Chapter 4 Case scenarios
4.1 Introduction
4.2 Case scenarios
Surgical example
• What type of assessment approach is appropriate for this situation?
• Suggest the main aim of your assessment at this stage?
• What assessment tools or other measurements might you need to use/obtain for this patient?
• What are the potential causes of this situation?
• What do you think is the main problem in the above-mentioned scenario?
Medical scenario
Some background information is provided as follows.
• Medical Research Council (MRC) breathlessness score: 4
– Mr Smith was admitted to hospital via A&E, very anxious, with severe SOB and is currently on a medical ward.
– His SOB had gradually worsened over the past 7 days with cough producing small amounts of thick yellow sputum and increasing wheeze. He is severely limited by breathlessness and at present he is in bed and does not feel able to mobilize.
• Observations and arterial blood gases (ABGs) on admission:
26.6 mmol l−1Physiotherapy assessment 1 (acute medical)
You are asked to assess this man shortly after his admission to the respiratory ward:
Physiotherapy assessment 2 (discharge assessment)
You are asked to re-assess Mr Smith in relation to discharge planning:
Neuromuscular scenario
– He is a former physical education teacher, married with two children. He lives with his wife in a four-bedroom house and has never smoked.
• Lung function tests (last performed 2 months ago) (height 185 cm, weight 86 kg and BMI (body mass index) 25.1)
• Observations taken on admission (on air):
30.8 mmol l−1• What type of assessment approach is appropriate for this situation?
• Suggest the main aims and priorities of your assessment at this stage.
• What type of respiratory disorder does this show?
• Why does an individual with a neuromuscular disorder have respiratory problems?
• What are the implications of this disorder?
• What assessment tools or other measurements might you need to use/obtain for this patient?
4.3 Suggested answers
Surgical scenario (James Williams)
• What type of assessment approach is appropriate for this situation?
• Suggest the main aim of your assessment at this stage?
– Is the patient safe? Remember: if a patient does not appear well from a handover or when you go to see them, always link with your senior and check: A (airway), B (breathing), C (circulation). They will be able to guide you.
• What assessment tools or other measurements might you need to use/obtain for this patient?
– AVPU or GCS: will be able to tell you how responsive this patient is. Remember: if there has been a change (better or worse), this is important to note and to feed back to the staff on the ward.
– Pupil response: check whether they are responsive and whether there are any changes; this should also be reported back to the ward team.
– Pain score: is the patient in pain or is he receiving too much analgesia? If it is the latter, he may not be able to communicate with you.
– HR and rhythm: does the patient have a pulse? Is it steady? What is the trend? Is HR above BP? Do you need help?
– BP: does the patient have a stable BP? Is the trend stable? If there is a trend for a falling BP, he may need more fluid or could be bleeding. If you are unsure about the stability of the patient’s BP it is important that you ask senior staff for assistance!
– Re-measure RR: at what rate would you be concerned? What has the trend been – this may tell you if the patient is getting better or worse. Do you need help?
– Oxygen and saturations: are saturations acceptable and stable? How much oxygen is the patient receiving and is his need for oxygen increasing?
– Auscultation: are there breath sounds to all zones? Are there any added sounds? If so, where and what may these indicate?
– Palpation: is the chest wall moving or is breathing so shallow that there is little movement and the patient is not effectively ventilating?
– Within 2 hours of surgery there may not be a chest radiograph or any ABGs, but if these have been done they need to be checked.
• What are the potential causes of this situation?
– Neurological problem: if a patient drops their level of consciousness after an operation, it could be due to a neurological incident (e.g. stroke). However, more commonly this is likely to be due to the effects of the anaesthetic or the side-effects of some drugs.
– Effect of anaesthesia: after an operation (especially prolonged surgical time) patients may remain ‘flat’ (damped responses) for a period. This may make a patient less responsive and thus lower their GCS. Anaesthetic drugs can also depress the respiratory drive and therefore make a person breathe more slowly and shallowly; however, the patient would be unlikely to be sent to the ward from the recovery area until this was resolved.
– Effect of analgesia: morphine is a strong analgesic that can depress the respiratory system and cause drowsiness. These effects can happen to a patient postoperatively, especially if they are sensitive to morphine – this can be described as opioid narcosis. In many hospitals, morphine is written up on the drug chart with naloxone – a drug that reverses the effect of morphine. If necessary, ward staff are able to administer this. Signs of opioid narcosis are reduced RR (<8 breaths per minute), reduced level of consciousness and pinpoint pupils.
• What do you think is the main problem in the above-mentioned scenario?
– Too much morphine is the most likely reason for the signs identified in this scenario, but it is important that you fully assess the patient. Although common things are the most likely cause, sometimes it may be the uncommon option that is responsible … a comprehensive assessment ensures that you do not miss anything obvious!
Medical scenario (John Smith)
Physiotherapy assessment 1 (acute medical)
• What type of assessment approach is appropriate for this situation?
• Suggest the main aims of your assessment at this stage.
– Once you are satisfied that his airway, breathing and circulation are all adequate and stable, your main focus will be to identify his main problems, i.e. sputum retention, low lung volumes or breathlessness, and then to select physiotherapy management options for treating these problems, if appropriate.
• What assessment tools might you need to focus on with this man?
– Oximetry and ABGs to check that his oxygenation and ventilation remain adequate. Any deterioration should be reported to the medical team.
– TPR chart is important as he needs frequent monitoring in this acute stage to identify deterioration – look for trends!
– Respiratory pattern and rate may help to determine whether he would benefit from breathing interventions such as breathing control. These should also be considered alongside ABGs to identify whether he is at risk of respiratory fatigue, which may require non-invasive ventilation.
– Breathlessness should be discussed and can also be used as an objective marker. It may help to change his position to make this more manageable.
Physiotherapy assessment 2 (discharge assessment)
• What type of assessment approach is appropriate for this situation?
– You could include aspects of both systematic and functional assessments in order to determine whether the acute condition that required admission has now stabilized and whether he is likely to need any help to be able to reach his previous level of function.
• What would be the main aim(s) of your assessment at this stage?
– To ensure that he is likely to be able to cope at home and that he understands how to manage his chest clearance and breathlessness, if appropriate. It is also important to explore his mobility and functional ability and make sure he knows how much exercise and activity he can do, and how to monitor and progress this at home.
• What assessment tools are you likely to use now?
– Breathlessness: to check that he can use breathing control and can manage his breathlessness, this can also be used as an objective measure and compared with the score on admission.
Physiotherapy assessment 3 (acute community)
• What type of assessment approach is appropriate for this situation?
– A combination of systematic assessment and a functional assessment. Although he is in the community he still appears to have an acute problem; therefore, a systematic assessment approach should not be forgotten.
• What would be the main aim of your assessment at this stage?
– To identify whether there are any problems that require physiotherapy or referral to another service.
– To ensure that the patient’s management has been optimized. In view of the continued breathlessness and sputum production you need to be satisfied that his airway, breathing and circulation are all adequate and are as stable as in the acute setting assessment to ensure that he has not deteriorated.
• What assessment tools are you likely to use now?
– Oxygen delivery assessment: does he still need to use his oxygen? Is he using it for long enough? When does he need to use his oxygen – at rest and/or during activity? Will it be appropriate to consider weaning him off the oxygen? These issues should be discussed with your senior and with medical staff prior to advising the patient.
– Drug assessment: you need to find out whether he is taking his medication appropriately. Is he taking his inhaler correctly and using the spacer device? He is still very breathless, so does he require more bronchodilator therapy? Does he need a further course of antibiotics or steroids? Can he be considered for weaning from the nebulizer? (Any concerns regarding medication should be discussed with a senior clinician with authority to prescribe before any decisions are made or any advice is given to the patient.)
– Auscultation and palpation: are there retained secretions and does this support the need for further chest clearance techniques or advice?
– RR and respiratory pattern: is Mr Smith becoming fatigued? How well is he managing his breathlessness?
Physiotherapy assessment 4 (rehabilitation assessment)
• What type of assessment approach is appropriate for this situation?
– A goal-oriented assessment would be most appropriate. (This may lead on to aspects of functional assessment, if required.)
• What would be the main aim of your assessment at this stage?
• What assessment tools are you likely to use now?
– Exercise tests may be appropriate if exercise tolerance is an issue (such as the incremental shuttle walking test or the 6 minute walk test). Does he need to pace himself more effectively when walking? Does he require a walking aid? Is he interested in pulmonary rehabilitation to improve his fitness and, if so, is there a local programme you could refer him to?
– Breathlessness: would he benefit from further breathing control practice? What is his breathlessness score now? Has it changed from the last review? Does he need advice regarding relaxation and stress?
– Anxiety regarding a further attack: does he know how to manage another attack and what he should do?
– Drug therapy: does he understand the purpose of the oxygen and nebulizers? Perhaps he needs further education about their use? Is his medication optimal at this point or would he benefit from a further medical review? Would it be appropriate for him to keep antibiotics and steroids at home to use as ‘rescue’ treatment? (Any decisions regarding medication should be discussed with a senior clinician with authority to prescribe before any advice is given to the patient.)
Neuromuscular scenario (Jack Jones)
• What type of assessment approach is appropriate for this situation?
– In the acute setting, a systems-based assessment would be the first choice; however, there are aspects of functional and social assessments that are important to include.
• Suggest the main aims and priorities of your assessment at this stage.
– As ever, the history is key. Motor neurone disease is a progressive degenerative disease characterized by muscle weakness. This affects all muscles, including the respiratory muscles. So, the first part of the assessment needs to be the safety aspect of ensuring that he is maintaining an adequate airway and breathing (ventilation).
• What type of respiratory disorder does this show?
– The measured volumes for FEV1 and FVC are both down considerably in comparison with the predicted values. Therefore, this is a restrictive lung disorder, due to his weak respiratory muscles.
– However, this is a progressive disease. The recommendations from the National Institute for Health and Clinical Excellence (NICE) are for spirometry to be repeated every 3 months. These were performed 2 months ago, and so probably do not represent his current respiratory function.
• Why does an individual with a neuromuscular disorder have respiratory problems?
– He has progressive weakness as a result of his disease. This will affect his respiratory muscles over time, and this is reflected in his poor respiratory function.
• What are the implications of this disorder?
– Over time he will find it difficult to breathe in and thus is likely to slip into respiratory failure. This is likely to start at night, and he will not be able to lie flat.
– There is a chance that the weakness will affect his bulbar function and he may well have trouble swallowing. This puts him at risk of aspiration.
– In this case, he is not sensitive to oxygen; he is just not maintaining an adequate tidal volume all the time to clear the retained CO2.
• What assessment tools or other measurements might you need to use/obtain for this patient?
– General observation of the patient will tell you a huge amount. Does this patient look distressed and uncomfortable or relaxed? Is the patient talking in complete sentences? If not, this will indicate that he is working hard.
– Breathlessness scoring: formal scoring may not be appropriate in the acute setting. A simple question of ‘do you feel breathless?’ is probably enough to indicate that he is struggling.
– ABGs: will need to be repeated. A rising level of CO2 would indicate a progression in his respiratory failure.
– Cough assessment: with a progressive weakening of the respiratory muscles, both inspiratory and expiratory, he may not have the ability to cough effectively. Assessment of his ability to clear his own airways is very important. If this is impaired you should consider whether this is a new symptom. It may be that with an acute infection he now cannot clear his airways, but with treatment he may recover.
– Imaging: in this case a chest radiograph will show the level of expansion of the lungs, and any areas of collapse or consolidation that you may need to treat.
