I cannot believe that 20 weeks of placements has finished and I am writing a blog for the last time! These past 5 weeks have gone by quickly and I think this is because I thoroughly enjoyed my cardio placement at Fremantle Hospital. Reflecting back on my initial entry I stated that I hoped that I would get placed in ICU, which I did, very lucky. I found ICU really interesting as I was able to see more acute patients since I had already done a general medical placement in Geraldton so I was able to see the other more acute care side of cardio, which I much prefer. Being in ICU was very challenging, because of the co-morbidites of patients and the fact that they are medically unstable, but that is what I enjoyed about it as I was able to expand on my skills such as able to do suctioning and bagging of patients.
I also stated in my initial entry that I would like to see more surgical patients, which was the majority of patients I saw as I was on the ward that all the cardio-thoracic patients came to post- surgery. This allowed me to practice handling attachments, which I found daunting at first but then it just became second nature. Even though I had an incident of a patient disconnecting his ICC, which at first really rattled me it turned out to be a very good learning experience which I will NEVER let happen again! Unfortunately I wasn't lucky enough to see a surgery!
I was again very lucky and thankful to have an amazing and very nice supervisor. She had a lot of great information and handy hints to give to Kristy and I and I feel confident after these 5 weeks that I could go out into the work force thanks to her. I am glad that know I have had the experience in working in acute care and more chronic/medical care. I can definitely see myself working in a hospital after graduation. I think this would be the most beneficial in consolidating all my skills because of the rotation systems they have and i thoroughly enjoyed this cardio placement!
Sunday, July 25, 2010
STARES 3 - Assesssment + Re-assessment
SITUATION
Mr D is a 77 year old man who is day 1 post elective CABG x 4 secondary to triple vessel disease and shortness of breath on minimal exertion. He had an uncomplicated surgery only being on bypass for 90 minutes. The morning of Day 1 post surgery he was extubated without complications and was alert and awake for most of the day. He was transferred to the ward later that afternoon as he was progressing extremely well. The only complaint Mr D had was that he suffered un-manageable pain under his sternal wound and SCC drain sites, rating it 8/10 with supported coughs and 7/10 with deep breathing. He was charted for tramadol, which made him vomit so oxynorm was used but to little effect. He lives alone, but has a supportive son close by. His house has no stairs but a big backyard which he likes to garden in. He still drives and is an avid fisher. He is normally independent with ambulation and activities of daily living. He is an ex-smoker, quitting 30 years ago, smoking 1.5 packs a day. He has a past medical history of hypertension and high cholesterol.
TASK
To perform a respiratory assessment of Mr D which would then lead to an appropriate intervention of if possible ambulating and sitting out of bed according to the Open Heart Surgery Pathway.
ACTION
I had previously met Mr D in the pre-operative education classes and earlier that day in ICU so I didn't need to re-introduce myself. Before heading in I checked with his nurse that it was okay for me to see him and asked if he could have any of his pain cover. I went into his room with a plan that i would check his nursing obs, get him to cough, sit him on the edge of the bed and auscultate then ambulated with him approx 40 which is standard for most patients and then sit him out of bed in a high back chair for the afternoon then go through his active cycle of breathing techniques.
RESULT
When I went into Mr D's room however he was poorly positioned in bed and desperately wanted to be repositioned. So i got him sitting over the edge of the bed helping him with his legs. Once in sitting I was then able to go through his supported cough and auscultation. On coughing his pain increased to 8/10 even though he had had his immediate release pain cover. On auscultation he had decreased breath sounds bibasally and coarse crackles throughout inspiration and expiration on the right middle and lower zones. Although he had a high pain score he was still keen to ambulate so I organised his attachments and oxygen. He stood with 1 minimal assistance and then we began to ambulate. After a couple of steps however he was complaining of 9/10 pain in his left leg, which is where his grafts were taken from. So after only 5 meters we turned around and he was happy to sit out of bed in the high back chair so we walked back to that and he sat down in that. As I was placing his attachments back he complained of nausea so I managed to quickly get him a vomit bag. I stayed with him for a little while and when his vomiting eased off - which took a while, I went and notified his nurse. This meant however that I wasn't able to go through the active cycle of breathing and I was unable to complete a re-assessment because of the amount of time that had elapsed.
EVALUATION
Unfortunately, even though I had what I wanted to do with Mr D planned out in my head, some things happen which make you scattered or events - like vomiting and increased pain stop you from completing/ making you forget what you need to. Because of Mr D's increased pain, we could not ambulate as far as I would have liked him to to maximize his respiratory benefits, and because of his vomiting I was unable to go through an active cycle of breathing technique and was not able to re-assess my treatment. Not being able to teach him the ACBT is quite a loss condisering he did not mobilise far and I wouldn't be seeing him till the next morning, and he needs to take breaths and cough to re-expand his lungs and expectorate stagnant sputum. Because of this I had to liase with his nurse to encourage him to this over the night once his vomiting settled.
STRATEGIES
If i had better time management I probably could have re-visited Mr D later that afternoon to go through the ACBT with him and educate him further on the importance of physio intervention. In regards to his pain cover I should have notified the nurses a bit earlier so that the medication had adequate time to take effect considering pain was inhibiting my treatment with Mr D. However even if i had done these things, sometimes things like vomiting happen, and you can't do anything about that!
Mr D is a 77 year old man who is day 1 post elective CABG x 4 secondary to triple vessel disease and shortness of breath on minimal exertion. He had an uncomplicated surgery only being on bypass for 90 minutes. The morning of Day 1 post surgery he was extubated without complications and was alert and awake for most of the day. He was transferred to the ward later that afternoon as he was progressing extremely well. The only complaint Mr D had was that he suffered un-manageable pain under his sternal wound and SCC drain sites, rating it 8/10 with supported coughs and 7/10 with deep breathing. He was charted for tramadol, which made him vomit so oxynorm was used but to little effect. He lives alone, but has a supportive son close by. His house has no stairs but a big backyard which he likes to garden in. He still drives and is an avid fisher. He is normally independent with ambulation and activities of daily living. He is an ex-smoker, quitting 30 years ago, smoking 1.5 packs a day. He has a past medical history of hypertension and high cholesterol.
TASK
To perform a respiratory assessment of Mr D which would then lead to an appropriate intervention of if possible ambulating and sitting out of bed according to the Open Heart Surgery Pathway.
ACTION
I had previously met Mr D in the pre-operative education classes and earlier that day in ICU so I didn't need to re-introduce myself. Before heading in I checked with his nurse that it was okay for me to see him and asked if he could have any of his pain cover. I went into his room with a plan that i would check his nursing obs, get him to cough, sit him on the edge of the bed and auscultate then ambulated with him approx 40 which is standard for most patients and then sit him out of bed in a high back chair for the afternoon then go through his active cycle of breathing techniques.
RESULT
When I went into Mr D's room however he was poorly positioned in bed and desperately wanted to be repositioned. So i got him sitting over the edge of the bed helping him with his legs. Once in sitting I was then able to go through his supported cough and auscultation. On coughing his pain increased to 8/10 even though he had had his immediate release pain cover. On auscultation he had decreased breath sounds bibasally and coarse crackles throughout inspiration and expiration on the right middle and lower zones. Although he had a high pain score he was still keen to ambulate so I organised his attachments and oxygen. He stood with 1 minimal assistance and then we began to ambulate. After a couple of steps however he was complaining of 9/10 pain in his left leg, which is where his grafts were taken from. So after only 5 meters we turned around and he was happy to sit out of bed in the high back chair so we walked back to that and he sat down in that. As I was placing his attachments back he complained of nausea so I managed to quickly get him a vomit bag. I stayed with him for a little while and when his vomiting eased off - which took a while, I went and notified his nurse. This meant however that I wasn't able to go through the active cycle of breathing and I was unable to complete a re-assessment because of the amount of time that had elapsed.
EVALUATION
Unfortunately, even though I had what I wanted to do with Mr D planned out in my head, some things happen which make you scattered or events - like vomiting and increased pain stop you from completing/ making you forget what you need to. Because of Mr D's increased pain, we could not ambulate as far as I would have liked him to to maximize his respiratory benefits, and because of his vomiting I was unable to go through an active cycle of breathing technique and was not able to re-assess my treatment. Not being able to teach him the ACBT is quite a loss condisering he did not mobilise far and I wouldn't be seeing him till the next morning, and he needs to take breaths and cough to re-expand his lungs and expectorate stagnant sputum. Because of this I had to liase with his nurse to encourage him to this over the night once his vomiting settled.
STRATEGIES
If i had better time management I probably could have re-visited Mr D later that afternoon to go through the ACBT with him and educate him further on the importance of physio intervention. In regards to his pain cover I should have notified the nurses a bit earlier so that the medication had adequate time to take effect considering pain was inhibiting my treatment with Mr D. However even if i had done these things, sometimes things like vomiting happen, and you can't do anything about that!
Sunday, July 11, 2010
STARES 2 - Risk Management
SITUATION
Mr B is a 57 year old male who is day 1 post elective right thoracotomy for an right upper lobectomy to remove a malignant mass. The history of presenting complaint was a few weeks of haemoptysis episodes with the occasional wheeze and cough during the night. He has a past medical history of a previous alcoholic cardiomyopathy, ex smoker quitting 7 years ago with a 80 pack/year history. He is also an ex heavy drinker having 10-12 cans of beer a day, but has not had a drink since 2003. He also has hypercholestoraemia, gout and hyperlipidaemia. Mr B lives with his wife in Perth and is currently not working. Mr B had an uncomplicated operation and ICU stay and returning to the monitored ward the night of his operation.
TASK
To complete a chest review and if the patient is suitable, ambulate.
ACTION
After introducing myself to Mr B I then explained the plan of the treatment session today, in which i was hoping to have a listen to his chest, teach him some deep breathing exercises to maintain healthy lungs, and if he was feeling up to it and his obs were stable to go for his first walk since the operation ending the session by sitting out in a high back chair. After getting Mr B's consent I began a quick subjective assessment. After this I then began a respiratory assessment, starting with his oxygen saturation then teaching him a supported cough. I then listened to his cough and his chest. After this I organised my environment, by getting a trolley for him to ambulate with which contained an oxygen bottle and a IV pole, which I attached his PCA to and also organised all his attachments in preparation to get him sitting on the edge of the bed. Once I had my environment organised I got Mr B to begin to walk his legs towards the edge of the bed and then come up into sitting. Once sitting on the edge of the bed I then attached his two ICC's which were on 5 kPa of suction, his nasal prongs and his IDC to the trolley for him to stand and ambulate. After ambulation, I then reassessed Mr B's cough and auscultation.
RESULT
Mr B was resting in bed, alert and orientated when I came to see him. Mr B was in 2/10 pain at rest. He had not been coughing/productive of any sputum since the operation, and was not normally productive of sputum prior to the operation. Mr B states that he wasn't that active prior to the lobectomy, walking one kilometer a day and did not require the use of any aids or services. I then taught him a supported cough, which was strong, dry and non-productive and didn't increase his pain. On auscultation he had decreased breath sounds bibasally, a fine end inspiratory wheeze and a gurgling/air leak sound in the R UL. Mr B only required 1 min assist into sitting. Once sitting Mr B felt a little light-headed which soon settled. Once the environment was set up and all of Mr B's attachments were on the trolley I instructed Mr B to come up into standing. As Mr B did this he pushed through his arms on the bed. What I didn't see was that underneath his gown, Mr B pushed through one of his ICC's as he went to stand up. This then caused Mr B to disconnect one of his ICC's from the most proximal connection. This was quite obvious because as soon as it happened you could hear the hiss of the suction. Once I managed to find where along the line of connection from his body to the wall where he had disconnected it I quickly reattached it. I immediately got him to lie down, watched his saturation while my supervisor told the nursing staff who informed the medical team. It was then decided, considering Mr B's oxygen saturation was maintained at 98% that Mr B was safe to continue to with physio, and ambulate. It was then onto take 2 in attempting to stand, where I made sure I could see his ICC tubes and that he didn't use his arms to stand. Once in standing Mr B ambulate with the trolley for support and the attachments and 1 stand-by assist. Mr B's O2 increased to 100% during ambulation and after ~10 m he was returned to the HBC and encouraged him to sit out of bed for at least and hour. On reassessment, Mr B's cough and auscultation did not change.
EVALUATION
I found that after treating this patient and after having his ICC be disconnected that I was really frustrated. The reasons for this was because the previous day I had told my supervisor that one thing I wanted to improve on was setting up my environment and becoming confident in the handling of attachments, so I had made extra effort in setting up my environment and making sure the 2 ICC drains were in the correct positions for when he sat up and then placing them on the trolley so that when he stood and ambulated he would stand on or trip over the tubing. So when he went to stand and leant on the tube, forcing it to disconnect I felt frustrated and annoyed that after making the conscious effort to be prepared and even more aware of the attachments, I was that unlucky to have my patient lean on the tube. As soon as the tube was disconnected I did become very flustered, however I think being like a duck on the water I remained cool on the outside but under the water I was frantically paddling my legs.
STRATEGIES
One good thing that comes out of this horrible experience is that I will never let something like this happen again. When seeing this patient next and any other patient I will make sure to check all connections of the attachments were disconnection to occur and make sure that all are visible to me and safe. When treating a patient I think it would be a good idea to just take a couple of seconds to familiarise with the environment and what attachments the patient has.
Mr B is a 57 year old male who is day 1 post elective right thoracotomy for an right upper lobectomy to remove a malignant mass. The history of presenting complaint was a few weeks of haemoptysis episodes with the occasional wheeze and cough during the night. He has a past medical history of a previous alcoholic cardiomyopathy, ex smoker quitting 7 years ago with a 80 pack/year history. He is also an ex heavy drinker having 10-12 cans of beer a day, but has not had a drink since 2003. He also has hypercholestoraemia, gout and hyperlipidaemia. Mr B lives with his wife in Perth and is currently not working. Mr B had an uncomplicated operation and ICU stay and returning to the monitored ward the night of his operation.
TASK
To complete a chest review and if the patient is suitable, ambulate.
ACTION
After introducing myself to Mr B I then explained the plan of the treatment session today, in which i was hoping to have a listen to his chest, teach him some deep breathing exercises to maintain healthy lungs, and if he was feeling up to it and his obs were stable to go for his first walk since the operation ending the session by sitting out in a high back chair. After getting Mr B's consent I began a quick subjective assessment. After this I then began a respiratory assessment, starting with his oxygen saturation then teaching him a supported cough. I then listened to his cough and his chest. After this I organised my environment, by getting a trolley for him to ambulate with which contained an oxygen bottle and a IV pole, which I attached his PCA to and also organised all his attachments in preparation to get him sitting on the edge of the bed. Once I had my environment organised I got Mr B to begin to walk his legs towards the edge of the bed and then come up into sitting. Once sitting on the edge of the bed I then attached his two ICC's which were on 5 kPa of suction, his nasal prongs and his IDC to the trolley for him to stand and ambulate. After ambulation, I then reassessed Mr B's cough and auscultation.
RESULT
Mr B was resting in bed, alert and orientated when I came to see him. Mr B was in 2/10 pain at rest. He had not been coughing/productive of any sputum since the operation, and was not normally productive of sputum prior to the operation. Mr B states that he wasn't that active prior to the lobectomy, walking one kilometer a day and did not require the use of any aids or services. I then taught him a supported cough, which was strong, dry and non-productive and didn't increase his pain. On auscultation he had decreased breath sounds bibasally, a fine end inspiratory wheeze and a gurgling/air leak sound in the R UL. Mr B only required 1 min assist into sitting. Once sitting Mr B felt a little light-headed which soon settled. Once the environment was set up and all of Mr B's attachments were on the trolley I instructed Mr B to come up into standing. As Mr B did this he pushed through his arms on the bed. What I didn't see was that underneath his gown, Mr B pushed through one of his ICC's as he went to stand up. This then caused Mr B to disconnect one of his ICC's from the most proximal connection. This was quite obvious because as soon as it happened you could hear the hiss of the suction. Once I managed to find where along the line of connection from his body to the wall where he had disconnected it I quickly reattached it. I immediately got him to lie down, watched his saturation while my supervisor told the nursing staff who informed the medical team. It was then decided, considering Mr B's oxygen saturation was maintained at 98% that Mr B was safe to continue to with physio, and ambulate. It was then onto take 2 in attempting to stand, where I made sure I could see his ICC tubes and that he didn't use his arms to stand. Once in standing Mr B ambulate with the trolley for support and the attachments and 1 stand-by assist. Mr B's O2 increased to 100% during ambulation and after ~10 m he was returned to the HBC and encouraged him to sit out of bed for at least and hour. On reassessment, Mr B's cough and auscultation did not change.
EVALUATION
I found that after treating this patient and after having his ICC be disconnected that I was really frustrated. The reasons for this was because the previous day I had told my supervisor that one thing I wanted to improve on was setting up my environment and becoming confident in the handling of attachments, so I had made extra effort in setting up my environment and making sure the 2 ICC drains were in the correct positions for when he sat up and then placing them on the trolley so that when he stood and ambulated he would stand on or trip over the tubing. So when he went to stand and leant on the tube, forcing it to disconnect I felt frustrated and annoyed that after making the conscious effort to be prepared and even more aware of the attachments, I was that unlucky to have my patient lean on the tube. As soon as the tube was disconnected I did become very flustered, however I think being like a duck on the water I remained cool on the outside but under the water I was frantically paddling my legs.
STRATEGIES
One good thing that comes out of this horrible experience is that I will never let something like this happen again. When seeing this patient next and any other patient I will make sure to check all connections of the attachments were disconnection to occur and make sure that all are visible to me and safe. When treating a patient I think it would be a good idea to just take a couple of seconds to familiarise with the environment and what attachments the patient has.
Thursday, June 24, 2010
STARES 1- Professional Behaviour
SITUATION
Ms E is a nineteen year old female who was brought in by ambulance to the emergency department of Fremantle Hospital two days ago after overdosing on anti-psychotic medications. Ms E's boyfriend had called the ambulance when he found Ms E sitting on their letterbox coming in and out of consciousness after they had a major argument. Ms E stated to the ambulance workers that she had been drinking alcohol and taken all of the remaining Seroquel (anti-psychotic) tablets in her container (60 x 300mg). On the way to ED the ambulance workers did an elective intubation on assumption she would lose consciousness. On admission to ICU Ms E was intubated with an ETT and sedated on Propofol and Midazolam. She is on BiPAP with a PEEP of 5. When nursing staff tried to wake Ms E, she became very agitated and did not tolerate the ETT, therefore was put back under sedation. On chest x-ray Ms E had decreased lung volumes along with infiltrates throughout the right lung showing that she has begun to go into respiratory failure. She has an extensive psychological history being diagnosed with bipolar disorder earlier this year. She began self-harm in the form of cutting at the age of 14, left school in year 11 and left home when she was 16. She lived with relatives and now lives with her boyfriend and his mother.
TASK
To watch and help when needed in the treatment of Ms E.
ACTION
Firstly we received the hand-over from the morning ICU physiotherapist on what treatment she did this morning and how Ms E tolerated it. We then read her notes and ICU observation chart. We then had to glove and gown up to stop infection spread to the patients. We then watched our supervisor treat Ms E by suctioning and bagging her to help with her sputum clearance.
RESULT
Ms E did not tolerate more than two suctions without dropping her oxygen saturation below 90 therefore her FiO2 had to be increased to 100% during suctioning and bagging. The normal suctioning catheter did not induce a cough in Ms E therefore an angle-tip catheter had to be used which is longer a tipped to an angle at the end to further try to induce a cough. This was successful in obtaining a large amount of M2P2 sputum.
EVALUATION
While I was reading her file I found it hard to grasp that this was the life that this 19 year old girl had gone through, considering I am only 20, it felt a little to close to home. Her psychologists report was over two pages long and I just could not imagine how this girl, let alone anyone has been subjected to the things she has. For someone so young to be lying there on an ICU bed with multiple attachments on her to help keep her alive was very confronting. Watching our supervisor suction this 19 year old girl was pretty confronting, especially when the catheter reached the spot that made her cough. This is because when she was coughing her whole body was shaking and she would go bright red and increase her blood pressure. This wasn't the nicest thing to witness a girl so young be so dependent on people to cough for her and have a machine breathe for her. Afterward I couldn't help but think that ignorance is bliss to this situation. But in saying this I was naive to think that these situations don't happen, because they do and unfortunately to a nineteen year old girl.
STRATEGIES
My supervisor explained to us that it is normal to feel a little confronted by some situations in ICU, as when she first started her rotation in ICU, she too had some cases that really tugged on her emotions. However being exposed to more and more cases that are confronting is the only way that you will 'build up a resistance' and not become so emotionally involved. It is very hard to try to think of strategies to deal with these kind of situations because emotions can sometime be very hard to control. I think I have handled knowing this patient's history and current situation well, I only really thought about the severity and its intensity for that day and night, however if I find myself in another similar situation and find that I am not coping, there is the option to handover the patient to another physio.
Ms E is a nineteen year old female who was brought in by ambulance to the emergency department of Fremantle Hospital two days ago after overdosing on anti-psychotic medications. Ms E's boyfriend had called the ambulance when he found Ms E sitting on their letterbox coming in and out of consciousness after they had a major argument. Ms E stated to the ambulance workers that she had been drinking alcohol and taken all of the remaining Seroquel (anti-psychotic) tablets in her container (60 x 300mg). On the way to ED the ambulance workers did an elective intubation on assumption she would lose consciousness. On admission to ICU Ms E was intubated with an ETT and sedated on Propofol and Midazolam. She is on BiPAP with a PEEP of 5. When nursing staff tried to wake Ms E, she became very agitated and did not tolerate the ETT, therefore was put back under sedation. On chest x-ray Ms E had decreased lung volumes along with infiltrates throughout the right lung showing that she has begun to go into respiratory failure. She has an extensive psychological history being diagnosed with bipolar disorder earlier this year. She began self-harm in the form of cutting at the age of 14, left school in year 11 and left home when she was 16. She lived with relatives and now lives with her boyfriend and his mother.
TASK
To watch and help when needed in the treatment of Ms E.
ACTION
Firstly we received the hand-over from the morning ICU physiotherapist on what treatment she did this morning and how Ms E tolerated it. We then read her notes and ICU observation chart. We then had to glove and gown up to stop infection spread to the patients. We then watched our supervisor treat Ms E by suctioning and bagging her to help with her sputum clearance.
RESULT
Ms E did not tolerate more than two suctions without dropping her oxygen saturation below 90 therefore her FiO2 had to be increased to 100% during suctioning and bagging. The normal suctioning catheter did not induce a cough in Ms E therefore an angle-tip catheter had to be used which is longer a tipped to an angle at the end to further try to induce a cough. This was successful in obtaining a large amount of M2P2 sputum.
EVALUATION
While I was reading her file I found it hard to grasp that this was the life that this 19 year old girl had gone through, considering I am only 20, it felt a little to close to home. Her psychologists report was over two pages long and I just could not imagine how this girl, let alone anyone has been subjected to the things she has. For someone so young to be lying there on an ICU bed with multiple attachments on her to help keep her alive was very confronting. Watching our supervisor suction this 19 year old girl was pretty confronting, especially when the catheter reached the spot that made her cough. This is because when she was coughing her whole body was shaking and she would go bright red and increase her blood pressure. This wasn't the nicest thing to witness a girl so young be so dependent on people to cough for her and have a machine breathe for her. Afterward I couldn't help but think that ignorance is bliss to this situation. But in saying this I was naive to think that these situations don't happen, because they do and unfortunately to a nineteen year old girl.
STRATEGIES
My supervisor explained to us that it is normal to feel a little confronted by some situations in ICU, as when she first started her rotation in ICU, she too had some cases that really tugged on her emotions. However being exposed to more and more cases that are confronting is the only way that you will 'build up a resistance' and not become so emotionally involved. It is very hard to try to think of strategies to deal with these kind of situations because emotions can sometime be very hard to control. I think I have handled knowing this patient's history and current situation well, I only really thought about the severity and its intensity for that day and night, however if I find myself in another similar situation and find that I am not coping, there is the option to handover the patient to another physio.
Saturday, June 19, 2010
Prac 4 - Initial Entry
Tomorrow is the first day of our final placement! This will be my cardiorespiratory placement at Fremantle Hospital. From what I have heard Fremantle Hospital is a really good placement, so I am excited to start and of course finish there and completing the all four placements. I am not as nervous for this placement as I have been for others, and this itself is a bit nerve-racking. I think this is because I am just so eager to start these five weeks, so that they can end and I can have a break! Another reason why I am really looking forward to this placement is because I find cardio interesting. I have had some previous exposure to cardio at Hollywood Hospital in second year and at Geraldton Regional Hospital on my second placement of this year, so hopefully I can expand on the things that I have learnt of this placement.
I am unsure, and will be until orientation of what type of placement this will be in regards to general medical, surgical, ICU or oncology. I am hoping it is not oncology as I don't think I would enjoy it and find it a little depressing, as I was on the oncology ward at Hollywood Hospital and I didn't enjoy it there. Although it may be daunting and challenging I would really like to be able to have some prac time in ICU as I find it very interesting and I also think it would be a good challenge. I also wouldn't mind medical or surgical but I think I would prefer general medical more. However if doing a surgical placement meant that I get to see a surgery then I would love to do that, as I have not been lucky enough to be able to see a surgery yet of any kind on any placement I have been on.
An obvious concern going into placement, like every other placement has been whether I will have a nice supervisor and whether I will get along with them. I have been very fortunate so far to have great supervisors who I have leant a lot from, and I hope I can learn a lot from my next one too. Another concern is whether I will get along with my tutor. I have only previously had one tutor and that was on my first placement here, so I have sort-of forgotten what it is like to have one. These are possibly the only two major concerns I have going into this placement - whether or not I will like/get along with my supervisor and tutor.
There is a minor concern of getting there on time for my first day, that is what makes me the most nervous! I shall be catching the train into Fremantle then getting the Cat bus from there, so hopefully TransPerth is running smoothly tomorrow!
I am unsure, and will be until orientation of what type of placement this will be in regards to general medical, surgical, ICU or oncology. I am hoping it is not oncology as I don't think I would enjoy it and find it a little depressing, as I was on the oncology ward at Hollywood Hospital and I didn't enjoy it there. Although it may be daunting and challenging I would really like to be able to have some prac time in ICU as I find it very interesting and I also think it would be a good challenge. I also wouldn't mind medical or surgical but I think I would prefer general medical more. However if doing a surgical placement meant that I get to see a surgery then I would love to do that, as I have not been lucky enough to be able to see a surgery yet of any kind on any placement I have been on.
An obvious concern going into placement, like every other placement has been whether I will have a nice supervisor and whether I will get along with them. I have been very fortunate so far to have great supervisors who I have leant a lot from, and I hope I can learn a lot from my next one too. Another concern is whether I will get along with my tutor. I have only previously had one tutor and that was on my first placement here, so I have sort-of forgotten what it is like to have one. These are possibly the only two major concerns I have going into this placement - whether or not I will like/get along with my supervisor and tutor.
There is a minor concern of getting there on time for my first day, that is what makes me the most nervous! I shall be catching the train into Fremantle then getting the Cat bus from there, so hopefully TransPerth is running smoothly tomorrow!
Saturday, June 12, 2010
STARES 3 - INTERVENTION
SITUATION
Mr M is a 64 yr old lady who was referred to physio after a fall on an outstretched arm that left her with a fractured proximal humerus that had to be fixed using a prosthesis on the left side. Since surgery she has had difficulties regaining her range of motion and when she tries to move her arm it feels a tight band around her arm stopping her moving. Mrs M has 50 degrees of flexion and 60 degrees of abduction, however the majority of the movement is through the shoulder girdle which she hitches for movement. This is severely limiting her function which is her main concern. She lives at home with her husband and they are both retired. She is right handed so still able to complete some tasks, however such activities like opening jars and washing her hair are limited. She has been attending physiotherapy for the past two months yet has only had limited gains. So far her treatment has included passive accessory movements, soft tissue mobilisations, heat packs and a home exercise program which consisted of pulley exercises, active assisted exercises and stretches.
TASK
To give Mrs M a appropriate and individualized treatment to help improve her range of movement in her left arm.
ACTION
Firstly I got Mrs M into supine, from there I started my treatment with trigger point release of lat dorsi, anterior and posterior deltoids as i found these muscles to be tight and had active trigger points. I then did grade 4 AP glide on the GHJ in 60 degrees of abduction, 3 sets of 30 secs. After this I did a grade 4 lateral glide the the GHJ 3 sets of 30 secs. Lastly we ran through her home exercise program to see if she was completing the exercises an whether she required progression of the exercises.
RESULT
At the end of the treatment Mrs M had and increase of her range of motion to 60 degrees flexion and 80 degrees of abduction. She still complained of the same tight-band feeling across her arm and she was still hitching her shoulder girdle significantly. She was performing her exercises correctly, however I regressed her from long lever pulley exercises to short lever pulley exercises which she found to be easier to achieve.
EVALUATION
Although I did manage to get a good result from the treatment that way I conducted the session could definitely be improved. Putting Mrs M in the supine position seemed like a good idea when performing trigger point releases the most appropriate position to put her in would have been side lying with her arm resting in flexion and horizontal adduction over a pillow to gain the best access to the shoulder and lat dorsi muscles. Having her arm over the pillow means that Mrs M could completely relax her muscles.
Another problem with my treatment session was that I probably did too much with her. Although I immediately saw improvements in Mrs M's range, I will not not know what part of my session that caused her to get the improvements. This will also be a problem if Mrs M returns next week to say she is worse, whether it was what she did after physio or whether it was my TPR, AP glides or just doing to much exercises with her.
STRATEGIES
Next time I see Mrs M I will only do one of my treatment options with her, then get her back later in the week and she if it improved, if not then try the other treatment option. Another way to suss out which technique improved her range, I should re-assess after each technique instead of at the end of the treatment session.I will also position her better in the side lying option, as that gives me better access to her shoulder complex.
Mr M is a 64 yr old lady who was referred to physio after a fall on an outstretched arm that left her with a fractured proximal humerus that had to be fixed using a prosthesis on the left side. Since surgery she has had difficulties regaining her range of motion and when she tries to move her arm it feels a tight band around her arm stopping her moving. Mrs M has 50 degrees of flexion and 60 degrees of abduction, however the majority of the movement is through the shoulder girdle which she hitches for movement. This is severely limiting her function which is her main concern. She lives at home with her husband and they are both retired. She is right handed so still able to complete some tasks, however such activities like opening jars and washing her hair are limited. She has been attending physiotherapy for the past two months yet has only had limited gains. So far her treatment has included passive accessory movements, soft tissue mobilisations, heat packs and a home exercise program which consisted of pulley exercises, active assisted exercises and stretches.
TASK
To give Mrs M a appropriate and individualized treatment to help improve her range of movement in her left arm.
ACTION
Firstly I got Mrs M into supine, from there I started my treatment with trigger point release of lat dorsi, anterior and posterior deltoids as i found these muscles to be tight and had active trigger points. I then did grade 4 AP glide on the GHJ in 60 degrees of abduction, 3 sets of 30 secs. After this I did a grade 4 lateral glide the the GHJ 3 sets of 30 secs. Lastly we ran through her home exercise program to see if she was completing the exercises an whether she required progression of the exercises.
RESULT
At the end of the treatment Mrs M had and increase of her range of motion to 60 degrees flexion and 80 degrees of abduction. She still complained of the same tight-band feeling across her arm and she was still hitching her shoulder girdle significantly. She was performing her exercises correctly, however I regressed her from long lever pulley exercises to short lever pulley exercises which she found to be easier to achieve.
EVALUATION
Although I did manage to get a good result from the treatment that way I conducted the session could definitely be improved. Putting Mrs M in the supine position seemed like a good idea when performing trigger point releases the most appropriate position to put her in would have been side lying with her arm resting in flexion and horizontal adduction over a pillow to gain the best access to the shoulder and lat dorsi muscles. Having her arm over the pillow means that Mrs M could completely relax her muscles.
Another problem with my treatment session was that I probably did too much with her. Although I immediately saw improvements in Mrs M's range, I will not not know what part of my session that caused her to get the improvements. This will also be a problem if Mrs M returns next week to say she is worse, whether it was what she did after physio or whether it was my TPR, AP glides or just doing to much exercises with her.
STRATEGIES
Next time I see Mrs M I will only do one of my treatment options with her, then get her back later in the week and she if it improved, if not then try the other treatment option. Another way to suss out which technique improved her range, I should re-assess after each technique instead of at the end of the treatment session.I will also position her better in the side lying option, as that gives me better access to her shoulder complex.
Thursday, June 10, 2010
Final Entry
Third placement down and it has been my favourite placement so far. Although I was very nervous about having an outpatient placement, when it came to the first day and seeing patients it was not so different and scary and it actually felt a bit more natural instead of seeing people in hospital beds. Communicating with patients in the cubicle instead of the hospital bed, I believe was a lot easier. This is because they were able to talk and voice their concerns a bit more than a usual sick hospital patient. I found that they gave a lot more information freely then patients on the ward. They were also able to get up and show you where there problems/pains were. It turns out that choosing the right objective assessment after a subjective wasn't the most daunting thing. As we were able to find out which patients we had the next day we could go home and prepare and make an assumption on the objective assessments you might have to perform and make a list. Throughout the subjective history you could then cross out the objective measures that you didn't think were appropriate. I found the hardest bit was from the objective assessment figuring out the most appropriate treatment to do in the time frame you had.
Having Lillie and 2 other Curtin students there was very handy. We all got on really well and were able to ask each other question and bounce ideas of each other. I found this really helpful because if I had a patient I was stuck on, I could feel confident in asking any of them what their opinion was. Another reason why having other student was handy was if any of us didn't have a patient we felt comfortable in asking each other if we could sit in with a person that had a patient to see how they assessed and handled patients and also get a broader experience of different patients. My supervisor Rhod was very nice and approachable and had such a vast knowledge in that area, I could ask him anything and he would have an answer and an clinical example he had to better explain it. One of my concerns when i started was that Rhod didn't closely supervise us. Even though he didn't supervise by sitting in the cubicle with us he made us come out after the subjective and objective assessments. I found this helpful and the situation less daunting because if you did miss anything Rhod would tell you and you would just go back in and do it.
I felt that I came away from this placement having learnt so much, being able to consolidate things I learnt at uni, and learning things uni didn't teach us.
Having Lillie and 2 other Curtin students there was very handy. We all got on really well and were able to ask each other question and bounce ideas of each other. I found this really helpful because if I had a patient I was stuck on, I could feel confident in asking any of them what their opinion was. Another reason why having other student was handy was if any of us didn't have a patient we felt comfortable in asking each other if we could sit in with a person that had a patient to see how they assessed and handled patients and also get a broader experience of different patients. My supervisor Rhod was very nice and approachable and had such a vast knowledge in that area, I could ask him anything and he would have an answer and an clinical example he had to better explain it. One of my concerns when i started was that Rhod didn't closely supervise us. Even though he didn't supervise by sitting in the cubicle with us he made us come out after the subjective and objective assessments. I found this helpful and the situation less daunting because if you did miss anything Rhod would tell you and you would just go back in and do it.
I felt that I came away from this placement having learnt so much, being able to consolidate things I learnt at uni, and learning things uni didn't teach us.
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