Diagnosis and treatment

On my current prac I work on the wards each morning, mainly with post-op and respiratory patients. Last week I was asked to see a young girl with 'left lower lobe pneumonia'. She had quite frank haemoptasis, and was in a great deal of pain, which was localised to the left side of her chest. She was short of breath, fluctuated between febrile and afebrile an back to febrile in the blink of an eye. For the first few days of her stay, she was quite uncooperative with breathing exercises ue to pain, and was refusing to get out of bed. Wary of her pain and blood stained sputum, I approached her with caution. Her sats were VERY low and she was in serious need of some treatment. The first treatment conisisted of teaching thoracic expansion exercises within pain limits, and bed exercises (ankle pumps, static quads and gluts), and instructing the patient to perform these at least every hour. I documented each treatment in great detail, and saw her everyday. Gradually she was able to get out of bed, and walk on the ward, but she was not getting better no matter what we tried. Each chest xray came back the same. After 10 days, the doctor finally ordered a CT scan and other investigations that had not yet been done. These picked up that my pneumonia patient actually had a PE and a DVT!!! No wonder she wasn't improving. On reviewing the notes, it was evident that we had done all we could to treat her, and had done our best to prevent the subsequently developing DVT. After being treated for the actual problem, the patient was back to health in just a few days. If I have taken anything away from this experience, it is to be conservative and cautious, and never underestimate simple bed exercises and good documentation. Even if you think a word of advice or basic exercises are not that important to document thoroughly, you never know when your documentation will be reviewed. My documentation in this case is evidence that we did everything within our power to offer the patient the best possible treatment.