week 5 cardio-treatment

STARES
S- Mrs C is a 63 year old lady admitted to the ward with ?pneumonia. She also has a 30-year history of bronchiectasis, which she has managed well throughout her life. Her husband passed away 2 years ago and she admits he played a large role in her care. He built a makeshift tilt table and percussed her chest daily to help her secretion removal. Since being in hospital, Mrs C’s secretions have increased. She feels that being out of her daily rhythm fatigues her and decreases her ability to self manage.

My assessment found the following asterisk signs, moist cough++, widespread scattered wheeze (low pitched) throughout lung field R>L, coarse expiratory crackles R LL. So, I concluded impaired airway clearance to be her major problem.

T- I had to plan an appropriate treatment session to best cater to Mrs C.

A-Firstly, I decided to ask Mrs C how she would usually manage her secretions…with a 30-year history of bronchiectasis I assumed she was fairly well versed in self-management.

Mrs C informed me that her husband percussed her chest daily on a tilt table they had made together. She stated this was the best thing for her and related her husband’s death to her now more frequent hospital admissions. She said she was most productive in prone lying with two pillows under her chest.

With this information on board I developed the following treatment plan.
1. Ambulation to encourage deep breathing (via demand ventilation principal) to hopefully begin to mobilise secretions in the lower lobes.
2. Percussions in L side lying, 2 pillows under chest and 30 degrees of head down tilt.
3. Mrs C performed ACBT cycles throughout (I had taught her previous to ambulating)
4. Percussions in prone lying, 2 pillows under chest with 30 degrees of head down tilt and ACT cycles.
-Throughout the treatment I continually asked Mrs C how she was going, if I was doing it correctly/with enough pressure, and when she felt she had had enough.

R-I feel that our first treatment session went really well. Mrs C was productive of about 10x M2P2 sputum plugs and stated that, although tired, she felt much better afterwards.

E- STRENGTHS:
-By asking Mrs C what she usually did enabled us to build a strong rapport. She instantly knew that I wanted to listen to what she had to say in regards to what has been successful for her in the past.
-I incorporated what Mrs C suggested as well as some new ideas (walking first to mobilise secretions, L side-lying as position 1 ad utilising the ACBT throughout treatment). I feel that my choice of treatments were very effective because I had clinically reasoned to justify them.
-I was safe in all treatments, ensuring to ask all relevant C/I and precautions for percussion and GADP. Mrs C was clear of anything that may have contraindicated the treatments. She had had an abscess removed from her brain over a year ago, which I felt was not recent enough to exclude head down tilt as a treatment option.

WEAKNESS
-I used auscultation as my asterisk sign and re-measured this after treatment. However, I also think monitoring her sats throughout treatment would have been wise. I could have monitored for improvement as well as ensuring she could cope from a respiratory sense with the treatments.
-I think my hands-on treatment was appropriate as an inpatient, but I needed to think to d/c planning from the moment I met her. Obviously she can’t continue percussions at home (and her husband passed away 2 years ago meaning he can no longer help her out). My supervisor suggested calling silver chain. They can go to her home 3x/week for hands-on chest physio. All I had to do then was think of something she could do independently. (We decided upon walking first, then performing ACBTs, using bubble pep during the TEE’s.)

S- LISTENING! I think the biggest help in my treatment was asking my patient what worked for her. People have to manage their own chronic disease and so obviously know the best strategies.
-Think to discharge planning from the first meeting. This makes their whole hospital stay smooth and ensures they can cope when they return home.
-Create a good problem list! From this, it is very easy to clinically reason appropriate treatment.
-Check all C/I’s and precautions.