Non compliant patients

A patient of mine has recently been admitted to hospital for some investigations and a possible surgery pending the outcome of the investigations. She is quite elderly but was previously independently mobile and living in her own at home, with family members coming in 2x a day to help with cooking and some ADLs.

A few days ago I was aiming to do a mobility assessment on her because she was new to the ward and I needed to document her current mobility status. I checked her obs, bloods and medication before going in to see her and these indicated that everything was stable. So I went in and introduced myself to the patient, only to have her tell me that she felt sick and didn't want to move.

I explained that my job was to see how she was getting around and compromised with her that we didn't have to walk if she felt ill and we could just transfer to a chair. She adamantly refused but with some assistance from my supervisor we managed to coax her to sit over the edge of the bed. It took 2x max assist to get this patient to SOOB even though her status prior to admission was independent. I asked her to sit and hold herself up without me supporting her and she started to fall backwards even though she was clearly capable of sitting independently.

Everyday since then, I have had this patient verbally abusing me and refusing any form of simple ambulation or any transfers. However I found that if I liased with nurses and planned my treatment around showering and toileting times, I can "trick" the patient into transferring and mobilising a little because it is something she needs. It is not optimal but its the most I can get from her at the time being. From this I have learnt that trying to coax non-compliant patients into treatment can sometimes require less effort than I previously thought.

Supervisors

I am currently on my cardio placement and my Curtin supervisor was meant to come on Fridays, in the first week he couldn’t come on Friday so it was rescheduled and he was going to come Tuesday and Friday of the second week. Because of work commitments my Curtin supervisor wasn’t able to come twice in the second week so he is now only coming on Friday of the second week. I think this is a bit unfair since my mid placement assessment will be the first time my supervisor has seen me so it doesn’t give me a chance to work on any problems I may have. I decided to discuss my concerns with my facility supervisor and asked if he could go through a patient with me like a Curtin supervisor would so I would be more prepared when the Curtin supervisor comes. He agreed to do this with me and also suggested I speak to my Curtin supervisor when he comes about making up the time I missed in the third week.

fine nursing line

A while ago now I was on an orthopaedic placement managing mainly total knee/hip replacements. I was asked by a patient(TKR) wether they could rest a pillow under their knee whilst lying supine, I replied to the patient that in the interest of regaining a straight leg, no you can't, I apologised for the tough love and suggested they could actively flex to relieve pressure on posterior structures. Moments later I was in earshot of this patients room and heard a nurse tell the patient that I didn't know what I talking about and she lets all her patients do it and know one has had a problem.
I returned to the patients room, sat down and explained in greater depth the rehab progress and desired outcomes. Tried desperately to regain some rapport and explain that I knew something about TKR's. I tried to do this all without disrespecting the nurse. In the end I put the responsibility on the patient to get the best for themselves, with correct advice put the onus of rehab back on them. I found that this worked really well and was a pretty good motivator for the patients/

Large Patients

While on my musculoskeletal placement I was recently treating a very lage patient with lower back pain. As I am quite small I found some components of the objective assessment quite difficult particularly flexion and extension PPIVM’s. This made me think about what the appropriate thing to do was, should I still attempt to assess these PPIVM’s and risk injuring myself or was it appropriate to skip this part of the assessment to save my back. I thought I would rather not risk injuring my back to perform a full objective assessment on this patient and it would be better to simply modify my assessment. When I did this I was still able to find objective asterix signs and come up with a diagnosis and treatment plan. Later I spoke to my supervisor about it and she said it was appropriate to not perform some parts of the assessment if it was likely to risk my back and usually in these situations it is possible to modify the treatment and still receive the same results. In the future if I have a very large patient I will modify my treatment to protect my back rather than trying to perform all parts of the assessment and risk injuring myself.

dealing with anxious family members

I was treating a pt with GB, and we were doing passive movements for all joints as he could only pump his ankles and we were also there with the speech therapist during the decuffing of the trache for any chest treatment that needed to be done. This pts wife was around for most of the day and was very anxious for a lot of the time. This pt had a few complications and didn’t tolerate the decuffing process very well. When his wife was around during decuffing times and physio treatment times she would constantly try to get us to stop what we were doing as she felt her husband couldn’t handle it and that we were hurting him. We explained to her our reasons for doing what we were doing and the importance of it but she still kept on with the comments and it wasn’t only to us students it was also to the speech therapist and one of the ward physios. The pt knew that what we were doing was only to benefit him in the long run so although our passive movements may have been uncomfortable at times he wanted us to continue even when his wife was trying to get us to stop. The wife was hard to handle and only had bad things to say about the staff. On my second last day of the placement this pt developed a PE in his (R) lung and pneumothorax with possibly pneumonia in the (L) lung so he wasn’t doing too well. I was asked to go in to treat him to do some chest treatment and possibly some passive movements. I walked into the room and before I could even speak to the pt his wife told me to leave him today that he couldn’t handle physio today. I went to the pt and asked him what he’d like me to do, if he just wanted me to do passive movements for his legs or arms or just a chest treatment. He asked me to just do some passive movements for his hands and wrists and leave the rest as he was exhausted. So that’s what I did as well as some suctioning as required and some DBE’s.
From dealing with this pts wife I learnt to just sort of ignore her comments and just go with what the pt wanted and needed. We also tried to educate her as to why we were doing what we were doing but this didn’t seem to change her behaviour so we just had to get on with what we were doing while monitoring the pts symptoms and responses. As this pt was on a trache the whole time we were on our placement and therefore non-verbal it also really tuned me into watching for facial expressions to monitor how he was going and tolerating the movements.

Unmotivated patients

Each afternoon at my neuro prac, we take a small group of patients to the gym for a high level balance class. This involves a gym circuit with light weights, cardio and balance exercises. One of the patients attending suffered an anoxic brain injury but doesn't have any major deficits apart from some very mild (L) sided weakness and decreased high level balance. He doesn't attend regular physio apart from the high level balance class. I always have difficulty trying to encourage this patient to participate in classes as his motivation levels are very low, and when I ask him if he's had a busy day with appointments and is tired, his reply is always "I haven't done anything, I've been so slack". 

This makes treatment hard because he does have the right to refuse it, but when this occurs everyday it is frustrating because it looks like I'm letting him get out of exercise. Most of the time we eventually come to some sort of compromise like going for a walk just so we can get him out of bed but when we are trying to give patients optimal treatment to allow them to go home and function closer to their previous level, simply walking is not really doing our job properly. Does anyone have any suggestions for motivating these type of patients?

Patients not attending appointments

I am currently on my musculoskeletal placement and have been getting frustrated by the number of patients that don’t show up to their appointments without cancelling. It has been happening to everyone on this placement, every day there at least one student (usually several) have patients that don’t show up. I am finding it frustrating as it is a waste of our time waiting for a patient that doesn’t show up. Also because we only have a limited amount of time in each area it is best for us to see as many patients as possible. If these patients called and cancelled it would give us the opportunity to book someone else in that place. I have found the best way to reduce this frustration is to use the time when I would have been treating that patient to catch up on notes and doctors letters/ handover summaries. I also think that if I was working in a private practice it would be a good idea to send out reminder emails or calls to patients before their appointments, particularly if they have not been for a while.

tone trouble

I’ve had trouble progressing a pt I’ve been treating over the past 3/52’s on my neuro placement because due to other complications this pt had a number of days that he could not stand up and weight bear. His tone in his (L) leg has increased and his ankle joint has also stiffened up as his foot has been in a bad position for the majority of the day. Therefore despite our best efforts doing foot mobilisations pre-treatment we cannot get this pt to weight bear through a flat foot on the (L). He also has parkinsons disease and therefore also has trouble straightening up to get his COM over his BOS. As we were struggling to get weightbearing through the (L) foot when doing STS and struggling to get his weight forward we couldn’t progress to ambulation. We decided at the beginning of last week to try the standing frame as this would help him get his weight forward and hopefully the weight through the foot would break the tone and the heel would drop to the floor for even weightbearing (L) and (R). We tried this the first two days but as soon as he tried to weight bear the tone kicked in even more and his foot inverted and plantar flexed and there was clonus through his whole (L) leg and he cannot get his heel to the ground and as a result his weight was over to the (R). We then decided to take it back a step further and try the tilt table with the thinking that as its more passive the leg can relax easier and the foot would remain in a better position and get some weight through it to once again try break the tone. With doing two treatment sessions per day it has got easier and the foot is getting into a better position each time and the foot is feeling better during the mobilisations but soon after moving up into a weightbearing position the tone starts kicking in and the foot slowly starts moving into the inverted and plantarflexed position and we have yet to get his heel to touch the floor fully even though in sitting and supine when doing the mobilisations we can get the foot into a neutral position. It is a very frustrating thing to deal with both for us as physios as we aren’t able to progress the pt, as well as for the pt as he is trying so hard and doesn’t seem to be improving much. This situation has taught me that sometimes as other complications interfere with treatment and pts decline in functional ability as a result that we may have to go back to treatment techniques that the pt should have past a long time ago and start close to the beginning before moving forward and once again progressing towards pre-admission status. It’s also shown that many factors can result in the pts inability to STS effectively and these all have to be worked on individually at times before the pt is able to put it altogether and complete the functional task. It has also highlighted the importance that daily treatment has in the acute setting and how easily tone can increase if the pt is unable to get out of bed or his chair and weight bear for a few days.

Treatment effectiveness

A patient of mine (B.H.) was involved in a serious MVA and as a result suffered many orthopaedic fractures and a head injury, rending him unable to walk. As a result of his car accident and head injury, he has heterotrophic ossification (growth of bone in muscles and tendons) of his (R) hip and his (L) knee. This makes flexing his hip and knee very painful and difficult even after analgesia. 

Currently we are working on ROM of his LL's and strengthening of his UL's, LL's and trunk. Progress is very slow because of his H.O. and varying pain levels. Other joints such as his (L) hip are also affected and not getting to their full ROM because of the painful (L) knee being unable to flex. We do the same basic slideboard exercises for ROM of his LL's everyday due to B.H.'s high pain levels. I feel that he is not really benefitting from doing slideboard exercises because of the restriction in his joints that we can't treat with physio. 

I still encourage the slideboard exercises to be part of our treatment program to maintain the remaining ROM left even though it isn't improving it. This has taught me the importance of still taking into consideration problems that can't be treated via physio but instead looking from the point of view of preventing further complications which ultimately could make a difference in a patient's quality of life.

organisational skills

I’m with 3 other students at the moment on my placement and we all have 3-4 very dependent pt’s who are 2x assist. We have different pairs for different pts so during the day we either work with 2 or all 3 other students and we have to all see our pts twice a day. The pts are also busy going off for investigations or on nasogastric feeds or being seen by other allied staff. So organizing the day becomes a very hard task.
I’ve had days where its been hard to organize firstly what times the pairs are both able to treat the pts and then after we pre-organized a time for the pts to be ready in their w/c with the nursing staff, we got to the pt who has either gone off for another investigation or is still in bed or has other issues which effect our treatment. This has caused times where we’ve been stuck unable to see any of the pts for a period of time and its been hard to then try get something constructive done in that waiting time and also means the treatment time with the pts decreases. To counteract this I’ve had to do treatments with the pt in bed or if waiting for another student who is busy with someone else I’ve taken the pt to the gym and started on preparatory treatments such as foot mobilizations or other treatments which don’t require 2x assist. Sometimes these types of things can’t even be done so I’ve found myself at times with spare time trying to think of something productive to do. I’ve generally then gone to look up different things like CT’s or read up a bit more on the pts notes or looked at assessment procedures in more depth. Any other ideas to fill free time?

Chatty Patients

While on my musculoskeletal prac I am treating an 80 year old man with subacromial impingment. He is extremely chatty and it is difficult to perform the subjective and objective examination as he tends to start talking about irrelevant things and it is hard to get a word in. This frustrated me as I only had a limited time for the assessment and wanted to keep him on topic. I wasn’t sure how to interrupt him once he started telling a story and get him back on track without seeming really rude. In the end I realised the only way to keep the examination and treatment running in a time efficient manner was to interrupt him from what he was saying with a question about his condition or telling him to do what I wanted from him. As the session went on it became clear that he didn’t seem to be offended by me interrupting him and then while I was performing hands on treatment he had an opportunity to talk about other things. I realised it is important to not let patients change the topic and talk about irrelevant things when I am trying to perform an assessment as we only have a limited amount of time with them and in the end they are there to get physio treatment. It is quite a common problem that patients will just want to have a chat, particularly with older patients as they may not have much other contact with people but we have to remember that they are there to be treated and we need to keep them on track to allow the assessment and treatment to be completed efficiently.