The patient developed sudden onset of cough associated with shortness of breath after feeding: Health and Physical Education Case Study, Singapore

Assessment Title: Logbook of patient assessment

Assessment Summary

Presenting problem: The patient developed sudden onset of cough associated with shortness of breath after feeding

Patient details and past medical history

Male, aged 60 , lives with wife and daughter. Previous history of Left Basal Ganglia Bleed in 2020. Risk factors for CVA include Hypertension and Hyperlipidemia Remains wheelchair-bound in the community and furniture walker at home Medication: Aspirin, Clopidogrel, Atorvastatin, Calcium.

Recently admitted to hospital for investigation shortness of breath after feeding milk through the mouth.

Assessment findings:

I helped the patient to lie on top of his bed to rest in a fowlers position with the head elevated at 30degree. I did his observation using the ABCDE approach.
AIRWAY- wet gurgly sound, patient coughing at times, able to talk in small sentences.

BREATHING- Respiration rate-28bpm, Sao2-90% on room air, chest expansion equal on both sides, chest fall and raise present, using accessory muscles to breath.

CIRCULATION: Pulse rate 98bpm, BP- 140/88 mmHg, warm and well perfused. CRT 2seconds, Temperature – 38degree Celcius

DISABILITY- Alert, good verbal response, no presence of Pain, check unresponsiveness
Blood Glucose- 5mmol/l

EXPOSURE and everything else –No evidence of bleeding/injury/rashes/scars seen. Still complaining of shortness of breath Further assessment of the patient revealed that the patient was still experiencing shortness of breath, patient unable to expectorate phlegm/secretions and body feels warm.

Any early intervention:

I reported the patient’s condition and his vital signs with parameters that I recorded to the doctor in charge.

It was agreed that patient has aspirated on milk feed so oxygen was given via nasal cannula at 4liters/minute, Suction apparatus was set up and I performed oral suction using a size 12 suction catheter which I passed gently through the patient’s mouth until I could see the catheter and stopped when I felt resistance. The patient was placed on NO FOOD NO DRINK by mouth, Intravenous therapy, Intravenous Paracetamolwas administered for pyrexia as ordered, Tepid sponging was done by me.

The patient was placed on continuous SPO2 monitoring.
Tests/investigations:

Due to a history of Left BG Bleed which has affected the patients swallowing, the patient was referred to Speech Therapist for assessment and evaluation once his condition was stabilized and SPO2 improved. I did not perform a bedside swallowing test as the patient was still experiencing some breathlessness.
CXR Routine bloods , Arterial Blood Gas , Blood Cultures for sensitivity, and gram stain had been taken

Findings/outcome:

The CXR showed mild consolidation in left lung lower lobe.
The Doctor in charge of the patient wasinformed and Intravenous Antibiotics Ceftriaxone , Paracetamolwas started .

Referral was made to Physiotherapist for Chest physio to drain secretions and to teach deep breathing exercise . Incentive Spirometryto improve lung capacity

Implications for future care such as any relevant health promotion

Since it is expected that dysphagia is still present from previous stroke ,thepatient will require more information on modified diet and fluid intake and importance of its compliance ..Advise on different diet textures .Health education was given to patient and his wife by me and demonstration of nectarthickened consistency fluids depending on speech therapist assessment, findings and recommendation.

Encouraged and educated patient on importance to comply on nectar thickened consistency fluids so that he will not develop aspiration pneumonia again.

Encouraged patient to sit in chair for meals and snack time instead of lying in bed ,to prevent aspiration and promote postural drainage
Regular Oral hygiene is very important to reduce risk of aspiration pneumonia.
Reflection:

I was pleased I remembered the importance of doing a full ABCDE

assessment and found this very helpful. It also meant I could report clearly the details of the patient condition to the Doctor in charge.

Following discussion with the doctor in charge ,I learned that it is very important to report patients vital signs to doctor immediately without any delay to relieve patients suffering .I also had the opportunity to visualize and read patients CXR findings ..I would like to learn more about Arterial Blood Gas report interpretation and memorize all the normal values.