Being Observant

Recently, on my Neurology placement, I encountered a situation which I would like to share with you. I had been given a new patient, and had not been able to do much with him for the first week of his admission as he was rest in bed. When I did get to see him, he was quite fatigued, as he had had extremely poor sleep due to 11/10 headaches.
I went in to see him in the morning during my final week, as I had hoped to see him for some Physiotherapy during the day. I noticed immediately on walking into his room, that his communcation was different. He almost looked as thoug he was in a different conscoius state- he took a long time to reply to my questions, and when he did, barely opened his eyes to make contact with me, and struggled to keep his eyes open.
I checked his med charts, and his nursing obs, and noticed that he had increased pain meds overnight which may have contributed to his present state, although his latest meds were given multiple hours previously. The patients nrusing obs were within his normal limits.
I immediately went to the nursing staff, and informed them of what I had seen with this patient, to ask if they had also noticed a change. The nurse came in to observe the patient, and the patient was well oriented to time, person and place. The nurse also acknowledged a change in his communicative state, and the medical staff were immediately contacted for a review.
Satisfied with this, I went to look in the medical notes, and noticed that the Reg had not recorded changes noted from my observation of the patients most recent CT scan. I immediately contacted the Reg, to ask if this patient was still fine to treat Physiotherapy wise, considering the new developments with the CT scan. The Reg, noted this, and stated it was fine – she must have failed to update this in her note-taking.
I did not manage to get this particular patient into Physiotherapy that day, and as the placement is now over, I do not know what happened further in this patient’s case, however, I did learn from this expereince.
One lesson is to always be very observant of your patients, as often we are the first ones who notice not only improvements, but also deteriorations in our patient’s status. The second point is the importance of the Multi-disciplinary team, and communicating effectively with all members for the well-being of the patient. Thirdly, don’t be scared to challenge or question Doctor’s from time to time,in a professional manner, as everybody makes mistakes. I will bring these lessons learnt into my future clinical practice.