Situation:
I was asked to review and mobilise a 70 year old male patient who was admitted to hospital 2 days ago with an acute exacerbation of chronic COPD and also for an ACAT review. This patient currently lives in a shared 22 stepped boarding house with nine other males, uses 2 litres home oxygen constantly throughout the day and previously refused moving to low-level care after his previous hospital admission 4 weeks ago for another acute exacerbation of COPD. This patient recently could not move for 4 days secondary to increased pain and shortness of breath and decided to succumb to moving into a low-level or high-level facility.
Task:
After an initial subjective history had been taken and relevant observations were made, I had to check this patient’s mobility. In order to qualify for a low-level care facility, the patient is required to ambulate independently 50 metres at least.
Action:
The patient complained of being too tired and refused to go for a walk after the subjective interview and chest examination. When asked if he felt short of breath in his seated resting position he answered “Yes” and when asked to rate his shortness of breath out of 10 with 0 being where your breathing is causing you no difficulty at all and 10 being where your breathing difficulty is maximal, he replied with “Seven”. This patient was not heavily breathing nor showing any signs of respiratory distress. His SpO2 was being maintained at 97% on 2LO2 via NP and when questioned, he stated that this level of breathing for him was ‘normal’. I explained to him that 7/10 on this particular scale would be equivalent to saying his breathing was “very severe” and he said, “No, it is not that bad” but would not give me another numerical value for his own perceived breathlessness. We eventually got up for the walk and whenever questioned about his shortness of breath on the Borg Scale he would always say “seven”. During the walk, his SpO2 did decrease, his breathing became heavier and he increased the use of his accessory muscles and upper limb support when breathing. He did not want to take a rest through the walk and was extremely short of breathe and physically drained after the 30 metre walk.
Result:
Due to a miscommunication of the Modified Borg Scale, I was unable to properly determine the patient’s dyspnoea changes during the walk. He was in a rush the whole time and did not understand the importance of this ambulation assessment. He was more interested in going too the toilet and returning to bed as fast as possible. This made it very difficult to get him to slow down and monitor how far he could walk before his dyspnoea started affecting him too much and thus made the walk assessment useless and it needed to be repeated the following day after the patient had adequate rest.
Evaluation:
My explanation of the Modified Borg Scale was not too poor but I don’t think I highlighted the importance of the mobility assessment adequately for the patient to take it seriously. I believe that without a visual guideline of the scale, this patient was unable to break the scale down into 10 and just said 7 every time as he wanted me to either leave him alone and/or though that 7 was what I wanted to hear. As a result, the mobility assessment was useless for this day as I know that he had the capability to walk a lot further and qualify for low-level care. I had to use other visual and non-verbal feedback to determine how hard the walk was for him.
The next time I visited him I knew I would have to repeat the assessment but firstly explain to him in why we needed to see how far he could walk and at the same time monitor his dyspnoea. I planned to print out a copy of the Borg scale so he would be able to have a visual guide of what each number stood for.
This situation taught me the importance of explaining to a patient why we need to do these assessments and also that some patients find it difficult to understand how to use a 0 to 10 scale.
Strategies:
Use a print out of the Borg Scale (like this one - http://www.pulmonaryrehab.com.au/pdfs/resourcesPatient%20Assessment_BorgScale.doc)
Explain that the assessment is not just for the physio but also important for planning their discharge out of the hospital.
I discussed this problem with my supervisor and she agreed that the best option was to provide a handout sheet of the scale and also reminded me that this scale is very subjective to the patient so he may only be getting to 7/10.
I was asked to review and mobilise a 70 year old male patient who was admitted to hospital 2 days ago with an acute exacerbation of chronic COPD and also for an ACAT review. This patient currently lives in a shared 22 stepped boarding house with nine other males, uses 2 litres home oxygen constantly throughout the day and previously refused moving to low-level care after his previous hospital admission 4 weeks ago for another acute exacerbation of COPD. This patient recently could not move for 4 days secondary to increased pain and shortness of breath and decided to succumb to moving into a low-level or high-level facility.
Task:
After an initial subjective history had been taken and relevant observations were made, I had to check this patient’s mobility. In order to qualify for a low-level care facility, the patient is required to ambulate independently 50 metres at least.
Action:
The patient complained of being too tired and refused to go for a walk after the subjective interview and chest examination. When asked if he felt short of breath in his seated resting position he answered “Yes” and when asked to rate his shortness of breath out of 10 with 0 being where your breathing is causing you no difficulty at all and 10 being where your breathing difficulty is maximal, he replied with “Seven”. This patient was not heavily breathing nor showing any signs of respiratory distress. His SpO2 was being maintained at 97% on 2LO2 via NP and when questioned, he stated that this level of breathing for him was ‘normal’. I explained to him that 7/10 on this particular scale would be equivalent to saying his breathing was “very severe” and he said, “No, it is not that bad” but would not give me another numerical value for his own perceived breathlessness. We eventually got up for the walk and whenever questioned about his shortness of breath on the Borg Scale he would always say “seven”. During the walk, his SpO2 did decrease, his breathing became heavier and he increased the use of his accessory muscles and upper limb support when breathing. He did not want to take a rest through the walk and was extremely short of breathe and physically drained after the 30 metre walk.
Result:
Due to a miscommunication of the Modified Borg Scale, I was unable to properly determine the patient’s dyspnoea changes during the walk. He was in a rush the whole time and did not understand the importance of this ambulation assessment. He was more interested in going too the toilet and returning to bed as fast as possible. This made it very difficult to get him to slow down and monitor how far he could walk before his dyspnoea started affecting him too much and thus made the walk assessment useless and it needed to be repeated the following day after the patient had adequate rest.
Evaluation:
My explanation of the Modified Borg Scale was not too poor but I don’t think I highlighted the importance of the mobility assessment adequately for the patient to take it seriously. I believe that without a visual guideline of the scale, this patient was unable to break the scale down into 10 and just said 7 every time as he wanted me to either leave him alone and/or though that 7 was what I wanted to hear. As a result, the mobility assessment was useless for this day as I know that he had the capability to walk a lot further and qualify for low-level care. I had to use other visual and non-verbal feedback to determine how hard the walk was for him.
The next time I visited him I knew I would have to repeat the assessment but firstly explain to him in why we needed to see how far he could walk and at the same time monitor his dyspnoea. I planned to print out a copy of the Borg scale so he would be able to have a visual guide of what each number stood for.
This situation taught me the importance of explaining to a patient why we need to do these assessments and also that some patients find it difficult to understand how to use a 0 to 10 scale.
Strategies:
Use a print out of the Borg Scale (like this one - http://www.pulmonaryrehab.com.au/pdfs/resourcesPatient%20Assessment_BorgScale.doc)
Explain that the assessment is not just for the physio but also important for planning their discharge out of the hospital.
I discussed this problem with my supervisor and she agreed that the best option was to provide a handout sheet of the scale and also reminded me that this scale is very subjective to the patient so he may only be getting to 7/10.
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