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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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

Process POMR


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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