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.
Thursday, March 18, 2010
Friday, March 12, 2010
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.
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.
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