Cardiopulmonary.

Preferred Practice Patterns: Cardiopulmonary

The following patterns describe the elements of patient/client management provided by physical therapists -- examination (History, systems review, and tests and measures). evaluation, diagnosis, prognosis, and intervention (with anticipated goals) -- in addition to reexamination, outcomes, and criteria for discharge.

Primary Prevention/Risk Factor Reduction for Cardiopulmonary Disorders

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients with decreased maximum aerobic capacity who are at risk for developing cardiac disease, pulmonary disease, or both, based on well-accepted risk factor profiles that have been published in the literature.

INCLUDES patients/clients who may have several of the following:

* Diabetes

* Family history of heart disease

* Hypercholesterolemia or hyperlipidemia

* Hypertension

* Obesity

* Significant smoking history

EXCLUDES patients/clients with:

* Known diagnosis of heart disease

* Known diagnosis of pulmonary disease

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client dignostic group is defined by impairments functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

250 Diabetes mellitus 272 Disorders of lipoid metabolism

272.0 Pure hypercholesterolemia 278 Obesity and other hyperalimentation

278.0 Obesity 305 Nondependent abuse of drugs

305.1 Tobacco use disorder 401 Essential hypertension

Factors Influencing Health Status and Contact With Health Services

V17 Family history of certain chronic, disabling diseases

V17.4 Other cardiovascular diseases

Examination

Through the examination (history, systems review, and measures) the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patients/ client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

* Sleep patterns and positions

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits (Past and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review

The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, effect, cognition, lanquage, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of autonomic responses to positional changes

* Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales

* Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test)

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Auscultation of the heart

* Auscultation of the lungs

* Auscultation of major vessels for bruits

* Claudication time tests

* interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Palpation of pulses

* Performance or analysis of an electrocardiogram

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Anthropometric Characteristics

* Measurement of body fat composition, using calipers, underwater weighing tanks, or electrical impedance

* Measurement of height, weight, length, and girth

Community and Work (Job/School/Play) integration or Reintegration (Including IADL)

* Analysis of community, work (job/school/play), and leisure activities

* Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment

* Analysis of environment and work (job/school/play) tasks

* Assessment of functional capacity

* Assessment of physiologic responses during community, work (job/school/play), and leisure activities

* Assessment of safety in community and work (job/school/play) environments

* Observation of response to nonroutine occurrences

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

Ergonomics and Body Mechanics

Ergonomics:

* Assessment of safety in work (job/school/play) environments

* Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status

* Assessment of work (job/school/play) performance through batteries of tests

* Determination of dynamic capabilities and limitations during specific work (job/school/play) activities

Muscle Performance (Including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Analysis of muscle strength, power, and endurance, using manual muscle testing or dynamometry

Posture

* Analysis of resting posture in any position

* Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography. videotape. or visual analysis

Range of Motion (ROM) (Including Muscle Length)

* Analysis of ROM using goniometers, tape measures, flexible rules, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging

Ventilation, Respiration (Gas Exchange), and Circulation

* Analysis of thoracoabdominal movements and breathing patterns at rest, during activity and during exercise

* Assessment of ability to clear airway

* Assessment of capillary refill time

* Assessment of chest wall mobility, expansion, and excursion

* Assessment of cough and sputum

* Assessment of perceived exertion and dyspnea

* Assessment of phonation

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of ventilatory muscle strength, power, and endurance

* Assessment of cyanosis

* Auscultation of the heart

* Auscultation and mediate percussion of the lungs

* Interpretation of blood gas analysis or oxygen consumption (VO.sub.2) studies

* Palpation of pulses

* Tests and measures of pulmonary function and ventilatory mechanics

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent. of loss of function social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the path" level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/client based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability If prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Patient/client will demonstrate independence in an aerobic exercise program and be able to identify personal risk factors for cardiopulmonary disease and the methods he or she will use to reduce risk.

Expected Range of Number of Visits Per Episode of Care 1 to 6 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within I to 6 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Modify Frequency of Visits

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioecomic stressors

* Support provided by family unit intervention

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determined the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, organization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of client and use of health care resources by patient/client, family, significant others, and caregivers.

Specific interventions

* Communication (direct or indirect)

* Coordination of care with client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of client management

* Education plans

* Referrals to other professionals or resources

Patient/client-related instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Client knowledge of personal and environmental factors associated with the condition is increased.

* Decision making is enhanced regarding health of client and use of health care resources by client.

* Performance levels in employment, recreational, or leisure activities are improved.

* Physical function and health status are improved

* Utilization and cost of health care services are decreased.

Specific interventions

* Computer-assisted instruction

* Demonstration by client in the appropriate environment

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct interventions Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Aerobic capacity is increased.

* Physical function and health status are improved.

* Physiologic response to increased oxygen demand is improved.

* Strength, power, and endurance are increased.

* Symptoms associated with increased oxygen demand are decreased.

Specific Direct Interventions

* Aerobic endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Aquatic exercises

* Body mechanics and ergonomics training

* Breathing exercises

* Conditioning and reconditioning

* Posture awareness training

* Strengthening:

- active

- active assistive

- resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Stretching

Functional Training in Self-care and Home Management (Including ADL and IADL)

Anticipated Goals

* Performance of and independence in ADL and IADL are increased.

Specific Direct interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

Functional Training in Community and Work (Job/School/Play) Integration or Reintegration (Including IADL, Work Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased.

* Risk of recurrence of condition is reduced.

Specific Direct interventions

* Ergonomic stressor reduction training

* Injury prevention or reduction training

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment ,primary or secondary prevention, and patient client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Health-related quality of life is enhanced.

* Optimal role function (eg, worker, student, spouse, grandparent) is maintained.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of prevention strategies is demonstrated.

Client Satisfaction

* Access, availability and services provided are acceptable to client.

* Administrative management of practice is acceptable to client.

* Clinical proficiency of physical therapist is acceptable to client.

* Coordination and conformity of care are acceptable to client.

* Interpersonal skills of physical therapist are acceptable to client, family, and significant others.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referml. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Impaired Aerobic Capacity and Endurance Secondary to Deconditioning Associated With Systemic Disorders

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients with impaired aerobic capacity associated with systemic disorders that impair mobility or interfere with systemic response to increased oxygen demand. Patients/clients may have any one or a combination of the following:

* Decreased ability. To perform endurance conditioning

* Decreased independence in activities of daily living (ADL) or instrumental activities of daily living IADL)

* Immediate prior history, of bed rest for more than 48 hours

* Increased symptoms with increased activity

* History of inactivity secondary. To systemic impairment

INCLUDES patients/clients with:

* Acquired immune deficiency syndrome (AIDS)

* Cancer

* Cardiopulmonary disorders

* Chronic system failure

* Multisystem impairments

* Musculoskeletal disorders

* Neuromuscular disorders

EXCLUDES patients/clients with:

* Acute cardiovascular pump failure

* Acute respiratory failure

* Airway clearance impairment

* Mechanical ventilation

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to two preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations are not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases. Ninth Revision, Clinical Modification ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes add instructions regarding fifth-digit requirements.

042 Human immunodeficiency virus [HIV] disease Acquired immune deficiency sydrome [AIDS]

250 Diabetes mellitus

250.4 Diabetes with renal manifestations

250.8 Diabetes with other specified manifestations

250.9 Diabetes with unspecified complications

332 Parkinson's disease

333 Other extrapyramidal disease and abnormal movement

disorders

333.0 Other degenerative diseases of the basal ganglia

333.3 Tics of organic origin

333.4 Huntington's chorea

333.9 Other and unspecified extrapyramidal disease and

abnormal movement disorders

334 Spinocerebellar disease

334.2 Primary cerebellar degeneration

335 Anterior horn cell disease

335.2 motor neuron disease

335.20 Amyotrophic lateral sclerosis

340 Multiple sclerosis

344 Other paralytic syndromes

344.0 Quadriplegia and quadriparesis

357 Inflammatory and toxic neuropathy

357.0 Acute infective polyneuritis

Guillain-Barre syndrome

359 Muscular dystrophies and other myopathies

359.1 Hereditary progressive muscular dystrophy

443 Other peripheral vascular disease

443.9 Peripheral vascular disease, unspecified

482 Other bacterial pneumonia

482.2 Pneumonia due to Hemophiluss influenzae

482.9 Bacterial pneumonia unspecified

491 Chronic bronchitis

491.9 Unspecified chronic bronchitis

492 Emphysema

492.8 Other emphysema

493 Asthma

494 Bronchiectasis 496 Chronic airway obstruction, not elsewhere classified Chronic obstructive pulmonary disease [COPD], not otherwise specified

508 Respiratory conditions due to other and unspecified external agents

508.9 Respiratory conditions, due to unspecified

external agent 513 Abscess of lung and mediastinum

513.0 Abscess of lung

514 Pulmonary congestion and hypostasis

516 Other alveolar and parietoalveolar pneumonopathy

516.9 Unspecified alveolar and parietoalveolar

pneumonopathy,

517 Lung involvement in conditions classified elsewhere

517.8 Lung involvement in other diseases classified

elsewhere

518 Other diseases of lung

518.0 Pulmonary collapse

518.8 Other diseases of lung

518.89 Other diseases of lung, not elsewhere

classified

519 Other diseases of respiratory system

519.4 Disorders of diaphragm

711 Arthropathy associated with infections

712 Crystal arthropathies

713 Arthropathy associated with other disorders classified

elsewhere

714 Rheumatoid arthritis and other inflammatory

polyarthropaties

715 Osteoarthrosis and allied disorders

786 Symptoms involving respiratory system and other chest

symptoms

786.0 Dyspnea and respiratory abnormalities

Procedure Codes

34 Operations on chest wall, pleura, mediastinum, and

diaphragm

34.9 Other operations on thorax

34.99 Other

54 Other operations on abdominal region

54.9 Other operations of abdominal region

54.99 Other

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

* Sleep patterns and positions

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits Post and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review

The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of autonomic responses to positional changes

* Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test)

* Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of thoracoabdominal movements and breathing patterns with activity

* Auscultation of the heart

* Auscultation of the lungs

* Auscultation of major vessels for bruits

* Claudication time tests

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Monitoring via telemetry during activity

* Palpation of pulses

* Performance or analysis of an electrocardiogram

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Anthropometric Characteristics

* Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion

* Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy)

* Measurement of body fat composition, using calipers, underwater weighing tanks, or electrical impedance

* Measurement of height, weight, length, and girth

* Observation and palpation of trunk and extremities at rest and during activity

Arousal, Attention, and Cognition

* Assessment of orientation to time, person, place, and situation

* Screening for level of cognition (eg, to determine ability to process commands, to measure safety awareness)

Assistive and Adaptive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device

* Analysis of patient/client and caregiver ability to care for device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers or other professionals concerning use of or need for device

Community and Work (Job/School/Play) integration or Reintegration (Including IADL)

* Analysis of adaptive skills

* Analysis of community, work (job/school/play), and leisure activities

* Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Analysis of environment and work (job/school/play) tasks

* Assessment of autonomic responses to positional changes

* Assessment of functional capacity

* Assessment of physiologic responses during community, work (job/school/play), and leisure activities

* Assessment of safety in community and work (job/school/play) environments

* IADL scales or indexes

* Observation of responses to nonroutine occurrences

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of daily activities logs

* Review of reports provided by patient/client, family, significant others, caregivers, or other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers'

* Compensation claims manager, employer)

Environmental, Home, and Work (Job/School/Play) Barriers

* Analysis of physical space using photography or videotape

* Assessment of current and potential barriers

* Measurement of physical space

* Physical inspection of environment

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

Ergonomics and Body Mechanics Ergonomics:

* Analysis of performance of selected tasks or activities

* Analysis of preferred postures during performance of tasks and activities

* Assessment of safety in work (job/school/play) environments

* Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status

* Assessment of work (job/school/play) performance through batteries of tests

* Determination of dynamic capabilities and limitations during specific work (job/school/play) activities

* Ergonomic analysis of the work and its inherent tasks or activities, including:

- analysis of repetition/work/rest cycling during task or activity

- assessment of tools, devices, or equipment used

- assessment of vibration

- assessment of workstation

- computer-assisted motion analysis of performance of

selected movements or activities

- identification of essential functions of task or activity

- identification of sources of actual and potential trauma,

cumulative trauma, or repetitive stress

* Videotape analysis of patient/client at work (job/school/play)

Gait, Locomotion, and Balance

* Analysis of arthrokinematic, biomechanical, kinematic and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment

* Gait, locomotion, and balance profiles

Joint Integrity and Mobility

* Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks

* Assessment of soft tissue swelling, inflammation or restriction

Motor Function (Motor Control and Motor Learning)

* Analysis of gait, locomotion, and balance

* Motor assessment scales

* Physical performance scales

Muscle Performance (Including Strength, Power, and Endurance)

* Analysis of functional muscle strength

* Analysis of muscle strength, power, and endurance, using manual muscle testing or dynamometry

* Assessment of muscle tone

* Assessment of pain and soreness

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation

* Assessment of muscle soreness

* Assessment of pain perception (eg, phantom pain)

* Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales

Posture

* Analysis of resting posture in any position

* Analysis of static and dynamic postures, using computer-assisted imaging, posture girds, plumb lines, still photography, videotape, or visual analysis

Prosthetic Requirements

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Range of Motion (ROM) including Muscle Length)

* Assessment of muscle, joint, or soft tissue characteristics Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging

Self-Care and Home Management including ADL and IADL)

* ADL scales or indexes

* Analysis of adaptive skills

* Analysis of environment and tasks

* Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Analysis of self-care in unfamiliar environments

* Assessment of ability to transfer

* Assessment of autonomic responses to positional changes

* Assessment of functional capacity

* Assessment of physiologic responses during self-care and home management activities

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of daily activities logs

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals

Ventilation, Respiration (Gas Exchange), and Circulation

* Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise

* Assessment of ability to clear airway

* Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms

* Assessment of capillary refill time

* Assessment of perceived exertion and dyspnea

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of chest wall mobility, expansion, and excursion

* Assessment and classification of edema using volume and girth measurements

* Assessment of ventilatory muscle strength, power, and endurance

* Assessment of cyanosis

* Auscultation of the heart

* Auscultation and mediate percussion of the lungs

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Palpation of pulses

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing he diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Within 6 weeks, patient/client will demonstrate improved functional capacity and increased ability to perform activities of dad), living (ADL) and instrumental activities of daily living (IADL) without exacerbation of signs and symptoms, or patient/client will demonstrate an increase in muscle strength and endurance and an increase in exercise tolerance.

Expected Range of Number of Visits Per Episode of Care

5 to 26 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 5 to 26 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify

Frequency of Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. F o r clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

* Resources are maximally utilized.

Specific interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, f", significant others, and caregivers.

* Disability associated with acute or chronic illnesses is reduced.

* Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased.

* Patient/client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment, recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Progress is enhanced through the participation of patient/client, family, significant others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific interventions

* Computer-assisted instruction

* Demonstration by patient/client or caregiver in the appropriate environment

* Periodic reexamination and reassessment of the home program

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct Interventions

Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Aerobic capacity is increased.

* Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased.

* Physiologic response to increased oxygen demand is improved.

* Strength, power, and endurance are increased.

* Symptoms associated with increased oxygen demand are decreased.

Specific Direct Interventions

* Aerobic endurance activities using treadmill, ergometer, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Body mechanics and ergonomics training

* Breathing exercises and ventilatory muscle training

* Conditioning and reconditioning

* Developmental activities training

* Posture awareness training

* Strengthening

- active

- active assistive

- resistive, using manual resistance, pulleys, weights,

hydraulics, elastic resistance bands, robotics, and mechanical

or electromechanical devices

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and

IADL)

Anticipated Goals

* Ability, to recognize and initiate treatment of a recurrence is improved through increased self-management of symptoms.

* Ability, to perform physical tasks related to self-care and home management (including ADL and IADL) is increased.

* Performance of and independence in ADL and IADL are increased.

Specific Direct Interventions

* ADL training (eg, bed mobility, and transfer training, gait training locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* Assistive and adaptive device and equipment training

* IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy, household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Orthotic, protective, or supportive device training

Functional Training in Community and Work (Job/School/Play) integration or

Reintegration (Including IADL, Work Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased.

Specific Direct Interventions

* IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

Prescription, Application, and, as Appropriate, Fabrication of Devices and

Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and

Prosthetic)

Anticipated Goals

* Ability to perform physical tasks is increased.

* Performance of and independence in ADL and AIDL are increased.

* Physical function and health status are improved.

* Risk of secondary impairments is reduced.

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* Adaptive devices or equipment (eg, raised toilet seats., seating systems, environmental controls)

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints)

* Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)

* Prosthetic devices or equipment (eg, artificial limbs)

* Protective devices or equipment (eg, braces, protective taping, cushions, helmets)

* Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen)

Reexamination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of life is improved.

* Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with deconditioning associated with systemic disorders is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (AIDL) -- are performed safely, efficiently and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced.

Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Level of patient/client adherence to the intervention program is maximized.

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings.

* Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes had been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Impaired Ventilation, Respiration (Gas Exchange), and Aerobic Capacity

Associated With Airway Clearance Dysfunction

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, ace, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients with impaired airway clearance, respiration (gas exchange), or ventilation accompanied by impaired aerobic capacity and impaired function. Patients/clients may have any one or a combination of the following:

* Change in baseline breath sounds

* Change in baseline chest radiograph

* Dyspnea

* Impaired respiratory function

* Impaired gas exchange

* Impaired performance in activities of daily living (ADL) or instrumental activities of daily living (IADL)

* Increased work of breathing

* Pulmonary infection, including frequent or recurring infections

INCLUDES patients/clients with:

* Acute lung disorders

* Acute or chronic oxygen dependency

* Bone marrow/cell transplants

* Cardiothoracic surgery

* Chronic obstructive pulmonary disease (COPD)

* Solid-organ transplants (eg, heart, lung, kidney)

* Tracheostomy or microtracheostomy

EXCLUDES patients/clients with:

* Age of fewer than 4 months

* Mechanical ventilation

* Multisystem failure

* Respiratory failure

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instruction regarding fifth-digit requirements.

136 Other and unspecified infectious and parasitic diseases 136.3 Pneumocytosis Pneumonia due to Pneumocystis carinii 277 Other and unspecified disorders of metabolism 277.0 Cystic fibrosis 482 Other bacterial pneumonia 482.2 Pneumonia due to Hemophilus influenzae [H.influenzae] 482.9 Bacterial pneumonia unspecified 491 Chronic bronchitis 491.8 Other chronic bronchitis 491.9 Unspecified chronic bronchitis 492 Emphysema 492.8 Other emphysema 493 Asthma 494 Bronchiectasis 496 Chronic airway obstruction, not elsewhere classified Chronic obstructive pulmonary disease [COPD], not otherwise specified 500 Coal workers' pneumoconiosis 501 Asbestosis 502 Pneumoconiosis due to other silica or silicates 503 Pneumoconiosis due to other inorganic dust 504 Pneumonopathy due to inhalation of other dust 505 Pneumoconiosis, unspecified 507 Pneumonitis due to solids and liquids 507.7 Due to inhalation of food or vomitus Aspiration pneumonia 508 Respiratory conditions due to other and unspecified external agents 508.9 Respiratory conditions due to unspecified external agent 510 Empyema 511 Pleurisy 513 Abscess of lung and mediastinum 513.0 Abscess of lung 514 Pulmonary congestion and hypostasis 515 Postinflammatory pulmonary fibrosis 516 Other alveolar and parietoalveolar pneumonopathy 516.9 Unspecified alveolar and parietoalveolar pneumonopathy 518 Other diseases of lung 518.0 Pulmonary collapse 518.8 Other diseases of lung 518.89 Other diseases of lung, not elsewhere classified 759 Other and unspecified congenital anomalies 759.3 Situs inversus Kartagener's syndrome or triad 770 Other respiratory conditions of fetus and newborn 770.7 Chronic respiratory disease arising in the perinatal period Bronchopulmonary dysplasia 786 Symptoms involving respiratory system and other chest symptoms 786.0 Dyspnea and respiratory abnormalities 786.00 Respiratory abnormality, unspecified 786.5 Chest pain 786.52 Painful respiration 861 Injury to heart and lung 861.2 Lung, without mention of open wound into thorax 861.21 Contusion 996 Complications peculiar to certain specified procedures 996.0 Mechanical complication of cardiac device, implant, and graft 996.1 Mechanical complication of other vascular device, implant, and graft 996.2 Mechanical complication of nervous system device, implant, and graft 996.3 Mechanical complication of genitourinary device, implant, and graft 996.4 Mechanical complication of internal orthopedic device, implant, and graft 996.5 Mechanical complication of other specified prosthetic device, implant, and graft 996.8 Complications of transplanted organ 996.85 Bone marrow complications 997 Complications affecting specified body systems, not elsewhere classified 997.3 Respiratory complications

Factors Influencing Health Status and Contact With Health Services V42 Organ or tissue replace by transplant V42.0 Kidney V42.2 Heart valve V42.3 Skin V42.4 Bone V42.6 Lung V42.7 Liver V42.8 Other specified organ or tissue V42.81 Bone marrow V42.82 Peripheral stem cells V42.83 Pancreas V42.89 Other

Procedures 32 Excision of lung and bronchus 34 Operations on chest wall, pleura, mediastinum, and diaphragm 34.9 Other operations on thorax 34.99 Other 36 Operations on vessels of heart 36.1 Bypass anastomosis for heart revascularization 54 Other operations on abdominal region 54.9 Other operations of abdominal region 54.99 Other

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination. based on patient/client age; severity of the problem; stage of recovery acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or Work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may includes:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

* Sleep patterns and positions

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits (Past and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of autonomic responses to positional changes

* Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales

* Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test)

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of thoracoabdominal movements and breathing patterns with activity

* Auscultation of the heart

* Auscultation of the lungs

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Monitoring via telemetry during activity

* Pulse oximetry

* Tests and measures of pulmonary posture and ventilatory mechanics

Anthropometric Characteristics

* Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effussion

* Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy)

* Measurement of height, weight, length, and girth

Arousal, Attention, and Cognition

* Assessment of level of consciousness

* Assessment of orientation to time, person, place, and situation

Assistive and Adaptive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of patient/client and caregiver ability to care for device.

* Assessment of safety during use of device

* Review of reports provided by patient/client family, significant others, family, caregivers, or other professionals concerning use of or need for device

Community and Work (Job/School/Play) Integration or Reintegration (Including IADL)

* Analysis of adaptive skills

* Analysis of community, work (job/school/play), and leisure activities

* Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Assessment of automic responses to positional changes

* Assessment of functional capacity

* Assessment of physiologic responses during community, work (job/school/play), and leisure activities

* Assessment of safety in community and work (job/school/play) environments

* IADL scales or indexes

* Observation of responses to nonroutine occurrences

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer)

Cranial Nerve Integrity

* Assessment of gag reflex

* Assessment of swallowing

Environmental, Home, and Work (Job/School/Play) Barriers

* Analysis of physical space using photography or videotape

* Assessment of current and potential barriers

* Measurement of physical space

* Physical inspection of the environment

* Questionnaires completed by and interviews conducted with

* patient/client and others as appropriate

Integumentary Integrity For skin associated with integumentary disruption:

* Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin

* Assessment of sensation (eg, pain, temperature, tactile)

* Assessment of nail beds

For wound:

* Assessment of activities, positioning, and postures that aggravate the wound or scar or that may produce additional trauma

* Assessment of ecchymosis

Muscle Performance (Including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Analysis of muscle strength, power, and endurance, using manual muscle testing or dynamometry

* Assessment of pain and soreness

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while Patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Posture

* Analysis of resting posture in any position

* Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb fines, still photography, videotape, or visual analysis

Self-Care and Home Management (Including ADL and IADL)

* ADL or IADL scales or indexes

* Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Analysis of self-care in unfamiliar environment

* Assessment of functional capacity

* Assessment of physiologic responses during self-care and home management activities

* Review of daily activities log

Ventilation, Respiration (Gas Exchange), and Circulation

* Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise

* Assessment and classification of edema using volume and girth measurements

* Assessment of ability to clear airway

* Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms

* Assessment of capillary refill time

* Assessment of chest wall mobility, expansion, and excursion

* Assessment of cough and sputum

* Assessment of perceived exertion and dyspnea

* Assessment of phonation

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of ventilatory muscle strength, power, and endurance

* Assessment of cyanosis

* Auscultation of the heart

* Auscultation and mediate percussion of the lungs

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Palpation of chest wall (eg, tactile fremitus, pain, diaphrugmatic motion)

* Palpation of pulses

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Within 6 weeks, one of the following will occur:

* Patient/client will have an absence of secretions or will be able to clear secretions independently.

* Chest radiograph will return to baseline.

* Caregiver will be able to manage the secretions.

Expected Range of Number of Visits Per Episode of Care

5 to 30 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of Patients/clients in this diagnostic group will achieve the goals and outcomes within 5 to 30 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions man, be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, or other professionals;

* Decision making is enhanced regarding the health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific Interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Decision making is enhanced regarding health of patient/client and use of health care resources by patient,/client, family, significant others, and caregivers.

* Disability associated with acute or chromic illnesses is reduced.

* Functional independence activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcome are increased.

* Patient/client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment, recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Progress is enhanced through the participation of patient/client, family significant others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific Interventions

* Computer-assisted instruction

* Demonstration by patient/client or caregiver in the appropriate environment

* Periodic reexamination and reassessment of the home program

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct Interventions

Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Aerobic capacity is increased.

* Airway clearance is improved.

* Atelectasis is decreased.

* Energy expenditure is decreased.

* Physical function and health status are improved.

* Pyschologic response to increased oxygen demand is improved.

* Quality and quantity of movement between and across body segments are improved

* Risk of recurrence of condition is reduced.

* Strength, power, and endurance are increased.

* Tissue perfusion and oxygenation are improved,

* Work of breathing is decreased.

Specific Direct Interventions

* Aerobic endurance activities using ergometers, treadmill, steppers, pulleys, weights, hydraulics, elastic resistance bands robotics, and mechanical or electromechanical devices

* Balance and coordination training

* Body, mechanics and ergonomics training

* Breathing exercises and ventilatory muscle training

* Conditioning and reconditioning

* Developmental activities training

* Neuromuscular relaxation, inhibition, and facilitation

* Posture awareness training

* Strengthening:

- active

- active assistive

- resistive, using manual resistance, pulleys, weights,

hydraulics, elastic resistance bands, robotics, and mechanical

or electromechanical devices

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and IADL)

Anticipated Goals

* Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Safety is improved during performance of self-care and home management tasks and activities.

Specific Direct Interventions

* ADL training (eg, bed mobility and transfer training,, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* Assistive and adaptive device and equipment training

* IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Orthotic, protective, or supportive device training

Functional Training in Community and Work (Job/School/Play) integration

or Reintegration (Including IADL, Work Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work job/school/play) integration and reintegration and leisure tasks. movements, or activities is increased.

* Costs of work-related injury or disability are reduced.

* Safety is improved during performance of community and work (job/school/play) tasks and activities.

Specific Direct Interventions

* Assistive and adaptive device and equipment training

* Environmental, community. work job/school/play), or leisure task adaptation

* Injury prevention or reduction training

* IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments)

* Orthotic,. protective, or supportive device and equipment training

Prescription, Application, and, as Appropriate, Fabrication of Devices

and Equipment (Assistive, Adaptive, Orthotic,

Protective, Supportive, and Prosthetic)

Anticipated Goals

* Joint integrity and mobility are improved.

* Performance of and independence in ADL and IADL are increased.

* Physical function and health status are improved.

* Risk of secondary impairments is reduced.

* Safety is improved.

Specific Direct Interventions

* Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints)

* Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)

* Protective devices or equipment (eg, braces, protective taping, cushions, helmets)

* Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen)

Airway Clearance Techniques

Anticipated Goals

* Airway clearance is improved.

* Cough is improved.

* Exercise tolerance is improved.

* Physical function and health status are improved.

* Risk of recurrence of condition is reduced.

* Ventilation, respiration (gas exchange), and circulation are improved.

* Work of breathing is decreased.

Specific Direct Interventions

* Assistive cough techniques

* Autogenic drainage

* Breathing strategies (eg, training in paced breathing, pursed-lip breathing)

* Chest percussion, vibration, and shaking

* Forced expiratory techniques

* Pulmonary postural drainage and positioning

* Suctioning

* Techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation)

Reexamination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of life is improved.

* Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with airway clearance dysfunction is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced.

Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Level of patient/client adherence to the intervention program is maximized.

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings.

* Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Impaired Aerobic Capacity and Endurance Associate With

Cardiovascular Pump Dysfunction

PATTERN D

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients who have impaired aerobic capacity associated with cardiovascular pump dysfunction and who may have one or a combination of the following:

* Abnormal heart rate response to increased oxygen demand

* Decreased ejection fraction (30%-50%)

* Exercise-induced myocardial ischemia (1-2 mm ST segment, depression)

* Functional capacity of less than or equal to 5 to 6 metabolic equivalent units (METs)

* Hypertensive blood pressure response to increased oxygen demand

* Nonmalignant arrhythmias

* Symptomatic response to increased oxygen demand

INCLUDES patients/clients with:

* Angioplasty or atherectomy

* Cardiomyopathy

* Coronary artery bypass grafting

* Coronary artery disease

* Hypertensive heart disease

* Uncomplicated myocardial infarction

* Valvular heart disease

EXCLUDES patients/clients with:

* Age of fewer than 4 months

* Airway clearance impairment

* Heart failure

* Mechanical ventilation

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

391 Rheumatic fever with heart involvement 394 Diseases of mitral valve 395 Diseases of aortic valve 396 Diseases of mitral and aortic valves 397 Diseases of other endocardial structures 398 Other rheumatic heart disease 402 Hypertensive heart disease 403 Hypertensive renal disease 404 Hypertensive heart and renal disease 410 Acute myocardial infarction 411 Other acute and subacute forms of ischemic heart disease 412 Old myocardial infarction 413 Angina pectoris 414 Other forms of chronic ischemic heart disease 416 Chronic pulmonary heart disease 416.0 Primary pulmonary hypertension

417 Other diseases of pulmonary circulation 417.0 Arteriovenous fistula of pulmonary vessels

422 Acute myocarditis 423 Other diseases of pericardium 423.2 Constrictive pericarditis

424 Other diseases of endocardium 424.0 Mitral valve disorders

425 Cardiomyopathy 426 Conduction disorders 426.0 Atrioventricular block, complete 426.1 Atrioventricular block, other and unspecified

427 Cardiac dysrhythmias 429 Ill-defined descriptions and complications of heart disease 429.0 Myocarditis, unspecified

440 Atherosclerosis 441 Aortic aneurysm and dissection 443 Other peripheral vascular disease

Procedures

34 Operations on chest wall, pleura, mediastinum, and diaphragm 34.9 Other operations on thorax 34.99 Other

36 Operations on vessels of heart 36.1 Bypass anastamosis for heart revascularization

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental History

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

* Sleep patterns and positions

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family

Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent) Social function (eg, social interaction, social activity, social support)

Social Habits (Past and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review

The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of autonomic responses to positional changes

* Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales

* Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test)

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of thoracoabdominal movements and breathing patterns with activity

* Auscultation of the heart

* Auscultation of the lungs

* Auscultation of major vessels for bruits

* Claudication time tests

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Monitoring via telemetry during activity

* Palpation of pulses

* Performance or analysis of an electrocardiogram

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Anthropometric Characteristics

* Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion

* Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy)

* Measurement of body fat composition using calipers, underwater weighing tanks, or electrical impedance

* Measurement of height, weight, length, and girth

Arousal, Attention, and Cognition

* Assessment of level of consciousness

* Assessment of orientation to time, person, place, and situation

* Screening for level of cognition (eg, to determine ability to process commands, to measure safety awareness)

Assistive and Adaptive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device

* Analysis of patient/client and caregiver ability to care for device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Community and Work (Job/School/Play) Integration or

Reintegration (Including IADL)

* Analysis of adaptive skills

* Analysis of community, work (job/school/play), and leisure activities

* Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Analysis of environment and tasks

* Assessment of autonomic responses to positional changes

* Assessment of functional capacity

* Assessment of physiologic responses during community, work (job/school/play), and leisure activities

* Assessment of safety in community and work (job/school/play) environments

* IADL scales or indexes

* Observation of responses to nonroutine occurrences

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of daily activities logs

* Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

Environmental, Home, and Work (Job/School/Play) Barriers

* Analysis of physical space using photography or videotape

* Assessment of current and potential barriers

* Measurement of physical space

* Physical inspection of the environment

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

Ergonomics and Body Mechanics

Ergonomics:

* Analysis of performance of selected tasks or activities

* Analysis of preferred postures during performance of tasks and activities

* Assessment of safety in work (job/school/play) environments

* Assessment of work hardening or work conditioning needs, including identification of needs related to physical, functional, behavioral, and vocational status

* Assessment of work (job/school/play) performance through batteries of tests

* Determination of dynamic capabilities and limitations during specific work (job/school/play) activities

* Ergonomic analysis of the work and its inherent tasks or activities, including:

- analysis of repetition/work/rest cycling during task or activity - assessment of tools, devices, or equipment used - assessment of vibration - assessment of workstation - computer-assisted motion analysis of performance of selected movements or activities - identification of essential functions of task or activity - identification of sources of actual and potential trauma, cumulative trauma, or repetitive stress

* Videotape analysis of patient/client at work (job/school/play)

Body Mechanics:

* Observation of performance of selected movements or activities

Gait, Locomotion, and Balance

* Analysis of arthrokinematic, biomechanical, kinematic and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment

* Gait, locomotion, and balance profiles

Joint Integrity and Mobility

* Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks

* Assessment of pain and soreness

* Assessment of soft tissue swelling, inflammation, or restriction

Motor Function (Motor Control and Motor Learning)

* Analysis of gait, locomotion, and balance

* Motor assessment scales

* Physical performance scales

Muscle Performance (Including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry

* Assessment of muscle tone

* Assessment of pain and soreness

Neuromotor Development and Sensory integration

* Analysis of reflex movement patterns

* Assessment of behavioral response

* Assessment of oromotor function, phonation, and speech production

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation tests

* Assessment of muscle soreness

* Assessment of pain perception (eg, phantom pain)

* Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales

Posture

* Analysis of resting posture in any position

* Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis

Range of Motion (ROM) (Including Muscle Length)

* Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging

* Assessment of muscle, joint, or soft tissue characteristics

Reflex integrity

* Assessment of normal reflexes (eg, stretch reflex)

* Assessment of pathologic reflexes (eg, Babinski's reflex)

Self-Care and Home Management (Including ADL and IADL)

* ADL scales or indexes

* Analysis of adaptive skills

* Analysis of environment and tasks

* Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Assessment of ability to transfer

* Assessment of autonomic responses to positional changes

* Assessment of functional capacity

* Assessment of physiologic responses during self-care and home management activities

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of daily activities logs

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals

Ventilation, Respiration (Gas Exchange), and Circulation

* Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise

* Assessment and classification of edema through volume and girth measurements

* Assessment of ability to clear airway

* Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms

* Assessment of capillary refill time

* Assessment of cough and sputum

* Assessment of perceived exertion and dyspnea

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of chest wall mobility, expansion, and excursion

* Assessment of ventilatory muscle strength, power, and endurance

* Assessment of cyanosis

* Auscultation of the heart

* Auscultation of major vessels for bruits

* Auscultation and mediate percussion of the lungs

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Palpation of chest wall (eg, tactile fremitus, pain, diaphragmatic motion)

* Palpation of pulses

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Within 12 weeks, patient/client will have a functional capacity of greater than or equal to 6 metabolic equivalent units (METS), will recognize signs and symptoms of cardiovascular compromise, will be independent and safe with an aerobic exercise program, and will be able to identify his or her own risk factors for heart disease and the interventions required to modify those risk factors.

Expected Range of Number of Visits Per Episode of Care

3 to 30 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 3 to 30 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Disability associated with acute or chronic illnesses is reduced.

* Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Patient/client, family. significant other, and caregiver knowledge and awareness of the diagnosis, prognosis. interventions., and goals and outcomes are increased.

* Patient/client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment, recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Progress is enhanced through the participation of patient/client, family, significant others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific interventions

* Computer-assisted instruction

* Demonstration by patient/client or caregiver in the appropriate environment

* Periodic reexamination and reassessment of the home program

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct Interventions

Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Aerobic capacity is increased.

* Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased.

* Physical function and health status are improved.

* Physiologic response to increased oxygen demand is improved.

* Strength, power, and endurance are increased.

* Symptoms associated with increased oxygen demand are decreased.

Specific Direct Interventions

* Aerobic endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Body mechanics and ergonomics training

* Breathing exercises and ventilatory muscle training

* Conditioning and reconditioning

* Developmental activities training

* Gait, locomotion, and balance training

* Posture awareness training

* Strengthening:

- active - active assistive - resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and

IADL)

Anticipated Goals

* Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased.

* Ability to recognize a recurrence is increased, and intervention is sought in a timely manner.

* Safety is improved during self-care and home management tasks and activities.

Specific Direct interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* Assistive and adaptive device and equipment training

* Injury prevention or reduction training

* IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Orthotic, protective, or supportive devices and equipment training

Functional Training in Community and Work (Job/School/Play) Integration or

Reintegration (Including IADL, Work Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased.

* Costs of work-related injury or disability are reduced.

* Risk of recurrence is reduced.

* Safety is improved during performance of community and work (job/school/play) tasks and activities.

* Utilization and cost of health care services are decreased.

Specific Direct interventions

* Environmental, community, work (job/school/play), or leisure task adaptation

* Ergonomic stressor reduction

* Injury prevention or reduction training

* IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments)

* job simulation

* Assistive and adaptive device or equipment training

* Orthotic, protective, or supportive device or equipment training

Prescription, Application, and, as Appropriate, Fabrication of Devices and

Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and

Prosthetic)

Anticipated Goals

* Ability to perform movement tasks is increased.

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

Specific Direct interventions

* Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints)

* Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)

* Prostheses (eg, artificial limbs)

* Protective devices or equipment (eg, braces. protective taping, cushions, helmets)

* Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen)

Airway Clearance Techniques

Anticipated Goals

* Airway clearance is improved.

* Exercise tolerance is improved.

* Risk of secondary complications is reduced.

* Ventilation, respiration (gas exchange), and circulation are improved.

Specific Direct interventions

* Assistive cough techniques

* Techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation)

Reexamination

The physical therapist relies on ree-xamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of life is improved.

* Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with cardiovascular pump dysfunction is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Level of patient/client adherence to the intervention program is maximized.

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings.

* Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient,/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Impaired Aerobic Capacity and Endurance Associated With Cardiovascular Pump

Failure

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients who have impaired aerobic capacity associated with cardiovascular pump failure and who may have any one or a combination of the following:

* Abnormal heart rate response to increased oxygen demand

* Complex ventricular arrhythmias

* Ejection fraction of less than 30%

* Flat or falling blood pressure response to increased oxygen demand

* Functional capacity of less than or equal to 4 or 5 metabolic equivalent units (METs)

* Severe exercise-induced myocardial ischemia ([is greater than]2 mm ST segment, depression)

* Symptomatic response to increased oxygen demand

INCLUDES patients/clients with:

* Atrioventricular block

* Cardiogenic shock

* Cardiomyopathy

* Complicated myocardial infarction

EXCLUDES patients/clients with:

* Age of fewer than 4 months

* Mechanical ventilation

* Membrane oxygenator

* Intra-aortic balloon pump support

* Left ventricular assist device

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

391 Rheumatic fever with heart involvement 394 Diseases of mitral valve 395 Diseases of aortic valve 396 Diseases of mitral and aortic valves 397 Diseases of other endocardial structures 398 Other rheumatic heart disease 402 Hypertensive heart disease 403 Hypertensive renal disease 404 Hypertensive heart and renal disease 410 Acute myocardial infarction 411 Other acute and subacute forms of ischemic heart disease 412 Old myocardial infarction 413 Angina pectoris 414 Other forms of chronic ischemic heart disease 415 Acute pulmonary heart disease 416 Chronic pulmonary heart disease

416.0 Primary pulmonary hypertension 422 Acute myocarditis 423 Other diseases of pericardium

423.2 Constrictive pericarditis 424 Other diseases of endocardium

424.0 Mitral valve disorders 425 Cardiomyopathy 426 Conduction disorders

426.0 Atrioventricular block, complete

426.1 Atrioventricular block, other and unspecified 427 Cardiac dysrhythmias 428 Heart failure

428.0 Congestive heart failure 429 Ill-defined descriptions and complications of heart disease

429.0 Myocarditis, unspecified 440 Atherosclerosis 441 Aortic aneurysm and dissection 444 Arterial embolism and thrombosis

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

* Sleep patterns and positions

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Post Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits (Past and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review

The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of autonomic responses to positional changes

* Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test)

* Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of thoracoabdominal movements and breathing patterns with activity

* Auscultation of the heart

* Auscultation of the lungs

* Auscultation of major vessels for bruits

* Claudication time tests

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Monitoring via telemetry during activity

* Palpation of pulses

* Performance or analysis of an electrocardiogram

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Anthropometric Characteristics

* Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion

* Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy)

* Measurement of body fat composition, using calipers, underwater weighing tanks, or electrical impedance

* Measurement of height, weight, length, and girth

Arousal, Attention, and Cognition

* Assessment of level of consciousness

* Assessment of orientation to time, person, place, and situation

* Screening for level of cognition (eg, to determine ability to process commands, to measure safety awareness)

Assistive and Adaptive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device

* Analysis of patient/client and caregiver ability to care for device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Community and Work (Job/School/Play) Integration or Reintegration

(Including IADL)

* Analysis of adaptive skills

* Analysis of community, work (job/school/play), and leisure activities

* Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Analysis of environment and tasks

* Assessment of autonomic responses to positional changes

* Assessment of functional capacity

* Assessment of physiologic responses during community, work (job/school/play), and leisure activities

* Assessment of safety in community and work (job/school/play) environments

* IADL scales or indexes

* Observation of responses to nonroutine occurrences

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of daily activities logs

* Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

Environmental, Home, and Work (Job/School/Play) Barriers

* Assessment of current and potential barriers

* Measurement of physical space

* Physical inspection of the environment

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

Ergonomics and Body Mechanics

Ergonomics:

* Analysis of performance of selected tasks or activities

* Analysis of preferred postures during performance of tasks and activities

* Assessment of safety in work (job/school/play) environments Body Mechanics:

* Observation of performance of selected movements or activities

Gait, Locomotion, and Balance

* Analysis of arthrokinematic, biomechanical, kinematic, and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment

* Analysis of gait, locomotion, and balance on various terrains, in different physical environments, or in water

* Analysis of wheelchair management and mobility

* Gait, locomotion, and balance profiles

Joint Integrity and Mobility

* Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks

* Assessment of soft tissue swelling, inflammation, or restriction

* Assessment of pain and soreness

Motor Function (Motor Control and Motor Learning)

* Motor assessment scales

* Physical performance scales

* Analysis of gait, locomotion, and balance

Muscle Performance (Including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry

* Assessment of muscle tone

* Assessment of pain and soreness

Neuromotor Development and Sensory Integration

* Analysis of gait and posture

* Analysis of reflex movement patterns

* Assessment of behavioral response

* Assessment of oromotor function, phonation, and speech production

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation tests

* Assessment of muscle soreness

* Assessment of pain perception (eg, phantom pain)

* Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales

Posture

* Analysis of resting posture in any position

* Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb fines, still photography, video-tape, or visual analysis

Range of Motion (ROM) (Including Muscle Length)

* Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging

* Assessment of muscle, joint, or soft tissue characteristics

Reflex Integrity

* Assessment of normal reflexes (eg, stretch reflex)

* Assessment of pathological reflexes (eg, Babinski's reflex)

Self-Care and Home Management (Including ADL and IADL)

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* ADL scales and indexes

* Analysis of adaptive skills

* Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Analysis of environment and tasks

* Assessment of ability to transfer

* Assessment of autonomic responses to positional changes

* Assessment of functional capacity

* Assessment of physiologic responses during self-care and home management activities

* Review of daily activities logs

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals

Ventilation, Respiration (Gas Exchange), and Circulation

* Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise

* Assessment of ability to clear airway

* Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms

* Assessment of capillary refill time

* Assessment classification of edema through volume and girth measurements

* Assessment of cough and sputum

* Assessment of perceived exertion and dyspnea

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of chest wall mobility, expansion, and excursion

* Assessment of ventilatory muscle strength, power, and endurance

* Assessment of cyanosis

* Auscultation of the heart

* Auscultation of major vessels for bruits

* Auscultation and mediate percussion of the lungs

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Palpation of chest wall (eg, tactile fremitus, pain, and diaphragmatic motion)

* Palpation of pulses

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Within 12 weeks, patient/client will have increased functional capacity; will be independent and safe with an aerobic exercise program; will be able to identify signs and symptoms of cardiac compromise and his or her own risk factors for heart disease and the interventions that modify those risks; and will demonstrate improved participation in activities of daily living (ADL) and instrumental activities of daily living (IADL) without exacerbation of signs and symptoms.

Expected Range of Number of Visits Per Episode of Care

14 to 44

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 14 to 44 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific Interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Disability, associated with acute or chronic illnesses is reduced.

* Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased.

* Patient/client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment, recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Progress is enhanced through the participation of patient/client, family, significant others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific Interventions

* Demonstration by patient/client or caregiver in the appropriate environment

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct Interventions

Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased.

* Joint integrity and mobility are improved.

* Performance of and independence in ADL and IADL are increased.

* Physiologic response to increased oxygen demand is improved.

* Safety is improved.

* Self-management of symptoms is improved.

* Strength, power, and endurance are increased.

* Symptoms associated with increased oxygen demand are decreased.

Specific Direct Interventions

* Aerobic endurance activities

* Breathing exercises and ventilatory muscle training

* Conditioning and reconditioning

* Gait, locomotion, and balance training

* Posture awareness training

* Strengthening:

- active

- active assistive

- resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and

IADL)

Anticipated Goals

* Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased.

* Ability to recognize a recurrence is increased, and intervention is sought in a timely manner.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* Assistive and adaptive device and equipment training

* IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Orthotic, protective, or supportive device and equipment training

* Prosthetic device or equipment training

Functional Training in Community and Work (Job/School/Play) Integration

or Reintegration (Including IADL, Work

Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is in

* Safety is improved during performance of community and work (job/school/play) tasks and activities.

* Utilization and cost of health care services are decreased.

Specific Direct Interventions

* Assistive and adaptive device or equipment training

* Environmental, community, work (job/school/play), or leisure task adaptation

* Ergonomic stressor reduction

* Injury prevention or reduction training

* IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children, negotiating school environments)

* Job simulation

* Orthotic, protective, and supportive device or equipment training

* Prosthetic device or equipment training

Prescription, Application, and, as Appropriate, Fabrication of Devices

and Equipment (Assistive, Adaptive, Orthotic,

Protective, Supportive, and Prosthetic)

Anticipated Goals

* Ability to perform physical tasks is increased.

* Intensity of care is decreased.

* Joint integrity and mobility are improved.

* Level of supervision required for task performance is decreased.

* Performance of and independence in ADL and IADL are increased.

* Physical function and health status are improved.

* Risk of secondary impairments is reduced.

* Safety is improved.

Specific Direct Interventions

* Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints)

* Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)

* Protective devices or equipment (eg, braces, protective taping, cushions, helmets)

* Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen)

Reexamination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of life is improved.

* Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with cardiovascular pump failure is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Level of patient/client adherence to the intervention program is maximized,

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings.

* Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status,

Impaired Ventilation, Respiration (Gas Exchange), and Aerobic Capacity

and Endurance Associated With Ventilatory Pump Dysfunction

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/client Diagnostic Group

Patients/clients with impaired respiration (gas exchange), ventilation, respiratory muscle performance (strength, power, endurance), and airway clearance accompanied by impaired aerobic capacity and functional limitation. Patients/clients may have any one or a combination of the following:

* Abnormal respiratory rate and pattern

* Change in baseline breath sounds

* Decreased strength or endurance of ventilatory muscles

* Decreased vital capacity or tidal volume

* Dyspnea

* Frequent or recurring pulmonary infection

* Impaired cough

* Impaired gas exchange

* Impaired performance of activities of daily living (ADL) or instrumental activities of daily living (IADL)

* Impaired posture

* Impaired secretion clearance

INCLUDES patients/clients with:

* Acute or chronic oxygen dependency

* Chronic obstructive pulmonary disease (COPD)

* Diaphragmatic disorders

* Intermittent negative pressure or assistive ventilatory support

* Musculoskeletal disorders affecting ventilation

* Neuromuscular disorders affecting ventilation

* Status pre-lung transplant

* Restrictive lung disease

* Tracheostomy/microtracheostomy

EXCLUDES patients/clients with:

* Acute respiratory failure

* Age of fewer than 4 months

* Mechanical ventilator dependency, 24 hours per day

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

045 Acute poliomyelitis 192 Malignant neoplasm of other and unspecified parts of nervous system

192.2 Spinal cord

Cauda equina 237 Neoplasm of uncertain behavior of endocrine glands and nervous system

237.5 Brain and spinal cord 277 Other and unspecified disorders of metabolism

277.0 Cystic fibrosis 332 Parkinson's disease 333 Other extrapyramidal disease and abnormal movement disorders

333.0 Other degenerative diseases of the basal ganglia

333.3 Tics of organic origin

333.4 Huntington's chorea

333.9 Other and unspecified extrapyramidal disease abnormal movement disorders 334 Spinocerebellar disease

334.2 Primary cerebellar degeneration 335 Anterior horn cell disease

335.2 Motor neuron disease

335.20 Amyotrophic lateral sclerosis 340 Multiple sclerosis 343 Infantile cerebral palsy 344 Other paralytic syndromes

344.0 Quadriplegia and quadriparesis 357 Inflammatory and toxic neuropathy

357.0 Acute infective polyneuritis

Guillain-Barre syndromes 359 Muscular dystrophies and other myopathies

359.1 Hereditary progressive muscular dystrophy 482 Other bacterial pneumonia

482.9 Bacterial pneumonia unspecified 491 Chronic bronchitis

491.8 Other chronic bronchitis

491.9 Unspecified chronic bronchitis 492 Emphysema

492.8 Other emphysema 493 Asthma 494 Bronchiectasis 496 Chronic airway obstruction, not elsewhere classified

Chronic obstructive pulmonary disease [COPD], not otherwise specified 513 Abscess of lung and mediastinum

513.0 Abscess of lung 515 Postinflammatory pulmonary fibrosis 516 Other alveolar and parietoalveolar pneumonopathy

516.9 Unspecified alveolar and parietoalveolar

pneumonopathy 518 Other diseases of lung

518.0 Pulmonary collapse

518.8 Other diseases of lung

518.89 Other diseases of lung, not elsewhere

classified 519 Other diseases of respiratory system

519.4 Disorders of diaphragm 737 Curvature of spine

737.3 Kyphoscoliosis and scoliosis 770 Other respiratory conditions of fetus and newborn

770.7 Chronic respiratory diseases arising in the

perinatal period

Bronchopulmonary dysplasia 786 Symptoms involving respiratory system and other chest symptoms

786.0 Dyspnea and respiratory abnormalities

786.00 Respiratory abnormality, unspecified

786.5 Chest, pain

786.52 Painful respiration 803 Other and unqualified skull fractures 850 Concussion 852 Subarachnoid, subdural, and extradural hemorrhage, following injury 853 Other and unspecified intracranial hemorrhage following injury 854 Intracranial injury of other and unspecified nature 861 Injury to heart and lung

861.2 Lung, without mention of open wound into thorax

861.21 Contusion 941 Burn of face, head, and neck 942 Burns of trunk 947 Burns of internal organs

947.1 Larynx, trachea, and lung

947.9 Unspecified site

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

Concerns that led patient/client to seek the services of a physical therapist

Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

* Sleep patterns and positions

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception * Physical function (eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits (Past and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review

The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of autonomic responses to positional changes

* Assessment of performance during established exercise protocols (eg, using treadmill, ergometer, 6-minute walk test, 3-minute step test)

* Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of thoracoabdominal movements and breathing patterns with activity

* Auscultation of the heart

* Auscultation of the lungs

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Monitoring via telemetry during activity

* Palpation of pulses

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Anthropometric Characteristics

* Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion

* Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy)

* Measurement of height, weight, length, and girth

Arousal, Attention, and Cognition

* Assessment of level of consciousness

* Assessment of orientation to time, person, place, and situation

Assistive and Adaptive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Community and Work Job/School/Play) Integration or Reintegration (Including IADL)

* Analysis of community, work (job/school/play), and leisure activities

* Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Assessment of functional capacity

* Assessment of physiologic responses during community, work (job/school/play), and leisure activities

* Assessment of safety in community and work (job/school/play) environments

* Observation of responses to nonroutine occurrences

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of reports provided by patient/client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

Cranial Nerve Integrity

* Assessment of gag reflex

* Assessment of swallowing

Environmental, Home, and Work (Job/School/Play) Barriers

* Assessment of current and potential barriers

* Physical inspection of the environment

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

Integumentary Integrity

For skin associated with integrumentary disruption:

* Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations

* Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin

* Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin)

* Assessment of nail beds

Muscle Performance (Including ;Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Analysis of muscle strength, power, and endurance using manual muscle testing or dynamometry

* Assessment of muscle tone

* Assessment of pain and soreness

Neuromotor Development and Sensory Integration

* Analysis of gait and posture

* Assessment of behavioral response

* Assessment of motor function (motor control and motor learning)

* Assessment of oromotor function, phonation, and speech production

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation tests

* Assessment of muscle soreness

* Assessment of pain perception (eg, phantom pain)

* Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales

Posture

* Analysis of resting posture in any position

* Analysis of static and dynamic postures, using computer-assisted imaging, posture grids, plumb lines, still photography, videotape, or visual analysis

Self-Care and Home Management (Including ADL and IADL)

* ADL scales and indexes

* Analysis of adaptive skills

* Analysis of environment and tasks

* Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Assessment of ability to transfer

* Assessment of autonomic responses to positional changes

* Assessment of functional capacity

* Assessment of physiologic responses during self-care and home management activities

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals

Ventilation, Respiration (Gas Exchange), and Circulation

* Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise

* Assessment of ability to clear airway

* Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms

* Assessment of capillary refill time

* Assessment of cough and sputum

* Assessment of perceived exertion and dyspnea

* Assessment of phonation

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of chest wall mobility, expansion, and excursion

* Assessment of ventilatory muscle strength, power, and endurance

* Assessment of cyanosis

* Auscultation of the heart

* Auscultation of major vessels for bruits

* Auscultation and mediate percussion of the lungs

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Palpation of chest wall (eg, tactile fremitus, pain, diaphragmatic motion)

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Within 10 weeks, patient/client will have maximized ventilatory muscle strength, endurance, and aerobic capacity, as demonstrated by maximal ventilatory independence, absence of secretions, and maximal independence in activities of daily living (ADL) and instrumental activities of daily living (IADL).

Expected Range of Number of Visits Per Episode of Care

10 to 65

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients clients in this diagnostic group will achieve the goals and outcomes within 10 to 65 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify Frequency

of Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased,

* Available resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific Interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Decision making is enhanced regarding health patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Disability associated with acute or chronic illnesses is reduced.

* Functional independence in activities of daily living (ADL) and instrumental activities of daily (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are

* Patient/client knowledge of personal and environmental factors associate with the condition is increased.

* Performance levels m employment, recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Progress is enhanced through die participation of patient/client, family, sinificant others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific Interventions

* Computer-assisted instruction

* Demonstration by patient/client or caregiver in the appropriate environment

* Periodic reexamination and reassessment of the home program

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise including Aerobic Conditioning)

Anticipated Goals

* Airway clearance is improved.

* Atelectasis is decreased.

* Ability to perform physical tasks related to self-care, home management, community and work job/school/play) integration or reintegration, and leisure activities is increased.

* Endurance is increased.

* Joint integrity and mobility are improved.

* Need for ventilatory assistance is decreased.

* Performance of and independence in ADL and IADL are increased.

* Physical function and health status are improved.

* Physiologic response to oxygen demand is improved.

* Strength., power, and endurance of the ventilatory muscles are increased.

* Symptoms associated with increased oxygen demand are decreased.

* Work of breathing is decreased.

Specific Direct interventions

* Aerobic endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Balance and coordination training

* Body mechanics and ergonomics training

* Breathing exercises and ventilatory muscle training

* Conditioning and reconditioning

* Developmental activities training

* Neuromuscular relaxation, inhibition, and facilitation

* Posture awareness training

* Strengthening:

- active

- active assistive

- resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Stretching

Functional Training in Self-Care and Home Management including ADL and IADL)

Anticipated Goals

* Ability to perform physical tasks related to self-care and home management (including ADL and IADL) is increased.

* Ability to recognize a recurrence is increased, and intervention is sought in a timely manner.

* Performance of and independence in ADL and IADL are increased.

* Risk of recurrence of condition is reduced.

* Safety, is improved during performance of self-care and home management tasks and activities.

* Tolerance to positions and activities is increased.

Specific Direct interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* Assistive and adaptive device and equipment training

* IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Orthotic, protective, or supportive device training

Functional Training in Community and Work Job/school/play) Integration or Reintegration including IADL, Work Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased.

* Costs of work-related injury or disability are reduced.

* Safety is improved during performance of community and work (job/school/play) tasks and activities.

* Tolerance to positions and activities is increased.

Specific Direct interventions

* Assistive and adaptive device and equipment training

* Environmental, community, work (job/school/play), and leisure task adaptation

* IDL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Orthotic, protective, or supportive device and equipment training

Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adoptive, Orthotic, Protective, Supportive, and Prosthetic)

Anticipated Goals

* Ability to perform physical tasks is increased. joint integrity and mobility are improved.

* Performance and independence in ADL and IADL are increased.

* Physical function and health status are improved.

* Tolerance to positions and activities is increased.

Specific Direct interventions

* Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints)

* Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)

* Protective devices or equipment (eg, braces, protective taping, cushions, helmets)

* Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen)

Airway Clearance Techniques

Anticipated Goals

* Airway clearance is improved.

* Cough is improved.

* Risk of recurrence of condition is prevented.

* Risk of secondary complications is reduced.

* Ventilation, respiration gas exchange), and circulation are improved.

* Work of breathing is decreased.

Specific Direct Interventions

* Active cycle of breathing/forced expiratory technique

* Assistive cough techniques

* Assistive devices for airway clearance (eg, flutter valve)

* Autogenic drainage

* Breathing strategies (eg, training in paced breathing, pursed-lip breathing)

* Chest percussion, vibration, and shaking

* Forced expiratory techniques

* Pulmonary postural drainage and positioning

* Suctioning

* Techniques to maximize ventilation (eg, maximum inspiratory hold, staircase breathing, manual hyperinflation)

Physical Agents and Mechanical Modalities

Anticipated Goals

* Independence in airway clearance is increased.

Specific Direct interventions

Mechanical modalities:

* Mechanical percussors

* Tilt table or standing table

Reexamination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups-may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of life is improved.

* optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with ventilatory pump dysfunction is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL) -- and work job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced.

* Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Level of patient/client adherence to the intervention program is maximized.

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings.

* Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achivement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achived. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over die life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Impaired Ventilation With Mechanical Ventilation Secondary to Ventilatory Pump Dysfunction

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/client Diagnostic Group

Patients/clients who are ventilator dependent with impaired ventilatory pump and decreased aerobic capacity and who may have associated impaired airway clearance. Patients/clients may have any one or a combination of the following:

* Abnormal or adventitious breath sounds

* Abnormal physiologic response to increased oxygen demand

* Decreased strength or endurance of respiratory muscles

* Airway clearance dysfunction secondary to artificial airway

* Impaired performance of activities of daily living (ADL) or instrumental activities of daily living (IADL)

INCLUDES patients/clients with (when not on mechanical ventilator):

* Abnormal respiratory rate and tidal volume at rest

* Dyspnea

* Dyssynchronous or paradoxical breathing

* Neuromuscular disorders

* Progressive decrease in arterial oxygen pressure and increase in arterial carbon dioxide pressure

* Ventilatory pump failure or chronic obstructive pulmonary disease (COPD)

INCLUDES patients/clients with:

* Mechanical ventilator dependency, 24 hours per day

EXCLUDES patients/clients with:

* Acute respiratory failure

* Adult respiratory distress syndrome

* Age of fewer than 4 months

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

045 Acute poliomyelitis 192 Malignant neoplasm of other and unspecified parts of nervous system 192.2 spinal cord Cauda equina 237 Neoplasm of uncertain behavior of endocrine glands and nervous system 237.5 Brain and spinal cord 239 Neoplasms of unspecified nature 239.9 site unspecified 277 Other and unspecified disorders of metabolism 277.0 Cystic fibrosis 332 Parkinson's disease 333 Other extrapyramidal disease and abnormal movement disorders 333.4 Huntington's chorea 334 Spinocerebellar disease 334.2 Primary cerebellar degeneration 335 Anterior horn disease 335.2 Motor neuron disease 335.20 Amyotrophic lateral sclerosis 340 Multiple sclerosis 343 Infantile cerebral palsy 344 Other paralytic syndromes 344.0 Quadriplegia and quadriparesis 348 Other conditions of brain 348.1 Anoxic brain damage 357 Inflammatory and toxic neuropathy 357.0 Acute infective polyneuritis

Guillain-Barre syndrome 359 Muscular dystrophies and other myopathies 359.1 Hereditary progressive muscle dystrophy 430 Subarachnoid hemorrhage 431 Intracerebral hemorrhage 432 Other and unspecified intracranial hemorrhage 434 Occlusion of cerebral arteries 434.1 Cerebral embolism 492 Emphysema 492.8 Other emphysema 493 Asthma 496 Chronic airway obstruction, not elsewhere classified Chronic obstructive pulmonary disease [COPD] 505 Pneumoconiosis, unspecified 515 Postinflammatory pulmonary fibrosis 518 Other diseases of lung 518 Other diseases of lung 518.81 Respiratory failure 519 Other diseases of respiratory system 519.4 Disorders of diaphragm 786 Symptoms involving respiratory system and other chest symptoms 786.0 Dyspnea and respiratory abnormalities 786.9 Dyspnea 852 Subarachnoid, subdural, and extradural hemorrhage, following injury 853 Other and unspecified intracranial hemorrhage following injury 854 Intracranial injury of other and unspecified nature 941 Burn of face, head, and neck 942 Burn of trunk, 943 Burn of upper limb, except wrist and hand 944 Burn of wrist(s) and hand(s) 945 Burn of lower limb(s) 946 Burns of mutiple specified sites 947 Burn of internal organs 948 Burns classified according to extent of body surface involved 949 Burn, unspecified 977 Poisoning by other and unspecified drugs and medicinal substances 977.9 Unspecified drug or medicinal substance

Procedures

96 Nonoperative intubation and irrigation 96.7 other continuous mechanical ventilation

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and totals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

* Sleep patterns and positions

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function(eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits (Post and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of automic responses to positional changes

* Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of thoracoabdominal movements and breathing patterns with activity

* Ausculation of the heart

* Ausculation of the lungs

* Interpretation of blood gas analysis or oxygen consumption (V[O.sub.2]) studies

* Monitoring via telemetry during activity

* Performance or analysis of an electrocardiogram

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Anthropometric Characteristics

* Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy)

* Measurement of height, weight, length, and girth

Arousal, Attention, and Cognition

* Assessment of level of consciousness

* Assessment of orientation to time, person, place, and situation

* Screening for level of cognition (eg, to determine ability to process commands, to measure safety awareness)

Assistive and Adaptive Devices

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Community and Work (Job/School/Play) Integration/ Reintegration (Including IADL)

* Analysis of adaptive skills

* Analysis of community, work (job/school/play), and leisure activities

* Analysis of community, work (job/school/play), and leisure activities that are performed using assistive, adaptive, orthotic, protective, supportive,.or prosthetic devices and equipment

* Analysis of environmental and (work job/school/play) tasks

* Assessment of automic responses to positional changes

* Assessment of functional capacity

* Assessment of physiologic responses during community, work, and leisure activities

* Assessment of safety in community and work (job/school/play) environments

* Observation of responses to nonroutine occurrences

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of reports provided by patient./client, family, significant others, caregivers, other health care professionals, or other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer)

Cranial Nerve Integrity

* Assessment of gag reflex

* Assessment of muscle innervated by the cranial nerves

* Assessment of swallowing

Environmental, Home, and Work (Job/School/Play) Barriers

* Analysis of physical space using photography or videotape

* Assessment of current and potential barriers

* Physical inspection of the environment

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

Ergonomics and Body Mechanics Ergonomics:

* Analysis of performance of selected tasks or activities

* Analysis of preferred postures during performance of tasks and activities

* Assessment of dexterity and coordination

* Assessment of safety in work (job/school/play) environments

* Assessment of work (job/school/play) performance through batteries of tests

* Determination of dynamic capabilities and limitations during specific work (job/school/play) activities

Body Mechanics:

* Determination of dynamic capabilities and limitations during specific work (job/school/play) activities

* Observation of performance of selected movements or activities

Gait, Locomotion, and Balance

* Analysis of arthrokinematic, biomechanical, kinematic and kinetic characteristics of gait, locomotion, and balance with and without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment ,

* Assessment of automic responses to positional changes

* Assessment of safety

* Gait, locomotion, and balance profiles

* Identification and quantification of gait characteristics

* Identification and quantification of static and dynamic balance characteristics

Integumentary Integrity For skin associated with integumentary description:

* Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations

* Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin

* Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin)

* Assessment of nail beds

* Assessment of sensation (eg, pain, temperature, tactile)

* Assessment of tissue mobility, turgor, and texture

Joint Integrity and Mobility

* Analysis of the nature and quality of movement of the joint or body part during performance of specific movements

Muscle Performance (Including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Analysis of muscle strength power, and endurance by manual testing or dynamometry

* Assessment of muscle tone

* Assessment of pain and soreness

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practically and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation tests

* Assessment of pain perception (eg, phantom pain)

* Assessment of pain using questionnaires, graphs, behavioral scales, symptoms magnification scales or indexes, and visual analog scales

Posture

* Analysis of resting posture in any position

Range of Motion (ROM) (Including Muscle Length)

* Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photographic or electronic devices, or computer-assisted graphic imaging

* Assessment of muscle, joint, or soft tissue characteristics

Reflex Integrity

* Assessment of normal reflexes (eg, stretch reflex)

* Assessment of pathological reflexes (eg, Babinski's reflex)

* Assessment of postural, postural, equilibrium, and righting reactions

Self-Care and Home Management (Including ADL and IADL)

* ADL scales or indexes

* Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Analysis of self-care in unfamiliar environments

* Assessment of ability to transfer

* Assessment of automic responses to positional changes

* Assessment of functional capacity

* Assessment of physiologic responses during self-care and home management activities

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals

Ventilation Respiration (Gas Exchange), and Circulation

* Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise

* Assessment of ability to clear airway

* Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms

* Assessment of capillary refill time

* Assessment of cough and sputum

* Assessment of perceived exertion and dyspnea

* Assessment of standard vital signs (eg, blood pressure, heart rate, and respiratory rate) at rest and during and after activity

* Assessment of chest wall mobility, expansion, and excursion

* Assessment of respiratory muscle strength, power, and endurance

* Assessment of cyanosis

* Auscultation of the heart

* Auscultation and mediate percussion of the lungs

* Interpretation of blood gas analysis or oxygen consumption ([V[O.sub.2]) studies

* Palpation of pulses

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Within 3 weeks,patient/client with acute reversible ventilatory pump failure will be weaned from mechanical ventilation and will demonstrate improved ventilatory muscle performance. Patient/client will show an absence of secretions or be able to independently clear secretions and win demonstrate independence in activities of daily living (ADL) and instrumental activities of daily living (IDL).

Within 8 weeks, patient/client with prolonged ventilatory pump failure will be weaned from the mechanical ventilator and with demonstrate improved ventilatory muscle performance. Patient/client will show an absence of secretions or be able to clear independently or with caregiver assistance and will demonstrate independence in ADL and IADL.

Patient/client with severe or chronic ventilatory failure with remain on mechanical ventilation and within 8 weeks will be able to perform ADL and IADL with caregiver assistance. Patient/client will show an absence of secretions or be able to clear secretions with caregiver assistance.

Expected Range of Number of Visits Per Episode of Care

5 to 20

20 to 40

10 to 60 These ranges represent the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/client in this diagnostic group will achieve the goals and outcomes within these ranges during a single continuous episode of care Frequency of visits and duration of the episode of care should be determined by die physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Availability resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific Interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are

* Decision making is enhanced regarding heath of patient/client and use of health care, resources by patient/client, family, significant others, and caregivers.

* Disability associated with acute or chronic illness is reduced.

* Functional independence in activities of that daily living (ADL) and instrumental activities of daily living (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Patient/client, family significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased.

* Patient/client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Progress is enhanced through the participation of patient/client, family, significant others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific Interventions

* Computer-assisted instruction

* Demonstration by patient/client or caregivers in the appropriate environment

* Periodic reexamination and reassessment of the home program

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct Interventions Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (including Aerobic Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to self-care, home management, community and work (job/school/play) integration or reintegration, and leisure activities is increased.

* Atelectasis is decreased.

* Joint integrity and mobility are improved.

* Motor function (motor control and motor learning) is improved.

* Need for assistive equipment or device (mechanical ventilator) is decreased.

* Self-management of symptoms is improved.

* Strength, power, and endurance of ventilatory muscles are increased.

* Symptoms associated with increased oxygen demand are increased.

* Tissue perfusion and oxygenation are increased.

* Tolerance for positions is increased.

* Work of breathing is decreased.

Specific Direct Interventions

* Aerobic endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Balance and coordination training

* Body mechanics and ergonomics training

* Breathing exercises and ventilatory muscle training

* Conditioning and reconditioning

* Motor function (motor control and motor learning) training or retraining

* Neuromuscular reeducation

* Neuromuscular relaxation, inhibition, and facilitation

* Posture awareness training

* Sensory training or retraining

* Strengthening

- active

- active assistive

- resistive, using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and IADL)

Anticipated Goals

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Performance of and independence in ADL and IADL are increased.

* Safety is improved during performance of self-care and home management tasks and activities.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, and toileting)

* Assistive and adaptive device and equipment training

* IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Orthotic, protective, or supportive device and equipment training

Functional Training in Community and Work (Job/School/Play) Integration or

Reintegration (Including IADL, Work Hardening, and Work Conditioning)

Anticipated Goals

* Ability to perform physical tasks related to community and work (job/school/play) integration and reintegration and leisure tasks, movements, or activities is increased.

* Costs of work-related injury or disability are reduced.

* Safety, is improved during performance of community and work (job/school/play) tasks and activities.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* Assistive and adaptive device and equipment training

* Environmental, community, work (job/school/play), or leisure task adaptation

* Ergonomic stressor reduction training

* IADL training (eg, maintaining a home, shopping, cooking, home chores, heavy household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Injury prevention or reduction training

* Job simulation

* Orthotic, protective, or supportive device and equipment training

Manual Therapy Techniques (Including Mobilization and Manipulation)

Anticipated Goals

* Ability to perform movement tasks is increased.

* Joint integrity and mobility are improved.

* Muscle spasm is reduced.

* Risk of secondary impairments is reduced.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* Joint mobilization and manipulation

* Passive range of motion

* Soft tissue mobilization and manipulation

Prescription, Application and, as Appropriate, Fabrication of Devices and

Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and

Prosthetic)

Anticipated Goals

* Ability to perform physical tasks is increased.

* Motor function (motor control and motor learning) is improved.

* Performance of and independence in ADL and IADL are increased.

* Safety is improved.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamics splints)

* Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)

* Protective devices or equipment (eg, braces, protective taping, cushions, helmets)

* Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen )

Airway Clearance Techniques

Anticipated Goals

* Airway clearance is improved.

* Cough is improved.

* Physical function and health status are improved.

* Secondary complications are decreased.

* Ventilation, respiration (gas exchange) and circulation are improved.

* Work of breathing is decreased.

Specific Direct Interventions

* Assistive cough techniques

* Autogenic drainage

* Chest percussion, vibration, and shaking

* Breathing strategies (eg, paced breathing, pursed-lip breathing)

* Forced expiratory techniques

* Pulmonary postural drainage and positioning

* Suctioning

* Techniques to maximize ventilation (eg, maximal inspiratory hold, staircase breathing, manual hyperinflation)

Electrotherapeutic Modalities

Anticipated Goals

* Ability to perform physical tasks is increased.

* Muscle performance is increased.

Specific Direct Interventions

* Biofeedback

* Electrical muscle stimulation

* Functional electrical stimulation (FES)

Physical Agents and Mechanical Modalities

Anticipated Goals

* Independence in airway clearance is increased.

Specific Direct Interventions

Mechanical modalities:

* Mechanical percussors

* Tilt table or standing table

Reexamination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identities the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of life is improved.

* Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with ventilatory pump dysfunction is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced.

Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Patient/client adherence to the intervention program is maximized.

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work job/school/play) settings.

* Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goats and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Impaired Ventilation and Respiration (Gas Exchange, With Potential for

Respiratory Failure

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients with acute respiratory distress and impaired ventilatory pump and gas exchange, with potential for respiratory failure. Patients/clients may have one or a combination of the following:

* Abnormal or adventitious breath sounds

* Central signs of cyanosis

* Dyspnea

* Dyssynchronous or paradoxical breathing pattern at rest

* Lethargy or confusion

* Oxygen saturation levels of less than 92% at rest

* Respiratory rate of greater than 32 at rest

* Use of accessory muscles at rest

INCLUDES patients/clients with:

* Acute or chronic neuromuscular dysfunction or trauma

* Acute pulmonary disease

* Asthma

* Chronic obstructive pulmonary disease (COPD)

* Cystic fibrosis

* Pneumonia

* Thoracic trauma

EXCLUDES patients/clients with:

* Age of fewer than 4 months

* Mechanical ventilation

ICD-9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

277 Other and unspecified disorders of metabolism 277.0 Cystic fibrosis 277.6 Other diseases of circulating enzymes Alpha 1-antitrypsin deficiency

482 Other bacterial pneumonia 482.2 Pneumonia due to Hemophilus influenzae [H.influenzae] 482.9 Bacterial pneumonia unspecified

491 Chronic bronchitis 491.8 Other chronic bronchitis 491.9 Unspecified chronic bronchitis

492 Emphysema 492.8 Other emphysema Emphysema (lung or pulmonary), not otherwise specified

493 Asthma

494 Bronchiectasis

496 Chronic airway obstruction, not elsewhere classified Chronic obstructive pulmonary disease [COPD]

513 Abscess of lung and mediastinum 513.0 Abscess of lung

514 Pulmonary congestion and hypostasis

516 Other alveolar and parietoalveolar pneumonopathy 516.9 Unspecified alveolar and parietoalveolar pneumonopathy

518 Other diseases of lung 518.0 Pulmonary collapse 518.5 Pulmonary insufficiency following trauma and surgery Adult respiratory distress syndrome

518.8 Other diseases of lung 518.89 Other diseases of lung, not elsewhere classified

519 Other diseases of respiratory system 519.4 Disorders of diaphragm

770 Other respiratory conditions of fetus and newborn 770.7 Chronic respiratory disease arising in perinatal period Bronchopulmonary dysplasia

786 Symptoms involving respiratory system and other chest symptoms 786.0 Dyspnea and respiratory abnormalities 786.00 Respiratory abnormality, unspecified 786.5 Chest pain 786.52 Painful respiration

861 Injury to heart and lung 861.2 Lung, without mention of open wound into thorax 861.21 Contusion

997 Complications affecting specified body systems, not elsewhere classified 997.3 Respiratory complication

Procedures

34 Operations on chest wall, pleura, mediastinum, and diaphragm 34.9 Other operations on thorax 34.99 Other

54 Other operations on abdominal wall 54.9 Other operations of abdominal region 54.99 Other

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

* Sleep patterns and positions

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits (Past and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review

The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of autonomic responses to positional changes

* Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceived-exertion (RPE) scales, dyspnea scales, anginal pain scales, or visual analog scales

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of thoracoabdominal movements and breathing patterns with activity

* Auscultation of the heart

* Auscultation of the lungs

* Auscultation of major vessels for bruits

* Monitoring via telemetry during activity

* Performance or analysis of an electrocardiogram

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Anthropometric Characteristics

* Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy)

* Measurement of height, weight, length, and girth

Arousal, Attention, and Cognition

* Assessment of level of consciousness

* Assessment of orientation to time, person, place, and situation

Cranial Nerve Integrity

* Assessment of gag reflex

* Assessment of swallowing

Ergonomics and Body Mechanics

* Analysis of performance of selected tasks or activities

* Analysis of preferred postures during performance of tasks and activities

* Assessment of safety in work (job/school/play) environments

Gait, Locomotion, and Balance

* Analysis of wheelchair management and mobility

* Assessment of autonomic responses to positional changes

* Assessment of safety

Integumentary Integrity

For skin associated with integumentary disruption:

* Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations

* Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin

* Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin)

* Assessment of nail beds

Joint Integrity and Mobility

* Analysis of the nature and quality of movement of the joint or body part during performance of specific movement tasks

* Assessment of pain and soreness

Motor Function (Motor Control and Motor Learning)

* Analysis of head, trunk, and limb movement

* Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping)

* Assessment of autonomic responses to positional changes

Muscle Performance (including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Assessment of pain and soreness

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation tests

* Assessment of muscle soreness

* Assessment of pain perception (eg, phantom pain)

* Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales

Posture

* Analysis of resting posture in any position

Reflex integrity

* Assessment of normal reflexes (eg, stretch reflex)

* Assessment of pathological reflexes (eg, Babinski's reflex)

Self-Care and Home Management (Including ADL and IADL)

* Analysis of adaptive skills

* Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Assessment of ability to transfer

Ventilation, Respiration (Gas Exchange), and Circulation

* Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise

* Assessment of ability to protect the airway

* Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms

* Assessment of capillary refill time

* Assessment of cough and sputum

* Assessment of perceived exertion and dyspnea

* Assessment of phonation

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of chest wall mobility, expansion, and excursion

* Assessment of ventilatory muscle strength, power, and endurance

* Assessment of cyanosis

* Auscultation of the heart

* Auscultation of major vessels for bruits

* Auscultation and mediate percussion of the lungs

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Palpation of chest wall (eg, tactile fremitus, pain, diaphragmatic motion)

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Within 72 hours, patient/client will have adequate gas exchange, with ventilatory parameters indicating ability to ventilate independently, or patient/client will be placed on mechanical ventilation.

Expected Range of Number of Visits Per Episode of Care

1 to 9 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 1 to 9 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That may Modify Frequency of Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific Interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Disability associated with acute or chronic illnesses is reduced.

* Functional independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased.

* Patient/client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment, recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Progress is enhanced through the participation of patient/client, family, significant others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family,significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific interventions

* Computer-assisted instruction

* Demonstration by patient/client or caregivers in the appropriate environment

* Periodic reexamination and reassessment of the home program

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct Interventions

Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Atelectasis is decreased.

* Motor function (motor control and motor learning) is improved.

* Muscle performance is increased.

* Need for assistive device (mechanical ventilation) is decreased,

* Quality and quantity of movement between and across body segments are improved.

Specific Direct Interventions

* Breathing exercises and ventilatory muscle training

* Neuromuscular relaxation, inhibition, and facilitation

* Posture awareness training

* Strengthening

active

active assistive

resistive, using manual resistance, pulleys, weights,

hydraulics, elastic resistance bands, robotics, and mechanical

or electromechanical devices

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and IADL)

Anticipated Goals

* Performance of and independence in ADL and IADL are increased.

* Risk of recurrence of condition is reduced.

Specific Direct Interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* Assistive and adaptive device and equipment training

* IADL training (eg, maintaining a home, shopping, cooking, home chores, home household chores, money management, driving a car or using public transportation, structured play for infants and children)

* Orthotic, protective, or supportive device training

Manual Therapy Techniques (Including Mobilization and Manipulation)

Anticipated Goals

* Ability to perform movement tasks is increased.

* Quality and quantity of movement between and across body segments are improved.

Specific Direct interventions

* Joint mobilization and manipulation

* Soft tissue mobilization and manipulation

* Therapeutic massage

Prescription, Application and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic)

Anticipated Goals

* Ability to perform physical tasks is increased.

* Intensity of care is decreased.

* Joint integrity and mobility are improved.

* Level of supervision required for task performance is decreased.

* Motor function (motor control and motor learning) is improved with decreased dyspnea.

* Performance of and independence in ADL and IADL are increased.

* Physical function and health status are improved.

* Risk of secondary impairments is reduced.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints)

* Protective devices or equipment (eg, braces, protective taping, cushions. helmets)

* Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen)

Airway Clearance Techniques

Anticipated Goals

* Airway clearance is improved.

* Cough is improved.

* Need for assistive device (mechanical ventilation) is decreased.

* Ventilation, respiration (gas exchange), and circulation is improved.

* Work of breathing is decreased.

Specific Direct interventions

* Assistive cough techniques

* Autogenic drainage

* Breathing strategies (eg, paced breathing, pursed-lip breathing)

* Chest percussion, vibration, and shaking

* Forced expiratory techniques

* Pulmonary postural drainage and positioning

* Suctioning

* Techniques to maximize ventilation (eg, maximal inspiratory hold, staircase breathing, manual hyperinflation)

Reexamination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment) primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of life is improved.

* Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with potential for respiratory failure is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL) -- and work job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced.

Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Patient/client adherence to the intervention program is maximized.

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings.

* Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Impaired Ventilation and Respiration (Gas Exchange) With

Mechanical Ventilation Secondary to Respiratory Failure

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients/clients who are ventilator dependent with severely impaired gas exchange and impaired ventilatory pump associated with airway clearance impairment. Patients/clients may have any one or a combination of the following:

* Abnormal or adventitious breath sounds

* Abnormal chest radiograph

* Airway clearance dysfunction

* Impaired respiration (gas exchange)

INCLUDES patients/clients with (when not on ventilator):

* Abnormal respiratory rate at rest

* Dyssynchronous or paradoxical breathing

* Inability to maintain arterial oxygen pressure (Pa[O.sub.2]) when receiving supplemental oxygen

* Progressive rise in arterial carbon dioxide pressure (Pa[CO.sub.2])

* Severe dyspnea

INCLUDES patients/clients with:

* Acute respiratory failure

* Adult respiratory distress syndrome

* Cardiothoratic surgery

* Multisystem failure

* Severe pneumonia

* Thoracic trauma

* Transplant rejection, infection, or failure

EXCLUDES patients/clients with:

* Age of fewer than 4 months

* Cardiovascular pump failure

ICD-9-CM Codes

As of press time, the Listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

136 Other and unspecified infectious and parasitic diseases 136.3 Pneumocystosis Pneumonia due to pneumocystis carinii 277 Other and unspecified disorders of metabolism 277.0 Cystic fibrosis 286 Coagulation defects 286.6 Defribrination syndrome Diffuse or disseminated intravascular coagulation [DIC syndrome] 348 Other conditions of brain 348.1 Anoxic brain damage 415 Acute Pulmonary heart disease 415.1 Pulmonary embolism and infarction 480 Viral pneumonia 481 Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia] 482 Other bacterial pneumonia 483 Pneumonia due to other specified organism 484 Pneumonia in infectious diseases classified elsewhere 485 Bronchopneunonia, organism unspecified 486 Pneumonia, organism unspecified 491 Chronic bronchitis 493 Asthma 495 Extrinsic allergic alveolitis 495.7 "Ventilation" pneumonitis 496 Chronic airway obstruction, not elsewhere classified Chronic obstructive pulmonary disease [COPD] 507 Pneumonitis due to solids and liquids 507 Due to inhalation of food or vomitus Aspiration pneumonia 511 Pleurisy 511.8 Other specified forms of effusion, except tuberculous Hemothorax 512 Pneumothorax 512.8 Other spontaneous pneumothorax 513 Abscess of lung and mediastinum 514 Pulmonary congestion and hypostasis Pulmonary edema, not otherwise specified 517 Lung involvement in conditions classified elsewhere 518 Other diseases of lung 518.5 Pulmonary insufficiency following trauma and surgery Adult respiratory distress syndrome 518.8 Other diseases of lung 518.81 Respiratory failure 518.82 Other pulmonary insufficiency, not elsewhere classified Acute respiratory distress 770 Other respiratory conditions of fetus and newborn 770.4 Primary atelactasis 770.7 Chronic respiratory diseases aarising in the perinatal period Bronchopulmonary dysplasia 852 Subarachnoid, subdural, and extradural hemorrhage, following injury 853 Other and unspecified intracranial hemorrhage, following injury 854 Intracnial injury of other and unspecified nature 861 Injury to heart and lung 861.2 Lung, without mention of open wound into thorax 861.21 Contusion 959 Injury, other and unspecified 996 Complications peculiar to certain specified procedures 996.0 Mechanical complication of cardiac device, implant, and graft 996.1 Mechanical complication of other vascular device, implant, and graft 996.2 Mechanical complication of nervous system device, implant, and graft 996.3 Mechanical complication of genitourinary device, implant, and graft 996.4 Mechanical complication of internal orthopedic device, implant, and graft 996.5 Mechanical complication of other specified prosthetic device, implant, and graft 996.8 Complications of transplanted organ 996.85 Bone marrow

Factors influencing Health Status and Contact With Health Services V42 Organ or tissue replaced by transplant V42.0 Kidney V42.1 Heart V42.4 Bone V42.6 Lung V42.7 Liver V42.8 Other specified organ or tissue V42.81 Bone marrow

Procedures 32 Excision of lung and bronchus 34 Operations on chest wall, pleura, mediastinum, and diaphragm 34.9 Other operations on thorax 34.99 Other 36 Operations on vessels of heart 36.1 Bypass anastomosis for heart revascularization 54 Other operations on abdominal region 54.9 Other operations of abdominal region 54.99 Other 96 Nonoperative intubation and irrigation 96.7 Other continuous mechanical ventilation

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, facility, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History Data generated from the history may include:

General Demographics

* Age

* Primary language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* Living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL)

* Sleep patterns and positions

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobolity, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

Social Habits (Post and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness self-care, home management, community, work job/school/play], and leisure activities)

Systems Review The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of autonomic responses to positional changes

* Assessment of perceived exertion, dyspnea, or angina during activity, using rating-of-perceived-exertion (RPE) scales, dyspnea scales,anginal pain scales, or visual analog scales

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of thoracoabdominal movements and breathing patterns with activity

* Auscultation of the heart

* Auscultation of the lungs

* Monitoring via telemetry during activity

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Anthropometric Characteristics

* Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy)

* Measurement of height, weight, length, and girth

Arousal, Attention, and Cognition

* Assessment of level of consciousness

* Assessment of orientation to time, person, place, and situation

* Screening for gross expressive (eg, verbalization) deficits

* Screening for level of cognition (eg, to determine ability to process commands, to measure safety awareness)

Assistive and Adaptive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of safety during use of device

* Review of reports provided by patient/client, significant others, family, caregivers, or other professionals concerning use of or need for device

Integumentary integrity For skin associated with integumentary disruption:

* Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations

* Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin

* Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin)

* Assessment of nail beds

* Assessment of sensation (eg, pain, temperature, tactile)

* Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors)

* Assessment of tissue mobolity turgor and texture

Joint integrity and Mobility

* Analysis of the nature and quality of movement of the joint or body part during performance of specific movements

* Assessment of soft tissue swelling, inflammation, or restriction

* Assessment of pain and soreness

Motor Function (Motor Control and Motor Learning)

* Analysis of gait, locomotion, and balance

* Analysis of head, trunk, and limb movement

* Analysis of posture during sitting, standing, and locomotor activities appropriate for age (eg, walking, hopping, skipping)

* Assessment of autonomic responses to positional changes

Muscle Performance including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Analysis of muscle strength, power, and endurance by manual muscle testing or dynamometry

* Assessment of muscle tone

* Assessment of pain and soreness

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effect; and benefits including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation tests

* Assessment of muscle soreness

* Assessment of pain perception (eg, phantom pain)

* Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales

Posture

* Analysis of resting posture in any position

Range of Motion (ROM) (Including Muscle Length)

* Analysis of multisegmental movement

* Analysis of ROM using goniometers, tape measures, flexible rulers, inclinometers, photograpbic or electronic devices, or computer-assisted graphic imaging

* Assessment of muscle, joint, or soft tissue characteristics

Reflex Integrity

* Assessment of normal reflexes (eg, stretch reflex)

* Assessment of pathological reflexes (eg, Babinski's reflex)

Self-care and Home Management (Including ADL and IADL)

* Analysis of self-care and home management activities that are performed using assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment

* Analysis of self-care in unfamiliar environments

* Assessment of ability to transfer

* Assessment of autonomic responses to positional changes

* Assessment of functional capacity

* Assessment of physiologic responses during self-care and home management activities

* Questionnaires completed by and interviews conducted with patient/client and others as appropriate

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals

Sensory Integrity (Including Proprioception and Kinesthesia)

* Assessment of deep (proprioceptive) sensations (eg, movement sense or kinesthesia, position sense)

* Assessment of gross receptive (eg, vision, hearing) abilities

* Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure)

Ventilation, Respiration (Gas Exchange), and Circulation

* Analysis of thoracoabdominal movements and breathing patterns at rest, during activity, and during exercise

* Assessment of ability to clear airway

* Assessment of activities that aggravate or relieve edema, pain,

* dyspnea, or other symptoms

* Assessment of capillary refill time

* Assessment of chest wall mobility, expansion, and excursion

* Assessment of cough and sputum

* Assessment of perceived exertion and dyspnea

* Assessment of phonation

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of ventilatory muscle strength, power, and endurance

* Assessment of cyanosis

* Auscultation of the heart

* Auscultation and mediate percussion of the lungs

* Palpation of chest wall (eg, tactile, fremitus pain, diaphragmatic motion)

* Palpation of pulses

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite or multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Within 72 hours, patient/client with acute reversible respiratory failure will be weaned from mechanical ventilation and will show an absence of secretions or be able to clear secretions independently, or caregiver will be able to manage the secretions and the chest radiograph will show significant improvement. Patient/client win demonstrate independence in activities of daily living (ADL) and instrumental activities of daily living (IADL).

Within 3 weeks, patient/client with prolonged respiratory failure will be weaned from mechanical ventilation and will show an absence of secretions or be able to clear secretions independently or with caregiver assistance. The chest radiograph will be clear, return to baseline, or show clearance of the acute process. Patient/client will demonstrate independence in ADL or IADL.

Patient/client with severe or chronic respiratory failure will remain mechanically ventilated indefinitely and within 4 to 6 weeks will demonstrate ability to clear secretions independently or with caregiver assistance. Patient/client will show improved participation in ADL and IADL.

Expected Range of Number of Visits Per Episode of Care

3 to 9

10 to 25

10 to 45

These ranges represent the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within these ranges during a single continuous episode of care Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care of That May Modify Frequency

of Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Level of patient/client adherence to the intervention program

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modifed by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased.

* Available resources are maximally utilized.

* Care is coordinated with patient/client, family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of patient/client and the use of health care resources by patient/client, family, significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Patient/client, family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific Interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with patient/client, family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources are improved.

* Behaviors that foster healthy habits, wellness, and prevention are acquired.

* Decision making is enhanced regarding health of patient/client and use of health care resources by patient/client, family, significant others, and caregivers.

* Disability associated with acute or chronic illnesses is reduced.

* Functional independence in activities of daily living (ADL) and instrumental activities of daily, living (IADL) is increased.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Patient/client, family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased.

* Patient/client knowledge of personal and environmental factors associated with the condition is increased.

* Performance levels in employment, recreational, or leisure activities are improved.

* Physical function and health status are improved.

* Progress is enhanced through the participation of patient/client, no, significant others, and caregivers.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Self-management of symptoms is improved.

* Utilization and cost of health care services are decreased.

Specific Interventions

* Demonstration by patient/client or caregivers in the appropriate environment

* Use of audiovisual aids for both teaching and home reference

* Verbal instruction

* Written or pictorial instruction

Direct Interventions

Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Atelactasis is decreased.

* Endurance is increased.

* Energy expenditure is decreased.

* Motor function (motor control and motor learning) is improved.

* Muscle performance is increased.

* Need for assistive device (mechanical ventilation) is decreased.

* Physiologic response to increased oxygen demand is improved.

* Tissue perfusion and oxygenation are increased.

* Work of breathing is decreased.

Specific Direct Interventions

* Aerobic endurance activities

* Breathing exercises and ventilatory muscle training

* Conditioning and reconditioning

* Neuromuscular relaxation, inhibition, and facilitation

* Strengthening

- active

- active assistive

- resistive

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and

IADL)

Anticipated Goals

* Intensity of care is decreased.

* Performance of and independence in ADL and IADL are increased.

* Level of supervision required for task performance is decreased.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* ADL training (eg, bed mobility and transfer training, gait training, locomotion, developmental activity, dressing, grooming, bathing, eating, and toileting)

* Assistive and adaptive device and equipment training

* Orthotic, protective, or supportive device training

Manual Therapy Techniques (Including Mobilization and Manipulation)

Anticipated Goals

* Joint integrity and mobility are improved.

* Pain is decreased.

* Risk of secondary impairments is reduced.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* Connective tissue massage

* Passive range of motion

* Soft tissue mobilization and manipulation

* Therapeutic massage

Prescription, Application, and, as Appropriate, Fabrication of Devices and

Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and

Prosthetic)

Anticipated Goals

* Deformities are prevented.

* Loading on a body part is decreased.

* Protection of body parts is increased.

* Safety is improved.

Specific Direct Interventions

* Adaptive devices or equipment (eg, raised toilet seats, seating systems, environmental controls)

* Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints)

* Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)

* Prosthetic devices or equipment (eg, braces, protective taping, cushions, helmets)

* Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen)

Airway Clearance Techniques

Anticipated Goals

* Airway clearance is improved.

* Ventilation, respiration (gas exchange), and circulation are improved.

* Work of breathing is decreased.

Specific Direct Interventions

* Assistive cough techniques

* Breathing strategies (eg, paced breathing, pursed-lip breathing)

* Chest percussion, vibration, and shaking

* Pulmonary postural drainage and positioning

* Suctioning

* Techniques to maximize ventilation (eg, maximal inspiratory hold, staircase breathing, manual hyperinflation)

Re examination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of life is improved.

* Optimal return to role function (eg, worker, student, spouse, grandparent) is achieved.

* Risk of disability associated with respiratory failure is reduced.

* Safety of patient/client and caregivers is increased.

* Self-care and home management activities, including activities of daily living (ADL) -- and work (job/school/play) and leisure activities, including instrumental activities of daily living (IADL) -- are performed safely, efficiently, and at a maximal level of independence with or without devices and equipment.

* Understanding of personal and environmental factors that promote optimal health status is demonstrated.

* Understanding of strategies to prevent further functional limitation and disability is demonstrated.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to patient/client, family, significant others, and caregivers.

* Administrative management of practice is acceptable to patient/client, family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to patient/client, family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to patient/client, family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to patient/client, family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced.

Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Patient/client adherence to the intervention program is maximized.

* Patient/client and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status, community adaptation, leisure or leisure activities, living environment, pathology or impairment that may affect function, or home or work (job/school/play) settings.

* Professional recommendations are integrated into home, community, work (job/school/play), or leisure environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.

Impaired Ventilation, Respiration (Gas Exchange), and Aerobic

Capacity and Endurance Secondary to Respiratory Failure in the Neonate

This preferred practice pattern describes the generally accepted elements of the patient/client management that physical therapists provide for the patient/client diagnostic group specified below. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical paths, based on consideration of a wide variety of factors, such as individual patient/client needs; the profession's code of ethics and standards of practice; and patient/client age, culture, gender roles, race, sex, sexual orientation, and socioeconomic status.

Patient/Client Diagnostic Group

Patients who are neonates or in early infancy (eg, up to 4 months of age) who have impaired gas exchange and ventilatory pump related to prematurity; postmaturity; congenital heart, lung, or diaphragm abnormalities; infection; complications of medical management; or impairments secondary to other systemic dysfunctions. These patients often require mechanical ventilation and may have any one or a combination of the following, on or off the ventilator:

* Apnea and bradycardia

* Cyanosis

* Impaired airway clearance

* Impaired cough

* Impaired respiration (gas exchange)

* Increased work of breathing

* Paradoxical and abnormal breathing pattern

* Physiologic intolerance of routine care

INCLUDES patients with:

* Abdominal/thoracic surgery

* Bronchopulmonary dysplasia

* Congenital anomalies

* Hyaline membrane disease

* Intermittent or continuous ventilatory support

* Meconium aspiration syndrome

* Neurovascular disorders

* Pneumonia

EXCLUDES patients with:

* Age of more than 4 months

ICD- 9-CM Codes

As of press time, the listing below contains the most typical ICD-9-CM codes related to this preferred practice pattern. Because the patient/client diagnostic group is defined by impairments and functional limitations and not by codes, it is possible for individuals to belong to the group even though the codes may not apply to them.

This listing is intended for general information only and should not be used for coding purposes. Codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

508 Respiratory condition due to unspecified and external agents 508.9 Respiratory condition due to unspecified external agent 514 Pulmonary congestion and hypostasis 516 Other alveolar and parietoalveolar pneumonopathy 516.9 Unspecified alveolar and parietoalveolar pneumonopathy 518 Other diseases of lung 518.0 Pulmonary collapse 518.8 Other diseases of lung 518.89 Other diseases of lung, not elsewhere classified 553 Other hernia of abdominal cavity without mention of obstruction or gangrene 553.3 Diaphragmatic hernia 769 Respiratory distress syndrome

Hyaline membrane disease (pulmonary)

770 Other respiratory conditions of fetus and newborn 770.1 Meconium aspiration syndrome 770.6 Transitory tachypnea of newborn 770.7 Chronic respiratory disease arising in the perinatal period

Bronchopulmonary dysplasia

786 Symptoms involving respiratory system and other chest symptoms 786.0 Dyspnea and respiratory abnormalities 786.00 Respiratory abnormality, unspecified

Examination

Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention. The patient/client, family, significant others, and caregivers participate by reporting activity performance and functional ability. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, community, or work (job/school/play) situation; and other relevant factors. For clinical indications and types of data generated by the tests and measures, refer to Part One, Chapter 2.

History

Data generated from the history may include:

General Demographics

* Age

* Primary Language

* Race/ethnicity

* Sex

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Occupation/Employment

* Current and prior community and work (job/school) activities

Growth and Development

* Hand and foot dominance

* Developmental history

Living Environment

* living environment and community characteristics

* Projected discharge destinations

History of Current Condition

* Concerns that led patient/client to seek the services of a physical therapist

* Concerns or needs of patient/client who requires the services of a physical therapist

* Current therapeutic interventions

* Mechanisms of injury or disease, including date of onset and course of events

* Onset and pattern of symptoms

* Patient/client, family, significant other, and caregiver expectations and goals for the therapeutic intervention

* Patient/client, family, significant other, and caregiver perceptions of patient's/ client's emotional response to the current clinical situation

Functional Status and Activity Level

* Current and prior functional status in self-care and home management activities, including activities of daily living (ADL) and instrumental activities of daily living (ML)

* Sleep patterns and positions

Medications

* Medications for current condition for which patient/client is seeking the services of a physical therapist

* Medications for other conditions

Other Tests and Measures

* Laboratory and diagnostic tests

* Review of available records

* Review of nutrition and hydration

Past History of Current Condition

* Prior therapeutic interventions

* Prior medications

Past Medical/Surgical History

* Cardiopulmonary

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Integumentary

* Musculoskeletal

* Neuromuscular

* Pregnancy, delivery, and postpartum

* Prior hospitalizations, surgeries, and preexisting medical and other health-related conditions

Family History

* Familial health risks

Health Status (Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep patterns, energy, fatigue)

* Psychological function (eg, memory, reasoning ability, anxiety, depression, morale)

* Role function (eg, worker, student, spouse, grandparent)

* Social function (eg, social interaction, social activity, social support)

* Social Habits (Past and Current)

* Behavioral health risks (eg, smoking, drug abuse)

* Level of physical fitness (self-care, home management, community, work [job/school/play], and leisure activities)

Systems Review

The systems review may include:

Physiologic and anatomic status

* Cardiopulmonary

* Integumentary,

* Musculoskeletal

* Neuromuscular

Communication, affect, cognition, language, and learning style

Tests and Measures

Tests and measures for this pattern may include, in alphabetical order:

Aerobic Capacity and Endurance

* Assessment of ability to control body temperature

* Assessment of autonomic responses to positional changes

* Assessment of signs of infant respiratory distress (eg, sternal and intercostal retractions, nasal flaring, paradoxical breathing pattern, expiratory grunting, cyanosis, pallor, apnea, bradycardia, head bobbing) at rest, during activity (eg, routine care, evaluation, and treatment), and during recovery

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of thoracoabdominal movements and breathing patterns with activity

* Auscultation of the heart

* Auscultation of the lungs

* Interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Monitoring via telemetry during activity

* Performance or analysis of an electrocardiogram

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Anthropometric Characteristics

* Assessment of activities and postures that aggravate or relieve edema, lymphedema, or effusion

* Assessment of edema through palpation and volume and girth measurements (eg, during pregnancy, in determining the effects of other medical or health-related conditions, during surgical procedures, after drug therapy)

* Measurement of height, weight, length, and girth

Arousal, Attention, and Cognition

* Assessment of arousal, attention, and cognition using standardized instruments

* Assessment of level of consciousness

Cranial Nerve integrity

* Assessment of gag reflex

* Assessment of response to the following stimuli:

- auditory

- gustatory

- olfactory

- vestibular

- visual

* Assessment of swallowing

Environmental, Home, and Work (Job/School/Play) Barriers

* Assessment of current and potential barriers

* Physical inspection of the environment

Integumentary Integrity

For skin associated with integumentary disruption:

* Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations

* Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin

* Assessment of continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin)

* Assessment of sensation (eg, pain, temperature, tactile)

* Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors)

* Assessment of nail beds

* Assessment of tissue mobility, turgor, and texture For wound:

* Assessment for presence of blistering

* Assessment of ecchymosis

Motor Function (Motor Control and Motor Learning)

* Motor assessment scales

* Analysis of head, trunk, and limb movement

* Assessment of autonomic responses to positional changes

Muscle Performance (Including Strength, Power, and Endurance)

* Analysis of functional muscle strength, power, and endurance

* Assessment of muscle tone

* Assessment of pain and soreness

Neuromotor Development and Sensory integration

* Analysis of age-appropriate and sex-appropriate development

* Analysis of reflex movement patterns

* Assessment of behavioral response

* Assessment of motor function (motor control and motor learning)

* Assessment of oromotor function, phonation, and speech production

Orthotic, Protective, and Supportive Devices

* Analysis of appropriate components of device

* Analysis of effects and benefits (including energy conservation and expenditure) while patient/client wears device

* Analysis of the potential to remediate impairment, functional limitation, or disability through use of device

* Analysis of practicality and ease of use of device

* Assessment of alignment and fit of device and inspection of related changes in skin condition

* Assessment of patient/client or caregiver ability to put on and remove device and to understand its use and care

* Assessment of patient/client use of device

* Assessment of safety during use of device

* Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device

Pain

* Analysis of pain behavior and reaction during specific movements and provocation tests

Posture

* Analysis of resting posture in any position

Reflex Integrity

* Assessment of developmentally appropriate reflexes over time

* Assessment of normal reflexes (eg, stretch reflex)

* Assessment of pathological reflexes (eg, Babinski's reflex)

* Assessment of postural, postural, equilibrium, and righting reactions

Ventilation, Respiration (Gas Exchange), and Circulation

* Analysis of thoracoabdominal movements and breathing patterns at rest and during activity, either on or off mechanical ventilation

* Assessment of ability to clear airway

* Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms

* Assessment of capillary refill time

* Assessment of cardiopulmonary response to performance of

* ADL (eg, feeding)

* Assessment of cough and sputum

* Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity

* Assessment of chest wa]l mobility, expansion, and excursion

* Assessment of ventilatory muscle strength, power, and endurance

* Assessment of cyanosis

* Auscultation of the heart

* Auscultation and mediate percussion of the lungs interpretation of blood gas analysis or oxygen consumption ([VO.sub.2]) studies

* Palpation of chest wall (eg, tactile, fremitus, pain, diaphragmatic motion)

* Pulse oximetry

* Tests and measures of pulmonary function and ventilatory mechanics

Evaluation, Diagnosis, and Prognosis

The physical therapist performs an evaluation (makes clinical judgments) for the purpose of establishing the diagnosis and the prognosis. Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, social considerations, and overall physical function and health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the diagnostic process, which includes evaluating, organizing, and interpreting examination data. The prognosis is the determination of the optimal level of improvement that might be attained and the amount of time required to reach that level. The prognosis also may include a prediction of the improvement levels that may be reached at various intervals during the course of physical therapy. During the prognostic process, the physical therapist develops the plan of care, which specifies goals and outcomes, specific direct interventions, the frequency of visits and duration of the episode of care required to achieve goals and outcomes, and criteria for discharge.

The frequency of visits and duration of the episode of care may vary from a short episode with a high intensity of intervention to a longer episode with a diminishing intensity of intervention. Frequency and duration may vary greatly among patients/clients based on a variety of factors that the physical therapist considers throughout the evaluation process, such as chronicity and severity of the problem; stability of the condition; preexisting systemic conditions or diseases; probability of prolonged impairment, functional limitation, or disability; multisite of multisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatomic and physiologic changes related to growth and development; and caregiver consistency or expertise.

Prognosis

Within 6 to 12 months, patient will achieve developmental milestones appropriate to adjusted age (based on prematurity). Within 6 months, patient will be weaned from the ventilator if applicable) and from supplemental oxygen. Caregiver will be able to manage the secretions.

Expected Range of Number of Visits Per Episode of Care

16 to 84 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and desired outcomes. It is anticipated that 80% of patients in this diagnostic group will achieve the goals and outcomes within 16 to 84 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

Factors That May Require New Episode of Care or That May Modify Frequency

of Visits/Duration of Episode

* Ability to transfer instruction to motor learning

* Accessibility of resources

* Age

* Availability of resources

* Caregiver (eg, family, home health aide) consistency or expertise

* Chronicity or severity of condition

* Comorbidities

* Preexisting systemic conditions or diseases

* Psychosocial and socioeconomic stressors of the family

* Support provided by family unit

Intervention

Intervention is the purposeful and skilled interaction of the physical therapist with the patient/client to produce changes in the condition that are consistent with the diagnosis and prognosis. In the plan of care, the physical therapist determines the degree to which intervention is likely to achieve anticipated goals (remediation of impairment) and desired outcomes (remediation of functional limitation, secondary or primary prevention of disability, optimization of patient/client satisfaction). In the event that the diagnostic process does not yield an identifiable cluster of signs and symptoms, syndrome, or category (diagnosis), intervention may be guided by the alleviation of symptoms and remediation of deficits. Intervention has three components. Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients, whereas a variety of direct interventions may be selected, applied, or modified by the physical therapist on the basis of the examination and evaluation findings, diagnosis, and prognosis for a specific patient/client. For clinical indications for the direct interventions, refer to Part One, Chapter 3.

Coordination, Communication, and Documentation

Anticipated Goals

* Accountability for services is increased

* Available resources are maximally utilized.

* Care is coordinated with family, significant others, caregivers, and other professionals.

* Decision making is enhanced regarding the health of patient/client and the use of health care resources by family, significant others, and caregivers.

* Other health care interventions (eg, medications) that may affect goals and outcomes are identified.

* Family, significant other, and caregiver understanding of expectations and goals and outcomes is increased.

* Placement needs are determined.

Specific Interventions

* Case management

* Communication (direct or indirect)

* Coordination of care with family, significant others, caregivers, other health care professionals, and other interested persons (eg, rehabilitation counselor, Workers' Compensation claims manager, employer)

* Discharge planning

* Documentation of all elements of patient/client management

* Education plans

* Patient care conferences

* Record reviews

* Referrals to other professionals or resources

Patient/Client-Related Instruction

Anticipated Goals

* Ability to perform physical tasks is increased.

* Awareness and use of community resources by family, significant others, and caregivers are improved.

* Decision making is enhanced regarding health of patient/client and the use of health care resources by family, significant others, and caregivers.

* Disability associated with acute or chronic illnesses is reduced.

* Intensity of care is decreased.

* Level of supervision required for task performance is decreased.

* Family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and goals and outcomes are increased.

* Family and caregiver knowledge of personal and environmental factors associated with the condition is increased.

* Physical function and health status are improved.

* Progress is enhanced through the participation of family, significant others, and caregivers.

* Risk of recurrence is reduced.

* Risk of secondary impairments is reduced.

* Safety of patient/client, family, significant others, and caregivers is improved.

* Utilization and cost of health care services are decreased.

Specific Interventions

* Computer-assisted instruction

* Demonstration by patient/client or caregivers in the appropriate environment

* Periodic reexamination and reassessment of the home program

* Use of audiovisual aids for both teaching and home reference

* Use of demonstration and modeling for teaching

* Verbal instruction

* Written or pictorial instruction

Direct Interventions

Direct interventions for this pattern may include, in order of preferred usage:

Therapeutic Exercise (Including Aerobic Conditioning)

Anticipated Goals

* Aerobic capacity is increased.

* Atelectasis is decreased.

* Endurance is increased.

* Physical function is improved.

* Physiologic response to increased oxygen demand is improved.

* Quality and quantity of movement between and across body segments are improved.

* Strength and endurance are increased.

* Tissue perfusion and oxygenation are increased.

Specific Direct Interventions

* Balance and coordination training

* Breathing exercises and ventilatory muscle training

* Conditioning and reconditioning

* Developmental activities training

* Motor function (motor control and motor learning) training or retraining

* Neuromuscular education

* Neuromuscular relaxation, inhibition, and facilitation

* Posture awareness training

* Sensory training

* Strengthening

- active

- active assistive

* Stretching

Functional Training in Self-Care and Home Management (Including ADL and IADL)

Anticipated Goals

* Risk of secondary impairments is reduced.

* Safety is improved during performance of self-care and home management tasks and activities.

Specific Direct Interventions

* ADL training (eg, bed mobility and transfer training, bathing) for caregiver

* Assistive and adaptive device and equipment training for caregiver

* Body mechanics training for caregiver

* Orthotic, protective, or supportive device or equipment training for caregiver

Manual Therapy Techniques (Including Mobilization and Manipulation)

Anticipated Goals

* Joint integrity and mobility are improved.

* Risk of secondary impairments is reduced.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* Connective tissue massage

* Joint mobilization and manipulation

* Passive range of motion

* Soft tissue mobilization and manipulation Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic)

Anticipated Goals

* Deformities are prevented.

* Protection of body parts is increased.

* Safety is improved.

* Tolerance to positions and activities is increased.

Specific Direct Interventions

* Orthotic devices or equipment (eg, splints, braces, shoe inserts, casts)

* Protective devices or equipment (eg, braces, protective taping, cushions, helmets)

* Supportive devices or equipment (eg, supportive taping, corsets, neck collars, serial casts, elastic wraps, oxygen)

Airway Clearance Techniques

Anticipated Goals

* Airway clearance is improved.

* Cough is improved.

* Risk of secondary complications is reduced.

* Ventilation, respiration (gas exchange), and circulation are improved.

Specific Direct Interventions

* Chest percussion, vibration, and shaking

* Pulmonary postural drainage and positioning

* Suctioning

* Techniques to maximize ventilation (eg, maximal inspiratory hold, staircase breathing, manual hyperinflation)

Reexamination

The physical therapist relies on reexamination, the process of performing selected tests and measures after the initial examination, to evaluate progress and to modify or redirect intervention. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease or a condition, which -- for some patient/client diagnostic groups -- may be the life span. Indications for reexamination include new clinical findings or failure to, respond to intervention.

Outcomes

Outcomes relate to functional limitation (restriction of the ability to perform, at the level of the whole person, a physical action, activity, or task in an efficient, typically expected, or competent manner), disability (inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment), primary or secondary prevention, and patient/client satisfaction. The physical therapist also identifies the patient's/client's expectations for therapeutic interventions and perceptions about the clinical situation and considers whether they are realistic, given the examination and evaluation findings. Optimal outcomes for patients/clients in this pattern include:

Functional Limitation/Disability

* Health-related quality of life is improved.

* Developmental delays associated with functional limitations and disability are reduced.

* Risk of disability associated with respiratory failure is reduced.

* Safety of patient/client and caregivers is increased.

Patient/Client Satisfaction

* Access, availability, and services provided are acceptable to family, significant others, and caregivers.

* Administrative management of practice is acceptable to family, significant others, and caregivers.

* Clinical proficiency of physical therapist is acceptable to family, significant others, and caregivers.

* Coordination and conformity of care are acceptable to family, significant others, and caregivers.

* Interpersonal skills of physical therapist are acceptable to family, significant others, and caregivers.

Secondary Prevention

* Risk of functional decline is reduced.

* Risk of impairment or of impairment progression is reduced. Other secondary prevention outcomes include:

* Need for additional physical therapist intervention is decreased.

* Family and caregivers are aware of the factors that may indicate need for reexamination or a new episode of care, including changes in the following: caregiver status; community adaptation; leisure activities; living environment; pathology or impairment that may affect function; or home or work (job/school/play) settings.

* Professional recommendations are integrated into home and community environments.

* Utilization and cost of health care services are decreased.

Criteria for Discharge

Discharge is the process of discontinuing interventions that are being provided in a single episode of care. Discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals (remediation of impairment, or loss or abnormality of physiological, psychological, or anatomical structure or function) and desired outcomes (described above). In consultation with appropriate individuals, the physical therapist plans for discharge and provides for appropriate follow-up or referral. The primary criterion for discharge: The anticipated goals and the desired outcomes have been achieved. Other indicators: patient/client, caregiver, or legal guardian declines to continue intervention; patient/client is unable to continue to progress toward goals because of medical or psychosocial complications; or the physical therapist determines that the patient/client will no longer benefit from physical therapy. When discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. For patients/clients who require multiple episodes of care, periodic follow-up is needed over the life span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands.