Final entry

WOW i cannot believe five weeks is over.
I thoroughly enjoyed every moment i spent at RPH in ward 8 and inpatient orthopaedics. I feel as though i was very lucky to have a young and vibrant physiotherapist as my supervisor because she made our time enjoyable and made me aware of how physiotherapy can be such a rewarding and enjoyable profession.
I feel as though the most valuable skill i have learnt as the result of the placement is how to effectively communicate with patients and to develop rapport. I feel this is so important because it makes your time more enjoyable, interesting and has massive implications on your assessment and treatment of patients.
Secondly i think i have been very lucky to participate in this placement because i feel very orientated to take on my next placement in a hospital/ orthopaedics. I feel confident with completing legible, correct soapier patient notes; Assessing patients and taking appropriate objective measures to monitor progress; Developing appropriate treatment based on patient goals and problem list; communicating with staff and i suppose negotiating the hospital environment.
Finally i think it has been very beneficial to my clinical reasoning because i have been having to work independently with patients and always consider WHY i am doing something and the implications it might have. Working with some multi trauma and orthopaedic patients really puts you on the spot and helps to develop my clinical reasoning
Although 5 weeks is a fairly long time i felt as though i could have made so much more out of the placement if i put more time/effort into reflecting on my own work, especially in regards to treatment and assessment of the patient. I felt very stressed towards the commencement of the placement affecting the time i had to spend time on extra reflections.
Overall i really enjoyed this placement and being a physiotherapist.

week 5 - friday

Today i had to prescribe a new patient her bed exercises. Usually this is a very simple procedure and most patients if cognitively aware remember the exercises and are capable of completing themselves as they please. I had difficulty with the patient today initially because i couldn't wake her up. This patient is very deaf and removed her hearing aids. When i woke her with a grasp of her hand she kept going back to sleep and when i asked to to put in her hearing aid she tried but did not seem to know what she was doing. I figured i would leave her and return in 30mins. On return she was still sleeping deeply and the nurses wanted her awake and in her chair. so it was up to me once again to get her going. i was curious as to why this patient was so drowsy at midday and checked her med charts which noted she had opiods this AM. I managed to wake her up and nurses helped to put on her hearing aid. Finally i was able to communicate with the patient but she appeared very confused and delirious. Due to this i decided to alter my treatment plan and just do the simple exercises (ankle pumps and circles, glut squeeze and static quads) and assist with the transfer to chair. I decided on only doing the simple exercises because i did not feel that she would understand or follow instructions sue to her current state of mind. I think this was good thinking on the spot and meant the patient could sit up have their lunch and rehydrate, so i could return later to run through the program.
I think that initially i could have asked for assistance with fitting the hearing aids which would have helped to engage the patient and allowed me to manage my time more sufficiently because i would have been able to sit the patient up and given her time to settle and be aware and not confused by the time i returned.
The major problem was that i did not get time in the PM to return and run through the exercise program with the patient because it was a LAD(low activity day) and RPH, which means that she will have not do any exercises over the weekend which may effect her progression and the amount of time she spends in hospital.
In future i would need to adopt new strategies to engage the patient and gain consent in order to promote a more positive outcome for the patient. One strategy that i might trial would be to wake the patient, sit them out of bed and get a cup of tea of coffee for them to sip on until you return which will give them time to wake up and be fully alert and orientated before commence therapy.
Unfortunately i don't have any more chance to adopt new strategies just yet because its my last day but this journal will be ever so helpful to reflect on before the commencement of 3rd year placement.

Week 5 - tuesday

Today a patient i have discussed previously during my blogging has a pneumonia. I was initially concerned about this issue with this patient because she was a very high risk due to the patient being poorly motivated with mobilising and non complaint with her bed exercises. I felt slightly responsible because she was under my care but i think it was inevitable. The main reason being because she couldn't complete her exercises without supervision because she had no reading glasses and although i did supervise her bed exercise program on occasions it was difficult because she was poorly motivated and non-compliant and when usually i would prioritise ambulating her with a wheeled zimma frame because mobility was the only thing preventing discharge. This was bad news in particular because it means her progress will go back to where she started and are looking at another couple of weeks rehab.
I wanted to reflect on this situation because i wanted to consider how we could have reinforced her exercises. I was considering putting a chart with her exercises on her wall with a notice to the nurses asking to encourage her exercises but this probably wouldn't solve the problem because she cannot read her exercise program but at least they could ask her to do ankle pumps, bum squeezes and bridging. And leave the more difficult exercises to supervise when i had the opportunity. I believe its important to come up with a good system that encourages patients to do there exercises because while this patients vision is a problem most other patients on he ward have dementia or other reason why they do not do any exercise, meanwhile elderly + bed rest will always have negative outcomes.
This is an area for me to discuss with my supervisor, shame it is so close to the end of the placement because it could have been an interesting project.

Week 5 - monday

I have been treating a patient which is a high falls risk and was previous to his hospital admission. He is another NOF patient. This patient has in particular has poor balance. His performance also fluctuates, in particular when he returns from dialysis, which he attends 3 times a week. He is very shaky and uncoordinated. Initially we have bee aiming our treatment at mobilising the patient safely but he fails to negotiate turns and corners safely. I also definitely think he has some cognitive problems because he needs to be prompted every time he is walked.
It will be simple to rehab this patient to his premorbid state but i think it will be very challenging to be able to send his home knowing that he is 'safe'! I think this is a massive challenge for the physio because while all the other parts of the medical team are happy to D/C a patient except for the physio because he has poor balance/ambulation which cannot really be effectively improved in the hospital environment anyway and he is possibly degrading due to excessive bed rest. Atleast at home he has social aspects to his life and will get up move around and be confident. Something that comes to mind for me is hip protectors atleast this way if he falls he will be protected to some degree, but they are very expensive and a doubt that this patient would comply to wearing them.
Meanwhile D/C is underway i have be assigned to carry out his balance and mobility training. The main techniques i have decided to use include balancing with eyes closed, balancing on foam mat, UL reaching and Functional ambulation with obstacles, figure 8's, outdoors etc. I think this is a excellent plan as it addresses all the components of balance and is not to time consuming. What i have had problems with is deciding on is an appropriate balance objective measure. Most of the balance Ax we have learnt are far to advanced such as bergs, step, Sharpened rhombergs. I decided on the TUG and Standard rhombergs which were decent objective measures and should allow me to track his progress.
Looking back on the treatment i could have used a more difficult task with UL reaching such as a heavy weight instead of TV remote (even though this is fairly functional). I would like to look into other objective measures which might be useful such as 360turn or FR test.
I feel fairly confident with managing this situation and have found it very informative being involved in the DC planning for this patient.

Week 4 - friday

One of my patients is very difficult to get motivated to do anything. She is very old and has an extensive medical history which includes lung cancer and IHD, t2DM, glaucoma, dementia, depression/anxiety, current smoker etc. furthermore this lady is very frail. She was admitted to my ward following mechanical fall and fractured NOF which was surgically managed with a DHS. Furthermore this patient is very frail. I have found it almost impossible to find a goal that can be used to motivate her to participate with physiotherapy because she lives at home by herself and has no hobbies or interests except smoking and watching tv. Furthermore the patient has no family and no friends. The main problem preventing her from going home is mobility because she needs to be independant with most ADLS. Motivation and pain is limiting her mobility. I feel concerned because the bed rest has already been and issue with bed sores and will have other consequences.
The patient is not compliant with exercise primarily because she cannot read her program due to poor vision and has no reading glasses. On most occasions when i visit this pt i run through bed exercises but it is very time consuming. The most important part of my treatment is to mobilise this patient and keep her on her feet but she often initially refuses therapy.
The only motivational tool i have to use is to encourage her participation in physiotherapy is that when she is safe to walk she can return home. This is an okay goal because you can base treatments around such tasks as walking to the bthrm etc. I have been using this as a motivational tool to ambulate her to the bthrm although it usually takes time to convince her. I think that it is very painful for her walking on the zimma frame.
I would like to walk her on the PF to encourage her walking further distance and to maintain strength in her legs. This would also be a good plan because it may help the patient realise they are progressing and achieving something significant. i look forwd to altering my treatment tomorrow.

Week 4 - tuesday

I found it very challenging today managing a patient that doesnot speak English as a first language. It was difficult to gain any subjective information from the patient and almost impossible to gauge an accurate level of pain that the patient was in. Although it was difficult to communicate he understood basic questions such as where are you, what is your name etc so it was possible to gauge cognition. I was able to encourage deep breathing and cough through demonstration which i found was fantastic. The main problem was with mobilising the patient and required 2 assist as prompting was not effective. This demonstrated to me the importance of clear concise instructions and feedback amongst other learning strategies that can be utilised through verbal communication.
Ambulating the patient was the final hurdle. It was particularly difficult because i was not sure how much pain the patient was in and had to gauge whether he was dizzy or unwell ect. i decided to use the PF to begin with because i thought this would be safest with 2 assist and the most efficient for the patient.
Overall i felt as though the situation was managed well and i felt confident to report in his notes. In future i think an excellent tool to use for the patient would be the VAS or BORG to be able to assess how the patient is feeling and even monitor BP, HR etc in supine vs sitting vs standing.
I am really enjoying being able to learn from such a vast variety of patients on the placement and look forwd to tomorrow.

Week 4 - monday

Today i was very happy because i felt i carried out an excellent initial assessment of a patient in particular i felt i communicated well with the patient. But there were a few pitfalls which i would like to reflect on. Previously to seeing the patient i covered the notes thoroughly and felt confident to handover any information from this patient. One item i thought was interesting was that he was required to wear a Richards splint post-op. Before approaching the patient i should have made myself aware of the splint the reasons for its use, and fully understand the equipment because when i was bombarded with questions such as when can i take it off, how do i know what position to put it in, do i need to use this strap i could have answered such questions. Because i couldn't answer any questions i made sure i asked my supervisor before informing the patient. I thought i acted appropriately but i could have developed alot more confidence of the patient within me if i had looked into his equipment before i approached him.
Another mistake i made was to measure the ROM and swelling of his affected limb but did not measure the other side rendering the objective measures useless. i was fairly disappointed i forgot to do this as it is a part of our assessment that has been mentioned to us students on many occasions.
Finally i mobilised the patient with bare feet which was ok but when i returned patient to his room i noticed he had shoes packed away in his bags. With this patient in particular because he needed to be taught a hoping gait and shoes are fantastic because they absorb alot of the torsion and compression through the leg. I explained to the patient in future to use his shoe when mobilising for these reasons.
overall the treatment was ok and i have made some small mistakes which i can learn from.

Week 3 - wednesday

I have been working particularly hard on developing my soapier writing skills. At the commencement of the second week i decided it was a major goal of mine to achieve by the end of this prac and i will be very happy if i can write excellent legible patient notes. Today i completed soapier notes for a patient i assessed this morning. I am beginning to find it easier to find descriptive words that correctly define the patients subjective feedback and general observation. It is becoming more obvious to me what information is important to include and the information that can be left out of patient notes. My supervisor has been helping me develop my soapier skills and gives me excellent feedback on every entry i put down. She is particularly keen on laying out your work sequentially and neatly that follows your steps though tout the interaction with the patient. The layout of patient interaction is particularly important and should be considered before approaching the patient in particular the equipment that may be required and the plan of attack (i.e what may be assessed in sitting or supine). In my notes today i had difficulty with describing auscultation and what i heard in the lungs. i discussed this with my tutor which was beneficial. Formulating a plan with priorities is another skill i am beginning to develop. For most patients on my ward it is mobility that is preventing discharge but it is important to look at the whole person and clinically reason why mobility is decreased and what goals can be established to get this patient back to normal.
I am beginning to feel more confident with my patient notes and clinical reasoning. Overall today was an enjoyable day and i look forwd to developing my soapier skills on the remainder of this prac.

Week 3 - tuesday

I have been treating a patient that is NWB on one leg and one arm. Yesterday i decided that using foot pedals would be an excellent exercise to address the patients CR fitness and decreased ROM LL. It is difficult to treat these problems because the patient cannot stand and is restricted with his UL function. I think it is important to address the patients CV fitness because he is a smoker and overweight. The patient was told that no weight was to be put through his left leg and that the pedals were to be pushed with R only. No resistance was set to the pedalling. The patient was very complaint and the exercise seemed to work well passively moving his left leg while working the right. I was surprised to find out today the patient reported pain in the right hip which must have been aggravated by the pedalling.
On reflection i still think that pedals would be a beneficial exercise but was ineffective because the intensity of the exercise was to high and the patient must have not adhered to the WB restrictions. I would like to trial the exercise one more time and encourage the importance of using the good leg only to pedal.
In future i would be more cautious with prescribing exercise to patients with pain++ because you donot want to halt progess/therapy.

Week 3 - monday

A beneficial aspect to my placement at RPH - shenton park is that i have been able to work in the hydrotherapy pool with a variety of orthopaedic patients. This is excellent as it further allows me to develop my clinical reasoning skills. I have learnt that when prescribing hydro exercises you need to consider the whole picture and reason fully why a certain exercise may be slightly more beneficial than another.
The hydrotherapy pool is a particularly useful tool for patients that are NWB to encourage walking, but i noticed many patients walking incorrectly. I was confident encouraging and assisting patients walking using a correct gait technique, in particular " heel through to toe" is a great way to encourage patients to ambulate 'normally'. One thing i did not encourage was weight transference. This could have been another tool or part of the exercise i could have used to progress the gait training and would have been effective and productive.
Furthermore gait training in hydro could be progressed other ways by adding distractions and disturbances to patients balance, OR combining UL exercise or scapula setting for example to progress the therapy. I would like o incorporate these ideas and more next week at hydrotherapy.

Week 2 - friday

This morning was an interesting challenge for me because it was my second chance to take on a new patient, carry out an initial assessment, formulate a plan and decide on appropriate treatment for the patient. Second chance means i get to improve on my first attempt. I looked at the patients notes to formulate a patient handover, a skill i am increasingly confident with. Working at RPH also gives me the opportunity to look at as many xrays as possible which i am trying to make the most of. Anyway moving onto the subjective assessment... which i think was fairly good. I feel much more comfortable already 'chatting' with my patient, which makes it easier to formulate the appropriate questions quickly. I also find it important to probe into the information which is important for the particular patient. I understand the importance of gaining a social history and that it is so beneficial to ask questions regarding this to begin with to develop rapport with the patient. I find it also useful to try and to relate to the patient in some way especially regarding their goals which is usually fairly simple. To improve my subjective assessment i need more and more practice to develop confidence and be able to think on the spot without pausing or checking my assessment sheet for which question needs to be ask next.
Also i need to explain certain things better to my patients such as the VAS.

Today was good, i feel like I'm slowly improving but there is so much to learn and it is very overwhelming.

Week 2 - tuesday

Today i learnt that dealing with an horribly aggressive, demented and anxious patient is more difficult than i thought. It is also frustrating for the therapist because they are capable of completing treatment program but simply not willing. Today part of the physio duties is to complete a mobility chart which acknowledges the amount of assistance a patient requires to transfer, mobilise etc. The patient had refused therapy previously but it was absolutely necessary on this occasion. The elderly patient was very anxious and aggressive which made everyone feel uncomfortable and made it almost impossible to develop any rapport with the patient. Overall the treatment was very fairly effective and the key was to use plenty of motivational strategies and explain the importance of her physiotherapy treatment. This way the patient understands the implications of non compliance and is still able to make own decisions. Physiotherapy needs to work both ways and consent is a massive issue here 'you help us, we help you'. If a patient still refused treatment then that is their decision and needs to be acknowledged. Overall treatment was effective and communication was a key. In the future it may be more beneficial to spend more time developing rapport with the patient which may aid cooperation. All the strategies learnt in geriatrics regarding cognitive deficit and Rx modifications become key skills for the therapist.

Today i learnt that yet again communication is the most valuable skill for a therapist to master.

Week 2 - monday

Today i was asked to prescribe a patient with an incentive inspiratory spirometer(IIS). I was fairly confident as my supervisor gave me a good handover and i felt i understood the reasoning behind using the spirometer well. I felt confident prescribing the treatment because i had previously developed rapport with the particular patient which made the Ax and Rx less confronting. I discussed the importance of the IIS with the patient and made it clear why the doctors hace prescribed and how it relates to his smoking and increased bed rest. I remembered to assess the patients cough which was dry and clear. I taught him how to use the IIS which is incredibly easy and challenged him to use it in a few different ways. I also provided the instructions to the patient to read as he has excellent cognition. To improve the treatment i could have combined the IIS with other deep breathing exercise such as the huff or TEE's. I could have also discussed how patient positioning can be combined with the IIS to improve its effectiveness. Next time i see this patient i would like to discuss these Rx modifications with him.

A second incident that occurred today involved the multidisciplinary team. There was a problem because a patient was discharged before the OT had arranged a home visit and for equipment to be fitted out in the house. This was a major problem because the patient was not fully independent and was unsafe. The problem occurred basically because of a lack of communication. This was an excellent learning curve and really demonstrated the importance of the TEAM approach to patient care.

Week 1 - wednesday

My clinical tutor put me on the spot today and asked me to carry out a full Sx assessment of a patient without any guidelines. Although she did choose a very friendly talkative lady which didn't make it so intimidating. I was initially concerned as was not sure which questions needed to be asked and how to ask them. On reflection i think my questions were appropriate to the patient presentation. I was initially concerned about interrupting the patient and using closed questioning to avoid patient rambling, but i did not find this to be an issue and it was generally easy to focus the patient on the topic with a simple question or comment. On the other hand i will need to develop good communication skills using open and leading questions as many patients on the ward are daffy and lack cognitive skill. Overall i thought my performance was good except i missed out on some important questions which my tutor brought to my attention. Most importantly i needed to ask questions regarding home living situation as this is the goal of rehabilitation for most NOF patients. One key lesson i learnt was therapist postitoning, because initially i kneeled beside the bed but as this got uncomfortable i had to interrupt the patient and excuse myself while i fetched a chair. In future i will properly prepare my environment.

Overall i felt fairly confident but i need to challenge myself myself to a different patient out of my comfort zone!

Week 1 - tuesday

This morning i found it very beneficial as my clinical tutor guided me through patient notes and skills required to communicate a succinct thorough handover. I found this was very helpful as understanding the pt.notes well allows for much better planning of pt assessment and treatment (especially with regards to Rx modifications and safety precautions).

An interesting aspect to my day occurred on the ward rounds. I found it a very beneficial experience watching the consultant geriatrician communicate with the patients in particular. The consultant spoke slowly and clearly and used layman's terms for the patient. He displayed good bedside manners and although rushed for time e introduced himself patients thoughts, feelings and mental state. He was always well positioned to talk to patients and displayed confidence and asserted his authority. I thought this was a useful experience to reflect on because these are all strategies i need to put into place while becoming comfortable communicating with and subjectively assessing patients of this age group.

Overall today was a positive learning experience.

Week 1 - monday

My first day was very enjoyable. I feel very orientated to the hospital and welcome in the ward. The ward has around 20 patients onboard and atleast half need to be seen by the physio each day. Emily our supervisor introduced us to most patients today and expects us to be able to SOIER most of these patients tommorow with assistance ahhhh! The skills learnt with annemarie in geriatrics should be very handy on this placement.

I would like to mention a situation from today. A nurse asked emily and myself for assistance to transfer a patient from supine onto a comode. This patient had cognitive difficulties, and didnt understand instructions at all. He was also very resistive to movement and very poor strength. the nurse mentioned he was high care and probably needed a hoist. Overall the transfer was fairly ineffective and the patient was uncomfortable and concerned. I felt also it was rushed and if i had planned the maneouver it would have be far more efficent. The main problem was that the patient had very poor posture while standing in the wzf which made it difficult for him to weight transfer, lift his feet and take steps (Both forwds and backwards). tactile stimulation would have assisted the patient with this task. Finally i think the hoist would have been a far more suitable transfer method and should have been properly considered.
When the same situation arises on another day i need to take my time to properly plan difficult transfers, aquire the correct amount of assistance and facilitate normal movement, which woul make me and my patients feel much more comfortable.

Overall today was an enjoyable experience and i am looking forwd to getting involved tomorow.

16 hours till placement begins

Im really looking forwd to my placement tomorow morning! After 2 years of hard work we finally get to go out and apply and consolidate some knowledge. Im really looking forwd to meeting new people, especially patients and also the experience of working in a hospital.

What makes me nervous is that im not really 100% sure of what is expected of me but hopefully this is something that will be cleared up on the first few days! Also dont wanna stuff up, which is a scary thought because i know already i am most likely going to do things wrong... but i just need to make sure i learn from any mistakes.

One thing i know i will be asked day one by my clinical educator is, what do you expect of me?
To me an efective clinical educator needs to be an excellent role model and stimulatemy interest in physiotherapy as all the ND staff have done over the past 2 years. Also they should be approachable, non judgemental and encouraging.


Describe how you see the physio woring with other physio and health care professional in the setting of ths clinical unit?
Im interested to find out if the physio specialises in the NoF ward or if they work in other area's also. I expect there to be a large medical team involved in NoF patients care because NoF injury is commonly associated with injuries. I expct physio and OT working closely together in this setting because discharge planning is so important to prevent deconditioning and decreased functioning of the patients.