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
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

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. 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

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
~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

8. 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

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

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

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

13. 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

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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. 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?

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

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
Example at the end

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 goals Short 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