I am currently on my cardiopulmonary placement where I came across a young male patient who had pneumonia and required physiotherapy. This normally would have been straight forward by doing ACBT’s plus cough/huff, however this person did not speak very good English. Not speaking English is hard enough when you’re trying to ask the patient for information, but it is even more complicated when you want them to actually do a task.
My main problem for this patient was trying to explain the ACBT procedure with a breath hold at the end. It seemed every time I got them to take a deep breath in, they found it difficult so would just stop! I couldn’t seem to make them understand that they were required to take the ‘biggest’ breath in and hold. After about 5 minutes of demonstrating and trying to explain to the patient, I just tried my best to do the ACBT’s with what the patient had understood.
Questions raised from this treatment session, included; is it benefitting the patient to do a technique slightly incorrect? Or is it more beneficial to find an interpreter or changing your physiotherapy treatment session to something that the patient may understand.
Looking back on my treatment session, I think for this particular patient ambulation whilst deep breathing would of been more beneficial, as it is easier to demonstrate than ACBT’s and the patient is still getting some benefit from it.
IF IN THE SAME SITUATION AGAIN I WOULD STILL TRY TO EXAPLAIN/DEMONSTRATE THE MOST BENEFICIAL TECHNIQUE TO THE PATIENT. IF THAT FAILED I WOULD TRY THE SECOND MOST OPTIMAL TECHNIQUE. IF FAMILY MEMBERS ARE AROUND I WOULD CONSIDER GETTING THEM TO INTERPRET TO THE PATIENT, HOWEVER IN MY SITUATION THERE WAS NO FAMILY AVAILABLE.
Monday, June 30, 2008
Tuesday, June 24, 2008
When a patient is progressing well in terms of there rehab then they have a setback and you have to start again.
Whilst on my musculoskeletal placement, I had a patient who had an acute back strain, they came in to see me about 3-4 days after the initial incident caused by picking something up off the ground and they were still in quite a lot of pain and had symptoms into the anterior thigh as well. So the first thing was to do was to decrease the pain and this was going swimmingly with both the back and thigh pain decreasing, i was happy with this progress as it would mean i could progress to more manual techniques which would hopefully help the patient continue to recover.
I was seeing the patient twice a week and on about the 3rd week the patient arrived and when i went to get them from the waiting room i could see they were in quite a bit of discomfort. On questioning the patient they said that they had been doing quite a bit of squatting and bending at work and the pain was back up to the level of the original incident if not worse. I was quite upset about this and with the patient as they were progressing so well and for this to occur was quite a shock to me. We were back at square one and back to the main focus being to decrease the patients pain.
On looking back at the situation i think i could have been more understanding of the patients situation as it may have been necessary for them to work and it may have also been partly my doing as even though i did specifically tell the patient to avoid flexion type activities, through my response to the improvements I may have given the wrong idea about where the patients recovery actually was at.
I THINK IF I WAS IN THIS SITUATION AGAIN I WOULD TRY TO GIVE THE PATIENT MORE INFORMATION ABOUT WHERE THEY ARE IN TERMS OF THERE RECOVERY AND EVEN THOUGH THE PATIENT HADN'T DISCUSSED THERE RETURN TO FULL ACTIVITY AT WORK IN FUTURE I WILL TRY TO BE MORE CLEAR ABOUT WHAT EXACTLY IS APPROPRIATE IN TERMS OF THE PATIENTS RECOVERY AT WHATEVER STAGE THEY ARE AT.
I was seeing the patient twice a week and on about the 3rd week the patient arrived and when i went to get them from the waiting room i could see they were in quite a bit of discomfort. On questioning the patient they said that they had been doing quite a bit of squatting and bending at work and the pain was back up to the level of the original incident if not worse. I was quite upset about this and with the patient as they were progressing so well and for this to occur was quite a shock to me. We were back at square one and back to the main focus being to decrease the patients pain.
On looking back at the situation i think i could have been more understanding of the patients situation as it may have been necessary for them to work and it may have also been partly my doing as even though i did specifically tell the patient to avoid flexion type activities, through my response to the improvements I may have given the wrong idea about where the patients recovery actually was at.
I THINK IF I WAS IN THIS SITUATION AGAIN I WOULD TRY TO GIVE THE PATIENT MORE INFORMATION ABOUT WHERE THEY ARE IN TERMS OF THERE RECOVERY AND EVEN THOUGH THE PATIENT HADN'T DISCUSSED THERE RETURN TO FULL ACTIVITY AT WORK IN FUTURE I WILL TRY TO BE MORE CLEAR ABOUT WHAT EXACTLY IS APPROPRIATE IN TERMS OF THE PATIENTS RECOVERY AT WHATEVER STAGE THEY ARE AT.
Monday, June 16, 2008
An over-enthusiastic patient
My first placement was in the musculoskeletal outpatient area. We had patients with a variety of musculoskeletal conditions and compliance towards PT treatment was variable across patients. We had patients attending clinic regularly but wouldn’t comply with their home exercise program and hence slowing down the recovery of their condition. Then we have patients at the other end of the spectrum that does too much in the hope of recovering in the shortest time span. I had one particular patient who initial diagnosis was rotator cuff tendinopathy secondary to a traumatic fall on the shoulder. He has been attending physiotherapy outpatient treatment for the past 6 months and is still attending treatment. Upon reading his notes, it appeared to me that his shoulder recovery has plateau about the 3rd month of PT with minimal improvement of ROM and pain symptoms. Upon subjective questioning, he did report that his shoulder is not much better from the start of his symptoms, in fact it sometimes feels like the pain has worsened. I started to wander if there were possibly any underlying issues apart from just a difficult shoulder.
The first step I thought was to go through his home exercise program and made sure that he was doing them right. Upon checking the exercises that he has been doing at home, he admitted that he was probably doing more than he should. Instead of the prescribed 3 sets of 8 reps, 3x/day, the patient decided to do 3 sets of 20 reps 6-8x/day. This is when I decided to give the patient some education on the possible negative effects of overdoing the prescribed exercises. I then checked to see if the patient was performing these exercises right. Upon doing that, I discovered that when performing the exercises, the quality and the mechanics of the movement was very poor. Part of his HEP also involved motor control retraining of LTrapz which was also performed in a wrong manner. Doing these exercises wrongly plus doing them in so many reps a day could only do more damage to an already compromised shoulder. I then reviewed his HEP, correction was done in stages and to help with proprioception and motor control of the shoulder, I attempted to tape the patient’s shoulder to facilitate LTrapz which had worked wonderfully for this patient. In the 5 weeks I was in this placement, I had seen this patient improved more than in the 6 months he was attending PT Rx. This was simply achieved by doing the right thing that best suited the patient together with some education for HEP.
My lesson in this scenario was that when confronted with a case that doesn’t quite add up when on clinics, it is important that we just do not passed it off as it’s a common thing but to look at things in all angles so that we do the right thing by the patient as well as our profession. Education played a vital role in this case where the patient was doing much more than is expected and doing the ex’s wrongly would have put him at risk of further damage to the shoulder. So a simple thing like reviewing his HEP brought a whole lot of improvement to his recovery.
The first step I thought was to go through his home exercise program and made sure that he was doing them right. Upon checking the exercises that he has been doing at home, he admitted that he was probably doing more than he should. Instead of the prescribed 3 sets of 8 reps, 3x/day, the patient decided to do 3 sets of 20 reps 6-8x/day. This is when I decided to give the patient some education on the possible negative effects of overdoing the prescribed exercises. I then checked to see if the patient was performing these exercises right. Upon doing that, I discovered that when performing the exercises, the quality and the mechanics of the movement was very poor. Part of his HEP also involved motor control retraining of LTrapz which was also performed in a wrong manner. Doing these exercises wrongly plus doing them in so many reps a day could only do more damage to an already compromised shoulder. I then reviewed his HEP, correction was done in stages and to help with proprioception and motor control of the shoulder, I attempted to tape the patient’s shoulder to facilitate LTrapz which had worked wonderfully for this patient. In the 5 weeks I was in this placement, I had seen this patient improved more than in the 6 months he was attending PT Rx. This was simply achieved by doing the right thing that best suited the patient together with some education for HEP.
My lesson in this scenario was that when confronted with a case that doesn’t quite add up when on clinics, it is important that we just do not passed it off as it’s a common thing but to look at things in all angles so that we do the right thing by the patient as well as our profession. Education played a vital role in this case where the patient was doing much more than is expected and doing the ex’s wrongly would have put him at risk of further damage to the shoulder. So a simple thing like reviewing his HEP brought a whole lot of improvement to his recovery.
IS PHYSIO INDICATED?
On neurology placement I treated an acute L. hemiplegic pt. On initial examination the pt was unable to maintain his airway and subsequently developed an aspiration pneumonia. The pt was completely flaccid on the L. side and had remained RIB since the stroke. I treated this pt for one whole week, seeing him twice daily as the pt was desaturating regularly.
A week passed and the pt’s condition had become stable, being fed with NGT and was able to cough up small amounts of secretions. It was at this time that the medical team requested that the pt not be seen for cardiorespiratory PT, a trial to see how the pt can mange his own chest. The plan for this pt was D/C to nursing home so the only thing holding him back was his respiratory problems.
At the time this confused and angered me as I felt the pt required PT input, as the pt had not progressed greatly since day 1 post stroke. I obliged and ceased treating this pt. The following week the pt to my surprise coped really well without PT managing his chest well, and subsequently discharged to a nursing home by the weeks end.
This above situation frustrated me at first but then I realised that this pt needed to be able to test themself without my input if he were able to be D/C and avoid long periods in hospital. This situation has resulted in me allowing pt to test things for themselves more often rather then giving them assistance. I have found that by allowing pt’s to attempt tasks such as getting out of bed for themselves they feel more independent and are able to make goals that impact on their lives. Also they find our help more valuable as we assist them through our treatment to achieve these goals, returning them to their previous level of function and leaving hospital.
A week passed and the pt’s condition had become stable, being fed with NGT and was able to cough up small amounts of secretions. It was at this time that the medical team requested that the pt not be seen for cardiorespiratory PT, a trial to see how the pt can mange his own chest. The plan for this pt was D/C to nursing home so the only thing holding him back was his respiratory problems.
At the time this confused and angered me as I felt the pt required PT input, as the pt had not progressed greatly since day 1 post stroke. I obliged and ceased treating this pt. The following week the pt to my surprise coped really well without PT managing his chest well, and subsequently discharged to a nursing home by the weeks end.
This above situation frustrated me at first but then I realised that this pt needed to be able to test themself without my input if he were able to be D/C and avoid long periods in hospital. This situation has resulted in me allowing pt to test things for themselves more often rather then giving them assistance. I have found that by allowing pt’s to attempt tasks such as getting out of bed for themselves they feel more independent and are able to make goals that impact on their lives. Also they find our help more valuable as we assist them through our treatment to achieve these goals, returning them to their previous level of function and leaving hospital.
Communication with medical staff
While on placement in a medical ward, my supervisor and I encountered a lady who was very deconditioed as she had been in hospital for a long period of time. My supervisor stated that the patient’s condition had grown worse in this period. The patient was no longer able to walk and needed maximal assistance with bed mobility. My supervisor had not witnessed any voluntary movement or contraction of the leg muscles and it appeared sensation was impaired. My supervisor came to the conclusion that the patient’s legs were not functioning possibly due to some kind of nerve block from the spinal cord. This was stated to the doctors and repeatedly written in the patient notes. However the medical team did not seem to pay much attention to this, until finally one day during ward rounds they asked the patient to stand up. Since the patient’s legs were not functioning the patient fell over. This then prompted the doctors to do a MRI and the results showed oedema which was compressing the spinal cord. The patient then received treatment for this.
This situation evoked strong frustration in my supervisor and I as it appeared the medical team did not respect our opinion and consequently placed the patient in danger and delivered compromised patient care. This situation occurred due to a suboptimal working relationship with the medical staff.
This situation shows the need for an open relationship between health professionals to exist to allow optimal patient care. This situation highlights the need for improvement in communication within this ward.
IF I WAS TO EXPERIENCE A SIMILAR SITUATION, I WOULD PURSUE THE ISSUE MORE STRONGLY AND VISIT THE PATIENT WITH THE TEAM AND SHOW THEM MY FINDINGS. I WOULD ALSO WORK HARD TO ESTABLISH A RELATIONSHIP WITH THE DOCTORS, WHICH ALLOWS CONCERNS FOR PATIENTS TO BE AIRED OPENLY.
This situation evoked strong frustration in my supervisor and I as it appeared the medical team did not respect our opinion and consequently placed the patient in danger and delivered compromised patient care. This situation occurred due to a suboptimal working relationship with the medical staff.
This situation shows the need for an open relationship between health professionals to exist to allow optimal patient care. This situation highlights the need for improvement in communication within this ward.
IF I WAS TO EXPERIENCE A SIMILAR SITUATION, I WOULD PURSUE THE ISSUE MORE STRONGLY AND VISIT THE PATIENT WITH THE TEAM AND SHOW THEM MY FINDINGS. I WOULD ALSO WORK HARD TO ESTABLISH A RELATIONSHIP WITH THE DOCTORS, WHICH ALLOWS CONCERNS FOR PATIENTS TO BE AIRED OPENLY.
compromise
On my surgical placement, i had to see a patient who was day 1 post op. He had an epidural insitu. My initial goal was to ambulate him when I saw him. Since he was attached to an epidural, it was necessary to check blood pressure in supine and standing, muscle strength and sensation in the LL's prior to walking the patient as a safety precaution.
In doing so, I found that he had slightly reduced sensation in his R LL and was unable to SLR with his R leg. Therefore, ambulating him would not have been a good idea, as he would have been at risk of a fall. I did not want to leave this patient without any physiotherapy input, so i decided to transfer the patient to a chair using a front on transfer, and did some deep br ex's, as sitting out of bed is a much better position for this patient than lying in bed.
THIS SCENARIO REAFFIRMS THE IMPORTANCE OF CHECKING THE SAFETY ASPECTS PRIOR TO STANDING A PATIENT UP. ALTHOUGH MOST OF THE TIME, IT WILL BE OK, SOME INCIDENTS HOWEVER, IF IT WERE NOT CHECKED THEN IT MAY BE UNSAFE FOR THE PATIENT. ALTHOUGH MY PLAN DID NOT GO AS I WANTED IT TO, I FEEL HE STILL HAD SOME BENEFIT FROM PHYSIO BY SITTING OUT OF BED. IN THE FUTURE, IF I AM UNABLE TO DO WHAT I INITIALLY PLANNED FOR THE PATIENT, I WILL COMPROMISE AND DO AS MUCH AS POSSIBLE WITH THE PATIENT, AS THIS WILL BE BETTER THAN NO PHYSIO TREATMENT.
In doing so, I found that he had slightly reduced sensation in his R LL and was unable to SLR with his R leg. Therefore, ambulating him would not have been a good idea, as he would have been at risk of a fall. I did not want to leave this patient without any physiotherapy input, so i decided to transfer the patient to a chair using a front on transfer, and did some deep br ex's, as sitting out of bed is a much better position for this patient than lying in bed.
THIS SCENARIO REAFFIRMS THE IMPORTANCE OF CHECKING THE SAFETY ASPECTS PRIOR TO STANDING A PATIENT UP. ALTHOUGH MOST OF THE TIME, IT WILL BE OK, SOME INCIDENTS HOWEVER, IF IT WERE NOT CHECKED THEN IT MAY BE UNSAFE FOR THE PATIENT. ALTHOUGH MY PLAN DID NOT GO AS I WANTED IT TO, I FEEL HE STILL HAD SOME BENEFIT FROM PHYSIO BY SITTING OUT OF BED. IN THE FUTURE, IF I AM UNABLE TO DO WHAT I INITIALLY PLANNED FOR THE PATIENT, I WILL COMPROMISE AND DO AS MUCH AS POSSIBLE WITH THE PATIENT, AS THIS WILL BE BETTER THAN NO PHYSIO TREATMENT.
Ask for assistance if you feel uncomfortable.
This week I went onto a different ward and met a burns pt in his early 20’s. The pt had approx 9% of his body unaffected from the incident. Talking to the other student and PT who usually attend to this pt, it was revealed that he had a very extensive PMHx with behavioural issues. The other PT student and myself begun performing hand stretches when he shouted ‘stop touching my hands, F**k off’. The other student who knew him better explained how important the stretches were but he kept on shouting. He then just stopped and calmed down, and then the PT walked into the room. The pt then looked at me and said “are you stoned, because you look really stoned’. From the initial swearing and then being asked this question I felt very uncomfortable and taken back by the behaviour of this pt. I responded ‘no, i’ve recently been sick’. The PT spoke to him about his professionalism towards us and he responded with an inappropriate answer. The pt then went on to ask me to just leave my number on the table before I left. I was so embarrassed by this comment. The PT again spoke to the pt about his behaviour.
I have worked with non compliant pts before but working with this one was different. I felt really uncomfortable being in that room with him. We all left the room and the PT explained that I handled that situation well and that I did not have to see that pt again. I believe that if you don’t feel comfortable working with a particular pt then you don’t have too. If I was to see that pt again I would ensure that there was another person in the room with me.
KEEPING A PROFESSIONAL RELATIONSHIP BETWEEN YOU AND YOUR PT'S CAN HAVE GREY AREAS. IF HOWEVER YOU FEEL LIKE THAT BARRIER IS BEING CROSSED IN A WAY THAT COMPROMISES YOUR WORKING ABILITY THEN ACTION NEEDS TO BE TAKEN. WE WILL ALL WORK WITH NON COMPLIANT PT'S BUT I HAVE LEARNT THAT THERE IS NO HARM IN ASKING FOR ASSISTANCE FROM ANOTHER PERSON TO AID IN TREATING THESE PTS. PT'S HAVE NO RIGHT TO DISCRIMINATE AGAINST US.
I have worked with non compliant pts before but working with this one was different. I felt really uncomfortable being in that room with him. We all left the room and the PT explained that I handled that situation well and that I did not have to see that pt again. I believe that if you don’t feel comfortable working with a particular pt then you don’t have too. If I was to see that pt again I would ensure that there was another person in the room with me.
KEEPING A PROFESSIONAL RELATIONSHIP BETWEEN YOU AND YOUR PT'S CAN HAVE GREY AREAS. IF HOWEVER YOU FEEL LIKE THAT BARRIER IS BEING CROSSED IN A WAY THAT COMPROMISES YOUR WORKING ABILITY THEN ACTION NEEDS TO BE TAKEN. WE WILL ALL WORK WITH NON COMPLIANT PT'S BUT I HAVE LEARNT THAT THERE IS NO HARM IN ASKING FOR ASSISTANCE FROM ANOTHER PERSON TO AID IN TREATING THESE PTS. PT'S HAVE NO RIGHT TO DISCRIMINATE AGAINST US.
Sunday, June 15, 2008
Splish Splash
I was treating a girl as an outpatient who was starting to lose motivation and become sad, after attending physio sessions 3 times a week for over 6 months. I thought it would be beneficial and more exciting to integrate a hydrotherapy session into her program once a week. This idea went down very well with the child. During the first session of hydro, the girl was very excited because she hadn’t been swimming for over 9 months due to medical treatment. The child got a little carried away during the hydro session, constantly swimming away, doing tumble turns, putting her head under water etc. I found it hard to keep her under control and to get her to follow exercises.
I felt like my patient wasn’t getting a ‘true’ physio session as any exercise I tried to do with her she would do only a few reps then do her own thing. I let her get away with more than I usually would have because I knew the child was having so much fun in the water and I didn’t want to spoil it for her. How much should I let a child (who’s usually emotionally down) get her own way if she’s having so much fun? On reflection after the session, it felt that although she wasn’t following the exercises as well as planned, she enjoyed herself. This may just be enough to regain her enjoyment of physio. In future hydro sessions with this pt I will discuss a plan for the session and negotiate exercises/games. Hopefully, a good combination of effective treatment and fun will be achieved.
From the initial hydro session I have learnt it is not a waste of a treatment session if exercises do not go to plan when treating children. The benefits of the child being happy and feeling like a child again can benefit future physio sessions.
IN FUTURE, I WILL UNDERSTAND THAT INITIAL TREATMENT SESSIONS WITH A CHILD MAY NOT FEEL LIKE AN EFFECTIVE TREATMENT. ALLOWING AN INITIAL TREATMENT SESSION TO BE MORE ABOUT FUN AND LESS STRUCTURED IS APPROPRIATE AS IT ALLOWS RAPPORT TO BE BUILT AND THE CHILDS CONFIDENCE TO BE BOOSTED. HOWEVER, FUTURE SESSIONS WITH A CHILD SHOULD AIM FOR EFFECTIVE EXERCISES THROUGH NEGOTIATION AND EXPECTATIONS MET WITH THE CHILD PRIOR TO THE SESSION.
I felt like my patient wasn’t getting a ‘true’ physio session as any exercise I tried to do with her she would do only a few reps then do her own thing. I let her get away with more than I usually would have because I knew the child was having so much fun in the water and I didn’t want to spoil it for her. How much should I let a child (who’s usually emotionally down) get her own way if she’s having so much fun? On reflection after the session, it felt that although she wasn’t following the exercises as well as planned, she enjoyed herself. This may just be enough to regain her enjoyment of physio. In future hydro sessions with this pt I will discuss a plan for the session and negotiate exercises/games. Hopefully, a good combination of effective treatment and fun will be achieved.
From the initial hydro session I have learnt it is not a waste of a treatment session if exercises do not go to plan when treating children. The benefits of the child being happy and feeling like a child again can benefit future physio sessions.
IN FUTURE, I WILL UNDERSTAND THAT INITIAL TREATMENT SESSIONS WITH A CHILD MAY NOT FEEL LIKE AN EFFECTIVE TREATMENT. ALLOWING AN INITIAL TREATMENT SESSION TO BE MORE ABOUT FUN AND LESS STRUCTURED IS APPROPRIATE AS IT ALLOWS RAPPORT TO BE BUILT AND THE CHILDS CONFIDENCE TO BE BOOSTED. HOWEVER, FUTURE SESSIONS WITH A CHILD SHOULD AIM FOR EFFECTIVE EXERCISES THROUGH NEGOTIATION AND EXPECTATIONS MET WITH THE CHILD PRIOR TO THE SESSION.
Saturday, June 14, 2008
Discussing goals with your patient
During my ortho inpatients placement I treated a 60 year old female patient that had been in and out of hospital for the past 3 months because of rare complications from what should of been a simple operation for a NOF fracture. On first impressions this patient was very compliant with physio treatment and was constantly sitting out of bed. The doctors had allowed her to start weight bearing on her affected leg, so the patient had started ambulating with a frame. However one week after getting the patient up out of bed and ambulating the doctors changed her to a non-weight bearing status.
At my next session with the patient, the doctor had just been in and told her that she was not to weight bear on her affected leg. I knew that this would severely affect how well she would progress as she was already very de-conditioned from being in hospital for such a long period of time. Over the next week the patient’s enthusiasm towards physio decreased significantly, whenever she got tired or couldn’t do one of the activities I asked her to try she would cry and give up. At first I felt like it was my fault that she was crying and would tell her that I would be back in the afternoon for another physio session. But as I took this approach the patient would do less and less treatment with me and sometimes refused to get out of bed. At this stage I felt I had failed with the patient and didn’t know how to motivate them to get out of bed.
After much thought I decided to go in and see the patient and for one whole treatment session just sit down and talk to them and find out exactly what they were feeling and what they thought they would be able to achieve. The patient was quite depressed and felt that they would never get out of hospital. After discussing the patient’s issues, I explained to her that if we strengthened her non affected leg, I believed she could hop with a frame. She agreed on the goal and for the next 2 weeks we focused on getting her to hop. By the time I left that placement the patient was back to her original cheerful self and was compliant with physio treatment
AFTER TREATING THIS PATIENT I HAVE LEARNT THAT IT IS VERY IMPORTANT TO WATCH YOUR PATIENTS MOTIVATION TOWARDS PHYSIO AND IF THEIR MOTIVATION DOES CHANGE START ASKING QUESTIONS. I HAVE LEARNT THERE ARE MANY WAYS TO FIND OUT HOW A PATIENT Is COPING ASKING THE NURSE, FAMILY AND THE PATIENT THEMSELVES ARE ALL GOOD WAYS TO FIND OUT HOW A PATIENT IS COPING. NEVER AVOID ISSUES BECAUSE IT DOESN’T BENEFIT YOU OR THE PATIENT!
At my next session with the patient, the doctor had just been in and told her that she was not to weight bear on her affected leg. I knew that this would severely affect how well she would progress as she was already very de-conditioned from being in hospital for such a long period of time. Over the next week the patient’s enthusiasm towards physio decreased significantly, whenever she got tired or couldn’t do one of the activities I asked her to try she would cry and give up. At first I felt like it was my fault that she was crying and would tell her that I would be back in the afternoon for another physio session. But as I took this approach the patient would do less and less treatment with me and sometimes refused to get out of bed. At this stage I felt I had failed with the patient and didn’t know how to motivate them to get out of bed.
After much thought I decided to go in and see the patient and for one whole treatment session just sit down and talk to them and find out exactly what they were feeling and what they thought they would be able to achieve. The patient was quite depressed and felt that they would never get out of hospital. After discussing the patient’s issues, I explained to her that if we strengthened her non affected leg, I believed she could hop with a frame. She agreed on the goal and for the next 2 weeks we focused on getting her to hop. By the time I left that placement the patient was back to her original cheerful self and was compliant with physio treatment
AFTER TREATING THIS PATIENT I HAVE LEARNT THAT IT IS VERY IMPORTANT TO WATCH YOUR PATIENTS MOTIVATION TOWARDS PHYSIO AND IF THEIR MOTIVATION DOES CHANGE START ASKING QUESTIONS. I HAVE LEARNT THERE ARE MANY WAYS TO FIND OUT HOW A PATIENT Is COPING ASKING THE NURSE, FAMILY AND THE PATIENT THEMSELVES ARE ALL GOOD WAYS TO FIND OUT HOW A PATIENT IS COPING. NEVER AVOID ISSUES BECAUSE IT DOESN’T BENEFIT YOU OR THE PATIENT!
Friday, June 13, 2008
It's for their benefit not ours
The sense of gratification that comes with helping people can be fairly addictive. Sometimes I forget that the patient can benefit even if I don't feel good by the end of the session. When taking a post-natal class recently, my fellow student reminded prior to starting that some of the women will be distracted by their babies and some babies will no doubt cry. This reminder helped me to continue with the session for those who were attentive at various times, and to continue talking when babies were crying. If I had become insecure or distracted when a participant stopped paying attention, the session would never have flowed or finished... then no one would have benefited. The achievement of keeping the class flowing despite so many distractions, in itself was satisfying.
This has reinforced to me that the patient comes first, and a professional approach rather than following your own emotions is very important. It shows the patient that you are rationale and in control of the situation, but they are ultimately in control of their own outcome. Empowering them would be more motivating than enforcing something on them and making them feel inferior or bossed around.
Thursday, June 12, 2008
patients who don't really want to do anything however if they do it would help with their d/c planning
Whilst on a placement recently in cardiopulmonary area there was a patient who had come in from a nursing home with shortness of breath and chest pain. On reading the patients notes I found out that the patient usually uses a stick and requires minimal assistance at the nursing home. It turned out the pt had empyema this was dealt with and the pt's lung function improved. When it came closer to the time when the pt was to be discharged i was to do a mobility review to determine what the patients previous level of function was and also what he was capable of now. The patient was very agitated and seemed like he wanted very much to leave the hospital, he refused to do anything and even with trying to motivate the patient to get up and moving he still wouldn't budge or comply with any request. I was not the only one to experience this either as the OT also had the same issues the patient was becoming quite the problem and was getting a reputation on the ward.
This lasted for a few sessions and after trying various things to get the patient motivated with no result i was beginning to become frustrated myself and thought if the patient wasn't going to move then how could i help.
On discussion with my supervisor we tried to think of ways in which we could get the patient to comply with our requests, i told the supervisor that the pt was just becomming more and more frustrated with his stay in hospital and then it clicked, we could use him going home as his motivation for completing the mobility review. On implementing this with the patient it worked and the patient although still agitated performed the review and could be dischared from a physio point of view.
For me this outlined how sometimes you must use anything you can in your disposal to get a patient motivated and i think by showing the patient that there was light at the end of the tunnel so to speak or by dangling a carrot in front of them (not saying that patients are donkeys) you can sometimes get a better outcome than with normal methods of trying to get a patient to comply to your requests. In future I think I will now be aware of this more and with the more stubborn patients i encounter i have a few more methods up my sleeve which i can use.
This lasted for a few sessions and after trying various things to get the patient motivated with no result i was beginning to become frustrated myself and thought if the patient wasn't going to move then how could i help.
On discussion with my supervisor we tried to think of ways in which we could get the patient to comply with our requests, i told the supervisor that the pt was just becomming more and more frustrated with his stay in hospital and then it clicked, we could use him going home as his motivation for completing the mobility review. On implementing this with the patient it worked and the patient although still agitated performed the review and could be dischared from a physio point of view.
For me this outlined how sometimes you must use anything you can in your disposal to get a patient motivated and i think by showing the patient that there was light at the end of the tunnel so to speak or by dangling a carrot in front of them (not saying that patients are donkeys) you can sometimes get a better outcome than with normal methods of trying to get a patient to comply to your requests. In future I think I will now be aware of this more and with the more stubborn patients i encounter i have a few more methods up my sleeve which i can use.
Tuesday, June 10, 2008
Knowing Ones Culture Makes A Difference
One of my previous placements was in the Women’s Health area, whereby a big part of it involved educating patients that had undergone gynae surgeries involving prolapse repairs amongst others. A huge part of the subjective questioning involved quite personal issues about their pre-op status including bowel and bladder symptoms and reasons why they developed a prolapse. Detailed questioning were carried out to determine patient’s risk factors so that the education given could be tailored to target individual cases. It can be a straightforward process if the patient is comfortable with the questioning. The majority of them were quite happy with the session even when they had family or friends around. Therefore, at some point I got use to the idea that people are generally quite unconcerned about having family or friends around for the education session that I sometimes overlook asking prior to the session.
I then came across one patient, a Moroccan lady who had just undergone a gynae surgery for repair of her bladder and bowel prolapse. Upon walking into the room, she had family there with her and I just assumed that it would be all right for me to start the session. I gave her a brief run of what the session was going to consist off and she appeared consenting at the start. She spoke very simple English and I checked regularly that she understood what I had meant. Midway through the questioning she appeared very uncomfortable and her answers was muffled and barely audible. Still, I just passed it as she did not quite understand me and I continued reiterating the question about her prolapse. Few moments later, her family started walking out one at a time. That is when I realized that I had generalized every patient and assumed that patients are generally comfortable around their family when issues concerning women’s health were discussed. I felt bad about my assumptions and apologized for being so insensitive. I then decided to just do part of the session that day and continue the other part the next so that she is not too overwhelmed with information that she is not used to taking in. The next day when I went to see her, she had no one with her. The difference in response and compliance was amazing. She even asked clarifying question, which surprised me, as she was quiet the day before when I saw her. I’m happy that I broke the session up into two parts as she appeared to be the type that needs a bit more time to open up on personal issues possibly due to her cultural background.
WHEN I LOOK BACK ON THIS INCIDENT, I HAVE LEARNT THAT NOT EVERY CULTURE IS READILY OPEN TO DISCUSSION ABOUT THEIR PERSONAL HEALTH ESPECIALLY IF THEY HAVE FAMILY MEMBERS OR FRIENDS IN THE ROOM. IT IS IMPORTANT FOR US TO REALISE THIS SO THAT WE DO NOT COMPROMISE ON PATIENTS COMPLIANCE TOWARDS OUR TREATMENT OR EDUCATION. WE MUST LEARN TO ACCOMMODATE FOR DIFFERENT CULTURAL NEEDS SO THAT WE HAVE SUCCESS IN OUR TREATMENT GOALS OF INDIVIDUALS.
I then came across one patient, a Moroccan lady who had just undergone a gynae surgery for repair of her bladder and bowel prolapse. Upon walking into the room, she had family there with her and I just assumed that it would be all right for me to start the session. I gave her a brief run of what the session was going to consist off and she appeared consenting at the start. She spoke very simple English and I checked regularly that she understood what I had meant. Midway through the questioning she appeared very uncomfortable and her answers was muffled and barely audible. Still, I just passed it as she did not quite understand me and I continued reiterating the question about her prolapse. Few moments later, her family started walking out one at a time. That is when I realized that I had generalized every patient and assumed that patients are generally comfortable around their family when issues concerning women’s health were discussed. I felt bad about my assumptions and apologized for being so insensitive. I then decided to just do part of the session that day and continue the other part the next so that she is not too overwhelmed with information that she is not used to taking in. The next day when I went to see her, she had no one with her. The difference in response and compliance was amazing. She even asked clarifying question, which surprised me, as she was quiet the day before when I saw her. I’m happy that I broke the session up into two parts as she appeared to be the type that needs a bit more time to open up on personal issues possibly due to her cultural background.
WHEN I LOOK BACK ON THIS INCIDENT, I HAVE LEARNT THAT NOT EVERY CULTURE IS READILY OPEN TO DISCUSSION ABOUT THEIR PERSONAL HEALTH ESPECIALLY IF THEY HAVE FAMILY MEMBERS OR FRIENDS IN THE ROOM. IT IS IMPORTANT FOR US TO REALISE THIS SO THAT WE DO NOT COMPROMISE ON PATIENTS COMPLIANCE TOWARDS OUR TREATMENT OR EDUCATION. WE MUST LEARN TO ACCOMMODATE FOR DIFFERENT CULTURAL NEEDS SO THAT WE HAVE SUCCESS IN OUR TREATMENT GOALS OF INDIVIDUALS.
Monday, June 9, 2008
lucky to get a one-word response
A young postnatal Aboriginal inpatient was referred for physio for assessment/treatment of engorged breasts. Reading her notes revealed complicated social issues, and the likelihood of a difficult subjective examination. When I knocked and asked to enter, there was no reply. I entered to check if it was empty but she was standing quite close to the door expressing milk (for those unfamiliar... its like a gentle human milking machine). Despite a stranger entering with an apology and an introduction (and she was exposed), she didn't look up. Initially I thought this might be due to cultural differences we learnt about in previous years: that eye contact is disrespectful. However, it became clear that this wasn't the main contributing factor when answers were often with-held. My presence wasn't acknowledged. It required 3 repetitions (not impatiently) of request for consent before I could asses the breasts. They were severely engorged and lumpy... ultrasound treatment was indicated, but is most effective just prior to breast-feeding or expressing. I treated the breast she hadn't yet expressed, and attempted to develop some rapport to encourage trust and avoid awkwardness. (10 minutes of treatment in silence can seem to last for eternity). After some silences and one word answers, I thought she might feel I'm prying into her personal life (eg whether she is from Perth), so I tried going through some of the post-natal education routinely offered. A mixture of uncooperativeness and inattentiveness eventually lead me to give up or risk angering her. I left the room feeling very dispondent and pessimistic about my chances of alleviating the atmosphere when I returned later to treat the other breast.
When I returned, something inspired me to keep trying my best. After some less successful attempts, I brought up the topic of a certain colleague of ours who was from her home town of Geraldton who now plays AFL. She piped up after this, and we started having normal conversations. Whether she's a footy fanatic or was simply in better spirits after a visit from her family, I'm not sure. In any case, she came out of her shell, which wouldn't have occurred without persistence. This lead to her asking questions and learning about important postnatal information.
I'm not saying we should harass every patient into constant chatter. If she had given the impression verbally or with body language that she preferred silence, that would be a different matter, but the patient appeared purely uncomfortable. Had I followed my initial desire to give up, I never would have known such a change in 'personality' could occur. This experience has taught me that I should always strive for rapport or at least trust, no matter how impossible it seems. It has also taught me that attitude problems on a first impression may not be an issue at all, its just that the invasion of privacy might be more intimidating for one particular patient than another.
Increasing patients motivation
A 56yo male presented to my neuro inpatients ward with a stroke to the basal ganglia. This patient had the stroke 2 months ago and was still in hospital receiving physiotherapy rehab. He had improved significantly in the first month according to the notes but now any improvements in gait were minimal.
During my time treating this patient, he told me that his major goal was to walk his daughter down the aisle of her wedding which was one month away. The patient’s present physical status warned me that this would be a huge deadline to meet as he required one assist to walk plus the aid of a 4 point walking stick. I explained to the patient that what he was asking was quite a huge challenge and that at best he should expected to walk down the aisle with his daughter helping him.
During the next week we focused mainly on improving the patients gait, this included 2 hourly sessions morning and afternoon to try to retrain the patients movement pattern. After one week of treating the patient this way I was aware that they were quiet and seemed to be withdrawn from the treatment session. I constantly asked the patient if they were ‘ok’ and they continually told me they were ‘fine’, yet their actions didn’t match what they were saying. After much thought on the inconsistencies of my patients behaviour I decided to talk to my supervisor and ask what they realistically thought this patient would achieve in terms of gait.
I then went to the patient and sat them down and explained how I noticed their attitude towards rehab had changed and how I wanted to reassure them that they were progressing. I had made a list of goals which he had achieved and ones which I thought were realistic with timeframes attached. He then told me that he didn’t feel he was progressing as much as other patients in the hospital. So I then explained how depending on the severity and the type of stroke people will improve at different rates. For this patient educating him on what was realistic and that all patients will progress differently, gave him the help he needed to continue with the rehab and not to give up.
AFTER THIS PLACEMENT I HAVE DECIDED THAT IT IS VERY IMPORTANT TO MATCH THE PHYSIOTHERAPISTS GOALS WITH THE PATIENTS GOALS, AS THIS INCREASES THEIR MOTIVATION TOWARDS REHAB. ALSO CONSTANTLY REMINDING THE PATIENT OF THEIR ACCOMPLISHMENTS DECREASES THE RISK OF THEM GETTING DEPRESSED FROM NOT IMPROVING.
During my time treating this patient, he told me that his major goal was to walk his daughter down the aisle of her wedding which was one month away. The patient’s present physical status warned me that this would be a huge deadline to meet as he required one assist to walk plus the aid of a 4 point walking stick. I explained to the patient that what he was asking was quite a huge challenge and that at best he should expected to walk down the aisle with his daughter helping him.
During the next week we focused mainly on improving the patients gait, this included 2 hourly sessions morning and afternoon to try to retrain the patients movement pattern. After one week of treating the patient this way I was aware that they were quiet and seemed to be withdrawn from the treatment session. I constantly asked the patient if they were ‘ok’ and they continually told me they were ‘fine’, yet their actions didn’t match what they were saying. After much thought on the inconsistencies of my patients behaviour I decided to talk to my supervisor and ask what they realistically thought this patient would achieve in terms of gait.
I then went to the patient and sat them down and explained how I noticed their attitude towards rehab had changed and how I wanted to reassure them that they were progressing. I had made a list of goals which he had achieved and ones which I thought were realistic with timeframes attached. He then told me that he didn’t feel he was progressing as much as other patients in the hospital. So I then explained how depending on the severity and the type of stroke people will improve at different rates. For this patient educating him on what was realistic and that all patients will progress differently, gave him the help he needed to continue with the rehab and not to give up.
AFTER THIS PLACEMENT I HAVE DECIDED THAT IT IS VERY IMPORTANT TO MATCH THE PHYSIOTHERAPISTS GOALS WITH THE PATIENTS GOALS, AS THIS INCREASES THEIR MOTIVATION TOWARDS REHAB. ALSO CONSTANTLY REMINDING THE PATIENT OF THEIR ACCOMPLISHMENTS DECREASES THE RISK OF THEM GETTING DEPRESSED FROM NOT IMPROVING.
Sunday, June 8, 2008
Is the family coping?
I am currently treating a 10 year old girl with leukaemia twice a week. Her exercise program consists of general strengthening, stretching, cardiovascular endurance and netball drills. Her mother attends all treatment sessions and says very little throughout the session. This stood out to me on the first session but I thought it was just because I was new person. After several more treatment sessions, the mother is still distant and it has become apparent that she doesn’t interact with her daughter at all. There is no encouragement from the mother to her daughter, nil engaging in conversation or saying anything about her.
The lack of encouragement by the mother stood out like a sore thumb. When I noticed that the pts ability to hop had improved I was very excited and encouraged the patient a lot, and reminded her that the hopping will help her get back to netball. I knew since the mother wasn’t encouraging that I had to give even more encouragement/praise. I told the mother at the end of the session how great her daughter’s improvement was and I spoke enthusiastically because I thought that maybe she wasn’t seeing the benefits of the treatment sessions. Once again, the mother had no reaction.
Although as a Physio student it is good to be engaging in conversation with the child alone, it felt odd that the mother wouldn’t say anything. Usually mothers and fathers like to talk about their child e.g. funny stories, what they did during the week that was good. Compared to all my other patients’ mothers who are encouraging, talkative to myself and the child, this child’s mother made me feel as if she was distant from her daughter. I wondered whether this mother was not coping well, or whether it was just her personality. I spoke to my supervisor regarding the girls’ mother. He told me that this family in particular has not coped as well as other families with a child with cancer.
THIS SITUATION HAS CLARIFIED THE PSYCHOLOGICAL ISSUES IN A FAMILY DEALING WITH A CHRONIC CONDITION. IN FUTURE TREATMENT SESSIONS WITH THIS PT, I WILL CONTINUE TO BE VERY ENCOURAGING TOWARDS THE CHILD AND PARENT. I ALSO UNDERSTAND THAT PARENTS WHO SEEM AS IF THEY ARE COPING AND ARE ENCOURAGING ARE STILL CONCERNED AND MANAGING THEIR EMOTIONS. THAT IS, SOME FAMILIES CAN DISGUISE THEIR CONCERNS IN FRONT OF THEIR CHILD, WHEREAS OTHERS FIND IT DIFFICULT. IT IS ALSO IMPORTANT TO KNOW WHAT FAMILY SUPPORT SERVICES ARE AVAILABLE TO OFFER TO A FAMILY.
The lack of encouragement by the mother stood out like a sore thumb. When I noticed that the pts ability to hop had improved I was very excited and encouraged the patient a lot, and reminded her that the hopping will help her get back to netball. I knew since the mother wasn’t encouraging that I had to give even more encouragement/praise. I told the mother at the end of the session how great her daughter’s improvement was and I spoke enthusiastically because I thought that maybe she wasn’t seeing the benefits of the treatment sessions. Once again, the mother had no reaction.
Although as a Physio student it is good to be engaging in conversation with the child alone, it felt odd that the mother wouldn’t say anything. Usually mothers and fathers like to talk about their child e.g. funny stories, what they did during the week that was good. Compared to all my other patients’ mothers who are encouraging, talkative to myself and the child, this child’s mother made me feel as if she was distant from her daughter. I wondered whether this mother was not coping well, or whether it was just her personality. I spoke to my supervisor regarding the girls’ mother. He told me that this family in particular has not coped as well as other families with a child with cancer.
THIS SITUATION HAS CLARIFIED THE PSYCHOLOGICAL ISSUES IN A FAMILY DEALING WITH A CHRONIC CONDITION. IN FUTURE TREATMENT SESSIONS WITH THIS PT, I WILL CONTINUE TO BE VERY ENCOURAGING TOWARDS THE CHILD AND PARENT. I ALSO UNDERSTAND THAT PARENTS WHO SEEM AS IF THEY ARE COPING AND ARE ENCOURAGING ARE STILL CONCERNED AND MANAGING THEIR EMOTIONS. THAT IS, SOME FAMILIES CAN DISGUISE THEIR CONCERNS IN FRONT OF THEIR CHILD, WHEREAS OTHERS FIND IT DIFFICULT. IT IS ALSO IMPORTANT TO KNOW WHAT FAMILY SUPPORT SERVICES ARE AVAILABLE TO OFFER TO A FAMILY.
anxiety
On my general surgery placement, I had a very anxious patient who underwent an anterior resection due to cancer. I saw him the day after his surgery. He constantly had beliefs that he was going to die soon, because he had known somebody who had a similar condition, and had passed away. These thoughts had made him very anxious.
The patient would continuously complain about his pain levels and his dizziness in a very anxious manner. He also seemed unusually anxious every time something happened. For example, he was bleeding slightly where the IV line inserted, and was excessively worried about this. My supervisor and I were constantly reassuring the patient that pain and dizziness are very normal after surgery, and that slight bleeding where the IV line inserts is nothing to be concerned about. I felt that this seemed to have reduced his anxiety, as well as improve his co-operation. I also found that setting goals for this patient had a positive effect, as he could see he was improving, therefore making him less anxious.
ANXIOUS PATIENTS REQUIRE A LOT OF REASSURANCE, AS WELL AS ENCOURAGEMENT. I THINK THAT A LACK OF REASSURANCE COULD THEN LEAD TO THE PATIENT BEING DEPRESSED, AND WITH DEPRESSION COMES A LACK OF MOTIVATION. THEREFORE A PATIENT WILL BE LESS LIKELY TO CO-OPERATE, AND THE OUTCOME WILL BE AFFECTED. IN THE FUTURE, I WILL ATTEMPT TO BE MORE POSITIVE, AND CONTINUE TO EDUCATE THE PATIENT THAT SYMPTOMS SUCH AS PAIN, DIZZINESS AND NAUSEA AFTER SURGERY ARE COMPLETELY NORMAL, THUS IMPROVING PATIENT COMPLIANCE. I WILL ALSO GIVE THE PATIENT AN IDEA OF HIS/HER IMPROVEMENT THROUGH GOAL SETTING AND POSITIVE FEEDBACK, WHICH WILL HOPEFULLY INCREASE PATIENT MOTIVATION.
The patient would continuously complain about his pain levels and his dizziness in a very anxious manner. He also seemed unusually anxious every time something happened. For example, he was bleeding slightly where the IV line inserted, and was excessively worried about this. My supervisor and I were constantly reassuring the patient that pain and dizziness are very normal after surgery, and that slight bleeding where the IV line inserts is nothing to be concerned about. I felt that this seemed to have reduced his anxiety, as well as improve his co-operation. I also found that setting goals for this patient had a positive effect, as he could see he was improving, therefore making him less anxious.
ANXIOUS PATIENTS REQUIRE A LOT OF REASSURANCE, AS WELL AS ENCOURAGEMENT. I THINK THAT A LACK OF REASSURANCE COULD THEN LEAD TO THE PATIENT BEING DEPRESSED, AND WITH DEPRESSION COMES A LACK OF MOTIVATION. THEREFORE A PATIENT WILL BE LESS LIKELY TO CO-OPERATE, AND THE OUTCOME WILL BE AFFECTED. IN THE FUTURE, I WILL ATTEMPT TO BE MORE POSITIVE, AND CONTINUE TO EDUCATE THE PATIENT THAT SYMPTOMS SUCH AS PAIN, DIZZINESS AND NAUSEA AFTER SURGERY ARE COMPLETELY NORMAL, THUS IMPROVING PATIENT COMPLIANCE. I WILL ALSO GIVE THE PATIENT AN IDEA OF HIS/HER IMPROVEMENT THROUGH GOAL SETTING AND POSITIVE FEEDBACK, WHICH WILL HOPEFULLY INCREASE PATIENT MOTIVATION.
Negotiation
On neurology placement physiotherapy sessions are structured to include a morning and afternoon session. One of my pts following cerebellar stroke continually lacked motivation to attend PT so I was experiencing great difficulty trying to get him to attend physio once per day let alone twice per day.
One strategy which I found well to work to convince my pt to attend PT was to ask the pt what he felt like doing during the morning and afternoon sessions so he felt more in control of what we were going to do and how long for. This worked really well as I negotiated with the pt to treat his UL impairment in the morning as he was tired following his showering and toileting, and return late in the afternoon following lunch and a couple of hours of rest to take him down to the gym to work on his balance and LL impairments.
Through using negotiation in this situation I felt I was able to treat the patient well and he seemed more motivated to come to PT because he determined what and when we were going to do. In subsequent session I successfully negotiated that we do more everyday, which was a way to progress the pt between treatments.
NEGOTIATION CAN BE SUCCESSFULLY USED TO TREAT DIFFICULT PATIENTS WHO DO NOT WANT TO HAVE PHYSIO TREATMENT. THIS CAN HELP SOLVE ISSUES SUCH AS LACK OF MOTIVATION SUCCESSFULLY. THROUGH NEGOTIATION THE PATIENT FEELS MORE IN CONTROL AND THEREFORE MORE LIKELY TO PARTICIPATE IN PHYSIO. THIS ALLOWS BOTH THE THERAPIST AND PATIENT TO ACHIEVE THE GOALS THAT HAVE BEEN SET OUT FOR THE PHYSIOTHERAPY SESSION.
One strategy which I found well to work to convince my pt to attend PT was to ask the pt what he felt like doing during the morning and afternoon sessions so he felt more in control of what we were going to do and how long for. This worked really well as I negotiated with the pt to treat his UL impairment in the morning as he was tired following his showering and toileting, and return late in the afternoon following lunch and a couple of hours of rest to take him down to the gym to work on his balance and LL impairments.
Through using negotiation in this situation I felt I was able to treat the patient well and he seemed more motivated to come to PT because he determined what and when we were going to do. In subsequent session I successfully negotiated that we do more everyday, which was a way to progress the pt between treatments.
NEGOTIATION CAN BE SUCCESSFULLY USED TO TREAT DIFFICULT PATIENTS WHO DO NOT WANT TO HAVE PHYSIO TREATMENT. THIS CAN HELP SOLVE ISSUES SUCH AS LACK OF MOTIVATION SUCCESSFULLY. THROUGH NEGOTIATION THE PATIENT FEELS MORE IN CONTROL AND THEREFORE MORE LIKELY TO PARTICIPATE IN PHYSIO. THIS ALLOWS BOTH THE THERAPIST AND PATIENT TO ACHIEVE THE GOALS THAT HAVE BEEN SET OUT FOR THE PHYSIOTHERAPY SESSION.
Patients with psychological issues
On placement in a stroke rehabilitation ward I worked with a lovely gentleman who had a CVA, but was recovering very quickly. This patient impressed staff with his quick recovery and improvement in function, however this patient did not seem happy with his progress. In one treatment session the patient began to get upset as he began to explain how he received some burn scars on his arms and trunk. The patient had been a solider in war where he sustained the burns. This prompted him to recount his experiences during this terrible time in his life. I began to realise this stroke and rehabilitation had resurfaced memories of this extremely traumatic period in his life. The patient stated the rehab he was receiving and his time in hospital was reminding him of the treatment for his burns. As the patient began to cry, I to felt I wanted to cry with him. However I knew I needed to remain calm and empathetic. Since the patient was obviously traumatised, I sat with him for a while and listened to his stories, however after a time I encouraged him to continue with his rehab session.
I feel it was important for the patient to feel his concerns were being heard without having to worry his family, but at the same time I knew the patient was starting to get into a negative frame of thinking and needed to be distracted. I believed focusing on his exercises would help him to break that feeling of sadness and that he needed to be reminded that he was going to fully recover and be leaving the hospital soon.
This experience reminded me that patients often have many issues and concerns, not just their physical limitations which I may be focusing on. It’s important these problems are acknowledged to gain the trust of the patient.
IN THE FUTURE I WILL BE MINDFUL OF PSYCHOLOGICAL ISSUES THAT A PATIENT MAY FACE, HOWEVER I WILL ALSO TRY AND REMIND THESE PATIENTS OF THE IMPORTANCE OF REHABILITATION. IN THE FUTURE, IF I AM CONFRONTED WITH PATIENTS WITH PSYCHOLOGICAL PROBLEMS I WILL RECOMMEND THEY TALK TO A COUNSELLOR.
I feel it was important for the patient to feel his concerns were being heard without having to worry his family, but at the same time I knew the patient was starting to get into a negative frame of thinking and needed to be distracted. I believed focusing on his exercises would help him to break that feeling of sadness and that he needed to be reminded that he was going to fully recover and be leaving the hospital soon.
This experience reminded me that patients often have many issues and concerns, not just their physical limitations which I may be focusing on. It’s important these problems are acknowledged to gain the trust of the patient.
IN THE FUTURE I WILL BE MINDFUL OF PSYCHOLOGICAL ISSUES THAT A PATIENT MAY FACE, HOWEVER I WILL ALSO TRY AND REMIND THESE PATIENTS OF THE IMPORTANCE OF REHABILITATION. IN THE FUTURE, IF I AM CONFRONTED WITH PATIENTS WITH PSYCHOLOGICAL PROBLEMS I WILL RECOMMEND THEY TALK TO A COUNSELLOR.
The dying pt
I was on my neurology placement and I was allocated a pt that had a dense (R) MCA CVA. The pt was 91 and had an extensive list of co-morbidities. On the initial day I assessed him, it seemed like his outcome was going to be positive despite the extent of the stroke and his medical background. With this he was referred onto the rehabilitation wards. The pt was dysphasic and had bilateral deafness more so in his (L) ear than (R). However despite these limitations we were able to communicate via utilizing simple questions and hand gestures. He was a very determined man and was always eager for PT Rx.
Over the weekend he went into heart failure and the outcome was not looking good. On the Thursday proceeding I went in to see the pt and he did not look well evident by his obs chart and the change in his breathing pattern. The pt c/o pain of his (R) upper traps being very sore, so I begun to rub them for him whilst I begun to realised that he was not going to be around for much longer. I have had no first hand experience with death and I find this to be a very saddening, emotional topic. I started to get sad and I felt like I had to leave the room because I couldn’t handle the emotions. However at the same time the momentary relief that I was providing for him kept me there. At the end I smiled to the pt and held his hand and said ‘thanks pt’s name, I’ll see you tomorrow’. He smiled back and I left.
The next morning before the handovers begun I had this strange feeling about the pt and really questioned if he was still alive. I begun to get nervous and anxious looking down the ward list and when I failed to locate his name I ask the PT. She informed me that he had died early this morning. I felt empty and just kept telling myself that he was no longer suffering. I did not show any emotion to the other staff; however they were very supportive and asked if I was ok.
DESPITE THE SAD LOSS OF THIS PERSON, I BELIEVE THAT IT MADE ME WAKEN TO THE FACT THAT I WILL ENCOUNTER PTS WHO WILL DIE AND IT IS SOMETHING THAT I HAVE TO COME TO TERMS WITH. DUE TO IT BEING SUCH AN ISUUE FOR ME, IF THERE IS A NECT TIME THAT I ENCOUNTER THIS I WILL ACCEPT THAT IT IS A NATURAL COURSE OF LIFE. UNFORTUNATELY IT IS ALOS SOMETHING THAT IS APART OF OUR CHOSEN CAREERS.
Over the weekend he went into heart failure and the outcome was not looking good. On the Thursday proceeding I went in to see the pt and he did not look well evident by his obs chart and the change in his breathing pattern. The pt c/o pain of his (R) upper traps being very sore, so I begun to rub them for him whilst I begun to realised that he was not going to be around for much longer. I have had no first hand experience with death and I find this to be a very saddening, emotional topic. I started to get sad and I felt like I had to leave the room because I couldn’t handle the emotions. However at the same time the momentary relief that I was providing for him kept me there. At the end I smiled to the pt and held his hand and said ‘thanks pt’s name, I’ll see you tomorrow’. He smiled back and I left.
The next morning before the handovers begun I had this strange feeling about the pt and really questioned if he was still alive. I begun to get nervous and anxious looking down the ward list and when I failed to locate his name I ask the PT. She informed me that he had died early this morning. I felt empty and just kept telling myself that he was no longer suffering. I did not show any emotion to the other staff; however they were very supportive and asked if I was ok.
DESPITE THE SAD LOSS OF THIS PERSON, I BELIEVE THAT IT MADE ME WAKEN TO THE FACT THAT I WILL ENCOUNTER PTS WHO WILL DIE AND IT IS SOMETHING THAT I HAVE TO COME TO TERMS WITH. DUE TO IT BEING SUCH AN ISUUE FOR ME, IF THERE IS A NECT TIME THAT I ENCOUNTER THIS I WILL ACCEPT THAT IT IS A NATURAL COURSE OF LIFE. UNFORTUNATELY IT IS ALOS SOMETHING THAT IS APART OF OUR CHOSEN CAREERS.
Thursday, June 5, 2008
little things can sometimes not be so little
(bit late internets been on the blink)
On my cardiopulmonary placement i was on a general medical ward, so this encompassed a wide range of patients. I was seeing a patient who had come in with an exacerbation of CAL and everything was going well and she was improving with each session. when it came time for the patients discharge i was going to see the patient for the last time and make sure she could do her exercises and also give her a home exercise program including upper limb exercises and lower limb exercises. When i went in to see the patient it was first thing in the morning as the plan was for the patient to be discharged by midday, I did a brief subjective with the patient and all was well except the patient said she had experienced a sensation of a 'dead' hand when she was having a shower and due to this she had some increased breathlessness as she relied on her other arm, when i saw her however it had resolved. The patient tried to brush this off as nothing as i think she was keen to get home. The patient kept trying to convince me that it wasn't an issue and that she was feeling fine.
On palpating the radial pulse i noticed slight irregularities which had not been present on previous occasions. I immediately notified her nurse and also the doctors of what had happened when i saw her. The the nurse and doctors performed an ECG and it turned out the patient had suffered a Transient Ischemic Attack when having her shower. With this being the case it was now not appropriate for the patient to be discharged. As well on further questioning from the doctors it turned out the patient had suffered similar occasions before however had just brushed them off.
From this situation it shows the importance of taking everything into consideration as even though the patient was ready for discharge from her initial problem at admission the new event had changed this. Also with the patient trying to brush it off as nothing it shows the importance of listening to every detail that the patient gives you and even if they say it is nothing from your informed judgement you should make the decision of what if any action needs to be taken, in this case it was notifying the doctors and nurse.
SO ANYTIME NO MATTER HOW SMALL SOMETHING SOUNDS OR IF A PATIENT TRY'S TO PLAY DOWN THE SIGNIFICANCE OF SOMETHING, THERE IS A CHANCE THAT SOMETHING MORE SINISTER IS GOING ON, SO IF NEED BE NOTIFY OTHER HEALTH PROFESSIONALS OR TAKE THE NECCESARY ACTION AS IN CASES LIKE THE ONE I DISCUSSED ITS BETTER TO BE ON THE SAFE SIDE.
On my cardiopulmonary placement i was on a general medical ward, so this encompassed a wide range of patients. I was seeing a patient who had come in with an exacerbation of CAL and everything was going well and she was improving with each session. when it came time for the patients discharge i was going to see the patient for the last time and make sure she could do her exercises and also give her a home exercise program including upper limb exercises and lower limb exercises. When i went in to see the patient it was first thing in the morning as the plan was for the patient to be discharged by midday, I did a brief subjective with the patient and all was well except the patient said she had experienced a sensation of a 'dead' hand when she was having a shower and due to this she had some increased breathlessness as she relied on her other arm, when i saw her however it had resolved. The patient tried to brush this off as nothing as i think she was keen to get home. The patient kept trying to convince me that it wasn't an issue and that she was feeling fine.
On palpating the radial pulse i noticed slight irregularities which had not been present on previous occasions. I immediately notified her nurse and also the doctors of what had happened when i saw her. The the nurse and doctors performed an ECG and it turned out the patient had suffered a Transient Ischemic Attack when having her shower. With this being the case it was now not appropriate for the patient to be discharged. As well on further questioning from the doctors it turned out the patient had suffered similar occasions before however had just brushed them off.
From this situation it shows the importance of taking everything into consideration as even though the patient was ready for discharge from her initial problem at admission the new event had changed this. Also with the patient trying to brush it off as nothing it shows the importance of listening to every detail that the patient gives you and even if they say it is nothing from your informed judgement you should make the decision of what if any action needs to be taken, in this case it was notifying the doctors and nurse.
SO ANYTIME NO MATTER HOW SMALL SOMETHING SOUNDS OR IF A PATIENT TRY'S TO PLAY DOWN THE SIGNIFICANCE OF SOMETHING, THERE IS A CHANCE THAT SOMETHING MORE SINISTER IS GOING ON, SO IF NEED BE NOTIFY OTHER HEALTH PROFESSIONALS OR TAKE THE NECCESARY ACTION AS IN CASES LIKE THE ONE I DISCUSSED ITS BETTER TO BE ON THE SAFE SIDE.
Tuesday, June 3, 2008
Belated blog
On a gerontology prac I was asked to attend a 'family meeting' about one of my patients. I had never come across these before. My supervisor explained that the family members meet with the health team to discuss an important issue about that patient. In this case it was simply about readiness for discharge. She recommended that I prepare a brief progress report supported with objective measures. During the meeting it became apparent that the family were very apprehensive about the patient's discharge, fearing that another fall would occur or exhaustion would prevent him from coping alone at home. The patient became very submissive around the family. Either standing up for himself wasn't the normal family dynamic, or their fears genuinely rubbed off on the patient. The family's expectation was that the patient be functioning 100% normally before discharge. From an allied health perspective their apprehension was completely unjustified, as the patient's performance was already at a much higher level than normally required for discharge. Our perspective is influenced by a health system that constantly requires beds be made available for new patients, however, this patient had very little room for further improvement in the hospital environment.
Our persuasion efforts included to gently explaining that a normal level of functioning can not be achieved in an environment where so much help is available, and that the initial difficulties (eg exhaustion) would not compromise the patient's safety, as he had good common sense about his own limitations, and had been provided safer alternatives for more difficult tasks. It felt like a court of law. In their fear, the family made unsupported claims about the patient's current level of independence. If my supervisor hadn't recommended that I prepare, my comments wouldn't have been convincing to the family. Being able to read a list of objective measures in terms meaningful to the family is more reassuring than simply disagreeing with their claims. I found it hard to 'present my case' without guaranteeing safety for the patient at home. It had to be explained to the family that risk of falling can never be totally eliminated, without substantiating their fears.
This experience has taught me to always be prepared for a situation where you must display your familiarity with a patient's progress. It has also taught me that I must be confident in my opinion of a patient's rehab status. The hardest part of the experience was not being intimidated by the family, and reminding myself that if something did happen to the patient after discharge, I can't blame myself. I rehabilitated the subject as thoroughly as I could and beyond that it's out of my control.
A compromise was eventually reached between the family and the doctor to stagger the discharge over a few days, with intervals at home and in hospital.
Panicky hands
Whilst on a placement in ICU, I was carrying out MHI on a patient with sepsis and multi-organ failure. The technique was chosen to facilitate AW clearance and improve lung volumes. In order to recruit atelectatic lung tissue (to increase LV), the bag is held squeezed for a moment after fully squeezing. This mimicks an inspiratory hold, which like SMIs, uses interdependence and collateral ventilation to aid re-expansion. In order to shear secretions, after the squeeze you release your hands to allow the bag to deflate as quickly as possible, which increases expiratory flow. When combined, the sequence is slow squeeze, hold, fast release, but you also have to watch for when the patient attempts to initiate a breath, so you can synchronize with them. If their respiratory rate is too fast, you hyperinflate on every second or third breath. Sounds simple? Being about my third attempt, I was starting to gain confidence that the patient won't die while I'm responsible for breathing for them. I just got into a rhythm, when the patient (who has a history of anxiety) started having an anxiety attack and her respiratory rate skyrocketed. Being someone who usually fakes calmness quite well, I managed to look reassuringly at the patient and with a calm voice encourage her to breath slowly and deeply. On the other hand (no pun intended) my hands reflected my true state of utter panic. I could remember squeeze/release, but timing and technique went out the window. My supervisor advised me to go consistently with every third breath so the patient knows what to expect, which will help calm her. I eventually managed this, and the with continued verbal reassurance, the patient settled. We could then swap her back onto the ventilator.
When stressful situations arise in future I will try to consciously calm my body, not just my mind (this is starting to sound new agey!) In a hands on job makes this an essential skill to ensure patient safety.
Monday, June 2, 2008
Convincing ain't Easy
During my placement in the Women’s Health area, I had a small load of outpatients that presented mainly with musculoskeletal problems during pregnancy. I had a patient who had a history of MVA 10 years ago which resulted in residual chronic LBP. Her LBP was worsening due to her pregnancy at 32 weeks at that time. She had been seeking chiropractor treatment for the past 10 years and had very strong believes that only chiropractic treatments could help ease her pain as long as she had regular visits. On subjective examination, she revealed that she frequently feels that her spine is out of place and needed to be “cracked” and therefore sees her chiropractor to re-align the spine so that it feels normal again. Ever since she became pregnant, she has not been visiting her chiropractor as her gynecologist had advised against spine manipulation. She therefore was referred to physio for treatment of her LBP.
She really appeared to have very strong beliefs about chiropractic and that there was no other fix to her back pain apart from spine manipulation by a chiro. She made it really difficult for me to convince her that physio can also help treat her LBP. She had also revealed that she only came to physio because her doctor had referred her and not because she thought that it would help. She was a challenging patient and I had to take a different approach in treating her compared to the rest of the patients I have seen. One of it being that I had to convince her that physio has something to offer for her condition. I gave her lots of education on the reason for her back pain and that if she does what I asked her to do then there is a good possibility her symptoms can be relieved. She did not looked too convinced and she said that she might just see her chiro and seek his opinion on it as well. When she said that, I really thought to myself that without patient’s compliance there was really not much I can do to help. The fact that she was going to seek chiro treatment just after that session really made me feel that there was no point in me treating her but I did leave her the option of booking in for a physio appointment if she ever changed her mind. At the end of the treatment, I was really frustrated because I felt like I have failed in some ways in convincing the patient of how much she will benefit from physio.
WHEN I LOOK BACK ON THIS EXPERIENCE I HAD WITH THIS PATIENT, I REALISED THAT SHE HAD BEEN TO CHIRO FOR THE PAST 10 YEARS FOR TREATMENT OF HER LBP AND NEVER BEEN TO A PHYSIO AT ALL. SHE WAS SOMEONE THAT NEEDED A LOT MORE CONVINCING THAN WHAT I GAVE HER. I COULD HAVE PROBABLY DONE MORE IN EXPLAINING TO HER THAT TECHNICALLY, HER SPINE CANNOT BE “OUT OF PLACE” AND IF THE SPINE WAS PHYSICALLY OUT OF PLACE, SHE WILL DEFINITELY HAVE NEURO SYMPTOMS THAT WILL CORRELATE TO THE SPINAL LEVEL. IN FUTURE IF I HAD A PATIENT LIKE THAT, I WILL BE MORE CONFIDENT IN MY EDUCATION AND WILL ENDEAVOR TO GIVE A THOROUGH EXPLAINATION BY USING A MODEL TO HELP ASSURE THEM THAT PHYSIO CAN HELP SO THAT THEY BECOME MORE COMPLIANT WITH TREATMENT. JUST WANDERING IF ANYONE WOULD HAVE DONE THINGS DIFFERENTLY IF THEY HAD A PATIENT LIKE THIS?
She really appeared to have very strong beliefs about chiropractic and that there was no other fix to her back pain apart from spine manipulation by a chiro. She made it really difficult for me to convince her that physio can also help treat her LBP. She had also revealed that she only came to physio because her doctor had referred her and not because she thought that it would help. She was a challenging patient and I had to take a different approach in treating her compared to the rest of the patients I have seen. One of it being that I had to convince her that physio has something to offer for her condition. I gave her lots of education on the reason for her back pain and that if she does what I asked her to do then there is a good possibility her symptoms can be relieved. She did not looked too convinced and she said that she might just see her chiro and seek his opinion on it as well. When she said that, I really thought to myself that without patient’s compliance there was really not much I can do to help. The fact that she was going to seek chiro treatment just after that session really made me feel that there was no point in me treating her but I did leave her the option of booking in for a physio appointment if she ever changed her mind. At the end of the treatment, I was really frustrated because I felt like I have failed in some ways in convincing the patient of how much she will benefit from physio.
WHEN I LOOK BACK ON THIS EXPERIENCE I HAD WITH THIS PATIENT, I REALISED THAT SHE HAD BEEN TO CHIRO FOR THE PAST 10 YEARS FOR TREATMENT OF HER LBP AND NEVER BEEN TO A PHYSIO AT ALL. SHE WAS SOMEONE THAT NEEDED A LOT MORE CONVINCING THAN WHAT I GAVE HER. I COULD HAVE PROBABLY DONE MORE IN EXPLAINING TO HER THAT TECHNICALLY, HER SPINE CANNOT BE “OUT OF PLACE” AND IF THE SPINE WAS PHYSICALLY OUT OF PLACE, SHE WILL DEFINITELY HAVE NEURO SYMPTOMS THAT WILL CORRELATE TO THE SPINAL LEVEL. IN FUTURE IF I HAD A PATIENT LIKE THAT, I WILL BE MORE CONFIDENT IN MY EDUCATION AND WILL ENDEAVOR TO GIVE A THOROUGH EXPLAINATION BY USING A MODEL TO HELP ASSURE THEM THAT PHYSIO CAN HELP SO THAT THEY BECOME MORE COMPLIANT WITH TREATMENT. JUST WANDERING IF ANYONE WOULD HAVE DONE THINGS DIFFERENTLY IF THEY HAD A PATIENT LIKE THIS?
Impatient Clients
On my musculoskeletal outpatients placement I was required to treat a previous patient who was presenting with a new complaint. This patient had been identified by the previous student as demanding and difficult, which I soon came to realise myself. Prior to commencing the session the patient complained about the lengthy sessions and the discussions with the supervisor which interrupted the session. She demanded the session should be short with no interruptions. Throughout the subjective assessment the patient was impatient and uncooperative and presented with “yellow flag behaviours”- such as being very pain focused and assuming her problems could be fixed by manual therapy alone.
Initially this patient needed to be managed by explaining the reason for the lengthy sessions and the discussions with supervisors and that we would not compromise on these issues. An explanation as to the importance of subjective assessment was also required, which I explained repeatedly throughout the session. Throughout the session I gave the patient detailed explanations to the rationale behind my assessment, treatment and management. By the end of the session the patient was pleased with her treatment and management plan.
The behaviour of the patient posed a challenge for me as I knew it would be difficult to gain the confidence of this patient. It was also difficult to be confronted with a patient who was impatient and did not see the value of assessment.
This incident raises the issue of how to deal with patients who are very demanding and those who come to physiotherapy with a very clear idea of what their treatment should involve. This is important because if these patients do not receive the treatment they were expecting without having a very thorough explanation to the reasoning behind it, their confidence in your skills may be affected and they may not return.
I believe it is necessary to identify patients who may present with barriers. It is essential to identify strategies to break down these barriers to ensure patients are satisfied with your treatment. Also it is important not to allow a patient to bully you into certain treatments. It is vital to come to a compromise with these patients to ensure both therapist and client are happy. Thorough explanations are also important as the patient may receive treatment that they are not expecting and include a management plan that is just as vital to decreases pain as the treatment.
A thorough explanation about the importance of assessment is particularly important with impatient clients. Thorough explanations into rationale for treatment and need for ongoing patient management is also vitally important.
IF I WAS TO ENCOUNTER AN IMPATIENT AND DEMANDING CLIENT I WOULD ENSURE I TAKE THE TIME TO EXPLAIN THOROUGHLY THE IMPORTANCE OF EACH ASPECT OF MY SESSION SO THE PATIENT DOES NOT LEAVE DISSATISFIED WITH YOUR TREATMENT. I WOULD ALSO IDENTIFY WAYS TO BREAK DOWN THEIR INDIVIDUAL BARRIERS.
Initially this patient needed to be managed by explaining the reason for the lengthy sessions and the discussions with supervisors and that we would not compromise on these issues. An explanation as to the importance of subjective assessment was also required, which I explained repeatedly throughout the session. Throughout the session I gave the patient detailed explanations to the rationale behind my assessment, treatment and management. By the end of the session the patient was pleased with her treatment and management plan.
The behaviour of the patient posed a challenge for me as I knew it would be difficult to gain the confidence of this patient. It was also difficult to be confronted with a patient who was impatient and did not see the value of assessment.
This incident raises the issue of how to deal with patients who are very demanding and those who come to physiotherapy with a very clear idea of what their treatment should involve. This is important because if these patients do not receive the treatment they were expecting without having a very thorough explanation to the reasoning behind it, their confidence in your skills may be affected and they may not return.
I believe it is necessary to identify patients who may present with barriers. It is essential to identify strategies to break down these barriers to ensure patients are satisfied with your treatment. Also it is important not to allow a patient to bully you into certain treatments. It is vital to come to a compromise with these patients to ensure both therapist and client are happy. Thorough explanations are also important as the patient may receive treatment that they are not expecting and include a management plan that is just as vital to decreases pain as the treatment.
A thorough explanation about the importance of assessment is particularly important with impatient clients. Thorough explanations into rationale for treatment and need for ongoing patient management is also vitally important.
IF I WAS TO ENCOUNTER AN IMPATIENT AND DEMANDING CLIENT I WOULD ENSURE I TAKE THE TIME TO EXPLAIN THOROUGHLY THE IMPORTANCE OF EACH ASPECT OF MY SESSION SO THE PATIENT DOES NOT LEAVE DISSATISFIED WITH YOUR TREATMENT. I WOULD ALSO IDENTIFY WAYS TO BREAK DOWN THEIR INDIVIDUAL BARRIERS.
Not just one role
I am currently treating a patient who I have worked with on two occasions but the latest session she did not attend. The PT informed me that in the past this lady can be tardy and has not showed up to two of her scheduled appointments without notice. On this particular day I was encouraged to emphasise the importance of punctuality to the pt. The pt attended her appointment 20 mins late and answered a telephone call as soon as the session started. Once she finished her call she then began talking about her week and how she has been forgetting to wear her hand splint.
I was slightly annoyed by the pt’s actions and I felt like she had no respect for her hand or other people. I remained polite about the attendance matter and further discussed that I would prefer if she could take future calls after the treatment sessions seeing she had already missed a large portion of the session. A second past and the lady burst into tears. I suddenly felt guilty and wondered if what I said or how I said it was too harsh. I the felt quite awkward and was not sure how to respond. I apologised about sounding like a nag but there are other pts waiting which is why being on time is vital. The crying slowed down and said “my best friend died last weekend and she has 3 children. I was just speaking to her husband...”. I felt very emotional and apologised on what had happened and advised her to keep wearing the splint as much as possible, and to give the clinic a call to reschedule another appointment in a few weeks once the situation has settled down a bit.
I HAVE LEARNT THAT WORKING IN AN OUTPATIENT SETTING YOU ARE SOMEWHAT DEPENDENT ON THE PUNCTUALITY OF YOUR CLIENTS TO ALLOW FOR EFFICIENT ORGANISTION. HOWEVER WE HAVE TO REALISE THAT OTHER THINGS GO ON IN THE PT'S LIVES. IT WAS UNFORTUNATE THAT THE SAME PT THAT I NEEDED TO ADVISE ABOUT ATTENDANCE ALSO HAD ANOTHER BIG ISSUE GOING ON IN HER LIFE. I BELIEVE THAT THIS SITUTAION HAS MADE ME REALISE THAT WE ARE NOT JUST PEOPLE WHO TREAT PHYSICAL PROBLEMS. AT TIMES, WHILST WE MAY HAVE TO TAKE A MANAGERIAL APPROACH TOWARDS OUR PT'S, WE MAY ALSO HAVE TO EXERCISE COMPASSION WHILST MAINTAINING A DEGREE OF PROFESSIONALISM.
I was slightly annoyed by the pt’s actions and I felt like she had no respect for her hand or other people. I remained polite about the attendance matter and further discussed that I would prefer if she could take future calls after the treatment sessions seeing she had already missed a large portion of the session. A second past and the lady burst into tears. I suddenly felt guilty and wondered if what I said or how I said it was too harsh. I the felt quite awkward and was not sure how to respond. I apologised about sounding like a nag but there are other pts waiting which is why being on time is vital. The crying slowed down and said “my best friend died last weekend and she has 3 children. I was just speaking to her husband...”. I felt very emotional and apologised on what had happened and advised her to keep wearing the splint as much as possible, and to give the clinic a call to reschedule another appointment in a few weeks once the situation has settled down a bit.
I HAVE LEARNT THAT WORKING IN AN OUTPATIENT SETTING YOU ARE SOMEWHAT DEPENDENT ON THE PUNCTUALITY OF YOUR CLIENTS TO ALLOW FOR EFFICIENT ORGANISTION. HOWEVER WE HAVE TO REALISE THAT OTHER THINGS GO ON IN THE PT'S LIVES. IT WAS UNFORTUNATE THAT THE SAME PT THAT I NEEDED TO ADVISE ABOUT ATTENDANCE ALSO HAD ANOTHER BIG ISSUE GOING ON IN HER LIFE. I BELIEVE THAT THIS SITUTAION HAS MADE ME REALISE THAT WE ARE NOT JUST PEOPLE WHO TREAT PHYSICAL PROBLEMS. AT TIMES, WHILST WE MAY HAVE TO TAKE A MANAGERIAL APPROACH TOWARDS OUR PT'S, WE MAY ALSO HAVE TO EXERCISE COMPASSION WHILST MAINTAINING A DEGREE OF PROFESSIONALISM.
Discharge Expectations
Whilst on a neurosurgical rehabilitation ward, I was treating a 22 year old male who had multitrauma after being hit by a truck 3 months prior. He had mild dyspraxia, moderate cognitive issues and significant fractures in the pelvis and both legs that were surgically managed (NWB). Treatment consisted of muscle strengthening, stretching and coordination games, restricted by his NWB status. Over 3 weeks of seeing him on a daily basis, he showed great improvement in his strength, communication, slide board transfers and dyspraxia.
When he was finally permitted to WB, his mother immediately wanted to discharge him home to their farm. He was unable to walk, unsafe to stand independently and his strength and balance were far from adequate to be discharged. I was concerned that the mother thought she could cope at home and disturbed that his rehabilitation would be cut short, as a result a return to his pre-accident status would be highly unlikely. I was irritated that the mother was persistent on discharging him so soon.
A team meeting and a family meeting were arranged quickly to discuss this patient and his family. The patient and his mother expressed the reasons for wanting to discontinue rehabilitation so soon. It turns out they were pleased with health professionals treating him but were sick of sharing a room with one particular patient who had significant behavioural and cognitive issues. The situation was resolved with moving the other patient to a single room. He was able to continue his rehabilitation and his mother was much more settled. Despite the patient’s mother previously mentioning that she didn’t like her son sharing a room with the other patient, it was never apparent to any staff that this caused her so much frustration (since all patients complain about sharing rooms!).
To us health professionals, whether a patient is ready for discharge from a functional point of view can be obvious, but to the family/friends it may seem that the patient is ready to go home when in actual fact they aren’t. This may lead to family and patient frustration and wanting to stop treatment against all medical opinion.
I HAVE LEARNT THAT FAMILY AND TEAM MEETINGS ARE VITAL IN THE REHABILITATION SETTING AS THEY GIVE A FORUM FOR ISSUES TO BE MADE CLEAR, PLANS MADE AND ACTIONS CARRIED OUT. IN FUTURE, I WILL DISCUSS DISCHARGE PLANNING WITH THE FAMILY SO THAT WE ARE ON THE SAME PAGE AND EXPECTATIONS ARE MADE CLEAR.HOPEFULLY WITH THE CONCERNS COMMUNICATED BETWEEN YOU AND THE PATIENT/FAMILY, A SOLUTION CAN BE MADE, WHICH ULTIMATELY IMPROVES THE PATIENT’S RECOVERY.
When he was finally permitted to WB, his mother immediately wanted to discharge him home to their farm. He was unable to walk, unsafe to stand independently and his strength and balance were far from adequate to be discharged. I was concerned that the mother thought she could cope at home and disturbed that his rehabilitation would be cut short, as a result a return to his pre-accident status would be highly unlikely. I was irritated that the mother was persistent on discharging him so soon.
A team meeting and a family meeting were arranged quickly to discuss this patient and his family. The patient and his mother expressed the reasons for wanting to discontinue rehabilitation so soon. It turns out they were pleased with health professionals treating him but were sick of sharing a room with one particular patient who had significant behavioural and cognitive issues. The situation was resolved with moving the other patient to a single room. He was able to continue his rehabilitation and his mother was much more settled. Despite the patient’s mother previously mentioning that she didn’t like her son sharing a room with the other patient, it was never apparent to any staff that this caused her so much frustration (since all patients complain about sharing rooms!).
To us health professionals, whether a patient is ready for discharge from a functional point of view can be obvious, but to the family/friends it may seem that the patient is ready to go home when in actual fact they aren’t. This may lead to family and patient frustration and wanting to stop treatment against all medical opinion.
I HAVE LEARNT THAT FAMILY AND TEAM MEETINGS ARE VITAL IN THE REHABILITATION SETTING AS THEY GIVE A FORUM FOR ISSUES TO BE MADE CLEAR, PLANS MADE AND ACTIONS CARRIED OUT. IN FUTURE, I WILL DISCUSS DISCHARGE PLANNING WITH THE FAMILY SO THAT WE ARE ON THE SAME PAGE AND EXPECTATIONS ARE MADE CLEAR.HOPEFULLY WITH THE CONCERNS COMMUNICATED BETWEEN YOU AND THE PATIENT/FAMILY, A SOLUTION CAN BE MADE, WHICH ULTIMATELY IMPROVES THE PATIENT’S RECOVERY.
COMPULSIVE PATIENTS
On orthopaedic inpatient placement I treated a male pt a following tib fib # post MVA. On reading the pt’s notes several other physios and nursing staff described the patient as compulsive and continually ignoring nursing and physiotherapy advice post surgery, NWB 6/52 in below knee brace.
The pt was a middle-aged fit martial arts instructor so the D/C planning for the pt was 2 days post op. My aims for day 1 physio session were to mobilise the pt using elbow crutches. On talking to the pt prior to mobilising he told me he had been up and out of bed already hopping around his room. I encouraged him that after my session to start using the elbow crutches depending on wether he was safe enough after the trial.
I wheeled the patient down to the physio gym on the ward and began measuring up elbow crutches. I gave him the elbow crutches and got a pair for myself to demonstrate to the patient. While I turned my back for just a few seconds the pt got up and started ambulating using them. The pt appeared unsteady so I asked him to stop but he continued ambulating. I closely guarded him while he ambulated although continued to instruct him to stop. He eventually returned to his chair and I immediately took the crutches off him.
Once I had the crutches I felt more in control of the pt and was able to give him a demonstration. By the patient not having crutches I felt more in control of the pt and he was too an extent forced to listen to me.
THIS INTERACTION WITH THIS PATIENT HIGHLIGHTED THE IMPORTANCE OF GAINING CONTROL OF THE PHYSIO SESSION BOTH FROM A SAFETY PERSPECTIVE AND ENCOURAGES THE PATIENT TO ENGAGE IN THE PHYSIO SESSION. IN THE FUTURE, WHEN I AM ASKED TO TREAT COMPULSIVE UNCOOPERATIVE PATIENTS IT IS IMPORTANT PARTICULARLY AS A STUDENT TO GAIN CONTROL OF THE SESSION SO THE PATIENT IS SAFE DURING THE SESSION AND GIVE A THOROUGH EXPLANATION AND DEMONSTRATION OF WHAT I EXPECT OF THE PATIENT.
The pt was a middle-aged fit martial arts instructor so the D/C planning for the pt was 2 days post op. My aims for day 1 physio session were to mobilise the pt using elbow crutches. On talking to the pt prior to mobilising he told me he had been up and out of bed already hopping around his room. I encouraged him that after my session to start using the elbow crutches depending on wether he was safe enough after the trial.
I wheeled the patient down to the physio gym on the ward and began measuring up elbow crutches. I gave him the elbow crutches and got a pair for myself to demonstrate to the patient. While I turned my back for just a few seconds the pt got up and started ambulating using them. The pt appeared unsteady so I asked him to stop but he continued ambulating. I closely guarded him while he ambulated although continued to instruct him to stop. He eventually returned to his chair and I immediately took the crutches off him.
Once I had the crutches I felt more in control of the pt and was able to give him a demonstration. By the patient not having crutches I felt more in control of the pt and he was too an extent forced to listen to me.
THIS INTERACTION WITH THIS PATIENT HIGHLIGHTED THE IMPORTANCE OF GAINING CONTROL OF THE PHYSIO SESSION BOTH FROM A SAFETY PERSPECTIVE AND ENCOURAGES THE PATIENT TO ENGAGE IN THE PHYSIO SESSION. IN THE FUTURE, WHEN I AM ASKED TO TREAT COMPULSIVE UNCOOPERATIVE PATIENTS IT IS IMPORTANT PARTICULARLY AS A STUDENT TO GAIN CONTROL OF THE SESSION SO THE PATIENT IS SAFE DURING THE SESSION AND GIVE A THOROUGH EXPLANATION AND DEMONSTRATION OF WHAT I EXPECT OF THE PATIENT.
The depressed patient
On one of my placements, I had a very depressed middle aged patient, who had a history of suicide attempts, and underwent a below knee amputation. He was friendly and compliant with physio, but occasionally he would make comments that I did not know how to respond to.
He was very concerned about the future, and would constantly ask if the below knee amputation will pass as disability, because he was worried about not getting disability pension. He would then ask “will an above knee amputation be considered as a disability?” He continuously made comments which were indicative of depression. At the time, I had no idea how to respond to such comments. Luckily for me, one of the senior physiotherapists was with me, and she dealt with the situation very well. She would respond by reassuring the patient, and also saying something along the lines of "I understand that you're worried about the future, but for now, we will do your exercises so you can have a better outcome, and we will get a counselor or psychiatrist to discuss these issues with you". Through this reassurance, the patient was making more of an effort in physio.
DEPRESSED AND SUICIDAL PATIENTS WHO ARE ANXIOUS ABOUT THE FUTURE REQUIRE A LOT OF REASSURANCE. THIS WILL HOPEFULLY LEAD TO THE PATIENT MAKING A GREATER EFFORT DURING THE PHYSIO SESSION, THEREFORE MAKING IT BETTER FOR THEM IN THE LONG RUN. IF I EVER COME ACROSS A SIMILAR PATIENT, I WILL ENCOURAGE HIM/HER TO FOCUS ON THE PRESENT DURING THE PHYSIO SESSION, SO HE/SHE CAN ACHIEVE A BETTER OUTCOME FOR THE FUTURE, AND TRY TO ORGANISE A MORE QUALIFIED PROFESSIONAL TO DISCUSS HIS/HER DEPRESSION ISSUES.
He was very concerned about the future, and would constantly ask if the below knee amputation will pass as disability, because he was worried about not getting disability pension. He would then ask “will an above knee amputation be considered as a disability?” He continuously made comments which were indicative of depression. At the time, I had no idea how to respond to such comments. Luckily for me, one of the senior physiotherapists was with me, and she dealt with the situation very well. She would respond by reassuring the patient, and also saying something along the lines of "I understand that you're worried about the future, but for now, we will do your exercises so you can have a better outcome, and we will get a counselor or psychiatrist to discuss these issues with you". Through this reassurance, the patient was making more of an effort in physio.
DEPRESSED AND SUICIDAL PATIENTS WHO ARE ANXIOUS ABOUT THE FUTURE REQUIRE A LOT OF REASSURANCE. THIS WILL HOPEFULLY LEAD TO THE PATIENT MAKING A GREATER EFFORT DURING THE PHYSIO SESSION, THEREFORE MAKING IT BETTER FOR THEM IN THE LONG RUN. IF I EVER COME ACROSS A SIMILAR PATIENT, I WILL ENCOURAGE HIM/HER TO FOCUS ON THE PRESENT DURING THE PHYSIO SESSION, SO HE/SHE CAN ACHIEVE A BETTER OUTCOME FOR THE FUTURE, AND TRY TO ORGANISE A MORE QUALIFIED PROFESSIONAL TO DISCUSS HIS/HER DEPRESSION ISSUES.
Subscribe to:
Comments (Atom)