Subjective and objective assessment Flashcards
What is clinical reasoning
it is the decision making process involved in identifying and solving problems in clinical practice. It involves you thinking about and evaluating your options before deciding on the specific course of action
What influences clinical reasoning
the clinical context, the decision maker, the patient/client/ service user, the complexity of the task
How to clinical reason
justify decisions, identify and solve problems, accurate assessment and gathering background information forms the foundation to clinical reasoning
questions to ask about symptoms
How long have they been a problem
Now v normal
Are they getting better/worse
What is the frequency and duration
What makes them worse (aggravating factors)
What makes them better (relieving factors)
Daily, seasonal pattern
specific questions to ask- cough
is it persistent/ painful/ productive
acute/chronic, what started it?
what triggers it- smoking/moving/exertion/lying down/eating and drinking (aspirating), is it effective/ painful, does it happen at night
specific questions to ask- sputum (colour)
mucoid- clear like raw egg white (normal), purulent- containing puss (yellow or green), pink- bloody, frothy= fluid
specific questions to ask- sputum ( consistency and quantity)
consistency= stringy/ plugs/ thick/ frothy
quantity, smell/taste/ contains blood
basic observations
early warning score (NEWS)- RR, saturations, temperature, BP, HR, level of consciousness
other= blood sugar, pain, urine output
how to determine physio problems
subjective information (patient reports difficulty clearing secretions)– objective findings (auscultations revels course inspiratory and expiratory crackles)– physio problems
common physio problems- respiratory muscle dysfunction
reduced strength or endurance- becomes physio problem with dyspnoea, impaired clearance or inability to wean from mechanical ventilation
common physio problems- airflow limitations
abnormal resistance or obstruction to airflow usually occurs with other problems= dyspnoea/ decreased ex tolerance
common physio problems- probs in airway wall
bronchospasm, smooth muscle hypertrophy or hyperplasia, inflammation of mucus glands, thickened bronchial wall, dilation/destruction of wall
common physio problems- work of breathing
v
what is WOB
the amount of muscle activity required to overcome the elastic (lung tissue, chest wall, abdominal wall components) and resistance (airways) elements of the respiratory system.
other patient problems
poor self management skills, co morbidities, incontinence, communication needs and difficulties, psychosocial barriers
