Chapter 1: Client Care

Question 1

Assessment

Chapt 1: Client Care

Answer 1

The measurement or quantification of a variable or the placement of a value on something (not to be confused with examination or evaluation)

Question 2

Caregiver

Answer 2

The person who is treating or working with the patient (ex. therapist, therapist assistant, aide, or family member)

Question 3

Documentation

Answer 3

written, printed, or electronic matter conveying authoritative information, records, or evidence

Question 4

Evaluation

Answer 4

Dynamic process in which the practitioner makes clinical judgments based on data gathered during the examination and identifies problems pertinent to patient management

Question 5

Examination

Answer 5

The process of obtaining a history, performing relevant systems reviews, and selecting and administering specific tests and measures

Question 6

Goniometry

Answer 6

The measurement of the range of motion of a joint of the body

Question 7

Kinesthesia

Answer 7

The sense by which position, weight, and movement are perceived (ex. walking without looking at the feet or typing without looking at the hands) “perception of movement”

Question 8

Orthosis

Answer 8

An orthopedic appliance used to support, align, prevent, or correct deformities or to replace the function of parts of the body (ex. a brace or splint)

Question 9

Outcome measure

Answer 9

a quantifiable or objective means to determine the effectiveness of treatment or performance that is usually expressed in functional terms

Question 10

Proprioception

Answer 10

Perception mediated by proprioceptors or proprioceptive testing; sensation and awareness about the movements and position of body parts or the body. Includes balance.

Question 11

Prosthesis

Answer 11

The artificial replacement of an absent body part (ex. an artificial limb)

Question 12

SOAP

Answer 12

An acronym that identifies a patient’s status
s = subjective
o = objective
a = assessment
p = plan

Question 13

Stereognosis

Answer 13

Ability to recognize the form (shape) of an object by touch

Question 14

Two-point discrimination

Answer 14

The ability to recognize or differentiate two blunt points when they are simultaneously applied to the skin

Question 15

Interprofessional Collaboration

Answer 15

When different professions work together to review a patient’s condition, determine problems to be treated, discuss treatment solutions, and made decisions to resolve problems (ex. SLP, OT, Nurses, Psychologists collaborating)

Question 16

Orientation

Answer 16

The introduction process before any treatment, examination, and evaluation can occur. It involves:
1. Introduce yourself - name and title to patient
2. Verify patient using 2 IDs (patient name, DOB, medical record number, or driver’s license)
3. Verify/confirm patient information you have such as name, diagnosis, purpose of treatment, and referral source
4. Interview patient to obtain relevant information: be aware of cultural norms or traditions
5. Perform assessment, examination, and evaluation activities to establish patient’s capabilities, condition, problems, needs, goals, and clinical diagnosis.
6. Establish treatment goals and functional outcomes with patient input
7. Inform patient of the treatment plan and techniques selected to fulfill outcome goals; include information about risks or adverse effects associated with treatment
6. Encourage patient to as questions to enable the person to consent to or decline treatment
7. Request that the patient sign an informed consent document or record the oral consent in the medical record

Question 17

Culture

Answer 17

Shared values, norms, traditions, customs, art, history, folklore, and institutions of a group of people

Question 18

Cultural Competence

Answer 18

A set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups. This requires a willingness and ability to draw on knowledgeable persons of and from the community in developing focused treatments, communications, and other supports

Question 19

Cultural Diversity

Answer 19

Differences in race, ethnicity, language, sexual identity, nationality, or religion among various groups within a community, organization, or nation; a city is said to be culturally diverse if its residents include members of different groups

Question 20

Cultural Sensitivity

Answer 20

An awareness of the nuances of one’s own and other cultures

Question 21

Culturally Appropriate

Answer 21

Demonstrating both sensitivity to cultural differences and similarities and effectiveness in using cultural symbols to communicate

Question 22

Ethnic

Answer 22

Belonging to a common group often linked by race, nationality, and language with a common cultural heritage or derivation

Question 23

Race

Answer 23

A socially defined population that is derived from distinguishable physical characteristics that are genetically transmitted

Question 24

Gender

Answer 24

Male, female, LGBTQ+ (Lesbian, gay, transgender, questioning or queer, intersex, asexual [+ all inclusive!])

Question 25

Sexual orientation

Answer 25

Describes sexual attraction only and is not directly related to gender identity.

Question 26

Health Insurance Portability and Accountability Act (HIPAA)

Answer 26

A federal law established in 1996 that protects healthcare-related information. HIPAA Privacy Rule protects all identifiable health information held or transmitted by a covered entity or its business associate in any form or media whether electronic, oral, or on paper. Allows patients access to their healthcare information and control over the use of it. Identifiable information includes: 1. Demographic data relating to a person’s past, present, or future physical/mental health condition; 2. Provision of health care to the individual; 3. The past, present, or future payment for the provision of health care to the individual. Protection information includes name, address, DOB, and SSN.

Question 27

Advance Health Directives

Answer 27

aka “living will.” A set of instructions to give an appointed individual the right to make decisions concerning the health care actions to be taken when a person is no longer able to make decisions because of illness or incapacity

Question 28

Informed Consent

Answer 28

Before treatment can begin, the caregiver is responsible for informing the patient about the proposed treatment, alternative treatments available, and associated known risks. The patient has the right to consent to or reject the proposed treatment. Document that this was provided and the patient’s decision to consent or refuse!

Question 29

Differential Diagnosis

Answer 29

A process in which the caregiver compares and contrasts the symptoms of one illness or condition with another to arrive at an initial therapy diagnosis (may differ from the medical pathologic diagnosis). 2 methods used to gather information: 1. observation and interviews; 2. specific tests and outcome measures

Question 30

Sentinel Event

Answer 30

Patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm) or severe permanent harm (regardless of severity of harm).

Question 31

Severe harm

Answer 31

An event or condition that reaches the individual resulting in life-threatening bodily injury (including pain and disfigurement) that interferes with or results in loss of functional ability or quality of life that requires continuous physiological monitoring or surgery

Question 32

Permanent harm

Answer 32

An event or condition that reaches an individual, resulting in any level of harm that permanently alters and/or affects an individual’s baseline

Question 33

Pharmacokinetics (PK)

Answer 33

Study of what the body does to the drug/medication.
1. Absorption
2. Distribution
3. Metabolism
4. Excretion

Question 34

Pharmacodynamics

Answer 34

What a drug does to the body

Question 35

Physiologic changes associated with aging

Answer 35

1. Decreased skin integrity - skin tears, poor wound healing
2. Loss of bone density
3. Decreased strength
4. Decreased physical condition
5. Decreased muscle and connective tissue elasticity - Contractures, difficulty performing daily activities
6. Altered hearing acuity - difficulty with tasks requiring auditory input
7. Altered hearing acuity - difficulty with tasks requiring auditory input
8. Decreased balance
9. Altered proprioception
10. Altered kinesthesia
11. Altered cognitive capacity
12. Decreased tactile sense - difficulty differentiating objects/materials by touch

Question 36

Contractures

Answer 36

A permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff. This prevents normal movement of a joint or other body part. May be caused by injury, scarring, and nerve damage or by not using the muscles

Question 37

Asepsis

Answer 37

Absence of microorganism that create disease

Question 38

Healthcare-associated infections (HAIs)

Answer 38

Infections associated with healthcare delivery in any healthcare setting; previously known as nosocomial infection