I have always known from our lectures that you sometimes need to push a patient to do things that they often don't want to for their own benefit, but it is important to not let a paitnet work harder than they are able as this will proabably set them back phsychologically as they will be unable to complete the task! It's one thing to know something and another to experience it.
On my cardio placement I had a patient who had been bed ridden for 5-6days and had become quite deconditioned. She got up on the 7th day and walked on the spot for a couple of mins. The next day she walked 10m. On the following day all I had wanted to accomplish was a walk a bit further than the 10m of the previous day. She had other idea's however and pushed herself to around 40m, the last 3m of this were hard going for her and she became extremely SOB and lost her confidence completely. I then spent the next 10-15mins reassuring the patient that she woudl eventually be able to walk that distance and even further again!
In this specific case there was nothing I could have done to prevent this lady's loss of confidence as I had attempted to get her to turn back and return to her room several times but she was determined to walk the further distance. It just made me think about other exs prescriptions we give patients and how important it is to get the prescription just right!
Wednesday, July 30, 2008
Osbervation
Whilst on my musculoskeletal outpatients prac I realised the value of taking note of every observation, no matter how insignificant it may appear. I also learnt that experience is worth it's weight in gold!
i had a patient come in, an elderly lady who presented with resting pain in both shoulders, her Cx, both elbows and occasionally pain in both legs. She had decreased range of motion bilaterally, limited by pain and it was impossible to make a complete assessment of her due to her pain levels! I treated her quite globally in the first session with STM of UT and LS combined with heat as well as AP mobs of both shoulders, both of these decreased her pain and increased her range slightly. On the second assessment she was back to the same pain levels and decreased range and the effects of the last treatment had only lasted a short period without her overexerting herself or doing anything different then normal. All of these findings tended to lean towards an inflamatory cause. I had noticed that she had quite widespread psoriasis but hadn't really thought enything of it. My supervisor came in to have a look at my patient and straight away noticed the psoriasis. It turned out that this lady had had the psoriasis for a long time and had not seeked any professional assistance with it.
We then referred this lady to her GP who referred her to a rhematologist aswe believed her problem to be psoriatic arthritis!!
I had remembered learning about this condition in our arthridities lectures and had noticed the psoriasis but had not made the connection. This expereice just showed to me the value of linking your observations, no matter how insignificant they appear to you, and your assessment findings. It did help that my supervisior had a few years of experience and had come across this condition before!
i had a patient come in, an elderly lady who presented with resting pain in both shoulders, her Cx, both elbows and occasionally pain in both legs. She had decreased range of motion bilaterally, limited by pain and it was impossible to make a complete assessment of her due to her pain levels! I treated her quite globally in the first session with STM of UT and LS combined with heat as well as AP mobs of both shoulders, both of these decreased her pain and increased her range slightly. On the second assessment she was back to the same pain levels and decreased range and the effects of the last treatment had only lasted a short period without her overexerting herself or doing anything different then normal. All of these findings tended to lean towards an inflamatory cause. I had noticed that she had quite widespread psoriasis but hadn't really thought enything of it. My supervisor came in to have a look at my patient and straight away noticed the psoriasis. It turned out that this lady had had the psoriasis for a long time and had not seeked any professional assistance with it.
We then referred this lady to her GP who referred her to a rhematologist aswe believed her problem to be psoriatic arthritis!!
I had remembered learning about this condition in our arthridities lectures and had noticed the psoriasis but had not made the connection. This expereice just showed to me the value of linking your observations, no matter how insignificant they appear to you, and your assessment findings. It did help that my supervisior had a few years of experience and had come across this condition before!
Sunday, July 27, 2008
Patient education
On my Musculo Outpatient placement, I have come to realize the importance of educating patients on their condition and your treatment rationale. Many of my patients have been educated in health and the human body (nurses, lecturers, teachers etc) and with these patients, I found I was automatically explaining exactly what I was finding on my assessment as well as the rationale for my treatments and home exercise programs. However, I found when I had an elderly patient or someone I thought wouldn’t really understand, I found myself not bothering with going into much detail.
I didn’t actually come to realize this, until I had a patient come in who had been an ongoing patient for around 5 sessions. Throughout the assessment and treatment, I gave her brief explanations of what I was doing. Towards the end of the session however, she asked me if it would be much trouble if I could possibly show her a picture or a skeleton so she could understand fully what was going on (in this case, bilateral patellofemoral syndrome due to poor biomechanics at the hip and foot and muscle imbalances). She seemed much more satisfied and eager for her HEP after I had given her a much more in-depth explanation of her condition.
It made me realize that although you might assume that a person in less educated or knowledgeable about the human body, they still appreciate knowing what is going on with their bodies as well as reasoning behind what you are doing (and what they are paying for). I also think it helps make the patient much more compliant with exercises if they know exactly why they are doing them, as well as making them more confident in your knowledge and expertise.
Sunday, July 20, 2008
The Mutli-diciplinary team
Whilst on a ward placement, i came to understand the importance of the whole team approach to treatment. I was quite shocked about how much communication there was between each field. The ward meetings, which previously seemed to be the doctors talking to each other about medications, turned into very detailed discussions about all aspects of treatment and the options available.
Throughout these meetings, each team, from doctors, to consultants, the pain team, physios, speach therapists, OT's, social workers, pharmacists, nurses and psychologists... everyone got a chance to talk through their treatments, how they are progressing and both the physical and mental sides to their health. Everything was discussed including what sports the patient likes, whats foods and their favourite colour. I began to understand how this very detailed discussion about the patient would improve the quality of their stay, their mental state of mind and ultimately their health.
I first attended these meetings in the 3rd of 5 weeks at the placement and from then on, i felt much more comfortable with my treatment plan, i felt i could bond with the patient much more and i was alot more efficient. Also i felt much more confident talking to other team members and asking for advice.
Since then, on my placements i have endevoured to communicate with other members of staff around the ward about how the patients are progressing or to seek advice about the best ways to bond with them. It has made the placements much easier and i have found that even though we are students are there are hundreds of us around the wards, most staff members are willing to take time to speak to us and help us out. All we have to do is smile and ask!
Throughout these meetings, each team, from doctors, to consultants, the pain team, physios, speach therapists, OT's, social workers, pharmacists, nurses and psychologists... everyone got a chance to talk through their treatments, how they are progressing and both the physical and mental sides to their health. Everything was discussed including what sports the patient likes, whats foods and their favourite colour. I began to understand how this very detailed discussion about the patient would improve the quality of their stay, their mental state of mind and ultimately their health.
I first attended these meetings in the 3rd of 5 weeks at the placement and from then on, i felt much more comfortable with my treatment plan, i felt i could bond with the patient much more and i was alot more efficient. Also i felt much more confident talking to other team members and asking for advice.
Since then, on my placements i have endevoured to communicate with other members of staff around the ward about how the patients are progressing or to seek advice about the best ways to bond with them. It has made the placements much easier and i have found that even though we are students are there are hundreds of us around the wards, most staff members are willing to take time to speak to us and help us out. All we have to do is smile and ask!
Supervision
Through the pracs completed so far i have experienced a wide range of different techniques used by the physio supervisors to teach and assess. The techniques that are used contribute largly to the enjoyment, the amount learned and also the stress felt whilst on placement. I am not talking here about the supervisors being really friendly or easy, more the way in which they go about their assesment.
Whilst on a prac earlier in the semester i experienced supervision that didnt really suit me and thus caused quite a stressful time. The supervisor was insistant that every aspect of the sessions were completed the way that they wanted and were taught. This came down to the ordering of the questions, the words i used to ask them, the way i wrote my notes and the types of intervention used. For the placement it felt like i was not utilising my clinical reasoning skills but just trying to copy the supervisor and please them. I felt that i didnt really learn much except for how to please them.
Contrary to this, a different placement i went on provided a very flexible supervision process which resulted in me enjoying the prac alot more and learning a great deal. At the beginning of the prac the supervisor sat down and discussed certain things about my learning and style of learning in order to best judge the way to supervise. All through out the placement they asked constantly what things i wanted to improve on, how much supervision they should give. This did not make the placement cushy, i felt it made the prac much more beneficial and i felt more comfortable and hence learnt a great deal more.
As a result of this i will endevour to speak to my supervisors more at the beginning of the placement so we can both get the most out of the 4 weeks!
Whilst on a prac earlier in the semester i experienced supervision that didnt really suit me and thus caused quite a stressful time. The supervisor was insistant that every aspect of the sessions were completed the way that they wanted and were taught. This came down to the ordering of the questions, the words i used to ask them, the way i wrote my notes and the types of intervention used. For the placement it felt like i was not utilising my clinical reasoning skills but just trying to copy the supervisor and please them. I felt that i didnt really learn much except for how to please them.
Contrary to this, a different placement i went on provided a very flexible supervision process which resulted in me enjoying the prac alot more and learning a great deal. At the beginning of the prac the supervisor sat down and discussed certain things about my learning and style of learning in order to best judge the way to supervise. All through out the placement they asked constantly what things i wanted to improve on, how much supervision they should give. This did not make the placement cushy, i felt it made the prac much more beneficial and i felt more comfortable and hence learnt a great deal more.
As a result of this i will endevour to speak to my supervisors more at the beginning of the placement so we can both get the most out of the 4 weeks!
Wednesday, June 25, 2008
Family Centred Practise
Whilst on my paediatric placement I came to learn the importance of the term 'family centered practise'. The physiotherapy department was situated at the school which the patient/child was currently attending. This yound boy was autistic, he was treated at the school and came to school every morning on the school bus. Therefore his mother did not come in regularly.
One morning a frantic call was made to the physio department and this young boy's mother was on the phone and was in a right state. Her son had started limping and she was terrified that she would be reported to child services as she believed that people would think that she had been abusing her child. Myself and the physiotherapist went to visit the mother at her home and managed to clam her down, assuring her that noone believed that she was abusing her son. We assessed her son and could not find any reason for his limping, and his limping was very inconsistent, we were able to get him walking normally after a few minuits.
The reason that the mother had worked herself up into such a state over this seemingly insignificant episode was that she was having to care for her son on her own. Her husband was working night shifts and would therefore be asleep in the days whilst she was caring for her son. Her son is only able to go to school 3/5 days due to medical reasons, her family lived a couple of hours away and the family were in a tight financial situation. As a result this poor woman had no time to herself, was unable to afford a carer or any respite for her son so that she could have some down time. We were able to find one of the teaching assistants at the school who offered to take her son for a couple of hours a week and we contacted a psychologist who she could talk to who would be able to place her in a better position to recieve respite.
From this I realised the value of looking at the whole family in a big picture and not just the patient/child that you are seeing. This mum had reached a breaking point and this was obviously beginning to effect her son, if we had been seeing her more often then this might not have happened.
One morning a frantic call was made to the physio department and this young boy's mother was on the phone and was in a right state. Her son had started limping and she was terrified that she would be reported to child services as she believed that people would think that she had been abusing her child. Myself and the physiotherapist went to visit the mother at her home and managed to clam her down, assuring her that noone believed that she was abusing her son. We assessed her son and could not find any reason for his limping, and his limping was very inconsistent, we were able to get him walking normally after a few minuits.
The reason that the mother had worked herself up into such a state over this seemingly insignificant episode was that she was having to care for her son on her own. Her husband was working night shifts and would therefore be asleep in the days whilst she was caring for her son. Her son is only able to go to school 3/5 days due to medical reasons, her family lived a couple of hours away and the family were in a tight financial situation. As a result this poor woman had no time to herself, was unable to afford a carer or any respite for her son so that she could have some down time. We were able to find one of the teaching assistants at the school who offered to take her son for a couple of hours a week and we contacted a psychologist who she could talk to who would be able to place her in a better position to recieve respite.
From this I realised the value of looking at the whole family in a big picture and not just the patient/child that you are seeing. This mum had reached a breaking point and this was obviously beginning to effect her son, if we had been seeing her more often then this might not have happened.
Wednesday, June 18, 2008
Dealing with kids
During my paediatric placement I felt right at home due to my ability to pretty much let go and be a kid with the patient and make everything a game where they don’t realise they're getting treated. This is great for compliance but I soon found out you had to be careful how 'young' you become and how you treat the kids due to their condition/past.
One of the kids had a very nasty past history so not only was I playing the friendly everything’s a game physio but I was treating her differently, more gently without even realising it. She therefore was getting a little bit carried away and suddenly I had lost control of what she did. She would just laugh and think it was a game when I tried to get her to do anything a certain way as she just didn’t take me seriously. When I tried to use the stern lowered tone that works a treat on most kids she got upset, as suddenly it wasn’t all a game. This meant the compliance level dropped and I got a kid doing the arms crossed hmph that I'm sure anyone with younger siblings or nieces or nephews have seen.
I carried on the session with the other child that was there and decided to talk to the principal of the special Ed department who happened to be one of the foster carers for this child. Straight away she was giving me tips on being firm from the start and not letting her past get in the way. I had to look at her as a child from the start and not let her push the boundaries even if I did feel extremely sorry for her. Whilst I could make things into a game for compliance, rules had to be set from the start. ‘You can do this or this’ (make them believe they have the choice) or set out a layout of the treatment at the start with them and stick to it. I was also told to maybe keep the sessions shorter as the child’s attention span was not good and was another thing that was being worked on in her behaviour modification classes.
The next week when I came back I laid down the rules from the start when she was all happy to see me. I let her chose from two games at each station (balance, strength, core posture) ‘as long as she listened to me as to when each finished and the order’ and that was enough to keep her happy. I still joined in and kept most of the exercises as games (as when you have an excitable kid you have to keep them occupied and keeps the session flowing). But I changed my approach to the treatment and child and therefore got the compliance and she stopped pushing the boundaries. I may not still be on placement but I do swim teaching and still use this way of dealing with any new kid. Be the nice physio but don’t let them push your boundaries, even one inch.
One of the kids had a very nasty past history so not only was I playing the friendly everything’s a game physio but I was treating her differently, more gently without even realising it. She therefore was getting a little bit carried away and suddenly I had lost control of what she did. She would just laugh and think it was a game when I tried to get her to do anything a certain way as she just didn’t take me seriously. When I tried to use the stern lowered tone that works a treat on most kids she got upset, as suddenly it wasn’t all a game. This meant the compliance level dropped and I got a kid doing the arms crossed hmph that I'm sure anyone with younger siblings or nieces or nephews have seen.
I carried on the session with the other child that was there and decided to talk to the principal of the special Ed department who happened to be one of the foster carers for this child. Straight away she was giving me tips on being firm from the start and not letting her past get in the way. I had to look at her as a child from the start and not let her push the boundaries even if I did feel extremely sorry for her. Whilst I could make things into a game for compliance, rules had to be set from the start. ‘You can do this or this’ (make them believe they have the choice) or set out a layout of the treatment at the start with them and stick to it. I was also told to maybe keep the sessions shorter as the child’s attention span was not good and was another thing that was being worked on in her behaviour modification classes.
The next week when I came back I laid down the rules from the start when she was all happy to see me. I let her chose from two games at each station (balance, strength, core posture) ‘as long as she listened to me as to when each finished and the order’ and that was enough to keep her happy. I still joined in and kept most of the exercises as games (as when you have an excitable kid you have to keep them occupied and keeps the session flowing). But I changed my approach to the treatment and child and therefore got the compliance and she stopped pushing the boundaries. I may not still be on placement but I do swim teaching and still use this way of dealing with any new kid. Be the nice physio but don’t let them push your boundaries, even one inch.
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