514915 research-article2014
SJP0010.1177/1403494813514915K.O. SundnesShort Title
Scandinavian Journal of Public Health, 2014; 42(Suppl 14): 21–28
Structural Framework Chapter 2
Clinical models applicable to disasters
Abstract Processes used for research of disasters are similar to those used for the assessment, determination of needs, planning, selection of interventions and their implementation, and evaluation of patient outcomes in the clinical setting. A patient suffering a stroke and another patient with an acute inflammation of the gallbladder serve as examples. Patients travel along the same longitudinal progression as do disasters and clinical assessments are conducted using the body’s organ systems. Key Words: Assessment, clinical models, disaster, evaluation, framework, implementation, interventions, longitudinal phases, needs, patients, phases, planning, society, systems, transectional
Introduction The processes by which clinicians approach a patient who is seeking care are similar to those that can be used to analyse disasters. Both utilise a longitudinal framework comprised of distinct but overlapping phases. Clinically, transectional assessments are conducted using body organ systems that describe the changes in the status from the baseline, pre-event health status along the longitudinal clinical course. From the observed functional changes (symptoms and signs), the clinician is able to identify the cause of the disturbances in functions (pathophysiology) and, thus, treat the cause(s) in a manner that will shorten convalescence, minimise the morbidity, and ultimately the possibility that the patient will die from the dysfunctions of the organ systems affected. Both the underlying pathology/pathophysiology and the symptoms are treated in an effort to return the patient as closely as possible to his/her pre-event functional status. Often, measures are taken during or following the recovery phase that are designed to minimise the risk that such an event will recur. Throughout a patient’s clinical course, repeated assessments of her/his physiological status are conducted and compared with the patient’s status before the precipitating event occurred. These assessments utilise indicators of functions to assess the status of specific organ systems and are performed throughout the patient’s clinical course until recovery has been achieved. Clinical models Both a patient’s clinical course and a disaster share longitudinal phases. Similar to what occurs in clinical medicine, disasters follow a longitudinal course from © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494813514915
the pre-event (baseline) status through the crisis, relief, and recovery. Therefore, clinical examples familiar to healthcare personnel are presented in order to facilitate the understanding of the longitudinal phases and transectional assessments, plans, and interventions (responses) that also are characteristics of disasters. Case 1 A 62-year-old man experienced sudden onset (timepoint zero, TPZ)1 of paralysis of his right leg, weakness of his right arm, and an inability to walk or to speak coherently. His clinical course is illustrated in Figure 2.1 and summarised in Table 2.1. The patient’s clinical course included: 1. Pre-event health status (baseline): He has been healthy except for a 30-year history of smoking cigarettes, being treated for high blood pressure and has been noted to have “high” blood cholesterol levels. His health status prior to the onset serves as the baseline to which all subsequent assessments are compared. 2. Event: He had experienced a sudden-onset event that occurred over seconds or minutes caused by a blood clot that obstructed a cerebral (brain) artery, which delivers blood containing essential oxygen and nutrients to a part of his brain. 3. Damage: The structural (anatomical) damage to his brain as a result of the obstructed blood flow, was rapidly progressive as cells were deprived of oxygen and, eventually, irreversible cell injuries (cell death) would cause substantial morbidity (if not death).
22 Chapter 2 4. Disturbances of functions: The cellular injury (damage) led to changes in function that present with symptoms and signs of neurological deficits (paralysis of his right leg and weakness and numbness of his right arm, inability to walk, inability to speak coherently, and asymmetry of his face). 5. Assessments: Since the clinician is unable to see the anatomical injury and its cause (blood clot in a cerebral artery), the clinician assesses the patient for changes in function (physiological abnormalities) (A1) (Figure 2.1) to identify the possible structural damage sustained and its likely causes (functional deficits lead to identification of anatomical damage that has occurred); this anticipated cause is confirmed using laboratory and imaging studies. 6. Needs: Based on the findings of the assessments, it is determined that the patient needs (N1) restoration of cerebral blood flow through the occluded artery.2 The options for therapeutic interventions to halt the ongoing destruction of brain cells and minimise the long-term disability are determined based on the findings from the first assessment (A1) and a plan (P1) for relief of the primary problem is developed – the blood clot must be dissolved). 7. Intervention: A treatment plan (P1) is developed based on the findings from the assessments (A1), the priorities assigned to the patient’s needs, the options available for treatment, the time elapsed from the onset (TPZ), and the overall condition of the patient. The options most likely to provide the greatest benefit with the least negative effects include: Option 1: Adopt a “wait and see” approach: let the process evolve, provide sedation, intensive physical and speech therapy, and prepare the patients for recovery of best possible function in a rehabilitation centre; or Option 2: Attempt to dissolve the blood clot using a fibrinolytic pharmacological agent plus intensive physical and speech therapy.3 In this case, an infusion of a fibrinolytic drug is implemented (I1). 8. Recovery: Following conclusion of the administration of the fibrinolytic drug, a second assessment (A2) of the functional status of the patient is conducted. Muscle strength of and sensation in his right arm have improved and he is able to move his right leg. His facial asymmetry has cleared, but his speech remains garbled. His blood pressure remains elevated (160/120 mmHg), and his cholesterol levels remain unchanged. Based on the findings of this assessment and his current needs, a new plan (P2)
is developed that includes initiation of physical therapy to improve muscle strength and restore his ability to walk and care for himself and speech therapy to restore his ability to communicate (recovery) (N2). In addition, an antihypertensive medication is begun to lower his blood pressure in an effort to prevent a recurrence of a stroke (I2). The effects of these therapeutic interventions (responses) are identified 1 month after his admission by using a third set of assessments (A3). At this time, his strength has improved further, but he still is unable to walk without assistance, he speaks coherently, blood pressure (BP) is 140/100 mmHg, and his cholesterol remains unchanged. The dose of antihypertensive medication is increased (I4), and a statin (cholesterol-lowering drug) is started in an effort to lower his blood cholesterol level. Full recovery to his pre-event functional status, or the lack thereof, is documented by conducting repeated assessments (A4–A5); 9. Development: Also, continued efforts are directed toward controlling his blood pressure and cholesterol levels (N3, N4, I4) and other treatments that will reduce the risk of a clot (e.g. cardiac arrhythmias). From this example, it is clear that if the damage was allowed to progress without interventions, it could have resulted in the further decline of vital functions to levels below critical thresholds and lead to the patient’s death. If damage is not lethal, it is likely that the ongoing damage will render the patient dysfunctional (i.e. he would remain below his functional threshold and would not recover to a fully functional life). If treatment is very successful, his functional status may be restored to a functional level equal to his functional threshold of his pre-event status. Case 24 A 50-year-old obese woman complained of pain in her right upper abdomen that had been progressive over several hours. Her clinical course can be mapped as diagrammed in Figure 2.2 and is summarised in Table 2.2. The patient’s clinical course included: 1. Pre-event health status (baseline): During the past 4 months, she has experienced intermittent episodes of upper abdominal pain and distension usually following eating. She also has been
Clinical models applicable to disasters 23 Pre-event Status BP 160/130 mmHg, Cholesterol = 320 mg/dl Event
Damage
Change in function
Blood clot cerebral artery Reduced oxygen delivery
Brain cell injury
Paralysis right leg; weakness right arm; facial asymmetry
N1 P1
Relief
Improved strength +speech; Cholesterol = 320 mg/dl
Improved strength; Speech improved; Cholesterol = 320 mg/dl
Walking; speech improved
I1: Fibrinolytic agent
N2 P2
Recovery
I2: Physical + speech therapy
N3 P3
I3: Discharge from hospital, Physical/speech
N4 P4
therapy
A1
A2
I4: Inc BP meds and statin dose BP = 125/95 mmHg; cholesterol = 300 mg/dl
I3:BP control + statin prescribed BP = 140/100 mmHg;
I2: BP treatment; BP = 160/120 mmHg
Development
A3
I4: Exercise; speech therapy
A4
A5
Time
Figure 2.1. Graphic representation of the clinical course of a patient who suffers a stroke using a longitudinal framework that similarly can be used in the description of a disaster. Assessments (A1–A5) of physiological status are repeated during the longitudinal course. Plans are made based on the findings of the assessments, and decisions are made as to which elements in the plan will be implemented. Then, chosen interventions are implemented and the assessments are repeated to note the changes that occur in functions related to the treatment (interventions) provided. Functional recovery may in this case come from recovery of brain cells or mobilising other cerebral structures due to specific training. BP: blood pressure; I1–I4: interventions; N1–N4: needs; P1–P4: plans.
2.
3.
4. 5.
unsuccessful in trying to lose weight and has been told that her blood cholesterol level is “too high”. Event: Over the past 6 hours (TPZ = −6 hours), she has experienced pain that has become steady and has been increasing in severity. The pain is related directly to a gallstone lodged in the cystic duct (event) Damage: The structural (anatomical) damage to the gallbladder is progressive and without intervention, may result in necrosis (death) and rupture of the gallbladder resulting in a serious threat to her life (critical threshold). Disturbances in functions: The structural damage has led to a change in function (indigestion, nausea, bloating, and pain). Assessment: The clinician is unable to visualise the damage occurring in the gallbladder and performs an assessment (A1) in order to identify changes in function (physiological abnormalities) that have resulted from the damage to the gallbladder and the cystic duct. The assessment
includes symptoms and physical signs, and laboratory, and imaging studies to help to identify the structural damage sustained. These assessments point to gallbladder disease (acute cholecystitis); (identification of functional deficits led to identification of the anatomical damage). 6. Needs: The needs (N1) for therapeutic interventions are determined based on the findings from the assessments (A1). Her pain must be relieved and the cause must be eliminated. 7. Interventions: A treatment plan (P1) is developed based on the priority assigned to identified needs, and the options available for treatment; priorities are selected based on the interventions available, the time elapsed from onset, and the overall condition of the patient: Relief: Symptomatic treatment, e.g. painkillers, are administered. Causative treatment Option 1: Immediate surgical removal of the gallbladder including administration of analgesic
24 Chapter 2 Table 2.1. Clinical course of Case 1. Assessment no. (A)
Findings
Needs (N)
Treatment option(s)
Plan (P)
Intervention (I)
1
1. Paralysis right leg and weak right arm 2. Facial asymmetry 3. BP = 200/130 mmHg 4. Cholesterol = 300mg/dl = 6.5 mmol/l 1. Improved muscle strength right leg 2. BP = 160/120 mmHg 3. Cholesterol = 320 mg/dl = 7 mmol/l
1. Removal of clot
1. Observation 2. Dissolve clot using fibrinolytic agent
1. Administer fibrinolytic agent
1. Fibrinolytic agent administered
1. Restore muscle strength and speech 2. Lower cholesterol 3. Control BP
1. Start physical and speech therapy 2. Lower BP
1. Provide daily physical and speech therapy 2. Initiate medication to control BP
3
1. Further improvement of muscle strength 2. Speech improved 3. BP = 140/100 mmHg 4. Cholesterol = 320 mg/dl = 7 mmol/l
1. Continued physical and speech therapy 2. Lower BP 3. Lower cholesterol 4. Discharge from hospital
1. Physical and speech therapy 2. Antihypertensive treatment 3. Lower blood cholesterol level 4. Discharge to rehabilitation facility for recovery 1. Discharge to home 2. Discharge to rehabilitation facility 3. Arrange for home care 4. Continue physical and speech therapy 5. Change dose/ drug for control of blood pressure 6. Add statin to lower blood cholesterol level
1. Arrange outpatient follow-up 2. Speech therapy outpatient 2 times/week 3. Physical therapy outpatient 3 times/week 4. Increase dose of blood pressure medication 5. Low dose statin prescribed
4
1. Near-normal muscle strength; able to walk without assistance 2. Speech clearer 3. BP = 125/95 mmHg 4. Cholesterol = 300 mg/dl = 6.5 mmol/l 1. Returns to normal physical and mental activities and employment 2. BP = 125/85 mmHg 3. Cholesterol = 270 mg/dl = 6.3 mmol/l
1. Exercise programme 2. Speech therapy 3. Lower BP 4. Lower cholesterol
1. Home exercise 2. Outpatient exercise 3. Continue speech therapy 4. Lower blood pressure further
1. Discharge to home 2. Arrange nurse visits 3. Increase antihypertensive drug dose 4. Physical therapy 3 times/week 5. Speech therapy 3 times/week 6. Begin statin for control of cholesterol 7. Follow-up consultation by physician 1. Enroll in supervised exercise programme 2. Additional BP control medication 3. Continue statin
1. Exercise programme 2. BP and cholesterol control medications
1. Resume normal activities 2. Continue current medications 3. Control diet
1. Discontinue home nurse visits 2. Resume normal activities 3. Consultation with dietician
1. Continue current medications and exercise 2. Continue current therapy 3. Modify diet 4. Follow-up visits to physician
2
5
1. Daily exercise programme initiated 2. Outpatient speech therapy once/week 3. 2nd BP control medication added 4. Statin continued
Normal BP values are age dependent but
SJP0010.1177/1403494813514915K.O. SundnesShort Title
Scandinavian Journal of Public Health, 2014; 42(Suppl 14): 21–28
Structural Framework Chapter 2
Clinical models applicable to disasters
Abstract Processes used for research of disasters are similar to those used for the assessment, determination of needs, planning, selection of interventions and their implementation, and evaluation of patient outcomes in the clinical setting. A patient suffering a stroke and another patient with an acute inflammation of the gallbladder serve as examples. Patients travel along the same longitudinal progression as do disasters and clinical assessments are conducted using the body’s organ systems. Key Words: Assessment, clinical models, disaster, evaluation, framework, implementation, interventions, longitudinal phases, needs, patients, phases, planning, society, systems, transectional
Introduction The processes by which clinicians approach a patient who is seeking care are similar to those that can be used to analyse disasters. Both utilise a longitudinal framework comprised of distinct but overlapping phases. Clinically, transectional assessments are conducted using body organ systems that describe the changes in the status from the baseline, pre-event health status along the longitudinal clinical course. From the observed functional changes (symptoms and signs), the clinician is able to identify the cause of the disturbances in functions (pathophysiology) and, thus, treat the cause(s) in a manner that will shorten convalescence, minimise the morbidity, and ultimately the possibility that the patient will die from the dysfunctions of the organ systems affected. Both the underlying pathology/pathophysiology and the symptoms are treated in an effort to return the patient as closely as possible to his/her pre-event functional status. Often, measures are taken during or following the recovery phase that are designed to minimise the risk that such an event will recur. Throughout a patient’s clinical course, repeated assessments of her/his physiological status are conducted and compared with the patient’s status before the precipitating event occurred. These assessments utilise indicators of functions to assess the status of specific organ systems and are performed throughout the patient’s clinical course until recovery has been achieved. Clinical models Both a patient’s clinical course and a disaster share longitudinal phases. Similar to what occurs in clinical medicine, disasters follow a longitudinal course from © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494813514915
the pre-event (baseline) status through the crisis, relief, and recovery. Therefore, clinical examples familiar to healthcare personnel are presented in order to facilitate the understanding of the longitudinal phases and transectional assessments, plans, and interventions (responses) that also are characteristics of disasters. Case 1 A 62-year-old man experienced sudden onset (timepoint zero, TPZ)1 of paralysis of his right leg, weakness of his right arm, and an inability to walk or to speak coherently. His clinical course is illustrated in Figure 2.1 and summarised in Table 2.1. The patient’s clinical course included: 1. Pre-event health status (baseline): He has been healthy except for a 30-year history of smoking cigarettes, being treated for high blood pressure and has been noted to have “high” blood cholesterol levels. His health status prior to the onset serves as the baseline to which all subsequent assessments are compared. 2. Event: He had experienced a sudden-onset event that occurred over seconds or minutes caused by a blood clot that obstructed a cerebral (brain) artery, which delivers blood containing essential oxygen and nutrients to a part of his brain. 3. Damage: The structural (anatomical) damage to his brain as a result of the obstructed blood flow, was rapidly progressive as cells were deprived of oxygen and, eventually, irreversible cell injuries (cell death) would cause substantial morbidity (if not death).
22 Chapter 2 4. Disturbances of functions: The cellular injury (damage) led to changes in function that present with symptoms and signs of neurological deficits (paralysis of his right leg and weakness and numbness of his right arm, inability to walk, inability to speak coherently, and asymmetry of his face). 5. Assessments: Since the clinician is unable to see the anatomical injury and its cause (blood clot in a cerebral artery), the clinician assesses the patient for changes in function (physiological abnormalities) (A1) (Figure 2.1) to identify the possible structural damage sustained and its likely causes (functional deficits lead to identification of anatomical damage that has occurred); this anticipated cause is confirmed using laboratory and imaging studies. 6. Needs: Based on the findings of the assessments, it is determined that the patient needs (N1) restoration of cerebral blood flow through the occluded artery.2 The options for therapeutic interventions to halt the ongoing destruction of brain cells and minimise the long-term disability are determined based on the findings from the first assessment (A1) and a plan (P1) for relief of the primary problem is developed – the blood clot must be dissolved). 7. Intervention: A treatment plan (P1) is developed based on the findings from the assessments (A1), the priorities assigned to the patient’s needs, the options available for treatment, the time elapsed from the onset (TPZ), and the overall condition of the patient. The options most likely to provide the greatest benefit with the least negative effects include: Option 1: Adopt a “wait and see” approach: let the process evolve, provide sedation, intensive physical and speech therapy, and prepare the patients for recovery of best possible function in a rehabilitation centre; or Option 2: Attempt to dissolve the blood clot using a fibrinolytic pharmacological agent plus intensive physical and speech therapy.3 In this case, an infusion of a fibrinolytic drug is implemented (I1). 8. Recovery: Following conclusion of the administration of the fibrinolytic drug, a second assessment (A2) of the functional status of the patient is conducted. Muscle strength of and sensation in his right arm have improved and he is able to move his right leg. His facial asymmetry has cleared, but his speech remains garbled. His blood pressure remains elevated (160/120 mmHg), and his cholesterol levels remain unchanged. Based on the findings of this assessment and his current needs, a new plan (P2)
is developed that includes initiation of physical therapy to improve muscle strength and restore his ability to walk and care for himself and speech therapy to restore his ability to communicate (recovery) (N2). In addition, an antihypertensive medication is begun to lower his blood pressure in an effort to prevent a recurrence of a stroke (I2). The effects of these therapeutic interventions (responses) are identified 1 month after his admission by using a third set of assessments (A3). At this time, his strength has improved further, but he still is unable to walk without assistance, he speaks coherently, blood pressure (BP) is 140/100 mmHg, and his cholesterol remains unchanged. The dose of antihypertensive medication is increased (I4), and a statin (cholesterol-lowering drug) is started in an effort to lower his blood cholesterol level. Full recovery to his pre-event functional status, or the lack thereof, is documented by conducting repeated assessments (A4–A5); 9. Development: Also, continued efforts are directed toward controlling his blood pressure and cholesterol levels (N3, N4, I4) and other treatments that will reduce the risk of a clot (e.g. cardiac arrhythmias). From this example, it is clear that if the damage was allowed to progress without interventions, it could have resulted in the further decline of vital functions to levels below critical thresholds and lead to the patient’s death. If damage is not lethal, it is likely that the ongoing damage will render the patient dysfunctional (i.e. he would remain below his functional threshold and would not recover to a fully functional life). If treatment is very successful, his functional status may be restored to a functional level equal to his functional threshold of his pre-event status. Case 24 A 50-year-old obese woman complained of pain in her right upper abdomen that had been progressive over several hours. Her clinical course can be mapped as diagrammed in Figure 2.2 and is summarised in Table 2.2. The patient’s clinical course included: 1. Pre-event health status (baseline): During the past 4 months, she has experienced intermittent episodes of upper abdominal pain and distension usually following eating. She also has been
Clinical models applicable to disasters 23 Pre-event Status BP 160/130 mmHg, Cholesterol = 320 mg/dl Event
Damage
Change in function
Blood clot cerebral artery Reduced oxygen delivery
Brain cell injury
Paralysis right leg; weakness right arm; facial asymmetry
N1 P1
Relief
Improved strength +speech; Cholesterol = 320 mg/dl
Improved strength; Speech improved; Cholesterol = 320 mg/dl
Walking; speech improved
I1: Fibrinolytic agent
N2 P2
Recovery
I2: Physical + speech therapy
N3 P3
I3: Discharge from hospital, Physical/speech
N4 P4
therapy
A1
A2
I4: Inc BP meds and statin dose BP = 125/95 mmHg; cholesterol = 300 mg/dl
I3:BP control + statin prescribed BP = 140/100 mmHg;
I2: BP treatment; BP = 160/120 mmHg
Development
A3
I4: Exercise; speech therapy
A4
A5
Time
Figure 2.1. Graphic representation of the clinical course of a patient who suffers a stroke using a longitudinal framework that similarly can be used in the description of a disaster. Assessments (A1–A5) of physiological status are repeated during the longitudinal course. Plans are made based on the findings of the assessments, and decisions are made as to which elements in the plan will be implemented. Then, chosen interventions are implemented and the assessments are repeated to note the changes that occur in functions related to the treatment (interventions) provided. Functional recovery may in this case come from recovery of brain cells or mobilising other cerebral structures due to specific training. BP: blood pressure; I1–I4: interventions; N1–N4: needs; P1–P4: plans.
2.
3.
4. 5.
unsuccessful in trying to lose weight and has been told that her blood cholesterol level is “too high”. Event: Over the past 6 hours (TPZ = −6 hours), she has experienced pain that has become steady and has been increasing in severity. The pain is related directly to a gallstone lodged in the cystic duct (event) Damage: The structural (anatomical) damage to the gallbladder is progressive and without intervention, may result in necrosis (death) and rupture of the gallbladder resulting in a serious threat to her life (critical threshold). Disturbances in functions: The structural damage has led to a change in function (indigestion, nausea, bloating, and pain). Assessment: The clinician is unable to visualise the damage occurring in the gallbladder and performs an assessment (A1) in order to identify changes in function (physiological abnormalities) that have resulted from the damage to the gallbladder and the cystic duct. The assessment
includes symptoms and physical signs, and laboratory, and imaging studies to help to identify the structural damage sustained. These assessments point to gallbladder disease (acute cholecystitis); (identification of functional deficits led to identification of the anatomical damage). 6. Needs: The needs (N1) for therapeutic interventions are determined based on the findings from the assessments (A1). Her pain must be relieved and the cause must be eliminated. 7. Interventions: A treatment plan (P1) is developed based on the priority assigned to identified needs, and the options available for treatment; priorities are selected based on the interventions available, the time elapsed from onset, and the overall condition of the patient: Relief: Symptomatic treatment, e.g. painkillers, are administered. Causative treatment Option 1: Immediate surgical removal of the gallbladder including administration of analgesic
24 Chapter 2 Table 2.1. Clinical course of Case 1. Assessment no. (A)
Findings
Needs (N)
Treatment option(s)
Plan (P)
Intervention (I)
1
1. Paralysis right leg and weak right arm 2. Facial asymmetry 3. BP = 200/130 mmHg 4. Cholesterol = 300mg/dl = 6.5 mmol/l 1. Improved muscle strength right leg 2. BP = 160/120 mmHg 3. Cholesterol = 320 mg/dl = 7 mmol/l
1. Removal of clot
1. Observation 2. Dissolve clot using fibrinolytic agent
1. Administer fibrinolytic agent
1. Fibrinolytic agent administered
1. Restore muscle strength and speech 2. Lower cholesterol 3. Control BP
1. Start physical and speech therapy 2. Lower BP
1. Provide daily physical and speech therapy 2. Initiate medication to control BP
3
1. Further improvement of muscle strength 2. Speech improved 3. BP = 140/100 mmHg 4. Cholesterol = 320 mg/dl = 7 mmol/l
1. Continued physical and speech therapy 2. Lower BP 3. Lower cholesterol 4. Discharge from hospital
1. Physical and speech therapy 2. Antihypertensive treatment 3. Lower blood cholesterol level 4. Discharge to rehabilitation facility for recovery 1. Discharge to home 2. Discharge to rehabilitation facility 3. Arrange for home care 4. Continue physical and speech therapy 5. Change dose/ drug for control of blood pressure 6. Add statin to lower blood cholesterol level
1. Arrange outpatient follow-up 2. Speech therapy outpatient 2 times/week 3. Physical therapy outpatient 3 times/week 4. Increase dose of blood pressure medication 5. Low dose statin prescribed
4
1. Near-normal muscle strength; able to walk without assistance 2. Speech clearer 3. BP = 125/95 mmHg 4. Cholesterol = 300 mg/dl = 6.5 mmol/l 1. Returns to normal physical and mental activities and employment 2. BP = 125/85 mmHg 3. Cholesterol = 270 mg/dl = 6.3 mmol/l
1. Exercise programme 2. Speech therapy 3. Lower BP 4. Lower cholesterol
1. Home exercise 2. Outpatient exercise 3. Continue speech therapy 4. Lower blood pressure further
1. Discharge to home 2. Arrange nurse visits 3. Increase antihypertensive drug dose 4. Physical therapy 3 times/week 5. Speech therapy 3 times/week 6. Begin statin for control of cholesterol 7. Follow-up consultation by physician 1. Enroll in supervised exercise programme 2. Additional BP control medication 3. Continue statin
1. Exercise programme 2. BP and cholesterol control medications
1. Resume normal activities 2. Continue current medications 3. Control diet
1. Discontinue home nurse visits 2. Resume normal activities 3. Consultation with dietician
1. Continue current medications and exercise 2. Continue current therapy 3. Modify diet 4. Follow-up visits to physician
2
5
1. Daily exercise programme initiated 2. Outpatient speech therapy once/week 3. 2nd BP control medication added 4. Statin continued
Normal BP values are age dependent but
