On one of my placements, I encountered a patient with cerebellar atrophy who was quite anxious. Consequently, his major problem was impaired balance. Therefore my treatment was based around improving his balance. To progress the patient, I would challenge his balance by reducing the base of support, adding a soft surface, eyes closed etc.
As the tasks increased in difficulty, the patient would be less compliant, and say comments like "I can't do that, I'll be too wobbly", I woud then reassure him and tell him that I wasn't going to let him fall. As I would try new positions, he required more convincing to try and get him to comply. I then decided to explain to him that the purpose of these exercises were to use positions which will challenge his balance, and will make him feel somewhat unsteady, as there is no point in practicing balance in a position where he can maintain his balance quite easily. I felt that once he understood the purpose of my treatment, he became more compliant.
THIS SITUATION HIGHLIGHTED THE IMPORTANCE OF THE PATIENT KNOWING THE PURPOSE OF TREATMENTS. I FEEL THAT IF THE PATIENT KNOWS WHY A CERTAIN EXERCISE MAKES HIM/HER FEEL UNSTEADY, OR CERTAIN TREATMENT TECHNIQUES CAN BE SLIGHTLY PAINFULL, HE/SHE WILL BE MORE COMPLIANT WITH PHYSIOTHERAPY, THUS MAXIMISING THE TREATMENT OUTCOME.
Monday, November 24, 2008
Friday, November 21, 2008
Discharge planning
On my rural placement, I had an eldery patient who presented with an exacerbation of COPD. Considering discharge planning, I came to the conclusion that if she were to go home, she would have to be fully independent, as she does not always have someone with her at home. Throughout her stay in hospital, she was often non compliant with physiotherapy, and refused walks several times.
When she was for discharge from a medical point of view, I was unsure how well she was able to ambulate, thus, I was not sure if she was safe for discharge from a physiotherapy point of view. The patient refused a mobility assessment, and I was not surprised, as she had refused to ambulate prior to this. I decided to use her going home as motivation to ambulate, and explained to her that she can only go home once she is deemed safe from a physiotherapy point of view. In doing so, she agreed on a mobility assessment.
NOT ONLY DOES THIS HIGHLIGHT THE NEED FOR EXPLANATIONS ON CERTAIN INTERVENTIONS, BUT ALSO THE IMPACT MOTIVATION CAN HAVE ON A PATIENT. IN THE FUTURE, I WILL SET GOALS FOR THE PATIENT, AND USE MOTIVATIONAL TOOLS TO IMPROVE PATIENT COMPLIANCE AND SATISFACTION FROM TREATMENTS.
When she was for discharge from a medical point of view, I was unsure how well she was able to ambulate, thus, I was not sure if she was safe for discharge from a physiotherapy point of view. The patient refused a mobility assessment, and I was not surprised, as she had refused to ambulate prior to this. I decided to use her going home as motivation to ambulate, and explained to her that she can only go home once she is deemed safe from a physiotherapy point of view. In doing so, she agreed on a mobility assessment.
NOT ONLY DOES THIS HIGHLIGHT THE NEED FOR EXPLANATIONS ON CERTAIN INTERVENTIONS, BUT ALSO THE IMPACT MOTIVATION CAN HAVE ON A PATIENT. IN THE FUTURE, I WILL SET GOALS FOR THE PATIENT, AND USE MOTIVATIONAL TOOLS TO IMPROVE PATIENT COMPLIANCE AND SATISFACTION FROM TREATMENTS.
What is better for the patient?
On my neuro placement, I had a patient who was about 4-5 days post R MCA. At this stage, the patient was still occasionally quite drowsy. Nevertheless, I took her to the gym for some rehabilitation. As it is still her early stages of recovery, the patient was quite fatigued by the end of the session.
From a physiotherapy point of view, we like out patients sitting out of bed whenever possible, as it is a much better position for there chest, and alignment. On discussion with the nursing staff, they suggested to put her back in bed as the patient was feeling tired. After my supervisor and I gave the nurse our justification for sitting out of bed (better for her chest, better for her trunk alignment etc) we decided on keeping the patient in the wheelchair for a little while.
I LEARNT THAT LIAISING WITH OTHER HEALTH PROFESSIONALS AND GIVING OUR JUSTIFICATION IS AN IMPORTANT FACTOR IN THE TREATMENT AND MANAGEMENT OF A PATIENT. I WILL CONTINUE TO GIVE MY RATIONALE FOR DIFFERENT ASPECTS OF MY MANAGEMENT NOT ONLY TO THE PATIENT, BUT TO OTHER ALLIED HEALTH STAFF, TO ALLOW A BETTER RECOVERY FOR THE PATIENTS.
From a physiotherapy point of view, we like out patients sitting out of bed whenever possible, as it is a much better position for there chest, and alignment. On discussion with the nursing staff, they suggested to put her back in bed as the patient was feeling tired. After my supervisor and I gave the nurse our justification for sitting out of bed (better for her chest, better for her trunk alignment etc) we decided on keeping the patient in the wheelchair for a little while.
I LEARNT THAT LIAISING WITH OTHER HEALTH PROFESSIONALS AND GIVING OUR JUSTIFICATION IS AN IMPORTANT FACTOR IN THE TREATMENT AND MANAGEMENT OF A PATIENT. I WILL CONTINUE TO GIVE MY RATIONALE FOR DIFFERENT ASPECTS OF MY MANAGEMENT NOT ONLY TO THE PATIENT, BUT TO OTHER ALLIED HEALTH STAFF, TO ALLOW A BETTER RECOVERY FOR THE PATIENTS.
Using different instructions
In my neuro placement, I was working on sitting balance with 2 different patients, both left hemis. My treatment mainly focused on promoting anterior pelvic tilt with these patients.
For one of these patients, i was using cues such as "grow tall", and that worked quite well with her. I tried to use the same cue for the other patient, and that wasn't so successful, as it did not encourage him to anteriorly tilt his pelvis. I found that using the cue "chest out" worked much better in promoting anterior pelvic tilt with this patient.
AFTER THIS INCIDENT, I LEARNT THAT DIFFERENT PATIENTS CAN REACT DIFFERENTLY TO DIFFERENT VERBAL INSTRUCTIONS, ESPECIALLY NEUROLOGICAL PATIENTS. IN THE FUTURE, I WILL DETERMINE WHICH INSTRUCTIONS SUIT THE PATIENT BEST, AND USE IT WHEN TREATING THE PATIENT.
For one of these patients, i was using cues such as "grow tall", and that worked quite well with her. I tried to use the same cue for the other patient, and that wasn't so successful, as it did not encourage him to anteriorly tilt his pelvis. I found that using the cue "chest out" worked much better in promoting anterior pelvic tilt with this patient.
AFTER THIS INCIDENT, I LEARNT THAT DIFFERENT PATIENTS CAN REACT DIFFERENTLY TO DIFFERENT VERBAL INSTRUCTIONS, ESPECIALLY NEUROLOGICAL PATIENTS. IN THE FUTURE, I WILL DETERMINE WHICH INSTRUCTIONS SUIT THE PATIENT BEST, AND USE IT WHEN TREATING THE PATIENT.
Monday, November 17, 2008
Pulse
On my rural placement I was treating orthopaedic inpatients. As most of you probably are aware by now, orthopaedic inpatients are very repetitive as it follows the post op routines as per each surgeon. Anyway, I was heading into a TKR patients room to walk him for the first time to the bathroom, and had seen him the day before in which he coped well at standing. The patient reported feeling well, nil complaints voiced. He was no longer on oxygen and all attachments removed. I checked his nursing charts which showed obs stable. I thought I should check them myself to get an immediate reading and for precaution. His oxygen and BP were normal, however his pulse rate was racing at 160 BPM!!! I was surprised, all other readings were fine, the patient was asymptomatic, and in fact the pt was quite cheerful. It was a little strange. I took his pulse manually, it was definitely high.
I decided not to walk him at this stage, and informed him why. I let his nurse know immediately. The patient was later taken to ED for a couple of hours, and his meds changed. He later returned to the ward, in which I was able to ambulate him to the bathroom when all his obs were stable.
This scenario highlighted to me the importance of checking stats prior to ambulating post op patients, even if the nursing obs are normal. Also, patients may be asymptomatic, therefore relying solely on pt responses is not adequate. I also feel that, with orthopaedic inpatients there is so much emphasis on checking Hb, Bp and oxygen that pulse rate gets a little ignored. In future I will take the extra 1 minute to take current obs of a patient that is post op as I have done in this scenario.
I decided not to walk him at this stage, and informed him why. I let his nurse know immediately. The patient was later taken to ED for a couple of hours, and his meds changed. He later returned to the ward, in which I was able to ambulate him to the bathroom when all his obs were stable.
This scenario highlighted to me the importance of checking stats prior to ambulating post op patients, even if the nursing obs are normal. Also, patients may be asymptomatic, therefore relying solely on pt responses is not adequate. I also feel that, with orthopaedic inpatients there is so much emphasis on checking Hb, Bp and oxygen that pulse rate gets a little ignored. In future I will take the extra 1 minute to take current obs of a patient that is post op as I have done in this scenario.
bad habbits
Whist on my rural placement I was treating a patient who had pneumonia. He had a 60 yr history of smoking and refused to quit while in hospital. Every day when I went to see him it would be a struggle to get him to complete any exercises and when he did he was quite negative towards the exercises and report that he just wanted to go home. I begun to develop an unenthusiastic mind set towards the patient and I found I would regularly tell him that he should consider quitting smoking and I was less motivational with my response towards treatment. I realised what was happening to y behaviour and decided to change my outlook towards the patient in a manner that I was required to educate him.
Everything I completed with him I educated him on the benefits of how he was going to return home sooner if he completed the exercises. In addition, I educated him on the negative effect s of smoking and the positive effects of quitting. We discussed options to help him quit and he begun to have a more positive approach towards quitting.
When the patient was D/C he still had not decided to quit smoking but was more aware of the options that are available to him.
I HAVE LEARNT THAT SOME HABITS ARE HARD TO BREAK AND EVEN IF THEY ARE HABITS THAT YOU CANNOT STAND, AS A PROFESSIONAL THE BEST YOU CAN DO IS EDUCATE THE PATIENT ON THE POSITIVES OF CEASING THAT HABBIT. IF I HAD ANOTHER PATIENT WHO WAS A LONG TERM SMOKER AND WAS NOT KEEN TO QUIT, I WILL ENSURE THAT I USE MY KNOWLEDGE TO GIVE THE CORRECT ADVICE, SUPPORT AND EDUCATION TO QUIT RATHER THAN DEVELOPING NEGATIVE BEHAVIOURS.
Everything I completed with him I educated him on the benefits of how he was going to return home sooner if he completed the exercises. In addition, I educated him on the negative effect s of smoking and the positive effects of quitting. We discussed options to help him quit and he begun to have a more positive approach towards quitting.
When the patient was D/C he still had not decided to quit smoking but was more aware of the options that are available to him.
I HAVE LEARNT THAT SOME HABITS ARE HARD TO BREAK AND EVEN IF THEY ARE HABITS THAT YOU CANNOT STAND, AS A PROFESSIONAL THE BEST YOU CAN DO IS EDUCATE THE PATIENT ON THE POSITIVES OF CEASING THAT HABBIT. IF I HAD ANOTHER PATIENT WHO WAS A LONG TERM SMOKER AND WAS NOT KEEN TO QUIT, I WILL ENSURE THAT I USE MY KNOWLEDGE TO GIVE THE CORRECT ADVICE, SUPPORT AND EDUCATION TO QUIT RATHER THAN DEVELOPING NEGATIVE BEHAVIOURS.
Team work
Whilst on my rural placement I was required to complete an initial assessment on a stroke patient. When I asked for a copy of particular stroke assessment the physiotherapist said that they did not have a copy of it. Being a regularly used stroke assessment I was surprised that they had not used it in the past and questioned their supply of resources to run a rehabilitation ward. I was able to access the university website and gain a copy of the assessment and complied a file of the assessment and other commonly used assessments.
At first I was taken aback by the lack of resources that the ward had and annoyed that I had to create a resource file. Although, I did not take into consideration that it was a rural hospital and it was a project to complete to benefit the other physiotherapists as well as the patients.
I BELIEVE THAT IT IS IMPORTANT TO BE ACTIVE IN CREATING AN EFFECTIVE AND WELL RESOURCED WORKING DEPARTMENT. IF WE ALL JUST SAID THAT WE COULD NOT BE ‘BOTHERED’ TO CREATE SUCH RESOURCES THEN THE DEVELOPMENT OF THE DEPARTMENT WOULD NOT EXIST. IF I HAD TO CREATE OR SERACH FOR ANOTHER RESOURCE AGAIN I WOULD HAPPILY DO SO KEEPING IN MIND THE ADVANTAGE OF TEAM COLABERTAION AND INPUT.
At first I was taken aback by the lack of resources that the ward had and annoyed that I had to create a resource file. Although, I did not take into consideration that it was a rural hospital and it was a project to complete to benefit the other physiotherapists as well as the patients.
I BELIEVE THAT IT IS IMPORTANT TO BE ACTIVE IN CREATING AN EFFECTIVE AND WELL RESOURCED WORKING DEPARTMENT. IF WE ALL JUST SAID THAT WE COULD NOT BE ‘BOTHERED’ TO CREATE SUCH RESOURCES THEN THE DEVELOPMENT OF THE DEPARTMENT WOULD NOT EXIST. IF I HAD TO CREATE OR SERACH FOR ANOTHER RESOURCE AGAIN I WOULD HAPPILY DO SO KEEPING IN MIND THE ADVANTAGE OF TEAM COLABERTAION AND INPUT.
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