Acute Care PT Flashcards
What are some consequences of prolonged bed rest?
- fluid volume redistribution
- altered distribution of body weight/pressure
- muscular inactivity
- aerobic deconditioning
PTs must establish a ________ in acute care units
Culture of Mobility
How is the cardiovascular system affected by bed rest/immobility?
- HR, SV, CO affected leading to poor endurance and ability to complete ADLs
- reduced cardiac, vagal tone, increased plasma NE enhanced beta-adrenergic receptor sensitivity
- hypovolemia
- increased venous compliance → venous pooling
- Orthostatic hypotension
what are some treatments for OH?
- early mobilizations → specifically getting them to EOB and sitting up
- LE exercises to increase blood circulation
- compression stockings
- Tilt table for very prolonged immobilization or profound ANS issues (SCI)
How is the hematologic system affected by bed rest/immobility?
- changes in blood composition place pts at risk for DVT and PEs
- RBC mass reduced by 5-25%
- decreased total blood volume, RBC mass, and plasma volume
- elevated HCT → increased risk for DVT
- reduced capillarization of peripheral muscle beds
what are the components of Virchow’s triad?
- Venous stasis
- hypercoagulability
- blood vessel damage
T/F: the length of bed rest is directly related to frequency of DVT
TRUE
there are often no clinical signs of DVT best way to screen/catch them is via doppler US, contrast venography
how are venous thromboembolisms treated?
- early ambulation, LE exercises
- compression stockings
- leg elevation
- Prophylactic methods
- low-dose heparin, intermittent, pneumatic compression
- pharmalogically to decrease blood coagulability
- unfractionated heparin (UFH)
- low molecular weight heparin (LMWH)
how is the MSK system affected by bed rest/immobility?
- changes in soft tissue affect muscle strength and size and greatly impair functional mobility
- immobilization in shortened position → enhances atrophy
- immobilization in lengthened/stretched position → may decrease loss of muscle fiber proteins
- changes in muscle metabolism greatly impairs endurance
- decreased aerobic metabolism
- early fatigue
- fiber atrophy reduced mitochondria content
what are some factors that contribute to joint contractures?
- denervated muscle (no opposition to antagonist)
- spasticity
- improper bed positioning
- adaptive shortening (cast)
- disease process (scleroderma, OA, burns)
what are some treatment options for MSK dysfunction resulting from bed rest/immobility?
- early mobilization is key
- perform AROM/PROM manual stretching
- modalities
- Splinting
- static vs dynamic
- hinged casts
- CPM
what is disuse osteoporosis?
reduced bone mass density (occurs within one week of bedrest)
hypercalciuria and negative calcium balance results from immobilization
loss of bone is the result of increased bone reabsorption
how is the neurologic system affected by bed rest/immobility?
- sensory and sleep deprivation
- decreased dopamine, noradrenaline, and serotonin levels
- depression, restlessness, insomnia
- decreased balance, coordination, visual acuity
- increased risk compression neuropathy
- reduced pain threshold
how is the integumentary system affected by bed rest/immobility?
changes in skin and prolonged immobility lead to decubitus ulcers
describe the pathogenesis of a pressure ulcer
- pressure causes ischemia (compresses capillaries and occludes blood flow)
- excessive pressure can lead ot tissue necrosis
- if pressure relieved, we can see temporary reactive hyperemia and no tissue damage
- if it is NON-BLANCHABLE ERYTHEMIA (Stage 1) then damage has begun
describe stages 2-4 for a decubitus ulcer
- Stage 2 → worn down to epidermis and dermis
- Stage 3 → worn down to the subcutaneous tissue
- Stage 4 → worn down to muscle and bone
describe the treatment for pressure ulcers
Prevention is key!!
bed-positioning with bed-bound pts (reposition high-risk pt at least every 2 hours)
wheelchair cushioning and unweighting/pressure relief exercises
how is the respiratory system affected by prolonged bed rest/immobility?
- reduced lung volumes, airflow rates, respiratory muscle strength, gas exchange
- supine position + prolonged bed rest = diminished vital capacity
- increased RR
- decreased FRC, FVC, and FEV1
prolonged bed rest increased the risk for what respiratory conditions?
- pneumonia
- atelectasis
- dyspnea on minimal exertion
how does prolonged bed rest/immobility impact metabolic systems?
- overall decreased metabolism
- insulin resistance
- muscle activity essential for expression of Glut4 proteins
- can occur after only 3 days
- plasma and urinary electrolyte concentrations
- endocrine function changes
- decreased EPO concentration
how does prolonged bed rest/immobility impact thermoregulatory systems?
- threshold for cutaneous vasodilation and sweating (for heat dissipation) shifted to higher core temp
- exercise limited by impaired regulation of body temp
- increased risk for heat-related abnormalities
- cramping, fatigue, syncope, heat stroke
what are some psychiatric effects of prolonged bed rest/immobility?
- more than 50% of pts of all ages experienced mood alterations during prolonged hospitilizations
- anxiety, agitation, delirium, depression
- reduced pysch functioning leads to increased morbidity and mortality
- intellectual and perceptual deficits result from altered sleep patterns, circadian rhythms, presence of noxious stimuli
list some acquired neuromuscular disorders
- CIP (critical illness polyneuropathy)
- CIM (critical illness mylopathy)
- CIPNM (ciritical illness polyneuromyopathy)
- Steroid induced myopathy
- Rhabdomyolysis
what is CIP?
impaired neuromuscular system
- weakness, decreased DTRs, impaired pain, temp and vibratory sense
- facial weakness (CNs spared)
- associated w/abnormal nerve conduction studies
- electrodiagnostic testing critical to confrim dx
what is CIM?
profound weakness, especially of proximal msucles
- DTRs may be preserved or diminished
- sensation intact
- EMG studies show preserved sensory nerve APs and an overall reduction in force generation of unhealthy muscle fibers
describe the score breakdown for the Medical Research Council Scoring System
scores range from 0-60
- scores less than 48 ID sig weakness
- scores less than 36 ID severe weakness that is a trigger for whether the person may have CIP or CIM
what is steroid induced mylopathy?
occurs acutely or from chronic glucocorticoid maintenance therapy
steroid induce muscle catabolism and myocyte apoptosis
what is rhabdomyolysis?
muscle injury that involves myoglobinuria, electrolyte abnormalities, and acute kidney injury
injury to myocyte membrane that results in increased intracellular Ca+ concentration
elevated Ca+ causes pathologic interaction of actin and myosin = muscle destruction and fiber necrosis
what are common clinical manifestations of rhabdomyolysis?
- myalgia
- pigmenturia
- elevated creatine kinase (CK) levels
- acute renal failure
- muscle weakness
T/F: early mobility is safe and important to do!
TRUE
as long as the pt is hemodynamically stable and meeting some criteria set aprior
getting out of bed w/PT is safe and effective
list some parameters that indicate a lack of readiness for PT interventions
- Pulmonary measures
- SaO2 <88 or pt experiences 10% O2 desaturation below resting SaO2
- RR >35
- PEEP >10cm
- FIO2 >0.6
- Lab values
- HCT <25% → no exercise
- HGB <8 → no exercise
- platelets <20,000 → no exercise
- platelet anticoag INR >2.4-3 → dicuss w/MD
what are some CV and metabolic parameters that indicate a lack of readiness for PT interventions?
- CV
- MAP <65 or >120 (or >10 lower than normal systolic or diastolic BP for pts recieving renal dialysis)
- RHR <50 or >140
- Systolic BP <90 or >200
- new arrhythmia developed
- new onset angina-type chest pain
- Metabolic
- glucose levels <70 or >200
list some activity measures for post acute-care (AM-PAC)
- turning over in bed
- supine to sit
- bed to chair
- sit to stand
- walk in room
- 3-5 steps with rail
List some broad intervention strategies
- respiratory
- ROM
- Pt education
- functional mobility training
- exercise prescription
following ICU and acute care, what inpatient options are there for D/C?
- Inpatient Rehab
- Subacute/TCU
- SNF
Describe and list the criteria for each inpatient D/C location
- Rehab → intense hospital based therapy due to daily 3 hr duration
- Subacute/TCU → less intense hospital-based therapy, usually 2 hr/day duration
- SNF → less intense skilled nursing-based therapy, usually 2 hr or less/day duration
