STARES #3, Topic: Intervention

SITUATION:
My patient was a 39 year old male diagnosed with severe diabetic ketoacidosis and a subsequent pneumonia after a night of binge drinking combined with Type 1 DM, currently in ICU, sedated and mechanically ventilated on BiPAP. He required physiotherapy intervention to gain a sputum sample and minimise further respiratory complications as well as treating his suspected pneumonia. I saw the patient with my supervisor for a chest assessment and treatment indicated as his CXR showed bilateral infiltrates. Following the assessment we decided the patient would be likely to benefit from manual hyperinflation (MHI), to simulate sustained maximal inspirations (SMIs), and oropharyngeal suctioning.

TASK:
My role in the intervention was to do the MHI prior to suctioning (which my supervisor did) to pre-oxygenate the patient and afterwards as SMIs. It was the first time I had performed the technique on a patient so I was given plenty of practice prior to the treatment.

ACTION:
Initially I practiced 'bagging the bag', that is performing MHI to the bag attached to would to the end which would usually be connected into the circuit to get air into the lungs. This was to practice the action and well as the timing of the technique. Following that, I watched my supervisor MHI the patient for the first few cycles and she also showed me how to connect it into the ventilator circuit as quickly as possible. When I started to perform the technique on the patient my supervisor initially did the timing for me as I got the hang of the action and then I progressed to timing it myself. This was when I began to have a few difficulties. On a couple of occasions I gave the patient to great an inspiration and he began to make a gurgling type noise. Although my supervisor was not concerned and I continued 'bagging' the patient, it made me nervous to know that it was very easy to injure his lungs by giving to large a breath.

RESULT:

The result of my intervention was not harmful or unsafe for the patient as I only held the breath slightly too long and I was under close supervision the whole time, it was more so a good learning experience for me. The treatment did achieve the goal of improved gas exchange as oxygen saturations went up and the patient had greater tidal volumes during the MHI, however these were both only short term changes. There were no detrimental effects to the patient or changes to cardiodynamic stability.

EVALUTATION

As it was the first time I performed MHI on a patient I was not expecting to have perfect technique and timing. From my experience I have learnt a new skill and also learnt a lot more about potential complication of MHI such as barotrauma and volutrauma. As I continued to practice on that patient I was able to adjust my hand positioning to be more efficient and effective as well as improving my timing by getting immediate feedback from my supervisor. I think that my strength was in the position and handling of the equipment where as my weakness was definitely in timing the technique. The aim is for the patient to take deeper breaths than normal however maintain a normal respiratory rate, that is, aiming for 12-16 breaths a minute. By giving my patient too great an inspiratory volume continuously it could have reduced his respiratory rate and reduced his oxygen saturations or a more severe consequence would be permanently damaging his lung tissue. As I only made this mistake a couple of times the intervention was still effective.

STRATEGIES:

Strategies that I implemented at the time included gaining direct feedback from my supervisor and asking questions as I performed the technique to adapt my treatment as I went along. I also used the method of 'bagging the bag' the bag again to improve my positioning and timing which was helpful despite the bag having far more resistance than normal lungs. Another method I used was to count in my head as my supervisor was performing MHI on the patient to cement the rhythm in my mind. After I had finished treating the patient, that night I went home and revised my notes on MHI as well as ventilator hyperinflation (VHI), especially taking note of the signs and symptoms that suggest adverse effects. Furthermore I revisited my information on the complications of the technique and when it is indicated to perform it. For my few days left on placement, whenever I was given the chance to go down to ICU, I asked my supervisor if she had any patients appropriate for MHI as I wanted gain as much experience with this technique as I could and hoped to be able to feel a variety of different lung compliance on various patients. I was able to perform MHI again, however only a couple more times but I felt that when compared to my first attempts, my technique had definitely improved.

STARES #2, Topic: Risk Management

Situation:
I was asked to do a chest review a 69yr old female just transferred out of ICU, following a Hartmann's procedure for a perforated bowel and diverticulitis complicated by multiple washouts of the wound as the patient was also septic and the wound infected. However, at day 8 post-op the main challenge for me during my assessment was the number of attachments this lady had. These included an IDC, CVC, NGT, IV line (for fluids and ABs), stoma bag, vac dressing on the wound, a wound drain and O2 via HM. Not only was it important for me to understand what each was for but also where they entered the body and which side of the bed they were on. This was my first experience with multiple attachments and an excellent learning curve in the principles of risk management.

Task:
My task in this situation was to safely assess this patient’s chest and bed mobility taking into account all of her attachments and also pain levels. This was necessary to best direct treatment but also important for me to develop the skills of organisation, awareness and planning ahead when it comes to attachments.

Action:
The patient was resting in bed when I arrived and after checking her observations chart and assessing the environment, I continued with my assessment. I began with the subjective which was relatively straightforward as I was able to raise the bed head up so the patient was more upright and better eye contact could be made. Following from the subjective, I began my specific chest assessment. To my surprise, even just getting the patient to use a pillow for a supported cough proved challenging. This was due to the increased pain levels at the incision during this and the fact that with the cough, the stoma bag began to leak slightly. After informing the nurse and getting her to empty the bag I continued with the assessment. I went on to auscultate, anteriorly, as asking the patient to lean forward to get behind placed a lot more pressure on the wound. The next part of the assessment was bed mobility. This included rolling, bridging and then transferring from supine to sit over the edge of the bed. Rolling and bridging were ok as the attachments were able to stay as they were as they were long enough to withstand the movement. Before assisting the patient to sit up over the edge of the bed, I move all of the attachments around to the side we were getting up on and then instructed the patient on the movement. However, I had moved all but one attachment over. Her IDC, which was tucked under a sheet, remained on the other side and with movement pulled slightly on the patient, although luckily didn’t dislodge. After moving the patient into sitting, she was very fatigued and didn’t tolerate the position for very long and so it was decided to continue the mobility assessment the next day.

Result:
The result was a less than perfect assessment of this patient as a result of ineffective risk management. Not only did the patient experience unnecessary increased levels of discomfort but also if anything had been dislodged there would have been a high risk of infection to the patient as well as staff with body fluids exposed. Despite the poor risk management and sub-optimal safety aspects, the assessment was completed and a good rapport still established with the patient who was very understanding that this was one of my first complicated patients, luckily!

Evaluation:
As a first attempt of dealing with multiple attachments although there are many areas for improvement, in terms of assessment skills, I believe they have improved immensely since the start of my placement. On reflection however the main areas I need to improve are, checking IDCs and stoma bags prior to assessment to make sure they aren’t overly full, ensuring that all attachments are on the side of the bed that I am moving the patient towards and being careful not to compromise IV lines and catheters with movements. This all requires a high level of planning ahead and assessing the environment prior to commencing a session.
Had I checked the stoma bag prior to assessment I would have noted it was very full and could have got the nurse to empty it before I commenced, avoiding patient’s discomfort and embarrassment as well as an awkward situation for myself.
Similarly, I increased patient discomfort and also risked dislodging the catheter because I didn’t check thoroughly that all the attachments were moved. If it had dislodged it would have meant a lot more work for nursing staff, patient discomfort and also risk of infection with urine exposed.

Strategies:
Strategies I have used sine this incident to improve my knowledge and handling of patients with many attachments have included familiarising myself with the attachments and any specific precautions relevant to each. I have also discussed with my supervisor the possibility of having more exposure to these types of patients. Furthermore, I have now adopted a systematic approach to entering a patient’s environment and managing ant potential risks, being extra cautious with complicated patients. Another method I have employed has been to enlist the assistance of nursing staff. Communication with the nursing staff has been an excellent help as they are aware of the specific patient and their individual attachments. They also have been more than happy to help with attachments when mobilising patients. Since the above occasion I am pleased to say I have greatly improved in my organisational skills in terms of setting up the environment as well as managing a wide variety of patients.

STARES #1, TOPIC: ASSESSMENT

SITUATION

Auscultation is an assessment technique that I quickly realised needs to be finely tuned on a cardio practical. Auscultation has been used for every patient I have seen this past week with a variety of conditions, from pneumonia and post-surgical patients to suspected pulmonary embolism. It is essential that this technique is effective to determine the severity of a patient's condition, how best to focus a treatment as well as whether the treatment has been effective or not.

TASK

Prior to this placement my auscultation skills were probably not as good as they should have been and on my first day when I was asked to auscultate a 66yr old male with left lower lobe pneumonia patient I didn't feel adequately prepared. It was used in this circumstance as part of my initial objective assessment to then determine the most appropriate treatment technique.

ACTION

I began by instructing the patient to cough and clear any secretions and then disrobed the patient appropriately so I wasn't auscultating through clothing. As the patient was slightly short of breath I chose to auscultate posteriorly as it was more accessible with less soft tissue that may obstruct the technique in case the patient wasn't able to tolerate all of the deeper breaths. I began at the bases posteriorly as this is where he was likely to have abnormal sounds. I instructed the patient not to talk during the auscultation and to take slightly deeper breaths in than normal. I compared the left side to the right systematically as I went along, segment by segment to determine if there was any differences between sides, listening to two breaths at each point. As I had thought, my patient became increasingly short of breath with the auscultation so I completed the posterior assessment but felt it was unsafe and also would be uncomfortable for the patient to continue.

RESULTS

My patient had fair breath sounds and bilateral crackles at the bases with the left worse than the right. This suggested that there was some sputum retained within the lungs especially at the left base, confirming the results of the CXR and the diagnosis.

EVALUATION

My technique was certainly far from perfect. Although I had remembered and implemented most of the theoretical knowledge, my practical skills were lacking. I auscultated too many points posteriorly, which probably contributed to my patient becoming quite SOB. As well as this, I began my auscultation too inferior and so my interpretation was less accurate as what I thought was reduced breath sounds was as a result of no lung tissue being where I was auscultating. Despite a few mistakes I was able to auscultate and gain the correct findings when compared to what my supervisor had heard, apart from the breath sounds. Another area where I was unsure about was what the different sounds actually reflected. I knew that crackles could be from sputum or the reopening of collapsed lung tissue but I didn't know how to clearly differentiate between the two. I now am aware that it is the quality of the crackles, coarse or fine, as well as whether they were heard on inspiration or expiration that determines this. That is, despite reaching the desired outcome, my technique was inefficient, with much room for improvement.

STRATEGIES

With feedback from my supervisor on board I went home and revised surface anatomy of the chest, listing key landmarks to assist in orientating me to exactly which lobe I'm auscultating. I also re-read the information regarding interpretation of findings and what the different abnormal sounds. I have since gained more practice in auscultating and feel far more confident in my ability to assess and interpret the results. I have also asked my supervisor to watch me auscultate again and give me feedback which was very helpful and positive with great improvement after only a few days. I will continue to practice my auscultation daily to further develop and fine tune my ability and hopefully get to listen to some interesting chests with more than just a little consolidation!

PRAC 1: Initial entry

My initial thoughts on finding out that my first placement was to be cardio based were that it would be great to be able to put into practice all the things that we learnt only last semester into practice while they were still fresh in my head. However, coming back after such a long break and after revising our cardio material this week I am getting more and more nervous about the placement and what the expectations of me are going to be as it's not as clear in my head as I thought it would have been.

Furthermore, I don't know what ward I will be on yet so have been fairly general with my revision which I hope will keep me in good stead, but if I get quizzed on the specifics of ICU patients day 1 I would be feeling quite unprepared.


In regards to expectations of myself on placement I am certain that professionalism and time management skills will be expected from day 1. In terms of knowledge I know that I must be confident in applying and reasoning a cardiorespiratory problem list as well as taking into consideration cardiac and respiratory conditions as well as other co-morbidities such as diabetes, when assessing and treating patients.

I have some great feedback from the clinical mix forms from other students who have been at my same facility which has been really beneficial in my preparation. From this information I have gathered that I will definitely be exposed to a lot of COPD and pneumonia patients, plenty of patients with chest infections on top of other co-morbidities and potentially post-op patients whether that is cardiac surgery, abdominal surgery or head and neck surgery. It will be essential for me to therefore be aware of the effects of anaesthesia on the respiratory system, the effect of pain and side effects of narcotics often used to manage post-op pain.

On top of this, working in a hospital with potentially very unwell patients it will be crucial to be aware of all the safety aspects that will be necessary to monitor and check when assessing, mobilising and treating a patient. This includes things such as checking a patients obs chart, noting medical results, e.g. haemoglobin levels as well as checking all attachments are functioning and are not interrupted by physio treatments.

I thoroughly enjoyed working in the private hospital setting on my last prac and it will be interesting to compare and contrast that with working in the public sector. I also am looking forward to again being a part of a MDT which I found a very useful tool last year to gain further insight into a patient's problems as well as expressing my own ideas and opinions in a forum of other health professionals and getting feedback from people with expertise in a different field.

Although I’m nervous at the moment I feel that I am well equipped to take on my cardio prac on Monday and all the challenges that come with it and can't wait to apply the many principles and techniques I’ve learnt so much about.

Final entry - review

I have thouroughly enjoyed this placement and now realise that although initially 'thrown in to the deep end', it made me become more confident in my own ablilities in the long run and develop much better skills in assessing and treating patients than if I had been only observing my supervisor.

I feel that I have improved my time management skills and ability to communicate my opinions and views with other members of the multidisciplinary team. My role in discharge planning has also made me far more aware of the team work that is required in planning when a patient can be discharged.

I learnt far more from this prac than I had imagined I would as in the rehab setting you are able to see a real variety of cases from orthopaedic to cardiorespiratory and musculoskeletal on top of the relevant gerontology issues.

Topic 3

Situation
The situation was such that I had a patient who was needing to be weaned off oxygen therapy in the rehab environment to assess whether or not he would be required to have oxygen therapy in his home following respiratory failure from AAA repair. The patient was 78yr old man who was previously completely independent in ADLs, ambulating without aids and still driving.

Task
The task was to measure his O2 saturation levels during physio sessions with decreased oxygen therapy (cont via NP) than prior to his rehab admission. As he was able to maintain his O2 sats above 90 during exertion the oxygen was to be removed.

Action
I completed a 6mwt with this patient initially, with him on 2L continuous O2 via NP, and after 3mins his saturation levels decreased to 88 so he was unable to continue walking the finally 3 minutes. A week later, after daily PT of ambulating, seated cycling and LL strength exercises, I re-assessed the 6mwt. The patient had been of O2 therapy during the day for the 3 days prior and off oxygen at night for 1 night.

Result
The result of this test was a much improved total distance at the conclusion of the test and on RA the patient's SpO2 levels remained between 92-93 on exertion. These were measured using pulse oximetry. He also had a lower maximum HR and a lower BORG rating of shortness of breath.

Evaluation
This reflects a positive outcome and suggests that my intervention of a PT program aiming to improve CR fitness and endurance assisted this patient in being able to maintain adequate O2 levels during physical exercise. However, this result can not simply be attributed to physio input but also nursing and medical management of the patient. During this process I realised the necessity of communication with nurses and doctors about the change in oxygen therapy the patient was to receive.


Strategies
Next time I feel that I may have been able to acheive the desired outcome earlier by using a gradual decline in O2 therapy rather than dropping the patient straight from 2L cont O2 throughout the day and on exertion to just RA. Perhaps it would have been more beneficial to the patient to have had periods during the day when he was at rest where the oxygen could have been removed, ensuring that SpO2 levels were regularly assessed.

Entry 2:

Situation:
I had a patient today who is a 97yr old man, admitted into the rehab unit 2 days ago after being in an acute ward following a postural collapse. He was mobilising with a wzf but at home was using a 4ww over a distance of 30m. His goal was to go back home and to do this he needed to be able to walk I with a 4ww over the required distance. His BBS was 33/56.

Task:
The task for me has been to improve his mobility so that he is ready for discharge when all other allied health and medical goals have been met. To achieve this I needed to make sure he was safe and independent on the wzf and then progress to a 4ww, ensuring that he was safe on that with stand-by assistance initially and then independently.

Action:
Day 1 treatment included assessing his ambulation on the wzf and also aiming to improve his dynamic balance reactions. Day 2, the patient was loaned a 4ww to ambulate with on the ward and reminded of extra safety precuations involved with having 4 wheels. Since the patient is so old it is expected his balance will improve sigificantly and the fact that the reason for his admission was not related to his poor balance, the main goal prior to discharge is to return the patient to his previous functional mobility level.
Communication was also another important aspect of this intervention as when a patients mobility status on the ward is changed it must be documented in the progress notes, changed on his bedside chart and the nurses need to be made aware of the change.

Result:
The result of my intervention has meant that the patient is now ready for discharge from a physio perspective and is mobilising at the level he was prior to his hospital admission.

Evaluation:
My actions in this situation were very effective and met the desired outcome of the patient being ok for discharge in terms of mobility. Ensuring good communication with the nursing staff is also essential and I made certain all the requirements of a mobility status change were met so all staff were aware.


Strategies:
I used the strategies of goal setting, communication with patient and staff and effective assessment and planning to ensure this patient was ready for discharge as soon as possible.