Clinical Applications Across the Lifespan

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Ophelia Webster
6 years ago
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1 Content & Format Case studies will be presented by groups of five people. Groups and clinical cases will be randomly assigned. Please carefully read the patient case study and respond to all questions as thoroughly as possible. Though it is important to be succinct in your writing, beware not to exclude any important details. Be sure to include a rationale for your answers where it is asked. You should work together as a group. Many of the questions have several possible correct answers. Sometimes a correct answer is not readily apparent. Use your best judgment, and openly discuss all ideas and options before deciding on a response. For every answer you give, you should always ask yourselves Why is this the best answer? You will submit your answers on a separate sheet of paper. Answers will be typed, double-spaced, with a minimum of 11 point type. Selected groups will present their patient to the class each week. A class discussion will follow. The presenting group can compare their ideas and answers with those of the class. HOMEWORK ASSIGNMENT: Entire class will be required to answer questions pertaining to the presentation. In order receive full credit for the homework assignment, questions will need to be answered accurately, thoroughly, and provide a rationale for the answer. Grading Each case study is graded on a 150 point scale. Format 25 All format criteria are followed according to established guidelines 20 Most format criteria are followed according to established guidelines 15 Some format criteria are followed according to established guidelines 10 Few format criteria are followed according to established guidelines 5 Little to no format criteria are followed according to established guidelines -1-

2 Focus and Purpose of Narrative 25 Well developed and clear, relevant statements that engage the reader 20 Well developed ideas in narrative 15 Mostly good ideas, but expression is weak 10 Mostly simplistic, unfocused ideas. Little or no sense of overall purpose 5 Ideas are extremely simplistic, showing signs of confusion and lack of purpose Writing Mechanics 25 Virtually free of punctuation, grammatical and spelling errors. Formatting is appropriate 20 Occasional punctuation, grammatical, spelling, and/or formatting errors 15 Contains a moderate amount of punctuation, grammatical, spelling, and/or formatting errors 10 Contains several punctuation, grammatical, spelling, and/or formatting errors 5 Contains serious errors in punctuation, grammar, spelling, and/or formatting Response to Questions 25 Answers all questions accurately and thoroughly. Provides a rationale for answers, when requested 20 Answers all questions thoroughly, though accuracy and/or rationale may contain some errors 15 Answers all questions. Responses are not thorough. Contains a moderate amount of errors or misjudgments 10 Does not answer all questions and is not thorough or accurate. 5 Minimal effort in responses. Contains significant errors or misjudgments -2-

3 Homework Assignment - Summary of Presentation 50 Answers questions accurately and thoroughly. Provides a rationale for answers, when requested 40 Answers questions thoroughly, though accuracy and/or rationale may contain some errors 20 Answers questions. Responses are not thorough. Contains a moderate amount of errors or misjudgments 30 Does not answer all questions and is not thorough or accurate 10 Minimal effort in responses. Contains significant errors or misjudgments Total Points: /150-3-

4 Patient Scenario A 65 year-old white female was admitted to the hospital with a diagnosis of acute bacterial pneumonia. She was treated with mechanical ventilation for 5 days, steroids, antibiotics, and bronchodilators. After the acute care hospital stay of 7 days, the patient was transferred to a rehabilitation facility for 5 days. She is now referred to outpatient therapy. Past Medical History: COPD, pneumonia x 4 over the past 2 years, s/p lumpectomy of right breast 8 years ago, smoking history of 45 pack/years. Quit on day of admission to hospital for acute bacterial pneumonia. Subjective Patient is a Secretary and works 32 hours a week. She is presently on medical leave. She lives with husband at home. The house has a ramp to front door and 6 stairs within home. Patient s desired functional outcome is to be oxygen free and able to care for grandchildren without shortness of breath. Objective Medications: 2 L/min 02, Atrovent 4 puffs AID, Ventilin PRN, prednisone 5mg/d. Mental status: Awake, alert, talks in 3-4 words sentences. Adequate historian. Chief complaint is shortness of breath limiting function. Ambulation: Patient is able to walk short distances MOD I (w/fww) before needing to rest to catch her breath. No complaints of increased secretions. Baseline Dyspnea Index: Functional impairment: Grade 1 Magnitude of Task: Grade 1 Magnitude of Effort: Grade 1 Vital Signs (seated): HR = 72bpm BP = 117/79 02sats = 98%, 2L/min 02, nasal cannula -4-

5 Vital Signs (during activity): HRmax = 121bpm BP = 121/81 02sats = 90%, 2L/min 02, nasal cannula Observation, Inspection, Palpation: Thin, frail-looking female wearing nasal cannula. Kyphosis noted. Patient uses posture of forward sitting with arms supported to enhance ventilator accessory muscle use. Increased AP diameter; increased accessory muscle use. Labored, symmetrical breathing pattern. No venous distention, no edema, no cyanosis, no digital clubbing evident. Ascultation: Decreased breath sounds throughout both lung fields, especially at bases. End expiratory wheezes at left lateral base. Strength: LE MMT: Grossly 4/5, except bilateral quadriceps strength 3/5 UE MMT: Grossly 4/5 Functional Independence Measurements (FIM Scores): Ambulation: 6 (modified independence slow gait with pacing necessary) Stairs: 6 (modified independence requires pacing and railing) Patient is dependent in shopping, house cleaning, and laundry Exercise Test Data: Patient performed a 7-minute staged exercise test using a modified protocol. Miles per hour was held constant at 2mph, grade increased from 0% to 2-3%. RHR was 84 bpm; HRmax was 121 bpm. 02 saturation was 98% on 2 L/min nasal cannula. 02saturation decreased to 93% at max exercise and decreased to 90% during the first minute of cool down on 2 L/min nasal cannula. Rate of perceived shortness of breath at max exercise was 7 on the BORG RPE 10-Point Scale. Exercise was terminated due to patient request. Laboratory Test Data: None available. -5-

6 Assessment Patient s mobility is limited as walks short distances before needing to rest to catch her breath. No complaints of increased secretions. Patient s vital signs are WNL while seated and during activity with 2L/min 02. Patient uses accessory muscles for breathing demonstrating forward sitting posture and labored breathing. Patient s strength is WNL, expect for bilateral quadriceps muscles which are graded as Fair causing limited strength in BLE for mobility; patient s gait is slow and patient requires pacing to complete functional activities. Patient s RPE is very strong during activity (Modified Borg 10-point Scale). Prognosis: Patient s rehab potential is fair given the progressive nature of COPD. Short Term Goals: 1. Patient will increase bilateral quadriceps strength to 3+/5 in 2 weeks 2. Patient will be independent in airway clearance prior to coming to pulmonary rehabilitation 3. Patient will able to walk > 1min IND before needing to rest to catch her breath 4. Patient will be IND on self pacing activities and Modified BORG 10-Point Scale 5. Patient will increase FIM Score to 7 to ambulate without an A.D. Long Term Goals: 1. Patient will ascend/descend 6 stairs IND with or without rail to functionally negotiate stairs in home 2. Patient will IND ascend/descend ramp to/from front door to functionally negotiate entering/exiting her home 3. Patient will be able to ambulate 15 minutes at 2mph with an RPE of 5 on the Modified BORG 10- Point Scale within 4 weeks for IND shopping, house cleaning, and laundry 4. Patient will increase Baseline Dyspnea Index as follows: Functional Impairment: Grade 3, Magnitude of Task: Grade 3; Magnitude of Effort: Grade 2 to improve performance of safe/functional activities 5. Patient will be IND in HEP Plan 1. Therapeutic Exercise: Aerobic training/conditioning, strength training/conditioning, stretching exercises 2. Gait training, including stairs 3. Balance activities 4. Secretion removal techniques 5. Breathing exercises and ventilator muscle training 6. Educate patient on self pacing activities and BORG RPE 10-Point Scale 7. HEP 8. Patient will be seen 3x/week for 6 weeks. -6-

7 Precautions: 1. Fall risk 2. Monitor vital signs 3. Monitor 02 levels 4. Monitor RPE Please answer the following questions regarding this patient: 1. How does exercise prescription differ for a patient with mild pulmonary disease and the patient with severe pulmonary disease? 2. What exercise interventions would you use with this patient during pulmonary rehabilitation sessions? How do you know when to progress an exercise program for a patient with COPD? What is the nature of that progression? When is another exercise test warranted? 3. Describe, in detail, how you would educate this patient on self pacing activities and Modified BORG 10-Point Scale 4. Design and describe, in detail, a secretion removal treatment plan for this patient that she can carry out prior to coming to pulmonary rehabilitation. As one of her goals is to be oxygen free and able to care for grandchildren without shortness of breath. At the end of Week 3 of her therapy sessions, she arrives at the clinic without her oxygen. After checking patient s vital signs in sitting, she presents as follows: HR = 90bpm BP = 140/90 Oxygen Saturation = 88%, room air 5. Would you report this information to your supervising therapist? Why or why not? Provide a rationale for your answer. At this point, you place the patient back on her oxygen as prescribed by the physician and let the patient rest, seated for 10 minutes. You take her vital signs again in seated. She presents as follows: HR = 74bpm BP = 118/79 Oxygen Saturation = 96%, 2L/min, nasal cannula -7-

8 6. Based on her vital signs, would you continue to proceed with her scheduled therapy session? Why or why not? Would you educate the patient on continuing to use oxygen? Why or why not? Also, do you think it necessary to contact the patient s primary care physician to report the patient s non-compliance with oxygen use? Why or why not? Provide a rationale for your answers. 7. Describe, in detail, treatment interventions for this patient to achieve her STGs 8. Is circuit training appropriate for this patient? Why or why not? Provide a rationale for your answer. 9. Describe, in detail, treatment interventions for this patient to achieve her LTGs 10. Design a well-rounded HEP for this patient -8-

Clinical Applications Across the Lifespan

Clinical Applications Across the Lifespan Content & Format Case studies will be presented by groups of five people. Groups and clinical cases will be randomly assigned. Please carefully read the patient case study and respond to all questions