1
Q
5 vitals
A
- temp
- pulse
- bp
- respiration
- mental state
2
Q
Normal vital signs
A
- temp: 97.7-99.5 (oral)
- pulse: 60-100
- bp: 90-140 / 60-90
- resp: 12-20 breaths/minute
3
Q
Procedure for temp:
A
- can do orally, rectally, axillary
- rectal temp will measure .5-.7 degrees higher than oral
- oral temp will measure .3-.4 degrees higher than axillary
4
Q
Procedure for pulse:
A
- Place two fingers (not thumb) on radial side of wrist.
- Press until you feel beats.
- Count for one minute to get rate per minute (can also count for less time and multiply).
5
Q
Procedure BP:
A
- Wrap cuff firmly around pt’s upper arm.
- Put sphygmomanometer over brachial artery; put stethoscope under cuff but over brachial artery (so you can hear pulsations of artery).
- Inflate cuff to > systolic pressure in artery (140-ish, usually), then slowly release air from cuff.
- Listen for artery - first “thud” is systolic pressure. Last “thud” is diastolic pressure.
6
Q
Respiratory rate procedure:
A
Watch pt’s chest rise and fall while counting # of breaths in one minute. (can do for less time and multiply)
7
Q
Identifiable features of oxygen tanks:
A
O2 ID’d by the color green, and most say “oxygen.”
8
Q
Safety procedures for transporting pt with portable O2?
A
- Be sure tank is full and charged prior to moving pt.
- If someone else is moving pt, tell them same.
- Remember: Portable tank won’t last as long with high delivery rate.
9
Q
When is it safe to completely remove O2 tank for OT?
A
Only when given permission by doctor or attending nurse, and be sure you follow their guidelines. Put Pt. back on O2 in time frame they specify.
10
Q
What do chest drainage systems look like?
A
- Tube inserted into 5th-6th intercoastal space, drains into bag/box usually hanging off bed.
- *Bag holding drained fluid needs to stay below level of the chest for proper drainage
11
Q
Therapist responsibilities, precautions, and tips related to chest tubes:
A
- Accidental removal can cause pneumothorax (air in pleural cavity; can result in collapsed lung)
- Keep drainage container vertical and below level of insertion site.
12
Q
Most common site for CVP line:
A
(Central Venous Pressure) line usually in subclavian vein; can be internal jugular or femoral veins.
13
Q
Precautions and tips for ventilators, ICP monitors, IV and central lines, and arterial lines:
A
- Arterial line: will bleed profusely if dislodged; can result in significant blood loss in short time.
- Keep catheter bags lower than the pt bladder to prevent retrograde flow.
- ICP monitor: Pt head/neck stays neutral pos. Have nurse relevel transducer if you alter bed ht.
- No kinked/dislodged tubes. Leave monitors on. Don’t remove anything w/o nurse OK.
- Avoid bp cuff on same arm as IV or PICC line.
- Be aware of equipment, lines and positioning during ther. ex/transfers.
14
Q
Hypotonus:
A
low tone, decrease of normal muscle tone
15
Q
Hypertonus:
A
- High tone, increase of normal muscle tone
- Co-contraction of flexor/extensor muscles.
- Extreme energy expenditure with effort to move, which is frequently unsuccessful.
16
Q
Flaccidity:
A
absence of tone; most extreme form of hypotonia
17
Q
Spasticity:
A
endpoint / most severe form of hypertonus
18
Q
Rigidity:
A
= co-contraction of agonist and antagonist muscles resulting in resistance to movement.
- lead pipe: constant resistance throughout ROM when part moved slowly (like bending a pipe)
- cogwheel: rhythmic resistance throughout ROM (like turning a cogwheel)
- decorticate and decerebrate: can occur immediately after severe tbi;
- decorticate appears as flexor tone in UE and extensor tone in LE
- decerebrate appears as extensor tone throughout.
19
Q
What other body functions affect movement besides tone?
A
- strength
- ROM
- joint or skin contracture
- fear / anxiety
20
Q
What is the difference between muscle tone and strength? Do they decline and improve simultaneously?
A
- Tone = resting level of tension in muscle. Origin is reflexive, involving CNS / PNS.
- Strength = muscle’s ability to contract to create a certain amount of force.
- Strength and tone not the same, but strength can be limited by hypertonicity.
21
Q
How to rate hypertonus:
A
Ashworth Scale rates hypertonus from 0-4: 0=normal and 4=rigidity.
22
Q
Evaluating trunk movement:
A
Examine the 4 separately, then assess impact of all components when viewed together.
- *trunk flexors: **full sitting to trunk extension and forward
- *trunk extensors**: 1) sitting in post. pelvic tilt –> full upright posture. 2) flex trunk forward from upright position, then return to full upright position from flexed position.
- *lateral flexors**: 1) from full upright, lean to one side, back to full upright. 2) hip and shoulder “crunch.”
- *trunk rotators**: 1) reach R arm to L and floor, then L arm to R and floor. 2) In supine, bring R shoulder –> L knee, then L shoulder –> R knee. 3) scoot right side forward with trunk stable, left side forward with trunk stable.
23
Q
Five NDT strategies:
A
- Align body segments
- Establish / maintain stable base of support
- Maintain adequate ROM
- NDT as 24 hour management…
- Interdisciplinary involvement and adoption of principles
- Transfer of learning from clinic to community
- Educate friends and family members
- Manual Cueing- Handling
24
Q
4 PNF strategies:
A
- Sequential movement: move limbs in sequential patterns from start to finish.
- Visual stimulation: encourage client to observe movement.
- Verbal cueing: Instruct client at key moments in the pattern.
- Manual contact: Tactile input with appropriate pressure and resistance from therapist.
25
3 facilitory and 3 inhibitory Rood strategies for adults
Facilitory:
1. heavy joint compression (weight bearing)
2. resistance (isotonic muscle contraction)
3. vestibular stimulation (rocking or walking)
4. inversion (not really with adults, but with kids!)
Inhibitory:
1. slow stroking along spinal cord
2. neutral warmth
3. light joint compression
4. rocking (again, not really with adults, but good with kids)
26
contraindications for therapeutic exercise
* swelling
* pain
* acute injury
* arthritis
* inflammation
27
what type of exercise is contraindicated for cardiac patients?
isometric exercise (because of risk associated with Valsalva maneuver)
28
At what MET level do you anticipate most of your clients in acute care will be safely able to function?
1-2 met level at the early stages of their recovery
29
What safety precautions would you take when doing ROM and movement recovery activities with a client with a hemiplegic shoulder?
1. Don't force ROM.
2. Resistance to flexion/abduction can indicate lack of scapular gliding; pain can indicate trauma or impingement to soft tissue in shoulder joint.
3. Don't use reciprocal overhead pulleys, which are proven to increase pain in shoulders.
4. Don’t flex/abduct past 90 without ER of humerus (thumbs up!) and scapular gliding - for safety.
5. Don't pull on hemiplegic arm to move client (bc traction injury). Place hand on pt trunk or scapula when helping them transfer or move.
6. Don't adjust client pos. by lifting them from under arms. Can cause shoulder impingement.
7. Avoid static positioning of UE in IR and adduction.
8. Slings maintains IR and ADD and contribute to soft tissue tightness/ shortened muscle length.
9. Don't strap UE to arm trough. Strapped-in weak arm at risk for impingement/traction injury.
30
9 rules for body mechanics
* proper alignment in all body parts
* wide base of support
* bend at the knees
* keep the back straight
* toes and feet follow direction of movement
* get as close to patient as possible
* don't twist
* use leverage - slide, don't life
* clear the path and loosen the lines
31
What to evaluate in patient before transfer:
**PHYSICAL:** strength, tone, ROM; wounds, incisions, drains; surgical precautions; trunk control; size compared to you; overall condition (can they help? if not, do you need help?)
**SENSORY:** pain; need to pee; neuro: weak side? prop/sensory/vision? shoulder subluxation?
**COGNITIVE:** oriented x5; cognition/attn for instructions; impulsivity, judgment, safety awareness
**EMOTIONAL: **are they angry, anxious or afraid by your plan to move them?
32
How to prepare yourself/environment for transfer:
* Read chart.
* Position (chair, wheelchair, commode, etc.). Transfer to strong side when possible.
* Prepare equipment (belt, board, disc, etc.); adjust bed; LOCK BRAKES on chair.
* Move items as necessary so you have space for safe transfer.
* Move leads/lines and clear path.
33
How to prepare client for transfer:
* Talk! Them them what you're doing. Emphasize need to work together and communicate.
* Pull back sheets/blankets respectfully. Cover pt (robe, gown, pants) for warmth and dignity.
* Make sure they have non-ski socks or shoes on.
34
Steps of a stand-pivot transfer:
_Stand-pivot transfers work for clients who are min A and can briefly bear some weight_
1. Patient:
- feet on floor (can scoot up), wide BOS, feet behind knees, pelvis neutral/anterior tilt
- head and trunk flexed slightly in front of hips ("about to stand up" stance)
2. Therapist:
- decides if pt puts arms at sides to help push off from bed OR has one arm cradling other over chest (pt. arms don't go around therapist neck or hips)
- Position for leverage (one foot behind other), easy movement, pt. safety. Hands on pt. hips or belt.
- Give verbal directions/physical cues (“ready, lean forward, now on the count of three: 1, 2, 3 up”)
3. Patient and therapist:
- Stand up, pause once standing to assure solid base of support for both.
- Pivot by shuffling feet, not twisting at hips. Bend together to reach down to chair.
- Pt. lowers self to chair without flopping ("like a snowflake")
_Never leave pt. til safe and secure in new seat.! _
35
Steps of a lateral transfer:
A lateral transfer is good for someone with less mobile independence (more than min A).
* Good trunk rotation helps
* Unweighting hips is key - push up with hands, down with feet
* Small movements rather than one is OK
* Realign feet and legs with every few lateral movements
* Use sliding board when needed
* Tell client to reach hands for new seat, keeping nose over toes
36
Hip precautions
For posterior approach:
no flexion past 90 degree
no internal rotation
For anterior approach:
no extension
no external rotation
no crossing midline
37
Lumbar precautions
NO BLT!
No bendling, lifting or twisting
38
Sternal precautions
Don't push, pull, lift
39
Overall evaluation of seating needs:
* person / tasks - goals, needs, routines / occupations, ADL/IADL level, prior seating system?
* environment: setting, support level, access, routine, transportation, occupation
* physical aspects: strength, ROM, deformity, tone, coordination, cardiac health, vision, hearing, tactile, cognition
40
Physical evaluation for seating:
PELVIS / LE:
* pelvis neutral or slight anterior tilt
* no ab or ad
* hips, knees, ankles at 90/90/90
TRUNK:
* upright
* aligned with pelvis and legs
* no lateral flexion
HEAD/NECK:
* consider needed head/neck support
* maximize person's field of vision
UE: (can adversely affect head/neck position if done poorly)
* no shoulder elevation / pronounced depression
* no scapular rotation; maximize scapular movement
* support surface for UEs (usually forearms on surface w elbows at 90):
* helps with position of head/neck
* reduces chance of damage to arms and shoulder joints
* places hands at midline to facilitate bilateral manual activities
41
What is pressure mapping, and why do you use it?
* sensor assessment of high-pressure areas on w/c seat.
* once you know what you need, you can choose the most appropriate seat
* also educational for patient
42
Three areas of w/c seating intervention:
* postural control
* tissue integrity
* comfort
43
Populations served by each seating intervention:
postural control: CP and other neuromuscular disorders; neurological disorders such as CVA / TBI
pressure management: mainly SCI; also MS, MD, elderly, those w limited mobility
comfort: need w/c to improve comfort through postural accommodation
44
`Levels of postural control for sitting:
* **Hands-free sitters** can sit for long periods without using hands for support. Their seating system is designed for mobility, stable BOS and comfort.
* **Hands-dependent sitters** need one or both hands to maintain support while sitting. Their seating system is designed to provide pelvic or trunk support to free the person's hands for functional activities.
* **Propped sitters** lack abliity to support self in sitting. Their seating system provides total body support.
45
Basic wheelchair characteristics a therapist should know to assure safety and practicality:
* *Back height**: adequate postural support / UE function
* *Seat width and depth**: accommodate body, disperse pressure, support pelvis / thighs, provide comfort, allow access
* *Seat-to-floor height**: too high to go under tables / desks?; too low to reach things overhead? and consider need for foot propulsion and ADL performance
* *Armrest height**: proper support, assist postural control, prevent elevation of shoulders, assist w transfers and pressure relief
* *Foot rests/leg rests**: find appropriate angle; choose swing away for standing transfers vs. fixed for sliding transfers; angle adjustable footrests / elevating leg rests for edema or limited ROM
* *Axle alignment**: prevent tipping
* *Brakes/brake extenders**
46
Three classifications of deformities that need special seating:
Fixed: has existed for a long time; related to joint fusion, not changing; surgical correction (if any)
Compensate/Adapt - seating system accommodates deformity
Flexible: short-term change, related to recent event; resolvable with time
Restore/Repair - seating system dynamic to promote alignment
Forming: no deformity present, but potential apparent
Prevent - seating system encourages proper alignment to prevent deformity
47
Deformities restricting mobility in pelvis:
* pelvic obliquity (one side of pelvis higher/hiked)
* pelvic rotation (one side forward of other)
* windswept hip (one hip adducted and other abducted).
Seating should **accommodate** rather than try to correct. Firm seating surface will level/stabilize pelvis. More support can come from contouring around buttocks and into lumbar area. \*Support can be provided from behind, side or front.
48
Deformities affecting trunk alignment:
Spinal deformities (scoliosis, lordosis, kyphosis or combo) affect trunk alignment.
* Seating support can come from back, side or front as needed.
* Recess seat (i.e. for kyphosis) or push forward as needed.
* 3-point harness is helpful for scoliosis.
* Tilt (dump) chair to offset gravity and keep client in. Considering effect on function though.
* Anterior support prevents fwd trunk flexion: use chest restraint, chest panel in butterfly, X or I shape, or rigid shoulder components.
49
Issues affecting head and neck:
Hyperextension of neck, weak neck musculature, lateral neck flexion, neck rotation. Support (headbands, elastic materials, pulleys for dynamic support) can right head when reclined or always.
50
Seat cushion materials:
Five properties: density, stiffness, resilience, dampening, envelopment
Materials: air, gel, open-cell and closed-cell foam.
* Air cushioins often used for pts with SCI or ALS for pressure relief.
* Foam is good for tone issues.
* Molded seats good for complicated deformities because they a) provide more points of contact to help prevent sores and b) can hold patient in place and prevent deformity from getting worse.
Adults Spring 2015
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Decks in class (5)
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