STARES 2

SITUATION

A 37year old female was diagnosed with multiple sclerosis at the age of 27years old. This patient had suffered frequent relapses in multiple sclerosis with a variety of presentations, including complete blindness, paralysis and incontinence. She presented to Royal Perth hospital under the recommendation of her neurologist when her latest episode failed to relinquish and seemed to be progressing. Early in May she reported waking up with loss of strength in her right lower limb. This further progressed in the week to a radiating “electric shock” sensation to touch, throughout the left side, below the T4 dermatome. On admission, an initial mobility screen and assessment was completed. From the subjective it was found that she had struggled with multiple sclerosis for 10 years. In this time she had had numerous relapses with some residual deficits including impaired sensation in her upper limbs. As well as this struggle against the unknown, on her journey she had discovered that she is immune-deficient and has severe life threatening reactions to most multiple sclerosis control medication. Her lifestyle choices like smoking and unhealthy diet, regular hospital admissions, steroid treatment and past wheelchair dependency for periods at a time, she had become obese. With the additional weight and regular steroid treatment, rehabilitation became very difficult and limited severely by fatigue. She had also had bad experiences with rehabilitation in the past, with little input and persistence, she had been deemed wheelchair dependent by her therapists. She then taught herself to walk independently at home, which resulted in shattered knee-caps and hip injury from repeated falls. Coming to Royal Perth she was astounded at the amount and quality of input she was receiving. On admission she was ambulating with a family walking stick and one assist for short distances, otherwise she used her wheel chair. On ambulation she had a poor pattern with excessive compensation. Rather than using the walking stick as an effective aid, it was used like a tripod to extend her base of support. From this we incorporated gait re-training as a fundamental component of her rehab. Upon discharge she was referred to Shenton Park campus for further inpatient rehabilitation.

TASK

For this patient, my task was to conduct a thorough subjective and objective examination to ascertain the full clinical picture. From this I was to develop a treatment plan with options to modify as her clinical presentation was changing slightly day by day. After 2 weeks of rehabilitation I had the task of planning her discharge and referring her to Shenton Park Campus.

ACTION

On commencement of the examination, I discovered through the subjective that she had a poor history with her therapists. I therefore took a sensitive approach to her history and struggle with her condition and thoroughly explained the process of examination and rehabilitation offered at Royal Perth. After gathering a clear clinical picture of this patient, with extensive questioning I conducted a brief neuro screen, assessing tone, sensation, proprioception, strength and coordination. I then began a mobility screen, starting with bed mobility, transfers and finally ambulation. I found she was independent with bed mobility and transfers, though required excessive effort to complete the tasks. On ambulation, I had to educate her on technique and aid use. From observation of her pattern I deemed it more appropriate for her to use a wheeled zimmer frame to provide the additional support and balance that she required to demonstrate a more efficient gait pattern. This mobility screen fatigued the patient. I discussed fatigue with the patient and educated her on knowing her limitations. We then organised an appropriate time to begin treatment the following day, at a time when she felt she had the most energy.

I devised a treatment plan to address her fear of the forward space, lack of trunkal dissociation and control, standing balance and foot awareness. With this treatment plan was a few other options or avenues we could try if the first idea wasn’t optimal. We commenced treatment the following morning, ensuring all treatments were related back to functional gains to provide motivation for participation. The patient worked well and at the onset of fatigue I took the patient back to her room. I prescribed her with an exercise program to continue in her room throughout the day when she was feeling up to it.

We continued rehabilitation throughout her stay, progressing her exercises to continually challenge her. I developed good rapport with the patient and we worked well together.

The multidisciplinary team discussed her discharge options and it was globally decided that further rehabilitation at Shenton Park was optimal. I discussed this with the patient and she was eager to begin. I completed her discharge summary and contacted Shenton Park to relay the relevant information.

RESULT

As a result of my assessment, I was able to coordinate an effective treatment plan and carry this out with my patient with success. With constant re-assessment and regular input we were able to progress her rehabilitation throughout her stay and improve her independence with transfers and her effectiveness in gait. We developed a good rapport and understanding and I feel this helped with her rehabilitation and acceptance of therapy input. She participated in her therapy sessions and from what I gathered, carried out her exercise program, this optimised her chance of recovery. My supervisor was satisfied with my performance with this patient and was confident with my approach, therefore allowed me to conduct majority of sessions independently. She was also pleased with my discharge planning and supported me in the decision to refer this patient to Shenton Park for further input.

EVALUATION

In this clinical situation I feel I communicated well and my ability to build rapport and understanding with this patient was good. With prior experience and knowledge of multiple sclerosis, this gave me an advantage in understanding the patients struggle and I was able to adequately relate to her difficulties.

My treatment plans were appropriate in their level and difficulty. They were challenging yet achievable, therefore the patient was satisfied with their performance and motivated to continue with therapy.

Elements I could improve on would be my questioning throughout the subjective as I feel there were crucial elements I didn’t thoroughly explore and gain a clear enough picture of. Throughout our treatment sessions, I was able to ascertain this information.

Also my confidence in the multidisciplinary team meetings could do with improvement. During the meeting I was asked for my input on the patients status in physiotherapy. I gave an overview of her mobility, her key issues that we were working on, and what we were doing specifically in treatment sessions. My supervisor then provided the additional information that I failed to mention of rehab potential and our plan to recommend Shenton Park.

STRATEGIES

Having multiple treatment strategies worked to my advantage, as I was able to modify my treatment sessions depending on the patients level of symptoms and alertness. An independent exercise program for the patient to do independently is also a strategy I will employ in the future as this gave my patient a degree of control over their rehabilitation and gains and I feel also improved the gains we made as she was practising what we did in our sessions throughout the day.

Breaking the subjective down into components that are easier to comprehend and handle would improve my efficiency in questioning.

Lastly preparing fundamental information that needs to be relayed in the team meeting for each of my patients would be handy to improve my confidence in these situations.

STARES 1

SITUATION:

A patient was transferred from the ED department to the neurology ward for further treatment. She had presented to the ED department complaining of a severe headache behind her right eye and a sense of vagueness and confusion. This was later diagnosed on CT scan as a haemorrhagic stroke in her right frontal lobe. On initial admission, the patient was medically unstable, therefore only the necessary mobility screen could be carried out on day one. Initially she required two people to assist transfers and could only step stand transfer over the right side. Her sitting balance was poor, standing balance almost non-existent and she was not ambulating. By day two, there was lingering drowsiness, though she was now medically stable and her headache had eased. A neuro assessment was commenced and it was found that she had a low affect, significant rigidity throughout her right side, lower and upper limb, mild problem with initiation of movement, reduced ROM in her right shoulder secondary to a rotator cuff repair a few months prior, poor postural control and poor pelvic, lower limb and trunk dissociation. On the Gowland assessment she scored level 6 on most parts. Day three her presentation had changed again. She was now requiring one assist to transfer and ambulating in physiotherapy only with maximal assist of one.

TASK

My task in this situation was to conduct the initial mobility screen of this patient, complete a full initial neuro assessment and plan and carry out daily physiotherapy sessions.

ACTION

After I had conducted the initial assessment and developed a problem list for this patient, I developed some ideas for treatment and presented this to my supervisor. We were in disagreement in the approach to this patient as I was adopting a more functional approach, where as my supervisor wanted to address the impairments specifically. I carried out a fairly standard treatment session addressing impairments, which incorporated bridging and trunk control activities in supine, encouraging glute activation. I then finished this session with a facilitated walk. As she had a haemorrhagic stroke, her presentation was highly variable and by day four, Friday, she was requiring moderate assist of one for transfers and ambulation. My treatment focus then turned to addressing her pelvic control in standing and her confidence towards the forward space to bring her centre of mass in front of her base of support, making sit to stand transfers and walking easier.

RESULTS

My supervisor didn’t encourage walking this patient, though after seeing me walk her in my treatment session with the tutor, she identified that with appropriate facilitation, her gait pattern was near normal. I was able to show my supervisor that my observation of this patient’s ability was good and the treatments I had chosen were suitable. Focusing treatment on a functional task involved the patient more as she understood the relevance of the activity. This also boosted her confidence in recovery and physiotherapy.

EVALUATION

It has been difficult to build rapport with my supervisor on this placement as I feel a functional approach in some cases is more appropriate than addressing impairments specifically. When the functional ability of a patient is high, I feel that the impairments can be addressed through fine-tuning of the functional tasks rather than taking the patient to a non-specific task that addresses the impairment in isolation. In this particular situation I had this difficulty. Though I was able to see this patient with my tutor who agreed with my decision to walk this patient, which was fairly successful. Something I could perhaps improve on is my confidence in my ideas and ability to translate this to my supervisor.

Also my neuro assessment wasn’t systematic and it was obvious that this was my first experience with this. This is something I will need to work on and practice to improve my efficiency in assessment.

My communication to my patient was appropriate and effective. I found it easy to develop rapport and engage the patient in treatment. Another element I need to work on is facilitation. This again comes with experience.

STRATEGIES

- Relate all treatments to tasks that the patient find relevant to their goals. This helps with engagement of the patient in treatment sessions

- Confidence in observations and treatment ideas to relay this to my supervisor.

- Planning assessment in order of position eg. Supine tests, sitting tests, standing etc. This improves the flow and efficiency of the assessment process.

Initial Entry - Royal Perth WSC Stroke unit

In anticipation of my third clinical placement at Royal Perth Hospital I have begun preparation for a highly demanding five weeks. From my peers I have heard that generally placements at Royal Perth are challenging, in that expectations of knowledge and ability are of the highest standard and that staff tend to derogate students. Combined with this feedback, is a pre-warning that my potential supervisor can appear to be “a bully.” With this in mind I am anxious, again. The sense of unknown is un-nerving and with the feedback I have received about this placement, it has not been comforting. As I am coming into this placement on such a high from my last placement, I feel this could work to my advantage as this has built my confidence.

Royal Perth is a hospital in the public sector. I am assuming this will be run like most hospitals in that there will be a high focus on the multi-disciplinary team and a more or less blanket referral of patients to the wards physiotherapist. As I have had prior placements on wards in hospitals, I am confident that I will know the structure and procedures in how the ward operates. I have also had practice in writing inpatient notes etc, so this should alleviate some initial pressure.

For this placement specifically, I have revised my neuro, in particular stroke symptoms and presentations as well as neuro assessments. I am hoping this is sufficient to get me through the first couple if days, until I get an idea of specific knowledge that is required from me.

I feel my role in this placement will be to support the existing structure, participate in the multidisciplinary treatment of patients and conduct myself professionally as a potential future physiotherapist.

Prior to commencing this placement I have the following concerns:

- That I will not be able to establish a positive learning relationship with my supervisor.

- There could potentially be barriers in terms of negative attitudes towards students, impairing my ability to gain a lot from the placement through interaction with colleagues.

- With little experience with stroke patients, I may appear inexperienced and uncoordinated in this area.

Overall I am most nervous about this placement, as it is a field I feel I have the littlest experience with and from the feedback I have received I will have barriers to overcome. I am also anxious that if I feel overly intimidated I may be less inclined to take advantage of learning opportunities, as I will be afraid to ask. With the support of the Notre Dame staff, that I can rely on if things become too overwhelming, hopefully I will be able to overcome any unnecessary anxiety and awkward situations I may fond myself in.