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.

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.

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.

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.