Final entry

I am very relieved that I passed this placement although I only scraped through by the skin of my teeth. I have a very idea now of how I can improve my performance thanks to the input of my clinical supervisor Maxine and clinical tutor Nicke. Now that the pressure and paranoia is off I can see how everybody was trying to help me. I am working full time at Shenton Park from Monday, and my clinical supervisor has suggested that I write clinical notes and soapiers for the people I see even if I don't have access to their clinical notes, I think this will be a very good strategy for me. I have a meeting next week with Jo to discuss further strategies. Another strategy suggested at the next placement is to ask the superisor at the end of each week what is expected in terms of patient workload, and expected knowledge outcomes at that point in the placement part of my problem during this placement related to not being sure what was expected.

The most important thing I have learned in this unit is the importance of following things through thoroughly in the SOAPIER format and not making leaps of logic for assessing patients.

I am expecting my next placement to be a better experience.

Week5 day3

Today I had another visit from my clinical tutor. I went through my plan with the tutor about what I would assess and why with a new patient and I think I did this quite well. I did a subjective assessment, 6m walk test and COVS assessment. One of the issues identified by the tutor is that when I explain things to the patient my instructions are not always clear so I need to concentrate on simplifying my language when dealing with patients.

The second patient I saw had a patella # and surgical neck of humerus # I wasn't quite as well prepared for this patient as I had been expecting to visit a different patient but they were unavailable for treatment. I had a look at the X-Rays and did a COVS assessment for this patient and assessed ROM and was a bit thrown by what to do with the #humerus. I didn't do the Assessment of ROM very well and could have done it a lot better, I wasn't very systematic with it. I hope that I get another opportunity to show that I can do it better. However the tutor did say that I had improved significantly since mid placement, however I feel will still need to work very hard over the last two days of placement. I also need to overcome a propensity to be a bit inhibited when a supervisor is supervising and take charge instead.

1) Need to practise clear instructions
2) Need to try not to get flustered and inhibited when supervised
3) Need to continue with existing strategies to follow a more logical approach
4) Need to speed up
5) I actually know how to do an assessment I just need to do it.

Week5 day2

Today was fairly hectic I had two new patients to see and two for discharge one on Wednesday and the other on Thursday. The first patient I was to do a dicharge COV's assessment, however the Gerontology assessment form was missing from the file, apparently quite a few documents have been misfiled as we have had a turnover of several ward clerks since I have been working there. This made some extra work for me as I had to re-assess the patents ROM and recall what the COVS entries were originally, this was one of the first patients Elle and I saw on prac, "originals lost" were then entered on the form. I filled in a problem list, treatment aims, patient/discharge goals and discharge summary as part of the gerentology assessment form for the two patients being discharged and a discharge summary form.

One of my strategies for improving my clinical reasoning with a more logical approach as mentioned in my blog last week is to write out new patients details from their file as if I was giving a handover, then prepare a potential problem list from the information gleaned from their notes and write a list of what I will assess and why based on what I have identified. This is similar to the A and P in a SOAPIER. Unfortunately one of my other issues is that I am slow with paperwork and all this writing made me even slower so that it was a rush to get everything completed and my notes written and signed by the end of the day and I felt bad that everybody had to wait around for me.

Despite this I think it is a worthwile exercise for me and has helped me to order my thoughts, particularly writing shortened SOAPIERS before entering a SOIER in the patient notes. However I still need to become more efficient at reading patient notes and faster with the paperwork.

Week4 day4

Today was a much better, I prepared an analysis of what I would assess and the reasoning behind it for my supervisor, she was pleased with my logic. I did SOAPIERS for all the patients I saw today and had positive feedback from my supervisor. My time management has improved today and I was able to see most of my patients before lunch. One of my patients who was discharged came back as a day therapy patient in the physio gym, she had cancelled a booking on Tuesday and almost cancelled todays session, she became more motivated during the session and enjoyed it looking forward to returning next Tuesday. This was very satisfying.

I also treated a patient who had a #distal femur in the parallel bars with gait retraining (touch weight bearing) she gained a lot of confidence with ambulation and felt positive about her progress which she imparted to me this made me feel confident in what I was doing. Tonight I am going to practise some A + P's from SOAPIERS and think about what I am going to do with my patients tomorrow.

Week4 day3

Today I sat down with the clinical tutor with a SOAPIER I had prepared and went over the analysis and plan the tutor was pleased that I a logical problem list that related to my objective assessment and a good plan that related to my problem list.

It had helped that my clinical supervisor had me write full soapiers for all the entries that I made in the clinical notes taking special note of the A and P. I also wrote down a summary of admission for each patient that both Elle and I had been dealing with which helped clarify in my mind the details required for a thorough and logical analysis and plan see below.

Age
Sex
Dates of admission to hospital Dates of admission to this hospital
Diagnosis including
Xray/CT
Dates and details of surgery/intervention
Complications
Past medical history
Medications
Social history + previous mobility and aids
Precautions

I am feeling a little more positive now due to some positive feedback but am still apprehensive.

Week4 day1

Jo came to see me today after driving down from Northam. I carried out part of an assessment on a new patient with a fractured distal femur with involving manual muscle testing and ROM, I was very nervous and did a poor assessment which was disorganised. Joe pointed out what I need to get a handle on by the end of the week. I am not feeling all that positive at this stage I will feel better when I start getting some positive feedback from my supervisor that my performance is improving. On Wednesday I will get an extra visit from my clinical tutor.

week3 day1

Today was not a great day as I only scraped through my mid place assessment, my clinical supervisor has put a plan in place with my clinical tutor to sharpen up my clinical reasoning and take a more logical approach to assessing a patient. It is difficult to focus on the job at hand as I am obsessing about passing the unit and have lost some confidence, I will need to work really hard to remain focused in the moment. I can expect extra sessions from the clinical tutor and a visit from Joe next week. Hopefully I can improve enough to get over the line.

Week3 day3

Today was a busy day, I had the clinical tutor with me this morning while assessing a new patient. The patient had bipolar disorder in its depressive phase had been on lithium for depression and a cocktail of other drugs, it was interesting to note that the patients drug regime had resulted in Parkinsons type symptoms of bradykinesia and freezing although the patient did not have Parkinsons disease. I did a COVS assessment as part of the gerontology assessment form which I thought was a little disorganized, next time I will force myself to do it in a more sequential fashion. This is the second patient that I have followed from admission, I have a good idea now about the gerontology assessment form and discharge procedure and will do a better job with this patient.

The previous patient I followed from initial assessment is on an OT home visit tomorrow and is being discharged afterwards, tomorrow I will fill out a discharge list and a home exercise for the patient. I will see the patient again as they are coming back for day therapy to Swan Districts Hospital which is nice as I feel I have made a difference to this patient.

I attended a meeting today discussing the patients on the ward and their progress and their plans for discharge I felt part of the multidisciplinary team as I was able to contribute information about a particular patient I had been seeing, it was unfortunate that my supervisor was not present at the time to see me in action.

The meeting clarified the discharge plans of two patients for me and the situation of a patient who was desperate to go home and see his frail wife for a day, the patient had quizzed me about it previously and I had discussed it with my supervisor who had said it was unlikely to happen, the meeting clarified this point so I can now give the patient good reasons why they can not go home yet. I felt uncomfortable previously not being able to give the patient good enough reasons.

Week3 day1

Today I worked with an elderly man who had a hemiarthroplasty of the right hip. He had other issues such as Parkinsons which made his recovery more difficult. He was able to ambulate with a pulpit frame*2(A). As he had a (R)#NOF I was not able to lie him on the affected side and I could not lie him prone due to his stiff flexed posture due to Parkinsons. I had to assess the muscle strength of glutes of his affected side in sidelying and test his unaffected side by doing a one legged bridge and palpating glutes. I did some glute work in standing with the pulpit frame with his legs against the plinth and was able to ambulate him 6m with the help of student collegue Beck.

The intervention went well and the Pt was much happier as there has been a noticable improvement in his mobility in the last few days and a change of scenery from the gloomy surrounds of his room also made him feel better.

The patient asked me if he could go home and see his wife on the weekend, she lives 3 hours drive away, it was difficult acting as an advocate then having to tell him it was better if he stayed in hospital after consulting with my supervisor.

My clinical supervisor suggested that I look at impairments specifically in relation to parkinsons for my next treatment plan. I will do some reading and formulate a plan for tomorrow.

Week2 day3

Today I took an elderly lady to the gym, some of her issues were ankylosing spondylitis, RA, she was admitted due to loss of mobility and independence.

Her primary impairments were a decrease in balance and ambulation endurance and loss of spinal curves and trunk mobility. Her main goal was to remove her intention tremor which impacted on her socially as she was prone to spill food and drink.

I went through her exercises in the gym which concentrated on her quad strength, hip exstensors, abductors dorsi flexors and plantar flexors. I also did some shoulder external rotation exercises to improve her shoulder mobility and mini sit to stands. I did some trunk rotational exercises getting her to reach across her body and turning her head to improve her thoracic spine and cervical mobility. I also carried out some upper limb strengthening exercises. It was good to see how her mood improved with exercise. She is being discharged soon so I will have to create a home exercise program for her.

It is difficult to know what to tell the patient as she is clearly hopeful that the doctors can help her tremor, however this goal may be an unrealistic goal for her. Part of her problem may be nerve compression caused by her extreme cervical hyperextension, she has had an MRI scan of her cervical spine taken but the results have not yet arrived.

I was quite happy with my intervention, I have been told however that my clinical reasoning is not quite up to scratch so I will need to work on this.

Week2 day2

Today I completed some components of a geriatric assessment form this included sitting balance (COVS), AROM, sternal push and 6m walk test and coordination. I was told to estimate AROM rather than use a goniometer, I think I would have been more comfortable measuring the joint angles, I did the 6m walk test well but could have done the sternal push test better as I did not use enough force due to the frailty of the patient, I will have to repeat the test at a later date to obtain meaningful results. I have obtained a booklet on outcome measures that I will have a look at. I have developed a problem list for this patient based on what I have learned from the geriatic assessment form and will develop a plan. The patient is due to be discharged next week and will come back for day therapy so I will need to be given an exercise sheet.

Week2 day1

Today I treated a female outpatient with a sore knee and quads who had a stroke previously, I did some mobilizations on her patella and trigger points and massage on vastus lateralis and ITB as well as some stretching to her quads in sidelying. Her issue was mainly knee pain due to weak VMO and tight lateral structures and some pain in her quads on her unaffected side as she was overusing the unaffected side. I taped her knee to improve patella tracking, but was not happy with it and had a physio to check it for me. Apart from the taping I did the intervention well, the patient reported 6/10 pain before the intervention and nil pain afterwards which was very satisfying. It was more challenging to do an intervention on a larger individual with limited mobility. Tonight I will read up about various taping techniques not just in relation to the knee but also taping the shoulder to inhibit and facilitate muscles.

I went to take an inpatient to the physio gym to carry out an exercise program, as their obs had not been taken I took them myself and noted that the pulse rate was very low at 40 beats per minute. I informed the nurse and posponed the exercise program. It turned out that the beta blocker dosage was too high and their medications were modified accordingly.

Week1 Day5

Today I had the opportunity to follow a patient from admission. The patient was admitted to the restorative unit with an intention tremor, ankylosing spondylitis poor balance and Parkinsons ticked in the medical notes. The clinical supervisor supervisor suggested that the symptoms were more consistant with RA than ankylosing spondylitis. When seeing the patient I noted that they had a reasonable lumbar lordosis and distinct ulnar deviation consistant with RA. The patient also had no resting tremor which is indicitive of Parkinsons, the clinical supervisor confirmed that it was not likely Parkinsons and due to something else such as medications. It was interesting to note that these details were incorrect in the medical notes. I felt that my observations and reasoning were sound when seeing the patient. I began to fill out the Geriatric Assessment sheet, and began with a 6 minute walk test which I did well, although I forgot to measure gait speed. Later in the afternoon I took the patient to the physio gym and ran through some exercises to improve muscle strength and balance, on Monday I will create a gym exercise program for the patient and an exercise sheet so they can do some bed and chair exercises independantly. I will also complete the balance component of the Geriatric Assessment sheet. My clinical tutor suggested that it is a good idea to mix intervention with assessment each session rather that completing the assessment all at once. I learned quite a bit today about time managing patients and the referal and initial assessment process. I have also been writing up patients in the medical notes. I liaised with the doctor about my patient as she had been for a neck x-ray and I wanted to check prior to undertaking any trunk rotation exercises.

Week1 day2

Today I was given three patients and a patient list. The first patient I ran through his exercise program in the gym and then created a home exercise program on the computer as the patient was to be discharged that afternoon.

A patient with aponea I had seen earlier I revisited to do some passive physiological movements and stretches in bed, I noted that he was nolonger on 2l of oxygen and followed up with the nursing staff to determine if this was correct in light of the patients aponea. It was OK as the doctor had deemed it unessessary to continue with oxygen the previous afternoon.

One of my patients was unavailable for treatment as he was undergoing dialysis, I followed him up on his return and carried out some cardio exercise (pedalling), I was shown his fistula where the dialysis needle is inserted, temporary in his case.

Another patient was due for discharge in a few days and a family meeting was organised. I expressed an interest in attending one of these meetings in future, however today too many people were involved so it was inappropriate at the time.

I wrote a SOIER for a stroke patient I treated with pedalling, sit to stand, bed to chair transfers and shoulder flexion and IR exercises, I was to enter this into the patient notes however the notes were at the patients family meeting with the consultant, I will write in the patient notes first thing tomorrow.

The day went well - I learned about time management of patients, where to find the patient notes when they are not in the pigeon holes and where to find items such as theraband, and have been given a small case load.

Tomorrow a clinical tutor arrives.

Week1 day1

Today I arrived early and was able to read through my induction folder. The folder was very useful outlining outcome measures used in detail and the structure of the hospital.

I observed a number of patients with stroke. I did a slide sheet transfer to reposition a heavy patient on the bed, this was done well and I recieved positive feedback from my supervisor, I also assisted the physio with suction to clear sputum as a result of pneumonia. This particular patient also had aponea and would stop breathing periodically, I observed a manual technique to facilitate this patient in taking a larger breath.

I supervised a patient in the physio gym with balance and strengthening exercises although this patient had reasonable balance and gait he had disphasia which was contollable if he took his time he had trouble finding words and constructing logical sentences. I undertook treatment of a stroke patient by undertaking passive shoulder flexion, abduction, external rotation and hip and knee flexion and extension noting spasicity in the flexors.

Another patient I assisted with sit to stand and learned how to avoid having the patient pushing onto his good side with assisted weight shift and having him reach to his bad side. I think that I could have been in a better position that would have required less effort.

I spoke to my supervisor regarding student progression over the five weeks, however there seems to be some confusion in relation to a full patient assessment that the university requires us to do - I will have to clarify this.

Generally I think the day went well and I have started to get a feel for the hospital.

Inital thoughts on placement

I am a little apprehensive about my first day on placement. I need to discuss with my supervisor what is expected in terms of progression of responsibility up to half way assessment then what is expected after that. I will make sure that I know what is expected of me from day one.

I have revised Gerentology and Neuro material and have looked back over outcome measures such as COVS, TUG, MMSE and have looked into Gowlands Motor Recovery Scale and revised the mechanisms of stroke and its effects. I have also revised the effects of aging and the impact this has for patents recovering in hospital and dementia.

I would expect that many of the patients I will be dealing with will have suffered stroke and will have numerous other co-morbidities related to aging that will make treatment more of a challenge. I am interested in the neurology component and would like to be exposed to rehabilitation of patents with conditions such as Parkinsons, Guillain-Barre, Motor Neurone disease, and impairments such as Ataxia, Dyspraxia and Dysdiadochokinesia. Many patients I would expect to be suffering from varying degrees of dementia.

In this placement I would hope to refine skills such as ascultation, transfers, SOAPIER writing and patient assessment and exersize prescription, and improve communication skills with patients and other health professionals as well as time management.