Fourth Year – Rotation One - Assessment STARES

Situation
An 85 year old male inpatient was referred to physio for his chest and mobilisation. He was admitted into hospital after a fall for further assessment of a suspected pulmonary embolism and/or cancer. This patient lives with his wife in a unit with no stairs and usually mobilises around the house with a 4 wheeled walker or with a gofer when outdoors. 4 months ago he suffered from an unknown skin condition that caused him to develop rashes and sores all over his body and since then his health and physical abilities have rapidly decreased secondary to lower limb weakness, shortness of breath and general lethargy. His main goals are to be able to become independent in transfers and activities of daily living as his wife has been struggling to cope looking after him at home over the last 4 months. This patient occasionally becomes confused and disorientated and is not keen to exercise as he constantly feels weak and tired and reports he is having trouble sleeping. His wife is keen for physio and pushes him to exercise as she realises this is the only way he is going to improve his strength and become independent and safe at home.

Task
I was asked to perform an initial objective assessment for this patient, identify his problem list and create a plan accordingly. No x-rays were available to be viewed at this point in time. A thorough examination was required to indicate what areas we could focus on and produce outcome measures we could reassess at a later point in time.

Action
My assessment began with a brief but clear explanation of who I was, what my role is and what I planned to do. I educated the patient on why he was referred to me and the benefits he will receive from physio input. This consisted of discussing his symptoms of shortness of breath and relating it to his recent sedentary lifestyle and the possible complications of him staying in bed for the majority of the day (ie. developing infections in the lungs). We discussed his new difficulty in walking due to the weakness in his legs, dyspnoea and discussed his goals and requirements for discharge. After checking his obs were stable within normal limits, I took his SpO2 which was sitting at 90% on room air. I explained to the patient that we needed to start with an assessment in order to have a baseline to refer back to observe any changes that are taking place. I started with listening to his cough which was moist, weak and produced frank haemoptysis. With further questioning I was able to discover that he doesn't cough often, has no pain when coughing but does cough up blood occasionally. He repeated the cough but it was unproductive. Next I auscultated him in his long sitting position on the bed. I observed a decrease in breath sounds in his left lower lobes. Chest expansion was decreased overall, more so on the left. His SpO2 was constantly monitored throughout the assessment and after his chest assessment, it was sitting at 96% on room air. Lower limb muscle strength testing came next while the patient was still on the bed in supine. I tested his static quads, static hamstrings, static gluteals, active knee flexion, inner range quads, abductors, adductors and his ability to do a straight leg raise. The assessment showed the lower limbs considerably weak but the left slightly worse than the right. I then observed the patient's ability to transfer himself into sitting on the edge of the bed where he needed 1 X minimal assist and in this position I finished his posterior lobes auscultation. At this time his SpO2 had risen to 98% on room air. I assessed his ability of sit to stand (1 X stand-by assist) and we went for a walk to his door with his 4 wheeled walker so I could observe his gait and distance he was able to ambulate. The patient reported shortness of breath 5 metres into the walk and his SpO2 dropped to 87% on room air. He was able to recover with 30 seconds of relaxed breathing while sitting on his 4 wheeled walker and his SpO2 rose to 97% on room air. He agreed to finish the walk back to his high back chair where he denied any feelings of shortness of breath, weakness or pain.

Result
After performing my assessments I was able to construct an exercise program to target his chest, lower limb muscle strength and could compare any improvements or changes to his initial presenting condition. I was able to learn that his shortness of breath related to a drop in his SpO2 but was easily recoverable with relaxed breathing. I noticed that he needed re-training in his transfers as I believe that he has the strength and is capable of performing them but has been relying on the support of others surrounding him to perform these tasks independently. His gait looks good but his leg weakness and dyspnoea was a limiting factor.

Evaluation
Overall I felt as though my assessment was very thorough in the areas that I checked. My performance of the above mentioned assessments were at a good standard also. On the other hand I believe my time management in this assessment should be reconsidered as it took quite a long time and I also could have looked at his seated and standing balance. I was able to explain to the patient how to perform the tasks well and also I was constantly monitoring his obs for his main complaint of shortness of breath. I was able to show him that by moving around and doing his exercises, he was able to increase his oxygen uptake compared to if he just lay in bed all day. I was conscious of the patients safety during the assessment and questioned him about if he needed a break or was feeling ill.

Strategies
For future assessments I need to consider the order of my assessments for example doing the lower limb strength test before sitting him up and doing all the auscultation in the upright position. I will realise from now on how hard it is for a person to do so many deep breaths while I'm auscultating and getting him to breathe normally with an open mouth will produce similar results without getting the patient dizzy from too much oxygen. Also I will discuss coughing with the patient first before getting them to perform the action as I was very surprised when he produced blood which concerned the patient as I myself was concerned. Further practice on different patients will improve my timing for assessments but my supervisors say that it's better to have a thorough assessment than a quick one.