STARES 2

Clinical Reasoning in Assessment and Treatment

SITUATION
An 86 year old male admitted with an exacerbation of Chronic Obstructive Pulmonary Disorder (COPD) and congestive cardiac failure (CCF). He normally lives with his wife and is independent with activities of daily living (ADLs). He has been coping at home until now, but had had a decrease in exercise tolerance for many years. He is normally slightly short of breath on exertion (SOBOE) with no cough or sputum. He can normally ambulate approximately 50m with no aids.

TASK
My task was to assess this patient, decide on a prioritised problem list and perform a treatment session.

ACTION
To start with I looked at his blood results and chest x-ray on the computer. His blood results were normal but his chest x-ray showed what appeared to be infiltrates in the bases. I thought this could be consolidation. As part of my assessment I took a subjective history. I found he had been coughing but it was non-productive. The patient said it felt like he needed to cough up phlegm but nothing was coming up. He was also short of breath (SOB) at rest and on exertion.
For my objective assessment I began by auscultating his chest. I heard decreased breath sounds bibasally and some crackles in both bases, left equal to right. I thought this might be due to the consolidation. I listened to his cough and it sounded strong and moist, but was non-productive.
I decided his main problems were impaired airway clearance, dyspnoea and decreased exercise tolerance.
My treatment started with Active Cycle of Breathing Technique (ACBT) to help with airway clearance. I did 3 cycles with the patient but it was non productive. His cough still sounded moist and on auscultation there were still crackles in the bases.
I then decided to mobilize the patient by marching on the spot. He managed 3x 20seconds of marching before his oxygen levels dropped to 84%. He stopped marching and sat down.
I ended the session with the plan to continue mobilizing the next day to increase exercise tolerance.

RESULTS
My treatment of mobilizing the patient targeted the exercise tolerance and shortness of breath. I feel this was an effective treatment and the patient tolerated it well. The ACBT was the airway clearance was not effective as it did not clear out any sputum and other outcome measures were the same on re-assessment.

EVALUATION
After discussing this patient was my supervisor I discovered my clinical reasoning had been wrong, and that was way my airway clearance had not been effective. He did not have large amounts of sputum in his lungs, it was fluid from CCF. This is why his cough sounded moist and I heard crackles on auscultation. My ACBT and airway clearance techniques were not necessary and therefore not effective. My problem list should have focused on the decreased exercise tolerance and shortness of breath.

STRATEGIES
In order to avoid this mistake again I have thought of the following strategies:
1. Check the chest x-ray to determine if it is fluid or infiltrates. Look for a meniscus to indicate fluid.
2. Check for a history of CCF and be aware of fluid overload.
3. Check infection markers to see the likelihood of having sputum.