Hey guys,
Throught this week as we start doing more and more PCR practice, the question has come up about prioritising problem lists. I'm on musculo prac at the moment and we were talking about whether we prioritise problems from the patients perspective or our perspective, or a combination of the two, or if we do them solely on what is most limiting the person functionally.
In cardio i always prioritised by what would be most likely to kill the patient if it was not addressed, in neuro, because i was in an inpatient setting i thought about the main reasons they were unable to go home at this stage.
I was just wondering what you guys think of this, and how you prioritise your problem lists if it's not using one of these ways?
Thanks alot, enjoy the last couple weeks,
James
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Hey James ~
I have been thinking about prioritization for some time now as well. For cardio, my way of prioritizing is pretty similar to yours I believe. It’s really thinking through the 10 problems and deciding which is most prominent / significant for the patient. Most of the time, targeting one helps with the other as well. It seems to me thinking about the amount of supporting evidence helps? I sort of observe the trend that the more pieces of evidence to support a particular problem, the higher the list it goes. Do you agree? There was this point in time during my cardio placement I was wondering should I prioritize according to the order of things I will do but I believe this is incorrect. Eg: if I am going to give bronchodilator which helps to make subsequent interventions more effective, then my first problem should be impaired gas exchange.
I am currently on musculo placement as well. It seems to me after having a few sessions with my curtin tutor that patient should go away feeling better than when they first come in. So I believe my first priority will be from patient’s perspective which most frequently is to pain and/or stiffness. And under this, we can list in order how we are going to achieve that. Subsequently, we can look at other things like poor posture, decreased mobility, decreased strength etc Again depending on what’s most pertinent with our assessment.
As for neuro, I have a giant question mark. I was looking at this PCR case with one question which goes what is your prioritized list of functional activity limitations. I just went blank, absolutely don’t know how I should go about it… If anyone reads this and can provide some insight it will be great… Should I go from ‘basic’ to ‘higher’ level functions? Eg: patient basically still needs assistance with rolling, supine to sitting, sit to stand, transfer and ambulation. So does that mean I prioritize according to this basic to higher level sequence? Or zoom into what they can manage at the higher level already eg: go for sit to stand as first priority? I understand you prioritize according to what will get them home soon. May I know how you will prioritize if patient presents this way as stated above? :D
Cheers, Peiying ~
Hi James. That is a good point. I think for all areas the number one problem is the main complain of the patient. In cardio can be the reason for admission/main complain ( eg. Increase in SOB, cough) or the problem that if addressed can improve the other problems. In the surgical patient for eg. Pain (or drowsiness) will be the number one, because if the patient is in pain, they won’t take deep breaths (affect lung vol and gas exchange), won’t have a effective cough (impair airway clearance) and won’t mobilize. In the medical patient, see what is affecting the patient most with regards their symptoms/worsening underlying pathology and function.
For the musculo patients usually see what they are coming to see you. That it will be your number one problem. For eg. Pain, stiffness, headache. You can also start from their functional limitation eg, unable to squat e after you S/E and O/E you find your *s, and see what is the main impairment. Remember to set you short term and long term goals. Short term it will be most of the time symptomatic (eg. Reduce pain, swelling, improve ROM, sometimes correct posture if related to the main complain…) and long term the focus is more specific on function. I think usually the main problem is focused on patient’s problem. If it doesn’t match to what you think is the problem, the number one problem can be yellow flags (psychosocial issues or patient understanding of their problem doesn’t really match with the cause of symptoms or expectations not realistic) and in this case your intervention number 1 will be education on the condition and treatment.
In neuro, sometimes I`m still not 100% sure, but the way I see is, again see the main complain, which will probably be a functional limitation eg. Unable to sit independent, sitstand or walk without assistance. In that case you assess the functional task, list the impairments and the number one it will be the main impairment influencing on the functional limitation. Focus on function and correct patterns of movement.
I hope it helps. Any other ideas please let me know.
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