1. Copyright © 2006 by Mosby, Inc. Slide 1 TDP REVIEW and APPLICATION

2. Copyright © 2006 by Mosby, Inc. Slide 2 Therapist-Driven Protocols (TDPs) Are an Integral Part of Respiratory Care Health Services

3. Copyright © 2006 by Mosby, Inc. Slide 3 The Purpose of TDPs  Deliver individualized diagnostic and therapeutic respiratory to patients  Assist the physician with evaluating patients’ respiratory care needs and to optimize the allocation of respiratory care services

4. Copyright © 2006 by Mosby, Inc. Slide 4 The Purpose of TDPs  Determine the indications for respiratory therapy and the appropriate modalities for providing quality, cost-effective care that improves patient outcomes and decreases length of stay  Empower respiratory care practitioners to allocate care using sign- and symptom-based algorithms for respiratory treatment

5. Copyright © 2006 by Mosby, Inc. Slide 5 Respiratory TDPs Give practitioner authority to:  Gather clinical information related to the patient’s respiratory status  Make an assessment of the clinical data collected  Start, increase, decrease, or discontinue certain respiratory therapies on a moment- to-moment basis

6. Copyright © 2006 by Mosby, Inc. Slide 6 The Innate Beauty of Respiratory TDPs Is That: 1. The physician is always in the “information loop” regarding patient care 2. Therapy can be quickly modified in response to the specific and immediate needs of the patient

7. Copyright © 2006 by Mosby, Inc. Slide 7 Clinical Research Verifies These Facts Respiratory TDPs 1. Significantly improve respiratory therapy outcomes, and 2. Appreciably lower therapy costs

8. Copyright © 2006 by Mosby, Inc. Slide 8 The Knowledge Base Required for a Successful TDP Program The essential knowledge base includes the:  Anatomic alterations of the lungs  Pathophysiologic mechanisms activated  Clinical manifestations that develop  Treatment modalities used to correct the problem

9. Copyright © 2006 by Mosby, Inc. Slide 9 The Assessment Process Skills Required for a Successful TDP Program The practitioner must:  Systematically gather clinical information  Formulate an assessment  Select an optimal treatment  Document in a clear and precise manner

10. Copyright © 2006 by Mosby, Inc. Slide 10 Figure 9-4. The way knowledge, assessment, and a TDP program interface.

11. Copyright © 2006 by Mosby, Inc. Slide 11 Overview Summary of a Good TDP Program

12. Copyright © 2006 by Mosby, Inc. Slide 12 Figure 9-5. Overview of the essential components of a good TDP program.

13. Copyright © 2006 by Mosby, Inc. Slide 13 Figure 9-5. Close-up.

14. Copyright © 2006 by Mosby, Inc. Slide 14 Figure 9-5. Close-up.

15. Copyright © 2006 by Mosby, Inc. Slide 15 Figure 9-6 Respiratory Care Protocol Program Assessment Form— Excerpts

16. Copyright © 2006 by Mosby, Inc. Slide 16 Oxygen Therapy Clinical Indicators  History  Sp O 2 <80%  Pa O 2 <60 mm Hg  Acute hypoxemia  ↑ Respiratory rate  ↑ Pulse  Cyanosis  Confusion Figure 9-6. Respiratory care protocol program assessment form—Example Excerpts

17. Copyright © 2006 by Mosby, Inc. Slide 17 Respiratory Assessment Examples  Mild hypoxemia  Moderate hypoxemia  Severe hypoxemia  Severity score: __________ Figure 9-6. Respiratory care protocol program assessment form—Example excerpts.

18. Copyright © 2006 by Mosby, Inc. Slide 18 Treatment Plan Oxygen Therapy Examples:  Nasal cannula  Oxygen mask  28% Venturi mask Frequency: _______________ Figure 9-6. Respiratory care protocol program assessment form—Example excerpts.

19. Copyright © 2006 by Mosby, Inc. Slide 19 Common Anatomic Alterations of the Lungs  Atelectasis  Alveolar consolidation  ↑ Alveolar-capillary membrane thickness  Bronchospasm  Excessive bronchial secretions  Distal airway and alveolar weakening

20. Copyright © 2006 by Mosby, Inc. Slide 20 Box 9-2. Pathophysiologic Mechanisms Commonly Activated in Respiratory Disorders  Decreased V/Q ratio  Alveolar diffusion block  Decreased lung compliance  Stimulation of oxygen receptors  Deflation reflex  Irritant reflex  Pulmonary reflex  Increased airway resistance  Air-trapping and alveolar hyperinflation (See clinical scenarios.)

21. Copyright © 2006 by Mosby, Inc. Slide 21 Severity Assessment

22. Copyright © 2006 by Mosby, Inc. Slide 22 Table 9-2. Respiratory Care Protocol Severity Assessment— Excerpts Item0 point1 point2 points3 points4 pointsTotal Points Breath soundsClearBilateralBilateralBilateralAbsent and/or______ cracklescrackleswheezing,diminish & rhonchicrackles &bilateral and/or rhonchisevere wheezing, crackles, or rhonchi CoughStrong,ExcessiveExcessiveThickThick______ spontaneous,bronchialbronchialbronchialbronchial nonproductivesecretions &secretions butsecretions &secretions but strong coughweak coughweak coughno cough

23. Copyright © 2006 by Mosby, Inc. Slide 23 Severity Assessment Case Example SEVERITY ASSESSMENT CASE EXAMPLE A 67-YEAR-OLD-MALE ARRIVED IN THE EMERGENCY ROOM IN RESPIRATORY DISTRESS. THE PATIENT WAS WELL KNOWN TO THE TDP TEAM; HE HAD BEEN DIAGNOSED WITH CHRONIC BRONCHITIS SEVERAL YEARS BEFORE THIS ADMISSION (3 POINTS). THE PATIENT HAD NO RECENT SURGERY HISTORY, AND HE WAS AMBULATORY, ALERT, AND COOPERATIVE (0 POINTS). HE COMPLAINED OF DYSPNEA AND WAS USING HIS ACCESSORY MUSCLES OF INSPIRATION (3 POINTS). AUSCULTATION REVEALED BILATERAL RHONCHI OVER BOTH LUNG FIELDS (3 POINTS). HIS COUGH WAS WEAK AND PRODUCTIVE OF THICK GRAY SECRETIONS (3 POINTS). A CHEST RADIOGRAPH REVEALED PNEUMONIA (CONSOLIDATION) IN THE LEFT LOWER LUNG LOBE (3 POINTS). ON ROOM AIR HIS ARTERIAL BLOOD GAS VALUES WERE pH 7.52, Pa CO 2 54, HCO 3 - 41, AND Pa O 2 52—ACUTE ALVEOLAR HYPERVENTILATION ON CHRONIC VENTILATORY FAILURE (3 POINTS). USING THE SEVERITY ASSESSMENT FORM SHOWN IN TABLE 9-2, THE FOLLOWING TREATMENT SELECTION AND ADMINISTRATION FREQUENCY WOULD BE APPROPRIATE: TOTAL SCORE: 17 TREATMENT SELECTION: CHEST PHYSICAL THERAPY FREQUENCY OF ADMINISTRATION: FOUR TIMES A DAY; AS NEEDED

24. Copyright © 2006 by Mosby, Inc. Slide 24 The Top Four Respiratory Protocols  Oxygen therapy protocol  Bronchopulmonary hygiene therapy protocol  Hyperinflation therapy protocol  Aerosolized medication therapy protocol

25. Copyright © 2006 by Mosby, Inc. Slide 25 Common Respiratory Assessments— Excerpts (see Table 9-1) Clinical DataAssessment WheezingBronchospasm RhonchiSecretions in large airways Weak coughPoor ability to mobilize secretions ABGsAcute ventilatory failure pH7.24 pH7.24 Pa CO 2 73 Pa CO 2 73 HCO 3 - 27 HCO 3 - 27 Pa O 2 53 Pa O 2 53

26. Copyright © 2006 by Mosby, Inc. Slide 26 Common Respiratory Assessments and Treatment Plans—Excerpts (see Table 9-1) Clinical DataAssessmentTx Plan WheezingBronchospasmbeta 2 agent Rhonchi &Secretions in large airways Weak coughPoor ability to mobilize secretionsCPT ABGsAcute ventilatory failureMechanical ventilation pH7.24 pH7.24 Pa CO 2 73 Pa CO 2 73 HCO 3 - 27 HCO 3 - 27 Pa O 2 53 Pa O 2 53

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