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From Task Oriented Therapy to Protocols and Respiratory Therapy Care Plans

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Scientific basis for ordering respiratory therapy provided with AARC Clinical ... Auscultation reveals bilateral wheezing with decreased aeration in both bases. ... – PowerPoint PPT presentation

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Title: From Task Oriented Therapy to Protocols and Respiratory Therapy Care Plans


1
From Task Oriented Therapy to Protocols and
Respiratory Therapy Care Plans
  • Jane Reynolds, MS, RN, RRT

2
Protocols
  • Scientific basis for ordering respiratory therapy
    provided with AARC Clinical Practice Guidelines
  • When respiratory therapists are allowed to
    provide respiratory therapy via protocols
  • Clinical outcomes improve,
  • Misallocation of respiratory therapy services
    decreases
  • Costs associated with respiratory therapy are
    reduced

3
Protocols and Care Plans
  • Protocols allow for clinical decision making in a
    real time basis
  • Control of ordering therapies thus better
    matching demand to supply of therapists
  • Promotes critical thinking and assessment skills
  • Match respiratory resources to those patients who
    really need respiratory therapy

4
Protocols and Care Plans
  • Value Respiratory Therapists as
  • The Experts
  • in knowing the indications for therapies and
    assessing the efficacy of the therapy for the
    patients receiving respiratory care

5
Protocols and Care Plans
Top Ten Reasons why patients get albuterol
  • 10. Because the patient has lots of secretions
  • 9. Because the patient is intubated
  • 8. Because the patient is going to surgery
  • 7. Because his attending, Dr. _ _ _ _ said so

6
Protocols and Care Plans
  • Top Ten . . .
  • 6. Because the pts cousin has asthma
  • 5. Because the patient is desaturating
  • 4. It is my philosophy
  • 3. The patient is DNR.
  • 2. The patient has terminal CA

7
  • And the
  • 1 reason
  • why patients get albuterol IS . . .

8
It wont hurt !
9
Protocols and Care Plans
  • QUESTION
  • What is the last thing most patients taste
    or smell, if they die in the hospital?
  • Answer
  • Albuterol!

10
Protocols and Care Plans
  • Words of wisdom when studying for your your
    boards . . .
  • Dont approach the questions the way you would
    at work think about what you learned in school.

11
Protocols and Care Plans
  • AARC Clinical Practice Guidelines have been
    available for over 20 years.
  • AARC recommendations are made as to
  • Appropriateness
  • Monitoring
  • Evaluation
  • Adjustments to therapy are made based
  • outcomes efficacy
  • Documentation
  • Equipment Personnel best suited for therapeutic
    modalities determined by evidence based research

12
Protocols and Care Plans
A visit to WWW. AARC.org on line provides all
the tools needed
Protocol Resources This is a collection of all
resources provided by the AARC on helping you
establish protocols. It includes a bibliography
of peer-reviewed articles, a bank of algorithms
and protocols to use as models, and a story about
one health system's implementation of protocols.
Clinical Practice Guidelines These AARC's
guidelines enhance respiratory practice and
provide a framework for RT protocols
Position Statements The AARC has adopted a number
of statements regarding the provision of services
or the practice of respiratory care.
13
Protocols and Care Plans
  • Services offered by Respiratory Care
  • Bronchoscopic procedures
  • Pulmonary Function Testing
  • Smoking Cessation
  • Sleep Studies
  • Asthma and COPD disease management and patient
    education
  • Metabolic Testing
  • Therapeutic Treatments
  • Cardio Pulmonary Stress Testing

14
(No Transcript)
15
Protocols and Care Plans
Quality Assessment for the Respiratory Care
Evaluation Form
Date Time RCP Name Eval completed properly ? Dx Appro-priate ? SS Appro-priate ? Indication for Tx Clear? Is tx appro-priate ? Goal achieved ? Is there reason to call MD ? If yes, was MD contact-ed ? Was the order changed ? Comments for other Rx ?
1
2
3
4
16
Quality Assessment for the Respiratory Care
Evaluation Form
Protocols and Care Plans
    of Unnecessary Treatments of Unnecessary Treatments 4   4   4  
of Pts / Asthma 18 0   of unnecessary changed to PRN 50
of Pts / COPD   6 2   D/C    11
of Pts / Pneumonia   5 3   of patients who received treatments    5
of Pts / CHF   1 4   changed back to frequency    0
17
Protocols and Care Plans
18
Protocols and Care Plans
  • Not indicated therapy
  • Estimated to be 40 nationally
  • 32 at our institution
  • Decreased to a sustained average rate of about 8
    to date
  • Many treatments that were not discontinued were
    changed to PRN and no therapy was ever given

19
Protocols and Care Plans
20
Protocols and Care Plans
21
Protocols and Care Plans
22
Protocols and Care Plans
23
Case Study 1
  • A 50-year old white male was admitted to a
    telemetry unit from the ED at 0430 with a chief
    complaint of severe shortness of breath.
  • He is 5 feet 10 inches tall and weighs 185
    lbs. His vital signs on admission are T
    101.1, P 114, RR 26, B/P is 166/110.
  • He has digital clubbing and cyanosis of his
    extremities. He has pedal edema and JVD is also
    noted. He uses pursed lip breathing and is
    audibly wheezing. He has a productive cough of
    small amounts of thick yellowish green sputum.
    Auscultation reveals bilateral wheezing with
    decreased aeration in both bases.
  • He states he has been taking antibiotics for
    almost a week. He was not feeling any better so
    he came to the ED because he couldnt take it
    any more.
  • He is receiving O2 therapy via nasal cannula
    at 2 lpm.

24
Case Study 1
  • Arterial blood gases PCO2 70, pH 7.31 PO2 50,
    HCO3 35, HB 20 Gm HBO2 Sat 71, CaO2 19.4 Vol .
  • CBC RBC 6.5, HB 20.1, HCT 61, WBC 18,000
  • Electrolytes Na 141, K 3.8, Cl 84, BUN 17, Cr
    1.2, HCO3- 38, Glucose 108
  • Two days later the patient requests information
    on smoking cessation.
  • The night shift therapist also notes the patient
    snores very loudly and appears to have OSA.
  • MD ordered albuterol Q4 hours around the clock

25
Respiratory Care Plan
  • Oxygenation
  • Ventilation
  • Bronchodilator Rx
  • Steroids
  • Mucus mobilization
  • Smoking cessation
  • PFT
  • Pulmonary Rehabilitation
  • Home O2

26
Case Study 2
  • A well known asthmatic 20 year old white
    female is admitted to the ED in a severely
    agitated state. She is 5 feet 6 inches tall and
    weighs 120 lbs. Her vital signs are T 97.4, P
    110, RR is 32, B/P is 98/50.
  • Her respirations are shallow and her chest
    appears hyperinflated. Breath sounds reveal
    minimal wheezing and decreased aeration in both
    lungs. She is receiving oxygen therapy via
    venturi mask, 0.4 FiO2.

27
Case Study 2
  • Arterial blood gases PCO2 67, pH 7.26, PO2 150
    , HCO3 22, HB 12 Gm, HBO2 Sat 98, CaO2 13.9
    Vol
  • CBC RBC 4, HB 12, HCT 36, WBC 15,000
  • Electrolytes Na 141, K 4.9, Cl 94, BUN 13, Cr
    0.8, HCO3 25, Glucose 88
  • Peak Flow 162 LPM
  • MD orders Xopenex 0.63mg Q 4 hours

28
Respiratory Care Plan
  • Oxygenation
  • Ventilation
  • Monitoring
  • Bronchodilator Rx
  • Steroids
  • Asthma Action Plan
  • Patient Education
  • Smoking cessation
  • PFTs
  • Allergy Testing Anti IGE Rx?
  • Home Environment Assessment

29
Case Study 3
  • A 49-year old African American male was
    brought to the ED at 0500 with a chief complaint
    of shortness of breath.
  • He is 5 feet 10 inches tall and weighs 180
    lbs.
  • Vital signs on admission T 99.3, P 124, RR
    14, B/P 160/90.
  • Breath sounds are markedly reduced
    bilaterally with some high pitched wheezing.
  • He is using inspiratory and expiratory
    accessory muscles of ventilation.
  • He is receiving O2 therapy via nasal cannula
    at 4 LPM. He has never been hospitalized before
    and states he has had a cold for two weeks.
  • __________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    ___________________________________________

30
Case Study 3
  • Arterial blood gases PCO2 55, pH 7.34 PO2 55,
    HCO3 23, HB 15 Gm HBO2 Sat 81, CaO2 16.52 Vol
    .
  • CBC RBC 5.5, HB 15.1, HCT 46, WBC 18,000
  • Electrolytes Na 137, K 4.4, Cl 104, BUN 25, Cr
    1.5, HCO3- 26, Glucose 91
  • MD order Albuterol 2.5 mg Q 6 hours
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