Stares entry 3 rotation 2 2010
Situation
Mrs T had initially presented to ED after a fall. After a diagnosis of a hip fracture and subsequent proximal femoral nail insertion (PFN), she had to be transferred to the cardiothoracic ward as she was in fast AF post-op. She was now day 3 post op and had not been out of bed due to complications with BP and AF. She had stabilised somewhat and the medical team had given the all clear for gentle ambulation. She was high priority for physio intervention as the nursing staff were having great difficulty mobilising this patient. After a fairly superficial investigation of the patient notes, I found out this patient was previously independent with mobility, living in a hostel. She also had a PMHx of dementure.
Task
Complete safe Ax and Rx of patient - aiming for mobilisation.
Action
Mrs T was very chatty when I initially went o asses her. TPP revealed orientation to place and person but not time. She was also unaware of her recent fall and subsequent surgery. Although it was clear Mrs T was not completely orientated, she seemed compliant.
There were no signs in the Hx or on subjective questioning of chest related complications, so I proceeded to a mobility review in bed. In particular I was most interested in quad strength (– 4/4 L and R), ability to do a bridge, and DF/PF strength. I deemed this patient safe for a sit to stand transfer using a frame for assistance.
After organising Mrs T attachments and helping her to the edge of the bed with minimal assistance, I asked Mrs T to stand up. All of a sudden she became very frightened. I suspect as she tried to move to a weight bearing position she felt a great deal of pain. Half way through the stand she began to push back against my support. I had to hold her upright using my bodyweight and arm strength. While in this position after allot of coaching I managed to get Mrs T into a full stand. She was still very frightened and confused. I asked Mrs T to take some steps to the side and the forward with great difficulty. She wasn’t really following my commands, pushing her frame away from herself instead of walking with the frame. She was very unsteady on her feet. After realising that Mrs T was near the end of her tether, her confusion and resistance to instruction increasing, i tried to return her to bed. Again she was not responding to commands, arguing with my instruction and shouting ‘I just want to get in my car and go home!’I ended up having to give her max assist to get back into bed.
Result
My physical wellbeing as well as the physical well being of the patient had been put at risk because I did not have enough support for the treatment. Although I was able to get the patient back in bed, I would say the result was quite unsafe.
Evaluation
In planning this treatment session I had not assessed to risk of the transfer thoroughly enough. This resulted in an unsafe treatment session. I could have minimised the risk of injury to myself and the patient by more closely assessing the patient’s cognitive state and further investigating what had happened on previous occasions when the nursing staff had attempted to get her out of bed. I think if I had better forward planning and a more thorough prior assessment of past interventions with this patient I could have better managed the risks of treating such a patient.
Strategies
· I need to more thoroughly assess the patient’s notes. In this case the patient had deviated from a normal path way, I should have further investigated this rather than accepting what I had been told about the patient’s medical instability.
· Communicate more readily with other HCPs from other disciplines. I am often reluctant to talk to nurses as they often seem too busy to talk to you. I will certainly change my attitude toward asking them questions after this experience.
· I need to improve forward planning. I need to visualise what I need to do and what the patient might be like before seeing the patient.
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