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


CONTENT

  • Background of clinical reasoning

  • Associated problem lists

    Common Respiratory problems

    • Problem list identification

    • Goal setting

    • Treatment planning

  • SOAP notes


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 reasoning

  • Documented using POMR

  • Professional liability

  • Physiotherapy standards


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

  • 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

  • Disease profile

  • Other documentation

  • Clinical assessment

  • Other documentation


Problem lists

  • Retention of secretions

  • Volume loss

  • Increased work of breathing

  • Reduced exercise tolerance


Associated problems

  • Poor pain control

  • Unstable cardiovascular system

  • Acute confusion

  • Musculoskeletal


Retention of secretions

  • Secretion retention

  • Inability to expectorate

  • Ineffective cough

  • Consolidation


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 secretionsGoals

  • Independent expectoration within X days

  • Sputum volume -???

  • Resolution of CXR findings

  • Resolution of auscultation findings


Retention of secretions Treatment plans

  • Positioning side lying

  • Nasopharyngeal suction

  • Manual techniques – vibs

  • See clearing techniques to clear secretion lecture


Increased work of breathing

  • Shortness of breath

  • Increased respiration rate

  • Use of accessory muscles


Increased WOBProblem identification

  • Disease profile and history

  • Increased respiration rate

  • Altered respiratory pattern

  • Use of accessory muscles

  • Breathlessness

  • Altered ABG


Increased WOBGoals

  • Borg scale of perceived breathlessness

  • Respiration rate decreased to X

  • No visible use of accessory muscles


Increased WOBTreatment options

  • Positioning

  • Breathing re-education/control

  • See increased work of breathing lecture


Decreased Volume

  • Volume loss

  • Anatomical area collapsed

  • Atelectasis


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 VolumeGoals

  • Auscultation changes

  • CXR resolution

  • Incentive spirometry


Decreased VolumeTreatment options

  • Positioning

  • Thoracic expansion exercises/hold/sniff

  • Incentive spirometry

  • IPPB

  • Mobilisation


Reduced Exercise Tolerance

  • Reduced mobility

  • Reduced fitness

  • Distance mobilised


Reduced Exercise Tolerance Identification

  • Disease profile and history

  • Mobility status

  • Distance mobilised

  • Six minute walk test

  • Shuttle walk test


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

  • Graduated mobilisation programme twice a day/daily routine

  • Walking aids

  • Oxygen therapy

  • Home programmes

  • Strengthening programmes


SOAP Notes

  • Subjective

  • Objective

  • Assessment/analysis

  • Plan


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

  • Pre-printed lists

  • Unitary records

  • Integrated Care Pathways


Conclusion

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


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

  • Reduced Volume

  • Decreased mobility


Physiotherapy goalsShort term

  • Normal breath sounds in all areas in three days

  • Mobilise independently 30m in three days


Physiotherapy goals Long term

  • CXR normal in 7 days

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


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 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

  • Coarse crackles central on auscultation

  • Increased temperature

  • Consolidation on CXR

  • Ineffective moist cough

  • Very drowsy


Physiotherapy Problems

  • Retention of secretions

  • ?Associated problem – reduced conscious level


Physiotherapy Goals

  • Expectoration with maximal assistance

  • Resolution of CXR findings


Physiotherapy Plan

  • Positioning

  • Vibrations

  • Ensure humidification

  • Nasopharyngeal suction


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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