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!