INTERVENTION

SITUATION
Patient A was admitted to the ward on the 13/2/10 post laparotomy due to a bowel obstruction. He had a colectomy in October 2009, and has been transferred from Peel hospital post enema via the stoma. Patient A lives with his wife in Waroona, he receives CACP weekly for medication dispersion and stoma care but is otherwise independent with his activities of daily living. He enjoys gardening and usually ambulates without an aid. Patient A has a history of cognitive impairment. His wife reports, he has poor short term memory, suffers from anxiety and often requires assistance in orientating himself to the environment. When I entered the room Patient A was resting in bed with his wife sitting next to him.

TASK
After completing an initial assessment I had decided that my problem list for patient A was:
1: Reduced mobility
2: Decreased lung volumes
3: Decreased airway clearance
My goals for the treatment session were to ambulate patient A with one assist, teach patient A deep breathing activities such as ‘active cycle of deep breathing’ and demonstrate a supported/ assisted cough.

ACTIONS
To commence my treatment session I explained what we would be doing today and gained consent. I assisted my patient to transfer to sitting on the edge of the bed. Patient A managed an independent sit to stand and then ambulated approximately ten meters. As Patient A’s oxygen saturation was only 89 % on three litres/ min I had decided to ambulate him with portable oxygen.
On return from the walk I tried to teach patient A an active cycle of deep breathing to improve his lung volumes and aid his air way clearance.

RESULTS
Once we had got 10 metres away from the bed, patient A took off his nasal prongs and refused to put them back on. Patient A then attempted to sit down in the middle of the corridor where there was no chair. I used a cross brace to force Patient A into hip extension so he could not sit down and tried to convince him to put the oxygen back on. Patient A became very distressed and anxious, his breathing pattern increased and when I checked his oxygen saturation it had dropped to 85%. I called for a nurse who came in behind him with a commode so that he could sit down. It took me 15minutes to convince patient A to put the nasal prongs back on, by which time he had desaturated further to 83%. I put him on a Hudson mask at 6 litres/ minute and tried to teach relaxed breathing. I then monitored the patient until his saturation was back at 95%. Patient A had difficulty following instructions and was not compliant with the exercise after I had demonstrated the technique. Patient A’s wife attempted to convince him to partake in the breathing exercises and explained that “the physio’s” were here to help him. Patient A in return got aggressive towards his wife and became extremely emotional. By this stage patient A refused further treatment for the day and his wife left the room in tears.

EVALUATION
Patient A is a very complex patient. I feel that the most significant problem is his cognitive impairment and anxiety. I needed another physio with me when I ambulated this patient as his behaviour was unpredictable and I did not feel it was safe to have only one assisting. As my patient had difficulty following my instructions I need to have more succinct, direct commands. I also feel it would have been better if I asked the wife to step out of the room during the treatment session. This would have hopefully minimised the emotional stress contributing to patient A’s non compliant behaviour. Patient A could not understand the thoracic expansion or relaxed breathing exercises when demonstrated or cued. His response to the instructions was to open his mouth wide and start gasping for air, resulting in a shallow and ineffective breathing pattern. I may need to try an alternative method of increasing his lung volumes such as incentive spirometry. This would stop Patient A from gasping as he would have a closed seal around the mouthpiece. I also feel that patient A will benefit from goal orientated exercise such as “first ball to the top, and see how long you can keep the second ball in the middle” In fore sight I did not go into this session prepared to manage someone with a cognitive impairment and I certainly did not tailor my treatment for my individual patient.

STRATEGIES
The first strategy that I will work on regards my communication. I am going to avoid open questions as patient A has poor short term memory and gets confused about his facts, which then upsets him. I will ask only closed questions such as “do you have pain?”
The second strategy regards my delivery and phrasing of verbal cues. I need to give very direct, firm cues to avoid confusion.
The third strategy is a method of motivating patient A to ambulate and keep him focused on the task. I am going to try goal orientated ambulation. For example “we need to walk to the shower”. “We need to practice walking so you can get around the garden”