Clinical Assessment Quiz 1

Clinical Assessment

systematic process of gathering and analyzing information about a patient/client to understand their condition and guide clinical decision making

Examination

the process of gathering information about a patient/client through the history, systems review and selection and administration of appropriate tests and measures

Evaluation

making judgements based on the data to form a diagnosis, prognosis, and plan of care

components of a patient examination

1) history

2) systems review

3) tests and measures

4) observation (throughout)

History

gathering of data from both the past & present —> why the patient is seeking the services of PT

Collect Info

open ended questions, specific questions, chart review, self report measures

Systems Review

part of examination that identifies possible health problems that require consultation with, or referral to another provider

• a brief exam of the anatomic and physiologic status of major body systems (myotomes)

• Why do it = is your patient appropriate for PT services

Screening

to identify the small prevalence of individuals who will require additional medical management

Things to do in system review

• Heart Rate, BP, Pulse Ox (SpO2)

• gross observation

• Upper quarter screen

• lower quarter screen

Tests and measures

the means of gathering specific data about the individual

observation

throughout the exam, helps guide diagnostic deductions and further examination

Measurement

the act of converting observations into data—> classifying, counting, ranking, and quantifying Ex: BP or Weight

Level of Measurement

how the measurement is classified

• nominal

• ordinal

• interval

• ratio

Types of measurement scales

Nominal: named values that are not ordered

Ordinal: named values that are ordered

Interval: distances between each value is equal

Ratio: distance between each value are equal and there is a true zero

Outcomes

the actual results of implementing the plan of care that indicate the impact on functioning

Outcome Measure

a measure used to assess the effect, both positive and negative, of an intervention or treatment

Patient Centered Communication

emphasizes understanding the patient’s unique experience

respecting each patient’s individual values, priorities, and concerns

communication

the process of exchanging information between individuals

• verbal, non verbal, written, visual

effective non-verbal communication

maintain a physical distance (18 inches to 4 feet)

eye level eye contact

attentive posture

First Interaction: AIDET +

A: acknowledge the patient by name

I: introduce yourself and your qualification

D: duration of session

E: explain what you would like to do and why

T: thank the patient

+: your commitment to the patient’s shared care experience

goals of AIDET+

patient to feel seen, respected, in control

patient to know what will happen and expect

to prioritize well being

3 Step Consent to touch

1) what you plan to do (and time frame)

2) why you plan to do it

3) seek consent to touch

short term positioning

positioning during a therapy intervention, exam, or activity

long term positioning

patient needs to remain in one position for an extended period

are unable to move voluntarily in a way that maintains health

WNL (within normal limits)

a person’s ability to do something compared to same age peers’ ability is the same or in a range of the normal ability of that skill

WFL (within functional limits)

outside of the normal range, but it is sufficient for activities of daily living

infection

the process by which the microorganism establishes a parasitic relationship with it host

soiled

the presence of pathogens or the possibility of exposure to pathogens

clean

a state of minimized infectious organisms (pathogens)

cleanliness

the attempt to minimize contamination and prevent the spread of infection through good hand hygiene, personal hygiene, and cleaning

Chain of Infection

1) infectious agents

2) reservoirs

3) portals of exit

4) modes of transmission

5) portals of entry

6) susceptible host

infectious agents

bacteria

fungi

parasites

prions

reservoirs

people

water

food

portals of exit

blood

secretions

excretions

skin

modes of transmission

physical

contact

droplets

airborne

portals of entry

mucous membrane

respiratory system

digestive system

broken skin

susceptible host

immune deficiency

diabetes

burns

surgery

age

types of pathogens

1) viral (most frequently encountered)

2) bacterial (most frequently encountered)

3) parasitic

4) fungal

5) prion disease

environments for proliferation

dark, warm, moist

transmission

1) contact

• direct

• indirect

2) droplet

3) airborne

contact transmission

direct

• physical transfer of pathogens directly from one to another

indirection

• a contaminated person touches an object/person and passes pathogens

• a person then becomes contaminated by touching the object/person

droplet transmission

large droplets encountering the host’s conjuctivae or mucus membrane of nose or mouth

droplets generated by coughing, sneezing, talking, or procedures

travel through the air at a short distance

Airborne

dissemination of small particles containing infectious agents that are inhaled or deposited on a host

may be in the air for a long time

types of isolation precautions

1) standard (with all patients)

2) transmission based/special

• contact

• droplet

• airborne

standard precautions

required with all patients

1) hand hygiene

2) respiratory hygiene

3) PPE

hand hygiene

the cleaning of or antimicrobial action on the hands

Hand rubbing

20-30 seconds

having hand sanitizer available increases use

hand washing

40-60 seconds, warm water

• when matter is visible = blood/dirt

• in presence of enteric infections (C difficile)

• after multiple applications of hand rub > 10 uses

Hand Rubbing: 20 -30 seconds

1) apply product in palm

2) rub hands palm to palm

3) right palm over left with fingers interlaced

4) left palm over right with fingers interlaced

5) palm to palm with fingers interlaced

6) back of fingers to opposing palm with fingers interlocked

7) roational rubbing of left thumb in right palm

8) rotational rubbing of right thumb in left palm

9) rotational rubbing backwards and forwards w/ clasped fingers of right hand in left palm

10) wait until dry

Hand Washing: 40-60 seconds

1) wet hands w/ water

2) apply soap to cover hands

3) rub hands palm to palm

4) right palm over left

5) left palm over right

6) palm to palm w/ fingers interlaced

7) back of fingers to opposing palms

8) rotational rubbing of left thumb

9) rotational rubbing of right thumb

10) rotational rubbing backwards & forwards w/ clasped fingers of right hand in left palm

11) rinse w/ water

12) use single use towel

13) use towel to turn off faucet

5 moments of hand hygiene

1) before touching patient

2) before clean procedure

3) after body fluid exposure

4) after touching a patient

5) after touching patient surroundings

PPE

choice of PPE is determined by the likelihood of encountering body fluids and contaminated areas by how known or suspected pathogens are transmitted

contact precautions

1) clean hands

2) gown

3) gloves

4) clean hands with soap and water on exit

droplet precautions

1) wash hands

2) gown

3) gloves

4) ear loop mask

5) eye shield

airborne precautions

1) wash hands

2) N95 mask

3) wash hands

Special Airborne/Contact Precautions

1) wash hands

2) gown

3) gloves

4) N95 masks

5) eye protection

6) use disposable or patient dedicated equipment

• clean shared equipment

Donning PPE

1) hand hygiene

2) gown

3) face mask

4) eye protection

5) gloves

Doffing PPE

1) gloves

2) gown

3) hand hygiene

4) eye protection

5) face mask

6) hand hygiene

mobility

the ability to move

• move = to change location

locomotion

getting from one place to another

patient guarding

to watch over in order to protect against damage or harm

patient assistance

the action of helping someone

• we can measure the level of assists a patient requires

center of mass

an object’s balance point

line of gravity

an imaginary vertical line from the center of mass to the ground or surface the object or person is on

base of support

the contact area of an object

• can include the body and/or object that is supporting the body

pressure

applying force over a larger area decreases the pressure

stability

BoS is larger

LoG is at or near BoS

CoM is at or near BoS (both low and close)

mobility

BoS is smaller

LoG moves beyond the center of BoS

distance of the CoM above the BoS is greater

Measurement of Vital Status

objective measurements of the body’s fundamental, life sustaining functions

Typical Vital Signs

Pulse Rate (PR)

Blood Pressure (BP)

Oxygen Saturation

Respiration Rate (RR)

• some consider temperature and pain

additional measurements of vital status

alertness and orientation (A&O)

• reflecting the brain’s functional state

When to assess vitals

system review

all new patient evaluations

maybe during PT interventions —> cardiopulmonary risk factors

patient has abnormal response to activity

Blood Pressure

the assessment of blood pressure provides

• effectiveness of the heart pump

• resistance to blood flow

• recorded in mmHg

• systolic BP/ diastolic BP

BP Background

pressure exerted by the blood on the walls of the blood vessels

peak pressure during contraction of left ventricle or systole provides systolic pressure (top number)

the lowest pressure in arteries during cardiac relaxation provides the diastolic pressure ( bottom number)

BP Equipment

width of bladder be 40% of circumference of arm

length of bladder be 80% of arm’s circumference

BP Prep

1) seated position w/ forearm at level of heart

2) uncrossed feet and back supported

3) patient rest for 1-2 minutes

4) palpate for brachial artery

5) midline cuff bladder in line with brachial artery & lower edge is 2-3 cm above the antecubital fossa

BP Prep Part 2

1) obliterate the pulse by first finding radial artery

2) inflate cuff until pulse disappears

3) quickly deflate cuff and wait 1-2 mintues

BP Steps

1) stethoscope in ears and diaphragm over brachial artery

2) inflate cuff 30 mmHg above point at radial pulse disappeard

3) released pressure at a 2-3 mmHg per second

4) first whoosing sound = systolic

5) final whoosing sound = diastolic

Normal BP

<120 and <80

High-Normal/Elevated

120-129 and <80

Stage 1 Hypertension

130-139 or 80-89

Stage 2 Hypertension

_>140 or _>90

Hypertensive Crisis

_>180 and/or >120

BP Communication

location taken

side of body

patient position

systolic/diastolic in mmHg

classification (ordinal scale)

BP Communication Example

Sitting, rest, R brachial BP: 117/65 mmHg, normal

BP Test Properties

accuracy dependent upon performing each step

manual blood pressures is more accurate than automatic BP

• automatic may reduce human error

Causes of Falsely Low Reading

cuff too large

arm above heart

pressure gauge below eye level

stethoscope applied too firmly

deflation too fast

underestimating inflation level

causes of falsely high reading

cuff too small

arm below heart

back unsupported

legs dangling

pressure gauge above eye level

deflation too slow

Alternate Methods of BP

arterial line = direct measurement

doppler/US blood pressure

automatic

Pulse Rate (PR)

the number of pulsations per minute (frequency)

left ventricle contracts, blood is ejected into the aorta and into the body = this pulse wave can be palpated

simplest way

Heart Rate (HR)

the electrical activity that occurs in the heart

reported from an electrocardiogram (ECG/EKG)

most accurate way

Radial Pulse

lateral side of anterior surface of wrist

index and middle finger flatly and lightly on artery

??

Rate

number of times the heart contracts (beats/min)

Rhythm

regularity of the contractions

Force

indicator of the strength of contraction of the left ventricle and volume of blood within the peripheral vessels

<60 beats/minute

Bradycardia

60-100 beats/minute

normal

>100 beats/minute

tachycardia

Nominal

Regular or Irregular

Absent

0

no perceptible pulse