Term
|
Definition
| Pathophysiology<-->Impairment<-->Funct. Lim.<-->Disability |
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Term
|
Definition
| International Model of Functioning Disability and Health |
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Term
|
Definition
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Term
Clinical Process /
Elements of pt. management |
|
Definition
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Term
Clinical Process /
Elements of pt. management
Examination |
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Definition
The Process of obtaining a history, performing relevant systems reviews, and selecting and administering specific tests and measures to obtain data
(Evaluation next) |
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Term
Elements of pt. management
Evaluation |
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Definition
A dynamic process in which the physical therapist makes clinical judgements based on data gathered during the examination
(followed by Diagnosis) |
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Term
Elements of pt. management
Diagnosis |
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Definition
The process and the result of evaluating information obtained from the examination, which the PT then organizes into defined clusters, syndromes or categories to help determine the most appropriate intervention strategies
(followed by prognosis) |
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Term
Elements of pt. management
Prognosis |
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Definition
Determination of the level of optimal improvement that might be attained through intervention and the amount of time required to reach that level
(Intervention follows) |
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Term
Elements of pt. management
Intervention |
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Definition
Purposeful and skilled interaction of the PT w/the pt. and if appropriate, other individuals involved in care of the pt., using various methods and techniques to produce changes in the condition that are consistent with the dx and prog.
(Outcomes next) |
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Term
Elements of pt. management
Outcomes |
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Definition
| Results of pt. management including remediation of functional limitations and disability, optomization of pt. satisfaction and primary or secondary prevention |
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Term
Standard Pxns
Lines of Defense Against Infection |
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Definition
1st line - skin
2nd line – inflammatory response
3rd line – Immune response |
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Term
Standard Pxns
Process of Transmission |
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Definition
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Term
Standard Pxns
Types of Precautions |
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Definition
Standard Precautions
Transmission Based Precautions |
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Term
Standard Pxns
Types of Standard Precautions |
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Definition
-Universal Precautions
-Body Substance Isolation |
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Term
Standard Precautions
Transmission Based Precautions |
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Definition
-Airborne Pxns
-Droplet Pxns
-Contact Pxns |
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Term
Standard Precautions
Direct Contact |
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Definition
Skin to skin contact
Physical Transfer
Contact btwn. residents or clients |
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Term
Standard Precautions
Indirect Contact |
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Definition
| Occurs when touching contaminated objects or environmental services |
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Term
Standard Pxns
Airborne Precautions |
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Definition
-Needed for aerosolized pathogens
-Some diseases can become airborne
ex. TB droplet-sometimes airborne
Handwashing
Mask (N-95)
Private room with Negative air flow. Keep door closed.
Minimize transport
Mask pt. during transport
No gown
No gloves |
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Term
Standard Pxns
Droplet Precautions |
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Definition
Handwashing
Mask if w/i 3 ft. of pt
Private room
Mask pt. during transport
No gown/gloves |
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Term
Standard Pxns
Contact Precautions |
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Definition
Handwashing
Gloves
Gown
Private or cohort room
Dedicated equipment |
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Term
Standard Pxns
Conditions for Contact Precautions |
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Definition
MRSA
VISA
VRE
Herpes simplex
Adenovirus
Infected Decubitis ulcer
C Diff
-Bugs that live outside the body for ~48hours |
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Term
Standard Pxns
Conditions for Droplet Precautions |
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Definition
Adenovirus
Diptheria
Meningitis
Some influenzas
Mumps
Pertussis
Pneumonia
Strept
etc. |
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Term
Standard Pxns
Conditions for Airborne Precautions |
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Definition
Diptheria, pharyngeal
Lassa fever
Plague
Smallpox
Varicella
Herpes Zoster
etc. |
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Term
Standard Precautions
Key Prevention Strategies |
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Definition
Prevent Infection
Dx and treat effectively
Use antimicrobials wisely
Prevent Transmission |
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Term
Standard Precautions
Handwashing |
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Definition
-Best way to protect yourself and your
patient
Methods:
-Sterile technique versus no touch
technique
Considerations:
-Glove and latex allergy
-Hospital procedures, policy and
guidelines
-Infectious Control department or
nurse |
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Term
Standard Precautions
Handwashing |
|
Definition
-Wash palms and back of hands with a strong frictional motion
-10 seconds each side
-Wash fingers and spaces between 10 seconds
-Wash wrists and 3-4 inches above with a rotary action 10-15 times
-Repeat each step to complete a two minute scrub
-Rinse well and point hands downward
-Shut facet with towel |
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Term
Standard Precautions
Medical Asepsis |
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Definition
| Practices that reduce the number and spread of microorganisms |
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Term
Standard Precautions
Surgical Asepsis |
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Definition
| Practices that keep areas and objects free of all microorganisms |
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Term
|
Definition
Blood Pressure
Heart Rate
Respirations
Temperature
(Pain is the 5th Vital) |
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Term
|
Definition
-Changes in vital signs indicate a the body’s physiological response
-Vitals must be taken before, during and
after intervention |
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Term
Vital Signs
Blood Pressure |
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Definition
-BP is highest in arteries, lower in capillaries, lowest in veins
-Systolic/Diastolic |
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Term
Vital Signs
Blood Pressure -influencing factors |
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Definition
Blood volume
Elasticity of arteries
Cardiac output
Age
Exercise
valsalva (p. 74 of Pierson) |
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Term
Vital Signs
Pulse Rate - Def |
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Definition
A wave of blood in an artery created by a
contraction of the left ventricle |
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Term
Vital Signs
Pulse Rate - Qualities |
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Definition
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Term
Vital Signs
Pulse Rate-Influencing factors |
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Definition
Age
Sex
Emotion
physical activity level
Body size
Systemic or local heat/cold |
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Term
| Vital Signs Pulse Rate-Rate, Rhythm, Volume |
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Definition
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|
Term
Vital Signs
Clinical Indicators |
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Definition
-Dyspnea
-Fatigue
-Chest pain
-Palpitations
-Cyanosis
-Intermittent Claudication
-Pedal Edema
Sample Interview/Follow-up:
What provokes it?
What alleviates it?
When does it occur?
Describe it…
Has this happened
before? |
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Term
|
Definition
Temporal
Carotid
Brachial
Radial
Femoral
Pedal
etc. |
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Term
Vital Signs
Blood Pressure-Korotkoff's Sounds |
|
Definition
I. First faint clear tapping sounds (systolic)
II. Sounds have a murmur/swish
III. Sounds become crisp and louder
IV. Sounds become muffled-soft blowing quality - diastolic
V. Sounds disappear -second diastolic |
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Term
|
Definition
-Changes in Vitals; extreme ranges of vitals
-Observations of distress
Patient report
-New equipment- I.e. IV, Monitors, Belts etc.
-Other discipline report |
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Term
|
Definition
-MD orders
-Notes: nursing, progress
-HX
-Meds
-Lab values
-Diet
-Current level of function |
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Term
|
Definition
-Imaging
-Doppler
-Scans
-Cultures
-Med Changes
Note the onset date and results of above |
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Term
|
Definition
1. Pt care record
2. Administrative mgt purposes
3. Reimbursement
4. Legal records
5. Research |
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Term
Documentation
Who looks at documentation? |
|
Definition
-Other professionals/colleagues
-Auditors {utilization review; accreditation}
-Third party payers
-Lawyers, attorney staff, juries, expert witnesses
-researchers |
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Term
Documentation
Information documented |
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Definition
-Who&why- purpose of intervention
-What specifically is being done (interventions)
-Progress status (evaluation)
-Evidence of change; goal achievement(outcome)
-How much longer? (prognosis)
-How much money will the intervention cost? |
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Term
|
Definition
-Narrative
-SOAP
-HCFA 700
-Generic Hospital Forms
-Guide Template |
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Term
|
Definition
IE - Initial Evaluation
Progress
D/C - Discharge |
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Term
Documentation
Consistent Components across formats/types |
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Definition
-Patient goals
-Agreement with treatment plan
-Patient collaboration throughout tx process
-Pain assessment and management
-Patient education
-Multidisciplinary approach |
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Term
|
Definition
Written at IE
Updated in Progress notes
Reviewed at D/C-achievement, outcomes |
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Term
Documentation
Goals-ABCD + time Method |
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Definition
-Audience
-Behavior
-Condition/Context
-Degree
(Sometimes an “E” = explanation)
+++Plus time frame |
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Term
Documentation
Goals-ABCD-Audience |
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Definition
who will perform the skill
i.e. “patient will perform ___”
“caregiver will perform ____” |
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Term
Documentation
Goals-ABCD-Behavior |
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Definition
what the person will do
i.e. “ ambulate, roll, stand, sit-stand” |
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Term
Documentation
Goals-ABCD-Condition |
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Definition
under what condition, environment, or
circumstance will the person perform the behavior;
this also may include device/adaptive equipment
specification and verbal cue notation
i.e. on the mat, on level surfaces; with a walker, with a grab bar |
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Term
Documentation
Goals-ABCD-Degree |
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Definition
how will the behavior be measurable;
assistance needed
i.e. # feet, w. Min A, # of times |
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Term
Documentation
Goals-ABCD-Time Frame |
|
Definition
Always include time frame to achieve behavior
i.e. 2 sessions, 2 weeks, at discharge
-Time frame of goals are limited to the interval of time you are treating the patient.
i.e. patient stay is 2.5 weeks, goals are written in that time frame. All other projections go in the D/C plan.
-LTG/STG |
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Term
|
Definition
Goals must be functional. Examples:
-Transfer
-Bed Mobility
-Gait
-Dressing; Toileting
Prevention
-Positioning
-Weight Shifting
Other:
Patient Education
Family Education
Impairments |
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Term
Documentation
Problem List |
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Definition
| List of Impairments and their associated functional limitations |
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Term
Documentation
Problem List |
|
Definition
Example
Impairments
-Strength
-ROM
-Sensation
-Balance
Functional Limitations
-Level of assist
-Type of transfer or gait
pattern
-Environment
-Distance/time |
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Term
Documentation
Goals and Outcomes |
|
Definition
-Should speak to your Functional problem list
-Interventions should align with Functional problem list and goals
-Impairments addressed in patient management and
treatment planning (ie. often in STGs).
-Goals for Impairments must also be measureable |
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Term
Documentation
Functional Assessment Terms |
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Definition
Should be used to write your goals and progress notes
-Independent
- Supervision
-Contact Guarding
- Minimum Assistance
-Moderate Assistance
-Maximum Assistance
Cues: manual vs verbal |
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Term
|
Definition
Subjective
Objective
Assessment
Plan
First Review chart to get
-DX
-Demographics
-PMHX
-Past surgical hx
-Test results |
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|
Term
Documentation
SOAP-Subjective |
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Definition
-Patient: “states… say… reports”
-Patient states goals
-PFS |
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Term
Documentation
SOAP-Objective |
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Definition
-Systems
-Tests and Measures
-Flow sheets
-Interventions and level of functions |
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Term
Documentation
SOAP-Assessment |
|
Definition
-Diagnosis
-Synopsis of patient status
-Prognosis |
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Term
|
Definition
-Goals
-Outcomes
-Intervention plan |
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Term
Documentation
Goals vs Outcomes |
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Definition
Goals are related to specific task or functions
Outcomes tend to go beyond treatment.
Goals are accomplished during treatment and form a foundation to reach the outcome.
Ex. Goal: Pt. will lift 15lbs overhead w/o P
Outcome: Return to work |
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Term
|
Definition
| Routine activities that people tend do everyday without needing assistance. There are six basic ADLs: eating, bathing, dressing, toileting, transferring (walking) and continence. |
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Term
|
Definition
| IADL'S (Instrumental Activities of Daily Living) are Driving, Preparing Meals, Doing Housework, Shopping, Managing Finances, Managing Medication, Using the Telephone. |
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Term
Documentation
Levels of Assist |
|
Definition
Supervision
Contact Guard
Min Assist
Mod Assist
Max Assist
Dependent
Independent |
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Term
Documentation
Levels of Assist-Supervision |
|
Definition
Includes Cues and Coaching
2 types
-Distance sup.=hands in pockets
-Close sup. = hands at the ready |
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Term
Documentation
Levels of Assist-Contact Guard |
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Definition
| Touching, but very little to 20% support |
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Term
Documentation
Levels of Assist-Min assit |
|
Definition
|
|
Term
Documentation
Levels of Assist-Mod assit |
|
Definition
|
|
Term
Documentation
Levels of Assist-Max assist |
|
Definition
|
|
Term
Documentation
Levels of Assist-dependent |
|
Definition
|
|
Term
Documentation
Levels of Assist-Independent |
|
Definition
0% assist
Can be with walker, cane or other assistive device |
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Term
|
Definition
Onset
Location
Duration
Character
Aggravations
Relief
Temporal-Frequency
Severity |
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|
Term
Positioning
Importance in PT |
|
Definition
-Prevent contractures
-Promote mobility
-Prevent pressure on skin, circulatory
and neuronal structures |
|
|
Term
Positioning
Pressure Injuries |
|
Definition
Occur over bony prominences
Causes vary:
-Decreased sensation
-Increased moisture
-Sheering
-Ischemia |
|
|
Term
| Positioning Bony prominences that cause Pressure Injuries |
|
Definition
|
|
Term
Positioning
Weight Shifting |
|
Definition
Best way to prevent pressure injuries is to teach pt. weight shifting
-in bed every 2 hours
-Seated 20min to 1 hour
Monitor pts who cannot shift w/o assist |
|
|
Term
Positioning
Rationale/Purpose |
|
Definition
-Prevent soft tissue and joint contractures
-Patient comfort
-Support and stability
-Expose areas to be treated
-Promote increased function of a given system
-Prevent pressure areas |
|
|
Term
Positioning
Common Contracture sites |
|
Definition
-Hip flexion; hip external rotation
-Knee flexion
-Ankle plantar flexion
-Shoulder adduction, internal rotation |
|
|
Term
Positioning
General Precautions |
|
Definition
-Avoid folds or wrinkles in linen-friction;ischemia
-Observe skin color before, during and
after intervention
-Caution with bony prominences |
|
|
Term
Draping
Rationale/Reason for Draping |
|
Definition
-Provide modesty
-Maintain body temperature
-Provide access and exposure to area to
be treated
-Protect skin or clothing from being
soiled or damaged |
|
|
Term
Positioning
THR precautions |
|
Definition
-No internal rotation
-No Adduction
-No flexion at the hip >90 degrees
-Consider surgical approach
-Scar area
-Abduction Wedge |
|
|
Term
Positioning
TKR precautions |
|
Definition
-No pillows under knee
-CPM device
-Scar area |
|
|
Term
|
Definition
Sit Pivot
Stand Pivot
Slide Board |
|
|
Term
|
Definition
Scapula
Iliac Crest
Femur
Occiput |
|
|
Term
Standard Precautions
Case Studies - 1 |
|
Definition
Pt: Mr. P 66 y.o.
Sign: Respiratory Pxns
Med Hx: Cardiac Sx 3 weeks ago; CABG x 3; post sx pneumonia
Rx/POC: ROM, Bed Mobility, Sitting Bedside; Breathing Exercises
************************************
Mr. P should be droplet precautions due to pneumonia, but we should find out what type as some are airborne.
Handwash pre/post, Mask, No Gown or gloves per pierson |
|
|
Term
Standard Precautions
Case Studies - 2 |
|
Definition
Patient: Mr TB 55y/o
Sign on Door: none
Medical Hx: TKR R secondary to Osteoarthritis; hx TB age 21; chart= pos TB test/ neg x-ray
Tx/Intervention Plan: ROM, Ambulation, Ther Ex
*************************************
Standard Precautions since TB not active
No glove per Dr. P; Handwash Pre/post
Questions: When was last chest x ray? |
|
|
Term
Standard Precautions
Case Studies - 3 |
|
Definition
Patient: Ms Hip 44y/o
Sign on Door: Enteric Pxns
Medical Hx: pt. fell off curb in NYC resulting in a fx hip R with ORIF s/p 1week; pos+ culture c-diff(clostridium difficile) in stool.
Tx/Intervention Plan: ROM, Bed Mobility; STM @ Scar.
***************************************
Contact Pxns; Grown and Glove-No mask |
|
|
Term
Standard Precautions
H1N1 virus |
|
Definition
Symptoms:fever, chills, headache, upper respiratory tract symptoms (cough, sore throat, rhinorrhea, shortness of breath), myalgias, arthralgias, fatigue, vomiting, or diarrhea.
Pxns: Droplet, but UMDNJ pol. is to mask
Not infectious after 48hrs w/o symptoms |
|
|
Term
Transfers
Transitional Movements |
|
Definition
Scooting
Sit to stand
Supine to Sit |
|
|
Term
Standard Precautions
Enteric Precautions |
|
Definition
Older term for precautions related to pathogens stored in feces and urine.
Now included as contact precautions |
|
|
Term
Documentation
Terminology: A&O x 3 |
|
Definition
Alert and Oriented to
-Person
-Place
-Time |
|
|
Term
Documentation
Weight Bearing |
|
Definition
FWB
PWB
TTWB
REMEMBER: We can't include changes in WB status as Goals. WB status is set by Doctors |
|
|
Term
|
Definition
Roll
Logroll
Supine to Sit
Bridging-Upper Body and Lower Body |
|
|
Term
|
Definition
(Describe rolling to right)
Start Supine
Abduct R shoulder to 90deg.
Rotate Head to R
Flex L knee- L foot flat on bed
(heel closer to glutes is better)
L arm Horiz Adduct toward R arm (Reach to my belt buckle)
Roll Through L knee and L Hum/Scap
Note: Avoid Pulling on bed or side rail
Make sure your COG is aligned |
|
|
Term
|
Definition
Both knees flexed w/feet flat
Heels as close as practical to glutes
Pillow btw. Knees-pt. squeezes
Unweight and Facilitate:
LB: Method 1
Scoop PSIS
pt. Hands on mat/bed-Push
Method 2:
pt. Hands on mat/bed-Push
PT flat hands on Femur-pull down as pt. lifts bottom and shifts |
|
|
Term
Bed Mobility
Supine to Sit |
|
Definition
Start with Rolling supine to side
In SL pt. lifts head,
PT top hand over top of scap
PT lower hand on side of pt. trunk
PT pulls w. top hand and slides bottom hand down trunk to hip-press on hip to kindof push hip under pt.
pt. contributes to their ability-prop on elbow, push on mat with hand |
|
|
Term
Examination Template
Introduction |
|
Definition
• Introductions: “Why are you here?”
• Patient’s goals and expected outcomes
• Current functional status
• Cognition and Communication screen : A&Ox3(person, place, and time), executive functioning, behavior
o Ask goals and outcomes at clinic |
|
|
Term
Examination Template
Current Problems |
|
Definition
• History of Current Condition
o Chief Complaint
o Onset
o Pain Assessment – OLDCARTS
Onset, Location, Duration, Character, Aggravates, Relief, Temporal Factors, Severity
o Progression of disorder
o Pxns:
o Weight Bearing Status: FULL___ PWB___ TTWB___ NWB____ |
|
|
Term
Examination Template
Demographics |
|
Definition
| • DOB, Gender, Height, Weight, Language, Race, Ethnicity, Education |
|
|
Term
Examination Template
Social/Occupational/Environmental |
|
Definition
• Social History
o Social supports, marital status, Recreational, day centers, etc
• Occupation and Employment
• Living Environment – type of residence
• Functional Status and activity level
o PFS – MAKE SURE TO ASK
o Equipment Use
• Growth and Development – age relevant inquiry |
|
|
Term
Examination Template
Medical History |
|
Definition
• Past history of current conditions
• Past medical and surgical history
• *Other Practitioners Seen: CAM?(Complimentary Alternative Medicine)*
• Medications – Known Allergies
• Other tests and measures
o X-Rays, MRI, etc.
• Family Hx – Heart disease, stroke, HTN, Diabetes, CA, COPD
o Other – Neuromuscular/developmental (CF/MD) – Family relationship and age onset
• Health Status – self report, family report, caregiver report (anything you observe)
o Major life changes in past year? See Holmes-Rahe Social adjustment scale
o Changes in weight? How would you rate your general health? Stress? Fatigue? Depression? |
|
|
Term
Examination Template
Social habits/Lifestyle Patterns |
|
Definition
• Nutrition, sleep, exercise, recreation
• Smoking, alcohol/drug use |
|
|
Term
Examination Template
Systems Review |
|
Definition
Systems Review – this is just a screen. If you see a problem, go into an exam
• Cardiovascular
• Integumentary
• Musculoskeletal
• Neuromuscular
• Other
• Prevention
• Safety
• Insurance |
|
|
Term
Examination Template
Systems Review-Cardiovascular |
|
Definition
o Vitals – resting/during/post exercise (never assume their fine from just sitting down)
o Pedal/distal pulses
o Aerobic capacity – cardio/resp endurance
o Auscultation
o Breathing efficiency patterns |
|
|
Term
Examination Template
Systems Review-Integumentary |
|
Definition
o Condition (color, disruption, texture, temperature, hair growth
o Wound (stage, exudates, etc.)
o Swelling (edema, effusion-intrarticular/extra, masses, girth/atrophy) |
|
|
Term
Examination Template
Systems Review-Musculoskeletal |
|
Definition
o Posture – initial conditions, gross ROM screen
o ROM
o Strength
o Muscle Length
o Palpation
o Joint Integrity |
|
|
Term
Examination Template
Systems Review-Neuromuscular |
|
Definition
o Sensory Integrity
o Cranial Nerves
o Reflexes
o Balance
o Coordination
o Neuromuscular endurance
o Cognition, communication, and behavior |
|
|
Term
Examination Template
Systems Review-Other |
|
Definition
• Prevention
• Safety
• Insurance |
|
|
Term
Examination Template
Evaluation |
|
Definition
• The purpose of this section is to assess and judge your data from your total examination. Your total examination includes the data from the history sections, systems review sections, and the tests and measures section
• Findings
o Impairments
o Functional Limitations
• Impression |
|
|
Term
Examination Template
Diagnosis |
|
Definition
• The purpose of this section is to determine “a label encompassing a cluster of signs and symptoms commonly associated with a disorder or syndrome, or category of impairment, functional limitation, or disability”
• Referring Dx
• Physical Therapy Dx |
|
|
Term
Examination Template
Classification of Dx |
|
Definition
• Clinical Decision – determine if the diagnosis is in the scope of practice
o Provide direct care
o Consult
o Refer (see interventions)
o Educate (ALWAYS circle educate)
• Acute, Sub-Acute, Chronic, Other
• Practice Pattern |
|
|
Term
Examination Template
Prognosis |
|
Definition
• The purpose of this section is to determine the level of improvement that might be attained through intervention and the amount of time required to reach that level. This section includes your Plan of Care
• Projected Outcome
• Anticipated Goals
• Expected Outcomes
• Interventions
o Always include exercise, HEP, safety education, pain management
• Education (including safety, exercise, and disease information)
o List who you are educating
• Informed Consent
• Signature
• Discharge Plan – what they need to do for discharge – goals, functional level at discharge, where to refer next |
|
|
Term
Standard Precautions
Universal Precautions |
|
Definition
• Wash hands
• Wear face masks and eye protection
• Handle used equipment with care. Dispose of needles properly
• Use private rooms or cohort
• Wear gloves
• Wear gown
• Clean and disinfect environmental surfaces
• Handle soiled linens with care
• Use resuscitation devices
Body Substance Isolation |
|
|
