10.11.08
whoops, missed a week back there...shows how much time i don't have!
Well last week was good, we were able to do a few more initial assessments and a home visit and our regular patients and classes. Overall a good week.
Twice a week we take turns in running a general fitness and strengthening class they call "Lodge group" which is in the psych/geri ward of the hospital. All the pts are self admitted to the ward with generally minor psych issues.
Usually we start with the "how are we all today?" "anything changed since last week" etc. and then straight into the exercises.
This week i thought i would try to make it more personal, i mean im not taking the class for my benefit, im doing it for their benefit so it should be more about them. so we began by going around the class and telling everyone our names and our favorite food. then throughout the class i was able to use their names and point out how good they were doing, some individualized positive encouragement which opened them up and got them smiling and laughing. It was good and i felt more confident rather than demonstrating an exercise and then counting them through it i was able to chat to them each one on one and fill the session with general chit chat and socialising.
I think it was a good session and will try this again next time. maybe get them all the suggest what exercise to do next as most of them are regulars.
I enjoy the class situation. It also transfers to the ward where we are now able to clinically select pts that are at approximately the same level, bring a couple to the physio area at the one time and conduct a mini class setting then while one rests we do another's individual exercises and rotate. This saves time, which is precious, and gets the pts interacting with eachother and they are able to compare with eachother...i think the slight sense of subconscious 'competition' between the pts also motivates them to get well.
Monday, November 10, 2008
Thursday, October 30, 2008
WEEK 3
30.10.08
OPERATING THEATER!!
Today i was privileged to see surgery. The pt was in her 60's and had had a past mastectomy of the L breast. The surgery involved implantation into the removed breast and scar revision. It was an absolutely amazing experience to just be in the room and see how they operate in terms of infection control, handling the pt and the actual operation, the skill and th technique is phenomenal.
There was a cut through the Pec Major muscle running parallel to the fibers of the muscle to have the least impact on the persons fn as possible. It put into perspective the pain that pt's feel post op and makes you see that they are indeed complaining for a reason.
We also saw a laproscopic choleoscopy? (the removal of the gall bladder, entering via the abdomen using small cameras through the small entry points.) This again was a real eye opener to where exactly all the PAIN comes from. no wonder the pt's hate you when you say "up you get we are going for a walk."
It was fascinating to watch and a real learning curve. I would have liked to have asked so many more questions but didn't want to distract the surgeon, even through he was pretty open to having me there. Will have to do a bit of research.
OPERATING THEATER!!
Today i was privileged to see surgery. The pt was in her 60's and had had a past mastectomy of the L breast. The surgery involved implantation into the removed breast and scar revision. It was an absolutely amazing experience to just be in the room and see how they operate in terms of infection control, handling the pt and the actual operation, the skill and th technique is phenomenal.
There was a cut through the Pec Major muscle running parallel to the fibers of the muscle to have the least impact on the persons fn as possible. It put into perspective the pain that pt's feel post op and makes you see that they are indeed complaining for a reason.
We also saw a laproscopic choleoscopy? (the removal of the gall bladder, entering via the abdomen using small cameras through the small entry points.) This again was a real eye opener to where exactly all the PAIN comes from. no wonder the pt's hate you when you say "up you get we are going for a walk."
It was fascinating to watch and a real learning curve. I would have liked to have asked so many more questions but didn't want to distract the surgeon, even through he was pretty open to having me there. Will have to do a bit of research.
Tuesday, October 28, 2008
WEEK 3
28.10.08
Almost half way through, time flies when having fun (or when you brain is going 100 miles an hour so the clock becomes irrelevant).
This week we are up to 6 pts a day between Chantelle and I. We have a couple we see together and others we see individually. The more challenging pts take both of us.
We had a new pt today who required a full initial geriatric assessment. The pt was admitted to RPH post fall. She was presenting with Obesity, Diabetes (which are both risk factors for CCF), R CCF which led to oedematous LL, asthma and arthritis, just to list a few of the main ones. For 67 years old this pt was presenting much worse of, mobility wise then some of our older pts with similar lists of medical conditions.
Weighing ~100kg our manual handling was the KEY FACTOR today.
We assessed function using a COVS and just generally looked at her bed mobility and transfers. We also assessed her sitting and standing balance and muscle strength. She had very decreased muscle strength and the extra weight she had to lift didn't help. Oedema also restricted a lot of movements. The decreased muscle strength then impaired her mobility as she found it difficult to roll in bed, struggled with supine to sit as she couldn't lift her LL's, used a rocking motion to get momentum to help her get from sit to stand and could only ambulate 75m before requiring a rest due to fatigue.
From this we summised that our treatment needed to increase ROM and LL strength, which we thought would be most functionally done in standing as she would be carrying her own weight. To help manage the oedema we leave her each day with her feet elevated and educate her on this, as well as instructing her on some ankle pumping exercises to do in the future. Her UL strength wasn't too bad so just strengthening these functionally with sit to stand and supine to sit transfers, using her arms, as well as some weights. For balance we would be aiming to improve her dynamic standing balance as this was her down fall.
Today Chantelle and I were quite efficient in our assessment. We were able to complete the geriatric assessment in good time and covered all of the elements required. We both noticed that we were getting better at doing the assessments, compared to our first attempt in week one.
Our Subjective Ax today was not thorough enough. In future we will include more questions about past mobility and home environment as we only touched this information and didn't go into details.
Almost half way through, time flies when having fun (or when you brain is going 100 miles an hour so the clock becomes irrelevant).
This week we are up to 6 pts a day between Chantelle and I. We have a couple we see together and others we see individually. The more challenging pts take both of us.
We had a new pt today who required a full initial geriatric assessment. The pt was admitted to RPH post fall. She was presenting with Obesity, Diabetes (which are both risk factors for CCF), R CCF which led to oedematous LL, asthma and arthritis, just to list a few of the main ones. For 67 years old this pt was presenting much worse of, mobility wise then some of our older pts with similar lists of medical conditions.
Weighing ~100kg our manual handling was the KEY FACTOR today.
We assessed function using a COVS and just generally looked at her bed mobility and transfers. We also assessed her sitting and standing balance and muscle strength. She had very decreased muscle strength and the extra weight she had to lift didn't help. Oedema also restricted a lot of movements. The decreased muscle strength then impaired her mobility as she found it difficult to roll in bed, struggled with supine to sit as she couldn't lift her LL's, used a rocking motion to get momentum to help her get from sit to stand and could only ambulate 75m before requiring a rest due to fatigue.
From this we summised that our treatment needed to increase ROM and LL strength, which we thought would be most functionally done in standing as she would be carrying her own weight. To help manage the oedema we leave her each day with her feet elevated and educate her on this, as well as instructing her on some ankle pumping exercises to do in the future. Her UL strength wasn't too bad so just strengthening these functionally with sit to stand and supine to sit transfers, using her arms, as well as some weights. For balance we would be aiming to improve her dynamic standing balance as this was her down fall.
Today Chantelle and I were quite efficient in our assessment. We were able to complete the geriatric assessment in good time and covered all of the elements required. We both noticed that we were getting better at doing the assessments, compared to our first attempt in week one.
Our Subjective Ax today was not thorough enough. In future we will include more questions about past mobility and home environment as we only touched this information and didn't go into details.
Friday, October 24, 2008
WEEK 2
24.10.08
My pt was successfully Discharged yesterday arvo. She was very happy to go home, which was was reflected well in her exercise that day as she was performing very well. Really shows the difference a positive attitude can make.
Losing a pt was a bit sad as you get to know them well, especially because you spend alot of time persuading them, trying to find ways of conning them into exercise and disctracting them from pain by talking about their life.
Lost one and Gain one.
A Nex patient today presenting with a L # NOF, dementia (MMSE 13/30) and with a PMHx including a pacemaker and hiatus hernia (a condition where part or all of the stomach passes from the abdominal cavity, through the diaphragm and into the thorax). Sounds reasonably simple, the complitation...huge non-compliance form the patient. The pt was refusing medication and found to be hiding them and spitting them out. On meeting, she had a very negative attitude toward exercise and felt it was too painful to move from bed. She has a habit of begging which made me feel cruel getting her up, though its for the best. Once down to the physio area she wasn't too bad. Incentives worked well...for example: do 10 and you get to sit down or to get her to walk we told her we were walking to her bed, and then took her all the way down the hall way. She is a very challenging pt to work with. Today we performed well as we got her to ambulate the furthest she has done since being admitted. we were able to do the full geriatric initial Ax in 2 sittings and managed to get her to do some exercicse aswell. Thought we did pretty well considerin it took the nurses about 30 minutes to get her out of bed for a shower.
Another challenge was having her family member present who is quite an extraverted and demanding individual, who was trying to provide constant input and confusing the pt. The pt also tended to beg the family member to make us stop, which was quite an awkward experience.
On Monday we plan to continue our exercise treatment with our pt and prehaps try to progress her distance of ambulation. We find distraction and ALOT of encouragement is the key. Today we did well and will try to progress further on monday.
My pt was successfully Discharged yesterday arvo. She was very happy to go home, which was was reflected well in her exercise that day as she was performing very well. Really shows the difference a positive attitude can make.
Losing a pt was a bit sad as you get to know them well, especially because you spend alot of time persuading them, trying to find ways of conning them into exercise and disctracting them from pain by talking about their life.
Lost one and Gain one.
A Nex patient today presenting with a L # NOF, dementia (MMSE 13/30) and with a PMHx including a pacemaker and hiatus hernia (a condition where part or all of the stomach passes from the abdominal cavity, through the diaphragm and into the thorax). Sounds reasonably simple, the complitation...huge non-compliance form the patient. The pt was refusing medication and found to be hiding them and spitting them out. On meeting, she had a very negative attitude toward exercise and felt it was too painful to move from bed. She has a habit of begging which made me feel cruel getting her up, though its for the best. Once down to the physio area she wasn't too bad. Incentives worked well...for example: do 10 and you get to sit down or to get her to walk we told her we were walking to her bed, and then took her all the way down the hall way. She is a very challenging pt to work with. Today we performed well as we got her to ambulate the furthest she has done since being admitted. we were able to do the full geriatric initial Ax in 2 sittings and managed to get her to do some exercicse aswell. Thought we did pretty well considerin it took the nurses about 30 minutes to get her out of bed for a shower.
Another challenge was having her family member present who is quite an extraverted and demanding individual, who was trying to provide constant input and confusing the pt. The pt also tended to beg the family member to make us stop, which was quite an awkward experience.
On Monday we plan to continue our exercise treatment with our pt and prehaps try to progress her distance of ambulation. We find distraction and ALOT of encouragement is the key. Today we did well and will try to progress further on monday.
Wednesday, October 22, 2008
WEEK 2
22.10.08
This afternoon we went to the orthopedics inpatient ward. Together Chantelle, Rhod (our supervisor) and I got a pt up for the first time following a CABG (coronary artery bipass graft). It was interesting to see the comparison with this pt and another pt down the ward following the same proceedure. Our pt had the additional complication of Polio affecting his (L) LL. We were able to get out pt out of bed and take him for a short walk.
Chantelle and I controlled the pt's anxiety well by pausing and distracting the pt from his past surgery by asking him about home and getting him to count his breaths.
This pt had a leg splint on his polio affected limb that was 30 years old and it isn't every day that one of this age is seen as they are so heavy and non-functional. Our supervisor explained to us and the pt the designs of newer models and how much easier it is with the latest design with much lighter metal and more flexibility. It would be an interesting area to do a little bit of research into just to see the progression and background of polio.
In future we would be more confident in cutting the pt off as he tended to want to talk about his problem and over think things, rather then just giving it a shot. Our supervisor demonstrated this ability well and we were able to learn from it.
This afternoon we went to the orthopedics inpatient ward. Together Chantelle, Rhod (our supervisor) and I got a pt up for the first time following a CABG (coronary artery bipass graft). It was interesting to see the comparison with this pt and another pt down the ward following the same proceedure. Our pt had the additional complication of Polio affecting his (L) LL. We were able to get out pt out of bed and take him for a short walk.
Chantelle and I controlled the pt's anxiety well by pausing and distracting the pt from his past surgery by asking him about home and getting him to count his breaths.
This pt had a leg splint on his polio affected limb that was 30 years old and it isn't every day that one of this age is seen as they are so heavy and non-functional. Our supervisor explained to us and the pt the designs of newer models and how much easier it is with the latest design with much lighter metal and more flexibility. It would be an interesting area to do a little bit of research into just to see the progression and background of polio.
In future we would be more confident in cutting the pt off as he tended to want to talk about his problem and over think things, rather then just giving it a shot. Our supervisor demonstrated this ability well and we were able to learn from it.
Monday, October 20, 2008
WEEK 2
20.10.08
The beginning of week 2, settling in well to the placement. Today I was to see a pt that was handed over to me by a 4th year Curtin Student who was finishing her placement.
My pt was presenting with "normal" cognition, emphysema, OA in LL, R hip pain and a low mood, GDS had a score of 10/15, though the score doesn't tell you much, the individual answers to the questions give more information about the status of the patient. I found she was just feeling anxious about her situation and bored with what her life entailed. Considering she had been bed bound for quite a few months and house bound for atleast a year, no wonder she was "bored."
This pt was different as she was ambulating with 2 AC's. She refused a ZF as it would not suit her home. AC's can cause tissue damage beneath the axilla so my ain is to get her fully I with EC's before discharge. One thing I did well with this patient was that i gave her appropriate education on the pros and cons of AC vs EC. Together we measured up some new EC's and trialed them up and down the hall way. we were able to build her confidence slightly and agreed to practice again tomorrow.
My pt also has great difficulty with bed mobility. With increased effort and SOB++ with this. After watching hos she does it in the hospital bed, the pt and I discussed what her bed at home is like and what she finds most difficult in the SOEOB to Supine T/F.
Over the weekend my pt had news from home that troubled her which made her anxious through our session. I asked her about this and we discussed what she must achieve to go home. This provided a goal to achieve and motivated her to continue with her physio and rehab.
Next time we meet we will be targeting Bed mobility as she currently T/F's and Ambulates w AC's Independently. We will do strengthening of the muscles she will require for the T/f and then applying it functionally to the task.
Today went well as we saw a definite improvement in her confidence, motivation and independence as we were able to progress her bed chart to mainly independent, which was awesome for us and for her as she is that one step closer to going home to her family.
Tomorrow before i treat her again i will be discussing my plans for bed mobility training and how i plan to target particular muscles and have devised a few strategies to hopefully breakdown and simplify the T/F for the pt.
The beginning of week 2, settling in well to the placement. Today I was to see a pt that was handed over to me by a 4th year Curtin Student who was finishing her placement.
My pt was presenting with "normal" cognition, emphysema, OA in LL, R hip pain and a low mood, GDS had a score of 10/15, though the score doesn't tell you much, the individual answers to the questions give more information about the status of the patient. I found she was just feeling anxious about her situation and bored with what her life entailed. Considering she had been bed bound for quite a few months and house bound for atleast a year, no wonder she was "bored."
This pt was different as she was ambulating with 2 AC's. She refused a ZF as it would not suit her home. AC's can cause tissue damage beneath the axilla so my ain is to get her fully I with EC's before discharge. One thing I did well with this patient was that i gave her appropriate education on the pros and cons of AC vs EC. Together we measured up some new EC's and trialed them up and down the hall way. we were able to build her confidence slightly and agreed to practice again tomorrow.
My pt also has great difficulty with bed mobility. With increased effort and SOB++ with this. After watching hos she does it in the hospital bed, the pt and I discussed what her bed at home is like and what she finds most difficult in the SOEOB to Supine T/F.
Over the weekend my pt had news from home that troubled her which made her anxious through our session. I asked her about this and we discussed what she must achieve to go home. This provided a goal to achieve and motivated her to continue with her physio and rehab.
Next time we meet we will be targeting Bed mobility as she currently T/F's and Ambulates w AC's Independently. We will do strengthening of the muscles she will require for the T/f and then applying it functionally to the task.
Today went well as we saw a definite improvement in her confidence, motivation and independence as we were able to progress her bed chart to mainly independent, which was awesome for us and for her as she is that one step closer to going home to her family.
Tomorrow before i treat her again i will be discussing my plans for bed mobility training and how i plan to target particular muscles and have devised a few strategies to hopefully breakdown and simplify the T/F for the pt.
Wednesday, October 15, 2008
WEEK 1
15.10.08
Today we did an initial full Geriatric Assessment of a new pt, presenting post (L) # NOF surgically Mx with PFN, WB as tolerated on (L). MMSE of 11/30, this pt was disorientated and confused. very simple communication and one step commands were necessary to complete COVS, BERG, TUG, Functional Reach, ROMS, 6MWT and Muscle Strength Testing. It was an exciting experience to get hands on and do all the tests that we had done in class.
We were able to complete all of the tests quite efficiently and used appropriate commands for our pt's status. Could have improved our timing of the tests as when the 6MWT was conducted the pain medication for the pt worn off and the outcome of the test was greatly limited by pain.
Next time we see the pt we will be conducting our first treatment session, incorporating all of the problems we identified on our problems list. The main ones being Cognition, Pain, decreased ROM and Strength at (L) hip and static and dynamic standing balance. Cognition can't be directly treated with physiotherapy and the pain will be managed by timing our Rx with pain cover medication. We will be doing various RM and strengthening exercises that are functional and incorporate balance.
Next time, become more efficient at the tests and order of tests as well as liasing with nursing staff for pain medication.
I still need to get used to communicating with the older population and need to fine tune my assessment technique. This will improve with practice and integration with pt's on the ward.
I have to get my supervisor to show me how to document a note in the pt's file.
Today we did an initial full Geriatric Assessment of a new pt, presenting post (L) # NOF surgically Mx with PFN, WB as tolerated on (L). MMSE of 11/30, this pt was disorientated and confused. very simple communication and one step commands were necessary to complete COVS, BERG, TUG, Functional Reach, ROMS, 6MWT and Muscle Strength Testing. It was an exciting experience to get hands on and do all the tests that we had done in class.
We were able to complete all of the tests quite efficiently and used appropriate commands for our pt's status. Could have improved our timing of the tests as when the 6MWT was conducted the pain medication for the pt worn off and the outcome of the test was greatly limited by pain.
Next time we see the pt we will be conducting our first treatment session, incorporating all of the problems we identified on our problems list. The main ones being Cognition, Pain, decreased ROM and Strength at (L) hip and static and dynamic standing balance. Cognition can't be directly treated with physiotherapy and the pain will be managed by timing our Rx with pain cover medication. We will be doing various RM and strengthening exercises that are functional and incorporate balance.
Next time, become more efficient at the tests and order of tests as well as liasing with nursing staff for pain medication.
I still need to get used to communicating with the older population and need to fine tune my assessment technique. This will improve with practice and integration with pt's on the ward.
I have to get my supervisor to show me how to document a note in the pt's file.
Monday, October 13, 2008
WEEK 1
13.10.08
DAY ONE, was mainly orientation based, familiarising us students at Bentley with the emergency proceedures, location of physiotherapy tools, introductions to other staff, standard proceedures etc.
We were given two patients to run through a 20 minute treatment session with. The two patients were infact husband and wife. The wife was admitted due to deconditioning secondary to dementia with an MMSE of 8/30, hypertension and her husband unable to care for her. When the wife was admitted the husband fell into depression and began to decondition also. Once reunited with his wife he recovered quickly, though it was decided that the best care for both patients would be to keep them together as her husband looks after her and takes alot of pressure off the nursing staff.
Our treatment session mainly targeted general strengthening and fitness as they did not have specific medical injuries or conditions that needed attention. Our supervisor hinted that with this level of cognitive impairement, demonstration and mimicing were the key to effective treatment. The husband joined in, and often corrected his wife and reminded her of things we had said (which was adorable). We then did a lap of the ward with their walking aids and returned to their room.
The strengthening exersices included UL exercises with weights (bicep curls, forward and upward punches) and LL exercises, targeting hip extensors, quads, ab/adductors, calf muscles and tib ant. We did a little bit of balance exercises and then functional activities were included by getting up from the chair to the parallel bars and walking around the ward with their aid.
Our supervisor told us we chose appropriate exercises and our instruction was appropriate for our patient. We didn't have time to prepare so were a little all over the place and not very structured which is something we could improve on for next time. We also didn't push our patients very hard and had them doing it quite easy which our supervisor told us we could push alot harder.
In the future i would structure the treatment and push the patient to near faigue to get the best outcome, challenge the system.
Today was quite a good exposure to the placement. An orientation to what we will be doing in the coming weeks which made me feel more confident in what we will be doing. We didn't do too much just got shown what to expect and the standard proceedure.
DAY ONE, was mainly orientation based, familiarising us students at Bentley with the emergency proceedures, location of physiotherapy tools, introductions to other staff, standard proceedures etc.
We were given two patients to run through a 20 minute treatment session with. The two patients were infact husband and wife. The wife was admitted due to deconditioning secondary to dementia with an MMSE of 8/30, hypertension and her husband unable to care for her. When the wife was admitted the husband fell into depression and began to decondition also. Once reunited with his wife he recovered quickly, though it was decided that the best care for both patients would be to keep them together as her husband looks after her and takes alot of pressure off the nursing staff.
Our treatment session mainly targeted general strengthening and fitness as they did not have specific medical injuries or conditions that needed attention. Our supervisor hinted that with this level of cognitive impairement, demonstration and mimicing were the key to effective treatment. The husband joined in, and often corrected his wife and reminded her of things we had said (which was adorable). We then did a lap of the ward with their walking aids and returned to their room.
The strengthening exersices included UL exercises with weights (bicep curls, forward and upward punches) and LL exercises, targeting hip extensors, quads, ab/adductors, calf muscles and tib ant. We did a little bit of balance exercises and then functional activities were included by getting up from the chair to the parallel bars and walking around the ward with their aid.
Our supervisor told us we chose appropriate exercises and our instruction was appropriate for our patient. We didn't have time to prepare so were a little all over the place and not very structured which is something we could improve on for next time. We also didn't push our patients very hard and had them doing it quite easy which our supervisor told us we could push alot harder.
In the future i would structure the treatment and push the patient to near faigue to get the best outcome, challenge the system.
Today was quite a good exposure to the placement. An orientation to what we will be doing in the coming weeks which made me feel more confident in what we will be doing. We didn't do too much just got shown what to expect and the standard proceedure.
INITIAL JOURNAL ENTRY
12.10.08
My placement is at Bentely Hospital doing Inpatient Rehabilitation.
I was glad to be placed in a secondary hospital as my initial placement, close to home. This hospital also has no emergency department so i think that may take a little bit of pressure off.
Being inpatient rehab i am expecting to see a broad spectrum of patients, mainly Gerontology as the catchment area for Bentley is largely an elderly population. Therefore expecting to see strokes, parkinsons, dementia, total hip and knee replacements and injuries due to falls.
I am looking forward to a challenge, getting in and seeing and applying the theory we have learnt to real life patients. Meeting fellow allied health professionals and experiencing the hospital setting.
The only concerns i have is that i won't be able to meet the challenge, or that we will be thrown into the deep end, which isn't necessarily the way i learn. I guess we are all nervous about stuffing up, but thats expected of this kind of situation.
I expect the physios will be working collaboratively with eachother and other health care professionals, together to get a holistic approach to the patient and achieve an optimum outcome.
Sharing workloads, offering support and collaborative opinions, have meetings to discuss difficult patients etc.
Thats it from me...
My placement is at Bentely Hospital doing Inpatient Rehabilitation.
I was glad to be placed in a secondary hospital as my initial placement, close to home. This hospital also has no emergency department so i think that may take a little bit of pressure off.
Being inpatient rehab i am expecting to see a broad spectrum of patients, mainly Gerontology as the catchment area for Bentley is largely an elderly population. Therefore expecting to see strokes, parkinsons, dementia, total hip and knee replacements and injuries due to falls.
I am looking forward to a challenge, getting in and seeing and applying the theory we have learnt to real life patients. Meeting fellow allied health professionals and experiencing the hospital setting.
The only concerns i have is that i won't be able to meet the challenge, or that we will be thrown into the deep end, which isn't necessarily the way i learn. I guess we are all nervous about stuffing up, but thats expected of this kind of situation.
I expect the physios will be working collaboratively with eachother and other health care professionals, together to get a holistic approach to the patient and achieve an optimum outcome.
Sharing workloads, offering support and collaborative opinions, have meetings to discuss difficult patients etc.
Thats it from me...
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