Preferred Practice Patterns: Integumentary.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 Integumentary 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 in 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) * Amputation * Congestive heart failure * Diabetes * Malnutrition * Neuromuscular dysfunction * Obesity * Peripheral nerve involvement * Polyneuropathy * Prior scar * Spinal cord involvement * Surgery * Vascular disease Impairments, Functional Limitations, or Disabilities * Decreased level of activity * Decreased sensation * Edema * Inflammation * Ischemia * Pain Note: Prevention and risk reduction are inherent in all diagnostic 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
263 Other and unspecified protein-calorie malnutrition
263.0 Malnutrition of moderate degree
263.1 Malnutrition of mild degree
277 Other and unspecified disorders of metabolism
277.6 Other deficiencies of circulating enzymes
Hereditary angioedema
278 Obesity and other hyperalimentation
278.0 Obesity
320 Bacterial meningitis
322 Meningitis of unspecified cause
322.9 Meningitis, unspecified
323 Encephalitis, myelitis, and encephalomyelitis
331 Other cerebral degenerations
331.7 Cerebral degeneration in diseases classified
elsewhere(*)
331.9 Cerebral degeneration, unspecified
332 Parkinson's disease
333 Other extrapyramidal disease and abnormal movement
disorders
333.2 Myoclonus
334 Spinocerebellar disease
334.0 Friedreich's ataxia
334.1 Hereditary spastic paraplegia
334.2 Primary cerebellar degeneration
334.9 Spinocerebellar disease, unspecified
335 Anterior horn cell disease
336 Other diseases of spinal cord
336.0 Syringomyelia and syringobulbia
336.1 Vascular myelopathies
336.9 Unspecified disease of spinal cord
337 Disorders of the autonomic nervous system
340 Multiple sclerosis
341 Other demyelinating diseases of central nervous system
342 Hemiplegia and hemiparesis
343 Infantile cerebral palsy
344 Other paralytic syndromes
344.0 Quadriplegia and quadriparesis
344.1 Paraplegia
344.3 Monoplegia of lower limb
353 Nerve root and plexus disorders
353.9 Unspecified nerve root and plexus disorder
357 Inflammatory and toxic neuropathy
357.2 Polyneuropathy in diabetes(*)
357.3 Polyneuropathy in malignant disease(*)
357.4 Polyneuropathy in other diseases classified
elsewhere(*)
357.6 Polyneuropathy due to drugs
428 Heart failure
428.0 Congestive heart failure
435 Transient cerebral ischemia
435.1 Vertebral artery syndrome
435.8 Other specified transient cerebral ischemias
440 Atherosclerosis
443 Other peripheral vascular disease
443.0 Raynaud's syndrome
443.1 Thromboangiitis obliterans [Buerger's disease]
443.9 Peripheral vascular disease, unspecified
454 Varicose veins of lower extremities
457 Noninfectious disorders of lymphatic channels
457.0 Postmastectomy lymphedema syndrome
457.1 Other lymphedema
459 Other disorders of circulatory system
459.1 Postphlebitic syndrome
459.8 Other specified disorders of circulatory system
459.81 Venous (peripheral) insufficiency,
unspecified
459.9 Unspecified circulatory system disorder
581 Nephrotic syndrome
581.9 Nephrotic syndrome with unspecified
pathological lesion in kidney
Nephritis with edema, not otherwise specified
593 Other disorders of kidney and ureter
593.8 Other specified disorders of kidney and ureter
593.81 Vascular disorders of kidney
686 Other local infections of skin and subcutaneous tissue
686.9 Unspecified local infection of skin and
subcutaneous tissue
701 Other hypertrophic and atrophic conditions of skin
701.4 Keloid scar
Hypertrophic scar
709 Other disorders of skin and subcutaneous tissue
709.2 Scar conditions and fibrosis of skin
716 Other and unspecified arthropathies
716.6 Unspecified monoarthritis
719 Other and unspecified disorders of joint
719.4 Pain in joint
728 Disorders of muscle, ligament, and fascia
728.9 Unspecified disorder of muscle, ligament,
and fascia
729 Other disorders of soft tissues
729.5 Pain in limb
757 Congenital anomalies of the integument
757.0 Hereditary edema of legs
782 Symptoms involving skin and other integumentary tissue
782.0 Disturbance of skin sensation
782.3 Edema
895 Traumatic amputation of toe(s) (complete) (partial)
895.0 Without mention of complication
896 Traumatic amputation of foot (complete) (partial)
896.2 Bilateral, without mention of complication
897 Traumatic amputation of leg(s) (complete) (partial)
897.0 Unilateral, below knee, without mention of
complication
897.2 Unilateral, at or above knee, without mention
of complication
897.4 Unilateral, level not specified, without mention
of complication
897.6 Bilateral [any level], without mention of
complication
995 Certain adverse effects not elsewhere classified
995.1 Angioneurotic edema
(*) 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/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: 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 * Motivation (eg, adaptive behavior scales) Circulation (Arterial, Venous, and Lymphatic) * Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation auscultation /aus·cul·ta·tion/ (aws?kul-ta´shun) listening for sounds within the body, chiefly to ascertain the condition of the thoracic or abdominal viscera and to detect pregnancy; it may be performed with the unaided ear (direct or immediate a.) or with a stethoscope (mediate a.) ., claudication scales, electrocardiography, palpation, sphygmomanometry, thermography) 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) 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) 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) * Safety during use of orthotic, protective, and supportive devices and equipment (eg, diaries, fall scales, interviews, logs, observations, reports) 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) Prosthetic Requirements * Components, alignment, fit, and ability to care for the prosthetic device (eg, interviews, logs, observations, pressure-sensing maps, reports) * Safety during use of the prosthetic device (eg, diaries, fall scales, interviews, logs, observations, reports) Sensory Integrity * Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration 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 Patient/client will reduce the risk of integumentary disorders through therapeutic exercise, functional training, and lifestyle modification. Expected Range of Number of Visits Per Episode of Care 1 to 6 This range represents the lower and upper limits of the number of physical therapist visits required to achieve anticipated goals and 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 1 to 6 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Modify Frequency of Visits * Accessibility 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 with the patient/client, 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 for primary prevention/risk reduction may include: Interventions * Addressing required functions - individualized family service plans (IFSPs) or individualized education plans (IEPs) - informed consent - mandatory communication and reporting (eg, patient/client advocacy and abuse reporting) * Collaboration and coordination with agencies, including: - equipment suppliers - home care agencies - payer groups - schools - transportation agencies * Communication, including: - education plans - documentation * Data collection, analysis and reporting - outcome data - peer review findings - record reviews * Documentation - elements of patient/client management (examination, evaluation, diagnosis, prognosis, intervention) - outcomes of intervention * Referrals to other professionals or resources Anticipated Goals and Expected Outcomes * Accountability for services is increased. * Individualized family service plans OFSPs) or individualized education plans (IEPs), informed consent, and mandatory communication and reporting (eg, patient/client advocacy and abuse reporting) are obtained or completed. * Available resources are maximally utilized. * Collaboration and coordination occurs with agencies, including equipment suppliers, home care agencies, payer groups, schools, and transportation agencies. * Communication occurs through education plans 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 patient/client, family, significant others, and caregivers. * Documentation occurs throughout patient/client management and follows APTA's Guidelines for Physical Therapy Documentation (Appendix 5). * Patient/client, family, significant other, and caregiver understanding of anticipated goals and expected outcomes is increased. * 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: - enhancement of performance - health, wellness, and fitness programs - plan for intervention - risk factors for pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities 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. * Health status is improved. * Performance levels in self-care, home management, work (job/school/play), community, or leisure actions, tasks, or activities are improved. * 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. * Physical function is improved. * Risk of recurrence of condition 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 * Aerobic capacity/endurance conditioning or reconditioning - 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 - postural control training - postural stabilization activities - posture awareness training * 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, eccentric, isokinetic, isometric, and plyometric) - standardized, programatic, complementary exercise approaches - task-specific performance training 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. - Tissue perfusion and oxygenation are enhanced. * Impact on impairments - Balance is improved. - Endurance is increased. - Energy expenditure per unit of work is decreased. - 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. - 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, 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 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. - 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 * 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) - Physiological response to increased oxygen demand is improved. * Impact on impairments - 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, home management, work (job/school/play), community, and leisure roles is improved. * Risk reduction/prevention - Risk factors are reduced. - Risk of secondary impairments 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 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. - 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 * 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) - Physiological response to increased oxygen demand is improved. * Impact on impairments - 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 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. * Impact on health, wellness, and fitness - Health status is improved. - 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. - 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 - shoe inserts - splints * Prosthetic devices (lower-extremity and upper-extremity) * Protective devices - braces - cushions - protective taping * Supportive devices - compression garments - elastic wraps - slings - supportive taping Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Pain is decreased. * Impact on impairments - Integumentary integrity is improved. - Joint stability is improved. - Optimal joint alignment is achieved. - Optimal loading on a body part is achieved. - 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 in 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 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 is acceptable to patient/client. - Cost of health care services 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 Integumentary Integrity Associated With Superficial Skin Involvement 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 integumentary integrity associated with superficial skin involvement--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/Pathophysiolagy (Disease, Disorder, or Condition) * Amputation * Burns (superficial/first degree) * Cellulitis * Contusion * Dermopathy diabetic dermopathy any of several cutaneous manifestations of diabetes. der·mop·a·thy (d  r-m p* Dermatitis * Malnutrition * Neuropathic ulcers (grade 0) * Pressure ulcers (stage 2) * Vascular disease * Arterial * Diabetic * Venous Impairments, Functional Limitations, or Disabilities * Edema * Impaired sensation * Impairments associated with abnormal fluid distribution * Impaired skin * Ischemia Note: Some risk factors or consequences of pathology/ pathophysiology--such as contusion with dermatitis--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 S606.) 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 * Frostbite * Recent amputation Findings That May Require Classification in Additional Patterns * Superficial burn with inhalation injury ICD-9-CM Codes The listing below contains the current (as of press time) and most typical 3and 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.
176 Kaposi's sarcoma
176.0 Skin
250 Diabetes mellitus
263 Other and unspecified protein-calorie malnutrition
269 Other nutritional deficiencies
337 Disorders of the autonomic nervous system
337.2 Reflex sympathetic dystrophy
344 Other paralytic syndromes
344.0 Quadriplegia and quadriparesis
344.1 Paraplegia
443 Other peripheral vascular disease
454 Varicose veins of lower extremities
454.1 With inflammation
459 Other disorders of circulatory system
681 Cellulitis and abscess of finger and toe
682 Other cellulitis and abscess
690 Erythematosquamous dermatosis
691 Atopic dermatitis and related conditions
692 Contact dermatitis and other eczema
692.7 Due to solar radiation
692.71 Sunburn
700 Corns and callosities
707 Chronic ulcer of skin
707.0 Decubitus ulcer
707.1 Ulcer of lower limbs, except decubitus
731 Osteitis deformans and osteopathies associated with
other disorders classified elsewhere
731.8 Other bone involvement in diseases classified
elsewhere(*)
782 Symptoms involving skin and other integumentary tissue
782.2 Localized superficial swelling, mass, or lump
782.7 Spontaneous ecchymoses
782.8 Changes in skin texture
920 Contusion of face, scalp, and neck except eye(s)
922 Contusion of trunk
922.0 Breast
922.1 Chest wall
922.2 Abdominal wall
922.3 Back
922.8 Multiple sites of trunk
923 Contusion of upper limb
923.0 Shoulder and upper arm
923.1 Elbow and forearm
923.2 Wrist and hand(s), except finger(s) alone
923.3 Finger
923.8 Multiple sites of upper limb
924 Contusion of lower limb and of other and unspecified
sites
924.0 Hip and thigh
924.1 Knee and lower leg
924.2 Ankle and foot, excluding toe(s)
924.3 Toe
924.4 Multiple sites of lower limb
942 Burn of trunk
942.1 Erythema [first degree]
943 Burn of upper limb, except wrist and hand
943.1 Erythema [first degree]
944 Burn of wrist(s) and hand(s)
944.1 Erythema [first degree]
945 Burn of lower limb(s)
945.1 Erythema [first degree]
946 Burns of multiple specified sites
946.1 Erythema [first degree]
948 Burns classified according to extent of body surface
involved
949 Burn, unspecified
949.1 Erythema [first degree]
997 Complications affecting specified body system, not
elsewhere classified
997.6 Amputation stump complication
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 (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: Anthropometric Characteristics * Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement) * Edema (eg, girth measurement, palpation, scales, volume measurement) Circulation (Arterial, Venous, and Lymphatic) * Cardiovascular signs, including heart rate, rhythm, and sounds; pressures and flow; and superficial vascular responses (eg, auscultation, claudication scales, palpation, sphygmomanometry, thermography) Cranial and Peripheral Nerve Integrity * Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration) * 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 * 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) * Burn (eg, body charts, planimetry) * 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 scar 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 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, diaries, fall scales, interviews, logs, observations, reports) Pain * Pain, soreness, and nociception (eg, analog scales, discrimination tests, pain drawings and maps, provocation tests, verbal and pictorial descriptor tests) * Pain in specific body parts (eg, pain indexes, pain questionnaires, structural provocation tests) Prosthetic Requirements * Components, alignment, fit, and ability to care for the prosthetic device (eg, interviews, logs, observations, pressure-sensing maps, reports) * Safety during use of the prosthetic device (eg, diaries, fall scales, interviews, logs, observations, reports) Range of Motion (ROM) (Including Muscle Length) * Muscle length, soft tissue extensibility, and flexibility (eg, contracture tests, goniometry, inclinometry, ligamentous tests, linear measurement, multisegment flexibility tests, palpation) Serf-Care and Home Management (Including ADL and IADL) * Safety in self-care and home management activities and environments (eg, diaries, fall scales, interviews, logs, observations, reports) Sensory Integrity * Deep sensations (eg, kinesthesiometry, observations, photographic assessments, vibration 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 2 weeks, patient/client will demonstrate optimal integumentary integrity 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 1 to 6 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 1 to 6 visits during a single continuous episode of care. Frequency of visits and duration of the episode of care should be determined by the physical therapist to maximize effectiveness of care and efficiency of service delivery. Factors That May Require New Episode of Care or T. hat 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 - education plans * 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], impairmems, 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 - walking and wheelchair propulsion programs * Body mechanics and postural stabilization - posture awareness training * Flexibility exercises - muscle lengthening - range of motion - stretching * 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, eccentric, isokinetic, isometric, and plyometric) - 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. - 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 - Integumentary integrity is improved. - Joint integrity and mobility are improved. - Muscle performance (strength, power, and endurance) is increased. - Postural control is improved. - Range of motion 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, 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 - 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 * Injury prevention or reduction - injury prevention education during self<are 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. * Impact on impairments - Sensory awareness is increased. - Weight-bearing stares 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 serf<are 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 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 * 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. * Impact on impairments - 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 - Health status is improved. - 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 - therapeutic massage 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 - Integumentary integrity is improved. - Relaxation is increased. - Sensory awareness 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 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 - hospital beds - 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 - elastic wraps - 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. - 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. - Optimal joint alignment is achieved. - Optimal loading on a body part is achieved. - Quality and quantity of movement between and across body segments are 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 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 - 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. - Stressors are decreased. Integumentary Repair and Protection Techniques Interventions * Dressings - wound coverings * Topical agents - cleansers - creams - moisturizers - ointments - sealants Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Debridement of nonviable tissue is achieved. - Pain is decreased. - Tissue perfusion and oxygenation are enhanced. - Soft tissue and wound healing is enhanced. - Wound size is reduced. * Impact on impairments - Integumentary integrity is improved. - 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 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 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) - high voltage pulsed current (HVPC) - 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. - Pain is decreased. - Soft tissue and 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. - 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 increased. - 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 secondary impairment is reduced. - Self-management of symptoms 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 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. Physical Agents and Mechanical Modalities Interventions Physical agents may include: * Hydrotherapy - whirlpool tanks * Light agents - ultraviolet * Sound agents - phonophoresis - ultrasound Mechanical modalities may include: * Compression therapies - compression bandaging - compression garments Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Debridement of nonviable tissue is achieved. - 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. - 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 axe 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 Integumentary Integrity Associated With Partial-Thickness Skin Involvement and Scar Formation 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 integumentary integrity associated with partial- thickness skin involvement and scar formation--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) * Amputation * Burns (partial thickness/ second degree) * Dermatologic disorders * Epidermolysis bullosa * Hematoma * Immature scar * Malnutrition * Neoplasms (including Kaposi's sarcoma) * Neuropathic ulcers (grade 1) * Pressure ulcers (stage 2) * Prior scar * Status post spinal cord injury * Surgical wounds * Toxic epidermal necrolysis * Traumatic injury * Vascular ulcers - Arterial - Diabetic - Venous Impairments, Functional Limitations, or Disabilities * Impairments associated with abnormal fluid distribution * Impaired sensation * Impaired skin * Muscle weakness Note: Some risk factors or consequences of pathology/ pathophysiology--such as infection--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 S625.) 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 * Electricity-related injuries * Frostbite * Multiple fractures * Recent amputation Findings That May Require Classification in Additional Patterns * Spinal cord injury 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.
017 Tuberculosis of other organs
017.0 Skin and subcutaneous cellular tissue
031 Diseases due to other mycobacteria
031.1 Cutaneous
176 Kaposi's sarcoma
176.0 Skin
216 Benign neoplasm of skin
216.5 Skin of trunk, except scrotum
216.6 Skin of upper limb, including shoulder
216.7 Skin of lower limb, including hip
232 Carcinoma in situ of skin
232.5 Skin of trunk, except scrotum
232.6 Skin of upper limb, including shoulder
232.7 Skin of lower limb, including hip
239 Neoplasms of unspecified nature
239.2 Bone, soft tissue, and skin
263 Other and unspecified protein-calorie malnutrition
269 Other nutritional deficiencies
344 Other paralytic syndromes
344.0 Quadriplegia and quadriparesis
344.1 Paraplegia
443 Other peripheral vascular disease
454 Varicose veins of lower extremities
454.0 With ulcer
454.2 With ulcer and inflammation
459 Other disorders of circulatory system
682 Other cellulitis and abscess
686 Other local infections of skin and subcutaneous tissue
694 Bullous dermatoses
694.5 Pemphigoid
695 Erythematous conditions
695.1 Erythema multiforme
Toxic epidermal necrolysis
695.4 Lupus erythematosus
696 Psoriasis and similar disorders
696.1 Other psoriasis
701 Other hypertrophic and atrophic conditions of skin
701.0 Circumscribed scleroderma
701.3 Striae atrophicae
Atrophy blanche (of Milian)
701.4 Keloid scar
707 Chronic ulcer of skin
707.0 Decubitus ulcer
707.1 Ulcer of lower limbs, except decubitus
707.8 Chronic ulcer of other specified sites
709 Other disorders of skin and subcutaneous tissue
709.2 Scar conditions and fibrosis of skin
709.3 Degenerative skin disorders
757 Congenital anomalies of the integument
911 Superficial injury of trunk
911.0 Abrasion or friction bum without mention of
infection
911.1 Abrasion or friction burn, infected
911.2 Blister without mention of infection
911.3 Blister, infected
912 Superficial injury of shoulder and upper arm
912.0 Abrasion or friction burn without mention of
infection
912.1 Abrasion or friction bum, infected
912.2 Blister without mention of infection
912.3 Blister, infected
913 Superficial injury of elbow, forearm, and wrist
913.0 Abrasion or friction burn without mention of
infection
913.1 Abrasion or friction bum, infected
913.2 Blister without mention of infection
913.3 Blister, infected
914 Superficial injury of hand(s), except finger(s) alone
914.0 Abrasion or friction burn without mention of
affection
914.1 Abrasion or friction burn, infected
914.2 Blister without mention of infection
914.3 Blister, infected
915 Superficial injury of finger(s)
915.0 Abrasion or friction burn without mention of
infection
915.1 Abrasion or friction burn, infected
915.2 Blister without mention of infection
915.3 Blister, infected
916 Superficial injury of hip, thigh, leg, and ankle
916.0 Abrasion or friction burn without mention of
affection
916.1 Abrasion or friction burn, infected
916.2 Blister without mention of infection
916.3 Blister, infected
917 Superficial injury of foot and toe(s)
917.0 Abrasion or friction bum without mention of
infection
917.1 Abrasion or friction bum, infected
917.2 Blister without mention of infection
917.3 Blister, infected
942 Burn of trunk
942.2 Blisters, epidermal loss [second degree]
943 Burn of upper limb, except wrist and hand
943.2 Blisters, epidermal loss [second degree]
944 Burn of wrist(s) and hand(s)
944.2 Blisters, epidermal loss [second degree]
945 Burn of lower limb(s)
945.2 Blisters, epidermal loss [second degree]
946 Burns of multiple specified sites
946.2 Blisters, epidermal loss [second degree]
948 Burns classified according to extent of body surface
involved
949 Burn, unspecified
949.2 Blisters, epidermal loss [second degree]
997 Complications affecting specified body system, not
elsewhere classified
997.6 Amputation stump complication
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 (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: Anthropometric Characteristics * Body composition (eg, body mass index, impedance measurement, skinfold thickness measurement) * Edema (eg, girth measurement, palpation, scales, volume measurement) * 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, palpation, sphygmomanometry, thermography) Cranial and Peripheral Nerve Integrity * Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration) * 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 * 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 * Activities, positioning, and postures that aggravate the wound or scar or that produce or relieve trauma (eg, observations, pressure-sensing maps) * Burn (eg, body charts, planimetry) * 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 scar tissue characteristics, including banding, pliability, sensation, and texture (eg, observations, scar-rating scales) Tests and measures for this pattern may include those that characterize or quantify: 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, 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) Prosthetic Requirements * Components, alignment, fit, and ability to care for the prosthetic device (eg, interviews, logs, observations, pressure-sensing maps, reports) * Safety during use of the prosthetic device (eg, diaries, fall scales, interviews, logs, observations, reports) 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) Self-Care and Home Management (Including ADL and IADL) * Safety in self-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) Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including IADL) * 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 4 weeks, patient/client will demonstrate optimal integumentary integrity 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 4 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 4 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 - education plans * 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 * Balance, coordination, and agility training - perceptual training - posture awareness training - sensory training or retraining - task-specific performance training * Body mechanics and postural stabilization - posture awareness training * Flexibility exercises - muscle lengthening - range of motion - stretching * Gait and locomotion training - perceptual training - 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, eccentric, isokinetic, isometric, and plyometric) - 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. - Pain is decreased. - Soft tissue swelling, inflammation, or restriction is reduced. - Tissue perfusion and oxygenation are enhanced. * Impact on impairments - Balance is improved. - 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. - Range of motion 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, 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 * 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. * Impact on impairments - Balance 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 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 * 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. * Impact on impairments - Balance 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 - Health status is improved. - 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 - therapeutic massage 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 - Integumentary integrity is improved. - Relaxation is increased. - Sensory awareness 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 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 - hospital beds - 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 - elastic wraps - 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. - 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 stability is improved. - Optimal joint alignment is achieved. - Optimal loading on a body part is achieved. - Quality and quantity of movement between and across body segments are 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. - 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. Integumentary Repair and Protection Techniques Interventions * Debridement--nonselective - enzymatic debridement - wet dressings - wet-to-dry dressings - wet-to-moist dressings * Debridement--selective - debridement with other agents (eg, autolysis 1. spontaneous disintegration of cells or tissues by autologous enzymes, as occurs after death and in some pathologic conditions. 2. destruction of cells of the body by its own serum.autolyt´ic au·tol·y·sis (ô-t) - enzymatic debridement - sharp debridement * Dressings - hydrogels - vacuum-assisted closure - wound coverings * Oxygen therapy - supplemental - topical * Topical agents - cleansers - creams - moisturizers - ointments - sealants Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Debridement of nonviable tissue is achieved. - Pain is decreased. - Soft tissue or wound healing is enhanced. - Tissue perfusion and oxygenation are enhanced. - Wound size is reduced. * Impact on impairments - Integumentary integrity 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 daffy living (ADL) and instrumental activities of daily living (IADL) with or without devices and equipment axe 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. - 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 axe 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) - high voltage pulsed current (HVPC) - 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. - 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. - Sensory awareness is increased. * 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 secondary impairment is reduced. - Self-management of symptoms 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 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. Physical Agents and Mechanical Modalities Interventions Physical agents may include: * Hydrotherapy - pulsatile lavage - whirlpool tanks * Light agents - laser - ultraviolet * Sound agents - phonophoresis - ultrasound * Thermotherapy - dry heat - hot packs - paraffin baths Mechanical modalities may include: * Compression therapies - compression bandaging - compression therapies - taping - total contact casting - vasopneumatic compression devices Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Debridement of nonviable tissue is achieved. - 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. - 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. Impaired Integumentary Integrity Associated With Full-Thickness Skin Involvement and Scar Formation 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 integumentary integrity associated with full-thickness skin involvement and scar formation--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, 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) * Abscess * Amputation * Burns * Frostbite * Hematoma * Immature, hypertrophic, or keloid scar * Lymphostatic ulcer * Malnutrition * Neoplasm * Neuropathic ulcers (grade 2) * Pressure ulcers (stage 3) * Prior scar * Surgical wounds * Toxic epidermal necrolysis * Vascular ulcers - Arterial - Diabetic - Venous Impairments, Functional Limitations, or Disabilities * Impairments associated with abnormal fluid distribution * Impaired sensation * Impaired skin * Muscle weakness Note: Some risk factors or consequences of pathology/ pathophysiology--such as infection and traumatic wounds--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 S642.) 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 * Crushing injury * Electricity related injury * Lymphedema * Recent amputation Findings That May Require Classification in Additional Patterns * Diabetic neuropathy 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.
017 Tuberculosis of other organs
017.0 Skin and subcutaneous cellular tissue
031 Diseases due to other mycobacteria
031.1 Cutaneous
036 Meningococcal infection
036.1 Meningococcal encephalitis
040 Other bacterial diseases
040.0 Gas gangrene
172 Malignant melanoma of skin
172.5 Trunk, except scrotum
172.6 Upper limb, including shoulder
172.7 Lower limb, including hip
172.8 Other specified sites of skin
173 Other malignant neoplasm of skin
173.5 Skin of trunk, except scrotum
173.6 Skin of upper limb, including shoulder
173.7 Skin of lower limb, including hip
173.8 Other specified sites of skin
176 Kaposi's sarcoma
176.0 Skin
216 Benign neoplasm of skin
232 Carcinoma in situ of skin
239 Neoplasms of unspecified nature
263 Other and unspecified protein-calorie malnutrition
269 Other nutritional deficiencies
443 Other peripheral vascular disease
443.1 Thromboangiitis obliterans [Buerger's disease]
454 Varicose veins of lower extremities
454.0 With ulcer
454.2 With ulcer and inflammation
459 Other disorders of circulatory system
680 Carbuncle and furuncle
680.2 Trunk
680.3 Upper arm and forearm
680.4 Hand
680.5 Buttock
680.6 Leg, except foot
680.7 Foot
681 Cellulitis and abscess of finger and toe
681.0 Finger
681.1 Toe
682 Other cellulitis and abscess
682.0 Face
682.2 Trunk
682.3 Upper arm and forearm
682.4 Hand, except fingers and thumb
682.5 Buttock
682.6 Leg, except foot
682.7 Foot, except toes
686 Other local infections of skin and subcutaneous tissue
686.0 Pyoderma
686.1 Pyogenic granuloma
686.8 Other specified local infections of skin and
subcutaneous tissue
694 Bullous dermatoses
695 Erythematous conditions
695.1 Erythema multiforme
Toxic epidermal nectolysis
695.4 Lupus erythematosus
701 Other hypertrophic and atrophic conditions of skin
701.0 Circumscribed scleroderma
701.4 Keloid scar
701.5 Other abnormal granulation tissue
707 Chronic ulcer of skin
707.1 Ulcer of lower limbs, except decubitus
707.8 Chronic ulcer of other specified sites
709 Other disorders of skin and subcutaneous tissue
709.2 Scar conditions and fibrosis of skin
709.3 Degenerative skin disorders
941 Burn of face, head, and neck
941.3 Full-thickness skin loss [third degree, not
otherwise specified]
942 Burn of trunk
942.3 Full-thickness skin loss [third degree, not
otherwise specified]
943 Burn of upper limb, except wrist and hand
943.3 Full-thickness skin loss [third degree, not
otherwise specified]
944 Burn of wrist(s) and hand(s)
944.3 Full-thickness skin loss [third degree, not
otherwise specified]
945 Burn of lower limb(s)
945.3 Full-thickness skin loss [third degree, not
otherwise specified]
946 Burns of multiple specified sites
946.3 Full-thickness skin loss [third degree, not
otherwise specified]
948 Burns classified according to extent of body surface
involved
949 Burn, unspecified
949.3 Full-thickness skin loss [third degree, not
otherwise specified]
991 Effects of reduced temperature
991.1 Frostbite of hand
991.2 Frostbite of foot
991.3 Frostbite of other and unspecified sites
997 Complications affecting specified body system, not
elsewhere classified
997.6 Amputation stump complication
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 (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: 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) 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) * Cardiovascular symptoms (eg, angina, claudication, dyspnea, and perceived exertion scales) Cranial and Peripheral Nerve Integrity * Electrophysiological integrity (eg, electroneuromyography) * Motor distribution of the cranial nerves (eg, dynamometry, muscle tests, observations) * Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests) * Response to neural provocation (eg, tension tests) * Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration) * 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 * 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 * Activities, positioning, and postures that aggravate the wound or scar or that produce or relieve trauma (eg, observations, pressure-sensing maps) * Burn (eg, body charts, planimetry) * 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 scar 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 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, 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) Prosthetic Requirements * Components, alignment, fit, and ability to care for the prosthetic device (eg, interviews, logs, observations, pressure-sensing maps, reports) * Safety during use of the prosthetic device (eg, diaries, fall scales, interviews, logs, observations, reports) 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) Self-Care and Home Management (Including ADL and IADL) * Safety in self-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) Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including IADL) * 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 4 to 12 weeks, patient/client will demonstrate optimal wound integumentary integrity and the highest level of functioning in home, work (job/school/play), community, and leisure environments. Over the course of 6 to 18 months, patient/client will demonstrate optimal scar maturity 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 12 to 50 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 12 to 50 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 T. hat 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 - education plans * 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 * Balance, coordination, and agility training - perceptual training - posture awareness training - sensory training or retraining - task-specific performance training * Body mechanics and postural stabilization - posture awareness training * Flexibility exercises - muscle lengthening - range of motion - stretching * Gait and locomotion training - perceptual training - 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, eccentric, isokinetic, isometric, and plyometric) - 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 - Balance is improved. - Endurance is increased. - 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. - Range of motion 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, 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 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 * 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 serf-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. * Impact on impairments - Balance is improved. - Endurance 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 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 * 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 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. - Muscle performance (strength, power, and endurance) 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 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 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 - Integumentary integrity is improved. - Joint integrity and mobility are improved. - Range of motion is improved. - Relaxation is increased. - Sensory awareness 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 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 axe acceptable to p 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 - elastic wraps - neck collars - serial casts - slings - supplemental oxygen - 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. - Energy expenditure per unit of work is decreased. - Gait, locomotion, and balance are improved. - Integumentary integrity is improved. - Joint stability is improved. - Optimal joint alignment is achieved. - Optimal loading on a body part is achieved. - Quality and quantity of movement between and across body segments are 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. Integumentary Repair and Protection Techniques Interventions * Debridement--nonselective - enzymatic debridement - wet dressings - wet-to-dry dressings - wet-to-moist dressings * Debridement--selective - debridement with other agents (eg, autolysis) - enzymatic debridement - sharp debridement * Dressings - hydrogels - vacuum-assisted closure - wound coverings * Oxygen therapy - supplemental - topical * Topical agents - cleansers - creams - moisturizers - ointments - sealants Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Debridement of nonviable tissue is achieved. - Pain is decreased. - Soft tissue or wound healing is enhanced. - Tissue perfusion and oxygenation are enhanced. - Wound size is reduced. * Impact on impairments - Integumentary integrity 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 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. - 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. - Stressors are decreased. Electrotherapeutic Modalities Interventions * Electrical stimulation - electrical muscle stimulation (EMS) - high voltage pulsed current (HVPC) - 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. - 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. - 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 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. Physical Agents and Mechanical Modalities Interventions Physical agents may include: * Hydrotherapy - pulsatile lavage - whirlpool tanks * Light agents - laser - ultraviolet * Sound agents - phonophoresis - ultrasound * Thermotherapy - dry heat - hot packs - paraffin baths Mechanical modalities may include: * Compression therapies - compression bandaging - compression garments - taping - total contact casting - vasopneumatic compression devices * Gravity-assisted compression devices - tilt table * Mechanical motion devices - continuous passive motion (CPM) Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Debridement of nonviable tissue is achieved. - 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. - 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-c, are, 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. Impaired Integumentary Integrity Associated With Skin Involvement Extending In. to Fascia, Muscle, or Bone and Scar Formation 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 integumentary integrity associated with skin involvement extending into fascia, muscle, or bone and scar formation--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, 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) * Abscess * Burns * Chronic surgical wound * Electrical burns * Frostbite * Hematoma * Kaposi's sarcoma * Lymphostatic ulcer * Necrotizing fasciitis * Neoplasm * Neuropathic ulcers (grades 3, 4, 5) * Pressure ulcers (stage 4) * Recent amputation * Subcutaneous arterial ulcer * Surgical wounds * Vascular ulcers - Diabetic - Venous Impairments, Functional Limitations, or Disabilities * Impaired joint integrity * Impaired sensation * Impaired skin * Impairments associated with abnormal fluid distribution * Muscle weakness * Decreased range of motion Note: Some risk factors or consequences of pathology/pathophysiology--such as paralysis--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 S662.) 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 lymphedema Findings That May Require Classification in Additional Patterns * Fracture * Impairments associated with diabetes 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 (ICI-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.
017 Tuberculosis of other organs
017.0 Skin and subcutaneous cellular tissue
036 Meningococcal infection
036.2 Meningococcemia
171 Malignant neoplasm of connective and other soft tissue
171.2 Upper limb, including shoulder
171.3 Lower limb, including hip
171.5 Abdomen
171.6 Pelvis
171.8 Other specified sites of connective and other
soft tissue
172 Malignant melanoma of skin
172.5 Trunk, except scrotum
172.6 Upper limb, including shoulder
172.7 Lower limb, including hip
172.8 Other specified sites of skin
173 Other malignant neoplasm of skin
173.5 Skin of trunk, except scrotum
173.6 Skin of upper limb, including shoulder
173.7 Skin of lower limb, including hip
173.8 Other specified sites of skin
176 Kaposi's sarcoma
176.0 Skin
176.1 Soft tissue
215 Other benign neoplasm of connective and other soft tissue
215.2 Upper limb, including shoulder
215.3 Lower limb, including hip
215.6 Pelvis
239 Neoplasms of unspecified nature
239.2 Bone, soft tissue, and skin
263 Other and unspecified protein-calorie malnutrition
269 Other nutritional deficiencies
440 Atherosclerosis
440.2 Of native arteries of the extremities
440.24 Atherosclerosis of the extremities with
gangrene
443 Other peripheral vascular disease
443.1 Thromboangiitis obliterans [Buerger's disease]
454 Varicose veins of lower extremities
454.0 With ulcer
454.2 With ulcer and inflammation
459 Other disorders of circulatory system
674 Other and unspecified complications of the puerperium,
not elsewhere classified
674.1 Disruption of cesarean wound
680 Carbuncle and furuncle
680.2 Trunk
680.3 Upper arm and forearm
680.4 Hand
680.5 Buttock
680.6 Leg, except foot
680.7 Foot
681 Cellulitis and abscess of finger and toe
681.0 Finger
686 Other local infections of skin and subcutaneous tissue
686.8 Other specified local infections of skin and
subcutaneous tissue
707 Chronic ulcer of skin
707.0 Decubitus ulcer
707.1 Ulcer of lower limbs, except decubitus
707.8 Chronic ulcer of other specified sites
710 Diffuse diseases of connective tissue
710.0 Systemic lupus erythematosus
710.1 Systemic sclerosis
710.3 Dermatomyositis
728 Disorders of muscle, ligament, and fascia
728.8 Other disorders of muscle, ligament, and fascia
728.86 Necrotizing fasciitis
880 Open wound of shoulder and upper arm
881 Open wound of elbow, forearm, and wrist
882 Open wound of hand except finger(s) alone
883 Open wound of finger(s)
884 Multiple and unspecified open wound of upper limb
885 Traumatic amputation of thumb (complete) (partial)
886 Traumatic amputation of other finger(s) (complete) (partial)
887 Traumatic amputation of arm and hand (complete) (partial)
890 Open wound of hip and thigh
891 Open wound of knee, leg [except thigh], and ankle
892 Open wound of foot except toe(s) alone
893 Open wound of toe(s)
894 Multiple and unspecified open wound of lower limb
895 Traumatic amputation of toe(s) (complete) (partial)
896 Traumatic amputation of foot (complete) (partial)
897 Traumatic amputation of leg(s) (complete) (partial)
927 Crushing injury of upper limb
928 Crushing injury of lower limb
929 Crushing injury of multiple and unspecified sites
941 Burn of face, head, and neck
941.4 Deep necrosis of underlying tissues [deep third
degree] without mention of loss of a body part
941.5 Deep necrosis of underlying tissues [deep third
degree] with loss of a body part
942 Burn of trunk
942.4 Deep necrosis of underlying tissues [deep third
degree] without mention of loss of a body part
942.5 Deep necrosis of underlying tissues [deep third
degree] with loss of a body part
943 Burn of upper limb, except wrist and hand
943.4 Deep necrosis of underlying tissues [deep third
degree] without mention of loss of a body part
943.5 Deep necrosis of underlying tissues [deep third
degree] with loss of a body part
944 Burn of wrist(s) and hand(s)
944.4 Deep necrosis of underlying tissues [deep third
degree] without mention of loss of a body part
944.5 Deep necrosis of underlying tissues [deep third
degree] with loss of a body part
946 Burns of multiple specified sites
946.4 Deep necrosis of underlying tissues [deep third.
degree] without mention of loss of a body part
946.5 Deep necrosis of underlying tissues [deep third
degree] with loss of a body part
948 Burns classified according to extent of body surface
involved
991 Effects of reduced temperature
991.1 Frostbite of hand
991.2 Frostbite of foot
991.3 Frostbite of other and unspecified sites
991.4 Immersion foot
991.5 Chilblains
997 Complications affecting specified body system, not
elsewhere classified
997.6 Amputation stump complication
998 Other complications of procedures, not elsewhere classified
998.3 Disruption of operation wound
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 (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: 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) * Motivation (eg, adaptive behavior scales) * Recall, including memory and retention (eg, assessment scales, interviews, questionnaires) 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, observations, palpation, sphygmomanometry) Cranial and Peripheral Nerve Integrity * Motor distribution of the cranial nerves (eg, dynamometry, muscle tests, observations) * Motor distribution of the peripheral nerves (eg, dynamometry, muscle tests, observations, thoracic outlet tests) * Sensory distribution of the cranial nerves (eg, discrimination tests; tactile tests, including coarse and light touch, cold and heat, pain, pressure, and vibration) * 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 * 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 * Activities, positioning, and postures that aggravate the wound or scar or that produce or relieve trauma (eg, observations, pressure-sensing maps) * Burn (eg, body charts, planimetry) * 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 scar tissue characteristics, including banding, pliability, sensation, and texture (eg, observations, scar-rating scales) Joint Integrity and Mobility * Specific body parts (eg, apprehension, compression and distraction, drawer, glide, impingement, shear, and valgus/varus stress tests; arthrometry ar·throm·e·try (är-thr m  -tr )n. )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, diaries, fall scales, interviews, logs, observations, reports) Pain * Pain, soreness, and nociception (eg, 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) * Specific body parts (eg, angle assessment, forward-bending test, goniometry, observations, palpation, positional tests) Prosthetic Requirements * Components, alignment, fit, and ability to care for the prosthetic device (eg, interviews, logs, observations, pressure-sensing maps, reports) * Safety during use of the prosthetic device (eg, diaries, fall scales, interviews, logs, observations, reports) 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) Self-Care and Home Management (including ADL and IADL) * 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) Work (Job/School/Play), Community, and Leisure Integration or Reintegration (Including IADL) * 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 4 to 16 weeks, patient/client will demonstrate optimal wound integumentary integrity and the highest level of functioning in home, work (job/school/play), community, and leisure environments. Over the course of 6 to 24 months, patient/client will demonstrate mature scar 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 12 to 90 12 to 90 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 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 OEPs) - 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 - education plans * 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, of 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 * Balance, coordination, and agility training - perceptual training - posture awareness training - sensory training or retraining - task-specific performance training * Body mechanics and postural stabilization - postural stabilization activities - posture awareness training * Flexibility exercises - muscle lengthening - range of motion - stretching * Gait and locomotion training - perceptual training - standardized, programmatic, complementary - exercise approaches * Strength, power, and endurance training liar head, neck, limb, pelvic-floor, trunk, and ventilatory muscles - active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) - 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 - Balance is improved. - Endurance is increased. - 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. - Range of motion 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 serf- care, home management, work (job/school/play), community, and leisure is increased. - 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 * 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. - 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 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 * 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 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. - Muscle performance (strength, power, and endurance) 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 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. * 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 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 - Integumentary integrity is improved. - Joint integrity and mobility are improved. - Range of motion is improved. - Relaxation is increased. - Sensory awareness 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 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 - elastic wraps - neck collars - serial casts - 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. - Energy expenditure per unit of work is decreased. - Gait, locomotion, and balance are improved. - Integumentary integrity is improved. - Joint stability is improved. - Optimal joint alignment is achieved. - Optimal loading on a body part is achieved. - Quality and quantity of movement between and across body segments are 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. Integumentary Repair and Protection Techniques Interventions * Debridement--nonselective - wet-to-dry dressings * Debridement--selective - debridement with other agents (eg, autolysis) - enzymatic debridement - sharp debridement * Dressings - hydrogels - vacuum-assisted closure - wound coverings * Oxygen therapy - supplemental - topical * Topical agents - cleansers - creams - moisturizers - ointments - sealants Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Debridement of nonviable tissue is achieved. - Pain is decreased. - Soft tissue or wound healing is enhanced. - Tissue perfusion and oxygenation are enhanced. - Wound size is reduced. * Impact on impairments - Integumentary integrity 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 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. - 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. - Stressors are decreased. Electrotherapeutic Modalities Interventions * Electrical stimulation - electrical muscle stimulation (EMS) - high voltage pulsed current (HYPC) - 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. - 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. - 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 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. Physical Agents and Mechanical Modalities Interventions Physical agents may include: * Hydrotherapy - pulsatile lavage - whirlpool tanks * Light agents - laser - ultraviolet * Sound agents - phonophoresis - ultrasound * Thermotherapy - dry heat - hot packs - paraffin baths Mechanical modalities may include: * Compression therapies - compression bandaging - compression garments - taping - total contact casting - vasopneumatic compression devices * Gravity-assisted compression devices - tilt table * Mechanical motion devices - continuous passive motion (CPM) Anticipated Goals and Expected Outcomes * Impact on pathology/pathophysiology (disease, disorder, or condition) - Debridement of nonviable tissue is achieved. - 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. - 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 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. * Glossary * Standards of Practice for Physical Therapy and the Criteria * Guide for Professional Conduct and Code of Ethics * Guide for Conduct of the Affiliate Member and Standards of Ethical Conduct for the Physical Therapist Assistant * Guidelines for Physical Therapy Documentation * Documentation Template for Physical Therapist Patient/Client Management * Patient/Client Satisfaction Questionnaire |
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