PCM 2 Unit 4 Acute Care Exam and Intervention Planning Flashcards
What is Clinical reasoning?
A cognitive process that requires:
- The synthesis of information
- Collaboration with the interprofessional team, patient and caregiver
What are Clinical Decisions?
- Outcome of clinical reasoning
- The basis of patient/client management
- Influenced by numerous factors:
-Practitioner specific
-Patient and practice context specific
In the Patient/Client Management Model, the Examination consist of?
- Hx
- Systems review
- Test and Measures
- Outcome Measures
After receiving an consult, PTs should do a Chart review of the patient and an Interview. What takes place with these two steps?
Chart Review
- We get the referral from MD
- Activity orders
- Meds
- Lab values
- Medical assessment
- Hx of present illness
Interview
Intro to patient HAND HYGEINE and infection control/PPE
- Here we explain our role
- Describe the session plan
- Receipt of consent (if able)
- Inquiry of patient experience and goals
When Interviewing the patient, what are some Relevent details we should know as the PT?
Contexual Factors:
- Level of support: Emotion, physical adn social support
- Type of residence and potential barriers associated with social support or physical environment
- Access and ownership of DME
- Ultimate DC plan per patient, who will be available to help - MUST CONFIRM
Activity-PLOF
- Abilities and need for assistance
- Endurance and activity tolerance - prior exercise/activity regime
- Fall hx
- Airway considerations
- Use of AD
Participation- Roles and responsibilites
With the Examination, what is a Systems Review?
Screening exams (brief systems review) to quickly scan the patient’s body systems and determine areas of dysfunction and intact function
- This confirms the need for further and more detailed examination
- Rule out or differentiate specific system involvement
- Determine if referral to another health care professional is warranted
After gathering all the information from the Systems Review during the Examination, is the pateint appropriate for a full PT exam? If no, then what? If yes, then what?
If no… Now what?
- Who do you communicate this with?
- How do you document this?
- When will the patient be appropriate?
If yes… Now what
- Select approptriate Test and Measures
- Select Performance OM as appropriate
- Begin formulating anticipation of response to activity
- Begin hypothesizing potential discharge destination
During the Examination, why are Test and Measures good for information?
- They are more definitive, they provide objective data to determine the degree of impairments and specific level of function and dysfunction
- It can support clinical judgement about the diagnosis, prognosis and POC
During the Examination, what are the Selection of Test and Measures and depth of the exam dependent on?
- Patient health condition (severity and
complexity of the problem) - Stage of recovery (acute, subacute, or chronic)
- Phase of rehabilitation (early, middle or late)
- Cognition and behavior (level of arousal, communication ability, ability to participate in the examination)
- Setting (hospital, home, community, work)
With the Selection of Test and Measures, what are some things we the PTs will test for Cognition?
- Alert and oriented in 4 domains
- Short-Term Memory (STM) recall
- Problem solving
- Motor planning
With the Selection of Test and Measures, what are some things we the PTs will note for Speech and Language?
We will note for Aphasia, dysarthria, and apraxia
With the Selection of Test and Measures, what are some things we the PTs will observe for Integumentary?
- Color and Temperature
- Position to assess relief
- We can also do wound assessment: measure of size, description of staging
With the Selection of Test and Measures, what are some things we the PTs will test for Neuromuscular?
- Balance
- Gait quality and speed
- CN
- Muscle tone
- Coordination
- Reflexes
- Sensation
- Vestibular
- Motor function (control/learning)
With the Selection of Test and Measures, what are some things we the PTs will test for Cardiopulmonary?
- RR
- HR
- BP
- Edema
- O2 saturation
- Observe ECG
- Observe posture/chest expansion
- Ascultation
- Endurance
With the Selection of Test and Measures, what are some things we the PTs will test for Musculoskeletal?
- ROM
- Muscle performance
- Anthropometrics
With the Selection of Test and Measures, what are some things we the PTs will assess for Pain (NRPS)?
- Whether there is pain at rest
- Whether there is recovery time with the pain
- The quality of pain
- The conditions that make the pain worser or better
In the Patient/Client Management Model, the Evaluation consist of?
- Organization and analysis of data collected from the initial examination
-This leads to the development of a problem list - An accurate evaluation supports the therapist’s ability to determine a diagnosis and prognosis and develop a POC
In the Patient/Client Management Model, the Diagnosis consist of?
- This is based on the collection of relevent information that determines if the patient clincial presentation is appropriate for PT intervention
- PT diagnosis includes descriptors used to identify the impact of the condition on function at the level of the system and the whole person
- It guides the prognosis and selection of interventions
- Medical diagnosis identifies the disease, disorder or condition at the cellular, tissue or organ level
In the Patient/Client Management Model, the Prognosis consist of?
- The predicted level of optimal functional gain and the time required to reach this level
- A statement of the patients overall rehabilitation potential that is often expressed as excellent, good, fair or poor
