rotation 4: Stares2 : intervention:

Situation:
I was treating a 77 year old female who came to my ward from SICU on day2 post CABG x2. She was admitted via the emergency department complaining of chest pain with associated shortness of breath and was diagnosed as having a heart attack (inferior STEMI). She has an extensive past medical history of: ischemic heart disease, previous heart attack in ’96, hypertension, Dyslipidaemia, Peripheral vascular disease, COPD: last hospital admission for exacerbation of COPD was last year, GORD and is a smoker (25 pack years). She has been on my ward for a day now and on auscultation her air entry into her lung bases is still very poor as well as having very poor lateral chest expansion which has not improved greatly with tactile feedback in deep breathing exercises. I am now deciding on whether the patient may benefit from using a positive breathing device like IPPB or CPAP.

Task:
To improve this patients air entry and later chest expansion to her lung bases. Plus assess whether a positive pressure breathing device maybe beneficial in assisting in this.

Action:
I reassessed this patient’s chest expansion and auscultation, which had not improved, plus assessed the way in which she was breathing which was very staccato in nature and demonstrated an upper breathing pattern. I felt that using a positive pressure device would be beneficial with this patient.

Result:
Using the positive pressure device helped this patient better recruit her respiratory muscles to allow for lateral chest expansion and air entry into the bases of her lungs during deep breathing exercises which ultimately made my treatment sessions with this patient more effective.

Evaluation:
I think my assessment of whether there was a need for a positive pressure device was quite good. Ultimately I did not want to rely on using these devices as my only intervention or first choice intervention. But I think I was able to clinically reason the benefits of using this device on this patient in the short term to help her recruit the correct breathing pattern to allow her to improve her lung function. I think I was also quite good at assessing when this patient no longer required positive pressure using clinical reasoning skills and her objective findings as her basal expansion and air entry improved. I did need help with setting up both the IPPB and CPAP machines as I have not used them often. Plus it did take me a while to work out all the equipment I needed for the machines so I could have been a lot more organised in asking for help and getting the machines ready to be more efficient with my time.

Strategies:
• Assess each individual patient on their appropriateness for positive pressure devices.
• Always use as an adjunct to therapy not as the only treatment
• Be prepared and familiar with all treatment equipment
• If in doubt ask for help and read the instructions!
• Be organised!