Inpatient CPD by

Reflection 06/11

hm6wjcj8d7_ — 2023-11-08 08:07:50 UTC

1 week into placement, I have taken the lead on a patient who is nearing discharge. I visited the patient to attempt to do a stairs assessment earlier that day, and deemed it not safe to do so until I had consulted the medical team, since his blood pressure was around 178/52. When it came time for the MDT meeting, I was the only member of the physiotherapy team present, so brought up the issue of the patient's BP. His consultant said that this was fine and that I should continue with the stairs assessment. I wanted to specify that I'd like the doctor to document this before I saw the patient, so that I could evidence having consulted the medical team in case anything went wrong, however I was nervous confronting the consultant about this and worried I was holding up the meeting.

I realised later that day that the consultant had not documented this confirmation. And, whilst I wasn't surprised, this was frustrating and meant that I had to reprioritise my afternoon and the afternoon of the band 5 physio accompanying me for the session.

I later found out that the original consultant had gone home, so I went to speak to another doctor, who was now managing my patient. This time, I specified that I needed written confirmation that she was happy for me to continue with this patient, and she agreed. I went to see another patient, giving this consultant another half hour or so to document our conversation in case she was busy. However, when I returned, there was still no note on the patient's records. I went back into this doctor's office and reiterated my request for documentation, and eventually she wrote a medical note on the patient’s record. I was then able to proceed with the stairs assessment, which has led to the patient's imminent discharge.

Waiting around for documentation led to a significant waste of my time and that of the physiotherapist supervising me, and potentially led to a later discharge for the patient. This could have been avoided if my communication was clearer.

If I had expressed my specific needs in the MDT meeting to begin with. The consultant could have documented our discussion much sooner, saving everyone time.

If I had been clearer with the second consultant that I wasn't comfortable seeing the patient without her documentation, she may have done it the first time I asked rather than me having to try again later and wait.

In the future, I will try to be more concise and specific with my communication within the MDT.

Interesting podcast on delirium

hm6wjcj8d7_ — 2023-11-09 08:35:08 UTC

https://open.spotify.com/episode/7LAWM6WvJsKuqk8RMQv5Go?si=SF8bPRsnT2SmVSre-_3pMg

‘Dr. Matt and Mike’s medical podcast’ - Delirium.

Professor Andy Teodorczuk

Delirium is described here as an acute brain failure.

Prof. Teodorczuk discusses the need for clearer diagnosis of delirium, factors leading to ‘incident’ vs ‘prevalent’ delirium, and ways in which we might prevent and treat it.

Cognitive reserve is described as space in a cup. When the cup fills up and spills over, we see delirium.

Neurodegenerative diseases such as dementia can be masked in their severity by the patient having a high cognitive reserve or high baseline cognition.

Factors that may pre-dispose people to delirium:

Age
Neurodegenerative disease such as dementia
Sensory impairment eg. hearing loss, vision loss
Frailty

Acute causes (PINCH ME):

Pain -

Infection - such as UTI's are a common cause of delirium. Pts may be at higher risk of infection due to certain medications.

Nutrition -

Constipation -

Hydration -

Medication - Perhaps the most common cause of incident delirium in the hospital setting.

Environment - Hospital environment contains a lot of new stimuli which may be confusing for a patient. Patients also frequently don't sleep well in hospital.

25% of ED patients will experience delirium.

Preventing incident delirium:

familiar pictures
family visits
reducing/ minimising/ reviewing medication
Appropriate pain management

First day leading PT for ASU

hm6wjcj8d7_ — 2023-11-20 11:21:44 UTC

Schreier AM. Nursing care, delirium, and pain management for the hospitalized older adult. Pain Management Nursing. 2010;11(3):177–185.

hm6wjcj8d7_ — 2023-11-21 16:14:31 UTC

Patients who received opioid pain relief were more likely to develop mild rather than moderate or severe delirium.

Generally worse pain management seems to cause more severe delirium, regardless of any effects of the pain medication itself, whether that is directly causing delirium or indirectly such as by causing constipation.

One of the reasons older pts are not prescribed opiate medication in the ED is because of the risk of delirium, this study may suggest that pain carries more weight in causing this phenomenon and therefore should be treated as a priority (Nassisi D, Korc B, Hahn S, Bruns J, Jagoda A. The evaluation and management of the acutely agitated elderly patient. Mount Sinai Journal of Medicine. 2006;73(7):976–984 also supports this).

MSD Manual on delirium

hm6wjcj8d7_ — 2023-11-21 22:32:15 UTC

still to read

hm6wjcj8d7_ — 2023-11-21 22:33:12 UTC

NICE guidelines for delirium

Reflection 23/11 - time management

hm6wjcj8d7_ — 2023-11-24 16:22:25 UTC

Today was a busy day for me. Leading on all my patients and seeing around half of them independently, therefore also having to write most of the notes, make several phone calls and liaise with the MDT.

Though I managed to see all of my patients for the day, I ran out of time to finish documenting all of their notes. Furthermore, these notes were more difficult to write as I left them all until the end of the day, when the details of my sessions were not fresh in my memory.

In the future, I will aim to ensure I complete all of these notes so that they don’t spill into the next day’s workload. I will achieve this by:

- discussing with coworkers that I see patients with and splitting these notes evenly after sessions.

- completing notes sooner following each session before moving on to other patients. Eg. Not seeing more than 2 different patients without completing the first note.

(This will ensure that I don’t forget details of my sessions so that documentation is as accurate as possible and will also mean that I have a better idea by the afternoon of how much time I will need/ if I require any help).

Reflection 24/11

hm6wjcj8d7_ — 2023-11-24 16:23:42 UTC

My time management was much better today. I had a similar-sized caseload but was able to manage it well and get all my notes done by delegating and completing notes sooner after completion of a session.

Postictal state

hm6wjcj8d7_ — 2023-11-27 18:43:45 UTC

Will mentioned something today which I wasn't familiar with. It explained the symptoms one of my patients was presenting with and why I was having trouble getting her to engage with physiotherapy, so thought id make a note.

Following seizure(s), patients may experience neurological deficits or psychiatric symptoms. This period between the end of the seizure and the pt returning to baseline is called the postictal period. It can last from less than an hour to days.

hm6wjcj8d7_ — 2024-09-03 14:20:12 UTC

Respiratory Failure:

Type 1: hypoxaemia (<75mmHg) with normocapnia (35-45 mmHg)

Type 2: Hypoxaemia (<75mmHg) with Hypercapnia (>45mmHg)

Type 1: Pulmonary-vascular disease

Type 2: due to ventilation

Arterial blood gases:

pH is the most important factor
If pO2 increases, pCO2 should decrease and vice versa
Describe activity in 2 systems: respiratory and metabolic:
- If one system is disturbed, the other compensates to restore balance
- resp system is quick responding (sec/mins) but metabolic system is slower (hours/days)

is it alkalotic or acidotic? (7.35-7.45)
Look at pCO2. If its acidosis and CO2 is low, the resp system has tried to compensate (increasing resp rate) and therefore the problem is metabolic: metabolic acidosis.
If paCO2 is low during an alkalosis, it is contributing rather than compensating, therefore it is respiratory.
sHCO3 (bicarb) will be high in alkalosis and low in acidosis.
sHCO3 can tell us about duration of a problem, for example in respiratory acidosis with pH outside normal values, if the bicarb is normal, it (the metabolic system) likely hasn't had time to respond, therefore this is an acute respiratory acidosis.
If we have a normal-low pH, but bicarb is high, the metabolic system has had time to compensate, therefore it is a chronic respiratory acidosis.
We cannot live long with a pH outside normal range, therefore nomatter the other values, if the pH is outside 7.35-7.45, there is an acute problem.

Fear of falling

hm6wjcj8d7_ — 2025-03-13 12:00:57 UTC

Wanted to learn more about assessment and management of fear of falling. Got a difficult patient at the moment who has very good strength and balance but is++anxious about falls when completing certain tasks. It has resulted in readmission and is a risk to the patient’s well-being, so I’m hoping to find out more about how I can better manage her condition.

Notes:

look for cautious gait, flat feet, like walking on ice
Falls efficacy scale or Icon FES (more Americanised but more detailed)
Frequency important: ideally 3x per week
Exercise programmes need to include resistance training, and exercising in standing, making the point that although chair based programmes have their place that falls prevention can’t be achieved by this alone.
Graded exposure as part of CBT: “out of 10 how confident would you be doing this without falling” -> add and remove levels of support accordingly and re-Ax.

AMCS

Uni-polar vs Bi-polar hemiarthroplasty

hm6wjcj8d7_ — 2025-06-04 09:46:09 UTC

Was unsure on differences and justification of THR vs uni- vs bi-polar hemiarthroplasty for NOF# patients so did some reading.

(RCT)

Bipolar hemi involves the addition of a secondary articular surface to the artificial femoral head. The acetabulum is not replaced as it is in a THR, but the addition of this secondary articulation reduces motion at the original femoroacetabular joint, theoretically reducing erosion of the acetabulum and perhaps reducing the prevalence of dislocations of the prosthesis.

no difference in complications or hip function directly following op between uni and bipolar.
But acetabular erosion 15% more prevalent in unipolar (20% vs 5%) at 1 year post-op.
Acetabular erosion was significantly less prevalent in patients with a lower BMI.
Bipolar is ~260USD more expensive

Bipolar hemi

hm6wjcj8d7_ — 2025-06-04 09:47:36 UTC

Oxygen delivery/ flow rates 03/09/25

hm6wjcj8d7_ — 2025-09-03 08:55:36 UTC

Room air is ~21% O2

NC:

1L - 24%

2L - 28%

3L - 32%

4L - 36%

Simple face mask:

Max 40-60% on 15L but variable. Should not be used with flow rate of <5L.

Non-rebreathe:

60%-90% on 10-15L.

03/09/25 Interpreting ABGs

hm6wjcj8d7_ — 2025-09-03 09:52:38 UTC

Normal Values:

pH: 7.35 – 7.45
PaCO₂: 4.7 – 6.0 kPa || 35.2 – 45 mmHg
PaO₂: 11 – 13 kPa || 82.5 – 97.5 mmHg
HCO₃–: 22 – 26 mEq/L
Base excess (BE): -2 to +2 mmol/L

Are they hypoxic? Hypoxia is the most immediate threat to life, so best to check this first. (aim for above 10kPa on RA, or 10kPa less than %fiO2 if on oxygen therapy.

Type 1 resp failure: Hypoxic but normal CO2

Type 2 resp failure: hypoxic, with hypercapnia.

Have found it very useful to work through practice cases through this website: ABG Interpretation

Completed approximately 30 practice ABG analyses during CPD time.