First Entry

Situation
Patient A is a seventy seven year old male who was transferred to the general medical ward three days ago after undergoing his second laprotomy complicated by adhesions in the pelvic region. I was instructed by my supervisor to complete a full cardio respiratory assessment of this patient and record my findings in the integrated notes. Patient A had been resting in bed for 3 days, he had and indwelling catheter, Hudson mask, and intra venous tubes in his elbow. Patient A was dressed in a bed gown under his covers with the privacy curtain open.

Task
Prior to entering the room I was asked to plan and record my investigative assessments. My list included:
1: I needed to make observations regarding the patient’s level of alertness, and interaction. I also needed to record my observations of patient A’s breathing pattern, attachments and bed position.
2: Check the bed chart for his latest statistics.
3: Check his oxygen support and his current oxygen saturation
4: Perform auscultation and record my findings for each lobe of the lungs.
5: Palpate his chest and document the movement.
6: Check the computer for his most recent chest X ray, and study it for any potential indicators of pathology in the lungs.

Actions
Observations: I observed and recorded all of the attachments. I made note of my patient’s breathing pattern and bed positioning. I also noted patient A’s level of alertness and response to vocal instruction.
Statistics: I remembered to check the bed chart for patient A’s statistics, however I forgot to record what time the last measurement had been recorded.
Oxygen: I noted that Patient A was on a Hudson mask and recorded the dose delivered. I did however forget to do a quick reading of his saturation prior to continuing the assessment.
Auscultation: I successfully listened to all lobes of the lungs and recorded my findings. However I forgot to instruct my patient to cough prior to commencing.
Chest palpation: I palpated for both bucket and pump handle action.
Chest x ray: I successfully orientated the x ray, identifying the structures and looking for abnormality. I diagnosed right middle lobe consolidation.

Results
When I entered the room I noticed Patient A was particularly drowsy and unhappy to have visitors. I would need to alter my assessment if he was not complaint.
From my observation I already knew my patient had an increased respiratory rate and upper chest breathing pattern. As I had checked his statistics I knew his blood pressure, heart rate and haemoglobin were within normal limits so he would be safe to ambulate. I identified the strength of the breath sounds in each lobe and noted inspiratory crackles in the right middle lobe. My chest palpation confirmed my findings from my observations of his chest wall movement. My chest x ray findings supported my auscultation findings.

Evaluation
As I did not note the time that the last statistics were recorded it was not an accurate measure. If the statistics were taken 2 hours ago then it is likely that the patient may have deteriorated and would not in fact be safe to ambulate. As I did not check the saturation prior to the assessment, I did not know how patient A was coping with 6 L/minute. If he had desaturated during my assessment he could have gone into respiratory distress. As I did not ask my patient to cough prior to auscultation, the crackling that I heard in the right middle lobe could have been due to secretions that patient A was capable of clearing, thus making my assessment inaccurate.

Strategies
When checking my statistics I need to ensure that I note the time they were recorded. If the latest entry is not recent then I need to reassess the statistics myself. I need to measure the oxygen saturation at the commencement of my assessment and then continuously check throughout the session. Prior to performing auscultation I need to ask my patient to cough. Finally, after speaking with my clinical tutor about analysis of chest x ray’s I feel I need to have a more methodological approach to the investigation. Instead of jumping to conclusions about the pathology I need to identify each finding and describe what I am seeing.