Fourth Year Rotation 4 - Final Entry

Initially I felt nervous about this placement as it was my first and only one at a tertiary hospital. I had heard that they were very fast paced and that the supervisors had very little time for their students, as their caseload was so large. I also heard that they expected very independent learners and had high expectations of student’s knowledge at the beginning of the placement. I had been told that students are not treated as part of the team, but are looked down upon and are constantly asked to prove themselves.

In fact my placement was exactly like this, except that there were only a few staff members who didn’t value student’s contributions, luckily none that I had to work with on a regular basis. My supervisor had very high expectations of the knowledge that I required and it was expected that we were to act with the confidence of a new graduate, making treatment and discharge decisions with very little consultation.

Whilst the expectations were high it therefore meant that I was put into situations that really tested my knowledge. When the time comes to make clinical decisions on my own I will be much better equipped than if I went through a placement that sheltered me and made decisions for me. Also, I would not have come out the other end with the skills and experiences that I have been lucky enough to gain from this placement.

Despite being on a general medical ward I was able to consolidate my skills and gain confidence in inserting nasopharyngeal and guedel airways and suctioning patients. I gained skills in dealing with patients with COPD, learning new treatments and reinforcing the skills already in my repertoire. My manual handling skills improved and my proficiency at risk assessment developed as the placement progressed. I was able to gain a full understanding of the public health system and a tertiary hospital, as well as successfully plan patient’s discharge, starting at day one of their stay on my ward.

Overall I feel my confidence in my knowledge and skills has improved greatly over this placement and I feel ready to move forward and work in the industry. I have decided that if I have the opportunity, a tertiary hospital or at the very least a secondary public hospital is the kind of work environment I would like to find myself in. This is due to the fantastic opportunities new graduates have with varied rotations and the large amount of clinical education offered.

Fourth Year Rotation 4 - STARES

Situation

A 74 year old man presented to Royal Perth Hospital emergency department with lethargy, malaise, confusion, decreased mobility and increased micturition. On diagnosis it was found that he had urosepsis and he was promptly admitted to the general medical ward.

Task

Due to the patients decrease in mobility, I was asked to review the patient’s mobility and treat him appropriately.

Action

On initial assessment the patient was one assist with all of his mobility and was able to ambulate one assist approximately 8m with a wheeled zimmer frame. He appeared slightly confused, for example, asking multiple times where the nurse was but then not having a reason for wanting her, however, he was able to follow instructions.

On return the next day the patient appeared more lucid. He was much more compliant with treatment and the confusion appeared to be resolving. I updated the mobility board to inform the nursing staff of the patient’s new mobility status. A few hours later, the nurse in charge of the patient’s care notified me that the patient’s mobility had regressed and he now required two assist with ambulation with a wheeled zimmer frame and one assist with all other mobility.

On the third day of the patient’s stay on the medical ward I again went to see him for a mobility review. Due to the events on the previous day I enlisted the help of a nurse to stand-by while I mobilized the patient. This was lucky as the patient was very confused, unaware of where he was and trying to get out of bed without the assistance of anyone. With encouragement the patient agreed to mobilize with both myself and the nurse assisting. After mobilizing approximately 2 metres around the patient’s bed he suddenly leapt for the bed behind him yelling “I’ve had enough!”. Fortunately he managed to sit himself on the edge of the bed and the nurse and I were able to stabilize him. We returned the patient to bed and notified the medical staff of his increased confusion.

On the Monday I returned to the patient to assess the situation and attempt to mobilize him if appropriate. The patient was sitting out of bed, which is something he had refused for the past week, and he was much more bright and lucid than I had seen him sine his admission. Previously he required a lot of encouragement to mobilise, however today he was asking if it was possible to go for a walk. On mobilisation the patient required only stand-by assistance with a wheeled zimmer frame and was able to ambulate approximately 30 metres. Due to his sudden improvement is was decided that he would be mobilized in the afternoon as well to enhance the rehabilitation potential of the patient.

Result

As a result of liaising with the nursing staff and ensuring there were enough staff present to assist with the patient I was able to mobilize the patient safely and avoid injury to the patient and to myself.

Evaluation

This situation really highlighted the importance of understanding delirium and the large effect that infection can have on a person’s mental state. It must be monitored well and treatment altered accordingly.

This situation could have ended very badly if communication between the nursing staff and myself wasn’t so open. It really brought to the forefront the importance of the multidisciplinary team and the vital role that each team member makes.

Strategies

Observation of the patient is vital for assessing levels of confusion or signs of delirium, as well as asking the patient time, person, place. Any changes in the patient’s mental state should be noted as well as documented in the notes and handed over to the medical team and nursing staff. Clear lines of communication between the nursing and medical staff and yourself are vital and good patient care relies on this.

Fourth Year Rotation 4 - Communication STARES

Situation
An 84 year old woman was readmitted to Royal Perth Hospital on the 3/7/2010 after a failed discharge on the 1/7/2010. The patient had been admitted originally for pneumonia and after a week in a general medical ward she was transferred to the short-term rehabilitation ward. On discharge services were organised for the patient; RITH for physiotherapy and occupational therapy and Silver Chain for meals, shopping and showering services, as the patients mobility and ability to perform her activities of daily living had declined in the weeks prior to and during her admission.

When the RITH physiotherapist arrived at the patient’s home for the second treatment session, the patient had been sitting on her four-wheeled walker for four hours, too afraid to get up as she feared the brakes were not working and she may lose her balance. The therapist helped the patient to her feet, but she refused to walk any further than the dining room table 3 metres away. On discussion with the patient the therapist also found that the patient had not been eating regularly, had mobilized minimally and had not been taking care of her indwelling catheter. As there were no services organised for the weekend and the patient’s family were unavailable to assist, the therapist organised for the patient to be readmitted for more suitable discharge planning.

Task
My task was to assess the patient and treat accordingly, keeping in mind that her discharge planning was an important aspect of her readmission.

Action
On assessment of the patient she appeared to be slightly confused and frustrated with why I was there. I had explained to her that I was a physiotherapy student, there to have look at her chest and how she was moving and if necessary to treat her and give her some tools in order to help her get home as soon as possible. The patient kept asking questions such as “Why do you need to know if I have a cough? Of course I have a cough, I have a chest infection”. While I kept explaining that I needed to have an understanding of what she was experiencing in order to help her, she still seemed to lack understanding. She did however have an understanding of why she was there and have a good grasp of her situation. All in all it was a difficult subjective assessment and it felt as though I was continually justifying my presence.

The patient appeared much calmer on objective assessment and it went smoothly until I asked her to get up so that we could go for a walk. Initially the patient refused to stand at all, but with some encouragement and assistance she did. However, after about 20 seconds the patient insisted on sitting back down. I asked the patient why she needed to sit down and she refused to answer me or even look in my direction. I explained that in order for me to help her she needed to tell me what was wrong. Again, the patient ignored me. On my third attempt to mobilize the patient I explained that I understood that she might be nervous of standing but I would be there to assist her and that if she wanted to return home she would need to be able to walk. Finally the patient responded, stating that she just couldn’t walk, that she didn’t know why and that there was nothing I could do to help, as it was all her responsibility to start walking again. I asked a few more times what was stopping her from walking, suggesting things such as leg weakness, anxiety, fear, breathlessness or pain but she stated no to all options. I reasoned that it was most likely anxiety as she had stated that she was too nervous to stand from her four-wheeled walker at home due to fear of falling and she appeared to be a proud person, wanting to maintain that there was nothing wrong with her. I asked her if she would consider walking if I brought in a strong male to assist her to walk and she nodded, saying that she might consider it after lunch.

I found a time that suited my supervisor that afternoon and together we went back to see the patient. My supervisor just acted as a physiotherapy assistant and with his appearance as a strong male the patient ambulated approximately 12 metres without any complaints.

Results
As a result of my treatment the patient ambulated 12 metres with one person assisting the first day, 30 metres with stand-by assistance the second day and 50m with stand-by assistance the third day. The patient has also been accepted into transitional care for 8 weeks with permanent low-level care following that.

The patient also apologised for her reaction to me at our first meeting, stating that she had so many weeks of people asking her questions that she was unsure where they were all from and why they all couldn’t communicate the information between each other.

Evaluation
The importance of explaining who you are and what you are there for has really become clear to me. Patients in acute medical wards are constantly being bombarded with different staff wanting different pieces of information and explaining very little to them. I have witnessed countless medical teams and nursing staff just waltz into a patient’s room, ask them questions, test multiple things, discuss the patient without including them in the conversation and walk straight out. It leaves the patient anxious and confused about their medical treatment and the path that they will be taking. As physiotherapists we have the skills and the training to offer our patients superior communication skills and the time to give them explanations regarding their treatment and the direction that they will be taking.

We also have the skills and time to really evaluate our patients from an angle other than their blood test results and their ability to mobilize. It is our ability to really listen to what they are saying and look at their body language to assess what is really going on. If I had just listened to this patient without taking in all of the information available I never would have realized that she was just really anxious about mobilizing and I could have mistaken her anxiety and frustration for confusion.

Strategies
As a physiotherapist we should always take the time to really listen to our patients. Not just to what they are saying directly in answer to our questions but also to what they are saying outside of the context of the question. It is also important to read their non-verbal communication and gauge their reactions to certain situations. An entire picture of a patient is required to treat them effectively and that takes superior communication skills.