Self Directed Learning Package - University of Queensland

20 • The Palliative Approach ToolkitWriteDocument your actionsDocument enough information to allow others in themultidisciplinary team a clear picture of the clinicalsituation.Avoid general statementsPOOR COMMUNICATIONGOOD COMMUNICATIONEvaluation of interventions‘Resident states dyspnoea has reduced to‘with effect’ or ‘effective’.2/10 score (was 5/10)’.Note to GP‘Careworkers report Bob is reporting‘Please review Bob ASAP re dyspnoea’. dyspnoea on exertion for the last threedays. He reports severity = moderate(5/10) when walking 20 metres to thedining room. Relieved by resting for5mins. Careworkers wheeling him downin chair until he is reviewed. Afebrile, nochest pain, wheezing or other symptoms’.ReviewEvaluate and reassess as necessaryThinking PointYou identified that Bob is breathless and conductedan assessment.You made sure careworkers implemented the simplemeasures you had documented on the care plan.There is appropriate medication ordered if necessary(opioids) and you have spent some time addressingBob’s anxiety about his breathing. Great job!Can you tick this off your list? Not quite yet.There is an important question to answer:Did your strategies work?You can check the effectiveness of your management strategiesby asking the resident to rate the severity of their dyspnoeaagain (using a rating scale), observing their breathing rate,or asking if their mood, sleep or function has improved.Key PointRemember, assessment of any clinical problemis an ongoing process rather than a single event.Undertaking a formal, scheduled assessment maybe more valuable than frequent, brief impressions.SUCCESS!You have completed Section 1 of the learning package.You may decide to pause now and answer the first sixquestions of the quiz at the back of this learning package.