Chapter 4: examination, evaluation, and plan of care Flashcards
PT diagnosis
Label encompassing a cluster of signs and symptoms commonly associated with a disorder or syndrome or cateogory of impairments in body structures and function, activity limitations or participation restrictions
Examination
Process of obtaining a history, performing relevant systems reviews. And selecting and administering specific test and measure. Performed by PT
Evaluation
Dynamic process in which the PT makes clinical judgements based on data gathered during the examination. Performed by PT
Specific data collection
Can be performed by PTA if requested because it’s just test and measurements
Pain description
Collected during examination (patient’s history) includes pain, extension or radiation, intensity, duration, onset, frequency, progression, aggravating or relieving factors, and previous test results in regard to pain
VAS
Visual Analog Scale: 10 cm line with verbal or pictorial anchors indicating a continuum from no pain at one end to sever at the other. Patient asked to mark line and pain measured in cm
NRS
Numerical rating system: range of number to reflect pain. Should be measureing before and after physical therapy interventions for pain
Patient history
Complete medical history of the patient’s chief complaints, present illness, past history, allergies, current medications, lifestyles and habits, social history, vocational or economic history, and family history
Sensory examination
Tests for superficial, deep, and combined sensations
Superficial sensory exam
Pain, temp, light touch and pressure
Deep sensory exam
Kinesthesia, proproiception, and vibration
Combined sensory exam
Tactile localization, 2-point discrimination, barognosis, stereognosis, graphesthesia, and recognition of texture
Cranial nerve integrity
Examination of function of 12 pairs of cranial nerves that are distributed to the head and neck - not cranial 10 (vagas nerve) that is distributed to thorax/abdomen
Vital signs
Investigation of cardiopulmonary system to examine vital signs (heart rate, respiration, and blood pressure) and to note any signe of cardiac decomposition - can interfere with physical therapy interventions as well as show patients aerobic capacity and endurance
Anthropometrics
Measurements that give in for about length, girth, volume of patient’s body. Also includes height, weight, and BMI
Mentation, hearing, and vision examination
Evaluate patient’s ability to concentrate/respond by examining patient’s attention, orientation, and cognition - gross examination of patient’s hearing during conversation - gross visual examination can assess patient’s visual acuity and peripheral field vision
Attention
Awareness of environment or ability to focus on a specific stimulus without distraction
Orientation
Refers to patient’s awareness of time, person, and place
Cognition
Complex process that examines thinking skills such as language - use and calculation - perception - memory awareness - reasoning - judgment - learning - intellect - social skills - imagination
Range of motion
ROM: evaluates amount of excursion through which a joint or a series of joints can move. Measured in degrees by a goniometer
Manual muscle testing
MMT: evaluates relative strength of specific muscles and identifies patterns of muscle weakness. Normal 5, good 4, fair 3, poor 2, trace activity 1, absent 0
Muscle tone
Abnormalities of muscular tone are common in neurological disorders. Spasticity — rigidity — flaccidity
Tone
Resistance of muscles to passive elongation or stretch. Or how much tension a muscle has at rest. Hypertonia — hypotonia —dystonia
Hypertonia
Muscle overactivity when communication between brain and spinal cord is affected by injury and weakness
Hypotonia
Weak muscle tone
Dystonia
Involuntary muscle contractions that cause repetitive or twisting movements
Flaccidity
Lack of tension when the muscle is at rest. Patient has poor or no ability to create enough tension to move muscle
Spasticity
Excessive contraction in response to stretch of a muscle that can occur when the patient is actively moving or being passively moved
Rigidity
Inability of muscles to relax normally
Postural analysis
Evaluates the position maintained by body when standing and sitting in relation to space and body parts - assessed from all angles (front, back, sides)
Balance and control
Examines patient’s ability to control positions of body and body parts using skeletal muscles with respect to gravity - berg balance test - timed up and go - tinetti performance oriented mobility assessment
Function
Determines the effect of the condition or injury on the patient’s daily life - ADLs BADLs and IADLs
ADL
Activities based on daily living
BADL
Basic activities of daily living; dressing, walking, transfer
IADL
Instrumental activities of daily living; meal prep, chores
Gait examination
Observing patient from pelvis and lumbar spine down to ankle and foot - also watches trunk and upper limbs - observe with/out shoes, devices, level surfaces, and stairs
Gait cycle
Moment one foot touches the ground until moment same foot touches agian
Outcome measures
Use of standardized tests and measurements at regular intervals during a patient’s physical therapy episode of care is important way to objectify patient’s function and abilities - look at functional abilities and identify if PT intervention is moving toward predicted outcomes
Orthopedic examination
Examine integrity of musculoskeletal components. Joint play movements examine the amount of passive motion available within a joint and help differentiate what structures may be injured
Neurological examiniation
Consider both therapeutic interventions and psychological aspects of rehabilitation
- patient’s adaptation to disability - patient’s and patient’s family’s stages to adjustment to disease and disability - effects of impairments, functional limitations, and disability - patient’s reintegration into environment, family, and work
Cardiopulmonary examintation
PTA must be able to reassess as necessary, moister patient in regard to treatment, monitor vital signs, and provide appropriate interventions to the patient
Elements of cardinac examintation
Evaluation of patient’s medical status and history, physical examination, assessment of extremities, and results of diagnostic tests
Symptoms of cardiac examination
Despeña or shortness of breath - feelings of fatigue - generalized weakness - palatations - dizziness - edema
Examinations for cardiac
Radial pulse - femoral pulse - popliteal pulse - pedal pulse - listening to hear sounds - blood pressure - counting respitory rate
Pulmonary examiniation
Eval through patient interview. PT inquires about patient’s habits, drugs, and alcohol - similar to cardiac but includes inspection / palpitation of neck and thorax - and listening to abnormal inspiration/expiration sounds
Pediatric examination
Need specific knowledge about theories of child development, motor control, and motor learning
Pediatric screening test
Patient history in regards to mother’s pregnancy and birth history and child’s medical history
Newborn/infant exams
Neurological exams including consciousness, skeletal system and ROM exams, posture and neonatal reflexes - includes developmental milestones in gross motor development, fine development, and adaptive skills
Children and adolescents
Monitoring of progressive diseases, mobility needs that need to grow as child grows, functional changes such as accomplishing school tasks and ADLs
Geriatric examination
Musculoskeletal and neuromuscular conditions and dysfunction common to older adults. Mostly focus on patient’s level of functioning and ability to remain independent.
- elderly patients in control of decisions - cultural/ethnic sensitivities - social support needs to be integrated - demands for continuity of care needs to be integrated p patient’s capacity for safe function - effects of activity/in on patient - effects of normal aging on patient vs desease pathology
Geriatric psychosocial exam
Includes mini-mental state assessment examination, a mental questionnaire, a drepression assessement, a stress assessment scale
Geriatric function tests (4)
- Physical: sensory and motor
- Mental funciton: intelligence, cognitive ability, memory
- Emotional function: ability to cope with stress and anxiety and the patient’s satisfaction with life
- Social function: patient’s interaction with family members and community as well as economic consideration
Geriatric optimal health
Contingent on health-conducive behavior, prevention of disability, compensation for health-related losses and impairment of age it
Environmental examination
Of patient’s home or living institution. Internal and external check. Includes lighting
Integumentary examination
Treats skin disorders. Assess patient for prurities (itching), rashes, excessive dryness, edema (swelling), unusual skin growths, changes in skin color/temp, sensory integrity, pain, soreness, and symptoms that indicate respiratory, circulatory, cardiac, or renal diseases - also treats wounds and burns (PT to determine location of wound, size, depth, drainage, skin changes, involved tissues color/temp, involved extremity’s girth, tissue, sensation
Burns
3 zones, 3 degrees, respiratory involvement, smoke inhalation and destruction of skin
- Zone of coagulation were cells are dead
- Zone of stasis where cells are injured and can die without specialized treatment
- Zone of hyper is where the injury is minimal and cells can recover
Plan of care
PT develops a problem list form evatuation and identifies interventions to help improve the problem
**Plan guides PTA, PTA cannot change it
Functional long term goals
Proposed outcomes for patient
Medicare POC
Must also include physical therapy diagnosis, type of therapy to be provided, potential of patient to reach functional goals, and intensity, frequency, and duration of POC
