Clinical Applications Across the Lifespan

Transcription

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 The patient is a 41-year old male marathon runner who presented to the ER with acutely evolving motor and sensory deficits resulting in motor neuropathy, flaccid paralysis of UEs and LEs, and loss of deep tendon reflexes (DTRs). Patient was absent of fever, tachycardia, and cardiac arrhythmias. Upon admission patient s BP=100/65, RR=15, O2 saturation = 88%, pain level 8/10 in BLE. Medical treatment included a combination of intravenous administration of immunoglobulins, plasmapheresis, and corticosteroids. Peak impairment occurred at two weeks. Once stabilized, patient was transferred to an acute rehabilitation facility. Subjective Patient reports he is a sales representative for a computer storage firm. He states he was training for a marathon during the time in which his symptoms began. He was above-average preexisting level of fitness. Patient has good family support. Patient states he experiences frequent bouts of fatigue and recently experienced a 15-lb weight loss. Patient states his goals for his stay at the acute rehabilitation facility is to return to living IND and to return to walking. His long-term goal is to continue training for a marathon. Objective Patient s vital signs seated: BP: 120/77 HR taken at radial pulse: 65 BPM SPO2 taken on right index finger: 96% on room air ROM: Patient in supine PROM: BLEs: Pt WNL throughout all ranges BUEs: Pt WNL throughout all ranges MMT: BLEs: 0/5 throughout all ranges BUEs: 4/5 throughout all ranges Assessment Patient denies current fever, chills, or sweating. His cardiopulmonary examination was unremarkable. He denies chest pain or SOB. Patient shows good skin color and no signs of redness or swelling, and no scars or incisions are noted. DTRs were absent for patellar tendon and Achilles tendon reflexes. Patient is alert and oriented. Patient shows excellent knowledge of his illness. -4-

5 Patient requires MIN A x 1 person with BLE for bed mobility, sit to supine, and supine to sit. Patient requires MIN A for set up and placement of slideboard. Patient requires MIN A x 1 person to transfer bed to wheelchair and wheelchair to bed with slideboard. Patient unable to complete stand pivot transfer at this time. Patient unable to ambulate at this time. Patient s primary mode of locomotion is wheelchair propulsion. Patient able to propel wheelchair 30 feet supervised; demonstrates signs and symptoms of fatigue with this task. STG: Will participate with three hours of activity daily STG: Will transfer bed to w/c and w/c to bed, IND with slide board STG: Propel w/c 300 ft, IND to attend therapy sessions in the gym STG: Will participate in 6 minutes of cardiovascular training STG: Will ambulate 8 feet in parallel bars MIN A x 1 person LTG: Will SPT transfer bed to w/c and w/c to bed IND LTG: Will ascend/descend 4 steps with least restrictive A.D. to safely enter and exit his home at time of discharge LTG: Will ambulate 50 feet using least restrictive A.D. for IND household mobility LTG: Participate with 6 hours of activity daily to return to work in computer sales Plan 1. Neuromuscular re-education 2. PNF, AAROM and AROM therapeutic exercise 3. Pre-gait and gait activities 4. Transfer activities 5. Cardiovascular conditioning 6. Functional activity training 7. Educate on energy conservation techniques Precautions Monitor vital signs Monitor for overuse and fatigue Fall risk -5-

6 Please answer the following questions regarding this patient: 1. What PNF patterns/principles, AAROM and AROM exercises would you use during Week 1 therapy sessions to achieve the stated goals. Provide a rationale for and detailed explanation for each. 2. Is cardiovascular fitness appropriate at the start of therapy during Week 1? Why or why not? If so, what equipment do you recommend? Provide a rationale for your answer. 3. Are there any other activities from the POC you would incorporate into Week 1 therapy sessions? Which ones? 4. What activities from the POC would you choose to progress patient to achieve STGs? Provide a rationale for your answer. You have been the primary PTA during the first few weeks of patient s therapy. It is now Week 3. Patient s current level of function is IND with all transfer activities w/slide board. He is able to propel a w/c IND 300 ft to the therapy gym. Patient static stands in parallel bars 3-5 minutes and ambulates 8 feet in parallel bars, CGA. However, patient requires frequent rest breaks during therapy sessions and tolerates 2 hours of activity. Towards the end of Week 3, patient presents with a decline in function and medical status. During one particular morning therapy session, BP decreases to 95/65, HR increases from 65bpm to 87bpm and oxygen saturation decreases to 87% on room air during cardiovascular activities. 5. Would you discuss this patient with you supervising therapist? Why or why not? 6. What information would you provide to the supervising therapist? 7. Would you present the recommendation of a nursing/physician referral at this time? Why or why not? Provide a rationale for your answers. -6-

7 After your discussion with the supervising therapist, a referral is made to nursing/physician. Patient is returned to the ER, stabilized and returned to the facility later that night. The supervising therapist reassesses the patient the next morning and recommends continuation of physical therapy services. Patient s level of function is IND with all transfer activities w/slide board. He is able to propel a w/c IND 300 ft to the therapy gym reporting minimal fatigue. POC is continued as previously established. 8. Based on the patient s current level of function, detail cardiovascular activities, gait training activities, functional strength activities, and advanced neuromuscular activities to progress patient and achieve LTGs preparing patient for discharge. Patient is now at end of Week 6, IND with all bed mobility skills, and completes SPT transfer IND to/from sit/stand and to/from a wheelchair to bed and bedside chair. Patient IND propels w/c 500 feet using UEs and LEs. He is able to ambulate 150 feet w/fww MOD I and negotiates curbs, stairs, ramps and uneven surfaces. He is also able to ascend/descend 4 stairs IND with one handrail. 9. What recommendations would you make to the supervising therapist regarding this patient s discharge? What adaptive equipment would you recommend? Provide a rationale for your answer. 10. Design a HEP for this patient. -7-