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”

Initial entry

After already completing one placement I find myself a little more relaxed heading into the second placement. I am at Alma street centre in Fremantle on the mental health ward. As far as I know I am the first student to complete this placement so finding out about what to expect has been quite difficult. With that in mind I know that my feedback on the end of this placement will be very important for future references. I am going into this placement with an open mind. I have a strong willingness to learn and see this as an exciting opportunity to be exposed to something I may not otherwise get a whole lot of exposure to.

I have spoken very briefly with my supervisor over the phone and look forward to being a student under her. Of course there is always the nervousness about living up to any expectations she might have of me. I want to show a good impression on the first day, and show my supervisor that I have a good theoretical basis and also have good practical capabilities. I hope that I can be very adaptable to my environment and then subsequently excel with my interaction with people, especially in this environment.

I have had only very limited experience with mental health in every day experiences and on previous placements. I hope that I will show a good ability to adjust my thinking and approach in light of my patient list. At the same time this experience I hope will take me out of my comfort zone. This will help me develop and make me, not only a better physio, but a better person as well. I think we grow and learn the most when we are made to challenge ourselves which is what I hope to do. Therefore I am both nervous and excited about working with mentally challenged patients.

I am very oblivious to what my role will be at this time. With this in mind I plan to heighten my skills as an observer watch my supervisor very closely. Hopefully once I have proven myself to my supervisor I will be given a lot of independence and can excel in this field. However I understand due to the nature of this placement and my limited understanding, my clinical reasoning and observations must be sound. I expect to gain a better understanding of what my role will be over the course of this placement, on day 1.

I think with this placement being a mental health situation, my role will be based on musculoskeletal therapy. Therefore my knowledge of anatomy and previous MSK units will have to be good. Of course I will also have to show the qualities that will be required of me in further placements and when I am qualified. Qualities such as professionalism, ability to learn, skills of practice and more, are all things that make the foundation of a good physio. Many different subcategories fall under some of those heading and having them well refined is pivotal. I look forward to this placement, especially the close proximity it is from home and the environment of Fremantle which I love. I’m excited about diving into it and making it a positive experience.

Evidence Based Practice

S: I was asked to complete a presentation before the two supervisors and the other student I was on placement with. The presentation was to be centered around a patient I was familiar with who had an interesting and challenging diagnosis. This presentation addresses the evidence based practice column of our overall assessment sheet. The supervisors must assess this to see whether or not the student has evidence behind the interventions they use.

T: I would have to research one of the treatments this pt was receiving from physiotherapy for their diagnosis. I would have to find the evidence for this treatment and provide the evidence before the supervisors. I would have to analyze the articles before presenting them so as to decide whether they were relative, representative and of a high quality. In summary I would have to use this evidence to decide whether this was an appropriate treatment technique for this pt.

A: firstly I decided what treatment technique I was going to find EBP for. I then looked through my uni notes on cardio-respiratory and found the relevant interventions. Shane always references his information very well, so I was able to look at where Shane got the evidence for his lecture notes. I then researched the cited Cochrane reviews that Shane had referenced. I found relevant articles to my study and analysed them for their quality. After I had 4 articles to use I fitted them into my presentation to present them as evidence for my intervention, which was long term oxygen therapy and O2 therapy with exercise in COPD pts.

R: I think the results were very positive. Firstly I gained good results for the searches in conducted. All the articles I chose were of high quality and relevance. I presented the topic in a clear and concise format which I believe successfully conveyed the information I had obtained. This topic of O2 therapy in pts with COPD is something both supervisors didn’t know a great deal about, therefore it was imperative that I was concise and conveyed correct information in my presentation. The feedback I got was that both supervisors learnt a lot and were happy with the topic and the information conveyed in my presentation.

E: I think my strengths included
• High quality articles used with high relevance to the topic.
• Presented in a clear and easy to follow format. At a level appropriate to both supervisors
• Choosing an intervention that was somewhat ambiguous and which the supervisors knew of little evidence for. This made it more relevant and useful for not just myself but for my supervisors also.
• Cited all my articles effectively so that they could be used as references by either supervisor in the future.

Some areas to improve on included:
• Presenting my analysis of the quality of the articles in more detail. This means including information such as cohort numbers, number needed to treat for the intervention, whether or not it was blind etc so it was clear how usable these research articles were.
• Conveying the information more concisely to prevent “waffling” where you can easily lose your audience. This would make the presentation more time efficient.
• Having some articles on hand so that the audience could make direct reference to when needed.

S: Some strategies to help improve for the future
• Review the evidence based practice unit from 3rd year semester 2 so that you can familiarize yourself with how to critically analyze research articles.
• Practice reading our presentation out aloud and editing it for irrelevant information. This will help make the presentation more concise and specific to your audience.
• Discuss with your supervisors areas which they feel they could find useful. Such as some areas where they have limited knowledge. This will make the presentation more useful to them and yourself.

assessment

S: When working on the oncology ward Assessment is a very important part of Physiotherapy. In this particular incident my patient had already been diagnosed with cancer and had been admitted for chemotherapy. My assessment however had to be thorough and concise so that I could identify any other problems this pt might experience along with their cancer treatment. I am required to go into the room and assess this pt. I must build rapport and then maintain the pts dignity with any assessments such as auscultation. I must also be diligent in meeting all parts of my required assessment including auscultation, cough, chest expansion, spo2, social hx and previous level of function.

T: in order to reach a desired outcome, I would have to complete a respiratory and mobility assessment of this pt. the respiratory assessment would identify further intervention this patient would require whilst having chemotherapy. The mobility part would allow the allied health and medical staff to be aware of the level of assistance this patient required or whether they were independent. The mobility assessment must also include the oxygen requirements this patient has and any walking aids. Once you have recorded all of your finding systematically you must then begin to analyze your findings into a problem list for this pt.

A: for this pt, I entered the room and worked on building quick rapport with the pt. this is important because when assessing a pt you are invading their personal space and it goes a long way to first build that rapport. Firstly I started with a subjective assessment. Keys questions to ask are; home situation, whether they were previously independent, if they might have been a primary carer for someone else, mobility qns regarding home, such as stairs, previous exercise tolerance, whether they are a smoker or have a past history of smoking and lots of further within these general guidelines. Then I got the pt to cough and assessed its quality i.e strength, texture, effectiveness and productivity. Then I auscultated to check for air entry into the lungs and any added sounds. The next step is to check chest expansion and spo2 using a pulse oximiter. Assessing oxygen saturations is very important because it indicates how the patient might react to mobilizing. Then I walked with the pt using a WZF and noted how they went in regards to balance and endurance. Also noting whether they required any assistance and o2 which, in this case, they did not. Then I recorded all my findings and liaised with the nurse regarding this pts mobility status which was independent with T/F’s and independent with a WZF over 50m//spo2 maintained at 98%.

R: As a result of my actions I obtained an in depth evaluation of my assessment that showed what sort of physiotherapy involvement this pt required. I was able to write in the pt notes a detailed O as part of my S,O,I,E,R. I recorded the pts vitals, then under a respiratory heading I recorded all my respiratory related findings. Under mobility, I recorded how far the pt can walk, assistance required and any walking aids used. As a result further allied health and medical staff could refer to my notes to see what other problems this pt was experiencing at that particular time. They could also compare assessment finding from a later date with mine, to monitor any changes in the pt. when consulting this pt, further health professionals could refer to my notes for the mobility status to allow them to safely and effectively mobilize the pt without first having to assess mobility.

E: over all I think my assessment was quite successful. My strengths included
• Building a good rapport with the pt so that I could assess them and maintain their dignity.
• Choosing the appropriate aid prior to mobilization based on the subjective assessment, this allowed a safe start to mobilization.
• Performing the assessment in sequential order. This means doing things like assessing the cough before auscultation, because the pt is required to cough before auscultation regardless.
Some of my weaknesses included
• Taking too long to auscultate which can cause the pt to become short of breath or dizzy due to prolonged deeper breathing.
• Not giving the pt a clear indication of the role for physiotherapy and hence the need for our initial assessment.
• During mobilization I wasn’t able to effectively monitor the spo2 levels because the probe had slipped off the finger.

S: some strategies to improve on or use for next time, specifically those addressing some of my weaknesses include
• Refining your auscultation landmarks so you can quickly and effectively listen to the breath sounds before the pt begins to fatigue.
• Explain how far you want the pt to walk during mobilization. This includes an explanation that you want to assess how far they can walk, so they should walk however far they feel they can manage. Another handy tip to remember is to explain to them however far they walk they must also turn around and walk back, so they should keep that in mind.
• Explain the importance of monitoring spo2 when mobilizing. The probe can be uncomfortable especially when using a WZF or walking stick. However even if the pt is asymptomatic when de saturating it is important to note that they are still building up a toxic environment which can be detrimental. You can then clip the pulse oximeter to the frame or your pocket so that it doesn’t pull.

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.