Fourth Year - Rotation One - Intervention STARES

Situation
71 year old male, day one post op left knee replacement. Besides having a previous medical history of medicated controlled hypertension and depression, he was generally a healthy fit man for his age. Unfortunately he also suffers from claustrophobia. My job was to do a routine day one physio post op assessment and treatment for him. This should usually consist of deep breathing exercises, bed exercises (to improve circulation and strengthen the operated limb) and also apply the CPM to the affected limb to help improve ROM.

Task
Altering my intervention so I am able to conduct a day one post op assessment and treatment session while taking into account the patient claustrophobia.

Action
By reading the patients notes previously before entering his room, I was able to note his fear of enclosed spaces. I also saw that he had identified in his own previous medical history that before he has an 'attack' he begins to perspire profusely and gets 'nervous' asthma. His claustrophobic condition was further evident from when I entered his room to find him already sitting out of bed without being prompted (a very rare case for day 1 post op patients). I decided to conduct the initial introduction to the role I'll be playing in his rehabilitation, his assessment and basic exercises in his comfortable seated position. I explained that being positioned out of bed and moving around is one of the best things he could be doing at this stage. Instead of making him return to his bed and going through the set bed exercises, I adapted them to a seated position (which is normally a progression usually done day 3-4 post op). I also explained the bed exercises to this patient while he was seated and only once they were explained fully did we return him to his bed to practice them. At this stage he started looking anxious and beads of sweat were dripping from his forehead. I concluded this part of the treatment and returned him to his chair.
About an hour later I returned to his room to apply the CPM machine. This was a requirement/order from his orthopaedic surgeon. Unfortunately this intervention requires the patient to lay in bed for an hour literally strapped to a machine constricting his leg. After I'd measured the patient, set up the machine and explained the use, I left him with the instructions on how to adjust the settings and stop the machine for emergencies. At this point in time he commented on the foot strap which I took off to ease him. I said I'd return in an hour to remove the CPM and apply an cryocuff to ease the pain.
Twenty minutes later, a nurse reported to me that my patient had turned off the CPM and jumped off the bed and back into his chair. I went to check on this patient and discussed with him his feelings of claustrophobia and he stated he couldn't tolerate the CPM for more than 10 minutes.
I told him to continue the previous seated exercise/stretches while I went to discuss this patient with my supervisor. Unfortunately my supervisor was treating an outpatient at the time so I returned to the patient with a skateboard and demonstrated how he could use that similarly to a CPM while in the seat.
My supervisor contacted the surgeon and discussed alternatives to the CPM and decided that he thought the skateboard was a good idea as long as my patient was able to achieve around 90 degrees of active knee flexion preferably by day 2 post op or he will have to be forced onto the CPM. We passed these details onto the patient who agreed to the terms.

Result
This patient was able to achieve 80 degrees active knee flexion by day 2 and his surgeon was happy to allow him to remain using the skateboard and seated exercises/stretches as an alternative to the CPM. This was great as it was a win from the patients perspective as he didn't need to suffer from the constriction of the machine to increase his range of motion in order to be discharged.

Evaluation
I felt pretty bad that I didn't consider the effect that the CPM would have on this patients condition. It seems so obvious in hindsight! I shouldn't have put my patient through that emotional situation as I was previously aware of his severe claustrophobia. Although I didn't totally dismiss his condition as I did respond to his signs of distress during the first time I saw him and took the action of stopping the session and restarting it after a break. I also went into the patients room with adapted exercises planned out ahead of time. Unfortunately I believe I still didn't consider the patient as an individual but continued with the routine knee intervention protocol and assumed that a CPM would be fine. Lesson learnt! At least I was able to sort out an alternative to the CPM problem on my own with a simple prop like a skateboard!

Strategies
I believe that initially I did the right thing of checking the patients notes and planning his treatment with claustrophobia in mind. Unfortunately his condition was more severe than I thought.
I have to be more aware of treating patients as individuals and not always follow routine exercises or protocol because they would always apply to everyone the same way.
Being aware of conditions is very important and luckily this time there were no lasting detrimental affects on the patient. Also not assuming the severity of a condition is important!
Look out of signs of discomfort especially if the patient has already indicated to you what those signs may be!