Final Entry Placement 4 – 2013

Prior to arriving at this placement I felt insecure about my ability to fit in and apply my Australian learnt skills in an English setting. I had already struggled during the year to adjust to an acute respiratory ward in Australia and was determined to have a flying start at this next placement. I had concerns the foreign environment would get the better of me and the five weeks would be up before I had a chance to settle and work efficiently and effectively (with consistency).

All my insecurities were compounded on the first day when I was assigned to a mental health ward within the geriatric population. I was working on the ward with my supervisor and another student who was finishing up that week. On the first day, patients were hitting staff with their frames, bashing the windows and generally being aggressive. I remembered back to the lecture given by our clinical co-ordinator on patients with mental health and realised I was now in the thick of it. My first nights reading consisted of revision of the various types of dementia, how they are diagnosed and how best to treat a patient’s mobility problems with these issues.

The other student and my supervisor were of great help in showing me subtle techniques to gain subjective and objective information from a patient and when to back off and try and get some collateral history from relatives or care homes. All my fears and concerns disappeared within the first few days as I realised the ward acted a bit more like a family and that I was accepted into the fold. The level of care and concern given to each patient was unprecedented from the consultants to the janitors. This was at a time when the UK health system was under fire for staff cuts and poor service reports. The heat wave (and lack of air-conditioning) had everyone at boiling point and somehow the staff in this area made it work.

The dreaded “discharge option” was a major hurdle for me prior to this placement and I continued to struggle. When some patient’s have limited capacity it adds to the complexity and decisions need to be made in the patient’s best interest. The discharge options were carefully explained to me as well as various sections of the mental health act. Deciding that a person is incapable of making rational and clear decisions about their future is extremely difficult for medical staff and families and was an incredible eye opener for me wanting to work in aged care, not in a negative way but defiantly knowing that I would have to increase my learning on the subject.

The hospital is attached to the local university and is essentially a learning hospital. That means that all the staff are trained at giving instruction and feedback to optimise the students learning as well as provide care to the patients. I was able to conduct a few respiratory assessments and treatments with my supervisor as well as gain experience on neurosurgery wards with a top class Bobath instructor (thank you Ali, I managed to answer some ‘on the spot’ questions).

Despite all the obstacles this has been a truly rewarding experience that will add to my overall ability as a holistic physiotherapist.

STARES Entry 3 – Treatment - Placement 4 – 2013

Situation

Forth week on a health care of the elderly placement in England. My supervisor is a respiratory specialist and is requested to attend another ward to assess a patient with a declining respiratory condition.

Task

Gain information from the integrated patient notes (IPN) and present the situation to the supervisor. Depending on the circumstances, I will be expected to assess and treat the patient at the bedside.

Action

I gain from the notes the patients current medical condition as well as relevant past medical history and social history. The female patient in her late seventies was admitted for dehydration following an episode of vomiting (gastroenteritis). The patient subsequently aspirated and developed a lung infection. Her condition deteriorated rapidly and she had lost consciousness. Her family had been notified that she was palliative care only as all other medical interventions had failed. Our role as physiotherapists was to assess her current condition and treat any impairment for comfort only. I passed the information on to my supervisor who suggested we observe her bedside and then discuss treatment.

When we entered the room we were greeted by one of the patient’s sons. The patient was unconscious on the bed positioned at 45˚ with a nasopharyngeal tube inserted and a Hudson mask supplying 10L O². I assessed the patient by visual observation and then by listening to her breath sounds. The airways were obstructed by evidence of loud audible bronchial fremitus. I auscultated the anterior segments of the patient’s chest, which had decreased breath sounds throughout with a projection of the bronchial fremitus that was heard earlier. The patient’s SPO² was 85%. I informed my supervisor of the findings and we excused ourselves to formulate a treatment. My problem list for the patient from the evidence was impaired airway clearance and decreased gas exchange. My treatment options were to suction the patient to improve airway clearance. This would hopefully improve the gas exchange as other measures where not viable at this point. My supervisor agreed that this was the best course of action but stressed that I should gain consent from the son as the process can be distressful. My supervisor demonstrated the procedure to me in the storage room and said he would conduct the treatment first and I could follow for a second treatment. We gathered the necessary equipment and returned to the patient’s bedside. I explained to the son that his mother had an obstructed airway and that we wanted to treat her for her comfort. He agreed and remained in the room. My supervisor then prepared the suction tubing and adjusted the suction to the required level. He inserted the suction catheter into the nasopharyngeal tube until he reached the carina and then slowly extracted the catheter removing large quantities of blood stained green mucus. Once he had completed the procedure he instructed me to repeat the treatment. I used single use gloves and removed the suction catheter from the packaging. I then connected the catheter to the vacuum and checked the pressure was at 20kPa (maximum prescribed). I inserted the suction catheter into the nasopharyngeal tube but found it difficult to know how far to insert the device. My supervisor instructed me by indicating at markings on the tubing and suggesting (discretely) the end feel I was looking for. I reached the carina and began to extract the tubing. Large quantities of bloodstained green mucus was extracted and I wrapped the suction catheter in the glove and disposed of it.

Result

The patient no longer had an audible bronchial fremitus although the SPO² remained low at 84%. I replaced the patients Hudson mask and ensured the O² flow was as 10L. We advised the son that we had completed the treatment and excused ourselves. My supervisor advised me that the bloodstaining was most probably a result of the nasopharyngeal tube insertion and that this would probably be removed to allow a more dignified passing for the patient and family. I wrote up the assessment findings and treatment session in the IPN’s and we returned to our ward.

Evaluation

I felt my communication with the family member had been compassionate yet professional and my supervisor agreed that he felt I had handled the difficult task with a professional attitude. My handling of the suction catheter and the depth required were not precise, but as this was my first attempt I felt with additional reading and subsequent treatments this would improve.

Strategies

Better understanding of suction catheter minimum and maximum pressures (8-20kPa)

Knowledge of contraindications (stridor, severe brochiospasm or pulmonary oedema) and precautions (clotting disorders or airway surgery) to suctioning.

Improve handling techniques of suction catheters by practicing with gloves and spare suction tubing.