I am currently on my cardiopulmonary placement, and had my first experience with a patient in ICU. The patient was a 77 y.o female, BIBA to ED 6/7 ago with a 3 month history of nausea and vomiting. A CXR revealed a L pulmonary effusion and empyema, and she underwent a thoracotomy the following day. She had received physiotherapy treatment for the past four days, but had not yet mobilised.
Her main problems include: reduced lung vol, impaired airway clearance, pain and impaired gas exchange.
On assessment, she had poor chest expansion bibasal with L>R, ausc revealed no B/S L lower lobe and poor b/s L upper lobe. The CXR taken that day showed a worsening of the L lung effusion, and the patients ABG’s were a concern with PaCO2 at 60mmhg. Overall the patient’s general condition was deteriorating.
The PT that treated her the day before expressed the goal of mobilising the pt with a hoist to assist with secretion clearance and improve gas exchange, but following the assessment in the am, I decided not to sit the patient OOB as she was quite unstable.
Treatment then consisted of deep breathing ex’s, upper limb exercises and repositioning. On evaluation, ausc findings revealed no change, her cough was still moist and non productive as her deep breaths were impaired by her increasing confused state and pain.
I saw this patient with my tutor, who encouraged me to rationalise my treatment choices and provide justification of my actions prior to treatment. She then agreed with my plan. The main problem of this scenario was my doubt as to the effectiveness of my treatment in a situation like this. I understand that the treatment options have sound theory as to why they work, yet I question how effective the implementation of these techniques where to the patient. The evaluation post treatment revealed no change in her respiratory status, despite my tutor deeming my treatment as competent.If any one would like to comment on other possible treatment options, or what they would have done in the situation that would be much appreciated.
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2 comments:
I think that given that my first port of call would have been GADP. Things no doubt would have been much much easier if she had been intubated, as the pain and confusion would have made any sort of facilitation or exercise extremely difficult. My experiences in ICU were mainly with intubated patients, but I found the hardest patients to treat were those who had recently been extubated, and had been recently weaned off sedation but were quite drowsy.
GADP would have been effective, but if the patient is in that much pain and confusion then it would be hard to keep her in any beneficial position. Facilitating deep breaths by using a quick stretch and pressure on her intercostals would theoretically be beneficial, but due to pain and thoracotomy, it is not that realistic an option (the same could be said for percs). vibes in addition to GADP may have been effective, or the use of humidified oxygen. This is all much easier to think of when I dont have the patient in front of me, and i cant vouch for the effectiveness of this for the specific patient, as most I saw were intubated.
I think if the supervisor said it had been competent then I would say it would have been. The other option is to bounce ideas off any other physios who may have been in ICU. But I did find that treating patients who had just been extubated and were still in pain were quite difficult to get the ideal outcome out of.
I have also had a prac in ICU and have found that we are limited in the types of treatment we would like to do due to the conscious state of the majority of the patients. I think what you did was appropriate and exactly what I would have done. If the experienced supervisor was happy with this and deemed termination of treatment before a clinically objective outcome measure was found appropriate, then I think we can trust her decision. We can take this situation to realise that not always will physio we clinically effective in objective terms, and that in the next few days when the patient is more cognitively aware treatment may then become more effective.
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