Introduction Flashcards
The Components of Patient Management (6)
Examination Evaluation Diagnosis Prognosis Intervention Outcomes
Purpose of the History
Develop patient-therapist relationship.
Establish communication.
Identify RED FLAGS.
Determine if the patient can continue to evaluate and Treat (appropriate of PT).
Determine activity limitations, participation restrictions.
Identify Patient Goals.
Determine what to further examine.
Observation provides?
Non-verbal cues Position of comfort/discomfort Level of physical function Introduction to systems review Level of pain, fatigue Emotional status
Systems Review
Breif Screening exam of: Cardiopulmonary Integumentary Neuromuscular Musculoskeletal Cognition
The Physical Therapy Examination Consist of?
History
Systems Review
Test & Measures
Cardiopulmoary Screen
Heart Rate Blood Pressure Respiration Rate Lung & Heart Auscultation Pulses Palpation of skin for temperature Observation of extremities for edema, discoloration, venous distention.
Integumentary Screen
Temperature (Norm 96.5-99.4)
Edema
Skin Changes
Palpation
Neuromuscular Screen
Observation of gait, locomotion, balance, coordination.
CNS and Peripheral nerve integrity (sensation, motor, reflex testing).
Cranial Nerve Testing
Musculoskeletal Screen
Posture
Gross ROM
Gross Strength Assessment
Functional Assessment
Cognition/Communication Screen
Communication ability/language. Affect Learning Style Ability to make needs known Consciousness/orientation Expected emotional/behavioral responses and leaning preferences.
Test and Measures
Continuation/Expansion of systems review.
Detailed physical examination of the patient.
Objective data gathered to identify activity limitations and participation restrictions.
Narrow down the hypotheses and help lead to a physical therapy diagnosis.
Evaluation
Data collected during he examination is analyzed and synthesized to determine the diagnosis, prognosis and plan of care.
Also can help identify potential problems outside the scope of PT.
Diagnosis
The process and end result of the examination and evaluation which the PT organizes into defined clusters, syndromes, or categories to help determine the prognosis, plan of care and appropriate interventions.
Identify the source/cause of the problem and provide a label.
Prognosis
Determine the level of optimal improvement.
Time to achieve.
Guides Plan of Care.
Frequency and number of visits.
Patient education and patient responsibility.
