Currently on my neuro prac, I have had a number of pt's that have come directly from ICU or become acutely unwell. Last week was no exception, with one pt i had been seeing bidaily, desaturated overnight and a code blue was called.
This pt has GB and Rx consists of chest management including ACBT's and suctioning via trache, with passive movements of UL's and Active assist of the LL. Early last week, the pt was tolerating Rx well and getting much better chest expansion and breath holds. This made me think that his intercostals or accessory muscles were again being activated after nerve conduction improving. I encouraged the pt to take deep breaths and the pt was satisfied with his new improvements.
The following day the pt was complaing of mild constant (L) chest pain, that was worse with deep breathing and passive movements of the (L) UL, particularly flexion of the shoulder. I thought the pain was possibly of a musculoskeletal origin, after the big session the previous day, maybe the pt had strained a number of intercostal muscles. The pain also could have been due to remylination of nerve fibres with muscle reinervation, which can cause pain. I checked with my supervisor and she shared my view. I limited DBing ex's and the pt had a gentle session.
The pt was diagnosed with a PE and spontaneous pneumo-thorax (L) the following day after crashing overnight, and was placed under more acute care. This was a surprise after our suspected diagnosis, and i thought if there was anything i had missed and could have alerted Dr's earlier. We checked the area and palpated, auscultated, subjective questioning and nothing indicated a sinister pathology. This situation just indicated even if you think you've covered all your basis this is not always the case. Even being cautious and getting an X-ray that day would have picked up the pneumo-thorax or other tests to indicate a PE. I felt like i should have known or done more, but i wasnt exactly sure. We tried to do DBing that day but cut it short, in hindsight avoiding this altogether would have been better. These situations probably happen alot in clinical practice, and hopefully if it can be prevented actions are taken for optimal pt outcomes.
1 comment:
Sounds like you handled the situation well with using your observation and active listening skills to be able to cut the previous days treatment session short. I guess ultimately it's not possible to routinely perform tests all the time on all inpatients unless specifically indicated and the fact that you didn't continue to push the DBing with your patient is a credit to you because you esseintially prevented the patient from any more trauma!
Post a Comment