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.

STARES WEEK ONE: Assessment

Situation: I was asked to see a patient day one post elective surgery for the removal of an abdominal hernia. Her obs were stable, she was saturating at 100% on 2L of oxygen via nasal prongs, she was alert, orientated and afebrile but had not mobilised since surgery. She had an indwelling catheter and nasal prongs as attachments. It was documented that the patient had experienced no operative complications, her chest was clear and that she was previously independent with her mobility. The only possible complication to early mobilisation was that she was overweight. Although it would be important to see her day one post op I had planned to see her in the afternoon as she was not a high priority patient for physiotherapy. The patients nurse, however, wanted to get her up for a shower in the morning and so had asked for my assistance. The task would have to be quick and brief as there were other patients that were a priority for me.

Task: Together with my peer, perform a brief subjective and objective assessment, and with the nurse transfer the patient from the bed to a commode so the patient could be showered.

Action: We performed a subjective assessment asking the patient about pain, nausea and vomiting, dizziness, shortness of breath, cough, previous level of mobility and how she ambulated pre surgery. When it came to the objective assessment we decided it would be important to do a quick manual muscle test of the lower limbs so we could get an idea on the best way to transfer her. As she reported that she did not have a cough and she didn't have any shortness of breath we decided, with the limited time available, to not perform a routine cardio objective assessment today.

Result: The patient reported pain, 5/10, over the incision site, which increased with movement. She reported no chest pain, no cough, no production of sputum and no shortness of breath. The patient was previously independent with her activities of daily living and ambulated independently over indefinite distances with a quad stick. We decided to transfer her from supine to sit so we could perform the manual muscle screening. She was a 2 x max assist to get into sitting over the edge of the bed. This increased her shortness of breath score from 0/10 to 4/10. From the screening it was established that she had on average a grade 4 strength in the muscles of her lower limb and so it was decided that a step transfer would be suitable. Using a pulse oximeter we measured her 02 sats on room air (RA) as we would need to remove the oxygen to get her into the commode. Her sats were stable at 100% on RA so we decided it was safe to perform the transfer. With 2 x minimal assist and the patient using her quad stick, she took 5-6 steps forward so we could simply place the commode behind her to sit back down.

Evaluation: I felt the actual transfer itself was done efficiently and in a safe manner. It was performed in a way that did not put strain on us as therapists and that did not increase the pain of the patient. Reflecting back on the situation we should have performed the manual muscle test prior to positioning the patient sitting over the edge of the bed. This would have given us an idea that the patient had reasonable muscle strength so we may have chosen to perform a "supine to sit" transfer that was not a 2 x max assist and instead chosen one that encouraged a greater level of patient involvement.

Strategies: I think it's always important to encourage as much patient involvement as possible in our treatment sessions, after all one of the main aims of physiotherapy treatment is to get patients back to there previous level of function. I think an important strategy is never to assume that a patient is at a certain level of function based on initial observations. I think the best way to choose a transfer option is to consider the most independent transfer first and then if you don't think the patient is capable, consider the next most independent transfer and so on. This way you will promote patient independence and speed up their recovery.

Initial Entry 2nd Placement 2010 (Cardiorespiratory)

All of my placements to date have been musculoskeletal based so I am quite nervous about my upcoming cardiorespiratory (cardio) placement at Fremantle hospital. Not only this but it is also my first placement in a purely inpatient setting of a hospital, which is further enhancing my anxiety. Amongst this uncertainty I am excited at the prospect of working on a ward with a multidisciplinary team (MDT) and working with patients with more complex and critical conditions.

I expect that on my first day I will have a general orientation, be introduced to how the department works, how the ward functions and some of the types of patients that I may be seeing. I don't think I will have the same level of responsibility as early as I did with my musculoskeletal placement. I'm expecting that initially I'll be under the supervision of a physiotherapist because I will be dealing with patients in a more critical condition, but by the end of the placement I am sure that my supervisor will be wanting me to manage my own caseload. Speaking to students whom have already attended the placement it seems in some circumstances there are a limited number of patients that require cardiorespiratory physio and so they have been paired up to work with another student. This could possibly create conflict when a pair has contrasting ideas on the treatment of a patient but overall I think it would be beneficial to be able to "bounce" ideas of each other and clinically reason as a team. It would probably enhance our communication skills and facilitate our learning.

I expect that knowing the cardiorespiratory problem list is a must. I will need to be able to use my objective findings to justify my analysis and be able to document all the information appropriately in a soapier format. I suspect that knowledge of the various cardiorespiratory pathologies, types of surgeries, the effects of anaesthesia and the different types of interventions will also be vital.

The fact there is so much information compiled into out third year cardio unit is one of my major concerns. The idea that I could be presented with any one of the conditions we have studied, and possibly more, then have to interpret the vast types of objective markers and treat accordingly seems a little daunting. As mentioned before, I'm also a little concerned about working in a hospital setting when I have never really worked in one before.

Although it probably seems that I am quite fearful about this forthcoming placement I am looking forward to the challenge. As I have been based in the musculoskeletal setting for each placement thus far I have always felt that musculoskeletal physiotherapy was for me. I see this placement as my first opportunity to experience and discover another aspect of physiotherapy that I may enjoy.

Final Entry

Reflecting back on my initial entry for this musculoskeletal placement I feel that I was reasonably accurate with my expectations. From day one I was given the autonomy to see my own patients without having someone over my shoulder. Although it seemed daunting to start with I think that it was the best way for me to learn and I have gained valuable skills from being put in that situation. For the first two weeks I needed to report back to my supervisor after both the subjective and objective to show that I was conducting a safe and relevant assessment and that my clinically reasoning was valid. By week three I was completing my assessment and then discussing the treatment with my senior and by week four I was assessing and treating my patients without having to consult my supervisor. I think it was in these last two weeks that I thrived and felt that I really improved. I think maybe it was because by him having the confidence in me to see my own caseload it gave me more confidence in myself.

The expectation that I was going to see an array of patients and those with complex cases was accurate. I treated patients with MRSA, pain dominant presentations, centrally dominant pain mechanisms, obesity, diabetes and cancer to name a few. It really made me have to take a holistic approach to treatment and consider issues of infection control, appropriate exercise prescription and education etc.

Time management was another key skill that was required and something that I feel I further need to improve on. As my caseload increased so did the paperwork and so being able to perform a relevant assessment then treat appropriately and document the session became a challenge. I learnt the key to time management is a thorough and accurate initial assessment, I think if this is achieved and assuming you have treated the diagnosis appropriately, it makes the follow up assessment easier. If you don't perform a thorough initial assessment the problem can become more complex than you initially thought and chew up time that don't have.

Overall I thoroughly enjoyed my musuloskeletal placement. Having the responsibility of seeing my own caseload has really prepared me for the future. Being put in the deep end at the start of the placment really challenged my assessment and clinical reasoning skills and I think I have really benefited from the experience. One of the biggest things that I learned on the placement is that although we learn a lot about common presentations and patterns for certain conditions, it is not always the case in real life. Patients are often more complex so it is important to have an open mind during assessment and restrain from looking for issues that you think make up the problem but are not there. I found that it's important to treat what you see and always ask yourself "why?" when there is an impairment. I feel that this placement was a truly valuable experience and one that has prepared me to step out in the workforce at the end of the year.

STARES WEEK THREE: Analysis and Planning

Situation: I had been treating a 60 year old female who had been referred for headaches. On presentation the patient reported that they had suffered from "migraines" for 20 years. The headaches sometimes came in clusters having 3 or 4 in a row every 3 weeks. She described the pain as an ache that started in the neck and worked its way into the head. The pain most commonly occurred on the right but could shift to the left between episodes. She complained of no nausea or vomiting and only had described an aura on one occasion. Aggravating factors included stress and fatigue.

On objective examination I was unable to reproduce the patients neck pain with active movements, over-pressures, sustained movements or combined movements. Passive accessory examination produced no asterisk level. The patient did have a chin poked posture so I decided to assess her deep neck flexor recruitment and sternocleidomastoid seemed quite overactive. Her neck pain was then reproduced on palpation of the sternocleidomastoid origin. She also had decreased muscle length of upper trapezius which could be a result of her stress.

Although I don't think the patient suffered from true cervicogenic headache, on examination it seemed that the neck pain could possibly be a trigger for a her headaches. Treatment therefore consisted on addressing the patients postural issues with deep neck flexor recruitment exercises, stretches for upper trapezius and education on pain management such as the use of heat and relaxation techniques.

Task: The patient had been progressing well and not suffered from headache since starting treatment so the task was to start organising her discharge.

Action: For discharge the patient would need a comprehensive home exercise program and learn to manage her own neck pain. I continued with postural activities and stretches to maintain muscle length. I also addressed her ergonomics when sitting at her computer. As her aggravating factors were stress I taught her some relaxation techniques and suggested the use of heat for pain management. Part of my intervention was to educate her on the different type of headaches that she suffered from. I had to explain the headaches that we could manage biomechanically but that if she suffered from another aura that she would need to take her medication for migraines. Overall I had to make sure she no longer suffered from her symptoms and that she would be able to self manage in the future.

Result: The patient was going on holidays for 6 weeks so I had to decide whether to discharge her or transfer her to another physio upon return. Although she had been progressing well I had only been treating her over a 2 week period and since she suffered from headaches in clusters every 3 weeks, I was unable to tell if my treatment had been truly effective. Hence it was decided to write a transfer summary explaining the clusters of headaches and that should she need a follow up she would book an appointment after her holiday.

Evaluation: Overall I think I made the right decision. The aim of treatment is to make improvements in a patients symptoms. I was unable to ascertain whether my treatment was effective or whether natural history was the reason for her not having suffered from a headache during the time I had been treating her. Therefore giving her the option of another appointment if she suffered from a cluster of headaches in a week or twos time seemed appropriate.

Strategies: Always consider a patients natural history of symptoms when considering discharge.

STARES WEEK THREE: Communication

Situation: I received a referral for a patient with chronic low back pain. The patient is in his 50's. On presentation he complained of pain in his lumbar spine and a broad pain in the lateral aspect of the thigh. The onset was insidious dating back 2 years ago. He has been working as a gardener three times a week for 5 hours a day in that time and was frustrated that he has been unable work more due to his back pain. Aggravating factors at work include lifting loads and bending. Pain is eased my sitting. After half an hour of work he needs to sit down as the pain is too severe and it takes 5-10 minutes for the pain to ease. The difficulty in communication was due to the fact that his primary language is Cantonese and although he does speak some English he tended to repeat himself and focus on how work has been so frustrating.

Task: To perform a subjective and objective assessment that was not only effective but safe.

Action: I had to make sure that I spoke clearly and precisely. I established early that it was going to be difficulty getting as much information as possible from the subjective so I decided to focus getting the basics first. Finding out where his pain was, what aggravated it, what eased it, how long its been going on for and making sure that an objective assessment was going to be safe to perform. Where I could I tried to use gestures to help. I overall had to spend more time on the assessment part of the session to get an understanding of the problem that I would normally.

Result: It was difficult to even get a basic understanding of the problem from the subjective. The body chart and aggravating factors were the two areas of the subjective that were most difficult. Even though I knew the general area of pain in both his leg and back he had difficulty understanding the concept of specifically mapping out the area of pain and couldn't really describe his pain. Nor did he have an understanding of what I meant by how bad the pain was. I was able to determine the aggravating factors to the pain but trying to get more information about them was hard. I didn't really know what part of lifting was hurting him and what the duties at work were the worst for his back. When performing an objective in the musculoskeletal setting it is important when finding the source of symptoms that we ask the patient "is that the pain you've come to see me about". Many people have pains that are not those they are complaining of but could be a contributing factor or a different problem completely. The barrier in communication meant that although I was finding structures that were painful but I didn't know if this was his main pain. Nor was I able to find a true asterisk motion segment in the lumbar spine because multiple levels were sore and he was unable to tell me which one was truly worst. Generally getting him to perform different movements was also difficult.

Evaluation: Overall I don't think I did all that well in this situation. As much as he was repeating himself I was probably repeating myself. I found it really difficult to get my messages across which meant I didn't have all the information I wanted from the subjective. I was able to get a basic understanding of the problem from the objective and eventually was able to determine which direction of movement caused his pain and what level seemed to be the worst from the way he reacted to my palpation. In saying that it meant that I had to spent a lot of time with this particular patient.

Strategies: I think next time rather then asking opened ended questions I should delve more into the aggravating factors about questioning him about certain things. Whats it like walking uphill? Downhill? Gardening above your head? and other questions of the like. Using visual cues and the reactions of the patient is also beneficial. Bentley Health Service also have the option of the interpreter so I think that if it is still too difficult next session I may have to go down that path. My hesitation to do so is that I think it makes it difficult to build rapport with the patient but I guess at the end of the day getting a true understanding of the problem is in the best interest of the patient and if communication is a barrier then it should be addressed. Hopefully my second session with the patient will be more successful.