Clinical reasoning and the cardiorespiratory patient
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CLINICAL REASONING AND THE CARDIORESPIRATORY PATIENT. CONTENT. Background of clinical reasoning Associated problem lists Common Respiratory problems Problem list identification Goal setting Treatment planning SOAP notes. Background of clinical reasoning.

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CLINICAL REASONING AND THE CARDIORESPIRATORY PATIENT

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Clinical reasoning and the cardiorespiratory patient

CLINICAL REASONING AND THE CARDIORESPIRATORY PATIENT


Content

CONTENT

  • Background of clinical reasoning

  • Associated problem lists

    Common Respiratory problems

    • Problem list identification

    • Goal setting

    • Treatment planning

  • SOAP notes


Background of clinical reasoning

Background of clinical reasoning

  • Aiming to pull together assessment findings, analyse these and therefore make treatment plans tailored to the individual patient

  • Clinical reasoning is therefore your justification for your patient management


Background of clinical reasoning1

Background of clinical reasoning

  • Documented using POMR

  • Professional liability

  • Physiotherapy standards


Process pomr

Identify patients physio issues

Set realistic targets for improvement

Devise management plan

Ongoing modification of plan

Problem list

Treatment goals

Treatment plans

SOAP notes

ProcessPOMR


Pomr general comments

POMR general comments

  • Patients can have similar diagnosis but have different problems/goals and plans

  • Format/layout can vary as can quality!

  • Dated and signed

  • Goals smart

  • Treatment plans must be progressed


Information gathering

Information gathering

  • Disease profile

  • Other documentation

  • Clinical assessment

  • Other documentation


Problem lists

Problem lists

  • Retention of secretions

  • Volume loss

  • Increased work of breathing

  • Reduced exercise tolerance


Associated problems

Associated problems

  • Poor pain control

  • Unstable cardiovascular system

  • Acute confusion

  • Musculoskeletal


Retention of secretions

Retention of secretions

  • Secretion retention

  • Inability to expectorate

  • Ineffective cough

  • Consolidation


Retention of secretions identification

Retention of secretions Identification

  • Disease profile and history

  • Secretions expectorated

  • CXR – consolidation/infiltrates

  • Moist cough

  • Coarse crackles on auscultation/fine crackles/bronchial breathing

  • +/- altered gas exchange

  • +/- raised temperature

  • Sputum culture


Retention of secretions goals

Retention of secretionsGoals

  • Independent expectoration within X days

  • Sputum volume -???

  • Resolution of CXR findings

  • Resolution of auscultation findings


Retention of secretions treatment plans

Retention of secretions Treatment plans

  • Positioning side lying

  • Nasopharyngeal suction

  • Manual techniques – vibs

  • See clearing techniques to clear secretion lecture


Increased work of breathing

Increased work of breathing

  • Shortness of breath

  • Increased respiration rate

  • Use of accessory muscles


Increased wob problem identification

Increased WOBProblem identification

  • Disease profile and history

  • Increased respiration rate

  • Altered respiratory pattern

  • Use of accessory muscles

  • Breathlessness

  • Altered ABG


Increased wob goals

Increased WOBGoals

  • Borg scale of perceived breathlessness

  • Respiration rate decreased to X

  • No visible use of accessory muscles


Increased wob treatment options

Increased WOBTreatment options

  • Positioning

  • Breathing re-education/control

  • See increased work of breathing lecture


Decreased volume

Decreased Volume

  • Volume loss

  • Anatomical area collapsed

  • Atelectasis


Decreased volume problem identification

Decreased VolumeProblem identification

  • Disease profile and history

  • Auscultation – Bronchial breathing, fine crackles, breath sounds

  • CXR – raised diaphragm, collapse

  • Observation – breathing pattern

  • Altered gas exchange

  • Spirometry


Decreased volume goals

Decreased VolumeGoals

  • Auscultation changes

  • CXR resolution

  • Incentive spirometry


Decreased volume treatment options

Decreased VolumeTreatment options

  • Positioning

  • Thoracic expansion exercises/hold/sniff

  • Incentive spirometry

  • IPPB

  • Mobilisation


Reduced exercise tolerance

Reduced Exercise Tolerance

  • Reduced mobility

  • Reduced fitness

  • Distance mobilised


Reduced exercise tolerance identification

Reduced Exercise Tolerance Identification

  • Disease profile and history

  • Mobility status

  • Distance mobilised

  • Six minute walk test

  • Shuttle walk test


Reduced exercise tolerance goals

Reduced Exercise Tolerance Goals

  • Mobilise X metres with assistance in Y days

  • Climb 1 flight of stairs independently in Y days

  • Walk at X pace for Y minutes

  • Jog at x pace for Y minutes


Reduced exercise tolerance treatment plans

Reduced Exercise Tolerance Treatment plans

  • Graduated mobilisation programme twice a day/daily routine

  • Walking aids

  • Oxygen therapy

  • Home programmes

  • Strengthening programmes


Soap notes

SOAP Notes

  • Subjective

  • Objective

  • Assessment/analysis

  • Plan


Soap notes1

SOAP Notes

  • Do not have to always use every component of SOAP

  • Use assessment to highlight clinical reasoning or explain treatment outcome

  • Can alter problem/goal/plan and use notes to explain


Advances

Advances

  • Pre-printed lists

  • Unitary records

  • Integrated Care Pathways


Conclusion

Conclusion

  • Clinical reasoning is vital in the effective and efficient management of the cardiorespiratory patient


Example 1 assessment findings

Example 1 Assessment findings

  • Post operative laparotomy

  • Bronchial breathing right base, reduced breath sounds left base

  • CXR – raised diaphragms R > L

  • Reduced expansion

  • Oxygen sats 94% on 4l oxygen


Physiotherapy problems

Physiotherapy Problems

  • Reduced Volume

  • Decreased mobility


Physiotherapy goals short term

Physiotherapy goalsShort term

  • Normal breath sounds in all areas in three days

  • Mobilise independently 30m in three days


Physiotherapy goals long term

Physiotherapy goals Long term

  • CXR normal in 7 days

  • Mobilise indep up and down 1 flight of stairs in 7 days


Physiotherapy plan

Physiotherapy plan

  • A) Positioning

    B) Thoracic expansion exercises

    C) Mobilisation

  • A) Sit out of bed with assitsance

    B) Mobilise 10m with assistance of 1


Soap notes2

SOAP NOTES

  • S) Patient’s pain has been well controlled. Has already sat out of bed today.

  • O) Auscn-fine crackles right base, normal breath sounds left. Oxygen sats 94% on air

  • A) Progressing well

  • P) Mobilise later today


Example 2 assessment findings

Example 2 Assessment findings

  • Coarse crackles central on auscultation

  • Increased temperature

  • Consolidation on CXR

  • Ineffective moist cough

  • Very drowsy


Physiotherapy problems1

Physiotherapy Problems

  • Retention of secretions

  • ?Associated problem – reduced conscious level


Physiotherapy goals

Physiotherapy Goals

  • Expectoration with maximal assistance

  • Resolution of CXR findings


Physiotherapy plan1

Physiotherapy Plan

  • Positioning

  • Vibrations

  • Ensure humidification

  • Nasopharyngeal suction


Soap notes3

SOAP NOTES

  • S) Nurses report patient more alert today able to comply with basic instructions

  • O) Auscn coarse crackles central. Cough on command fair

  • A) Patient too alert for suction

  • P) Add assistance and encouragement to cough to positioning and vibs


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