I was previously on an orthopaedic ward where I had an 80-something male patient who had undergone a standard protocol total knee replacement. Treatment however, was not so standard. As some of you know following replacements the patient is often on a spinal epidural and pain cover is a priority. This man however appeared allergic to opoids and his pain was poorly managed. Even trying to move him in bed caused him to cry, and that was at a week post-surgery (most knee replacements are in hospital 7-10 days). Not only this he would often ask why his leg hurt, or would forget who I was or what he did yesterday. I had to repeat instructions several times and demonstrate before he understood. Furthermore he would start sobbing for no apparent reason so loudly that the entire ward could hear him. Most on the ward assumed this unusual behaviour was from the pain medication and for a week I tried my best to increase his limb strength, ROM and mobility. The more i worked with him the more it became apparent that clearly he had an altered mental state. From his subjective history in notes and from him it appeared he had lived independently prior to this, and had been driving no less.
Finally his daughter came in and I asked about his social background. Turned out he lived with her and her husband, however they left for work at 6:30am and came home around 7:30, so he was alone all day and that sometimes she'd find him stuck in a room or not knowing what he was doing. When I informed her about his sobbing, she assured me that 'he always does that around the house'. not only this, she went on to explain that he self-medicates with panadol and alcohol. She appeared to believe there was nothing wrong with this, and asked me when he would be discharged. I informed a social worker and he was eventually discharged to ongoing rehab with a suggested diagnoses of alzihemers.
I learnt from this that although I am a student and it is easier to just 'go along' with the rest of the wards opinion, at times we do have to take it into our own hands and use our own initiative to find the cause of a patient's problems. Had this man been discharged home who knows what state he would have ended up in. Furthermore his family clearly had no idea of the care he required or of his mental state, or how much damage his 'self medication' could be doing him! It made me realise that we can't always take the 'notes' or more experienced allied health professionals, such as nurses, opinions as gospel, and that as students we also have a duty of care to our patients and have an obligation to investigate into every aspect of their care as required.
Wednesday, June 4, 2008
Monday, June 2, 2008
Building Rapport
Whilst on an elective placement, my communication skills were tested when I was required to facilitate the return of functional mobility to a teenage girl post burn injury. My skills were required not only to achieve the functional outcome of mobilizing my patient but to provide motivation and education in order to achieve my goal.
Due to poor pain tolerance, anxiety and poor coping strategies my patient was very reluctant to get out of bed to shower and toilet herself, let alone walk up and down the corridor and facilitate circulation and healing. Due to her age and anxiety of the unknown I found that education would play a vital role in my first interaction with her. By explaining to her the process of burns and their stages of healing, the importance of early mobilisation to reduce the risk of contracture and later functional limitations and allowing her time to process and ask questions placed her at ease. The next step was to provide some ‘orientation’ to what my role as a physiotherapist was, the expectations for daily treatment (what time, for how long) and exercises (bike, walking, squats etc) and the gym set up, reinforced to her what would be expected in terms of time and activities. I feel that this communication with her built up a good rapport and trust. This further led to some distraction methods of my ability to copy her words in a joking manner when correcting her “waddling like a duck”. If I hadn’t established a good bond with her through my communication and interpersonal skills, I would not have been able to adopt some of the treatment techniques and language used. The rapport built during that initial stage allowed me to gain her trust and compliance with my exercise program and resulted in successful mobilization and gait correction.
After this experience it reinforced that time spent with a patient providing education in some situations is more beneficial than our treatment itself as it can provide further long-term benefits via the patients compliance. Spending time building rapport with a patient is important and shouldn’t be overlooked.
Due to poor pain tolerance, anxiety and poor coping strategies my patient was very reluctant to get out of bed to shower and toilet herself, let alone walk up and down the corridor and facilitate circulation and healing. Due to her age and anxiety of the unknown I found that education would play a vital role in my first interaction with her. By explaining to her the process of burns and their stages of healing, the importance of early mobilisation to reduce the risk of contracture and later functional limitations and allowing her time to process and ask questions placed her at ease. The next step was to provide some ‘orientation’ to what my role as a physiotherapist was, the expectations for daily treatment (what time, for how long) and exercises (bike, walking, squats etc) and the gym set up, reinforced to her what would be expected in terms of time and activities. I feel that this communication with her built up a good rapport and trust. This further led to some distraction methods of my ability to copy her words in a joking manner when correcting her “waddling like a duck”. If I hadn’t established a good bond with her through my communication and interpersonal skills, I would not have been able to adopt some of the treatment techniques and language used. The rapport built during that initial stage allowed me to gain her trust and compliance with my exercise program and resulted in successful mobilization and gait correction.
After this experience it reinforced that time spent with a patient providing education in some situations is more beneficial than our treatment itself as it can provide further long-term benefits via the patients compliance. Spending time building rapport with a patient is important and shouldn’t be overlooked.
Teamwork
I am currently on my Cardiopulmonary placement in an Oncology Ward and it is here that I have come to realise the benefits of effective teamwork between staff.
This ward can often highlight patients’ misfortunes and times of grief, however these also often become uplifted by the strength and truly heroic nature of other patients. But the one thing that has stood out most since I have started on this prac, is the exceptional teamwork between the nurses, doctors and allied health team.
I started my placement on my supervisors first day on the ward, so we were both unfamiliar with the ward and its workings. The nurses and doctors were extremely helpful in showing us around and helping us out when we needed. We also tried our best to work all our treatments in with the nurses- checking when the patients were due to be showered so we could review their mobility or walk with them, letting them know when we would be walking/ exercising patient’s, ensuring timing of pain medication prior to treatments, notifying eachother of outside appointments (Xrays, CT scans etc) and keeping eachother informed about patients’ general status each day. This system has worked extremely well, as the nurses will now often ask us when we are free to walk a patient to the shower/ toilet, help to transfer them and let us know of any change in a patients status (mobility, chest symptoms) that we may need to review. They will also often ask us how they can help to carry on the benefits of our treatments, such as positioning and reminding patients of exercises. This sort of thing has also been the same with the OTs, dieticians, doctors (where one actually took the time to take me through a chest Xray and showed me a pleural drain procedure) and other team members.
On other pracs I have had, wards often run with everyone in isolation- where the main form of communication is through patient notes. I’ve found all the staff on my current placement to be so helpful and supportive of one another, that not only does it improve patient care but also team morale- which is so important on a ward like this.
The patient’s receive much more thorough care because everyone is aware of each patients’ most current status, which also ensures when patients are discharged nothing has been missed and we can all be confident the patient and their family will cope fine at home.
I think more wards should adopt this sort of teamwork, were everyone is involved and updated on the patients care. It has certainly helped to make our time more efficient- which is so important as time always seems to be precious!
Renae
This ward can often highlight patients’ misfortunes and times of grief, however these also often become uplifted by the strength and truly heroic nature of other patients. But the one thing that has stood out most since I have started on this prac, is the exceptional teamwork between the nurses, doctors and allied health team.
I started my placement on my supervisors first day on the ward, so we were both unfamiliar with the ward and its workings. The nurses and doctors were extremely helpful in showing us around and helping us out when we needed. We also tried our best to work all our treatments in with the nurses- checking when the patients were due to be showered so we could review their mobility or walk with them, letting them know when we would be walking/ exercising patient’s, ensuring timing of pain medication prior to treatments, notifying eachother of outside appointments (Xrays, CT scans etc) and keeping eachother informed about patients’ general status each day. This system has worked extremely well, as the nurses will now often ask us when we are free to walk a patient to the shower/ toilet, help to transfer them and let us know of any change in a patients status (mobility, chest symptoms) that we may need to review. They will also often ask us how they can help to carry on the benefits of our treatments, such as positioning and reminding patients of exercises. This sort of thing has also been the same with the OTs, dieticians, doctors (where one actually took the time to take me through a chest Xray and showed me a pleural drain procedure) and other team members.
On other pracs I have had, wards often run with everyone in isolation- where the main form of communication is through patient notes. I’ve found all the staff on my current placement to be so helpful and supportive of one another, that not only does it improve patient care but also team morale- which is so important on a ward like this.
The patient’s receive much more thorough care because everyone is aware of each patients’ most current status, which also ensures when patients are discharged nothing has been missed and we can all be confident the patient and their family will cope fine at home.
I think more wards should adopt this sort of teamwork, were everyone is involved and updated on the patients care. It has certainly helped to make our time more efficient- which is so important as time always seems to be precious!
Renae
Walking children
I am on my paeds prac at the moment. Most of the children have down syndrome and are delayed in their walking. I thought it was quite interesting that the Physios tend to not push the child to walk by assisting them to walk or allowing them to weight bear in a standing frame for instance. Treatments are performed in positions that the children can do independantly to improve their strength and control and hence the quality of movement when they eventually choose to walk. It sounds straight forward that you wouldn't push them to walk, but I never really thought about it in that way. One of the children I see was walking but with no control and no quality of movement because the parents wanted her to walk because they thought it was normal. We had to explain that standing their child isn't the best scenario even if at their age they should be walking. It made me realise that to get the best quality of movement, you should allow the child to develop through all the milestones even if you know they should be doing a particular task at their age normally. It's also important to explain to the parents the importance of this and pushing them to be developing normally isn't always the best approach.
Angel transfers
I was assisting the phsyiotherapist on my neuro placement to transfer a non weight bearing patient with Rhabdomyolisis into his wheelchair via an angel transfer. The wheel chair was a tilt in space chair which had a high seat and inorder to complete the transfer the bed had to be raised so that the slide board could be placed across the bed and wheelchair. The physiotherapist instructed me to place the patients feet on the foot plates of the wheelchair so that we could beging the transfer.
I was not happy with this arrangement as the patients feet would then be on an unstable surface as we transferred them. I then asked the physiotherapist if they were sure that I should place the patients feet on the footplates. He reassured me that this was fine. I was still not happy but decided that the physiotherapist had more experience than I did and knew what he was doing and decided to carry on with the transfer.
My instincts turned out to be correct and as we began to transfer the patient his feet slipped off the foot plates and he fell. Luckily we managed to break his fall and he was not injured but this experience left the patient feeling very anxious and nervous about transferring and his recovery!
From this experience I have learned that your instincts are extremely important and you should follow them. We have learnt how to complete activites such as patient transfers safely at uni for a reason and even if you feel a physiotherapist has more experience than you it is more than alright to reason your thoughts with them. It is alright to stop and question what you are doing or about to do as many times as you need. The patient's safety is of utmost importance in situations like these!!
I was not happy with this arrangement as the patients feet would then be on an unstable surface as we transferred them. I then asked the physiotherapist if they were sure that I should place the patients feet on the footplates. He reassured me that this was fine. I was still not happy but decided that the physiotherapist had more experience than I did and knew what he was doing and decided to carry on with the transfer.
My instincts turned out to be correct and as we began to transfer the patient his feet slipped off the foot plates and he fell. Luckily we managed to break his fall and he was not injured but this experience left the patient feeling very anxious and nervous about transferring and his recovery!
From this experience I have learned that your instincts are extremely important and you should follow them. We have learnt how to complete activites such as patient transfers safely at uni for a reason and even if you feel a physiotherapist has more experience than you it is more than alright to reason your thoughts with them. It is alright to stop and question what you are doing or about to do as many times as you need. The patient's safety is of utmost importance in situations like these!!
acute pain post TKR
I am currently on my ortho inpatients prac and have come to realise just how much pain people who have had TKR`s must have to experience in the first few days. Although they have a PCR and all sorts of drugs available to them, there are still those patients who are in so much pain they find it so hard to bend their knee, which is so important to do as soon as possible. The situation I faced recently involved a 47 year old lady who was day 1 post-op and I was assigned to treat her. She was very teary and in so much pain, and I felt so bad making her do all her exercises. So instead of really pushing her, especially since she was only getting to 30 degrees on the CPM, I would just let her carry on getting to that range, seeing as she was already almost in tears at this stage.
So on day 2, I was assuming she would be automatically better, but again she was at the same range and still in tears. So I started to feel really bad and that I must be really doing something wrong. So eventually I asked my supervisor to go in and see her, which she was happy to do. My supervisor had enough confidence and knowledge that she was able to push her CPM right up to 55 degrees, even though the woman was in so much pain. I felt really bad after this and spoke with my supervisor and said that I felt that I had failed the patient because I had not been cruel to be kind with her. But I also explained that at this stage I did not have the confidence to do what she did without fearing I would really damage the patient.
My question to her was, `when do you learn how far you can push someone`, and `how do you deal with your feelings of guilt when you know you are really hurting someone, even though what you are doing is for their own good`. My supervisor was great and made me realise I had done nothing wrong and that I had done the right thing coming to her for help instead of carrying on as I was, because the patients knee would have suffered. So she made me realise its ok to admit that we cant handle every kind of situation yet, even though we feel we should be able to. So I did learn from this that you can push these patients past their limits and it wont damage their knee, we just need to make absolutely sure they have enough pain cover as possible and always check with your supervisor first so they are aware of the situation.
After this situation, with another patient, I did manage to be a bit firmer with his exercises, and it had such a good result that my confidence in dealing with patients with such bad pain has increased, although it still has a long way to come.
So on day 2, I was assuming she would be automatically better, but again she was at the same range and still in tears. So I started to feel really bad and that I must be really doing something wrong. So eventually I asked my supervisor to go in and see her, which she was happy to do. My supervisor had enough confidence and knowledge that she was able to push her CPM right up to 55 degrees, even though the woman was in so much pain. I felt really bad after this and spoke with my supervisor and said that I felt that I had failed the patient because I had not been cruel to be kind with her. But I also explained that at this stage I did not have the confidence to do what she did without fearing I would really damage the patient.
My question to her was, `when do you learn how far you can push someone`, and `how do you deal with your feelings of guilt when you know you are really hurting someone, even though what you are doing is for their own good`. My supervisor was great and made me realise I had done nothing wrong and that I had done the right thing coming to her for help instead of carrying on as I was, because the patients knee would have suffered. So she made me realise its ok to admit that we cant handle every kind of situation yet, even though we feel we should be able to. So I did learn from this that you can push these patients past their limits and it wont damage their knee, we just need to make absolutely sure they have enough pain cover as possible and always check with your supervisor first so they are aware of the situation.
After this situation, with another patient, I did manage to be a bit firmer with his exercises, and it had such a good result that my confidence in dealing with patients with such bad pain has increased, although it still has a long way to come.
Sunday, June 1, 2008
Chronic pain
After just two weeks at my musculoskeletal clinic im surprised by just how much I've learnt. All those prac classes taught us the tecniques needed and the lectures taught us the conditions but I've found that theres nothing like seeing the actual problem. Feeling the abnormal end feel, the really really tight joint and the results that one treatment can have on pain and decreased function. There is however patients whom you don't really understand why they are coming to a physio, when their pain is more serious and yellow flags are present.
A recent patient I saw had been coming to the physiotherapy clinic for a couple of years for more than one problem. Her problems had gone from bad to better with physiotherapy treatment, of course, but she seemed to have plateaued even with weekly treatment. After assessing her, I had planned on just giving her the same treatment that had been working - STM, PPIVMs and going over her HEP, changing/increasing it depending on my assessment. My supervisor however talked to me about the yellow flag, chronic pain side of her problem and told me how to help with this, treatment had to become less hands on (a nice massage and her back loosened each week) and handed over to the patient. On inspection of her home exercises, she reported she was doing her TA/PF exercises and her Lower traps exercises but she was just doing the set exercises and hadn't applied them to everyday life. She was therefore still experiencing lower back and neck pain and relying on physio every week to get her pain relief.
I used my supervisors advice and although i still gave her the STM as in previous treatments it had a great effect on her pain, i spent most of the treatment talking over functional uses of the exercises she had been given. She picked it up straight away using TA/PF for STS, rolling, bending and even got in before me when she bent over to do up her shoes "tighten those pelvic floor muscles". I went through sitting and standing posture and how correct posture stems from the pelvis. Its position aswell as switching on her TA which made her stand/sit straigher, her chin retract and her "chest bone lift" slightly, automatically using her upper traps. I ended the session by rebooking her for 2 weeks time to break the every week trend.
I do realise that chronic pain does not go away that easily but by handing the information and treatment over to the patient I feel she will feel powered to get herself better and be in control of her pain.
A recent patient I saw had been coming to the physiotherapy clinic for a couple of years for more than one problem. Her problems had gone from bad to better with physiotherapy treatment, of course, but she seemed to have plateaued even with weekly treatment. After assessing her, I had planned on just giving her the same treatment that had been working - STM, PPIVMs and going over her HEP, changing/increasing it depending on my assessment. My supervisor however talked to me about the yellow flag, chronic pain side of her problem and told me how to help with this, treatment had to become less hands on (a nice massage and her back loosened each week) and handed over to the patient. On inspection of her home exercises, she reported she was doing her TA/PF exercises and her Lower traps exercises but she was just doing the set exercises and hadn't applied them to everyday life. She was therefore still experiencing lower back and neck pain and relying on physio every week to get her pain relief.
I used my supervisors advice and although i still gave her the STM as in previous treatments it had a great effect on her pain, i spent most of the treatment talking over functional uses of the exercises she had been given. She picked it up straight away using TA/PF for STS, rolling, bending and even got in before me when she bent over to do up her shoes "tighten those pelvic floor muscles". I went through sitting and standing posture and how correct posture stems from the pelvis. Its position aswell as switching on her TA which made her stand/sit straigher, her chin retract and her "chest bone lift" slightly, automatically using her upper traps. I ended the session by rebooking her for 2 weeks time to break the every week trend.
I do realise that chronic pain does not go away that easily but by handing the information and treatment over to the patient I feel she will feel powered to get herself better and be in control of her pain.
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