Physical Therapy Patient Management - PDF

Patient Management Model, ICF and Clinical Road Map Putting it All Together for Patient Exam 1 Patient Management Model Review § Patient Examination occurs during the examination portion of the PMM § During the examination, the physical therapist condu...

Patient Management Model, ICF and Clinical Road Map Putting it All Together for Patient Exam 1 Patient Management Model Review § Patient Examination occurs during the examination portion of the PMM § During the examination, the physical therapist conducts tests and measures § The outcomes of tests and measures help guide the PT through the model 2 1  ICF Review § Examination relates to the body function and structure component of the ICF 3 Clinical Road Map § In this course we are focusing on the purple section of the clinical road map – the Examination 4 2  Examination § History Taking review 5 Physical Examination of Tests & Measures Remember to PAUSE & Self-Reflect after each test and measure (think about your thinking) § Am I performing test/measure adequately? § What is the finding/data from the test & measure? § What does the positive/negative finding tell you? Should I defer any future tests or measures at this time? Why? § What additional tests and measures do I need to consider/perform? Why? § How does each test & measure relate back to the initial hypotheses? 6 3  TEST & MEASURE DATA Structural Inspection (Posture, Skeletal Integrity, Integumentary Integrity, anthropometric characteristics) Task Analysis Physical Examination (community, social & civic life, education life, self-care & domestic life, of Tests & Measures work & community integration) Range of Motion (Active & Passive) Muscle Performance (strength, power, endurance, length) Coordination/Motor Function (balance, gait, mobility) Nerve (cranial & peripheral nerve, neuromotor development and sensory processing, pain, reflex integrity, sensory integrity) Joint Integrity & Mobility Others (aerobic capacity & endurance, adaptive & assistive technology, circulation, cognitive & mental function, environmental factors, ventilation & respiration) 7 Conclusion § The physical examination includes a foundational understanding of the Patient Management Model, the ICF and the Clinical Road Map § Selection of tests/measures should be based on patient history and clinical presentation § Data gathered from your tests/measures will serve as a guide for your plan of care and treatment interventions 8 4  Observations on Patient Posture and Positioning 1 Importance of Positioning § Safety § Comfort § Precautions 3 1  Dependent Positioning versus Treatment § Positioning for treatment is short lived § Dependent positioning longer term § CNS related impairments § Limb impairments § Injury, pressure, and edema 4 Precautions for Positioning § Maintain Head/Neck in Neutral § Extremities supported § Follow diagnosis specific precautions 5 2  Prevention: General Items to Avoid § Spine/Thorax o Rotation o Bending o Forward head o Chest compression § Upper extremities o Scapular abduction o Adduction and internal rotation at the GH joint § Lower extremities o Plantar flexion at the ankles o Knee flexion o Knee hyperextension o Hip adduction or internal/external rotation 6 Patient Positions § Supine § Prone § Sidelying § Semi-Fowler’s § Fowler’s § Sims’ § Trendelenberg 7 3  Supine 9 Prone 10 4  Sidelying 11 Semi-Fowler’s: 30 Degrees 12 5  Fowler’s: 60 Degrees 13 Sims’ Position (lateral recumbent) 14 6  Trendelenberg 15 Patient Postures: Wheelchairs 17 7  Patient Postures: Workplace 18 Conclusion § Understanding proper patient positioning enhances safety and patient comfort throughout the Physical Therapy Plan of Care. § Recognize when precautions and/or contraindications influence how you position a patient prior to treatment. § Understanding workplace posture/ergonomics will help you as a therapist maintain career longevity. 19 8  Safe Patient Handling 1 Safety Recommendations § Prevent medical errors: correct person, place, time… § Hand hygiene and personal protective equipment § Proper and safe equipment § Environment safe from hazards § Proper body mechanics § Never leave patient unattended § Proper training and competent personnel 3 1  Preparation for Patient Handling § Scan the § Secure the surfaces environment § Communicate § Scan the patient § Coordinate § Scan the situation § Assure appropriate § Assure appropriate body mechanics draping § Position patient safely § Gather equipment § Assure items are § Position and prepare within reach the surfaces 4 Body Mechanics § Consider proper body mechanics when handling patient 5 2  Gait/Transfer Belt § Safety during mobility tasks § Teeth § Positioned at waist or above as needed § Not a substitute for body mechanics 6 Applying the Gait Belt § Communicate with your patient § Put the belt around the patient § “Teeth” first § Snug not tight 7 3  Gripping a Gait Belt § Underhand grip § Usually behind the patient 8 Summary § Safe Patient Handling begins with preparation § Scan environment, patient, situation § Check lines/tubes, equipment § Set up equipment including wheelchairs § Proper body mechanics § Gait belt considerations 9 4  References § Johansson C, Ramsey C, Chinworth SA. Mobility in Context: Principles of Patient Care Skills, 3rd ed. FA Davis; 2022. ISBN-13: 978-1719642866 § Pierson FM, Fairchild SL, O SRK. Pierson and Fairchild’s Principles & Techniques of Patient Care. Seventh edition. Elsevier; 2022. Chapter 4, Body Mechanics, pp 69-82. § Gait belt demo by M. Sawtelle, 2022. § www.physiou.health 10 5  Body Mechanics for the Physical Therapist 1 Body Mechanics Introduction § Critical for safe patient handling § Longevity as a PT § Anyone involved in patient care § Conserve energy, reduce injury risk, reduce stress and strain § What in this image is going well for body mechanics, what may not be going so well? 3 1  Body Mechanics and Trunk Stabilization § Body mechanics: safe, energy conserving, efficient § Requires balance and Control § Bracing versus hollowing § Valsalva = potentially harmful 4 Two Requirements for Body Mechanics § Center of Gravity (COG) § Base of Support (BOS) 5 2  Lifting Principles § Visualize and plan § Short lever arms § Close center of gravity § Maintain gravity line § Use stabilizing muscles § Maintain normal lumbar lordosis § avoid trunk rotation and flexion § Warm up § Take your time § Direct and ensure cooperation and instructions 6 Therapist Positions for Examination Skills § Think about the test and measure you are going to perform § How much effort will it take for you to perform the technique § Position your feet in staggered stance in the direction of the motion § Avoid power stance when test and measures require the therapist to move 7 3  Lift Types § Deep Squat Lift § Power Lift § Straight Leg Lift § One-Leg Stance Lift (“Golfer’s Lift”) § Half-Kneeling Lift § Traditional Lift § Stoop Lift 8 Pushing and Pulling § Similar principles to lifting § Parallel force to line of movement § Multiple techniques for redirection § Face the object square § Straight line when possible § Arms partially flexed 10 4  Reaching and Carrying § Raise your position to an object overhead § Move object closer before reaching or carrying § Carry on waist or the back § Balance the load § When in hands, alternate hands when possible § Shoulder carry for heavy or bulky items 12 Conclusion § Body Mechanics is important for patient safety and career longevity § Understanding the position of your Center of Gravity (COG) and Base of Support (BOS) can reduce load on your spine § Preparing the environment can facilitate increased safety for you, your patients and other members of the healthcare team 14 5  Review of Systems and Systems Review 1 Objectives § Understand the Review of Systems and its part in the physical therapy examination § Understand the Systems Review and its part in the physical therapy examination 2 1  Review of Systems and Systems Review Review of Systems Systems Review § Part of history taking (subjective) § DOING something to test the system § Screening major body systems (objective) § Directs the systems review (what do you § Directs further tests and measures need to take a closer look at?) 3 Review of Systems Review of § Questions in the patient history Systems § Identify signs and symptoms beyond PT scope § Observation § Seek information relevant to major body systems Sequencing § Ask questions § Refer to other healthcare professionals as needed 4 2  Review of Systems – Major Body Systems § Cardiopulmonary system § Nervous system § Endocrine system § Musculoskeletal system § Gastrointestinal system § Integumentary system § Hematologic/lymphatic system § Genitourinary § Immune system 5 Systems Review The physical exam begins with the Systems Review § Cardiovascular: Vital signs § Integumentary and Surface Anatomy: Observation & Testing § Musculoskeletal system: Observation & Testing § Neurological system: Observation & Testing § Communication and cognition: Ability, affect, language, consciousness, orientation § Movement: Observation in context with function and performance 6 3  Gross Neuromuscular Observation 1 Neuro Screen Characteristics § Assess function of CNS/PNS § Guide for more in-depth testing § Patient specific, not all tests for all patients 3 1  Review of Systems Musculoskeletal/Neurologic § ___ Joint pain, redness, warmth, swelling, stiffness, deformity § ___ Frequent or severe headache § ___ Change in vision or hearing § ___ Vertigo § ___ Paresthesias (numbness, tingling, “pins and needles” sensation) § ___ Change in muscle tone § ___ Weakness; atrophy § ___ Abnormal deep tendon (or other) reflexes § ___ Problems with coordination or balance; falling § ___ Involuntary movements; tremors § ___ Radicular pain § ___ Seizure or loss of consciousness § ___ Memory loss § ___ Paralysis § ___ Mood swings; hallucination 4 Observation § Motor function § Fluidity of motion § Balance 5 2  Patient Subjective Reports Video receivedfrom youtube.com 6 Cranial Nerve Screen § Depends highly on patient history and review of systems § Does not need to include all 12 cranial nerves, unless….. 7 3  Coordination Screen Coordination: Dysdiadochokinesia Coordination: Heel-to-Shin 8 Reflex Screen § Absent § Present § Exaggerated 9 4  Summary § Observation is key § Patient reports and history guide the extent of screening § Usually involves coordination and reflex testing § May involve cranial nerve testing 10 References § O'Sullivan S, Schmitz T, Fulk G. Physical Rehabilitation Assessment and Treatment, 7th ed. F.A. Davis Co; 2019. ISBN-13:9780803625792 § Goodman and Snyder’s Differential Diagnosis for Physical Therapists - E-Book. Available from: Elsevier eBooks+, (7th Edition). Elsevier - OHCE, 2022. § Coordination: Dysdiadochokinesia. PhysioU. https://app.clinicalpattern.com/neurorehab/p9740/ § Coordination: Heel-to-Shin. PhysioU. https://app.clinicalpattern.com/neurorehab/p9738/ 11 5  Gross Integumentary Observation 1 Objectives § Understand techniques for safe patient handling. § Recognize typical and atypical characteristics of the integumentary system. § Demonstrate a general integumentary assessment including girth measurements 2 1  Safe Patient Handling § Standard precautions o Wash hands or sanitize hands o Gloves o Allergies to latex § Contact Precautions § Droplet Precautions 3 Review of Systems § Integumentary (Include Skin, Hair, and Nails) § ___Recent rashes, nodules, or other skin changes § ___Unusual hair loss or breakage § ___Increased hair growth (hirsutism) § ___Change in nail beds § ___Itching (pruritus) 4 2  Screening Characteristics § Color § Moisture § Palpation Characteristics § Texture § Firmness § Temperature § Elasticity § Symmetry § Shape 5 Skin Coloration 6 3  Rashes and Lesions 7 Incisions and Wounds 8 4  Edema Images from creativecommons.org; Edema photo received with permission from P. Scarborough, PT; Girth measurement photo by M Sawtelle 9 Volumetric Measurement/Displacement § Used for edema § Volumeter § Patient dips extremity into the volumeter § Water displaced = objective measure for charting § Physio U: Volumetric Measurement of the Upper Extremity 10 5  Palpation § Texture § Firmness § Turgor § Mobility § Temperature 11 Capillary Refill Capillary refill test for great toe: Main 12 6  Summary § Observation § Palpation § Quick Screens 13 References § O'Sullivan S, Schmitz T, Fulk G. Physical Rehabilitation Assessment and Treatment, 7th ed. F.A. Davis Co; 2019. ISBN-13:9780 § Pressure injury, deep tissue injury, venous wound, incision, and lymphedema images received with permission from P. Scarborough 2017. Accessed Sept 17, 2022. § Capillary Refill video by M. Sawtelle, 2022. § Goodman and Snyder’s Differential Diagnosis for Physical Therapists - E-Book. Available from: Elsevier eBooks+, (7th Edition). Elsevier - OHCE, 2022.Guide to PT Practice 14 7  Gross Musculoskeletal Screening Observation 1 Objectives § Discuss typical and atypical observations about the patient's musculoskeletal system, posture, and positioning § Understand the parts of the musculoskeletal screening observation 2 1  Components of the MSK System § Tissues § i.e. Muscle, tendon, ligament, bone § Typical Shape and Size § Major muscle groups § Hypertrophied or atrophied § Typical Length § Moves appropriately or not § Typical Appearance § Proportions, location 3 Review of Systems § Neuro-Musculoskeletal § Part of the patient history 4 2  Observation of the Musculoskeletal System § Bony contours, alignment, symmetry § Posture, position § Gross muscle groups- hypertrophy, atrophy, contours 5 Gross UE and LE ROM Screening § AROM across cardinal planes for a given joint, against gravity. § Goal: to determine if the patient has a ROM limitation that could limit their function o For example: § Bed mobility § Use of an assistive device § Grooming, getting dressed, reaching, walking 6 3  Gross UE and LE ROM Screening § Orthopedic setting: the MSK screen is part of the examination § If pain-free or as therapist desires, apply overpressure to feel quality and quantity of tissue resistance ("end feel"). § For a screen to be clear, consider o Quantity as compared to a normative value o Quality of tissue resistance- is it as expected? o Symptom production o Symmetry § If the screen is clear, it decreases likelihood that patient's symptoms arise from that joint § During lab, you will have opportunities to practice this skill 7 Gross UE and LE ROM Screening § Videos: o https://youtu.be/QX79GVeW7Uk?si=i4PvP2w50t9dSM9v o https://youtu.be/LAxI3DIWa4g?si=d7JKr5-0sq15YY1L § During lab, you will have opportunities to practice this skill 8 4  Muscle Strength Screening § Quick assessment of general level of muscle strength § Test major muscle groups § Not detailed and specific strength tests § Not a break test § Acute care versus orthopedic screening § Review: § https://www.youtube.com/watch?v=vsYJdc2xhEQ § https://www.youtube.com/watch?v=87Z-R48q-r8 9 References § Goodman and Snyder’s Differential Diagnosis for Physical Therapists - E-Book. Available from: Elsevier eBooks+, (7th Edition). Elsevier - OHCE, 2022. § https://www.youtube.com/@wendyhuddleston9304 10 5  Cardiopulmonary Observation 1 Cardiopulmonary Observation § Cardiovascular Disease is the leading cause of mortality, morbidity, and disability in the United States (CDC, 2022). § Approximately 47% of the US adult population has hypertension (Severin, 2022). § Every 10% improvement in management could save 14,000 lives (Farley et al., 2010). 3 1  How to Perform Cardiopulmonary Observation Review of Systems Subjective questions related to specific physiological systems in the body Systems Review Objective measurements that assess the physiologic systems in the body 4 Review of Systems § ___Chest pain or sense of heaviness or discomfort § ___Palpitations § ___Limb pain during activity (claudication; cramps, limping) § ___Discolored or painful feet; swelling of hands and feet § ___Pulsating or throbbing pain anywhere, but especially in the back or abdomen § ___Peripheral edema; nocturia § ___Sudden weight gain; unable to fasten waistband or belt, unable to wear regular shoes § ___Persistent cough § ___Fatigue, dyspnea, orthopnea, syncope § ___High or low blood pressure, unusual pulses § ___Differences in blood pressure from side to side with position change (10 mm Hg or more; increase or decrease/diastolic or systolic; associated symptoms: dizziness, headache, nausea, vomiting, diaphoresis, heart palpitations, increased primary pain or symptoms) § ___Positive findings during auscultation 5 2  Systems Review Objective Measurements associated with a physiological system 6 Vitals § HR § RR § BP § SpO2 7 3  Vitals are Vital https://www.aptacvp.org/-vitals-are-vital 8 Chart Information § Vitals § Labs § Comorbidities § Testing results 9 4  Lab Values 10 References § Center for Disease and Control (CDC). (2022). Leading Causes of Death. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm § Goodman and Snyder’s Differential Diagnosis for Physical Therapists - E-Book. Available from: Elsevier eBooks+, (7th Edition). Elsevier - OHCE, 2022. § “Resource Guides - Academy of Acute Care Physical Therapy.” Accessed July 9, 2024. https://www.aptaacutecare.org/page/ResourceGuides. § Severin, R. (2022). Vitals are Still Vital, Now More than Ever. https://www.apta.org/article/2022/02/22/vitals-still-vital-now-more-ever § Severin, R. (et al. 2022). Precision medicine and physical therapy: A healthy living medicine approach for the next century. PTJ. https://academic.oup.com/ptj/article/102/1/pzab253/6413905?login=true 11 5