Exam 1 Flashcards
Indication of mechanical ventilation
acute respiratory failure, protection of airway, relief of upper airway obstruction, and Improvement of pulmonary toilet in patients with excessive secretions or inability to clear secretions by coughing
Lines of an EKG monitor in order from top down
HR BP arterial line blood pressure central venous catheter O2 sat
Types of artificial airways
tracheostomy, endotracheal tube (both oral and nasal)
Types of ventilatory support
hand controlled ventilation (bag) and mechanical ventilators (ICU ventilator and PAP ventilators)
Type of artificial airway used for someone who needs help breathing for a longer period of time (longer than a week)
tracheostomy
What are 3 things you need to do with a trach tube
Make sure to secure straps around the neck.
Make sure inner cannula is locked in place.
Make sure the cuff is fully deflated before placing a passy muir valve.
Airway pressure at the end of expiration that forces alveoli open and maintains greater lung volume.
PEEP (Positive End-Expiratory Pressure)
If PEEP is greater than ___ then typically you won’t see the pt
10
Each spontaneous respiratory effort generated by patient, machine delivers pre-set tidal volume
CMV (controlled mechanical ventilation)
Pressure support is to be added to augment patients tidal volume
CPAP (continuous positive airway pressure)
Patient is able to breath spontaneously between ventilator breaths
On each spontaneous breath, patient will receive as much volume as he can generate
SIMV – Synchronized Intermittent Mandatory Ventilation
Applies to spontaneous breaths only
Once pt triggers vent, pre-set positive pressure is delivered
PSV – Pressure Support Ventilation
What activity restrictions are there for a patient with an arterial sheath
strict bedrest (while catheter is in place and for several hours after sheath is removed). No ROM!
what should you do if an arterial line becomes dislodged
apply pressure with sterile gauze immediately and alert the RN.
catheter that runs directly to the heart to measure cardiac output
Pulmonary Artery Catheter aka Swan-Ganz
What activity restrictions are there for a patient with a Swan Ganz catheter
Patients with a PA catheter are usually not candidates for mobilization because of the risks
Avoid full ROM and therapeutic exercise to the ipsilateral shoulder
You CAN manually move the scapula or passively move them
feeding tube that is interested through a surgical opening through the skin into the stomach through abdominal wall
G Tube
type of G tube where tube is placed endoscopically under local anesthesia using the PEG method
PEG Tube
feeding tube that goes directly into the jejunum
J Tube
catheter tube inserted through mouth down esophagus to stomach, usually positioned just past stomach with weighted tip in duodenum
Dobhoff Feeding Tube
temporary small thin tube inserted through nose, throat and down into stomach – held in place with tape. Don’t push it back down if it becomes dislodged
NG Tube
tube inserted through the mouth into stomach usually used for patients with poor gastrointestinal function
OG Tube
tube inserted via patients nasopharynx and esophagus with distal tip in stomach or duodenum
Nasoenteric Feeding Tube
Are you allowed to see a patient receiving dialysis on the same day
NO!
long term. Tunneled catheter that goes into the arteries
dialysis catheter
Restrictions for pacemakers that are placed via the jugular or subclavian vein
No ROM assessment or therapeutic exercise to the involved shoulder
If cleared for mobilization, use caution avoid dislodging the wires
Have the RN reinforce the dressing over the wires
Keep the temporary pacing box in a safe location close to the patient
Restrictions for pacemakers that are placed via the femoral vein
Strict bedrest while the pacemaker is in place.
No ROM assessment or therapeutic exercise to the involved hip.
Restrictions for epicardial pacer
No UE ROM restrictions as the wires are transthoracic
When epicardial pacing wires are removed through skin: Typically on bedrest for 1-2 hours before being able to do OT(check post procedure orders or check with MD/RN)
catheter that measures the pressure inside the head
ventriculostomy catheter
What types of activities would you want to avoid with a patient who has a ventriculostomy catheter
Laying flat supine and trendelenburg (head down, feet up)
Valsalva maneuver (forcing exhalation against closed airway i.e. plugging nose)
Isometric exercises (due to holding breath)
Coughing (stop movement)
Pain
Agitation
what is the usual positioning of someone with a ventriculostomy catheter
bed rest with head of bed locked at ~30 degrees
Device that increases cardiac output and coronary blood flow
IABP: intra-aortic balloon pump
With an IABP inserted via femoral artery, what are the restrictions
Strict bedrest
Do not flex the involved hip
With an IABP inserted via subclavian artery
Able to mobilize with caution
Requires a perfusionist (the person who runs the heart/lung machine during cardiothoracic surgery) with you at all times.
No ROM/exercises of ipsilateral shoulder
Therapeutic Intensity in the ICU
Therapeutic Intensity
15 to 30 minute sessions
1-2 X day
3-5 X a week
What are the goals of OT in an acute setting
Prevent secondary complications
Improve functional mobility
Prevent falls & improve balance
Improve sensorimotor function & facilitate return of movement
Promote cognitive & perceptual performance needed for basic functional activities
Improve or relearn BADL skills through remedial or compensatory techniques
Recognize affective issues (depression) institute coping strategies; make referrals
Promote participation in valued occupation & leisure
Recognize client & family as integral components of intervention process
Promote interdisciplinary collaboration & d/c planning
Therapeutic intensity in a rehabilitation and skilled care environment
Therapeutic Intensity 30 to 90 minute sessions 1-2 X day 5-7 X a week Average LOS ~ 10 to 35 days
Goals of OT in Rehab Environments
Promote independence in areas of occupation
Prevent secondary complications
Improve functional mobility
Prevent falls & improve balance
Improve sensorimotor function & facilitate return of movement
Promote cognitive & perceptual performance needed for basic functional activities
Dysphagia management
Recognize affective issues & institute coping strategies; make referrals
Recognize client & family as integral components of intervention process
Patient/support system education
Interdisciplinary collaboration & d/c planning
Facilitate patient directing their own care
Prepare for next stage of recovery
Therapeutic Intensity in the Community Setting
30 to 90 minute sessions
1-2 X a week
Potential barriers to engaging in occupation and social participation
Falls Lack of access to community mobility Environmental distractions Socio-economic limitations Personal biases ( Home accessibility issues
Goals of OT in community environments
Explore more fully independence in areas of occupational performance
Prevent secondary complications & manage the effects of secondary complications
Improve functional mobility
Prevent falls & improve balance
Improve sensorimotor function & facilitate return of movement
Promote cognitive & perceptual performance needed for basic functional activities
Dysphagia management
Recognize affective issues & institute coping strategies; make referrals
Patient/support system/community education
Facilitate patient directing their own care
Environmental modifications
Address barriers
Symptoms of low Hgb and/or low HCT include
weakness, fatigue, tachycardia, dyspnea on exertion, decreased activity tolerance
Therapy considerations for low platelet count
Use soft bristle toothbrush only
Avoid flossing
Use an electric razor for shaving
Don’t allow pt. to blow their nose, only wipe
Useful screening tool for renal disease and diabetes
Measures electrolyte levels, acid-base balance, renal function and blood sugar levels
BMP: Basic Metabolic Panel
If you mobilize a patient whose vital signs fall outside of the “normal” parameters, treatment should be terminated if any of the following symptoms are observed:
Numbness or tingling in any body part.
Dizziness not resolved within 60 seconds of obtaining upright.
Nausea
Blurred vision
Dilated pupils
change in patient’s heart rate of 30 bpm over baseline.
A change in the patient’s systolic blood pressure of 30 mmHg or a change in the diastolic blood pressure of 10 mmHg.
Anginal pain
Shortness of breath
Complaints specific to neurology
pain, headaches, vertigo, and nausea/vomiting
Types of questions you ask about pain
location, quality, severity, duration, precipitating factors, associated symptoms, exasperation/diminished pain, onset
Sensation of moving around in space or objects moving around them
vertigo
associated symptoms of vertigo
nausea, light-headed, off-balance
What do you asses for cerebral function
Mental status Intellectual function Thought content Emotional status Perception Motor ability Language ability
Level of consciousness
Rostral-caudal Progression
mental status
Open eyes spontaneously
Responds appropriately, briskly
Oriented
alert
Opens eyes to verbal stimuli
Slow to respond, but appropriate
Short attention span
Obtunded (sleepy, mentally dulled from some sort of head trauma)
lethargic
Responds to stimuli (usually physical) with moans and groans
Never fully awake
Confused
Conversation unclear
stupor
Responds to painful stimuli
No conversation
Protective reflexes present
semi-comatose
Unresponsive EXCEPT to severe pain
Protective reflexes absent
Pupils fixed
No voluntary movement
Coma
No cognitive brain function
Wake sleep cycles
Very poor prognosis (if in state > 3-6 months)
persistent vegetative state
Types of stimulus for coma
Voice Touch Shaking Voice + Shaking Noxious/painful stimuli (Rubbing on sternum w/knuckles Pen on nailbed )
No brain function
Only reflexive movements
brain dead
Types of nature of response
Eye opens
Remove stimuli
Abnormal posturing
No response
Glasgow Coma Scale GCS
Eye Opening Spontaneous – 4 To speech – 3 To pain – 2 Nil – 1
Best Motor Response Obeys -6 Localizes – 5 Withdraws – 4 Abnormal flexion – 3 Extension response – 2 Nil - 1
Verbal response Oriented – 5 Confused conversation – 4 Inappropriate words – 3 Incomprehensible sounds – 2 Nil - 1
A strong predictor of outcome
13: mild brain injury
9-12: Moderate brain injury
< 8: Severe brain injury (coma)
General Appearance Evaluation
How do they look? Grooming Dress Aids Eye deviation Skin integrity
Bruising over the Mastoid, behind ear.
Suggests skull fracture
Battle sign
Periorbital edema and bruising
Suggests frontal- basal fracture
Can affect vision
Raccoon’s eyes
Drainage of CSF from the nose
Suggests Fracture of the cribiform with torn meninges
Rhinorrhea
Drainage of CSF from the ear
Suggests:
Fracture of the temporal bone with torn meninges
Otorrhea
Flexed Posturing Flexed arm/elbow Flexed wrists/fingers Adducted arms Legs with internal rotation Foot: Plantar flexed Suggests Damage to the cortico-spinal tract
decorticate posture
Extension posturing Extended arm/elbow Flexed wrist/fingers Adducted arm Pronation of arm Foot: Plantar flexed Suggests severe injury to the brain at the level of the brainstem
Decerebrate posture
severe muscle spasm of the neck and back
More ominous posture: extension posturing back with arched back and extended neck
opisthotonos
when we look at someone bottom up we measure ____
component skills
when we look at someone top down we look at _____
performance in task
Where should you gather data for an evaluation
Medical Record / Chart Review
Observation of client including with family, staff, other clients
Interviews with client and family
Quantitative Assessment
occupation based evaluations
Doing performance tasks
FIM
Critical Evaluations
Sensation Head and neck ROM Upper Extremity ROM Head and UE motor control Wrist and hand function Trunk Control Deformity control Activities of daily living (FIM scoring)
Assess ability to tolerate activity in following positions:
Bed
Sitting edge of bed
Sitting in chair
Standing
Evaluate disturbances in what 3 areas
Thinking
Memory
Personality
Evaluation of psychosocial elements
Client’s understanding of the situation Coping skills available Problem solving skills Ability to direct others Family involvement Discharge plans/options Motivation/Participation in goal setting
ability to regulate and direct the mechanisms essential to movement
motor control
Damage to any of these areas will impact motor movement
Cerebral cortex: motor, visual, auditory, cognition, intellect
Basal ganglia: coordination, tone, equilibrium
Cerebellum: coordinated movements
Brain stem (midbrain, pons, medulla): righting reactions
what do we look at in persons with CNS insults when trying to evaluate how well movement is regulated and directed
selective movements
tone
postural control and mechanisms (balance, reflexes)
coordination
resistance of a muscle to passive elongation or stretching
tone
characteristics of normal tone
Effective co activation of axial and proximal joints
Ability to move against gravity and resistance
Can maintain position of limb passively placed and released
Balanced agonist and antagonist muscle tone
Ease of shifting from stability to mobility & vice-versa
Ability to use muscles in groups or separately
Resilience or slight resistance in response to passive movement
Muscle Tone Continuum
(high tone to low tone) Rigidity Spasticity Normal Hypotonia Flaccidity
Complete loss of muscle tone
flaccidity
Reduction in muscles stiffness
Characterized by low tone, weak neck & trunk control, poor muscular co-contraction, limited stability
hypotonia
Hypertonicity
spasticity
Hypertonicity with heightened resistance to passive movement
rigidity
what type of activity can stop clonus
weight bearing
uncontrolled oscillations in spastic muscle groups
repetitive contractions in the antagonistic muscles in response to rapid stretch
clonus
jerky resistance
cogwheel rigidity
severe rigidity – sustained stretch will relax muscle group & give way (like when you’re returning the blade on a pocket knife)
clasp knife syndrome
What is tone like following an insult
Typically, flaccid first 48 hours
Followed by increasing resistance to PROM
Spasticity pronounced in UE flexor muscles and LE extensors
Treatment: encourage voluntary movement, ROM, meds, splinting (elbow, resting hand)
Normalize tone
Ability to maintain a steady position in weight bearing, antigravity posture
postural control
What is postural control influenced by
Neuromuscular mechanisms—postural alignment, muscle tone & postural tone
Musculoskeletal mechanisms e.g. ROM, strength
Sensory mechanisms-vision, vestibular, somatosensory
Perceptual mechanisms e.g. body image, laterality
Cognitive mechanism e.g. attention, judgement
Automatic movements: provide an appropriate level of stability & mobility
normal postural control
Controlling the center of mass (COM) in relation to the base of support (BOS). Maintaining an appropriate relationship between body segments and between the body, the environment and task—orientation
balance
first response against falling or first line of defense
equilibrium reactions
ability to produce accurate, controlled movement
coordination
Coordination problems
Synergy (Abnormal or disordered motor control) Coactivation (Agonist & antagonist muscles both fire, preventing functional movement (extremity will lock out)) Timing problems
accuracy without making corrective movements
precisision
quality of movement
smoothness
what is incoordination caused by
trauma to muscles or peripheral nerve diseases
lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg, or eye
dysmetria
inability to perform rapid alternating movements
ataxia
involuntary quick movements of the feet or hands are comparable to dancing
chorea
slow, involuntary, convoluted, writhing movements of the fingers, hands, toes, and feet and in some cases, arms, legs, neck and tongue
athetoid movements
uncontrolled sustained muscle contraction
dystonia
violent flinging of extremities
ballism
Secondary effect factors that may impair purposeful coordinated movement
Contractures Pain Edema Subluxation Decreased endurance—muscular and cardiovascular
The study of the acquisition and/or modification of movement
A set of processes associated with practice and experience that leads to permanent change in behavior or capacity to respond
motor learning
therapeutic intervention structure
instruction, feedback, opportunities for practice, encouragement/ feedback
temporary change that occurs when performer is provided with solutions to problems
training
relatively permanent change in capability for responding that occurs as a result of practice or experience
learning
most potent factors that influence motor learning
feedback and practice
stages of motor learning
cognitive, associate, autonomous
stage of motor learning where Info gathered about task demands (learn elements)
Movement slow with lots of errors
Explanations & demonstrations valuable
cognitive
stage of motor learning where Distinguish between correct performance and error
Attention to finer details
associative
stage of motor learning where Skill automatic, does not require attention
Performance is stable
autonomous
feedback offered during movement
concurrent
feedback offered offered at the end of movement
terminal
feedback from individual’s sensory systems as a result of movement
intrinsic
feedback from the environment (e.g. therapist or a device)
extrinsic
knowledge of what the movement produces (outcome) in terms of achieving goal or result
knowledge of results
knowledge about the movement pattern or process used during task performance
knowledge of performance
effort to become proficient
practice
types of practice
Physical: direct experience of them doing it
Mental: motor imagery
practice condition where practice time is greater than amount of time between trails (fatigue)
massed
two practice conditions that focus on building endurance
massed and distributed
practice condition where rest time between trials equals or is greater than time in trial
distributed
practice condition where performance of task in same way (may improve performance but fatiguing, less effect)
constant
practice condition where perform task in different way by varying characteristics of the task (improves ability to generalize to various situations)
variable
practice condition where practicing each task in a block before progressing to a new task (better for cog. impair)
blocked
practice condition where you’re practicing a series of tasks in a random order
random
practicing a subset of task component (maybe they don’t have endurance or get frustrated)
part practice
what type of feedback and practice should you give for acquisition (learning new skill)
Feedback: frequent extrinsic, concurrent
Practice: physical & mental, repetition, consistency
Provide manual & verbal cueing
what type of feedback and practice should you give for retention and transfer (such as getting ready to go home)
Feedback: less frequent, terminal
Practice: promote entire pattern, encourage problem solving, variable
Allow for error & refinement; don’t over cue
Therapeutic considerations for motor learning
Therapeutic Environment (TV’s, family members, lighting, yourself) Arousal and Attention (Inquire about their day, sleep schedule, etc.) Motivation and Meaning Instruction (Prepping them ahead of time. Game plan) Feedback Practice
process therapists use to facilitate learning
Therapeutic intervention: Select tasks/activities to use during session Provide instruction Provided feedback about performance Always leave on a positive note Structure opportunities for practice Provide encouragement
treatment assumptions
Return is cephalo-caudal & proximal-distal & medial-lateral
Mobility established 1st, then proximal stability, then controlled mobility, & finally distal skilled movement
Mass patterns replaced by selective voluntary movement
Gross to fine
Large mass movements before discrete
Undifferentiated to specific
