Topic Two

Situation: Patient with Lateral Medullary Stroke on the Stroke Rehab ward who requires physiotherapy to improve his ambulation so he is safe for discharge. He has L) sided weakness and leans to the L) in standing due to impaired vertical alignment.

Task: My task today was to continue rehab with this patient to improve his quality of gait and transfers.

Action: I spent the morning working on foot placement and weight shift to the R) during gait and dynamic balance. The session was shortened due to a mild onset of nausea and exacerbation of longstanding right hip pain during exercises. The patient had complained of nausea over the past few days so I decided it was safer to shorten the session for today and talk to his doctor about what the possible source of the nausea was.

Result: By the end of the session the patient’s gait had improved with an increased stance phase on the R) LL and larger steps with the L) LL. He reported that his confidence with walking had improved as well. After consulting with the Doctor I found that the nausea was a likely symptom from the stroke or a symptom from their medication and was still safe to exercise.

Evaluation: I feel that the intervention I conducted targeted the patient’s impairments and activity limitations. However the intermittent nature of the session meant that it lacked efficiency and discharge would be prolonged if sessions were continually shortened due to complaints of nausea.

Strategies: The next session with this patient I will educate them on the likely reasons for the bouts of nausea. I will inform him that as long as the nausea is bearable it is important to continue with therapy to help him recover his function efficiently and that by working through it can help to manage and control it. Thereby ensuring that he is discharged as early as can be.

Topic One: Communication/Assessment

Situation: Today there was a new patient admitted to the stroke-rehab ward and therefore required an initial neurological assessment.

Task: The task set by my supervisor was to conduct a subjective assessment with this patient as there were gaps in the medical notes in regards to history of presenting complaint, past medical history and social history.

Actions: I spent the afternoon conducting a subjective and objective assessment of the patient.

Result: After conducting the assessment I gained an insight into the patient’s history leading up to admission to hospital. I also had an understanding of the communication strategies that I needed to use to conduct a time effective session.

Evaluation: I feel that I conducted an adequate subjective assessment and extracted the information that I required. However the patient’s responses to my questions were quite long winded and tangential. I found myself struggling to refocus the conversation to my subjective aims without interrupting the patient and seeming rude. On completion I felt that I had the information that I required although it took a lot longer than I had intended. On reflection it was positive that the patient felt comfortable to talk to me unreservedly although I feel that it wasn’t a time efficient method of conducting a subjective assessment. I need to remember that although I want the patient to feel comfortable and at ease in a patient-therapist relationship, I also have a role as a clinician to extract the necessary information in a timely manner to ensure that further assessment and intervention can be conducted.

Strategies: In future sessions with this patient I will endeavor to use closed ended questions. I will also try to be more assertive with refocusing the conversation and time questions when there is a pause in a response that I feel is going off track. In doing this I will need to be conscious of not coming across as being rude and insensitive to the patient's response. I also believe multi-tasking during the session will be beneficial such as allowing the patient to continue talking however continue with the objective assessment or intervention whilst doing so.

Initial Entry

My first placement is at Swan Kalamunda Health Service for my neurology placement. I expect this placement to be predominantly stroke orientated with the exception of an assorted neurological conditions in the outpatients department. I expect/hope that as a fourth year I will have more independence with managing a case load and that I will have the opportunity to eventually work on my own. I think there will be a heavy emphasis on working within a multidisplinary team, as many professions will be working towards the goal of discharging the patient.

In terms of structure I think that I will participate in both inpatient and outpatient rehabilitation and this I am excited for as I have yet to experience an outpatient setting. I think that I will have the chance to run independent outpatient appointments. As a student in the facility I think my role will be intially observing and learning practically the expectations of my supervisor, I am on prac placement for the learning opportunity but I also understand that as a student I am also there to help out the supervisor and other team members to manage the case load. I am both nervous and excited to start my first practical placement for the year. I am mostly nervous about the expectations of me as a now fourth year graduate and whether my theoretical knowledge will be easily transferred into practical/clinical skills.