Fourth Year Rotation 4 - STARES

Situation

A 74 year old man presented to Royal Perth Hospital emergency department with lethargy, malaise, confusion, decreased mobility and increased micturition. On diagnosis it was found that he had urosepsis and he was promptly admitted to the general medical ward.

Task

Due to the patients decrease in mobility, I was asked to review the patient’s mobility and treat him appropriately.

Action

On initial assessment the patient was one assist with all of his mobility and was able to ambulate one assist approximately 8m with a wheeled zimmer frame. He appeared slightly confused, for example, asking multiple times where the nurse was but then not having a reason for wanting her, however, he was able to follow instructions.

On return the next day the patient appeared more lucid. He was much more compliant with treatment and the confusion appeared to be resolving. I updated the mobility board to inform the nursing staff of the patient’s new mobility status. A few hours later, the nurse in charge of the patient’s care notified me that the patient’s mobility had regressed and he now required two assist with ambulation with a wheeled zimmer frame and one assist with all other mobility.

On the third day of the patient’s stay on the medical ward I again went to see him for a mobility review. Due to the events on the previous day I enlisted the help of a nurse to stand-by while I mobilized the patient. This was lucky as the patient was very confused, unaware of where he was and trying to get out of bed without the assistance of anyone. With encouragement the patient agreed to mobilize with both myself and the nurse assisting. After mobilizing approximately 2 metres around the patient’s bed he suddenly leapt for the bed behind him yelling “I’ve had enough!”. Fortunately he managed to sit himself on the edge of the bed and the nurse and I were able to stabilize him. We returned the patient to bed and notified the medical staff of his increased confusion.

On the Monday I returned to the patient to assess the situation and attempt to mobilize him if appropriate. The patient was sitting out of bed, which is something he had refused for the past week, and he was much more bright and lucid than I had seen him sine his admission. Previously he required a lot of encouragement to mobilise, however today he was asking if it was possible to go for a walk. On mobilisation the patient required only stand-by assistance with a wheeled zimmer frame and was able to ambulate approximately 30 metres. Due to his sudden improvement is was decided that he would be mobilized in the afternoon as well to enhance the rehabilitation potential of the patient.

Result

As a result of liaising with the nursing staff and ensuring there were enough staff present to assist with the patient I was able to mobilize the patient safely and avoid injury to the patient and to myself.

Evaluation

This situation really highlighted the importance of understanding delirium and the large effect that infection can have on a person’s mental state. It must be monitored well and treatment altered accordingly.

This situation could have ended very badly if communication between the nursing staff and myself wasn’t so open. It really brought to the forefront the importance of the multidisciplinary team and the vital role that each team member makes.

Strategies

Observation of the patient is vital for assessing levels of confusion or signs of delirium, as well as asking the patient time, person, place. Any changes in the patient’s mental state should be noted as well as documented in the notes and handed over to the medical team and nursing staff. Clear lines of communication between the nursing and medical staff and yourself are vital and good patient care relies on this.