Guide to PT Practice Flashcards
(24 cards)
Elements or the PT/ Client Management Model
Examination Evaluation Diagnosis Prognosis Intervention Outcomes
3 components of an evaluation
history
systems review
tests and measures
leads to diagnositc classification
History- part of evaluation
PT systematically gathers data related to why individual is seeking pt servies
symptoms
review of symptoms- gather information about major body systems
need to make sure referral for medical evluation is not necessary
History review of systems- systems include
Cardiovascular pulmonary endocrine eyes, ear, nose and throat gastrointestinal genitourinary/reproductive hematologic/lymphatic integumentary neurologic musculoskeletal
History includes
demographics social history employment growth and development living environment general health social health habits family history medical/surgical history current conditions functional status medications other clinical tests
*Systems Review include a limited examination of
Cardiovascular/Pulmonary (HR, BP, Respiratory Rate)
Integumentary (skin) color, wounds, scars, integrity
Musculoskeletal
Neuromuscular (Gait, Balance)
Communication ability, affect, cognition, language and learning style
this is done so we know what tests and measures to do
during an evalation a PT makes clinical judgments based on data gathered during examination to
synethisze and integrate all findings from history, systems review and tests and measures to establish a diagnosis , prognosis and plan of care
Diangosis
a cluster of signs and symptoms, syndromes or categories
ex. For a heart attack patient pt diagnosis would be decreased aerobic capacity - (would not diagnose the heart attack)
Medical Diagnosis
a label that identifies a disease, disorder or condition at the level of cell, tssue organ or system
PT Diagnosis
a diagnostic label that identifies the impact of a condition on function at the level of the system (especially the movement system) and at the level of the whole person
this can be different then medical diagnosis and is the primary dysfunction for which the pt directs care
what is Prognosis
determination of the preficted optima level of improvement in function and the amount of time needed to reach that level
Prognosis is associated with improved or maintained health status achieved through
risk reduction
health, wellness, and fitness programs
remediation of impairments, activity limitations, participaion restrictions or environmental barriers
Plan of care is designed
to improve, enhance and maximize function
Plan of care specifies
Goals
Predicted level of optimal improvement
specific interventions to be used
proposed duration and frequency of interventions that are required to achieve the goals and outcomes
Goals
intended impact on functioning as a result of implementing plan of care
GOALS SHOULD BE MEASURABLE FUNCTIONALLY DRIVEN AND TIME LIMITED
what is the difference between goals and outcomes
goals predict things you want to happen, outcomes are what actually happen
Intervention categories
Patient or client instruction airway clearance techniques assistive technology biophysical agents (modalities) functional training, in selfcare and domestic, work, community, social and civic life Integumentary repair and protection techniques Manual therapy techniques Motor function training Therapeutic exercise
Parameters included in PT Interventions
method, mode or device
intensity load or tempo
duration and frequency
progression
Indications for reexamninaion
new clinical findings
failure to respond to interventions
Coordination
the working together of all parties involved with the patient or client
communication
exchange of information
Documentation
any entry into the patient or client record that identified the care or sevice provided and the individuals response to intervention
What does the physical therapist do at the conclusion of the episode of care
plans for appropriate follow up or referal
Criteria for concluding an episode of care
goals or outcomes achieved
Individual unable to continue to progress toward goals
individual chooses to end care
PT determines the patient or client will no longer benefit from PT services
