On completing my placement at Armadale hospital I realized some of my expectations were met, and many of my concerns turned out not to be a problem. For example, as I expected I did have to do a presentation to the physio department. I did a presentation on COPD and it went well. I wasn’t sure at the start if I would be on a surgical or medical ward, and it turns out I was on both (although I spent most of my time on the medical ward).
Based on the information I was sent by the hospital prior to starting my placement I expected to observe for the first couple of days. On my first day however I did end up assessing and treating a patient with my supervisor’s input. This was better than just observing, as I would rather get hands-on experience while I have a supervisor who can give feedback. I did have my own caseload (starting day 2) and was seeing about 7-8 patients a day by the end of my placement. By the end I was working fairly independently and asking for advice when I needed it.
I was right about discharge planning being extremely important, and my supervisor spent time going through all the different options and services with me. There was obviously a lot of importance placed on discharge planning so I am glad I was prepared and had already thought about it.
My concerns were not founded. I was worried that my supervisor would expect a lot of me in the first week but they were fair with their expectations and made it clear to me what I needed to do. I received a lot of feedback as I went along, which was very helpful. I was also eased into my caseload but I found I was able to manage it better than I thought (which is a good thing to find out before I start work!)
I feel my assessment skills have really been developed over the five weeks (both subjective and objective). There was also a huge focus on my clinical reasoning and I feel I did well in this area. To start with I could work out a problem list for my patients but needed a bit of help to prioritise it. Now that I have finished the placement I feel I am much better at prioritising the problem list.
At my mid-placement assessment my supervisor mentioned I should liaise with other allied health and nursing staff more often. I took this on board and feel I had improved in this area by the end of the placement. I started talking to nursing staff before going to see a patient, just to check how they had been going. I also started referring to the occupational therapist more often for equipment my patients needed.
I thoroughly enjoyed my placement at Armadale and feel I am now ready to start working as a physiotherapist.
Friday, November 26, 2010
Wednesday, November 17, 2010
STARES 3 - Difficult patient with an unreliable history
SITUATION
A 26 year old male presented to ED with vomiting, shortness of breath, a cough and chest pain. He was admitted to the ward with pneumonia, with the aim of having a psychological review. His past medical history included borderline personality disorder. He also complained of weakness in his left side from a car accident two years ago. He claimed it had not gone away but he had been managing. He said he could hardly stand as he was so weak on that side he would fall over. Nursing staff had been helping him transfer and ambulate. He was being assisted with showering and activities of daily living (ADLs). There was evidence however that what he told hospital staff was not accurate or reliable. For example, while he claimed to be too weak to stand, nursing staff had witnessed his walking around his room independently when he thought nobody was watching. Similarly, he told the physio he had vomited in the shower, however the nurse was helping him shower and she stated he had no vomited at all. His notes indicated he was not as sick as he wanted everyone to believe (and possible believed it himself).
TASK
My task was to assess and treat this patient without reinforcing his behaviour.
ACTION
While taking a subjective history I asked about his cough and shortness of breath. While I took note of his answers I needed to weigh them up against the objective evidence. Although he claimed to have shortness of breath at rest, and was claiming to cough up black/brown sputum, I could find no evidence to back this up. There was no indication of shortness of breath at rest and no increased work of breathing. His oxygen saturation was 100% on room air. On auscultation his chest was clear and the sputum he coughed up was very minimal and white/clear. His chest x-ray also showed his chest was clear. He claimed in the subjective assessment his left side was very weak, and on manual muscle testing he only scored a 3+ in his left lower limb. It was clear he was deliberately trying to act weak, and when I asked him to stand he was able to support his weight.
I then had to sort out treatment for this patient. While the chest was clear I could not ignore treating this as I had a duty of care to this patient, and he said he was having trouble bringing up sputum. I went through the ACBT with him and taught him how to do it. His cough was dry and non-productive. I then explained he needed to do the ACBT by himself and that he didn't need a physio with him when he did it, I encouraged him to be independent in this treatment. Before I could mobilize him he started deliberate dry-wretching so I stopped treatment.
RESULTS
Through my assessment the chest was cleared, and ACBT was non-productive. I provided education on ACBT to allow the patient to manage any sputum independently. I also provided the patient with a walking stick to encourage him to be independent and ambulate around the room. Unfortunately I did not get to assess the patient's mobility.
EVALUATION
I feel my session was fairly successful as I was able to clear the chest and we no longer had to worry about treating it. I provided education so he could manage any sputum, so in this way I did provide the patient with treatment without making it too passive and encouraging his behaviour. The plan is to review his mobility and then discharge him from physio as he no longer requires our services. It is a psych issue, not for physio. I believe I was effective with my assessment and treatment and found the relevant information, rather than continuing to treat him for many sessions which would be unnecessary.
STRATEGIES
When dealing with this situation the following strategies can help:
1. Discuss with nursing staff to see how the patient is when they are not being "assessed".
2. Compare subjective findings with objective findings to get a clear clinical picture, especially if the patient seems unreliable or a poor historian.
3. Don't take everything the patient says as the truth if he has a personality disorder. See what you can back up (either objectively or by asking other staff).
4. Don't use passive treatments as it will likely reinforce their behaviour. Get them actively involved in their treatment.
A 26 year old male presented to ED with vomiting, shortness of breath, a cough and chest pain. He was admitted to the ward with pneumonia, with the aim of having a psychological review. His past medical history included borderline personality disorder. He also complained of weakness in his left side from a car accident two years ago. He claimed it had not gone away but he had been managing. He said he could hardly stand as he was so weak on that side he would fall over. Nursing staff had been helping him transfer and ambulate. He was being assisted with showering and activities of daily living (ADLs). There was evidence however that what he told hospital staff was not accurate or reliable. For example, while he claimed to be too weak to stand, nursing staff had witnessed his walking around his room independently when he thought nobody was watching. Similarly, he told the physio he had vomited in the shower, however the nurse was helping him shower and she stated he had no vomited at all. His notes indicated he was not as sick as he wanted everyone to believe (and possible believed it himself).
TASK
My task was to assess and treat this patient without reinforcing his behaviour.
ACTION
While taking a subjective history I asked about his cough and shortness of breath. While I took note of his answers I needed to weigh them up against the objective evidence. Although he claimed to have shortness of breath at rest, and was claiming to cough up black/brown sputum, I could find no evidence to back this up. There was no indication of shortness of breath at rest and no increased work of breathing. His oxygen saturation was 100% on room air. On auscultation his chest was clear and the sputum he coughed up was very minimal and white/clear. His chest x-ray also showed his chest was clear. He claimed in the subjective assessment his left side was very weak, and on manual muscle testing he only scored a 3+ in his left lower limb. It was clear he was deliberately trying to act weak, and when I asked him to stand he was able to support his weight.
I then had to sort out treatment for this patient. While the chest was clear I could not ignore treating this as I had a duty of care to this patient, and he said he was having trouble bringing up sputum. I went through the ACBT with him and taught him how to do it. His cough was dry and non-productive. I then explained he needed to do the ACBT by himself and that he didn't need a physio with him when he did it, I encouraged him to be independent in this treatment. Before I could mobilize him he started deliberate dry-wretching so I stopped treatment.
RESULTS
Through my assessment the chest was cleared, and ACBT was non-productive. I provided education on ACBT to allow the patient to manage any sputum independently. I also provided the patient with a walking stick to encourage him to be independent and ambulate around the room. Unfortunately I did not get to assess the patient's mobility.
EVALUATION
I feel my session was fairly successful as I was able to clear the chest and we no longer had to worry about treating it. I provided education so he could manage any sputum, so in this way I did provide the patient with treatment without making it too passive and encouraging his behaviour. The plan is to review his mobility and then discharge him from physio as he no longer requires our services. It is a psych issue, not for physio. I believe I was effective with my assessment and treatment and found the relevant information, rather than continuing to treat him for many sessions which would be unnecessary.
STRATEGIES
When dealing with this situation the following strategies can help:
1. Discuss with nursing staff to see how the patient is when they are not being "assessed".
2. Compare subjective findings with objective findings to get a clear clinical picture, especially if the patient seems unreliable or a poor historian.
3. Don't take everything the patient says as the truth if he has a personality disorder. See what you can back up (either objectively or by asking other staff).
4. Don't use passive treatments as it will likely reinforce their behaviour. Get them actively involved in their treatment.
Tuesday, November 9, 2010
STARES 2
Clinical Reasoning in Assessment and Treatment
SITUATION
An 86 year old male admitted with an exacerbation of Chronic Obstructive Pulmonary Disorder (COPD) and congestive cardiac failure (CCF). He normally lives with his wife and is independent with activities of daily living (ADLs). He has been coping at home until now, but had had a decrease in exercise tolerance for many years. He is normally slightly short of breath on exertion (SOBOE) with no cough or sputum. He can normally ambulate approximately 50m with no aids.
TASK
My task was to assess this patient, decide on a prioritised problem list and perform a treatment session.
ACTION
To start with I looked at his blood results and chest x-ray on the computer. His blood results were normal but his chest x-ray showed what appeared to be infiltrates in the bases. I thought this could be consolidation. As part of my assessment I took a subjective history. I found he had been coughing but it was non-productive. The patient said it felt like he needed to cough up phlegm but nothing was coming up. He was also short of breath (SOB) at rest and on exertion.
For my objective assessment I began by auscultating his chest. I heard decreased breath sounds bibasally and some crackles in both bases, left equal to right. I thought this might be due to the consolidation. I listened to his cough and it sounded strong and moist, but was non-productive.
I decided his main problems were impaired airway clearance, dyspnoea and decreased exercise tolerance.
My treatment started with Active Cycle of Breathing Technique (ACBT) to help with airway clearance. I did 3 cycles with the patient but it was non productive. His cough still sounded moist and on auscultation there were still crackles in the bases.
I then decided to mobilize the patient by marching on the spot. He managed 3x 20seconds of marching before his oxygen levels dropped to 84%. He stopped marching and sat down.
I ended the session with the plan to continue mobilizing the next day to increase exercise tolerance.
RESULTS
My treatment of mobilizing the patient targeted the exercise tolerance and shortness of breath. I feel this was an effective treatment and the patient tolerated it well. The ACBT was the airway clearance was not effective as it did not clear out any sputum and other outcome measures were the same on re-assessment.
EVALUATION
After discussing this patient was my supervisor I discovered my clinical reasoning had been wrong, and that was way my airway clearance had not been effective. He did not have large amounts of sputum in his lungs, it was fluid from CCF. This is why his cough sounded moist and I heard crackles on auscultation. My ACBT and airway clearance techniques were not necessary and therefore not effective. My problem list should have focused on the decreased exercise tolerance and shortness of breath.
STRATEGIES
In order to avoid this mistake again I have thought of the following strategies:
1. Check the chest x-ray to determine if it is fluid or infiltrates. Look for a meniscus to indicate fluid.
2. Check for a history of CCF and be aware of fluid overload.
3. Check infection markers to see the likelihood of having sputum.
SITUATION
An 86 year old male admitted with an exacerbation of Chronic Obstructive Pulmonary Disorder (COPD) and congestive cardiac failure (CCF). He normally lives with his wife and is independent with activities of daily living (ADLs). He has been coping at home until now, but had had a decrease in exercise tolerance for many years. He is normally slightly short of breath on exertion (SOBOE) with no cough or sputum. He can normally ambulate approximately 50m with no aids.
TASK
My task was to assess this patient, decide on a prioritised problem list and perform a treatment session.
ACTION
To start with I looked at his blood results and chest x-ray on the computer. His blood results were normal but his chest x-ray showed what appeared to be infiltrates in the bases. I thought this could be consolidation. As part of my assessment I took a subjective history. I found he had been coughing but it was non-productive. The patient said it felt like he needed to cough up phlegm but nothing was coming up. He was also short of breath (SOB) at rest and on exertion.
For my objective assessment I began by auscultating his chest. I heard decreased breath sounds bibasally and some crackles in both bases, left equal to right. I thought this might be due to the consolidation. I listened to his cough and it sounded strong and moist, but was non-productive.
I decided his main problems were impaired airway clearance, dyspnoea and decreased exercise tolerance.
My treatment started with Active Cycle of Breathing Technique (ACBT) to help with airway clearance. I did 3 cycles with the patient but it was non productive. His cough still sounded moist and on auscultation there were still crackles in the bases.
I then decided to mobilize the patient by marching on the spot. He managed 3x 20seconds of marching before his oxygen levels dropped to 84%. He stopped marching and sat down.
I ended the session with the plan to continue mobilizing the next day to increase exercise tolerance.
RESULTS
My treatment of mobilizing the patient targeted the exercise tolerance and shortness of breath. I feel this was an effective treatment and the patient tolerated it well. The ACBT was the airway clearance was not effective as it did not clear out any sputum and other outcome measures were the same on re-assessment.
EVALUATION
After discussing this patient was my supervisor I discovered my clinical reasoning had been wrong, and that was way my airway clearance had not been effective. He did not have large amounts of sputum in his lungs, it was fluid from CCF. This is why his cough sounded moist and I heard crackles on auscultation. My ACBT and airway clearance techniques were not necessary and therefore not effective. My problem list should have focused on the decreased exercise tolerance and shortness of breath.
STRATEGIES
In order to avoid this mistake again I have thought of the following strategies:
1. Check the chest x-ray to determine if it is fluid or infiltrates. Look for a meniscus to indicate fluid.
2. Check for a history of CCF and be aware of fluid overload.
3. Check infection markers to see the likelihood of having sputum.
Monday, November 1, 2010
STARES 1
STARES 1
Situation
A 79 year old male was admitted for a non-infective exacerbation of COPD. He lives with his daughter and son in law but is fairly independent. His daughter helps with some activities of daily living (ADLs). He has no history of dementia and has been managing well at home. He was not on oxygen and had been ambulating to the toilet by himself. His main complaint was shortness of breath (SOB). Upon being admitted to hospital he became confused and delirious. His notes mentioned he was unsteady on his feet.
Task
My task was to safely ambulate this patient and to assess his oxygen saturation over a longer distance (further than he had been walking by himself).
Action
I started by checking that the environment was clear and safe, and made sure there was a chair by the door in case he needed a rest. I asked him to put his shoes on as he was only wearing socks which could have slipped on the floor. The patient was very impulsive and kept trying to stand up and walk without shoes or a frame. I made sure his frame was right in front of him and reminded him to use it. I also asked my supervisor to stand on the other side of the patient for safety reasons. I monitored his oxygen and heart rate as he walked and kept my commands short and simple (for example “slow down” and “stop”).
Results
The patient ambulated to the doorway of his room and back to his bed, which was approximately 20 metres. He was stopped because I felt it was unsafe. He was unsteady on his feet and particularly unsafe when turning. He liked to walk very quickly at an unsafe speed. This patient did not realize how unsafe he actually was.
Evaluation
I think I made the right decision to stop this patient after 20 metres. Although we could not assess his oxygen over a distance (our initial aim) I believe it would have been unsafe to continue. By stopping him early in the walk I may have prevented a fall, which may have injured the patient or myself. Weighing up the pros and cons of the decision I think the right one was made.
Strategies
There are several strategies that can be employed to prevent falls when ambulating a patient:
1. Be aware of their medical history and current status – i.e. if they are confused, have dementia, are delirious.
2. Clear the environment of where you are planning to walk.
3. Make sure you have a second person if the person seems unsteady or unsafe.
4. Stop straight away if they are not safe, it’s not worth the risk.
Situation
A 79 year old male was admitted for a non-infective exacerbation of COPD. He lives with his daughter and son in law but is fairly independent. His daughter helps with some activities of daily living (ADLs). He has no history of dementia and has been managing well at home. He was not on oxygen and had been ambulating to the toilet by himself. His main complaint was shortness of breath (SOB). Upon being admitted to hospital he became confused and delirious. His notes mentioned he was unsteady on his feet.
Task
My task was to safely ambulate this patient and to assess his oxygen saturation over a longer distance (further than he had been walking by himself).
Action
I started by checking that the environment was clear and safe, and made sure there was a chair by the door in case he needed a rest. I asked him to put his shoes on as he was only wearing socks which could have slipped on the floor. The patient was very impulsive and kept trying to stand up and walk without shoes or a frame. I made sure his frame was right in front of him and reminded him to use it. I also asked my supervisor to stand on the other side of the patient for safety reasons. I monitored his oxygen and heart rate as he walked and kept my commands short and simple (for example “slow down” and “stop”).
Results
The patient ambulated to the doorway of his room and back to his bed, which was approximately 20 metres. He was stopped because I felt it was unsafe. He was unsteady on his feet and particularly unsafe when turning. He liked to walk very quickly at an unsafe speed. This patient did not realize how unsafe he actually was.
Evaluation
I think I made the right decision to stop this patient after 20 metres. Although we could not assess his oxygen over a distance (our initial aim) I believe it would have been unsafe to continue. By stopping him early in the walk I may have prevented a fall, which may have injured the patient or myself. Weighing up the pros and cons of the decision I think the right one was made.
Strategies
There are several strategies that can be employed to prevent falls when ambulating a patient:
1. Be aware of their medical history and current status – i.e. if they are confused, have dementia, are delirious.
2. Clear the environment of where you are planning to walk.
3. Make sure you have a second person if the person seems unsteady or unsafe.
4. Stop straight away if they are not safe, it’s not worth the risk.
Saturday, October 23, 2010
Initial Entry - Cardio at Armadale
Initial Entry
I will be completing my final prac at Armadale Hospital. I was sent some information from the facility so I have based my expectations on that, as well as information other students have given me.
I have the following expectations:
• I know I will be on the wards but am not sure if it will be a general medical ward or a post-surgical ward. I am hoping I get to spend time on both.
• I can expect to observe for the first couple of days before doing an assessment and treatment myself.
• By the end of the placement I expect to have my own caseload of patients and be working fairly independently.
• At some stage I will have to give a presentation to the physio department.
• As a student I believe my role will initially be to observe, before jumping in to get as much hands-on practical experience as possible. I believe it will be expected of my to revise my theoretical knowledge each night and the brush up on anything I am not sure about (such as assessment or treatment techniques.)
• I expect I will be asked to begin with a subjective assessment of a patient and then discuss the case with my supervisor before doing any treatment.
• Discharge planning will be an important element of my treatment, as it is at any hospital.
While I am looking forward to this placement I do have a few concerns:
• I am worried that my supervisor might treat me like I have already completed a 5 week cardio placement (whereas I only did one week) and she might have high expectations in week 1.
• I am worried about managing the case load – I am hoping I get eased into it.
I will be completing my final prac at Armadale Hospital. I was sent some information from the facility so I have based my expectations on that, as well as information other students have given me.
I have the following expectations:
• I know I will be on the wards but am not sure if it will be a general medical ward or a post-surgical ward. I am hoping I get to spend time on both.
• I can expect to observe for the first couple of days before doing an assessment and treatment myself.
• By the end of the placement I expect to have my own caseload of patients and be working fairly independently.
• At some stage I will have to give a presentation to the physio department.
• As a student I believe my role will initially be to observe, before jumping in to get as much hands-on practical experience as possible. I believe it will be expected of my to revise my theoretical knowledge each night and the brush up on anything I am not sure about (such as assessment or treatment techniques.)
• I expect I will be asked to begin with a subjective assessment of a patient and then discuss the case with my supervisor before doing any treatment.
• Discharge planning will be an important element of my treatment, as it is at any hospital.
While I am looking forward to this placement I do have a few concerns:
• I am worried that my supervisor might treat me like I have already completed a 5 week cardio placement (whereas I only did one week) and she might have high expectations in week 1.
• I am worried about managing the case load – I am hoping I get eased into it.
Thursday, July 22, 2010
Bentley Outpatients – Final Entry
I really enjoyed my time at Bentley and learnt a lot!! Some of my expectations were correct (which was to be expected as I had an orientation prior to starting placement).
I expected to do hydrotherapy every week, however we only had to do it 3 out of the 5 weeks. It was a good experience but not the best weather for hydro! The hydro was individual programs for patients, not one big group exercise class like I thought it might be.
I expected to see 3 patient a day to start with (which is what happened) but originally thought I’d build up to 8 or 9. I saw a maximum of 6 patients, although I probably could have squeezed in more on some days.
My supervisor was great in that he really helped develop my clinical reasoning. He questioned why I was doing a specific treatment and tried to guide me without just giving me the answers. It really helped my lateral thinking.
While we had access to the referrals and handovers the day before seeing the patient, by the end of the placement I wasn’t so worried about studying up for each patient the night before. I started off by doing this but as I got more confident I knew I could tackle it the morning of seeing the patient. We had planning sessions with out supervisor each morning to discuss the patients we were seeing that day. This was great for developing clinical reasoning but also made me feel more comfortable in that I would know what to do with my patients.
There is a PD session for all the staff once a week and everyone takes it in turns to do a presentation. The students are also included in this and I did my presentation on the link between depression and back pain. I had expected to do a presentation but I didn’t realize how much I would learn from doing it. A lot of the physios in the department also commented it was such a relevant topic.
I had some concerns coming into this placement, but none of them turned out to be a problem! I was concerned I might get a patient who I could not diagnose or work out a treatment plan for, but our supervisor explained how we should treat what we see instead of trying to come up with a diagnosis. In time it would be worked out. The fact we were given so much support also made this less of a worry because I knew I would be able to get help from other physios with my patients if I needed. I was also concerned I wouldn’t remember everything from the past 3 years at university, but I found this wasn’t a problem. If there was anything I forgot I could look it up or try a different technique. We were shown a lot of new techniques while on this placement and I found they gelled really well with what we already knew.
The most important lesson I learned at Bentley was to treat what I see. Just because a person is referred with a specific diagnosis doesn’t mean your assessment findings will match that diagnosis. When this happens trust in your assessment and treat the problems that you actually found. Don’t try and fit you assessment to the referral’s diagnosis.
I expected to do hydrotherapy every week, however we only had to do it 3 out of the 5 weeks. It was a good experience but not the best weather for hydro! The hydro was individual programs for patients, not one big group exercise class like I thought it might be.
I expected to see 3 patient a day to start with (which is what happened) but originally thought I’d build up to 8 or 9. I saw a maximum of 6 patients, although I probably could have squeezed in more on some days.
My supervisor was great in that he really helped develop my clinical reasoning. He questioned why I was doing a specific treatment and tried to guide me without just giving me the answers. It really helped my lateral thinking.
While we had access to the referrals and handovers the day before seeing the patient, by the end of the placement I wasn’t so worried about studying up for each patient the night before. I started off by doing this but as I got more confident I knew I could tackle it the morning of seeing the patient. We had planning sessions with out supervisor each morning to discuss the patients we were seeing that day. This was great for developing clinical reasoning but also made me feel more comfortable in that I would know what to do with my patients.
There is a PD session for all the staff once a week and everyone takes it in turns to do a presentation. The students are also included in this and I did my presentation on the link between depression and back pain. I had expected to do a presentation but I didn’t realize how much I would learn from doing it. A lot of the physios in the department also commented it was such a relevant topic.
I had some concerns coming into this placement, but none of them turned out to be a problem! I was concerned I might get a patient who I could not diagnose or work out a treatment plan for, but our supervisor explained how we should treat what we see instead of trying to come up with a diagnosis. In time it would be worked out. The fact we were given so much support also made this less of a worry because I knew I would be able to get help from other physios with my patients if I needed. I was also concerned I wouldn’t remember everything from the past 3 years at university, but I found this wasn’t a problem. If there was anything I forgot I could look it up or try a different technique. We were shown a lot of new techniques while on this placement and I found they gelled really well with what we already knew.
The most important lesson I learned at Bentley was to treat what I see. Just because a person is referred with a specific diagnosis doesn’t mean your assessment findings will match that diagnosis. When this happens trust in your assessment and treat the problems that you actually found. Don’t try and fit you assessment to the referral’s diagnosis.
STARES 3 – Treatment for patient with knee pain
SITUATION
I had been referred a patient suffering from knee pain. The referral mentioned “patello-femoral syndrome” and through my subjective and objective assessment I found she had lateral mal-tracking of the patella. I also found she had very pronated feet when walking with low arches. Her lateral thigh structures were very tight and her vastus medialis oblique (VMO) was barely activating. Her quadriceps were weak with an obvious quads lag. Her pain was at the worst when she had to go up and down stairs. When a medial glide was applied to the patella it was not as painful to go up and down stairs. There were a number of factors contributing to this knee pain.
TASK
My task was to provide a treatment session for this patient, targeting the knee pain and lateral tracking of the patella.
ACTION
My first part of the treatment was education. It is important for the patient to understand what is going on and what the treatment plan is. I explained that the knee pain would be a result of the mal-tracking patella, which is sitting too far to one side (and therefore not sitting in the groove). I explained it could be mal-tracking as a result of the tight lateral structures pulling it one way and the weak medial structures (particularly VMO) could not pull it back to midline.
The second part of my treatment was aimed at decreasing the tension of the lateral structures. I used massage and advised her on the use of heat and stretches at home.
My final part of the treatment was exercises aimed at increasing the quadriceps and VMO strength. I prescribed step exercises which are very good for quad strength and can be modified slightly to target VMO. I used strapping tape to put a medial glide on the patella to relieve pain temporarily. The aim was to reduce pain to allow the patient to make a start on the exercises at home.
I also sent a referral to the podiatrist regarding the pronated feet to see if orthotics to raise the arches were possible. I feel it would take some of the pressure off the knee (which could be a contributing facto in the knee pain).
RESULT
I completed this treatment session in the allocated time and the patient understood how each treatment component could help to decrease her knee pain. The treatment had an immediate effect on the pain, and strapping provided temporary relief from the pain completely.
EVALUATION
I feel this was a god treatment session as it had an immediate effect on decreasing the knee pain and the patient knew what to do at home to continue this pain relief. I think a good treatment session gives the patient something to do at home to self-manage their pain, rather than waiting until their next physio appointment. It also encourages them to actively participate in the treatment, rather than having it purely passive (which has been shown to have a poor outcome). By prescribing exercises for this patient to do at home it will be a lot more effective than only being seen by a physio once a week. The fact there was an immediate decrease in the pain will encourage the patient to be compliant with the home exercise program as she knows this treatment really can help.
By referring her to the podiatrist I was taking a multidisciplinary approach, which will benefit the patient. Overall I feel it was a well-rounded approach that decreased the pain during the session but also focussed on how we would decrease the pain permanently.
There were a few improvements I would have made in this session. When demonstrating the step exercises I tried to explain too much first when I should have just shown her. Actions speak louder than words! I think I may have temporarily confused the patient with the exercise.
Also, I chose to use a plastic massage device over her clothes, rather than using cream directly on the skin. I feel massaging with cream may have been more effective (I can put more pressure through my forearm than the plastic device in my hand). The patient was wearing long pants that could not be rolled high enough to reveal the thigh. I did not think she would be comfortable taking her trousers off and being covered with a towel, however I should have given her the option instead of assuming what she would prefer.
STRATEGIES
1. Save time trying to explain a complicated exercise to a patient and just demonstrate it instead.
2. Don’t assume what the patient is comfortable with or not, always ask them what they would prefer.
I had been referred a patient suffering from knee pain. The referral mentioned “patello-femoral syndrome” and through my subjective and objective assessment I found she had lateral mal-tracking of the patella. I also found she had very pronated feet when walking with low arches. Her lateral thigh structures were very tight and her vastus medialis oblique (VMO) was barely activating. Her quadriceps were weak with an obvious quads lag. Her pain was at the worst when she had to go up and down stairs. When a medial glide was applied to the patella it was not as painful to go up and down stairs. There were a number of factors contributing to this knee pain.
TASK
My task was to provide a treatment session for this patient, targeting the knee pain and lateral tracking of the patella.
ACTION
My first part of the treatment was education. It is important for the patient to understand what is going on and what the treatment plan is. I explained that the knee pain would be a result of the mal-tracking patella, which is sitting too far to one side (and therefore not sitting in the groove). I explained it could be mal-tracking as a result of the tight lateral structures pulling it one way and the weak medial structures (particularly VMO) could not pull it back to midline.
The second part of my treatment was aimed at decreasing the tension of the lateral structures. I used massage and advised her on the use of heat and stretches at home.
My final part of the treatment was exercises aimed at increasing the quadriceps and VMO strength. I prescribed step exercises which are very good for quad strength and can be modified slightly to target VMO. I used strapping tape to put a medial glide on the patella to relieve pain temporarily. The aim was to reduce pain to allow the patient to make a start on the exercises at home.
I also sent a referral to the podiatrist regarding the pronated feet to see if orthotics to raise the arches were possible. I feel it would take some of the pressure off the knee (which could be a contributing facto in the knee pain).
RESULT
I completed this treatment session in the allocated time and the patient understood how each treatment component could help to decrease her knee pain. The treatment had an immediate effect on the pain, and strapping provided temporary relief from the pain completely.
EVALUATION
I feel this was a god treatment session as it had an immediate effect on decreasing the knee pain and the patient knew what to do at home to continue this pain relief. I think a good treatment session gives the patient something to do at home to self-manage their pain, rather than waiting until their next physio appointment. It also encourages them to actively participate in the treatment, rather than having it purely passive (which has been shown to have a poor outcome). By prescribing exercises for this patient to do at home it will be a lot more effective than only being seen by a physio once a week. The fact there was an immediate decrease in the pain will encourage the patient to be compliant with the home exercise program as she knows this treatment really can help.
By referring her to the podiatrist I was taking a multidisciplinary approach, which will benefit the patient. Overall I feel it was a well-rounded approach that decreased the pain during the session but also focussed on how we would decrease the pain permanently.
There were a few improvements I would have made in this session. When demonstrating the step exercises I tried to explain too much first when I should have just shown her. Actions speak louder than words! I think I may have temporarily confused the patient with the exercise.
Also, I chose to use a plastic massage device over her clothes, rather than using cream directly on the skin. I feel massaging with cream may have been more effective (I can put more pressure through my forearm than the plastic device in my hand). The patient was wearing long pants that could not be rolled high enough to reveal the thigh. I did not think she would be comfortable taking her trousers off and being covered with a towel, however I should have given her the option instead of assuming what she would prefer.
STRATEGIES
1. Save time trying to explain a complicated exercise to a patient and just demonstrate it instead.
2. Don’t assume what the patient is comfortable with or not, always ask them what they would prefer.
Saturday, July 10, 2010
STARES 2 – Communication
SITUATION
I had a patient transfer to me from a previous student. I read in the notes that she had been suffering from headaches caused by increased tension in the cervical spine (primarily due to increased muscle tension through trapezius, rhomboids and levator scapulae). Her headaches were better when the muscles were relaxed, however she had not been very compliant with her home program and her headaches gradually got worse again following each treatment session (after her feeling really good at the end of each session). As a result of her not doing her home exercise program (HEP) the muscles would tighten up after treatment and she would not do anything to help it until the next time she came in for physio.
TASK
My task was to perform a follow-up assessment for this patient and a treatment session. I had the job of telling this patient that is she wasn’t complying with the HEP then we couldn’t do much else for her.
ACTION
I began the subjective assessment by asking how her headaches had been. When she said they were good after the last treatment session but got worse again as time went on I asked her if she had been doing her HEP. She replied that she hadn’t been doing it every day, only occasionally as she had been busy. I took this opportunity to remind her that I could do a treatment for her but she needed to continue it at home to have a long-lasting effect from it. I didn’t want to have a go at her but I needed to make my point. I then performed my objective assessment and started my treatment by working on the muscles around the shoulders and neck. As I massaged I explained again how she could prolong the benefits of this treatment session at home. I thought that if I explained this to her while I was performing a hands-on treatment, she would realize I was still going to treat her and not just send her away to deal with it at home by herself. I tried to make her understand it was a two-way street. I could only help her if she was going to help herself. After I had finished my treatment and was winding up the session I explained to her that we knew what her problem was and we know how to get rid of the pain and headaches, it was just a matter of her actually doing her exercises at home. I put it back on her, saying SHE had to do the hard work to get rid of the pain, rather than expecting our physio session to be a miracle cure.
RESULTS
My patient seemed to understand the point I was trying to make without me having to be too blunt about it. I have given her the idea that if she doesn’t do her HEP then we will not continue with her treatment at the hospital as it was just wasting everyone’s time. The patient agreed to do her program and admitted she needed to lift her game a little. I think she now understands the consequences if she does not actively participate in her treatment. I was able to get this point across to her without ruining my rapport (or the rapport developed with the patient by the previous student). If I had been blunt about it she may have felt that I was blaming her and decided she didn’t want to attend physio. This would have been a shame as physio is definitely something that can help her problem if she complies with her exercises.
STRATEGIES
It can be difficult to have to tell a patient off for not doing their exercises and that if they don’t do them then there is nothing else we can do. Some ways of dealing with this are:
1. Say you don’t want to waste THEIR time coming into hospital when it’s not a very effective treatment by itself. This is better than you saying it’s wasting YOUR time.
2. Be sensitive and sympathetic – find out if there is a reason they haven’t been doing their exercises before you assume they are just non-compliant.
3. Be strong and as forceful as necessary to make your point but avoid being tactless or overly blunt.
4. Compromise – see how many exercises they think they can commit to doing if they think the whole lot you prescribed is too much. This is better than them doing none at all.
I had a patient transfer to me from a previous student. I read in the notes that she had been suffering from headaches caused by increased tension in the cervical spine (primarily due to increased muscle tension through trapezius, rhomboids and levator scapulae). Her headaches were better when the muscles were relaxed, however she had not been very compliant with her home program and her headaches gradually got worse again following each treatment session (after her feeling really good at the end of each session). As a result of her not doing her home exercise program (HEP) the muscles would tighten up after treatment and she would not do anything to help it until the next time she came in for physio.
TASK
My task was to perform a follow-up assessment for this patient and a treatment session. I had the job of telling this patient that is she wasn’t complying with the HEP then we couldn’t do much else for her.
ACTION
I began the subjective assessment by asking how her headaches had been. When she said they were good after the last treatment session but got worse again as time went on I asked her if she had been doing her HEP. She replied that she hadn’t been doing it every day, only occasionally as she had been busy. I took this opportunity to remind her that I could do a treatment for her but she needed to continue it at home to have a long-lasting effect from it. I didn’t want to have a go at her but I needed to make my point. I then performed my objective assessment and started my treatment by working on the muscles around the shoulders and neck. As I massaged I explained again how she could prolong the benefits of this treatment session at home. I thought that if I explained this to her while I was performing a hands-on treatment, she would realize I was still going to treat her and not just send her away to deal with it at home by herself. I tried to make her understand it was a two-way street. I could only help her if she was going to help herself. After I had finished my treatment and was winding up the session I explained to her that we knew what her problem was and we know how to get rid of the pain and headaches, it was just a matter of her actually doing her exercises at home. I put it back on her, saying SHE had to do the hard work to get rid of the pain, rather than expecting our physio session to be a miracle cure.
RESULTS
My patient seemed to understand the point I was trying to make without me having to be too blunt about it. I have given her the idea that if she doesn’t do her HEP then we will not continue with her treatment at the hospital as it was just wasting everyone’s time. The patient agreed to do her program and admitted she needed to lift her game a little. I think she now understands the consequences if she does not actively participate in her treatment. I was able to get this point across to her without ruining my rapport (or the rapport developed with the patient by the previous student). If I had been blunt about it she may have felt that I was blaming her and decided she didn’t want to attend physio. This would have been a shame as physio is definitely something that can help her problem if she complies with her exercises.
STRATEGIES
It can be difficult to have to tell a patient off for not doing their exercises and that if they don’t do them then there is nothing else we can do. Some ways of dealing with this are:
1. Say you don’t want to waste THEIR time coming into hospital when it’s not a very effective treatment by itself. This is better than you saying it’s wasting YOUR time.
2. Be sensitive and sympathetic – find out if there is a reason they haven’t been doing their exercises before you assume they are just non-compliant.
3. Be strong and as forceful as necessary to make your point but avoid being tactless or overly blunt.
4. Compromise – see how many exercises they think they can commit to doing if they think the whole lot you prescribed is too much. This is better than them doing none at all.
Monday, June 28, 2010
STARES WEEK 1
SITUATION
I had a new patient referred to outpatients for hip and knee pain, but the referral also said they were suffering from “sciatica” and “lumbago”. The patient had attended outpatients at Bentley for low back pain approximately ten years ago. This patient had a history of osteoarthritis (OA), currently being treated with analgesics. The doctor had asked for a regular exercise program on the referral.
TASK
I had to perform an initial assessment for this patient and determine the treatment I would perform, based on my assessment findings.
ACTION
I began the subjective assessment with the plan being to focus on the hip and knee pain, rather than the general umbrella diagnosis of “lumbago” and “sciatica”. The patient told me he had a sharp knee pain but minimal hip pain. He also had numbness in his lower back which could also go down the side of his leg. The knee pain was brought on with flexion or loading and the numbness in his back came on after approximately fifteen minutes of standing. Heat had been helping ease the pain in his knee.
Objectively his hip and knee range of movement was good. The movements caused slight stretching through his lower spine and legs. Muscle length tests showed his quads were shortened (with increased tension) and on palpation I found increased tension through the lateral structures of his thigh. Neural testing did not show anything abnormal. I observed his gait and noted his feet were turned out and his legs were externally rotated. There was also swelling on the medial side of his knee.
After gathering this information on my assessment I tried working out a diagnosis and treatment plan. This became difficult when I kept going back to the doctor’s referral letter that said “lumbago” and “sciatica”. My assessment did not find these problems, but rather it found knee pain and problems with the muscles around the knee. I tried working out how the “sciatica” or “lumbago” would be related to the knee pain and got very confused.
It was only when I disregarded the diagnosis from the doctor and decided to treat what I had found in my assessment that things started to make sense. Rather than looking at his back or sciatic nerve as a cause of the knee problem, I looked at my results from the gait analysis and muscle tests.
RESULTS
By looking at the assessment findings to work out the patient’s problem (rather than trying to fit my findings into a diagnosis from the doctor) I worked out what could be causing the knee pain. His externally rotated feet were putting pressure on the medial aspect of his knee, what was causing a problem at the insertion of pes anserinus. His medial thigh muscles were not working properly, causing an imbalance with the muscles on the lateral thigh. Due to this imbalance the muscles on the lateral thigh were very tight and over-working.
By developing this diagnosis I could then start working on a treatment plan.
EVALUATION
When I was focused on the diagnosis from the doctor’s referral I had tunnel vision. I did not properly analyze my results from my assessment as I was trying to make them fit to a specific problem. After opening up and looking at my results alone it was much easier to work out what was going on. My supervisor gave me the advice to treat what I see, rather than what the referral letter says.
I do feel I did some things well. The subjective questioning was difficult as the patient’s English was not very good, but I managed to get a complete history and most of the information I wanted. It took a long time but I was patient and it paid off. I also think I performed the objective tests fairly well, but then had difficulty making sense of my findings.
STRATEGIES
While the referral is important it should not be the only source of information I use. What the patient tells me is much more important in developing a diagnosis. From now on I should work with what my assessment finds and use clinical reasoning to ensure I do not get tunnel vision when working out what is wrong with a patient. It is too unreliable to only go by what is on the referral.
I had a new patient referred to outpatients for hip and knee pain, but the referral also said they were suffering from “sciatica” and “lumbago”. The patient had attended outpatients at Bentley for low back pain approximately ten years ago. This patient had a history of osteoarthritis (OA), currently being treated with analgesics. The doctor had asked for a regular exercise program on the referral.
TASK
I had to perform an initial assessment for this patient and determine the treatment I would perform, based on my assessment findings.
ACTION
I began the subjective assessment with the plan being to focus on the hip and knee pain, rather than the general umbrella diagnosis of “lumbago” and “sciatica”. The patient told me he had a sharp knee pain but minimal hip pain. He also had numbness in his lower back which could also go down the side of his leg. The knee pain was brought on with flexion or loading and the numbness in his back came on after approximately fifteen minutes of standing. Heat had been helping ease the pain in his knee.
Objectively his hip and knee range of movement was good. The movements caused slight stretching through his lower spine and legs. Muscle length tests showed his quads were shortened (with increased tension) and on palpation I found increased tension through the lateral structures of his thigh. Neural testing did not show anything abnormal. I observed his gait and noted his feet were turned out and his legs were externally rotated. There was also swelling on the medial side of his knee.
After gathering this information on my assessment I tried working out a diagnosis and treatment plan. This became difficult when I kept going back to the doctor’s referral letter that said “lumbago” and “sciatica”. My assessment did not find these problems, but rather it found knee pain and problems with the muscles around the knee. I tried working out how the “sciatica” or “lumbago” would be related to the knee pain and got very confused.
It was only when I disregarded the diagnosis from the doctor and decided to treat what I had found in my assessment that things started to make sense. Rather than looking at his back or sciatic nerve as a cause of the knee problem, I looked at my results from the gait analysis and muscle tests.
RESULTS
By looking at the assessment findings to work out the patient’s problem (rather than trying to fit my findings into a diagnosis from the doctor) I worked out what could be causing the knee pain. His externally rotated feet were putting pressure on the medial aspect of his knee, what was causing a problem at the insertion of pes anserinus. His medial thigh muscles were not working properly, causing an imbalance with the muscles on the lateral thigh. Due to this imbalance the muscles on the lateral thigh were very tight and over-working.
By developing this diagnosis I could then start working on a treatment plan.
EVALUATION
When I was focused on the diagnosis from the doctor’s referral I had tunnel vision. I did not properly analyze my results from my assessment as I was trying to make them fit to a specific problem. After opening up and looking at my results alone it was much easier to work out what was going on. My supervisor gave me the advice to treat what I see, rather than what the referral letter says.
I do feel I did some things well. The subjective questioning was difficult as the patient’s English was not very good, but I managed to get a complete history and most of the information I wanted. It took a long time but I was patient and it paid off. I also think I performed the objective tests fairly well, but then had difficulty making sense of my findings.
STRATEGIES
While the referral is important it should not be the only source of information I use. What the patient tells me is much more important in developing a diagnosis. From now on I should work with what my assessment finds and use clinical reasoning to ensure I do not get tunnel vision when working out what is wrong with a patient. It is too unreliable to only go by what is on the referral.
Monday, June 21, 2010
Bentley Outpatients – Initial Entry
Bentley Outpatients
I am writing this entry after my orientation earlier this week, which changed some of my expectations of this placement. My expectations were initially based on my prac in musculoskeletal outpatients at Swan Districts in second year.
I now expect:
1. To treat 3 patients per day in my first week and to gradually build up to 8 or 9 by the end of prac.
2. To have to do a lot of clinical reasoning and not have the answers handed to me by my supervisor.
3. I expect to be doing hydrotherapy once every week but I’m not sure if it is a group class of if everyone has an individual program.
4. To be able to see referrals or handovers the day before I see the patient so I can start to prepare over night.
5. To do a presentation for the department.
6. To challenge myself (and be challenged by my supervisor) to ask WHY I am doing a particular treatment or assessment (rather than just “this is what we were taught”).
7. I also expect to really enjoy this placement and learn a lot – I even learnt new things just at the orientation when we had a little impromptu tutorial.
I also have some concerns:
1. I am concerned I won’t remember everything I learnt in musculoskeletal over the past 3 years.
2. Public speaking – when I do my presentation.
3. I am also concerned I may get a patient who I cannot diagnose or work out a treatment plan for.
I am writing this entry after my orientation earlier this week, which changed some of my expectations of this placement. My expectations were initially based on my prac in musculoskeletal outpatients at Swan Districts in second year.
I now expect:
1. To treat 3 patients per day in my first week and to gradually build up to 8 or 9 by the end of prac.
2. To have to do a lot of clinical reasoning and not have the answers handed to me by my supervisor.
3. I expect to be doing hydrotherapy once every week but I’m not sure if it is a group class of if everyone has an individual program.
4. To be able to see referrals or handovers the day before I see the patient so I can start to prepare over night.
5. To do a presentation for the department.
6. To challenge myself (and be challenged by my supervisor) to ask WHY I am doing a particular treatment or assessment (rather than just “this is what we were taught”).
7. I also expect to really enjoy this placement and learn a lot – I even learnt new things just at the orientation when we had a little impromptu tutorial.
I also have some concerns:
1. I am concerned I won’t remember everything I learnt in musculoskeletal over the past 3 years.
2. Public speaking – when I do my presentation.
3. I am also concerned I may get a patient who I cannot diagnose or work out a treatment plan for.
Saturday, June 12, 2010
Final Entry - Women's Health
FINAL ENTRY
I enjoyed my placement at Fremantle/Kaleeya in the Women’s Health area, however a lot of my thoughts prior to going on the placement were not entirely correct. I had expected to do a lot of observing (which I did, especially in the continence area) but I did get to treat my own patients too. I did not expect the role to be so much about education, but I quickly learnt that it is a very important skill in this area. Rather than the typical “hands-on” approach I am used to, my role was primarily educating the patients (such as the new mum’s at Kaleeya).
There was so much information I had not learnt at uni, so it was an amazing learning experience. I was expected to be able to conduct the subjective questioning, even if I could not do the treatment or develop a plan. I had expected this and was comfortable using the assessment forms. My favourite aspect of this prac was running a variety of group classes. These included ante-natal education classes and post-natal exercises classes.
I found it difficult having 5 different supervisors, who sometimes gave me different feedback but it was also great to see so many areas of Women’s Health. I had not expected to spend so much time in the maternity ward, however I also spent time in outpatients and the community setting.
This prac has taught me the importance of treating each patient as an individual, even if it seems that they all have the same “problem”. For example, in educating the women who have just given birth the information needs to be tailored specifically to them and delivered in the best way for them to understand it. You cannot educate every woman the same way, it is important to find the best way to get them the information.
I enjoyed my placement at Fremantle/Kaleeya in the Women’s Health area, however a lot of my thoughts prior to going on the placement were not entirely correct. I had expected to do a lot of observing (which I did, especially in the continence area) but I did get to treat my own patients too. I did not expect the role to be so much about education, but I quickly learnt that it is a very important skill in this area. Rather than the typical “hands-on” approach I am used to, my role was primarily educating the patients (such as the new mum’s at Kaleeya).
There was so much information I had not learnt at uni, so it was an amazing learning experience. I was expected to be able to conduct the subjective questioning, even if I could not do the treatment or develop a plan. I had expected this and was comfortable using the assessment forms. My favourite aspect of this prac was running a variety of group classes. These included ante-natal education classes and post-natal exercises classes.
I found it difficult having 5 different supervisors, who sometimes gave me different feedback but it was also great to see so many areas of Women’s Health. I had not expected to spend so much time in the maternity ward, however I also spent time in outpatients and the community setting.
This prac has taught me the importance of treating each patient as an individual, even if it seems that they all have the same “problem”. For example, in educating the women who have just given birth the information needs to be tailored specifically to them and delivered in the best way for them to understand it. You cannot educate every woman the same way, it is important to find the best way to get them the information.
Saturday, June 5, 2010
STARES 3 - women's health
STARES 3
SITUATION
I had been referred a 26 year old patient in outpatients who was pregnant and suffering from low back pain and sacro-iliac joint (SIJ) pain. Initially it was right sided but over time had become worse on the left side. Aggravating factors included prolonged sitting, sleeping on one side and putting trousers on in standing. Heat packs were being used to ease the pain but it was worse in the morning and the severity it reached throughout the day was dependent on the activities she did. She was not currently working (maternity leave) and had a 5 year old son.
TASK
My task was the assess this patient and conduct a treatment session with her.
ACTION
I began my assessment by observing the patient’s posture in sitting then standing. It was symmetrical but the patient had an increased lumbar lordosis. I assessed active range of movement of the lumbar spine which was all normal, and did not cause her pain. I palpated through the area and she was a little tender on the inferior sulcus of the SIJ (left more so than right). I performed the single leg stand test (without then with compression) and the same with the active straight leg raise test. The single leg stand did not show anything significant, but the active straight leg raise test was interesting. The patient first lifted her left leg, then her right, and both caused her pain. When I used my hands to provide some compression and stabilization around the pelvis it had no effect on her pain as she lifted her leg. I then got her to push her elbow into my hand as a resisted cross-over movement. While doing this her global muscles were activated. I got her to left one leg while doing this and the pain was completely gone. The same result occurred when she used her other leg. This indicated to me that there was some instability (or increased movement) through the SIJ or lower lumbar spine (which is not unusual in pregnancy with the hormone changes). Her pelvis could be stabilized by her muscles if they were activated, which would stop her pain. I then taught her how to contract her pelvic floor muscles and transversus abdominus (TAs). Once she could do this I tried the active straight leg raise again, this time with the patient contracting the pelvis floor and Tas (rather than her more global muscles). She was able to lift her leg without pain. I then tried this in functional ways, such as getting up from a chair with the pelvic floor muscles turned on. It was effective in relieving her pain and the patient was very happy to know how to do this. I gave her some lower back mobility exercises to at home first thing in the morning, as well as a pelvic floor muscle exercise program. We made a plan to review in one week to see if it made a difference in her every day living, and then possibly progress the exercises.
RESULTS
The patient knew how to use her pelvic floor muscles by the end of this session (which was important in her pregnancy even if it didn’t solve her pain problem). The patient left with functional exercises and the knowledge of how to move without causing her pain.
EVALUATION
I feel this session went well and the patient was extremely happy the end of it. I feel my subjective questioning could have gone into a little more detail though, as I missed some questions. I feel my objective assessment was good as I thought outside the box of what I would usually do in a low back pain assessment. I was effective in finding her pain(and what brought it on) and feel she was given an effective treatment session. I could possibly have given her harder pelvic floor exercises however I think it is important she gets used to contracting these muscles before trying endurance exercises. If it was too hard she may not have done them at all.
STRATEGIES
I need to carefully follow the assessment form to ensure I do not miss out any questions. If I find I am regularly missing out on asking a particular question I could make a note on the assessment form before I start the session, so it prompts me to ask it when I see the patient. With exercise prescription maybe I could give easier exercises to begin with and teach them a progression during the first session. If they seem to understand the progression I could five them the instructions to start with the easy ones at home and only do the harder ones if they feel up to it after a set time. If they attempt it at the first session and they don’t seem to understand the concept I would tell them to only do the easy ones at home. This way it allows the patient to progress is they are capable before their next appointment.
SITUATION
I had been referred a 26 year old patient in outpatients who was pregnant and suffering from low back pain and sacro-iliac joint (SIJ) pain. Initially it was right sided but over time had become worse on the left side. Aggravating factors included prolonged sitting, sleeping on one side and putting trousers on in standing. Heat packs were being used to ease the pain but it was worse in the morning and the severity it reached throughout the day was dependent on the activities she did. She was not currently working (maternity leave) and had a 5 year old son.
TASK
My task was the assess this patient and conduct a treatment session with her.
ACTION
I began my assessment by observing the patient’s posture in sitting then standing. It was symmetrical but the patient had an increased lumbar lordosis. I assessed active range of movement of the lumbar spine which was all normal, and did not cause her pain. I palpated through the area and she was a little tender on the inferior sulcus of the SIJ (left more so than right). I performed the single leg stand test (without then with compression) and the same with the active straight leg raise test. The single leg stand did not show anything significant, but the active straight leg raise test was interesting. The patient first lifted her left leg, then her right, and both caused her pain. When I used my hands to provide some compression and stabilization around the pelvis it had no effect on her pain as she lifted her leg. I then got her to push her elbow into my hand as a resisted cross-over movement. While doing this her global muscles were activated. I got her to left one leg while doing this and the pain was completely gone. The same result occurred when she used her other leg. This indicated to me that there was some instability (or increased movement) through the SIJ or lower lumbar spine (which is not unusual in pregnancy with the hormone changes). Her pelvis could be stabilized by her muscles if they were activated, which would stop her pain. I then taught her how to contract her pelvic floor muscles and transversus abdominus (TAs). Once she could do this I tried the active straight leg raise again, this time with the patient contracting the pelvis floor and Tas (rather than her more global muscles). She was able to lift her leg without pain. I then tried this in functional ways, such as getting up from a chair with the pelvic floor muscles turned on. It was effective in relieving her pain and the patient was very happy to know how to do this. I gave her some lower back mobility exercises to at home first thing in the morning, as well as a pelvic floor muscle exercise program. We made a plan to review in one week to see if it made a difference in her every day living, and then possibly progress the exercises.
RESULTS
The patient knew how to use her pelvic floor muscles by the end of this session (which was important in her pregnancy even if it didn’t solve her pain problem). The patient left with functional exercises and the knowledge of how to move without causing her pain.
EVALUATION
I feel this session went well and the patient was extremely happy the end of it. I feel my subjective questioning could have gone into a little more detail though, as I missed some questions. I feel my objective assessment was good as I thought outside the box of what I would usually do in a low back pain assessment. I was effective in finding her pain(and what brought it on) and feel she was given an effective treatment session. I could possibly have given her harder pelvic floor exercises however I think it is important she gets used to contracting these muscles before trying endurance exercises. If it was too hard she may not have done them at all.
STRATEGIES
I need to carefully follow the assessment form to ensure I do not miss out any questions. If I find I am regularly missing out on asking a particular question I could make a note on the assessment form before I start the session, so it prompts me to ask it when I see the patient. With exercise prescription maybe I could give easier exercises to begin with and teach them a progression during the first session. If they seem to understand the progression I could five them the instructions to start with the easy ones at home and only do the harder ones if they feel up to it after a set time. If they attempt it at the first session and they don’t seem to understand the concept I would tell them to only do the easy ones at home. This way it allows the patient to progress is they are capable before their next appointment.
Monday, May 31, 2010
STARES 2
STARES 2
SITUATION
In outpatients I had been referred a patient who was approximately 26 weeks pregnant. She had been suffering from back pain for a few weeks. This referral did not give any more information. After talking to the patient I found it was a fairly constant pain that gets worse when she sits for long periods (especially at work when she often crosses her legs or sits slumped to one side). Although she had tried heat packs and other forms of pain relief it did not seem to get better. I pin-pointed the pain to the lower thoracic spine but found it could also go down into her lumbar spine.
On objective examination I found that her most painful movements were left rotation and right side flexion. On palpation there was a little tenderness through the spine, and I found quadratus lumborum on the left was quite tight in comparison to the right side.
TASK
I had to treat this patient’s back pain while taking into consideration the fact she is pregnant (which has physiological effects on the body but can also affect my treatment and the positions I can get the patient into).
ACTION
I thought that opening the spine on the left may be the problem. I started with some rotation snags where the patient rotated to the left. After a set of these there was no change in the patient’s pain levels or range of movement. I then tried snags into right side flexion. After one set of these the patient’s pain levels had decreased and she found it easier to move into right side flexion. I decided to do another three sets into side flexion and by the end the patient’s pain had decreased into side flexion (but had not changed into left rotation).
I decided to treat the left quadratus lumborum which was tight in comparison to the right. I decided to massage the muscle on the left, however I would normally do this in prone. This patient could not lie on her stomach as she was pregnant, so I chose to modify this position where the patient was in standing, supporting herself by leaning over the plinth. I could feel the muscle releasing as I massaged, and after finishing the patient could move into left rotation and right side flexion much more easily. I showed her some stretches to do at home and encouraged her to get her partner to continue with the massage at home.
Next I addressed her posture. She commonly crossed her legs and was sitting slumped to the side without even realizing it. I used proprioceptive taping to make her aware of her posture. The tape would not hold her in a specific posture but would remind her she was doing something wrong if she slumped.
To finish with I taught her some pelvic floor muscle exercises. These wuld benefit her in improving core stability (which may help with her bacj pain) but also prepare her pelvic floor muscles before childbirth.
RESULT
The patient’s back pain had improved during the session and she had a home exercise program to continue with on her own to help prevent the quadratus lumborum from tightening up again (and therefore preventing her back pain from returning). I am planning to see this patient again in one week to see if this treatment has longer lasting results and if she can manage this on her own at home.
EVALUATION
I feel I did a good job with this treatment. Although my first choice of rotation snags were not effective, I changed what I was doing instead of wasting time on a treatment that was not working. I felt I did a good job of modifying my massage by choosing an appropriate position for a pregnant lady. I think it was a good well-rounded treatment session as it included a lot of education, some hands on treatment and exercises for her to do at home.
One thing I did not do so well was getting the patient to move around too much. I did my assessment in standing, before getting her to sit on the plinth, then lie down. This part was good, however in my treatment I had her lie down, then sit, the lie, then sit again, then on the floor for an exercise. This is particularly uncomfortable for someone with back pain (especially when they are pregnant).
STRATEGIES
I should structure my treatment so I do everything I need to in one position before getting them to move into another. I need to think ahead of what I will likely be doing throughout the session.
SITUATION
In outpatients I had been referred a patient who was approximately 26 weeks pregnant. She had been suffering from back pain for a few weeks. This referral did not give any more information. After talking to the patient I found it was a fairly constant pain that gets worse when she sits for long periods (especially at work when she often crosses her legs or sits slumped to one side). Although she had tried heat packs and other forms of pain relief it did not seem to get better. I pin-pointed the pain to the lower thoracic spine but found it could also go down into her lumbar spine.
On objective examination I found that her most painful movements were left rotation and right side flexion. On palpation there was a little tenderness through the spine, and I found quadratus lumborum on the left was quite tight in comparison to the right side.
TASK
I had to treat this patient’s back pain while taking into consideration the fact she is pregnant (which has physiological effects on the body but can also affect my treatment and the positions I can get the patient into).
ACTION
I thought that opening the spine on the left may be the problem. I started with some rotation snags where the patient rotated to the left. After a set of these there was no change in the patient’s pain levels or range of movement. I then tried snags into right side flexion. After one set of these the patient’s pain levels had decreased and she found it easier to move into right side flexion. I decided to do another three sets into side flexion and by the end the patient’s pain had decreased into side flexion (but had not changed into left rotation).
I decided to treat the left quadratus lumborum which was tight in comparison to the right. I decided to massage the muscle on the left, however I would normally do this in prone. This patient could not lie on her stomach as she was pregnant, so I chose to modify this position where the patient was in standing, supporting herself by leaning over the plinth. I could feel the muscle releasing as I massaged, and after finishing the patient could move into left rotation and right side flexion much more easily. I showed her some stretches to do at home and encouraged her to get her partner to continue with the massage at home.
Next I addressed her posture. She commonly crossed her legs and was sitting slumped to the side without even realizing it. I used proprioceptive taping to make her aware of her posture. The tape would not hold her in a specific posture but would remind her she was doing something wrong if she slumped.
To finish with I taught her some pelvic floor muscle exercises. These wuld benefit her in improving core stability (which may help with her bacj pain) but also prepare her pelvic floor muscles before childbirth.
RESULT
The patient’s back pain had improved during the session and she had a home exercise program to continue with on her own to help prevent the quadratus lumborum from tightening up again (and therefore preventing her back pain from returning). I am planning to see this patient again in one week to see if this treatment has longer lasting results and if she can manage this on her own at home.
EVALUATION
I feel I did a good job with this treatment. Although my first choice of rotation snags were not effective, I changed what I was doing instead of wasting time on a treatment that was not working. I felt I did a good job of modifying my massage by choosing an appropriate position for a pregnant lady. I think it was a good well-rounded treatment session as it included a lot of education, some hands on treatment and exercises for her to do at home.
One thing I did not do so well was getting the patient to move around too much. I did my assessment in standing, before getting her to sit on the plinth, then lie down. This part was good, however in my treatment I had her lie down, then sit, the lie, then sit again, then on the floor for an exercise. This is particularly uncomfortable for someone with back pain (especially when they are pregnant).
STRATEGIES
I should structure my treatment so I do everything I need to in one position before getting them to move into another. I need to think ahead of what I will likely be doing throughout the session.
Saturday, May 15, 2010
STARES WEEK 1
Women's Health Prac
SITUATION
I was seeing a young male patient with a continence problem. One of the things I needed to assess was if he was emptying his bladder completely when going to the toilet. It is important information for me to know. If he is not emptying completely then there will be a residual volume, which means less urine can then be stored in the bladder. To look at his bladder (and see how much urine is in there) real time ultrasound (RTUS) can be used.
TASK
I had to use the RTUS to look at the patient’s bladder pre and post void to see how much urine was being stored in there and if he was completely emptying it when going to the toilet.
ACTION
I asked the patient to lie on the plinth then I prepared him with the paper towels in place to stop the gel getting on his clothes. He had done this before with my supervisor so was used to the procedure. I then prepared the ultrasound head with gel and placed it over his bladder. It was quite easy to identify it on the screen as he had a moderate amount of urine in there (the fuller the bladder the easier to see it by ultrasound). After using the RTUS machine to measure the size of the bladder I asked the patient to go to the toilet. After this we did the whole process again and I needed to re-measure the size of his bladder.
RESULT
The second time I could not find his bladder using RTUS, which means he had emptied it properly. I did have my supervisor check as well, just in case I had made an error when trying to find it. She could not find it either, so we came to the conclusion that it had been completely emptied.
EVALUATION
Overall I felt that I used the RTUS effectively. I could find the patient’s bladder but needed to be shown how to measure the size of it. I was worried when I could not find it the second time, but was reassured it was because it had been emptied, not because I had the ultrasound head in the wrong spot. One thing I could improve on is how I was set up. My supervisor is left handed, so she had the machine set up to hold the ultrasound head in her left hand and use her right hand on the controls (to measure the bladder). I left it set up in this way, which made it a bit awkward when I had to use my left hand to hold the ultrasound head. I would have been more comfortable to have it in my right hand.
STRATEGIES
I should make sure I am prepared before jumping into a procedure with the RTUS. Next time I should position the machine on my left, instead of my right, so I can use my dominant hand. The machine sits on a trolley with wheels so it would be very easy to move (I would just have to be careful of cords that need to be plugged into the wall). Having had this experience, I think I will be more prepared for next time I use the RTUS but can apply this lesson to all things: be completely prepared before starting a procedure!
Women's Health Prac
SITUATION
I was seeing a young male patient with a continence problem. One of the things I needed to assess was if he was emptying his bladder completely when going to the toilet. It is important information for me to know. If he is not emptying completely then there will be a residual volume, which means less urine can then be stored in the bladder. To look at his bladder (and see how much urine is in there) real time ultrasound (RTUS) can be used.
TASK
I had to use the RTUS to look at the patient’s bladder pre and post void to see how much urine was being stored in there and if he was completely emptying it when going to the toilet.
ACTION
I asked the patient to lie on the plinth then I prepared him with the paper towels in place to stop the gel getting on his clothes. He had done this before with my supervisor so was used to the procedure. I then prepared the ultrasound head with gel and placed it over his bladder. It was quite easy to identify it on the screen as he had a moderate amount of urine in there (the fuller the bladder the easier to see it by ultrasound). After using the RTUS machine to measure the size of the bladder I asked the patient to go to the toilet. After this we did the whole process again and I needed to re-measure the size of his bladder.
RESULT
The second time I could not find his bladder using RTUS, which means he had emptied it properly. I did have my supervisor check as well, just in case I had made an error when trying to find it. She could not find it either, so we came to the conclusion that it had been completely emptied.
EVALUATION
Overall I felt that I used the RTUS effectively. I could find the patient’s bladder but needed to be shown how to measure the size of it. I was worried when I could not find it the second time, but was reassured it was because it had been emptied, not because I had the ultrasound head in the wrong spot. One thing I could improve on is how I was set up. My supervisor is left handed, so she had the machine set up to hold the ultrasound head in her left hand and use her right hand on the controls (to measure the bladder). I left it set up in this way, which made it a bit awkward when I had to use my left hand to hold the ultrasound head. I would have been more comfortable to have it in my right hand.
STRATEGIES
I should make sure I am prepared before jumping into a procedure with the RTUS. Next time I should position the machine on my left, instead of my right, so I can use my dominant hand. The machine sits on a trolley with wheels so it would be very easy to move (I would just have to be careful of cords that need to be plugged into the wall). Having had this experience, I think I will be more prepared for next time I use the RTUS but can apply this lesson to all things: be completely prepared before starting a procedure!
Monday, May 10, 2010
Fremantle Women’s Health
Fremantle Women’s Health
I am very excited to be starting my women’s health placement as it is an area I am really interested in. My expectations come from talking to a previous student and one of my supervisors. I am expecting:
1. I am expecting to be supervised by a number of different physios, especially being between Fremantle Hospital and Kaleeya.
2. I expect to do a lot of observing rather than hands-on work as we will not have covered a lot of the post-grad techniques. Having said that, I expect I will be able to do some continence work (as we covered this at uni) and some work in the pregnancy area.
3. I expect my role as the student will be to learn as much as possible and take advantage of learning things we may not necessarily learn at uni from very experienced physios. I will probably be expected to perform subjective assessments even if I cannot do all the treatment.
4. I expect I will have to complete some sort of project or presentation while on this placement as the previous student did.
I have a few concerns, including the fact I don’t think I know enough in this area! I have revised everything from our Women’s Health unit so am planning to learn new things as I go. I have been told I am at Kaleeya in the mornings and Fremantle hospital in the afternoons so I am very concerned about getting parking at Fremantle at this time! My final concern is that some of the patients may have sensitive issues or situations, so I just have to do my job and not be awkward about any of it.
I am very excited to be starting my women’s health placement as it is an area I am really interested in. My expectations come from talking to a previous student and one of my supervisors. I am expecting:
1. I am expecting to be supervised by a number of different physios, especially being between Fremantle Hospital and Kaleeya.
2. I expect to do a lot of observing rather than hands-on work as we will not have covered a lot of the post-grad techniques. Having said that, I expect I will be able to do some continence work (as we covered this at uni) and some work in the pregnancy area.
3. I expect my role as the student will be to learn as much as possible and take advantage of learning things we may not necessarily learn at uni from very experienced physios. I will probably be expected to perform subjective assessments even if I cannot do all the treatment.
4. I expect I will have to complete some sort of project or presentation while on this placement as the previous student did.
I have a few concerns, including the fact I don’t think I know enough in this area! I have revised everything from our Women’s Health unit so am planning to learn new things as I go. I have been told I am at Kaleeya in the mornings and Fremantle hospital in the afternoons so I am very concerned about getting parking at Fremantle at this time! My final concern is that some of the patients may have sensitive issues or situations, so I just have to do my job and not be awkward about any of it.
Sunday, March 28, 2010
Freo Cardio STARES week 1
STARES WEEK 1
SITUATION
I have a client on a general medical ward. Their presenting complain was eye pain and photophobia (they have a diagnosis of herpes zoster involving the optic nerve), increased shortness of breath (SOB) and production of yellow sputum. Their past medical history includes shingles, COPD and falls.
Their chest x-ray shows infiltrates in the right and left middle and upper zones. There is consolidation/effusion bibasally and evidence of hyperinflation.
My assessment found nil SOB when resting in bed, but SOB with a score of 7 out of 10 after deep breathing exercises. There was no wheeze. Their cough was regular and spontaneous. It produced small amounts of white creamy sputum. On auscultation there were decreased breath sounds on the right and left upper lobes, and a late expiratory wheeze and rattle in the left lower lobe. This patient had an upper chest breathing pattern with decreased chest expansion bibasally. Their obs were stable with his oxygen saturation (SpO2) at 94% on room air.
In terms of mobility they were independent in bed mobility and transfers. Ambulation was independent over short distances with no aids, although this resulted in increased work of breathing and accessory muscle use during movement.
TASK
Having previously performed an assessment on this patient, my task was to perform a treatment session for him. The aim of this session was the improve/facilitate airway clearance and to mobilize.
ACTION
I started the treatment session by teaching the Active Cycle of Breathing Technique (ACBT). I explained what is was first and why it was important for this patient. I went through how it would benefit him in clearing out the sputum and preventing infection. I then taught the patient each component of the ACBT (controlled breathing, thoracic expansion exercise and a huff). After he had practiced each component I explained how to join them all together. I talked the patient through it, but then asked them to perform it a few times without me instructing him on how to do it. This was to ensure he could perform it independently as I ask him to do it regularly throughout the day.
I then did some exercises with him. Due to his light sensitivity I did these exercises in him darkened room. I asked the patient to stand at the end of the bed so he had something to hold onto. The exercises consisted of standing hip abduction, heel raises, knee bends into flexion (heel to bottom), squats and marching on the spot. While he was performing these exercises I monitored his SpO2 and SOB.
RESULT
The client performed the ACBT with good technique. It was successful in increasing bibasal chest expansion. His huff was weak and unproductive. On re-auscultation he has less crackles in the left lower lobe though. This patient agreed to continue practicing the ACBT independently, and if performed more regularly it might be more effective.
The standing exercise were perform with a safe and correct technique. After heel raises the patient’s SpO2 decreased to 85% on room air. I sat the patient down and his SpO2 recovered to 93% within approximately one minute. He continued with the above exercise and his SpO2 was at 87% by the end of it. His SpO2 recovered and the patient reported feeling tired.
EVALUATION
I thought my conduction of this treatment session went well and mostly according to plan. Some of the things that I feel I did well include:
• Being organized – I had the right equipment (SpO2 and heart rate monitor) that would be needed in the session.
• Explaining the reason for why we were doing the ACBT and how it would benefit him.
• Monitoring the SpO2 during the exercises (if I hadn’t been I would not have noticed that it dropped to 85% at one stage). With some patients who I have spent more time with and I know to be more stable I sometimes take their obs prior to exercise and then following the exercise. As I had not seen this patient before for a treatment session I thought it best to monitor throughout the session. This was a good clinical judgment.
• Matching my treatments to his specific problems (which I devised from my assessment). A generic “cardio” treatment session will not benefit all patients and is certainly not the best option.
Some things I think I could improve on include:
• Remembering to check the obs chart outside the patient’s room before I start the session. In this case I started a quick subjective, then I had to duck outside to check the chart. The obs were stable and within normal limits in this case but it is always important to check incase they aren’t. If a patient’s obs aren’t within normal limits it could be dangerous to get them up, so it really is important to check them!
• When I am teaching a huff I need to have some tissues by the bed, just in case the patient does produce some sputum.
STRATEGIES
I have made a checklist of things to prepare before entering the room, which included checking the obs chart. I should also prepare the environment (i.e. the patient’s room) when I first enter, before starting any treatment. This way I can make sure I have tissues and anything else I need within reach. I can also move furniture and anything else in the way if I am going to mobilize the patient.
SITUATION
I have a client on a general medical ward. Their presenting complain was eye pain and photophobia (they have a diagnosis of herpes zoster involving the optic nerve), increased shortness of breath (SOB) and production of yellow sputum. Their past medical history includes shingles, COPD and falls.
Their chest x-ray shows infiltrates in the right and left middle and upper zones. There is consolidation/effusion bibasally and evidence of hyperinflation.
My assessment found nil SOB when resting in bed, but SOB with a score of 7 out of 10 after deep breathing exercises. There was no wheeze. Their cough was regular and spontaneous. It produced small amounts of white creamy sputum. On auscultation there were decreased breath sounds on the right and left upper lobes, and a late expiratory wheeze and rattle in the left lower lobe. This patient had an upper chest breathing pattern with decreased chest expansion bibasally. Their obs were stable with his oxygen saturation (SpO2) at 94% on room air.
In terms of mobility they were independent in bed mobility and transfers. Ambulation was independent over short distances with no aids, although this resulted in increased work of breathing and accessory muscle use during movement.
TASK
Having previously performed an assessment on this patient, my task was to perform a treatment session for him. The aim of this session was the improve/facilitate airway clearance and to mobilize.
ACTION
I started the treatment session by teaching the Active Cycle of Breathing Technique (ACBT). I explained what is was first and why it was important for this patient. I went through how it would benefit him in clearing out the sputum and preventing infection. I then taught the patient each component of the ACBT (controlled breathing, thoracic expansion exercise and a huff). After he had practiced each component I explained how to join them all together. I talked the patient through it, but then asked them to perform it a few times without me instructing him on how to do it. This was to ensure he could perform it independently as I ask him to do it regularly throughout the day.
I then did some exercises with him. Due to his light sensitivity I did these exercises in him darkened room. I asked the patient to stand at the end of the bed so he had something to hold onto. The exercises consisted of standing hip abduction, heel raises, knee bends into flexion (heel to bottom), squats and marching on the spot. While he was performing these exercises I monitored his SpO2 and SOB.
RESULT
The client performed the ACBT with good technique. It was successful in increasing bibasal chest expansion. His huff was weak and unproductive. On re-auscultation he has less crackles in the left lower lobe though. This patient agreed to continue practicing the ACBT independently, and if performed more regularly it might be more effective.
The standing exercise were perform with a safe and correct technique. After heel raises the patient’s SpO2 decreased to 85% on room air. I sat the patient down and his SpO2 recovered to 93% within approximately one minute. He continued with the above exercise and his SpO2 was at 87% by the end of it. His SpO2 recovered and the patient reported feeling tired.
EVALUATION
I thought my conduction of this treatment session went well and mostly according to plan. Some of the things that I feel I did well include:
• Being organized – I had the right equipment (SpO2 and heart rate monitor) that would be needed in the session.
• Explaining the reason for why we were doing the ACBT and how it would benefit him.
• Monitoring the SpO2 during the exercises (if I hadn’t been I would not have noticed that it dropped to 85% at one stage). With some patients who I have spent more time with and I know to be more stable I sometimes take their obs prior to exercise and then following the exercise. As I had not seen this patient before for a treatment session I thought it best to monitor throughout the session. This was a good clinical judgment.
• Matching my treatments to his specific problems (which I devised from my assessment). A generic “cardio” treatment session will not benefit all patients and is certainly not the best option.
Some things I think I could improve on include:
• Remembering to check the obs chart outside the patient’s room before I start the session. In this case I started a quick subjective, then I had to duck outside to check the chart. The obs were stable and within normal limits in this case but it is always important to check incase they aren’t. If a patient’s obs aren’t within normal limits it could be dangerous to get them up, so it really is important to check them!
• When I am teaching a huff I need to have some tissues by the bed, just in case the patient does produce some sputum.
STRATEGIES
I have made a checklist of things to prepare before entering the room, which included checking the obs chart. I should also prepare the environment (i.e. the patient’s room) when I first enter, before starting any treatment. This way I can make sure I have tissues and anything else I need within reach. I can also move furniture and anything else in the way if I am going to mobilize the patient.
Monday, March 22, 2010
Initial Post - Fremantle Cardio
My second placement is at Fremantle Hospital for cardiorespiratory. I know I will be in the wards, but I am not sure exactly which ward. I have the following expectations of my placement:
• I will be expected to know the cardio theory very well! In the orientation package it suggested specific things to revise.
• I will be in one specific area such as surgical or general medical. I am not sure if I will swap between wards or not.
• I may have to do a presentation of some sort as I know previous students at Fremantle had to.
• I will have a clinical tutor. I have not yet been on a placement with a tutor so this will be a new experience. I expect the tutor will help consolidate the information I already know and help find gaps in my theory.
• I expect to see a large number of patients a day but I hope we can build up to it! I would expect to start with maybe 4 a day and build up to around 10. This is just a guess and may be completely wrong.
• I understand we are paired up on the first day and work as partners for the first week. I like this idea and feel it is a good way to start and ease into this placement. I feel less nervous knowing this! I have heard from previous students we do not get to choose our partners, but I am sure I will be able to work with anyone I am paired with. It’s all part of professional behaviour and working in a team.
I don’t have too many concerns about this placement. I think this is because I have just finished one prac and it went well, so I am not so concerned. Unlike my previous prac, I am worried about the level of knowledge I will be expected to have. I am planning to work very hard on the theory. I am a little worried about developing a problem list. I am confident on the theory, but have never devised a problem list for a real patient before (only case studies). I think it may be hard to prioritize. I have been told by previous students at Fremantle that it is common to have different supervisors throughout the five weeks. This concerns me a little in terms of being assessed.
My final concern is finding parking! We have been warned it may be difficult but my plan is to get there early enough to park at the hospital.
• I will be expected to know the cardio theory very well! In the orientation package it suggested specific things to revise.
• I will be in one specific area such as surgical or general medical. I am not sure if I will swap between wards or not.
• I may have to do a presentation of some sort as I know previous students at Fremantle had to.
• I will have a clinical tutor. I have not yet been on a placement with a tutor so this will be a new experience. I expect the tutor will help consolidate the information I already know and help find gaps in my theory.
• I expect to see a large number of patients a day but I hope we can build up to it! I would expect to start with maybe 4 a day and build up to around 10. This is just a guess and may be completely wrong.
• I understand we are paired up on the first day and work as partners for the first week. I like this idea and feel it is a good way to start and ease into this placement. I feel less nervous knowing this! I have heard from previous students we do not get to choose our partners, but I am sure I will be able to work with anyone I am paired with. It’s all part of professional behaviour and working in a team.
I don’t have too many concerns about this placement. I think this is because I have just finished one prac and it went well, so I am not so concerned. Unlike my previous prac, I am worried about the level of knowledge I will be expected to have. I am planning to work very hard on the theory. I am a little worried about developing a problem list. I am confident on the theory, but have never devised a problem list for a real patient before (only case studies). I think it may be hard to prioritize. I have been told by previous students at Fremantle that it is common to have different supervisors throughout the five weeks. This concerns me a little in terms of being assessed.
My final concern is finding parking! We have been warned it may be difficult but my plan is to get there early enough to park at the hospital.
Saturday, March 13, 2010
Final Entry at Carinya
Final Entry
I really enjoyed my 5 weeks at Carinya. I was correct about some of the assumptions and expectations I had at the start of placement. Carinya is a slow-stream rehabilitation place. It is a transitional care service. Clients can stay for the twelve week program before going home or into care.
I was expected to do a lot of rehab with my clients. Treatment was very focused on functionality and I did have to do some discharge planning (but not nearly as much as I expected). This could partly be due to the act only one of my clients was discharged in the time I was there. A lot of the discharge planning seems to be done by the social working. At first I had difficulty on prioritizing my client’s problem list, and I was not sure of what were the most functional tasks to focus on. My supervisor said this came with experience, but I do believe I was better at it by the end of the placement.
The staff were very supportive. I mainly worked with the two physios, the physio assistant and the occupational therapy assistant. I was giving my own caseload. I started with a few clients and quickly built up to 7 or 8 clients per day. I felt I managed this really well, as I was organized and prepared for each day. I had to manage my time carefully or I would not have been able to fit all my clients in each day. As we did not have set session times with the clients, it was sometime difficult getting them at a good time for a session. We had to fit in with meals, showers, group therapy sessions, visitors etc. To start with I felt bad about taking the client for a session while they had visitors, but this made my day difficult when I couldn’t fit all my clients in. By the end of the first week or so I was interrupting visits and other agendas to take a client to physio (which was more important). Most of the visitors were very understanding and were happy to wait, or even watch the session.
One of my jobs was to run the daily group exercise session. It was a general rehab class and all clients were expected to attend. I ran it every Wednesday and Damien did it on Fridays. The physiotherapy assistant and occupational therapy assistant ran it on other days.
My role was not quite what I expected. I did not have to attend as many meetings as I expected (however the physio had to attend a weekly meeting). I did a lot of one-on-one rehab sessions with clients (as I had expected). I also had the job of assessing any new clients I was given, but the assessment forms were supplied to it was an easy assessment to perform. I was made aware of just how important goals are, as is tracking progress. We used a number of outcome measures (including the BERG, TUG, GOWLAND) to see if out clients were improving. It was also a good motivation tactic with clients.
While most of my expectations were met, I would have liked to have seen more neuro clients with different conditions. I mainly saw clients were had suffered from strokes (and the rest were post-fractures and not neurology related). There wasn’t much variety of neuro conditions, and the one client with Parkinson’s was admitted the day before I left, so I didn’t get to spend much time with them. I was a bit disappointed.
Any concerns I had at the start of prac were put to red in the first few days of placement. There was an MDT at Carinya, and I did work within that. I did get lost at the facility a number of times, and while I was better by the end of the 5 weeks, I still had trouble finding my way around sometimes.
I learnt two very important things while on placement at Carinya, that will stick with me and help me out in future pracs. Firstly, setting goals with the clients (both short term and long term) is a very important part of the treatment process. It gives them something to work towards, it lets them know what to expect, it motivates them and lets them know when they have achieved something in their rehab journey. The other thing I learnt is to focus on functionality. The top priority in treating the client is to ensure they are functional and have the best quality of life possible.
I really enjoyed my 5 weeks at Carinya. I was correct about some of the assumptions and expectations I had at the start of placement. Carinya is a slow-stream rehabilitation place. It is a transitional care service. Clients can stay for the twelve week program before going home or into care.
I was expected to do a lot of rehab with my clients. Treatment was very focused on functionality and I did have to do some discharge planning (but not nearly as much as I expected). This could partly be due to the act only one of my clients was discharged in the time I was there. A lot of the discharge planning seems to be done by the social working. At first I had difficulty on prioritizing my client’s problem list, and I was not sure of what were the most functional tasks to focus on. My supervisor said this came with experience, but I do believe I was better at it by the end of the placement.
The staff were very supportive. I mainly worked with the two physios, the physio assistant and the occupational therapy assistant. I was giving my own caseload. I started with a few clients and quickly built up to 7 or 8 clients per day. I felt I managed this really well, as I was organized and prepared for each day. I had to manage my time carefully or I would not have been able to fit all my clients in each day. As we did not have set session times with the clients, it was sometime difficult getting them at a good time for a session. We had to fit in with meals, showers, group therapy sessions, visitors etc. To start with I felt bad about taking the client for a session while they had visitors, but this made my day difficult when I couldn’t fit all my clients in. By the end of the first week or so I was interrupting visits and other agendas to take a client to physio (which was more important). Most of the visitors were very understanding and were happy to wait, or even watch the session.
One of my jobs was to run the daily group exercise session. It was a general rehab class and all clients were expected to attend. I ran it every Wednesday and Damien did it on Fridays. The physiotherapy assistant and occupational therapy assistant ran it on other days.
My role was not quite what I expected. I did not have to attend as many meetings as I expected (however the physio had to attend a weekly meeting). I did a lot of one-on-one rehab sessions with clients (as I had expected). I also had the job of assessing any new clients I was given, but the assessment forms were supplied to it was an easy assessment to perform. I was made aware of just how important goals are, as is tracking progress. We used a number of outcome measures (including the BERG, TUG, GOWLAND) to see if out clients were improving. It was also a good motivation tactic with clients.
While most of my expectations were met, I would have liked to have seen more neuro clients with different conditions. I mainly saw clients were had suffered from strokes (and the rest were post-fractures and not neurology related). There wasn’t much variety of neuro conditions, and the one client with Parkinson’s was admitted the day before I left, so I didn’t get to spend much time with them. I was a bit disappointed.
Any concerns I had at the start of prac were put to red in the first few days of placement. There was an MDT at Carinya, and I did work within that. I did get lost at the facility a number of times, and while I was better by the end of the 5 weeks, I still had trouble finding my way around sometimes.
I learnt two very important things while on placement at Carinya, that will stick with me and help me out in future pracs. Firstly, setting goals with the clients (both short term and long term) is a very important part of the treatment process. It gives them something to work towards, it lets them know what to expect, it motivates them and lets them know when they have achieved something in their rehab journey. The other thing I learnt is to focus on functionality. The top priority in treating the client is to ensure they are functional and have the best quality of life possible.
Wednesday, March 10, 2010
STARES - 3
Situation
I have a client with an extensive medical history. She is 70 years old and is recovering from a stroke. There are many complications as she is PEG fed and has general deconditioning as a result of immobility. She also suffers from aspiration pneumonia and has a poor cough and swallow. Her chest is compromised as a result of this. She has speech trouble (primarily expressive). This client requires a standing hoist from transfers and has very limited use of her right upper limb.
Task
I am required to provide rehab for this client. As she is PEG fed I must organise treatment around feeding times. This client requires a lot of encouragement and motivation. She often becomes depressed and refuses to do physio sessions. The goal of physio is to improve overall conditioning, increase the strength of upper and lower limbs and improve transfers (so a standing hoist is not necessary).
At one particular session the client did not want to do physio. I had to get her to participate in a rehab session without forcing her (as she has the right to say no and not give consent).
Action
I started by asking the client to come to a physio session. She frowned at me and said “no”. I explained to her that she had to do some form of exercise today and went on to say how it would help her (i.e. it would make her stronger, she would be able to stand up etc.). She still wasn’t convinced and was getting upset. I took a different approach. I tried bargaining with her. I said to her we wouldn’t do the strength exercises that we normally did, we would only do some standing practice. She considered this and with a little more prompting she agreed (albeit rather grumpily!). I took the client down to the gym in her wheelchair. By positioning the wheelchair in front of the parallel bars the client could practice standing and sitting without transferring first (we would normally transfer onto the plinth first).
Result
The client stood three times, holding each stand for 30-45 seconds. The fourth attempt was not successful as the client was exhausted. This was the end of the session and I returned the client to her room.
Evaluation
The client can normally stand three to four times after completing all the other strength exercises. In this case she had not done any other exercises so it was not one of the best sessions. The client gave it her best effort and was exhausted by the end of it, so it was better than nothing. The client was happier by the end of the session an was glad she had come to physio.
Strategies
It can be difficult when you have a client who does not want to do physio. Some ways of dealing with this include:
• Come back later (although in this case the client is PEG fed and there are only two specific times each day I can see her to fit in with her feeds).
• Compromise – at least the client will end up doing something (even if it’s not everything you had planned for them) which is better than nothing.
• Find something to motivate them and set a specific goal – for example, going home or being able to walk independently. Aim to reach this specific goal that is important to them, and remind them that this is what physio sessions will do. It it to encourage them to attend physio.
• Set a specific time each day with the client to they know when you will be coming and can psych themselves up for exercise!
• Bring in reinforcements – for example, your supervisor or another physio. Also get the family onboard so they can encourage the client to do physio as well.
I have a client with an extensive medical history. She is 70 years old and is recovering from a stroke. There are many complications as she is PEG fed and has general deconditioning as a result of immobility. She also suffers from aspiration pneumonia and has a poor cough and swallow. Her chest is compromised as a result of this. She has speech trouble (primarily expressive). This client requires a standing hoist from transfers and has very limited use of her right upper limb.
Task
I am required to provide rehab for this client. As she is PEG fed I must organise treatment around feeding times. This client requires a lot of encouragement and motivation. She often becomes depressed and refuses to do physio sessions. The goal of physio is to improve overall conditioning, increase the strength of upper and lower limbs and improve transfers (so a standing hoist is not necessary).
At one particular session the client did not want to do physio. I had to get her to participate in a rehab session without forcing her (as she has the right to say no and not give consent).
Action
I started by asking the client to come to a physio session. She frowned at me and said “no”. I explained to her that she had to do some form of exercise today and went on to say how it would help her (i.e. it would make her stronger, she would be able to stand up etc.). She still wasn’t convinced and was getting upset. I took a different approach. I tried bargaining with her. I said to her we wouldn’t do the strength exercises that we normally did, we would only do some standing practice. She considered this and with a little more prompting she agreed (albeit rather grumpily!). I took the client down to the gym in her wheelchair. By positioning the wheelchair in front of the parallel bars the client could practice standing and sitting without transferring first (we would normally transfer onto the plinth first).
Result
The client stood three times, holding each stand for 30-45 seconds. The fourth attempt was not successful as the client was exhausted. This was the end of the session and I returned the client to her room.
Evaluation
The client can normally stand three to four times after completing all the other strength exercises. In this case she had not done any other exercises so it was not one of the best sessions. The client gave it her best effort and was exhausted by the end of it, so it was better than nothing. The client was happier by the end of the session an was glad she had come to physio.
Strategies
It can be difficult when you have a client who does not want to do physio. Some ways of dealing with this include:
• Come back later (although in this case the client is PEG fed and there are only two specific times each day I can see her to fit in with her feeds).
• Compromise – at least the client will end up doing something (even if it’s not everything you had planned for them) which is better than nothing.
• Find something to motivate them and set a specific goal – for example, going home or being able to walk independently. Aim to reach this specific goal that is important to them, and remind them that this is what physio sessions will do. It it to encourage them to attend physio.
• Set a specific time each day with the client to they know when you will be coming and can psych themselves up for exercise!
• Bring in reinforcements – for example, your supervisor or another physio. Also get the family onboard so they can encourage the client to do physio as well.
Saturday, February 27, 2010
Second Stares Entry
SITUATION
I have a female client who is recovering from a right sided CVA. Her left side is affected (upper limb more so than the lower limb). The stroke occurred approximately 4 months ago. Her left arm has no functional movement and is supported by a sling, however her left leg has had some recovery and she is able to ambulate with a quad-stick approximately 50 metres. This client is not safe to ambulate by herself, and must have somebody to walk with her and assist. She has decreased control of her left foot, creating a high falls risk situation as she cannot always place it in the correct spot on the floor. This client has been slowly improving using the quad-stick and one of my supervisors suggested we try a pulpit frame instead.
TASK
I had to assist this client to transfer from her bed into a wheelchair. Once we were out in the main corridor there was another transfer to perform as the client stood up and held onto the pulpit frame. I then had the task of assisting her to walk with the pulpit frame. This required two people (one each side of the client).
ACTION
I used verbal cues and minimal hands on assistance to help the client transfer from the bed to the wheelchair. I was more a “stand-by assist” in case she needed it. While the client is capable of performing this transfer, it is not always performed correctly and can be unsafe if nobody is there to help. Once in the wheelchair we went out into the main corridor. This was chosen so we had a long, straight distance to practice walking with the pulpit frame. I helped her stand up from the chair (with minimal hands-on assistance) and hold onto the frame. I then went through where the brakes were and how to use them. As this client’s left arm has no movement, I had to help steer from my side. I was also trying to help her place her left foot in the correct spot.
RESULT
Ambulating with the pulpit frame was difficult for this client as she could not see where her left foot was being placed. As she has decreased awareness of where this foot is in space she normally relies on her vision to know where to place it while walking. When she could not see her foot she had difficulty putting it in the right spot, and it was often placed too close to the midline. This was unsafe as it could cause her to trip, resulting in a fall. There were a few times her right foot was caught behind her left foot. The client managed to walk approximately 20 metres with the frame.
EVALUATION
I didn’t think this was particularly successful as it did not feel safe for the client. While there were two people there to assist her there was only very small risk she would fall. It would not be possible for her to do this by herself. Due to this, I do not believe it was a functional task. It may have improved her gait pattern (particularly the swing-through of her right left) but when the client returns to the quad-stick I don’t think it would have made much of a difference to her gait. There is more of a chance of this client walking independently with a quad-stick than a pulpit frame so I think it would be better to spend time practicing with the stick. My other supervisor agreed the pulpit frame may not the best option as the client has difficulty when she cannot see her foot. This supervisor suggested sticking to the quad-stick. My other supervisor (who suggested trying the pulpit frame) thought it would be worth pursuing this option and spending time practicing. As this lady is my client it was ultimately up to me, however I found it confusing with my supervisors saying different things. Both had good reasons for what they said, however I spent time thinking of my own reasons (both for and against) each mobility aid. In the end I decided to stick with the quadstick. Some of my reasons were as follows:
1. It is likely to be more functional for the client in the long-term (important for her discharge)
2. Often I am working with the client by myself and it could be difficult to find someone else to help (as it needed one person on each side)
3. The client said she didn’t like the pulpit frame as she couldn’t see where to put her foot (and the client’s opinion is very important)
4. The pulpit frame did not seem like the safest option
STRATEGIES
In the future when I have supervisors suggesting different ideas there are a few strategies I can utilize to help me make my own decision. I think these strategies also apply in situations where a supervisor suggests a treatment idea and I have a different idea of how to treat the client. The strategies are:
1. Research: I can research the topic and see what evidence there is. I would feel more confident with my choice if I have evidence to back it up.
2. Pros and Cons: I think making a list of reasons for and against all the options or choices is a good idea. It certainly helped me make my decision in this situation.
3. Client: Asking the client what they would prefer. It is also important to find out why the client chose a particular option (as their reasoning may be very different from yours!)
I have a female client who is recovering from a right sided CVA. Her left side is affected (upper limb more so than the lower limb). The stroke occurred approximately 4 months ago. Her left arm has no functional movement and is supported by a sling, however her left leg has had some recovery and she is able to ambulate with a quad-stick approximately 50 metres. This client is not safe to ambulate by herself, and must have somebody to walk with her and assist. She has decreased control of her left foot, creating a high falls risk situation as she cannot always place it in the correct spot on the floor. This client has been slowly improving using the quad-stick and one of my supervisors suggested we try a pulpit frame instead.
TASK
I had to assist this client to transfer from her bed into a wheelchair. Once we were out in the main corridor there was another transfer to perform as the client stood up and held onto the pulpit frame. I then had the task of assisting her to walk with the pulpit frame. This required two people (one each side of the client).
ACTION
I used verbal cues and minimal hands on assistance to help the client transfer from the bed to the wheelchair. I was more a “stand-by assist” in case she needed it. While the client is capable of performing this transfer, it is not always performed correctly and can be unsafe if nobody is there to help. Once in the wheelchair we went out into the main corridor. This was chosen so we had a long, straight distance to practice walking with the pulpit frame. I helped her stand up from the chair (with minimal hands-on assistance) and hold onto the frame. I then went through where the brakes were and how to use them. As this client’s left arm has no movement, I had to help steer from my side. I was also trying to help her place her left foot in the correct spot.
RESULT
Ambulating with the pulpit frame was difficult for this client as she could not see where her left foot was being placed. As she has decreased awareness of where this foot is in space she normally relies on her vision to know where to place it while walking. When she could not see her foot she had difficulty putting it in the right spot, and it was often placed too close to the midline. This was unsafe as it could cause her to trip, resulting in a fall. There were a few times her right foot was caught behind her left foot. The client managed to walk approximately 20 metres with the frame.
EVALUATION
I didn’t think this was particularly successful as it did not feel safe for the client. While there were two people there to assist her there was only very small risk she would fall. It would not be possible for her to do this by herself. Due to this, I do not believe it was a functional task. It may have improved her gait pattern (particularly the swing-through of her right left) but when the client returns to the quad-stick I don’t think it would have made much of a difference to her gait. There is more of a chance of this client walking independently with a quad-stick than a pulpit frame so I think it would be better to spend time practicing with the stick. My other supervisor agreed the pulpit frame may not the best option as the client has difficulty when she cannot see her foot. This supervisor suggested sticking to the quad-stick. My other supervisor (who suggested trying the pulpit frame) thought it would be worth pursuing this option and spending time practicing. As this lady is my client it was ultimately up to me, however I found it confusing with my supervisors saying different things. Both had good reasons for what they said, however I spent time thinking of my own reasons (both for and against) each mobility aid. In the end I decided to stick with the quadstick. Some of my reasons were as follows:
1. It is likely to be more functional for the client in the long-term (important for her discharge)
2. Often I am working with the client by myself and it could be difficult to find someone else to help (as it needed one person on each side)
3. The client said she didn’t like the pulpit frame as she couldn’t see where to put her foot (and the client’s opinion is very important)
4. The pulpit frame did not seem like the safest option
STRATEGIES
In the future when I have supervisors suggesting different ideas there are a few strategies I can utilize to help me make my own decision. I think these strategies also apply in situations where a supervisor suggests a treatment idea and I have a different idea of how to treat the client. The strategies are:
1. Research: I can research the topic and see what evidence there is. I would feel more confident with my choice if I have evidence to back it up.
2. Pros and Cons: I think making a list of reasons for and against all the options or choices is a good idea. It certainly helped me make my decision in this situation.
3. Client: Asking the client what they would prefer. It is also important to find out why the client chose a particular option (as their reasoning may be very different from yours!)
Sunday, February 14, 2010
Week 1
SITUATION
I am currently on prac at a rehab place and every morning a general exercise class is run by the physio assistants. I was asked to watch a class while the physio assistant was in charge, with the plan being for me to run it one day a week (on Wednesdays) from then on. I have had lots of experience running classes (both from previous prac placements and part time jobs) so I wasn’t too worried about it. I watched the first class which consisted of basic exercises with a warm up and cool down. I thought I would then have a week to prepare for the class I was going to run and was going to come up with a plan of what I would do. The following day however a different physio assistant asked if I could run the class for her as she had something else important to do. I agreed and felt fairly confident I could do a good job of it. I still had clients to see that morning before the class, so I didn’t have much time to plan for it.
TASK
I had to run a general exercise class aimed at an older age group of clients. I had a fair bit of equipment to choose from (such as therabands, dumbbells, noodles and balls). The class was chair-based, so all of my exercises had to be performed sitting down. It was a general exercise class with the aim of overall conditioning and rehab, rather than focusing on specific conditions (as the clients were quite varied). The class was approximately an hour long.
ACTION
I didn’t have much time to plan for the class so I quickly wrote down all the warm-up exercises I could remember from watching the previous class. These included things like marching in the chair, shoulder shrugs and knee extensions. I planned to keep that piece of paper in my lap during the class so I could refer to it in case I forgot what to do next. I then looked through all the available equipment. The physio assistant had used therabands the day before so I needed to find something different. I chose dumbbells as it was fairly easy to come up with exercises for that equipment. I also used two balls with soft spikes (for easy grip) and a set of quoits. I used the balls in an exercise where they are passed around the circle from person to person above their heads and we played a game of quoits at the end where the spoke was set in the middle of the circle.
RESULT
The class started off well as I ran through the exercises I had written down for the warm up. It was going well until I ran out of exercises! The ones I had written down did not take as long as I thought they would, and I had time to spare. I thought of some exercises on the spot but couldn’t think under the pressure and moved on from the warm up to the main exercises with the dumbbells. Again, these exercises did not take as long as I thought they would. I thought about doing a greater amount of repetitions for each exercise but the participants in the class were getting tired and could not handle it. I changed over to the ball-passing game and after passing the two balls around the circle four or five times it was time to move on. We played a few rounds of quoits and the group was having so much fun with it I continued with this, filling in time before the cool down. For the cool down I ran through some basic stretches and breathing exercises and finished the class right in time for lunch.
EVALUATION
I thought the class was successful and ran fairly smoothly. I received positive feedback from the participants who said they loved the new games and ideas. I was glad they had enjoyed it as sometimes it is hard to convince them to come to the class. If they consider it a fun activity rather than an “exercise class” they are more likely to want to come. I found it a little stressful trying to think of ideas of exercises on the spot. My weakness was definitely not working well under the pressure, however I believe my strength was not getting flustered. I continued on with what I had planned and went with what worked (such as running the quoits game longer than I had planned). I was glad I had written things down however I should have thought of more exercises prior to the class. The class did run for the required time and the participants enjoyed it and had a good work-out so overall it was a success.
STRATEGIES
In the future I will have a whole list of exercises written down, and make sure I have more ideas than I think I will need! I have also thought of some games (such as balloon volleyball) to make the classes more enjoyable so the participants can have fun while still exercising. I will continue to seek feedback from the group so I can make the class more appropriate for them and their needs.
I am currently on prac at a rehab place and every morning a general exercise class is run by the physio assistants. I was asked to watch a class while the physio assistant was in charge, with the plan being for me to run it one day a week (on Wednesdays) from then on. I have had lots of experience running classes (both from previous prac placements and part time jobs) so I wasn’t too worried about it. I watched the first class which consisted of basic exercises with a warm up and cool down. I thought I would then have a week to prepare for the class I was going to run and was going to come up with a plan of what I would do. The following day however a different physio assistant asked if I could run the class for her as she had something else important to do. I agreed and felt fairly confident I could do a good job of it. I still had clients to see that morning before the class, so I didn’t have much time to plan for it.
TASK
I had to run a general exercise class aimed at an older age group of clients. I had a fair bit of equipment to choose from (such as therabands, dumbbells, noodles and balls). The class was chair-based, so all of my exercises had to be performed sitting down. It was a general exercise class with the aim of overall conditioning and rehab, rather than focusing on specific conditions (as the clients were quite varied). The class was approximately an hour long.
ACTION
I didn’t have much time to plan for the class so I quickly wrote down all the warm-up exercises I could remember from watching the previous class. These included things like marching in the chair, shoulder shrugs and knee extensions. I planned to keep that piece of paper in my lap during the class so I could refer to it in case I forgot what to do next. I then looked through all the available equipment. The physio assistant had used therabands the day before so I needed to find something different. I chose dumbbells as it was fairly easy to come up with exercises for that equipment. I also used two balls with soft spikes (for easy grip) and a set of quoits. I used the balls in an exercise where they are passed around the circle from person to person above their heads and we played a game of quoits at the end where the spoke was set in the middle of the circle.
RESULT
The class started off well as I ran through the exercises I had written down for the warm up. It was going well until I ran out of exercises! The ones I had written down did not take as long as I thought they would, and I had time to spare. I thought of some exercises on the spot but couldn’t think under the pressure and moved on from the warm up to the main exercises with the dumbbells. Again, these exercises did not take as long as I thought they would. I thought about doing a greater amount of repetitions for each exercise but the participants in the class were getting tired and could not handle it. I changed over to the ball-passing game and after passing the two balls around the circle four or five times it was time to move on. We played a few rounds of quoits and the group was having so much fun with it I continued with this, filling in time before the cool down. For the cool down I ran through some basic stretches and breathing exercises and finished the class right in time for lunch.
EVALUATION
I thought the class was successful and ran fairly smoothly. I received positive feedback from the participants who said they loved the new games and ideas. I was glad they had enjoyed it as sometimes it is hard to convince them to come to the class. If they consider it a fun activity rather than an “exercise class” they are more likely to want to come. I found it a little stressful trying to think of ideas of exercises on the spot. My weakness was definitely not working well under the pressure, however I believe my strength was not getting flustered. I continued on with what I had planned and went with what worked (such as running the quoits game longer than I had planned). I was glad I had written things down however I should have thought of more exercises prior to the class. The class did run for the required time and the participants enjoyed it and had a good work-out so overall it was a success.
STRATEGIES
In the future I will have a whole list of exercises written down, and make sure I have more ideas than I think I will need! I have also thought of some games (such as balloon volleyball) to make the classes more enjoyable so the participants can have fun while still exercising. I will continue to seek feedback from the group so I can make the class more appropriate for them and their needs.
Sunday, February 7, 2010
Initial Entry - Carinya
When I first found out I was going to Carinya for my first placement I was nervous as I had never heard of it before and there were so many unknowns. I thought that if I found out more information I’d feel more comfortable and prepared. Using the clinical mix form, information from the placement and information from talking to the clinical ed team and previous prac students, I came up with the following expectations:
1. I think Carinya is a rehabilitation place for people who have been discharged from hospital and aren’t quite ready to go home, but are too good to stay in hospital. Carinya is a place where they can continue their rehab and still receive care.
2.For this reason I expect to do a lot of rehab and discharge planning. I know previous students have had lots of fracture rehab so I expect my patients will be similar. I am also expecting stroke rehab, and anything neuro related (as this is classed as a neuro placement).
3.The staff are really friendly, supportive and knowledgeable. I was concerned that they would expect me to know everything and manage on my own but other students have said the staff are helpful and understand we are students. I am prepared to put in the work and brush up on anything I have forgotten! It sounds like the staff will facilitate the practical side of my learning if I know the theory.
4.As a student I will be left to deal with my own patients a fair bit. I have the understanding I will have my own patients (and see around 6-7 per day by the end of placement) as well as run classes. I have had lots of experience running group classes (generally rehab ones) from previous placements so I am not worried about this.
5.As a student I think my role will be to carry my own caseload and run classes. I imagine I will be attending discharge planning meetings. I plan to make the most of this placement and learn as much as I can from my supervisor and other clinicians working there. I may see some unusual conditions I haven’t dealt with before (especially on the neuro side of things) so it would be great to learn from their experience.
I also have some concerns. Hopefully these will be addressed quickly at the start of the placement to ensure it's smooth sailing for the 5 weeks. My concerns are as follows:
1.I am not sure if there is a whole allied health team working at Carinya. It would make sense if there was, and I am prepared to work within a multi-disciplinary team (MDT) but I will have to wait and find out. I have worked in an MDT while on previous placements so have experience with this. It’s all about communication and being prepared before team meetings so you have something to offer. As I am expecting to do a lot of discharge planning it would be great to have input from other professionals aside from physios.
2.I am a little concerned I won’t see many neuro patients. I would really like the experience of treating neuro conditions as this is the only neuro placement I get.
3.I am not sure on the structure of Carinya or who works there. Hopefully this will become clear within the first week. From previous placements I know it’s not just the physios who can teach me something so it would be great to get to know everyone who works there and learn as much as I can from them.
4.I am concerned about finding my way around. It normally takes me awhile to get used to the place I’m working (slightly directionally challenged!) and sometimes it can be embarrassing when I get lost! I’ll pay extra attention during my orientation.
I am feeling confident and prepared for prac tomorrow. Once I know what type of patients I am seeing I can do some extra study on particular conditions. I am taking my notes and ILPs with me so I can look up anything I need to. I have gone over the areas I think I will need to know. I am feeling less nervous and now really excited about tomorrow.
1. I think Carinya is a rehabilitation place for people who have been discharged from hospital and aren’t quite ready to go home, but are too good to stay in hospital. Carinya is a place where they can continue their rehab and still receive care.
2.For this reason I expect to do a lot of rehab and discharge planning. I know previous students have had lots of fracture rehab so I expect my patients will be similar. I am also expecting stroke rehab, and anything neuro related (as this is classed as a neuro placement).
3.The staff are really friendly, supportive and knowledgeable. I was concerned that they would expect me to know everything and manage on my own but other students have said the staff are helpful and understand we are students. I am prepared to put in the work and brush up on anything I have forgotten! It sounds like the staff will facilitate the practical side of my learning if I know the theory.
4.As a student I will be left to deal with my own patients a fair bit. I have the understanding I will have my own patients (and see around 6-7 per day by the end of placement) as well as run classes. I have had lots of experience running group classes (generally rehab ones) from previous placements so I am not worried about this.
5.As a student I think my role will be to carry my own caseload and run classes. I imagine I will be attending discharge planning meetings. I plan to make the most of this placement and learn as much as I can from my supervisor and other clinicians working there. I may see some unusual conditions I haven’t dealt with before (especially on the neuro side of things) so it would be great to learn from their experience.
I also have some concerns. Hopefully these will be addressed quickly at the start of the placement to ensure it's smooth sailing for the 5 weeks. My concerns are as follows:
1.I am not sure if there is a whole allied health team working at Carinya. It would make sense if there was, and I am prepared to work within a multi-disciplinary team (MDT) but I will have to wait and find out. I have worked in an MDT while on previous placements so have experience with this. It’s all about communication and being prepared before team meetings so you have something to offer. As I am expecting to do a lot of discharge planning it would be great to have input from other professionals aside from physios.
2.I am a little concerned I won’t see many neuro patients. I would really like the experience of treating neuro conditions as this is the only neuro placement I get.
3.I am not sure on the structure of Carinya or who works there. Hopefully this will become clear within the first week. From previous placements I know it’s not just the physios who can teach me something so it would be great to get to know everyone who works there and learn as much as I can from them.
4.I am concerned about finding my way around. It normally takes me awhile to get used to the place I’m working (slightly directionally challenged!) and sometimes it can be embarrassing when I get lost! I’ll pay extra attention during my orientation.
I am feeling confident and prepared for prac tomorrow. Once I know what type of patients I am seeing I can do some extra study on particular conditions. I am taking my notes and ILPs with me so I can look up anything I need to. I have gone over the areas I think I will need to know. I am feeling less nervous and now really excited about tomorrow.
Subscribe to:
Posts (Atom)