Assessment STARES 2 – PLACEMENT 4 2013

SITUATION

Week three on a dementia ward at a large tertiary hospital in the UK.

TASK

Initial assessment on an 82-year-old gentleman with a background of dementia who was initially admitted on another ward with a diagnosis of dehydration. The patient had subsequently had a fall with a bump to the back of the head and a laceration on the right forearm. Although no adverse behavior was noted, the patient is transferred to our ward, which is more specialized to dementia patients.

ACTION

I receive a hand-over from nursing staff, who stated the patient appears unstable on his feet but determined to walk independently with no aids.  I check the patient’s medical history, which stated the patient had been previously independent using a stick and living at home with his wife. I noted the falls incident report and that the last physiotherapy entry prior to the fall had cleared stated he was back to baseline and required no further input. The doctors on the ward have not had a chance to review the patient. I approach the patient’s bed and check his most recent observations, which are stable. 

I introduce myself to the patient who is sitting up in bed. I begin my subjective questioning by asking if how he is feeling and if he has had any falls recently. The patient confirms that he has had a fall the previous evening. He also confirms that he usually walks independently with a stick and he lives with his wife in a two-story home. I am finding the patient coherent and orientated so I progress with the mobility review. I check the patients sitting balance, active range of motion (ROM) and strength. During the ROM assessment I notice the patient appears slightly ataxic so I conduct the finger-nose and heel-shin test. The patient displays significant past-pointing and is unable to complete the heel-shin test due to an inability to follow the instructions. I feel it is safe to attempt a stand so I instruct the patient to stand up. He completes this task safely but requires support from the bed to maintain balance. As I get him to step forward the patient becomes unsteady. I sit the patient back down and ask if he is feeling okay. He tells me his is fine and that he would like to check on his car. I ask where his car is and the patient starts to become confused and agitated. He is no longer orientated to time, person or place. He believes that his wife has just been in and he still has the car keys. I ask if he knows where he is and the patient states that he is in a room. I ask if he knows he is in hospital, which alarms him. The patient stands up and begins to walk, saying that he has to leave. I manage to get a frame from another patient’s bedside and convince him to lean forward and use the frame as support. The patient agrees stating that he uses one at home. I request assistance from my supervisor who is close by and we are able to ambulate the patient with use of the frame. I ask the patient to demonstrate a turn with the frame and return the patient to his bed. I ask the patient to remove his shoes and return to bed. The patient removes one shoe and then replaces it, and then lies himself diagonally across the bed. When I ask if he could position himself in the centre on the bed he is unable to co-ordinate the movements to complete this task. I assist the patient to the centre of the bed and raise the bed head. I thank him for his time and update his mobility chart to mobilize with frame and two assist. I make comment that mobility could be variable, with the patient being impulsive and unstable. 

I inform the nursing staff that the patient is a falls risk and must not mobilize without a frame and 2 assist. I liaise with the medical team prior to their ward round and inform them of the patient’s mixed historical accounts, unsteady gait and expressing a wish to leave the ward. I enter my initial assessment findings in the integrated progress notes with a plan to gain collateral history from family members and follow up on any new medical findings.

RESULT

The patient continues to display erratic behavior throughout the day displaying signs of short-term memory loss, ataxia and dyspraxia. The medical team requests a CT image of the patient’s head and a full blood screen and urine dip.

EVALUATION

My assessment of the patient’s mobility was effective. I knew that a fall the previous evening and the information from the nursing staff indicated another fall could occur. Having had experience on the ward with ‘variable’ patients, I was able to adapt and guide the session without completely distressing the patient. I was able to re-assess the patient’s mental state when I realized that his cognitive ability had changed. Where I feel I was unclear on reflection, was the patient presenting with new symptoms post fall, secondary to a possible urinary tract infection (UTI) or as a complication from his dementia. On subsequent discussions with the consultant, the differentiation is very difficult to define clinically. The combination of the fall and a UTI could temporarily added symptoms to his dementia, but currently the patient does not have capacity and needs to remain on the ward. A collateral history from caregivers would give a better insight into his current deterioration. Further physio input may be required to help prescribe walking aids or mobility strategies.

STRATEGIES

Being extra prepared is important on a dementia ward. Make sure to check the surroundings, have additional mobility aids close by and staff close by if assistance is needed. Knowing the patient's background and the multiple complications that go with dementia and the risks of anonther fall

Placement 4 - Stares Entry 1 - Assessment

Situation

Day three on a gerontology ward. The physio department is understaffed and my supervisor and I are requested to assist on another ward where some patients have developed respiratory complications.

Task

Assess and treat (if appropriate) a 68 year-old male with prostate cancer and secondary bony metastasis who has developed hospital acquired right-sided lower lobe (LL) pneumonia.

Action

I checked the recent chest x-ray (CXR), which showed opacity in the right-sided lower zone, suggestive of consolidation in the lung tissue from the pneumonia. A recent blood test showed elevated white cell count (WCC) of 13, and there was an increase in the patient’s temperature on the nurses observations of 38.3˚ C, both indications of infection. The CXR, WCC and increased temperature are a good indication that pneumonia is present. To complete the picture with my assessment I am expecting to see decreased chest expansion on the right side, decreased breath sounds right LL on auscultation and a moist productive cough with purulent sputum (if produced).  Respiratory rate may be higher and, depending on O² delivery, SpO² could be decreased. I made sure the stethoscope was clean and I wore gloves to ensure safety for the patient and myself. On entering the room the patient was positioned at 45˚ sitting up in bed but slumped down, slightly grey and drawn in appearance and very drowsy. He was attached to a Hudson mask on low flow O² delivered at 10L (98%) with cold humidification. I introduced my supervisor and myself to the patient and informed him that we were from the physiotherapy team. I explained that part of our job was to assess and treat patient’s chests if they needed it. He gave his consent and I began by placing the SPO² monitor on the patient’s finger. His saturation was at 98% on the current O² delivery system. I began the subjective by asking the patient if he had any difficulty breathing or if he had any pain. The patient denied any pain but stated he felt short of breath. He appeared to be gasping for breath a little and I decided not to ask the modified Borg to quantify the SOB because he did have difficulty speaking. I asked the patient if he had been coughing at all, to which he shook his head. I asked him if he was able to cough. He nodded and gave a moderate effort cough that sounded dry and non-productive. The patient said that he felt “squeaky” when he breathed. On auscultation the patient had decreased breath sounds bilaterally in the lower lobes R>L, and course bronchial breath sounds in the middle zones R>L. Chest expansion was decreased on the right and respiratory rate was 24 bpm. As the patient was complaining of dyspnoea, I decided not to attempt to ween the O2 but rather treat with Active Cycle of Breathing. This technique combines relaxed breathing with thoracic expansions and either a huff or a cough. Hopefully this would relieve the breathless feeling and perhaps loosen some secretions in the lower lobes. The relaxed breathing seemed to calm the patient and his respiratory rate lowered. I palpated the patient’s chest as he took three deep breaths and his expansion was slightly improved on the right. After a few failed attempts at a huff, the patient managed a good effort followed by a cough, which was strong, moist and productive, nil sputum. On re-auscultation the patient no longer had bronchial breath sounds but a loud wheeze on exhalation. I asked my supervisor why this was and he informed me that occasionally the ACBT could cause bronchiospasm in some patients. We repositioned the patient to be more upright (less slumped). We checked the patient’s medical chart and he had salbutimol (ventolin) nebulisers prescribed as required. I requested that the nursing staff organise the nebuliser as soon as possible to prevent any further respiratory complications. We left the patient with the nursing staff to complete the documentation. The ward physio was informed and could contact us if further treatment was required.

Result

Although I had created a bronciospasm thereby introducing another problem for the patient, this was easily reversible with medication as we confirmed later in the day. I had taught the patient how to reduce his shortness of breath and improved his cough effectiveness. On follow-up the patient would hopefully be responding to antibiotics and would be able to be sat up out of bed or even mobilised.

Evaluation

Although the patient was very unwell, I was able to modify my assessment and I feel I made a good connection with him as well as improve his quality of breathing. The added airflow limitation was unexpected and I will show more caution in future to take treatment slow and re-assess regularly during the session. A big issue I have been struggling with is time management and have begun to rush my sessions. This was a good example of when extra time should be taken to give extra care to the patient. Although he was acutely unwell he still had the ability to be understanding and kind to a student physio. I should have watched the clock less and watched the patient more.

Strategies

Variations in the patient’s condition can occur at anytime during treatment. Be prepared to re-assess all components and know how to treat any outcome if physio indicated, or refer if needed.

Initial Entry – Placement 4 2013

On this next placement I have traveled over to England to gain experience on a geriatric rehabilitation ward at a University Hospital. I am relieved to be returning to some familiar territory after being in a more acute setting on my previous placement. Although my confidence is a bit down, I feel I am much better equipped to deal with and overcome a variety of challenges that come with working in new and unfamiliar environments. One of the skills a physiotherapist must possess is the ability to quickly adjust to the requirements of the facility they are working in while still applying the fundamental rules of assessment, analysis and treatment.

One of the biggest mistakes I have made this past year is assuming that a placement will be a learning environment. This is not the case always the case. Placements are working environments that accept students to actively participate. Some learning does occur but it is mainly to put theory into practice. Much more emphasis is then placed on getting a work habit established within the first week so as to maximize your working knowledge of the area over the remaining weeks. This will be my main focus during this placement. I am expecting to build a caseload and work independently as if I were employed by the facility.

I will be unfamiliar with the various discharge options available so as early as possible I will discuss this with my supervisor and find out what the protocols are. I am expecting there to be a similar setup with nursing homes, transitional care facilities and rehab in the home available. Returning patients to baseline is not always a realistic goal with the geriatric population and compensations need to be considered early. “Rehab potential” has been difficult for me to assess in the past as I always strive for optimal outcomes and never want to consider “no potential to improve”. The healthcare system is cost based however and these hard decisions need to be clinically reasoned and made in order to provide service to those who may benefit from it more.

Most physiotherapists that I have encountered in the past have one thing in common – the love of learning and being able to adapt to new research based techniques. I am hoping that as much as I learn I can also give back in the way of perhaps demonstrating some differences in assessments and techniques and seeing what works best with different patients. This could prove tricky and I am going to take this as it comes. I don’t want to constantly be saying “we do things differently in Australia”. From speaking with the various lecturers that studied in the UK, most aspects are very similar with only minor differences.

I am excited about this learning experience and feel proud to be representing the university abroad.