Final Reflection

This was my first placement in the field of neurology. It was refreshing to be learning and practicing new skills. Although I was on the stroke unit, I also had a few non-stroke patients with neurological deficit secondary to pathology such as a meningioma or an abscess. These patients were very interesting to follow as their rate of recovery was often quite unpredictable, and as physio’s we spent a lot of time liaising with the MDT about their medical status and their improvement in performance. I had a nice variety of stroke patients, for example I had a TACS, a PACS, POCS and a LACS. Because of this varied caseload, I had exposure to cognitive, perceptual, motor and sensory deficit.

Throughout my 5-week placement I found I needed to be extremely versatile with my treatment techniques for different patients. I discovered that although patient A and patient B may have the same motor deficit (left hemiplegia) they are unlikely to respond to the same approach and technique as they have different co impairments, such as dyspraxia, or poor insight.

As expected a large focus of my placement was on discharge planning. From the initial assessment of each patient we would device a problem list and set likely short and long term goals. There would be regular meetings with the multi disciplinary team and the patient’s family to discuss progress and set new goals. This was a great opportunity for me to become more familiar with the discharge options and the services or facilities available in both metropolitan and rural districts. During these meetings I was often asked to present a progress report. This enabled me to develop good liaisons with other members of the MDT, and gave me confidence in both my analytical skills and my public speaking skills.

Although my manual handling skills were adequate at the commencement of this placement, I feel I have refined my techniques and gained confidence in deciding upon the most appropriate transfer technique for a particular patient. I have been responsible for updating my patients’ mobility status to the nursing staff. For example if the patient requires minimal assistance or only supervision for their ambulation.

Prior to the commencement of this placement, I was concerned about what treatment approaches and techniques they might use on the stroke unit. I was curious as to whether the physiotherapists would be more dominant in Bobath or motor relearning techniques, and whether the focus would be on function, or facilitation of normal movement and error free practice. What I discovered on my placement was that according to the evidence, most recovery from stroke occurs in the first 4 to 6 weeks. For this reason, the stroke unit would focus on facilitating normal movement and getting recovery of voluntary movement for the first month. The team would then look realistically at the long-term goal, and start to focus on function and if need be compensatory movement.

This was an excellent placement; I had exposure to many different types of strokes and neurological conditions. Although a lot of my patients required the assistance of two physiotherapists, I had a lot of autonomy in the assessment, treatment and discharge planning procedure for each patient. I had the opportunity to work with 5 different physiotherapists, thus was exposed to a broad range of neurological techniques and treatment approaches. I feel very lucky that I have had such a good learning experience in the neurological field.

week five post

Situation:
Pt A had a left MCA CVA six weeks ago. She has a right hemiplegia and dysphasia. Pt A attends daily physio for gait re education, balance training and lower limb strengthening. Patient A is a stand by transfer with the nurses and ambulates using a walking stick with moderate assistance from one person. During the family meeting it was discussed that the goal is for patient A to return home with her husband as the primary care giver. I had not previously met patient A’s husband, or observed their interaction during his visits.

Task:
It was discussed during the meeting that in the preparation for discharge, we would need to teach patient A’s husband how to safely assist her to transfer into and out of the car. I booked a session with patient A and her husband to teach him the transfer and assess his appropriateness as the primary care giver.

Actions:
I took patient A down to the car in her wheel chair. First I explained to the husband that patient A needed constant assistance on her weak side. I demonstrated correct use of the wheel chair, indicating where the brakes and the tilt option were. I then showed the husband how to put her supportive sling on her right arm correctly. After this I explained that we wanted patient A to always lead with her strong side, so her approach to the car seat was very important. I suggested that as the car seat was low, she was likely to need assistance getting her legs into the car. To finish off I demonstrated the full transfer into the car. I then asked the husband to perform the same task as I had done.

Results:
Patient A’s husband attempted to put the sling on the wrong arm, when I corrected the sling; he explained ‘that he had got confused’. He then tried to get patient A into standing without putting the wheel chair brakes on. Once in standing, the husband stood at over a meters distance from his wife, and tried to control her movement by holding onto her right arm that was in the sling. He directed her into the car leading with her weak side, and did not assist to get her right leg into the car. When I asked patient A’s husband about his current health, he informed me that he had bilateral ongoing rotator cuff problems and had just recently been back to hospital for a scan and ultrasound. The husband told me that he often has sleepless nights due to pain and has next to no overhead shoulder movement.

Evaluation:
It was very clear from the husbands attempt at assisting a car transfer; he would not currently be a safe primary care giver for her. He appeared disengaged and disinterested in the advice provided. He also did not demonstrate any understanding of providing support or assistance for her right hemiplegia. I was unsure whether the husband’s lack of involvement was indicative of disinterest or of fear of responsibility. We have not had any previous interaction or discussion with him, so it is difficult to gage how he feels about being a full time carer. The husband’s health will also need to be discussed, as his shoulder pain is likely to impede on his capabilities as a carer.

Strategies:
1: Document the events of the session and reflect on my current thoughts about the husband ‘s potential as a full time carer
2: Liaise with the Occupational Therapist
- Discuss home visits, a repeat session with the OT on car transfers + slings + night splints
3: Liaise with the social worker
- Discuss organising a family meeting so we can do some realistic goal setting with the husband and their kids.
4: Liaise with my physio supervisor about getting the husband to come in for physio sessions so that he can start to learn how we help patient A transfer and ambulate.

Week 3

Situation:
Pt A had a Left MCA CVA on the 21/05/2010 and was found on the floor by her husband. She was transferred to SCGH with right-sided weakness. Patient A has a pacemaker and a previous medical history of paroxysmal atrial fibrillation and mitral regurgitation. The progress notes handed over from SCGH indicated that patient A had been non ambulant on the ward and was a two assist step transfer. When I entered the room, the patient was alert and sitting out of bed.

Task:
My task was to perform an initial objective assessment of patient A. I needed to assess gowlands, Covs the motor assessment and Berg balance. I then needed to create a mobility chart for the patient’s room to direct the nurses as to the appropriate transfer and aids.

Actions:
I got consent and then took patient A down to the gym in her wheel chair to commence the assessment. I did a two assist step transfer from the chair to the plinth, as was previously recorded in her notes from SCGH. Once lying on her back I commenced the gowlands assessment. On completion of gowlands I assessed Covs and MAS. I did not have time to assess patient A’s berg balance, proprioception, sensation or vision.

Results:
Patient A had expressive dysphasia. This made it very difficult to interpret her response to questions. Patient A would often muddle up her ‘yes’ and ‘no’ response. I needed to repeat myself numerous times throughout the assessment. It was also very difficult to determine the limiting factors in each assessment. For example when I asked patient A to perform a task I did not know if the limited performance was due to pain, weakness or confusion. I did not get the opportunity to discuss goals with my patient. When I assessed Gowlands, I had to constantly transfer my patient from supine to sitting for the different starting positions. This caused my patient to fatigue very quickly, resulting in deterioration in the performance level during the second half of the assessment.

Evaluation:
Due to patient A’s dysphasia, it was very difficult to determine the accuracy of her verbal responses. For example patient A would often say ‘yes’ when she actually meant ‘no’. When analysing my problem list, I found it very difficult to interpret the cause of her impairments. For example during the assessment of patient A’s shoulder, it was hard to tell if her limited range of motion was due to pain or weakness. I felt that my Gowlands assessment was very inefficient and poorly structured. As I was unfamiliar with the outcome measure I did not choose an appropriate order of assessment.

Strategies:
1: Find alternative means of communication e.g. facial expressions, body language, hand gestures, Draw or write, I could ask the husband to assist in interpretation during the sessions.

2: Plan my assessment better. If my patient is likely to fatigue quickly, I need to think about the sort of things I will assess in each different position (supine/ sitting/ standing For example, assessing Gowlands). This will enable me to structure my session more efficiently with less transfers.

3: I will plan a shorter session, so that my patient does not fatigue so much. (Split the initial assessment over two days)

Week 1

Situation:
patient A is a 65yr old who had a left anterior cerebral artery stroke one month ago. He has a right hemiplegia, very poor sensation in his Right upper and lower limb (particularly lower limb), he has short term memory loss, and is confused and disorientated. Patient A is leaning to the right in sitting, and pushes to the right when assisted to perform a sit to stand. Patient A also has a history of chronic lower back pain, which he has been complaining of over the last month. Today patient A is sitting in his recliner wheel chair, he has an arm support for his right arm. Patient A's wife has been visiting for approximately 5 hours every day and attending the physiotherapy sessions.

Task:
My task is to work on Patient A's sitting posture. I need to try and stop him from leaning to the right, increase his trunk extension and get him into more of an anteriorly pelvic tilted position, as he has been sitting very 'slumped'. My next task to practice a sit to stand. As patient A is 2 assist for all of his mobility, my supervisor will be assisting in the session. My final task is to practice standing posture and facilitate some weight transfer.

Actions:
I started off by asking Patient A if he could feel that his alignment was off center. I asked him to line his nose up with the middle of his knees. I then asked him to reach to the left for my hand, and kept him reaching until he brought his trunk back to the center of his body. As patient A was having difficulty with these tasks, i used a mirror to give him some visual feedback. I then progressed the treatment to a sit to stand with 2 assist. We blocked the right lower limb and facilitated hip extension, using a zimmer frame for support whilst we worked on standing posture.

Results:
Patient A was extremely distracted throughout today's session. He complained of back pain the whole time and seemed very confused and very distressed about something. When we questioned him as to what it was he was thinking about, patient A explained to us that he was confused about what had happened to him and why his body would not do as his brain wanted it to. He explained that he had lost all sense of time, and he was constantly paranoid that his wife was leaving him and not returning. Patient A stated he thought it had been a whole year since he had seen his wife, when really it had been one day. When i asked patient A if he could feel where his trunk was in space, or if he could feel how much pressure he had on each buttock and through his feet, he explained he couldn't feel anything and that he felt like he was sitting 'in the middle'. We had to stop the session early as patient A was experiencing very bad lower back pain and was very distressed and fatigued.

Evaluation:
It was apparent from patient A's behavior and response to the treatment today that Patient A has a lot of frontal lobe changes that are interfering with his physical progression. We are unaware as to whether the confusion is a result of his medications or whether it is a result of the stroke. Patient A 's lower back pain also seems to be exacerbated by his decreased mobility and poor sitting posture. We will need to liaise with the occupational therapist and the nursing staff to find some strategies to decrease patient A's level of distress. We will also need to give patient A's wife some strategies to manage his behavior.

Strategies:
1: Sensory bombardment; I am going to try and give patient A's right LL and UL lots of sensory input such as, pounding, approximation, weight bearing through the right lower limb and tapping of the muscles to see if i can awaken any of his sensory receptors, to give him more feed back about his posture and body position.
2: educate his wife and the nurses to constantly correct his sitting posture by asking him to reach out to the left.
3: Ask his wife to write down and date whenever she comes into the hospital or leaves, so that patient A is not distressed by her absence.
4: Start getting patient A to use a diary to write down his daily activities and thoughts. This may help to lessen the confusion and disorientation.
5: get some routine into patient A's daily activities. For example arrange physio so that it is at the same time every day. Twill enable patient A to have some consistency in his day to day life.
6: liaise with the nursing staff and doctors about giving patient A his pain medication before physio so that the lower back pain does not interfere with the session.
7: Liaise with the occupational therapy staff about a cushion for patient A's wheel chair (maybe one side more raised, to help correct the right lean.)

Initial Entry

This is my first placement in the field of neurology. I am excited to be nearing the end of my practical experience and still be looking to develop new skills. My placement is at the Osborne park stroke unit. According to my clinical mix form my caseload will be all stroke inpatients, the majority over 65 years old. I suspect that I will be spending at least an hour with each patient. As my caseload is all stroke patients, I think I will be treating impairments and activity limitations such as abnormal tone, sensation, strength, balance and gait. I think there will be a large focus on discharge planning and working with patients to achieve their optimum function so they can return to their home environment.

Although we spent a lot of time in tutor sessions going through various assessments and treatment techniques, I have never actually assessed or treated a patient with real neurological deficits. For example, although I am comfortable with my techniques to assess tone, I have never actually felt what abnormal tone feels like. I think I am likely to be challenged by the physical component of my sessions; I am going to need to focus on my manual handling skills.

My other concern for this placement is the treatment approach that my supervisor and co workers will be dominant in. During our university studies, we were exposed to many different methods and techniques. Although our course focused largely on motor relearning and functional rehabilitation we were also educated on bobath and techniques such as sensory bombardment. At the time, our lecturer informed us that depending on which facility we would attend the methods of treating and techniques used would vary. I hope that my depth of knowledge will enable me to adjust and modify my techniques as appropriate for my environment.

Final post

My placement at Bentley hospital was very different to what I had expected. As it was my third experience in a musculoskeletal outpatient department it was interesting to compare the differences in the structure, the physiotherapy techniques used and the patient caseload. I found that there was a very strong focus on soft tissue techniques and massage, with a very minor focus on mobilisation. This was very different to both my university experience and my previous learning experiences on placement.

During my placement at Bentley I found I was liaising with my supervisor a lot more than previous placements. My supervisor asked that I come and speak to him after my subjective assessment and before I commenced my treatment, so that we could discuss my findings. I found this strategy really challenged my clinical reasoning. My supervisor questioned my analysis and my planning of my treatment sessions, where we often had conflicting treatment plans, and analysis findings. Initially I found these discussions with my supervisor testing. I felt that my previous methods of reasoning and treating conflicted with those that my supervisor was advising. However as the placement progressed I learnt to have a more flexible treatment plan and be more open minded to different treatment techniques.

The patient presentation was quite different to what I had expected. There was a much more pronounced population of chronic, central pain patients. This population required me to alter my treatment approaches. I gained a lot of experience in the education and self management component of a treatment session. My supervisor showed me various home exercises and pain relief techniques that I was not previously familiar with. For example the use of a walking stick for self massage of the shoulder and neck region. I also found that there was a large Middle Eastern population that attended the clinic. This was very culturally challenging as my patients were often unfamiliar with colloquial terminology and had a very different understanding of the human body and movement. I had to find more simplistic and precise instructions for these patients. I also found it very difficult to gain the trust of these patients. I needed to do a thorough subjective assessment, and ensure that I informed my patient of why I was performing each technique. One skill that I did improve on was my ability to design an effective home exercise program around a patient’s lifestyle and activities of daily living. For example “Do this shoulder exercise every time you pray” (8 times a day).

Prior to commencing this placement I was concerned about the accuracy of my assessment. Previous feed back has been consistent with my tendencies to get excited about a diagnosis and rush through a certain part of the assessment. My supervisor at Bentley has spent a lot of time encouraging me to slow down my patient time, in order to gain an accurate assessment and a depth of understanding of my patient prior to initiating my treatment. During my end of placement assessment my supervisor explained to me that he felt I had really improved in this area and that my assessments and my reasoning had improved in accuracy over the final two weeks.

This placement was very different to my previous musculoskeletal theory and practical experiences. I feel I have finished these 5 weeks with more of an open attitude and flexible approach to clinical reasoning and planning. I am aware that there are many different techniques available to us as physiotherapists, and that each practitioner has unique preferences and strengths based upon their clinical experiences and background. On this placement I feel I have strengthened my soft tissue techniques and I have gained accuracy and depth in my assessment and analysis.

week 5: Proffessional behavior

SITUATION:
Patient A presented of 31/05/2010 two months post right medial collateral ligament rupture. Patient A was a young, athletic 22yo male. It was his first appointment at Bentley outpatient hospital.

TASK:
My task was to perform a subjective and objective assessement. In my subjective i would need the history of the trauma, any related history of knee pain, general health, social history and i would also need to find out what my patient's goals were in terms of work and return to sport. In my objective assessement i would need to assess gait, general function, palpation, ROM, Strength and proprioception.

ACTIONS:
I carried out my full subjective and objective assessement as above. I then discussed my treatment plan with my supervisor. Before finishing the session i gave my patient some education on modyfying his exercise as appropriate and pacing himself with his daily activieties. I also went through two exercises for him to practice at home. The first exercise was a wall squat. I facilitated the correct foot position and palpated his VMO to check he was getting a co contraction of his quadracepts. The second exercise was a balance exercise in which i needed to facilitate glut medius. After i was happy patient A could perform the exercises correctly i booked him in for a follow up appointment in one weeks time.

RESULTS:
During the 'social history' conponent of the subjective assessement Patient A began to ask me questions about my study and practical experience. None of the questions were inapprpriate so i breifly responded to the questions and then returned the conversation back to my patient's general health. I had no difficulties carrying out the rest of the assessement and my supervisor was happy for me to teach the home exercises i had chosen. My patient performed the wall squat well with verbal feedback, however had difficulty with the balance exercise. I could see that patient A was not activating his glut med, as his hips were tilted and he was hyperextending his stance knee to balance. I facilitated glut med by putting his hips so they were on an even plane, prompting his knee to go into fifteen degrees flexion and slightly externally rotating the non stance hip. With this feed back Patient A was able to activate his glud med.

During the week leading up to patient A's consecutive appointment, i recieved a facebook email from him. The email was not harmful or threatening however i knew it was extremely inappropriate for a patient to contact me on a social level. It was quite clear that patient A had searched my name on facebook and seeked out my email adress. I informed my supervisor immediately of the situation and put all of my facebook settings on private so they were no longer accessible or visible to the public eye.

EVALUATION:
After this episode i realised that i needed to take more care with my body language and my approach to younger patients, in particular males. It was not that i acted inappropriately in this scenario, however what i realised is that it is sometimes necessary to adapt my body language, my approach, the type of questions i may ask my patient and the form of feed back i may give them for their exercises. For example whether i use verbal or tactile cues, or whether i use a wall for support during a balancing exercise or whether i use my hands. I also discovered that there are ways in which i can set the professional boundaries with my patients without having to discuss with them what is or is not appropriate conduct. I realsied i needed to change some of my strategies and methods of communication before my next treatment session with this patient.

STRATEGIES:
1: Body language: I need to have slightly less open body language and more formality in my approach. I think it is important to establish my status as a practitioner.

2: Verbal instructions: I need to direct the discussion more in my subjective assessement, so that when my patient starts to discuss anything non physio related i can quickly divert the discussion back to what is appropriate and relevent.

3: When giving feed back for the exercises i am choose to give less tactile feedback and more verbal prompts. The other option is that i can use a mirror for feedback rather than physically corrected the patients body position myself.

4: Ensure all of my email and facebook settings are on private and are not accessible to my patients!

Week 3: Communication

Situation:
Patient A immigrated from Egypt four months ago. She lives alone with her husband in a single storey house. Patient A was referred to the outpatient clinic for reveiw and management of her left shoulder pain after two recent falls. One fall involved a bus door closing on her and the other "tripping over the kurb on the road." Patient A had recent x rays indicating no fractures and an ultrasound in which bursal inflamation, a supraspinatus tear and biceps tendon thickening were detected. Patient A was accompanied by her husband.

Task
To complete a thorough subjective assessement in which i would need a detailed pain chart, the history of the incident, any relevent previous injuries, a social history and a thorough medical screening. Before commencing my objective assessement my supervisor requested that i come and discuss my findings with him and inform him of my intended approach for my objective assessement.

Actions
I chose to start with the history of the incident. this required me to ask detailed questions about both falls. I not only required the details of the mechanism of the fall, but also the management of the injuries immediately after the incident. After i was satisfied with this history i progressed on to the body chart. I started with the left shoulder and then allowed my patient to inform me of the other aches and pains she was experiencing associated with the falls. From the pain chart i went into a social history. I asked about my patients current living situation, employement, hobbies and daily activities. After i had attempted to get a medical history, i informed my patient that i was going to speak with my supervisor and that i would return to continue the assessement very shortly.

Results:
From the start of my subjective assessement i knew that the language barrier was going to interfere with me retrieving the information i required to make an accurate diagnosis. With the assistance of body language and a lot of questioning i was able to obtain a clear history of both falls. The first real problem i encountered was on the body chart. My patient seemed extremely eager to inform me of all her aches and pains. It was however very difficult to distinguish which pain came from which fall. My patient had difficulty describing the nature of the pain. She did not understnad words such as ache, pulling, dull or sharp. With the assistance of her hands and facial expressions i was able to assume the difference between the three main pains that she was experiencing. Patient A also had difficulty describing the aggravating factors. She appeared to have difficulty conveying which activity brought each different pain on. All of the pains seemed to blur into one. Patient A gave me a very brief social history, in which she revealled she did not work but had been studying english at tafe untill recently. She did not reveal any hobbies and her daily activities consisted only of housework and an occasional visit to the shops. I had a lot of difficulty getting a medical history of my patient as she did not understand any medical terminology. My discussion with my supervisor took longer than expected. When i returned to the room to continue my assessement 15 minutes later, my patient had left and was sitting back in the waiting room with an angry husband. I apologised for the wait and after gaining consent again, directed my patient and her husband back into the treatment room.

Evaluation:
This patient was particularly challenging as i not only had a cultural barrier but also a communication barrier. When i was asking questions for my body chart i needed to make it clear that we would discuss one pain at a time. I feel this directed approach would give me more accuracy in my assessement and more detail of each different pain. As my patient was new in the country and was unfamiliar with australian culture and lifestyle i feel i should have probed into my patient's social, cultural and religious background a bit more. I feel this would enable me to engage with my patient and give me a better understanding of their 'pain' experience.The next thing i need to monitor is the explanations and instructions i give to my patients. My patient's husband decided that she should leave the treatment room as the session was completed. As i later discovered, in muslim culture the husband is the authoritive figure. Therefore i needed to explain to the husband who was waiting outside, that i was going to speak with my supervisor and that i would return to continue.

Strategies:
1: I need to identify that there is a language barrier early in the assessement and organise for an interpreter to sit in on the session and assist with the communication
2: I need to do do a more thorough social history to engage with my patient. In this case i had no understanding of their culture, religion or way of life. This information is crucial for me to gain trust from my patient and design an appropriate home exercise program for their lifestyle.
3: I need to be more specific with my body chart and work chronologically through each pain, rather than discussing them all at once.

Week 1

Situation
Patient A was referred to the Bentley outpatient hospital by the pain clinic with request for a graduated exercise program for ongoing and progressive lower back and right hip pain secondary to osteoarthritis and fibromyalgia. Patient A is on the disability pension and had an extensive medical history of depression, sleeping difficulties, vertigo, tinnitus, left upper limb lymphodema post left mastectomy in 2002, chronic ongoing pain over the left scapular region and narrowing of the c5/c6 resulting in a progressive right radiculopathy for the past fifteen years. Patient A underwent facet joint injections for her chronic lower back pain one year ago with no success. She is on numerous medications and regularly takes antinflammatories for her back and hip pain however has never previously recieved physiotherapy services. During the subjective assessement patient A described herself as an obssessive personality. She lives independently in a one storey house and recieves help for domestic activities from her daughter. She explained recent difficulties with her daily cleaning and vacuming regime as her daughter has returned to full time work, and her pain levels do not enable her to do the daily cleaning. Patient A has relatively low activity levels outside of her cleaning regime, she stopped gardening one year ago and only takes occasional 20 minute walks outside. Patient A explained the only two things that helped ease her pain was a forward supported sitting position with her arms fixed and heat. Objectively, i could not find a preferential movement direction during the active range of motion assessement. All movement was painful. Patient A had a slow waddling gait and a slight right trendelenburg. Sit to stand and stand to sit was slow and difficult with alot of assistance from her upper limbs and very poor quadricept control. Patient A also had difficulty moving in and out of supine as she could not move through sidelying due to her hip pain. I did not perform an accessory or passive physiological intervertebral assessement.
Task
To educate my patient on pain management techniques and discuss the goals and intentions of a graded exercise program. I then needed to choose an appropriate starting point for the mobility program in which the patient would be challenged but would not cause her pain levels to sky rocket.
Actions
I started off by educating my patient on different methods of handling her pain. I explained that it is better to take lots of breaks throughout the day rather than taking a bust boom approach and doing too much and then needing to rest for two days, i wanted her to take regular breaks before her pain peaked. I advised use of a heat pack throughout the day and as her pain levels would usually increase mid day and throughout the afternoon, i suggested she break the day up with a hot shower. Patient A was concerned that "her leg joints were stiffening up and she was not getting enough exercise" as she could not walk on days when the pain was bad. I suggested an unloaded mobility routine she could do when the pain was restricting. I adviced foot pumps, active knee extension and hip flexion in sitting. I then needed to device a mobility program for her lower back pain. This was particularly difficult as all movement caused her pain to jump straight to a 7-8/10. I finally decided to put my patient in crook lying where she could do gentle lumbar rotation, flexion and pelvic tilts.
Results
Patient A agreed that she needed to break up her daily activities with more regular breaks howver she was concerned that it would be difficult not to let her pain peak as some days the pain would go straight to a 9/10 as soon as she commenced activity or before she had even started. Patient A was very happy with the seated lower limb exercises and responded well to the light lumbar mobility exercises in crook lying. She then informed me that it would be impossible to perform the lumbar exercises on her bed as it is a water bed and her couch is too small to lie on so she did not have anywhere in the house to perform the exercises.
Evaluation
I decided that i would somehow need to give my patient a means of objectively monitoring her pain scores and her breaks so that she could ensure her pain did not reach a peak throughout her daily activity. Patient A and myself her both happy with the alternative to walking when the pain was bad, as seated lower limb range of motion exercises would enable her to sustain lower limb flexibility without further increasing her pain. I did however have a conflict with the lumbar exercises. I knew the floor was not an option as patient A was currently unable to get down and back up from the floor. The only option i had was to change the position she performed the exercises in. I decided to adapt the lumbar flexion, rotation and pelvic tilts to a seated position. This required further feedback and correction of body position, however it was relatively pain free for my patient and she was still getting the same benefits from the exercise.
Strategies
1: I used a two point pain discrimination rule where by Patient A was only allowed to carry out activity or exercise if her pain was below or equal to 5/10. Once the pain got to 7/10 she needed to sit down, have a rest and apply heat if necessary untill the pain dropped back to a 5/10. This strategy will enable my patient to monitor her pain scores and stop her from letting the pain peak during activity.
2: Have the flexibility to adapt my exercises as necessary. This may mean a change of body position or a change of equipment. It is important that i make the exercises easy and accessible to the patient, otherwise they will not be performed.

Initial Entry

One week prior to the commencement of my Bently Outpatient placement i have attended an orientation and made contact with my supervisor. As this is my second musculo skeletal placement, my own expectations have changed. I have increased expectations of my level of clinical reasoning, my time efficiency in managing my caseload and the accuracy and effectiveness of my techniques. During the orientation day my supervisor discussed our caseload and the plan of attack for the first week. I will be seeing on average two to three patients per day for the first week and consulting my supervisor inbetween my subjective, objective and treatment sessions. This is a lot more supervision than i have previously recieved on placement, it is also a much smaller caseload than i would normally manage in a day. I expect that my caseload will gradually increase over the five weeks and that i will become more independent with my assessement and treatment sessions.

As it is an outpatient hospital ward i am expecting to be seeing a mixed presentation of musculoskeletal patients, orthopaedic patients, maybe some cardiorespiratory and even postnatal patients. As in previous placements i expect to be constantly referring to text books and journal articles to reveiw the relevent material for the different presentations.

During my orientation day my supervisor went through our initial patient assessement form in thorough detail, explaining the detail he will be expecting. My supervisor explained that he is looking for a very thorough and accurate subjective and objective assessement rather than speed and efficiency. Throughout my previous placements my feedback has been consistent with excellent time management and clinical reasoning however i need to ensure that my assessements are more thorough and that i don't jump to a diagnosis too early. I am concerned that i am going to find this very challenging during my Bently placement as i will have more supervision and input from my supervisor than previously and i will be constantly challenged to dig deeper into the patient presentation and do a thorough assessment before i diagnose.

The Bentley hospital seems like a very friendly and welcoming environment, i have no concerns that i will enjoy my placement there. I hope that throughout this five weeks i can take my musculoskeletal knowledge, my clinical reasoning and my practical skills to a more advanced level. I am hoping to get a few complex patients to challenge my clinical reasoning, i intend to hone my soft tissue and mobilisation techniques and work on the depth and accuracy of my assessments.

Final Entry

On completing my 5 weeks in Broome, my rural experience at the hospital was very similar to what i had anticipated. The Broome hospital was an extremely friendly environment. It had a very multidisciplinary approach to the care of all patients in both the inpatient, emergency and out patient wards. At the commencememnt of every day there was a half an hour hand over meeting held with all members of the team from the speech patholologist, pallitive care nurse, occupational therapist, physiotherapist and the doctors to a surgical representative. This is quite dis -similar to the handover's i have recieved at my metropolitan placements where the day was usually started with a quick summary from the nurse coordinator, and there was no liaison with other practitioners unless specifically requested by the doctor in charge.

As predicted i gained exposure to so many different feilds of physiotherapy. This was the first placement where i felt i was required to utilise all of the information i have gained over the last four years of study from paediatrics and womens health to musculoskeletal, orthopaedics and cardiorespiratory. I was pleasantly suprised to find there was a maternity ward at the hospital so i would be required to do postnatal assessments. I was constantly referring to text books and notes to refine my knowledge and skills. Unfortunatley i did not get the opportunity to do any rural home visits, i did however make up for this by getting out to different local communities to explore on week end camping trips.

As i had expected, i was required to use my initiative constantly on this placement. My supervisor and the other members of the physiotherapy team were always available if i had any questions, however i was mostly treating and assessing my patients independently. I started off with quite a light caseload, allowing myself a full hour for all of my outpatient appointments. By the end of the placement my treatment sessions had become far more effective and efficient so i was able to increase my caseload.

One of my concerns prior to the commencement of this placement was my lack of exposure to aboriginal culture. I was previously concerned that my cultrual naivty would interfere with my subjective assessments. One of the best experiences i had was treating a traditional aboriginal elder. The patient presented with chronic right sided shoulder pain. When i asked him to describe the pain, he explained to me what happened to the wind, the birds, the colour and the noises of the sky when a storm was coming. The patient taught me that it is sometimes easy to use language my patient is familiar with rather than terminology he has never heard before. As i became more familiar with aboriginal culture and the common colloquial terms, i began to find communication with some of my aboriginal patients alot easier. I also discovered that my observational skills were very powerful, and i could gain alot of information just from watching my patients movement.

This was a fantastic placement that went far and beyond my expectations. I experienced life in a rural community, gained experience in all feilds of physiotherapy and engaged in aboriginal culture and tradition.

Initial Entry

One week prior to the commencement of my placement in Broome i have made contact with my supervisor and read through the details on posted on the clinical mix form and power point presentation. The brome hospital is described as a very friendly environment with only a small physiotherapy group of four practitioners. I am expecting this to be a real "rural" hospital experience in the sense that i will have exposure to all different feilds of physiotherapy and will need to draw upon all of my knowledge and sources throughout the five weeks. My supervisor has confirmed that i will be treating and assessing both in the inpatient and outpatient wards on a daily basis inclusive of one or two rural home visits.
On the impatient ward i expect to be practicing my cardiorespiratory skills and using my background in orthopaedics and gerontology to prescribe aids manage post operative orthopaedic presentations. On the outpatient ward i expect to be applying my musculoskeletal theory and practice to a varied caseload of both chronic and acute presentations. I envisage the home visit to require an indepth environmental assessment, an evaluation of the most effective treatment method and the ability to design a personalised, challenging but acheivable home program.
In regards to the structure of my placement, i think that given i will be working in two different wards with a small team, it is likley that i will recieve less supervision than i have in other metropolitan facilities. This may require me to use more initiative and refer to my books or research .
My role as a student physiotherapist initially will be treating and assessing a varied caseload of both inpatient and outpatients. I will liase with both the physiotherapy team and other members of the multi disciplinary team. It will be my job to familiarise my self with settings and the routines of the different wards, gradually increasing my caseload as i gain increased efficiency. I will need to use my initiative to undergo any required research or readings. Finally i think it is my role to engage with the indiginous culture, and discover the customs and traditions that may effect my communication with patients and my treatment effectiveness.
During this placement i am a visitor in a new and unfamiliar town. I am going to be exposed to many new traditions and cultural experiences both on campus at the broome hospital and off campus in the town. I am concerned that i may be out of my comfort zone in such a new environement. Whilst i am excited about the cultural challenge, i am also concerned that my lack of exposure to indigenous culture will limit my ability to communicate efefctively with my patients. I am looking forward to the challenge of such a mixed caseload and having the opportunity to compile all of the knowledge i have gained over the last three years into one placement.

Final Post

I have thoroughly enjoyed my placement on the general surgical ward at Royal Perth. I have had exposure to a number of different surgeries; abdominal and bowel surgery, reversal of Hartman’s, breast mastectomies and many more. As I predicted, there was a file with all of the surgeries and post operative protocols in the physiotherapy office that I could consult prior to any of my assessment or treatment sessions. At the commencement of my placement I had approximately 6 patients to assess, review or treat daily. After each I would consult my supervisor as to my results, my analysis and my plan for the patient. This method of working enabled me to work independently with the patients, whilst my supervisor gave me feedback on my performance and guided my reflective thinking process. By week two my caseload had increased. I only consulted my supervisor on difficult patients, at the end of the day we would briefly go through my notes whilst I gave a verbal handover. By week three I had started to see some more complex patients of whom often had post operative sepsis or other post operative complications, and many had acute confusion and cognitive impairments. These complex patients challenged me particularly when it came to discharge. I was constantly required to use my lateral thinking and investigative tools to decipher the best possible discharge plan. I was constantly liaising with other members of the multidisciplinary team to come to common goals for each patient. All of my prior concerns were resolved during this placement. I became extremely comfortable with weaning patients off oxygen and often found myself advising the nurses as to what may be more beneficial for each patient. For example instead of leaving a patient in bed of six litres/ minute via Hudson mask, I would advise the nurse to transfer the patient into a seat, and position them in an upright, supported position on four/litres/minute. Identifying and handling attachments became an automated skill after the first week. My manual handling skills were constantly improving throughout the placement however my planning of my transfers is one area that I noticed a significant improvement. As I became more familiar with the different kinds of surgery and incision sites I could provide better verbal and tactile cues to the patient. Another area that I was concerned about prior to this placement was identification of medications. Throughout my placement I was encouraged by my tutor and my supervisor to take note of the medications as soon as I entered the room. I liaised with the pain team when my patient’s pain levels were interfering with their post operative rehabilitation. This has been an excellent placement. I feel have gained not only theoretical knowledge but I have enhanced my analytical and interpretive methods and gained confidence in my practical skills.

Analysis and planning

SITUATION:
Patient A is a 38 year old female who was admitted to the general surgical ward with peritonitis secondary to pelvic ischemic disease. Patient A presented with severe abdominal pain, nausea, vomiting and no bowel movements. Patient A has a medical history of asthma, type two diabetes mellitus and an appendicectomy in 2008. Patient A is currently medically stable, one day post laparotomy. Patient A has been on a Hudson mask over night after refusing to keep the nasal prongs in. Patient A is resting in bed, asleep when I enter the room.

TASK:
This is my initial assessment of patient A. My task is to assess her chest and mobility. When I enter the room I will check the patient’s blood pressure and oxygen saturation. I intend on doing a quick subjective assessment. My objective assessment will then comprise of auscultation, cough assessment, chest palpation and a mobility assessment of which I will consider a transfer from supine lie to sitting on the edge of the bed and ambulation.

ACTIONS:
On entering the room I quickly checked and recorded my patient’s blood pressure and oxygen saturation. I then continued with a subjective assessment before prompting patient A to transfer to the edge of the bed. I provided assistance for rolling into side lying when she had difficulty. Patient A wished to transfer from side lying to sitting independently but required help with her upper body as she did not have the UL strength. I used a side lunge to assist. Patient A had difficulty taking deep breaths during my auscultation and refused to continue the assessment as the pain was too great. After completing my chest assessment I gave verbal cues to get patient A standing up and ambulating to the corridor with a moose trolley. I supervised as patient A ambulated to the shower with her moose. I then gave verbal cues to get her seated safely in the commode whilst she waited for the nurse.

RESULTS:
My subjective assessment concluded that patient A was very nervous about being in a hospital environment and very distressed about not having her family here for support when she was in such a foreign environment. Patient A was quite emotional and was obviously going to require a lot of encouragement and support to complete the assessment.
During the transfer to sitting on the edge of the bed, Patient A got very upset and angry when I gave her tactile cues, reporting that she did not want to be pushed and that she could manage it independently at a slow pace. During my chest assessment I did not get to assess patient A’s lower lobes posteriorly, as her pain was too great. After ambulating the patient to the corridor, I discovered there were chairs and oximiters cluttering the corridor space. When patient A had to navigate through the equipment with her moose she became uncomfortable and increasingly nervous resulting in a stooped posture and smaller steps. Patient A transferred from standing to sitting safely with one assist however, I had not informed the nurse that I was taking patient A to the shower thus she was left waiting on a commode in the shower cubicle for 10 minutes.

EVALUATION:
As patient A was nervous and distressed about being in a hospital environment, she was not going to respond well to tactile cues. I needed to use much clearer, simple instructions and provide the patient with a visual demonstration of what was required to minimise the use of tactile prompts. With full knowledge that patient A had eight out of ten pain at rest, I should have insightfully considered the potential difficulty of completing my auscultative assessment.
Arriving at the corridor to find a cluttered space is potentially a safety hazard. I could not leave my patient to clear the walkway however there was not enough space to walk between the objects. This meant that I had to ask the nurse near by for assistance to clear the space.
The next problem I encountered was due to a lack of communication. Leaving a patient sitting in a shower cubicle for 10 minutes waiting for the nurse is not a positive experience. I should have informed the nurse that I was taking patient A to the shower before I got her up so that the nurse had time to get organised.

STRATEGIES:
1: Apply the knowledge I have gained from my subjective and objective assessment to determine how the patient will best respond to instruction. This may include verbal, tactile or visual cues. In this situation I needed to use visual rather than tactile cues. For example demonstrate a transfer from lying to sitting.
2: If the patient is likely to be non compliant with my auscultative assessment, listen to the area I am likely to be most concerned about first. For example this patient had been lying in supine for two days they were likely to have poor breath sounds in their lower lobes.
3: I need to ensure that I check my working space prior to getting my patient out of bed. This means that if there is clutter or obstacles in the road, I can successfully clear the road without being a safety risk and having to leave my patient by themselves or asking for help from a third person.
4: I need to liaise with the multidisciplinary team in order to provide optimal treatment for the patient. For example, if I had informed the nurse of my plans prior to mobilising the patient, they would not have been left waiting in the cubicle.

INTERVENTION

SITUATION
Patient A was admitted to the ward on the 13/2/10 post laparotomy due to a bowel obstruction. He had a colectomy in October 2009, and has been transferred from Peel hospital post enema via the stoma. Patient A lives with his wife in Waroona, he receives CACP weekly for medication dispersion and stoma care but is otherwise independent with his activities of daily living. He enjoys gardening and usually ambulates without an aid. Patient A has a history of cognitive impairment. His wife reports, he has poor short term memory, suffers from anxiety and often requires assistance in orientating himself to the environment. When I entered the room Patient A was resting in bed with his wife sitting next to him.

TASK
After completing an initial assessment I had decided that my problem list for patient A was:
1: Reduced mobility
2: Decreased lung volumes
3: Decreased airway clearance
My goals for the treatment session were to ambulate patient A with one assist, teach patient A deep breathing activities such as ‘active cycle of deep breathing’ and demonstrate a supported/ assisted cough.

ACTIONS
To commence my treatment session I explained what we would be doing today and gained consent. I assisted my patient to transfer to sitting on the edge of the bed. Patient A managed an independent sit to stand and then ambulated approximately ten meters. As Patient A’s oxygen saturation was only 89 % on three litres/ min I had decided to ambulate him with portable oxygen.
On return from the walk I tried to teach patient A an active cycle of deep breathing to improve his lung volumes and aid his air way clearance.

RESULTS
Once we had got 10 metres away from the bed, patient A took off his nasal prongs and refused to put them back on. Patient A then attempted to sit down in the middle of the corridor where there was no chair. I used a cross brace to force Patient A into hip extension so he could not sit down and tried to convince him to put the oxygen back on. Patient A became very distressed and anxious, his breathing pattern increased and when I checked his oxygen saturation it had dropped to 85%. I called for a nurse who came in behind him with a commode so that he could sit down. It took me 15minutes to convince patient A to put the nasal prongs back on, by which time he had desaturated further to 83%. I put him on a Hudson mask at 6 litres/ minute and tried to teach relaxed breathing. I then monitored the patient until his saturation was back at 95%. Patient A had difficulty following instructions and was not compliant with the exercise after I had demonstrated the technique. Patient A’s wife attempted to convince him to partake in the breathing exercises and explained that “the physio’s” were here to help him. Patient A in return got aggressive towards his wife and became extremely emotional. By this stage patient A refused further treatment for the day and his wife left the room in tears.

EVALUATION
Patient A is a very complex patient. I feel that the most significant problem is his cognitive impairment and anxiety. I needed another physio with me when I ambulated this patient as his behaviour was unpredictable and I did not feel it was safe to have only one assisting. As my patient had difficulty following my instructions I need to have more succinct, direct commands. I also feel it would have been better if I asked the wife to step out of the room during the treatment session. This would have hopefully minimised the emotional stress contributing to patient A’s non compliant behaviour. Patient A could not understand the thoracic expansion or relaxed breathing exercises when demonstrated or cued. His response to the instructions was to open his mouth wide and start gasping for air, resulting in a shallow and ineffective breathing pattern. I may need to try an alternative method of increasing his lung volumes such as incentive spirometry. This would stop Patient A from gasping as he would have a closed seal around the mouthpiece. I also feel that patient A will benefit from goal orientated exercise such as “first ball to the top, and see how long you can keep the second ball in the middle” In fore sight I did not go into this session prepared to manage someone with a cognitive impairment and I certainly did not tailor my treatment for my individual patient.

STRATEGIES
The first strategy that I will work on regards my communication. I am going to avoid open questions as patient A has poor short term memory and gets confused about his facts, which then upsets him. I will ask only closed questions such as “do you have pain?”
The second strategy regards my delivery and phrasing of verbal cues. I need to give very direct, firm cues to avoid confusion.
The third strategy is a method of motivating patient A to ambulate and keep him focused on the task. I am going to try goal orientated ambulation. For example “we need to walk to the shower”. “We need to practice walking so you can get around the garden”

First Entry

Situation
Patient A is a seventy seven year old male who was transferred to the general medical ward three days ago after undergoing his second laprotomy complicated by adhesions in the pelvic region. I was instructed by my supervisor to complete a full cardio respiratory assessment of this patient and record my findings in the integrated notes. Patient A had been resting in bed for 3 days, he had and indwelling catheter, Hudson mask, and intra venous tubes in his elbow. Patient A was dressed in a bed gown under his covers with the privacy curtain open.

Task
Prior to entering the room I was asked to plan and record my investigative assessments. My list included:
1: I needed to make observations regarding the patient’s level of alertness, and interaction. I also needed to record my observations of patient A’s breathing pattern, attachments and bed position.
2: Check the bed chart for his latest statistics.
3: Check his oxygen support and his current oxygen saturation
4: Perform auscultation and record my findings for each lobe of the lungs.
5: Palpate his chest and document the movement.
6: Check the computer for his most recent chest X ray, and study it for any potential indicators of pathology in the lungs.

Actions
Observations: I observed and recorded all of the attachments. I made note of my patient’s breathing pattern and bed positioning. I also noted patient A’s level of alertness and response to vocal instruction.
Statistics: I remembered to check the bed chart for patient A’s statistics, however I forgot to record what time the last measurement had been recorded.
Oxygen: I noted that Patient A was on a Hudson mask and recorded the dose delivered. I did however forget to do a quick reading of his saturation prior to continuing the assessment.
Auscultation: I successfully listened to all lobes of the lungs and recorded my findings. However I forgot to instruct my patient to cough prior to commencing.
Chest palpation: I palpated for both bucket and pump handle action.
Chest x ray: I successfully orientated the x ray, identifying the structures and looking for abnormality. I diagnosed right middle lobe consolidation.

Results
When I entered the room I noticed Patient A was particularly drowsy and unhappy to have visitors. I would need to alter my assessment if he was not complaint.
From my observation I already knew my patient had an increased respiratory rate and upper chest breathing pattern. As I had checked his statistics I knew his blood pressure, heart rate and haemoglobin were within normal limits so he would be safe to ambulate. I identified the strength of the breath sounds in each lobe and noted inspiratory crackles in the right middle lobe. My chest palpation confirmed my findings from my observations of his chest wall movement. My chest x ray findings supported my auscultation findings.

Evaluation
As I did not note the time that the last statistics were recorded it was not an accurate measure. If the statistics were taken 2 hours ago then it is likely that the patient may have deteriorated and would not in fact be safe to ambulate. As I did not check the saturation prior to the assessment, I did not know how patient A was coping with 6 L/minute. If he had desaturated during my assessment he could have gone into respiratory distress. As I did not ask my patient to cough prior to auscultation, the crackling that I heard in the right middle lobe could have been due to secretions that patient A was capable of clearing, thus making my assessment inaccurate.

Strategies
When checking my statistics I need to ensure that I note the time they were recorded. If the latest entry is not recent then I need to reassess the statistics myself. I need to measure the oxygen saturation at the commencement of my assessment and then continuously check throughout the session. Prior to performing auscultation I need to ask my patient to cough. Finally, after speaking with my clinical tutor about analysis of chest x ray’s I feel I need to have a more methodological approach to the investigation. Instead of jumping to conclusions about the pathology I need to identify each finding and describe what I am seeing.

Intitial Entry

My first placement is on the surgical specialties ward in RPH. I suspect that i will be exposed to a number of different surgical procedures over my five weeks at RPH and will be expected to familiarise myself with the individual post operative protocols for each. I have read through the procedures, precautions and contraindications for each surgical procedure that we covered during our cardiorespiratory unit, i am however expecting to be given access to a file regarding specific protocol instructions for each individual surgical operation.
As a fourth year student I expect my role will be to independently manage a caseload, performing assessement, treatement, ongoing management and a discharge plan for each patient. One of my concerns is my lack of exposure to a an inpatient hospital setting. I am nervous about identifying the different attatchments. I am also nervous about giving patients oxygen support, deciding what settings are appropriate for the patient and whether the patient is safe to mobilise without it. Throughout the semester we had alot of discussion about weaning patients off oxygen. I am concerned about my role in deciding when the patient is ready, and how quickly they should be weaned off the support. My next concern regards my ability to plan how i will mobilise the patient out of bed, using my manual handling skills to ensure that i do not put any stress on the incision site. My final concern is in regards to my ability to identify the medications that each patient is on and use my knowledge of the adverse effects to plan and adjust my treatment sessions for a safe and more effective session. In order to achieve this, i have tried to familiarise myself with some of the more common names and will continue to build on this repertoire as i come acome across more medications. I am looking forward to using my theoretical cardiorespiratory knowledge and applying it to post surgical patients with various medical histories, co morbidities and post surgical goals.