Subjective examination revealed no pain at rest, moderate dyspnoea and a productive cough as the main findings. O2 saturations were at 98% on 37% high flow nasal prongs, BP was 131/69 and other obs were stable. Cough was strong, dry, productive of minimal clear sputum and effective. Auscultation revealed early fine inspiratory crackles bibasally and fair breath sounds throughout. Basal expansion was fair bibasally and left equaled right.
Task: Plan an appropriate treatment for the patient.
Action: I decided that transferring the patient to a high back chair would be an appropriate intervention. This would help to improve lung volumes and encourage basal expansion. Mobilising the patient would also improve tidal volumes and help shear secretions off the airway walls. The plan was to sit the patient over the edge of the bed. I would expect that the patient would be dizzy from lying in bed for an extended period of time. Once the dizziness subsides, with a wheeled zimmer frame we would stand and perform a step transfer to a chair next to the bed. I would require the assistance of another physiotherapist/nurse throughout and due to the nature of her condition I would be monitoring her vital signs closely.
Result: The patient was a 1 x minimal assist with rolling onto her side and a 2 x max assist to sit over the edge of the bed. As expected the patient experienced substantial dizziness and nausea when sitting over the edge of the bed, which eased after approx. 3 mins. Sats were stable at 97% and HR was within normal limits. Even so my supervisor suggested that we take a blood pressure reading. It indicated a drop in systolic BP with a reading of 120/67. We still deemed it safe to attempt a transfer as the patients symptoms had subsided. Upon standing with 2 x max assistance and a wheeled zimmer frame the patient reported dizziness and nausea. The patient could only tolerate standing for 5 secs before the dizziness increased so we sat her back on the bed. This time the dizziness took 5-6 mins to ease, her saturations had dropped to around 90 and she reported some minimal chest pain. I decided that transferring her to a chair would be a bit optimistic. Hence once her symptoms eased I got to perform one more sit to stand and take a few steps sideways so that I could position her in a more upright position in bed. When she stood up the second time the patient was a lot more stable and her work of breathing was not as high so I encouraged her to attempt stepping towards the chair for a transfer. The pt was reluctant to do so, even with encouragement, so we sat her down and transferred back into bed, with it tilted in an upright position.
Evaluation: I think transferring the patient to a chair was an appropriate choice of treatment. I think where I needed to improve was my ability to quickly change my plan when things don't go as expected. I thought that the patient would be able to complete the transfer after the second standing attempt but because the patient was reluctant to do so we had to decide on the next best option. I guess I feel my ability to plan before treatment was sufficient but where I need to improve is my ability to quickly plan the next step throughout the treatment session.
I always need to remember to ask "why?" when symptoms appear and then think of what I can do to ascertain the cause of the symptoms. In this case I should have realised that taking the patients blood pressure would have been a appropriate measure to ensure safety with performing the transfer.
Strategies: I think this is going to take practice and will improve with experience. The more patients I see the better I'm going to get a planning ahead. It's important not to get flustered in situations such as these so taking a few seconds to pause, think and take a breath would be a good strategy.
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