Patient compliance with home programs

I had a number of pts on my rural placement with chronic conditions where I had to write up care plans for them and give them home programs to try to improve their condition. I gave them the exercises and then reviewed in 2/52’s to see how they were going and if the program needed modifications, progressions etc. With these types of programs it always seems questionable whether or not the pt will be compliant with their program but self management is the only way to try to improve their condition. One of my pts had had a number of TIA’s and as a consequence had decreased mobility, was walking with a 4WW and had a few balance issues. During the initial treatment session after writing up the careplan, I went through some balance exercises and some strengthening exercises with him and wrote them out as a home program. His wife was present during the session and she was very encouraging and happy with the program. On review his wife told me that over the past 2 weeks the pt had hardly ever done his exercises and said she had tried to get him to do them but he wouldn’t. I ask him why he wasn’t doing them, if they were too hard or if it was more just him not being bothered to do them. He said it was just him being lazy, so I emphasised along with his wife the need and benefits of him doing his home program and told him it was up to him to do something about his decreased mobility and balance problems because at the end of the day he is only disadvantaging himself. I went through his exercises with him again to make sure he at least did his exercises with me and to make sure again that he would manage fine at home with them. While we were doing the exercises (I did them with him as encouragement) his wife said maybe she should do the exercises with him as well at home and that may increase compliance, I told her that was a great idea. I also referred him to the mobility group exercise class that we ran twice a week for him to also get some added exercise and which could possible add to the motivation of exercising. Two days later the pt came to our mobility class and his wife said she had done his exercises with him that morning. From these experiences I have found that most pts are noncompliant most of the time with their home programs but its still best to give them the exercises and hope they will at least do something. It has also shown me that we have to try many different things to motivate the pt to do their exercises and having family involvement is one of the best ways to do this especially in the older population. Also if there is some community based exercise program that is also a good thing to get the pts to attend because at least you know if they attend that twice a week they are getting some exercise. At the end of the day the pt has to take some ownership of their management and it is important to emphasise this to them that if they want to improve they have got to do their exercises.

baby talk

On a previous prac i observed several therapists treating a 10yo boy who had a variety of neurological problems. The child was often non-compliant in treatment sessions and regularly punched the therapists in frustration and anger. I felt the reason for this is that the therapists' rewards, instructions, intonation and consequences were innapropriate for this child. I believe they treated this boy like he was much younger than he was.

I decided to talk to the child's clinical psychologist about her opinion on the therapists management of this child. I was glad to hear that the clinical psychologist felt the same way about this matter. In a series of discussions about this i told the clinical psychologist that i did not feel comfortable talking to my supervisor about the appropriateness of the treatment sesssions. Together we compiled a list of recommendations that could would be more appropriate for the child in the treatment session. Following this the Clinical Psychologist presented these recommendations to the therapists'. Several of the recommendations were implented and resulted in greater patient compliance, no more hitting in treatment sessions and improved patient-therapist rapport.

I decided to not discuss this issue directly wiht my supervisor as i didnt feel comfortable at the time. This may have been different if i had known my supervisor for longer than a week and if i was a qualified physiotherapist.

I feel that i acted appropriately by discussing this issue with a health professional that is well educated in this area of health care. If i encountered this situation again i would act in the same manner (providing i was still a student...).

LISTEN

After performing the usual subjective and objective assessments on a patient with pleural effusion complicated with pneumothorax, I was in preparation to ambulate the patient when she blurted out, “What is a shadow (on CXR)?” So I explained the possible interpretation of a shadow, which could have either been a tumour, fluid or foreign particles in the lung where x-rays were unable to penetrate.

Shortly after, she began to cry as she expressed her concern for her recent CXR result (which at that moment hadn’t yet confirmed her diagnosis). She further stated that she recently lost a good friend who died of a lung cancer, and was afraid she was to follow. I was speechless. Although I sympathised with her, I wasn’t able to empathise her feelings as I hadn’t experienced such an encounter.

However, I decided to take a moment of my schedule for the day to listen and allow her to express her emotions, as well as to provide some reassurance. I realised it was crucial that someone paid a listening ear so that she wouldn’t end up bottling up her feelings, which could pose detrimental effects on her health.

After that incident, the patient became more compliant with ambulation and other interventions. I learned that rapport with patient can be built with a step as simple as taking the time to listen.

Aboriginal Patients

I am currently on a general surgery ward and treating a 45 year old aboriginal lady from a remote aboriginal community who underwent a right hemicolectomy about 2 weeks ago, she developed several complications and is having a fairly slow recovery therefore she is still on the ward. As she is from an aboriginal community she is not used to being in the city and doesn’t have any family in Perth communicating with her is quite difficult. It is very difficult performing the subjective assessment on this patient as she will rarely speak. To overcome this I have found the best way get information from her is asking very specific questions and generally she will answer them, also I can read her body language to determine some things such as if she is in pain. The more I have treated this patient I have also found that she has become more responsive to me as she is familiar with me. In the future when treating aboriginal patients who are not comfortable in the city I will remember my experiences with this patient and use similar strategies.

Conflict between staff

Currently, the hospital I am on prac at is undergoing refurbishment and expansion. The wards had to shift down to new wards the other day, which meant that the staff were very busy trying to shift everything down on time and order things. The physio department has a drawer of information usually kept in the nurses office which was moved earlier and placed in an empty space in the new ward before everything else was moved. One staff member decided that was "innappropriate" and the physios were taking up the nurse's space. She also disliked how the allied health staff (physios, OTs and social work) sat in the old nurses office and wrote notes, even though I have never heard the nurses complain about this.

When the ward was moved to the new facilities, she still had a problem with this even though she is not a member of the nursing or medical staff. Fortunately, there was more space in which we could sit and write notes. However, the staff member continued to cause conflict with the allied health staff, saying that it was the nurses handover room and no-one else should be using it. We all thought this was ridiculous, as there is extra rooms to do notes. The issue was resolved during a meeting between staff later that day. This demonstrates that some people still don't understand that allied health staff and nursing staff play equally important roles and all staff need to collaborate to create a pleasant and efficient work environment.

New Grad Supervisors

I am currently on my cardio placement and my supervisor only graduated last year and has been rotating wards. This means he doesn’t have as much knowledge in the area as a supervisor who is a senior in that area. This made me a little bit concerned that I wouldn’t get as much out of the placement and therefore not be as prepared for my PCR as if I had a more experienced supervisor. To overcome this problem I decided I needed to make the most of my curtin supervisor visits and use him to answer any questions that my facility supervisor wasn’t sure about. This worked well as my curtin supervisor was happy to help as he understood my facility supervisor was a new grad.

Dealing with difficult patients

I have recently had a chronic LBP patient (mentioned in my previous blog entry) who had a lot of psychological yellow flags. Firstly, he was ignoring my advice to decrease his activity levels and continuing to garden for 6+ hours nonstop lifting heavy loads because he was "competing" with his neighbour to have the best garden. Thus every time he came in, his pain levels hadn't improved and the treatment that I had done previously had been undone. 

His expectations of physiotherapy were also quite unrealistic. The hospital only offers a maximum of 8 outpatient treatment sessions and he wanted a lot more. He also expected that I would give him an in depth maintenance program incorporating hydro and a gym program. I explained to him that his Dr referred him to outpatients as a trial to see if it would help his pain because his other option was to have spinal surgery. I also explained that outpatients didn't really have the resources to give him an in depth program and that we should sort out his problem of immediate pain first before thinking of anything further. 

My patient was also unavailable for afternoon appointments, as he had to work as a crossing guard in the afternoon for an hour. I asked him if he could schedule an afternoon off to get physio but he said he had to work (which is understandable). Due to this factor and his uncompliance, physio wasn't going to be very successful in addressing his problem. After I explained this to him (not using those exact words), he self discharged (fortunately) and from this experience I have learnt how to tactfully deal with difficult uncompliant patients.

unsafe vs non compliant

Week 4 of my ortho ip placement (Final Ax). I treated a 48 y.o male who has a # L tibfib as a result of a fall. He has to remain NWB for 6/52. He is a construction worker. When his PCA was removed, I took him to the gym to try him out on crutches. He said he doesn't need to be taught how to use the crutches as he has used them before, I insisted and said that I need to review his mobility before the doctors decide to discharge him. I gave him brief instructions on using the crutches. When he stood up he didn't wait for my command and began ambulating. He got the sequence of movement right, but it seems to me that he was rushing through movement and is potentially unsafe, I had to keep telling him to slow down. I taught him how to get up and down stairs the same day. He didn't have trouble with that either but he was rushing through the movement as well. He managed the stairs safely but its a falls risk if he rushes through the movement and i explained that to him. My supervisor was there with me and she told him that 'if you fall here, you will have to stay longer in the hospital' and he slowed down. I took him back to his room and wrote in his progress notes that he is currently ambulating independently and is safe to go home. Despite him being potentially unsafe, I thought that given he is a 48 y.o. construction worker who is physically fit and able, and it is in his nature to tend to rush things and just want to get things done quickly. My supervisor told me that it was good that i managed to keep calm and be appropriately assertive with the patient but to actually get this patient to be compliant I will have to tell him the consequence of his action and be more than 'appropriately assertive'.
From this experience I have learn that sometimes we just have to adjust to our patients behavior and alter our sessions and judgments regarding their safety accordingly.

PMH

On the 3rd week of my ortho ip placement, I treated a 65 y.o lady from Sydney with # R tib fib as a result of a fall , she is currently on holidays in Perth. She has to remain NWB for 6 weeks. It is now day 3 and to date she only manages transfers. I took her to the rehab gym to do a mobility review and to practice ambulation in the parallel bars. Prior to her fall, she is independent with her ADLS but she has poor exercise tolerance. When ambulating within the parallel bars, she was struggling to weight bear through her upper limbs as she hop forwards, she has really poor upper limb strength. She managed one lap on the parallel bars doing mini-hops and shuffling her left foot instead of stepping through. She looked really exhausted and her RR has clearly increased. I didn't really take notice of this and i just assumed that it was because it was her first time ambulating after her operation. I took her to the gym again the next day for ambulation in the parallel bars, her quality of movement doesn't seem to have improved and she is as exhausted as she was yesterday. There was nothing listed in her PMH. I then decided to ask her if she is normally this puffy and exhausted with walking, and she said yes, and it was since her MVR that she has limited exercise tolerance. I then decided that i should go easy on her and keep monitoring her PR. I told my supervisor about it and she said that the doctor may have missed it as she is from Sydney and her PMH may have been purely subjective. I was glad that I was able to pick up the signs and manage to alter my treatment to suit the patient. When the patient was discharged, she was given a zimmer frame instead of e/c as she has weak UL strength and her husband was taught how to assist her when going up and down step.

pt's comment vs PT's observation

Week 2 of my orth ip placement. A 58 y.0 lady was going to be discharged from the hospital after the revision of her THR (post-op order PWB). I was going to teaching her how to use her e/c when going up and down the stairs. On s/e she reported that she only has one step going into the house and going to the shower but i decided to do the stairs (~4steps) that they have in the gym as she is a 58y.o previously independent lady. Prior to practicing the stairs, I told her to walk ~5 m within the gym with her crutches just to double check that she is really safe with it. We were going up the steps and she looked as though she was struggling (breathless) but still manage to keep up with conversation, she was rushing through her movements too. She told me that she is fine and wants to keep going, I was going to allow that but my supervisor stopped me and told the patient to take a breather. After ~ 2 minutes we went down the stairs. She rested in her wheelchair and had a glass of water, still look breathless but very involved in conversations. I told her that we are going to practice the stairs one more time and if that is okay with her and if she's feeling dizzy or fainty or pain, she said she'd be happy to do it again (my supervisor asked my why i chose to do it again as the patient looked as shes struggling, I told her that i wanted the patient to be really familiar with the e/c when going up and down stairs). We practiced the stairs again after ~10 minutes of rest, and this time the patient manage the stairs well and with less difficulties. After the treatment session, my supervisor told me that it was a good idea to re-check her stairs mobility. My supervisor was worried that the patient was not coping well during the treatments session. I then told my supervisor that I have seen this patient for a few days now and she always look breathless but she still manage well (i.e. obs stable and able to keep up with conversations, nothing significant in her PMH) and the patient reported that she is feeling okay. I trusted that the patient is telling the truth and i trusted my gut feelings, but I am still not quite sure if it is the right thing to do. Anyone has any comments feel free to post them up.

Micro alerts

Week 1 of my orthopaedic in pt placement, I was asked to bring a patient to the rehab gym for some exercises in the parallel bars. The patient was micro-C alert and I consulted my supervisor about that. She told me to bring the patient down to the gym only when there is no other patient using the gym (which is hardly the case as there is only one in pt gym), I consulted the nurse looking after the patient and she said it was totally fine taking her out of her into the gym and micro-C is only a hospital precaution and there are many micro-C carriers out in the community. I told my supervisor about what the nurse said and she decided it was okay to take her to the gym at anytime as long as her wound is dry and covered. When i took the patient to the gym with gown and gloves on the other physios were wondering why i took the patient in when she has some infection precaution going on, they too had to double check with other physios and nursing staff to make sure it was really okay to have the patient there amongst others. From this experience, i have decided to then read up on the micro alerts and the specific precautions for each of them (although, in general they all requires gown and gloves, equipment rub down, handwash).

Covering your back

A patient was recently referred to me for treatment of chronic LBP which he sustained after an accident 10 years ago. Since his accident was workplace related, he got workers comp and lots of intensive physio and hydro after his operations. However his worker's comp ran out a long time ago and he found he was able to manage his pain by going to the gym and doing hydro. In spite of his pain, he works a job which involves periods of standing and enjoys gardening.

This patient reported much higher levels of pain and neuro symptoms which had been increasing over the past 18 months. His neurosurgeon suggested he have a spinal fusion +/- laminectomy of his Lx spine due to central canal narrowing and disc degeneration, and my pt has to make a decision by November. My patient asked me if physio or surgery would be the better option and he would rather not have surgery because the surgeon gave him a 50% chance of improving. 

He also told me he didn't want to be a burden on the health system and having lots of physio would mean that he didn't need to take up a bed in a hospital. He said that he knew that it would take more than 8 sessions (the maximum the outpatient dept offers) to get better. I wasn't comfortable in telling him what to decide but advised him that his CT's showed degeneration which wasn't going to get better over time and if he continued to do heavy gardening and not rest while he was standing up to work he probably wouldn't see a decrease in symptoms. I also told him that outpatients couldn't see him for anymore than 8 sessions and he would get physio after an operation if he decided to have one. I advised him to go and seek the opinion of his neurosurgeon and ask specific questions about why it was in his best interests to have the operation and then he could make an informed decision rather than asking someone (me) who doesn't have the knowledge to give him accurate advice. 

From this experience, I have realised the  important for pts to be informed and educated about their condition by the right people so they can make decisions themselves and we can decrease the chance of legal repercussions back on us. 

Uncooperative Patients

I am currently on a general surgery ward and treating a patient who is very non compliant with physiotherapy. He was previously living with his wife and independent with all ADL’s but since his operation has been refusing to ambulate and has the idea in his head that when he gets home every thing will be back to normal and he will be able to do everything he used to do. When treating this patient he will usually consent to chest physio but will refuse to ambulate or even sit out of bed at times. This makes progressing him and preparing for discharge very difficult as he has been in hospital for about 3 weeks and is therefore very deconditioned. On a couple of occasions I have been able to convince him to ambulate but usually he will just become very agitated with me and refuse. When my supervisor has attempted to treat this patient he has received the same reaction. This has really frustrated me as no matter what strategy I use with this patient to convince him to ambulate he refuses as he is under the impression that everything will just fall into place when he gets home. I have now realised there is nothing I can do if the patient refuses to ambulate and all I can do is keep trying. I have also found this patient is more likely to be compliant if I see him when he is sitting out of bed rather than lying down and also if I plan with the nurses to attempt to ambulate him when he is about to have a shower. In the future I will attempt to treat this patient when he is out of bed but if he still refuses to ambulate there is nothing I can do except come back later and try again.

Infection Control

Whilst on my international placement in Borneo I had to get used to a very different hygiene and infection control standards in the hospital.
As I was working in a private hospital we had to charge the patients for every single thing that we used during their treatment session, including gloves or gauze. This often resulted in things being reused which really shouldn’t be reused, such as suction catheters. On more than one occasion I saw a member of the nursing staff suction a patient, rest the catheter on the bed, resuction and then put the catheter back into its wrapper so they don’t have to charge a patient next time they suction then.
This goes against absolutely everything we have been taught in uni and on prac. After speaking to the physios there, in particular the physios that were trained in Australia, I realized that they were all aware this happened but when medical care is so expensive and most of the patients struggle to pay for the basic treatment there is not much else they can do. It took a while to get used to but it is understandable why it does happen.