Currently I am on my neuro outpatients prac which has really highlighted for me the importance of non verbal communication.
Last week I treated a patient who has had a bilateral pontine infarction. Basically this patient has limited movement of her upper limbs, lower limbs, trunk and aphasic. Upon reading her patient notes I became quite stressed thinking in my head “how do I communicate with this women?” She arrived and on her lap was a mini keyboard which she communicated thru (spoke on her behalf) using one of her fingers to press the appropriate letters.
At first I kind of froze… I was not used to speaking to someone who did not respond back to me immediately. However throughout the session I became more comfortable. I began to really recognize ways of understanding someone non verbally. With this patient I followed her facial expressions, head movements, singular words she typed, and slight noises indicating whether she was uncomfortable or in pain. I found that I could even have a conversation and find out personal information about the patient like her favourite type of music, hobbies etc. Even in how you touch a patient; manual handling, stroking to activate sensory input to parts of the body, pressure of touch etc are forms of non verbal communication which contribute to a PT building patient rapport. I found that my treatment session was quite successful with the pt gaining as much from the session as I had intended
We learn so many skills as future therapists and in our blue assessment forms communication skills contribute a considerable amount. I traditionally have thought this referred more specifically to how you spoke with patients to make them feel comfortable in your hands. I think this situation highlighted to me the importance of non verbal communication. If you can’t speak to someone there are so many ways of building rapport through being more conscious of facial expression, manual handling, touch and body language. I ask anyone to express your thoughts on whether you too have become more conscious of non verbal forms of communication with some of the patients you have seen
Sunday, July 27, 2008
Overprotective parents
I am currently on my rural placement which has involved a number of individual assessments with children and their parent(s). Last week I was assessing a 10 year old boy’s motor skills with his mother present. This boy had a condition that affected numerous systems including his growth, vision and co-ordination amongst others. He had been identified as a young child with developmental delay as a result of this condition and had participated in many OT/PT individual and group sessions working on developing his gross and fine motor skills. This was a school aged assessment aimed at tracking his progress and whether or not the PT/OT intervention was assisting his development.
During the subjective interview the mother stated that she had no concerns regrading her son’s gross motor skills and that he appeared to be doing well. However, her next statement undermined this as she mentioned that her son was a ‘very slow runner’ and that he was always picked last for the sports teams during PE. For this reason she lets her son stay home from school on the days sports are on. The therapist and I felt this was because the son did not want to participate, which we could understand (though didn’t agree with) and to prevent him from being bullied at school the mother protected him by allowing him to stay at home (note that this child had a poor attendance record at school and the mother had stated that one of their goals for the term was to improve this – implying that it was the child that wanted to stay home).
I reflected on this and thought whilst it is an important part of developing social skills as well as the benefits of participating in sports in regard to developing motor skills it would be extremely difficult as a parent to watch your child suffering and being unhappy when being repeatedly picked last for every game at school. I could understand if your child was that unhappy you would do everything you could to protect them, especially since this particular boy also had numerous other impairments and challenges in life. However as I was reflecting upon this the boy excitedly told us that it was the cross country carnival the next day and he was really looking forwards to it (even though he said he was ‘pretty slow!’). The mother quickly intervened and said to the boy that he wouldn’t be able to participate and he may have to stay home. The boy got upset at this and a small argument between the two occurred. Once the argument had resolved we continued with the assessment.
As we were completing the assessment I re evaluated what I had thought before. Clearly the mother was preventing her son from participating to protect him, however the son was still keen to join in even though he recognised he wasn’t as strong or fast as the other children in his class. It’s a fine line between protecting the children with disabilities from bullying of the other children that don’t understand and letting them have a go even if it means they may fail.
At the end of the session the therapist and I explained to the son and the mother that his motor skills were developing well but that he still needed to complete the HEP every day. We also added that to further improve his motor skills it would be beneficial for the boy to participate in sports at school or out of school as then he would be able to apply what he does in the HEP into a real context. I realised that we as therapists are only able to guide the parents towards what we feel will assist in the development of their child’s motor skills. It is up to the parent to decide whether they will take this advice or continue to protect their child, whether the child feels as though they need this protection or not.
During the subjective interview the mother stated that she had no concerns regrading her son’s gross motor skills and that he appeared to be doing well. However, her next statement undermined this as she mentioned that her son was a ‘very slow runner’ and that he was always picked last for the sports teams during PE. For this reason she lets her son stay home from school on the days sports are on. The therapist and I felt this was because the son did not want to participate, which we could understand (though didn’t agree with) and to prevent him from being bullied at school the mother protected him by allowing him to stay at home (note that this child had a poor attendance record at school and the mother had stated that one of their goals for the term was to improve this – implying that it was the child that wanted to stay home).
I reflected on this and thought whilst it is an important part of developing social skills as well as the benefits of participating in sports in regard to developing motor skills it would be extremely difficult as a parent to watch your child suffering and being unhappy when being repeatedly picked last for every game at school. I could understand if your child was that unhappy you would do everything you could to protect them, especially since this particular boy also had numerous other impairments and challenges in life. However as I was reflecting upon this the boy excitedly told us that it was the cross country carnival the next day and he was really looking forwards to it (even though he said he was ‘pretty slow!’). The mother quickly intervened and said to the boy that he wouldn’t be able to participate and he may have to stay home. The boy got upset at this and a small argument between the two occurred. Once the argument had resolved we continued with the assessment.
As we were completing the assessment I re evaluated what I had thought before. Clearly the mother was preventing her son from participating to protect him, however the son was still keen to join in even though he recognised he wasn’t as strong or fast as the other children in his class. It’s a fine line between protecting the children with disabilities from bullying of the other children that don’t understand and letting them have a go even if it means they may fail.
At the end of the session the therapist and I explained to the son and the mother that his motor skills were developing well but that he still needed to complete the HEP every day. We also added that to further improve his motor skills it would be beneficial for the boy to participate in sports at school or out of school as then he would be able to apply what he does in the HEP into a real context. I realised that we as therapists are only able to guide the parents towards what we feel will assist in the development of their child’s motor skills. It is up to the parent to decide whether they will take this advice or continue to protect their child, whether the child feels as though they need this protection or not.
Tuesday, June 24, 2008
Continence and continence pads
sorry for the late post, I had some "cookie" problem with this site :S
This happened while I was working as a physio assistant last year. I was working in a tertiary hospital rehabilitation ward. The work involved mainly supervise and assisting patients doing exercises and ambulation. One of my patients there was about 80 years old asian lady. She was able to speak and understand English however as it’s not her first language, she wasn’t too fluent and had limited vocabulary. She has no children and her closest relatives are her sister and her family.
She was in the rehab ward, however she’s waiting for available beds at a nursing home (or something similar). Therefore her daily exercise was strengthening exercise and ambulation for purpose of maintenance. She needs minimal assistance to get out of bed, standby supervision with ambulation and mostly independent with all exercises. I was able to ambulate about 40m with no rest in between. She did walk very slowly though. To me she was very shy lady and was often worried that she was causing trouble on other staff.
However, one day she was talking to me about her nights. She expressed to me that the night staff were not very friendly. She needed to go toilet a few times a night, however night staff were slow to respond to her bell. When they were unable to walk to the toilet, and instead gave her a bed pan on her bed. She was very uncomfortable with this arrangement. As a result, she could not sleep well at night. A week later, I walked in as she conversed with her doctor who suggested wearing pads at night. I was shocked to hear this. She was not urinary incontinence. She was physically able to get to toilet. I was not sure if other options had been considered such as commode in the room. As it was my last week there as a physio assistance, I did not chase this issue on. Staff on at night might have been too busy to take her to toilet, I was unable to find out why as I was not familiar with the ward and ward staff. There may well be other issues that I’m not aware of. Nontheless, wearing pads for non-incontinent patients would decrease their dignity and self esteem, and at the same time it would increase the possibilities of having urinary infections.
Now with more experience in the hospital setting, I would have to find out the reason that night staff were unable to walk this patient to toilet and encourage them to ambulate patients more frequently. If there is issue with time constraints, other options such as commodes should be considered before using bed pans or pads.
Has anyone had similar experience as a physio? What other approaches are possible apart from bed commodes that’s time efficient?
This happened while I was working as a physio assistant last year. I was working in a tertiary hospital rehabilitation ward. The work involved mainly supervise and assisting patients doing exercises and ambulation. One of my patients there was about 80 years old asian lady. She was able to speak and understand English however as it’s not her first language, she wasn’t too fluent and had limited vocabulary. She has no children and her closest relatives are her sister and her family.
She was in the rehab ward, however she’s waiting for available beds at a nursing home (or something similar). Therefore her daily exercise was strengthening exercise and ambulation for purpose of maintenance. She needs minimal assistance to get out of bed, standby supervision with ambulation and mostly independent with all exercises. I was able to ambulate about 40m with no rest in between. She did walk very slowly though. To me she was very shy lady and was often worried that she was causing trouble on other staff.
However, one day she was talking to me about her nights. She expressed to me that the night staff were not very friendly. She needed to go toilet a few times a night, however night staff were slow to respond to her bell. When they were unable to walk to the toilet, and instead gave her a bed pan on her bed. She was very uncomfortable with this arrangement. As a result, she could not sleep well at night. A week later, I walked in as she conversed with her doctor who suggested wearing pads at night. I was shocked to hear this. She was not urinary incontinence. She was physically able to get to toilet. I was not sure if other options had been considered such as commode in the room. As it was my last week there as a physio assistance, I did not chase this issue on. Staff on at night might have been too busy to take her to toilet, I was unable to find out why as I was not familiar with the ward and ward staff. There may well be other issues that I’m not aware of. Nontheless, wearing pads for non-incontinent patients would decrease their dignity and self esteem, and at the same time it would increase the possibilities of having urinary infections.
Now with more experience in the hospital setting, I would have to find out the reason that night staff were unable to walk this patient to toilet and encourage them to ambulate patients more frequently. If there is issue with time constraints, other options such as commodes should be considered before using bed pans or pads.
Has anyone had similar experience as a physio? What other approaches are possible apart from bed commodes that’s time efficient?
Sunday, June 22, 2008
Calm down!
I am currently on my musculoskeletal outpatient placement and am seeing a patient for a shoulder problem. She presented to clinic 10 days following a fall onto an outstretched hand. After a subjective assessment it was determined that the severity and irritability of her condition was very mild and so a full objective examination was indicated, with minimal caution required.
Objective examination began with AROM of the shoulder joint. The patient had demonstrated full and pain free shoulder abduction, flexion, external rotation and extension, but experienced extreme pain when returning from extension to neutral. Her pain did not settle for the remainder of the session and further accurate examination was difficult. With help from my supervisor we proposed a diagnosis of glenoid labrum tear (SLAP lesion) and decided to tape to support the shoulder joint for one week to allow the condition to settle before re-assessing.
When the patient returned for taping 3 days later she expressed that the symptoms had decreased significantly and was more than happy to have the tape reapplied for a further few days.
Upon return to the clinic for further assessment she once again noted a significant improvement in symptoms, with only mild pain performing repetitive movements (eg washing dishes or dusting) for more than 15 minutes. We therefore began further physical examination. This time, gentle palpation of her upper trapezius muscle caused severe pain and made the physical examination difficult. My supervisor decided to perform further physical assessment regardless of this – testing for impingement, instability etc. Her pain mid way through this session appeared to be extremely severe. The patient became quite teary and was very reluctant to move her shoulder. She expressed that the pain had spread to her neck and upon closer examination the cervical paravertabrals had significantly increased tone compared to the beginning of the session, with a large visible lump at the proximal attachment of her upper trapezius.
I guess you could say I freaked out. The lump honestly looked and felt like displaced bone and was very painful to palpate. My supervisor had a look but didn’t seem too concerned, and she suggested heat followed by very gentle soft tissue massage which relieved the symptoms significantly.
Afterwards my supervisor spoke to me about how my display of anxiety may have increased the patients already elevated anxiety levels. Looking back on the situation I could see how my reaction may have reinforced the patients perception of their pain being caused by a more sinister pathology.
A similar event happened the next time I saw this patient. This time I new what I had to do. I talked to the patient and explained why she was feeling the pain and that there was indeed no pathology in her neck, but rather that her muscles were trying to protect her shoulder, and in doing so were becoming very tense, causing the pain in her neck. This reassurance alone had a positive impact on her symptoms.
Though it is difficult when faced with new/ confronting situations to hide your concern I now realise that the way we react to certain things can greatly influence a patient. Next time I am faced with a patient like this I will know to take a deep breath and remain calm... for their sake and mine!
Objective examination began with AROM of the shoulder joint. The patient had demonstrated full and pain free shoulder abduction, flexion, external rotation and extension, but experienced extreme pain when returning from extension to neutral. Her pain did not settle for the remainder of the session and further accurate examination was difficult. With help from my supervisor we proposed a diagnosis of glenoid labrum tear (SLAP lesion) and decided to tape to support the shoulder joint for one week to allow the condition to settle before re-assessing.
When the patient returned for taping 3 days later she expressed that the symptoms had decreased significantly and was more than happy to have the tape reapplied for a further few days.
Upon return to the clinic for further assessment she once again noted a significant improvement in symptoms, with only mild pain performing repetitive movements (eg washing dishes or dusting) for more than 15 minutes. We therefore began further physical examination. This time, gentle palpation of her upper trapezius muscle caused severe pain and made the physical examination difficult. My supervisor decided to perform further physical assessment regardless of this – testing for impingement, instability etc. Her pain mid way through this session appeared to be extremely severe. The patient became quite teary and was very reluctant to move her shoulder. She expressed that the pain had spread to her neck and upon closer examination the cervical paravertabrals had significantly increased tone compared to the beginning of the session, with a large visible lump at the proximal attachment of her upper trapezius.
I guess you could say I freaked out. The lump honestly looked and felt like displaced bone and was very painful to palpate. My supervisor had a look but didn’t seem too concerned, and she suggested heat followed by very gentle soft tissue massage which relieved the symptoms significantly.
Afterwards my supervisor spoke to me about how my display of anxiety may have increased the patients already elevated anxiety levels. Looking back on the situation I could see how my reaction may have reinforced the patients perception of their pain being caused by a more sinister pathology.
A similar event happened the next time I saw this patient. This time I new what I had to do. I talked to the patient and explained why she was feeling the pain and that there was indeed no pathology in her neck, but rather that her muscles were trying to protect her shoulder, and in doing so were becoming very tense, causing the pain in her neck. This reassurance alone had a positive impact on her symptoms.
Though it is difficult when faced with new/ confronting situations to hide your concern I now realise that the way we react to certain things can greatly influence a patient. Next time I am faced with a patient like this I will know to take a deep breath and remain calm... for their sake and mine!
Tuesday, June 17, 2008
Settling for less
Whilst on orthopaedic inpatients placement I came across a situation that disappointed me regarding patient compliance. I was going to see a patient with an ankle injury who simply needed motivation to ambulate. The patient was in her sixties, overweight, had a right ankle splint, and a history of left knee pain. She was weight bearing as tolerated and previously used no walking aids prior to admission. I was informed by another physio that the patient was able to ambulate independently with elbow crutches.
After introductions, when asked to ambulate, the patient was reluctant to get out of bed. The patient was not in pain, however, simply didn’t want to come for a walk. I found this frustrating, but eventually convinced the patient to get up for a walk. What disappointed me more, was that once up, the patient refused to walk with elbow crutches and insisted that if she was to go for a walk that she would only go with a walking frame. This annoyed me as I knew she was capable of using the elbow crutches and that she didn’t use walking aids at home, yet she wouldn’t use the more appropriate aid.
Since the patient made it abundantly clear that no frame meant no walk, after trying my best to convince her to at least try the elbow crutches, I just accepted the situation and ambulated her with the frame. The patient had no problems with the frame and elbow crutches were clearly the more appropriate aid in her situation.
I later found out that since injuring her right ankle, the patient was starting to develop a fear of falling or injuring her left knee that she had a history of pain with. Because of this the patient said that they now felt as though they needed to use the frame so to prevent loosing independence if something were to happen to her left knee. I tried to explain to the patient that elbow crutches were more appropriate for her, especially if she wanted to maintain independence and return to her previous function, however, she simply purchased a frame and no elbow crutches and refused to listen to my advice. This frustrated me as I know that if the patient was to try a little harder with her rehabilitation that she would be far better off than simply settling for the easy option and expecting everything to take care of itself.
Later on in my placement I started to notice when patients would refuse treatment or make up childish excuses to get out of a treatment session. It made me start to think, and upon further reflection I realised that as long as they are properly informed, there is no point in getting frustrated and angry with a patient if they are stubborn and refuse treatment, or if they don’t push themselves for the best, simply settling for an easier option. If they know the benefits of treatment, and negative effects of poor rehabilitation, and you have tried your best to persuade them into undertaking treatment and trying their best, then they can make their own choice if they want to do it or not. And if they don’t want to, then our time is better spent on other patients who are more motivated. Through this experience now when I am in a similar situation instead of getting frustrated and angry, I accept the patient’s choice and concentrate my energy on treating patients who are willing to participate in treatment.
After introductions, when asked to ambulate, the patient was reluctant to get out of bed. The patient was not in pain, however, simply didn’t want to come for a walk. I found this frustrating, but eventually convinced the patient to get up for a walk. What disappointed me more, was that once up, the patient refused to walk with elbow crutches and insisted that if she was to go for a walk that she would only go with a walking frame. This annoyed me as I knew she was capable of using the elbow crutches and that she didn’t use walking aids at home, yet she wouldn’t use the more appropriate aid.
Since the patient made it abundantly clear that no frame meant no walk, after trying my best to convince her to at least try the elbow crutches, I just accepted the situation and ambulated her with the frame. The patient had no problems with the frame and elbow crutches were clearly the more appropriate aid in her situation.
I later found out that since injuring her right ankle, the patient was starting to develop a fear of falling or injuring her left knee that she had a history of pain with. Because of this the patient said that they now felt as though they needed to use the frame so to prevent loosing independence if something were to happen to her left knee. I tried to explain to the patient that elbow crutches were more appropriate for her, especially if she wanted to maintain independence and return to her previous function, however, she simply purchased a frame and no elbow crutches and refused to listen to my advice. This frustrated me as I know that if the patient was to try a little harder with her rehabilitation that she would be far better off than simply settling for the easy option and expecting everything to take care of itself.
Later on in my placement I started to notice when patients would refuse treatment or make up childish excuses to get out of a treatment session. It made me start to think, and upon further reflection I realised that as long as they are properly informed, there is no point in getting frustrated and angry with a patient if they are stubborn and refuse treatment, or if they don’t push themselves for the best, simply settling for an easier option. If they know the benefits of treatment, and negative effects of poor rehabilitation, and you have tried your best to persuade them into undertaking treatment and trying their best, then they can make their own choice if they want to do it or not. And if they don’t want to, then our time is better spent on other patients who are more motivated. Through this experience now when I am in a similar situation instead of getting frustrated and angry, I accept the patient’s choice and concentrate my energy on treating patients who are willing to participate in treatment.
Monday, June 16, 2008
Taking charge
Recently, on my paediatric placement i encountered a difficult situation which involved finding the balance between being friendly and performing an effective treatment. The situation arose when i was seeing a boy on a school visit. I had seen this boy for 2 half hour sessions a week for 3 weeks and we had developed a fairly good rapport. The previous treatment sessions had run reasonably smoothly, however the boy could be difficult as he has a short attention span and can not normally tolerate more than half an hour of treatment.
The boy has a diagnosis of developmental delay and especially has difficulty with arm movements crossing the midline. Treatment has consisted of practicing various arm movements such as windmills, swimming strokes, throwing and catching. The boy is generally a nice kid but he can be a bit cheeky and its important to stay in control. For the treatment session to be effective the boy needs to understand that you're the boss and not just his friend.
On this particular day it was the boy's birthday and he was turning 9. I started off the session wishing the boy happy birthday asking him what presents he got. After this i told him we still had work to do and that we better get started. Things were going fine until the boy became frustrated trying things that he wasnt very good at and then gave up. The boy said that it was his birthday and that he shouldnt have to do anything hard on his birthday. I told him that we still needed to practice even though it was his birthday.
I was trying to be firm but i still came across as being friendly. We ended up fininshing the session after not much longer as the boy was struggling to stay focused on what we were trying to do. It was taking a lot of bargaining and convincing to get the boy to do anything so i thought it was best that we left it there for the day. After the session my supervisor said that overall it was good but that i needed to be more firm with the boy and take charge.
I thought about the session later that day and realised that even though its good to be friendly, its more important to achieve an effective treatment session. Most of the time its possible to do that in a friendly way, but occasionally you need to be cruel to be kind. Consistently getting the best out of the treatment sessions is always going to be better in the long term. Does anyone else have any ideas, or any suggestions for what you can say to stay in control and take charge?
The boy has a diagnosis of developmental delay and especially has difficulty with arm movements crossing the midline. Treatment has consisted of practicing various arm movements such as windmills, swimming strokes, throwing and catching. The boy is generally a nice kid but he can be a bit cheeky and its important to stay in control. For the treatment session to be effective the boy needs to understand that you're the boss and not just his friend.
On this particular day it was the boy's birthday and he was turning 9. I started off the session wishing the boy happy birthday asking him what presents he got. After this i told him we still had work to do and that we better get started. Things were going fine until the boy became frustrated trying things that he wasnt very good at and then gave up. The boy said that it was his birthday and that he shouldnt have to do anything hard on his birthday. I told him that we still needed to practice even though it was his birthday.
I was trying to be firm but i still came across as being friendly. We ended up fininshing the session after not much longer as the boy was struggling to stay focused on what we were trying to do. It was taking a lot of bargaining and convincing to get the boy to do anything so i thought it was best that we left it there for the day. After the session my supervisor said that overall it was good but that i needed to be more firm with the boy and take charge.
I thought about the session later that day and realised that even though its good to be friendly, its more important to achieve an effective treatment session. Most of the time its possible to do that in a friendly way, but occasionally you need to be cruel to be kind. Consistently getting the best out of the treatment sessions is always going to be better in the long term. Does anyone else have any ideas, or any suggestions for what you can say to stay in control and take charge?
Taking classes..
Hi everyone,
I was faced with having to lead part of a post-natal fitness class this week..It would have been fine, however, as I had not attended the class before, my Supervisor told me I was not expected to present anything - just participate : ) However, the Physio taking the class had different ideas!
Sure enough, the Supervisor got everyone's attention towards the end of the class, and told them that 'Angela will be taking you now for the rest of the session'.
I haven't been in this situation on this placement before, however, I managed to take the ladies through to the end of the class, and actually quite enjoyed it..Everything I taught them I have already been implementing on my post-natal treatment up on the wards, it is just different when you are standing up in front of a whole bunch of eager patients..
I am really glad this physio did this - although not impressed at the time..It highlighted what I did know, and also gave me the confidence in knowing that I can lead a group effectively.
If this situation presents itself in the future, I will not hesitate to take the challenge on board. We are faced with so many challenges through prac, but I know I have already improved so much from them. The situation has also highlighted that I, and we all have the knowledge, and the skills, we just need to believe that we do...
; )
I was faced with having to lead part of a post-natal fitness class this week..It would have been fine, however, as I had not attended the class before, my Supervisor told me I was not expected to present anything - just participate : ) However, the Physio taking the class had different ideas!
Sure enough, the Supervisor got everyone's attention towards the end of the class, and told them that 'Angela will be taking you now for the rest of the session'.
I haven't been in this situation on this placement before, however, I managed to take the ladies through to the end of the class, and actually quite enjoyed it..Everything I taught them I have already been implementing on my post-natal treatment up on the wards, it is just different when you are standing up in front of a whole bunch of eager patients..
I am really glad this physio did this - although not impressed at the time..It highlighted what I did know, and also gave me the confidence in knowing that I can lead a group effectively.
If this situation presents itself in the future, I will not hesitate to take the challenge on board. We are faced with so many challenges through prac, but I know I have already improved so much from them. The situation has also highlighted that I, and we all have the knowledge, and the skills, we just need to believe that we do...
; )
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