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.
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