• Situation – Having missed out on week two because of illness, I was starting to get my confidence back with patients. The clinic had gone through a very busy time and I had been involved in many hours of patient rehab based on assessments from the physiotherapists. I had become proficient in this area and had my own caseload to manage and reports to present and the allied health meetings. I had been involved in discharge planning including RITH referrals. Where I was lacking in experience was with initial assessments. The form that the physio assessments are conducted on contain many of the tools that we have learnt about in our Gerontology unit and I was keen to have some initial assessments so as to go through these in some detail. At the start of week 5 I was to be supervised by my clinical tutor and I was given a new patient to conduct an initial assessment on.
• Task – Conduct initial assessment on a 70 year old female patient with an ORIF on fractured neck of femur secondary to a mechanical fall, day 7 post-op on transfer to rehab hospital.
• Action – I was handed the patient in the morning to conduct initial assessment on with clinical tutor in the afternoon. During lunch break I went through patients file to get information on the initial trauma, the surgical procedure and precautions, past medical history, current medication list and the patients social history. There were no previous notes from the physio or an official hand-over. Having struggled with past attempts to record all relevant information I made a concerted effort to source all the data that could be used for analysis and planning, including a mention of foot pain from a past accident. X-rays of the foot only reveal arthritic degeneration.
• Result – Having geared myself up to see this patient I was flustered when we entered the patients room only to find them in a deep, peaceful sleep. We approached my hospital supervisor to adjust schedule for the afternoon and we attended to other patients in the meantime. We were successful in our second attempt to start our initial assessment. We encouraged the patient to be transported by wheel chair to the gym for the assessment, as the shared ward room is busy with visitors. Consent was given and the patient was happy and compliant. On arrival in the gym I transfer the patient to the plinth to assess range of motion, strength and considering ending the assessment with a timed up and go (TUG) as a baseline evaluation. Once on the plinth the patient began to demonstrate extreme pain on mobilization of the knee joint that radiated up to the groin. My tutor suggested we conclude the assessment. The patient’s knee is swollen and bruised and she still complains of foot pain. The patient mentions that she feels that the pain in her foot caused the mechanical fall. We had noted that the patient’s crutches were too long so we made adjustments to improve the patients gait stability. I my documentation I noted that the source of the patient’s foot and knee pain would have to be addressed to correctly rehabilitate the patients mobility. Following up with the doctors on the patient’s pain led to another X-ray on the foot and a Doppler on the knee for a possible Deep Vein Thrombosis. A missed fractured metatarsal was picked up on the X-ray and the Doppler results had not been received as yet.
• Evaluation – A number of issues were raised by my tutor and helped explain why I felt the assessment had not gone well. Having prepared as well as I thought I could have for the afternoon, I had not informed the patient of our intentions and had not organised for her to have her pain medication. I was so intent on completing the assessment the way I wanted it I forgot to consider the patient. This wasted valuable time trying to reorganize the patient list and made me less confident.
• Strategies – Planning is a very important part of the health care professional’s day, but being able to change the plan at short notice and still maintain composure seems just as important. At the centre of all treatment is the patient, and the health care provider should work backwards from there. My need to conduct a full assessment comes second to the patients needs. Reading notes does not replace a face-to-face conversation. A patient’s pain needs to be controlled in order to treat their impairment and this needs to be organised in advance with the nursing staff. In this case the unexpected pain led to further investigations, which were valuable information, but could have been achieved with a conversation and visual inspection.
Make a plan
Make a back-up plan
Have alternative ideas
Think on your feet
Be ready to change direction
Be well prepared
Be flexible…
This list could go on and on but the main outcome that I have learned is that the patient comes first and time, energy and resources can be saved to being less focused on paperwork on more focused on the person. Then be a damned good physio to back it up.
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