Final Entry – Placement 2 – 2013

I have recently completed a five-week placement on a gerontology rehabilitation ward. I found this placement to be highly rewarding and reaffirmed that this is the area I would like to work in. I felt I worked well with the physiotherapists, the staff and the patients and received good feedback highlighting my strong points and constructive criticism suggesting where I could improve. One of my biggest concerns was that I would not have developed greatly from my second year placement. I addressed a number of these inconsistencies and insufficiencies and feel I have emerged a much better therapist.

During my first week I endeavored to get familiar with the procedures and environment of the hospital. I found out that hospitals are not all the same and the forms and systems can be quite different. I was also off sick for two days in the first week so missed out on some valuable time.

In the weeks following I addressed the key areas that I felt were holding me back in my confidence as a gerontology physiotherapist.

Patient assessment – I have always struggled in this area, as it is a time when the most care with the patient is needed. You are unsure of their actual abilities and have to get a good understanding of where they are and where they are heading. A good mobility assessment is really critical as it is the cornerstone to nursing care and patient progression.

Team meetings – These take some getting used to and I am grateful that my supervisor took such care in ensuring I was on the right path when presenting to the multi-disciplinary team (MDT). Mobility status, rate of progression and discharge planning are all the consultants need to hear about from the physio. I enjoyed these meetings and felt I contributed well to the patients’ outcomes.

Time management – I improved slightly from my last placement in the amount of patients I was able to manage in a day. I feel the hold up in this area is being confident with any type of patient and knowing when to ask for assistance. I was reluctant to increase the patient load in fear of rushing and causing injury or not leaving enough time to complete documentation. I fell in to this trap at one point but made sure I stayed behind to complete what was needed.

Presentation – I was pleased to present to the physiotherapy group some background on Progressive Supranuclear Palsy (PSP) following a stroke patient I had treated with PSP as a previous condition. I identified some key treatment strategies that was supported in several research reports and highlighted the difference between PSP and Parkinson’s disease at diagnosis and progression.

One of the biggest hurdles to overcome in gerontology, I feel, is painting by the numbers. Create a problem list from the top six impairments and roll out the treatment plan. There is of course the risk of over thinking things as well, but each patient comes complete with their own set of diagnosis, co-morbidities and social history that needs to be considered during each session. All these factors make the area of gerontology physiotherapy interesting and rewarding and an area that I feel I could be successful in.

STARES 3 – Communication - 2013

Situation

85-year-old female is having difficulty returning home with services following a right total shoulder replacement 4/52 secondary to a mechanical fall (the patient is right hand dominant). The patient’s mobility has returned to prior admission levels, however, due to the surgical precautions (sling and pendulum ROM exercises progressing to active assist exercises within 2/52), the patient will not be considered totally independent until following a surgical review 3/52. The patient’s son is her full time carer but because of his hearing impairment he is concerned that she may have another fall and he will not hear her. He is also concerned with the management of the shoulder sling and toileting needs. The patient had been offered a Transitional Care Placement but due to costs she declined.

Task

Communicate with the patient and family and liaise with the MDT regarding the patient’s discharge requirements. Find strategies that could reduce the anxiety of the son and contribute to the care of the patient.

Action

I coordinated with the social worker and occupational therapist an appropriate time to get together with the patient and family. I made sure I had a good understanding of the patient’s current mobility, sling requirements and surgical review date. I also took some time jotting down the family member’s names and their social history/level of assistance they where able to provide to the patient. An appropriate time was organized and I touched base with my supervisor to make sure I had covered all points. At the meeting I spoke of the patient’s progress and her current ability. We had spent some time with the OT’s making sure that she was able to manage the sling independently during morning routines and during the day. This was explained to the son that he would not have to be concerned and his mother could direct any minor assistance. The patient’s Berg Balance Scale Assessment indicated that she should be frame mobility but because of her shoulder restrictions she had be on a quad stick. She was deemed safe with this aid and had been given sufficient falls education to reduce the risk of another fall

Result

I feel my contribution helped increase the carer’s confidence to fulfill their role as well as increase the patient’s confidence to return home. I had spent some time with various family members and due to a lighter caseload, I was able to get to know them and their social situations. The professional OT and social worker had managed to accomplish this with their full caseloads. This was of great benefit during the meeting as there was an atmosphere of care and understanding from the MDT that showed genuine concern from the team. This deconstructed many barriers that may have otherwise been obstructing the patient’s care and provided a good outcome from the meeting that saved time and resources.

Evaluation

I feel I made a good contribution to the meeting and the patient’s care plan. My supervisor gave me timely feedback following the meeting regarding any follow-up information I would need and how to document the meeting in the integrated notes. I had gained the patient’s and family’s trust during the treatment sessions and on the ward that would later prove to save resources. If I had not been up to a satisfactory level or had an altercation with any of the family members during the patient’s rehab, this may have proved a sticking point during the meeting and delayed the patient’s discharge.

Strategies

Develop good working relationships with patients and their family members.

Have all the relevant information pertaining to the patient jotted down for quick reference during the meeting.

Be aware of discharge planning and the costs involved with various services.

Know what services are provided by OT and social work so as to not double up on work.

Follow-up on any decisions made during the meeting in a timely manner.

Assessment – Placement 2 - 2013

Situation

Follow-up Gowland Assessment on an 83 year old male requiring discharge from rehab hospital post CVA 4/52 with complications of previous Progressive Supranuclear Palsy (PSP) with expressive dysphasia. The patient was previously a doctor.

Task

Conduct an updated Gowland Assessment on the patient and complete all discharge documentation including Rehab in the Home (RITH) referral. The patient had been discharged early at the request of the family. Discharge was scheduled for early the following week but needed to be prior to the weekend. It was Friday at 14:30 when the consultant agreed to the discharge.

Action

I had been through the discharge procedures the day before with another patient and knew where to find the discharge checklist and documentation forms. My supervisor informs me that most of the documentation can be completed next week but to focus on conducting the Gowland Assessment, issuing the walking aids (stick and wheeled zimmer frame) and getting the consent signature for RITH. As the patient has expressive dysphasia and only able to write his communication, all discharge procedures will take awhile. I start with the Gowland Assessment and explain to the patient that it is a similar test to one he had done before but we were going to look at slightly harder tasks.

It was the first time I had looked at the Gowland since my Neuro labs but it is part of the CMII that I had used at my previous Neuro placement. I looked over the assessment and realized that the patient would not greatly improve on his original attempts, having worked with him for the past three weeks and seen his capabilities. We had worked well on his balance and ambulation but this would not translate well when broken down into “Hand, Arm, Leg, Foot and Postural control”. The patient seemed keen to try and I was also interested in seeing the outcome so we progressed with the assessment. The patient had improved on some of his scores for hand and foot control but not done very well in the other areas. This seemed to distress the patient and he communicated that he had not slept very well the night before. I explained that it was just a measure of progress to pass on the RITH team but he seemed very down and requested to speak with the doctors about increasing his medication.

I accompanied the patient from the gym to the registrars office and left the to discuss medications. I explained to the doctor the assessment we had conducted and how the patient had felt he could have done better with rest and a boost in medication. There would not be any time to redo the assessment and I informed the doctor of this. He understood the dilemma and knew the patient well. He agreed to the medication boost but instructed me to just continue with the discharge.

Occupational and speech therapy as well as the pharmacy needs to spend some time to get their discharges in order. I write up the equipment and RITH form and liaise with OT and the speech pathologist in regards to their RITH needs. I am able to get the patient to sign the required documents before the other health professionals begin to move in to finalise the discharge.

Result

On reflection I realized how important it was to the patient to feel like he had improved on his scores. He had been a medical professional and realized that all rehab support would stem from objective measures. If he was not improving, he would be left to make compensations, and he had felt he could do more. I could have structured my assessment better to allow him to complete the tasks he was capable of first and then progressed to the harder stages. As their were time constraints this was not and option but worth remembering in future.

Evaluation

The Gowland Assessment is not a quick process especially when a patient has any difficulty in understanding instructions or in communicating with the therapist. I should have taken the time to review my plan and take consideration of the patient. A few easier tasks would not have increased the assessment time greatly and may have lifted the confidence of the patient and he may have not been left feeling so despondent. The patient had overcome many obstacles in the last few years of his life and shouldn’t have left feeling that he had failed a task.

Strategies

• ·      Good assessment structure that is flexible
• ·      Forward planning (Gowland could have been completed in an earlier session).
• ·      Clear assessment purpose and instructions
• ·      Timely feedback to the patient and positive encouragement if required.
• ·      Know the limitations of your patients from other Co-morbidities.