Topic 3- treatment

Situation: 81yo female admitted to emergency at Royal Perth Hospital 19/7/10 with an increased cough, drowsiness, shortness of breath (SOB), increased thick green sputum, decreased exercise tolerance and decreased appetite. The medical team diagnosed it as an exacerbation of Bronchiectasis. Her past medical history is as follows: chronic knee and back pain, end stage Bronchiectasis, GORD, HTN, mini mal seizures, high cholesterol and osteoarthritis. She currently lives at home alone with services (showering, cleaning and meals on wheels). She has a daughter and a son that live in Perth and visit regularly. She normally ambulates with a 4WW independently within the house (she rare walks outside). She has had 2 falls this year (prior to prescription of 4WW, when she was ambulating with a walking stick). Her house has no steps internally or externally and is not fitted with any rails. She is also a non smoker.
She is currently on tobramycin nebulisers (which she just finished), salbutamol and antibiotics to overcome the exacerbation. She is complaining of SOB at rest and increased with movement. She has no chest pain and has been walking to the bathroom independently on ward with 4ww no oxygen. She has a productive cough of thick yellow/green sputum. She has a temperature of 35.8, BP 130/70, PR 95, RR 28 and SpO2 88% 8L via Venturi mask. Her ABGs on 19/7/10= 7.39/61/73/36/10 95% (fully compensated respiratory acidosis). These show that the patient is a CO2 retainer and so medical staff have asked to keep patients sats at 88-92%. Her haemoglobin on 19/7/10 was 129, White cell count= 12.90, Platelets 406, C-reactive protein 100. On auscultation she had decreased air entry bibasally. Expiratory wheeze Left upper and middle lobe. Fine inspiratory crackles throughout right lung and left lower lobe. Chest expansion was fair L=R. Cough was strong, moist and productive of a small amount yellow/green M2p3 sputum.

Task: To determine the patients main problems and treat accordingly

Action: From my assessment I concluded that my patients main concerns were Airway clearance, decreased exercise tolerance, Impaired Gas exchange and Airflow limitation.
From this problem list I decided to aim my first treatment session at completing a mobility review and doing some airway clearance techniques. The patient fatigues fairly quickly and so I was limited in how much I could do with the patient. We ambulated ~15m 1x standby assist with 4WW on 8L via Venturi mask. Patient fatigued quickly and required a rest half way for ~30secs. Patients sats 86-88% during ambulation. I then did some deep breathing exercises with vibes in right and left side lying. I had the bed almost flat, as I was aware I could not tilt the head of the bed down for drainage. I was able to get a small amount of thick yellow/green sputum in right sidelying and a very large amount in left side lying with 3 cycles of vibes in each side. On auscultation post treatment there was increased air entry bibasally. Course inspiratory crackles R lung and expiratory wheeze throught left lung.

Result: As a result of my treatment the patients oxygen saturation increased to 92% on 8L via venturi mask. With mucus plug obviously removed with drainage and vibrations, she was able to successfully improve her oxygenation. I was very pleased with the results of my treatment.

Discharge planning for this patient at this stage, I believe would be: ? home with RITH or ACAT for low level care.

Evaluation: As mentioned above, I was extremely happy with the results of my treatment session. I believe I used my time effectively and was able to target her main problems. I feel I was an effective communicator and education to this patient. If I was to do this treatment over again I feel I probably would have done the airway clearance prior to ambulation as the patient's airway clearance was more important in this case then her mobility at this stage, and as the patient fatigues quickly that may have allowed more cycles of deep breathing exercises and vibrations to be performed.

Strategies: To improve on concern I raised above, I believe I could practice writing a prioritised problem list and having a better plan of my treatment session prior to seeing the patient.