I have a patient on my caseload who is my first really confused patient. She has a #NOF and has been in hospital about 1 week. This lady is a real handful, she will not move out of bed at all. Initially this was because of pain, but now she has become very stubborn and will not move for anyone. The physio and myself will go into her room about 2-3 times per day and spend anywhere from 10-20 minutes trying to convince or "trick" her to get up, but she wont budge and despite our best efforts she is now developing a chest infection.
I consider myself a rather patient person, but this lady has been very trying. It is a difficult situation because I know she needs to mobilise to get out of hospital and not end up in a nursing home. But we need to have some form of consent to be able to help her with this. When we try a 2x max assist but she fights it and screams for us to stop every time despite us giving her all the advice and education we can. Its dissapointing to think that she could have been back at home already had she not developed this confusion and that there isnt a lot more that I can do to help her, even with all of her physio-relevant impairments...but i guess that happens sometimes.
Sunday, September 7, 2008
Saturday, September 6, 2008
Inappropriate patients
This was in relation to a new patient on the ward that i was assessing
Initially on our ward which mainly deals with acute strokes a general subjective, obs/CV and mobility/balance assessment is performed prior to commencing more formal neuro assessment and treatment. On this occassion my supervisor had chosen to come into the patients room with me and another student who were assessing this gentleman. Cognitively he appreaed normal but slightly drowsy and we decided to look at his mobility in bed which was max assist and decided to assess his sitting balance. We assisted him to SOEB with close guarding and the other student kneeled in front to stabilise him and commence assessing static/dyamic sitting balance. At this point the patient decided to make an extremely inappropriate comment which caught us all by surprise. Instead of paying attention to it the supervisor, other student and myself chose to ignore/laugh it off and continue with the session.
It made me realise that sometimes like many other professions we are placed in comprimising situation that need to be dealt with professionally. If we had reacted the situation could have become uncomfortable and potentially confrontational. The supervisor said everyone involved had done the right thing and handled the situation appropriately. In regards to similar situations in the future i would most probably do the same thing as light was not made of his comments and the session continued without incident.
Initially on our ward which mainly deals with acute strokes a general subjective, obs/CV and mobility/balance assessment is performed prior to commencing more formal neuro assessment and treatment. On this occassion my supervisor had chosen to come into the patients room with me and another student who were assessing this gentleman. Cognitively he appreaed normal but slightly drowsy and we decided to look at his mobility in bed which was max assist and decided to assess his sitting balance. We assisted him to SOEB with close guarding and the other student kneeled in front to stabilise him and commence assessing static/dyamic sitting balance. At this point the patient decided to make an extremely inappropriate comment which caught us all by surprise. Instead of paying attention to it the supervisor, other student and myself chose to ignore/laugh it off and continue with the session.
It made me realise that sometimes like many other professions we are placed in comprimising situation that need to be dealt with professionally. If we had reacted the situation could have become uncomfortable and potentially confrontational. The supervisor said everyone involved had done the right thing and handled the situation appropriately. In regards to similar situations in the future i would most probably do the same thing as light was not made of his comments and the session continued without incident.
Friday, September 5, 2008
Draw a line for discharge
Have you guys ever had experience to make a decision for your patient to be safe for discharge? It is happening to me with a couple of my patients.
A gentle man who suffers right hemiparesis from stroke. He is quite capable in terms of physically, however his balance is still questionable. In addition, he has right neglect, dyspraxia, dysphasia, spatial disorder, big problems in proprioception and sensation, and is impulsive as well. He walks with supervision on even surface, but he requires constant verbal cues for right foot clearance, right side awareness, and motor planning. As a result of these problems, the right side of his body hit everywhere like doorways, trolleys, W/C, and stools etc that he was totally unaware of hitting. He is easily to stumble over anything as you can imagine. And he cuts a corner or turns himself very quickly due to impulsive, so he is easily to lose his balance as he does so.
He also has problems on his right hand which is his dominant side. Because of his sensory problem and dyspraxia, he quite often puts his right hand onto a hot meal without any attempting of picking up fork/spoon/knife according to his family. One day, it happened three times within 1 min in front of me while I was talking to his family in his room. That happened really quick because of impulsive and nothing we could do to stop him from that. He was aware it was wrong, because he wiped his right hand right away, but he did it twice after that. Fortunately the meal was warm and not hot. However he has burning marks on his fingers from previous repetitions. This is another episode from his family. He grabbed knife by holding the blade side instead of holding proper way. There are some minor areas that I still concern regarding safety issue on him.
Now, isn’t that enough to be concerned his safety issue? I know some of his issue would not be necessary to be recovered before discharge and might not be happened for long period of time or will not be ever. Maybe I am too cautious regarding safety issue.
He has been seeing by his doctor and nurses that walking around without any problems with his family in corridor. Well, most of the corridors at the hospital are wide enough with even surface and do not have lots of equipments around, thus easy for him to manoeuvre I would think. Plus, they have not seen him turning or stumble yet, so his doctor was wondering why physio was holding him back to be discharged.
I explained to his doctor why I did not feel safe for discharge, however I have got impression that his doctor was still unclear why. I just can’t work it out where I should draw the line to be safe for discharge. He will be able to get some help from community services, and I know his wife will help him as needed because she is very supportive, but she can’t be babysitting him 24 hrs a day. He might be fine (I hope) at home, but what if something happen to him?
Do you guys have any suggestions for me?
A gentle man who suffers right hemiparesis from stroke. He is quite capable in terms of physically, however his balance is still questionable. In addition, he has right neglect, dyspraxia, dysphasia, spatial disorder, big problems in proprioception and sensation, and is impulsive as well. He walks with supervision on even surface, but he requires constant verbal cues for right foot clearance, right side awareness, and motor planning. As a result of these problems, the right side of his body hit everywhere like doorways, trolleys, W/C, and stools etc that he was totally unaware of hitting. He is easily to stumble over anything as you can imagine. And he cuts a corner or turns himself very quickly due to impulsive, so he is easily to lose his balance as he does so.
He also has problems on his right hand which is his dominant side. Because of his sensory problem and dyspraxia, he quite often puts his right hand onto a hot meal without any attempting of picking up fork/spoon/knife according to his family. One day, it happened three times within 1 min in front of me while I was talking to his family in his room. That happened really quick because of impulsive and nothing we could do to stop him from that. He was aware it was wrong, because he wiped his right hand right away, but he did it twice after that. Fortunately the meal was warm and not hot. However he has burning marks on his fingers from previous repetitions. This is another episode from his family. He grabbed knife by holding the blade side instead of holding proper way. There are some minor areas that I still concern regarding safety issue on him.
Now, isn’t that enough to be concerned his safety issue? I know some of his issue would not be necessary to be recovered before discharge and might not be happened for long period of time or will not be ever. Maybe I am too cautious regarding safety issue.
He has been seeing by his doctor and nurses that walking around without any problems with his family in corridor. Well, most of the corridors at the hospital are wide enough with even surface and do not have lots of equipments around, thus easy for him to manoeuvre I would think. Plus, they have not seen him turning or stumble yet, so his doctor was wondering why physio was holding him back to be discharged.
I explained to his doctor why I did not feel safe for discharge, however I have got impression that his doctor was still unclear why. I just can’t work it out where I should draw the line to be safe for discharge. He will be able to get some help from community services, and I know his wife will help him as needed because she is very supportive, but she can’t be babysitting him 24 hrs a day. He might be fine (I hope) at home, but what if something happen to him?
Do you guys have any suggestions for me?
Thursday, September 4, 2008
Dramatic Accidents
I was treating a day 1 THR with another therapist the other day. When talking to her while laying in bed apart from some pain everything was fine, all instructions understood and she was keen to get up and moving. Once standing up and a few metres away from the bed she was a bit quiet and i noticed her skin going plae. At that time she fainted and collapsed onto my knee luckily I was at arms reach of a chair and we placed her down into it. I was asked to get oxygen for her and as i turned to get it, she passed out completely, slipped through the grasp of the physio, off the chair and proceeded to dislocate her hip.
Obviously I found this somewhat of a frightening situation to be in with my first THR patient. This situation had never happened to me with a surgical patient before. In reflection perhaps it was the best thing to happen to me as a student. It has really reinforced the importance of monitoring the whole of the patient very closely after surgery and I find I am being more vigilant about it now. If i hadnt seen her face go pale, I might have dropped her - resulting in a fail for my clinic and probably a bad reputation in the hospital. Hopefully I wont have to experience this for a long time to come! (the patient is now doing fine you'll be glad to hear).
Tuesday, September 2, 2008
assessment of voluntary movement
I am currently at the head injuries ward at Shenton Park and was asked last week to do an indepth SOAPIER on one of my patients. Within this SOAPIER you need to explain the patients movement patterns fo all limbs. This patient presented as a left hemi (LL>UL) and with some dyspraxia of all limbs. Due to the limited movement of this patient Gowland was not appropriate for assessment. My supervisor therefore showed me another way to assess voluntary movement in a 1, 2, or 3 joint control format in varying positions. This isnt a really easy way to assessment the movement but after some practice it seems the best way to explain exactly what the patient can do, in what range and what type of movement. I was suprised that we didnt actually learn how to do this form of assessment in uni. I know it is pretty specific to head injuries etc but itis also just a good way to get your head around exactly what needs to be worked on and what the impairments etc are. Has anyone come across this particular assessment or similar assessments that they thought we should have been taught. I found that I felt quite unequipped to perform an effective assessment on this patient with what I was taught at uni.
Monday, September 1, 2008
Private vs. Public
My last placement was women’s health and during my time there I had a conversation with my Curtin supervisor about private and public patients. As I was on placement in a public hospital and my supervisor worked elsewhere in a private hospital, she made the comment that often we see patients in the private sector more enthusiastic to learn what a women’s health physio has to educate them on, more so following childbirth, than in the public sector, as patients in the private sector had to pay for the service to see a physio.
Whereas in the public sector, well in the facility I was at, we got a blanket referral to see all the patients on the ward and if there were any patients with specific complications needing intervention then we would of course see them for that particular complication. In the beginning I thought that this was quite an over generalisation, but as the weeks went by it became more and more clear those patients who were of a higher socio-economic status in the public hospital were more inclined to take on board the information provided and ask questions and consciously practice the exercises because they could clearly see the benefit of doing it correctly, than those who presented with relative disinterest to the topic of conversation. I know that women’s health is the nicest topic of conversation or education however it is so much more important to try and somehow develop rapport with those disinterested patients to help even bring to their attention some health issues that they may never had heard of or cared about previously because they are the ones, more often than not, who are at a greater risk of women’s health issues later on in life.
From that placement I think I most importantly learnt how to read patients non verbal communication signs better than most of my other placements, and those patients who were interested obviously gained the most out of the education session, but it’s a reminder that we can not forget about the other relatively disinterested patients, in all areas of physio, because these are the patients that actually have the most to gain even out of a simple 10 minute education session.
Whereas in the public sector, well in the facility I was at, we got a blanket referral to see all the patients on the ward and if there were any patients with specific complications needing intervention then we would of course see them for that particular complication. In the beginning I thought that this was quite an over generalisation, but as the weeks went by it became more and more clear those patients who were of a higher socio-economic status in the public hospital were more inclined to take on board the information provided and ask questions and consciously practice the exercises because they could clearly see the benefit of doing it correctly, than those who presented with relative disinterest to the topic of conversation. I know that women’s health is the nicest topic of conversation or education however it is so much more important to try and somehow develop rapport with those disinterested patients to help even bring to their attention some health issues that they may never had heard of or cared about previously because they are the ones, more often than not, who are at a greater risk of women’s health issues later on in life.
From that placement I think I most importantly learnt how to read patients non verbal communication signs better than most of my other placements, and those patients who were interested obviously gained the most out of the education session, but it’s a reminder that we can not forget about the other relatively disinterested patients, in all areas of physio, because these are the patients that actually have the most to gain even out of a simple 10 minute education session.
Importance of Passive Movements
I'm currently on my cardio placement and in the ward that i'm on there is a high dependency unit, which is mainly used as a step down from ICU or for patients who are ventilated. One of the patients there is a 37 year old man who has motor neuron disease. He was diagnosed only 18 months ago but it has very rapidly progressed. He is now completely chair/bed bound, a full hoist transfer, and has had a permanent nasogastric tube inserted as he has pretty much lost his swallowing. I was asked to see him by my superviser for some upper and lower limb passive movements and muscle stretches.
As I am on my cardio prac I thought that doing passive movements and muscle stretches is a little bit of a waste of time, but of course I will do what i'm told! The patient has lost a lot of his ability to project and articulate words and as a result is very difficult to understand. From the conversation I was able to have with him and his family he had told me how much the passive movements and muscle stretches actually do make a difference to him. He had said that they really do make him so much more comfortable and he feels so much better after having them done. As he has been told that he only has 6-8 weeks to live, he was extremely grateful for us taking the time out to do this for him.
This experience has just shown that something that we find a little tedious and somewhat unneccessary can actually make a really big difference to someones life. So even though we dont think we're doing much, a patient is very appreciative of it as it may do a lot to increase their comfort and, in this case, his quality of life for the time he has left. This has definately given me a different perspective to doing simple passive movements as a treatment.
As I am on my cardio prac I thought that doing passive movements and muscle stretches is a little bit of a waste of time, but of course I will do what i'm told! The patient has lost a lot of his ability to project and articulate words and as a result is very difficult to understand. From the conversation I was able to have with him and his family he had told me how much the passive movements and muscle stretches actually do make a difference to him. He had said that they really do make him so much more comfortable and he feels so much better after having them done. As he has been told that he only has 6-8 weeks to live, he was extremely grateful for us taking the time out to do this for him.
This experience has just shown that something that we find a little tedious and somewhat unneccessary can actually make a really big difference to someones life. So even though we dont think we're doing much, a patient is very appreciative of it as it may do a lot to increase their comfort and, in this case, his quality of life for the time he has left. This has definately given me a different perspective to doing simple passive movements as a treatment.
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