Week 2- Documentation Prognosis, Documentation Plan of Care, Communication: SBAR, E-Stim Basics, E-Stem Types/Uses Flashcards
1
Q
DOCUMENTATION: PROGNOSIS
A
DOCUMENTATION: PROGNOSIS
2
Q
What is prognosis?
A
Predicted optimal level of improvement in function and amount of time needed to reach that level.
3
Q
The prognosis is established after the _________ is determined and is crucial in the development of the _____.
A
- diagnosis
- POC (Plan of Care)
4
Q
What are the 2 main things that must be included in a prognosis?
A
- ) Predicted level of improvement
2. ) Time needed to reach said level of improvement
5
Q
A prognosis must also include a discussion of _______ likely to influence prognosis to justify your reasoning for determining the prognosis.
A
factors
6
Q
What are 6 things that affect prognostic considerations?
A
- ) Severity
- ) Complexity
- ) Acuity of Pathology or Pathophysiology
- ) Impairements in Body Function and Structures
- ) Activity Limitations
- ) Participation Restrictions
7
Q
What are examples of complexity when looking at prognostic considerations?
A
- comorbities
- pre-existing conditions
- social and emotional status
8
Q
Factors That Can Influence Prognosis:
- Age
- Motivation/Patient __________
- Prior activity level
- Home support
- Cognitive/mental status
- Comorbidities
- Anatomical changes__________ to dysfunction
- Health status
- Psychosocial and ___________ factors
- Availability to resources
- Acute vs _________ problem
- Concomitant conditions
- Severity of the current condition/level of impairment
A
- compliance
- secondary
- socioeconomic
- chronic
9
Q
Do acute or chronic problems have better prognosis?
A
Acute
10
Q
What model do we use to help determine prognosis?
A
ICF model
11
Q
Prognosis Examples:
1.) “Patient demonstrates significant deficit in quad strength and activation”. What might be a likely conclusion based off this information?
2.) “Patient highly motivated to return to their sport coupled with the fact that the patient was healthy and active prior to injury”. What might be a likely conclusion based off this information?
A
- ) Likely to conclude that regaining full quad strength/control will exceed normal or expected timeframe.
- ) Likely to determine that the patient will achieve predicted optimal level of function at an accelerated rate.
12
Q
Where is the prognosis documented in the initial evaluation?
A
POC (Plan of Care) or Assessment
13
Q
When documenting prognosis it is important to make an ______ statement (excellent, good, fair, poor) regarding the patient’s capacity to improve to the level you have designated as their predicted optimal level of function.
A
explicit
14
Q
- In documenting a prognosis it is important to include the _______ regarding why you are making this judgement as well as a ________ of the factors influencing the prognosis.
- Why is this important?
A
- details
- discussion
-Justifies the need for skilled physical therapy.
15
Q
Documentation: Prognosis
- Need to include _____________ potential
- Documented in the ______ or __________
- Typically a ____-word statement
- However, the statement needs to be sustained by your ___________ for coming to this conclusion
A
- rehabilitation
- POC or Assessment
- one
- clinical reasoning
16
Q
Is this a good example of a proper prognosis?
“The patient demonstrates excellent prognosis and rehab potential.”
Why or why not?
A
-No, does not have clinical reasoning as to why they have an excellent prognosis and why they have potential for rehab.
17
Q
DOCUMENTATION: PLAN OF CARE
A
DOCUMENTATION: PLAN OF CARE
18
Q
What is the purpose of the POC (Plan of Care)?
A
Specifies general interventions to be used and anticipated frequency and duration of physical therapy visits.
19
Q
What are the 4 components of the POC?
A
- ) Specific goals
- ) Predicted level of optimal improvement/ anticipated discharge plans
- ) General interventions to be used
- ) Proposed duration and frequency
20
Q
Our goals should include ______ and _____ term goals. We should apply the ____ model to goal writing. Finally, goals must be ______-centered, objective, measurable, functional and include a time element for achieving the goal.
A
- short and long-term
- ICF
- patient
21
Q
It is IMPORTANT to relate goals back to _________.
A
function
22
Q
What are the 5 criteria for goals?
A
- Patient/client centered
- Objective
- Measurable
- Functional
- Time-dependent
23
Q
Goals should be directly related to impairments, ______ limitations and _______ restrictions.
A
- activity
- participation
24
Q
If you did not measure a specific characteristic, can you set a goal for it?
A
No
25
What would be a better example of this goal?
| "Improve active shoulder flexion ROM by 20 degrees."
The patient will demonstrate improved active shoulder flexion range of motion by 20 degrees to allow patient to reach overhead shelf in the bathroom in 2 weeks.
26
When do we start our planning for discharge?
Day 1
27
Where is the predicted level of optimal improvement documented?
Assessment or POC
28
It is important to also list additional details regarding discharge plans for your patient including things such as what?
- Recommendations for transitioning to an alternative setting at DC
- Coordination with other team members required for pt education
29
POC also involves listing specific ___________ to be used.
interventions
30
Interventions implemented need to be consistent with the ________ and _________ of the patient.
- diagnosis
| - prognosis
31
It is also appropriate to indicate how the intervention is intended to be _________.
delivered
- PT/PTA team
- By a PT other that the evaluating PT
32
Interventions should be specifically chosen for the patient based on the impairments, ______ limitations, ___________ restrictions and contextual factors identified for your specific patient.
- activity
| - participation
33
Factors Influencing the Selection of Interventions:
- Chronicity/severity of the condition
- Level of current impairment/probability of prolonged impairment of body functions/structures
- _______ limitations
- _________ restrictions
- Living environment
- Multisite or multisystem involvement
- Overall physical function and health status
- Potential destination at conclusion of care
- Preexisting systemic conditions or diseases
- Social supports
- _________ of the condition
- Activity
- Participation
- Stability
34
Lastly, a POC involves the proposed _________ and __________.
- duration
| - frequency
35
Both duration and frequency may be estimated by taking what into consideration?
- setting you practice in
- capacity of your patient to participate in the POC
- patient transportation needs
- limitations mandated by 3rd party payers
36
Who is important to include in the decision of duration and frequency of POC?
- patient
| - family
37
Modifications to the POC require a _____________ to be performed.
reevaluation
38
What 3 things constitute a change in status?
- patient's function has diminished
- patient's function has not changed
- patient's function has improved
39
What is performed to evaluate progress and to modify or redirect intervention?
Reexamination
40
What are some reasons to perform a reexamination?
- Unanticipated change in the patient's status
- Failure to respond to PT intervention as expected
- The need for a new POC and/or time factors based on state practice act or other requirements
41
What are the 4 components of the reexamination?
1. ) Clinical impression or diagnosis
2. ) Objective reassessment of tests and measures and outcome tools
3. ) Goal status
4. ) Evaluation
42
EFFECTIVE AND SAFE COMMUNICATION: SBAR
EFFECTIVE AND SAFE COMMUNICATION: SBAR
43
- Hospital medical errors are the _____ leading cause of death in the United States; upward of 700 people die per day due to medical errors.
- Communication failure has been found to be the root cause in nearly __% of these deaths.
- third
| - 70%
44
What are some communication barriers in healthcare?
- lack of structure and standardization for communication
- the existance of cultural differences in authority, gender, and race
- healthcare team members may have different communication styles
45
What does SBAR stand for?
S- Situation
-What is the immediate problem/situation?
B- Background
-What is the relevant background to the issue/problem?
A- Assessment
-What are your conclusions about the present situation?
R- Recommendation
-What can be done to correct the problem?
46
SBAR creates a common ________ as well as a format for discussion and partnerships via collaborative communication.
language
47
_____ provides effective and efficient ways to communicate and also offers a simple way to standardize communication by using 4 common elements.
SBAR
48
What preparation is needed to communicate with SBAR?
- gather relevant info
- formulate thoughts in a concise manner
- make sure your message is clear
49
ELECTRICAL STIMULATION: THE BASICS
ELECTRICAL STIMULATION: THE BASICS
50
Goals and Indications for E-Stim:
- _____ modulation
- Decrease muscle spasm
- Improve ____
- Muscle re-education
- Improve muscle strength/reduce _______
- Wound healing
- Edema reduction
- Stimulate denervated muscle
- Pain
- ROM
- atrophy
51
What are the contraindications for performing E-stim?
- Anywhere in the body for someone with a pacemaker or other electronic medical device (insulin pump)
- Over carotid artery, thrombosis, eyes, phrenic nerve, pelvis and/or low back in pregnant women
- Transcerebrally
- In presence of active bleeding or infection
- Over superficial metal implants
- Over malignant tumors
- Over pharyngeal or laryngeal muscles
- Motor-level stimulation in conditions that prohibit motion
52
What are the precautions for performing E-stim?
- Cardiac disease
- Impaired mentation
- Impaired sensation
- In areas of skin irritation or open wounds
- In patient with uncontrolled hypotension or hypertension
- Bleeding disorders
53
- Like charges _____ while opposite _______.
| - Can charges be transferred from one object to another?
- repel, attract
| - Yes
54
- What is polarity?
- What is cathode?
- What is anode?
- polarity= net charge of an object
- cathode= net negativity
- anode= net positivity
55
What is voltage?
Driving force that moves electrons; force of attraction or repulsion (amplitude)
56
What is amperage/current? What is it measured in?
- Rate of flow of electrons
| - milliamps (mA)
57
What is the equation for Ohm's law and what does it describe?
- I=V/R
- Expresses the relationship between amperage/current (I), voltage (V), and resistance (R). The current is directly proportional to voltage and inversely proportional to resistance.
58
What parts of the body provide increased resistance to current flow?
- Skin
- Hair
- Fascia
- Ligament
- Callus
- Fat
- Bone
- Tendon
- Scar
59
If resistance increases, what must happen to the voltage in order to maintain the same current flow? What can this cause in the patient?
- Voltage must increase to counter increased resistance
| - Can lead to discomfort and possible burns
60
Use the _______ electrode that will selectively stimulate the target tissue.
largest
61
What is a monophasic current?
- unidirectional flow of charged particles
| - one pad to the other
62
What is a biphasic current?
- bidirectional flow of charged particles
| - bounces back and forth between pads
63
What is a direct current?
- uninterrupted unidirectional flow
- one pad to the other
- type of monophasic current
64
What is a alternating current?
- uninterrupted bidirectional flow
- bouncing back and forth between pads
- type of biphasic current
65
What is the most common type of current used?
Pulsed current
66
Pulsed current can be either ___________ or __________ that periodically ceases for short time period.
- unidirectional (monophasic)
| - bidirectional (biphasic)
67
What are the 3 values that a pulsed current will have?
- frequency: pulses/second (pps) or beats/second (bps)
- pulse duration: how long each pulse lasts (µsec)
- amplitude: voltage of individual pulses
68
Can we tolerate constant or pulsed currents more?
Pulsed currents- allow for short breaks between
69
Electrophysiology:
- What is the RMP for neuronal cells?
- What is the RMP for skeletal muscle cells?
- Gradients are maintained through what leak channels?
- Electrical stimulation leads to an influx of ___, causing reduction of RMP leading to DEPOLARIZATION of the membrane.
- Results in ___________.
- (-70mV)
- (-90mV)
- Na+, K+
- Na+
- action potential
70
What happens to the action potential of a alternating/direct current?
-Voltage stays on causing AP to remain depolarized.
71
Characteristics of ES Necessary to Initiate Excitable Cell Depolarization:
- Amplitude/intensity of the stimulus must be ___________ to cause the membrane potential to be lowered sufficiently to reach threshold levels.
- Duration of stimulus must be _____________ to produce depolarization of the cell membrane
- Rate of rise of the current peak of the intensity of the ES must be ___________ to prevent accommodation (adjustment of the membrane to stimuli to prevent depolarization)
- great enough
- long enough
- rapid enough
72
Electrothermal effects of E-Stim:
- Heat is created by ________ and _______ of particles moving through the material.
- Amount of heat produced depends on _______ of the current.
- friction and vibration
| - intensity
73
Why do we care about the electrothermal effects of E-Stim?
Patients may be at risk for burns if intensity is too high. This is why it is important to reduce resistance when possible so a lower current strength is needed.
74
Electrode size has a direct impact on current _______.
density
75
A large electrode disperses the current over a large area resulting in what?
Small current density = more tolerated by patient
76
A small electrode disperses the current over a small area resulting in what?
Large current density = less tolerated by patient
77
What would we do to increase the current density?
- increase the current
| - decrease the size of the electrode
78
Increasing current density can cause skin burns, how can we avoid this?
- Remove resistance: clean the skin
- Listen to patient perception
- Use large electrodes when possible
- Maintain good contact
- Use appropriate coupling agent if appropriate
79
What are the 3 electrode configurations?
- Monopolar
- Bipolar
- Quadripolar
80
What is monopolar electrode configuration?
One small electrode over target area, and a large electrode placed over remote area (to complete the current).
81
Monopolar configuration is the method of choice when _________ is a concern (wound healing, edema control, iontophoresis).
polarity
82
What is bipolar electrode configuration?
Both electrodes of similar size and over the target area to allow the current to bounce between the two pads.
83
Bipolar configuration is used with any waveform except ___________.
DC (direct current)
84
What are the preferred uses of bipolar configuration?
- disuse atrophy
- neuromuscular facilitation
- ROM
- spasms
- circulatory disorders
85
What is quadripolar electrode configuration?
2 electrodes from two seperate stimulating circuits positioned so the individual currents intersect with each other (IFC).
86
- The distance between electrodes influences the ______ and _______ of the current.
- It is recommended that the distance be at least ____ the diameter of each electrode.
- depth and course
| - 1/2
87
Motor stimulation is to be over the point where the motor nerve is _______ excitable.
easily
88
What are 2 common mistakes when applying electrodes?
1. ) Placing one electrode over a muscle belly and the other over a distal area without much muscle.
2. ) Placing electrodes too close together when trying to stimulate a deep muscle.
89
ELECTRICAL STIMULATION: THE TYPES
ELECTRICAL STIMULATION: THE TYPES
90
What are the goals of Neuromuscular E-stim (NMES)?
- atrophy treatment/prevention
- strengthening
- achieve synchronous firing/recruitment of motor units
91
The typical settings of NMES include ___ burst modulated waveforms.
pulsed current (PC)
92
What are the differences between voluntary and NMES muscle recruitment?
Voluntary
- muscle recruitment goes from smaller to larger motor units
- number of motor units can be altered
NMES "Artificial" Contractions
- large and small motor units are recruited together
- cannot alter number of motor units recruited
93
- What is the most common form of NMES?
| - What is it?
- Russian (Burst Modulation)
| - Variation of alternating current that is interrupted and delivered in short bursts
94
List the Typical Parameters for Russian:
-Pulse width/duration = ____-____ µsec
-Pulse frequency = ____-____ pps
On:Off time = ___sec on: ___ sec off for ___ reps
Ramp = __-__ sec up/down
-________electrode placement
-Determine treatment on number of _________ not length of time
-Amplitude = _______ contraction/tolerance
- 150-200 µsec
- 50-70 pps
- 10 sec on: 50 sec off for 10+ reps
- 1-5 sec
- Bipolar
- contractions
- maximal
95
List the Typical Parameters for NMES:
- Pulse width/Duration= ____-____ µsec
- Pulse Frequency= ___-___ pps
- On:Off time = ___sec on: ___ sec off for ___ reps
- Ramp: __-__ sec up/down
- _______ electrode placement
- Determine treatment based on number of __________ not length of time (similar to therapeutic exercise prescription)
- Amplitude = _________ contraction/tolerance
- 200-800 µsec
- 30-100 pps
- 10 sec on: 50 sec off for 10+ reps
- 1-5 sec
- Bipolar
- contractions
- maximal
96
Force output is found to ________ if current amplitude is not increased both in and between NMES treatments.
decrease
97
Shorter off time and longer on time = ________ chance for fatigue with NMES.
greater
98
Aligning 2 electrodes ______ to the direction of the muscle fibers produces greater force than a transverse configuration.
parallel
99
What is the goal of Functional Electrical Stimulation (FES)?
Type of NMES in which the electrical stimulation is utilized as an alternative or supplement to orthotic devices or braces
100
Does the peripheral nerve have to be intact with FES? Why?
- Yes, but not functioning
| - Muscle contraction only occurs from nerve firing to muscle fiber. Must be intact to cause depolarization.
101
What are two common uses for FES?
- shoulder subluxation
| - foot drop
102
What phase of gait would we want FES to help with dorsiflexion?
Swing phase
103
How is Interferential Current (IFC) characterized?
-Crossing of two currents that interfere with one another to generate an amplitude-modulated beat frequency
104
- Interferential Current is most commonly used for what?
| - Interferential Current can also be used for what?
- most commonly used for pain modulation
| - production of contraction and reduction of edema
105
With Interferential Current, we can have _________ or _________ interference. What is the difference?
Constructive Interference
-When the 2 waves are in phase, the sum of the superimposed wave is large
Destructive Interference
-Sum of the 2 waves is zero when the waves are 180 degrees out of phase
106
What is the beat frequency of Interferential Current?
Resultant frequency produced by the 2 frequencies going into and out of phase
107
List the Typical Parameters for Interferential Current:
- Wave form = _________ current amplitude modulated beats
- Pulse width/duration = ____-____ µsec
- Pulse frequency = ____-____ pps
- Duration = ___-___ min
- ________electrode placement
- Goal = _____ reduction
- Amplitude = _______ but tolerable sensation
- alternating
- 200-400 µsec
- 10-150 pps
- 10-30 min
- quadripolar
- pain
- strong
108
Is IFC more or less comfortable than equal amplitudes delivered by conventional means? Why?
More comfortable because sensory nerve fibers are receiving a lower amplitude stimulation than the "middle" area of tissue affected by the vector.
109
Are modalities effective on their own?
No, a combination with other PT treatments leads to differences in pain.
110
What is another type of pain modulation used through the activation of central inhibition of pain transmission (gate control theory)?
Conventional (High Rate) Transcutaneous Electrical Stimulation (TENS)
111
How does the gate control theory work?
- Large diameter A-beta fibers activate inhibitory interneurons located in the dorsal horn of the spinal cord, producing inhibition of smaller A-delta and C-fibers (pain fibers).
- Presynaptic inhibition of the T-cells close the “gate” and modulates pain. Gating mechanism also includes release of enkephalins which combine with opiate receptors to depress the release of substance P from the A-delta and C-fibers.
112
What is the most common mode of TENS and can it be applied during acute or chronic phase of pain?
- Most common = High Rate TENS
| - Both acute and chronic
113
List the Typical Parameters for High Rate TENS:
- Wave form = typically asymmetrical ________
- Current = continuous, pulsatile, or _____
- Amplitude = comfortable tingling sensating; no muscle response
- Pulse width/duration = ____-____ µsec
- Pulse frequency = ____-____ pps
- Duration = ___-___
- Onset of pain relief = relatively _____
- Duration of pain relief = __________
- biphasic
- burst
- 50-100 µsec
- 50-80 pps
- 10 min- several hours
- fast
- temporary
114
What is a less common mode of TENS that modulated pain through descending pathways generating endogenous opiates?
Acupuncture-like (Low Rate) TENS
115
How does the descending pathway theory work?
- Noxious stimuli generate endorphin production from pituitary gland and other CNS areas
- Endogenous opiate-rich nuclei, periaqueductal gray matter (PAG) in midbrain and thalmus are also activated by noxious stimulus leading to presynaptic inhibition of the release of substance P from the A-delta and C-fibers
116
What is the less common mode of TENS and can it be applied during acute or chronic phase of pain?
- Less common = Low Rate
| - chronic
117
List the Typical Parameters for Low Rate TENS:
- Wave form = typically asymmetrical ________
- Current = continuous, pulsatile, or _____
- Amplitude = strong, but comfortable rhythmic muscle twitch
- Pulse width/duration = ____-____ µsec
- Pulse frequency = ____-____ pps
- Duration = ___-___ min
- Onset of pain relief = ___-___ min
- Duration of pain relief = __________
- biphasic
- burst
- 150-300 µsec
- 1-5 pps
- 20-40 min
- 20-40 min
- long lasting >1 hour
118
Does Low Rate or High Rate TENS produce muscle twitch?
Low Rate
119
What are the 3 main modalities for pain relief?
- High Rate TENS
- Low Rate TENS
- Interferential Current (IFC)
120
What is another form of TENS used to provide rapid-onset, short term pain relief during painful procedures such as wound debridement, passive stretching, and joint mobs?
Brief Intense TENS
121
List the Typical Parameters for Brief Intense TENS:
- Wave form = typically asymmetrical ________
- Current = continuous, pulsatile, or _____
- Amplitude = patient's tolerance
- Pulse width/duration = ____-____ µsec
- Pulse frequency = ____-____ pps
- Duration = ___ min
- Onset of pain relief = relatively _____
- Duration of pain relief = __________
- biphasic
- burst
- 50-250 µsec
- 80-150 pps
- 15 min
- fast
- temporary (30-60 min)
122
What is another form of TENS that combines characteristics of both high and low rate TENS by stimulation of endogenous opiates, but the current is more tolerable than low rate TENS?
Burst-Mode TENS
123
List the Typical Parameters for Burst-Mode TENS:
- Wave form = typically asymmetrical ________
- Current = continuous, pulsatile, or _____
- Amplitude = comfortable, intermittent paresthesia
- Pulse width/duration = ____-____ µsec
- Pulse frequency = ____-____ pps delivered in packets or BURSTS __-__ pps
- Duration = ___-___ min
- Onset of pain relief = ___-___ min
- Duration of pain relief = __________
- biphasic
- burst
- 50-200 µsec
- 50-100 pps, 1-4 pps
- 20-30 min
- 20-40 min
- long lasting (hours)
124
What is another form of TENS that noxiously stimulates trigger point or local area of pain such as tendonitis?
Hyperstimulation (point stimulation) TENS
125
List the Typical Parameters for Hyperstimulation TENS:
- Wave form = typically asymmetrical ________
- Current = continuous, pulsatile, or _____
- Amplitude = maximum tolerance should be uncomfortable
- Pulse width/duration = ____-____ µsec
- Pulse frequency = ____-____ pps
- On/off cycle = ___-___ sec increments
- Duration = ___-___ min
- Onset of pain relief = ___-___ min
- Duration of pain relief = __________
- biphasic
- burst
- 150-300 µsec
- 1-5 pps
- 15-30 sec increments
- 15-20 min
- 20-40 min
- long lasting
126
What is the purpose of amplitude modulation?
- Improve patient tolerance
| - Limit adaptation
127
What is the purpose of modulation mode TENS?
Method of modulating parameters of any of the TENS modalities to prevent adaptation due to constant stimulation by altering the frequency/intensity by ≥10%.
128
- What are the 2 types of currents used for would healing?
| - Are they both monophasic or biphasic?
- Low Intensity DC (micro-current)
- High-Volt Pulsed Current (HVPC)
-Monophasic (polarity matters)
129
Low Intensity DC is used for tissue repair and wound healing, does it stimulate sensory/motor nerves?
No
130
High-Volt Pulsed Current (HVPC) is used for tissue repair and wound healing, but also can be used for what?
Pain
131
How does E-Stim impact wound healing?
Can help to either attract cells and repel cells away from an injury.
132
List the Typical Parameters for Wound Healing E-Stim:
- Current = ___________
- Amplitude = comfortable tingling, sensation, paresthesia, no muscle response
- Pulse width/duration = ____-____ µsec
- Pulse frequency = ____-____ pps
- Mode = _________
- Duration = ___-___ min
- Current type = ____-_____ Pulsed Current or Continuous ___-____ Direct Current
- monophasic
- 20-100 µsec
- 50-200 pps
- continuous
- 20-60 min
- High-Volt / Low-Volt
133
What is the goal of Iontophoresis?
- Treating inflammation
- Application of a continuous DC to transport medicinal agents throught the skin or mucous membrane for therapeutic purposes.
134
List the Typical Parameters for Iontophoresis:
- Wave form = _________
- Amplitude maximum intensity = _________
- Electrode placement = positive (______) or negative (________) electrode will depend on the medicinal agent being utilized
- direct current (DC)
- 4-5 mA
- anode, cathode
135
What are some other less common uses of E-Stim?
- decrease muscle spasm: types of NMES alter on/off time to achieve goal
- edema reduction: NMES muscle pump to increase lymph and venous flow
- denervated muscle: activate muscle membrane (sarcolemma) instead / CONTROVERSIAL
136
What parameters do we need to know?
-Need to know for each E-stim whether it is bipolar or monopolar and where electrodes go, theory behind how they work, when to utilize them
- Need to know full parameters for:
- NMES
- High Rate TENS
- Low Rate TENS
- IFC
