exam two - rec therapy

APIED
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Terms in this set (50)
APIED
assessment, planning, implementation, evaluation, documentation
assessment
clinical reasoning of a client's disorder area(s)
planning
(using assessment information) prioritize treatment, develop treatment and strategies/interventions to achieve goals/objectives
implementation
delivery of strategies/interventions to bring a functional change
documentation
evidence/proof of patient's health history/goals/objectives
documentation can be delivered in....
any setting: hospitals, schools, private practices, skilled nursing facilities, psychiatric/behavioral facilities, etc.
assessment
create list snd rule out/identify problems, what should be addresses, resources, strengths - helps and aids to define data to analyze/collect, actual problems, interventions and goals/objectives
assessment: observation
general appearance, comfort of client, physical/cognitive functions, interpersonal interactions, verbal/nonverbal communications (including congruence), and effect on environment on individual
assessment (standardize instrument)
norm-reference assessment: how individual performs compared to others of similar age, sex, etc.
assessment: criterion-referenced test
measure to achievement toward established standard: does the patient have specific skills/abilities
must pay attention to psychometric properties of reliability and validity
assessment: interviewsopen-ended questions: "what do you like to do?" close-ended questions: "do you like..." , "how old are you?"assessment: secondary resourcesrecords: charts, family, other therapists and assessments, progress and interdisciplinary notes (confidential)assessment: areasbiological, psychological, social, spiritual, functionings, and strengths/weaknessesassessment: datasubjective data - decisions are dependent on POV of patient objective data - information that has a standardized assessment and similar/not dependent on patient (distance walked, # of coping mechanisms, positive/negative self-comments)planningestablishes priorities, sets goals, develops objectives and treatment plan (part of master treatment plan)planning: stepssetting priorities, formulation of strategies/actions, to meet and assessing methods of progress for goals/objectives,planning: goalslong-term(achievement), stated in terms of client/patient needs, and to direct therapistsplanning: objectivesspecific steps, enabling 3-4 per objective, and manageable behaviorsplanning: objective "SMART"specific, measurable, attainable, relevant, and timedplanning: strategies(evidence-based) expertise therapist, literature of publication of research related to interventions, problem-solving approachplanning: 5 step approach1. develop clinical question 2. related research 3. evaluate evidence (structure, statistics, and outcomes) 4. using clinical judgement and patient preferences (implement into practice) 5. does it work (evaluation pf interventions)implementationtheoretical foundation which provides basis of provision of interventions and theory flowimplementation: interventionsgoal directed, active participation in patient, meaning/value w/ patient, potential for pleasure, and selection under direction of rec. therapistsevaluationdid the interventions work? were goals/objectives met? re-evaluate (re-assess using same assessment used when initiaed in process)assessment for rec therapyFOX, OHIO, BANRT, BUS, FIM, Grocery store, CERT, apgar scale, mini-mental state exam, ROM, and RAIassessment for rec therapy: FOXassessing: evaluates a patient's level of skill of social interaction category: dementia, mental retardation, developmental disabilities 6 social levels: client's reaction to others and objects, attention seeing from others, interaction with object and others, and concept of selfassessment for rec therapy: OHIOassessing options(3): functional living skills, quick functional screening test, and rec. and leisure profileassessment for rec therapy: BANRT (Bond-Howard Assessment on Neglect in RT)assessing: density - measure average seconds in the neglected area scope - document areas of neglect in the patient's field of vision category: individuals with visual neglectassessment for rec therapy: BUS (Bus Utilization Skills)assessing: ability to us public bus systems category: patient groups (cognitive and physical impairments)assessment for rec therapy: FIM (Functional Independence Measurement7 - complete independence 6 - modified independence 5 - supervision/setup 4 - minimal contact assistance -75% or more effort 3 - moderate assistance - 50-75% effort 2 - maximal assistance - 25-50% effort 1 - total assistance - less than 25% effortassessment for rec therapy: grocery store (community - integration/reintegration)assessing - planning, future leisure, environmental skills needed, cognitive and social behaviors category - new setting for patientsassessment for rec therapy: CERT (Psych/R)assessing: identify, define, and evaluate behaviors relevant to person's ability to successfully integrate into society using social skills category: 1 to 1, or in groupsassessment for rec therapy: CERT (Rehab)assessing: loss of function and establish baseline functioning after admission to hospital - gross motor function, fine motor function, locomotion, motor skills, sensory, cognitive, communication, and behavior actions levels: rancho scale (1-8), developmental level, 5 years and aboveassessment for rec therapy: CERT (Rehab) - gross motor functionendurance/movement ability (arms, legs...)assessment for rec therapy: CERT (Rehab) - fine motor functionability of handassessment for rec therapy: CERT (Rehab) - locomotionskills to move one place to anotherassessment for rec therapy: CERT (Rehab) - motor skillssequence of actions (processing information)assessment for rec therapy: CERT (Rehab) - sensorydemonstration of awarenessassessment for rec therapy: CERT (Rehab) - cognitionhigher mental process involving awarenessassessment for rec therapy: CERT (Rehab) - communicationskills in receiving/relating messagesassessment for rec therapy: CERT (Rehab) - behavioractions (reflecting feelings)assessment for rec therapy: CERT (Rehab) - extremitiesRUE - right upper extremities LUE - light upper extremities RLE - right lower extremities LLE - left lower extremitiesassessment for rec therapy: apgar scaleassessing: provides insight of newborn of breathing, heart rate, muscle tone, grimace response, and skin color category: child 1-5 minutes after birthassessment for rec therapy: mini-mental examassessment: cognitive functions and document subsequent cognitive function decline (get better or worse) areas: orientation, registration, attention and calculations, language, repetition, and complex commands (two pentagons intersecting!!!)assessment for rec therapy: ROM (range of motion)assessment : reflects angle joint is to designed to move through 0 degrees - joint flat on table top 360 degrees - completely dislocated active ROM - moves through ROM w/o assistance passive ROM - moves through ROM w/ varying assistanceassessment for rec therapy: ROM (range of motion) - goniometercommon ROM instrumentassessment for rec therapy: ROM (range of motion) - manual muscle evaluation (strength chart)^ 100% - 5 - Normal(N) - Complete ROM against gravity full resistance ^ 75% - 4 Good (G) - Complete ROM against gravity some resistance ^ 50% - 3 - Fair (F) - Complete Range of motion against gravity ^ 25% - 2 Poor (P) - Complete ROM gravity removed ^ 10% - 1 - Trace (T) - Evidence of contractility ^ 0% - 0 - Zero (0) - No evidence of contractility ^ S - Spasm - Place after rating if exists ^ C - Contractureassessment for rec therapy: RAI (Resident Assessment Instrument)- minimum data set (mds): as of 2012, 3.0 mds timeline (providesfoundation for assessments) - initial, quarterly, and significant changes (stroke, death, hip replacement, etc.) - care area assessment (caa): suggested problems/stengths for care planning - section F: daily preferences, personal belongings, bathing, snacks/food, bedtime, friends, and phone section O: special treatments, procedures, and programs (cancer treatments, respiratory, and other)assessment for rec therapy: RAI (Resident Assessment Instrument) - timelineinitial - 14 days - completed 3rd quarterly - partial seeking to identify changes annual - full RAI assessmentsassessment for rec therapy: FACES (Wong-Baker pain rating scale)assessing: individuals point to faces on a scale to describe intensity of pain and therapists record # category: 3 years or older