今日は、前回のブログで書いた問題の答えを英語ですが載せたいとおもいます。ここに書いてある答えが全て正しいわけではないと思いますが、一応大学で教わっていることに沿って書いてあるので、こちらの病院ではこんな感じで治療が行われているんだなぁぐらいでみてもらえるといいかなと思います。
QUESTIONS
1 What is your cardiopulmonary problem list for this patient and any
additional ‘considerations’ for your treatment?
Problem list
· 1. Decreased lung volume
o E:CXR (bibasal atelectasis, loss of lung volume), upper chest breathing pattern, poor chest expansion (decreased bibasally), Auscultation findings (decreased BS bibasally)
o R: UAS, General anaesthesia, slumped position,
· 2. Impaired gas exchange
o E: SpO2 -91% on 28%O2, ABGs on 2L O2: hypoxaemia, Hypercapnia
o R: V-Q mismatch/shunt secondary to atelectasis and reduced lung volume
· 3. Impaired airway clearance
o E: subjective assessment (cough - difficult clearing sputum), cough is weak, tight and moist sounding
o R: Difficult to cough due to pain, ex-smoker – impaired MCC, effect of general anaesthesia
· 4. Pain
o E: subjective Ax: movement/cough, PCA use
o R: upper abdominal incision – post day 2 patient
· 5. Airflow limitation
o E: Auscultation – polyphonic expiratory wheeze throughout, usage of ventolin nebs 4hourly, COPD, uses spiriva
o R: COPD patient – potentially having bronchospasm,
· 6. Decreased mobility
o E: has not been out of bed
o R: secondary to surgery
Considerations
· Weight loss (10kg)-fatigue/frail
· Nausea (maxolon)
· Atrial fibrillation
· Hypertensive
· Looking unwell
· Pancres Ca - poor prognosis
· Lack of social support
2 Describe your short-term management strategies for the patient
addressing the main problems and provide a rationale.
· Short-term management/day 1 treatment I would apply for this patient would be:
o Adequate pain relieve – PCA, analgesics, realise with medical team (address 4)
§ R: before commencing the treatment, applying adequate pain relief can optimise patient’s compliant with treatment and it will be more effective for patient to cough/ambulate
o Ventolin/hypotonic saline nebs and ACBT (active cycle of breathing technique) /supported cough (address 1,2,3,4,5)
§ R: ventolin nebs will reduce patient’s bronchospasm therefore addresses airflow limitation. Also, hypotonic saline nebs will liquify the sputum and will be easier for patient to clear the airway. By combining with ACBT it will save some time as patient has a history of weight loss and may feel fatigue easily. Also by taking deep breaths, atelectatic lungs will be re-expand as the air will go through co-lateral channel and will also mobilise the sputum which is blocking the airways. That contributes to the recruitment of more of alveoli and V-Q mismatch will be improved. Supported cough with pillow/towel will minimise patient pain and improve airway clearance.
o Ambulation and leaving in high back chair on completion (address 1,2,3,6)
§ R: by ambulating the patient, he will be in upright position and will take deeper breaths. It will help re-expand the atelectatic alveoli and will improve gas exchange. Also the abdominal contents will be displaced inferiorly in upright position and there will be more space for the diaphragm to move with respiration therefore the patient will be able to take more volume into the lungs and have more expiratory volume for effective cough.
o Education on deep breathing exercise, positioning, effective pain relief
§ As this patient forgotten about breathing exercise, it is important to educate this patient for deep breathing exercise as well as upright positioning which increases the lung volume and therefore improve gas exchange. Also, educate on pain relief/PCA use to minimise the pain and optimise the patient mobility (patient will less likely to ambulate by himself if pain relief is inadequate).
§ Also educate on breathing strategies if patient requires; may or may not feel SOB but as patient has a history of COPD, leaning forward position, PLB, upper limb support may help reduce SOB.
3 Discuss any precautions you should consider in your treatment of this
Patient
· As patient has history of COPD, we need to monitor SpO2 during treatment as well as skin colour (pale, blue), perspiration, subjective feeling (SOB)
· BP monitoring for hypertensive, and ask nausea
· Monitor HR/PR (manually) for AF
· Monitor fatigue as patient has Hx of weight loss
· Wound check – make sure there is no ooze
·
4 Your patient developed pneumonia post-operatively and spent 1 week
in the Intensive Care Unit. He was then transferred to a medical ward.
Three weeks later, he is ready for discharge and is very deconditioned
and breathless on minimal physical activity. Discuss your discharge
plan for this patient.
This patient previously lived alone, independent in self-care and lives in 2nd floor, it is likely to be challenging to go home without support. If patient is able to be supported by his children that would be easier than him to go his own home as he will require a lot of effort for ADLs such as cooking, cleaning, shopping, and personal care. And this will be challenging as he is currently very deconditioned and breathless on MINIMAL PHYSICAL ACTIVITY. Thus, if his children can support at their home and can provide all of ADLs and personal-care support, then that would be one option. Another option would be referring to rehabilitation hospital as this patient may benefit from further rehab for improving his exercise tolerance and providing some information with regards to his COPD. Community referral (Community Linkage COPD) may also be a good option for this patient. In any case, he will likely to require ongoing input/rehab/assist to improve his current conditions.
このような感じです。今週からはMusculoskeletal （いわゆる整形外科外来）の実習が始まりました。クリニックでは、個人の部屋を用意してもらって、そこで患者さんと一対一の問診から始まり、理学療法評価を実施してその後、Diagnosisの仮説を自分達のスーパーバイザーに伝え、治療プログラムの立案、そして次回のアポイントメントを取るといった形を日々くり返しています。とくに多い疾患は首、腰などの痛みで来る方、肩の痛みで来る方などとても興味深い症例をたくさん経験させてもらってます。また時間があるときにどのような評価、治療を行っているのか書いてみたいと思います☆