STARES 3 FH

Situation

A 79 year old male patient was admitted to the cardiothoracic ward 8 days post booked right thoracotomy. The procedure involved a resection of the middle and lower lobes of the right lung to remove a malignancy, a significant mass that was easily identifiable on his pre-operative chest x-ray. Prior to admission the patient had a 6 week history of coughing, productive of creamy white sputum and increasing shortness of breath on exertion. This patient had a background of previous myocardial infarct in 1989, hypercholesterolaemia, hypertension, type II diabetes myelitis, gastric ulcers, arthritis and asthma. The patient had a delayed progression post operatively secondary to multiple complications including episodes of tachycardia of greater than 200bpm and acute renal failure resulting in an extended stay in the intensive care unit.

On the day of admission to the cardiothoracics ward the patient’s blood results were unremarkable except for a low haemaglobin reading of 90, the chest x-ray showed marked decreased volume of the right lung field and a significant trachea deviation to the right. This is to be expected following a lobectomy of the right middle and lower lobes. The patient currently had an inter-costal catheter insitu, on 5kpa of suction, an in-dwelling catheter, oxygen requirements and intravenous drugs being administered regularly. With a right thoracotomy, his incision was postero-laterally on the right.

Previously the patient had managed all activities of daily living independently, living with his wife in their own home. He was independently ambulating with nil aids required. The patient was an ex smoker of 21 years with an 80 pack year history, resulting in poor overall lung health and integrity.

Task

In this particular clinical situation I was to see this patient with my clinical supervisor, conduct a full cardiorespiratory and mobility assessment and complete the relevant treatment session.

Action

Prior to seeing the patient I gathered the relevant information regarding medical history, current medical progress, nursing obs, most recent chest x-ray reports and blood results. Using this information I developed a rough idea for treatment and planning of the session. I then proceeded to see the patient. As the patient was attached to an IV drip that the nursing staff informed me would be finished in 10 minutes, I completed my assessment in this period. This involved the regular auscultation, cough assessment and evaluation of patients chest expansion. After completing the assessment I explained my findings to the patient and how we could best address these and optimise his recovery. By this stage the IV drip was complete, which the nursing staff detached. As the patient was on suction, the patient had about 5 metres of tubing allowing him to walk 5 metres from the bed. As I had not yet seen a patient with this set-up, I proceeded to ambulate the patient as any other with the tubing coming behind, keeping an eye on the catheter to ensure it didn’t become disconnected. My tutor instructed me to drop the tubing and then pick it up again as we walked. This then made it difficult to bring along a monitor and hold the patient, so I did not take the monitor so I could have hands on the patient in the case of a fall. After ambulating I positioned the patient in bed and demonstrated some breathing exercises, which I encouraged the patient to carry out independently.

Result

After this session I discussed the outcome with my tutor. I was unhappy with my performance as I felt under-prepared throughout the session and under-pressure as I had not been assessed one on one since 3^rd year exams, the thought of an assessment threw me off. On discussing with my tutor I pointed out the things I felt I could have improved on and would have normally done had I been more prepared. The tutor felt I was unsafe in this instance as the patient could have potentially tripped over the tubing had I left it dragging and as a result of holding the patient, was not monitoring.

Evaluation

Overall a poor performance on my behalf and I knew I could have been doing / done a better job which was most disappointing, especially considering it was my assessment with the tutor.

Main point – don’t be afraid to ask for help. My tutor had told me to ignore her presence and act as if I was the ward physio seeing a patient independently, which I took to mean that I couldn’t seek her help. Mistake number one. Had I requested her assistance, the session would have run a lot smoother and been safer for the patient.

I also needed to plan ahead to familiarise myself with the patients environment, plan my treatment and organise attachments and equipment I needed for the session.

To optimise my session, having the patient sitting out of bed in a chair would have been optimal, again emphasising the planning of the session.

Otherwise, I was able to quickly build rapport with the patient, despite my lack of confidence in my performance, I still had the patients full participation and support. I was able to effectively translate medical jargon to simple language and answer any questions the patient had.

Strategies

- Ask for help when needed

- Plan ahead – equipment, environment, attachments, expectations

- Aim for optimal treatment session

- Continue effective communication