CLINICAL REASONING AND THE CARDIORESPIRATORY PATIENT

1. CLINICAL REASONING AND THE CARDIORESPIRATORY PATIENT

2. CONTENT • Background of clinical reasoning • Associated problem lists Common Respiratory problems • Problem list identification • Goal setting • Treatment planning • SOAP notes

3. 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

4. Background of clinical reasoning • Documented using POMR • Professional liability • Physiotherapy standards

5. 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

6. 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

7. Information gathering • Disease profile • Other documentation • Clinical assessment • Other documentation

8. Problem lists • Retention of secretions • Volume loss • Increased work of breathing • Reduced exercise tolerance

9. Associated problems • Poor pain control • Unstable cardiovascular system • Acute confusion • Musculoskeletal

10. Retention of secretions • Secretion retention • Inability to expectorate • Ineffective cough • Consolidation

11. 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

12. Retention of secretionsGoals • Independent expectoration within X days • Sputum volume -??? • Resolution of CXR findings • Resolution of auscultation findings

13. Retention of secretions Treatment plans • Positioning side lying • Nasopharyngeal suction • Manual techniques – vibs • See clearing techniques to clear secretion lecture

14. Increased work of breathing • Shortness of breath • Increased respiration rate • Use of accessory muscles

15. Increased WOBProblem identification • Disease profile and history • Increased respiration rate • Altered respiratory pattern • Use of accessory muscles • Breathlessness • Altered ABG

16. Increased WOBGoals • Borg scale of perceived breathlessness • Respiration rate decreased to X • No visible use of accessory muscles

17. Increased WOBTreatment options • Positioning • Breathing re-education/control • See increased work of breathing lecture

18. Decreased Volume • Volume loss • Anatomical area collapsed • Atelectasis

19. 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

20. Decreased VolumeGoals • Auscultation changes • CXR resolution • Incentive spirometry

21. Decreased VolumeTreatment options • Positioning • Thoracic expansion exercises/hold/sniff • Incentive spirometry • IPPB • Mobilisation

22. Reduced Exercise Tolerance • Reduced mobility • Reduced fitness • Distance mobilised

23. Reduced Exercise Tolerance Identification • Disease profile and history • Mobility status • Distance mobilised • Six minute walk test • Shuttle walk test

24. 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

25. Reduced Exercise Tolerance Treatment plans • Graduated mobilisation programme twice a day/daily routine • Walking aids • Oxygen therapy • Home programmes • Strengthening programmes

26. SOAP Notes • Subjective • Objective • Assessment/analysis • Plan

27. 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

28. Advances • Pre-printed lists • Unitary records • Integrated Care Pathways

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

30. 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

31. Physiotherapy Problems • Reduced Volume • Decreased mobility

32. Physiotherapy goalsShort term • Normal breath sounds in all areas in three days • Mobilise independently 30m in three days

33. Physiotherapy goals Long term • CXR normal in 7 days • Mobilise indep up and down 1 flight of stairs in 7 days

34. Physiotherapy plan • A) Positioning B) Thoracic expansion exercises C) Mobilisation • A) Sit out of bed with assitsance B) Mobilise 10m with assistance of 1

35. 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

36. Example 2 Assessment findings • Coarse crackles central on auscultation • Increased temperature • Consolidation on CXR • Ineffective moist cough • Very drowsy

37. Physiotherapy Problems • Retention of secretions • ?Associated problem – reduced conscious level

38. Physiotherapy Goals • Expectoration with maximal assistance • Resolution of CXR findings

39. Physiotherapy Plan • Positioning • Vibrations • Ensure humidification • Nasopharyngeal suction

40. 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