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.
Subscribe to:
Posts (Atom)