I am now finished my first week of my cardio placement. I am on the general medical ward which is great because we have been exposed to numerous different types of patients.
I have been working with a 97 year old COPD patient. She was admitted with complaints of breathlessness (SOB). She is productive in the morning with about a tablespoon of M3P3 sputum, however her main complaint is of SOB. During our treatment session we go through her ACBT’s and then go for a walk. She walks 20m on RA and requires 2 short rests. Pre ambulation she was 88% on RA and she then de-saturates to 83% when walking. Strategies she uses is pursed lip breathing however she is very adamant that oxygen therapy (2L via NP) gives her the relief she needs. As we have learned from cardio lectures, we know that oxygen therapy is not a treatment for dyspnoea.
I find it very difficult with this patient as she is convinced that she lives with this problem and she knows best what helps her SOB. I have educated her on proper strategies to help manage her SOB such as (forward lean, relaxed breathing, and the fan). However attempts at convincing her that she does not need oxygen as her Sats aren’t that bad have been unsuccessful. I think the nurses find it difficult to manage as well. They often end up just giving her oxygen because she is so persistent and makes a fuss if she does not get it.
The last visit I had with her I entered her room and her oxygen was actually at 2 ¾ L. I adjusted the flow rate back down to 2L. Her SATS were 94 %. On the return from our walk it was perfect timing as the doctor was waiting for us to return and she was able to see how the patient recovered from exercise without oxygen. I was also able to mention the flow rate that she was on when I entered the room. From our discussion and due to the fact she re-saturated within 2 min to 88-90 % without oxygen after exercise the doctor documented in the notes to avoid overuse of oxygen therapy as the patient is very dependent on it however does not require it.
It was a great conversation with the doctors and I feel more confident that this issue will be taken more seriously with a note from the doctor rather than a note from the physiotherapy student.
The plan is to reinforce the education I have already discussed with her. I know that discussing physiological reasoning with a 94 year old is not ideal however I think that will be my next approach to inform her why too much oxygen is not necessary and it interferes with her hypoxic drive to breath. Any thoughts of ways to get my message across?
This situation is a multidisciplinary approach as well. When working in the hospital if all the members of the team are not all consistent with the goal and treatment plan for the patient, managing the patient becomes challenging. Thus when I enter the room and she is sitting at rest with her oxygen on, it becomes that much more difficult to convince her she does not need it. I am hoping with the entry the doctor made the team will be a bit more consistent with not giving in to her request for oxygen.
Dani
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I think you're right in the fact that this is a problem that needs to be dealt with from all members of the healthcare team. It can be very frustrating when as a physio you want the patient to do something and the rest of the team isn't on the same page as you.
I did my cardio placement on a respiratory med ward and because the ward was specialised to deal with resp problems we didn't have much of a problem when it came to oxygen therapy because evryone had the same goal in mind and knew how to deal with patients requesing more O2. I can see how this could be different on a gen med ward tho. I think its situations like these that make us realise how broad our knowledge base is and that we need to share this info with other healthcare members.
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