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.
Sunday, June 8, 2008
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.
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