Freo Cardio STARES week 1

STARES WEEK 1

SITUATION

I have a client on a general medical ward. Their presenting complain was eye pain and photophobia (they have a diagnosis of herpes zoster involving the optic nerve), increased shortness of breath (SOB) and production of yellow sputum. Their past medical history includes shingles, COPD and falls.
Their chest x-ray shows infiltrates in the right and left middle and upper zones. There is consolidation/effusion bibasally and evidence of hyperinflation.
My assessment found nil SOB when resting in bed, but SOB with a score of 7 out of 10 after deep breathing exercises. There was no wheeze. Their cough was regular and spontaneous. It produced small amounts of white creamy sputum. On auscultation there were decreased breath sounds on the right and left upper lobes, and a late expiratory wheeze and rattle in the left lower lobe. This patient had an upper chest breathing pattern with decreased chest expansion bibasally. Their obs were stable with his oxygen saturation (SpO2) at 94% on room air.
In terms of mobility they were independent in bed mobility and transfers. Ambulation was independent over short distances with no aids, although this resulted in increased work of breathing and accessory muscle use during movement.

TASK

Having previously performed an assessment on this patient, my task was to perform a treatment session for him. The aim of this session was the improve/facilitate airway clearance and to mobilize.

ACTION

I started the treatment session by teaching the Active Cycle of Breathing Technique (ACBT). I explained what is was first and why it was important for this patient. I went through how it would benefit him in clearing out the sputum and preventing infection. I then taught the patient each component of the ACBT (controlled breathing, thoracic expansion exercise and a huff). After he had practiced each component I explained how to join them all together. I talked the patient through it, but then asked them to perform it a few times without me instructing him on how to do it. This was to ensure he could perform it independently as I ask him to do it regularly throughout the day.
I then did some exercises with him. Due to his light sensitivity I did these exercises in him darkened room. I asked the patient to stand at the end of the bed so he had something to hold onto. The exercises consisted of standing hip abduction, heel raises, knee bends into flexion (heel to bottom), squats and marching on the spot. While he was performing these exercises I monitored his SpO2 and SOB.

RESULT

The client performed the ACBT with good technique. It was successful in increasing bibasal chest expansion. His huff was weak and unproductive. On re-auscultation he has less crackles in the left lower lobe though. This patient agreed to continue practicing the ACBT independently, and if performed more regularly it might be more effective.
The standing exercise were perform with a safe and correct technique. After heel raises the patient’s SpO2 decreased to 85% on room air. I sat the patient down and his SpO2 recovered to 93% within approximately one minute. He continued with the above exercise and his SpO2 was at 87% by the end of it. His SpO2 recovered and the patient reported feeling tired.

EVALUATION

I thought my conduction of this treatment session went well and mostly according to plan. Some of the things that I feel I did well include:
• Being organized – I had the right equipment (SpO2 and heart rate monitor) that would be needed in the session.
• Explaining the reason for why we were doing the ACBT and how it would benefit him.
• Monitoring the SpO2 during the exercises (if I hadn’t been I would not have noticed that it dropped to 85% at one stage). With some patients who I have spent more time with and I know to be more stable I sometimes take their obs prior to exercise and then following the exercise. As I had not seen this patient before for a treatment session I thought it best to monitor throughout the session. This was a good clinical judgment.
• Matching my treatments to his specific problems (which I devised from my assessment). A generic “cardio” treatment session will not benefit all patients and is certainly not the best option.

Some things I think I could improve on include:
• Remembering to check the obs chart outside the patient’s room before I start the session. In this case I started a quick subjective, then I had to duck outside to check the chart. The obs were stable and within normal limits in this case but it is always important to check incase they aren’t. If a patient’s obs aren’t within normal limits it could be dangerous to get them up, so it really is important to check them!
• When I am teaching a huff I need to have some tissues by the bed, just in case the patient does produce some sputum.

STRATEGIES

I have made a checklist of things to prepare before entering the room, which included checking the obs chart. I should also prepare the environment (i.e. the patient’s room) when I first enter, before starting any treatment. This way I can make sure I have tissues and anything else I need within reach. I can also move furniture and anything else in the way if I am going to mobilize the patient.