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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  • 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


  • Pre-printed lists

  • Unitary records

  • Integrated Care Pathways


  • 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

  • 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

  • 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