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.