I had an absolute ball on my placement at Fremantle Hospital. I really feel like my skills and communication has developed a lot over the 5 weeks. When i came home on day 1 i was so overwhelmed in the hospital setting and was unsure how i was going to go in the placement. However by day 2 i was much more composed and settled in the placement and i feel like my skills and knowledge certainly improved.
I thought orthopaedics was going to be fairly repetitive however i discovered the mainly due to co-morbidities a patients progress can vary quite dramatically. I thought ACL reconstructions would have been on the ward however i soon learnt that they are done at Kaleeya and rehab is done as an outpatient or inpatient at Kaleeya. I got to scrub in on an ACL reconstruction and a tibial tubercle transfer surgeries which were amazing. I highly recommend watching surgery if students get a chance as it really gave you an understanding of the surgery and what has been done to the patient, and so you gain a better understanding of the pain they are in.
I learnt how to check on patients xrays and blood results, about different conditions especially NOFs, fractures, amputations, arthritis, TKR and THR, fixations, research, co-morbidities, acute management post surgery, d/c planning for patients, communications skills and the importance of communication especially to the patient and the Multi disciplinary team.
I had a fantastic time on placement and really did not want to leave. I was managing the ward by week 5 and had a great relationship with the staff. Having the tutor was a great help and very worthwhile. If i had a chance to stay longer on placement, i definately wouldnt refuse!!!
Sunday, August 30, 2009
Week 5 Entry
Situation: Patient C 28yo Male. Admitted with fractured femur following a MBA. PMHx: depression, suicide attempts, ETOH >5/day. SHx: lives at home with wife, 4 children, his parents and brother. Smoker 10/day.
Task: Day 1 post op- aim was to get patient up on crutches today and hopefully d/c in a couple days.
Obs were stable but his Hb=79, Which was very low.
Action: Discussed with Intern regarding Hb. Doctor happy for patient to be mobilise today as long as patient is not symptomatic. I did my subjective Ax, and patient c/o minimal pain and slight dizziness. Pt was Independent in bed mobilty and lie to sit, however i decided that pt was to be 1x standby assist for STS and ambulation 6m with EC as patient was fairly wobbly on crutches and a bit dizzy. The patient was fairly impulsive and wanted to do everything independently and before instruction.
Result: I had to make my instructions clear and ensure the patient was co-operative, which i think i did well. It was important for the patients safety that he did not rush getting up with being a bit dizzy and wobbly even though he knew how to use crutches from previous use. Patient ambulated 6m on EC before too painful and tired.
Evaluation: I think i did well with my mobility ax. I didnt realise just how impulsive he was till he got up and out of bed without instruction to do so. So i had to tell him to wait for my commands and i believe my patient education was good. I noticed patient's R knee was swollen when patient got back into bed. So i got some tubigrip and educated pt on tubigrip and ways to get rid of swelling.
Strategies: Ensure patient does not get up before demonstration and instructions are completed.
Task: Day 1 post op- aim was to get patient up on crutches today and hopefully d/c in a couple days.
Obs were stable but his Hb=79, Which was very low.
Action: Discussed with Intern regarding Hb. Doctor happy for patient to be mobilise today as long as patient is not symptomatic. I did my subjective Ax, and patient c/o minimal pain and slight dizziness. Pt was Independent in bed mobilty and lie to sit, however i decided that pt was to be 1x standby assist for STS and ambulation 6m with EC as patient was fairly wobbly on crutches and a bit dizzy. The patient was fairly impulsive and wanted to do everything independently and before instruction.
Result: I had to make my instructions clear and ensure the patient was co-operative, which i think i did well. It was important for the patients safety that he did not rush getting up with being a bit dizzy and wobbly even though he knew how to use crutches from previous use. Patient ambulated 6m on EC before too painful and tired.
Evaluation: I think i did well with my mobility ax. I didnt realise just how impulsive he was till he got up and out of bed without instruction to do so. So i had to tell him to wait for my commands and i believe my patient education was good. I noticed patient's R knee was swollen when patient got back into bed. So i got some tubigrip and educated pt on tubigrip and ways to get rid of swelling.
Strategies: Ensure patient does not get up before demonstration and instructions are completed.
Sunday, August 23, 2009
Week3 entry
Topic: Communication
S: Patient B 75 yo male admitted on 10/07/2009 with infected hemi arthroplasty. Patient had a removal of the prothesis L hip on 5/8, washout, debridement and head change on 14/7, washout L hip on 11/7. PMHx: L hemi june 09, T1DM, HTN, glaucoma, amplitated toes R foot. Currently on IVABs, WBAT ambulating 2 x A with WZF. Obs stable.
T: I have been seeing this patient on a daily basis for ambulation practice and exercise during the NWB stage and now the WBAT stage. He has been WBAT for 2 days and ambulated ~8m with WZF x A with little pain however when i went to see patient on day 3 WBAT he was sitting in the commode with the nurse about the help him back into bed. He complained of 10/10 pain in standing and was unsteady on his feet due to the pain. Pain has never been a problem and after reading his charts the had taken him off paracetamol and oxycodone as he had stomache probs and other side effects. i knew this was unusual for this patient to complain of pain and so i felt it would not be appropriate to do manual therapy today. I helped the patient back into bed with the nurse and gave the patient education on pain relief methods and how i would consult with the doctor about how we can best manage his pain.
A: I asked the intern to review this patients pain relief and i was explained to me why he was taken off the drugs he was on and was then prescribed new pain analgesia.
R: This seemed to take the edge off the pain however he was not pain free like in previous days. Patient wanted to try to participate in therapy but felt he could not walk far. So i decided to try standing and weight shift exercises, and marching on the spot. Patient felt pain on STS however said he was pleasantly surprised the pain wasnt too bad in standing. Increased slightly with weight transferance exercises but was managable.
E: patient was happy he stood up and did exercise as he didnt want his progression to deteriorate. I was happy with my treatment and for being the one to pick up the change in his pain status. I felt my communication skills with the patient and intern were effective and adequate.
S: i probably could have tried other pain relief strategies with this patient such as heat or cold to help relieve pain however i was happy with my communication skills
S: Patient B 75 yo male admitted on 10/07/2009 with infected hemi arthroplasty. Patient had a removal of the prothesis L hip on 5/8, washout, debridement and head change on 14/7, washout L hip on 11/7. PMHx: L hemi june 09, T1DM, HTN, glaucoma, amplitated toes R foot. Currently on IVABs, WBAT ambulating 2 x A with WZF. Obs stable.
T: I have been seeing this patient on a daily basis for ambulation practice and exercise during the NWB stage and now the WBAT stage. He has been WBAT for 2 days and ambulated ~8m with WZF x A with little pain however when i went to see patient on day 3 WBAT he was sitting in the commode with the nurse about the help him back into bed. He complained of 10/10 pain in standing and was unsteady on his feet due to the pain. Pain has never been a problem and after reading his charts the had taken him off paracetamol and oxycodone as he had stomache probs and other side effects. i knew this was unusual for this patient to complain of pain and so i felt it would not be appropriate to do manual therapy today. I helped the patient back into bed with the nurse and gave the patient education on pain relief methods and how i would consult with the doctor about how we can best manage his pain.
A: I asked the intern to review this patients pain relief and i was explained to me why he was taken off the drugs he was on and was then prescribed new pain analgesia.
R: This seemed to take the edge off the pain however he was not pain free like in previous days. Patient wanted to try to participate in therapy but felt he could not walk far. So i decided to try standing and weight shift exercises, and marching on the spot. Patient felt pain on STS however said he was pleasantly surprised the pain wasnt too bad in standing. Increased slightly with weight transferance exercises but was managable.
E: patient was happy he stood up and did exercise as he didnt want his progression to deteriorate. I was happy with my treatment and for being the one to pick up the change in his pain status. I felt my communication skills with the patient and intern were effective and adequate.
S: i probably could have tried other pain relief strategies with this patient such as heat or cold to help relieve pain however i was happy with my communication skills
Sunday, August 2, 2009
Week 1 entry
Patient A 46 yo male with infection of TWB R patella. Had surgery where they removed the metal work in his knee. PMHx: ORIF R patella and ruptured EDP tendon in L hand. Through completing the subjective hx and reading the patients notes i discovered he was homeless and was unsure about where he was going to go after discharge. He had a IDC and wound drain attached to him at this stage so it was important to consider then before trying to get him up.
Upon objective hx, i discovered he was independent in bed mobility, lie to sit and sit to stand.
I saw patient day 1 post op where the goal was to get him up so that he could be discharged.
The wound was looking good today not much swelling as the drain was draining it. We had to work out what aid to prescribe, and because he has used crutches before and he can not grip properly with the splint on his L hand i decided to give him 1 elbow crutch on the R side and a gutter crutch on the L. Hand therapy were organised to see patient A that afternoon so until then we had to assume the splint was to stay on (there was no info about his hand in the notes).
With ambulation on this day we had him 2 min assist as he was fairly stable on them and need 1 person to standby and one to hold the drain and IDC bag.
Result= He walked approx 60m with 1 elbow crutch and 1 gutter crutch, And was considered stable enough to be discharged the next day.
He was a lot more stable then we expected as we though because of his ETOH ++++, and because he had the shakes from withdrawl in bed that it may make him unsteady but there was no hit of this whilst he was walking. I was happy with the way we handled this patient. It was probably a little bit disjointed as we did the subjective and objective then went to talk to out supervisor before getting him up and consulted the notes to see if we could find anymore information regarding his hand. Strengths: we thought it would be important for the social worker to see him as he is homeless and because of his ETOH. We considered the hand splint in our aids prescription. We gave the patient lots of education regarding the use of crutches and prescribed him exercises for strength and ROM of the hip and ankle (the knee was to remain in the Rochards splint).
Strategies: plan subjective further so can ensure ask all questions in 1 go. Motivate patient to stand and walk. Ensure appropriate allied health members involved.
This patient was then seen by me the next morning before discharge, however i noticed the gross amount of swelling in his knee upon removal of the drain. IDC had been removed at this stage and my original plan was to check the patients was independent on crutches upon removal of attachments. I decided it would not be safe to get this patient up with his knee that swollen and so consulted with my supervisor and the nurse, which also decided that amount of swelling was not normal. Doctors reviewed it and decided they removed the drain to early and it was full of blood. The knee was then elevated on a wedge and drain was put back in. I was happy with my decision and consequent actions however i could have elevated the leg myself in the mean time whilst i consulted with the relevant people.
Upon objective hx, i discovered he was independent in bed mobility, lie to sit and sit to stand.
I saw patient day 1 post op where the goal was to get him up so that he could be discharged.
The wound was looking good today not much swelling as the drain was draining it. We had to work out what aid to prescribe, and because he has used crutches before and he can not grip properly with the splint on his L hand i decided to give him 1 elbow crutch on the R side and a gutter crutch on the L. Hand therapy were organised to see patient A that afternoon so until then we had to assume the splint was to stay on (there was no info about his hand in the notes).
With ambulation on this day we had him 2 min assist as he was fairly stable on them and need 1 person to standby and one to hold the drain and IDC bag.
Result= He walked approx 60m with 1 elbow crutch and 1 gutter crutch, And was considered stable enough to be discharged the next day.
He was a lot more stable then we expected as we though because of his ETOH ++++, and because he had the shakes from withdrawl in bed that it may make him unsteady but there was no hit of this whilst he was walking. I was happy with the way we handled this patient. It was probably a little bit disjointed as we did the subjective and objective then went to talk to out supervisor before getting him up and consulted the notes to see if we could find anymore information regarding his hand. Strengths: we thought it would be important for the social worker to see him as he is homeless and because of his ETOH. We considered the hand splint in our aids prescription. We gave the patient lots of education regarding the use of crutches and prescribed him exercises for strength and ROM of the hip and ankle (the knee was to remain in the Rochards splint).
Strategies: plan subjective further so can ensure ask all questions in 1 go. Motivate patient to stand and walk. Ensure appropriate allied health members involved.
This patient was then seen by me the next morning before discharge, however i noticed the gross amount of swelling in his knee upon removal of the drain. IDC had been removed at this stage and my original plan was to check the patients was independent on crutches upon removal of attachments. I decided it would not be safe to get this patient up with his knee that swollen and so consulted with my supervisor and the nurse, which also decided that amount of swelling was not normal. Doctors reviewed it and decided they removed the drain to early and it was full of blood. The knee was then elevated on a wedge and drain was put back in. I was happy with my decision and consequent actions however i could have elevated the leg myself in the mean time whilst i consulted with the relevant people.
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