I was previously on an orthopaedic ward where I had an 80-something male patient who had undergone a standard protocol total knee replacement. Treatment however, was not so standard. As some of you know following replacements the patient is often on a spinal epidural and pain cover is a priority. This man however appeared allergic to opoids and his pain was poorly managed. Even trying to move him in bed caused him to cry, and that was at a week post-surgery (most knee replacements are in hospital 7-10 days). Not only this he would often ask why his leg hurt, or would forget who I was or what he did yesterday. I had to repeat instructions several times and demonstrate before he understood. Furthermore he would start sobbing for no apparent reason so loudly that the entire ward could hear him. Most on the ward assumed this unusual behaviour was from the pain medication and for a week I tried my best to increase his limb strength, ROM and mobility. The more i worked with him the more it became apparent that clearly he had an altered mental state. From his subjective history in notes and from him it appeared he had lived independently prior to this, and had been driving no less.
Finally his daughter came in and I asked about his social background. Turned out he lived with her and her husband, however they left for work at 6:30am and came home around 7:30, so he was alone all day and that sometimes she'd find him stuck in a room or not knowing what he was doing. When I informed her about his sobbing, she assured me that 'he always does that around the house'. not only this, she went on to explain that he self-medicates with panadol and alcohol. She appeared to believe there was nothing wrong with this, and asked me when he would be discharged. I informed a social worker and he was eventually discharged to ongoing rehab with a suggested diagnoses of alzihemers.
I learnt from this that although I am a student and it is easier to just 'go along' with the rest of the wards opinion, at times we do have to take it into our own hands and use our own initiative to find the cause of a patient's problems. Had this man been discharged home who knows what state he would have ended up in. Furthermore his family clearly had no idea of the care he required or of his mental state, or how much damage his 'self medication' could be doing him! It made me realise that we can't always take the 'notes' or more experienced allied health professionals, such as nurses, opinions as gospel, and that as students we also have a duty of care to our patients and have an obligation to investigate into every aspect of their care as required.
3 comments:
I have also come to realise how important a patients social history is, and i think it is something we dont really think about when we learn about subjective examinations. It is so important to know who is going to be looking after your patient at home, and so often I have picked up serious issues just listening to the patients conversations with family members. I now understand the reason why we need to view the person as a whole, not focus just on their impairments.
This is a great example of how we should continually be questioning our selves and what we are doing and what is happening with our patients. I have found that on placement if you notice unusual behaviour by a patient there is usually a cause behind this and it is just a matter of finding out what this is! And as you explained talking to their family is a great way to start!
This situation presents a potential problem with our subjective questioning. With the aging population group, on simple SH questioning many patients may say that they live with their family but I found with some of my patients further probing showed that similar to this man they spent most of their time alone at home and therefore were required to be more independent for their ADL's than initially expected. Its really important that we aren't just asking questions for the sake of it, but actually making sure that we're getting the whole picture.
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