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.