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Neuro Eval > Management of Severe-Mod Deficits > Flashcards

Management of Severe-Mod Deficits Flashcards

1
Q

Neuro ICU Must Do’s

A

 Mobilize patient ASAP
 Check for orders in medical chart
 Talk with nursing
 Will likely need multiple people

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2
Q

What should you monitor in neuro ICU?

A

 Intracranial pressure
 Hemodynamics
 Vitals

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3
Q

How to set up environment in neuro ICU

A

 Prediction of patient’s mobility/ability
 Consider medical constraints- lines/drains/monitors

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4
Q

Common barriers to mobility - intrinsic to patient

A

 Elevated ICP
 Neurological storming
 Unstable hemodynamics
 Absence of Bone Flap
 Pain
 Decreased arousal
 Impaired cognition
 Physical impairments
 Obesity
 Unstable spine
 Surgical precautions

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5
Q

what is neurological storming

A

hypothalamic stimulation of sympathetic nervous system and adrenal glands causing increase in corticosteroids and catecholamines- symptoms include altered LOC, increased posturing, dystonia, HTN, hyperthermia, tachycardia, tachypnea, diaphoresis, and agitation

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6
Q

Common barriers to mobility - extrinsic

A

 External Ventricular drains that cannot be clamped
 Lines/Tubes
 Staffing/resources
 Fear/Uncertainty/Safety/Knowledge
 Adequate Equipment
 Inappropriate or absence of activity orders
 Timing of PT consults

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7
Q

things to consider when mobilizing s/p stroke

A

 Severity and Type
 Timing
 Interventions received- tPA, evacuation, thromectomy
 Hemodynamic parameters
 Neuroimaging
 Discussion with MD/RN
 Close monitoring with activity

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8
Q

things to consider when mobilizing s/p TBI

A

 Severity of injury
 Presence of skull/facial fractures- CSF leaking
 Intracranial Pressure parameters
 Neurologic Storming
 Bone Flap/Helmut

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9
Q

Daily Assessments

A

 Avoid any injury
– People moving patients need appropriate training
— UEs
— Safety
 Emphasis to maximize active involvement

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10
Q

Neurologic factors to consider for positioning needs

A

– Normalize tone
– Decrease influence of pathologic reflexes
– Facilitation to midline
– Interaction with environment
– Awareness of body and body part

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11
Q

Musculoskeletal factors to consider for positioning needs

A

prevent ROM issues

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12
Q

Physiologic factors to consider for positioning needs

A

 Prevent skin irritation/breakdown
— Ability to move
— Sensation
— Visual/Perceptual
— Bony prominences
— Be good about bowel/bladder management and hygeine
 Minimize medical problems
— NG or PEG tube – 30 degrees HOB elevated to decrease risk of aspiration
— ICP pressure monitor

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13
Q

features of UMN lesion

A

deficits in motor behavior, weakness, slowness of movement, loss of dexterity, fatiguability

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14
Q

Positive features of UMN lesion

A

exaggerations of normal phenomena or release phenomena
 Tone, exaggerated tendon jerk, clonus
 Flexor withdrawal, extensor or flexor spasms

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15
Q

adaptive features of UMN lesion

A

 Physiological, mechanical, and functional changes in muscle and other soft tissue
 Adaptive Motor Behavior
 Abnormal Posturing- immobility, disuse changes to soft tissue, adaptations in resting length of muscles
 Abnormal Patterns of movement- synergy, difficulty controlling muscles, difficulty in timing, imbalance in strengths

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16
Q

Exaggerated Reflexes - STNR

A

 Flexion of neck elicits flexion of UE, Extension LE
 Extension of neck elicits extension of UE, flexion LE

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17
Q

Exaggerated Reflexes - ATNR

A

Extension to side facing, flexion to side not facing

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18
Q

Exaggerated Reflexes - Tonic Lumbar

A

Rotation to R- elicits flexion RUE, extension RLE, extension LUE, flexion LLE

19
Q

How do exaggerated reflexes impact us?

A
  • initial conditions
  • positioning in bed and chair
20
Q

What is spasticity and when should you manage it?

A
  • velocity dependent resistance to passive movement
  • Need to manage when it limits person’s ability to move, move fully, or for therapist to move person
21
Q

Prevent noxious stimuli – both internal and external

A

 Internal stimuli- pain, pressure sores, agitation, constipation,
incontinence
 External stimuli- positioning in bed or wheelchair

22
Q

Prevent consequences of spasticity

A

 Tightness
 Contracture
 Sores

23
Q

Physical management of spasticity

A

 Range of motion to maintain or increase muscle length
 Slow sustain traction to improve mobility and reduce pain; consider joint mobilization Grade 1 and 2
 Prolonged stretch- Evokes a higher threshold response
 Stimulus- slowly applied, maintained stretch to inhibit or dampen muscle contraction and tone

24
Q

Exteroceptive Stimulation for Management of Spasticity

A

 Neutral warmth- applied for 10-20 minutes- useful for managing high arousal and increased sympathetic activity, impact tone/spasticity
 Generalized inhibition of ton
 Wrapping body or parts with warm towel
 Monitor for overheating- patient will not be able to tell you-cognition/communication

25
Q

Techniques for using a stimulus to dampen muscle contraction and tone

A

 Manual contacts
 Inhibitory splinting/casting – dynamic splinting, tone inhibiting serial casting
 WEIGHT BEARING- weightbearing normalizes tone
— Sitting with limbs supported
— Standing Frame- long prolonged stretch; great tool for lower level patient- get prolonged stretch, get upright for attention/engagment

26
Q

Pharmacologic Management of Spasticity

A

 Second line of defense or adjunct to physical management
 Need to understand if patient has more general or focal spasticity

27
Q

Generalized spasticity

A
  • extensor spasms
  • oral medication
28
Q

Focal Spasticity

A

clenched hand, PF contracture unresponsive to
physical management and oral medication

 Phenol block – washes general area
 Botox (more expensive)- more precise

29
Q

Surgery for Spasticity Management

A

 Surgery- last option
 Last resort when all other attempts to manage have failed
 Could be neurologic- insertion of baclofen pump
 Could be musculoskeletal- tendon lengthening

30
Q

How to Manage agitation

A

 Activate parasympathetic division of autonomic nervous system
 Calming effect for a high arousal patient
- Neutral warmth
- Rocking
- Stroking paraspinals
- Maintained touch/support

31
Q

Cognitive Dysfunction Ranchos Level II/III

A

 Elicit response to sensory input
 Elicit specific response
 Increase ability to focus and sustain attention
 Consider ability to track object, reach for object
 Utilize for functional activities –> Rolling: having them reaching for picture across body for example

32
Q

Cognitive Dysfunction Ranchos Level IV

A

 Decrease intensity, duration, and frequency of agitation
 Increase attention to environmental stimuli
 Try to engage in movement – try to move uncontrolled and non-purposeful movement →controlled and purposeful movement
 Principles of treatment- limit external stimuli
 Consistency in place, staff, time if possible
 Structure patient/therapist interaction
 Explanation of activities/goals
 Communication- calm, clear, concise
 Give choices as able
 Response to inappropriate behavior
 Behavior contract

33
Q

Cognitive Dysfunction Ranchos Levels V and VI

A

 Rancho Levels 5 and 6
 Decrease confusion
 Improve orientation- A&O x 4
 Improve cognitive processes
- Attention, selective attention, attention span
- Recent memory
- Categorization/Organization
 Incorporate cognitive function into functional activities

34
Q

Where should activities be performed for Ranchos Level V and VI

A

 Treatment should occur in actual setting patient will perform
 Poor carryover of an activity

35
Q

What should be provided for Ranchos level V and VI

A

 Written instructions/Pictures

36
Q

Cognitive Dysfunction Levels 7 and 8

A

 Adapt activities to more complex tasks, environments
 Consider carryover
 Removal of structure
 Interactions

37
Q

essential elements of rolling

A

 Rotation and flexion of neck
 Hip and knee flexion
 Flexion of shoulder and protraction of shoulder girdle
 Rotation in trunk

38
Q

significant impairments of rolling

A

 Extremity hypertonicity
 Loss of Trunk Control
 Extremity Weakness
 Loss of alignment due to muscle shortening
 Pain

39
Q

undesirable compensatory patterns

A

 Grabbing and pulling with unaffected arm
 Use of excessive hypertonicity in arm/leg
 Learned disuse of hemiparetic limbs

40
Q

movement elements of sidelying to sitting

A

 Lateral flexion of the trunk
 Extended arm- weightbearing through forearm
 Body weight taken over hip

41
Q

essential elements of sidelying to sitting

A

 Lateral flexion of neck
 Lateral flexion of trunk
 Legs lifted and lowered over side of bed

42
Q

significant impairments that interfere with sidelying to sitting

A

 Weakness of trunk and extremities
 Loss of alignment
 Inability to accept weight through extremities
 Hypertonicity of extremities

43
Q

undesirable compensatory patterns for sidelying to sitting

A

 Sitting straight up
 Use unaffected arm to pull body up and out of bed
 Patient hooks leg under affected leg to lift both over bed

Neuro Eval (18 decks)

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