Physical Therapy Advisory: Take Blood Pressure. Now.
By Erika Jayne, PT, DPT, CDP
Physical therapist
What is your worth and how do you stand out as a physical therapist?
Is it your ability to assess the foundations of our autonomy?
Is it your ability to prescribe exercise?
Is it your ability to prevent or stymie impairments?
Of course, each of these factor in our worth.
We must treat the whole patient— not just the broken wrist, balance deficits, or back pain. Yes, you learn it in school but in a traditional outpatient clinic, it can be easy to fall into that rut and forget.
2020 is quickly approaching and what sticks out in my head from when I graduated in 2012 is a question that was posed to my graduating class and me: “In the year 2020, physical therapists will be practitioners of choice. What is your worth and how will you achieve this goal? How will you set yourself apart from the cookie-cutter therapist?”
As a newly graduated physical therapist, I had no idea how to answer this question. I was not even sure I would survive in the physical therapy world. It actually was not until I started working with FOX Rehabilitation and started working with patients who had multiple comorbidities that I knew what the answers to those questions were.
With FOX, I see one patient at a time. We tailor each individual plan of care to meet the needs of the individual. Taking vitals is probably one of the single-most important interventions you can do for your patient. Blood pressure, lung sounds, and heart rate can provide valuable information about a patient’s current health. We have the ability to treat the whole patient and set ourselves apart as clinicians.
I recently spoke to a gentleman about FOX Rehabilitation and he said to me, “If a physical therapy screen was a part of everyone’s yearly physical; older adults would be much healthier because problems would be caught earlier.”
I agree with this statement 100percent. If physical therapy was a part of a yearly physical maybe people would be more likely to have their condition be treated sooner rather than later.
PHYSICAL THERAPISTS ARE IN A UNIQUE POSITION TO CATCH ORTHOSTATIC HYPOTENSION.
Have you ever said to yourself, “Thank God I checked that patient’s vitals today!” I know I have said this several times.
Most recently I had a patient whose blood pressure was consistently 126/66. He had been told he “may” have COPD but did not have a diagnosis. He had a history of oxygen levels dropping to 88 with gait.
The day I saw him the sun was shining and we decided that it would be the perfect day to start focusing on gait outside. He wanted to be able to leave the senior living community with his family. We got approximately 25 feet out the door when he said, “I can not walk anymore.”
He could not explain his symptoms, his only response was, “I am short of breath and I need to sit down.”
He was not visibly showing signs of shortness of breath or distress. His oxygen was 98 percent and BP was still 126/66, HR 76 and regular, lungs sounded clear. With him not being able to explain his symptoms properly, I decided to have him stand again. His BP dropped to 98/52. He was experiencing orthostatic hypotension.
This prompted a call to his primary care physician, which in turn prompted a referral to the cardiologist. In this patient’s case, his Lisinopril needed adjusting. I’m happy to say he has not experienced any more symptoms and his oxygen has been discontinued.
Orthostatic hypotension can tell us a lot about our patients’ health. It can tell us if someone is anemic, low in protein, dehydrated, or having a reaction to beta-blockers or antidepressants. Additionally, this may be an indicator for other cardiovascular diseases such as irregular heart rate and heart failure and be one of the first signs of Parkinson’s disease or lead to falling and further injuries. With a combination of rapid HR, it can also result in an undiagnosed UTI progressing toward septic shock.
By starting with the simple but important responsibility of checking vitals, physical therapists can recognize and report hypotension. You can aid in the diagnosis of conditions that were undetected during the 15 minutes of a PCP’s office visit. We are a critical support in providing excellent health care.
A PT TAKING VITALS SHOULD NOTE THE IMPORTANCE OF HYPERTENSION.
There are two types of hypertension: primary and secondary.
Primary hypertension is referred to as high blood pressure that has no secondary cause unlike secondary hypertension can be linked to genetics, lack of exercise, and poor diet.
Secondary is usually sudden can caused by another medical condition. Secondary hypertension can be a result of kidney issues, thyroid issues, obstructive sleep apnea, and adrenal gland complications. It can also be caused by certain cold and pain medications. In many cases, stress and headaches can be indicative of high blood pressure. This can lead to stroke, myocardial infarction, vision problems, heart failure, memory issues, or vascular dementia if untreated.
We all have had those patients who have had no prior medical history of HTN and then we have one visit where the BP is a little higher than normal. The patient reports an increased stress level but, on the next visit, it’s still high. That should prompt a call to the PCP and lead to a follow-up visit.
Conversely, low blood pressure can indicate kidney failure, heart attack, and stroke. So what is the cause of a patient’s new symptoms? Again, I stress, we are the PCP’s support. We see our patients two-to-three times per week. A PCP may only see a patient once every six months to a year if they are generally healthy.
LUNG SOUNDS ARE IMPORTANT, TOO.
If the lungs sound bad then it is bad. If something sounds wrong then call the doctor. Ask questions. I would rather be the squeaky wheel, call the PCP, and find out those sounds are nothing than do nothing when the sound’s source is something bad.
Just last week I had a patient on the stairs. Her goal is to get home and clean her house. Visits prior, we had practiced two or three sets of stairs at a time. On this particular day we got halfway up the first set of steps when she says, “Wow, I am tired today. I need to sit.” So we sat down on the steps and when she was ready we finished going up.
On the way down she says, “I need to sit again. I am just really tired. I feel a little shortness of breath.” We got to the bottom of the stairs and I retook her vitals. BP was normal, HR normal, oxygen 91 percent which was low for her, but with cues for proper breathing her 02 returned to 95 percent.
I listened to her lungs. They sounded slightly diminished, but nothing that would warrant me to panic. I did worry though.
About one month prior, I had sent her to the physician to have a Doppler done because she had all the signs of deep vein thrombosis. The Doppler test was positive. Two weeks later she was cleared to do physical therapy. My worry at this moment was that now she may have a pulmonary embolism.
So I called her physician and asked them to do a chest X-ray. It turns out I was wrong about it being a PE, however, I was right that something was off. She was diagnosed with pneumonia. It was caught early enough to avoid hospitalization and she was put on antibiotics.
COMMUNICATE WHEN VITALS SEEM OFF.
On another occasion, a different team member went to do an evaluation and the patient’s HR was 38 bpm and irregular. He was not symptomatic, able to carry on a conversation, got up and ambulated to the bathroom, no dizziness or lightheadedness. My colleague, the clinician, alerted the nurse who called the PCP, which prompted the patient being sent to the hospital.
Later, we got a report that said the hospital called and by the time he got to the hospital he had been in and out of consciousness. IV fluids and medication were given. That patient is doing fine now.
How about being in the right place at the right time?
I have been hearing, as my colleagues have:
“That is not within your scope of practice.”
“You take too many vitals”
Finally, we will hear, “Thank you for your great work we are glad to work with FOX,” because one of our clinicians was that squeaky wheel and kept taking vitals.
A patient had been diagnosed with multiple pulmonary embolisms. I am so proud of my fellow colleagues for being the squeaky wheel and advocating for our patients when other professionals don’t share our concerns.
HOW A PHYSICAL THERAPIST CAN SHOW THEIR WORTH.
We as clinicians need to show our value. We need to be making sound clinical judgments. We are not just therapists who walk people. We must take vitals pre, post, and during treatment.
We cannot just be therapists who go through the motions. Next, to the patient’s family members, we spend the most time with these older adults. We need to be paying attention to the small details.
Part of our worth comes from being primary care physicians’ support. By presenting physicians with the clinical facts every time and for every patient, we provide our patients with the best care possible.
You may be saving a life.