week 1

Topic: Analysis and planning

S: On my first week, on a Tuesday, I spent 3 hours with my Notre Dame tutor. We saw two patients (pt) together and ran through and discussed our analysis of our problem list and our plan of intervention. After already completing a subjective with the patient, we proceeded to sit down and discuss our A and P before returning to the pt. this was all done on the ward and took about 30 minutes. This A and P would later have to be documented in a full SOAPIER.

T: I was required to run through a problem list and prioritize it according to what required the most attention and so forth. Once I had done this, my plan had to incorporate all of what I intended to do to manage my problem list. A and P are both very important parts of the SOAPIER so finding a thought process that suited my strengths was something I had to focus on.

A: The process I went through to draw up an appropriate A and P was as follows.
• After completing a subjective I wrote out my 10 cardio-respiratory specific problems according to Pryor and Prasad.
• I then asterisked each problem that my pt was experiencing.
• I then prioritized by looking at each problem I had documented and began clinically reasoning which problems were most underlying of other problems in my list.
• I also drew up a heading of mobility and further thought out what problems this pt was having with mobility.
• Once I had my prioritized analysis I began writing out a plan. This involved looking at each problem and listing appropriate intervention to directly address that problem
• A lot of my intervention addressed more than one problem, as is the nature of the cardio-respiratory problem list.
• I then documented this A and P in my full SOAPIER and used it as a guide when I treated this pt.

R: the result of this was a detailed and concise A and P. Because I went through it with my tutor I was able to tailor into it a very holistic and detailed method. My tutor is a very experienced and knowledgeable physiotherapist so with her as a guide I believe the result was a good one. There were a few methods in my thinking process that were different to hers, but as long as I justified my thought process then that was fine. The A included the problem list as well as risks that would potentially be problems. It also addressed why these were problems. With the tutor keeping me on track and guiding me when appropriate, I was able to achieve an A and P that was concise and effective in my overall treatment of this pt. The result was therefore a positive one.

E: looking back on my performance, I thing there were both strengths and aspects that require work. ,y strengths included,
• I was thinking in quite a lot of depth, including problems that weren’t necessarily a high priority but were still evident.
• I was able to discuss the problem list in detail with my tutor because I had recently studied and revised my 10 problems from Pryor and Prasad.
• I believe a strength of mine is being able to clinically reason my priorities for my problem list. Such as gas exchange effecting exercise tolerance and so forth. This meant that if I prioritized correctly then treating one problem would also address the subsequent problems.
Some of weaknesses included,
• Possibly going into too much detail and including problems that weren’t necessarily relevant to why the pt required physio. With our intervention we need to include a plan that addresses the pts main and most limiting problems.
• My terminology has room for improvement. By not understanding some of the abbreviations and disease terminology it hindered, not just my A and P, but my overall SOAPIER.

S: Some strategies to acknowledge for the most desired outcome include.
• Gaining a handover form the nurse to gain the best idea of the pt and their main problems.
• Researching the main problems you will encounter in a disease process such as cancer and the effects of chemotherapy. This will give you a better understanding of the ramifications of the disease process.
• Find a suitable train of thought that suits your strengths, such as writing down the goals of your intervention and plan your interventions according to those goals.
• Read previous medical and allied health notes to gain a holistic understanding of other health professionals' analysis of this pts problems and their subsequent intervention.

Initial entry

I will be starting at Sir Charles Gairdner Hospital on my cardio-respiratory placement. Firstly I would like to note that I believe the “cardio” placement to be a very prominent one. By this I mean there is a substantial theoretical basis behind it, which I will obviously have to have a firm grasp of. SCGH is a big tertiary hospital with a prominent emphasis on “cardio” so as far as my placement is concerned I believe im doing an important placement which I have looked forward to, in an advanced and challenging setting. I found the cardio theory to be quite interesting and rewarding and I only hope that I can apply that effectively to the practical element. I think the nature of the cardio unit means there is quite a gap between the prac and theory components, so I am quite nervous about my practical knowledge and how much I can do by myself.

I was advised a few days before my first day that I would be working on the oncology and general surgery wards. This information gave me mixed emotions. Firstly I hoped that this would still give me adequate exposure to cardio-respiratory cases because I believe the cardio-respiratory placement to be of very high importance. However I was also very excited to be able to see and experience some general surgery cases and unique cases which I otherwise would not be exposed to. Whilst reading the clinical mix I did notice an expectation to be able to talk about death. I have had very limited exposure to cancers and the very real subject of its mortality. Also my oncology knowledge is very limited, so therefore I was very nervous about entering an environment that was very confronting, whilst having fairly limited knowledge. As for the general surgery, am I mentioned, I was excited about seeing unique cases which I might not normally get to see

So I would say im nervous about applying my knowledge practically, and nervous about working in oncology and general surgery which I otherwise would not be as confident in. I always think about my supervisors before I begin, and I guess always hoping that it’s someone who I can work well under. There are a lot of things that go through my head such as trying to be confident but not intimidating. If you come across too confident I believe the supervisor sometimes can feel a need to exercise their superiority. This is not something im worried about, but I just want to give a good impression and be confident enough so they feel confident in my abilities. I also hope I meet their expectations of a 4th year Notre Dame student. I guess by this stage I want them to be confident enough to let me treat patients and work as if I was a new graduate. However I realize the gap in experience between a new graduate with 4 prac experiences under their belt and myself. So I am trying to keep my goals realistic. In conclusion im excited about working at SCGH and considering I really enjoy a hospital setting, I cant see why I cant make the best out of this opportunity and learn lots with invaluable experience.

as i mentioned, this prac will be in a hsopital setting which is something i very much enjoy. therefore i expect to be working within a multidisciplinary team and gaining a lot of knowledge and expectations of different allied health professions. i expect that i will be working in a hsopital setting upon graduating so i therefore expect to excel on the ward setting and gain good confidence in dealing with doctors and nurses and the other professions. therefore i am using this prac as a gage of where i am and what i need to improve on and how i can prepare for graduation. first and foremost im very excited and as the clinical mix form said "we expect student to enjoy themselves and have fun so that they can maximise their learning" and thats what i expect.

Final Thoughts

well firstly i was wrong about it being a ward setting. it was outpatient parkinsons so i was working in day hospital with scheduled appointments. I was working alongside OT's so i got to see a fair bit of what they do. the placement got a bit repetitive at times and there were several cancellations which meant i had a lot of free time on my hands. good to learn a lot about PD but i think i prefer working on a ward or something with a bit more variety. i was really excited going into the placement and there were some positive aspects but it possibly wasnt quite a exciting as i had anticipated. the message i would take home is PD is a very common diseaese and there are many factors involved. we still dont know exactly what causes it as its pretty much all idiopathic but there are many things to learn form it. this prac allows you to think more laterally about strategies and try new things which can be very fulfilling.

Analysis and Planning

S
I was seeing a new pt and at the end of the session I had to write a detailed soapier in the notes. There is a staff changeover next week so the handovers must be detailed to give the supervising clinician a good understanding of what is expected during the next session. My analysis and plan for the problem list was the most important part of my notes.
T
In order to complete a successful handover, I had document a problem list (analysis) from my Ax which had to be specific and enclose all the pts problems. I then had to write a plan both for the next week and future planning for this pt that the next clinician could read off and understand clearly to go ahead with the Rx next week.
A
Once I was finished the initial session I wrote up a detailed A,P. I had to focus on including everything that was evident through my Ax. My Analysis appropriate and I wrote a plan for the next session in one week.
R
My analysis was not in order from the biggest problem to the smallest. Your problem list should be ordered so that the most important problem to be addressed is first and so on. My plan was only written for the next week. It should have been written for future planning. Then the next physio could have an idea for d/c planning and what the overall plan is.
E
I think my A and P were comprehensive in some respects but lacked in other ways. To look at it from the next physio’s point of view I don’t think it was quite good enough. My analysis was good except for the order and my plan needed a bit of work. My plan needed to address the analysis and have written for the next week and for overall Rx.
S
I think the best strategy is to look at it as if you were the physio seeing the pt next and ask yourself is this comprehensive in that I would feel confident going to see this pt with information on hand. Write out your A and P and then review it from an objective point of view.

Communication

S:
Whether completing a baseline Ax to a pt you are seeing for the first time or providing ongoing Rx to a regular pt, communication is very important. In this particular scenario I was seeing a pt for the first time. He was a 65 yr old gentleman who had a speech and hearing deficit and had arrived for Physiotherapy regarding his Parkinson Disease (PD).

T:
In regards to communication my desired outcome was to Ax and Rx this pt using an appropriate level of communication taking into account any disabilities or cognitive deficits. This included everything from voice projection to tone and how much I explained the tasks we were about to do.

A:
Through reading his notes I realised that he has an inner ear device that accounted for his decreased hearing, however I wasn’t sure about cognition and speech. I spoke to him at a normal voice projection and in a tone that more reflected the way I would speak to an elderly pt with cognitive deficits.

R:
At the end of the Rx my supervisor provided feedback about my communication. My communication throughout the Ax and Rx was inappropriate. This gentleman would delay his response for a few seconds before answering any qn’s. This was not because of any cognitive deficits, but due to delayed processing of words due to his hearing impairment and the PD. I misinterpreted this delay as him not understanding me and hence adjusted my communication for someone with a cognitive deficit. This made me appear to be condescending towards the pt, which he could have found very offensive considering he was cognitively sound.

E:
Although my communication wasn’t effective I believe there were some things I did right and other I could have done better. I would prefer to over explain to a pt and be interpreted as condescending to under explain and not get the task completed. However I initially did not give the pt enough time to respond, which if I had, I would have realised he understood perfectly it just took him time to respond. Although I felt rather disappointed I did take the feedback on board and the next week I improved ten fold and as a result gained much more rapport with the pt.

S:
Firstly ask someone appropriate rather than just read the notes. Say to someone “I have read that this person has hearing and speech difficulties, what is the most effective way to communicate with this pt?” From the first introduction, start to think about how this person presents wholistically, including cognitively so that you communicate effectively form the word go.

Assessment

S:
For all new pts in the Pd clinic an initial assessment must be completed. This assessment includes both subjective and objective components. the subjective focuses on components such as balance, falls, mobility and PD symptoms i.e festinating gait. The objective is based on time trials for tests like the TUG, 6m walk test etc. the assessment form is filed and used as a baseline measure for future assessments to identify any deterioration in the pts function between interventions.
T:
To successfully complete this assessment form it is important that I ask the right qns in the subjective. I must gain a good understanding of anything the pt is having trouble with at home. For the objective it is important to do the tests correctly and explain them effectively to the pt. I must document correctly also, commenting on whether the pt used an aid during the tests etc.
A:
I sat the pt down and had a conversation with them. I started with an open ended qn and allowed the pt to explain to me what they were worried about. I then explored my main subjective topics to gain insight into where my intervention would be based. For the objective I ran through all the tests and took the pt through them.
R:
Overall my assessment was fairly good. There were however some extra qns I could have asked regarding some of the things the pt said. I took my filled in my assessment form and filed it in the pts file for further reference. All my time trials were done well.
E:
Overall I was effective in reaching my outcome of a detailed subjective and objective assessment. My weak points were communication, I was sometimes a bit condescending towards pts assuming their cognition level to be lower than it was. My strengths were my normative values knowledge and my rapport with pts.
S:
Some strategies for improvement are; becoming familiar with the subjective qns and knowing what to ask. Finding ways to explain certain terms to a pt such as festinating. Gaining insight into their cognition early as possible to decide upon the ;evel of explanation required.

placement number 2

well i finally found my password for my blog since last year, so here is my first blog. so what am i expecting? im at the Parkinsons disease clinic at Osborn park Hospital. i suppose being a hospital setting im expecting the nature of this prac to be your typical ward setting, working as part of an allied health team. its Parkinsons outpatients so i will be working a with a range of patients from high level function to mid/lower level function. this means structuring my treatment differently from things like education to treating joint range of motion to muscle strength. the structure i believe will be basic supervisor student relationship with opportunities to research my area of practice and also treat patients and take classes. my role as a student like any placement will be to conduct myself as professionally as possible, represent the university in a positive and exemplarary fassion. to respect hospital guidelines such as patient confidentialilty. also to be competent to treat patients as a show of respect for them giving their time for me. starting this placement, im inspired to get into a routine and achieve all the things i have set out to achieve like a positive experience with good marks. im worried about not being able to earn any money while on prac and how im going to handle that. however i believe that i can make this experience an absolute positive experience and make it go a long way in my journey to being the best possible physiotherpaist i can be. thankyou and good luck to everyone