This prac has been better than I expected. I was a lot more confident on my way to the prac than I first thought I would be and actually didn't have any nerves at all. I was still a little shy when first introducing myself to patients in situations like the hydro pool where I was supposed to just chat but I gained more and more confidence as I went along.
The staff we absolutely fantastic and included two Notre Dame new grads, so they understood exactly what it was like to be a student from ND. They were constantly trying to teach us new skills and were always happy to give feedback. We were just tested on the knowledge that we should have but more so on how we took feedback and whether we improved the next time we tried. It was a great learning environment where I was comfortable to ask questions.
The variety of areas kept me always interested as I was able to see inpatients, outpatients, community classes, transitional care services and hydro classes. We were even able to spend a day at a residential care facility teaching staff manual handling. The days seemed to go so quickly.
My confidence has especially grown in the inpatients side of things which will be great for my fourth year cardio prac, and also for the cardio unit we're about to start.
Overall a great prac where I've learnt a lot and gained a lot of confidence.
Thursday, August 27, 2009
Monday, August 24, 2009
Rural Prac '09 Topic Three - Conversion Disorder
Situation
In the medical ward there was a patient admitted for suspected myelitis. She presented with pins and needles, weakness and numbness on the left side of her body. Full neuro examinations were done by the neurologist in Bunbury and smaller neuro exams by the physios, but the results were variable and it was concluded that the problem was not neurological. Other medical tests were also done to rule out other possible causes. After 2-3 weeks with no answers the patient was becoming frustrated and asked for a second opinion up in Perth. She was transferred to Sir Charlse Gardiner Hospital where she was seen by 2 neurologists, an OT and a physio who all agreed that there was no known cause for the symptoms. It was fianlly diagnosed as conversion disorder which was further confirmed by a very full psychiatric history of the patient. After the diagnosis the patient was transferred back to Bunbury SJOG to be treated by her doctor here and monitored for a few days before discharge.
Task
My task was to give the patient a home rehab program before discharge. This was challenging because I had very little knowledge of conversion disorder or why she needed a home program, and I had also never met the patient before.
Action
After discussing it with my supervisor I decided to give her a generalised exercise program so that it appeared to her that the strength she has 'lost' was being regained, and also because she was so deconditioned from spending weeks in bed when she was normally very active, cardiorespiratory fitness and functional activities would be the focus of the treatment. She was given squats, heel raises and single leg standing to do at least three times a week. The focus was to be a walking program that increased on a weekly basis in conjunction with a diary so that she could monitor her progress. ADL's were to be undertaken as possible, adding 1 task or increasing the length of the task on a weekly basis. For instance, week 1 putting on one load of washing and hanging it out independently and week 2 doing two loads etc.
Result
The patient seemed very happy with the program as she appeared keen to get back to being active. This was a change from what I had read in the notes as from others accounts she had a severe external locus of control and appeared to feign symptoms if she wasn't getting enough attention.
Evaluation
Instead of pushing her outrightly, I decided to push her in a way she wouldn't realise. I told her that she could rest as much as she wanted during her exercises, but under no circumstance was she to not finish the exercises. I also told her to walk without a rest for a set amount of time for her walking program and then turn back, but she could take as long as she wanted and as many rests as she wanted on the way back. This seemed to appeal to her.
Strategies
I think incorporating her exercise program into her functional tasks was a good strategy, as well as given her some room to move in her program whilst still getting her through it all. I did involve her husband in the discussion, but I think some more family involvement and more time to spend with her to get a detailed social history would have really helped the patient.
In the medical ward there was a patient admitted for suspected myelitis. She presented with pins and needles, weakness and numbness on the left side of her body. Full neuro examinations were done by the neurologist in Bunbury and smaller neuro exams by the physios, but the results were variable and it was concluded that the problem was not neurological. Other medical tests were also done to rule out other possible causes. After 2-3 weeks with no answers the patient was becoming frustrated and asked for a second opinion up in Perth. She was transferred to Sir Charlse Gardiner Hospital where she was seen by 2 neurologists, an OT and a physio who all agreed that there was no known cause for the symptoms. It was fianlly diagnosed as conversion disorder which was further confirmed by a very full psychiatric history of the patient. After the diagnosis the patient was transferred back to Bunbury SJOG to be treated by her doctor here and monitored for a few days before discharge.
Task
My task was to give the patient a home rehab program before discharge. This was challenging because I had very little knowledge of conversion disorder or why she needed a home program, and I had also never met the patient before.
Action
After discussing it with my supervisor I decided to give her a generalised exercise program so that it appeared to her that the strength she has 'lost' was being regained, and also because she was so deconditioned from spending weeks in bed when she was normally very active, cardiorespiratory fitness and functional activities would be the focus of the treatment. She was given squats, heel raises and single leg standing to do at least three times a week. The focus was to be a walking program that increased on a weekly basis in conjunction with a diary so that she could monitor her progress. ADL's were to be undertaken as possible, adding 1 task or increasing the length of the task on a weekly basis. For instance, week 1 putting on one load of washing and hanging it out independently and week 2 doing two loads etc.
Result
The patient seemed very happy with the program as she appeared keen to get back to being active. This was a change from what I had read in the notes as from others accounts she had a severe external locus of control and appeared to feign symptoms if she wasn't getting enough attention.
Evaluation
Instead of pushing her outrightly, I decided to push her in a way she wouldn't realise. I told her that she could rest as much as she wanted during her exercises, but under no circumstance was she to not finish the exercises. I also told her to walk without a rest for a set amount of time for her walking program and then turn back, but she could take as long as she wanted and as many rests as she wanted on the way back. This seemed to appeal to her.
Strategies
I think incorporating her exercise program into her functional tasks was a good strategy, as well as given her some room to move in her program whilst still getting her through it all. I did involve her husband in the discussion, but I think some more family involvement and more time to spend with her to get a detailed social history would have really helped the patient.
Wednesday, August 12, 2009
Rural Prac '09 Topic Two - Intervention
Situation
In my first week on the orthopaedic ward I was suprised at how similar each patient's acute rehab was for total hip and total knee replacements. Each patient was given the same program with the same timelines and exercises to do, and they all appeared to leave the hospital at about the same stage. But by week 2 my thinking started to change.
Task
I realised that the reason I was thinking that every patient was the same was because I was observing their interventions and learning the ropes, but not really having any input at that stage. By week 2 my supervisors were starting to ask me what stage I thought the patients were at in terms of their rehab, and the terms 'Day one, day two etc' started to take on new meanings. I was having to seriously analyse each patient and decide what stage they were at in their rehab despite what the timeline was stating or what was 'normal'.
Action
This really hit home with two patients that had their surgery at around the same time. One was a total hip and the other a total knee, and in terms of protocols they are almost identical. However, despite the total knee patient having their operation before the total hip, the total hip was much better off. I had to really look at the patients goals, past medical history, current medical complications and management and age to determine what stage of rehab they were at and then organise their post discharge services (along with other health care professionals).
Result
The total hip patient ended up walking over 100m day one, only staying in for 7 days (the hospitals minimum), walking out with only one crutch and being able to walk over a km before he left. He was very healthy before he came in, listened to every piece of advice he was given from every health care professional, took complete control of his own rehab and had very clear goals. The total knee on the other hand had COPD, severe asthma, was bariatric, didn't walk until day 3, came in using a walking frame and left only being able to ambulate about 10m.
Evaluation
I have learnt that no matter what the medical notes, charts and nurses tell you, you cannot predict the outcome for any patient until you walk in there and assess them yourself. Every patient is different and a different approach must therefore be taken every time you walk in to see them.
Strategies
I think being flexible is very important and not having expectations before you walk in to see the patient. I also think very thorough assessment is necessary to ensure that it isn't something you've missed that is holding up the rehab process.
In my first week on the orthopaedic ward I was suprised at how similar each patient's acute rehab was for total hip and total knee replacements. Each patient was given the same program with the same timelines and exercises to do, and they all appeared to leave the hospital at about the same stage. But by week 2 my thinking started to change.
Task
I realised that the reason I was thinking that every patient was the same was because I was observing their interventions and learning the ropes, but not really having any input at that stage. By week 2 my supervisors were starting to ask me what stage I thought the patients were at in terms of their rehab, and the terms 'Day one, day two etc' started to take on new meanings. I was having to seriously analyse each patient and decide what stage they were at in their rehab despite what the timeline was stating or what was 'normal'.
Action
This really hit home with two patients that had their surgery at around the same time. One was a total hip and the other a total knee, and in terms of protocols they are almost identical. However, despite the total knee patient having their operation before the total hip, the total hip was much better off. I had to really look at the patients goals, past medical history, current medical complications and management and age to determine what stage of rehab they were at and then organise their post discharge services (along with other health care professionals).
Result
The total hip patient ended up walking over 100m day one, only staying in for 7 days (the hospitals minimum), walking out with only one crutch and being able to walk over a km before he left. He was very healthy before he came in, listened to every piece of advice he was given from every health care professional, took complete control of his own rehab and had very clear goals. The total knee on the other hand had COPD, severe asthma, was bariatric, didn't walk until day 3, came in using a walking frame and left only being able to ambulate about 10m.
Evaluation
I have learnt that no matter what the medical notes, charts and nurses tell you, you cannot predict the outcome for any patient until you walk in there and assess them yourself. Every patient is different and a different approach must therefore be taken every time you walk in to see them.
Strategies
I think being flexible is very important and not having expectations before you walk in to see the patient. I also think very thorough assessment is necessary to ensure that it isn't something you've missed that is holding up the rehab process.
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