STARES 2 - Communication (1st placement)
Situation
A 12 year old female patient came in with a sore back from an injury 1 week prior. She was trying to do a back flip on school camp and felt her back “go”. She had pain all the time in her back after a gradual onset of pain the morning after the event. On palpation she was very painful on all spinous processes and through her erector spinae. The patient came into the treatment room without her mother who wanted to stay out in the foyer with her young son.
Task
The task was to assess and then treat this patient. In this patients case the main goal of treatment was to reduce her pain. In this patient’s case, she has a significant injury to still be as sore as she was one week after the incident. Therefore the other aspect of the treatment was to communicate and educate the importance of no heavy lifting or activities that could provoke or further injure this patient’s back
Action
While I was assessing the patient and then treating her according I talked to her about school and what she does at school and after school, focusing on “sport” like activities that could further injure her back. I worked out when her next physical education lesion was at school and talked about playing at recess and lunch times in terms of what not to do. After she told me she had danced and it had made her back feel worse I suggested that going to dancing at the moment time in her recovery wouldn’t be the best idea, just as trying to do back flips again would not be recommended.
Result
I do not know whether the way I communicated it to her sent her the message strong enough. I talked to her whilst I was massaging her back which meant she had her face in the bed head hole, so I couldn’t see her face to see if she was understanding or taking me seriously. The tone of my voice may have also suggested that I wasn’t serious since I was trying to build a rapport with her and may have not come across as serious as I would have liked. I also did not give her clear instruction on what she could and couldn’t do; I had decided to just bring it up in conversation. After the treatment she was feeling somewhat better, which could mean that everything I had suggested to her would have been forgotten. I also taped her back, which could have given her the false impression that she was ok to do activity now she was taped.
Evaluation
The way I approached the issue of rest and restricted actions probably turned out to be not the best method of portraying what I wanted to this patient. My strength in this situation was the way I dealt with a young girl. I believe I made her feel comfortable by talking to her about school and relating to her through different things she said about school. I was also pleased with the way I dealt with a young female who had to disrobe. I made sure that she had her privacy and robes to ensure she was covered when I re-entered the room. My weaknesses’ in this situation was the way in which I communicated what I wanted to in terms of activity restrictions of this patient for the short term. I was not strong enough on my opinion or clear enough on what I was trying to explain to her. Her follow up appointment was with another physio, who I have not seen yet, so I am unsure what type of impact this had on her. If she wasn’t to rest like I was trying to explain to her she possibly had not got any better, possibly worse.
Strategies
1. Discuss important issues at the end of the treatment when the patient is sitting up and fully focused
2. Involve the child’s mother to ensure the message has been given to both parties
3. Write down important information so that it can be taken home and remembered. This is also evidence that they have been given the required information, by attaching a photocopy to their notes
Monday, February 22, 2010
Friday, February 12, 2010
Stares 1 - Assessment
STARES 1 - Assessment
Situation
A patient came into our practice with a referral from the doctor. After having a cataract operation, she got symptoms of weakness down her left side, dysphagia and dysphasia. She has had numerous tests but with no results so far. The referral from the doctor stated possible upper motor neuron disease or a tauopathy and asked for an exercise problem for this lady. The initial assessment was done by my supervisor where I just watched. The following is about her second appointment, a full muscle chart and functional assessment. This appointment I took on my own.
Task
The task ahead was to complete a full muscle chart (muscle strength) and a functional assessment of this patient. Due to this lady’s difficulty in communication, it was going to be a good learning experience for myself
Action
I completed a full muscle assessment on this lady, followed by a functional assessment. I had guidelines on an assessment form for all the muscles and then a scale to rate them on. This scale was 0 – 6, which confused me since I am used to the Oxford scale, which is 0 – 5. This lady had trouble moving from sitting to lying so I tried to make sure that I did all her standing, then all her sitting, then all her lying tests. This was hard because there were 3 pages of muscles to test, so I felt like I was “all over the place”.
Result
The muscle chart was completed for this lady. I found it difficult to get used to the scale they used. I believed that there was a big gap between grade 1 and 2, so I often became unsure which one I was to grad her as. This could have caused my result to be inconsistent between different muscles and the consistency between myself and another therapist if they were to retest. At the end of the assessment the patient was feeling a bit sore in both her lower limbs and was frustrated with her lack of strength in her left side.
Evaluation
I found it hard to determine what the patient was trying to say. This meant I had to ask her repeatedly to restate what she had said. I think in future I would establish clear signals for basic words like yes, no and pain. I possibly could have seen what her writing was like and used that as a form of communication. In future I would have liked to have got to look at the muscle chart earlier so I could get used to the grades, however the chart had only been faxed over from the other practice as my patient walked through the door. I could have taken more responsibility and looked in the Mandurah practice the day before for the assessment form so I could be more familiar with it. If I was more familiar with the form I may have been able to pre plan which muscles to test in which position. I was pleased with the time I did it in, I finished within 45 minutes. I had an hour timeslot but I am meant to aim for half an hour by time I finish placement, so for my first muscle chart I was happy. When I first started giving her instructions I don’t think she fully understood what I meant so I demonstrated to her, which made it easier.
Strategies
1. To pre-plan what I am going to do next time I see patients – so that I can prepare (for example the muscle chart)
2. To establish communication strategies with patients that are unable to communicate fully
3. To determine easier directions for patients by demonstrating – used and worked
Situation
A patient came into our practice with a referral from the doctor. After having a cataract operation, she got symptoms of weakness down her left side, dysphagia and dysphasia. She has had numerous tests but with no results so far. The referral from the doctor stated possible upper motor neuron disease or a tauopathy and asked for an exercise problem for this lady. The initial assessment was done by my supervisor where I just watched. The following is about her second appointment, a full muscle chart and functional assessment. This appointment I took on my own.
Task
The task ahead was to complete a full muscle chart (muscle strength) and a functional assessment of this patient. Due to this lady’s difficulty in communication, it was going to be a good learning experience for myself
Action
I completed a full muscle assessment on this lady, followed by a functional assessment. I had guidelines on an assessment form for all the muscles and then a scale to rate them on. This scale was 0 – 6, which confused me since I am used to the Oxford scale, which is 0 – 5. This lady had trouble moving from sitting to lying so I tried to make sure that I did all her standing, then all her sitting, then all her lying tests. This was hard because there were 3 pages of muscles to test, so I felt like I was “all over the place”.
Result
The muscle chart was completed for this lady. I found it difficult to get used to the scale they used. I believed that there was a big gap between grade 1 and 2, so I often became unsure which one I was to grad her as. This could have caused my result to be inconsistent between different muscles and the consistency between myself and another therapist if they were to retest. At the end of the assessment the patient was feeling a bit sore in both her lower limbs and was frustrated with her lack of strength in her left side.
Evaluation
I found it hard to determine what the patient was trying to say. This meant I had to ask her repeatedly to restate what she had said. I think in future I would establish clear signals for basic words like yes, no and pain. I possibly could have seen what her writing was like and used that as a form of communication. In future I would have liked to have got to look at the muscle chart earlier so I could get used to the grades, however the chart had only been faxed over from the other practice as my patient walked through the door. I could have taken more responsibility and looked in the Mandurah practice the day before for the assessment form so I could be more familiar with it. If I was more familiar with the form I may have been able to pre plan which muscles to test in which position. I was pleased with the time I did it in, I finished within 45 minutes. I had an hour timeslot but I am meant to aim for half an hour by time I finish placement, so for my first muscle chart I was happy. When I first started giving her instructions I don’t think she fully understood what I meant so I demonstrated to her, which made it easier.
Strategies
1. To pre-plan what I am going to do next time I see patients – so that I can prepare (for example the muscle chart)
2. To establish communication strategies with patients that are unable to communicate fully
3. To determine easier directions for patients by demonstrating – used and worked
Friday, February 5, 2010
Initial Entry - Placement 1 Yr 4
Initial Entry – Placement 1, Year 4
I will be attending Mandurah and Pinjarra Physiotherapy Clinic for a musculoskeletal placement. I am feeling both excited and very nervous for this placement. I am feeling excited because I believed I will be challenged in this placement with a variety of musculoskeletal conditions and excited for the opportunity to have my own patient load and cases. The nervous feeling I have comes from the case mixes I have read that says that we only have half hour appointments, even for the initial assessment. This concerns me since I haven’t had much previous practice with a shot time restraint in my other placements.
After phoning the placement, I have the understanding that I will be given my own full case load early on in the 5 weeks. The placement has 2 clinics, where I will spend 3 days at the Pinjarra clinic and 2 days at the Mandurah clinic. I believe that at the Pinjarra clinic it will be structured where I will be working as an independent with the supervisor treating her own patients, but there for assistance when needed. This placement also allows me to attend a hydrotherapy session which I am looking forward to after doing my 4P hours in a hydro pool. When driving past the placement to work out parking, I noticed a Pilates sign on their signage, which I would be interested in learning about if possible as well.
I believe my role as a student in this facility will be one as a team member of their practice. As a 4th year I believe that it will be expected to be an equal party and have my own learning, gaining experience and patient care, as well as their practice’s reputation at heart. I, however hope that consideration is taken into the fact that I am a student and that I will be given situations to learn and ask questions/advice.
My main concern of this placement is the time restraint placed upon me with initial assessments. Despite this concern, I believe that it will make me become a more efficient practitioner; I would just worry that initially I may leave out things due to the time. Another concern I have is wearing myself out on this placement, due to the 12 hour days I will have with driving time. A way to overcome this is to ensure good rest times and making sure I am eating properly.
This placement should provide great experience to work on my musculoskeletal skills and to see how a private practice works compared to a hospital.
I will be attending Mandurah and Pinjarra Physiotherapy Clinic for a musculoskeletal placement. I am feeling both excited and very nervous for this placement. I am feeling excited because I believed I will be challenged in this placement with a variety of musculoskeletal conditions and excited for the opportunity to have my own patient load and cases. The nervous feeling I have comes from the case mixes I have read that says that we only have half hour appointments, even for the initial assessment. This concerns me since I haven’t had much previous practice with a shot time restraint in my other placements.
After phoning the placement, I have the understanding that I will be given my own full case load early on in the 5 weeks. The placement has 2 clinics, where I will spend 3 days at the Pinjarra clinic and 2 days at the Mandurah clinic. I believe that at the Pinjarra clinic it will be structured where I will be working as an independent with the supervisor treating her own patients, but there for assistance when needed. This placement also allows me to attend a hydrotherapy session which I am looking forward to after doing my 4P hours in a hydro pool. When driving past the placement to work out parking, I noticed a Pilates sign on their signage, which I would be interested in learning about if possible as well.
I believe my role as a student in this facility will be one as a team member of their practice. As a 4th year I believe that it will be expected to be an equal party and have my own learning, gaining experience and patient care, as well as their practice’s reputation at heart. I, however hope that consideration is taken into the fact that I am a student and that I will be given situations to learn and ask questions/advice.
My main concern of this placement is the time restraint placed upon me with initial assessments. Despite this concern, I believe that it will make me become a more efficient practitioner; I would just worry that initially I may leave out things due to the time. Another concern I have is wearing myself out on this placement, due to the 12 hour days I will have with driving time. A way to overcome this is to ensure good rest times and making sure I am eating properly.
This placement should provide great experience to work on my musculoskeletal skills and to see how a private practice works compared to a hospital.
Friday, August 28, 2009
Final Entry
This placement allowed me to learn so much. This placement was more of a Urogynae placement, rather than an obstetrics placement. Though we did get some experience in obstetrics. Instead of running post natal classes like I thought in my initial assessment, we ran a ward. We gave information to patients post op (Urogynae/oncology patients).
Having a tutor was amazing we spend 2 half days with 2 tutors and learnt so much. The tutor was able to educate us greatly on different things and situations that we weren’t seeing daily on the ward. We then would go and see some if those things with the tutor.
I was able to see surgery – I saw 3 c sections and one assisted delivery, but the day I was meant to see urogynae surgery I couldn’t go in due to complications and they were running late. That was a shame since we had worked on the ward that got those patients post op.
I didn’t become emotionally involved, there was only once when a sick cancer patient “got” to me a bit, but it is your job.
I learnt so much on this placement and I am further excited about women’s health. I learnt all about treatment for incontinence, giving post op advice, giving post natal advice, subjective in urogynae, breast US, peri Ax, identifying and writing referrals just to name a little.
Having a tutor was amazing we spend 2 half days with 2 tutors and learnt so much. The tutor was able to educate us greatly on different things and situations that we weren’t seeing daily on the ward. We then would go and see some if those things with the tutor.
I was able to see surgery – I saw 3 c sections and one assisted delivery, but the day I was meant to see urogynae surgery I couldn’t go in due to complications and they were running late. That was a shame since we had worked on the ward that got those patients post op.
I didn’t become emotionally involved, there was only once when a sick cancer patient “got” to me a bit, but it is your job.
I learnt so much on this placement and I am further excited about women’s health. I learnt all about treatment for incontinence, giving post op advice, giving post natal advice, subjective in urogynae, breast US, peri Ax, identifying and writing referrals just to name a little.
Third Stares
Assessment
Situation
It was an out patients patient coming in to see the Continence Physio. She was a new patient coming in after a feeling of a prolapse when her baby was around 8 months old.
Task
I was to complete her subjective assessment. I was aiming to do her initial assessment to work out what the problem was and then give her some education before she came back for her second appointment the week after.
Action
I did her subjective assessment, on the continence Ax form. I used a ‘cheat’ sheet to cue me what questions to ask and what to note as important. Throughout the assessment I gave her a few education tips and used charts to explain some things.
Result
During the assessment I discovered that the patient was moving back to England in 2 weeks time. We normally would send her home with some education and a bladder chart to do. But since she was moving away she was given more education than we would normally do on an initial Ax. This isn’t ideal since you don’t want the patient overloaded, but due to the circumstances we had to.
Evaluation
After I had done the assessment, I could think of so much more education I could have done while I was going, rather than at the end and my supervisor doing a lot of the education at the end (also because she was leaving so more was done). However, once my supervisor talked to me and I thought about it, I did the subjective fine and managed some education – which is a post grad level. I think that I need to be less hard on myself. With practice I would become more fluent and be able to give education throughout better. I was happy with education that I did put in there and being able to know and understand what her answers meant.
Strategies
In the future I would become better with practice. I would use a cheat sheet again when doing the subjective. It was really good that that patient came in for second appt on my last day so I go to follow her through and do real time US to see what was happening (she wasn’t emptying properly, she had small volumes, residual urine, recurring UTIs and urgency). It was good to see that what I had thought of from her subjective was proven with her bladder chart and RTUS. I think that being able to follow patients through is a good strategy to see how effective your questioning was.
Situation
It was an out patients patient coming in to see the Continence Physio. She was a new patient coming in after a feeling of a prolapse when her baby was around 8 months old.
Task
I was to complete her subjective assessment. I was aiming to do her initial assessment to work out what the problem was and then give her some education before she came back for her second appointment the week after.
Action
I did her subjective assessment, on the continence Ax form. I used a ‘cheat’ sheet to cue me what questions to ask and what to note as important. Throughout the assessment I gave her a few education tips and used charts to explain some things.
Result
During the assessment I discovered that the patient was moving back to England in 2 weeks time. We normally would send her home with some education and a bladder chart to do. But since she was moving away she was given more education than we would normally do on an initial Ax. This isn’t ideal since you don’t want the patient overloaded, but due to the circumstances we had to.
Evaluation
After I had done the assessment, I could think of so much more education I could have done while I was going, rather than at the end and my supervisor doing a lot of the education at the end (also because she was leaving so more was done). However, once my supervisor talked to me and I thought about it, I did the subjective fine and managed some education – which is a post grad level. I think that I need to be less hard on myself. With practice I would become more fluent and be able to give education throughout better. I was happy with education that I did put in there and being able to know and understand what her answers meant.
Strategies
In the future I would become better with practice. I would use a cheat sheet again when doing the subjective. It was really good that that patient came in for second appt on my last day so I go to follow her through and do real time US to see what was happening (she wasn’t emptying properly, she had small volumes, residual urine, recurring UTIs and urgency). It was good to see that what I had thought of from her subjective was proven with her bladder chart and RTUS. I think that being able to follow patients through is a good strategy to see how effective your questioning was.
Wednesday, August 12, 2009
2nd Stares - Communication
Communication
Situation
We were paged (along with our tutor) to Rx an emergency out patient, with engorged breast. This patient had her 5 day old baby, her 1 year old son and her husband with her. Her husband took the 1 year old. It was then discovered that the patient was non English speaking.
Task
The patient had been sent up from the breast feeding clinic to be treated, so she could go back down to feed her baby after treatment. The aim was to ease the patients discomfort and help the breasts to become softer to allow better let down of milk
Action
Due to the patient being unable to fully communicate with us or our tutor, the Subjective Ax was limited. Our tutor went on to do the objective Ax, finding 2 very engorged breasts. The patient didn’t understand “is that sore?” but she could understand the word “pain”. It was decided that ultrasound to both whole breasts would be needed. US was given by both Jenna and I at the same time, while the tutor tried to get an interpreter on the phone. The patient’s baby then was upset so the tutor had to nurse the baby and change the nappy
Result
The patient received the treatment which was possible because there were 3 of us. She received a total of 45 mins on each breast. If there was only one physio then it would have been hard to give the treatment for 90 mins and look after an upset baby. No phone interpreter was available, so communication was very hard. An explanation was given of the treatment and what she should feel, however it was very hard to know if she really understood.
Evaluation
We had to keep communication to simple words, like “Pain” and “cold”, which the patient seemed to understand. She was an anxious mother about her baby and didn’t want her baby to get cold
Strategies
Since it was an emergency out patient, an interpreter couldn’t be previously organised. The husband didn’t seem supportive and wouldn’t take the baby, let alone interpret for his wife. I don’t believe that we could do any more in the way we and our tutor communicated, besides refuse her treatment if we didn’t believe she had informed consent. It was very hard to gauge if she really understood and therefore if it was informed consent.
Situation
We were paged (along with our tutor) to Rx an emergency out patient, with engorged breast. This patient had her 5 day old baby, her 1 year old son and her husband with her. Her husband took the 1 year old. It was then discovered that the patient was non English speaking.
Task
The patient had been sent up from the breast feeding clinic to be treated, so she could go back down to feed her baby after treatment. The aim was to ease the patients discomfort and help the breasts to become softer to allow better let down of milk
Action
Due to the patient being unable to fully communicate with us or our tutor, the Subjective Ax was limited. Our tutor went on to do the objective Ax, finding 2 very engorged breasts. The patient didn’t understand “is that sore?” but she could understand the word “pain”. It was decided that ultrasound to both whole breasts would be needed. US was given by both Jenna and I at the same time, while the tutor tried to get an interpreter on the phone. The patient’s baby then was upset so the tutor had to nurse the baby and change the nappy
Result
The patient received the treatment which was possible because there were 3 of us. She received a total of 45 mins on each breast. If there was only one physio then it would have been hard to give the treatment for 90 mins and look after an upset baby. No phone interpreter was available, so communication was very hard. An explanation was given of the treatment and what she should feel, however it was very hard to know if she really understood.
Evaluation
We had to keep communication to simple words, like “Pain” and “cold”, which the patient seemed to understand. She was an anxious mother about her baby and didn’t want her baby to get cold
Strategies
Since it was an emergency out patient, an interpreter couldn’t be previously organised. The husband didn’t seem supportive and wouldn’t take the baby, let alone interpret for his wife. I don’t believe that we could do any more in the way we and our tutor communicated, besides refuse her treatment if we didn’t believe she had informed consent. It was very hard to gauge if she really understood and therefore if it was informed consent.
Wednesday, July 29, 2009
Initial STARES: Intervention
Situation: Pt presented with nipple trauma day 4 post natal. Discharged from hospital day before. Was Rx’ed with LASER Rx day before on ward. Baby not getting good attachment, expressing milk for 24 hrs before seeing the lactation/breast feeding clinic next day. Also has 2 yr old, expressed for 3 months with that child. Wants to breast feed this child. Hx of post natal depression, currently being managed
Task: On Subjective Ax patient complained that (L) nipple was the problem and that LASER treatment on the ward the previous day had helped extremely. On Physical Examination, (L) nipple had horizontal crease, with small scab. Desired outcome is to decrease pain and increase healing in preparation for breast feeding and lactation clinic
Action: Laser treatment to the (L) nipple, along the crease line and over the scab. Explanation of treatment, contraindications and risks given. Glasses put on, warning sign on door and all reflective material removed. Machine set up and turned on. Patient is seated in chair, I was in a half kneel position. Turn on the LASER and treat the area
Result: Patient happy with treatment, no redness cited
Evaluation: I was happy with the way I delivered the treatment, especially it being the first time in using LASER. Just before the treatment started the patients partner called in distress with the baby in emergency awaiting test results and the 2 yr old chucking a tantrum. This meant that the patient wanted to get to him to help him out quickly, so we only treated the 2 worst points on the crease. If I was to do again I would like to have more time with the patient.
Strategies: The LASER has to be perpendicular to the treating area and you must stay very still. I was happy with my position, however after the treatment when the machine was turned off, I got to practice in different positions and I found that if I held it as a pen I was more stable, so if given the opportunity again I would try that hand grip
Task: On Subjective Ax patient complained that (L) nipple was the problem and that LASER treatment on the ward the previous day had helped extremely. On Physical Examination, (L) nipple had horizontal crease, with small scab. Desired outcome is to decrease pain and increase healing in preparation for breast feeding and lactation clinic
Action: Laser treatment to the (L) nipple, along the crease line and over the scab. Explanation of treatment, contraindications and risks given. Glasses put on, warning sign on door and all reflective material removed. Machine set up and turned on. Patient is seated in chair, I was in a half kneel position. Turn on the LASER and treat the area
Result: Patient happy with treatment, no redness cited
Evaluation: I was happy with the way I delivered the treatment, especially it being the first time in using LASER. Just before the treatment started the patients partner called in distress with the baby in emergency awaiting test results and the 2 yr old chucking a tantrum. This meant that the patient wanted to get to him to help him out quickly, so we only treated the 2 worst points on the crease. If I was to do again I would like to have more time with the patient.
Strategies: The LASER has to be perpendicular to the treating area and you must stay very still. I was happy with my position, however after the treatment when the machine was turned off, I got to practice in different positions and I found that if I held it as a pen I was more stable, so if given the opportunity again I would try that hand grip
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