Week 1- Hand Hygiene and Standard Precautions, Documentation: Eval/Diag and Assessment, Joint Mobs Flashcards
HAND HYGIENE
HAND HYGIENE
What are HAIs?
Health care-associated infections
-Infections people get while recieving health care for another condition.
In American hospitals alone, the Centers for Disease Control (CDC) estimates that HAIs account for an estimated ____ million infections and ________ associated deaths each year.
- 1.7 million
- 99,000 deaths
What is the most effective infection control measure in prevention of HAIs?
hand hygiene
What is the “patient zone”?
- patient
- surfaces and items that are temporarily and exclusively dedicated to him/her
What is the “health care area”?
all surfaces in the health care setting outside the patient zone
What are the key 5 moments for hand hygiene?
- BEFORE touching a patient
- BEFORE clean/aseptic procedures
- AFTER a body fluid exposure risk
- AFTER touching a patient
- AFTER touching a patients surroundings
What are the three things to avoid prolonged hand contamination?
- use the appropriate technique
- use an adequate quantity
- use for recommended length of time
Do gloves take the place of hand hygiene?
NO
- gloves neither alter nor replace the performance of hand hygiene
- Gloves should be removed and hand hygiene performed when indicated by the 5 moments of hand hygiene and clean gloves put back on
If medical gloves don’t take the place of hand hygiene, then what are the 2 reasons we use them?
- reduce risk of contamination of health-care workers hands
- reduce risk of germ dissemination to the environment and from worker to patient/ patient to worker/ patient to patient
What are the order of the 6 parts of the chain of infection?
- ) Harmful germ spread by contact (MRSA, Norovirus, C.diff)
- ) Hide/Grow/Multiply (GI tract, Nose, Wound)
- ) Way Out (Nose, Skin, Rectum, Urine)
- ) Going Mobile (HCW Hands, Surfaces, Equipment)
- ) Way In (Nose, Mouth, Wound, Devices)
- ) Next Person At Risk
What are standard precautions?
-Group of infection prevention practices applied during care of ALL individuals, regardless of suspected or confirmed infection status, in any health care setting.
Standard precuations assume that _____ blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious microbes.
ALL
What are the 6 elements of standard precautions?
- Hand Hygiene
- PPE (Personal Protective Equipment)
- Resident Placement (single resident rooms, cohorting)
- Respiratory Hygiene/ Cough Etiquette
- Safe Injection Practices
- Textiles and Laundry Handling
What PPE to wear and when?
- PPE usage is based on the type of task being performed.
- Also whether or not anticipating contact with blood, and/or body fluids, or pathogen exposure
We wear gloves when there is any anticipation of contact in what 5 instances?
- ) Blood or body substances
- ) Mucous membrane
- ) Non-intact skin
- ) Indwelling device insertion site
- ) Handling potentially contaminated items
We wear gowns when there is anticipation of contact in what 3 instances?
- ) Procedures likely to generate splashes, sprays, or droplets of blood and body fluids
- ) When in contact with non-intact skin
- ) Handling fluid containers likely to leak or spill when moved
Transmission-based Precautions are specific practices added to ________ precautions when the spread of infection or organisms is not completely stopped using _________ precautions alone.
- standard
- standard
What are the 3 main kinds of Transmission-based Precautions?
- Contact Precautions
- Droplet Precautions
- Airborne Precautions
What is the goal of contact precuations?
Prevent transmission of infectious pathogens that are spread by direct or indirect contact with a resident or their environment
Illnesses requiring contact precaution include, but are not limited to:
- uncontained excessive wound ________
- uncontained fecal or urine __________ or other body fluids
- infection or colonization with MDROs (multi-drug resistant organisms) or other epidemiologically significant organisms
- drainage
- incontinence
For contact precaution strategies, in addition to standard precautions care providers should wear _______ and _______.
gloves and gowns
In addition to wearing gloves and gowns for contact precaution strategies, you should ensure proper _________ and _________ care.
environment and equipment
- use disposable equipment or equipment dedicated to that patient when possible
- clean and disinfect resident room (at least daily) with a focus on high-touch surfaces
Contact precaution strategies also include assessing _______ placement (single room, cohort, existing roommates) and establishing policies for movement of resident outside of the room.
resident
What is the goal of droplet precautions?
Prevention of transmission of infectious pathogens that are spread to others by speaking, sneezing, or coughing
Should care providers be wearing masks and gloves when interacting with patients on droplet precautions?
Yes
What is the goal of airborne precautions?
Prevention against transmission of airborne pathogens
Airborne transmission occurs through the dissemination of either _________________ or _______________ that contain an infectious agent.
- airborne droplet nuclei
- dust particles
What should care providers wear when interacting with patients on airborne precautions in addition to standard precautions?
Masks and respirators (N95)
Patients on airborne precautions should be placed in an ____________________ (AIIR) which is a negative pressure room.
Airborne Infection Isolation Room
EVALUATION/DIAGNOSIS AND ASSESSMENT
EVALUATION/DIAGNOSIS AND ASSESSMENT
Why do we document?
- To serve as a record of patient care
- To convey our unique body of knowledge and our practice
- To communicate among different providers
- To be used for policy or research purposes
- To reflect appropriate provision of care in accordance with local, state, and federal regulations
- To record the episode of care of the patient/client
Insurance reports consistently indicate error rate for PT services primarily due to _________ problems.
documentation
Of the top 20 list of services with insufficient documentation, 3 were from PT, what are they?
- Therapeutic Exercise (97110) - $33 million
- Manual Therapy (97140) - $12 million
- Therapeutic Activities (97530) - $10 million
Reasons for denial include:
- No documentation for date of service
- ___________ documentation
- Documentation not understood due to ___________
- Goals are not written as _________ outcomes
- Medical necessity is not identified clearly
- Does not support the billing (coding)
- Does not demonstrate __________
- Does not demonstrate ________ care
- incomplete
- abbreviations
- functional
- progress
- skilled
- The _________ _________ list developed by the PT may include several conditions.
- Is it always possible to come to an immediate decision about a medical diagnosis? If not, what would the PT consider?
- differential diagnosis
- No, consider the problems that might explain the signs and symptoms
What is the physical therapist’s diagnosis guided by?
Patient/client response to intervention
What is a medical diagnosis?
The anatomical, biochemical, physiological, or psychological derangement
A medical diagnosis is a _______ or _________ based diagnostic label that can be useful in identifying necessary health care services or prevention methods.
disease or pathology
What is a physical therapy diagnosis?
The primary dysfunction toward which the physical therapist directs treatment
What may be a physical therapy diagnosis for these 2 medical diagnosis:
- Lumbar herniated disc
- CVA
Lumbar Herniated Disc
-Right-sided lower extremity radiculopathy centralizing with repeated extension
CVA
-Left-sided hemiplegia – 3 on the Modified Ashworth Scale, moving with a flexion synergy in UE
What is primary diagnosis?
Condition established to be chiefly responsible for patient to seek medical care
What are some examples of primary diagnosis?
- Total knee replacement
- Patellofemoral pain syndrome
- CVA
What is secondary diagnosis?
Any additional conditions that affect patient care
What are some examples of secondary diagnosis?
- Patient being treated s/p TKA with hypertension
- Patient with patellofemoral pain syndrome with history of MS
- Patient being treated s/p CVA with history of heart disease and cancer
The assessment is based on the information gathered from the ________ and _____________.
- history
- tests and measures
For an assessment, a PT must determine what 3 things?
- ) Is PT appropriate
- ) Do they need consultation with another health care provider in conjunction with PT
- ) Is intervention by a PT indicated or do they need to be referred to another health care professional
- An assessment interprets data from ________ and _________ sections using sound clinical judgement.
- Should we introduce new subjective or objective data?
- subjective and objective
- NO
Use the ____ model to link medical and physical therapy dx with impairements, activity limitations, and participation restrictions.
TIE THE PIECES TOGETHER
ICF
Where do a majority of users of your notes go to find out why the patient requires physical therapy services?
Assessment
What are the 6 parts of the ICF model?
- Health Condition
- Body Functions and Structure
- Activity
- Participation
- Environmental Factors
- Personal Factors
Examples of Body Functions and Structure?
- ROM
- Strength
- Balance
- Cognition
Examples of Activity Limitations?
- ADLs
- Functional Mobility
- Learning
Examples of Participation Restrictions?
- Work Activities
- Community Activities
- Leisure Activities
- Relational Activities
Examples of Personal Factors?
- Age/Gender
- Coping Styles
- Education/Profession
- Past Experiences
Examples of Environmental Factors?
- Social Attitudes
- Stress
- Physical Space
- Legal/Social Structures
Assessment:
- Should clearly outline the _____ for physical therapy services.
- Simply reporting patient has experienced a “decline in function” or “patient improving” is ___ enough.
- Include details you want highlighted to your patient’s referral source or anyone using the note to make a decisions.
- Include recommendations and actions taken to address concerns.
- Conveys professional judgment for predicted ________ outcome and the required duration of services to obtain this __________ outcome.
- NEED
- NOT
- functional, functional
Can an assessment change?
Yes, based on new or changing information
Therapy services are considered reasonable and necessary when what conditions are met?
- The services are consistent with the nature and severity of the illness, injury, and medical needs.
- The services are specific, safe, and effective treatment for the condition according to accepted medical practice.
- There should be a reasonable expectation that observable improvement in functional ability will occur.
- The services do not just promote the general welfare of the beneficiary.
Document complications and safety issues as a result of the patient current status. What are some examples?
- Fall Risk
- Reduced Mobility - increased risk for further complications
- Inability to complete tasks ie. ADLs
Services must be at a level of complexity that it requires physical therapy services to safely and effectively perform and progress interventions. A therapist’s skill may also be required for _______ reasons.
safety
Justifying physical therapy services also requires demonstrating __________.
progression
When demonstrating progression, we document _______ as compared to current function. We also use percentages, levels of assistance or function but make sure that they are _______ understood. Finally, we use __________ outcome measures.
- previous
- easily
- standardized
JOINT MOBILIZATIONS
JOINT MOBILIZATIONS
Injury to a joint or structures surrounding a joint will often lead to what 3 things?
- Pain
- Loss of Motion
- Excessive Motion
Joint loss of motion could be due to what reasons?
- Pain and muscle guarding
- Joint hypomobility
- Joint effusion
- Contractures or adhesion in joint capsule or supporting structures
- Combination
What are the objectives of manual therapy?
- Pain modulation
- Address tissue extensibility
- Address muscle guarding
- Peripheral effects (improve circulation, fluid/waste uptake, improve healing)
- Improve tolerance for other interventions
There are many different frameworks (Maitland, Kaltenborn, Mulligan, etc.) and the effectiveness should be assessed via _____ _______.
test re-test
-have patient do 5 squats, do joint mobs, have them do 5 squats, ask if better/worse/same
Should we assess/re-assess every time?
Yes, to make sure the joint mobilizations we are doing are still needed (maybe their pain was gone after visit 2 joint mobilizations and were on visit 6).
We perform the assessment in the _______ position of the joint and assess both ________ and _______ of movement.
- resting
- quality and quantity
When assessing joint mobility, what 3 things are we assessing?
Gross Quantity of Movement -hypomobile, normal, hypermobile Quality of Movement (End-Feel) -firm, hard, empty Provocation -painful, painless
Joint Mobilizations are manual therapy techniques involving movement of articulating surfaces with the intention of doing what?
- Regaining ROM
- Improving joint capsule extensibility
- Regaining normal distribution of forces on a joint
- Reducing pain
- Lubricating joint surfaces
- Providing nutrition to joint structures
Should we do anything after performing joint mobilizations?
Yes, do something active to use the “new” ROM
What are the absolute contraindications to performing joint mobilizations?
- Malignancy
- Infectious arthritis
- Joint fusion
- Joint fracture
- Practitioner lack of ability
- Neurological deterioration
- Upper cervical spine instability
- Cervical arterial dysfunction
What are the relative contraindication to performing joint mobilizations?
- Excessive pain or swelling
- Arthroplasty
- Hypermobility
- Osteoporosis
- Spondylolisthesis
Joint mobilization biomechanical effects?
- Motion improvement
- Positional improvement
- Increase joint capsule extensibility
Joint mobilization nutritional effects?
- Synovial fluid movement
- Improve nutrient exchange
Joint mobilization neurophysiological effects?
- Stimulates mechanoreceptors to inhibit pain impulses
- Gate control theory
- Descending pathway inhibition theory
- Peripheral inflammatory modulation
3 regions of the stress strain curve?
- Toe region
- Elastic region
- Plastic region
Compression is the ___________ of joint surfaces; force is ___________ to joint plane.
- approximation
- perpendicular
Traction/Distraction is the _________ of joint surfaces; force is ___________ to joint plane.
- seperation
- perpendicular
Gliding is a force direction __________ to the joint surface.
parallel
How many distraction joint mobilization Grades are there?
- Grade I = piccilo
- Grade II = slack
- Grade III = stretch
How many joint glide mobilization Grades are there?
- Grade I = first 25%
- Grade II = 25%-75%
- Grade III = 50%-100%
- Grade IV = 75%-100%
- Grade V = joint manip
What joint glide mobilization grades are used for pain and muscle guarding?
Grade I and II
What joint glide mobilization grades are used for stretching joint capsule and associated structures?
Grade III and IV
Grade V joint glide mobilizations are often referred to as what?
Joint manipulation (high velocity thrust technique)
What are the 2 other joint mobilizations other than distractions and oscillation mobilizations?
- Sustained hold mobilizations
- Mobilization with movement
Sustained hold mobilizations can target both ___________ and ______.
joint mobility and pain
If performing sustained hold mobilizations for pain, we will be holding from _______ range to _____ range.
beginning to mid
If performing sustained hold mobilizations for joint mobility, we will be holding at _____ range.
end
How do you know what direction to push for joint glides?
Convex/Concave Rule
Joint positions:
- Resting position used for assessment, acute stage, during grade __ and __ oscillations.
- When attempting to improve ____ (grades III and IV) should place joint at end ROM if tolerable
- One half of joint should be _______, while the other half is _______.
- I and II
- ROM
- stabilized, mobilized
Therapist position:
- Both stabilizing and mobilizing hands should be as close as possible to the _________
- Clinician’s hands should make ________ contact with patient’s body
- Arm should be in-line with direction you want to mobilize
- joint line
- maximum
Oscillation mobilizations are - seconds and typically have - sets for __-__ seconds each.
- 1-3 seconds
- 1-5 sets
- 15-60 seconds
Sustained hald mobilizations are typically - sets for - seconds each. They are also more commonly used to treat ____.
- 1-5 sets
- 5-30 seconds
- ROM
Techniques to joint mobilizations:
- Allow _______ to assist when possible
- Your body and the mobilizing part should act as one unit as much as possible
- Body ________!!!
- When possible your forearm should align with the intended direction of your force
- ________ afterwards
- Stop for the day when a large improvement has been obtained or when improvement ceases
- gravity
- mechanics
- reassess
Grade I and II mobilizations direction _____ important as not stretching the joint capsule. Perform grade I and II in direction which initially caused their pain. Often done in ___________ position.
- less
- open pack (resting)
Deciding Which Direction To Perform A Joint Glide:
- ) Determine what motion you want to improve and the direction of the roll (ie hip extension)
- ) Determine what joint you are going to mobilize (ie ___ joint)
- ) Determine which part of the joint you are going to mobilize which part is going to be stationary (ie femur=________, acetabulum=__________)
- ) Determine if bone mobilizing is convex or concave (femur=______)
- ) Convex on concave=mobilize opposite direction as roll; if concave on convex=mobilize in same direction as roll
- ) If tolerated should mobilize at the ___ range (where restriction likely is)
- coxofemoral (hip) joint
- femur=mobilizing, acetabulum=stationary
- convex
- end
Mobilization with Movement (MWMs) are typically combined ______ and ______ joint mobilization
active and passive
What is the golden rule of MWMs?
Should be painless, if pain occurs either need to change direction of force, correct pressure, or not use MWMs
What is the theory behind MWMs?
Bony positional faults contribute to painful joint restrictions and MWMs help to correct the bony positional faults.
What are the 3 guidelines to follow for MWMs?
- should be pain free
- apply 10 times before reassessing joint motion
- overpressure should be applied at end range of AROM
What direction of joint glide would you perform in non-weight bearing to improve ROM in the following areas:
- Ankle dorsiflexion
- Tibiofemoral flexion
- Radiocarpal extension
- Ankle DF = Posterior Glide
- Tibiofemoral Flexion = Posterior Glide
- Radiocarpal Extension = Anterior Glide
What grade(s) of joint mobilization glides would you want to perform for the following:
- GH hypomobility without pain = ____________
- GH pain without hypomobility = _____________
- GH hypomobility with pain = ______________
- Grade III or IV
- Grade I or II
- Grade I or II before and after Grade III and IV
What are working to improve if the following is performed:
- Grade III GH joint distraction?
- Grade II inferior patellofemoral mobilization?
- Grade III anterior hip mobilization?
- Grade III posterior radiohumeral mobilization?
- Improve general mobility of GH joint
- Reducing pain or muscle spasms
- Improve hip extension and ER
- Improve radiohumeral extension
