Hi Guys, I thought i'd go back to my first prac, musculo outpatients, for the final blog. This patient was an elderly Italian lady who was always accompanied by her husband. She has been diagnosed with Fibromyalgia and also has shoulder and neck issues. Her husband is there mainly as an interpreter when needed as she speaks only basic english.
This lady was in a lot of pain which was mainly the neck/shoulder/fibromyalgia and a little bit of emotional. She was in a cycle of decreased activity d/t increased pain and her husband always helped her if she had to roll over while on the plinth. She was approaching d/c and had a set of exercises to do. However not all were particularly appropriate and she found them hard to perform during a flare.
I spoke to my supervisor about possible strategies to increase this ladies compliance to the HEP and generally get her moving more. Her husband was very supportive and obviously did not like to see her in pain. The supervisor and I came up with a way to improve her HEP compliance and also to help the husband so he did not feel so helpless. I gave her some basic neck and shoulder stretches to perform at home. The difference was that the husband helped with applying overpressure and with helping her to attain the positions required to do these exercises. It was immediately obvious that he was really happy to be included in his wifes exercises. When they came back she was feeling a bit better and had been doing all her exercises.
The husband had also been massaging her and watched closely what I was doing so he could add this at home. Where I had to draw the line was when he asked me to show him how to do Cx mobilisations.
Involving the husband made a big difference to both of them. She was performing her exercises more often and was able to do some she couldn't do without her husbands help. On the other hand he didn't feel so helpless and felt that he was actively involved in looking after her.
What I learnt from this situation is that involving a person's partner can really help to improve the patients outcome and also help the partner cope with the situation.
Hope everyone has a great time on rural and good luck with PCR results.
Friday, March 7, 2008
Thursday, March 6, 2008
To treat or not to treat.
Hello all
So, the end is near finally, I thought this day would never come!!
Thought I would write about an experience from the last week of my placement. One of my supervisor’s patients is palliative care. There have been several meetings with the family in regards to his treatment. Unfortunately, at this stage there is not much treatment that can be done for him. He has severe spasticity and has a trachy in place. The only treatment the physio can do is positioning, suction and try to make him as comfortable as possible.
The family however insist that he has treatment at least every second day. The physio’s on the ward are very busy and unfortunately feel their time is a lot more beneficial treating patients who are making recovery.
I thought I would ask your thoughts on this. Should these impairments and the fact that this patient is pretty much palliative restrict or stop treatment or should we still fulfil the family’s requests?
Heidi
Wednesday, March 5, 2008
Chronic Pain
Hey guys,
My question this week is about a patient i had during the last week of my placement. I'm in musculoskeletal outpatients and my patient was a 60 yo man with OA of back, shoulder, knee and hip, he also had a skin lymphoma condition which had been succeccfully treated with chemo late last year, he had been getting physio for his shoulder prior to the chemo, but had to stop for his treatment.
On assessment he had widespread pain, the worst of which being 8-10/10 pain in his lower back, so bad that he occasionally passed out from the pain. He had a reduction in range and pain in all directions, and i could only use very very light pressure for my palpation and PAIVMS as he would jump and claim 8/10 pain with contact through his lumbar and thoracic spine.
As my tutor was completing a final assessment with another student, i wasn't able to get his feedback, however due to the chronic and severe nature of his symptoms, i was reluctant to perform manual therapy. I ended up doing 10-15 minutes soft tissue massage, followed by a heat pack over his lumbar spine for 20 minutes. Looking back i think perhaps i should not have done the soft tissue massage, as this is a manual technique and i don't want to make him reliant on manual therapy. I ended up referring him for hydrotherapy and booking a review in 3 weeks.
What i was wondering is what you guys think of this situation, would you have done the same as i did, or taken a different approach?
Thanks for the input, and all the entertaining and insightful blogs :-)
James
My question this week is about a patient i had during the last week of my placement. I'm in musculoskeletal outpatients and my patient was a 60 yo man with OA of back, shoulder, knee and hip, he also had a skin lymphoma condition which had been succeccfully treated with chemo late last year, he had been getting physio for his shoulder prior to the chemo, but had to stop for his treatment.
On assessment he had widespread pain, the worst of which being 8-10/10 pain in his lower back, so bad that he occasionally passed out from the pain. He had a reduction in range and pain in all directions, and i could only use very very light pressure for my palpation and PAIVMS as he would jump and claim 8/10 pain with contact through his lumbar and thoracic spine.
As my tutor was completing a final assessment with another student, i wasn't able to get his feedback, however due to the chronic and severe nature of his symptoms, i was reluctant to perform manual therapy. I ended up doing 10-15 minutes soft tissue massage, followed by a heat pack over his lumbar spine for 20 minutes. Looking back i think perhaps i should not have done the soft tissue massage, as this is a manual technique and i don't want to make him reliant on manual therapy. I ended up referring him for hydrotherapy and booking a review in 3 weeks.
What i was wondering is what you guys think of this situation, would you have done the same as i did, or taken a different approach?
Thanks for the input, and all the entertaining and insightful blogs :-)
James
Monday, March 3, 2008
Dealing with difficult family situation
Hey Guys….we’re almost there!!! I hope you’re all going well with PCR prep.
I’m going to discuss my patient who has been diagnosed with hereditary spastic paresis. I have written a previous blog about her condition, but I will give a quick review to her situation. She has been noticing a decline in her functional abilities over the past 12 months due to progressively diminishing strength and increasing tone, particularly in her lower limbs. She has remained independent with her mobility, using a manual wheel chair while at home and doing all transfers and bed mobility on her own. However, these tasks are getting more and more difficult as she gets weaker. Her husband has been helping with her ADL’s (dressing, personal care, etc.), but is quite frail and has been told he should no longer assist.
Over our last 2 weeks working together she has mentioned, and demonstrated an increase in tone and decrease in strength in her hands (L)>(R). This has caused further problems with her functional ability as she can no longer rely on her upper limbs with transferring (which was a very large part of her transfers). She is also having trouble feeding herself as she can’t hold her utensils very well. This progression to her upper limbs was sudden and unexpected, as she was told that this progression would not occur for ~30yrs after her diagnosis and initial deterioration of her LL’s. Thus, she would most likely not have to deal with it as she was diagnosed when she was ~70 yrs old.
As her condition is becoming vastly worse in a short period of time, my patient is very interested in going into a nursing home, as she can no longer care for herself and her husband isn’t fit to help her. She has carers come to help her bath and dress, but are not there 24hrs. She feels she now needs 24hr care, to ensure she can maintain adequate safety and hygiene.
Unfortunately, her daughters and husband do not agree and feel she would be much happier remaining at home. We would spend a large portion of our sessions discussing her need for extra care and the benefits, both physically and emotionally, of being in a nursing home where she could be at ease and not worry if she was going to make it to the toilet on time, for example.
I discussed this situation with my supervisor, who then got in contact with her specialist regarding her further deterioration, but I’m not sure what will be done with regards to her living arrangements. I am not sure what my position is, as a physio student, to recommend to her family that she investigate a nursing home. I’m also not sure how I would handle this recommendation to a family who is strongly against it. They don’t seem to listen to her when she says that she would be happier there, would they listen to me? How would you guys handle this situation?
I’m going to discuss my patient who has been diagnosed with hereditary spastic paresis. I have written a previous blog about her condition, but I will give a quick review to her situation. She has been noticing a decline in her functional abilities over the past 12 months due to progressively diminishing strength and increasing tone, particularly in her lower limbs. She has remained independent with her mobility, using a manual wheel chair while at home and doing all transfers and bed mobility on her own. However, these tasks are getting more and more difficult as she gets weaker. Her husband has been helping with her ADL’s (dressing, personal care, etc.), but is quite frail and has been told he should no longer assist.
Over our last 2 weeks working together she has mentioned, and demonstrated an increase in tone and decrease in strength in her hands (L)>(R). This has caused further problems with her functional ability as she can no longer rely on her upper limbs with transferring (which was a very large part of her transfers). She is also having trouble feeding herself as she can’t hold her utensils very well. This progression to her upper limbs was sudden and unexpected, as she was told that this progression would not occur for ~30yrs after her diagnosis and initial deterioration of her LL’s. Thus, she would most likely not have to deal with it as she was diagnosed when she was ~70 yrs old.
As her condition is becoming vastly worse in a short period of time, my patient is very interested in going into a nursing home, as she can no longer care for herself and her husband isn’t fit to help her. She has carers come to help her bath and dress, but are not there 24hrs. She feels she now needs 24hr care, to ensure she can maintain adequate safety and hygiene.
Unfortunately, her daughters and husband do not agree and feel she would be much happier remaining at home. We would spend a large portion of our sessions discussing her need for extra care and the benefits, both physically and emotionally, of being in a nursing home where she could be at ease and not worry if she was going to make it to the toilet on time, for example.
I discussed this situation with my supervisor, who then got in contact with her specialist regarding her further deterioration, but I’m not sure what will be done with regards to her living arrangements. I am not sure what my position is, as a physio student, to recommend to her family that she investigate a nursing home. I’m also not sure how I would handle this recommendation to a family who is strongly against it. They don’t seem to listen to her when she says that she would be happier there, would they listen to me? How would you guys handle this situation?
Patient monitoring
Can't believe we've survived 2 years...well done guys on finishing placements and good luck on wednesday!
I had a patient (82 year old woman)that was admitted for a ?TIA with minor right sided weakness and the doctors wanted a mobility review. On assessment, the lady presented with decresed muscle strenth (Gr 2+ - 3+) of LL muscles (R = L), no perceptual probs (that I could detect) and poor balance - was unable to bring feet together or tandem stance with EO. Obs were stable, transfers fine, gait - required supervision.
My treatment therefore consited of LL strenthening ex's - bridging, clamshells, IRQ, isometric glut squeezes then progressed on to balance tasks. She appeared fine throughout the session, frustrated at her balance but able to complete tasks. When I left her she was on assumption that she was going home though I told her the doctors would more than likely keep her for observation and was due for a MRI later that day. She felt offended that I wouldn't let her go, but I continued to explain that she was at risk of falling over and it was a safety precaution that she was staying there and "we're just getting you stronger to go home." She continued to pack her bags, claiming she just fainted and didn't have a stroke...we were being silly. Her family later told me her behaviour just wasn't here and very concerned that she had changed.
Half an hour later she had an OT review in which she had a code blue - had 2 episodes of unresponsiveness.
Moral of the story is to keep monitoring your patients even if they seem fairly straight forward, don't push them too hard which may (or may not) have been the cause of this code blue. Can't help but feel it was my fault. I learnt my lesson not to expect your patient to be ok even if they appear ok - continue to look, listen and monitor and observe. There's a reason why they are on a nuero ward.
Fan
I had a patient (82 year old woman)that was admitted for a ?TIA with minor right sided weakness and the doctors wanted a mobility review. On assessment, the lady presented with decresed muscle strenth (Gr 2+ - 3+) of LL muscles (R = L), no perceptual probs (that I could detect) and poor balance - was unable to bring feet together or tandem stance with EO. Obs were stable, transfers fine, gait - required supervision.
My treatment therefore consited of LL strenthening ex's - bridging, clamshells, IRQ, isometric glut squeezes then progressed on to balance tasks. She appeared fine throughout the session, frustrated at her balance but able to complete tasks. When I left her she was on assumption that she was going home though I told her the doctors would more than likely keep her for observation and was due for a MRI later that day. She felt offended that I wouldn't let her go, but I continued to explain that she was at risk of falling over and it was a safety precaution that she was staying there and "we're just getting you stronger to go home." She continued to pack her bags, claiming she just fainted and didn't have a stroke...we were being silly. Her family later told me her behaviour just wasn't here and very concerned that she had changed.
Half an hour later she had an OT review in which she had a code blue - had 2 episodes of unresponsiveness.
Moral of the story is to keep monitoring your patients even if they seem fairly straight forward, don't push them too hard which may (or may not) have been the cause of this code blue. Can't help but feel it was my fault. I learnt my lesson not to expect your patient to be ok even if they appear ok - continue to look, listen and monitor and observe. There's a reason why they are on a nuero ward.
Fan
Sunday, March 2, 2008
Approach with caution!
Hey guys
I have just completed my cardio placement on a medical respiratory ward at a major hospital. I was required to assess a patient who had been admitted to ED the previous night with a stab wound to the chest. Luckily the weapon did not pierce the lung, but the patient did lose quite a lot of blood. The incident occurred in a pub fight, and my patient was still quite agitated about the whole situation from the night before, and had been quite rude to the nurses on the ward.
I decided to approach the initial assessment in a calm and composed manner, and although I was required to obtain the essential facts about the mechanism of injury, I certainly did not dwell on the incident. Lucky for me, we did actually manage to get on quite well because we found some common ground (both proud Victorians!), so I was able to carry out the full assessment without any problems. From a respiratory point of view, the patient was in really good shape, and I took him for a long walk (approx. 300m) without any problems, and he was discharged later that day.
The lesson I learned here was just to sum up each situation individually, and not jump in too quickly before you have gained the patient’s trust.
Steve
I have just completed my cardio placement on a medical respiratory ward at a major hospital. I was required to assess a patient who had been admitted to ED the previous night with a stab wound to the chest. Luckily the weapon did not pierce the lung, but the patient did lose quite a lot of blood. The incident occurred in a pub fight, and my patient was still quite agitated about the whole situation from the night before, and had been quite rude to the nurses on the ward.
I decided to approach the initial assessment in a calm and composed manner, and although I was required to obtain the essential facts about the mechanism of injury, I certainly did not dwell on the incident. Lucky for me, we did actually manage to get on quite well because we found some common ground (both proud Victorians!), so I was able to carry out the full assessment without any problems. From a respiratory point of view, the patient was in really good shape, and I took him for a long walk (approx. 300m) without any problems, and he was discharged later that day.
The lesson I learned here was just to sum up each situation individually, and not jump in too quickly before you have gained the patient’s trust.
Steve
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