Week 12 (EXAM 3)

Question 1

For acute care, explain the steps of log roll for bed mobility

Answer 1

Question 2

What are the steps of assisted log roll?

Answer 2

Question 3

How to assist pt in transition from side lying to sitting?

Answer 3

Question 4

Explain the steps of bridging and scooting

Answer 4

Question 5

How to assist pt when scooting at side of bed?

Answer 5

Question 6

Explain sit to stand motion

Answer 6

Question 7

Identify 3 supine exercises (can be performed in a hospital bed) that could be implemented for acute care.

Answer 7

Question 8

Identify 3 sitting exercises that could be implemented for acute care.

Answer 8

Question 9

List indications for surgical interventions for MSK conditions of the spine and extremities

Answer 9

Question 10

Define pre-rehabilitation

Answer 10

Question 11

List the phases of post op rehab

Answer 11

Question 12

What can you expect in the max protection phase? POC?

Answer 12

Question 13

What can you expect in the moderate protection phase? POC?

Answer 13

Question 14

What is the POC in the minimum protection phase?

Answer 14

Question 15

List possible post op complications and how to prevent them

Answer 15

Question 16

What metric can test for deep vein thrombosis?

Answer 16

Question 17

What is the usual sequence of events for wells score <1, 1-2, >2?

Answer 17

Question 18

List and explain common orthopedic surgical procedure approaches

Answer 18

Question 19

Explain post op management for muscle vs tendon

Answer 19

Question 20

Rotator cuff repair: explain rehab progression and the guidelines for each phase of recovery

Answer 20

Question 21

How long does ligament rehab usually take?

Answer 21

Question 22

ACL reconstruction: explain rehab progression and the guidelines for each phase of recovery

Answer 22

Question 23

What are common joint surgical procedures? Post op management?

Answer 23

Question 24

What are the contraindications of total joint arthroplasty?

Answer 24

Question 25

Total shoulder arthroplasty (rotator cuff intact): explain rehab progression and the guidelines for each phase of recovery

Answer 25

Question 26

Reverse total shoulder arthroplasty: explain rehab progression and the guidelines for each phase of recovery

Answer 26

Question 27

Total hip arthroplasty: explain rehab progression and the guidelines for each phase of recovery

Answer 27

Question 28

Total knee arthroplasty: explain rehab progression and the guidelines for each phase of recovery

Answer 28

Question 29

Spinal surgery: what are the indications and post op restrictions?

Answer 29

Question 30

Spinal surgery: explain rehab progression and the guidelines for each phase of recovery

Answer 30

Question 31

Solve question 1

Answer 31

Question 32

Solve question 2

Answer 32

Question 33

Solve question 1

Answer 33

Question 34

Solve question 2

Answer 34

Question 35

Solve question 1

Answer 35

Question 36

Solve question 2

Answer 36

Question 37

Solve question 1

Answer 37

Question 38

solve question 2

Answer 38

Question 39

What are post op R hip precautions? Case: A 78-year-old woman was admitted to acute care following a right total hip replacement due to severe osteoarthritis that caused longstanding pain radiating to the buttock and low back, worsened by weight bearing and stairs. Her history includes pneumonia, coronary artery disease (CAD), and four coronary artery bypass grafts (CABG). She has an IV, Foley catheter, and is on 2L O₂ via nasal cannula. Previously independent in all ADLs, she had used a walker and required home aide assistance due to pain, which recent conservative measures failed to relieve. Socially, she is a retired accounting manager and active community volunteer who lives alone in a 5th-floor apartment with elevator access and a 4” step at entry. She is highly motivated to regain independence and resume family, volunteer, and leisure activities, and wishes to discontinue home care support as soon as possible.

Answer 39

Question 40

How would you approach 1) supine to sitting, 2) sitting static balance, 3) sitting dynamic balance? Case: A 78-year-old woman was admitted to acute care following a right total hip replacement due to severe osteoarthritis that caused longstanding pain radiating to the buttock and low back, worsened by weight bearing and stairs. Her history includes pneumonia, coronary artery disease (CAD), and four coronary artery bypass grafts (CABG). She has an IV, Foley catheter, and is on 2L O₂ via nasal cannula. Previously independent in all ADLs, she had used a walker and required home aide assistance due to pain, which recent conservative measures failed to relieve. Socially, she is a retired accounting manager and active community volunteer who lives alone in a 5th-floor apartment with elevator access and a 4” step at entry. She is highly motivated to regain independence and resume family, volunteer, and leisure activities, and wishes to discontinue home care support as soon as possible.

Answer 40

Question 41

How would you approach 1) stand to sit, 2) dynamic and static standing balance, 3) gait? Case: A 78-year-old woman was admitted to acute care following a right total hip replacement due to severe osteoarthritis that caused longstanding pain radiating to the buttock and low back, worsened by weight bearing and stairs. Her history includes pneumonia, coronary artery disease (CAD), and four coronary artery bypass grafts (CABG). She has an IV, Foley catheter, and is on 2L O₂ via nasal cannula. Previously independent in all ADLs, she had used a walker and required home aide assistance due to pain, which recent conservative measures failed to relieve. Socially, she is a retired accounting manager and active community volunteer who lives alone in a 5th-floor apartment with elevator access and a 4” step at entry. She is highly motivated to regain independence and resume family, volunteer, and leisure activities, and wishes to discontinue home care support as soon as possible.

Answer 41

Question 42

Explain her ROM and strength for UE and LE Case: A 78-year-old woman was admitted to acute care following a right total hip replacement due to severe osteoarthritis that caused longstanding pain radiating to the buttock and low back, worsened by weight bearing and stairs. Her history includes pneumonia, coronary artery disease (CAD), and four coronary artery bypass grafts (CABG). She has an IV, Foley catheter, and is on 2L O₂ via nasal cannula. Previously independent in all ADLs, she had used a walker and required home aide assistance due to pain, which recent conservative measures failed to relieve. Socially, she is a retired accounting manager and active community volunteer who lives alone in a 5th-floor apartment with elevator access and a 4” step at entry. She is highly motivated to regain independence and resume family, volunteer, and leisure activities, and wishes to discontinue home care support as soon as possible.

Answer 42

Question 43

Identify 1) ADL skills that need to be examined for return to function, 2) functional status info that would be used for goals and POC development Case: A 78-year-old woman was admitted to acute care following a right total hip replacement due to severe osteoarthritis that caused longstanding pain radiating to the buttock and low back, worsened by weight bearing and stairs. Her history includes pneumonia, coronary artery disease (CAD), and four coronary artery bypass grafts (CABG). She has an IV, Foley catheter, and is on 2L O₂ via nasal cannula. Previously independent in all ADLs, she had used a walker and required home aide assistance due to pain, which recent conservative measures failed to relieve. Socially, she is a retired accounting manager and active community volunteer who lives alone in a 5th-floor apartment with elevator access and a 4” step at entry. She is highly motivated to regain independence and resume family, volunteer, and leisure activities, and wishes to discontinue home care support as soon as possible.

Answer 43

Question 44

Create a POC Case: A 78-year-old woman was admitted to acute care following a right total hip replacement due to severe osteoarthritis that caused longstanding pain radiating to the buttock and low back, worsened by weight bearing and stairs. Her history includes pneumonia, coronary artery disease (CAD), and four coronary artery bypass grafts (CABG). She has an IV, Foley catheter, and is on 2L O₂ via nasal cannula. Previously independent in all ADLs, she had used a walker and required home aide assistance due to pain, which recent conservative measures failed to relieve. Socially, she is a retired accounting manager and active community volunteer who lives alone in a 5th-floor apartment with elevator access and a 4” step at entry. She is highly motivated to regain independence and resume family, volunteer, and leisure activities, and wishes to discontinue home care support as soon as possible.

Answer 44

Question 45

Identify the impairments Case: A 78-year-old woman was admitted to acute care following a right total hip replacement due to severe osteoarthritis that caused longstanding pain radiating to the buttock and low back, worsened by weight bearing and stairs. Her history includes pneumonia, coronary artery disease (CAD), and four coronary artery bypass grafts (CABG). She has an IV, Foley catheter, and is on 2L O₂ via nasal cannula. Previously independent in all ADLs, she had used a walker and required home aide assistance due to pain, which recent conservative measures failed to relieve. Socially, she is a retired accounting manager and active community volunteer who lives alone in a 5th-floor apartment with elevator access and a 4” step at entry. She is highly motivated to regain independence and resume family, volunteer, and leisure activities, and wishes to discontinue home care support as soon as possible.

Answer 45

Question 46

Identify the interventions Case: A 78-year-old woman was admitted to acute care following a right total hip replacement due to severe osteoarthritis that caused longstanding pain radiating to the buttock and low back, worsened by weight bearing and stairs. Her history includes pneumonia, coronary artery disease (CAD), and four coronary artery bypass grafts (CABG). She has an IV, Foley catheter, and is on 2L O₂ via nasal cannula. Previously independent in all ADLs, she had used a walker and required home aide assistance due to pain, which recent conservative measures failed to relieve. Socially, she is a retired accounting manager and active community volunteer who lives alone in a 5th-floor apartment with elevator access and a 4” step at entry. She is highly motivated to regain independence and resume family, volunteer, and leisure activities, and wishes to discontinue home care support as soon as possible.

Answer 46

1. Bed Mobility and Transfer Training * Intervention: Teach log rolling, supine to sit, and sit to stand using proper technique and hip precautions * Goal: Improve independence with functional movement and prevent dislocation * Parameters: 3–5 reps per session, 2–3 sessions/day ⸻ 2. Gait Training with Walker * Intervention: Ambulation training on level surfaces using a rolling walker * Include: Cueing for step-through pattern and upright posture * Parameters: Start with short distances (e.g., 50–100 feet), progress as tolerated 2–3x/day * Monitor: O₂ saturation, vital signs, and fatigue ⸻ 3. Stair Step Training (if safe and cleared) * Intervention: Train step-up with assist on a 4” step to simulate home entry * Include: Use of railing or walker on step * Parameters: 2–3 trials, 1–2x/day, as tolerated ⸻ 4. Therapeutic Exercises * Focus: Improve circulation, prevent DVT, initiate gentle strengthening * Ankle pumps * Quad sets * Glute sets * Heel slides (as allowed) * Parameters: 1–2 sets of 10 reps, 2–3x/day ⸻ 5. Balance Training (as tolerated) * Intervention: Seated and standing balance tasks with support * Goal: Reduce fall risk, improve weight shifting * Parameters: 1–2 mins per activity, 2x/day ⸻ 6. Functional ADL Training * Intervention: Practice dressing (with adaptive equipment), toileting, reaching, meal prep setup * Goal: Improve independence with daily tasks * Parameters: Incorporated into daily routine and PT sessions ⸻ 7. Patient Education * Topics: * Hip precautions (no bending past 90°, no crossing legs or twisting) * Safe mobility at home * Use of assistive devices * Energy conservation * Mode: Verbal instruction and written handouts ⸻ 8. Oxygen Monitoring and Pacing * Intervention: Monitor SpO₂ during activity; incorporate rest breaks * Goal: Prevent hypoxia and support safe mobilization * Parameters: Check before/during/after ambulation

Question 47

What are some functional interventions for day 1 and day 2? Case: A 78-year-old woman was admitted to acute care following a right total hip replacement due to severe osteoarthritis that caused longstanding pain radiating to the buttock and low back, worsened by weight bearing and stairs. Her history includes pneumonia, coronary artery disease (CAD), and four coronary artery bypass grafts (CABG). She has an IV, Foley catheter, and is on 2L O₂ via nasal cannula. Previously independent in all ADLs, she had used a walker and required home aide assistance due to pain, which recent conservative measures failed to relieve. Socially, she is a retired accounting manager and active community volunteer who lives alone in a 5th-floor apartment with elevator access and a 4” step at entry. She is highly motivated to regain independence and resume family, volunteer, and leisure activities, and wishes to discontinue home care support as soon as possible.

Answer 47

Day 1 Functional Interventions (Goals: initiate mobility, promote independence, educate on precautions) 1. Bed Mobility Training * Teach log rolling technique (to avoid adduction and rotation) * Supine → sit transition with minimal trunk rotation * Goal: Patient performs with min assist or supervision 2. Sit-to-Stand Transfers * From hospital bed or chair using rolling walker * Emphasize hip precautions and safe hand placement * Goal: Practice 3–5 transfers 3. Gait Training (Short Distance) * Ambulate in room or hallway (e.g., 10–25 feet) using walker * Cue for weight shifting, heel-toe pattern, and upright posture * Monitor oxygen saturation and fatigue * Goal: Begin safe, short ambulation 4. Patient Education * Hip precautions (posterior approach) * Use of walker, energy conservation * Reinforce safety strategies (e.g., avoiding low chairs or twisting) ⸻ Day 2 Functional Interventions (Goals: build endurance, expand mobility, reinforce self-care) 1. Progress Gait Training * Increase distance (e.g., 50–100 feet) * Navigate slight turns or doorway thresholds * Goal: Tolerate 100+ ft with rolling walker and steady vitals 2. Stair Simulation (if safe) * Practice 4” step with hand support * Cue: “Up with the good, down with the bad” * Goal: Prepare for home entry step 3. Toileting and Lower Body Dressing Training * Practice safe reach strategies and use of adaptive equipment * Sit-to-stand transfers to/from commode * Goal: Initiate return to ADL independence 4. Standing Functional Tasks * Reach for light objects (maintaining precautions) * Simulate basic IADLs like grooming at sink * Goal: Improve standing tolerance and self-care confidence

Question 48

Create 3 specific goals with one addressing function (S.M.A.R.T.) Case: A 78-year-old woman was admitted to acute care following a right total hip replacement due to severe osteoarthritis that caused longstanding pain radiating to the buttock and low back, worsened by weight bearing and stairs. Her history includes pneumonia, coronary artery disease (CAD), and four coronary artery bypass grafts (CABG). She has an IV, Foley catheter, and is on 2L O₂ via nasal cannula. Previously independent in all ADLs, she had used a walker and required home aide assistance due to pain, which recent conservative measures failed to relieve. Socially, she is a retired accounting manager and active community volunteer who lives alone in a 5th-floor apartment with elevator access and a 4” step at entry. She is highly motivated to regain independence and resume family, volunteer, and leisure activities, and wishes to discontinue home care support as soon as possible.

Answer 48

Question 49

If on day 2, she will be discharged tomorrow (day 3), she has a step to enter her house and she is unsure how to navigate it. There are also uneven surfaces around her house and she wants to navigate them safely. What would you add to POC on day 3? Case: A 78-year-old woman was admitted to acute care following a right total hip replacement due to severe osteoarthritis that caused longstanding pain radiating to the buttock and low back, worsened by weight bearing and stairs. Her history includes pneumonia, coronary artery disease (CAD), and four coronary artery bypass grafts (CABG). She has an IV, Foley catheter, and is on 2L O₂ via nasal cannula. Previously independent in all ADLs, she had used a walker and required home aide assistance due to pain, which recent conservative measures failed to relieve. Socially, she is a retired accounting manager and active community volunteer who lives alone in a 5th-floor apartment with elevator access and a 4” step at entry. She is highly motivated to regain independence and resume family, volunteer, and leisure activities, and wishes to discontinue home care support as soon as possible.

Answer 49

Question 50

Create a home exercise program Case: A 78-year-old woman was admitted to acute care following a right total hip replacement due to severe osteoarthritis that caused longstanding pain radiating to the buttock and low back, worsened by weight bearing and stairs. Her history includes pneumonia, coronary artery disease (CAD), and four coronary artery bypass grafts (CABG). She has an IV, Foley catheter, and is on 2L O₂ via nasal cannula. Previously independent in all ADLs, she had used a walker and required home aide assistance due to pain, which recent conservative measures failed to relieve. Socially, she is a retired accounting manager and active community volunteer who lives alone in a 5th-floor apartment with elevator access and a 4” step at entry. She is highly motivated to regain independence and resume family, volunteer, and leisure activities, and wishes to discontinue home care support as soon as possible.

Answer 50

Home Exercise Program (HEP) – s/p Right THR (Posterior Approach) Frequency: 2–3 times per day Reps/Sets: 10 reps x 1–2 sets (unless otherwise noted) Precautions: * No hip flexion past 90° * No internal rotation or crossing legs * Use walker for ambulation until cleared ⸻ 1. Ankle Pumps * Purpose: Improve circulation, prevent blood clots * How: While sitting or lying down, pump ankles up and down * Tip: Do throughout the day, especially after sitting for long periods ⸻ 2. Quad Sets * Purpose: Strengthen thigh muscles (quadriceps) * How: Lie on your back, tighten the thigh muscle by pushing the back of your knee into the bed. Hold for 5 seconds. * Tip: Don’t hold your breath ⸻ 3. Glute Sets * Purpose: Activate hip extensors * How: Squeeze buttocks together and hold for 5 seconds * Tip: Can be done lying down or seated ⸻ 4. Heel Slides (within ROM limits) * Purpose: Improve knee and hip mobility * How: Slide heel toward buttocks on bed, keeping heel in contact and maintaining hip precautions * Tip: Stop if it causes discomfort or approaches 90° hip flexion ⸻ 5. Standing Hip Abduction (Walker Support) * Purpose: Strengthen hip abductors * How: Stand with support, slowly move surgical leg out to the side, keeping toes forward * Tip: Keep body upright—no leaning ⸻ 6. Standing Mini Marches (if cleared by PT) * Purpose: Improve hip flexor endurance within safe range * How: Gently lift one knee a few inches (not above 90°), alternating legs while holding walker * Tip: Slow and controlled movements ⸻ Optional (If tolerated and safe): 7. Step Training * Purpose: Prepare for entering/exiting home * How: Step up and down on a 4” step using walker or railing * Tip: “Up with the good, down with the bad” – surgical leg goes second when going up, first when going down ⸻ Walking Program * Start with: 5–10 minutes, 2–3x/day using walker * Progress to: 10–15 minutes as endurance improves * Surfaces: Begin on flat indoor ground, progress to uneven terrain with caution

Question 51

List and prioritize patient’s impairments Case: A 70-year-old retired corporate lawyer with a history of COPD, pneumonia, HTN, hypercholesterolemia, atrial fibrillation, and prior left knee replacement presented to the ED with worsening shortness of breath and a productive cough after a recent COPD exacerbation and failed outpatient treatment. He is on 2L O₂ via nasal cannula, has a fall precaution, and takes multiple medications including Lisinopril, Warfarin, and Albuterol. He resides in a multi-level home with his wife and has stairs to access his bedroom. Prior to admission, he was independent with ADLs and modified independent on stairs, though now he requires moderate assistance for bed mobility and minimal assistance for sit-to-stand and ambulation using a rolling walker. On exam, he presents with accessory muscle use, tight pectorals and hip flexors, and decreased hip flexion strength (3/5). His balance is impaired, requiring minimal assist for sitting and standing. Vitals on admission showed low oxygen saturation (84%) and elevated respiratory rate (36). His main goal is to return home safely.

Answer 51

1. Impaired Oxygenation & Respiratory Function * Evidence: O₂ saturation 84% on 2L via nasal cannula, RR = 36, accessory muscle use, shortness of breath * Priority: High – Limits endurance, increases fall risk, and is a barrier to safe mobility and discharge ⸻ 2. Generalized Weakness * Evidence: * Hip flexion: 3/5 * Knee extension: 4/5 * UE and LE strength deficits (esp. proximally) * Priority: High – Affects transfers, stair climbing, and independence with ADLs ⸻ 3. Impaired Balance * Evidence: Requires minimal assist for static/dynamic standing and static sitting * Priority: High – Increases fall risk and impairs mobility safety, especially in home with stairs ⸻ 4. Decreased Functional Mobility * Evidence: * Moderate assist for supine to sit * Minimal assist for sit ↔ stand * Ambulation only 3 ft with walker * Priority: High – Directly impacts discharge planning and return to independence ⸻ 5. Impaired Endurance/Activity Tolerance * Evidence: Fatigues quickly, cannot tolerate gardening anymore, needs increased time for stairs * Priority: Moderate to High – Impacts ability to safely complete tasks and participate in PT sessions ⸻ 6. Flexibility Limitations * Evidence: Tight pecs (rounded posture) and suspected tight hip flexors * Priority: Moderate – May contribute to posture, breathing inefficiency, and mobility limits ⸻ 7. Postural Impairments * Evidence: Rounded shoulders due to pec tightness * Priority: Low to Moderate – Secondary concern but may impact breathing and functional reach

Question 52

Design 2 interventions (and how to implement them). One strengthening, and one stretching to improve posture Case: A 70-year-old retired corporate lawyer with a history of COPD, pneumonia, HTN, hypercholesterolemia, atrial fibrillation, and prior left knee replacement presented to the ED with worsening shortness of breath and a productive cough after a recent COPD exacerbation and failed outpatient treatment. He is on 2L O₂ via nasal cannula, has a fall precaution, and takes multiple medications including Lisinopril, Warfarin, and Albuterol. He resides in a multi-level home with his wife and has stairs to access his bedroom. Prior to admission, he was independent with ADLs and modified independent on stairs, though now he requires moderate assistance for bed mobility and minimal assistance for sit-to-stand and ambulation using a rolling walker. On exam, he presents with accessory muscle use, tight pectorals and hip flexors, and decreased hip flexion strength (3/5). His balance is impaired, requiring minimal assist for sitting and standing. Vitals on admission showed low oxygen saturation (84%) and elevated respiratory rate (36). His main goal is to return home safely.

Answer 52

1. Strengthening Intervention: Seated Marching (Hip Flexor Strengthening) Goal: Improve lower extremity strength, especially hip flexors (3/5), to support functional mobility and stair negotiation How to Implement: * Position: Seated in a firm chair with back support * Instructions: * Instruct the patient to sit upright with feet flat on the floor. * While holding the chair armrests for stability, lift one knee toward the ceiling without leaning backward. * Lower with control and repeat on the opposite leg. * Sets/Reps: 2 sets of 8–10 reps per leg, 1–2x/day * Intensity: Low to moderate; ensure breathing is steady—avoid Valsalva * Progression: Add ankle weights or hold for 3–5 seconds as tolerated ⸻ 2. Stretching Intervention: Seated Pec Stretch (Postural Improvement) Goal: Improve thoracic extension and reduce rounded shoulder posture caused by tight pectorals How to Implement: * Position: Sitting in a chair without armrests or standing at corner/wall * Instructions (Chair Version): * Patient clasps hands behind the back or places them behind head/neck (if tolerated). * Gently squeeze shoulder blades together and lift chest upward. * Hold the position while maintaining normal breathing. * Hold: 20–30 seconds * Reps: 3–5 times, 2x/day * Alternate Option: Use a doorway stretch with arms at shoulder height and a gentle forward lean * Cueing: “Lift your chest, open your shoulders—take deep breaths in this position.”

Question 53

Design and implement 2 functional training interventions Case: A 70-year-old retired corporate lawyer with a history of COPD, pneumonia, HTN, hypercholesterolemia, atrial fibrillation, and prior left knee replacement presented to the ED with worsening shortness of breath and a productive cough after a recent COPD exacerbation and failed outpatient treatment. He is on 2L O₂ via nasal cannula, has a fall precaution, and takes multiple medications including Lisinopril, Warfarin, and Albuterol. He resides in a multi-level home with his wife and has stairs to access his bedroom. Prior to admission, he was independent with ADLs and modified independent on stairs, though now he requires moderate assistance for bed mobility and minimal assistance for sit-to-stand and ambulation using a rolling walker. On exam, he presents with accessory muscle use, tight pectorals and hip flexors, and decreased hip flexion strength (3/5). His balance is impaired, requiring minimal assist for sitting and standing. Vitals on admission showed low oxygen saturation (84%) and elevated respiratory rate (36). His main goal is to return home safely.

Answer 53

1. Functional Training: Sit-to-Stand with Energy Conservation Strategies Goal: Improve transfer ability, strength, and independence with one of the most frequent daily tasks How to Implement: * Position: Patient seated in a standard-height chair with armrests * Instructions: * Cue patient to scoot to the edge of the chair * Instruct: “Nose over toes,” then push up using arms and legs * Use the rolling walker immediately upon rising * Focus: Upright posture and breathing control during movement * Modifications: * Perform with rest breaks between reps * Monitor SpO₂ and HR if needed due to COPD * Sets/Reps: 5–8 transfers per session, 2–3x/day * Progression: Reduce hand use, vary chair height, or transition to bed ↔ chair transfers ⸻ 2. Functional Training: Step-Up Simulation for Home Safety Goal: Safely navigate 3 steps and prepare for stair use at home How to Implement: * Setup: Use a 4–6” step or curb in the therapy gym or hallway with a sturdy railing * Instructions: * Begin with “up with the stronger leg, down with the weaker leg” * Use the handrail for support, and walker if safe * Cue the patient to maintain upright posture, avoid overexertion, and rest as needed * Safety: Closely guard patient, use gait belt, monitor O₂ saturation during task * Reps: 4–6 step-ups total, with 1–2 minutes of rest between trials * Frequency: 1–2x/day * Progression: Add more reps or increase step height as tolerated

Question 54

Review the patient’s home setting and social history, what interventions do you want to include prior to discharge? Case: A 70-year-old retired corporate lawyer with a history of COPD, pneumonia, HTN, hypercholesterolemia, atrial fibrillation, and prior left knee replacement presented to the ED with worsening shortness of breath and a productive cough after a recent COPD exacerbation and failed outpatient treatment. He is on 2L O₂ via nasal cannula, has a fall precaution, and takes multiple medications including Lisinopril, Warfarin, and Albuterol. He resides in a multi-level home with his wife and has stairs to access his bedroom. Prior to admission, he was independent with ADLs and modified independent on stairs, though now he requires moderate assistance for bed mobility and minimal assistance for sit-to-stand and ambulation using a rolling walker. On exam, he presents with accessory muscle use, tight pectorals and hip flexors, and decreased hip flexion strength (3/5). His balance is impaired, requiring minimal assist for sitting and standing. Vitals on admission showed low oxygen saturation (84%) and elevated respiratory rate (36). His main goal is to return home safely.

Answer 54

Interventions to Include Prior to Discharge: 1. Stair Training * Simulate 3-step entryway and full staircase if possible * Train with “up with the good, down with the bad” strategy * Emphasize walker use or handrail safety * Monitor fatigue and O₂ levels 2. Ambulation on Uneven Surfaces * Simulate outdoor terrain (e.g., thresholds, ramps, rugs, foam pads) * Teach how to navigate these areas with walker or cane * Practice scanning and stepping strategies for fall prevention 3. Energy Conservation & Pacing Education * Due to COPD and fatigue, teach strategies like: * Sitting while dressing * Breaking tasks into segments * Pursed-lip breathing during activity * Emphasize rest breaks and slow transitions (e.g., sit → stand) 4. Safe Transfer Training * Bed ↔ chair, toilet, and shower transfers * Incorporate bathroom safety practice if setup is known (e.g., simulate grab bar use) 5. Caregiver Education * Teach wife how to assist safely with mobility and O₂ management * Include signs of fatigue, shortness of breath, or when to seek help 6. Equipment Recommendations * Ensure he has: * Proper walker or assistive device * Portable O₂ system if needed for stairs/outdoor use * Consider recommending grab bars or stair railings if not already installed

Question 55

Design and home exercise program Case: A 70-year-old retired corporate lawyer with a history of COPD, pneumonia, HTN, hypercholesterolemia, atrial fibrillation, and prior left knee replacement presented to the ED with worsening shortness of breath and a productive cough after a recent COPD exacerbation and failed outpatient treatment. He is on 2L O₂ via nasal cannula, has a fall precaution, and takes multiple medications including Lisinopril, Warfarin, and Albuterol. He resides in a multi-level home with his wife and has stairs to access his bedroom. Prior to admission, he was independent with ADLs and modified independent on stairs, though now he requires moderate assistance for bed mobility and minimal assistance for sit-to-stand and ambulation using a rolling walker. On exam, he presents with accessory muscle use, tight pectorals and hip flexors, and decreased hip flexion strength (3/5). His balance is impaired, requiring minimal assist for sitting and standing. Vitals on admission showed low oxygen saturation (84%) and elevated respiratory rate (36). His main goal is to return home safely.

Answer 55

1. Seated Marching * Goal: Strengthen hip flexors, improve functional mobility * How: While seated, lift one knee toward the chest without leaning backward. Alternate legs. * Tip: Maintain upright posture. Exhale with each lift. ⸻ 2. Sit-to-Stand Transfers * Goal: Strengthen quads and glutes, improve independence with transfers * How: From a firm chair, scoot forward, lean “nose over toes,” and stand up using arms if needed. * Reps: 5–8 per session * Tip: Inhale before, exhale during the movement. Rest as needed. ⸻ 3. Standing Heel Raises (with walker or counter for support) * Goal: Improve ankle strength and balance * How: Slowly lift heels off the floor, hold for 2 seconds, lower down. * Progression: Try without holding on if balance improves. ⸻ 4. Standing Postural Stretch (Pec Stretch at Wall) * Goal: Open chest, reduce rounded posture from accessory breathing * How: Place forearms on doorway or wall corner, gently lean forward until a stretch is felt in the chest. * Hold: 20–30 seconds, 2–3 reps ⸻ 5. Pursed-Lip Breathing with Marching or Arm Movements * Goal: Improve breathing efficiency and coordination * How: Inhale through nose, exhale slowly through pursed lips while performing light movements (e.g., marching in place or arm lifts) * Duration: 1–2 minutes per set ⸻ 6. Walking Program * Goal: Improve endurance and independence * How: Walk indoors with a walker for 5–10 minutes, 1–2x/day * Tip: Use pacing strategies, take rest breaks, monitor oxygen if needed

Question 56

List 3 exercises (beneficial to his case) that the patient can do at home Case: A 70-year-old retired corporate lawyer with a history of COPD, pneumonia, HTN, hypercholesterolemia, atrial fibrillation, and prior left knee replacement presented to the ED with worsening shortness of breath and a productive cough after a recent COPD exacerbation and failed outpatient treatment. He is on 2L O₂ via nasal cannula, has a fall precaution, and takes multiple medications including Lisinopril, Warfarin, and Albuterol. He resides in a multi-level home with his wife and has stairs to access his bedroom. Prior to admission, he was independent with ADLs and modified independent on stairs, though now he requires moderate assistance for bed mobility and minimal assistance for sit-to-stand and ambulation using a rolling walker. On exam, he presents with accessory muscle use, tight pectorals and hip flexors, and decreased hip flexion strength (3/5). His balance is impaired, requiring minimal assist for sitting and standing. Vitals on admission showed low oxygen saturation (84%) and elevated respiratory rate (36). His main goal is to return home safely.

Answer 56

1. Seated Marching * Purpose: Strengthens hip flexors, improves circulation and functional mobility * How to Do It: While seated in a sturdy chair, lift one knee toward the chest, lower, then repeat with the other leg. * Reps: 10 reps per leg * Tip: Maintain upright posture; breathe steadily—exhale with the lift ⸻ 2. Sit-to-Stand from Chair * Purpose: Strengthens quads and glutes; mimics functional movement needed for daily tasks * How to Do It: From a firm chair, scoot to the edge, lean forward (“nose over toes”), and stand up. Sit back down slowly. * Reps: 5–8 reps * Tip: Use armrests or walker for support if needed; avoid breath-holding ⸻ 3. Standing Heel Raises (with support) * Purpose: Improves lower leg strength and balance for safer walking * How to Do It: Holding onto a countertop or walker, raise heels off the ground slowly, hold for 2 seconds, then lower. * Reps: 10 reps * Tip: Keep knees straight, don’t lean forward; rest if SOB develops