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It’s no news flash that walking requires quite a bit of lower-body strength. You need powerful glutes, quads, hamstrings and calves to propel you forward. You might also recognize the crucial role your abs play in keeping you upright and lightening the load on your lower half. But there’s one muscle you probably never even think about when it comes to your stride. We’re talking about your “lats” (or latissimus dorsi), the biggest muscle of your upper body. Affording itself a large attachment centrally from the T7 to L5 spinouses, laterally to the iliac crest and thoracolumbar fascia, to the lower three or four ribs and inferior angle of the scapula, to travel superiorly and laterally to attach to the medial lip of the intertubercular sulcus, it is perfectly situated to effect both the upper and lower extremities in a large variety of movements. It is one of the quintessential and often overlooked muscles in gait. It is generally quiet electrophysiologically (EMG) during pre-gait activities (1,2) but as speed increases, the muscle becomes more engaged and active (2-4). The latissimus dorsi is the functional link between the upper and lower extremity, particularly through its connections with the thoracolumbar fascia (5,6).

The lat muscle is a key driver in the Posterior Oblique Sling System, which helps explain the relationship between the arms and legs during the gait “walking” cycle. The posterior oblique sling is a cross-body pattern composed of the gluteus maximus, thoracolumbar fascia (TLF) and contralateral latissimus dorsi muscle, which connects the shoulder with the opposite hip to facilitate locomotion. Dysfunction in this system puts the brakes on power, strength, speed and performance. To understand how your lats affect your walking performance, think about your gait or your movement pattern while you walk: “As your left leg steps forward, your right arm swings forward, thus you’re creating a rotational force, the abdominals and lats help with this rotational movement. The stronger your lats, the easier this twisting motion becomes and the more efficiently you nail your stride. Plus, strong lats help ensure the rest of your muscles don’t have to work in overdrive. Translation: You won’t tire out so fast and you’ll be able to walk/jog/run for longer time frames. Whatever was fatiguing you before won’t fatigue as fast, because you’re bringing more muscles to the party. You’ll be surprised just how much your lats are a part of the equation once you focus on strengthening them.

An easy way to tell whether you need to increase your patient’s or perhaps even your own lat strength is to assess form. Here are a couple of tell-tale signs to look for when walking: If the patient/client starts to fall forward or slouch their head forward, and if the shoulder blades are creeping up by the ears, this most likely indicates an opportunity to strengthen the lats. But before you get started with those strengthening exercises, you need to make sure the surrounding muscles aren’t getting in the way, for example, tight triceps (the backside of the arm) or upper trapezius (where your shoulder meets your neck) can inhibit the lats from activating during exercises. This would work against the patient/clients best efforts. Once you have had the patient/client complete a few tricep and upper trap stretches, it’s time to start strengthening the lats. Some suggestions to start with include:

1. Seated Row
   ● Using a resistance band or a cable row machine, sit upright with your legs out straight. If using a resistance band, hook it around your feet. No matter the equipment, roll your shoulders back and down, “packing” them into your lats.
   ● Keeping the elbows tight and close to your body, row your elbows straight back, pinching your shoulder blades together.
   ● Reset with control, then repeat.
   ● Do 3 sets of 10 to 15 reps.
2. Bent-Over Fly
   ● Stand with soft knees, holding a dumbbell in each hand by your sides. Hinge forward at the hips with a flat back and neutral neck. Allow your arms to hang down under your chin with a slight bend in the elbows.
   ● Leading with your elbows, bring your arms back and imagine you’re hugging a tree backward, squeezing your shoulder blades together. Hold for one second before lowering down with control.
   ● Do 3 sets of 10 to 12 reps with dumbbells appropriate for your patient/client.
3. Superman Lift
   ● Lie face-down on the floor with your arms and legs extended. Squeeze your glutes to glue your ankles together and lock your arms tight next to your ears. Keep your neck neutral, and gaze down toward the floor throughout the whole movement.
   ● Use your back to lift your legs off the ground, trying to lift your quads off the ground without bending at the knees. Lower with control. Repeat with just the upper body.
   ● Once you’ve mastered isolating the lower and upper, add them together, lifting all four extremities off the ground and holding at the top before lowering with control.
   ● Do 4 sets of 15 to 20 reps.

Beyond strengthening and stretching the lats to improve gait function, it’s also important to remember that if the patient/client has latissimus dorsi pain and/or referred pain, this can also impact range of motion and muscle activation patterns, including the patient’s gait quality. Dry needling is one modality that PTs may be able to use to decrease lat pain and improve the overall performance of this muscle by improving its function, thus improving range of motion and muscle activation patterns (7-9).

By Jon Anderson, DPT, Therapy Resource

References:

1. Houglum P, Bertoti D in: Brunstrums Clinical Kinesiology 6th Edition, FA Davis 2012 p.558
2. G. Cappellini, Y. P. Ivanenko, R. E. Poppele, F. Lacquaniti Motor Patterns in Human Walking and Running Journal of Neurophysiology Published 1 June 2006 Vol. 95 no. 6, 3426-3437 DOI: 10.1152/jn.00081.2006
3. Shin S, Kim T, Yoo W. Effects of Various Gait Speeds on the Latissimus Dorsi and Gluteus Maximus Muscles Associated with the Posterior Oblique Sling System. Journal of Physical Therapy Science. 2013;25(11):1391-1392. doi:10.1589/jpts.25.1391.
4. Kim T, Yoo W, An D, Oh J, Shin S. The Effects of Different Gait Speeds and Lower Arm Weight on the Activities of the Latissimus Dorsi, Gluteus Medius, and Gluteus Maximus Muscles. Journal of Physical Therapy Science. 2013;25(11):1483-1484. doi:10.1589/jpts.25.1483.
5. Vleeming A, Pool-Goudzwaard AL, Stoeckart R, van Wingerden JP, Snijders CJ. The posterior layer of the thoracolumbar fascia. Its function in load transfer from spine to legs. Spine (Phila Pa 1976). 1995 Apr 1;20(7):753-8.
6. Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip R. The thoracolumbar fascia:anatomy, function and clinical considerations. Journal of Anatomy. 2012;221(6):507-536.doi:10.1111/j.1469-7580.2012.01511.x.
7. Dar G, Hicks GE. The immediate effect of dry needling on multifidus muscles function in healthy individuals. J Back Musculoskelet Rehabil. 2016 Apr 27;29(2):273-278.
8. Ortega-Cebrian S, Luchini N, Whiteley R. Dry needling: Effects on activation and passive mechanical properties of the quadriceps, pain and range during late stage rehabilitation of ACL reconstructed patients.Phys Ther Sport. 2016 Sep;21:57-62. doi: 10.1016/j.ptsp.2016.02.001. Epub 2016 Feb 24.
9. Dommerholt J. Dry needling — peripheral and central considerations. The Journal of Manual & Manipulative Therapy. 2011;19(4):223-227. doi:10.1179/106698111X13129729552065.

With our focus on meeting all the needs of our communities, we wanted to provide some information about our Colonial Manor of Randolph outpatient program. Randolph, Nebraska, is a town with a population of 894. Despite that, they have found a way to operate as one of the largest outpatient programs as an Ensign Affiliate. Here is what Eric Feilmeier, OT, CLT, DOR, has to say about why they have been able to have success!

When working to build a successful outpatient clinic, it is important to begin with Core Values. Here are few values that we have found to be important:

1. Deliver WOW through service.
2. Embrace and drive change.
3. Create fun.
4. Be adventurous, creative and open-minded.
5. Pursue growth and learning.
6. Build open and honest relationships with communication.
7. Build a positive team and family spirit.
8. Do more with less.
9. Be passionate and determined.
10. Be humble.

We have had success in our Nebraska market due to a number of reasons. First and foremost, be supportive of your therapists. Provide clinically centered CEU opportunities that focus on problems in your area. Here at Colonial Manor, we are LSVT certified and are going through power moves certification, urinary incontinence certification and Lymphedema Certification. Provide programming around the skills of your Therapists so they can get to the bottom of each patient’s problems. It’s important to educate on HEP for patients, but then leave that to them and focus on the true needs, utilize the specialty equipment in our gyms and provide proper intensity of treatment.

• Make sure the patient feels that they got a lot out of each session.
• Provide proper frequency. MAKE IT COUNT IN THE GYM! Remember, the patient won’t typically do as much at home. Modalities: We work closely with ACP rep to provide the best adjunct treatment options to assist with improving care. Patient’s Love modalities- modalities provide physical and psychosomatic results.

When working with your outpatient, always assess additional problems and needs that the patient may not realize themselves. Ask questions, because there might be a higher need for another discipline to step in. We are always looking out for one another’s skill sets and the potential benefit to collaborate our services to further meet the needs of our client.

Cancellation Management is the biggest obstacle of our Outpatient business. We do our best to stop cancellations, but that is not always easy. Some tips to reduce cancellations include:

Evaluations:

• Provide a message. Ask the patient why they are in your clinic, what they expect and what they want to gain.
• Hold their answers against them (In a positive way). Always have a conversation during the evaluation about the frequency and the importance of coming to therapy when they are scheduled, expressing to them that we can help them but they must come to scheduled appointments to make a difference (hold them accountable).Call ins: Problem-solve
• When you get the patient on the phone and they want to cancel, ask, Why? What are you experiencing? Many times, the reason for the cancelation is exactly why they should be coming into their appointment. Be adamant and convince them to come in, if you believe you can help them.
• When a patient leaves a message, call them and ask them the same questions. They may just need to be convinced that you can help them!
• Move treatment times to another time of day or to a whole other day. Flexibility in your clinic is the key!

Last but not least, build and maintain relationships with your Physicians and Nursing. Frequent updates to communicate patient results to Physicians is always appreciated. Send notes or small updates with the patient to their next doctor appointments, even if the doctor doesn’t request it. These notes can be a quick word Doc, a progress note that is timed with an appointment, or even a nicely handwritten note.

All in all, have goals to grow your Outpatient clinics. Focus on the patient, and you will see excellent results. I even encourage devising a patient satisfaction survey to monitor your success and areas of opportunity. Good luck!

By Eric Feilmeier, OT, CLT, DOR, Colonial Manor, Randolph, NE, and Ryan Hough, Therapy Resource, Gateway, NE

According to a recent article in The Wall Street Journal, “Cognitive problems are among the most persistent and common lasting effects of COVID.” Many of these cognitive issues are becoming long-term symptoms months after an active COVID dx.

It’s important that we understand Post-COVID-19 syndrome, which is signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks, and are not explained by an alternative diagnosis. Post-COVID-19 syndrome may be considered before 12 weeks while the possibility of an alternative underlying disease is also being assessed. These patients are also commonly referred to as “long-haulers.”

Therapy teams need to take an active role in the ongoing assessment and intervention of cognition. It’s especially important to know the patient’s PLOF and not discontinue services too soon, knowing that cognitive impairments with this population will continue long after the active diagnosis. Cognitive intervention is also important for our outpatient population in both ALFs and in the community. Physicians need to know that we are available to partner with post-COVID patients who have lingering cognitive issues.

Starting with a brief assessment such as the St. Louis University Mental Status Exam (SLUMS); Clock Drawing Test; Addenbrooke’s Cognitive Exam (ACE); or MINI-COG will provide initial information on the level of cognitive impairment (none, mild, Dementia level).

Once determined, it is clinically recommended to complete a formal standardized assessment and log Cognitive Performance Assessment 96125. Examples include: Ross Information Processing Assessment-Geriatric Edition (RIPA-G); Cognitive Linguistic Quick Test (CLQT); Functional Linguistic Communication Inventory (FLCI); The Scales of Cognitive and Communicative Ability for Neurorehabilitation (SCCAN); and Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES). Utilize assessments that at minimum can address: memory (i.e., list learning task; paragraph recall task; digit repetition, etc.); working memory/executive function; executive function (problem solving; planning; inhibition/initiation); and processing speed.

Once the assessments are completed, clinicians will know which areas of cognition to target with skilled intervention. Please refer to the various POSTettes (Post COVID; Cognitive Performance Assessment; SLP Cognitive Impairments) and the Cognitive Impairments Clinical Guide for additional information.

https://www.wsj.com/amp/articles/new-long-covid-treatments-borrow-from-brain-rehab-tactics-11617652800

By Tamala Sammons, M.A., CCC-SLP, Therapy Resource

By Ryan Hough, Therapy Resource – Gateway NE
Kim cooper, our lead OT at Wayne Countryview Care and Rehab in Wayne NE, is a very clinically driven therapist who is always creatively implementing programming to address the needs of the residents. Kim recently identified several patients with low vision, and immediately went to work to strategize ways to improve their lives. She pursued a partnership with The Nebraska Commission for the Blind and Visually Impaired, and with their help and generous donations, they now have products for these residents to enhance their ability to participate and do day-to-day tasks. Some examples of the products donated are large bingo cards, large playing cards, writing templates, glare reducing sunglasses, dice with raised numbers, and an Eschenbach magnifier that works like a smart phone that you can move with fingers. When implementing any of these strategic interventions, remember to work with nursing to care plan the findings and the interventions provided.

Case Scenarios

Kim has a resident with severe macular degeneration. She has been staying in her room for meals because she was constantly spilling at meal time. Kim initiated therapy and worked closely with Nebraska Commission for the Blind. Kim designed a placement (picture attached) that lays out where the meal is all located so that she can find all of her utensils, foods and liquids. The placement is laminated and fits into the tray based on her vision loss. Patient was educated on the design of the placement along with the caregivers so that the lay out is always the same. This has resulted increased independence and self-esteem, as she now doesn’t need to stay in her room to eat meals. In part because of this success, they are exploring a discharge to an ALF that otherwise may not be possible.

Resident number 2 has severe glaucoma. This resulted in not being able to read the lunch menu, read the clock, read the activities schedule, and she stopped playing bingo because she couldn’t see the cards. They worked with Commission for Blind to get a talking clock, a magnifier similar to IPad size/Eschenbach magnifier that gives her color contrast, up to 12x the magnification, and camera to take a picture. Resident is much more engaged in daily activities within the facility and even resumed doing her cross-word puzzles.

Do you have similar commissions in your market? Take a look for a great partnership opportunity!

By Kelly Alvord, Therapy Resource, Sunstone-Utah
In the Sunstone market, as we continue to partner with ALF to enhance Outpatient (OP) business, a lot of emphasis has been put on strengthening partnerships with Home Health providers versus seeing them as competition. This partnership has led to increased referrals for OP services and OP growth. Here are some insights that the DORs have found helpful.

From Kirk Player, DOR Pinnacle
As far as PDGM goes from a HH agencies prospective:
● It benefits the agencies to get their patients better with as few visits as possible, including therapy. This is basically a 180 turn from the previous HH payment model.
● It also benefits the agencies to have LOS around 40 days when appropriate and possible. This allows them to enter the second 30-day period but still maintain visits to only those necessary.
We realized that in-home or in ALF outpatient therapy can help with both above points by allowing a safe d/c sooner by continuing and likely increasing the frequency of skilled therapy.
● This keeps a skilled clinician in with the patient to observe and assess any change of condition, which reduces readmissions.
● It also keeps the patient progressing with functional mobility and reduces other adverse events such as falls.

From Wes Spivey, DOR Hurricane
I got a head start being the discharge coordinator at St. George Rehab, allowing me to grow relationships with a lot of the home health companies in the area. Because of these strong relationships, we are starting to see our outpatient program grow. We got our first patient this week and will have our second in 1-2 weeks.

I have also met with a few ALF ownership groups through our home health partners, and once we hire a full time PT, OT, and SLP we have the green light to start working in that ALF.

From Scott Hollander, DOR Pointe Meadows It isn’t just Symbii (Pennant affiliated company) that I work with for ALF marketing. I get in touch with HH marketers and ask for an audience at their company IDT and IDG meetings. At these meetings, I take about 10 min. to share with their therapists and nurses how we can support them (especially with PDGM). They have fewer visits they can offer and I explain how we can come in behind them to continue therapy services. This turns into referrals from their clinicians, and many times during their d/c call to the MD office, they ask for an outpatient therapy order that is given to us!

I educate them on how we can also provide therapy to hospice patients in certain circumstances as long we code the cases as “07” on the billing side and that the hospice MD signs our orders. (This is a whole other conversation to have on another day.)

I also spend time with HH companies that are regulars for our patients that are discharged and ask for the return referral when they are finished. I have spent time actually going to ALFs with HH marketers to market for outpatient to show the ALFs that we are a team and that Pointe Meadows isn’t encroaching on HH patients. We discuss how if our outpatient therapists find a medical problem when treating a resident of theirs, we refer back to the MD, and if nursing is needed, back to HH.

Lately, Symbii HH has seen how much benefit this is to them and have actually been setting up marketing meetings for me! They are partnering with us in offering balance assessment clinics (We use CDC STEADI program for this). From these clinics, we gain patients every time.

Right before COVID hit last March, we had awesome momentum of our outpatient flywheel and were growing in 6 ALFs; then it all stopped. This last month, we’ve been pushing hard on the flywheel, and it is starting to pick up speed. The local ALFs are beginning to open their doors for us again, and we are excited to get back to a powerful outpatient program!

Why is respiratory function so important for SLP involvement?
● Successful phonation is dependent upon effective respiration.
● Uncoordinated breathing patterns or open vocal folds increase risk for aspiration. Compromised breath support limits cough strength and effectiveness to remove any substances that pass the vocal folds.
Low oxygen levels can affect:
● The heart due to the need for it to pump harder
● The brain, resulting in mood changes, reasoning and memory deficits (i.e. decreased cognitive function; increased safety risk)
● Physical abilities due to decreased sensory or motor planning (i.e., increased risk for falls)

The focus of SLP respiratory intervention is to improve the patient’s quality of breathing patterns for improved communication, swallow, and patient performance during ADLs or other physical activities. The goal of Respiratory Muscle Strength Training (RMST) is to increase the “force-generating capacity” of the muscles of inspiration and expiration; RMST can be used to target inspiratory or expiratory muscles, depending on patient needs (Sapienza, Troche, Pitts, Davenport, 2011).

Always measure the patient’s oxygen level and respiratory rate pre-, during and post-therapy activities. If oxygen falls below 90%, cue for deep nasal inhalation and/or other breathing techniques such as pursed lip breathing until levels resume. If levels are unable to resume, notify Nursing immediately. Additionally, assess and document the patient’s demeanor/anxiety levels during intervention.

Respiratory treatment interventions need to address:
● Proper breath control/breathing patterns
● Pursed lip/diaphragmatic breathing
● Sustained phonation
● Phrase production
● Respiration with swallow when issues are identified
● Airway protection

Create a Breath Support Tool Kit
● Straws, whistles, cotton balls, pinwheels, party horns, bubbles, etc.
● Professional tools, i.e., The Breathertm; EMST 150/75

Resistive Device Training Videos:

The Breather
https://www.pnmedical.com/lessons/in-service-video/

EMST 1500
https://emst150.com/how-to-train/

Sustained Airflow/Phrasing
● Have patient draw circles or other items while sustaining “ah”
● Blow bubbles at a target, blow cotton balls across a table/into a cup, blow pinwheels, whistles, etc. Add a straw for resistance.
● Utilize pre-made phrases already established in the number of syllables needed.
● Dual task: have patient read phrases while on exercise bike

Refer to SLP Respiratory Rehab POSTette for additional information

 

Wound debridement codes are intended for acute wounds that are debrided of devitalized tissue. Debridement is measured in total depth and surface area, going from skin level down to the bone.

● 97597 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less.

● 97598 Debridement each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure). Use 97598 in conjunction with 97597. Note: Log 97598 for each occasion of 20 sq cm after the initial 20 sq cm.

Example: If the treatment area is 60 sq cm
Log codes as follows:
97597 x 1
97598 x 2

Please see WoundCare POSTette for additional information and clinical examples when using the Wound Debridement CPT codes.

Log this code when:

1. The combined time it takes to conduct the evaluation, interpret the results, and write the evaluation report* is at least 31 minutes to report the first hour, 91 minutes to report the second hour, and so on.
2. The test is completed using a standardized assessment, independently or in conjunction with subjective observations and findings.

*Note: Clinicians may count interpretation and documentation time toward the minimum minutes only when billing for 96125, and only for Medicare Part B patients. Medicare Part A minutes still follow RAI manual guidelines of direct face-to-face time, which is followed regardless of code definition. Additionally, when administered as the initial evaluation, this code is non-MDS for Part A payers.

Completing standardized assessments supports evidence-based practice and helps to clearly identify where to target intervention for the best results. While tools like the SLUMs offer insight as to where a deficit may be occurring, they only allow a general categorization of cognitive impairment: normal, mild, or severe/dementia.

Utilizing formal standardized assessments for cognition will help determine which component of the cognitive impairments need intervention. With so many components of cognition, it’s best to assess as many areas as possible. Cognition is the greatest predictor of function. The more areas assessed, the stronger the plan of care and better patient outcomes.

Please refer to the Cognitive Performance Assessment POSTette for additional information.

By Tamala Sammons, MA, CCC/SLP, Therapy Resource
COVID-19 is a respiratory viral disease with multi-organ involvement resulting in potentially temporary and episodic health challenges such as impaired lung function, physical deconditioning, cognitive impairments, impaired swallow and communication, and mental health disorders.

The effect of the virus on the respiratory system appears to range from a simple respiratory tract infection to acute respiratory distress syndrome (ARDS) with multi-organ failure.
People with COVID-19 may also develop coagulopathy that can lead to venous thromboembolism (VTE) and microvascular thrombosis throughout the body, increasing the risk of negative mental health outcomes (https://academic.oup.com/ptj/article/100/12/2127/5903663).

Older adults respond to their own stress and that experienced by staff, which can increase the risk of behavioral problems. Isolation and lack of stimulation may also lead to loneliness and depression. Each of these negative psychological outcomes has a significant impact on an individual’s immune system and the ability to fight infection.

An increasing number of patients recovering from COVID-19 are having lingering cognitive symptoms, including confusion and impaired executive functions, short-term memory issues, and learning difficulties. For those who had compromised cognitive-communication status before COVID-19, we need to be ready for ongoing exacerbation of symptoms.

New survey standards: Surveyors are advised to investigate any concerns as part of the focused infection control survey related to residents who have had a significant decline in condition. Emphasis is on decline with the resident’s condition, both physical and/or psychosocial.
Therapy Interventions must address the clinical changes in our patients from this pandemic.

Occupational Therapy Intervention/Strategies
● Measure the effects of cardiac function and respiration, including any increased oxygen and/or oxygen weaning with ADLs (respiratory rehab ADLs; OT COPD treatment protocol)
● Assess functional mobility — high fall risk
● Provide energy conservation and work simplification interventions
● Consider cognition, cognitive rehabilitation and occupational performance; and address cognitive impairments
● Address psychosocial (OT psychosocial interventions), mental health (AOTA OT’s role with mental health recovery), stress (HRV training), and coping-related PTSD or anxiety disorder post-COVID-19
● Community reintegration

Physical Therapy Intervention/Strategies
● Measure the effects of cardiac function and respiration, including any increased oxygen and/or oxygen weaning with physical performance (respiratory rehab physical exercise; PT COPD treatment protocol)
● Provide strength and mobility interventions — exercise prescription, fall risk, take longer to regain strength
o Note: For exercise prescription, go back to pulmonary rehab principles and exercise prescription for older adults and modify based on symptoms, vital signs and RPE
o Aerobic exercise, strength training, flexibility intervention
o It is critical that physical therapists are aware of the clinical implications of coagulopathy and the prevalence of venous thromboembolism (VTE) in patients diagnosed with and recovering from COVID-19 through the promotion of early mobility and physical activity
● Provide pain assessments and intervention
● Community reintegration as indicated
● Need for outpatient services

Speech-Language Pathology Intervention/Strategies
● Measure the effects of cardiac function and respiration, including any increased oxygen and/or oxygen weaning with communication and swallow (respiratory rehab breathing interventions and using resistive devices; SLP COPD treatment protocol)
● Assess effective communication as it relates to respiratory function
● Assess cognition (great opportunity to use comprehensive cognitive assessments), provide cognitive rehabilitation to address cognitive impairments
o Note: Studies are emerging that suggest some type of association between neurological symptoms and COVID-19. Symptoms like headache, stiff neck, and loss of taste and smell raise suspicion of central nervous system involvement.
● Assess swallow; airway protection and cough strength. Integrate resistive breathing devices for intervention.
● Assess for continued loss of taste and smell and how that impacts hydration and nutrition.
● Need for outpatient services.