Integumentary.Preferred Practice Patterns: Integumentary 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. Pattern A: Primary Prevention/Risk Factor Reduction for Integumentary Disorders 7A-1 Pattern B: Impaired Integumentary Integrity Secondary to Superficial Skin Involvement 7B-1 Pattern C: Impaired Integumentary Integrity Secondary to Partial-Thickness Skin Involvement and Scar Formation 7C-1 Pattern D: Impaired Integumentary Integrity Secondary to Full-Thickness Skin Involvement and Scar Formation 7D-1 Pattern E: Impaired Integumentary Integrity Secondary to Skin Involvement Extending Into Fascia, Muscle, or Bone 7E-1 Pattern F: Impaired Anthropometric Dimensions Secondary to Lymphatic System Disorders 7F-1 Primary Prevention/Risk Factor Reduction for Integumentary 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 a potential risk for disruption in the integument. Patients/clients may have any one or a combination of the following: * Edema * Inflammation * Integument repaired by primary intention * Ischemia * Low or moderate risk assessment score (eg, for pressure, insensitivity) * Pain * Prior scar INCLUDES patients/clients at any stage with: * Amputation * Central nervous system disorder * Congestive heart failure * Diabetes * Obesity * Spinal cord involvement * Surgery * Vascular disease EXCLUDES patients/clients with: * Flaps * Grafts 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. 250 Diabetes mellitus 277 Other and unspecified disorders of metabolism 277.6 Other deficiencies of circulating enzymes Hereditary angioedema 278 Obesity and other hyperalimentation 278.0 Obesity 320 Bacterial meningitis 322 Meningitis of unspecified cause 322.9 Meningitis, unspecified 323 Encephalitis, myelitis, and encephalomyelitis 331 Other cerebral degenerations 331.7 Cerebral degeneration in diseases classified elsewhere 331.9 Cerebral degeneration, unspecified 332 Parkinson's disease 333 Other extrapyramidal disease and abnormal movement disorders 333.2 Myoclonus 334 Spinocerebellar disease 334.0 Friedreich's ataxia 334.1 Hereditary spastic paraplegia 334.2 Primary cerebellar degeneration 334.9 Spinocerebellar disease, unspecified 335 Anterior horn cell disease 336 Other diseases of spinal cord 336.0 Syringomyelia and syringobulbia 336.1 Vascular myelopathies 336.9 Unspecified disease of spinal cord 337 Disorders of the autonomic nervous system 340 Multiple sclerosis 341 Other demyelinating diseases of central nervous system 342 Hemiplegia and hemiparesis 343 Infantile cerebral palsy 344 Other paralytic syndromes 344.0 Quadriplegia and quadriparesis 344.1 Paraplegia 344.3 Monoplegia of lower limb 353 Nerve root and plexus disorders 353.9 Unspecified nerve root and plexus disorder 357 Inflammatory and toxic neuropathy 357.2 Polyneuropathy in diabetes 357.3 Polyneuropathy in malignant disease 357.4 Polyneuropathy in other diseases classified elsewhere 357.6 Polyneuropathy due to drugs 428 Heart failure 428.0 Congestive heart failure 435 Transient cerebral ischemia Cerebrovascular insufficiency (acute) with transient focal neurological signs and symptoms; insufficiency of carotid artery 435.1 Vertebral artery syndrome 435.8 Other specified transient cerebral ischemias 440 Atherosclerosis 443 Other peripheral vascular disease 443.0 Raynaud's syndrome 443.1 Thromboangiitis obliterans [Buerger's disease] 443.9 Peripheral vascular disease, unspecified 454 Varicose veins of lower extremities 457 Noninfectious disorders of lymphatic channels 457.0 Postmastectomy lymphedema syndrome 457.1 Other lymphedema 459 Other disorders of circulatory system 459.1 Postphlebitic syndrome 459.8 Other specified disorders of circulatory system 459.81 Venous (peripheral) insufficiency, unspecified 459.9 Unspecified circulatory system disorder 581 Nephrotic syndrome 581.9 Nephrotic syndrome with unspecified pathological lesion in kidney Nephritis with edema, not otherwise specified 593 Other disorders of kidney and ureter 593.8 Other specified disorders of kidney and ureter 593.81 Vascular disorders of kidney 686 Other local infections of skin and subcutaneous tissue 686.9 Unspecified local infection of skin and subcutaneous tissue 701 Other hypertrophic and atrophic atrophic /atro·phic/ (a-tro´fik) pertaining to or characterized by atrophy. conditions of skin 701.4 Keloid scar Hypertrophic scar 709 Other disorders of skin and subcutaneous tissue 709.2 Scar conditions and fibrosis of skin 716 Other and unspecified arthropathies 716.6 Unspecified monoarthritis 719 Other and unspecified disorders of joint 719.4 Pain in joint 728 Disorders of muscle, ligament, and fascia 728.9 Unspecified disorder of muscle, ligament, and fascia 729 Other disorders of soft tissues 729.5 Pain in limb 757 Congenital anomalies of the integument 757.0 Hereditary edema of legs 782 Symptoms involving skin and other integumentary tissue 782.0 Disturbance of skin sensation 782.3 Edema 895 Traumatic amputation of toe(s) (complete) (partial) 895.0 Without mention of complication 896 Traumatic amputation of foot (complete) (partial) 896.2 Bilateral, without mention of complication 897 Traumatic amputation of leg(s) (complete) (partial) 897.0 Unilateral, below knee, without mention of complication 897.2 Unilateral, at or above knee, without mention of complication 897.4 Unilateral, level not specified, without mention of complication 897.6 Bilateral [any level], without mention of complication 995.1 Angioneurotic edema 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: 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 in darkly pigmented skin) * Assessment of nail beds * Assessment of sensation (eg, pain, temperature, itch, tactile) * Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) * Assessment of tissue mobility, turgor, and texture For wound: * Assessment for presence of dermatitis (eg, rash, fungus) * Assessment for presence of hair growth * Assessment of ecchymosis * Assessment of scar tissue (cicatrix vicious cicatrix one causing deformity or impairing the function of a limb. cic·a·trix (s  k ), including banding, pliability sensation, and texture 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 pain perception (eg, phantom pain) * Assessment of pain using questionnaires, graphs, behavioral scales, symptom magnification scales or indexes, and visual analog scales Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of capillary refill time * Palpation of pulses 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 night 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 Over the course of 1 to 3 weeks, patient/client or caregiver will be independent in skin inspection. Patient/client will demonstrate knowledge of disease-preventing behavior and will demonstrate knowledge of risk factors of integumentary disruption and methods to modify those risk factors. 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 1 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 * Accessibility of resources * Age * Allergic reaction (eg, to medication, tape, latex) * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities (eg, chronic obstructive pulmonary disease, renal disease, cerebrovascular accident) * Immunosuppresion (eg, human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], cancer) * Level of patient/client adherence to the intervention program * Need for ventilatory support * Nutritional status * Preexisting systemic conditions or diseases (eg, diabetes, peripheral vascular disease, peripheral neuropathy) * Presence of infection * Support provided by family unit * Total body surface area (TBSA) of burn 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 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. * Decision making is enhanced regarding health of client and use of health care resources by client. * 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. * 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 * Joint integrity and mobility are improved. * Nutrient delivery to tissue is increased. * Physiologic response to increased oxygen demand is improved. * Risk factors are reduced. * Risk of recurrence is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Sensory awareness is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * Breathing exercises * Posture awareness training 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 or 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) Manual Therapy Techniques including Mobilization and Manipulation) Anticipated Goals * Integumentary integrity is improved. * Pain is decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions * Manual lymphatic drainage * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Deformities are prevented. * Gait, locomotion, and balance are improved. * Joint stability is increased. * Loading on a body part is decreased. * Optimal joint alignment is achieved. * Pain is decreased. * Protection of body parts is increased. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Stresses precipitating injury are decreased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * 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, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) 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. * Optimal role function (eg, worker, student, spouse, grandparent) is maintained. * Health-related quality of life is enhanced. * 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 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 fife span to ensure safety and effective adaptation following changes in physical status, caregivers, environment, or task demands. Impaired Integumentary Integrity Secondary to Superficial Skin Involvement PATTERN B 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 superficial skin involvement. Patients/clients may have any one or a combination of the following: * Burns (first degree) * Contusion * Dermopathy * Neuropathic ulcers (grade) * Pressure ulcers (stage I) * Vascular disease (eg, venous, arterial, diabetic) INCLUDES patients/clients with: * Cellulitis * Dermatitis EXCLUDES patients/clients with: * Any break in skin integrity * Frostbite 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. 250 Diabetes mellitus 454 varicose veins of lower extremities 454.1 With inflammation 690 Erythematosquainous dermatosis dermatosis papulo´sa ni´gra a form of seborrheic keratosis seen chiefly in blacks, with multiple miliary pigmented papules usually on the cheek bones, but sometimes occurring more widely on the face and neck. progressive pigmentary dermatosis Schamberg's disease. 691 Atopic dermatitis and related conditions 692 Contact dermatitis and other eczema 692.7 Due to solar radiation 692.71 Sunburn 700 Corns and callosities 707 Chronic ulcer of skin 707.0 Decubitus ulcer 707.1 Ulcer of lower limbs, except decubitus 731 Osteitis deformans and osteopathies associated with other disorders classified elsewhere 731.8 Other bone involvement in diseases classified elsewhere 782 Symptoms involving skin and other integumentary tissue 782.2 Localized superficial swelling, mass, or lump 782.7 Spontaneous ecchymoses 782.8 Changes in skin texture 920 Contusion of face, scalp, and neck, except eye(s) 922 Contusion of trunk 922.0 Breast 922.1 Chest wall 922.2 Abdominal wall 922.31 Back 922.32 Buttock 922.33 Interscapular region 922.8 Multiple sites of trunk 923 Contusion of upper limb 923.0 Shoulder and upper arm 923.1 Elbow and forearm 923.2 Wrist and hand(s), except finger(s) alone 923.3 Finger 923.8 Multiple sites of upper limb 924 Contusion of lower limb and of other unspecified sites 924.0 Hip and thigh 924.1 Knee and lower leg 924.2 Ankle and foot, excluding toe(s) 924.3 Toe 924.4 Multiple sites of lower limb 942 Burn of trunk 942.1 Erythema [first degree] 943 Burn of upper limb, except wrist and hand 943.1 Erythema [first degree] 944 Burn of wrist(s) and hand(s) 944.1 Erythema [first degree] 945 Burn of lower limb (s) 945.1 Erythema [first degree] 946 Burns of multiple specified sites 946.1 Erythema [first degree] 948 Burns classified according to extent of body surface involved 949 Burn, unspecified 949.1 Erythema [first degree] Examination Through the examination (history, systems review, and tests and measures), the physical therapist identifies impairment, 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 Post History of Current Condition * Prior therapeutic interventions * Prior medications Past Medical/Surgical History * Cardiopulmonary * Endocrine/metabolic * Gastrointestinal * Geritourinary * 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) * Behaviorl 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: 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 * Assessment of level of recall (eg, short- and long-term memory) Assistive and Adaptive Devices * Assessment of alignment and fit of device and inspection of related changes in skin condition * Assessment of safety during use of device * Assessment of patient/client and caregiver ability to care for device * Review of reports provided by patient/client, family, significant others, caregivers, or other professionals concerning use of or need for device 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 safety Integumentary Integrity For skin associated with integumentary disruption: * Assessment for presence of hair growth * 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 mobility, turgor, and texture For wound: * Assessment for presence of blistering * Assessment for presence of dermatitis (eg, rash, fungus) * Assessment for presence of hair growth * Assessment for signs of infection * Assessment of activities, devices, positioning, and postures that aggravate the wound or scar or that may produce additional trauma * Assessment of burn * Assessment of ecchymosis * Assessment of pigment (color) * Assessment of sensation (eg, pain, temperature, (tactile) * Assessment of shape and size of skin involvement 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 * Assessment of pain and soreness Range of Motion (ROM) (Including Muscle Length) * Analysis of ROM using goniometers, tape measures, flexible rulers, inchnometers, photographic or electronic devices, or computer-assisted graphic imaging Sensory Integrity * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of capilary refill time * Assessment of standard vital signs (eg, blood pressure, hearth rate, respiratory rate) * Palpation of pulses 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, 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 Over the course of 2 weeks, patient/client will show resolution of skin involvement. 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 1 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 Require New Episode of Care or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home heath aide) consistency or expertise * Chronicity or severity of condition * Comorbidities (eg, chronic obstructive pulmonary disease, renal disease, cerebrovascular accident) * Immunosuppression (eg, human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], cancer) * Level of patient/client adherence to * the intervention program * Nutritional status * Preexisting systemic conditions or diseases (eg, diabetes, peripheral vascular disease, peripheral neuropathy) * Presence of infection * Support provided by family unit * Total body surface area (TBSA) of burn 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 of optimization 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 die 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 that 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 impairment 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 * Aerobic capacity is increased. * Gait, locomotion, and balance are improved. * Pain is decreased. * Postural control is improved. * Risk factors are reduced. * Risk of recurrence is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Utilization and cost of health care services are decreased. * Tolerance to positions and activities is increased. * Weight-bearing status is improved. Specific Direct Interventions * Breathing exercises * Gait, locomotion, and balance training * Posture awareness training 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. * Risk of recurrence of condition is reduced. * 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 or 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 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 increased. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of conditions is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions * Assistive and adaptive device or 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) * Injury prevention or reduction training * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions * Manual lymphatic drainage * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Deformities are prevented. * Gait, locomotion, and balance are improved. * Joint stability is increased. * Loading on a body part is decreased. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Protection of body parts is increased. * Pressure areas (eg, pressure over bony prominence) are prevented. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. Specific Direct Interventions * Assistive devices or equipment (eg, crutches, canes, walkers, wheelchairs, power devices, long-handled reachers, static and dynamic splints) * Orthotic devices or equipment (eg, braces, shoe inserts, casts, splints, casts) * Protective devices or equipment (eg, braces, protective taping, cushions, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Wound Management Anticipated Goals * Complications are reduced. * Risk factors for infection are reduced. * Risk of secondary, impairments is reduced. * Tissue perfusion and oxygenation are enhanced. * Wound and soft tissue healing is enhanced. * Wound size is reduced. Specific Direct Interventions * Dressings (eg, wound coverings) * Orthotic, protective, and supportive devices * Topical agents (eg, ointments, moisturizers, creams, cleansers, sealants) Electrotherapeutic Modalities Anticipated Goals * Complications are reduced. * Pain is decreased. * Risk of secondary, impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue heating is enhanced. Specific Direct Interventions * Electrical muscle stimulation * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Complications of soft tissue and circulatory disorders are decreased. * Pain is decreased. * Risk of secondary impairments is decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * Hydrotherapy (eg, aquatic therapy, whirlpool tanks, contrast baths, pulsatile lavage) * Phototherapy (eg, ultraviolet) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities: * Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compression garments, taping, and total contact casting) * 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 superficial skin involvement 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. 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 partial-thickness skin involvement. Patients/clients may have any one or a combination of the following: * Burns (second degree) * Dermatologic disorders * Hematoma * Neuropathic ulcers (grade 1) * Pressure ulcers (stage II) * Prior scar * Surgical wounds * Traumatic injury * Vascular ulcers (eg, venous, arterial, diabetic) INCLUDES patients/clients at any stage with: * Epidermolysis bullosa * Immature scar * Neoplasms (including Kaposi's sarcoma) * Pemphigus vulgaris * Status post-spinal cord injury * Toxic epidermal necrolyzing syndrome (Stevens-Johnson syndrome) EXCLUDES patients/clients with: * A total body surface area (TBSA) involvement of more than 25% in adults and more than 20% in children who are medically unstable * Acute amputation * Frostbite * Injury secondary to trauma (eg, multiple fractures, amputations, electricity-related injuries) 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) coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements. 017 Tuberculosis of other organs 017.0 Skin and subcutaneous cellular tissue 031 Diseases due to other mycobacteria 031.1 Cutaneous 216 Benign neoplasm of skin 216.5 Skin of trunk, except scrotum 216.6 Skin of upper limb, including shoulder 216.7 Skin of lower limb, including hip 232 Carcinoma in situ of skin 232.5 skin of trunk, except scrotum 232.6 Skin of upper limb, including shoulder 232.7 skin of lower limb, including hip 239 Neoplasms of unspecified nature 239.2 Bone, soft tissue, and skin 454 Varicose veins of lower extremities 454.0 With ulcer 454.2 With ulcer and inflammation 682 Other cellulitis and abscess 686 Other local infections of skin and subcutaneous tissue 694 Bullous bullous /bul·lous/ (bul´us) pertaining to or characterized by bullae. bul·lous (b  l dermatoses 694.5 Pemphigoid 695 Erythematous conditions 695.1 Erythema multiforme 695.4 Lupus erythematosus 696 Psoriasis and similar disorders 696.1 other psoriasis 701 Other hypertrophic and atrophic conditions of skin 701.0 Circumscribed scleroderma 701.3 Striae atrophicae Atrophy blanche (of Milian) 701.4 Keloid scar 707 Chronic ulcer of skin 707.0 Decubitus ulcer 707.1 Ulcer of lower limbs, except decubitus 707.8 Chronic ulcer of other specified sites 709 Other disorders of skin and subcutaneous tissue 709.2 Scar conditions and fibrosis of skin 709.3 Degenerative skin disorders 757 Congenital anomalies of the integument 911 Superficial injury of trunk 911.0 Abrasion or friction burn without mention of infection 911.1 Abrasion or friction bum, infected 911.2 Blister without mention of infection 911.3 Blister, infected 912 Superficial injury of shoulder and upper arm 912.0 Abrasion or friction burn without mention of infection 912.1 Abrasion or friction bum, infected 912.2 Blister without mention of infection 912.3 Blister, infected 913 Superficial injury of elbow, forearm, and wrist 913.0 Abrasion or friction burn without mention of infection 913.1 Abrasion or friction burn, infected 913.2 Blister without mention of infection 913.3 Blister, infected 914 Superficial injury of hand(s), except finger(s) alone 914.0 Abrasion or friction burn without mention of infection 914.1 Abrasion or friction burn, infected 914.2 Blister without mention of infection 914.3 Blister, infected 915 Superficial injury of finger(s) 915.0 Abrasion or friction burn without mention of infection 915.1 Abrasion or friction burn, infected 915.2 Blister without mention of infection 915.3 Blister, infected 916 Superficial injury of hip, thigh, leg, and ankle 916.0 Abrasion or friction burn without mention of infection 916.1 Abrasion or friction burn, infected 916.2 Blister without mention of infection 916.3 Blister, infected 917 Superficial injury of foot and toe(s) 917.0 Abrasion or friction burn without mention of infection 917.1 Abrasion or friction burn, infected 917.2 Blister without mention of infection 917.3 Blister, infected 942 Burn of trunk 942.2 Blisters, epidermal loss [second degree] 943 Burn of upper limb, except wrist and hand 943.2 Epidermal loss [second degree] 944 Burn of wrist(s) and hand(s) 944.2 Blisters, epidermal loss [second degree] 945 Burn of lower limb(s) 945.2 Blisters, epidermal loss [second degree] 946 Burns of multiple specified sites 946.2 Blisters, epidermal loss [second degree] 948 Burns classified according to extent of body surface involved 949 Burn, unspecified 949.2 Blisters, epidermal loss [second degree] 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 anotomic 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: 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 * Assessment of level of recall (eg, short-term and long-term memory) Assistive and Adaptive Devices * Assessment of patient/client and caregiver ability to care for 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 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 safety Integumentary Integrity For skin associated with integumentary disruption: * Assessment for presence of hair growth * 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 skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) * Assessment of tissue mobility, turgor, and texture For wound: * Assessment for presence of blistering * Assessment for presence of dermatitis (eg, rash, fungus) * Assessment for presence of hair growth * Assessment for signs of infection * Assessment of burn * Assessment of activities, positioning, and postures that aggravate the wound or scar or that may produce additional trauma * Assessment of bleeding * Assessment of pigment (color) * Assessment of scar tissue cicatrix), including banding, pliability, sensation, and texture * Assessment of scar tissue mobility, turgor, and texture * Assessment of sensation (eg, pain, temperature, tactile) * Assessment of wound contraction, drainage location, odor, shape, size, and depth (eg, linear, tracing, photography) * Assessment of wound tissue, including epithelium, granulation, necrosis, slough, texture, and turgor * Assessment of ecchymosis 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 * Assessment of pain and soreness 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 Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of superficial sensations (eg, sharp or dull discrimination, temperature, light touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of capillary refill time * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Palpation of pulses 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 Over the course of 4 weeks, patient/client will achieve wound closure. Expected Range of Number of Visits Per Episode of Care 4 to 40 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 4 to 40 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 * Accessibility of resources * Age * Allergic reaction (eg, to medication, tape, latex) * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities (eg, chronic obstructive pulmonary disease, renal disease, cerebrovascular accident) * Immunosuppression (eg, human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], cancer) * Level of patient/client adherence to the intervention program * Need for ventilatory support * Nutritional status * Preexisting systemic conditions or diseases (eg, diabetes, peripheral vascular disease, peripheral neuropathy) * Presence of infection * Support provided by family unit * Total body surface area (TBSA) of burn 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 * Aerobic capacity is increased. * Gait, locomotion, and balance are improved. * Joint and soft tissue swelling, inflammation, or restriction is reduced. * Joint integrity and mobility are improved, * Pain is decreased. * Postural control is improved, * Risk factors are reduced. * Risk of recurrence is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Strength, power, and endurance are increased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased, * Weight-bearing status is improved. Specific Direct Interventions * Breathing exercises * Gait, locomotion, and balance training * Posture awareness training * Strengthening 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. * Risk of recurrence of condition is reduced. * 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 or 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 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 increased. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of conditions is reduced. * Tolerance to positions and activities is increased, Specific Direct Interventions * Assistive and adaptive device or 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) * Injury prevention or reduction training * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Manual lymphatic drainage * Therapeutic massage Prescription, Application, and, as Appropriate, Fabrication of Devices and Equipment (Assistive, Adaptive, Orthotic, Protective, Supportive, and Prosthetic) Anticipated Goals * Deformities are prevented. * Gait, locomotion, and balance are improved. * Joint stability is increased. * Loading on a body part is decreased. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Pressure areas (eg, pressure over bony prominences) are prevented * Protection of body parts is increased. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * 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, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Wound Management Anticipated Goals * Complications are reduced. * Debridement of nonviable tissue is achieved. * Physical function and health status are improved. * Risk factors for infection are reduced. * Risk of secondary impairments is reduced. * Tissue perfusion and oxygenation are enhanced. * Wound size is reduced. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Debridement -- nonselective - enzymatic debridement - wet dressings - wet-to-dry dressings - wet-to-moist dressings * Debridement -- selective - debridement with other agents (eg, autolysis 1. spontaneous disintegration of cells or tissues by autologous enzymes, as occurs after death and in some pathologic conditions. 2. destruction of cells of the body by its own serum.autolyt´ic au·tol·y·sis (ô-t) - enzymatic debridement - sharp debridement * Dressings (eg, wound coverings, hydrogels, vacuum-assisted closure) * Electrotherapeutic modalities (see Electrotherapeutic Modalities) * Orthotic, protective, and supportive devices * Oxygen therapy (eg, topical, supplemental) * Physical agents and mechanical modalities (see Physical Agents and Mechanical Modalities) * Topical agents (eg, ointments, moisturizers, creams, cleansers, sealants) Electrotherapeutic Modalities Anticipated Goals * Complications are reduced. * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Electrical muscle stimulation * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Complications of soft tissue and circulatory disorders are decreased. * Debridement of nonviable tissue is achieved. * Pain is decreased. * Risk of secondary impairments is decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed electromagnetic fields) * Deep thermal modalities (eg, ultrasound, pulsed shortwave diathermy) * Hydrotherapy (eg, whirlpool tanks, pulsatile lavage) * Phototherapy (eg, ultraviolet) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities: * Compression therapies (eg, vasopneumatic compression devices, compression bandaging, compression garments, taping, and total contact casting) * Tilt table or standing table 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 partial-thickness skin involvement and scar tissue 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 goats (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 Integumentary Integrity Secondary to Full-Thickness Skin Involvement and Scar Formation 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 with full-thickness involvement. Patients/clients may have any one or a combination of the following: * Burns * Dermatologic disorders * Hematoma * Lymphostatic ulcers * Necrotizing fasciitis * Neuropathic ulcers (grade 2) * Pressure ulcer (stage 3) * Prior scar * Vascular ulcers (eg, venous, arterial, diabetic) INCLUDES patients/clients at any stage with: * Abscess * Frostbite * Immature, hypertrophic, or keloid scar * Neoplasm * Surgical wound * Toxic epidermal necrolysis (Stevens-Johnson syndrome) EXCLUDES patients/clients with: * Amputations * Crushing injury * Electricity-related injury * Lymphedema * Traumatic wound 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. 017 Tuberculosis of other organs 017.0 Skin and subcutaneous cellular tissue 031 Diseases due to other mycobacteria 031.1 Cutaneous 036 Meningococcal infection 036.1 Meningococcal encephalitis 040 Other bacterial diseases 040.0 Gas gangrene 172 Malignant melanoma of skin 172.5 Trunk, except scrotum 172.6 Upper limb, including shoulder 172.7 Lower limb, including hip 172.8 Other specific sites of skin 173 Other malignant neoplasm of skin 173.5 Skin of trunk, except scrotum 173.6 Skin of upper limb, including shoulder 173.7 Skin of lower limb, including hip 173.8 Other specified sites of skin 176 Kaposi's sarcoma 176.0 Skin 216 Benign neoplasm of skin 232 Carcinoma in situ of skin 239 Neoplasms of unspecified nature 443 Other peripheral vascular disease 443.1 Thromboangiitis obliterans [Buerger's disease] 454 Varicose veins of lower extremities 454.0 With ulcer 454.2 With ulcer and inflammation 680 Carbuncle malignant carbuncle anthrax. car·bun·cle (kär b ng k and furuncle 680.2 Trunk 680.3 Upper arm and forearm 680.4 Hand 680.5 Buttock 680.6 Leg, except foot 680.7 Foot 681 Cellulitis and abscess of finger and toe 681.0 Finger 681.1 Toe 682 Other cellulitis and abscess 682.0 Face 682.2 Trunk 682.3 Upper arm and forearm 682.4 Hand, except fingers and thumb 682.5 Buttock 682.6 Leg, except foot 682.7 Foot, except toes 686 Other local infections of skin and subcutaneous tissue 686.0 Pyoderma 686.1 Pyogenic granuloma 686.8 Other specified local infections of skin and subcutaneous tissue 694 Bullous dermatoses 695 Erythematous conditions 695.1 Erythema multiforme 695.4 Lupus erythematosus 701 Other hypertrophic and atrophic conditions of skin 701.0 Circumscribed scleroderma 701.4 Keloid scar 701.5 Other abnormal granulation tissue 707 Chronic ulcer of skin 707.1 Ulcer of lower limbs, except decubitus 707.8 Chronic ulcer of other specified sites 709 Other disorders of skin and subcutaneous tissue 709.2 Scar conditions and fibrosis of skin 709.3 Degenerative skin disorders 941 Burn of face, head, and neck 941.3 Full-thickness skin loss [third degree, not otherwise specified] 942 Burn of trunk 942.3 Full-thickness skin loss [third degree, not otherwise specified) 943 Burn of upper limb, except wrist and hand 943.3 Full-thickness skin loss [third degree, not otherwise specified] 944 Burn of wrist(s) and hand(s) 944.3 Full-thickness skin loss [third degree, not otherwise specified] 945 Burn of lower limb(s) 945.3 Full-thickness, skin loss [third degree, not otherwise specified] 946 Burns of multiple specified sites 946.3 Full-thickness skin loss [third degree, not otherwise specified] 948 Burns classified according to extent of body surface involved 949 Burn, unspecified 949.3 Full-thickness skin loss [third degree, not otherwise specified] 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 Post 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: 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 * Assessment of level of recall (eg, short-term and long-term memory) Assistive and Adaptive Devices * Analysis of patient/client and caregiver ability to care for 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 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 safety Integumentary Integrity For skin associated with integumentary disruption: * Assessment for presence of hair growth * Assessment of activities, positioning, postures, and assistive and adaptive devices that may result in trauma to associated skin * Assessment of activities, positioning, and postures that aggravate or relieve pain or other disturbed sensations * 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 tissue mobility, turgor, and texture For wound: * Assessment for presence of blistering * Assessment for signs of infection * Assessment of activities, positioning, and postures that aggravate the scar or that may produce additional trauma * Assessment of burn * Assessment of bleeding * Assessment of ecchymosis * Assessment for presence of hair growth * Assessment of pigment (color) * Assessment of scar mobility, turgor, and texture * Assessment of scar tissue (cicatrix), including banding, pliability, sensation, and texture * Assessment of sensation (eg, pain, temperature, tactile) * Assessment of wound contraction, drainage, location, odor, shape, size, depth (eg, linear, tracing, photography), tunneling, and undermining * Assessment of wound tissue, including epithelium, granulation, necrosis, slough, and texture 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 * Assessment of pain and soreness 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 Sensory Integrity (Including Proprioception and Kinesthesia) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of capillary refill time * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) * Palpation of pulses 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 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 Wound Over the course of 4 to 12 weeks, one of the following will occur: * Wound will be clean and stable. * Wound will be prepared for closure. * Wound will be closed. Scar Over the course of 6 to 12 months, scar will be mature. Expected Range of Number of Visits Per Episode of Care 12 to 60 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 12 to 60 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 * Accessibility of resources * Age * Allergic reaction (eg, to medication, tape, latex) * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities (eg, chronic obstructive * pulmonary disease, renal disease, cerebrovascular accident) * Immunosuppression (eg, human immunodeficiency virus/acquired immunodeficiency syndrome [IHV/AIDS), cancer) * Level of patient/client adherence to the intervention program * Need for ventilatory support * Nutritional status * Preexisting systemic conditions or diseases (eg, diabetes, peripheral vascular disease, peripheral neuropathy) * Presence of infection * Support provided by family unit * Total body surface area (TBSA) of burn 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 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. * Gait, locomotion, and balance are improved. * Joint integrity and mobility are improved. * Pain is decreased. * Postural control is improved. * Risk factors are reduced. * Risk of recurrence is reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Utilization and cost of health care services are decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Strength is increased. * Tolerance to positions and activities is increased. * Weight-bearing status is improved. Specific Direct Interventions * Breathing exercises * Gait, locomotion, and balance training * Posture awareness training * Strengthening Functional Training in Self-Care and Home Management (Including ADL and IADL) Anticipated Goals * Ability to recognize and intiate 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. * Risk of recurrence of condition is reduced. * 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 or 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 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 increased. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of conditions is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Assistive and adaptive device or equipment training * IADL training (eg, maintaining a time, 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 * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Pain is decreased. * Quality and quantity of movement between and across body segments are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Connective tissue massage * Manual lymphatic drainage * 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. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Joint integrity and mobility are improved. * Joint stability is increased. * Loading on a body part is decreased. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Pressure areas (eg, pressure over bony prominences) are prevented. * Protection of body parts is increased. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restricted is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status 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, compression garments, corsets, slings, neck collars, serial casts, elastic wraps, oxygen) Wound Management Anticipated Goals * Complications are reduced. * Debridement of nonviable tissue is achieved. * Physical function and health status are improved. * Risk factors for infection are reduced. * Risk of secondary impairment is reduced. * Tissue perfusion and oxygenation are enhanced. * Wound size is reduced. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Debridement -- nonselective - enzymatic debridement - wet dressings - wet-to-dry dressings - wet-to-moist dressings * Debridement -- selective - debridement with other agents (eg, autolysis) - enzymatic debridement - sharp debridement * Dressings (eg, wound coverings, hydrogels, vacuum-assisted closure) * Electrotherapeutic modalities (see Electrotherapeutic * Modalities) * Orthotic, protective, and supportive devices * Oxygen therapy (eg, topical, supplemental) * Physical agents and mechanical modalities (see Physical Agents and Mechanical Modalities) * Topical agents (eg, ointments, moisturizers, creams, cleansers, sealants) Electrotherapeutic Modalities Anticipated Goals * Complications are reduced. * Edema, lymphedema, or effusion is decreased. * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Electrical muscle Stimulation * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Complications of soft tissue and circulatory disorders are decreased. * Debridement of nonviable tissue is achieved. * Joint integrity and mobility are improved. * Pain is decreased. * Risk of secondary impairments is decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed radio frequency energy) * Deep thermal modalities (eg, ultrasound, pulsed shortwave diathermy) * Hydrotherapy (eg, whirlpool tanks, pulsatile lavage) * Phototherapy (eg, ultraviolet) * Superficial thermal modalities (eg, heat, paraffin baths, hot * packs, fluidotherapy) Mechanical modalities: * Continuous passive motion (CPM) * Compression therapies (eg, all compression devices, compression bandaging, compression garments, taping, and total contact casting) * Tilt table or standing table 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 full-thickness skin involvement and scar formation is reduced. * Safety of patient/client and caregivers is increased. * Self-care and home management activities, including activities of daily living (IADL) -- 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 Integumentary Integrity Secondary to Skin Involvement Extending Into Fascia, Muscle, or Bone 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 subcutaneous tissue involvement that may extend into underlying tissue; patients/clients may have any one or a combination of the following: * Abscess * Hematoma * Necrotizing fasciitis * Neuropathic ulcers (grades 3, 4, 5) * Pressure ulcers (stage 4) * Surgical wounds * Vascular ulcers (eg, venous, diabetic) INCLUDES patients/clients with: * Acute amputation * Burn * Chronic surgical wound * Electrical burns * Frostbite * Kaposi's sarcoma * Lymphostatic ulcer * Neoplasm * Subcutaneous arterial ulcer * Surgical wound EXCLUDES patients/clients with: * Lymphedema 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. 017 Tuberculosis of other organs 017.0 Skin and subcutaneous cellular tissue 036 Meningococcal infection 036.2 Meningococcemia 171 Malignant neoplasm of connective and other soft tissue 171.2 Upper limb, including shoulder 171.3 Lower limb, including hip 171.5 Abdomen 171.6 Pelvis 171.8 Other specified sites of connective and other soft tissue 172 Malignant melanoma of skin 172.5 Trunk, excluding scrotum 172.6 Upper limb,includingshoulder 172.7 Lower limb, including hip 172.8 Other specific sites of skin 173 Other malignant neoplasm of skin 173.5 Skin of trunk, except scrotum 173.6 Skin of upper limb, including shoulder 173.7 Skin of lower limb, including hip 173.8 Other specified sites of skin 176 Kaposi's sarcoma 176.0 skin 176.1 Soft tissue 215 Other benign neoplasm of connective and other soft tissue 215.2 Upper limb,including shoulder 215.3 Lower limb, including hip 215.6 Pelvis 239 Neoplasms of unspecified nature 239.2 Bone, soft tissue, and skin 440 Atherosclerosis 440.2 Of native arteries of the extremities 440.24 Atherosclerosis of the extremities with gangrene 443 Other peripheral vascular disease 443.1 Thromboangiitis obliterans [Buerger's disease] 454 Varicose veins of lower extremities 454.0 With ulcer 454.2 With ulcer and inflammation 674 Other and unspecified complications of the perperium, not elsewhere classified 674.1 Disruption of cesarean wound 680 Carbuncle and furuncle 680.2 Trunk 680.3 Upper arm and forearm 680.4 Hand 680.5 Buttock 680.6 Leg, except foot 680.7 Foot 681 Cellulitis and abscess of finger and toe 681.0 Finger 686 Other local infections of skin and subcutaneous tissue 686.8 Other specified local infections of skin and subcutaneous tissue 707 Chronic ulcer of skin 707.0 Decubitus ulcer 707.1 Ulcer of lower limbs, except decubitus 707.8 Chronic ulcer of other specified sites 710 Diffuse diseases of connective tissue 710.0 Systemic lupus erythematosus 710.1 Systemic sclerosis 710.3 Dermatomyositis dermatomyositis /der·ma·to·myo·si·tis/ (-mi?o-si´tis) a collagen disease marked by nonsuppurative inflammation of the skin, subcutaneous tissue, and muscles, with necrosis of muscle fibers. der·ma·to·my·o·si·tis (dûr 880 Open wound of shoulder and upper arm 881 Open wound of elbow, forearm, and wrist 882 Open wound of hand except figer(s) alone 883 Open wound of finger(s) 884 Multiple and unspecified open wound of upper limb 885 Traumatic amputation of thumb (complete) (partial) 886 Traumatic amputation of other finger(s) (complete) (partial) 887 Traumatic amputation of arm and hand (complete) (partial) 890 Open wound of hip and thigh 891 Open wound of knee, leg [except thigh], and ankle 892 Open wound of foot except toe(s) alone 893 Open wound of toe(s) 894 Multiple and unspecified open wound of lower limb 895 Traumatic amputation of toe(s) (complete) (partial) 896 Traumatic amputation of foot (complete) (partial) 897 Traumatic amputation of leg(s ) (complete) (partial) 927 Crushing injury of upper limb 928 Crushing injury of lower limb 929 Crushing injury of multiple and unspecified sites 941 Burn of face, head, and neck 941.4 Deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part 941.5 Deep necrosis of underlying tissues [deep third degree] with loss of a body part 942 Burn of trunk 942.4 Deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part 942.5 Deep necrosis of underlying tissues [deep third degree] with loss of a body part 943 Burn of upper limb, except wrist and hand 943.4 Deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part 943.5 Deep necrosis of underlying tissues [deep third degree] with loss of a body part 944 Burn of wrist(s) and hand(s) 944.4 Deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part 944.5 Deep necrosis of underlying tissues [deep third degree] with loss of a body part 946 Burns of multiple specified sites 946.4 Deep necrosis of underlying tissues [deep third degree] without mention of loss of a body part 946.5 Deep necrosis of underlying tissues [deep third degree] with loss of a body part 948 Burns classified according to extent of body surface involved 991 Effects of reduced temperature 991.1 Frostbite of hand 991.2 Frostbite of foot 991.3 Frostbite of other and unspecified sites 991.4 Immersion foot 991.5 Chilblains chilblain /chil·blain/ (chil´blan) a recurrent localized itching, swelling, and painful erythema of the fingers, toes, or ears, caused by mild frostbite and dampness. Called also chilblains . chil·blain (ch 998 Other complications of procedures, not elsewhere classified 998.3 Disruption of operation wound 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 Test and Measures Tests and measures for this pattern may include, in alphabetical order: 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 * Observation and palpation of trunk and extremities at rest and during activity Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition using standardized instruments * Assessment of level of recall (eg, short-term and long-term memory) Assistive and Adaptive Devices * Analysis of effects and benefits (including energy conservation and expenditure) while patient/client uses device * Analysis of patient/client or caregiver ability to care for 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 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 safety Integumentary Integrity For skin associated with integumentary disruption: * Assessment for presence of dermatitis (eg, rush, fungus) * Assessment for presence of hair growth * Assessment of activities 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) * Asessment of tissue mobility, turgor, and texture For wound: * Assessment for presence of blistering * Assessment for presence of hair and nail growth * Assessment for signs of infection * Assessment of activities, positioning, and postures that aggravate the wound or scar or that may produce additional trauma * Assessment of bleeding * Assessment of ecchymosis * Assessment of exposed anatomical structures * Assessment of pigment (color) * Assessment of scar mobility, turgor, and texture * Assessment of scar tissue (cicatrix), including banding, pliability, sensation, and texture * Assessment of sensation (eg, pain, protective, temperature, tactile) * Assessment of wound contraction, drainage, location, odor, shape, size, depth (eg, linear, tracing, photography), tunneling and undermining * Assessment of wound tissue, including epithelium, granulation, mobility, necrosis, slough, texture, and turgor Joint integrity and Mobility * Assessment of soft tissue swelling, inflammation, or restriction 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 * Assessment of pain and soreness 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 Sensory integrity (Including Proprioception and Kinesthesia) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, fight touch, pressure) Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of capillary refill time * Assessment of chest wall mobility, expansion, and excursion * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) * Palpation of pulses 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 interpretion examination data. The prognosis is the determination of the optimal level of improvement that might be answer 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 midtisystem involvement; social supports; living environment; potential discharge destinations; patient/client and family expectations; anatonxic and physiologic changes related to growth and development; and caregiver consistency or expertise. Prognosis Wound Over the course of 4 to 16 weeks, one of the following will occur: * Wound will be clean and stable. * Wound will be prepared for closure. * Wound will be closed. Scar Over the course of 4 to 16 weeks, immature scar will be evident. Expected Range of Number of Visits Per Episode of Care 12 to 112 12 to 112 These ranges represents the lower and upper limits of the number of physical therapist visits required to achieve the anticipated goals and desired outcomes. It is anticipated that 80% of patients/clients in this diagnostic group will achieve the goals and outcomes within 12 to 112 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 * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities (eg, chronic obstructive * Pulmonary disease, renal disease, cerebrovascular accident) * Imununosuppression (eg, human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], cancer) * Intrusion beyond tissue-protective surface (eg, fascial plane, peritenon, periosteum) * Level of patient/client adherence to the intervention program * Need for ventilatory support * Nutritional status * Preexisting systemic conditions or diseases (eg, diabetes, peripheral vascular disease, peripheral neuropathy) * Presence of infection * Support provided by family unit * Total body surface area (TBSA) of burn 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 bmitation, 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 planting * 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 chromic phosphate P 32 a radiolabeled phosphate salt of chromium used in the treatment of metastatic intrapleural or intraperitoneal effusions and of certain ovarian and prostate carcinomas. illness 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 * Aerobic capacity is increased. * Gait, locomotion, and balance are improved. joint integrity and mobility are improved. * Pain is decreased. * Postural control is improved. * Preoperative and postoperative complication are reduced. * Risk factors are reduced. * Risk of recurrence is reduced. * Risk of secondary impairment is reduced. * Safety is impaired. * Self-management of symptoms is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Strength, power, and endurance are increased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct interventions * Breathing exercises * Strengthening * Gait, locomotion, and balance training * Posture awareness training 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. * Risk of recurrence of condition is reduced. * 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 or 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 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 increased. * Risk of recurrence of condition is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Assistive and adaptive device or 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 and children) * Injury prevention or reduction training * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques including Mobilization and Manipulation) Anticipated Goals * Ability, to perform movement tasks is increased. * Joint integrity and mobility are improved. * Pain is decreased. * Quality and quantity of movement between and across body segments are improved. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions * Connective tissue massage * 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. * Deformities are prevented. * Gait, locomotion, and balance are improved * Joint integrity and mobility are improved joint stability is increased. * Loading on a body part is decreased. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Pressure areas (eg, pressure over bony prominence)are prevented * Prosthetic fit is achieved. * Protection of body parts is increased. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Utilization and cost of health care services are decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Weight-bearing status 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, solints, 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, compression garments, corsets, stings, neck collars, serial casts, elastic wraps) Wound Management Anticipated Goals * Complications are reduced. * Debridement of nonviable tissue is achieved. * Physical function and health status are unproved. * Risk factors for infection are reduced. * Risk of secondary improvement is reduced. * Tissue perfussion and oxygenation are enhanced. * Wound size is reduced. * Wound and soft tissue healing is enhanced. Specific Direct Interventions * Debridement -- nonselective - enzymatic debridement - wet dressings - wet-to-dry dressings - wet-to-moist dressings * Debridement-selective - debridement with other agents (eg, autolysis) - enzymatic debridement - sharp debridement * Dressings (eg, wound coverings, hydrogels, vacuum-assisted closure) * Electrotherapeutic modalities (see Electrotherapeutic Modalities) * Orthotic, protective, and supportive devices * Oxygen therapy (eg, topical, supplemental) * Physical agents and mechanical modalities (see Physical agents and Mechanical Modalities) * Topical agents (eg, ointments, moisturizers, creams, cleansers, sealants) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Edema, lymphederna, or effusion is decreased. joint integrity and mobility are improved. * Pain is decreased. * Risk of secondary impairment is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enhanced. Specific Direct interventions * Electrical muscle stimulation * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Complications of soft tissue and circulatory disorders are decreased. * Debridement of nonviable tissue is achieved. * Joint integrity and mobility are improved. * Pain is decreased. * Risk of secondary impairment is decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct interventions Physical agents: * Athermal modalities (eg, pulsed ultrasound, pulsed radio frequency stimulation) * Deep thermal modalities (eg, ultrasound, pulsed shortwave diathermy) * Hydrotherapy (eg, whirlpool tanks, pulsatie lavage) * Phototherapy (eg, ultraviolet) * Superficial thermal modalities (eg, heat, paraffin baths, hot packs, fluidotherapy) Mechanical modalities: * Compression therapies (eg, all compression devices, compression bandaging, compression garments, taping, and total contact casting) * Continuous passive motion (CPM) * Tilt table or standing table 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 skin involvement extending into fascia, muscle, or bone 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 * (ADL) -- 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 finger function 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. * Clinically 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, giving environment, pathology or impairment that may affect function, or home or work (job/school/play) settings. * Professional recommendation 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 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 participated goals and the desired outcomes hate 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. N"en discharge occurs prior to achievement of goals and outcomes, patient/client status and the rationale for discontinuation are documented. F()r 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 Anthropometric Dimensions Secondary to Lympathic System 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 lymphatic system involvement. Patients/ clients may have any one or a combination of the following: * Acquired immune deficiency syndrome (AIDS) * Lymphedema * Status postcancer * Status postinfection * Status posttrauma * Vascular/lymphatic malfunction INCLUDES patients/clients with: * Amputation with lymphedema * Filariasis (elephantiasis) * Multiple abdominal surgeries * Postradiation status * Status post-lymph node dissection in the groin or abdomen * Status post-axillary lymph node dissection * Reconstructive surgery EXCLUDES patients/clients with: * Acute traumatic edema * Acute surgical edema * Congestive heart failure * Deep vein thrombosis (DVT) * Dependent edema * Lymphangiosarcoma * Lymphangitis 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. 040 Other bacterial diseases 040.0 Gas gangrene malignant edema) 176 Kaposi's sarcoma 176.5 Lymph nodes 457 Noninfectious disorders of lymphatic channels 457.0 Postmastectomy lymphedema syndrome 457.1 Other lymphedema 457.8 Other noninfectious disorders of lymphatic channels 457.9 Unspecified noninfectious disorder of lymphatic channels 646 Other complications of pregnancy not elsewhere classified 646.1 Edema or excessive weight gain in pregnancy, without mention of hypertension 683 Acute lymphadenitis 757 Congenital anomalies of the integument 757.0 Hereditary edema of legs 782 Symptoms involving skin and other integumentary tissue 782.8 Changes in skin texture 995 Certain adverse effects not elsewhere classified 995.1 Angioneurotic edema 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: 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 observation and palpation of trunk and extremities at rest and during activity Arousal, Attention, and Cognition * Assessment of arousal, attention, and cognition using standardized instruments * Assessment of factors that influence motivation level * Screening for level of cognition (eg, to determine ability to process commands, to measure safety awareness) * Screening for gross expressive (eg, verbalization) deficits Assistive and Adaptive Devices * 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 * 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 Gait, Locomotion, and Balance * Assessment of safety * 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 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 continuity of skin color (eg, redness in lightly pigmented skin, violescent coloration in darkly pigmented skin, signs of cellulitis, or infection) * Assessment of skin temperature as compared with that of an adjacent area or an opposite extremity (eg, using thermistors) * Assessment of tissue mobility, turgor, and texture (eg, dry, flaky, cracked skin) For the wound: * Assessment for presence of blistering * Assessment for presence of dermatitis (eg, rash, fungus) * Assessment of drainage Joint integrity and Mobility * 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 * Assessment of muscle soreness 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 Sensory integrity including Proprioception and Kinesthesia) * Assessment of superficial sensations (eg, sharp/dull discrimination, temperature, light touch, pressure) * Assessment of receptive (eg, vision, hearing) abilities Ventilation, Respiration (Gas Exchange), and Circulation * Assessment of activities that aggravate or relieve edema, pain, dyspnea, or other symptoms * Assessment of capillary refill time * Assessment of standard vital signs (eg, blood pressure, heart rate, respiratory rate) at rest and during and after activity * Palpation of pulses 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 Over the course of 1 to 8 weeks: Patient/client with mild lymphedema (less than 3-cm differential between affected limb and unaffected limb) will show decreased lymphatic congestion, allowing return to highest level of function and quality of life. Patient/client with moderate lymphedema (3- to 5-cm differential between affected limb and unaffected limb) will show decreased lymphatic congestion, allowing return to highest level of function and quality of life. Patient/client with severe lymphedema (5-plus-cm differential between affected limb and unaffected limb) will show decreased lymphatic congestion, allowing return to highest level of function and quality of life. Management of lymphatic involvement may he required over the life span. Expected Range of Number of Visits Per Episode of Care 5 to 7 7 to 14 14-20 These ranges represent the lower and upper limits of the number of physical therapist visits required to achieve the 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 or That May Modify Frequency of Visits/Duration of Episode * Accessibility of resources * Age * Availability of resources * Caregiver (eg, family, home health aide) consistency or expertise * Chronicity or severity of condition * Comorbidities (eg, chronic obstructive pulmonary disease, renal disease, cerebrovascular accident) * Hardening, fibrosis of limb tissue * Immunosuppression (eg, human * Immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], cancer) * Level of patient/client adherence to the intervention program * Lymphatic ulceration * Multilimb involvement * Need for ventilatory support * Nutritional status * Preexisting systemic conditions or diseases (eg, diabetes, peripheral vascular disease, peripheral neuropathy) * Presence of infection * Presence of wound * 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 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 Intervention for this 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. * Endurance is increased. * Gait, locomotion, and balance are improved. * Joint integrity and mobility are improved, * Pain is decreased. * Postural control is improved. * Risk of recurrence is reduced. * Risk factors are reduced. * Risk of secondary impairments is reduced. * Safety is improved. * Self-management of symptoms is improved. * Sense of well-being is improved. * Soft tissue swelling, inflammation, or restriction is reduced. * Strength is increased. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status is improved. Specific Direct Interventions * Gait, locomotion, and balance training * Posture awareness training * Strengthening 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. * Risk of recurrence of condition is reduced. * 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 or 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 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) integr-ation and reintegration and leisure tasks, movements, or activities is increased. * Performance of and independence in ADL and IADL are increased. * Risk of recurrence of conditions is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Assistive and adaptive device or 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) * Injury prevention or reduction training * Orthotic, protective, or supportive device or equipment training Manual Therapy Techniques (Including Mobilization and Manipulation) Anticipated Goals * Ability to perform movement tasks is increased. * Joint integrity and mobility are improved. * Pain is decreased. * Risk of secondary. impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions * Connective tissue massage * Manual lymphatic drainage * 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. * Deformities are prevented. * Gait, locomotion, and balance are improved. * Joint integrity and mobility are improved. * Loading on a body part is decreased. * Optimal joint alignment is achieved. * Pain is decreased. * Performance of and independence in ADL and IADL are increased. * Pressure areas (eg, pressure over bony prominence) are prevented, * Protection of body parts is increased. * Risk of secondary impairments is reduced. * Safety is improved. * Sense of well-being is improved. * Soft tissue swelling. inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. * Utilization and cost of health care services are decreased. * Weight-bearing status 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, cushions, protective taping, helmets) * Supportive devices or equipment (eg, supportive taping, compression garments, corsets, slings, neck collars, serial casts, elastic wrap, oxygen) Electrotherapeutic Modalities Anticipated Goals * Ability to perform physical tasks is increased. * Complications are reduced. * Joint integrity and mobility are improved. * Muscle performance is increased.. * Pain is decreased. * Risk of secondary impairments is reduced. * Soft tissue swelling, inflammation, or restriction is reduced. * Wound and soft tissue healing is enchanced. Specific Direct Interventions * Electrical muscle stimulation * Transcutaneous electrical nerve stimulation (TENS) Physical Agents and Mechanical Modalities Anticipated Goals * Ability to perform movement tasks is increased. * Complications of soft tissue and circulatory disorders are decreased. * Joint integrity and mobility are improved. * Pain is decreased. * Risk of secondary impairments is decreased. * Soft tissue swelling, inflammation, or restriction is reduced. * Tolerance to positions and activities is increased. Specific Direct Interventions Physical agents: * Compression therapies (eg, all compression devices, compression bandaging, compression garments) * Continuous passive motion (CPM) * Cryotherapy (eg, cold packs, ice massage) Mechanical modalities: * Compression therapies (eg, vasopneumatic compression devices compression bandaging, compression garments, taping, and total contact casting) * Continuous passive motion (CPM) 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 spain. 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. * Optional return to role function (eg, worker, student, spouse, grandparent) is achieved. * Risk of disability associated with lymphatic system 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 (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, |
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