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.