4.1 Monitor, Reassessing and Modifying the Plan

Question 1

1. Monitor

Answer 1

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

Question 2

2. Reassessing

Answer 2

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)

Question 3

3. Modifying the Plan

Answer 3

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

Question 4

• Are they demonstrating an improvement or a decline?

Answer 4

1. 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
2. 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
3. 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

Question 5

Refer to the Problem list

Answer 5

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

Question 6

1. Dyspnea
- Modified Borg scale
- Sing talk gasp scale

Answer 6

To monitor the Pt dyspnea

1. What Outcome measure you will use?
   I would use the modified Borg scale and the sing talk gasp scale.
2. 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.
3. 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

Question 7

Decreased functional mobility
- 10 meter walk test
- 6-minute walk test
- Time up and go

Answer 7

To monitor their decreased mobility status

1. 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.
2. 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.
3. 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.

Question 8

3. Currently smoking (Pt-specific measure)
- Time since the last cigarette

Answer 8

The issue of the Pt smoking is something that I would want to support them with as mentioned in my treatment plan.

2. How is the reassessment frequency?
   I would not directly monitor this other than to check in to support them in this journey.
3. What Outcome measure you will use?
   I could encourage them by keeping track of how many days since their last cigarette.
4. 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.

Question 9

4. Presence of secretions
- Auscultation
- Amount of secretions removed
- Strength of cough
- Colour of sputum

Answer 9

To monitor the presence of secretions

1. 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.
2. How is the reassessment frequency?
   - I would reassess this during each session.
3. 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.

Question 10

5. Co-morbidities: HT & Type II DM
- Blood pressure
- Watch for signs of hypoglycemia during exercise

Answer 10

To monitor the issue of hypertension,

1. 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.
2. 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.
3. What Outcome measure you will use?+
4. 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
5. 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.