Situation
On one of my last days at my placement (10/03/2010), I was asked to treat a 10 year old girl with my visiting clinical supervisor. This girl had severe left sided weakness only present in her right arm. The day before my treatment session with her, she had undergone a MRI which revealed that she had a cavernoma ( benign tumour) in the frontal lobe of her brain which was occasionally bleeding. This bleed resulted in her presenting with left hemorrhagic stroke like symptoms. On assessment it was found that her strength was severely affected with varying degrees through her whole right arm, her sensation was completely intact and her tone was generally low (hypotonic) in her right shoulder and arm.
The girl told me she was occasionally banging into things on the right side and on observation I noticed she tended to “leave the right arm behind” when she was completing tasks.
Task
I was asked to treat (with my clinical supervisor watching) and address the problems this girl had as a result of the hemorrhagic stroke.
Action
I firstly identified the areas which the girl needed treatment on. She had; 1) decreased neural input/altered neural pathways to her right upper limb. 2) low tone in her shoulder girdle, possibly leading to a subluxation. 3) significant decreased right upper limb strength. 4) increased weight bearing to the right side in sitting/altered midline in sitting.
So I treated her, and gave her exercises that, encouraged weight bearing to the left side in sitting (increased her awareness of her midline, by showing her a mirror), I gave her neural input and stimulation to the right hand using different textured materials. I educated her about taking care of her right upper limb and refraining from doing any movements that would injure the joint and lastly I gave her some strengthening exercises for her right arm.
Result
The result was a straighter alignment in sitting on reassessment, with almost a even weight bearing on both sides. Other improvements from the treatment could be seen further down the track.
Evaluation
I think my intervention was a bit mediocre. I think I had some strengths in the treatment but I had a lot of weaknesses as well.
My strengths were that I engaged the child well during the treatment session and I think I selected appropriate exercises that targeted her problems.
My weaknesses were that; Firstly, I needed to cater my exercises to a more paediatric level, I needed to make them more exciting. Secondly I needed to have progressions on the exercises. I needed to make the exercise more difficult by adding in different and harder dimensions once the child had mastered the easier version of the exercise. Thirdly the treatment session needed to be longer, it was only 40 minutes when it was supposed to be a hour; I needed to plan out a variety of exercises that would achieve the same result. Lastly my supervisor said I needed to also investigate the fact that the child was banging into things on the right side. I needed to check her vision filed on the right.
Strategies
I think next time I will try to improve my treatment session by implementing these strategies;
1) Plan out the treatment session so I know how long each activity will take and hence I will be able to treat the patient for their given time.
2) Research treatment ideas, if I cant think of enough exercises, I will go research some different ideas that achieve the same result.
3) If the child identifies a new problem in my subjective, make sure I assess it at the beginning of the session to find out if it is a problem.
4) Try to incorporate childish games into my treatment to make the session more appealing to the child.
Sunday, March 14, 2010
Sunday, February 28, 2010
Reflection 2- Week 3
Situation
On the third week of my placement, on a Wednesday the 24th of February, I was asked to conduct an individual hydrotherapy session for a 14 year old girl with Transverse Myolitis. She contracted the virus 2 months ago and this virus manifested itself as a neural virus. The virus caused inflammation and scarring of the spinal cord at level T8, the result of this was paralysis of her legs (she now mobilised in a wheelchair), bowel and bladder, a loss of sensation to her legs and a loss of reflexes to her legs as well. As a result of these consequences this girl was having an enema administered in the morning before she entered the pool to make sure she had completely emptied her bowels. Another complication to this girl’s condition was that she was very obese, and her tolerance for exercise was low, it was very difficult to motivate her.
The girl I was conducting the hydrotherapy session for was receiving hydrotherapy 3 times a week and 2 land sessions a week. She had been having hydrotherapy sessions for over a month now and she was quiet confident in the pool.
The recovery from Transverse Myolitis is variable, with some people recovering completely while others are totally paralysed for the rest of their lives. Therefore physiotherapy had to include the possibility that this girl will be wheelchair bound for the rest of her life.
Task
I was asked to perform a 40 minute hydrotherapy session that catered to this girl’s needs. I was conducting the session with my supervisor present beside the pool. I based a lot of my treatment around firstly preventing generalised deconditioning, secondly improving the strength of her upper limbs, thirdly encouraging any recovery of her lower limb muscles and lastly raising her cardiovascular fitness ( in the hopes of addressing her weight issue as well).
Action
After transferring the girl to the pool using a chair lift; I began my treatment session. I asked her to perform;
1) 2 laps of the pool, choosing her preferred stroke.
2) shoulder, arm, wrist and chest exercises using resistor pads.
3) 2 attempts at diving for sunken objects ( rings etc.)
4) treading water for 2 minutes
5) facilitated hip flexion, encouraging any activity of lower limb muscles.
Result
The girl did enjoy the hydrotherapy session however she did seem tired after the session commenced. During the session I did see a bit of hip flexion being exerted on the left hip, which is encouraging and is something to work with in the future.
Evaluation
I think the session went well. I addressed the girls deconditioning by giving her lots of cardiovascular exercise such as the laps in the pool and treading water. I also gave her some choice as to which activities she wanted to do (so she felt as though she had some control over the session). My supervisor said my arm exercises were a bit too general and I needed to concentrate on giving her more specific exercises that would target muscle groups that she would defiantly need to be stronger (eg. the triceps for the ease of transferring between her wheelchair and her bed/toilet etc.). My supervisor also said that I needed to allow her to keep her independence in things, so teaching her how to move around the pool on the steps and the hand rails independently and without the use of her legs is also pertinent in her hydrotherapy session.
Strategies
I think next time I would firstly try to make the session more tailored to my patients needs. The girl was having difficulty with her transfers (as she couldn’t clear her bottom off the surface it was on) so I should have focused on strengthening her tricep muscles to improve her independence in transferring herself. Next time I would also keep the activity as fun as possible. I would try to add in some music, or ask her if she had an activity in mind that she would like to do for 5 minutes. Lastly another good strategy would be to incorporate into the session activities that allowed her to keep her independence in and around the pool. I would teach her how to get on and off the steps and teach her how to take care of her legs when other people are helping her into the pool.
On the third week of my placement, on a Wednesday the 24th of February, I was asked to conduct an individual hydrotherapy session for a 14 year old girl with Transverse Myolitis. She contracted the virus 2 months ago and this virus manifested itself as a neural virus. The virus caused inflammation and scarring of the spinal cord at level T8, the result of this was paralysis of her legs (she now mobilised in a wheelchair), bowel and bladder, a loss of sensation to her legs and a loss of reflexes to her legs as well. As a result of these consequences this girl was having an enema administered in the morning before she entered the pool to make sure she had completely emptied her bowels. Another complication to this girl’s condition was that she was very obese, and her tolerance for exercise was low, it was very difficult to motivate her.
The girl I was conducting the hydrotherapy session for was receiving hydrotherapy 3 times a week and 2 land sessions a week. She had been having hydrotherapy sessions for over a month now and she was quiet confident in the pool.
The recovery from Transverse Myolitis is variable, with some people recovering completely while others are totally paralysed for the rest of their lives. Therefore physiotherapy had to include the possibility that this girl will be wheelchair bound for the rest of her life.
Task
I was asked to perform a 40 minute hydrotherapy session that catered to this girl’s needs. I was conducting the session with my supervisor present beside the pool. I based a lot of my treatment around firstly preventing generalised deconditioning, secondly improving the strength of her upper limbs, thirdly encouraging any recovery of her lower limb muscles and lastly raising her cardiovascular fitness ( in the hopes of addressing her weight issue as well).
Action
After transferring the girl to the pool using a chair lift; I began my treatment session. I asked her to perform;
1) 2 laps of the pool, choosing her preferred stroke.
2) shoulder, arm, wrist and chest exercises using resistor pads.
3) 2 attempts at diving for sunken objects ( rings etc.)
4) treading water for 2 minutes
5) facilitated hip flexion, encouraging any activity of lower limb muscles.
Result
The girl did enjoy the hydrotherapy session however she did seem tired after the session commenced. During the session I did see a bit of hip flexion being exerted on the left hip, which is encouraging and is something to work with in the future.
Evaluation
I think the session went well. I addressed the girls deconditioning by giving her lots of cardiovascular exercise such as the laps in the pool and treading water. I also gave her some choice as to which activities she wanted to do (so she felt as though she had some control over the session). My supervisor said my arm exercises were a bit too general and I needed to concentrate on giving her more specific exercises that would target muscle groups that she would defiantly need to be stronger (eg. the triceps for the ease of transferring between her wheelchair and her bed/toilet etc.). My supervisor also said that I needed to allow her to keep her independence in things, so teaching her how to move around the pool on the steps and the hand rails independently and without the use of her legs is also pertinent in her hydrotherapy session.
Strategies
I think next time I would firstly try to make the session more tailored to my patients needs. The girl was having difficulty with her transfers (as she couldn’t clear her bottom off the surface it was on) so I should have focused on strengthening her tricep muscles to improve her independence in transferring herself. Next time I would also keep the activity as fun as possible. I would try to add in some music, or ask her if she had an activity in mind that she would like to do for 5 minutes. Lastly another good strategy would be to incorporate into the session activities that allowed her to keep her independence in and around the pool. I would teach her how to get on and off the steps and teach her how to take care of her legs when other people are helping her into the pool.
Saturday, February 13, 2010
FIRST ENTRY- WEEK 1
Situation
It was the third day on my placement (10/02/2010) that I was asked to treat a child with my visiting clinical tutor. This was the first time I had seen this child. My patient was a four year old girl who had sustained a hypoxic brain injury post resuscitation. My patient had endured damage to her basal ganglia and cerebellum. With the help of my supervisor we had established the child had difficulty initiating movements, continuing in automatic movements, poor balance, and a high level of weakness and spacticity in her lower limbs. All of these factors had considerably contributed to her delay and even regression in her age appropriate developmental milestones. My patient could not move from a seated position to a lying position, she had difficulty rolling over and could not crawl or even walk without assistance.
Due to the fact that most of the damage was on the right side of her brain, my patients speech and level of understanding of words had also regressed significantly. Therefore communicating with her was also very challenging.
Task
My treatment was therefore not only to address her physical delay in developmental milestones, but also to encourage her to talk instead of pointing with her hands to communicate. In addition to encouraging my patient to talk I needed to be able to make sure the language I used was appropriate to my patient’s age.
Action
I was facilitating my patient to transition for a seated position to a lying position on a mat on the floor, all the while I was talking to her trying to get her to communicate with me.
Result
My patient ended up moving from a seated position to a lying position on the mat, however it took several attempts. I needed to change how I spoke to her several times as well.
Evaluation
I don’t think I was affective in this first treatment session with my patient. I found it hard to get her to “ speak up” and talk to me, especially when I was facilitating her to progress in her physical development. Her reluctance to talk to me could have been that my patient was shy around me but most likely it was because I was not using age appropriate language and I was failing to use techniques that would facilitate her to talk to me.
Strategies
My clinical tutor and I worked out some ideas that I could use when talking to this patient. Firstly; to use one command at a time. Secondly to give my patient choices by asking her simple questions (that required basic answers) encouraging her to verbally communicate with me. Lastly to use more age appropriate language. For example “try to stretch your leg out like a long long snake” instead of “can you straighten your knee?”.
I tried using some of these strategies the second time I saw this patient, and I found she was much more outspoken and she seemed to have a better understanding of what I was asking her to do. Overall, the treatment session was more efficient and I think it was more successful when I implemented these strategies.
It was the third day on my placement (10/02/2010) that I was asked to treat a child with my visiting clinical tutor. This was the first time I had seen this child. My patient was a four year old girl who had sustained a hypoxic brain injury post resuscitation. My patient had endured damage to her basal ganglia and cerebellum. With the help of my supervisor we had established the child had difficulty initiating movements, continuing in automatic movements, poor balance, and a high level of weakness and spacticity in her lower limbs. All of these factors had considerably contributed to her delay and even regression in her age appropriate developmental milestones. My patient could not move from a seated position to a lying position, she had difficulty rolling over and could not crawl or even walk without assistance.
Due to the fact that most of the damage was on the right side of her brain, my patients speech and level of understanding of words had also regressed significantly. Therefore communicating with her was also very challenging.
Task
My treatment was therefore not only to address her physical delay in developmental milestones, but also to encourage her to talk instead of pointing with her hands to communicate. In addition to encouraging my patient to talk I needed to be able to make sure the language I used was appropriate to my patient’s age.
Action
I was facilitating my patient to transition for a seated position to a lying position on a mat on the floor, all the while I was talking to her trying to get her to communicate with me.
Result
My patient ended up moving from a seated position to a lying position on the mat, however it took several attempts. I needed to change how I spoke to her several times as well.
Evaluation
I don’t think I was affective in this first treatment session with my patient. I found it hard to get her to “ speak up” and talk to me, especially when I was facilitating her to progress in her physical development. Her reluctance to talk to me could have been that my patient was shy around me but most likely it was because I was not using age appropriate language and I was failing to use techniques that would facilitate her to talk to me.
Strategies
My clinical tutor and I worked out some ideas that I could use when talking to this patient. Firstly; to use one command at a time. Secondly to give my patient choices by asking her simple questions (that required basic answers) encouraging her to verbally communicate with me. Lastly to use more age appropriate language. For example “try to stretch your leg out like a long long snake” instead of “can you straighten your knee?”.
I tried using some of these strategies the second time I saw this patient, and I found she was much more outspoken and she seemed to have a better understanding of what I was asking her to do. Overall, the treatment session was more efficient and I think it was more successful when I implemented these strategies.
Saturday, February 6, 2010
Initial Entry- Princess Margaret Hospital
Initial entry
I have been placed at Princess Margaret Hospital in the Neurology Department. Most days I start at 8 am and finish at 5 pm, however Monday I start later and Thursday I finish earlier. The first day on placement I am supposed to be given a pamphlet on the hospital and will introduced to people and procedures in and around the hospital.
I really do love working with children so I am very excited about this placement. However, at the same time, I am a bit apprehensive about this placement. I think in this environment it could be a bit taxing, both emotionally and physically. The reason for this being; that the children I will be treating will most likely have conditions which will affect them for the rest of their lives. I will have to be careful I don’t become too emotionally involved with my patients. I have talked to a few of my other classmates who have also been on this placement. According to them I will have mostly patients with acute brain injuries, hydrochephalus and Guillian Barre Syndrome. However, because the ward is titled ‘neurology’ I think I may see a range of neurological conditions. I hope I see a range of children with different ages, as this is also my one and only paediatric placement, I hope to see children that are in the midst of development and hopefully even some neonates.
I am hoping I will eventually be able to have my own caseload ( with a supervisor present) however, I can understand how this may not be possible as parents can be quiet understandably concerned about their child’s welfare and hence, wish their child to receive optimal treatment by an experienced therapist.
I have been placed at Princess Margaret Hospital in the Neurology Department. Most days I start at 8 am and finish at 5 pm, however Monday I start later and Thursday I finish earlier. The first day on placement I am supposed to be given a pamphlet on the hospital and will introduced to people and procedures in and around the hospital.
I really do love working with children so I am very excited about this placement. However, at the same time, I am a bit apprehensive about this placement. I think in this environment it could be a bit taxing, both emotionally and physically. The reason for this being; that the children I will be treating will most likely have conditions which will affect them for the rest of their lives. I will have to be careful I don’t become too emotionally involved with my patients. I have talked to a few of my other classmates who have also been on this placement. According to them I will have mostly patients with acute brain injuries, hydrochephalus and Guillian Barre Syndrome. However, because the ward is titled ‘neurology’ I think I may see a range of neurological conditions. I hope I see a range of children with different ages, as this is also my one and only paediatric placement, I hope to see children that are in the midst of development and hopefully even some neonates.
I am hoping I will eventually be able to have my own caseload ( with a supervisor present) however, I can understand how this may not be possible as parents can be quiet understandably concerned about their child’s welfare and hence, wish their child to receive optimal treatment by an experienced therapist.
Monday, August 31, 2009
FINAL ENTRY
I really really enjoyed this placement!.
In my initial entry i was really worried and stressed about the responsibility of having my own patients, however this was a really big learning experience for me, we wern't just thrown into the deep end but they slowley eased us into having our own patients.
I also said in the initial entry that i was apprehensive about this being a neuro placement. Although we did see some neuro patients, we were always accompanied with a supervisor, so this wasn't as stressfull as i thought it would be. All my single patients were gerentology based.
I found each day i went to this placement i learnt so many new things. we contributed to team meatings, we discharged patients, we referred patients on. We saw a complete variety of patients aswell ranging from THR, to occipital strokes, temporal strokes, COPD patients, neurological compramise patients... the list was really broad. At times i was really stressed about my case load and often left late however i felt as though i was learning so much. i liked this placement alot better than my last!.
In my initial entry i was really worried and stressed about the responsibility of having my own patients, however this was a really big learning experience for me, we wern't just thrown into the deep end but they slowley eased us into having our own patients.
I also said in the initial entry that i was apprehensive about this being a neuro placement. Although we did see some neuro patients, we were always accompanied with a supervisor, so this wasn't as stressfull as i thought it would be. All my single patients were gerentology based.
I found each day i went to this placement i learnt so many new things. we contributed to team meatings, we discharged patients, we referred patients on. We saw a complete variety of patients aswell ranging from THR, to occipital strokes, temporal strokes, COPD patients, neurological compramise patients... the list was really broad. At times i was really stressed about my case load and often left late however i felt as though i was learning so much. i liked this placement alot better than my last!.
THIRD ENTRY- WEEK 5
S-i was asked to Ax and Rx a83 y.o F patient who had come in with a broken femur fixed with a femoral nail 2 weeks ago. She had a past medical history of parkinsons disease and hypertension. She had broken her hip when she fell over at a resturant.
T- my supervisor asked me to continue on with the Ax and Rx.
A-I began assessing her with the subjective questions and then the objective movements, i was however very wary about her ORIF , and restricted some of the Ax and Rx movements as i didn't want my patient to dislocate.
R-as a result i didn't get my patient to complete all the exercises necessary for hip rehabilitation.
E- i dont think this session went well with the patient. However she was very gracefull and next time i saw her i made amendments, ajusting her Rx programme and her exercises.
S-I think next time i am faced with a patient who has had replacement surgury or an ORIF put in i will read up on my orthopedics restrictions and be clear about what surgury requires restrictions. i learnt very quickly that ORIFS do not have any restrictions on them!. My supervisor mentioned that i need to take into consideration her other problems as well, in this case it was parkinsons disease. If her PD wasn't being effectivley managed with medication, then this could be the reason she is having the falls.
S-
T- my supervisor asked me to continue on with the Ax and Rx.
A-I began assessing her with the subjective questions and then the objective movements, i was however very wary about her ORIF , and restricted some of the Ax and Rx movements as i didn't want my patient to dislocate.
R-as a result i didn't get my patient to complete all the exercises necessary for hip rehabilitation.
E- i dont think this session went well with the patient. However she was very gracefull and next time i saw her i made amendments, ajusting her Rx programme and her exercises.
S-I think next time i am faced with a patient who has had replacement surgury or an ORIF put in i will read up on my orthopedics restrictions and be clear about what surgury requires restrictions. i learnt very quickly that ORIFS do not have any restrictions on them!. My supervisor mentioned that i need to take into consideration her other problems as well, in this case it was parkinsons disease. If her PD wasn't being effectivley managed with medication, then this could be the reason she is having the falls.
S-
Monday, August 24, 2009
SECOND ENTRY- WEEK 3
S- On placement, I was assigned one particular patient that had had a TKR. He was 84 y.o and had severe dementia. At times he appeared agitated and aggressive. Previous to admission this patient was independent in his ADL’s and living alone. He had the operation 2/52 ago and was admitted to the rehabilitation unit I was working in because he didn’t achieve the required degrees of knee flexion in order to be discharged.
T- I assessed this patient and begun treating him. He had approximately 52 degress of knee flexion, the hospital required at least 70 degrees of knee flexion for discharge. I knew from the orthopaedic handover that this patient was very distressed about using a pulley system to encourage knee flexion, and had the potential to get abusive.
A- I began increasing his knee flexion using Active Assisted movements. I used a sideboard with a towel under it so he could control the amount of knee flexion that was occurring himself. I then attached him to a CPM machine in the time he wasn’t at physio. I avoided completely the use of the pulley system. He seemed to like the systems I was using, however when the CPM machine pushed him a bit too far he called me some abusive names!.
R- the result wasn’t the best ;I did end up increasing his knee flexion to 59 degrees, however over the weekend my patient discharged himself. I suspect my patient would have had to have a MUA, because his knee would no longer be functional with the amount of knee flexion he had.
E-I though my methods of dealing with this patient were good considering his mental state. I think I have learnt from this situation that you have to be able to tailor your treatment to your patient and their needs. I would have loved to use all the pulleys and active assisted towel exercises for a patient with such poor knee flexion ROM however, his lack of understanding and mental state prevented me from allowing these treatments.
S-Maybe next time I should focus a lot more of my treatment time on education for the patient so they have a greater understanding of how the treatment can help their condition. Maybe next time I would try to get the family or loved ones to reason with a patient who had such a poor mental state. This could have prevented the patient from discharging himself.
T- I assessed this patient and begun treating him. He had approximately 52 degress of knee flexion, the hospital required at least 70 degrees of knee flexion for discharge. I knew from the orthopaedic handover that this patient was very distressed about using a pulley system to encourage knee flexion, and had the potential to get abusive.
A- I began increasing his knee flexion using Active Assisted movements. I used a sideboard with a towel under it so he could control the amount of knee flexion that was occurring himself. I then attached him to a CPM machine in the time he wasn’t at physio. I avoided completely the use of the pulley system. He seemed to like the systems I was using, however when the CPM machine pushed him a bit too far he called me some abusive names!.
R- the result wasn’t the best ;I did end up increasing his knee flexion to 59 degrees, however over the weekend my patient discharged himself. I suspect my patient would have had to have a MUA, because his knee would no longer be functional with the amount of knee flexion he had.
E-I though my methods of dealing with this patient were good considering his mental state. I think I have learnt from this situation that you have to be able to tailor your treatment to your patient and their needs. I would have loved to use all the pulleys and active assisted towel exercises for a patient with such poor knee flexion ROM however, his lack of understanding and mental state prevented me from allowing these treatments.
S-Maybe next time I should focus a lot more of my treatment time on education for the patient so they have a greater understanding of how the treatment can help their condition. Maybe next time I would try to get the family or loved ones to reason with a patient who had such a poor mental state. This could have prevented the patient from discharging himself.
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