Assessment

S: When working in the neurology field, your assessment is very important. This is partially because physiotherapists play a very significant role in the overall handling of the pt. handling meaning both, assessing, treating and providing feasible discharge options. When dealing in particular with stroke pts, the medical team will do the appropriate tests to decide what the underlying pathology is. This normally means a CT scan. However this test is not always reliable in determining the type or cause of stroke. Many other assessment tools are used based on the pts presentation and symptoms. Many of these assessments are performed by the physiotherapist. The assessment also extends to things such as mobility status that the nurses will use when caring for the pt.
T: The task is to fill out a thorough stroke assessment form to use as a baseline as well as an indicator of impairment and problem list. However to also think outside the box and not just focusing on filling out the generic form, but also looking at the pt holistically from the very first time you see them.
A: I was given a pt that I had to conduct an initial assessment. The stroke ward that I am working on is an acute ward. This means that we are the initial health care they seek and there has been no previous physiotherapy input into this pt. this makes the assessment even more important because it is pivotal that the physiotherapist does not miss any vital details. Prior to seeing this pt I went onto the ward and read through their medical file. This was to give me a general idea as to what I was expecting and some background social and medical history. After I became familiar with the pts medical notes I consulted the nursing staff for any other useful information. Then I approached the pt in their bed and this is where the assessment began. I was sure to be very observant from the time I first laid eyes on them. I had gained an idea from my notes what I wanted to assess and I was already looking for particular things. I then took a brief verbal history from the pt and then accompanied them to the gym. Once at the gym I went through the thorough generic stroke assessment form.
R: The result came with some help from my supervisor. My supervisor, being a very experienced and knowledgeable physiotherapist was able to guide me through the assessment to get all the information I needed. The result was, I gained a very thorough assessment, which allowed me to determine all the impairments forming my problem list. This gave me a baseline to refer to on discharge. I also gained a good understanding of the pts mobility and ambulatory status. This helped me inform the nurses what the most appropriate form of transfer was. It also allowed me to choose the best transfer that would allow the pt to move in a way that facilitated normal movement, to help the brain recognize normal movement while it was still “plastic”.
E: overall I thing the result was good. However a stroke assessment is not an easy method to grasp. Having never performed a proper stroke assessment before, I think there were plenty of things I could have done differently. For example, almost all stroke pts suffer very heavily form fatigue and drowsiness. On my initial assessment I perhaps was to methodical with the assessment sheet rather than using some common sense. I went ahead and tested everything in order, which is not necessarily in order of importance. As the assessment moved on, my pt became very tired and fatigued and I still hadn’t assessed some very important indicators. I should really have assessed them in order of importance so that I could decide upon things such as their transfer status and ambulation.
S: Some strategies I would have found helpful include –
- Becoming very familiar with the assessment form so that you know what questions you should be asking and don’t have to refer to the sheet to often.
- Being able to tick off certain parts of the assessment without having to formally assess them. Such as when testing active muscle control, watching them when they get out of bed will give you a good idea of lower limb strength. This is good for saving time.
- Understanding all the terms in the assessment form and how to assess them. The difference between receptive and expressive dysphasia can be hard to differentiate, so by first understanding what each means, will give a good idea of how to assess for them.

initial entry

The fourth and final rotation brings with it many different emotions. There is of course the element of fatigue beginning to set in. as you rotate through the working world it is only normal that you become anxious to start earning and working. There is also the beginning of another new setting with new people and surroundings. Starting any job is hard at first, when you are trying to find your feet and learn everything about the place. Starting 4 new jobs in 5 months is obviously even tougher. Im starting this one at Royal Perth Hospital. Obviously being the biggest tertiary hospital in Perth it can be a very daunting place. Unfortunately very few people will know who you are or even care to find out and add the student label on that and that’s really all you are… a student. So having to make it in the real world with a stereotypical label can be tough, however it is what it is and you must get through that. Im starting in neurology on the stroke ward. This is the first exposure to neurology that I have had since the 3rd year first semester unit. That in itself is a very daunting experience. There is no doubt in my mind that neurology is the most challenging area of physiotherapy. Yes you can clinically reason nearly everything you do, however you cannot clinical reason your way around explaining the spinal tracts in detail at your supervisors command. So there is a lot to know and it does seem very daunting. Im definitely very nervous. I have no idea what to learn and if what im learning is even relevant. Does it really matter if you can spiel off the arterial distribution of the brain or is it enough to know what will be affected with infarcts in certain areas? Lots of thoughts pop into my head and I think “oh my god I haven’t looked at that” and when I do it seems like a constant path of repeating that same question on and on. However on a more positive note I always told myself that I wanted a neuro placement that was challenging and where even if I struggled, I learnt bucket loads… and this placement seems like it will be exactly that. My attitude is, im here to give it my all for 5 more weeks learn as much as I can, accept criticism not personally but professionally. If my supervisor is strict its because they are trying to get me to learn and they want me to be competent, so it wont take it personally but instead get on with it. This is my only neuro prac and I have to be competent when im done so I can work as a new grad effectively, so im here to learn as much as I can and even when it gets tough which I know it will, remember that I only have 5 weeks and then its done. So im looking forward to this prac and although slightly nervous about the challenges that will come, im confident that I have what it takes to do well and be the best I can be so I graduate as not only a competent physio but a good one when it comes to neuro.

Final Thoughts

Tom Price was a fantastic experience over all. I learnt so much and got exposed to exactly what I had hoped for. I was left to be independent but at the same time was given the support I needed. I was nervous about doing my musculoskeletal placement and wasn’t sure what to expect. In the end I was confident with my knowledge and learnt many techniques that I will use. I had pts ranging from 10 years old to 80 and dealing with all sorts of pathologies. I go to see problems with most of the joints of the body and learnt so much. The working environment was fantastic. I had my own desk and was working next to two other very good physios. The hospital itself was small but very good. The staff were very friendly and excellent to work with. They were very accepting and tried to make me fit in as easy as possible. The social aspect was very good for a small town. There were plenty of sporting activities and it was easy to get involved. This made weekends much more bearable. There was no mobile coverage which was hard. There was also no access to social networking sites on the government computers which made it very hard to keep in contact with friends. However I managed to get by ok. We moved around to some aboriginal communities which was a great experience. It meant I got exposed to a different culture and learnt some different aspects of msk. It also made it unique and not repetitious. I was able to travel somewhere every week and that was exciting. The landscape of Tom Price is amazing. I was able to climb mount nameless and look out over Tom Price and the surrounding region. Karijini national park is absolutely amazing. One of the most beautiful spots I have seen. I was able to get along and see some of the gorges and despite being rescued by the SES it was a very good experience. I think that was my favorite part of the placement, was getting along to karijini. The placement was an excellent networking opportunity. I was able to work alongside Beth Rogers for 5 weeks. I learnt so much about work and working in rural areas. I learnt about the pay and different incentives, and different tips for finding work. A lot of these things you can only learn from people with experience so that was something I found invaluable. So overall it was a great experience and I learnt so much. I now know what working in rural areas are like and its been a great preview to help me in deciding whether I want to work in a rural area at all at some point in my professional career. I would recommend to anyone to put Tom Price at the top of their priorities for future placements.

evidence based pratice

S: at ASC one of the main interventions is exercise. Interventions for exercise have very poor evidence behind them. The student is expected to make a presentation in the 4th week from a topic of their choice.

T: my task was to choose a topic and present on that topic. I would have to choose something with evidence based practice behind it to meet that area of the marking schema for my overall APP grade. It would also have to be relevant and interesting or the staff.

A: I decided I would choose the topic of exercise as that is the intervention carried out the most. I then searched on PEDro and PUBMED for relevant articles concerning the topic I had chosen. I found 4 articles that were of relevance to my topic.

R: all 4 articles were relevant and useful. They addressed the effects of exercise in relation with several different types of mental illnesses including dementia and depression. I presented on the evidence in the articles and also critically analysed the articles. The presentation went for 30mins

E: I thought overall the presentation went quite well. However on another note I found that still the evidence for exercise was inconclusive. Therefore I thought it was a bit disappointing not being able to present on something with hard evidence. The feedback from the presentation was positive, mainly because is important to have up to date evidence for the current interventions used.

S: some hints for improvement in the future include-
- choose a topic that the staff aren’t very familiar with so that it is useful for everyone
- make sure that it is relevant to the placement you are on eg; mental health
- think of some questions that might be asked so that you are prepared to answer them on the day

final thoughts

My final thoughts for this placement were very positive. I thoroughly enjoyed my time at ASC. The physio staff there were very helpful and knowledgeable. There is ample opportunity to take responsibility for your own learning. I found the placement to be a very generic type of physio with the added spectrum of mental health. Daily tasks included musculoskeletal assessments and treatments to neurological assessment and treatment. The added spectrum of mental health added another challenge and variety to the whole placement. I believe this mental health experience has given me a very valuable exposure that not everyone will have the opportunity to experience.

My supervisors were very helpful throughout. They constantly challenged me and provided tasks to develop my learning. They were very knowledgeable so having them as a resource was extremely useful. I learnt many things whilst there, including physiotherapy techniques to building rapport with metal health patients with differing challenges to there behaviour. I believe this placement gave me a very wide scope of preparation for my last 2 placements. I think I had time to focus on areas that I needed to improve on in preparation for musculo and neuro placements. Overall I think that ASC is a very good opportunity and the physios there are committed and good role models/examples for the physiotherapy profession

Communication

S: The Alma street mental health clinic has 2 full time, 1 part time physiotherapy staff and 1 physiotherapy assistant. There are 4 wards with over 60 beds all together. This means that appropriate communication between the physiotherapy staff is very important. Every morning the staff meet for a handover on all the pts. This is good because all the pts use the same gym regardless of the ward they are on. So when a pt is in the gym and the physio looking after that pt is not there, the other physio staff know about the pt. There are several other instances where good communication is important and it adds to the efficiency and professionalism of the physio dept.

T: being a new face in the physio dept. it is important to work hard to learn the system that they use and be easily adaptable to fit in. the staff are working together every day and to have an added member can change the dynamics a bit. One of the big emphasizes is on communication, therefore my task was to show outstanding communication skills to maintain the standard of the physio dept. in this particular instance, I was in the gym by myself when a pt entered for some exercise. I knew who this pt was and had been given a handover on this pt at the start of the morning. This pt was now under my care so I had to make sure there were no particular measures to take into account.

A: with this being the case, I paged the physio who was looking after this pt. I knew this pt had recently been transferred from a locked ward. The physio informed me that this pt required an escort to leave the ward. I then called the nurse on that ward and informed them that the pt was in the gym. The nurse said that they hadn’t realized the pt had left and that this pt was at risk of absconding. She asked me to please escort the pt back onto the ward when they were finished. A simple act of good communication between the multi-disciplinary team had ensured safe and efficient practice.

R: the result in this case was a positive one. The pt was returned safely to the ward without any complications. In many instances pts leave the gym or the ward and become AWOL. This creates problems for the whole team. In an instance of doubt it is quite easy to communicate to prevent such measures or dramas from playing out. Both the nursing staff and physio looking after that pt thanked me for communicating effectively. This creates a good professional relationship with the whole team because it proves that you have a wide scope and are not just concerned with your role.

E: I believe in this instance I was an effective communicator. This was a fairly simple act so it doesn’t require much evaluation. However the things I believe I did that made it effective were –
• I was composed and didn’t elevate the situation by over reacting.
• I was friendly and had previously made myself known to the staff on the wards so they knew who I was.
• I made sure the gym was not left unattended when I was escorting the pt back to the ward.
• I allowed the pt to exercise and the returned them to the ward and made sure the nursing staff knew the pt was back.

S: Some tips to ensure that these situations are easily resolved include –
• Making sure you know the phone numbers for the wards.
• Knowing the pts by name and by face.
• Having a good back-round knowledge of the pts.
• Being pro-active and acting upon any element of doubt just to be on the safe side.
• De-elevating any drama by being very casual and explaining to the pt that you will walk with them back to the ward and explain that they must let someone know when leaving the ward.

assessment

S: At my placement at the alma street mental health ward, every patient that is admitted to this facility has a blanket referral. This means that regardless of their admittance status, they will be seen by the physiotherapist. Part of the initial consultation is an assessment screening process that is used as a baseline measure for their time on the ward. This allows a very generic scope of how the pt is going and any areas they can improve in.

T: my task was to complete an initial assessment form for all new pts. The assessment form is a very generic health and fitness indicator. It measures the very basics of fitness and health for each pt. My task each day is to run through this process with these new pts and complete this initial assessment form. This is also a good opportunity to build some rapport with these pts for further practice. There are approx 10 exercises to complete on the screening form so having some direction and consistency with the process is important.

A: On this given occasion I went to the ward and organized an appropriate time to see my pt. on the scheduled time I went to the ward and escorted them to the physiotherapy gym. Once at the gym I explained the whole process and approx, how long it would take. Then I took them through step by step with clear instructions regarding the process. I completed the whole screening process in approx 30 minutes and explained what the results indicated to the pt.

R: The result was a fairly in depth summary of this pts physical well being. The screening process has been carefully constructed to give an all round, appropriate indication of the pts status. This allows the PT to adequately assess how the pt is initially and the areas that require improvement. This particular pt was a heavy smoker and had a lot of room for improvement. Being a heavy smoke at such a young age, many people think it is too late to quit and that they will never return to their previous fitness levels. After explaining the benefits of quitting whilst they are still young and the positive prognosis for their health fitness, this pt was quite determined to make lifestyle improvements which was very rewarding.

E: aspects that could require improvement included –
• Conducting the assessment in a more systematic and linear form. This would allow the pt to have a smooth and easy assessment process.
• Adjusting my behavior appropriately to deal with mental health pts. Every mental health pt is different and unfortunately that means you must adjust your form of thinking and your attitude appropriately to deal with the different personality traits.
Aspects I thought I did well with included
• Giving an appropriate explanation of what the process involved. This means the pt knew what to expect and how long it would take etc.
• Giving a good explanation and the process behind why each exercise was useful for the pt and what it represented for the pt.

S: some strategies for improvement in the future include –
• Maintaining your environment prior to starting the assessment. Making sure you have a vacant gym and clear schedule so that you have access to all of the equipment is very important.
• Understand and know how to explain the normative values for all the assessments that you do so that you can give the pt a clear indication of where they stand in the context of each assessment.
• Have prior knowledge of the mental health disorder prior to staring so that you know what is “normal” for that pt and what to expect. Sometimes this prior knowledge will help you in your decision whether or not to proceed with the assessment when things begin to look “pear shaped”