STARES 1 Assessment

S- 41 year old female patient who is day 1 after a laparoscopic cholesectomy that was successful and it was requested by the surgeon. She was a healthy lady with her only PMHx was an appendectomy and her SHx is that she lives with her husband at home. She has nothing that suggest any complications.

T- To do a routine post-op chest and mobility review of the patient and provide necessary information regarding this.

A-I introduced myself and explained that I was asked by her surgeon to see her post op regarding her breathing and the way she moves around. I then went on to ask how she was feeling ie dizzy/pain/nauseous/vomiting/coughing? I also asked if she had been up to walk around yet. As was feeling well with none of the above symptoms except slight pain which is been managed with oral analgesics I went on to teach her deep breathing, ankle and lower limb circulation exercise and how to support her wound, especially when she coughs. After I thought she understood what I had told her, I taught her how to more effectively get up out of bed by rolling onto her side first. In sitting I again asked her to cough with her wound supported. I then auscultated her chest ensuring the patient was taking deep breathes through her mouth as I auscultated each lobe of the lung ensuring no added sounds. Finally gave the patient a hand out which explained everything we went through and if she had any other questions the physiotherapy department’s phone number was on the front of the sheet.

R- The patient understood and was compliant with everything I had suggested to her and she would be fine considering her lack of a PMHx and her being young. Also this means that she no longer required physiotherapy input unless she requests it.

E-I feel as if my assessment of this patient went well. I thought that I systematically went through each stage that needed to be covered without jumping from one thing to another too much. However there was a few things I could improve on. Firstly I think I should check the Obs Chart earlier on in the session, as I forgot too until part way through, luckily for me she was stable (as I read it in her integrated notes but I feel its an important habit to get into). Also making sure I use the hand wash/sanitiser more and more obviously initially just to keep it safe between the patient and myself and the surroundings. However all in all I think I did well with my first patient of this nature.

S- Notice how other Physios interact and perform these day 1 post-op assessments.
-Keep practicing
-Know all the protocols for each different operation for day 1, especially when different surgeons have different protocols.
-Ask for feedback