Patient Management Flashcards
what are the 6 elements to the patient management model?
1: examination
2: evaluation
3: diagnosis
4: prognosis
5: intervention
6: outcome
*patient related- satisfaction
service delivery- efficacy & efficiency
examination
process of obtaining a history, performing a relevant systems review and selecting and administering specific tests & measurements to obtain data
- used to generate a diagnosis
- ongoing process throughout treatment to evaluate response to intervention
examination- history
- dynamic process used to generate and refine hypothesis
- thorough and detailed hx is critical to the problem solving process leading to dx
- good questioning: non-leading, educational level
- active listening: red flags, word choices
- controlling the conversation
- many different forms to help organize- all will need a review of the pt response
- demographic profile & social hx
- occupation
- general health hx (co morbidities, surgeries, properly managed?)
- past (PMH) and current (HPC) hx of physical condition
- extra-individual & intra-individual interventions (sucess? pt experience?)
get the story-history
**think SINSS
what happened? when? why? what did you do about it? where does it hurt now? has it changed? have you experienced this before? what makes it better/worse?
examination- systems review
cardiopulmonary (HR)
musculoskeletal (gross ROM)
neuromuscular (coordinated movement)
integumentary (skin integrity)
communication ability, affect, cognition, language, and learning style (consciousness, orientation)
examination- tests and measures
- guide organizes tests and measures performed by PTs into 24 categories
- hx and systems review guides to choice of relevant tests and measures
- observation/inspection
- palpation
- clearing tests
- movement tests
- muscle strength
- neurological
- special tests
- functional tests
for MS system:
- pain
- strength/endurance
- goniometry/flexibility
- reflexes/sensory/peripheral nerve
- posture/gait/balance
- anthropometrics
- accessory joint motion
- special tests
evaluation
=dynamic process in which the PT makes judgements based on data gathered during the exam
- prioritize problems to be assessed based on PMH, systems review, subjective complaints
- implement the examination
- interpret the data
“which tests have i done?”
“do i have enough info to proceed w/ rx?”
“do my objective tests match subjective complaints?”
evaluation- interpretation of data
interpretation used to determine:
- progression, stage and stability of the signs & symptoms (SINSS)
- presence of preexisting conditions
- relationships among involved systems and sites
evaluation- pathology
lab tests
radiologic studies
neurologic exams
these tests help identify the pathology, and lead to medical dx. PT focus should be on examination and evaluation of impairments, functional limitations and disabilities.
**elevator speech
impairment questions
- is the impairment directly related to a functional limitation?
- is the impairment secondary to the pathology or impairment?
- can the impairment be related to future functional limitation?
- is the impairment unrelated to the functional limitation?
**target impairments that are related to functional limitations!!
functional limitations
- lack of function (unable to make the bed) is why the pt seeks therapy
- which and to what degree are the impairments linked to functional limitations?
- success=ability to achieve functional outcomes
tests/measures of physical functional limitations
- self reports or proxy reports of the level of difficulty performing tasks
- observation of performance, rating the level of difficulty (measuring distances, weight lifted, # of reps, or quality of motion)
- clinical tests of physical mobility
- equipment based evaluation of performance
disability
involves social context of functional loss- limits patient’s ability to function socially
social interaction
social activity
social role
social interaction-disability
limited due to functional limitations (unable to leave the home)
social activity-disability
limited due to functional limitation (unable to attend functions where stair climbing is required)
social role-disability
limited due to functional limitation (unable to perform tasks that require stair climbing)
diagnosis
the process and end result of information obtained in the exam and veal
Includes:
- examination (hx & systems review)
- evaluation (interpretation)
- diagnosis=clinical classification- organization into cluster, syndrome, or category
cluster
a set of observations or data that frequently occur as a group or single patient
syndrome
an aggregate of signs and symptoms that characterize a given disease or condition
diagnosis
a label encompassing a cluster of signs and symptoms commonly associated with a disorder, syndrome, or category of impairment, functional, limitation or disability
prognosis
the process of determining level of optimal improvement that may be obtained from intervention, and the amount of time required to reach that level
plan of care
specify interventions to be used and the proposed duration and frequency of intervention(s) that are required to reach the anticipated goals and outcomes
why do we need to form a prognosis?
- grasp potential course a patients care can take
- to guide expectations for recovery
- to assist in planning, formulating interventions, promoting lifestyle changes
- to identify those as risk for poorer outcomes
- to guide future assessment
- to craft appropriate educational messages
- to identify opportunities to intervene and alter outcomes
What do we need to form a prognosis?
understanding of the natural history and course of pathology or diagnosis
prognostic factors:
- expert opinion and/or evidence based
- physical and/or psychosocial
proper examination, evaluation, and diagnostic process…
- pt’s health status & hx
- pt’s prior function, needs & goals
- SINSS
- responses to tx
what is intervention?
the purposeful and skilled interaction of the PT with the pt using various methods and techniques to produce changes in the pt’s condition consistent with the evaluation, diagnosis and prognosis
*key is to do the right things well
treat the right impairment
Will the pt benefit from the intervention? (will tx improve function?)
Are there any possible negative effects of the tx?
What is the cost:benefit ratio?
Types of intervention
1: direct intervention (there ex, manual therapy, etc)
2: pt-related instruction (education provided to the pt and other caregivers)
3: coordination, communication and documentation (pt care conferences, record views, discharge planning)
selecting treatment interventions
- therapeutic exercise
- functional training in self care
- manual therapy
- airway clearance techniques
- integumentary repair and protection
- physical agents
- electrotherapeutic modalities
patient-related instruction
educate the pt (and caregivers) regarding the entire process
- why PT is appropriate
- what they can expect
- what you will do for them
- what they can do for themselves
treat all involved as a TEAM
benefits=increased compliance
“things I can do for you, and things only you can do for you”
outcome
successful when:
- physical function is improved or maintained whenever possible
- functional decline is minimized or slowed when status quo cannot be maintained
- the pt is satisfied
quantify impact of interventions on disablement model
clinical decision making- patient management
examination- prioritize problems and tests
evaluation- consider and analyze findings
diagnosis- segregate findings into clusters and signs by common causes, mechanisms and effects
intervention- determine correlation between impairment and functional limitation. select and justify method of intervention
outcome- measure success of intervention plan; modify if necessary
common elements of initial documentation forms
- PMH
- HPI=history of present illness
- S
- O
- A
- P
progress notes
- if it isn’t documented, it didn’t happen
- clinical note required for EVERY visit
- styles of clinical notes vary across facilities; good ones have common elements of SOAP
SOAP
S: changes in pain/function since last time
O: at least 1 objective measure each time. description of what tx was done
A: how pt tolerated tx, goals achieved, progress/barriers
P: what to do between tx (PT call MD, pt continued HEP), what to do next tx
therapeutic exercise intervention
- which ELEMENTS of movement system need to be addressed to restore function?
- which ACTIVITIES OR TECHNIQUES are chosen to achieve a functional outcome?
- what is the PURPOSE of each specific activity or technique chosen?
- what is the POSTURE, MODE, AND MOVEMENT for each activity or technique?
- what are the DOSAGE PARAMETERS for each activity or technique?
**CONSIDER ALL THE VARIABLES!
3 axes of the 3D therapeutic exercise intervention model
1: elements of the movement system as they relate to the purpose of each activity or technique
2: the specific activity or technique
3: the specific dosage
1: elements of movement system
1: support
2: base
3: modulator
4: biomechanical
5: cognitive or affective
support
functional status of cardiac, pulmonary, and metabolic systems
base
functional status of the muscular and skeletal systems (jt mobility, muscle performance)
modulator
physiologic status of the neuromuscular system (patterns of muscle activ)
biomechanical
functional status of static and dynamic kinetics and kinematics (interface between motor control and muscle function, reaction to external forces)
cognitive or affective
functional status of psychological system as it relates to movement
clinical decision making of the elements of the movement system
consideration of the movement system elements allows the PT to:
- identify functional limitations and related impairments to be treated
- relate functional limitations and impairments to be treated with the appropriate elements of the movement system
- prioritize treatments aimed at elements of the movement system
- decide on activities and dosages
activities/techniques
- stretching (active/passive) :BASE
- ROM exercises: BASE
- strengthening: BASE
- neuromuscular re-education: MODULATOR
- developmental activities: MODULATOR
- breathing exercises: SUPPORT
- aquatic exercises: BIOMECHANICS
- posture exercises: BIOMECHANICS
factors when choosing an activity; stages of movement control
fundamental->advanced
Stability
Mobility
controlled mobility
skill
stability
ability to provide stable foundation from which to move
mobility
functional range through which to move and the ability to sustain active movement through the range
controlled mobility
ability to control movement of individual and multiple joints within and between limbs
skill
ability to maintain consistency in performing functional tasks with economy of effort
2: choice of activity
posture, mode, movement
*can do 2 of the exact same exercises for 2 very different reasons
posture
pt position, amount of support, angle of force application
mode
method of performing activity (strengthening- mode may be weights, manual resistance, etc)
movement
quality of movement/quality of performance
3: dosage
1: type of contraction
2: intensity
3: speed of activity or technique
4: duration/repetition
5: frequency
6: sequence
7: environment
8: feedback
elements of dosage depend STRONGLY on:
Physiologic status/stage of tissues
- atrophy, normal or hypertrophy
- stage of tissue healing
Anatomic elements (bone, ligamentous, muscular)
Patient’s ability to learn
exercise modification
required when pt outcome is not met in reasonable timeframe
Factors relating to PT:
-PT may have chosen the wrong activity and/or dosage
-PT may not be able to effectively implement or teach the exercise
factors related to the pt:
- may not be able to learn the exercise well, or misunderstand or forget the instructions or dosage
- pt may not follow through with prescription
**recurrent exams and evals are necessary
adjunctive interventions
may be complementary to there ex prescription, not essential components
- physical agents
- mechanical modalities- traction, CPM, tilt tables, compression devices, etc
- electrotherapy
progression/regression sequence
gravity
weight
band
unstable surface
