4.1 Monitor, Reassessing and Modifying the Plan Flashcards
- Monitor
Using outcome measures to determine if my Pt is demonstrating change over time
For each impairment in the problem list→select an outcome measure to monitor it
6-8 outcome measure in Case 2
- You can also use Pt-specific measures based on tasks that are meaningful to the patient
E.g.
- Pt has breathlessness when walking up 5 stairs
→the no. of stairs climbed before breathlessness
- Pt has difficulty laying flat for more than 10 minutes as they start to feel breathless
→time supine before feeling breathless - Pt has orthostatic hypotension and becomes dizzy when moving from supine to sit
→use a rating scale out of 10 of dizziness upon sitting
- Reassessing
State the frequency you would reassess the patient using that outcome measure
How often will you reassess?
* Stage of recover: acute stage→change happen quicker & reassessment at shorter intervals vs chronic stage
E.g.
- Pt with grade 2 ATFL sprain 2 days ago
→change significantly over the course of 6 weeks
→reassessment using outcome measure more regularly (weekly) over the course of those 6 weeks
- Pt with chronic degenerative Lx spinal stenosis
→only mild improvement with PT intervention over 6 weeks
→reassessment less regularly (e.g. monthly)
- Modifying the Plan
Using the data you’ve collected in your outcome measures through monitoring and reassessing, determine if modification is needed.
- State a few examples of what you would do to modify your plan. Look back at the treatment plan to help guide your modifications
- Are they demonstrating an improvement or a decline?
- Improvement= progress treatment plan
E.g.
* Inc. reps/sets/intensity/duration or distance
* Add a new more challenging exercise
* Decrease the amount of cueing/assistance required - Decline= regress treatment plan or check in with the care team to see if there is an underlying unaddressed issue
E.g.
* Decrease reps/sets/intensity/duration or distance
* Allow for longer rest breaks between sets
* Remove an exercise or substitute it for a less challenging one
* Increase the amount of cueing/assistance required
* Review exercise program/education with Pt to ensure adherence/proper technique - No change= use your clinical reasoning to determine if a reasonable amount of time has occurred between measurements to allow for a significant change
* If change should have occurred, adjust the Rx plan to include new treatment options
Refer to the Problem list
1. Dyspnea
- Modified Borg scale
- Sing talk gasp scale
2. Decreased functional mobility
- 10 meter walk test
- 6-minute walk test
- Time up and go
3. Currently smoking (Pt-specific measure)
- Time since the last cigarette
4. Presence of secretions
- Auscultation
- Amount of secretions removed
- Strength of cough
- Colour of sputum
5. Co-morbidities: HT & Type II DM
- Blood pressure
- Watch for signs of hypoglycemia during exercise
1. Dyspnea
- Modified Borg scale
- Sing talk gasp scale
To monitor the Pt dyspnea
- What Outcome measure you will use?
I would use the modified Borg scale and the sing talk gasp scale. - How is the reassessment frequency?
Since the patient is in an acute exacerbation, I would monitor dyspnea at the start of our session together, at rest, and during activity such as ambulation or exercise.
I would reassess dyspnea during each session. - How would you modify the plan?
Improvment:
If the Pt demonstrated decreased ratings of dyspnea while ambulating/exercising, I would increase their ambulation distance and reps/sets in their exercise program.
Decline:
If the patient was demonstrating increased ratings of dyspnea while ambulating/exercising,
I would revisit their PLB technique to ensure proper technique and decrease the distance ambulated or the number of reps/sets of the exercise
Decreased functional mobility
- 10 meter walk test
- 6-minute walk test
- Time up and go
To monitor their decreased mobility status
- What Outcome measure you will use?
I would use a few different outcome measures.
- I would use the 10m walk test to look at short-distance endurance and speed.
- I would use the 6-minute walk test to assess cardiovascular health and endurance
- I would use timed up and go to assess their ability to move from sit to stand, turning, gait speed and overall balance. - How is the reassessment frequency?
I would reassess each of these measures once a week in order to give enough time between tests to see a measurable change. - How would you modify the plan?
Improvment:
If I noted improvements in all mobility outcome measures, I would progress the Pt endurance by increasing the distance/duration of ambulation.
Decline:
If there was a decrease in mobility outcome measures, I would connect with the Pt to determine if there were any new underlying issues that could be impacting outcomes and then regress distance/duration of ambulation to see if fatigue/overexertion is playing a role in the decline in outcome measures.
3. Currently smoking (Pt-specific measure)
- Time since the last cigarette
The issue of the Pt smoking is something that I would want to support them with as mentioned in my treatment plan.
- How is the reassessment frequency?
I would not directly monitor this other than to check in to support them in this journey. - What Outcome measure you will use?
I could encourage them by keeping track of how many days since their last cigarette. - How would you modify the plan?
Improvment:
If the Pt was staying on track with their smoking cessation plan I would continue to provide support/encouragement.
Decline:
If they were struggling and were actively smoking, I would encourage community support groups.
4. Presence of secretions
- Auscultation
- Amount of secretions removed
- Strength of cough
- Colour of sputum
To monitor the presence of secretions
- What Outcome measure you will use?
- I would auscultate,
- look at the volume of secretions removed,
- the strength of their cough and
- the colour of the sputum removed. - How is the reassessment frequency?
- I would reassess this during each session. - How would you modify the plan?
Improvment:
If I notice a decrease in the amount of secretions on ausculation, I would decrease the frequency of secretion removal techniques.
Decline:
If I noticed an increase in the amount of secretions on auscultation or the presence of green sputum, I would increase the frequency of secretion removal or try an alternative secretion removal technique and advise the team.
5. Co-morbidities: HT & Type II DM
- Blood pressure
- Watch for signs of hypoglycemia during exercise
To monitor the issue of hypertension,
- What Outcome measure you will use?
I would either take their blood pressure or look in their chart to see when it was last taken. - How is the reassessment frequency?
I would reassess their blood pressure each session, whether that means I take their blood pressure or check to see another practitioners measure. - What Outcome measure you will use?+
- How is the reassessment frequency?
I would not directly monitor their type 2 diabetes other than to ensure I am aware of signs and symptoms associated with hypoglycemia during activity - How would you modify the plan?
Decline (HT):
If I noticed an increase in the Pt’s blood pressure, I would advise the team.
Improvment (HT):
If I noted improvements in the patient’s blood pressure, I would encourage ongoing participation in their physiotherapy program
Decline (DM):
If I noticed episodes of hypoglycemia during exercise, I would stop exercising and provide the Pt with glucose and notify the nursing staff.