Exam 2 Flashcards
Stage 1 pressure sore
intact skin, nonblanchable, redness, differences in thickness and temperature
stage 2 pressure sore
shallow open ulcer, partial thickness loss, red/pink wound without slough
success for stage 2 healing
75% heal in 8 weeks
Stage 3 pressure sore
full thickness tissue loss, subcutaneous fat may be visible, may have undermining or tunneling, sloughing around edges
undermining
erosion under wound edges= large wound with small opening, measure parallel with a probe
tunneling
destruction of fascial planes creates a narrow passageway, open dead space can lead to abscess, measure depth with a probe to wound edge
stage 4 pressure ulcer
full thickness tissue loss with visible bone, tendon, muscle
success for healing of stage 4
62% ever heal, 52% heal in 1 year
prevention for ulcers
good skin care, nutrition, stop smoking, exercise, FES bike
position changes time frames
15 minutes in wheelchair, 2 hours in bed
wheelchair pressure relief techniques
hook and lean or shoulder extension/ER with scapular depress(C5/C6), weak push up(C7), strong push up(T6), lean forward 1, lean forward 2
powerchair best type for pressure relief
tilt in space–recliner causes migration
causes of pressure sores
sustained pressure(more frequent over atrophied muscle or fat), friction, shear
complications of pressure sores
osteomyelitis, joint infection, cellulitis, sepsis
wheelchair cushions
foam(not considered to reduce ulcer formation), air–ROHO, gel–Jay
quality of the cushion
distribution of pressure, decreased shear, heat dissipation, corrects hip obliquities, cover may absorb moisture
weight limits of wheelchairs and type
standard= less than 250 lbs, heavy duty= greater than 250 lbs
hemiplegic chair
has a lower seat for foot propulsion
standard wheel chair
less than 250lbs, durable, low maintenance, short term- infrequent use, no frills, chrome, non-adjustable usually, hospitals, nursing homes
custom, light weight chair
often rigid frame, low profile back, high end, narrow angled wheels, camber 0-9 degrees, may or may not have armrests, ALWAYS add a premier cushion
ultra light weight chair
less force to propel, adjustable, better components, cost less to operate and last 13.2x longer—–Provide manual wheelchair users with a high-strength, fully customizable manual wheelchair made of the lightest possible material
for SCI pt.
reclining vs tilt in space
User who can’t maintain an upright posture due to respiratory compromise, cardiac issues, orthostatic hypotension, toileting, musculoskeletal impairments; pressure relief; rear wheels are further back, anti-tippers must be present, reclining 0-180, tilt maintains 90 degree hip.
power chair
for increased UE weakness or motor loss, must have cognitive, function, and coordination to operate, have battery, different types of controllers–chin, sip/puff, joystick, head control, tongue touch
stair climbing chairs
climb stairs, rough terrain, not covered by most insurances–$$$
specialized chairs
sports, amputee-axle 2” behind COG & anti tippers, one arm drive
standing wheelchairs
may be be needed for job
Components- frame types
standard non-folding vs folding vs rigid; steel, chrome, titanium
Components- seats and backs
nylon sling/hammock, custom molded, contoured, solid, adjustable tension backs
Components- wheels
spoke vs magnum 12-24”. the more spokes=heavier, but lasts longer
rubber, polyurethane, tread
drive tires–pneumatic(more comfortable ride), solid, semi-pneumatic(won’t deflate)
Components- axle plates
standard, adjustable height and length, quick release
forward axle= tippier, easier to push
back axle= stability (double amputee)
Components- casters
3-8” soft roll, polyurethane
pneumatic, solid, semi-pneumatic, micro-lighted—smaller are better for turning, but worse for getting caught in cracks
Components- arm rests
removable or fixed, full length or desk cut out, tubular, adjustable height, flip back
clothing guards
Components- handrims
smooth- aluminum vs black plastic, projections- oblique(can get caught in doorways) vs vertical, theratubing trick
Components-leg rest
swing away/removable, fixed, elevating
Components- foot plates
heel loops, fixed, swing up, plates-smooth or ridge
Hanger angle
angle of footrest–70, 80, 90 degrees, 90 allows for better turning radius
Camber angle
angle of wheels, 0-9 degrees, lowers center of gravity= sharper turns, increase base of support, too much may prevent doorway entry
Seat slope
difference between seat to floor height in front and rear.
have a slight slope (buttocks below knees) for improved balance and body stability
too much can cause poor posture, sacral sit, lumbar flexion, thoracic kyphosis
Floor to Seat height AKA leg length
functionally- PT fingers horizontal, easily fit under thigh
CONSIDER CUSHIONS
measure heel to popliteal fold with shoes on–add 2” for footrest clearance
access to push rims- hands dangling, fingertips should just pass axle
too high- tipping, poor propulsion, poor fit under surfaces, unable to touch floor
too short- increased hip angle & pressure to tuberosities
Seat depth
functionally- 2-3 PT fingers between popliteal fold and front edge of seat
pt. all the way back in seat
measure from posterior buttock to popliteal fold–subtract 2” for clearance of pop. fold
too long- no 90 degree knee flexion, pressure sores
too short- pressure on tuberosities, skin irritation to post. thigh, decreased back stability
components- accessories
backpacks/bags, lap boards/tray, 02 tank carrier, grade aids
art of caring
combination of theory, experience, creativity, and sensitivity
Finishing a patient–balance, comfort, clothing, etc.
Science of healing
use of evidence-based examination tools, interventions, and decision making
art of caring
combination of theory, experience, creativity, and sensitivity
care for yourself, patient, and instructor
Seat Width
Functionally-both PT hands fit between greater trochanter and clothing guard/arm rest panel
measure- from widest point of each hip while patient sitting–add 1-2 inches for growth, coats, efficient push stroke or narrow doorways
Back Height
Functionally-2-4 fingers held vertically between top of back rest and axilla, clear inferior angles of scapula
CONSIDER CUSHIONS–upright posture
measure-shoulder flexed to 90 degrees, measure from flat surface to axilla–subtract 4 inches
-also measure flat surface to inferior angle with arms neutral
too high- limits ROM for propulsion, irritates
too low-no trunk support, sacral sitting, kyphosis, lumbar flexion
Seat Width
Functionally-both PT hands fit between greater trochanter and clothing guard/arm rest panel at same time with pt. centered
measure- from widest point of each hip while patient sitting–add 1-2 inches for growth, coats, efficient push stroke or narrow doorways
If too tight-pressure sores, transfer difficult if too wide-ML stability, scoliotic posture, doorways
Armrest Height
measure from flat surface to olecranon with arm in 90 degree flexion and slightly forward in sagittal plane–add 1”
CONSIDER CUSHION
too high- posture deviation, propulsion, poor UE function and transfers
too low- inadequate support, fatigue of UE, slumped posture
Propelling pattern
oval spatial pattern, long, smooth push strokes 10-2, proper upper body posture, more rim contact, reduce high impacts to handrim, keep hand below handrim level when not in use for pushing
Forward axle position
Place as far forward as possible w/out compromising stability
tippier(decrease rearward stability), easier propulsion b/c decreases rolling resistance, increases hand contact angle, less muscle effort, smoother jt excursion, fewer push strokes, decreases overuse injury and strain
ADJUST for balance and shoulder strain
Wheelchair adjustments of axle
place axle so that at top of pushrim, arm forms 100-120 degree angle with forearm
lowered seat position or higher rear axle= improved propulsion biomechanics
initial parts of mobility activity
review chart/history/record; pain, abrasions, wounds, hardware, vitals, cognition, fear/apprehension in moving
What to document in session
EVERYTHING! dizziness, light headedness, vitals associated, notable pain-all aspects, skin check for wounds/abrasions, falls or near falls, balance and coordination, description of movements(accessory motions needed to perform activity), time to complete, level of assistance needed
safe handling
- assess situation and patients level of assistance, cooperation, and comprehension
- plan ahead and get help if needed and use equipment–especially if patient is large or unable to help with mobility
Matched physical assistance
is as much or as little physical assistance as the patient needs at this moment in time
Body mechanics and safe patient handling
position for optimal mechanics, skin checks, pressure points, minimize shear forces, protective padding/gloves, move as slow as necessary to prevent pain and control movement–however, may need momentum forces to aid, engage the patient, facilitate typical/normal movement patterns
Rolling
initially see what the patient can perform on own to help assess how much matched assistance is needed. ask patient to help as much as possible.
PT assists on posterior shoulder and hip, knee bent, pt. reaches and looks in direction of roll., bottom arm up and out of way at 90 degrees if tolerated
Rolling special considerations
FIM level
total hip arthroplasty: no hip flexion past 90, no add., no int. rotation
hemiplegia: shoulder pain, 1st attempts use stronger on top, later use weaker on top
back surgery/unstable spine: log roll with spinal align
Hooklying rolling
both knees bent, better use of muscles, improved jt stability with co-contraction of hams and quads, improved leverage
Supine bridging
“squeeze butt and lift up off bed, push down through feet”, stabilize core, can push down through elbows, DON’T extend neck.
PT facilitates with pressure at hips, traction at distal femur
Supine scooting up in bed
assume hook lying, elevate shoulders and tuck chin, press elbows and feet down into bed, bridge at hips and extend both legs.
PT facilitates as in bridging, head of bed down, sheet/sliders under pt.
Supine scooting side to side
hook lying position, elbows and feet push down into bed, one arm abd. and one add., upon lift shift right with hips then shift upper body.
PT facilitates with bridging or hands under upper trunk to pull body towards you
supine to short sit special circumstances
Total hip: pillows to prevent add. and IR
Hemiplegia: start with strong side down then go weak side down
Spinal instability: log roll, spine neutral, no Valsalva
supine to short sit
roll to sidelying, knees and legs off side of bed, then have patient place top arm palm down and push up while PT assists at shoulder and hip
CHECK for BALANCE, guard front of patient ALWAYS, never leave patient, lower bed to floor for assist in balance
Scoot forward to EOB
off-load one side and move leg forward from posterior pelvis, then switch sides
PT facilitates the lean and cues elongation on weight shift side, cues lateral flexion on off-load side. head on side of off load
Short sit scooting
place 1 (push)hand close to buttock, 1 (pull)hand abducted in direction of scoot, place feet in direction of scoot, then push down into hands and scoot butt in desired direction while controlled throwing head in opposite direction
Stability vs mobility
maintaining a position precedes attaining/assuming a position.
stability precedes mobility
prone on elbows
roll to prone then place elbows directly under shoulder
maintain POE 1st, stability–“dynamic” flat back, head neutral
progress to mobility or weight shift, then to off load
finally, progress to assuming POE
4 point position
shoulders over hands, hips over knees, neutral spine
place a peanut under stomach, stabilize at hips, and bolster behind knees and under ankles “dynamic core”
maintain, mobility, weight shifting, then assuming
Developmental sequence
POE to 4 point–which leads to pre-gait crawling with a harness then without support, to short kneel, tall kneel (and tall kneel walking), then 1/2 kneel
Short kneeling
walk hands back from 4 point, bolster under knees and ankles, “dynamic core”, PT facilitates co-contract of abdominals and paraspinal, or anterior manual contact
Tall kneeling
elevate from short kneel, 2 bolsters still, “dynamic core”, may use parallel bars, PT facilitate hip extension and anterior chest elevation, can progress to tall kneel walking
1/2 kneeling
weight shift to opposite side of moving LE, PT facilitate patient maintaining back and hip extension, bring moving foot in place out front, “dynamic core”, parallel bars if needed
Letter of medical necessity
may be needed for any piece of equipment, describe patient and needs, evidence for why specific components of equipment are needed as compared to patient needs, and PT and MD both sign.
Transfers-general trajectory of each body part
need to facilitate spatial trajectories:
head and chest both come forward 1st then curve up and back
hips follow an oblique line up and forward
knees come forward first(anterior translation) then pop back into standing
Key joint motion for STS
all go flexion to extension(neck, trunk, pelvis, hip, ankle) EXCEPT knee which remains in extension the whole time
STS momentum strategy
requires acceleration for forward and upward, eccentric force for deceleration, a certain amount of speed and no breaks in motion
SAFETY: make sure the patient gets far enough forward, can result in a backward fall or a forward fall if forces are not perfect
STS Force strategy
at least 1 stop, lean forward to bring COM over BOS, STOP, then use LE to vertically lift the body to standing
Pre-transfer considerations
Protect yourself, know your patient–history, record, documents (just like in mobility), make sure to check for weight bearing ability, devices, assistance level, etc.
Conditions that affect transfer:skin, weight, amputation, paralysis, language, cognition
Facilitation vs. man-handling
Facilitate: request assistance from patient–emphasizes engagement and motor recovery
Man-handle: doing all the work ourselves–no active participation or motor recovery
Types of facilitation
verbal cueing, physical cueing, demonstration, alignment of patient for biomechanical advantage, set up environment to promote engagement/function
first step in STS
Place gait belt on patient
mobile vs stable posiitioning
balls under knees= mobile
heels under knees= stable
set-up for STS
gait belt, EOB, appropriate bed height, balls of feet under knees, feet shoulder width, with/without arms, encourage trunk/hip flexion–nose over toes
STS from front
EOB, feet behind knees, leaned forward.
PT facilitates at anterior knee, posterior hip, and anterior chest
NEED trunk, hip, and knee extension for safe stance
Stand to sit
reverse STS, bend knees, flex trunk, flex hips–lean forward stick butt back–continue SLOWLY
STS from side/with walker
PT controls weaker side with a pinch grip pressing down then back on knee, other hand open grip on hip opposite. Patient leans forward and pushes through both legs utilizing good leg for support
Horizontal transfers-slide board
used with amputees, SCI, dependent patients.
shift weight/off-load/cross legs and place slide board.–chair at 45 degrees from side of table
scoot using Head to Hip ratio–opp. head to direction of hips- a couple times across board to transfer surface
off-load to remove slide board, scoot back into seat
For wheelchair, locked, initially have inside arm rest remove and any feet rests swung away, then replace once in seat.
PT GUARDS AT ALL TIMES
Horizontal transfers-squat pivot
for more dependent patients-no wt bearing capability
PT facilitates at posterior hip, anterior trunk, and traps knees
Horizontal transfers-stand pivot
for patients who can bear some weight, but deconditioned, fearful
PT facilitates with posterior hip and anterior knee blocking if needed
horizontal transfers 1st step
make sure everything is prepared–slide board close, chair at 45 degrees and close enough, pt. at EOB, surfaces at right height, with sheet, etc., communicate verbally
horizontal transfers- step pivot
STS then off load one side and step with that foot, then lean and off load other side and step with that foot until reach chair, then stand to sit
PT facilitates with posterior hip, anterior knee blocking, balance while walking
Dependent Transfers-special considerations
bariatrics–body mechanics!, elicit help for transfers/repositioning, all equipment must have higher weight rating–EC or XL
Dependent Transfers- slide board or squat pivot
1 person
FIM 1-2, PT facilitates posterior hip, anterior chest and knees. Trap knees, bring patient very close to you, lean back and pivot to surface
Dependent Transfers- wheelchair to/from bed/mat/chair
2 person
option 1: front PT does squat pivot, back PT assist with lift and slide
option 2: 1 PT behind–takes lead–patient crosses arms and PT does t-rex lock(under shoulders over arms). PT hugs patient to chest lift with knees/lean
1 PT front–arms under thighs, lifts with knees/lean
Dependent Transfers- mechanical lift
2 person
fold the slide in half, with outside out and folded edge against patient back in roll, then roll to other side and pull top layer only. attach hooks and loops appropriately, full coverage at shoulders and head–2nd person aids with neck position upon lifting.
raise lift until clear of surface and move lift to chair, positioning as desired then lower and finish patient with clothes, call button, etc.
Dependent Transfers- 4 person lateral transfer
position patient onto sheet or slide, 2 people pull, 2 people lift and push, person at patient head on push side is in charge. good mechanics. slides reduce friction, lift reduces shear
Wheelies
always have a guard!
find balance point, then practice 10 and 2 o’clock positions. Slowly roll back to 10 then quickly forward to 2. Repeat popping until you can find balance pt.
Wheelchair falls body position
flex head and upper trunk, reach for wheelchair frame and cross arms to prevent being hit in face by legs. if arms cannot be crossed, turn head to side so legs hit side of head, not face
Wheelchair fall recovery
- position butt back into chair seat with knees over front of frame
- pull on chair frame to lift head and upper body to reach and lock wheel locks may need to reach across
- release 1 hand and place it on the floor near wheel chair back(stronger side)
- reach across with weaker side to grasp wheel
- pull on wheel and walk supporting hand forward toward the chair until it resumes upright position
- eventually it passes the balance point and will tip forward, brace for impact and forward forces
PT ALWAYS GUARDING
Wheelchair to floor transfer knees
place both feet as far under chair as possible, then scoot to edge of chair by lifting and tossing head backwards, then grasp edges of frame and slowly lower to floor. release with 1 hand at a time to assume 4 point then slowly pivot and lower to side sit
Wheelchair to floor transfer rotate
can twist legs while in chair–side rotating to has leg behind other leg, scoot to edge of chair, turn upper body and place hands on either side of chair frame then lift and twist, lower to floor, then down to 4 point
Floor to wheelchair foreward
approach chair in 4 point then tall kneel and get close then put inside knee of rotation slightly in front of the other and place both hands on wheelchair frame on that side. head hips relationship twist and lift butt to seat then adjust positioning in chair
floor to wheelchair backward
place a slight elevation cushion in front of chair and assume long sit with back against wheelchair seat. then reach up with both hands to find the frame and push up, then throw head forward and hips back to get onto seat and position
