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