FINAL ENTRY: Placement 2 2010

Reflecting back on my initial entry for this placement it appears there were a few expectations that were accurate but there were other aspects of the placement that i had not considered.

Having the ability to interpret your objective findings and create an appropriate problem list was a must, as expected. This ability not only provided the foundation for treatment but was also how our supervisors judged our clinical reasoning. Needless to say it was a necessary skill to have.

Teamwork proved to be an important part of my placement. As per my initial inclinations, there were times where there were a lack of high priority cardiorespiratory patients and so you would treat patients together with another student. Furthermore, working on an acute surgical ward meant that patients had many attachments and so most of the time there were at least two of us working with the patient. Having the ability to manage attachments was something that I had not considered prior to the placement and proved to be an important skill.

I was right when I thought that I would not have the same level of autonomy as with my musculoskeletal placement. My supervisor needed to be sure that I was safe in regards to interpreting obs and with my manual handling before I was able to see patients on my own. As mentioned before I often needed an extra set of hands with patients which meant that I also had to be able to communicate effectively and take control of the situation at hand. I also found it beneficial having the support of my supervisor in the early stages. I felt more confident dealing with patients and it was great having a another person there to "bounce" thoughts off each other when there were alarms going off and a medically unwell patient lying in bed. I think if I didn't have that support early on it would have been too overwhelming.

I thought that I would need an extensive knowledge of pathology for this placement. This tended not to be the case for me because I was working on an acute surgical unit. Although I needed to have a basic understanding of some cardiorespiratory conditions what was more important was having a knowledge of the various procedures and how that surgery would effect a persons risk of developing a post op complication. I also needed to know the various protocols for each surgery.

Overall I have really enjoyed this placement. I have learnt a lot about how to deal with complex patients and prioritise them appropriately. I enjoyed the opportunity to work with other health care professionals and work as part of a team to improve a persons wellbeing. As I previously expected by the end of the placement I was managing my own caseload and running the ward and I feel that having that responsibility has progressed my learning immensely.

Week Five Entry: Discharge Planning

Situation: I had been seeing a patient a couple of weeks ago who had been admitted to emergency via ambulance with respiratory distress. He had collapsed and was transfered to ICU with the diagnosis of an infective exacerbation of his COPD. The 68 yr old male underwent a surgical trancheostomy as he was heavily sedated and was therefore unable to manage his own airway and secretions. He was transfered to the ward I was working on after a length of stay in ICU of close to two weeks and upon removal of his tracheostomy.

After the initial assessment it appeared that his chest was clear and that his main cardiorespiratory problems were airflow limitation (as a result of his asthma) and decreased exercise tolerance. He was morbidly obese and was a full sling hoist transfer, when previously he was independant with a walking stick. Something that further complicated the situation was that he was experiencing significant memory loss in regards to some aspects of his lifestyle prior to admission. He was confident about his living situation at home and how many flights of stairs etc. he had but was unable to identify whether he drunk alcohol or whether he normally had a cough, to name a few. His confusion was gradually improving but he occasionally was inconsitent with his answers to subjective questioning and often responded inappropriately.

Task: As the patient was improving medically and his chest was clear it was time to start thinking about discharge planning. My task was to come up with an appropriate discharge plan for the patient and discuss it with my supervisor.

Action: As the patient was significantly deconditioned and nowhere near his baseline, as he reported to us, I knew that this patient would require some form of rehab. Currently he was able to stand with a wheeled zimmer frame with 2 x mod assist and was able to stand for 30 secs only. Because the medical team was close to discharging the patient I automatically thought that they were thinking of sending him home so I had decided that sending him with RITH and possibly a home care package would be appropriate.

Result: It was decided by the team that he would require inpatient rehab and that V5, the rehab ward at Fremantle, would be an appropriate option.

Evaluation: Reflecting back i felt like i performed this task poorly and my discharge planning requires significant improvement.Unfortunately up to that date I did not really understand all possible discharge options available. Being on a surgical ward most patients that I had seen were close to there baseline by the time they were medically stable, so discharge tended to be simple. I automatically thought that because this patient was independant beforehand that he would be able to return home with a program such as RITH and be fine. I never even asked myself the obvious question, "can the patient go home?". I think if I had asked myself this I would have planned a lot better. I guess I also didn't realise how quickly the medical team were planning on discharging him and did not consider factors such as his length of stay and confused mental state. Looking back it seems obvious that he required further intensive rehab so inpatient rehab would be appropriate.

As the patient was quite confused and suffering from considerable memory loss it would have also been appropriate to contact the next of kin to identify what his true baseline was and how he was coping at home prior to admission. This would have given me some valuable information to make an educated decision about his discharge plan.

Strategies: Whenever I attend a new placement or am working at a new facility I am going to make sure that I understand all the discharge options available. I think that now that it is week 5 of my placement that my discharge planning has improved significantly because I have progressed my understanding of each of the discharge options and the various packages and services available. I think that as I become more experienced this will naturally improve and I will be able to make better discharge decisions.

Week Three Entry- Analysis and Planning

Situation: I was asked to see a 80 year old female for mobilisation on 8.4.10 . She was admitted via the emergency department with the onset of severe abdominal pain within 24 hours and underwent a incisional hernia repair on the 30.3.10 by midline incision. She had a revision laparotomy and hernia repair 2 days later due to complications. The patient had a past medical history of unstable angina, myocardial infarcts, postural hypotension and multiple transient ischemic attacks. Between the time of her revision surgery and the day I was due to review her mobility she had had 3 codes, all for decreased oxygen saturations. I had already seen the patient for chest physiotherapy and she had been taught deep breathing exercises, a supported cough and techniques to relieve shortness of breath. The fact that she had not yet mobilised was due to her unstable medical condition. On the 8.4.10 it was handed over that the patient was now medically stable enough to commence mobilisation.

Subjective examination revealed no pain at rest, moderate dyspnoea and a productive cough as the main findings. O2 saturations were at 98% on 37% high flow nasal prongs, BP was 131/69 and other obs were stable. Cough was strong, dry, productive of minimal clear sputum and effective. Auscultation revealed early fine inspiratory crackles bibasally and fair breath sounds throughout. Basal expansion was fair bibasally and left equaled right.

Task: Plan an appropriate treatment for the patient.

Action: I decided that transferring the patient to a high back chair would be an appropriate intervention. This would help to improve lung volumes and encourage basal expansion. Mobilising the patient would also improve tidal volumes and help shear secretions off the airway walls. The plan was to sit the patient over the edge of the bed. I would expect that the patient would be dizzy from lying in bed for an extended period of time. Once the dizziness subsides, with a wheeled zimmer frame we would stand and perform a step transfer to a chair next to the bed. I would require the assistance of another physiotherapist/nurse throughout and due to the nature of her condition I would be monitoring her vital signs closely.

Result: The patient was a 1 x minimal assist with rolling onto her side and a 2 x max assist to sit over the edge of the bed. As expected the patient experienced substantial dizziness and nausea when sitting over the edge of the bed, which eased after approx. 3 mins. Sats were stable at 97% and HR was within normal limits. Even so my supervisor suggested that we take a blood pressure reading. It indicated a drop in systolic BP with a reading of 120/67. We still deemed it safe to attempt a transfer as the patients symptoms had subsided. Upon standing with 2 x max assistance and a wheeled zimmer frame the patient reported dizziness and nausea. The patient could only tolerate standing for 5 secs before the dizziness increased so we sat her back on the bed. This time the dizziness took 5-6 mins to ease, her saturations had dropped to around 90 and she reported some minimal chest pain. I decided that transferring her to a chair would be a bit optimistic. Hence once her symptoms eased I got to perform one more sit to stand and take a few steps sideways so that I could position her in a more upright position in bed. When she stood up the second time the patient was a lot more stable and her work of breathing was not as high so I encouraged her to attempt stepping towards the chair for a transfer. The pt was reluctant to do so, even with encouragement, so we sat her down and transferred back into bed, with it tilted in an upright position.

Evaluation: I think transferring the patient to a chair was an appropriate choice of treatment. I think where I needed to improve was my ability to quickly change my plan when things don't go as expected. I thought that the patient would be able to complete the transfer after the second standing attempt but because the patient was reluctant to do so we had to decide on the next best option. I guess I feel my ability to plan before treatment was sufficient but where I need to improve is my ability to quickly plan the next step throughout the treatment session.

I always need to remember to ask "why?" when symptoms appear and then think of what I can do to ascertain the cause of the symptoms. In this case I should have realised that taking the patients blood pressure would have been a appropriate measure to ensure safety with performing the transfer.

Strategies: I think this is going to take practice and will improve with experience. The more patients I see the better I'm going to get a planning ahead. It's important not to get flustered in situations such as these so taking a few seconds to pause, think and take a breath would be a good strategy.