CLINICAL REASONING AND THE

CARDIORESPIRATORY PATIENT

CONTENT Background of clinical reasoning Associated problem listsCommon 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

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

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

1. Reduced Volume

2. Decreased mobility

Physiotherapy goalsShort term

1. Normal breath sounds in all areas in three days

2. 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

1. A) PositioningB) Thoracic expansion exercisesC) Mobilisation

2. A) Sit out of bed with assitsanceB) 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