TDP REVIEW and APPLICATION
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Copyright © 2006 by Mosby, Inc.Slide 1
TDPTDPREVIEW and APPLICATIONREVIEW and APPLICATION
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Copyright © 2006 by Mosby, Inc.Slide 2
Therapist-Driven Protocols Therapist-Driven Protocols (TDPs) Are an Integral Part of (TDPs) Are an Integral Part of
Respiratory Care Health ServicesRespiratory Care Health Services
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Copyright © 2006 by Mosby, Inc.Slide 3
The Purpose of TDPsThe Purpose of TDPs
Deliver individualized diagnostic and Deliver individualized diagnostic and therapeutic respiratory to patientstherapeutic respiratory to patients
Assist the physician with evaluating patients’ Assist the physician with evaluating patients’ respiratory care needs and to optimize the respiratory care needs and to optimize the allocation of respiratory care servicesallocation of respiratory care services
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Copyright © 2006 by Mosby, Inc.Slide 4
The Purpose of TDPsThe Purpose of TDPs
Determine the indications for respiratory Determine the indications for respiratory therapy and the appropriate modalities for therapy and the appropriate modalities for providing quality, cost-effective care that providing quality, cost-effective care that improves patient outcomes and decreases improves patient outcomes and decreases length of staylength of stay
Empower respiratory care practitioners to Empower respiratory care practitioners to allocate care using sign- and symptom-based allocate care using sign- and symptom-based algorithms for respiratory treatmentalgorithms for respiratory treatment
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Copyright © 2006 by Mosby, Inc.Slide 5
Respiratory TDPsRespiratory TDPs
Give practitioner authority to:Give practitioner authority to:
Gather clinical information related to the Gather clinical information related to the patient’s respiratory statuspatient’s respiratory status
Make an assessment of the clinical data Make an assessment of the clinical data collectedcollected
Start, increase, decrease, or discontinue Start, increase, decrease, or discontinue certain respiratory therapies on a moment-certain respiratory therapies on a moment-to-moment basisto-moment basis
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Copyright © 2006 by Mosby, Inc.Slide 6
The Innate Beauty of Respiratory The Innate Beauty of Respiratory TDPs Is That:TDPs Is That:
1.1. The physician is always in the “information The physician is always in the “information loop” regarding patient careloop” regarding patient care
2.2. Therapy can be quickly modified in response Therapy can be quickly modified in response to the specific and immediate needs of the to the specific and immediate needs of the patientpatient
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Copyright © 2006 by Mosby, Inc.Slide 7
Clinical Research VerifiesClinical Research VerifiesThese FactsThese Facts
Respiratory TDPsRespiratory TDPs
1.1. Significantly improve respiratory therapy Significantly improve respiratory therapy outcomes, andoutcomes, and
2.2. Appreciably lower therapy costsAppreciably lower therapy costs
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Copyright © 2006 by Mosby, Inc.Slide 8
The Knowledge Base Required for a The Knowledge Base Required for a Successful TDP ProgramSuccessful TDP Program
The essential knowledge base includes the:The essential knowledge base includes the:
Anatomic alterations of the lungsAnatomic alterations of the lungs
Pathophysiologic mechanisms activatedPathophysiologic mechanisms activated
Clinical manifestations that developClinical manifestations that develop
Treatment modalities used to correct the Treatment modalities used to correct the problemproblem
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Copyright © 2006 by Mosby, Inc.Slide 9
The Assessment Process Skills Required The Assessment Process Skills Required for a Successful TDP Programfor a Successful TDP Program
The practitioner must: The practitioner must:
Systematically gather clinical informationSystematically gather clinical information
Formulate an assessmentFormulate an assessment
Select an optimal treatmentSelect an optimal treatment
Document in a clear and precise mannerDocument in a clear and precise manner
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Figure 9-4. Figure 9-4. The way knowledge, assessment, and a TDP program interface.The way knowledge, assessment, and a TDP program interface.
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Overview Summary of a Good Overview Summary of a Good TDP ProgramTDP Program
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Figure 9-5. Figure 9-5. Overview of the essential components of a good TDP program.Overview of the essential components of a good TDP program.
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Figure 9-5. Close-up.Figure 9-5. Close-up.
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Figure 9-5. Close-up.Figure 9-5. Close-up.
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Copyright © 2006 by Mosby, Inc.Slide 15
Figure 9-6Figure 9-6Respiratory Care Protocol Respiratory Care Protocol
Program Assessment Form— Program Assessment Form— ExcerptsExcerpts
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Copyright © 2006 by Mosby, Inc.Slide 16
Oxygen TherapyOxygen Therapy
Clinical IndicatorsClinical Indicators
HistoryHistory
SpSpOO22 <80% <80%
PaPaOO22 <60 mm Hg <60 mm Hg
Acute hypoxemiaAcute hypoxemia ↑ ↑ Respiratory rateRespiratory rate
↑ ↑ PulsePulse
CyanosisCyanosis
ConfusionConfusion
Figure 9-6. Respiratory care protocol program assessment formFigure 9-6. Respiratory care protocol program assessment form—Example Excerpts—Example Excerpts
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Copyright © 2006 by Mosby, Inc.Slide 17
Respiratory AssessmentRespiratory Assessment
ExamplesExamples
Mild hypoxemiaMild hypoxemia
Moderate hypoxemiaModerate hypoxemia
Severe hypoxemiaSevere hypoxemia
Severity score: __________Severity score: __________
Figure 9-6. Respiratory care protocol program assessment form—Figure 9-6. Respiratory care protocol program assessment form—ExampleExample excerpts. excerpts.
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Copyright © 2006 by Mosby, Inc.Slide 18
Treatment PlanTreatment Plan
Oxygen TherapyOxygen Therapy
Examples:Examples:
Nasal cannulaNasal cannula
Oxygen maskOxygen mask
28% Venturi mask28% Venturi mask
Frequency: _______________Frequency: _______________
Figure 9-6. Respiratory care protocol program assessment form—Figure 9-6. Respiratory care protocol program assessment form—ExampleExample excerpts. excerpts.
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Copyright © 2006 by Mosby, Inc.Slide 19
Common Anatomic AlterationsCommon Anatomic Alterationsof the Lungsof the Lungs
AtelectasisAtelectasis
Alveolar consolidationAlveolar consolidation
↑ ↑ Alveolar-capillary membrane thicknessAlveolar-capillary membrane thickness
BronchospasmBronchospasm
Excessive bronchial secretionsExcessive bronchial secretions
Distal airway and alveolar weakeningDistal airway and alveolar weakening
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Box 9-2. PathophysiologicBox 9-2. PathophysiologicMechanisms Commonly Mechanisms Commonly
ActivatedActivatedin Respiratory Disordersin Respiratory Disorders
Decreased V/Q ratioDecreased V/Q ratio
Alveolar diffusion blockAlveolar diffusion block
Decreased lung complianceDecreased lung compliance
Stimulation of oxygen receptorsStimulation of oxygen receptors
Deflation reflexDeflation reflex
Irritant reflexIrritant reflex
Pulmonary reflexPulmonary reflex
Increased airway resistanceIncreased airway resistance
Air-trapping and alveolar hyperinflationAir-trapping and alveolar hyperinflation(See clinical scenarios.)(See clinical scenarios.)
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Copyright © 2006 by Mosby, Inc.Slide 21
Severity AssessmentSeverity Assessment
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Table 9-2. Respiratory Care Protocol Table 9-2. Respiratory Care Protocol Severity Assessment—Severity Assessment—ExcerptsExcerpts
ItemItem 0 point0 point 1 point1 point 2 points2 points 3 points3 points 4 points4 points Total PointsTotal Points
Breath soundsBreath sounds ClearClear BilateralBilateral BilateralBilateral BilateralBilateral Absent and/orAbsent and/or ____________
cracklescrackles cracklescrackles wheezing,wheezing, diminishdiminish
& rhonchi& rhonchi crackles &crackles & bilateral and/orbilateral and/or
rhonchirhonchi severe wheezing,severe wheezing,
crackles, orcrackles, or
rhonchirhonchi
CoughCough Strong,Strong, ExcessiveExcessive ExcessiveExcessive ThickThick ThickThick ____________
spontaneous,spontaneous, bronchialbronchial bronchialbronchial bronchialbronchial bronchialbronchial
nonproductivenonproductive secretions &secretions & secretions butsecretions but secretions &secretions & secretions butsecretions but
strong coughstrong cough weak coughweak cough weak coughweak cough no coughno cough
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Copyright © 2006 by Mosby, Inc.Slide 23
Severity Assessment Case ExampleSeverity Assessment Case ExampleSEVERITY ASSESSMENT CASE EXAMPLESEVERITY ASSESSMENT CASE EXAMPLE
A 67-YEAR-OLD-MALE ARRIVED IN THE EMERGENCY ROOM IN RESPIRATORY DISTRESS. THE PATIENT WAS 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 WELL KNOWN TO THE TDP TEAM; HE HAD BEEN DIAGNOSED WITH CHRONIC BRONCHITIS SEVERAL
YEARS BEFORE THIS ADMISSIONYEARS BEFORE THIS ADMISSION (3 POINTS)(3 POINTS). THE PATIENT HAD NO RECENT SURGERY HISTORY, AND HE . THE PATIENT HAD NO RECENT SURGERY HISTORY, AND HE
WAS AMBULATORY, ALERT, AND COOPERATIVEWAS AMBULATORY, ALERT, AND COOPERATIVE (0 POINTS)(0 POINTS).. HE COMPLAINED OF DYSPNEA AND WAS HE COMPLAINED OF DYSPNEA AND WAS
USING HIS ACCESSORY MUSCLES OF INSPIRATIONUSING HIS ACCESSORY MUSCLES OF INSPIRATION (3 POINTS).(3 POINTS). AUSCULTATION REVEALED BILATERAL AUSCULTATION REVEALED BILATERAL
RHONCHI OVER BOTH LUNG FIELDSRHONCHI OVER BOTH LUNG FIELDS (3 POINTS)(3 POINTS). HIS COUGH WAS WEAK AND PRODUCTIVE OF THICK . HIS COUGH WAS WEAK AND PRODUCTIVE OF THICK
GRAY SECRETIONSGRAY SECRETIONS (3 POINTS)(3 POINTS).. A CHEST RADIOGRAPH REVEALED PNEUMONIA (CONSOLIDATION) IN THE A CHEST RADIOGRAPH REVEALED PNEUMONIA (CONSOLIDATION) IN THE
LEFT LOWER LUNG LOBELEFT LOWER LUNG LOBE (3 POINTS)(3 POINTS).. ON ROOM AIR HIS ARTERIAL BLOOD GAS VALUES WERE pH 7.52, ON ROOM AIR HIS ARTERIAL BLOOD GAS VALUES WERE pH 7.52,
PaPaCOCO22 54, HCO 54, HCO33-- 41, AND Pa 41, AND PaOO22 52—ACUTE ALVEOLAR HYPERVENTILATION ON CHRONIC VENTILATORY 52—ACUTE ALVEOLAR HYPERVENTILATION ON CHRONIC VENTILATORY
FAILUREFAILURE (3 POINTS)(3 POINTS)..
USING THE SEVERITY ASSESSMENT FORM SHOWN IN TABLE 9-2, THE FOLLOWING TREATMENT SELECTION USING THE SEVERITY ASSESSMENT FORM SHOWN IN TABLE 9-2, THE FOLLOWING TREATMENT SELECTION
AND ADMINISTRATION FREQUENCY WOULD BE APPROPRIATE: AND ADMINISTRATION FREQUENCY WOULD BE APPROPRIATE:
TOTAL SCORE:TOTAL SCORE: 1717
TREATMENT SELECTION:TREATMENT SELECTION: CHEST PHYSICAL THERAPYCHEST PHYSICAL THERAPY
FREQUENCY OF ADMINISTRATION:FREQUENCY OF ADMINISTRATION: FOUR TIMES A DAY; AS NEEDEDFOUR TIMES A DAY; AS NEEDED
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Copyright © 2006 by Mosby, Inc.Slide 24
The Top Four Respiratory ProtocolsThe Top Four Respiratory Protocols
Oxygen therapy protocolOxygen therapy protocol
Bronchopulmonary hygiene therapy protocolBronchopulmonary hygiene therapy protocol
Hyperinflation therapy protocolHyperinflation therapy protocol
Aerosolized medication therapy protocolAerosolized medication therapy protocol
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Common Respiratory Assessments—Common Respiratory Assessments—Excerpts (see Table 9-1)Excerpts (see Table 9-1)
Clinical DataClinical Data AssessmentAssessment
WheezingWheezing BronchospasmBronchospasm
RhonchiRhonchi Secretions in large airwaysSecretions in large airways
Weak coughWeak cough Poor ability to mobilize Poor ability to mobilize secretionssecretions
ABGsABGs Acute ventilatory failureAcute ventilatory failure pHpH 7.24 7.24 PaPaCOCO22 73 73
HCOHCO33-- 27 27
PaPaOO22 5353
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Copyright © 2006 by Mosby, Inc.Slide 26
Common Respiratory Assessments Common Respiratory Assessments and Treatment Plans—Excerpts (see and Treatment Plans—Excerpts (see
Table 9-1)Table 9-1)
Clinical DataClinical Data AssessmentAssessment Tx PlanTx Plan
WheezingWheezing BronchospasmBronchospasm betabeta22 agent agent
Rhonchi &Rhonchi & Secretions in large airwaysSecretions in large airwaysWeak coughWeak cough Poor ability to mobilize secretionsPoor ability to mobilize secretions CPTCPT
ABGsABGs Acute ventilatory failureAcute ventilatory failure Mechanical ventilationMechanical ventilation
pHpH7.24 7.24
PaPaCOCO22 73 73
HCOHCO33-- 27 27
PaPaOO22 5353
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