Currently on my neuro prac, many of the pt's i see have a comprehensive PMH prior to being diagnosed with a neuro condition or having a stroke of some kind. One pt that i was treating last week was diagnosed with GB about 6/52 ago and had minimal PMH, with nothing contraindicating chest Mx, passive movements or sitting balance and stregthening exercises.
In the regular UL passive movements and chest physio session in the morning, the pt was complaining of pain at EOR with nearly all movements which was common for him. We gave more attention to his hands this session as we were waiting for the speech therapist to arrive. The pt was communicating via facial expressions that his L thumb was particularly painful. I continued doing these movements trying to avoid EOR and a painful response.
Later that day, another student saw the pt and reported to me that he had OA of the L thumb and he was needing pain medication to ease his symptoms. The pt normally had nil c/o pain at rest so this was alarming. From his social history of working a desk job, with minimal sporting activities, i would not have thought this was a possibility and when pain was present i didnt think to ask if he had any past history. This was likely because all movements were painful and my attention during PROM was to either get the pt to join in, or get the pt to think about something else to distract him.
To play this scenario again, subjective questioning about this OA would be a priority and due to the difficulat communication, follow this up with the pt's wife that visits regularly. If this was achieved techniques such as distraction could have been implemented to ease symptoms and increase pt comfort. Also relating symptoms back to previous days or the other side would give an indication of a past or developing pathology. I think its important to not just get into the habit of treating a pt a certain way, but rather continuous questioning and being flexible with assessment and treatment to tailer your session to the ever changing pt.
Monday, September 1, 2008
Tuesday, August 26, 2008
Cardio Placement
I'm currently on a cardio placement on a surgical ward and have been treating a 31yo lady who had a history of non healing gastric and duodenal ulcers. Her condition worsened and she presented to her GP with haematemesis and upper quadrant pain. Nine days later she admitted to surgery for a distal gastrectomy and resection, followed the next day by an exploratory laproscopic evacuation of haematoma. This patient was handed over to me as someone who was extremely difficult to mobilise, due to a very low pain threshold.
On our first treatment she was 7 days post op and had only been mobilising 2-3 metres with an IV pole. When we arrived she was RIB, clearly bracing and just keeping as still as possible. It appeared that she had been lying in the position she had been left in for the last couple of hours. It took heaps of encouragement to finally get her up and walking, the whole process being filled with many tears and complaints of pain. The patient showed this kind of behaviour through all of the sessions and after discussing her condition with her, she revealed that she didnt feel that the surgery was at all necessary and she wished she hadnt had it. This appeared to be the reason why she wasnt coping well with the pain, because she felt she had made a poor decision in having the surgery at all. While I empathised with her, by the third day she was mobilising independantly. What I found from this situation is that, it is very difficult to understand pain from a patients point of view, it is so subjective and depends on so many different factors. This patient would probably have stayed in bed for months if we let her, but once she was moving her recover was very fast. The important thing was that we did mobilise her and use as much encouragement as we could to achieve a common goal
On our first treatment she was 7 days post op and had only been mobilising 2-3 metres with an IV pole. When we arrived she was RIB, clearly bracing and just keeping as still as possible. It appeared that she had been lying in the position she had been left in for the last couple of hours. It took heaps of encouragement to finally get her up and walking, the whole process being filled with many tears and complaints of pain. The patient showed this kind of behaviour through all of the sessions and after discussing her condition with her, she revealed that she didnt feel that the surgery was at all necessary and she wished she hadnt had it. This appeared to be the reason why she wasnt coping well with the pain, because she felt she had made a poor decision in having the surgery at all. While I empathised with her, by the third day she was mobilising independantly. What I found from this situation is that, it is very difficult to understand pain from a patients point of view, it is so subjective and depends on so many different factors. This patient would probably have stayed in bed for months if we let her, but once she was moving her recover was very fast. The important thing was that we did mobilise her and use as much encouragement as we could to achieve a common goal
Suctioning
I'm currently on a cardio placement in a hospital with a lot of ventilated patients (either via trachy's or ETT's). When i started this placement i gathered that i would probably have to perform some suctioning. I was a little worried about this as in our cardio prac class is seemed a little daunting when we had to put tubes up each others noses and i have that memory embedded in my head. I didn't want to really perform the procedure because i thought it would cause discomfort to the patient and also i didn't really trust myself to do it adequately.
I had to perform my first suction on a patient on the first full day of my clinic. I didn't really have any time to comprehend that i was worried about this so i just went ahead and followed our supervisors instructions and performed my first suction.
It really surprised me about my reaction to the procedure. I thought i wouldn't like performing it and even thought i might struggle with not feeling nauseous etc. while performing it. I was shocked by how non invasive it felt. It was all so sanitary and the sputum was well contained within the suction tube and the patients cough wasn't too vigorous so they didn't appear in discomfort at all.
As i have suctioned people more throughout this prac i have found that different people have a stronger cough reflex than others and there is a large variance of secretions between patients as well. Although i always new that suctioning was a relevant treatment necessary for some cardio patients i naively hoped i would never have to perform it myself due to my pre conceived ideas about the process.
I always new about its relevance in treatment for cardio patients especially intubated patients who have trouble clearing secretions independently and now i have been able to experience first hand the difference it can make in someone who is unable to clear their secretions and i have also changed my ideas about suctioning being a "scary" procedure. I now consider it to be not scary at all and the difference in auscultation after suctioning is sometimes remarkable.
In the future i will not hesitate to suction a patient if it is indicated as i now realise it is not a procedure that i need to be scared of and it really does work.
I had to perform my first suction on a patient on the first full day of my clinic. I didn't really have any time to comprehend that i was worried about this so i just went ahead and followed our supervisors instructions and performed my first suction.
It really surprised me about my reaction to the procedure. I thought i wouldn't like performing it and even thought i might struggle with not feeling nauseous etc. while performing it. I was shocked by how non invasive it felt. It was all so sanitary and the sputum was well contained within the suction tube and the patients cough wasn't too vigorous so they didn't appear in discomfort at all.
As i have suctioned people more throughout this prac i have found that different people have a stronger cough reflex than others and there is a large variance of secretions between patients as well. Although i always new that suctioning was a relevant treatment necessary for some cardio patients i naively hoped i would never have to perform it myself due to my pre conceived ideas about the process.
I always new about its relevance in treatment for cardio patients especially intubated patients who have trouble clearing secretions independently and now i have been able to experience first hand the difference it can make in someone who is unable to clear their secretions and i have also changed my ideas about suctioning being a "scary" procedure. I now consider it to be not scary at all and the difference in auscultation after suctioning is sometimes remarkable.
In the future i will not hesitate to suction a patient if it is indicated as i now realise it is not a procedure that i need to be scared of and it really does work.
Sunday, August 24, 2008
Conflict of interest
Im currently on my neuro prac where organising physio sessions with other appointments is a priority. We are told to plan our day one day ahead, though be flexible as things often dont pan out as they are foreseen. Last week was no exception, where a GB pt i had been seeing was organised to be SOOB for the afternoon session at 3:00. I had written on the white board in the nurses station and coordinated with the nurse looking after the pt.
When i arrived at 3:00, the pt had just started a NG feed and it was not appropriate to get him SOOB at this time. The nurse apologised saying she was told by the nurse manager to give the pt a feed at this time, and that he would be t/f'd via hoist to the chair in 15 minutes. We agreed that physio would then be commenced.
On arrival 15 minutes later, the pt had finished his feed but was still in supine and had been given a NEB. The nurse again said she was told to administer this and that he would be moved once this was finished. This was estimated to be 10-15 minutes later. On arrival at this time, the pt was just getting ready to be t/f'd and i stepped in to give the nurses a hand. Once the pt was in the correct position i had only 15 minutes with the pt that i had spent an hour with in the morning.
This situation was disappointing as the pt was deprived of a thorough treatment because the staff were unable to coordinate effictively. I had tried to plan my day and effectively treat all the pt's i had been given, but this had been insufficient. This nurse that i had been organising my treatment with was being given instructions by the nurse manager, so i think to cover my basis next treatment i will try to liase with both the nurse and nurse manager. I will also try and reinforce the importance of physio for these pt's and the time required for outcomes to be achieved. I think this is just one of the hurdles in in-pt care that must be overcome to handle a full caseload and give a number of effective treatments.
When i arrived at 3:00, the pt had just started a NG feed and it was not appropriate to get him SOOB at this time. The nurse apologised saying she was told by the nurse manager to give the pt a feed at this time, and that he would be t/f'd via hoist to the chair in 15 minutes. We agreed that physio would then be commenced.
On arrival 15 minutes later, the pt had finished his feed but was still in supine and had been given a NEB. The nurse again said she was told to administer this and that he would be moved once this was finished. This was estimated to be 10-15 minutes later. On arrival at this time, the pt was just getting ready to be t/f'd and i stepped in to give the nurses a hand. Once the pt was in the correct position i had only 15 minutes with the pt that i had spent an hour with in the morning.
This situation was disappointing as the pt was deprived of a thorough treatment because the staff were unable to coordinate effictively. I had tried to plan my day and effectively treat all the pt's i had been given, but this had been insufficient. This nurse that i had been organising my treatment with was being given instructions by the nurse manager, so i think to cover my basis next treatment i will try to liase with both the nurse and nurse manager. I will also try and reinforce the importance of physio for these pt's and the time required for outcomes to be achieved. I think this is just one of the hurdles in in-pt care that must be overcome to handle a full caseload and give a number of effective treatments.
Wednesday, August 20, 2008
Differing Opinions
On my last placement i had 2 supervisors at the facility and 1 Curtin supervisor whom we saw quite frequently throughout the week. Having 3 different supervisors meant that very often we had 3 different treatment approaches. All of them were quite familiar with our patient caseload so each of them were able to offer quite specific suggestions for our treatment plan. This made it quite difficult as it is impossible to always try and use all three suggestions in some combination. For the most part, however, that is what i tried to do. I tried to accommodate all suggestions and use them with the patient to see which had the best effect for that patient and then continued to use that one for the next few sessions. I learnt that sometimes you can't apply all suggestions...sometimes you have to modify the suggestion based on the patient's cognitive level, communication difficulties or co-ordination issues. On all occasions you have to use your own clinical judgement because you are spending more time than anyone with the patient and so the reality is you know their impairments and challenges better than anyone.
I learnt from this experience that much of the time you have to adapt the information that is given to you by senior staff members and use your own clinical judgement to best treat your patients. The aspect I found most beneficial when receiving 3 different opinions is that sometimes if you combine 2 or 3 of the suggestions you get an outcome that is much better than anything you would have thought of and better than just one sole suggestion.
I learnt from this experience that much of the time you have to adapt the information that is given to you by senior staff members and use your own clinical judgement to best treat your patients. The aspect I found most beneficial when receiving 3 different opinions is that sometimes if you combine 2 or 3 of the suggestions you get an outcome that is much better than anything you would have thought of and better than just one sole suggestion.
Monday, August 11, 2008
TKR'S
I had three patient's who had total knee replacements (TKR) all around about the same time. It was really interesting to treat all three at the same time as i was able to gain an understaning of how everyone is different.
One patient's epidural wasn't working day 1 post op so her first day was a bit of a disaster. I thought she might take a while longer than the other two patient's to recover and ultimately would be a hospital inpatient for longer. This patient surprised me though and was ready for discharge a day earlier than the other two TKR patients. (day 6)
Another patient had no complications at all and the CPM machine was applied religiously twice daily from day 1 post op and was standing and ambulating (although short distances at first) day 1 post op. This patient however was a bit non complient with exercises and her attitude was a little less desireable than the other two (for instance she refused to even try elbow crutches as a progression from the wheeled zimmer frame as "crutches weren't for her"). I originally assumed this patient would be first to get discharged out of the three as she had no complications and was on track with all of her clinical pathway milestones (i.e. achieving increasing active flexion, walking independently with her frame etc.). This patient surprised me as she was ready day 7 post op which was the same or more than the other two patients who had a complicated post op period.
The third total knee replacement patient was on track day one and day two post op (CPM twice daily, ambulating with supervision and a frame day 1 and day two) however when her epidural was due to come out her pain cover that day (day three) was inadequate and i didn't manage to do anything apart from one session of mild CPM that day. This patient is also legally blind (so she can make out faces and smiles etc. but no finer details) so i was unable to just leave her to do her exercises by herself initally because she couldn't just read it off the handouts. I assumed this patient would take the longest but she surprised me by being discharged on day 7.
On reflection it was interesting to me to consider these three cases. All TKR's took roughly about the same ammount of time from operation until discharge despite the huge differences these people experienced on their road to recovery. It showed me that despite someone's obvious disability (i.e. lack of sight) it wont necessarily affect their abitlity to recover. I can't help but wonder if attitude in these cases plays more of a role. The sight impaired patient always tried everything i asked of her and always performed exercises i asked her to review with me while the other patient whose road to recovery was without complication was almost the opposite in willingness to try. It reinforces to me that attitude has a large role in paving the road to recovery.
One patient's epidural wasn't working day 1 post op so her first day was a bit of a disaster. I thought she might take a while longer than the other two patient's to recover and ultimately would be a hospital inpatient for longer. This patient surprised me though and was ready for discharge a day earlier than the other two TKR patients. (day 6)
Another patient had no complications at all and the CPM machine was applied religiously twice daily from day 1 post op and was standing and ambulating (although short distances at first) day 1 post op. This patient however was a bit non complient with exercises and her attitude was a little less desireable than the other two (for instance she refused to even try elbow crutches as a progression from the wheeled zimmer frame as "crutches weren't for her"). I originally assumed this patient would be first to get discharged out of the three as she had no complications and was on track with all of her clinical pathway milestones (i.e. achieving increasing active flexion, walking independently with her frame etc.). This patient surprised me as she was ready day 7 post op which was the same or more than the other two patients who had a complicated post op period.
The third total knee replacement patient was on track day one and day two post op (CPM twice daily, ambulating with supervision and a frame day 1 and day two) however when her epidural was due to come out her pain cover that day (day three) was inadequate and i didn't manage to do anything apart from one session of mild CPM that day. This patient is also legally blind (so she can make out faces and smiles etc. but no finer details) so i was unable to just leave her to do her exercises by herself initally because she couldn't just read it off the handouts. I assumed this patient would take the longest but she surprised me by being discharged on day 7.
On reflection it was interesting to me to consider these three cases. All TKR's took roughly about the same ammount of time from operation until discharge despite the huge differences these people experienced on their road to recovery. It showed me that despite someone's obvious disability (i.e. lack of sight) it wont necessarily affect their abitlity to recover. I can't help but wonder if attitude in these cases plays more of a role. The sight impaired patient always tried everything i asked of her and always performed exercises i asked her to review with me while the other patient whose road to recovery was without complication was almost the opposite in willingness to try. It reinforces to me that attitude has a large role in paving the road to recovery.
Doesn't Listen...
What do you do with the patient who doesn't listen???? Especially when it makes transfers unsafe!!! On my neuro prac we have a patient who has had frontal lobe damage and is extremely impulsive with all tasks. He is now restrained in his wheelchair as he has a tendency to leap out of his chair with no prior warning. One particular Rx session we had him in the gym and he wasn't particularly compliant. This session he wasn't restrained as the restraints were applied following these incidents. We were just getting ready to transfer him to a plinth and getting the area prepared. We instructed him to sit still till we were ready. Neither of us were prepared for what happened next. All of a sudden he was leaning forward and MOVING!!! We managed to support him half way through the transfer and help him on to the plinth. He's getting better at responding and now using the restraints makes it much easier to control him.
This situation presented us with a few issues to consider regarding patient communication and management. In terms of communication we now use very simple commands and keep repeating the same commands throughout the session and keep them constant over the weeks. He needs very clear direction and if you need his attention or need him to stop what he's doing yelling STOP works quite effectively. When treating this patient you can't treat the impairments because he gets confused and then does his own thing. We have to make the Rx functional. For example, part practice of a task doesn't work but if you say "stand up" and "walk" he is able to do it with assistance. It was quite a challenging experience and we needed the assistance of those with more clinical experience to deal with this patient. However, I think we handled the situation well and once we were aware of the patient's impulsiveness we were better able to manage the situation and direct the Rx sessions while still achieving the goals we set.
This situation presented us with a few issues to consider regarding patient communication and management. In terms of communication we now use very simple commands and keep repeating the same commands throughout the session and keep them constant over the weeks. He needs very clear direction and if you need his attention or need him to stop what he's doing yelling STOP works quite effectively. When treating this patient you can't treat the impairments because he gets confused and then does his own thing. We have to make the Rx functional. For example, part practice of a task doesn't work but if you say "stand up" and "walk" he is able to do it with assistance. It was quite a challenging experience and we needed the assistance of those with more clinical experience to deal with this patient. However, I think we handled the situation well and once we were aware of the patient's impulsiveness we were better able to manage the situation and direct the Rx sessions while still achieving the goals we set.
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