STARES 2

SITUATION:

A 69-year-old patient was brought in by ambulance to the emergency department, presenting with infection of a pacing wire, left insitu following heart surgery in 2009. After removal of the wire in theatre, he was transferred to the cardiothoracic ward for monitoring. The patient was initially flagged by the nursing staff for a physiotherapy mobility review only. My supervising physiotherapist reviewed the patient and deemed him inappropriate for further physiotherapy input prior to discharge as the patient was complaining of significant pain that limited any mobilisation. As this patient was of low priority it was documented that he would only be seen by physiotherapy on request or for discharge planning.

The following day the patient was reviewed by occupational therapy that requested a mobility assessment from physiotherapy as the patient’s pain was now controlled at a manageable level and was now able to mobilise and actively participate. The patient was normally ambulant indoors with a walking stick and outdoors with a 4ww. He lived with his wife in a single storey home and had nil complaints of pain, SOB or coughing during my assessment. His main complaint was a marked tremour in his upper limbs that was a new presentation since being in hospital and had increased significantly over his admission. He also appeared mildly confused, repeatedly asking what day it was, mixing up his wife’s name and unable to remember his address.

TASK

It was my task to use my assessment findings to establish the patient’s mobility and level of assistance required and to undertake this in the safest possible manner. From this I was to begin appropriate discharge planning in collaboration with the other members of the disciplinary team.

ACTION

After gathering relevant information from the medical and nursing notes, as well as subjectively from the patient, I then gathered relevant aids including a portable IV pole, SpO2 monitor and WZF in anticipation of ambulating the patient down the corridor to assess his mobility and ambulation tolerance. I began formal assessments with a quick cardiorespiratory assessment, which was found to be clear. The patient’s main complaint throughout his stay had been pain in his lower limbs, which was unremarkable at the time of my visit. From gathering this information I deemed it appropriate to further assess the patient’s mobility and attempt a walk. For cautionary purposes, I had Kendall assist me in getting the patient up for the first time. We first got the patient into sitting, where he displayed good independent sitting balance, though had an evident tremor in his upper limbs at rest. The patient remarked on this as abnormal, though felt comfortable to continue. On standing the patient’s tremor increased and now incorporated the trunk. The patient tolerated standing for less then 10 seconds before his legs gave way and we guided him back onto the bed. I reassured the patient that he had done nothing wrong and that I would consult the medical team in regards to the increasing tremor. We got the patient back into bed and reassured him once again. I then consulted the medical team in regards to the origin of the patient’s symptoms and documented my actions and findings.

RESULTS

As a result of my assessment, I deemed the patient unsafe to be transferred at this time as the tremor impeded his ability to stand independently or even with the maximum assistance of 2 people. I notified his nurse of what had occurred and my suggestions for transfers. I then consulted the medical staff with my supervisor to discuss potential causes for the patient’s symptoms. I deemed it appropriate to regularly monitor the patient to report back on any improvement or decline in status to aid the medical team in their treatments. The nursing staff and medical team found my findings and input very helpful in their treatment of the patient. My supervisor was also satisfied with my consideration of safety and my collaboration with the team to benefit my patient.

EVALUATION

In this situation my emphasis on safety of the patient and my decision to proceed with caution and recruit Kendall to assist me, was appropriate and necessary. Also my communication with the patient and ability to establish trust and rapport was to my credit in that the patient felt confident in my ability, confidence that was maintained even after the patient had lost his strength in standing and was guided back into sitting.

Working in collaboration with fellow members of the team was fundamental in this situation, as it required a combined understanding and effort in order to identify the underlying cause of the patient’s symptoms.

One thing to work on is awareness of medication side effects, in that this patient was on a few medications that could potentially have the side effect of shaking. Even though the patient had been on these drugs long term, other new drugs could be influencing their action.

STRATEGIES

Obviously emphasising safety in every situation, especially with new patients on their first time out of bed as with drug reactions and illness it is unknown whether the patient will be as able as they report.

Finally, always including and utilising the strengths of all the team members to allow for optimal outcome for the patient.