Stares 1 - Assessment - 2013

Situation

Week one conducting mobility and respiratory assessments in a secondary hospital rotating between surgical ward, medical assessment ward and ICU.

Task

Conduct an initial respiratory assessment in an outpatient setting. Provide the client with information about their condition and implement airway clearance techniques. Determine the suitability of the client to join a pulmonary rehabilitation class run at the hospital.

Action

I looked at the patient file in regards to the referral and any previous admissions to hospital. The client had been a patient 3 months prior for IV antibiotics to control an infective exacerbation of COPD. This had progressed to hospital in the home and she was soon after discharged from care.

I greeted the client in the outpatient lounge and escorted her to the treatment room. She seemed agitated and out of breath. When I enquired if she was all right she stated she had rushed from the car park (approximately 30 meters) and it was her normal exercise tolerance.

Once she felt comfortable and rested I conducted the subjective history gathering that she had a 40-pack year history and had quit 10 years prior. Her husband works away but she has supportive family and friends that live close by. Her respiratory physician had informed her that she had emphysema and bronchiectasis.  She was a little unsure of her condition and her husband was concerned and anxious because she would wake up in coughing fits during the night. She reports 2 specimen jars of sputum on a good day. She had been prescribed Seretide and Ventolin as well as Predisterone to manage her condition.  I asked if she could demonstrate the use of her Ventolin inhaler which she did. Her method showed very little inspiratory effort and I corrected her with education about deeper breaths allowing the medication to go deeper into the bases of the lungs. Her second attempt appeared more successful and gave her more relieve from her shortness of breath symptoms. I informed her that the Ventolin should be used before the Seretide inhaler as this would maximize the effect of the medication. I discussed with the patient the pulmonary rehabilitation class that was run at the hospital with physiotherapy staff and she seemed interested to participate. She was having two week holiday with her husband starting the following Saturday but would like to begin after that. I excused myself to consult with my supervisor before beginning the objective history. My supervisor checked over the history and Okayed for me to begin the objective and treatment if all measures were in normal range.  I gathered the SpO2 monitor and a saline bottle and tubing to construct a bubble PEP devise.

I returned to the client and placed the SpO2 monitor on while discussing her goals. She informed me that she babysits her grandchildren and would like to have more energy to keep up with them. She would also like to be able to walk the dog again without feeling anxious or excessively out of breath.

Her SpO2 is 96% and he pulse rate is 98bpm. On auscultation she has decreased breath sounds throughout with course inspiratory crackles bilateral midzones.  Good chest expansion left=right. Cough was strong, moist and productive of ½ tablespoon green sputum (M1-P2). The client reported feeling that the sputum was sticky and she was finding it hard to clear. She became anxious and short of breath and I asked her if she could try and control her breathing. She was able to do this and I put together the bubble PEP device and explained its use in splinting open the airways during exhalation to allow a greater gas exchange, mobilize secretions and reduce the feeling of breathlessness. She tried the device and after a couple of false starts she got the hang of it. After two cycles of relaxed breathing followed by bubble PEP she spontaneously began to cough. She produced two table spoons green sputum into a tissue and then reported feeling like her chest was better. Her SpO2 remained at 96% but her pulse rate had reduced to 88bpm. On re-auscultation she had no added sounds. I handed some education pamphlets onto her, described various postures and sleeping positions to alleviate her symptoms as well as some home care advice for her bubble PEP device. I rebooked her for the following week and introduced her to the coordinator of the pulmonary rehabilitation group.

Result

The patient had been able to clear her airways after a few cycles of controlled breathing with bubble PEP. Her mood and attitude toward her condition seemed improved and the use of her medications had been optimized.

Evaluation

I was happy with my performance as an educator and health professional and felt I had made a difference to someone living with a chronic illness.

Strategies

Knowing more about how to describe the conditions to the patient in layman terms would have been useful as I feel I avoided this topic and passed over less personalised printed material.