Fourth Year - Rotation 3 - Assessment STARES

Situation:
The other physio student and myself were asked to perform an assessment on a 75 year old female who was transferred to this hospital following a fall. When presented to the hospital, she was found to have a NSTEMI and further developed left sided weakness, confusion and a transient fever. Scans revealed a right frontal lobe lesion which was surgically drained four weeks ago. Since then the patient had been recovering well but was suspected of having a minor stroke or acute pulmonary oedema over the weekend and was moved back into the High Dependency Unit (HDU) for close observation. She just been transferred back onto the ward where we have been asked to take over the physio management of this patient - starting with an assessment. Previously this patient lived at home alone but has a son in Perth. She is usually independent with all activities of daily living including ambulation and requires no aids.

Task:
To perform an initial assessment on this patient taking into consideration her recent surgery, current condition and past medical history. This assessment is key for deciding what her current limitations are, establishing a baseline for outcome measures which will ultimately aid in choosing her appropriate intervention during her stay in this hospital.

Action:
The day before the assessment, we met the patient in the HDU where she appeared highly distractible and seemed to not attend to her left side when our supervising physio was trying to treat her. These are aspects we considered and discussed before entering her room for the assessment. After reading the patient's integrated notes, the other student and I decided to enter the room and approach the patient's bed from the left side - aiming to draw attention to this side. After re-introducing ourselves and explaining our aim of today's session, we checked her 'obs' which were stable and the patient appeared alert and was able to identify the correct time, person and place. As the patient was already positioned high sitting in bed with a C cushion supporting her left arm, indwelling catheter, a PICC line and IV antibiotic treatment insitu, we were limited in our ability to move the patient around. We were also requested by her nurse to not get her out of bed. Just watching the patient, we did not see any spontaneous movement of her left lower and upper limbs, increased upper chest movement and effort for breathing and still the patient seemed to avoid turning her head to the left past midline.
We auscultated the patient's chest next which revealed atelectasis in her right and left lower lobes but otherwise good air entry throughout. She had decreased but equal lateral expansion when breathing but with facilitation and encouragement was able to increase this. The patient had a weak, moist but productive cough which was followed by a swallow.
The other student and I then took turns with the rest of the assessment. We asked the patient to move her left upper limb but there was no visual or palpable activation of any muscles in her left upper and lower limbs. Although when we resisted the movement, there was evidence of the patient initiating left hip flexion and extension. The patient had no increased tone in either limbs at rest or with velocity applied and her strength was weak but normal for a woman of her age on her right. Sensation was tested next and the patient had decreased light touch sensation all the way up her left upper and lower limb but normal sharp/blunt sensation. She also had very good joint position and motion proprioception in her thumb and big toe which meant that we didn't have to waste time testing the remainder of the joints.
The patient at this time was getting very fatigued and started losing concentration easily so we decided to wrap up the assessment here and see the patient the next day for treatment.

Result:
This assessment highlighted to us that the main impairments for this patient is the decreased voluntary movement of the left limbs followed by her decreased air entry to the lower lobes of her chest. The patient's fatigue at the end of the session may have impaired some of the testing as well as she started to just say "Same. Same. Same." instead of saying "up" or "down" during the proprioception tests which may have given a false negative. Our tactic of addressing the patient from the left may have also influenced some results and possibly tired her out more.

Evaluation:
I think that the other student and I performed this assessment well but occasionally had to alter our hand positions especially when doing the proprioception tests. As this was our first assessment of a neuro patient, the assessment was very stop/start while we checked with our supervisor about the best position to be in and discussing the meaning to the results of the tests performed. This meant that a lot of time was wasted as we re-performed tests so that both us students were able to feel the patient's 'abnormalities'. I realised my auscultation skills are not very good for these neuro patients as I tend to take too much time listening to one area and this tires out the patient or they get distracted and need continuous prompting to deep breathe. Also as there were two students in the room trying to take control of the assessment, we may have been bombarding the patient with too many questions and information. Next time we need to discuss who is going to take lead before going into the room.

Strategies:
The best thing to do is to practice on a variety of patients to improve handling techniques, time management and choosing the appropriate tests to perform.
One main thing picked up with this assessment is that we don't have to perform every single neuro assessment out there in the first session! Just choose the most appropriate ones for the patient at the time.
Be aware of the patient's fatigue and emotional state as this can influence the test results and how you perform the tests.
I can definitely benefit from reviewing how to handle and move neuro patients as well as looking over my auscultation techniques again!
Our supervisor has pointed out a neuro revision file in the office for us to go over in our own time and we have also started practicing assessments with our tutor.