Analysis and planning

SITUATION:
Patient A is a 38 year old female who was admitted to the general surgical ward with peritonitis secondary to pelvic ischemic disease. Patient A presented with severe abdominal pain, nausea, vomiting and no bowel movements. Patient A has a medical history of asthma, type two diabetes mellitus and an appendicectomy in 2008. Patient A is currently medically stable, one day post laparotomy. Patient A has been on a Hudson mask over night after refusing to keep the nasal prongs in. Patient A is resting in bed, asleep when I enter the room.

TASK:
This is my initial assessment of patient A. My task is to assess her chest and mobility. When I enter the room I will check the patient’s blood pressure and oxygen saturation. I intend on doing a quick subjective assessment. My objective assessment will then comprise of auscultation, cough assessment, chest palpation and a mobility assessment of which I will consider a transfer from supine lie to sitting on the edge of the bed and ambulation.

ACTIONS:
On entering the room I quickly checked and recorded my patient’s blood pressure and oxygen saturation. I then continued with a subjective assessment before prompting patient A to transfer to the edge of the bed. I provided assistance for rolling into side lying when she had difficulty. Patient A wished to transfer from side lying to sitting independently but required help with her upper body as she did not have the UL strength. I used a side lunge to assist. Patient A had difficulty taking deep breaths during my auscultation and refused to continue the assessment as the pain was too great. After completing my chest assessment I gave verbal cues to get patient A standing up and ambulating to the corridor with a moose trolley. I supervised as patient A ambulated to the shower with her moose. I then gave verbal cues to get her seated safely in the commode whilst she waited for the nurse.

RESULTS:
My subjective assessment concluded that patient A was very nervous about being in a hospital environment and very distressed about not having her family here for support when she was in such a foreign environment. Patient A was quite emotional and was obviously going to require a lot of encouragement and support to complete the assessment.
During the transfer to sitting on the edge of the bed, Patient A got very upset and angry when I gave her tactile cues, reporting that she did not want to be pushed and that she could manage it independently at a slow pace. During my chest assessment I did not get to assess patient A’s lower lobes posteriorly, as her pain was too great. After ambulating the patient to the corridor, I discovered there were chairs and oximiters cluttering the corridor space. When patient A had to navigate through the equipment with her moose she became uncomfortable and increasingly nervous resulting in a stooped posture and smaller steps. Patient A transferred from standing to sitting safely with one assist however, I had not informed the nurse that I was taking patient A to the shower thus she was left waiting on a commode in the shower cubicle for 10 minutes.

EVALUATION:
As patient A was nervous and distressed about being in a hospital environment, she was not going to respond well to tactile cues. I needed to use much clearer, simple instructions and provide the patient with a visual demonstration of what was required to minimise the use of tactile prompts. With full knowledge that patient A had eight out of ten pain at rest, I should have insightfully considered the potential difficulty of completing my auscultative assessment.
Arriving at the corridor to find a cluttered space is potentially a safety hazard. I could not leave my patient to clear the walkway however there was not enough space to walk between the objects. This meant that I had to ask the nurse near by for assistance to clear the space.
The next problem I encountered was due to a lack of communication. Leaving a patient sitting in a shower cubicle for 10 minutes waiting for the nurse is not a positive experience. I should have informed the nurse that I was taking patient A to the shower before I got her up so that the nurse had time to get organised.

STRATEGIES:
1: Apply the knowledge I have gained from my subjective and objective assessment to determine how the patient will best respond to instruction. This may include verbal, tactile or visual cues. In this situation I needed to use visual rather than tactile cues. For example demonstrate a transfer from lying to sitting.
2: If the patient is likely to be non compliant with my auscultative assessment, listen to the area I am likely to be most concerned about first. For example this patient had been lying in supine for two days they were likely to have poor breath sounds in their lower lobes.
3: I need to ensure that I check my working space prior to getting my patient out of bed. This means that if there is clutter or obstacles in the road, I can successfully clear the road without being a safety risk and having to leave my patient by themselves or asking for help from a third person.
4: I need to liaise with the multidisciplinary team in order to provide optimal treatment for the patient. For example, if I had informed the nurse of my plans prior to mobilising the patient, they would not have been left waiting in the cubicle.