I have just completed my final placement at Royal Perth Hospital on the respiratory ward. The ward is a 30 bed ward used for patients with conditions such as: tuberculosis, pneumonia, COPD, swine flu and respiratory failure just to list a few. They also include 6 renal beds and will take outliers if required. I had a great supervisor who had a great balance between independence and supervision. The senior on the ward was also specialised in non-invasive ventilation (NIV), which I found increased my understanding and knowledge of NIV. The hospital provided a huge amount of continuing education, which I found very beneficial. Especially the weekly xray tutorial. I enjoyed the hospital environment where you are able to liaise with the multi-disciplinary team, and doctors and nurses are very in tune with the benefits of physiotherapy and value their input. Having a tutor every week was also beneficial for gaining feedback.
I have no concerns or disappointment at the end of this prac. The issues I had prior to the commencement of the placement we definitely never an issue. I found my knowledge and time management was sound. And I had plenty of opportunities to expand my knowledge and ask questions.
Treatments I commonly used included suctioning, active cycle of breathing, percussions and vibrations, breathlessness relieving positions, mobilisation and exercise. I was involved in the Pulmonary rehab classes but was mainly based on the ward. I saw up to 7/8 patients a day on average, including generally 1-2 new patients a day. My tips for future students would be to have a good knowledge base of respiratory conditions, normative values, assessment and treatment. Be an active member in team member in meetings and weekly case studies.
I thoroughly enjoyed my time at Royal Perth Hospital, much to my surprise and I would happy apply for a job here!!
Friday, July 23, 2010
Saturday, July 17, 2010
Topic 3- treatment
Situation: 81yo female admitted to emergency at Royal Perth Hospital 19/7/10 with an increased cough, drowsiness, shortness of breath (SOB), increased thick green sputum, decreased exercise tolerance and decreased appetite. The medical team diagnosed it as an exacerbation of Bronchiectasis. Her past medical history is as follows: chronic knee and back pain, end stage Bronchiectasis, GORD, HTN, mini mal seizures, high cholesterol and osteoarthritis. She currently lives at home alone with services (showering, cleaning and meals on wheels). She has a daughter and a son that live in Perth and visit regularly. She normally ambulates with a 4WW independently within the house (she rare walks outside). She has had 2 falls this year (prior to prescription of 4WW, when she was ambulating with a walking stick). Her house has no steps internally or externally and is not fitted with any rails. She is also a non smoker.
She is currently on tobramycin nebulisers (which she just finished), salbutamol and antibiotics to overcome the exacerbation. She is complaining of SOB at rest and increased with movement. She has no chest pain and has been walking to the bathroom independently on ward with 4ww no oxygen. She has a productive cough of thick yellow/green sputum. She has a temperature of 35.8, BP 130/70, PR 95, RR 28 and SpO2 88% 8L via Venturi mask. Her ABGs on 19/7/10= 7.39/61/73/36/10 95% (fully compensated respiratory acidosis). These show that the patient is a CO2 retainer and so medical staff have asked to keep patients sats at 88-92%. Her haemoglobin on 19/7/10 was 129, White cell count= 12.90, Platelets 406, C-reactive protein 100. On auscultation she had decreased air entry bibasally. Expiratory wheeze Left upper and middle lobe. Fine inspiratory crackles throughout right lung and left lower lobe. Chest expansion was fair L=R. Cough was strong, moist and productive of a small amount yellow/green M2p3 sputum.
Task: To determine the patients main problems and treat accordingly
Action: From my assessment I concluded that my patients main concerns were Airway clearance, decreased exercise tolerance, Impaired Gas exchange and Airflow limitation.
From this problem list I decided to aim my first treatment session at completing a mobility review and doing some airway clearance techniques. The patient fatigues fairly quickly and so I was limited in how much I could do with the patient. We ambulated ~15m 1x standby assist with 4WW on 8L via Venturi mask. Patient fatigued quickly and required a rest half way for ~30secs. Patients sats 86-88% during ambulation. I then did some deep breathing exercises with vibes in right and left side lying. I had the bed almost flat, as I was aware I could not tilt the head of the bed down for drainage. I was able to get a small amount of thick yellow/green sputum in right sidelying and a very large amount in left side lying with 3 cycles of vibes in each side. On auscultation post treatment there was increased air entry bibasally. Course inspiratory crackles R lung and expiratory wheeze throught left lung.
Result: As a result of my treatment the patients oxygen saturation increased to 92% on 8L via venturi mask. With mucus plug obviously removed with drainage and vibrations, she was able to successfully improve her oxygenation. I was very pleased with the results of my treatment.
Discharge planning for this patient at this stage, I believe would be: ? home with RITH or ACAT for low level care.
Evaluation: As mentioned above, I was extremely happy with the results of my treatment session. I believe I used my time effectively and was able to target her main problems. I feel I was an effective communicator and education to this patient. If I was to do this treatment over again I feel I probably would have done the airway clearance prior to ambulation as the patient's airway clearance was more important in this case then her mobility at this stage, and as the patient fatigues quickly that may have allowed more cycles of deep breathing exercises and vibrations to be performed.
Strategies: To improve on concern I raised above, I believe I could practice writing a prioritised problem list and having a better plan of my treatment session prior to seeing the patient.
She is currently on tobramycin nebulisers (which she just finished), salbutamol and antibiotics to overcome the exacerbation. She is complaining of SOB at rest and increased with movement. She has no chest pain and has been walking to the bathroom independently on ward with 4ww no oxygen. She has a productive cough of thick yellow/green sputum. She has a temperature of 35.8, BP 130/70, PR 95, RR 28 and SpO2 88% 8L via Venturi mask. Her ABGs on 19/7/10= 7.39/61/73/36/10 95% (fully compensated respiratory acidosis). These show that the patient is a CO2 retainer and so medical staff have asked to keep patients sats at 88-92%. Her haemoglobin on 19/7/10 was 129, White cell count= 12.90, Platelets 406, C-reactive protein 100. On auscultation she had decreased air entry bibasally. Expiratory wheeze Left upper and middle lobe. Fine inspiratory crackles throughout right lung and left lower lobe. Chest expansion was fair L=R. Cough was strong, moist and productive of a small amount yellow/green M2p3 sputum.
Task: To determine the patients main problems and treat accordingly
Action: From my assessment I concluded that my patients main concerns were Airway clearance, decreased exercise tolerance, Impaired Gas exchange and Airflow limitation.
From this problem list I decided to aim my first treatment session at completing a mobility review and doing some airway clearance techniques. The patient fatigues fairly quickly and so I was limited in how much I could do with the patient. We ambulated ~15m 1x standby assist with 4WW on 8L via Venturi mask. Patient fatigued quickly and required a rest half way for ~30secs. Patients sats 86-88% during ambulation. I then did some deep breathing exercises with vibes in right and left side lying. I had the bed almost flat, as I was aware I could not tilt the head of the bed down for drainage. I was able to get a small amount of thick yellow/green sputum in right sidelying and a very large amount in left side lying with 3 cycles of vibes in each side. On auscultation post treatment there was increased air entry bibasally. Course inspiratory crackles R lung and expiratory wheeze throught left lung.
Result: As a result of my treatment the patients oxygen saturation increased to 92% on 8L via venturi mask. With mucus plug obviously removed with drainage and vibrations, she was able to successfully improve her oxygenation. I was very pleased with the results of my treatment.
Discharge planning for this patient at this stage, I believe would be: ? home with RITH or ACAT for low level care.
Evaluation: As mentioned above, I was extremely happy with the results of my treatment session. I believe I used my time effectively and was able to target her main problems. I feel I was an effective communicator and education to this patient. If I was to do this treatment over again I feel I probably would have done the airway clearance prior to ambulation as the patient's airway clearance was more important in this case then her mobility at this stage, and as the patient fatigues quickly that may have allowed more cycles of deep breathing exercises and vibrations to be performed.
Strategies: To improve on concern I raised above, I believe I could practice writing a prioritised problem list and having a better plan of my treatment session prior to seeing the patient.
Saturday, July 3, 2010
Topic 2- Communication
Situation: 63yo male brought in by ambulance to Royal Perth Hospital with acute onset of shortness of breath (SOB). He appeared cyanotic, anxious, had an increased work of breathing, and was pale/clammy. He was only able to speak in words, not sentences. He had his last dialysis 2 days earlier (unsure if he is fluid restriction compliant), and he makes minimum urine.
His past medical history includes: Renal Failure (dialysed 3x/week via a Hickman Line), Uraemia, Non insulin dependent diabetes Mellitus, Cardiovascular accident, Schizophrenia, Hypertension, Splenectomy. Chest xray showed an increased opacity L lower lobe and R costophrenic angle. Bloods showed an increase in potassium, urea, creatinine, white cell count, platelets and troponin, and a decrease in bicarbonate, haemoglobin and red cell count. Arterial blood gases showed a uncompensated metabolic acidosis. The social history for this pt is as follows: he lives alone, no help at home, no stairs or rails at home, he normally walked independently with no aid for about 5-10mins before needing a rest. He is retired and a non-smoker. Upon return to the ward, the patient was confused and convinced that the doctors were trying to kill him.
Task: To conduct an initial assessment and treatment session for this patient.
Action: I was able to conduct and assessment on this patient, where he gave me a idea of his social history, and he was able to report to me that he was SOB all the time ("it is hard to breathe"). He had no chest pain today and had an unproductive cough. He reported that he has been walking independent to the toilet today. His Obs today were as follows: temp: 36.1, BP: 160/95, PR 95, RR 22 and SpO2 95% on Room air. The previous day the patient had been very confused and believed that the doctors were out to kill him. Today the patient refused further assessment or treatment as he believed that he did not require it, and that he was much better. I used my communication skills to explain to the patient about the role of physiotherapy and its importance, as well as how the doctors wanted to know how far he could walk before they send him home.
Results: I tried for about 15mins to convince him that physio would be beneficial through the means of education and by trying to convince him that the doctor needed him to do it. I tried to vary my approaches and my tutor even tried to reiterate the points I had made but the patient still refused further assessment and treatment, just as he has refused some necessary medical interventions as well.
Evaluation: I think I did well trying to convince this difficult patient. I was an effective communicator and educator to this patient. I had good body language and was also an effective listener. The only criticism that I have is that I was slightly too polite. I gave the patient too much opportunity to refuse treatment by asking him "if that is ok?" and "would you like to".
Strategies: The strategy that I feel would help my communication skills would be to become more assertive. I need to find the balance between being polite and not giving the patient too much opportunity to turn down therapy. I think further practice of my subjective and interview questioning would greatly improve my skills. Constructive feedback from my supervisor or tudor (like I am currently getting) will help to consolidate my questioning.
His past medical history includes: Renal Failure (dialysed 3x/week via a Hickman Line), Uraemia, Non insulin dependent diabetes Mellitus, Cardiovascular accident, Schizophrenia, Hypertension, Splenectomy. Chest xray showed an increased opacity L lower lobe and R costophrenic angle. Bloods showed an increase in potassium, urea, creatinine, white cell count, platelets and troponin, and a decrease in bicarbonate, haemoglobin and red cell count. Arterial blood gases showed a uncompensated metabolic acidosis. The social history for this pt is as follows: he lives alone, no help at home, no stairs or rails at home, he normally walked independently with no aid for about 5-10mins before needing a rest. He is retired and a non-smoker. Upon return to the ward, the patient was confused and convinced that the doctors were trying to kill him.
Task: To conduct an initial assessment and treatment session for this patient.
Action: I was able to conduct and assessment on this patient, where he gave me a idea of his social history, and he was able to report to me that he was SOB all the time ("it is hard to breathe"). He had no chest pain today and had an unproductive cough. He reported that he has been walking independent to the toilet today. His Obs today were as follows: temp: 36.1, BP: 160/95, PR 95, RR 22 and SpO2 95% on Room air. The previous day the patient had been very confused and believed that the doctors were out to kill him. Today the patient refused further assessment or treatment as he believed that he did not require it, and that he was much better. I used my communication skills to explain to the patient about the role of physiotherapy and its importance, as well as how the doctors wanted to know how far he could walk before they send him home.
Results: I tried for about 15mins to convince him that physio would be beneficial through the means of education and by trying to convince him that the doctor needed him to do it. I tried to vary my approaches and my tutor even tried to reiterate the points I had made but the patient still refused further assessment and treatment, just as he has refused some necessary medical interventions as well.
Evaluation: I think I did well trying to convince this difficult patient. I was an effective communicator and educator to this patient. I had good body language and was also an effective listener. The only criticism that I have is that I was slightly too polite. I gave the patient too much opportunity to refuse treatment by asking him "if that is ok?" and "would you like to".
Strategies: The strategy that I feel would help my communication skills would be to become more assertive. I need to find the balance between being polite and not giving the patient too much opportunity to turn down therapy. I think further practice of my subjective and interview questioning would greatly improve my skills. Constructive feedback from my supervisor or tudor (like I am currently getting) will help to consolidate my questioning.
Saturday, June 26, 2010
Topic 1- Assessment
Situation: 80yo male who presented to ED at Royal Perth Hospital with epigastric/chest pain. He also had a productive cough and pain that radiated down both arms and to his back. He described the pain as sharp and stabbing, and it was associated with nausea and vomiting and shortness of breath. He was well prior to admission, there was no report of upper respiratory tract infection symptoms however upon further questioning he reported that he was coughing more than usual and was coughing up green sputum. His chest xray showed L sided Pleural Effusion and Pulmonary Oedema in both upper lobes. His bloods from the day prior to my assessment of this patient were as follows- haemoglobin 108 (lower than normal), white cell count 16.6 (higher than normal), Platelet count 188, Urea 10.8 (higher than normal), creatinine 168 (higher than normal), troponin 0.06 (higher than normal). He had been seen by emergency department team physiotherapist in emergency for some deep breathing exercises and education.
Task: My role was to assess and treat this patient upon return to the respiratory ward.
Action: My assessment of this patient was as follows-
HPC: as above
PMHx: Coronary Artery Bypass Graft (CABG) (1992)- angina symptoms on exertion, Chronic cardiac failure
Severe Chronic Obstructive Pulmonary Disease (COPD)/bronchiectasis, on home oxygen 3L 12hrs a day
Cholecystectomy
Peptic Ulcer Disease (PUD)
? Atrial fibrillation
Social History: Patient lives at home with his wife, his son who lives in the eastern states is a nurse, non smoker, Independent with all activities of daily living, receives home help from Silver Chain, he is known to COPD linkage, His wife had a stroke last year, She still has good function but he worries about her, Normally walks to the post office box which takes approx 10 minutes and he requires 2 rests in that trip. He does not use his oxygen out of the house as he is embarrassed. His house has no stairs and has rails in the toilet and bathroom. He also has a 4 wheeled walker but does not use it much as he shares it with his wife.
Day of Assessment
S/ Patient felt well, slightly short of breath (SOB) with movement, ok at rest. Reports coughing more in the morning than afternoon but less than the last few days. Feels that he is improving as sputum is becoming less coloured and there is less of it. Patient reports no chest pain today.
O/ Patient walking around room before sitting on the edge of the bed.
CVS: Obs Stable; Temp-36.2, BP 125/60, HR 85, RR 20, SpO2 99% on room air.
Resp: Ausc- slight fine inspiratory crackles bibasally, decreased breath sounds throughout, especially L lingular lobe and R middle and lower zone as patient as had a bilateral thoracotomy.
Cough: dry, non productive, strong
Sputum: nil produced to be assessed
Chest Expansion: fair, R =L
Mobility: Independent all transfers and ambulation on room air, ambulated ~150m no aids independently on ward today
Results: Patient had improved from previous reports in the notes, cough was mostly effective for airway clearance and patient was independent with his ambulation and transfers. Patient had a decreased exercise tolerance even prior to admission and so as treatment I mobilised the patient and prescribed patient a home exercise program, and educated him on increasing his ambulation, and using his oxygen therapy whilst walking and doing his exercises. Patient understood and was happy to be compliant. Through careful history taking I was able to get a thorough idea of the status of the patient at present and prior to admission, as well as the major problems for the patient so that treatment can be designed accordingly.
Evaluation: I was very happy with my assessment of this patient. I feel that I was able to get a thorought history of this premorbid history and social history as well as a good objective history. I feel that I was able to get all of the important aspects of a cardiorespiratory assessment with this patient and was able to determine an appropriate treatment plan from my history. I also felt that I was confident with my assessment and communicated well with the patient. My only criticism is that I was keen to do a 6MWT on this patient however my supervisor advised me that it possibly was no important at this time, that is was no asked for my the consultant and that I possibly had to be super cautious with this patient because even though he is improving greatly, doing too much too soon could just be enough to tip him over the edge.
Strategies: Strategies I thought of that could help with the criticism listed above was to continue practicing doing an assessment, to understand and continue to learn how the ward works (ie. they only tend to do 6MWTs when asked by a consultant or another staff member for discharge) and to always consider the patients status and not to be too try to do too much to soon as these patients are very variable and can very easily deteriorate again.
Task: My role was to assess and treat this patient upon return to the respiratory ward.
Action: My assessment of this patient was as follows-
HPC: as above
PMHx: Coronary Artery Bypass Graft (CABG) (1992)- angina symptoms on exertion, Chronic cardiac failure
Severe Chronic Obstructive Pulmonary Disease (COPD)/bronchiectasis, on home oxygen 3L 12hrs a day
Cholecystectomy
Peptic Ulcer Disease (PUD)
? Atrial fibrillation
Social History: Patient lives at home with his wife, his son who lives in the eastern states is a nurse, non smoker, Independent with all activities of daily living, receives home help from Silver Chain, he is known to COPD linkage, His wife had a stroke last year, She still has good function but he worries about her, Normally walks to the post office box which takes approx 10 minutes and he requires 2 rests in that trip. He does not use his oxygen out of the house as he is embarrassed. His house has no stairs and has rails in the toilet and bathroom. He also has a 4 wheeled walker but does not use it much as he shares it with his wife.
Day of Assessment
S/ Patient felt well, slightly short of breath (SOB) with movement, ok at rest. Reports coughing more in the morning than afternoon but less than the last few days. Feels that he is improving as sputum is becoming less coloured and there is less of it. Patient reports no chest pain today.
O/ Patient walking around room before sitting on the edge of the bed.
CVS: Obs Stable; Temp-36.2, BP 125/60, HR 85, RR 20, SpO2 99% on room air.
Resp: Ausc- slight fine inspiratory crackles bibasally, decreased breath sounds throughout, especially L lingular lobe and R middle and lower zone as patient as had a bilateral thoracotomy.
Cough: dry, non productive, strong
Sputum: nil produced to be assessed
Chest Expansion: fair, R =L
Mobility: Independent all transfers and ambulation on room air, ambulated ~150m no aids independently on ward today
Results: Patient had improved from previous reports in the notes, cough was mostly effective for airway clearance and patient was independent with his ambulation and transfers. Patient had a decreased exercise tolerance even prior to admission and so as treatment I mobilised the patient and prescribed patient a home exercise program, and educated him on increasing his ambulation, and using his oxygen therapy whilst walking and doing his exercises. Patient understood and was happy to be compliant. Through careful history taking I was able to get a thorough idea of the status of the patient at present and prior to admission, as well as the major problems for the patient so that treatment can be designed accordingly.
Evaluation: I was very happy with my assessment of this patient. I feel that I was able to get a thorought history of this premorbid history and social history as well as a good objective history. I feel that I was able to get all of the important aspects of a cardiorespiratory assessment with this patient and was able to determine an appropriate treatment plan from my history. I also felt that I was confident with my assessment and communicated well with the patient. My only criticism is that I was keen to do a 6MWT on this patient however my supervisor advised me that it possibly was no important at this time, that is was no asked for my the consultant and that I possibly had to be super cautious with this patient because even though he is improving greatly, doing too much too soon could just be enough to tip him over the edge.
Strategies: Strategies I thought of that could help with the criticism listed above was to continue practicing doing an assessment, to understand and continue to learn how the ward works (ie. they only tend to do 6MWTs when asked by a consultant or another staff member for discharge) and to always consider the patients status and not to be too try to do too much to soon as these patients are very variable and can very easily deteriorate again.
Saturday, June 19, 2010
Initial Entry 4
For my final rotation I will be going to Royal Perth Hospital (RPH) for Medical Cardiopulmonary. I have heard mix feelings from other students and physiotherapists regarding RPH, which makes me a little bit nervous about the commencement of this placement. My expectation of RPH is that it will be very busy, with a patient list from day 1. I do not have much of an idea how it will be structured. I believe that I will be allocated a ward, through which I have to work though the patient list, determining who needs treatment and then treating them. I believe the ward will be full of patients who have had acute exacerbations of conditions such as asthma, chronic obstructive pulmonary disease, cystic fibrosis, bronchiectasis and pneumonia, just to list a few. I believe my role a a physiotherapy student at RPH will be to assist the physiotherapists with the load of the ward, whilst increasing my cardiorespiratory knowledge.
My concern prior to beginning this placement are that I am not prepared enough, that my supervisor will be nasty and that I will have to stay back most days. I have undertaken some study during this study week, however with cardiorespiratory being a huge unit, I found it difficult just to find the most important aspects to learn. I tried to learn as much as I could but I am scared that it is not enough. I do have faith that I will learn a lot more on this placement and so as long as I have a reasonably sound knowledge on assessment, medications, treatment and safety, and have the ability to ask questions, I should be fine. I have heard about some supervisors being very harsh to students and not letting them even sit with the staff at morning tea and lunch. I hope that my supervisor will not be like this, however I am prepared to face what ever challenges confront me at this placement. My final concern is that I may have to stay back for finish unfinished work. I have a fairly tight night time schedule at the moment as well as prac and so if possible I would rather not have to stay back. I have good time-management skills and so I am hoping this will help me, but I also understand that prac takes total precedence over all other aspects of my life at the moment.
I did enjoy cardiorespiratory at university and I am excited to expand my knowledge and hopefully love for this area of physiotherapy.
My concern prior to beginning this placement are that I am not prepared enough, that my supervisor will be nasty and that I will have to stay back most days. I have undertaken some study during this study week, however with cardiorespiratory being a huge unit, I found it difficult just to find the most important aspects to learn. I tried to learn as much as I could but I am scared that it is not enough. I do have faith that I will learn a lot more on this placement and so as long as I have a reasonably sound knowledge on assessment, medications, treatment and safety, and have the ability to ask questions, I should be fine. I have heard about some supervisors being very harsh to students and not letting them even sit with the staff at morning tea and lunch. I hope that my supervisor will not be like this, however I am prepared to face what ever challenges confront me at this placement. My final concern is that I may have to stay back for finish unfinished work. I have a fairly tight night time schedule at the moment as well as prac and so if possible I would rather not have to stay back. I have good time-management skills and so I am hoping this will help me, but I also understand that prac takes total precedence over all other aspects of my life at the moment.
I did enjoy cardiorespiratory at university and I am excited to expand my knowledge and hopefully love for this area of physiotherapy.
Sunday, June 13, 2010
Final Entry
I have just completed my third rotation at King Edward Memorial Hospital for women. The placement was urogynaecological based rather than obstetric. Most mornings were spent on ward 6 for post operative patients. The ward was all urology and oncology patients. My roll was to give necessary patients going home advice prior to discharge, as well as mobility and chest physiotherapy as required. The afternoons were spent either in outpatients or with our Notre Dame tutors. We were also lucky enough to watch urology surgeries, go to clinics and sit in with consultants, watch urodynamics, and watch a post natal exercise class and premature babies playgroup.
The 3 supervisors I had were all lovely. and were similar in their teaching methods. It was great because they asked on the first day what our learning styles were and were accommodating to them. The notre dame tutors were also very helpful in expanding our knowledge in both the areas of urogynaecology and obstetrics.
I did not have any concerns going into or coming out of this placement. The expectations for this placement was that we would expand our knowledge of women's health physiotherapy. I didn't think our undergraduate knowledge would be enough to get me throught the placement, however both the supervisors and tutors reported that our knowledge was very sound.
A take home message for future student would be to push hard to see a Birth if possible, and take every opportunity presented to you to gain as much exposure as possible.
I absolutely loved this placement. The staff were lovely and very supportive and the area is definately one that I would consider working in. If I had a few extra days I would have liked to have seen the nursery, see a birth and watch a vaginal examination. Besides that I was very happy with the exposure I received on this placement.
The 3 supervisors I had were all lovely. and were similar in their teaching methods. It was great because they asked on the first day what our learning styles were and were accommodating to them. The notre dame tutors were also very helpful in expanding our knowledge in both the areas of urogynaecology and obstetrics.
I did not have any concerns going into or coming out of this placement. The expectations for this placement was that we would expand our knowledge of women's health physiotherapy. I didn't think our undergraduate knowledge would be enough to get me throught the placement, however both the supervisors and tutors reported that our knowledge was very sound.
A take home message for future student would be to push hard to see a Birth if possible, and take every opportunity presented to you to gain as much exposure as possible.
I absolutely loved this placement. The staff were lovely and very supportive and the area is definately one that I would consider working in. If I had a few extra days I would have liked to have seen the nursery, see a birth and watch a vaginal examination. Besides that I was very happy with the exposure I received on this placement.
Topic 3- Assessment
Situation: Pt A is a 68 year old female, who was referred to King Edward Memorial Hospital outpatient physiotherapy department for an uncomfortable prolapse (complete vault prolapse_ and urgency. She could not walk for long period of time without discomfort and found herself modifying her lifestyle, due to her urgency, so that she was never far from a toilet. More about this patient will be explained below.
Task: To complete a subjective history on this patient and subsequently.
Action: Using the assessment forms set out by King Edward Memorial Hospital (KEMH), I completed the subjective history of this patient.
History Presenting Complaint: ? onset of prolapse ?2-3 yr onset of urgency
No Stress incontinence, urinary incontinence or report of faecal problems
Has done a lot of heavy lifting recently
Urgency: she can hold on for ~10mins, it has no triggers
Prolapse: Shelf pessary 1/2/10, history of feeling of a vaginal bump/lump/bulge and vaginal/ pelvic heaviness/drag. She reports the feelings are worsening.
Past Medical History: She has had 3 pregnancies and delivered 3 babies all via spontaneous vaginal deliveries, She also had 1 episiotomy
Borderline Diabetic- monitored
Asthma
Hayfever (seasonal)
Arthritis
Surgical History: Hysterectomy (age 49), cholecystectomy (age 52)
Medications: osteo panadol, anti-histamines, ventolin as required, Livial (hormone replacement therapy)
Visual analogue scale for botherness of problems: 3/5 for both urgency and prolapse.
(an objective assessment was not performed)
From this information was able to analyse this patients problems. Her main impairments were: (i) prolapse, (ii) urgency, (iii) voiding dysfunction- hesitancy, double voiding, start/stop stream, ?incomplete voiding occasionally, (iv) ? weak pelvic floor muscles.
Result: I was able to successfully complete a subjective assessment on this patient and as a result, I was able to devise a treatment plan. The plan for this patient was:
(i) Prolapse: voiding dynamics (reduce straining), education to avoid heavy lifting and about heavy lifting, postural advice, advise on possibly resting on back once during the day and pelvic floor awareness, education, exercises (+/- real time ultrasound)
(ii)Urgency: bladder chart, bladder calming techniques, education on voiding frequency and fluid intake.
(iii) Voiding Dysfunction: voiding dynamics and education on relaxation, real time ultrasound, education on double voiding.
(iv) Pelvic Floor Muscles: education, teach contraction, real time ultrasound or vaginal examination, prescribe a program.
Evaluation: I think I did a good job taking the subjective history of this patient. I was able to gain enough information to determine the impairments, activity limitations and participation restrictions for this patient. I feel my questioning was clear and concise and that I used an appropriate language level for the patient. I do feel however that there was times that I asked questions that weren't appropriate to this individual patient. For example " do you have any difficulties with tampons?", after I was already aware that she was on hormone replacement therapy and would no longer get a period.
Strategies: I think by being more aware of the relevance of the questions i was asking and making link between answers, I would me more successful in my questioning. Also by practising asking subjective assessments with the other student would also make me more confident in what I was asking.
Task: To complete a subjective history on this patient and subsequently.
Action: Using the assessment forms set out by King Edward Memorial Hospital (KEMH), I completed the subjective history of this patient.
History Presenting Complaint: ? onset of prolapse ?2-3 yr onset of urgency
No Stress incontinence, urinary incontinence or report of faecal problems
Has done a lot of heavy lifting recently
Urgency: she can hold on for ~10mins, it has no triggers
Prolapse: Shelf pessary 1/2/10, history of feeling of a vaginal bump/lump/bulge and vaginal/ pelvic heaviness/drag. She reports the feelings are worsening.
Past Medical History: She has had 3 pregnancies and delivered 3 babies all via spontaneous vaginal deliveries, She also had 1 episiotomy
Borderline Diabetic- monitored
Asthma
Hayfever (seasonal)
Arthritis
Surgical History: Hysterectomy (age 49), cholecystectomy (age 52)
Medications: osteo panadol, anti-histamines, ventolin as required, Livial (hormone replacement therapy)
Visual analogue scale for botherness of problems: 3/5 for both urgency and prolapse.
(an objective assessment was not performed)
From this information was able to analyse this patients problems. Her main impairments were: (i) prolapse, (ii) urgency, (iii) voiding dysfunction- hesitancy, double voiding, start/stop stream, ?incomplete voiding occasionally, (iv) ? weak pelvic floor muscles.
Result: I was able to successfully complete a subjective assessment on this patient and as a result, I was able to devise a treatment plan. The plan for this patient was:
(i) Prolapse: voiding dynamics (reduce straining), education to avoid heavy lifting and about heavy lifting, postural advice, advise on possibly resting on back once during the day and pelvic floor awareness, education, exercises (+/- real time ultrasound)
(ii)Urgency: bladder chart, bladder calming techniques, education on voiding frequency and fluid intake.
(iii) Voiding Dysfunction: voiding dynamics and education on relaxation, real time ultrasound, education on double voiding.
(iv) Pelvic Floor Muscles: education, teach contraction, real time ultrasound or vaginal examination, prescribe a program.
Evaluation: I think I did a good job taking the subjective history of this patient. I was able to gain enough information to determine the impairments, activity limitations and participation restrictions for this patient. I feel my questioning was clear and concise and that I used an appropriate language level for the patient. I do feel however that there was times that I asked questions that weren't appropriate to this individual patient. For example " do you have any difficulties with tampons?", after I was already aware that she was on hormone replacement therapy and would no longer get a period.
Strategies: I think by being more aware of the relevance of the questions i was asking and making link between answers, I would me more successful in my questioning. Also by practising asking subjective assessments with the other student would also make me more confident in what I was asking.
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