My last entry

During my last week of prac, my supervisor gave me far more independence with my assessment, treatment and management of my patients. One of my tasks was to write a couple of transfer summaries for patients i had been treating over the 5 week period. This involved a detailed check up of the patients level of independence, care assistance required, walking aid, home services etc... I then needed to state where the patient was both medically medically and physically stable. The patient needed to be medically stable prior to discharge and needed to be functioning at the required level depending on the discharge setting. For example for a patient going into a low level of care... ie; hostel setting. I needed to make sure the patient could safely ambulate to the dining room for meals and usually toilet independently. I also needed top state the type of assistance the patient would require daily, for example assistance with showering. dressing etc... For a patient being discharged to a high level of care setting such as a nursing home i would need to carefully document the type of assistance required, paying particular attention to transfers. For example whether the patient requires a standing hoist or whether they are two people assist to ambulate.

Another challenge i faced during my last week of prac was aid prescription. Throughout my first 4 weeks of placement i had been assessing my patients using the aids that my supervisor had prescribed them on admission. I would approach my supervisor at at any point if i felt that the aid needed progressing or that it was a safety hazard however i would of always have assistance in the decision making of what would be the most appropriate choice. During my last week of prac i had 3 different patients that needed to be progressed onto a new aid. For example patient G was a complex medical patient. She suffered from fibromyalgia and had been ambulating with a pulpit frame as she was non weight bearing on her L femur. During my last week of prac patient G was cleared for WB so i decided to try her on a 4 wheeled zimmer frame. As patient G was not medically stable and was a rather tall patient i decided to ask for assistance when i ambulated her for the first time. I made sure i demonstrated a step 2 gait and explained that she was allowed to put weight through her L leg. Before i got patient g ambulating i did some rhythmic stabilization and corrected her posture. This is something that i feel really comfortable with by the end of my prac. I discovered that when ambulating a gerontology patient it is very important to make sure that they are steady on their feet and that their static standing balance is ok. I also found that rhythmic stabilization is an excellent way to teach the patient about maintaining their center of gravity over their center of mass. It allows you to make sure that their protective, and righting reactions are working in a stable environment.

I thoroughly enjoyed my 5week placement at Carinya. I felt after just completing my gerontology unit, much of the information that i learn t this semester was directly applicable and having the ability to directly apply my knowledge to a practical setting enabled me to cement my learning. Over the 5 week period i developed some really excellent skills whilst also identifying some areas that i am not so strong in and may need a little bit more attention.

One of the areas that i feel i could improve on is my order of assessment. I feel that i could get far better results from my patients during the initial assessment if i take more time to plan it. I need to take more time looking at my patient's notes and history prior to entering the room in order to better plan my initial assessment. During my prac i have discovered that not only muscular injuries and medical conditions need to be considered but also the patient's degree of frailty and their current emotional state. For example a few of my patients that i assessed and treated throughout my time on prac, arrived at the facility very overwhelmed and emotionally unstable after a stressful day involving an ambulance transfer, frequent visits from family members and regular check ups from the nurses. By the time i reached the patient they were often teary and incapable of adhering to any major physical assessments. In this case i needed to prioritize... If i was mainly concerned with their lower limb strength then i should assess that first and do a quick ROM assessment in supine before i asked/ assisted them to transfer.

Another area that i need to further develop is my exercise prescription. I found that i managed to progress my exercises effectively but was unsure as to how many repetitions i should prescribe when i increased my load. This is an area that i can further research. I found it difficult with my gerontology patients to interpret fatigue from dramatizations and unwillingness to physically challenge themselves. This was particularly hard when i was treating complex medical patients as i had to monitor their medical stability and level of exhaustion constantly whilst still challenging and progressing their musculoskeletal exercises. For example patient F; Patient F was recovering from pneumonia, post 6 wks FNOF. She was diagnosed with fibromyalgia, CT scans had recently revealed a brain tumor, along with a history of smoking, hypertension and angina. Due to her medications for both her angina and hypertension, i needed to monitor any dizziness, signs of low blood pressure or shortness of breath (pneumonia) whilst prescribing strengthening exercises. As my patient did not enjoy the strengthening program i had prescribed her it was my job to assess constant complaints of SOB, fatigue and sickness and decide whether or not to progress her exercises or allow her to rest.

Another important tool that i feel i need to document more during my assessments is pain. I found that for many patients, there was a constant reference to pain and discomfort. As i was unsure whether this was predominantly a psychological barrier to 'exercise' or whether it was a legitimate complaint, i often discussed the patients level of discomfort with them but did not document it. I feel that this could be useful in assisting my exercise prescription, and noting the patients pain tolerance. I also found during my placement that it is also important to assess whether the patient is on adequate pain medication etc...

I felt by the end of my placement one of my stronger areas was communication. Throughout my time at Carinya i gained a lot of experience in interviewing patients. I felt at the start of my placement i had difficulty getting the required information from my patients as each of them wanted to strike up conversation or question me on my studies, my interests, family etc... In my first two weeks of placement i found it very hard to conduct a professional, efficient but friendly interview. I did however develop this skill throughout my 5 weeks on placement. I began to ask far more direct 'closed' questions This enabled me to politely gain the information that i needed without drifting of track and waisting time. For example instead of asking
"have you had any difficulties with your back this week?" i would ask only what i wanted to know:
" Has your back stopped you from walking this week?"
This style of question would limit any irrelevant complaints or concerns and provide me with only the relevant information that i needed regarding the patient's back pain and it's effect on her walking activity.