Adult and Older Adult Cardiorespiratory Sample Cases

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Case A

A 58-year-old woman had a left lower lobectomy yesterday. The patient has stable vital signs and post-operative orders state ‘activity as tolerated’. The nurse reports the patient’s chest x-ray shows some atelectasis in the right lower lobe, and the patient has been expectorating green sputum. The patient has not seen a physical therapist before.

1.  When the physical therapist approaches the patient, she states she does not need to see a physical therapist and she ‘is doing fine’. How should the physical therapist proceed? (Select 1)

1 – Respect the patient’s decision not to participate in physical therapy and document the refusal in the chart.

2 – Report the patient’s response to the physician and request the physician speak to the patient about the importance of physical therapy.

3 – Wait until a family member visits the patient and ask him/her to convince the patient to participate in treatment.

4 – Explain to the patient the potential risks of not participating in treatment and then ask again if she would participate.

2. The nurse reports the patient’s chest x-ray shows some atelectasis in the right lower lobe, and the patient has been expectorating green sputum. How should the physical therapist proceed? (Select 3)

1 – Assess standing.

2 – Ask the patient to huff.

3 – Demonstrate the Active Cycle of Breathing.

4 – Auscultate the chest.

5 – Review the chest X-ray.

6 – Recommend that arterial blood gases and a V/Q (ventilation / perfusion) scan be done.

7 – Check oxygen saturation.

3.  The patient is independent in her bed mobility. She has a weak cough, and decreased breath sounds over the right lower lobe. Oxygen saturation is 95% and the chest X-ray shows right lower lobe atelectasis. What should the physical therapist include in the initial treatment plan for the patient? (Select 4)

1 – Bed range of motion exercises.

2 – Active Cycle of Breathing.

3 – CPAP (continuous positive airway pressure) machine.

4 – Mechanical vibrations.

5 – Postural drainage in prone.

6 – Supported coughing.

7 – Deep breathing and coughing exercise.

8 – Mobilisation as tolerated.

4.  What should the physical therapist include in the patient’s chart related to the physical therapy treatment provided? Indicate True or False.

1 – Shoulder range of movement.

2 – Chest sounds.

3 – Past medical history.

4 – Patient response to treatment.

5 – Patient consent to treatment.

6 – Status of the incision.

5.  What should the physical therapist use to evaluate the treatment outcomes for the patient? (Select 3)

1 – Auscultation.

2 – Visual Analog Pain Scale.

3 – Borg’s Perceived Exertion Scale.

4 – Chest expansion.

5 – Heart rate.

6 – Timed Up and Go.

7 – Respiratory rate.

Case B

The physical therapist is asked to assess a 76-year-old man who was admitted to the emergency department with a history of shortness of breath, fever, and a productive cough for the last four days. The patient is diagnosed with right lower lobe pneumonia. He is having difficulty mobilizing due to weakness. He has a remote history of a stroke with residual right-sided weakness and mild dysphagia.

1.  The physical therapist reviews the patient’s chest x-ray and notes a positive silhouette sign. What loss of structure should the physical therapist also note on the x-ray? (Select 1)

1 – Right hemi-diaphragm.

2 – Right heart border.

3 – Aortic knob.

4 – Ascending aorta.

2.  The patient is having difficulty coughing due to weakness of his abdominal muscles secondary to his previous stroke. To increase the effectiveness of the patient’s cough, what technique should the physical therapist use for a manual-assisted cough? (Select 1)

1 – Place heel of hand on patient’s epigastric area with second hand over first, compress upward and inward as the patient attempts a cough.

2 – With the patient in prone lying, place hands on lower ribs bilaterally, and compress when the patient attempts a cough.

3 – Position the patient in side-lying, encourage him to take a deep breath and when the patient coughs, compress his rib cage.

4 – Ask the patient to cross his arms over his abdomen, then compress through the patient’s crossed arms as he coughs.

3.  The patient’s first language is Farsi and he understands some basic English. The physical therapist teaches the patient about an assisted cough, but he does not understand her explanation. How should the physical therapist proceed? Indicate True or False.

1 – Go ahead with the technique, as it is necessary to clear the patient’s secretions.

2 – Show the patient pictures of the technique and automatically proceed.

3 – Go ahead with the procedure, as the patient has not refused.

4 – Choose an alternate technique that the patient understands.

5 – Arrange for an interpreter to explain the new technique to the patient.

4.  During treatment sessions, the patient is coughing and expectorating purulent sputum. He requires assistance to expectorate into a collection cup. What infection control measures should the physical therapist take? (Select 1)

1 – Wear gloves and a face mask when treating the patient.

2 – No protection is necessary except hand washing after treatment.

3 – Restrict patient ambulation to the inside of his room only.

4 – Ensure the patient is the last patient of the day to be treated.

Case C

A 63-year-old man was admitted through emergency and underwent an urgent total colectomy. The surgeon has ordered “Physiotherapy to assess and treat”. The patient lives alone in a three-storey townhouse.

1. During the physical therapist’s initial assessment at one day post-operatively, the patient rated his post-surgical pain at 3 out of 10 on the numeric pain rating scale and demonstrated shallow and rapid breathing. On auscultation, there were decreased breath sounds and fine end-inspiratory crackles to the lower lung field. What interventions would be appropriate for the physical therapist to use to treat the patient? Indicate True or False.

1 – Sitting at the edge of the hospital bed.

2 – Walking with a standard walker.

3 – Use of a splinted coughing technique.

4 – Postural drainage in prone with head down 30 degrees.

2. The patient is now eight days post-operative and has expressed to the care team that he would like to be discharged home today. He is able to walk slowly with a walker around the unit but could only safely negotiate one step on the stairs. How should the physical therapist proceed? (Select 1)

1 – Discharge the patient as he has achieved the treatment goals.

2 – Discuss safety risks associated with his inability to negotiate stairs with the team.

3 – Add active shoulder exercises to enable the patient to better pull on the handrail.

4 – Offer to go to the home to recommend modifications to improve accessibility.

3. During his hospital stay, the patient’s daughter was appointed Power of Attorney for personal care. Based on the physical therapist’s ongoing assessment, the use of a two-wheeled walker was deemed appropriate and the patient agrees with this. The patient’s daughter insists that walking is unsafe for the patient and would like to purchase a wheelchair for the patient instead. How should the physical therapist proceed? Indicate True or False.

1 – Agree with the daughter’s choice to purchase a wheelchair.

2 – Ensure the patient demonstrates how to safely use a two-wheeled walker.

3 – Provide the daughter with the rationale for use of two-wheeled walker.

4. The patient was admitted to inpatient rehabilitation to prepare him for discharge home. After three weeks of inpatient rehabilitation, the patient is now able to negotiate one flight of stairs safely and would like to be discharged home. The patient is motivated and would like to continue a home exercise program to get himself “back in shape”. What should the physical therapist prescribe? (Select 3)

1 – Step up and down the bottom step of the stairs 10 times, twice a day.

2 – Complete three sets of active cycle of breathing every hour while awake.

3 – Complete five partial squat exercises with back against the wall twice a day.

4 – Daily stationary cycling starting at 5 minutes and progress by 5 minute increments, as tolerated.

5 – Postural drainage for 15 minutes in prone lying followed by a supported cough.

6 – Perform fine motor hand exercises using pick-up sticks, twice a day.

Case D

A 52-year-old woman is admitted to the Emergency Department, with gradual onset neuromuscular weakness and respiratory distress, after returning to Canada from a trip to India five days previously. The patient reports having a flu-like illness a week prior to catching her flight home. The patient has been diagnosed with Guillain-Barré Syndrome.

1. The physical therapist received a referral from the respirologist ‘to assess and treat chest’ within three hours of the patient’s admission to the Emergency Department. A respiratory therapist has just completed an assessment. What items of information should the physical therapist collect prior to seeing the patient? (Select 3)

1 – Physician orders.

2 – Arterial blood gas results.

3 – Name of attending doctor.

4 – Plans for transfer to hospital ward.

5 – Record of last bowel movement.

6 – Chest X-ray results.

2. The nurse reports the patient has required oral suctioning for moderate amounts of purulent secretions in the past 30 minutes. How should the physical therapist proceed? (Select 1)

1 – Raise the bed into high fowler’s position, insert an oral airway and perform deep suction to stimulate cough.

2 – Turn patient onto her right side, perform upper extremity elevation timed with inspiration, then manually assist cough.

3 – Call the respiratory therapist (RT) to the bedside and request the RT perform a nasopharangeal suction.

4 – Position bed in a 30-degree head down position and perform manual vibrations to the right lower lobe, and then manually assist cough.

3. The patient settles following the initial physical therapy intervention; three hours later, the physical therapist receives a page to return to the bedside. The patient’s vital capacity has dropped below 1000 cc. The chest x-ray now indicates complete white out of the right lung. Oxygen saturation has dropped to 85%. The respirologist has just intubated the patient with the following settings: Assist Control 15, Tidal Volume 500, FiO2 .40, and PEEP +5. What should the physical therapist expect to be the reason for the worsening clinical presentation of the patient? (Select 1)

1 – Loculated abscess in right lung.

2 – Mucus plug in the right lung.

3 – Pneumothorax on the right side.

4 – Pleural effusion on the right.

4. When the physical therapist leaves the ward, the patient’s co-worker approaches and asks whether the patient’s recent intubation means she is likely going to die. How should the physical therapist respond? (Select 1)

1 – Recommend he talk to the respirologist concerning the intubation and the patient’s prognosis.

2 – Confirm the patient is critically ill and her prognosis is poor.

3 – Suggest he talk to the patient’s husband who is the temporary decision maker.

4 – Suggest he talk to the social worker about his concerns and the patient’s prognosis.