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 Apologise to MSC students as will have used clinical reasoning/POMR system before but this lecture specifically deals with clinical reasoning and the cardiorespiratory patient

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

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

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 ~To begin process need information to base problem list on Example of older COPD patient versus a asthmatic. ~Pre printed sheets can be used ~Minimum data set ~Treatment plans heirarchy

Problem lists Retention of secretions Volume loss Increased work of breathing Reduced exercise tolerance Highlight again that not disease specific e.g. asthma or pneumonia Can be more specific Tend to only put issues that as physiotherapists we can have a direct effect on Can have all four – e.g. #ribs and smoker

Associated problems Poor pain control Unstable cardiovascular system Acute confusion Musculoskeletal ~Useful as will affect treatment options

Retention of secretions Secretion retention Inability to expectorate Ineffective cough Consolidation Chest infection, exacerbation COPD

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 Independent expectoration within X days Sputum volume -??? Resolution of CXR findings Resolution of auscultation findings ~Can break down where expectorate with assistance

Retention of secretions Treatment plans Positioning side lying Nasopharyngeal suction Manual techniques – vibs See clearing techniques to clear secretion lecture ~ How much assistance does the individual need? ~Can you carry out the easier option of mobilisation? e.g. stroke patient who is uncounsious

Increased work of breathing Shortness of breath Increased respiration rate Use of accessory muscles week5

Increased WOB Problem identification Disease profile and history Increased respiration rate Altered respiratory pattern Use of accessory muscles Breathlessness Altered ABG ~COPD, pneumonia, asthma, pulmonary oedema Pathology which increases the effort or breathing WOB is not confined to the medical patient e.g. the cardiac surgery patient with pleural effusion, surgical patient in pain with splinted diaphragm

Increased WOB Goals Borg scale of perceived breathlessness Respiration rate decreased to X No visible use of accessory muscles ~Can progress from rest to moving

Increased WOB Treatment options Positioning Breathing re-education/control See increased work of breathing lecture ~Identifying starting point can help appropriate goal setting ~Could ultimately lead to mobilisation or exercise

Decreased Volume Volume loss Anatomical area collapsed Atelectasis e.g. lower lobe collapse

Decreased Volume Problem identification Disease profile and history Auscultation – Bronchial breathing, fine crackles, breath sounds CXR – raised diaphragm, collapse Observation – breathing pattern Altered gas exchange Spirometry ~Reduced breath sounds, fine crackles, bronchial breathing ~Collapse/raised hemidiaphragm ~Shallow breathing ~May have altered Abg or oxygen saturations

Decreased Volume Goals Auscultation changes CXR resolution Incentive spirometry ~Note auscultation changes may go through stages – bronchial breathing to fine crackles ~Oxygen saturations can also be a guide

Decreased Volume Treatment options Positioning Thoracic expansion exercises/hold/sniff Incentive spirometry IPPB Mobilisation ~Treatment hierarchy how much can the individual do? Are there any associated problems?

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 Distance mobilised on ward, can they climb stairs? Does the individual require oxygen to mobilise?

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 Example at the end

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 goals Short 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