I cannot believe that 20 weeks of placements has finished and I am writing a blog for the last time! These past 5 weeks have gone by quickly and I think this is because I thoroughly enjoyed my cardio placement at Fremantle Hospital. Reflecting back on my initial entry I stated that I hoped that I would get placed in ICU, which I did, very lucky. I found ICU really interesting as I was able to see more acute patients since I had already done a general medical placement in Geraldton so I was able to see the other more acute care side of cardio, which I much prefer. Being in ICU was very challenging, because of the co-morbidites of patients and the fact that they are medically unstable, but that is what I enjoyed about it as I was able to expand on my skills such as able to do suctioning and bagging of patients.
I also stated in my initial entry that I would like to see more surgical patients, which was the majority of patients I saw as I was on the ward that all the cardio-thoracic patients came to post- surgery. This allowed me to practice handling attachments, which I found daunting at first but then it just became second nature. Even though I had an incident of a patient disconnecting his ICC, which at first really rattled me it turned out to be a very good learning experience which I will NEVER let happen again! Unfortunately I wasn't lucky enough to see a surgery!
I was again very lucky and thankful to have an amazing and very nice supervisor. She had a lot of great information and handy hints to give to Kristy and I and I feel confident after these 5 weeks that I could go out into the work force thanks to her. I am glad that know I have had the experience in working in acute care and more chronic/medical care. I can definitely see myself working in a hospital after graduation. I think this would be the most beneficial in consolidating all my skills because of the rotation systems they have and i thoroughly enjoyed this cardio placement!
Sunday, July 25, 2010
STARES 3 - Assesssment + Re-assessment
SITUATION
Mr D is a 77 year old man who is day 1 post elective CABG x 4 secondary to triple vessel disease and shortness of breath on minimal exertion. He had an uncomplicated surgery only being on bypass for 90 minutes. The morning of Day 1 post surgery he was extubated without complications and was alert and awake for most of the day. He was transferred to the ward later that afternoon as he was progressing extremely well. The only complaint Mr D had was that he suffered un-manageable pain under his sternal wound and SCC drain sites, rating it 8/10 with supported coughs and 7/10 with deep breathing. He was charted for tramadol, which made him vomit so oxynorm was used but to little effect. He lives alone, but has a supportive son close by. His house has no stairs but a big backyard which he likes to garden in. He still drives and is an avid fisher. He is normally independent with ambulation and activities of daily living. He is an ex-smoker, quitting 30 years ago, smoking 1.5 packs a day. He has a past medical history of hypertension and high cholesterol.
TASK
To perform a respiratory assessment of Mr D which would then lead to an appropriate intervention of if possible ambulating and sitting out of bed according to the Open Heart Surgery Pathway.
ACTION
I had previously met Mr D in the pre-operative education classes and earlier that day in ICU so I didn't need to re-introduce myself. Before heading in I checked with his nurse that it was okay for me to see him and asked if he could have any of his pain cover. I went into his room with a plan that i would check his nursing obs, get him to cough, sit him on the edge of the bed and auscultate then ambulated with him approx 40 which is standard for most patients and then sit him out of bed in a high back chair for the afternoon then go through his active cycle of breathing techniques.
RESULT
When I went into Mr D's room however he was poorly positioned in bed and desperately wanted to be repositioned. So i got him sitting over the edge of the bed helping him with his legs. Once in sitting I was then able to go through his supported cough and auscultation. On coughing his pain increased to 8/10 even though he had had his immediate release pain cover. On auscultation he had decreased breath sounds bibasally and coarse crackles throughout inspiration and expiration on the right middle and lower zones. Although he had a high pain score he was still keen to ambulate so I organised his attachments and oxygen. He stood with 1 minimal assistance and then we began to ambulate. After a couple of steps however he was complaining of 9/10 pain in his left leg, which is where his grafts were taken from. So after only 5 meters we turned around and he was happy to sit out of bed in the high back chair so we walked back to that and he sat down in that. As I was placing his attachments back he complained of nausea so I managed to quickly get him a vomit bag. I stayed with him for a little while and when his vomiting eased off - which took a while, I went and notified his nurse. This meant however that I wasn't able to go through the active cycle of breathing and I was unable to complete a re-assessment because of the amount of time that had elapsed.
EVALUATION
Unfortunately, even though I had what I wanted to do with Mr D planned out in my head, some things happen which make you scattered or events - like vomiting and increased pain stop you from completing/ making you forget what you need to. Because of Mr D's increased pain, we could not ambulate as far as I would have liked him to to maximize his respiratory benefits, and because of his vomiting I was unable to go through an active cycle of breathing technique and was not able to re-assess my treatment. Not being able to teach him the ACBT is quite a loss condisering he did not mobilise far and I wouldn't be seeing him till the next morning, and he needs to take breaths and cough to re-expand his lungs and expectorate stagnant sputum. Because of this I had to liase with his nurse to encourage him to this over the night once his vomiting settled.
STRATEGIES
If i had better time management I probably could have re-visited Mr D later that afternoon to go through the ACBT with him and educate him further on the importance of physio intervention. In regards to his pain cover I should have notified the nurses a bit earlier so that the medication had adequate time to take effect considering pain was inhibiting my treatment with Mr D. However even if i had done these things, sometimes things like vomiting happen, and you can't do anything about that!
Mr D is a 77 year old man who is day 1 post elective CABG x 4 secondary to triple vessel disease and shortness of breath on minimal exertion. He had an uncomplicated surgery only being on bypass for 90 minutes. The morning of Day 1 post surgery he was extubated without complications and was alert and awake for most of the day. He was transferred to the ward later that afternoon as he was progressing extremely well. The only complaint Mr D had was that he suffered un-manageable pain under his sternal wound and SCC drain sites, rating it 8/10 with supported coughs and 7/10 with deep breathing. He was charted for tramadol, which made him vomit so oxynorm was used but to little effect. He lives alone, but has a supportive son close by. His house has no stairs but a big backyard which he likes to garden in. He still drives and is an avid fisher. He is normally independent with ambulation and activities of daily living. He is an ex-smoker, quitting 30 years ago, smoking 1.5 packs a day. He has a past medical history of hypertension and high cholesterol.
TASK
To perform a respiratory assessment of Mr D which would then lead to an appropriate intervention of if possible ambulating and sitting out of bed according to the Open Heart Surgery Pathway.
ACTION
I had previously met Mr D in the pre-operative education classes and earlier that day in ICU so I didn't need to re-introduce myself. Before heading in I checked with his nurse that it was okay for me to see him and asked if he could have any of his pain cover. I went into his room with a plan that i would check his nursing obs, get him to cough, sit him on the edge of the bed and auscultate then ambulated with him approx 40 which is standard for most patients and then sit him out of bed in a high back chair for the afternoon then go through his active cycle of breathing techniques.
RESULT
When I went into Mr D's room however he was poorly positioned in bed and desperately wanted to be repositioned. So i got him sitting over the edge of the bed helping him with his legs. Once in sitting I was then able to go through his supported cough and auscultation. On coughing his pain increased to 8/10 even though he had had his immediate release pain cover. On auscultation he had decreased breath sounds bibasally and coarse crackles throughout inspiration and expiration on the right middle and lower zones. Although he had a high pain score he was still keen to ambulate so I organised his attachments and oxygen. He stood with 1 minimal assistance and then we began to ambulate. After a couple of steps however he was complaining of 9/10 pain in his left leg, which is where his grafts were taken from. So after only 5 meters we turned around and he was happy to sit out of bed in the high back chair so we walked back to that and he sat down in that. As I was placing his attachments back he complained of nausea so I managed to quickly get him a vomit bag. I stayed with him for a little while and when his vomiting eased off - which took a while, I went and notified his nurse. This meant however that I wasn't able to go through the active cycle of breathing and I was unable to complete a re-assessment because of the amount of time that had elapsed.
EVALUATION
Unfortunately, even though I had what I wanted to do with Mr D planned out in my head, some things happen which make you scattered or events - like vomiting and increased pain stop you from completing/ making you forget what you need to. Because of Mr D's increased pain, we could not ambulate as far as I would have liked him to to maximize his respiratory benefits, and because of his vomiting I was unable to go through an active cycle of breathing technique and was not able to re-assess my treatment. Not being able to teach him the ACBT is quite a loss condisering he did not mobilise far and I wouldn't be seeing him till the next morning, and he needs to take breaths and cough to re-expand his lungs and expectorate stagnant sputum. Because of this I had to liase with his nurse to encourage him to this over the night once his vomiting settled.
STRATEGIES
If i had better time management I probably could have re-visited Mr D later that afternoon to go through the ACBT with him and educate him further on the importance of physio intervention. In regards to his pain cover I should have notified the nurses a bit earlier so that the medication had adequate time to take effect considering pain was inhibiting my treatment with Mr D. However even if i had done these things, sometimes things like vomiting happen, and you can't do anything about that!
Sunday, July 11, 2010
STARES 2 - Risk Management
SITUATION
Mr B is a 57 year old male who is day 1 post elective right thoracotomy for an right upper lobectomy to remove a malignant mass. The history of presenting complaint was a few weeks of haemoptysis episodes with the occasional wheeze and cough during the night. He has a past medical history of a previous alcoholic cardiomyopathy, ex smoker quitting 7 years ago with a 80 pack/year history. He is also an ex heavy drinker having 10-12 cans of beer a day, but has not had a drink since 2003. He also has hypercholestoraemia, gout and hyperlipidaemia. Mr B lives with his wife in Perth and is currently not working. Mr B had an uncomplicated operation and ICU stay and returning to the monitored ward the night of his operation.
TASK
To complete a chest review and if the patient is suitable, ambulate.
ACTION
After introducing myself to Mr B I then explained the plan of the treatment session today, in which i was hoping to have a listen to his chest, teach him some deep breathing exercises to maintain healthy lungs, and if he was feeling up to it and his obs were stable to go for his first walk since the operation ending the session by sitting out in a high back chair. After getting Mr B's consent I began a quick subjective assessment. After this I then began a respiratory assessment, starting with his oxygen saturation then teaching him a supported cough. I then listened to his cough and his chest. After this I organised my environment, by getting a trolley for him to ambulate with which contained an oxygen bottle and a IV pole, which I attached his PCA to and also organised all his attachments in preparation to get him sitting on the edge of the bed. Once I had my environment organised I got Mr B to begin to walk his legs towards the edge of the bed and then come up into sitting. Once sitting on the edge of the bed I then attached his two ICC's which were on 5 kPa of suction, his nasal prongs and his IDC to the trolley for him to stand and ambulate. After ambulation, I then reassessed Mr B's cough and auscultation.
RESULT
Mr B was resting in bed, alert and orientated when I came to see him. Mr B was in 2/10 pain at rest. He had not been coughing/productive of any sputum since the operation, and was not normally productive of sputum prior to the operation. Mr B states that he wasn't that active prior to the lobectomy, walking one kilometer a day and did not require the use of any aids or services. I then taught him a supported cough, which was strong, dry and non-productive and didn't increase his pain. On auscultation he had decreased breath sounds bibasally, a fine end inspiratory wheeze and a gurgling/air leak sound in the R UL. Mr B only required 1 min assist into sitting. Once sitting Mr B felt a little light-headed which soon settled. Once the environment was set up and all of Mr B's attachments were on the trolley I instructed Mr B to come up into standing. As Mr B did this he pushed through his arms on the bed. What I didn't see was that underneath his gown, Mr B pushed through one of his ICC's as he went to stand up. This then caused Mr B to disconnect one of his ICC's from the most proximal connection. This was quite obvious because as soon as it happened you could hear the hiss of the suction. Once I managed to find where along the line of connection from his body to the wall where he had disconnected it I quickly reattached it. I immediately got him to lie down, watched his saturation while my supervisor told the nursing staff who informed the medical team. It was then decided, considering Mr B's oxygen saturation was maintained at 98% that Mr B was safe to continue to with physio, and ambulate. It was then onto take 2 in attempting to stand, where I made sure I could see his ICC tubes and that he didn't use his arms to stand. Once in standing Mr B ambulate with the trolley for support and the attachments and 1 stand-by assist. Mr B's O2 increased to 100% during ambulation and after ~10 m he was returned to the HBC and encouraged him to sit out of bed for at least and hour. On reassessment, Mr B's cough and auscultation did not change.
EVALUATION
I found that after treating this patient and after having his ICC be disconnected that I was really frustrated. The reasons for this was because the previous day I had told my supervisor that one thing I wanted to improve on was setting up my environment and becoming confident in the handling of attachments, so I had made extra effort in setting up my environment and making sure the 2 ICC drains were in the correct positions for when he sat up and then placing them on the trolley so that when he stood and ambulated he would stand on or trip over the tubing. So when he went to stand and leant on the tube, forcing it to disconnect I felt frustrated and annoyed that after making the conscious effort to be prepared and even more aware of the attachments, I was that unlucky to have my patient lean on the tube. As soon as the tube was disconnected I did become very flustered, however I think being like a duck on the water I remained cool on the outside but under the water I was frantically paddling my legs.
STRATEGIES
One good thing that comes out of this horrible experience is that I will never let something like this happen again. When seeing this patient next and any other patient I will make sure to check all connections of the attachments were disconnection to occur and make sure that all are visible to me and safe. When treating a patient I think it would be a good idea to just take a couple of seconds to familiarise with the environment and what attachments the patient has.
Mr B is a 57 year old male who is day 1 post elective right thoracotomy for an right upper lobectomy to remove a malignant mass. The history of presenting complaint was a few weeks of haemoptysis episodes with the occasional wheeze and cough during the night. He has a past medical history of a previous alcoholic cardiomyopathy, ex smoker quitting 7 years ago with a 80 pack/year history. He is also an ex heavy drinker having 10-12 cans of beer a day, but has not had a drink since 2003. He also has hypercholestoraemia, gout and hyperlipidaemia. Mr B lives with his wife in Perth and is currently not working. Mr B had an uncomplicated operation and ICU stay and returning to the monitored ward the night of his operation.
TASK
To complete a chest review and if the patient is suitable, ambulate.
ACTION
After introducing myself to Mr B I then explained the plan of the treatment session today, in which i was hoping to have a listen to his chest, teach him some deep breathing exercises to maintain healthy lungs, and if he was feeling up to it and his obs were stable to go for his first walk since the operation ending the session by sitting out in a high back chair. After getting Mr B's consent I began a quick subjective assessment. After this I then began a respiratory assessment, starting with his oxygen saturation then teaching him a supported cough. I then listened to his cough and his chest. After this I organised my environment, by getting a trolley for him to ambulate with which contained an oxygen bottle and a IV pole, which I attached his PCA to and also organised all his attachments in preparation to get him sitting on the edge of the bed. Once I had my environment organised I got Mr B to begin to walk his legs towards the edge of the bed and then come up into sitting. Once sitting on the edge of the bed I then attached his two ICC's which were on 5 kPa of suction, his nasal prongs and his IDC to the trolley for him to stand and ambulate. After ambulation, I then reassessed Mr B's cough and auscultation.
RESULT
Mr B was resting in bed, alert and orientated when I came to see him. Mr B was in 2/10 pain at rest. He had not been coughing/productive of any sputum since the operation, and was not normally productive of sputum prior to the operation. Mr B states that he wasn't that active prior to the lobectomy, walking one kilometer a day and did not require the use of any aids or services. I then taught him a supported cough, which was strong, dry and non-productive and didn't increase his pain. On auscultation he had decreased breath sounds bibasally, a fine end inspiratory wheeze and a gurgling/air leak sound in the R UL. Mr B only required 1 min assist into sitting. Once sitting Mr B felt a little light-headed which soon settled. Once the environment was set up and all of Mr B's attachments were on the trolley I instructed Mr B to come up into standing. As Mr B did this he pushed through his arms on the bed. What I didn't see was that underneath his gown, Mr B pushed through one of his ICC's as he went to stand up. This then caused Mr B to disconnect one of his ICC's from the most proximal connection. This was quite obvious because as soon as it happened you could hear the hiss of the suction. Once I managed to find where along the line of connection from his body to the wall where he had disconnected it I quickly reattached it. I immediately got him to lie down, watched his saturation while my supervisor told the nursing staff who informed the medical team. It was then decided, considering Mr B's oxygen saturation was maintained at 98% that Mr B was safe to continue to with physio, and ambulate. It was then onto take 2 in attempting to stand, where I made sure I could see his ICC tubes and that he didn't use his arms to stand. Once in standing Mr B ambulate with the trolley for support and the attachments and 1 stand-by assist. Mr B's O2 increased to 100% during ambulation and after ~10 m he was returned to the HBC and encouraged him to sit out of bed for at least and hour. On reassessment, Mr B's cough and auscultation did not change.
EVALUATION
I found that after treating this patient and after having his ICC be disconnected that I was really frustrated. The reasons for this was because the previous day I had told my supervisor that one thing I wanted to improve on was setting up my environment and becoming confident in the handling of attachments, so I had made extra effort in setting up my environment and making sure the 2 ICC drains were in the correct positions for when he sat up and then placing them on the trolley so that when he stood and ambulated he would stand on or trip over the tubing. So when he went to stand and leant on the tube, forcing it to disconnect I felt frustrated and annoyed that after making the conscious effort to be prepared and even more aware of the attachments, I was that unlucky to have my patient lean on the tube. As soon as the tube was disconnected I did become very flustered, however I think being like a duck on the water I remained cool on the outside but under the water I was frantically paddling my legs.
STRATEGIES
One good thing that comes out of this horrible experience is that I will never let something like this happen again. When seeing this patient next and any other patient I will make sure to check all connections of the attachments were disconnection to occur and make sure that all are visible to me and safe. When treating a patient I think it would be a good idea to just take a couple of seconds to familiarise with the environment and what attachments the patient has.
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