Preferred Practice Patterns: Cardiovascular/Pulmonary.

Preferred practice patterns describe the five elements of patient/client management that are provided by physical therapists: examination (history, systems review, and tests and measures), evaluation, diagnosis, prognosis (including plan of care), and intervention (with anticipated goals and expected outcomes). Each pattern also addresses reexamination, global outcomes, and criteria for termination of physical therapy services. Examples of ICD-9-CM codes are included.

Primary Prevention/ Risk Reduction for Cardiovascular/Pulmonary Disorders

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified into this primary prevention/risk reduction pattern as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the need for a prevention/risk reduction program. The physical therapist integrates, synthesizes, and interprets the data to determine inclusion in this diagnostic category.

Inclusion

The following examples of examination findings may support the. inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Diabetes

* Family history of heart disease

* Hypercholesterolemia or hyperlipidemia

* Hypertension

* Obesity

* Sedentary lifestyle

* Smoking

Impairments, Functional Limitations, or Disabilities

* Decreased functional work capacity

* Decreased maximum aerobic capacity

* Dyspnea on exertion

* Sedentary job role

Note:

Prevention and risk reduction are inherent in all practice patterns. Patients/clients included in this pattern are in need of primary prevention/risk reduction only.

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9, CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes--patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those patients/clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, Ill: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

250 Diabetes mellitus
272 Disorders of lipoid metabolism
    272.0 Pure hypercholesterolemia
278 Obesity and other hyperalimentation
    278.0 Obesity
305 Nondependent abuse of drugs
    305.1 Tobacco use disorder
401 Essential hypertension

Supplemental Classification of Factors Influencing Health Status and Contact With Health Services

V17 Family history of certain chronic disabling diseases
    V17.4 Other cardiovascular diseases

042 Human immunodeficiency virus [HIV] disease
    Acquired immune deficiency syndrome
250 Diabetes mellitus
    250.4 Diabetes with renal manifestations
    250.8 Diabetes with other specified manifestations
    250.9 Diabetes with unspecified complication
332 Parkinson's disease
333 Other extrapyramidal disease and abnormal movement
    disorders
    333.0 Other degenerative diseases of the basal ganglia
    333.3 Tics of organic origin
    333.4 Huntington's chorea
    333.9 Other and unspecified extrapyramidal diseases
          and abnormal movement disorders
334 Spinocerebellar disease
    334.2 Primary cerebellar degeneration
335 Anterior horn cell disease
    335.2 Motor neuron disease
          335.20 Amyotrophic lateral sclerosis
340 Multiple sclerosis
344 Other paralytic syndromes
    344.0 Quadriplegia and quadriparesis
357 Inflammatory and toxic neuropathy
    357.0 Acute infective polyneuritis
          Guillain-Barre syndrome
359 Muscular dystrophies and other myopathies
    359.1 Hereditary progressive muscular dystrophy
394 Diseases of mitral valve
396 Diseases of mitral and aortic valves
397 Diseases of other endocardial structures
398 Other rheumatic heart disease
402 Hypertensive heart disease
413 Angina pectoris
414 Other forms of chronic ischemic heart disease
416 Chronic pulmonary heart disease
424 Other diseases of endocardium
425 Cardiomyopathy
428 Heart failure
    428.0 Congestive heart failure
429 Ill-defined descriptions and complications of heart disease
440 Atherosclerosis
443 Other peripheral vascular disease
    443.9 Peripheral vascular disease, unspecified
482 Other bacterial pneumonia
    482.2 Pneumonia due to Hemophilus influenzae
    482.9 Bacterial pneumonia unspecified
491 Chronic bronchitis
    491.9 Unspecified chronic bronchitis
492 Emphysema
    492.8 Other emphysema
493 Asthma
494 Bronchiectasis
496 Chronic airway obstruction, not elsewhere classified
    Chronic obstructive pulmonary disease [COPD], not
    otherwise specified
508 Respiratory conditions due to other and unspecified
    external agents
    508.9 Respiratory conditions due to unspecified
          external agent
513 Abscess of lung and mediastinum
513.0 Abscess of lung
514 Pulmonary congestion and hypostasis
516 Other alveolar and parietoalveolar pneumonopathy
    516.9 Unspecified alveolar and parietoalveolar
          pneumonopathy
517 Lung involvement in conditions classified elsewhere
    517.8 Lung involvement in other diseases classified
          elsewhere(*)
518 Other diseases of lung
    518.0 Pulmonary collapse
    518.8 Other diseases of lung
519 Other diseases of respiratory system
    519.4 Disorders of diaphragm
711 Arthropathy associated with infections
712 Crystal arthropathies
713 Arthropathy associated with other disorders classified
    elsewhere
714 Rheumatoid arthritis and other inflammatory
    polyarthropathies
715 Osteoarthrosis and allied disorders
786 Symptoms involving respiratory system and other chest
    symptoms
    786.0 Dyspnea and respiratory abnormalities

Note:

Patients/clients who have surgical procedures involving the abdomen, chest wall, diaphragm, mediastinum, and thorax also may be classified into this pattern.

(*) Not a primary diagnosis

Examination

Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness. The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process.

Examination has three components: the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

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, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics

* Age

* Sex

* Race/ethnicity

* Primary language

* Education

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Employment/Work (Job/School/Work)

* Current and prior work (job/school/play), community, and leisure actions, tasks, or activities

Growth and Development

* Developmental history

* Hand dominance

Living Environment

* Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic)

* Living environment and community characteristics

* Projected discharge destinations

General Health Status {Self-Report, Family Report, Caregiver Report)

* General health perception

* Physical function (eg, mobility, sleep patterns, restricted bed days)

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

* Role function (eg, community, leisure, social, work)

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

Social/Health Habits (Past and Current)

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

* Level of physical fitness

Family History

* Familial health risks

Medical/Surgical History

* Cardiovascular

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Gynecological

* Integumentary

* Musculoskeletal

* Neuromuscular

* Obstetrical

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

* Psychological

* Pulmonary

Current Condition(s)/Chief Complaint(s)

* 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

* Previous occurrence of chief complaint(s)

* Prior therapeutic interventions

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)

* Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities

Medications

* Medications for current condition

* Medications previously taken for current condition

* Medications for other conditions

Other Clinical Tests

* Laboratory and diagnostic tests

* Review of available records (eg, medical, education, surgical)

* Review of other clinical findings (eg, nutrition and hydration)

Systems Review

The systems review may include:

Anatomical and Physiological Status

* Cardiovascular/Pulmonary

- Blood pressure

- Edema

- Heart rate

- Respiratory rate

* Integumentary

- Presence of scar formation

- Skin color

- Skin integrity

* Musculoskeletal

- Gross range of motion

- Gross strength

- Gross symmetry

- Height

- Weight

* Neuromuscular

- Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

* Ability to make needs known

* Consciousness

* Expected emotional/behavioral responses

* Learning preferences (eg, education needs, learning barriers)

* Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:

Aerobic Capacity and Endurance

* Aerobic capacity during functional activities (eg, activities of daffy living [ADL] scales, indexes, instrumental activities of daffy living [IADL] scales, observations)

* Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests)

* Cardiovascular signs and symptoms in response to increased oxygen demand with exercise or activity, including pressures and flow; heart rate, rhythm, and sounds; and superficial vascular responses (eg, angina, claudication, dyspnea, and exertion scales; electrocardiography; observations; palpation; sphygmomanometry)

* Pulmonary signs and symptoms in response to increased oxygen demand with exercise or activity, including breath and voice sounds; cyanosis; gas exchange; respiratory pattern, rate, and rhythm; and ventilatory flow, force, and volume (eg, auscultation, dyspnea and exertion scales, observations, oximetry, palpation)

Anthropometric Characteristics

* Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement)

* Body dimensions (eg, body mass index, girth measurement, length measurement)

Arousal, Attention, and Cognition

* Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires)

* Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists)

* Motivation (eg, adaptive behavior scales)

* Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales)

* Recall, including memory and retention (eg, assessment scales, interviews, questionnaires)

Assistive and Adaptive Devices

* Assistive or adaptive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations)

* Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Circulation (Arterial, Venous, and Lymphatic)

* Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, claudication scales, electrocardiography, palpation, sphygmomanometry, thermography)

* Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales)

* Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry)

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

* Current and potential barriers (eg, checklists, interviews, observations, questionnaires)

* Physical space and environment (eg, compliance standards, observations, photographic assessments, questionnaires, structural specifications, videographic assessments)

Ergonomics and Body Mechanics

Body mechanics

* Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg, ADL scales, IADL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance

* Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, IADL scales, observations, videographic assessments)

* Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests)

* Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments)

* Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobility skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobility tests)

* Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)

Motor Function (Motor Control and Motor Learning)

* Initiation, modification, and control of movement patterns and voluntary postures (eg, activity indexes, observations, physical performance tests, postural challenge tests, videographic assessments)

Muscle Performance (Including Strength, Power, and Endurance)

* Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests)

* Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

* Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, logs, interviews, observations, reports)

Pain

* Pain, soreness, and nociception (eg, angina scales, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments)

Range of Motion (ROM) (Including Muscle Length)

* Functional ROM (eg, observations, squat tests, toe touch tests)

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

* Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests)

* Ability to perform serf-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles)

* Safety in serf-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)

Sensory Integrity

* Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)

Ventilation and Respiration/Gas Exchange

* Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry)

* Pulmonary signs of ventilatory function, including airway protection; breath and voice sounds; respiratory rate, rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary function tests, ventilatory muscle force tests)

* Pulmonary symptoms (eg, dyspnea and perceived exertion indexes and scales)

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

* Ability to assume or resume work (job/school/play), community, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests)

* Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments)

* Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status.

A diagnosis is a label encompassing a duster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 6 to 12 weeks, patient/client will demonstrate optimal aerobic capacity/endurance and the highest level of functioning in home, work (job/school/play), community, and leisure environments.

During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

6 to 30

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 6 to 30 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

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

* Accessibility and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status

* Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors

* Psychomotor abilities

* Social support

* Stability of the condition

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions

- advance directives

- individualized family service plans (IFSPs) or individualized education plans (IEPs)

- informed consent

- mandatory communication and reporting (eg, patient advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including:

- equipment suppliers

- home care agencies

- payer groups

- schools

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

* Cost-effective resource utilization

* Data collection, analysis, and reporting

- outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for

Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork

- case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, individualized family service plans (IFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across settings through case conferences, education plans, and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews.

* Decision making is enhanced regarding health, wellness, and fitness needs.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings. * Patient/client, family, significant other, and caregiver understanding of anticipated goals and expected outcomes is increased.

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/Client-Related Instruction

Patient/client-related instruction may include:

Interventions

* Instruction, education and training of patients/clients and caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- enhancement of performance

- health, wellness, and fitness programs

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities

- transitions across settings

- transitions to new roles

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources are improved.

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

* Decision making is enhanced regarding patient/client health and the 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.

* Health status is improved.

* 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 anticipated goals and expected outcomes are increased.

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

* Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved.

* Physical function is improved.

* 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.

Procedural Interventions

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions

* Aerobic capacity/endurance conditioning or reconditioning

- aquatic programs

- gait and locomotor training

- increased workload over time

- walking and wheelchair propulsion programs

* Balance, coordination, and agility training

- developmental activities training

- motor function (motor control and motor learning) training or retraining

- neuromuscular education or reeducation

- standardized, programmatic, complementary exercise approaches

* Body mechanics and postural stabilization

- body mechanics training

- postural control training

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Gait and locomotion training

- developmental activities training

- gait training

- implement and device training

- standardized, programmatic, complementary exercise approaches

- wheelchair training

* Relaxation

- breathing strategies

- movement strategies

- relaxation techniques

- standardized, programmatic, complementary exercise approaches

* Strength, power, and endurance training for head and neck, limb, pelvic-floor, trunk, and ventilatory muscles

- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric)

- aquatic programs

- standardized, programmatic, complementary exercise approaches

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Aerobic capacity is increased.

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Relaxation is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to serf-care, home management, work (job/school/play), community, and leisure is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL])

Interventions

* ADL training

- bathing

- bed mobility and transfer training

- developmental activities

* Devices and equipment use and training

- assistive and adaptive device or equipment training during ADL and IADL

- orthotic, protective, or supportive device or equipment training during ADL and IADL

* Functional training programs

- simulated environments and tasks

* IADL training

- home maintenance

- household chores

- shopping

- structured play for infants and children

- yard work

* Injury prevention or reduction

- safety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care and home management is increased.

- Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care and home management roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairments is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living [IADL], Work Hardening, and Work Conditioning)

Interventions

* Devices and equipment use and training

- assistive and adaptive device or equipment training during IADL

- orthotic, protective, or supportive device or equipment training during IADL

* Functional training programs

- simulated environments and tasks

- task adaptation

- task training

- work conditioning

- work hardening

* IADL training

- community service training involving instruments

- school and play activities training including tools and instruments

- work training with tools

* Injury prevention or reduction

- injury prevention or reduction with use of devices and equipment

- safety awareness training during work (job/school/play), community, and leisure integration and reintegration

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to work (job/school/play), community, and leisure integration or reintegration is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required and work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

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

Interventions

* Adaptive devices

- seating systems

* Assistive devices

- canes

- crutches

- power devices

- static and dynamic splints

- walkers

- wheelchairs

* Orthotic devices

- braces

- casts

- shoe inserts

- splints

* Protective devices

- braces

- cushions

* Supportive devices

- compression garments

- corsets

- elastic wraps

- mechanical ventilators

- neck collars

- supplemental oxygen

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Joint stability is improved.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Optimal joint alignment is achieved.

- Optimal loading on a body part is achieved.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self<are, home management, work (job/school/play), community, and leisure is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is improved.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

- Stresses precipitating injury are decreased.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Airway Clearance Techniques

Interventions

* Breathing strategies

- paced breathing

- pursed lip breathing

- techniques to maximize ventilation (eg, maximum inspiratory hold, stair case breathing, manual hyperinflation)

* Positioning

- positioning to alter work of breathing

- positioning to maximize ventilation and perfusion

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Nutrient delivery to tissue is increased.

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Exercise tolerance is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Ventilation and respiration/gas exchange are improved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living OADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

Impaired Ventilation, Respiration/ Gas Exchange, and Aerobic Capacity/Endurance Associated With Airway Clearance Dysfunction

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified into this pattern--for impaired ventilation, respiration/gas exchange, and aerobic capacity/endurance associated with airway clearance dysfunction--as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Acute lung disorders

* Acute or chronic oxygen dependency

* Bone marrow/stem cell transplants

* Cardiothoracic surgery

* Change in baseline breath sounds

* Change in baseline chest radiograph

* Chronic obstructive pulmonary disease (COPD)

* Frequent or recurring pulmonary infection

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

* Tracheostomy or microtracheostomy

Impairments, Functional Limitations, or Disabilities

* Dyspnea at rest or with exertion

* Impaired airway clearance

* Impaired cough

* Impaired gas exchange

* Impaired ventilatory forces and flow

* Impaired ventilatory volumes

* Inability to perform self-care due to dyspnea

* Inability to perform work tasks due to dyspnea

Note:

Some risk factors or consequences of pathology/ pathophysiology -- such as cardiac surgery with aspiration pneumonia, emphysema with acute pneumonia, and lung transplant with rejection--may be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," page S495.)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.

Findings That May Require Classification in a Different Pattern

* Neonate with respiratory failure

* Respiratory failure with mechanical ventilation

Findings That May Require Classification in Additional Patterns

* Chronic obstructive pulmonary disease with diabetes

* Impairments associated with acute cerebrovascular accident with aspiration pneumonia

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes-patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, Ill:American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

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

Supplemental Classification of Factors Influencing Health Status and Contact With Health Services

V42 Organ or tissue replaced by transplant
    V42.0 Kidney
    V42.2 Heart valve
    V42.3 Skin
    V42.4 Bone
    V42.6 Lung
    V42.7 Liver
    V42.8 Other specified organ or tissue
          V42.81 Bone marrow
          V42.82 Peripheral stem cells
          V42.83 Pancreas
          V42.89 Other

Note:

Patients/clients who have surgical procedures involving the abdomen, chest wall, diaphragm, lung, mediastinum, thorax, and vessels of the heart also may be classified into this pattern.

Examination

Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness. The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process.

Examination has three components: the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acme, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics

* Age

* Sex

* Race/ethnicity

* Primary language

* Education

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Employment/Work (Job/School/Play)

* Current and prior work (job/school/play), community, and leisure actions, tasks, or activities

Growth and Development

* Developmental history

* Hand dominance

Living Environment

* Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic)

* Living environment and community characteristics

* Projected discharge destinations

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

* General health perception

* Physical function (eg, mobility, sleep patterns, restricted bed days)

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

* Role function (eg, community, leisure, social, work)

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

Social/Health Habits (Past and Current)

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

* Level of physical fitness

Family History

* Familial health risks

Medical/Surgical History

* Cardiovascular

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Gynecological

* Integumentary

* Musculoskeletal

* Neuromuscular

* Obstetrical

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

* Psychological

* Pulmonary

Current Condition(s)/Chief Complaint(s)

* 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

* Previous occurrence of chief complaint(s)

* Prior therapeutic interventions

Functional Status and Activity Level

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

* Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities

Medications

* Medications for current condition

* Medications previously taken for current condition

* Medications for other conditions

Other Clinical Tests

* Laboratory and diagnostic tests

* Review of available records (eg, medical, education, surgical)

* Review of other clinical findings (eg, nutrition and hydration)

Systems Review

The systems review may include:

Anatomical and Physiological Status

* Cardiovascular/Pulmonary

- Blood pressure

- Edema

- Heart rate

- Respiratory rate

* Integumentary

- Presence of scar formation

- Skin color

- Skin integrity

Musculoskeletal

- Gross range of motion

- Gross strength

- Gross symmetry

- Height

- Weight

Neuromuscular

- Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

* Ability to make needs known

* Consciousness

* Expected emotional/behavioral responses

* Learning preferences (eg, education needs, learning barriers)

* Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:

Aerobic Capacity and Endurance

* Aerobic capacity during functional activities (eg, activities of daily living [ADL] scales, indexes, instrumental activities of daily living [IADL] scales, observations)

* Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/nm tests, treadmill tests, wheelchair tests)

* Cardiovascular signs and symptoms in response to increased oxygen demand with exercise or activity, including pressures and flow; heart rate, rhythm, and sounds; and superficial vascular responses (eg, angina, claudication, dyspnea, and exertion scales; electrocardiography; observations; palpation; sphygmomanometry)

* Pulmonary signs and symptoms in response to increased oxygen demand with exercise or activity, including breath and voice sounds; cyanosis; gas exchange; respiratory pattern, rate, and rhythm; ventilatory flow, force, and volume (eg, auscultation, dyspnea and exertion scales, gas analyses, observations, oximetry, palpation, pulmonary function tests)

Anthropometric Characteristics

* Edema (eg, girth measurement, palpation, scales, volume measurement)

Arousal, Attention, and Cognition

* Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires)

* Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists)

* Motivation (eg, adaptive behavior scales)

* Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales)

* Recall, including memory and retention (eg, assessment scales, interviews, questionnaires)

Assistive and Adaptive Devices

* Assistive or adaptive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations)

* Components, alignment, fit, and ability to care for assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of assistive or adaptive devices and equipment (eg, diaries, interviews, logs, observations, reports)

Circulation (Arterial, Venous, and Lymphatic)

* Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, electrocardiography, palpation, sphygmomanometry, thermography)

* Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales)

* Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry)

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

* current and potential barriers (eg, checklists, interviews, observations, questionnaires)

* Physical space and environment (eg, compliance standards, observations, photographic assessments, questionnaires, structural specifications, videographic assessments)

Integumentary Integrity

Associated skin

* Activities, positioning, and postures that produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, scales)

* Assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment that may produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, risk assessment scales)

* Skin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography)

Muscle Performance (Including Strength, Power, and Endurance)

* Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

Neuromotor Development and Sensory Integration

* Oral motor function, phonation, and speech production (eg, interviews, observations)

Orthotic, Protective, and Supportive Devices

* Orthotic, protective, and supportive devices and equipment use during functional activities (eg,ADL scales, functional scales, IADL scales, interviews, observations, profiles)

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Pain

* Pain, soreness, and nociception (eg, angina scales, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments)

* Specific body parts (eg, angle assessment, forward-bending test, goniometry, observations, palpation, positional tests)

Range of Motion (ROM) (Including Muscle Length)

* Functional ROM (eg, observations)

* Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments)

* Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

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

* Ability to perform serf-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles)

Ventilation and Respiration/Gas Exchange

* Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry)

* Pulmonary signs of ventilatory function, including airway protection; breath and voice sounds; respiratory rate, rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary function tests, ventilatory muscle force tests)

* Pulmonary symptoms (eg, dyspnea and perceived exertion indexes and scales)

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

* Ability to assume or resume work (job/school/play), community, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests)

* Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments)

* Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status.

A diagnosis is a label encompassing a duster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 12 to 16 weeks, patient/client will demonstrate optimal ventilation, respiration/gas exchange, and aerobic capacity/endurance and the highest level of functioning in home, work (job/school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities.

During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

5 to 30

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. /t is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 5 to 30 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

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

* Accessibility and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status

* Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors * Psychomotor abilities

* Social support

* Stability of the condition

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions

- Advance directives

- individualized family service plans (IFSPs) or individualized

- education plans (IEPs)

- informed consent

- mandatory communication and reporting (eg, patient advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including:

- equipment suppliers

- home care agencies

- payer groups

- schools

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

* Cost-effective resource utilization

* Data collection, analysis, and reporting

- outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork

- case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, individualized family service plans (IFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across settings through case conferences, and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews.

* Decision making is enhanced regarding health, wellness, and fitness needs.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.

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

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/Client-Related Instruction

Patient/client-related instruction may include:

Interventions

* Instruction, education and training of patients/clients and caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- enhancement of performance

- health, wellness, and fitness programs

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities

- transitions across settings

- transitions to new roles

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources are improved.

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

* Decision making is enhanced regarding patient/client health and the 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 0ADL) is increased.

* Health status is improved.

* 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 anticipated goals and expected outcomes are increased.

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

* Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved.

* Physical function is improved.

* 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.

Procedural Interventions

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions

* Aerobic capacity/endurance conditioning or reconditioning

- aquatic programs

- gait and locomotor training

- increased workload over time

- walking and wheelchair propulsion programs

* Body mechanics and postural stabilization

- posture awareness training

- postural control training

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Relaxation

- breathing strategies

- movement strategies

- relaxation techniques

- standardized, programmatic, complementary exercise approaches

* Strength, power, and endurance training for head and neck, limb, pelvic-floor, trunk, and ventilatory muscles

- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric)

- aquatic programs

- standardized, programmatic, complementary exercise approaches task-specific performance training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Atelectasis

absorption atelectasis , acquired atelectasis obstructive atelectasis; that caused by an obstruction of the airway that prevents intake of air, e.g., secretions, foreign body, tumor, or external pressure.

congenital atelectasis that present at birth (primary a.) or immediately thereafter (secondary a.) .

is decreased.

- Nutrient delivery to tissue is increased.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Aerobic capacity is increased.

- Airway clearance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased. -

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Relaxation is increased.

- Ventilation and respiration/gas exchange are improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to serf-care, home management, work (job/school/play), community, and leisure is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daffy living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Preoperative and postoperative complications are reduced.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL])

Interventions

* ADL training

- bed mobility and transfer training

- developmental activities

* Devices and equipment use and training

- assistive and adaptive device or equipment training during ADL and IADL

- orthotic, protective, or supportive device or equipment training during ADL and IADL

- prosthetic device or equipment training during ADL and IADL

* Functional training programs

- simulated environments and tasks

- task adaptation

* IADL training

- home maintenance

- household chores

- shopping

- structured play for infants and children

- yard work

* Injury prevention or reduction

- injury prevention education during serf-care and home management

- injury prevention or reduction with use of devices and equipment

- safety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Muscle performance (strength, power, and endurance) is increased.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care and home management is increased.

- Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care and home management roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairments is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living [IADL], Work Hardening, and Work Conditioning)

Interventions

* Devices and equipment use and training

- assistive and adaptive device or equipment training during IADL

- orthotic, protective, or supportive device or equipment training during IADL

* Injury prevention or reduction

- injury prevention education during work (job/school/play), community, and leisure integration or reintegration

- injury prevention or reduction with use of devices and equipment

- safety awareness training during work (job/school/play), community, and leisure integration or reintegration

Anticipated Cools and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

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

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization/manipulation

- soft tissue

- spinal and peripheral joints

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

- Soft tissue swelling, inflammation, or restriction is reduced.

* Impact on impairments

- Airway clearance is improved.

- Energy expenditure per unit of work is decreased.

- Joint integrity and mobility are improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Relaxation is increased.

- Work of breathing is decreased.

* Impact on functional limitations - Ability to perform movement tasks is improved.

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

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

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

Interventions

* Adaptive devices

- environmental controls

* Assistive devices

- canes

- crutches

- long-handled reachers

- percussors and vibrators

- power devices

- walkers

- wheelchairs

* Orthotic devices

- braces

* Protective devices

- braces

- cushions

* Supportive devices

- compression garments

- corsets

- elastic wraps

- mechanical ventilators

- neck collars

- supplemental oxygen

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Soft tissue swelling, inflammation, or restriction is reduced.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint stability is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Optimal joint alignment is achieved.

- Optimal loading on a body part is achieved.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Ventilation and respiration/gas exchange are improved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (ADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is improved.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

Airway Clearance Techniques

Interventions

* Breathing strategies

- active cycle of breathing or forced expiratory techniques

- assisted cough/huff techniques

- autogenic drainage

- paced breathing

- pursed lip breathing

- techniques to maximize ventilation (eg, maximum inspiratory hold, stair case breathing, manual hyperinflation)

* Manual/mechanical techniques

- assistive devices (eg, percussors, vibrators)

- chest percussion, vibration, and shaking

- chest wall manipulation

- suctioning

- ventilatory aids

* Positioning

- positioning to alter work of breathing

- positioning to maximize ventilation and perfusion

- pulmonary postural drainage

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Atelectasis is decreased.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Airway clearance is improved.

- Cough is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Exercise tolerance is improved.

- Ventilation and respiration/gas exchange are improved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/diem reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/diem will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client stares and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

Impaired Aerobic Capacity/Endurance Associated With Cardiovascular Pump Dysfunction or Failure

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified into this pattern--for impaired aerobic capacity/endurance associated with cardiovascular pump dysfunction or failure--as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Angioplasty or atherectomy

* Atrioventricular atrioventricular /atrio·ven·tric·u·lar/ (-ven-trik´u-ler) pertaining to both an atrium and a ventricle of the heart.

a·tri·o·ven·tric·u·lar (

block

* Cardiogenic shock

* Cardiomyopathy

* Cardiothoracic surgery

* Complex ventricular arrhythmias

* Complicated myocardial infarction (failure); uncomplicated myocardial infarction (dysfunction)

* Congenital cardiac anomalies

* Coronary artery disease

* Decrease in ejection fraction (EF) on exercise testing (EF of 30-50% with dysfunction; [is less than] 30% with failure)

* Diabetes

* Exercise-induced myocardial ischemia (1-2 mm ST segment depression with dysfunction; [is greater than] 2 mm ST segment with failure)

* Hypertensive heart disease

* Nonmalignant arrhythmias

* Valvular heart disease

Impairments, Functional Limitations, or Disabilities

* Abnormal heart rate response to increased oxygen demand

* Abnormal pulmonary response to increased oxygen demand

* Decreased ability or the inability to perform activities of daily living (ADL) because of symptoms

* Change in baseline breath sounds with activity

* Flat or falling blood pressure response to increased oxygen demand (failure)

* Hypertensive blood pressure response to increased oxygen demand (dysfunction)

* Impaired aerobic capacity of [is less than or equal to] 5 or 6 metabolic equivalents (METS) (dysfunction) or [is less than or equal to] 4 or 5 METS (failure)

* Impaired gas exchange

* Inability or decreased ability to perform work roles because of symptoms

* Presence of or increase in cardiovascular symptoms in response to increased oxygen demand

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.

Findings That May Require Classification in a Different Pattern

* Heart failure with respiratory failure

* Neonate with cardiovascular anomaly and respiratory failure

Findings That May Require Classification in Additional Patterns

* Airway clearance impairments with pericarditis status post chest trauma

Note:

Some risk factors or consequences of pathology/pathophysiology--such as cardiovascular pump dysfunction with multisystem impairments--may be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," page S511.)

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes--patients/ clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICL-9-CM 2001), Volumes 1 and 3 (Chicago, Ill:American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

391 Rheumatic fever with heart involvement
394 Diseases of mitral valve
395 Diseases of aortic valve
396 Diseases of mitral and aortic valves
397 Diseases of other endocardial structures
398 Other rheumatic heart disease
402 Hypertensive heart disease
403 Hypertensive renal disease
404 Hypertensive heart and renal disease
410 Acute myocardial infarction
411 Other acute and subacute forms of ischemic heart disease
412 Old myocardial infarction
413 Angina pectoris
414 Other forms of chronic ischemic heart disease
416 Chronic pulmonary heart disease
417 Other diseases of pulmonary circulation
    417.0 Arteriovenous fistula of pulmonary vessels
422 Acute myocarditis
423 Other diseases of pericardium
423.2 Constrictive pericarditis
424 Other diseases of endocardium
    424.0 Mitral valve disorders
425 Cardiomyopathy
426 Conduction disorders
427 Cardiac dysrhythmias
428 Heart failure
429 Ill-defined descriptions and complications of heart disease
    429.0 Myocarditis, unspecified
    429.4 Functional disturbances following cardiac surgery
440 Atherosclerosis
441 Aortic aneurysm and dissection
443 Other peripheral vascular disease
444 Arterial embolism and thrombosis
745 Bulbus cordis anomalies and anomalies of cardic septal
    closure
    745.0 Common truncus
    745.1 Transposition of great vessels
    745.2 Tetralogy of Fallot
    745.4 Ventricular septal defect
    745.5 Ostium secundum type atrial septal defect
746 Other congenital anomalies of heart
747 Other congenital anonalies of circulatory system
    747.0 Patent ductus botalli
    747.1 Coarctation of aorta
785 Symptoms involving cardiovascular system
    785.5 Shock without mention of trauma
    785.51 Cardiogenic shock

Note:

Patients/clients who have surgical procedures involving the chest wall, diaphragm, pleura, mediastinum, thorax, and vessels of the heart also may be classified into this pattern.

Examination

Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness. The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process.

Examination has three components: the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

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, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics

* Age

* Sex

* Race/ethnicity

* Primary language

* Education

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Employment/Work (Job/School/Play)

* Current and prior work (job/school/play), community, and leisure actions, tasks, or activities

Growth and Development

* Developmental history

* Hand dominance

Living Environment

* Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic)

* Living environment and community characteristics

* Projected discharge destinations

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

* General health perception

* Physical function (eg, mobility, sleep patterns, restricted bed days)

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

* Role function (eg, community, leisure, social, work)

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

Social/Health Habits (Past and Current)

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

* Level of physical fitness

Family History

* Familial health risks

Medical/Surgical History

* Cardiovascular

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Gynecological

* Integumentary

* Musculoskeletal

* Neuromuscular

* Obstetrical

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

* Psychological

* Pulmonary

Current Condition(s)/Chief Complaint(s)

* 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

* Previous occurrence of chief complaint(s)

* Prior therapeutic interventions

Functional Status and Activity Level

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

* Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities

Medications

* Medications for current condition

* Medications previously taken for current condition

* Medications for other conditions

Other Clinical Tests

* Laboratory and diagnostic tests

* Review of available records (eg, medical, education, surgical)

* Review of other clinical findings (eg, nutrition and hydration)

Systems Review

The systems review may include:

Anatomical and Physiological Status

* Cardiovascular/Pulmonary

- Blood pressure

- Edema

- Heart rate

- Respiratory rate

* Integumentary

- Presence of scar formation

- Skin color

- Skin integrity

* Musculoskeletal

- Gross range of motion

- Gross strength

- Gross symmetry

- Height

- Weight

* Neuromuscular

- Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

* Ability to make needs known

* Consciousness

* Expected emotional/behavioral responses

* Learning preferences (eg, education needs, learning barriers)

* Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:

Aerobic Capacity and Endurance

* Aerobic capacity during functional activities (eg, activities of daily living [ADL] scales, indexes, instrumental activities of daily living [IADL] scales, observations)

* Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests)

* Cardiovascular signs and symptoms in response to increased oxygen demand with exercise or activity, including pressures and flow; heart rate, rhythm, and sounds; and superficial vascular responses (eg, angina, claudication, dyspnea, and exertion scales; electrocardiography; observations; palpation; sphygmomanometry)

* Pulmonary signs and symptoms in response to increased oxygen demand with exercise or activity, including breath and voice sounds; cyanosis; gas exchange; respiratory pattern, rate, and rhythm; ventilatory flow, force, and volume (eg, auscultation, dyspnea and exertion scales, gas analyses, observations, oximetry, palpation, pulmonary function tests)

Anthropometric Characteristics

* Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement)

* Body dimensions (eg, body mass index, girth measurement, length measurement)

* Edema (eg, girth measurement, palpation, scales, volume measurement)

Arousal, Attention, and Cognition

* Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires)

* Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists)

* Motivation (eg, adaptive behavior scales)

* Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales)

* Recall, including memory and retention (eg, assessment scales, interviews, questionnaires)

Assistive and Adaptive Devices

* Assistive or adaptive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations)

* Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Circulation (Arterial, Venous, and Lymphatic)

* Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, claudication scales, electrocardiography, palpation, sphygmomanometry, thermography)

* Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales)

* Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry)

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

* Current and potential barriers (eg, checklists, interviews, observations, questionnaires)

* Physical space and environment (eg, compliance standards, observations, photographic assessments, questionnaires, structural specifications, videographic assessments)

Ergonomics and Body Mechanics

Ergonomics

* Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses)

* Safety in work environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits)

Body mechanics

* Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg, ADL scales, IADL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance

* Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, IADL scales, observations, videographic assessments)

* Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments)

* Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)

Integumentary Integrity

Associated skin

*Activities, positioning, and postures that produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, scales)

* Assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment that may produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, risk assessment scales)

* Skin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography)

Wound

* Signs of infection (eg, culture results, observations, palpation)

Motor Function {Motor Control and Motor Learning}

* Dexterity, coordination, and agility (eg, coordination screens, motor impairment tests, motor proficiency tests, observations, videographic assessments)

Muscle Performance (Including Strength, Power, and Endurance)

* Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests)

* Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

* Muscle tension (eg, palpation)

Neuromotor Development and Sensory Integration

* Oral motor function, phonation, and speech production (eg, interviews, observations)

Orthotic, Protective, and Supportive Devices

* Components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Orthotic, protective, and supportive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations, profiles)

* Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Pain

* Pain, soreness, and nociception (eg, angina scales, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments)

Range of Motion (ROM) (Including Muscle Length)

* Functional ROM (eg, observations, squat tests, toe touch tests)

* Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

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

* Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests)

* Ability to perform serf-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles)

* Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)

Ventilation and Respiration/Gas Exchange

* Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry)

* Pulmonary signs of ventilatory function, including airway protection; breath and voice sounds; respiratory rate, rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary function tests, ventilatory muscle force tests)

* Pulmonary symptoms (eg, dyspnea and perceived exertion indexes and scales)

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

* Ability to assume or resume work (job/school/play), community, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests)

* Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments)

* Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status.

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency, and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 6 to 12 weeks, patient/ client with cardiovascular pump dysfunction will demonstrate optimal aerobic capacity/endurance and the highest level of functioning in home, work (job/ school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities.

Over the course of 8 to 16 weeks, patient/client with cardiovascular pump failure will demonstrate optimal aerobic capacity/endurance and the highest level of functioning in home, work (job/ school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities.

During the episode of care, patient/client with cardiovascular pump dysfunction or failure will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

3 to 30

14 to 44

These ranges represent the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected 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 and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status

* Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors

* Psychomotor abilities

* Social support

* Stability of the condition

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions

- advance directives

- individualized family service plans (IFSPs) or individualized education plans (IEPs)

- informed consent

- mandatory communication and reporting (eg, patient advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including:

- equipment suppliers

- home care agencies

- payer groups

- schools

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

* Cost-effective resource utilization

* Data collection, analysis, and reporting outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork

- case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, individualized family service plans OTSPs) or individualized education plans OEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across settings through case conferences, and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews.

* Decision making is enhanced regarding health, wellness, and fitness needs.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.

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

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/Client-Related Instruction

Patient/client-related instruction may include:

Interventions

* Instruction, education and training of patients/clients and caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- enhancement of performance

- health, wellness, and fitness programs

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities

- transitions across settings

- transitions to new roles

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources are improved.

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

* Decision making is enhanced regarding patient/client health and the 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.

* Health status is improved.

* 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 anticipated goals and expected outcomes are increased.

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

* Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved.

* Physical function is improved.

* 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.

Procedural Interventions

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions

* Aerobic capacity/endurance conditioning or reconditioning

- gait and locomotor training

- increased workload over time

- movement efficiency and energy conservation training

- walking and wheelchair propulsion programs

* Balance, coordination, and agility training

- developmental activities training

- motor function (motor control and motor learning) training or retraining

- neuromuscular education or reeducation posture awareness training

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

* Body mechanics and postural stabilization

- body mechanics training

- posture awareness training

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Gait and locomotion training

- developmental activities training

- gait training

- implement and device training

- standardized, programmatic, complementary exercise approaches

- wheelchair training

* Relaxation

- breathing strategies

- movement strategies

- relaxation techniques

- standardized, programmatic, complementary exercise approaches

* Strength, power, and endurance training for head and neck, limb, pelvic-floor, trunk, and ventilatory muscles

- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric)

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Atelectasis is decreased.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Soft tissue swelling, inflammation, or restriction is reduced.

- Symptoms associated with increased oxygen demand are decreased.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Aerobic capacity is increased.

- Airway clearance is improved.

- Endurance is increased.

- Energy expenditure per trait of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Range of motion is improved.

- Relaxation is increased.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self<are, home management, work (job/school/play), community, and leisure is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Preoperative and postoperative complications are reduced.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL])

Interventions

* ADL training

- bathing

- bed mobility and transfer training

- developmental activities

- dressing

- eating

- grooming

- toileting

* Devices and equipment use and training

- assistive and adaptive device or equipment training during ADL and IADL

- orthotic, protective, or supportive device or equipment training during ADL and IADL

- prosthetic device or equipment training during ADL and IADL

* Functional training programs simulated environments and tasks task adaptation

* IADL training

- caring for dependents

- home maintenance

- household chores

- shopping

- structured play for infants and children

- yard work

* Injury prevention or reduction

- injury prevention education during self-care and home management

- injury prevention or reduction with use of devices and equipment

- safety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition) Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Muscle performance (strength, power, and endurance) is increased.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care and home management is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required serf-care and home management roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairments is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Work {Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living [IADL], Work Hardening, and Work Conditioning)

Interventions

* Devices and equipment use and training

- assistive and adaptive device or equipment training during IADL

- orthotic, protective, or supportive device or equipment training during IADL

- prosthetic device or equipment training during IADL

* Functional training programs

- job coaching

- simulated environments and tasks

- task adaptation

- task training

* IADL training

- community service training involving instruments

- school and play activities training including tools and instruments

- work training with tools

* Injury prevention or reduction

- injury prevention education during work (job/school/play), community, and leisure integration or reintegration

- injury prevention or reduction with use of devices and equipment

- safety awareness training during work (job/school/play), community, and leisure integration or reintegration

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Muscle performance (strength, power, and endurance) is increased.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to work (job/school/play), community, and leisure integration or reintegration is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

-Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

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

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Manual Therapy Techniques (Including Mobile/Manipulation)

Interventions

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization/manipulation

- soft tissue

* Passive range of motion

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

- Soft tissue swelling, inflammation, or restriction is reduced.

* Impact on impairments

- Airway clearance is improved.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

- Muscle performance (strength, power, and endurance) is increased.

- Range of motion is improved.

- Relaxation is increased.

* Impact on functional limitations

- Ability to perform movement tasks is improved.

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

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

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

Interventions

* Adaptive devices

- environmental controls

- hospital beds

- raised toilet seats

- seating systems

* Assistive devices

- canes

- crutches

- long-handled reachers

- power devices

- static and dynamic splints

- walkers

- wheelchairs

* Orthotic devices

- braces

- shoe inserts

- splints

* Protective devices

- braces

- cushions

* Supportive devices

- compression garments

- elastic wraps

- mechanical ventilators

- neck collars

- supplemental oxygen

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Soft tissue swelling, inflammation, or restriction is reduced.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint stability is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Optimal joint alignment is achieved.

- Optimal loading on a body part is achieved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is improved.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Airway Clearance Techniques

Interventions

* Breathing strategies

- active cycle of breathing or forced expiratory techniques

- paced breathing

- pursed lip breathing

- techniques to maximize ventilation (eg, maximum inspiratory hold, stair case breathing, manual hyperinflation)

* Positioning

- positioning to alter work of breathing

- positioning to maximize ventilation and perfusion

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition) Atelectasis is decreased.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Airway clearance is improved.

- Cough is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Exercise tolerance is improved.

- Ventilation and respiration/gas exchange are improved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

* Impact on disabilities

- Ability to assume or resume required serf-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

Impaired. Ventilation and Respiration/ Gas Exchange Associated With Ventilatory Pump Dysfunction or Failure

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified into this pattern--for impaired ventilation and respiration/gas exchange associated with ventilatory pump dysfunction or failure--as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Elevated diaphragm and volume loss on chest radiograph

* Neuromuscular disorders

* Partial or complete diaphragmatic paralysis

* Poliomyelitis

* Pulmonary fibrosis

* Restrictive lung disease

* Severe kyphoscoliosis

* Spinal/cerebral neoplasm

* Spinal cord injury

Impairments, Functional Limitations, or Disabilities

* Abnormal or adventitious

1. accidental or acquired; not natural or hereditary.

2. found out of the normal or usual place.

3. adventitial.

ad·ven·ti·tious (

d breath sounds

* Abnormal increased respiratory rate and decreased tidal volume at rest

* Airway clearance dysfunction secondary to ventilatory pump impairment

* Decreased to severely impaired strength and endurance of ventilatory muscles

* Dyspnea with self-care

* Dyspnea with work tasks

* Dyssynchronous or paradoxical breathing at rest or with activity

* Progressive decrease in arterial oxygen and increase in carbon dioxide off ventilator

* Ventilatory pump impairment requiring assistive ventilatory support to maintain gas exchange

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.

Findings That May Require Classification in a Different Pattern

* Impairments associated with acute pneumonia

* Impairments associated with acute respiratory failure

* Impairments associated with primary airway clearance disorders

Findings That May Require Classification in Additional Patterns

* Cardiothoracic surgery

* Decubitus ulcer

Note:

Some risk factors or consequences of pathology/ pathophysiology--such as spinal cord injury with joint contracture --may be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," page S527.)

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes-patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, Ill: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

045 Acute poliomyelitis
192 Malignant neoplasm of other and unspecified parts of
    nervous system
    192.2 Spinal cord
          Cauda equina
237 Neoplasm of uncertain behavior of endocrine glands and
    nervous system
    237.5 Brain and spinal cord
239 Neoplasms of unspecified nature
    239.9 Site unspecified
277 Other and unspecified disorders of metabolism
    277.0 Cystic fibrosis
332 Parkinson's disease
333 Other extrapyramidal disease and abnormal movement
    disorders
    333.4 Huntington's chorea
334 Spinocerebellar disease
    334.2 Primary cerebellar degeneration
335 Anterior horn cell disease
    335.2 Motor neuron disease
          335.20 Amyotrophic lateral sclerosis
340 Multiple sclerosis
343 Infantile cerebral palsy
344 Other paralytic syndromes
    344.0 Quadriplegia and quadriparesis
348 Other conditions of brain
    348.1 Anoxic brain damage
357 Inflammatory and toxic neuropathy
    357.0 Acute infective polyneuritis
          Guillain-Barre syndrome
359 Muscular dystrophies and other myopathies
    359.1 Hereditary progressive muscular dystrophy
430 Subarachnoid hemorrhage
431 Intracerebral hemorrhage
432 Other and unspecified intracranial hemorrhage
434 Occlusion of cerebral arteries
    434.1 Cerebral embolism
492 Emphysema
    492.8 Other emphysema
493 Asthma
505 Pneumoconiosis, unspecified
515 Postinflammatory pulmonary fibrosis
518 Other diseases of lung
519 Other diseases of respiratory system
    519.4 Disorders of diaphragm
737 Curvature of spine
    737.3 Kyphoscoliosis and scoliosis
786 Symptoms involving respiratory system and other chest
    symptoms
    786.0 Dyspnea and respiratory abnormalities
    786.9 Other symptoms involving respiratory system and
          chest
852 Subarachnoid, subdural, and extradural hemorrhage,
    following injury
853 Other and unspecified intracranial hemorrhage following
    injury
854 Intracranial injury of other and unspecified nature
941 Burn of face, head, and neck
942 Burn of trunk
946 Burns of multiple specified sites
947 Burn of internal organs
948 Burns classified according to extent of body surface
    involved
949 Burn, unspecified
977 Poisoning by other and unspecified drugs and medicinal
    substances
    977.9 Unspecified drug or medicinal substance

Note:

Patients/clients who have nonsurgical procedures such as intubation, irrigation, and other continuous mechanical ventilation also may be classified into this pattern.

Examination

Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness. The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process.

Examination has three components: the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

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, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics

* Age

* Sex

* Race/ethnicity

* Primary language

* Education

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Employment/Work (Job/School/Play)

* Current and prior work (job/school/play), community, and leisure actions, tasks, or activities

Growth and Development

* Developmental history

* Hand dominance

Living Environment

* Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic)

* Living environment and community characteristics

* Projected discharge destinations

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

* General health perception

* Physical function (eg, mobility, sleep patterns, restricted bed days)

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

* Role function (eg, community, leisure, social, work)

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

Social/Health Habits (Past and Current)

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

* Level of physical fitness

Family History

* Familial health risks

Medical/Surgical History

* Cardiovascular

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Gynecological

* Integumentary

* Musculoskeletal

* Neuromuscular

* Obstetrical

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

* Psychological

* Pulmonary

Current Condition{s)/Chief Complaint(s)

* 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

* Previous occurrence of chief complaint(s)

* Prior therapeutic interventions

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 OADL)

* Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities

Medications

* Medications for current condition

* Medications previously taken for current condition

* Medications for other conditions

Other Clinical Tests

* Laboratory and diagnostic tests

* Review of available records (eg, medical, education, surgical)

* Review of other clinical findings (eg, nutrition and hydration)

Systems Review

The systems review may include:

Anatomical and Physiological Status

* Cardiovascular/Pulmonary

- Blood pressure

- Edema

- Heart rate

- Respiratory rate

* Integumentary

- Presence of scar formation

- Skin color

- Skin integrity

* Musculoskeletal

- Gross range of motion

- Gross strength

- Gross symmetry

- Height

- Weight

* Neuromuscular

- Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

* Ability to make needs known

* Consciousness

* Expected emotional/behavioral responses

* Learning preferences (eg, education needs, learning barriers)

* Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:

Aerobic Capacity and Endurance

* Aerobic capacity during functional activities (eg, activities of daffy living [ADL] scales, indexes, instrumental activities of daily living [IADL] scales, observations)

* Aerobic capacity during standardized exercise test protocols (eg, ergometry, step tests, time/distance walk/run tests, treadmill tests, wheelchair tests)

* Cardiovascular signs and symptoms in response to increased oxygen demand with exercise or activity, including pressures and flow; heart rate, rhythm, and sounds; and superficial vascular responses (eg, angina, claudication, dyspnea, and exertion scales; electrocardiography; observations; palpation; sphygmomanometry)

* Pulmonary signs and symptoms in response to increased oxygen demand with exercise or activity, including breath and voice sounds; cyanosis; gas exchange; respiratory pattern, rate, and rhythm; ventilatory flow, force, and volume (eg, auscultation, dyspnea and exertion scales, gas analyses, observations, oximetry, palpation, pulmonary function tests)

Anthropometric Characteristics

* Body dimensions (eg, body mass index, girth measurement, length measurement)

* Edema (eg, girth measurement, palpation, scales, volume measurement)

Arousal, Attention, and Cognition

* Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires)

* Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists)

* Motivation (eg, adaptive behavior scales)

* Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales)

* Recall, including memory and retention (eg, assessment scales, interviews, questionnaires)

Assistive and Adaptive Devices

* Assistive or adaptive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations)

* Components, alignment, fit, and ability to care for assistive or adaptive devices and equipment (eg, interviews, logs, observations, reports)

* Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Circulation (Arterial, Venous, and Lymphatic)

* Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, electrocardiography, palpation, sphygmomanometry, thermography)

* Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales)

* Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry)

Cranial Nerve Integrity

* Motor distribution of the cranial nerves (eg, dynamometry, muscle tests, observations)

* Response to stimuli, including auditory, gustatory, olfactory, pharyngeal, vestibular, and visual (eg, observations, provocation tests)

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

* Current and potential barriers (eg, checklists, interviews, observations, questionnaires)

* Physical space and environment (eg, compliance standards, observations, photographic assessments, questionnaires, structural specifications, videographic assessments)

Ergonomics and Body Mechanics

Ergonomics

* Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses)

* Safety in work environments (eg, hazard identification check-lists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits)

Gait, Locomotion, and Balance

* Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, IADL scales, observations, videographic assessments)

* Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests)

* Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments)

* Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)

Integumentary Integrity

Associated skin

* Activities, positioning, and postures that produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, scales)

* Assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment that may produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, risk assessment scales)

* Skin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography)

Wound

* Signs of infection (eg, cultures, observations, palpation)

* Wound scar tissue characteristics including banding, pliability, sensation, and texture (eg, observations, scar-rating scales)

Muscle Performance (Including Strength, Power, and Endurance)

* Electrophysiological integrity (eg, electroneuromyography)

* Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests)

* Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

Neuromotor Development and Sensory Integration

* Oral motor function, phonation, and speech production (eg, interviews, observations)

Orthotic, Protective, and Supportive Devices

* Components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Orthotic, protective, and supportive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations, profiles)

* Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Pain

* Pain, soreness, and nociception (eg, angina scales, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments)

Range of Motion (ROM) (Including Muscle Length)

* Functional ROM (eg, observations)

* Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments)

* Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

Reflex Integrity

* Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)

* Electrophysiological integrity (eg, electroneuromyography)

* Superficial reflexes and reactions (eg, observations, provocation tests)

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

* Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests)

* Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles)

* Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)

Sensory Integrity

* Electrophysiological integrity (eg, electroneuromyography)

Ventilation and Respiration/Gas Exchange

* Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry)

* Pulmonary signs of ventilatory function, including airway protection; breath and voice sounds; respiratory rate, rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary function tests, ventilatory muscle force tests)

* Pulmonary symptoms (eg, dyspnea and perceived exertion indexes and scales)

Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living [IADL])

* Ability to assume or resume work (job/school/play), community, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests)

* Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments)

* Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status.

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 3 to 6 weeks, patient/client with ventilatory pump dysfunction or reversible ventilatory pump failure will demonstrate optimal independence with ventilation and respiration/gas exchange and the highest level of functioning in home, work (job/ school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities.

Over the course of 8 to 10 weeks, patient/client with prolonged, severe, or chronic ventilatory pump failure will demonstrate optimal independence with ventilation and respiration/gas exchange and the highest level of functioning in home, work (job/school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities.

During the episode of care, patient/client with ventilatory pump dysfunction, with reversible ventilatory pump failure, or with prolonged, severe, or chronic ventilatory pump failure will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (21) the global outcomes for patients/clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

5 to 20

20 to 60

These ranges represent the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected 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 and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status

* Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors

* Psychomotor abilities

* Social support

* Stability of the condition

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions

- advance directives

- individualized family service plans (IFSPs) or individualized education plans (IEPs)

- informed consent

- mandatory communication and reporting (eg, patient advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including:

- equipment suppliers

- home care agencies

- payer groups

- schools

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

* Cost-effective resource utilization

* Data collection, analysis, and reporting

- outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork

- case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, individualized family service plans (IFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across settings through case conferences, and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews.

* Decision making is enhanced regarding health, wellness, and fitness needs.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.

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

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/Client-Related Instruction

Patient/client-related instruction may include:

Interventions

* Instruction, education and training of patients/clients and caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- enhancement of performance

- health, wellness, and fitness programs

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities

- transitions across settings

- transitions to new roles

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources are improved.

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

* Decision making is enhanced regarding patient/client health and the 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.

* Health status is improved.

* 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 anticipated goals and expected outcomes are increased.

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

* Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved.

* Physical function is improved.

* 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.

Procedural Interventions

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions

* Aerobic capacity/endurance conditioning or reconditioning

- gait and locomotor training

- increased workload over time

- movement efficiency and energy conservation training

- walking and wheelchair propulsion programs

* Balance, coordination, and agility training

- developmental activities training

- motor function (motor control and motor learning) training or retraining

- neuromuscular education or reeducation

- posture awareness training

- task-specific performance training

* Body mechanics and postural stabilization

- body mechanics training

- postural control training

- postural stabilization activities

- posture awareness training

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Gait and locomotion training

- developmental activities training

- gait training

- implement and device training

- perceptual training

- standardized, programmatic, complementary exercise approaches

- wheelchair training

* Relaxation

- breathing strategies

- movement strategies

- relaxation techniques

- standardized, programmatic, complementary exercise approaches

* Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles

- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric)

- task-specific performance training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Atelectasis is decreased.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Soft tissue swelling, inflammation, or restriction is reduced.

- Symptoms associated with increased oxygen demand are decreased.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Aerobic capacity is increased.

- Airway clearance is improved.

- Balance is improved.

- Endurance is increased.

- Energy expenditure per trait of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Ventilation and respiration/gas exchange are improved.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daffy living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL])

Interventions

* ADL training

- bathing

- bed mobility and transfer training

- developmental activities

- dressing

- eating

- grooming

- toileting

* Devices and equipment use and training

- assistive and adaptive device or equipment training during ADL and IADL

- orthotic, protective, or supportive device or equipment training during ADL and IADL

- prosthetic device or equipment training during ADL and IADL

* Functional training programs

- simulated environments and tasks

- task adaptation

* IADL training

- caring for dependents

- home maintenance

- shopping

- structured play for infants and children

* Injury prevention or reduction

- injury prevention education during self-care and home management

- injury prevention or reduction with use of devices and equipment

- safety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease/disorder/ condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care and home management is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care and home management roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairments is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services results in efficient use of health care dollars.

- Utilization of physical therapy services is optimized.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living [IADL], Work Hardening, and Work Conditioning)

Interventions

* Devices and equipment use and training

- assistive and adaptive device or equipment training during IADL

- orthotic, protective, or supportive device or equipment training during IADL

- prosthetic device or equipment training during IADL

* Functional training programs

- job coaching

- simulated environments and tasks

- task adaptation

- task training

* IADL training

- community service training involving instruments

- school and play activities training including tools and instruments

- work training with tools

* Injury prevention or reduction

- injury prevention education during work (job/school/play), community, and leisure integration

- injury prevention or reduction with use of devices and equipment

- safety awareness training during work (job/school/play), community, and leisure integration

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to work (job/school/play), community, and leisure integration or reintegration is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

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

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client,

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization/manipulation

- soft tissue

- spinal and peripheral joints

* Passive range of motion

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

- Soft tissue swelling, inflammation, or restriction is reduced.

* Impact on impairments

- Airway clearance is improved.

- Balance is improved.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform movement tasks is improved.

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

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

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

Interventions

* Adaptive devices

- environmental controls

- hospital beds

- raised toilet seats

- seating systems

* Assistive devices

- canes

- crutches

- long-handled reachers

- percussors and vibrators

- power devices

- static and dynamic splints

- walkers

- wheelchairs

* Orthotic devices

- braces

- casts

- shoe inserts

- splints

* Prosthetic devices (lower-extremity and upper-extremity)

* Protective devices

- cushions

* Supportive devices

- compression garments

- mechanical ventilators

- supplemental oxygen

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Soft tissue swelling, inflammation, or restriction is reduced.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint stability is improved.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Optimal joint alignment is achieved.

- Optimal loading on a body part is achieved.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Ventilation and respiratory/gas exchange are improved.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment Are increased.

- Tolerance of positions and activities is improved.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Airway Clearance Techniques

Interventions

* Breathing strategies

- active cycle of breathing or forced expiratory techniques

- assisted cough/huff techniques

- autogenic drainage

- paced breathing

- pursed lip breathing

- techniques to maximize ventilation (eg, maximum inspiratory hold, stair case breathing, manual hyperinflation)

* Manual/mechanical techniques

- assistive devices

- chest percussion, vibration, and shaking

- chest wall manipulation

- suctioning

- ventilatory aids

* Positioning

- positioning to alter work of breathing

- positioning to maximize ventilation and perfusion

- pulmonary postural drainage

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Atelectasis is decreased.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Airway clearance is improved.

- Cough is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Exercise tolerance is improved.

- Ventilation and respiration/gas exchange are improved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Electrotherapeutic Modalities

Interventions

* Biofeedback

* Electrical stimulation

- electrical muscle stimulation (EMS)

- functional electrical stimulation (FES)

- neuromuscular electrical stimulation (NMES)

- transcutaneous electrical nerve stimulation (TENS)

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Nutrient delivery to tissue is increased.

- Pain is decreased.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of immobility are reduced.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

Impaired Ventilation and Respiration/ Gas Exchange Associated With Respiratory Failure

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified into this pattern--for impaired ventilation and respiration/gas exchange associated with respiratory failure--as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Abnormal chest radiograph

* Acute neuromuscular dysfunction

* Adult respiratory distress syndrome

* Abnormal alveolar to arterial oxygen tension differences

* Asthma

* Cardiothoracic surgery

* Chronic obstructive pulmonary disease (COPD)

* Inability to maintain adequate oxygen tension with supplemental oxygen

* Multisystem failure

* Pneumonia

* Pre- and post-lung transplant or rejection

* Rapid rise in arterial carbon dioxide at rest or with activity

* Sepsis

* Thoracic or multisystem trauma

Impairments, Functional Limitations, or Disabilities

* Abnormal or adventitious breath sounds

* Abnormal vital capacity

* Airway clearance dysfunction

* Dyspnea at rest

* Dyssynchronous or paradoxical breathing pattern

* Impaired gas exchange

* Significantly increased respiratory rate at rest (>35)

Note:

Some risk factors or consequences of pathology/ pathophysiology--such as respiratory failure with sepsis--may be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis, page S545.)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.

Findings That May Require Classification in a Different Pattern

* Age of less than 4 months

* Impairments associated with cardiovascular pump failure

* Impairments associated with chronic ventilatory pump failure

Findings That May Require Classification in Additional Patterns

* Multisite fracture

* Multitrauma with open wounds

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes--patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, Ill: American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

136 Other and unspecified infectious and parasitic diseases
    136.3 Pneumocystosis
277 Other and unspecified disorders of metabolism
    277.0 Cystic fibrosis
286 Coagulation defects
    286.6 Defribrination syndrome
          Diffuse or disseminated intravascular
          coagulation [DIC syndrome]
348 Other conditions of brain
    348.1 Anoxic brain damage
415 Acute pulmonary heart disease
    415.1 Pulmonary embolism and infarction
480 Viral pneumonia
481 Pneumococcal pneumonia [Streptococcus pneumoniae
    pneumonia]
482 Other bacterial pneumonia
483 Pneumonia due to other specified organism
484 Pneumonia in infectious diseases classified elsewhere
485 Bronchopneumonia, organism unspecified
486 Pneumonia, organism unspecified
491 Chronic bronchitis
492 Emphysema
    492.8 Other emphysema
          Emphysema (lung or pulmonary), not
          otherwise specified
493 Asthma
494 Bronchiectasis
495 Extrinsic allergic alveolitis
    495.7 "Ventilation" pneumonitis
496 Chronic airway obstruction, not elsewhere classified
    Chronic obstructive pulmonary disease [COPD], not
    otherwise specified
507 Pneumonitis due to solids and liquids
    507.0 Due to inhalation of food or vomitus
          Aspiration pneumonia
511 Pleurisy
    511.8 Other specified forms of effusion, except
          tuberculous Hemothorax
512 Pneumothorax
    512.8 Other spontaneous pneumothorax
513 Abscess of lung and mediastinum
514 Pulmonary congestion and hypostasis
    Pulmonary edema, not otherwise specified
516 Other alveolar and parietoalveolar pneumonopathy
    516.9 Unspecified alveolar and parietoalveolar
          pneumonopathy
517 Lung involvement in conditions classified elsewhere
518 Other diseases of lung
    518.0 Pulmonary collapse
    518.5 Pulmonary insufficiency following trauma and
          surgery
          Adult respiratory distress syndrome
    518.8 Other diseases of lung
          518.81 Acute respiratory failure
          518.82 Other pulmonary insufficiency, not
                 elsewhere classified
                 Acute respiratory distress
519 Other diseases of respiratory system
    519.4 Disorders of diaphragm
786 Symptoms involving respiratory system and other chest
    symptoms
852 Subarachnoid, subdural, and extradural hemorrhage,
    following injury
853 Other and unspecified intracranial hemorrhage following
    injury
854 Intracranial injury of other and unspecified nature
861 Injury to heart and lung
    861.2 Lung, without mention of open wound into
          thorax
          861.21 Contusion
959 Injury, other and unspecified
996 Complications peculiar to certain specified procedures
    996.0 Mechanical complication of cardiac device,
          implant, and graft
    996.1 Mechanical complication of other vascular device,
          implant, and graft
    996.2 Mechanical complication of nervous system
          device, implant, and graft
    996.3 Mechanical complication of genitourinary device,
          implant, and graft
    996.4 Mechanical complication of internal orthopedic
          device, implant, and graft
    996.5 Mechanical complications of other specified
          prosthetic device, implant, and graft
    996.8 Complications of transplanted organ
          996.85 Bone marrow
997 Complications affecting specified body system, not
    elsewhere classified
    997.3 Respiratory complications

Supplemental Classification of Factors Influencing Health Status and Contact With Health Services

V42 Organ or tissue replaced by transplant
    V42.0 Kidney
    V42.1 Heart
    V42.4 Bone
    V42.6 Lung
    V42.7 Liver
    V42.8 Other specified organ or tissue
          V42.81 Bone marrow

Note:

Patients/clients who have surgical procedures involving the abdomen, chest wall, diaphragm, lung, pleura, mediastinum, thorax, and vessels of the heart and patients/clients who have nonsurgical procedures such as intubation, irrigation, and other continuous mechanical ventilation also may be classified into this pattern.

Examination

Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness. The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process.

Examination has three components: the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client. The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acme, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics

* Age

* Sex

* Race/ethnicity

* Primary language

* Education

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Employment/Work (Job/School/Play)

* Current and prior work (job/school/play), community, and leisure actions, tasks, or activities

Growth and Development

* Developmental history

* Hand dominance

Living Environment

* Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic)

* Living environment and community characteristics

* Projected discharge destinations

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

* General health perception

* Physical function (eg, mobility, sleep patterns, restricted bed days)

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

* Role function (eg, community, leisure, social, work)

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

Social/Health Habits (Past and Current)

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

* Level of physical fitness

Family History

* Familial health risks

Medical/Surgical History

* Cardiovascular

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Gynecological

* Integumentary

* Musculoskeletal

* Neuromuscular

* Obstetrical

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

* Psychological

* Pulmonary

Current Condition(s)/Chief Complaint(s)

* 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

* Previous occurrence of chief complaint(s)

* Prior therapeutic interventions

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)

* Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities

Medications

* Medications for current condition

* Medications previously taken for current condition

* Medications for other conditions

Other Clinical Tests

* Laboratory and diagnostic tests

* Review of available records (eg, medical, education, surgical)

* Review of other clinical findings (eg, nutrition and hydration)

Systems Review

The systems review may include:

Anatomical and Physiological Status

* Cardiovascular/Pulmonary

- Blood pressure

- Edema

- Heart rate

- Respiratory rate

* Integumentary

- Presence of scar

- formation

- Skin color

- Skin integrity

* Musculoskeletal

- Gross range of motion

- Gross strength

- Gross symmetry

- Height

- Weight

Neuromuscular

* Gross coordinated

- movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

* Ability to make needs known

* Consciousness

* Expected emotional/behavioral responses

* Learning preferences (eg, education needs, learning barriers)

* Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:

Aerobic Capacity and Endurance

* Cardiovascular signs and symptoms in response to increased oxygen demand with exercise or activity, including pressures and flow; heart rate, rhythm, and sounds; and superficial vascular responses (eg, angina, claudication, dyspnea, and exertion scales; electrocardiography; observations; palpation; sphygmomanometry)

* Pulmonary signs and symptoms in response to increased oxygen demand with exercise or activity, including breath and voice sounds; cyanosis; gas exchange; respiratory pattern, rate, and rhythm; ventilatory flow, force, and volume (eg, auscultation, dyspnea and exertion scales, gas analyses, observations, oximetry, palpation, pulmonary function tests)

Anthropometric Characteristics

* Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement)

* Edema (eg, girth measurement, palpation, scales, volume measurement)

Arousal, Attention, and Cognition

* Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires)

* Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists)

* Motivation (eg, adaptive behavior scales)

* Orientation to time, person, place, and situation (eg, attention tests, learning profiles, mental state scales)

* Recall, including memory and retention (eg, assessment scales, interviews, questionnaires)

Assistive and Adaptive Devices

* Assistive or adaptive devices and equipment use during functional activities (eg, ADL scales, functional scales, interviews, observations)

Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of assistive or adaptive devices and equipment (eg, fall scales, interviews, logs, observations, reports)

Circulation (Arterial, Venous, and Lymphatic)

* Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, claudication scales, electrocardiography, girth measurement, palpation, sphygmomanometry, thermography)

* Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales)

* Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry)

Cranial and Peripheral Nerve Integrity

* Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests)

* Response to stimuli, including auditory, gustatory, olfactory, pharyngeal, vestibular, and visual (eg, observations, provocation tests)

* Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)

Gait, Locomotion, and Balance

* Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, IADL scales, observations, videographic assessments)

* Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests)

* Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments)

* Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)

Integumentary Integrity

Associated skin

* Activities, positioning, and postures that produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, scales)

* Assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment that may produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, risk assessment scales)

* Skin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography)

Motor Function (Motor Control and Motor Learning)

* Initiation, modification, and control of movement patterns and voluntary postures (eg, activity indexes, developmental scales, gross motor function profiles, motor scales, movement assessment batteries, neuromotor tests, observations, physical performance tests, postural challenge tests, videographic assessments)

Muscle Performance (Including Strength, Power, and Endurance)

* Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

Orthotic, Protective, and Supportive Devices

* Components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Orthotic, protective, and supportive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations, profiles)

* Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, reports)

Pain

* Pain, soreness, and nociception (eg, angina scales, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests)

* Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, observations)

Range of Motion (ROM) (Including Muscle Length)

* Functional ROM (eg, observations)

* Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments)

* Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

Reflex Integrity

* Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)

* Resistance to passive stretch (eg, tone scales)

* Superficial reflexes and reactions (eg, observations, provocation tests)

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

* Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles)

Sensory Integrity

* Combined/cortical sensations (eg, stereognosis, tactile discrimination tests)

* Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)

Ventilation and Respiration/Gas Exchange

* Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry)

* Pulmonary signs of ventilatory function, including airway protection; breath and voice sounds; respiratory rate, rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary function tests, ventilatory muscle force tests)

* Pulmonary symptoms (eg, dyspnea and perceived exertion indexes and scales)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status. A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 72 hours, patient/ client with acute reversible respiratory failure will demonstrate optimal independence with ventilation and respiration/ gas exchange and the highest level of functioning in home, work (job/ school/play), community, and leisure environments.

Over the course of 3 weeks, patient/client with prolonged respiratory failure will demonstrate optimal independence with ventilation and respiration/gas exchange and the highest level of functioning in home, work (job/school/play), community, and leisure environments.

Over the course of 4 to 6 weeks, patient/ client with severe or chronic respiratory failure will demonstrate optimal independence with ventilation and respiration/gas exchange and the highest level of functioning in home, work (job/school/play), community, and leisure environments.

During the episode of care, patient/client with acute reversible respiratory failure, prolonged respiratory failure, or severe or chronic respiratory failure will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

3 to 9

10 to 25

20 to 45

These ranges represent the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected 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 and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status

* Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors

* Psychomotor abilities

* Social support

* Stability of the condition

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions

- advance directives

- informed consent

- mandatory communication and reporting (eg, patient advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including:

- equipment suppliers

- home care agencies

- payer groups

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

* Cost-effective resource utilization

* Data collection, analysis, and reporting

- outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork

- case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across settings through case conferences and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews.

* Decision making is enhanced regarding health, wellness, and fitness needs.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.

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

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/Client-Related Instruction

Patient/client-related instruction may include:

Interventions

* Instruction, education and training of patients/clients and caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- enhancement of performance

- health, wellness, and fitness programs

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities

- transitions across settings

- transitions to new roles

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources are improved.

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

* Decision making is enhanced regarding patient/client health and the 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.

* Health status is improved.

* 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 anticipated goals and expected outcomes are increased.

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

* Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved.

* Physical function is improved.

* 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.

Direct Interventions

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

Therapeutic Exercise

Interventions

* Aerobic capacity/endurance conditioning or reconditioning

- gait and locomotor training

- increased workload over time

- movement efficiency and energy conservation training

- walking and wheelchair propulsion programs

* Balance, coordination, and agility training

- neuromuscular education or reeducation

- posture awareness training

* Body mechanics and postural stabilization

- body mechanics training

- postural control training

- posture awareness training

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Relaxation

- breathing strategies

- movement strategies

- relaxation techniques

- standardized, programmatic, complementary exercise approaches

* Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles

- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric)

- task-specific performance training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Atelectasis is decreased.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Soft tissue swelling, inflammation, or restriction is reduced.

- Symptoms associated with increased oxygen demand are decreased.

- Tissue perfusion and oxygenation are enhanced.

- Ventilation and respiration/gas exchange are improved.

* Impact on impairments

- Aerobic capacity is increased.

- Airway clearance is improved.

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (Al)L) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play);community, and leisure roles is improved.

* Risk reduction/prevention

- Preoperative and postoperative complications are reduced.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Self-Care and Home Management (including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL])

Interventions

* ADL training

- bathing

- bed mobility and transfer training

- developmental activities

- dressing

- eating

- grooming

- toileting

* Devices and equipment use and training

- assistive and adaptive device or equipment training during ADL and IADL

- orthotic, protective, or supportive device or equipment training during ADL and IADL

- prosthetic device or equipment training during ADL and IADL

* IADL training

- home maintenance

- household chores

* Injury prevention or reduction

- injury prevention education during self-care and home management

- injury prevention or reduction with use of devices and equipment

- safety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care and home management is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

Ability to assume or resume required self-care and home management roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairments is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization/manipulation

- soft tissue

* Passive range of motion

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

- Soft tissue swelling, inflammation, or restriction is reduced.

* Impact on impairments

- Airway clearance is improved.

- Balance is improved.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform movement tasks is improved.

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

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

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

Interventions

* Adaptive devices

- environmental controls

- hospital beds

- raised toilet seats

- seating systems

* Assistive devices

- canes

- crutches

- long-handled reachers

- percussors and vibrators

- power devices

- static and dynamic splints

- walkers

- wheelchairs

* Orthotic devices

- braces

- casts

- shoe inserts

- splints

* Protective devices

- braces

- cushions

* Supportive devices

- compression garments

- elastic wrap

- mechanical ventilators

- neck collars

- supplemental oxygen

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Soft tissue swelling, inflammation, or restriction is reduced.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint stability is improved.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Optimal joint alignment is achieved.

- Optimal loading on a body part is achieved.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Weight-bearing status is improved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is improved.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

- Procedural Interventions

- Airway Clearance Techniques

- Interventions

* Breathing strategies

- active cycle of breathing or forced expiratory techniques

- assisted cough/huff techniques

- autogenic drainage

- paced breathing

- pursed lip breathing

- techniques to maximize ventilation (eg, maximum inspiratory hold, stair case breathing, manual hyperinflation)

* Manual/mechanical techniques

- assistive devices

- chest percussion, vibration, and shaking

- chest wall manipulation

- suctioning

- ventilatory aids

* Positioning

- positioning to alter work of breathing

- positioning to maximize ventilation and

- perfusion

- pulmonary postural drainage

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Atelectasis is decreased.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Airway clearance is improved.

- Cough is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Exercise tolerance is improved.

- Ventilation and respiration/gas exchange are improved.

- Work of breathing is decreased.

* Impact on functional limitations

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

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

- Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

Impaired Ventilation, Respiration/ Gas Exchange, and Aerobic Capacity/ Endurance Associated With Respiratory Failure in the Neonate

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified into this pattern--for impaired ventilation, respiration/gas exchange, and aerobic capacity/endurance associated with respiratory failure in the neonate--as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Abdominal thoracic surgeries

* Apnea and bradycardia

* Bronchopulmonary dysphasia

* Congenital anomalies

* Hyaline membranes disease

* Meconium aspiration syndrome

* Neurovascular disorders

* Pneumonia

* Rapid desaturation with movement or crying

Impairments, Functional Limitations, or Disabilities

* Abnormal pulmonary responses to activity

* Impaired airway clearance

* Impaired cough

* Impaired gas exchange

* Intercostal or subcostal retraction on inspiration

* Paradoxical or abnormal breathing pattern at rest or with activity

* Physiological intolerance of routine care

Note:

Some risk factors or consequences of pathology/pathophysiology--such as bronchopulmonary dysphasia--may be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," page S560.)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.

Findings That May Require Classification in a Different Pattern

* Age of greater than 4 months

* Neonate with central nervous system disorder without respiratory failure

Findings That May Require Classification in Additional Patterns

* Neonate with an intracranial bleed and respiratory failure

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3-and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes-patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICL-9-CM 2001), Volumes 1 and 3 (Chicago, Ill:American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

508 Respiratory conditions due to other and unspecified
    external agents
    508.9 Respiratory conditions due to unspecified
          external agent
514 Pulmonary congestion and hypostasis
516 Other alveolar and parietoalveolar pneumonopathy
    516.9 Unspecified alveolar and parietoalveolar
          pneumonopathy
518 Other diseases of lung
    518.0 Pulmonary collapse
    518.8 Other diseases of lung
          518.89 Other diseases of lung, not elsewhere
                 classified
553 Other hernia of abdominal cavity without mention of
    obstruction or gangrene
    553.3 Diaphragmatic hernia
748 Congenital anomalies of respiratory system
    748.3 Other anomalies of larynx, trachea, and bronchus
    748.5 Agenesis, hypoplasia, and dysplasia of lung
    748.6 Other anomalies of lung
750 Other congenital anomalies of upper alimentary tract
    750.3 Tracheoesophageal fistula, esophageal atresia and
          stenosis
765 Disorders relating to short gestation and unspecified low
    birth weight
    765.0 Extreme immaturity
    765.1 Other preterm infants
767 Birth trauma
    767.7 Other cranial and peripheral nerve injuries
          Phrenic nerve paralysis
769 Respiratory distress syndrome
    Hyaline membrane disease (pulmonary)
770 Other respiratory conditions of fetus and newborn
    770.1 Meconium aspiration syndrome
    770.6 Transitory tachypnea of newborn
    770.7 Chronic respiratory disease arising in the
          perinatal period
          Bronchopulmonary dysplasia
786 Symptoms involving respiratory system and other chest
    symptoms
    786.0 Dyspnea and respiratory abnormalities
          786.00 Respiratory abnormality, unspecified

Examination

Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness. The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process.

Examination has three components: the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

The selection of examination procedures and the depth of the examination vary based on patient/client age; severity of the problem; stage of recovery (acme, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); home, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics

* Age

* Sex

* Race/ethnicity

* Primary language

* Education

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Employment/Work (Job/School/Play)

* Current and prior work (job/school/play), community, and leisure actions, tasks, or activities

Growth and Development

* Developmental history

* Hand dominance

Living Environment

* Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic)

* Living environment and community characteristics

* Projected discharge destinations

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

* General health perception

* Physical function (eg, mobility, sleep patterns, restricted bed days)

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

* Role function (eg, community, leisure, social, work)

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

Social/Health Habits (Past and Current)

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

* Level of physical fitness

Family History

* Familial health risks

Medical/Surgical History

* Cardiovascular

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Gynecological

* Integumentary

* Musculoskeletal

* Neuromuscular

* Obstetrical

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

* Psychological

* Pulmonary

Current Condition(s)/Chief Complaint(s)

* 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

* Previous occurrence of chief complaint(s)

* Prior therapeutic interventions

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)

* Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities

Medications

* Medications for current condition

* Medications previously taken for current condition

* Medications for other conditions

Other Clinical Tests

* Laboratory and diagnostic tests

* Review of available records (eg, medical, education, surgical)

* Review of other clinical findings (eg, nutrition and hydration)

Systems Review

The systems review may include:

Anatomical and Physiological Status

* Cardiovascular/Pulmonary

- Blood pressure

- Edema

- Heart rate

- Respiratory rate

* Integumentary

- Presence of scar formation

- Skin color

- Skin integrity

* Musculoskeletal

- Gross range of motion

- Gross strength

- Gross symmetry

- Height

- Weight

* Neuromuscular

- Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

* Ability to make needs known

* Consciousness

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:

Aerobic Capacity and Endurance

* Cardiovascular signs and symptoms in response to increased oxygen demand with exercise or activity, including pressures and flow; heart rate, rhythm, and sounds; and superficial vascular responses (eg, electrocardiography, observations, palpation, sphygmomanometry)

* Pulmonary signs and symptoms in response to increased oxygen demand with exercise or activity, including breath and voice sounds; cyanosis; gas exchange; respiratory pattern, rate, and rhythm; ventilatory flow, force, and volume (eg, auscultation, gas analyses, observations, oximetry, palpation, pulmonary function tests)

Anthropometric Characteristics

* Body dimensions (eg, body mass index, girth measurement, length measurement)

* Edema (eg, girth measurement, palpation, scales, volume measurement)

Arousal, Attention, and Cognition

* Arousal and attention (eg, adaptability tests, arousal and awareness scales, indexes, profiles, questionnaires)

Circulation (Arterial, Venous, and Lymphatic)

* Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, electrocardiography, palpation, sphygmomanometry, thermography)

* Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry)

Cranial and Peripheral Nerve Integrity

* Motor distribution of the cranial nerves (eg, observations)

* Motor distribution of the peripheral nerves (eg, observations)

* Response to stimuli, including auditory, gustatory, olfactory, pharyngeal, vestibular, and visual (eg, observations, provocation tests)

* Sensory distribution of the cranial nerves (eg, tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration)

* Sensory distribution of the peripheral nerves (eg, tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration)

Integumentary Integrity

Associated skin

* Activities, positioning, and postures that produce or relieve trauma to the skin (eg, observations)

* Skin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography)

Motor Function (Motor Control and Motor Learning)

* Initiation, modification, and control of movement patterns and voluntary postures (eg, activity indexes, developmental scales, gross motor function profiles, motor scales, movement assessment batteries, neuromotor tests, observations, physical performance tests, postural challenge tests, videographic assessments)

Muscle Performance (Including Strength, Power, and Endurance)

* Muscle strength, power, and endurance during functional activities (eg,ADL scales)

Neuromotor Development and Sensory Integration

* Acquisition and evolution of motor skills, including age-appropriate development (eg, activity indexes, developmental inventories and questionnaires, infant motor assessments, motor function tests, motor proficiency assessments, neuromotor assessments, reflex tests)

* Oral motor function, phonation, and speech production (eg, interviews, observations)

* Sensorimotor integration, including postural, equilibrium, and righting reactions (eg, behavioral assessment scales, motor and processing skill tests, postural challenge tests, observations, reflex tests, sensory profiles)

Orthotic, Protective, and Supportive Devices

* Components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, reports)

* Orthotic, protective, and supportive devices and equipment use during functional activities (eg, activities of daily living [ADL] scales, functional scales, interviews, observations, profiles)

* Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes,ADL scales, pain scales)

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, reports, observations)

Pain

* Pain, soreness, and nociception (eg, provocation tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments)

Range of Motion (ROM) {Including Muscle Length)

* Functional ROM (eg, observations)

Reflex Integrity

* Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)

* Postural reflexes and reactions, including righting, equilibrium, and protective reactions (eg, observations, postural challenge tests, reflex profiles, videographic assessments)

* Primitive reflexes and reactions, including developmental (eg, reflex profiles, screening tests)

* Resistance to passive stretch (eg, tone scales)

* Superficial reflexes and reactions (eg, observations, provocation tests)

Ventilation and Respiration/Gas Exchange

* Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry)

* Pulmonary signs of ventilatory function, including airway protection; breath and voice sounds; respiratory rate, rhythm, and pattern; ventilatory flow, forces, and volumes (eg, airway clearance tests, observations, palpation, pulmonary function tests, ventilatory muscle force tests)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status.

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 6 to 12 months, patient/client will demonstrate optimal ventilation, respiration/gas exchange, and aerobic capacity/endurance and the highest level of age-appropriate functioning.

During the episode of care, patient/client will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/ clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

16 to 84

This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and expected outcomes. It is anticipated that 80% of patients/clients who are classified into this pattern will achieve the anticipated goals and expected outcomes within 16 to 84 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery.

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

* Accessibility and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status

* Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors

* Psychomotor abilities

* Social support

* Stability of the condition

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, settings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions

- advance directives

- individualized family service plans (IFSPs)

- informed parent/guardian consent

- mandatory communication and reporting (eg, patient advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including: equipment suppliers

- home care agencies

- payer groups

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

* Cost-effective resource utilization

* Data collection, analysis, and reporting

- outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination,evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork

- case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, individualized family service plans (IFSPs), informed consent, and mandatory communication and reporting (eg, patient/client advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across settings through case conferences and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.

* Family, significant other, and caregiver understanding of anticipated goals and expected outcomes is increased.

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/Client-Related Instruction

Patient/client-related instruction may include:

Interventions

* Instruction, education and training of caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities

- transitions across settings

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources by family or caregivers are improved.

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

* Disability associated with acute or chronic illnesses is reduced.

* Family, significant other, and caregiver knowledge and awareness of the diagnosis, prognosis, interventions, and anticipated goals and expected outcomes are increased.

* Health status is improved.

* Intensity of care is decreased.

* Level of supervision required for task performance by family or caregiver is decreased.

* Physical function is improved.

* Risk of recurrence of condition is reduced.

* Risk of secondary impairment is reduced.

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

* Utilization and cost of health care services are decreased.

Procedural Interventions

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Neuromotor development training

- developmental activities training

- motor training

- movement patterns

- neuromuscular education or reeducation

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Atelectasis is decreased.

- Nutrient delivery to tissue is increased.

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Airway clearance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Muscle performance (strength, power, and endurance) is increased.

- Quality and quantity of movement between and across body segments are improved.

- Ventilation and respiration/gas exchange are improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform age-appropriate physical actions, tasks, or activities is improved.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume required age-appropriate roles is improved.

* Risk reduction/prevention

- Preoperative and postoperative complications are reduced.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to caregiver.

- Administrative management of practice is acceptable to caregiver.

- Caregiver's sense of well-being is improved.

- Caregiver's stressors are decreased.

- Clinical proficiency of physical therapist is acceptable to caregiver.

- Coordination of care is acceptable to caregiver.

- Cost of health care services is decreased.

- Intensity of care is decreased.

- Interpersonal skills of physical therapist are acceptable to caregiver.

Functional Training in Self-Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL])

Interventions

* ADL training for caregivers

- developmental activities

- feeding

* Devices and equipment use and training for caregivers

- assistive and adaptive device or equipment training during ADL

- orthotic, protective, or supportive device or equipment training during ADL

* Injury prevention or reduction

- injury prevention education for caregivers during ADL

- safety awareness training for caregivers during ADL

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Physiological response to increased oxygen demand is improved.

- Symptoms associated with increased oxygen demand are decreased.

* Impact on impairments

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Muscle performance (strength, power, and endurance) is increased.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform age-appropriate physical actions, tasks, or activities is improved.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume age-appropriate roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairments is reduced.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to caregiver.

- Administrative management of practice is acceptable to caregiver.

- Caregiver's sense of well-being is improved.

- Caregiver's stressors are decreased.

- Clinical proficiency of physical therapist is acceptable to caregiver.

- Coordination of care is acceptable to caregiver.

- Cost of health care services is decreased.

- Intensity of care is decreased.

- Interpersonal skills of physical therapist are acceptable to caregiver.

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization/manipulation

- soft tissue

* Passive range of motion

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Soft tissue swelling, inflammation, or restriction is reduced.

* Impact on impairments

- Joint integrity and mobility are improved.

* Impact on functional limitations

- Ability to perform age-appropriate physical actions, tasks, or activities is improved.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume age-appropriate roles is improved.

* Risk reduction/prevention

- Risk of secondary impairment is reduced.

* Impact on health, wellness, and fitness

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to caregiver.

- Administrative management of practice is acceptable to caregiver.

- Caregiver's sense of well-being is improved.

- Caregiver's stressors are decreased.

- Clinical proficiency of physical therapist is acceptable to caregiver.

- Coordination of care is acceptable to caregiver.

- Cost of health care services is decreased.

- Intensity of care is decreased.

- Interpersonal skills of physical therapist are acceptable to caregiver.

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

Interventions

* Assistive devices

- percussors and vibrators

* Orthotic devices

- braces

- casts

- splints

* Protective devices

- braces

- cushions

* Supportive devices

- mechanical ventilators

- supplemental oxygen

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Physiological response to increased oxygen demand is improved.

* Impact on impairments

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform age-appropriate physical actions, tasks, or activities is improved.

- Tolerance of positions and activities is improved.

* Impact on disabilities

- Ability to assume age-appropriate roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

* Impact on health, wellness, and fitness

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to caregiver.

- Administrative management of practice is acceptable to caregiver.

- Caregiver's sense of well-being is improved.

- Caregiver's stressors are decreased.

- Clinical proficiency of physical therapist is acceptable to caregiver.

- Coordination of care is acceptable to caregiver.

- Cost of health care services is decreased.

- Intensity of care is decreased.

- Interpersonal skills of physical therapist are acceptable to caregiver.

Procedural Interventions

Airway Clearance Techniques

Interventions

* Manual/mechanical techniques

- assistive devices

- chest percussion, vibration, and shaking

- suctioning

- ventilatory aids

* Positioning

- positioning to alter work of breathing

- positioning to maximize ventilation and perfusion

- pulmonary postural drainage

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Atelectasis is decreased.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Airway clearance is improved.

- Cough is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Ventilation and respiration/gas exchange are improved.

- Work of breathing is decreased.

* Impact on functional limitations

- Ability to perform age-appropriate physical actions, tasks, or activities is improved.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume age-appropriate roles is improved.

* Risk reduction/prevention

- Risk of secondary impairment is reduced.

* Impact on health, wellness, and fitness

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to caregiver.

- Administrative management of practice is acceptable to caregiver.

- Caregiver's sense of well-being is improved.

- Caregiver's stressors are decreased.

- Clinical proficiency of physical therapist is acceptable to caregiver.

- Coordination of care is acceptable to caregiver.

- Cost of health care services is decreased.

- Intensity of care is decreased.

- Interpersonal skills of physical therapist are acceptable to caregiver.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/diem status and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

Impaired Circulation and Anthropometric Dimensions Associated With Lymphatic System Disorders

This preferred practice pattern describes the generally accepted elements of patient/client management that physical therapists provide for patients/clients who are classified in this pattern. The pattern title reflects the diagnosis made by the physical therapist. APTA emphasizes that preferred practice patterns are the boundaries within which a physical therapist may select any of a number of clinical alternatives, 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 Classification

Patients/clients will be classified into this pattern--for impaired circulation and anthropometric dimensions associated with lymphatic system disorders--as a result of the physical therapist's evaluation of the examination data. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs. The physical therapist integrates, synthesizes, and interprets the data to determine the diagnostic classification.

Inclusion

The following examples of examination findings may support the inclusion of patients/clients in this pattern:

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

* Acquired immune deficiency syndrome

* Cellulitis

* Filariasis

* Infection/sepsis

* Lymphedema

* Post-radiation

* Reconstructive surgery

* Reflex sympathetic dystrophy

* Status post lymph node dissection

* Trauma

Impairments, Functional Limitations, or Disabilities

* Decreased participation in social activities as a result of perceived body image

* Difficulty dressing

* Edema

* Impaired skin integrity

* Pain

Note:

Some risk factors or consequences of pathology/ pathophysiology--such as deep vein thrombosis, lymphangiosarcoma, and lymphangitis--may be severe and complex; however, they do not necessarily exclude patients/clients from this pattern. Severe and complex risk factors or consequences may require modification of the frequency of visits and duration of care. (See "Evaluation, Diagnosis, and Prognosis," page S575.)

Exclusion or Multiple-Pattern Classification

The following examples of examination findings may support exclusion from this pattern or classification into additional patterns. Depending on the level of severity or complexity of the examination findings, the physical therapist may determine that the patient/client would be more appropriately managed through (1) classification in an entirely different pattern or (2) classification in both this and another pattern.

Findings That May Require Classification in a Different Pattern

* Impairments associated with congestive heart failure

Findings That May Require Classification in Additional Patterns

* Dependent edema with cellulitis

ICD-9-CM Codes

The listing below contains the current (as of press time) and most typical 3- and 4-digit ICD-9-CM codes related to this preferred practice pattern. Because patient/client diagnostic classification is based on impairments, functional limitations, and disabilities--not on codes--patients/clients may be classified into the pattern even though the codes listed with the pattern may not apply to those clients.

This listing is intended for general information only and should not be used for coding purposes. The codes should be confirmed by referring to the World Health Organization's International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 2001), Volumes 1 and 3 (Chicago, Ill:American Medical Association; 2000) or subsequent revisions or by referring to other ICD-9-CM coding manuals that contain exclusion notes and instructions regarding fifth-digit requirements.

038 Septicemia
    038.9 Unspecified septicemia
040 Other bacterial diseases
    040.0 Gas gangrene
          Malignant edema
125 Filarial infection and dracontiasis
    125.9 Unspecified filariasis
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
682 Other cellulitis and abscess
    682.3 Upper arm and forearm
    682.4 Hand, except fingers and thumb
    682.6 Leg, except foot
    682.7 Foot, except toes
    682.9 Unspecified site
          Abscess not otherwise specified
          Cellulitis not otherwise specified
          Lymphangitis, acute not otherwise specified
683 Acute lymphadenitis
757 Congenital anomalies of the integument
    757.0 Hereditary edema of legs
782 Symptoms involving skin and other integumentary tissue
    782.3 Edema
    782.8 Changes in skin texture
995 Certain adverse effects not elsewhere classified
    995.1 Angioneurotic edema

Examination

Examination is a comprehensive screening and specific testing process that leads to a diagnostic classification or, when appropriate, to a referral to another practitioner. Examination is required prior to the initial intervention and is performed for all patients/clients. Through the examination, the physical therapist may identify impairments, functional limitations, disabilities, changes in physical function or overall health status, and needs related to restoration of health and to prevention, wellness, and fitness. The physical therapist synthesizes the examination findings to establish the diagnosis and the prognosis (including the plan of care). The patient/client, family, significant others, and caregivers may provide information during the examination process.

Examination has three components: the patient/client history, the systems review, and tests and measures. The history is a systematic gathering of past and current information (often from the patient/client) related to why the patient/client is seeking the services of the physical therapist. The systems review is a brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient/client. Tests and measures are the means of gathering data about the patient/client.

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, work (job/school/play), or community situation; and other relevant factors. For clinical indications in selecting tests and measures and for listings of tests and measures, tools used to gather data, and the types of data generated by tests and measures, refer to Chapter 2.

Patient/Client History

The history may include:

General Demographics

* Age

* Sex

* Race/ethnicity

* Primary language

* Education

Social History

* Cultural beliefs and behaviors

* Family and caregiver resources

* Social interactions, social activities, and support systems

Employment/Work (Job/School/Play)

* Current and prior work (job/school/play), community, and leisure actions, tasks, or activities

Growth and Development

* Developmental history

* Hand dominance

Living Environment

* Devices and equipment (eg, assistive, adaptive, orthotic, protective, supportive, prosthetic)

* Living environment and community characteristics

* Projected discharge destinations

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

* General health perception

* Physical function (eg, mobility, sleep patterns, restricted bed days)

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

* Role function (eg, community, leisure, social, work)

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

Social/Health Habits (Past and Current)

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

* Level of physical fitness

Family History

* Familial health risks

Medical/Surgical History

* Cardiovascular

* Endocrine/metabolic

* Gastrointestinal

* Genitourinary

* Gynecological

* Integumentary

* Musculoskeletal

* Neuromuscular

* Obstetrical

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

* Psychological

* Pulmonary

Current Condition(s)/Chief Complaint(s)

* 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

* Previous occurrence of chief complaint(s)

* Prior therapeutic interventions

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 (ADL)

* Current and prior functional status in work (job/school/play), community, and leisure actions, tasks, or activities

Medications

* Medications for current condition

* Medications previously taken for current condition

* Medications for other conditions

Other Clinical Tests

* Laboratory and diagnostic tests

* Review of available records (eg, medical, education, surgical)

* Review of other clinical findings (eg, nutrition and hydration)

Systems Review

The systems review may include:

Anatomical and Physiological Status

* Cardiovascular/Pulmonary

- Blood pressure

- Edema

- Heart rate

- Respiratory rate

* Integumentary

- Presence of scar formation

- Skin color

- Skin integrity

* Musculoskeletal

- Gross range of motion

- Gross strength

- Gross symmetry

- Height

- Weight

* Neuromuscular

- Gross coordinated movements (eg, balance, locomotion, transfers, transitions)

Communication, Affect, Cognition, Language, and Learning Style

* Ability to make needs known

* Consciousness

* Expected emotional/behavioral responses

* Learning preferences (eg, education needs, learning barriers)

* Orientation (person, place, time)

Tests and Measures

Tests and measures for this pattern may include those that characterize or quantify:

Aerobic Capacity and Endurance

* Cardiovascular signs and symptoms in response to increased oxygen demand with exercise or activity, including pressures and flow; heart rate, rhythm, and sounds; and superficial vascular responses (eg, claudication, dyspnea, and exertion scales; observations; palpation; sphygmomanometry)

* Pulmonary signs and symptoms in response to increased oxygen demand with exercise or activity, including breath and voice sounds; cyanosis; gas exchange; respiratory pattern, rate, and rhythm; ventilatory flow, force, and volume (eg, auscultation, dyspnea and exertion scales, observations, oximetry, palpation)

Anthropometric Characteristics

* Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement)

* Body dimensions (eg, body mass index, girth measurement, length measurement)

* Edema (eg, girth measurement, palpation, scales, volume measurement)

Arousal, Attention, and Cognition

* Cognition, including ability to process commands (eg, developmental inventories, indexes, interviews, mental state scales, observations, questionnaires, safety checklists)

* Motivation (eg, adaptive behavior scales)

* Recall, including memory and retention (eg, assessment scales, interviews, questionnaires)

Assistive and Adaptive Devices

* Assistive or adaptive devices and equipment use during functional activities (eg, activities of daily living [ADL] scales, functional scales, instrumental activities of daffy living [IADL] scales, interviews, observations)

* Components, alignment, fit, and ability to care for assistive or adaptive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Remediation of impairments, functional limitations, or disabilities with use of assistive or adaptive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of assistive or adaptive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Circulation (Arterial, Venous, and Lymphatic)

* Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, claudication scales, girth measurement, palpation, sphygmomanometry, thermography)

* Physiological responses to position change, including autonomic responses, central and peripheral pressures, heart rate and rhythm, respiratory rate and rhythm, ventilatory pattern (eg, auscultation, electrocardiography, observations, palpation, sphygmomanometry)

Cranial and Peripheral Nerve Integrity

* Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests)

* Sensory distribution of the peripheral nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration; thoracic outlet tests)

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

* Current and potential barriers (eg, checklists, interviews, observations, questionnaires)

Ergonomics and Body Mechanics

Ergonomics

* Dexterity and coordination during work (job/school/play) (eg, hand function tests, impairment rating scales, manipulative ability tests)

* Functional capacity and performance during work actions, tasks, or activities (eg, accelerometry, dynamometry, electroneuromyography, endurance tests, force platform tests, goniometry, interviews, observations, photographic assessments, physical capacity tests, postural loading analyses, technology-assisted analyses, videographic assessments, work analyses)

* Safety in work environments (eg, hazard identification checklists, job severity indexes, lifting standards, risk assessment scales, standards for exposure limits)

* Specific work conditions or activities (eg, handling checklists, job simulations, lifting models, preemployment screenings, task analysis checklists, workstation checklists)

* Tools, devices, equipment, and workstations related to work actions, tasks, or activities (eg, observations, tool analysis checklists, vibration assessments)

Body mechanics

* Body mechanics during self-care, home management, work, community, or leisure actions, tasks, or activities (eg,ADL scales, IADL scales, observations, photographic assessments, technology-assisted analyses, videographic assessments)

Gait, Locomotion, and Balance

* Balance during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, ADL scales, IADL scales, observations, videographic assessments)

* Balance (dynamic and static) with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, balance scales, dizziness inventories, dynamic posturography, fall scales, motor impairment tests, observations, photographic assessments, postural control tests)

* Gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg,ADL scales, gait profiles, IADL scales, mobility skill profiles, observations, videographic assessments)

* Gait and locomotion with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices or equipment (eg, dynamometry, electroneuromyography, footprint analyses, gait profiles, mobility skill profiles, observations, photographic assessments, technology-assisted assessments, videographic assessments, weight-bearing scales, wheelchair mobility tests)

* Safety during gait, locomotion, and balance (eg, confidence scales, diaries, fall scales, functional assessment profiles, logs, reports)

Integumentary Integrity

Associated skin

* Activities, positioning, and postures that produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, scales)

* Assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment that may produce or relieve trauma to the skin (eg, observations, pressure-sensing maps, risk assessment scales)

* Skin characteristics, including blistering, continuity of skin color, dermatitis, hair growth, mobility, nail growth, temperature, texture, and turgor (eg, observations, palpation, photographic assessments, thermography)

Wound

* Activities, positioning, and postures that aggravate the wound or scar or that produce or relieve trauma (eg, observations, pressure-sensing maps)

* Signs of infection (eg, cultures, observations, palpation)

* Wound characteristics, including bleeding, contraction, depth, drainage, exposed anatomical structures, location, odor, pigment, shape, size, staging and progression, tunneling, and undermining (eg, digital and grid measurement, grading of sores and ulcers, observations, palpation, photographic assessments, wound tracing)

* Wound sear tissue characteristics, including banding, pliability, sensation, and texture (eg, observations, scar-rating scales)

Muscle Performance (Including Strength, Power, and Endurance)

* Muscle strength, power, and endurance (eg, dynamometry, manual muscle tests, muscle performance tests, physical capacity tests, technology-assisted analyses, timed activity tests)

* Muscle strength, power, and endurance during functional activities (eg, ADL scales, functional muscle tests, IADL scales, observations, videographic assessments)

* Muscle tension (eg, palpation)

Orthotic, Protective, and Supportive Devices

* components, alignment, fit, and ability to care for orthotic, protective, and supportive devices and equipment (eg, interviews, logs, observations, pressure-sensing maps, reports)

* Orthotic, protective, and supportive devices and equipment use during functional activities (eg, ADL scales, functional scales, IADL scales, interviews, observations, profiles)

* Remediation of impairments, functional limitations, or disabilities with use of orthotic, protective, and supportive devices and equipment (eg, activity status indexes, ADL scales, aerobic capacity tests, functional performance inventories, health assessment questionnaires, IADL scales, pain scales, play scales, videographic assessments)

* Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports)

Pain

* Pain, soreness, and nociception (eg, angina scales, analog scales, discrimination tests, dyspnea scales, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests)

* Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests)

Posture

* Postural alignment and position (dynamic), including symmetry and deviation from midline (eg, observations, technology-assisted analyses, videographic assessments)

* Postural alignment and position (static), including symmetry and deviation from midline (eg, grid measurement, observations, photographic assessments)

Range of Motion (ROM) (including Muscle Length)

* Functional ROM (eg, observations, squat tests, toe touch tests)

* Joint active and passive movement (eg, goniometry, inclinometry, observations, photographic assessments, videographic assessments)

* Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation)

Reflex Integrity

* Deep reflexes (eg, myotatic reflex scale, observations, reflex tests)

* Superficial reflexes and reactions (eg, observations, provocation tests)

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

* Ability to gain access to home environments (eg, barrier identification, observations, physical performance tests)

* Ability to perform self-care and home management activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, ADL scales, aerobic capacity tests, IADL scales, interviews, observations, profiles)

* Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports, videographic assessments)

Sensory Integrity

* Combined/cortical sensations (eg, stereognosis, tactile discrimination tests)

* Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration tests)

* Electrophysiological integrity (eg, electroneuromyography)

Ventilation and Respiration/Gas Exchange

* Pulmonary signs of respiration/gas exchange, including breath sounds (eg, gas analyses, observations, oximetry)

* Pulmonary symptoms (eg, dyspnea and perceived exertion indexes and scales)

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

* Ability to assume or resume work (job/school/play), community, and leisure activities with or without assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment (eg, activity profiles, disability indexes, functional status questionnaires, IADL scales, observations, physical capacity tests)

* Ability to gain access to work (job/school/play), community, and leisure environments (eg, barrier identification, interviews, observations, physical capacity tests, transportation assessments)

* Safety in work (job/school/play), community, and leisure activities and environments (eg, diaries, fall scales, interviews, logs, observations, videographic assessments)

Evaluation, Diagnosis, and Prognosis (Including Plan of Care)

Physical therapists perform evaluations (make clinical judgments) based on the data gathered from the history, systems review, and tests and measures. In the evaluation process, physical therapists synthesize the examination data to establish the diagnosis and prognosis (including the plan of care). Factors that influence the complexity of the evaluation include the clinical findings, extent of loss of function, chronicity or severity of the problem, possibility of multisite or multisystem involvement, preexisting condition(s), potential discharge destination, social considerations, physical function, and overall health status.

A diagnosis is a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the result of the systematic diagnostic process, which includes integrating and evaluating the data from the examination. The diagnostic label indicates the primary dysfunction(s) toward which the therapist will direct interventions. The prognosis is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and may also include a prediction of levels of improvement that may be reached at various intervals during the course of therapy. During the prognostic process, the physical therapist develops the plan of care. The plan of care identifies specific interventions, proposed frequency and duration of the interventions, anticipated goals, expected outcomes, and discharge plans. The plan of care identifies realistic anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others. These anticipated goals and expected outcomes should be measureable and time limited.

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 anatomical and physiological changes related to growth and development; caregiver consistency or expertise; chronicity or severity of the current condition; living environment; multisite or multisystem involvement; social support; potential discharge destinations; probability of prolonged impairment, functional limitation, or disability; and stability of the condition.

Prognosis

Over the course of 1 to 8 weeks, patient/ client with mild lymphedema (less than 3-on differential between affected limb and unaffected limb) will demonstrate optimal circulation and anthropometric dimensions and the highest level of functioning in home, work (job/school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities.

Over the course of 1 to 8 weeks, patient/ client with moderate lymphedema (3- to 5-cm differential between affected limb and unaffected limb) will demonstrate optimal circulation and anthropometric dimensions and the highest level of functioning in home, work (job/school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities.

Over the course of 1 to 8 weeks, patient/ client with severe lymphedema (5-plus-cm differential between affected limb and unaffected limb) will demonstrate optimal circulation and anthropometric dimensions and the highest level of functioning in home, work (job/school/play), community, and leisure environments, within the context of the impairments, functional limitations, and disabilities.

During the episode of care, patient/client with lymphedema will achieve (1) the anticipated goals and expected outcomes of the interventions that are described in the plan of care and (2) the global outcomes for patients/clients who are classified in this pattern.

Expected Range of Number of Visits Per Episode of Care

5 to 10

8 to 16

14 to 24

These ranges represent the lower and upper limits of the number of physical therapist visits required to achieve the anticipated goals and expected outcomes. It is anticipated that 80% of patients/ clients who are classified into this pattern will achieve the anticipated goals and expected 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 and availability of resources

* Adherence to the intervention program

* Age

* Anatomical and physiological changes related to growth and development

* Caregiver consistency or expertise

* Chronicity or severity of the current condition

* Cognitive status

* Comorbitities, complications, or secondary impairments

* Concurrent medical, surgical, and therapeutic interventions

* Decline in functional independence

* Level of impairment

* Level of physical function

* Living environment

* Multisite or multisystem involvement

* Nutritional status

* Overall health status * Potential discharge destinations

* Premorbid conditions

* Probability of prolonged impairment, functional limitation, or disability

* Psychological and socioeconomic factors

* Psychomotor abilities

* Social support

* Stability of the condition

Note:

Patients/clients may require multiple episodes of care for lymphatic management over the lifetime.

Intervention

Intervention is the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis. Decisions about interventions are contingent on the timely monitoring of patient/client response and the progress made toward achieving the anticipated goals and expected outcomes.

Communication, coordination, and documentation and patient/client-related instruction are provided for all patients/clients across all settings. Procedural interventions are selected or modified based on the examination data and the evaluation, the diagnosis and the prognosis, and the anticipated goals and expected outcomes for a particular patient/client. For clinical considerations in selecting interventions, listings of interventions, and listings of anticipated goals and expected outcomes, refer to Chapter 3.

Coordination, Communication, and Documentation

Coordination, communication, and documentation may include:

Interventions

* Addressing required functions

- advance directives

- individualized family service plans (IFSPs) or individualized education plans (IEPs)

- informed consent

- mandatory communication and reporting (eg, patient advocacy and abuse reporting)

* Admission and discharge planning

* Case management

* Collaboration and coordination with agencies, including:

- equipment suppliers

- home care agencies

- payer groups

- schools

- transportation agencies

* Communication across settings, including:

- case conferences

- documentation

* Cost-effective resource utilization

* Data collection, analysis, and reporting

- outcome data

- peer review findings

- record reviews

* Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation (Appendix 5), including:

- changes in impairments, functional limitations, and disabilities

- changes in interventions

- elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention)

- outcomes of intervention

* Interdisciplinary teamwork case conferences

- patient care rounds

- patient/client family meetings

* Referrals to other professionals or resources

Anticipated Goals and Expected Outcomes

* Accountability for services is increased.

* Admission data and discharge planning are completed.

* Advance directives, individualized family service plans (IFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient advocacy and abuse reporting) are obtained or completed.

* Available resources are maximally utilized.

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

* Case is managed throughout the episode of care.

* Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies.

* Communication enhances risk reduction and prevention.

* Communication occurs across settings through case conferences, and documentation.

* Data are collected, analyzed, and reported, including outcome data, peer review findings, and record reviews.

* Decision making is enhanced regarding health, wellness, and fitness needs.

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

* Documentation occurs throughout patient/client management and across settings and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5).

* Interdisciplinary collaboration occurs through case conferences, patient care rounds, and patient/client family meetings.

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

* Placement needs are determined.

* Referrals are made to other professionals or resources whenever necessary and appropriate.

* Resources are utilized in a cost-effective way.

Patient/Client-Related Instruction

Patient/client-related instruction may include:

Interventions

* Instruction, education and training of patients/clients and caregivers regarding:

- current condition (pathology/pathophysiology [disease, disorder, or condition], impairments, functional limitations, or disabilities)

- enhancement of performance

- health, wellness, and fitness programs

- plan of care

- risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities

- transitions across settings

- transitions to new roles

Anticipated Goals and Expected Outcomes

* Ability to perform physical actions, tasks, or activities is improved.

* Awareness and use of community resources are improved.

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

* Decision making is enhanced regarding patient/client health and the 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.

* Health status is improved.

* 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 anticipated goals and expected outcomes are increased.

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

* Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved.

* Physical function is improved.

* 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.

Procedural Interventions

Procedural interventions for this pattern may include:

Therapeutic Exercise

Interventions

* Aerobic capacity/endurance conditioning or reconditioning

- aquatic programs

- gait and locomotor training

- increased workload over time

- walking and wheelchair propulsion programs

* Balance, coordination, and agility training

- developmental activities training

- motor function (motor control and motor learning) training or retraining

- neuromuscular education or reeducation

- perceptual training

- posture awareness training

- standardized, programmatic, complementary exercise approaches

- sensory training and retraining

- task-specific performance training

* Body mechanics and postural stabilization

- body mechanics training

- postural control training

- postural stabilization activities

- posture awareness training

* Flexibility exercises

- muscle lengthening

- range of motion

- stretching

* Gait and locomotion training

- developmental activities training

- gait training

- implement and device training

- perceptual training standardized, programmatic, complementary exercise approaches

- wheelchair training

* Relaxation

- breathing strategies

- movement strategies

- relaxation techniques standardized, programmatic, complementary exercise approaches

* Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles

- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric)

- aquatic programs

- standardized, programmatic, complementary exercise approaches

- task-specific performance training

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Soft tissue swelling, inflammation, or restriction is reduced.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Aerobic capacity is increased.

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to serf-care, home management, work (job/school/play), community, and leisure is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Preoperative and postoperative complications are reduced.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Serf, Care and Home Management (Including Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL])

Interventions

* ADL training

- bathing

- bed mobility and transfer training

- developmental activities

- dressing

- eating

- grooming

- toileting

* Devices and equipment use and training

- assistive and adaptive device or equipment training during ADL and IADL

- orthotic, protective, or supportive device or equipment training during ADL and IADL

- prosthetic device or equipment training during ADL and IADL

* Functional training programs

- simulated environments and tasks

- task adaptation

* IADL training

- caring for dependents

- home maintenance

- household chores

- shopping

- structured play for infants and children

- yard work

* Injury prevention or reduction

- injury prevention education during self-care and home management

- injury prevention or reduction with use of devices and equipment

- safety awareness training during self-care and home management

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care and home management is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in ADL and IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care and home management roles is improved.

* Risk reduction/prevention

* Risk factors are reduced.

- Risk of secondary impairments is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Functional Training in Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including Instrumental Activities of Daily Living [IADL], Work Hardening, and Work Conditioning)

Interventions

* Devices and equipment use and training

- assistive and adaptive device or equipment training during IADL

- orthotic, protective, or supportive device or equipment training during IADL

- prosthetic device or equipment training during IADL

* IADL training

- community service training involving instruments

- school and play activities training including tools and instruments

- work training with tools

* Injury prevention or reduction

- injury prevention education during work (job/school/play), community, and leisure integration or reintegration

- injury prevention or reduction with use of devices and equipment

- safety awareness training during work (job/school/play), community, and leisure integration or reintegration

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to work (job/school/play), community, and leisure integration or reintegration is improved.

- Level of supervision required for task performance is decreased.

- Performance of and independence in IADL with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required work (job/school/play), community, and leisure roles is improved.

- Risk reduction/prevention

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Fitness is improved.

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

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

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Manual Therapy Techniques (Including Mobilization/Manipulation)

Interventions

* Manual lymphatic drainage

* Massage

- connective tissue massage

- therapeutic massage

* Mobilization/manipulation

- soft tissue

* Passive range of motion

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

- Soft tissue swelling, inflammation, or restriction is reduced.

* Impact on impairments

- Balance is improved.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint integrity and mobility are improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved. - Relaxation is increased.

- Sensory awareness is increased.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform movement tasks is improved.

- Ability to perform physical actions, tasks, or activities related to serf-care, home management, work (job/school/play), community, and leisure is improved.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

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

Interventions

* Adaptive devices

- environmental controls

- hospital beds

- raised toilet seats

- seating systems

* Assistive devices

- canes

- crutches

- long-handled reachers

- power devices

- static and dynamic splints

- walkers

- wheelchairs

* Orthotic devices

- braces

- casts

- shoe inserts

- splints

* Prosthetic devices (lower-extremity and upper-extremity)

* Protective devices

- braces

- cushions

- protective taping

* Supportive devices

- compression garments

- corsets

- elastic wraps

- neck collars

- slings

- supportive taping

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition) Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Pain is decreased.

- Physiological response to increased oxygen demand is improved.

- Soft tissue swelling, inflammation, or restriction is reduced.

* Impact on impairments

- Balance is improved.

- Endurance is increased.

- Energy expenditure per unit of work is decreased.

- Gait, locomotion, and balance are improved.

- Integumentary integrity is improved.

- Joint stability is improved.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Optimal joint alignment is achieved.

- Optimal loading on a body part is achieved.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Weight-bearing status is improved.

* Impact on functional limitations

- Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved. Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is improved.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Pressure on body tissues is reduced.

- Protection of body parts is increased.

- Risk factors are reduced.

- Risk of secondary impairment is reduced.

- Safety is improved.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Health status is improved.

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

- Cost of health care services is decreased.

- Intensity of care is decreased.

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

- Sense of well-being is improved.

- Stressors are decreased.

Electrotherapeutic Modalities

Interventions

* Electrical stimulation

- electrical muscle stimulation (EMS)

- transcutaneous electrical nerve stimulation (TENS)

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased.

- Osteogenic effects of exercise are maximized.

- Pain is decreased.

- Soft tissue or wound healing is enhanced.

- Soft tissue swelling, inflammation, or restriction is reduced.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Integumentary integrity is improved.

- Motor function (motor control and motor learning) is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Postural control is improved.

- Quality and quantity of movement between and across body segments are improved.

- Range of motion is improved.

- Relaxation is increased.

- Sensory awareness is increased.

* Impact on functional limitations

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

- Level of supervision required for task performance is decreased.

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of immobility are reduced.

- Preoperative and postoperative complications are reduced.

- Risk factors are reduced.

- Risk of recurrence of condition is reduced.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

* Impact on health, wellness, and fitness

- Physical capacity is increased.

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

- Utilization of physical therapy services results in efficient use of health care dollars.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are reduced.

Physical Agents and Mechanical Modalities

Interventions

Physical agents may include:

* Cryotherapy

- cold packs

- ice massage

* Hydrotherapy

- contrast bath

- pools

- whirlpool tanks

* Sound agents

- phonophoresis

- ultrasound

* Thermotherapy

- dry heat

- hot packs

Mechanical modalities may include:

* Compression therapies

- compression bandaging

- compression garments

- vasopneumatic compression devices

* Mechanical motion devices

- continuous passive motion (CPM)

Anticipated Goals and Expected Outcomes

* Impact on pathology/pathophysiology (disease, disorder, or condition)

- Edema, lymphedema, or effusion is reduced.

- Joint swelling, inflammation, or restriction is reduced.

- Nutrient delivery to tissue is increased,

- Pain is decreased.

- Soft tissue swelling, inflammation, or restriction is reduced.

- Tissue perfusion and oxygenation are enhanced.

* Impact on impairments

- Integumentary integrity is improved.

- Muscle performance (strength, power, and endurance) is increased.

- Range of motion is improved.

- Weight-bearing status is improved.

* Impact on functional limitations

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

- Performance of and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment are increased.

- Tolerance of positions and activities is increased.

* Impact on disabilities

- Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

* Risk reduction/prevention

- Complications of soft tissue and circulatory disorders are decreased.

- Risk of secondary impairment is reduced.

- Self-management of symptoms is improved.

- Stresses precipitating injury are decreased.

* Impact on health, wellness, and fitness

- Physical function is improved.

* Impact on societal resources

- Utilization of physical therapy services is optimized.

* Patient/client satisfaction

- Access, availability, and services provided are acceptable, to patient/client.

- Administrative management of practice is acceptable to patient/client.

- Clinical proficiency of physical therapist is acceptable to patient/client.

- Coordination of care is acceptable to patient/client.

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

- Sense of well-being is improved.

- Stressors are decreased.

Reexamination

Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Reexamination may be indicated more than once during a single episode of care. It also may be performed over the course of a disease, disorder, or condition, which for some patients/clients may be over the life span. Indications for reexamination include new clinical findings or failure to respond to physical therapy interventions.

Global Outcomes for Patients/Clients in This Pattern

Throughout the entire episode of care, the physical therapist determines the anticipated goals and expected outcomes for each intervention. These anticipated goals and expected outcomes are delineated in shaded boxes that accompany the lists of interventions in each preferred practice pattern. As the patient/client reaches the termination of physical therapy services and the end of the episode of care, the physical therapist measures the global outcomes of the physical therapy services by characterizing or quantifying the impact of the physical therapy interventions in the following domains:

* Pathology/pathophysiology (disease, disorder, or condition)

* Impairments

* Functional limitations

* Disabilities

* Risk reduction/prevention

* Health, wellness, and fitness

* Societal resources

* Patient/client satisfaction

In some instances, a particular anticipated goal or expected outcome is thoroughly achieved through implementation of a single form of intervention. More commonly, however, the anticipated goals and expected outcomes are achieved as a result of the combined effects of several forms of interventions, leading to enhancement of both health status and health-related quality of life.

Criteria for Termination of Physical Therapy Services

Discharge is the process of ending physical therapy services that have been provided during a single episode of care. It occurs when the anticipated goals and expected outcomes have been achieved. Discharge does not occur with a transfer (defined as the time when a patient is moved from one site to another site within the same setting or across settings during a single episode of care). Although there may be facility-specific or payer-specific requirements for documentation regarding the conclusion of physical therapy services, discharge occurs based on the physical therapist's analysis of the achievement of anticipated goals and expected outcomes.

Discontinuation is the process of ending physical therapy services that have been provided during a single episode of care when (1) the patient/client, caregiver, or legal guardian declines to continue intervention; (2) the patient/client is unable to continue to progress toward outcomes because of medical or psychosocial complications or because financial/insurance resources have been expended; or (3) the physical therapist determines that the patient/client will no longer benefit from physical therapy. When physical therapy services are terminated prior to achievement of anticipated goals and expected outcomes, patient/client status and the rationale for termination 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. In consultation with appropriate individuals, and in consideration of the outcomes, the physical therapist plans for discharge or discontinuation and provides for appropriate follow-up or referral.

COPYRIGHT 2001 American Physical Therapy Association, Inc.
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Publication:	Physical Therapy
Date:	Jan 1, 2001
Words:	52644
Previous Article:	Preferred Practice Patterns: Neuromuscular.
Next Article:	Preferred Practice Patterns: Integumentary.
Topics:	Physical therapy Practice

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