Eval and Discharge Flashcards
evaluation consists of
interpretation of an individuals response to sub questioning
integration of objective
diagnosis
prognosis
POC
what needs to be correlated in an examination
subjective and objective portions
necessary for diagnosis, POC and prognosis
how is evaluation integration completed
following ICF model
- around a diagnosis that limits certain aspects of one’s life and the positive or negative external factors
what does health condition provide
medical information that could influence POC
- precautions
- complexity
- timeline
- possible prognosis
participation limitation provides us with
- IADLs to return to
- helpful in goal setting
- focused interventions
what information does activity limitation give us? can it help us with anything?
- ADLs
- what is specifically limiting them from participation
- planning the exam and possible interventions
what is considered in body structure impairments
ROM
muscle performance
cardiac function
starting point for interventions
diagnosis definition
level of irritability and key impairments
prognosis definition
predicted optimal level of improvement in function and
associated amount of time necessary to get there
what may a prognosis include
prediction of levels of improvement at various intervals of time over course of PT
plan of care consists of
specification of goals
predicted level of optimal improvement
specific interventions
proposed duration and frequency
what does a PT’s diagnosis consist of
level of irritability / primary problem
- will change over time
- guidance of specific rehab intervention
- may inform prognosis
what does a MD’s diagnosis consist of
primary tissue pathology
- will remain stable through care
- guides general treatment strategy
- informs prognosis
common subjective report of a mobility deficit
pain and limitation at end ROM
consistent reproduction of symptoms at end ROM
common objective report of a mobility deficit
AROM and PROM loss
- pain, guarding, tightness
types of health conditions that mobility deficits are found in? what is the goal for interventions?
arthritis, post-op, impingement
improve ROM and recover function
common subjective report of a movement coordination deficit
pain during/throughout motion and pain in specific end range
common objective report of a movement coordination deficit
laxity, weakness
poor coordination/balance
poor muscle activation
AROM loss > PROM loss
hypermobile or hypomobile jts above and below
types of health conditions associated with movement coordination deficit
ligament sprain
joint instability
disc pathologies
trauma
goal for intervention in those with movement coordination deficit
muscle activation and strength
heal and progressively load tissues
improve coordination and balance
common subjective report of a muscle power deficit
pain with specific contraction
+/- pain during PROM in opposite direction
common objective report of a muscle power deficit
point tenderness at tendon or insertion
pain with AROM and passive stx
abnormal mechanism of mvmt in jts above and below
types of health conditions associated with muscle power deficit
tendinopathies
tendon rupture
goal for intervention of muscle power deficit
reduce stress to tissue
promote healing/correct mechanism
subjective report of referred pain
pain moves from spine with one specific movement
and
will return to the spine while completing the opposite motion
objective report of referred pain
symptoms centralize or peripheralize with motion
may present with another impairment
no hard neuro symptoms
goal of treatment for referred pain
centralize the symptoms and normalize the movement
- more so education
types of conditions associated with radicular pain
nerve root compression at spinal level
subjective report of radicular pain
pain going down an extremity
- lightning like
- specific sensory or muscle deficits
objective report of radicular pain
spine motion that sends pain to extremity
neuro symptoms
- dematome/myotome pattern
- reduced reflexes
interventions of radicular pain
reduce stress to nerve root
recover weakness
prevent reoccurance
health conditions associated with sensory deficits
nerve entrapment syndromes in periphery
subjective report of sensory deficits
pain with repetitive or compressive tasks
numbness/tingling, weakness, or both may be present
objective finding of sensory deficits
sensory/motor changes in dermatome/myotome pattern
- may have one or both
interventions for sensory deficits
reduce cause of symptoms
recover deficits
allow nerve to heal
generalized pain health conditions
any condition lasting >3 mo without neuropathic or nocioceptive qualifications
subjective reports associated with generalized pain
pain that isn’t specific or appropriate
objective reports of generalized pain
general impairments noted symptoms are disproportionate
positive yellow flags
positive nocioceptive findings
interventions for generalized pain
pain science education
centralization training
general aerobic exercise
manual therapy
TENS
systemic interventions
evaluation components
diagnosis
prognosis
plan of care
prognosis is greatly affected by
contextual factors
documentation of prognosis is categorized as
excellent
good
fair
poor
how is POC documented
overall goals
statement of interventions to be used
duration/frequency
discharge plans (outcomes)
PT goals need to be
focused on anticipated status at DX
focused on function via ICF
have reliable methods of assessment
key elements to consider in frequency and duration
contextual factors
patient’s perspective/requests
reassessment intervals
what does a patient need to know about discharge
progress reviewed often
understanding / agreement of timeline and methods to be used
planning from today till our DX
necessary question associated with PASS
ask pt to recall the previous 2 days with their condition and ask if they had to live the next few months in this way, would it be acceptable?
