are so soft…” or “ you’re very nice to look at” and things like that, which I just kinda let go with a thankyou and didn’t think much more about it. Those sorts of comments kept coming over the next few sessions and I’d find that he’d stare at me while I was treating him, and I’d really have to try hard to make him concentrate on what he was doing instead of what I was doing and it started to creep me out.
He never said or did anything that was really inappropriate but it was just a feeling that I got about him and made me very conscious of how I was with him during treatments. I never felt unsafe or anything around him, and because the gym was open with no curtains or anything it was fine, but I guess because physio is very hands on and there is a lot of close contact that we have with patients sometimes, we just have to be careful about some patients like this who are a bit “friendlier” than most. Especially when we’re treating pts of the opposite sex we have to be very careful that they don’t get the wrong idea, and that there’s always someone else around that can see what’s going on if needed. I hope no one else has had a pt like mine!
Tara
Tuesday, February 5, 2008
appropriate goal setting
Hi all,
I’ve finally completed my neuro placement last Friday and I was assessed on the new patient who I had two sessions with.
He had a ponto-cerebellar bleeding in 1989 and significantly deteriorated in Sep last year. His main issues are severe ataxia trunk and upper limb worse than lower limb, decreased tone in his UL&LL and poor righting/equilibrium reaction in both sitting and standing. Based on my assessment, I’ve started bed exercises including bridging, sit-ups, AI/RS in 4pt kneeling and arm/leg lift in 4pt kneeling. My plan was to improve sitting posture and balance prior to work on his standing balance and gait. After one and a half hours of exercises, he was totally worn out and was not able to continue the last exercise that I planned which was balancing in sitting on fit ball. Also, he told me that he would be on weekend leave in the afternoon, so he wanted to practice walking and stairs which was what he needed when he goes back home.
I realized that I should have discussed what patient’s priority is and integrated into what I think he needs to improve. I learned how important communication skills with patient are as well as between the staff which I posted about last week.
Hope everyone learned a lot during the placement and good luck with next one!
I’ve finally completed my neuro placement last Friday and I was assessed on the new patient who I had two sessions with.
He had a ponto-cerebellar bleeding in 1989 and significantly deteriorated in Sep last year. His main issues are severe ataxia trunk and upper limb worse than lower limb, decreased tone in his UL&LL and poor righting/equilibrium reaction in both sitting and standing. Based on my assessment, I’ve started bed exercises including bridging, sit-ups, AI/RS in 4pt kneeling and arm/leg lift in 4pt kneeling. My plan was to improve sitting posture and balance prior to work on his standing balance and gait. After one and a half hours of exercises, he was totally worn out and was not able to continue the last exercise that I planned which was balancing in sitting on fit ball. Also, he told me that he would be on weekend leave in the afternoon, so he wanted to practice walking and stairs which was what he needed when he goes back home.
I realized that I should have discussed what patient’s priority is and integrated into what I think he needs to improve. I learned how important communication skills with patient are as well as between the staff which I posted about last week.
Hope everyone learned a lot during the placement and good luck with next one!
Monday, February 4, 2008
Communication/Interpretation (Daria's Post)
Hi All,
During my neuro placement I have learnt how important is communication both verbal as well as written. There are many reasons for this such as benefit of patient, from the legal point of view, better team work and relations with other health professionals.
One of my patients is after PCI with severely impaired posterior circulation presents with very ataxic gait. This patient balance varies sigificantly from day to day or even during the same day, for example one day patient can maintain his static standing balance with eyes open then closed for 60 seconds, another day can not perform these tasks at all. I have noticed that patient's balance and functional level were generally worse after weekend as patient hasn't have chance to "experiance"/practice his balance and walking. Other factors that influence on patient's balance are mediacations, especially sedative ones that patient receives if he is restless and "significantly impaired memory"(assessment performed by OT).
The patient that I mentioned above is at a hospital ward therefore nursing staff rely on information regarding functional level of each patient provided by physio. Functional level assessment is assessed/reviewed on daily basis and has to be documented in the notes and on functional chart in a patient's room. Then any changes have to be handovered to nurse who looks after patient as well as to co-ordinator nurse. When I have assessed my ataxic patient functional level and I found his balance deteriorated a lot that I wasn't able to walk him on my own (for mine and my patient safety) I asked another physio student to give me hand. After session I have reported my concern about patient's balance to medical staff.I documented in notes my assessment, findings and changes in functional level then I changed information on functional chart in patient's room ( ambulation: 2 A max). I was very suprised when I showed/informed coordinator nurse and I found that her interpretation was different to what I meant. When I have written "ambulation: 2 A max" (this is commonly used abbrivation used on this ward) I meant that patient can ambulate with maximun assistance from two staff members. The nurse understood that patient needs assistance maximum two staff members ( can be less than two but not more than two). It was good lesson!
Daria
During my neuro placement I have learnt how important is communication both verbal as well as written. There are many reasons for this such as benefit of patient, from the legal point of view, better team work and relations with other health professionals.
One of my patients is after PCI with severely impaired posterior circulation presents with very ataxic gait. This patient balance varies sigificantly from day to day or even during the same day, for example one day patient can maintain his static standing balance with eyes open then closed for 60 seconds, another day can not perform these tasks at all. I have noticed that patient's balance and functional level were generally worse after weekend as patient hasn't have chance to "experiance"/practice his balance and walking. Other factors that influence on patient's balance are mediacations, especially sedative ones that patient receives if he is restless and "significantly impaired memory"(assessment performed by OT).
The patient that I mentioned above is at a hospital ward therefore nursing staff rely on information regarding functional level of each patient provided by physio. Functional level assessment is assessed/reviewed on daily basis and has to be documented in the notes and on functional chart in a patient's room. Then any changes have to be handovered to nurse who looks after patient as well as to co-ordinator nurse. When I have assessed my ataxic patient functional level and I found his balance deteriorated a lot that I wasn't able to walk him on my own (for mine and my patient safety) I asked another physio student to give me hand. After session I have reported my concern about patient's balance to medical staff.I documented in notes my assessment, findings and changes in functional level then I changed information on functional chart in patient's room ( ambulation: 2 A max). I was very suprised when I showed/informed coordinator nurse and I found that her interpretation was different to what I meant. When I have written "ambulation: 2 A max" (this is commonly used abbrivation used on this ward) I meant that patient can ambulate with maximun assistance from two staff members. The nurse understood that patient needs assistance maximum two staff members ( can be less than two but not more than two). It was good lesson!
Daria
Fantastic Reflections
Just wanting to congratulate you all for the contributions you have made to this blog over the course of the last placement. There have been a wide range of issues discussed with teamwork and communication being recurring themes through many of them. It is clear that you are all experiencing examples of good and poor communication in teams, which is hopefully highlighting the importance to you of this skill. Remember to keep your posts about clinical issues and include concluding statements about what you have learned from the scenario and how you might change clinical practice based on your experiences.
Sunday, February 3, 2008
Progressions in Lumbopelvic Motor Control Exercises
Hi guys,
In the last couple of weeks of my musculoskeletal placement I starting having patients with motor control issues of the lumbar spine. For each of these patients the reason they actually came into the clinic was for an acute onset of low back pain. But after a few sessions and their pain started to decrease, it became apparent during re-assessment that their underlying problem was a motor control disorder of the lumbar spine.
Their pattern of pain changed from onset at the start of most active movements to the onset low back pain only in the mid ranges of active movements. For example, the patient would only complain of low back pain at about ¼ - ¾ range flexion but no pain at both ends of the range. This is a good indication that these patients were experiencing a lack of lumbar control when their passive structures were not able to give them stability. They also presented with poor activation of the local muscle system and an inability to find neutral lumbar spine.
Therefore, treatment became focused on teaching activation of the lower abdominals and multifidus as well as finding a neutral lumbar spine on the stability ball. This leads me to my blog this week, as I was able to teach the first stages of lumbopelvic motor retraining but then found that I was less than effective on providing progressions for these patients.
So I was able to progress the patients from TA activation in crook-lying to a sitting position but was unsure of how to make the task more functional and still ensure the patient was using the LMS and not reverting back to abdominal splinting.
Patients were also practicing finding their neutral spine while sitting on the stability ball but where I got stuck was in teaching progressions for lumbopelvic dissociation. We talked about the importance of dissociation in labs but I was unsure of how to actually make these exercises more functional.
So if you guys have some ideas about progressions for lumbar motor control disorder cases that would be much appreciated as I’m sure these types of patients will be a fairly common occurrence.
Thanks
Gareth
In the last couple of weeks of my musculoskeletal placement I starting having patients with motor control issues of the lumbar spine. For each of these patients the reason they actually came into the clinic was for an acute onset of low back pain. But after a few sessions and their pain started to decrease, it became apparent during re-assessment that their underlying problem was a motor control disorder of the lumbar spine.
Their pattern of pain changed from onset at the start of most active movements to the onset low back pain only in the mid ranges of active movements. For example, the patient would only complain of low back pain at about ¼ - ¾ range flexion but no pain at both ends of the range. This is a good indication that these patients were experiencing a lack of lumbar control when their passive structures were not able to give them stability. They also presented with poor activation of the local muscle system and an inability to find neutral lumbar spine.
Therefore, treatment became focused on teaching activation of the lower abdominals and multifidus as well as finding a neutral lumbar spine on the stability ball. This leads me to my blog this week, as I was able to teach the first stages of lumbopelvic motor retraining but then found that I was less than effective on providing progressions for these patients.
So I was able to progress the patients from TA activation in crook-lying to a sitting position but was unsure of how to make the task more functional and still ensure the patient was using the LMS and not reverting back to abdominal splinting.
Patients were also practicing finding their neutral spine while sitting on the stability ball but where I got stuck was in teaching progressions for lumbopelvic dissociation. We talked about the importance of dissociation in labs but I was unsure of how to actually make these exercises more functional.
So if you guys have some ideas about progressions for lumbar motor control disorder cases that would be much appreciated as I’m sure these types of patients will be a fairly common occurrence.
Thanks
Gareth
Poor professionalism
Hey guys,
This week on placement I had to deal with a nurse who was less than friendly and showed some very poor professionalism which I was extremely disappointed with. I was treating a patient who is doubly incontinent and for some reason always decides to empty his bowel once in physiotherapy (after being transferred to the plinth).
The first two times I saw this patient he emptied his bowels while in physiotherapy; the protocol is to call the nurse down to change him, which on both occasions they did so promptly (and I did help out a little, which was quite an experience). The nurse was appreciative of this.
As this patient was going to be used for my final Ax with my Curtin clinical tutor I had pre-warned her that the session may be interrupted by a change of pad. After transferring the patient to the bed a familiar smell started to waft around the patient and sure enough like clock work the patient had once again opened their bowel.
This time I went to personally find the patient’s nurse to request a change. Upon requesting the patients nurse that their patient required a change I was greeted with the response “For f*#@!k sake, I’m busy I have a meeting to attend”. The nurse then walked away, I was totally shocked and really disappointed with this reaction; I had never even met this nurse before. Now I can understand that people may get stressed and be under pressure at work from time to time but you still have to maintain a certain level of professionalism. If this outburst was due to me being a student then her behaviour is even more disappointing and inappropriate.
I returned to the physiotherapy gym and waited for her, instead she sent down two other nurses to her ‘dirty work’. I hope she felt really bad about the way she handled herself and was too embarrassed to come face to face with me, as she didn’t even apologise when I passed her in the hallway later that day.
I felt really disappointed with the whole situation and generally I feel that as a student quite often we get treated as second rate people by other staff when on prac.
That’s my gripe, hope everyone enjoys their last 4 week placement in Perth.
Cheers
This week on placement I had to deal with a nurse who was less than friendly and showed some very poor professionalism which I was extremely disappointed with. I was treating a patient who is doubly incontinent and for some reason always decides to empty his bowel once in physiotherapy (after being transferred to the plinth).
The first two times I saw this patient he emptied his bowels while in physiotherapy; the protocol is to call the nurse down to change him, which on both occasions they did so promptly (and I did help out a little, which was quite an experience). The nurse was appreciative of this.
As this patient was going to be used for my final Ax with my Curtin clinical tutor I had pre-warned her that the session may be interrupted by a change of pad. After transferring the patient to the bed a familiar smell started to waft around the patient and sure enough like clock work the patient had once again opened their bowel.
This time I went to personally find the patient’s nurse to request a change. Upon requesting the patients nurse that their patient required a change I was greeted with the response “For f*#@!k sake, I’m busy I have a meeting to attend”. The nurse then walked away, I was totally shocked and really disappointed with this reaction; I had never even met this nurse before. Now I can understand that people may get stressed and be under pressure at work from time to time but you still have to maintain a certain level of professionalism. If this outburst was due to me being a student then her behaviour is even more disappointing and inappropriate.
I returned to the physiotherapy gym and waited for her, instead she sent down two other nurses to her ‘dirty work’. I hope she felt really bad about the way she handled herself and was too embarrassed to come face to face with me, as she didn’t even apologise when I passed her in the hallway later that day.
I felt really disappointed with the whole situation and generally I feel that as a student quite often we get treated as second rate people by other staff when on prac.
That’s my gripe, hope everyone enjoys their last 4 week placement in Perth.
Cheers
Maximising recovery for our patients
Hey guys
If there is one take home message I have learnt from my neuro placement is that with our assessment and treatment of neurologically impaired patients, we are alwyas looking for movement, which will ensure that they are given the best opportunity for recovery. What this means is that we have to give our patients the opportunity and the time to show us what they can do, not just assume what they cant.
For example, one of my patients (mentioned in my first blog) who suffered a TACS affecting almost her whole left hemisphere, was left with global aphasis, right hemiparesis and, initially, very little movement on her left side as well. Given the nature of the stroke and the areas it affected, I had a picture in my mind (as we should) of her impairments. And after examination, these impairments were found to be present. Initially this patient was treated by loking after her chest, passive movements and positioning. This went on for a few treatment sessions and it wasnt until my supervisor came and sat in on a session that I realised how much more we could be doing. For some reason I had this block in my mind, in that I was performing passive movements and stretches on this patients, not even attempting to see if she was capable of anything more. My supervisor then took her through some movements, with heaps of encouraging feedback and found that she was activating some of these muscles, on her hemi side! I would have totally missed this progress if not for her.
A couple of weeks after this as I saw this patiens with my Curtin tutor, who was very suprised that we had not stood this patient yet and wanted to know why. Again, I had not given my patient every opportunity to show us exactly what she could do, instead just assuming that I knew what she couldnt. And she stood and is improving. While she may not walk in any functional way, we have all learnt the importance of being upright and weight-bearing, and standing a patient after a neurological insult is something that needs to be achieved as soon as the patients is able.
So it is crucial that we do not hold pre-conceptions about what patients can do and will achieve, but give them every chance to suceed.
Cheers guys, and enjoy!
Bini
If there is one take home message I have learnt from my neuro placement is that with our assessment and treatment of neurologically impaired patients, we are alwyas looking for movement, which will ensure that they are given the best opportunity for recovery. What this means is that we have to give our patients the opportunity and the time to show us what they can do, not just assume what they cant.
For example, one of my patients (mentioned in my first blog) who suffered a TACS affecting almost her whole left hemisphere, was left with global aphasis, right hemiparesis and, initially, very little movement on her left side as well. Given the nature of the stroke and the areas it affected, I had a picture in my mind (as we should) of her impairments. And after examination, these impairments were found to be present. Initially this patient was treated by loking after her chest, passive movements and positioning. This went on for a few treatment sessions and it wasnt until my supervisor came and sat in on a session that I realised how much more we could be doing. For some reason I had this block in my mind, in that I was performing passive movements and stretches on this patients, not even attempting to see if she was capable of anything more. My supervisor then took her through some movements, with heaps of encouraging feedback and found that she was activating some of these muscles, on her hemi side! I would have totally missed this progress if not for her.
A couple of weeks after this as I saw this patiens with my Curtin tutor, who was very suprised that we had not stood this patient yet and wanted to know why. Again, I had not given my patient every opportunity to show us exactly what she could do, instead just assuming that I knew what she couldnt. And she stood and is improving. While she may not walk in any functional way, we have all learnt the importance of being upright and weight-bearing, and standing a patient after a neurological insult is something that needs to be achieved as soon as the patients is able.
So it is crucial that we do not hold pre-conceptions about what patients can do and will achieve, but give them every chance to suceed.
Cheers guys, and enjoy!
Bini
Allied health team
Hi everyone,
This week it has really honed on me how important it is to work effectively as part of the Allied Health Team. Since this week was our last week on prac my supervisor was asking me to think about discharges of the patients I was currently managing. In the area of Cardiopulmonary physiotherapy majority of the patients fall into the older age category and therefore a more complex discharge arises. In considering allowing the patient to go home, we, as physiotherapists- a key component of the health team, need to ensure that the patient is safe for discharge and will be able to cope at home on discharge.
In planning these discharges I developed my knowledge and skills at working with the entire health team. I realized the importance of continued communication with all members of the team to ensure all the required services were in place including home help, rails for the bathroom and any required aids the patient may need on discharge.
I guess it enabled me to recognize the importance of communication within the hospitals and developing effective working relationships with other key allied health team members.
Just a little insight into my thoughts as I had run out of interesting patients to discuss. Looking forward to sharing my Musculo experiences with you next week!!
Hope everyone enjoys there final 4 weeks prac in Perth!
Debs
This week it has really honed on me how important it is to work effectively as part of the Allied Health Team. Since this week was our last week on prac my supervisor was asking me to think about discharges of the patients I was currently managing. In the area of Cardiopulmonary physiotherapy majority of the patients fall into the older age category and therefore a more complex discharge arises. In considering allowing the patient to go home, we, as physiotherapists- a key component of the health team, need to ensure that the patient is safe for discharge and will be able to cope at home on discharge.
In planning these discharges I developed my knowledge and skills at working with the entire health team. I realized the importance of continued communication with all members of the team to ensure all the required services were in place including home help, rails for the bathroom and any required aids the patient may need on discharge.
I guess it enabled me to recognize the importance of communication within the hospitals and developing effective working relationships with other key allied health team members.
Just a little insight into my thoughts as I had run out of interesting patients to discuss. Looking forward to sharing my Musculo experiences with you next week!!
Hope everyone enjoys there final 4 weeks prac in Perth!
Debs
Ask for help if you need it.
Hello everyone,
This week I learned the importance of asking for help when you need it. I was asked to do a 6 MWT for one of the patients on the ward. I was thinking a 6MWT is very straight forward process however on this occasion there were additional factors which complicated this test. First of all my patient did not speak English and his family was not around for translating. Secondly he was on portable oxygen and third the ward did not have any hand held oximeters available so I had to push the machine along side. I did not feel confident I could have control my patient. With the additional equipment I didn’t think I would be close enough to the patient to record relevant information and guard him as I administered the test.
I had seen this patient before hand which was a positive, we walked him 40 m and he de-saturated to 80 % spO2 while on 2 L of oxygen via nasal prongs. So I was aware and ready for him to de-saturate again. Despite documenting these findings in the notes the doctors still ordered a 6MWT to see if he was appropriate for home oxygen.
I prepared the hallway before hand with chairs positioned at each end of the hall. In the back of my mind I wanted to ask my supervisor to help me however did not want to be a burden therefore I convinced myself I would be alright on my own. But knew in my heart I was nervous conducting the test.
We began the test and I tried to explain to my patient the procedure. However I don’t think he understood very much. He began the test at 97 % spO2 on 2L within the first minute he was down to 87 %. At 1 min 30 he was at 84 % and I asked him how he was doing and showed him the chair was available because in class they tell us 85 % sit them down. I observed carefully for signs hypoxaemia however it was difficult as he had an abnormal breathing pattern and was unable to communicate effectively with me. He continued walking to the other end and at 2 min 20 seconds he was at 74 %. At this point I told him to sit down due to his sats and his heart rate being 165. I aborted the test. It took him 6 min to recover to 93 %. But I still had not recovered from the stress I felt during the test.
After the test I really did not feel happy with how the test was conducted. He was safe and nothing ended up happening. However I believe if I had of asked for help the test would have been much safer and more reliable. After speaking to my supervisor she said never hesitate trust your gut if you think you need a second pair of hands then just ask.
So if you find your self in a similar situation learn from what I did and ask for help.
This week I learned the importance of asking for help when you need it. I was asked to do a 6 MWT for one of the patients on the ward. I was thinking a 6MWT is very straight forward process however on this occasion there were additional factors which complicated this test. First of all my patient did not speak English and his family was not around for translating. Secondly he was on portable oxygen and third the ward did not have any hand held oximeters available so I had to push the machine along side. I did not feel confident I could have control my patient. With the additional equipment I didn’t think I would be close enough to the patient to record relevant information and guard him as I administered the test.
I had seen this patient before hand which was a positive, we walked him 40 m and he de-saturated to 80 % spO2 while on 2 L of oxygen via nasal prongs. So I was aware and ready for him to de-saturate again. Despite documenting these findings in the notes the doctors still ordered a 6MWT to see if he was appropriate for home oxygen.
I prepared the hallway before hand with chairs positioned at each end of the hall. In the back of my mind I wanted to ask my supervisor to help me however did not want to be a burden therefore I convinced myself I would be alright on my own. But knew in my heart I was nervous conducting the test.
We began the test and I tried to explain to my patient the procedure. However I don’t think he understood very much. He began the test at 97 % spO2 on 2L within the first minute he was down to 87 %. At 1 min 30 he was at 84 % and I asked him how he was doing and showed him the chair was available because in class they tell us 85 % sit them down. I observed carefully for signs hypoxaemia however it was difficult as he had an abnormal breathing pattern and was unable to communicate effectively with me. He continued walking to the other end and at 2 min 20 seconds he was at 74 %. At this point I told him to sit down due to his sats and his heart rate being 165. I aborted the test. It took him 6 min to recover to 93 %. But I still had not recovered from the stress I felt during the test.
After the test I really did not feel happy with how the test was conducted. He was safe and nothing ended up happening. However I believe if I had of asked for help the test would have been much safer and more reliable. After speaking to my supervisor she said never hesitate trust your gut if you think you need a second pair of hands then just ask.
So if you find your self in a similar situation learn from what I did and ask for help.
Patella tendon rupture info
Hi all,
Thanks lads for the useful info re; my last post on the subject. With this post I thought that I could provide some info on the subject, an updated treatment protocol sourced from one of the Orthopods at the facility, and some info on my patient.
Patella tendon rupture is fairly rare, third in terms of number of injury to the knee extensor mechanism after patella fracture and quad tendon rupture. Surgery is nearly always indicated so as to allow recovery of motion and strength. Post surgery the Rx protocol is as follows.
0-3d= No WB, knee brace locked in ext, no exercise or modalities.
4-13d= TWB, knee brace locked in ext, active flx to 45 and passive ext to 0 (no active ext), swelling control with ice, gentle medial lateral glide, isometric hamstring exs, contralateral quad exs.
2-4w= PWB, knee brace locked in ext, active flx to 90 and passive ext to 0 (no active ext), isometric quads (no SLRs) + above.
4-6w=WBAT and crutches discontinued when good quads control, knee brace locked in ext, full active flxn and passive extn, + above.
6-12w= WBAT, knee brace discontinued when good active quads control and normal gait are obtained, aggressive medial/lateral glides, SLR without reistance + above, and stationary cycling at 8 weeks.
12-16w=FWB, quads strengthening and neuromuscular retraining.
16-24w = FWB, running and sports/work specific training.
>6m= may return to jumping and contact sport when 90% of strength of contralateral extremity.
Of course this protocol is slighty different for every pt. My pt was a fit guy (boxer), however he had received no PT Rx since discharge (well over 3months post op when seeing me)!! Thus his AROM was only 5-80 deg and he also had decreased strength with severe quads wasting and quads lag. He had seen the orthopod the week before who immediately took him off the sticks, removed the brace and referred to the clinic for physio. So my initial Rx session focused on increasing ROM. I found the old hold/relax quite good for this with immediate beneficial effects.
One interesting part of my Ax was palpation of the tendon. It felt really wide and flat, unlike normal, where it is quite narrow with palpable edges. My supervisor said that this was quite common in these tendon injuries and often occurred after achilles surgery too. He said that narrowing of the tendon and scar mangement was an important part of physio treatment. As we have not been taught much about this at school I thought I would open this up to the crew and see if you have any ideas on this. I was reading in Brukner and Khan that cross friction massage is one option.
Thats it, hope you were not all bored to death, take it easy!
Nico
Thanks lads for the useful info re; my last post on the subject. With this post I thought that I could provide some info on the subject, an updated treatment protocol sourced from one of the Orthopods at the facility, and some info on my patient.
Patella tendon rupture is fairly rare, third in terms of number of injury to the knee extensor mechanism after patella fracture and quad tendon rupture. Surgery is nearly always indicated so as to allow recovery of motion and strength. Post surgery the Rx protocol is as follows.
0-3d= No WB, knee brace locked in ext, no exercise or modalities.
4-13d= TWB, knee brace locked in ext, active flx to 45 and passive ext to 0 (no active ext), swelling control with ice, gentle medial lateral glide, isometric hamstring exs, contralateral quad exs.
2-4w= PWB, knee brace locked in ext, active flx to 90 and passive ext to 0 (no active ext), isometric quads (no SLRs) + above.
4-6w=WBAT and crutches discontinued when good quads control, knee brace locked in ext, full active flxn and passive extn, + above.
6-12w= WBAT, knee brace discontinued when good active quads control and normal gait are obtained, aggressive medial/lateral glides, SLR without reistance + above, and stationary cycling at 8 weeks.
12-16w=FWB, quads strengthening and neuromuscular retraining.
16-24w = FWB, running and sports/work specific training.
>6m= may return to jumping and contact sport when 90% of strength of contralateral extremity.
Of course this protocol is slighty different for every pt. My pt was a fit guy (boxer), however he had received no PT Rx since discharge (well over 3months post op when seeing me)!! Thus his AROM was only 5-80 deg and he also had decreased strength with severe quads wasting and quads lag. He had seen the orthopod the week before who immediately took him off the sticks, removed the brace and referred to the clinic for physio. So my initial Rx session focused on increasing ROM. I found the old hold/relax quite good for this with immediate beneficial effects.
One interesting part of my Ax was palpation of the tendon. It felt really wide and flat, unlike normal, where it is quite narrow with palpable edges. My supervisor said that this was quite common in these tendon injuries and often occurred after achilles surgery too. He said that narrowing of the tendon and scar mangement was an important part of physio treatment. As we have not been taught much about this at school I thought I would open this up to the crew and see if you have any ideas on this. I was reading in Brukner and Khan that cross friction massage is one option.
Thats it, hope you were not all bored to death, take it easy!
Nico
Subscribe to:
Comments (Atom)