I was in paediatrics unit in my rural prac. One of the greatest challenges I faced was to create compliance of a paediatric client. It was my first time working in this area and I thought to myself, they’re only kids how hard can it get. Then I had my first patient and the notes read.. a bit of autism and a bit of developmental delay. Well, how different can they be to other kids? So I started doing assessment like I would normally do and 5 minutes into the session things started to fall apart. The little boy started to cry and just wanted to do his stuff, like pretend to fly. I was frustrated because I was thrown into the deep end left to figure things out for myself for the first time. So I kept myself together and thought to myself that I have to take control of the situation before it gets me. So i went with the flow and played with him. By playing with him I actually won him over for another 5 minutes. So I tried my best, modified every single assessment to make it “fun” and it was not easy.
Can you imagine, having to think of a way to modify assessment for muscle strength and endurance of the UL, LL and trunk turning it into something outstandingly “fun”? So I started using cartoon characters like superman and spiderman then doing some animal walks to test trunk strength and endurance. Just I was getting somewhere with the assessment, a sudden machinery noise started coming from the construction site nearby. The mother looked like she had given up not knowing what to do as well. I remembered reading somewhere that some autistic kids are affected terribly by unfamiliar noises. I quickly went and found some headphones to try and filter the noise out for him. It worked but only for a short time, enough for me to at least finish the last part of my assessment so that I could device a program to address the delay in his gross motor skills.
Form this experience I’ve learnt that things do not always go according to plan and that I have to be flexible with whatever challenges I face during a session with a client. I must be able to think and act promptly in difficult situations so that I am able to maximise the limited time I have with clients to gain sufficient information through an assessment. In this case, perserverance did pay off as I was able to gain enough information to provide a treatment strategy.
Wednesday, November 26, 2008
Monday, November 24, 2008
"I don't feel I am improving"
On my musculoskeletal outpatients placement, I had a patient who presented with lower back pain, with the main aggravating factor being prolonged sitting (approximately 30 minutes). My treatment and management with this patient involved mobilisations and postural retraining.
About 3 weeks from her initial visit, I began with my subjective assessment to see how she is progressing. She stated that she did not feel that she was improving, as the intensity of her pain was at a similar level as when she first started physiotherapy. I thought to myself that she must have had some improvement, as she has been having treatment for the past 3 weeks. I then decided to focus on the aggravating factors, and asked her how long can she stay in sitting until the pain increases. She then stated that she was able to sit comfortably for longer than that of the initial session (approximately 1 hr), making her realise that she has made some improvement.
I FEEL THAT MONITORING THE PATIENTS RESPONSE TO TREATMENT FROM THE PATIENT'S PERSPECTIVE AND GOAL SETTING WILL HELP GIVE THE PATIENT AN IDEA ON HOW MUCH THEY ARE IMPROVING, THEREFORE MAINTAINING THEIR FAITH IN PHYSIOTHERAPY TREATMENT. IN THE FUTURE, I WILL CONTINUE TO THINK ABOUT PATIENT'S GOALS AND THEIR FUNCTIONAL LIMITATIONS IN TERMS OF MONITORING RESPONSE TO TREATMENT, THUS, HOPEFULLY INCREASING PATIENT SATISFACTION.
About 3 weeks from her initial visit, I began with my subjective assessment to see how she is progressing. She stated that she did not feel that she was improving, as the intensity of her pain was at a similar level as when she first started physiotherapy. I thought to myself that she must have had some improvement, as she has been having treatment for the past 3 weeks. I then decided to focus on the aggravating factors, and asked her how long can she stay in sitting until the pain increases. She then stated that she was able to sit comfortably for longer than that of the initial session (approximately 1 hr), making her realise that she has made some improvement.
I FEEL THAT MONITORING THE PATIENTS RESPONSE TO TREATMENT FROM THE PATIENT'S PERSPECTIVE AND GOAL SETTING WILL HELP GIVE THE PATIENT AN IDEA ON HOW MUCH THEY ARE IMPROVING, THEREFORE MAINTAINING THEIR FAITH IN PHYSIOTHERAPY TREATMENT. IN THE FUTURE, I WILL CONTINUE TO THINK ABOUT PATIENT'S GOALS AND THEIR FUNCTIONAL LIMITATIONS IN TERMS OF MONITORING RESPONSE TO TREATMENT, THUS, HOPEFULLY INCREASING PATIENT SATISFACTION.
Telling the patient the purpose of your treatment
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.
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.
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.
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