FCS, Gen Med, etc (Gait, w/c, ADA, t/f assistance levels, lines/tubes, etc) Flashcards
Difference between sign and symptoms
Sign – What the therapist can observe (swelling, brusing, etc)
Symptoms – something the patient reports (pain, headache, etc)
SMART goals
Specific
Measurable
Agreed upon
Realistic
Time based
What % is stance phase of gait?
60%
….if it is 45% than it is significantly less than normal fyi…
What percentage of gait is double limb stance?
Initial double stance 10%
Terminal double stance 10%
Total = 20% of double limb support
What percentage of gait is single limb support?
40%
What % of gait is swing?
40%
Initial contact
First phase of stance phase. Occurs the instance the first foot hits the ground
Muscles Active:
- quads to extend and control small amount of knee flexion for shock absorption
- DF (tib ant, ext. hallucis long, extensor digitorum long) control lowering from DF.
“aka heel strike”
Hip: 20 deg flexion
Loading Response
First period of double limb support. From IC until contralateral LE leave the ground
Muscles Active:
- gastroc soleus eccentrically controlling tibial advancement
“aka foot flat”
Hip and knee ~20 deg flexion; Ankle ~0-10 deg of PF and eversion
Midstance
From contralateral LE leaving ground. Body weight is transferred onto forward limb. First period of single limb support.
Muscle Active:
- hip, knee, and ankle extensors: to stabilize. Hip to control forward motion of the trunk
- Hip abductors: stabilize
- Gastroc soleus control forward tibial advancement.
Terminal Stance
last period of single limb support.
Heel rise of ipsilateral LE until contralateral LE contacts LE.
Muscles Active:
- PF peak activity generates forward propulsion
Hip: 20 deg extension, knee extended, ankle 10 deg of DF
“aka Heel off”
PreSwing
Begins with floor contact of opposite limb to lift off of support limb
Second phase of double support
Muscle Active:
- hip and knee extensors
Hip 10 deg ext; knee 40 deg flexion; ankle 20 deg PF
“aka toe-off”
Initial Swing
from toe-off of reference limb until maximum knee flexion of same limb.
Muscles Active:
- Initially quadriceps
- Hip Flexors (iliopsoas)
Hip 15 deg flexion; knee 60 deg flexion; ankle 10 deg PF
Midswing
reference extremity moves directly below the body. Maximum knee flexion to vertical tibial position
Muscle Active:
- hip and knee flexors, DF
Hip 25 deg flexion; knee 60 deg flexion; ankle 0 deg
Terminal Swing
Begins with vertical tibial and completed by knee extension just prior to IC.
Muscles Active:
- Hamstrings to decelerate the limb
- Quads and ankle DF to prepare for heel strike
Hip 20 deg flexion; knee full extension; ankle 0 deg.
“aka deceleration”
ROM Requirements for Initial Contact
Hip - 20 deg flexion
Knee - fully extended
Ankle - neutral (0 deg)
ROM Requirements for Loading Response
Hip - 20 deg flexion
Knee - 20 deg flexion
Ankle - 5 deg PF
ROM Requirements for Midstance
Hip - Neutral
Knee - fully extended
Ankle - 5 deg DF
ROM Requirements for Terminal Stance
Hip - 20 deg hip extension
Knee - nearly fully extended
Ankle - 10 deg DF
ROM Requirements for Preswing
Hip - 10 deg hip extension
Knee - 40 deg flexion
Ankle - 15 deg PF
ROM Requirements for Initial Swing
Hip - 15 deg flexion
Knee - 60 deg flexion
Ankle - 5 PF
ROM Requirements for MidSwing
Hip - 25 deg flexion
Knee - 25 deg flexion
Ankle - Neutral DF
ROM Requirements for Terminal Swing
Hip - 20 deg flexion
Knee - Full extension
Ankle - Neutral DF
Step length
between heel at intial contact on subseqeuent steps (ipsilateral vs contralateral heels)
Stride length
between two consecutive contact of the same limb
Average velocity of gait
1.3 m/s.
Lateral trunk bend gait deviation
AKA trendelenburg
weak glute med will see bending to same side as weakness
Backward Trunk lean gait deviation
aka Glut Max gait
weak glut max
Forward trunk lean gait deviation
weak quads; hip/knee flexor contractures
Excessive hip flexors gait deviation
weak hip extensors; tight hip/knee flexors
Excessive knee flexion gait deviation
weak quadricepss; knee flexor contractures
Hyperextension of knee gait deviation
weak quads; PF contracture; extensor spasticity (of quads or PF)
Equinus gait
heel does not touch ground. Spasticity or contracture of the PF
Excessive hip and knee flexion gait deviation
AKA steppage gait
Compensatory response to shorten the limb; result of weak DF
(diabetic neuropathy, fibular neuropathy, L4-5 radiuclopathy)
A patient who has been on bed rest for three weeks has developed a plantar flexion contracture. Which phase of the gait cycle would be the MOST problematic for the patient based on the described impairment?
Midstance since it requires the greatest amount of DF (at 10-15 deg of DF)
How to measure for cane?
- 6 inches to the side of the toes to the ulnar styloid or wrist crease with a 20-30 deg elbow flexion
- minimal stability…more for balance.
- used opposite of the deficit side
2 gait patterns performed with cane?
Two point: cane with involved LE followed by uninvolved LE
Delayed two point: cane – involved LE – uninvolved LE
Right height for // bars for pt?
20-25* elbow flexion while arms are 4-6 inches in front of body,
How to measure for walker?
20-25* elbow flexion
~ at ulnar styloid process
How to measure for crutches?
- 6 in in front of 2 inches lateral.
- Axillary pads should sit 2-3 fingers widths below the axilla (no more than 3)
- The elbow should allow for 20-25 deg elbow flexion
- ~ at ulnar styloid process
How to measure for Lofstrands?
- highest level of coordination
- 20-25* elbow flexion with handgrip
- positioned 6 inches in front and 2 inches lateral
- arm cuff - 1-1.5” below olecranon process
Swing-Through Gait
- Crutches advanced first, lower extremities swing for-
ward beyond the point of crutch. - Used in non-weight-bearing status or bilateral lower
extremity involvement.
Two-point gait pattern with AD
- One crutch and opposite extremity move together, fol-
lowed by the opposite crutch and extremity; requires
use of two assistive devices (canes or crutches). - Allows for natural arm and leg motion during gait,
good support and stability from two opposing points
of contact.
Three-point gait pattern with AD
- Crutches and involved lower extremity are advanced
together, followed by the uninvolved limb. - Indicated for use with involvement of one extremity;
e.g., lower extremity fracture.
Delayed Three point gait pattern with AD
- Crutches advanced first followed by the involved
lower extremity; then uninvolved lower extremity. - Indicated when patient requires increased stability
and slower movement.
Four point gait pattern with AD
- One crutch is advanced forward, followed by the con-
tralateral lower extremity, then the second crutch is
advanced forward, followed by that contralateral limb. - Used with bilateral lower extremity involvement.
Where to guard during ascending the stairs/ramp?
- With handrail, stand opposite and behind
- No handrail, stand behind pt and twds affected
Where to guard during descending the stairs/ramp?
- with handrail, stand opposite side and in front of pt
- No handrail, stand in front and twds affected side
When guarding on stairs where is therapist?
Pt is always below pt and typically on weaker side.
If pt looses balance on the stairs with crutches what should you do.
Pt releases crutches
Grab handrail
Help lower to the ground
What is bad about sling seat w/c?
hip tend to slide forward, thighs tend to adduct and IR. Also tend to go into PPT position.
Poor support
What are foam cushions good for on w/c?
pressure-relieving
accommodates moderate to sever postural deformity
They are low maintence
They may get interfere with slide transfers
What are fluid/gel or combination cushion good for on w/c?
Can be custom molded
Accommodates moderate to severe postural deformity
Some maintenance required, they are heavier, and more expensive
What are air cushions good for on w/c?
Accommodates moderate to sever postural deformity
Lightweight with improved pressure distribution
Expensive
May be unstable for some
Requires continuous maintenance
Benefits of rigid frame
facilitates stroke efficiency, increases distance per stroke
lighter weight
Standard rubber tires vs pneumatic tires on w/c
Standard rubber: durable, low maintenance, indoor only, heavier; rougher ride
Pneumatic: smoother, increased shock absorption; require more maintenance
What is a Tilt-in-space w/c good for?
pts with extensor spasms that may throw the pt out of the chair
or for pressure relief
It maintains normal seat to back angle for duration.
In normal w/c what is the seat to back angle?
at a slight anterior pelvic tilt.
Hemi chair
lower to the ground for propulsion with noninvolved arm and leg
Can potentially add one-arm drive
Wheel camber
Cambered to add better access to the wheel and better on the shoulders.
Also helps with stability
Amputee w/c
Places the drive wheels POSTERIOR (by 2 inches) to the vertical back support.
This increases length off BOS and posterior stability.
On w/c how to measure seat width?
width of hips at widest part and add 2 inches
*If too wide: difficulties reaching drive wheels and effectively propelling chair
- If too narrow: pressure/discomfort on the lateral pelvis
Average: 18 inches
On w/c how to measure seat depth?
posterior buttock to posterior aspect of lower leg in popliteal fossa and subtract 2-3 inches
*Too long: compromise posterior knee circulation, kyphotic posture, or PPT/sacral sitting.
*Too short: fails to support the thigh and decreases surface area to distribute the forces
- Avg: 16 inches
On w/c how to measure leg length/seat to footplate length
bottom of shoe to below popliteal fossa. Must include cushion height into measurement. Should be in 90/90 position
- Too long: encourage sacral sitting and sliding forward in chair
- Too short: uneven weight distribution on thigh and excessive weight on the ischial seat.
On w/c how to measure seat height from floor
Minimum clearance between floor and footplate is 2 inches
On w/c how to measure arm rest height
(add 1 inch!)
seat platform just below the elbow held at 90 deg with shoulder in neutral position. Add 1 inch to the pts hanging elbow measurement.
- Too tall/high: shoulder elevation
- Too short/low: encourage leaning forward or laterally
Measurements of a normal adult standard w/c
Seat width: 18 inches
Seat depth 16 inches
Seat height: 20 inches
How to ascend and descend curb in w/c?
Ascend: front casters up on curb, lean forward, push rear wheels up curb using momentum to assist
Descend: descending backward with forward head and trunk lean OR descend forward in a wheelie position
Standard door width/minimum door width for ADA compliance
32 inches (barely enough to fit the w/c or walker)
Minimum hallway width for ADA compliance
36 inches
Toilet seat height
17-19 inches from the floor
Normal step height and depth (for stairs)
7 inches height
11 inches depth (minimum)
Steps should no exceed 7 inches. Greater makes increasingly more difficulty for those with disabilities
Ratio of slope to rise of a ramp
1:12 (8.3% grade)
For every inch of vertical rise there must be 12 inches of length.
Must be a minimum of 36 inches wide.
Ramp landing - 60 inches (straight)
According to ADA what is the max pile of carpet allowed to be in compliance?
1/2”
What is the ADA?
Americans with Disability Act – 1990
Prohibits discrimination and ensures equal opportunity for persons with diabilities
What does HIPPA stand for?
Health Insurance Portability and Accountability Act
Stability precedes mobility means
Pts are usually able to maintain a position before they can attain it.
Sternal precautions
No shoulder flexion above 90 degrees
No shoulder abduction
No pushing/pulling with bilateral UE’s
No lifting > 8-10 pounds (gallon of milk)
Stand by assist (Supervision) means
Pt. does not require physical assist
May need supervision for decreased safety
May require verbal cues for sequencing of t/f
May require verbal cues for problem solving
May require assistance in an emergency
Does not necessarily mean close proximity
Pt requires therapist to observe throughout task. (usually for safety)
Contact Guard Assistance (CGA) means
Can perform activity without physical assist but requires clinician maintain contact with pt. to be able to provide assistance immediately
Occurs when there is a significant likelihood that the pt. with require physical assistance for support or balance
Usually because of LOB
Minimal Assistance means
Pt performs ≥75% of task
(Pt requires <25% of help)
Moderate Assistance means
pt. performs 50-74% of task
(pt requires ~50% of help)
Maximal Assistance means
pt. performs 25-49% of task
(pt requires ~75% from theapist to complete task)
Dependent (Total) Assistance means
pt. performs <25% of task
* pt is unable to participate or therapist must provide all of the effort to perform task.
Which side to t/f to first?
Strong side or unaffected side to maximize safety and build pt confidence.
Who is the leader during t/f?
The person at the head of the pt with multiple person t/f
3-person lift/carry (dependent)
- t/f from stretcher t bed/treatment plinth.
- one at head, trunk, and feet.
2 person lift/carry (dependent)
- t/f b/n surfaces of differing heights or when t/f from floor
- 1 behind pt with arms under axilla and other at mid thigh
Dependent squat pivot transfer
- for someone that can’t stand Ind but can bear some weight through trunk and LE
- pt positioned 45* to surface and pts arm on therapists arm (but not pulling)
- arms around hips and under buttock with blocking pts knees.
- use momentum and maintain in a squatted position as the therapist.
What is the difference between clean technique and sterile technique?
Clean technique: refers to efforts to reduce infectious organisms in the immediate environment.
Sterile technique: is a specialized process designed to eliminate pathogens from the clinical environment
Hydraulic lift transfer
- when pt is obese
- 1 therapist is avaialbe t assist when pt is totally dependent
- keeping webbing in place for return trip.
Sliding board t/f (assisted transfer)
- some sitting balance, some UE strength, and can adequately follow directions.
- position at end of w/c and lean to one side while placing one end sufficiently under proximal thigh
- place lead hand ~4-6inches away from sliding board and use both arms to initiate a push-up and scoot across board.
- Avoid direct contact between skin and sliding board
Stand pivot transfer
- for pts able to stand and bear weight through one or both LE.
- Must have functional balance ability to pivot.
- Unilateral WB restriction or hemiplegia – lead with uninvolved side (strong side)
Stand step transfer
*pt has necessary strength and balance to weight shift and step during the t/f.
* actually takes a step versus pivoting
Pseudomonas aeruginosa
Bacteria that thrives in water and is opportunistic in moist tissue of burn victims
Gram negative (-)
Resistant to many antibiotics – require antibiotic cocktail – these may work (fluoroquinolones, gentamicin, and imipenem)
Smells “icky sweet” or “fruity”
May have blue pus
Staphylococcus aureus
Gram (+) positive
Normally present in nose and on the skin
Causes pus-forming infections and toxinosis in humans
Superficial skin lesions - Boils (furuncles), styles (infection of gland or hair follicle of eyelid
More serious infections - Pneumonia, mastitis, phlebitis, meningitis, & UTI
Deep-seated infections - Osteomyelitis (infection of the bone) & endocarditis
Methicillin-resistant staphylococcus aureus (MRSA)
Spread by skin-to-skin contact
Common with compromised immune systems
S&S of skin infection: Red, swollen, and painful area to the skin; Pus or other fluids drain from the area; May look like a boil
S&S of severe infections: Chest pain, Cough or shortness of breath, Fatigue, Fever & chills, Headache, Rash, Wounds that do not heal
Vancomycin-resistant Enterococci (VRE)
Gram (+) positive found in human intestines and in female genital tract
Spread person to person or contaminated surfaces
Clostridium difficile (C-diff)
Infection of the colon
Causes diarrhea (watery diarrhea 3 or more times /day for 2 or more days)
Usually develops during or shortly after course of antibiotics.
Standard Precautions includes
Gloves and mask
Contact Precautions includes
Private room, gown, gloves, leave pt equipment in pts room.
MRSA, VRE, c-diff
Droplet Precautions includes
Private room, gown, gloves, MASK (if within 3 ft of pt)
Pt wears mask if transported out of room
Mumps, flu/influenza, RSV, pertussis, strep
What type of precuations does MRSA require?
Contact precautions
- private room, gown, gloves, and private equipment in room
Airborne Precautions
N95 respirator, private isolation room (negative air flow room), essential transport only.
Measles, Tuberculosis (TB), chickenpox, herpes zoster
What requires contact precautions?
MRSA, VRE, c-diff
What requires droplet precautions?
Mumps, Influenza/flue, RSV, pertussis, strep
What requires airborne precautions?
TB, Measles, chickenpox, herpes zoster
When should you perform hand hygiene with sanitizer/hand rub vs antimicrobial soap and water
Sanitizer/hand rub: remove jewelry and cover all surfaces of hands with the cleansing agent. Rub dry (~15 sec); do not rinse.
Antimicrobial soap and water: MUST use - when hands are visibly dirty. - when pathogen is known to be C. difficile. - after multiple applications of sanitizer or hand rub. Wash 15-60 sec.
How long should you wash your hands?
Soap and water – wet hands, apply soap product, rub vigorously for 15 sec
Alcohol based hand sanitizer – put on hands and rub all surfaces for 20 seconds
How often for repositioning in supine? How often for pressure relief off buttocks?
Supine: reposition at least every 2 hours (for dependent patients)
Sitting: pressure relief off buttocks at least every 10-15 mins.
Which side is it typically easier for pt with hemiplegia to t/f from supine to sitting?
On the weaker side
Magnesium (Mg) Values
1.5-2.5 mEq/L
Phosphate (P) values
2.6-4.5 mg/dL
Red flag > 5.1
Potassium (K+) Values
3.5-5.0 mEq/L
Red flag < 3.2; 5.1
Calcium (Ca+) Values
8.5-10.5 mg/dL
Blood Urea Nitrogen (BUN) Values
10-20 mg/dL
Caution >20
Bicarbonate (HCO3) Values
22-26 mEq/L
Cholride (Cl-) values
98-106 mEq/L
Sodium (Na+) Values
135-145 mEq/L
Caution <120
Plasma Creatinine Values
0.5-1.1 mg/dL Females
0.6-1.2 mg/dL Males
Caution > 1.2
Creatinine Clearance Values
87-107 mL/min Females
107-139 mL/min Males
Fasting Glucose Values
70-110 mg/dL
Red flag < 60 or > 300-350
Hb A1C values
(average over 3 months)
5.7-6.4% - Pre diabetic range
6.5% - diagnosed with diabetes
** goal of individuals with diabetes is to maintain A1C less than 7%
Hemoglobin Values
iron containing protein that has strong affinity for oxygen
14-18 g/100mL Males
12-16 g/100mL Females
Caution 8-10
Red flag <8
Hematocrit Values
measure of % of whole blood occupied by cells
42-52% Males
36%-48% Females (Text says 37-47)
Caution 25-30%
Red flag < 25%
Blood cell count values
Leukocytosis – WBC > 11,000/mm3
Leukopenia – WBC < 4,000/mm3 or <5,000 with fever
Thrombocytosis - PLT > 400,000/mm3
Thrombocytopenia –PLT < 140,000/mm3
INR Therapeutic values
2.0-3.0
Prophylaxis of venous thrombosis (high risk surgery)
DVT and PE
DIC (disseminated intravascular coagulation) prevention and treatment
Afib
Valvular heart dz
*Recurrent systemic embolism
Cardiomyopathy
2.5 – 3.5
Acute MI
Mechanical prosthetic heart valve replacement
INR Yellow Flags
Values between 3.5-5.0
Consider fall risks
Possible bleeding during debridement
INR Red Flags
> 5.0 (some references site 6.0 as bedrest)
Consider holding all debridement and pulsed lavage
May be on bed rest
Consult MD
Hypercalcemia
- excessive levels of calcium in blood (Norm: 8.5-10.5)
- Most commonly associated with hyperparathyroidism since excessive parathyroid hormone raises the level of circulating calcium above normal.
- Symptoms: constipation, pain, nausea, vomiting.
Hyperkalemia
- excessive levels of potassium in blood (Norm 3.5 - 5)
- (>7): Can cause significant hemodynamic and neurologic consequences
- (>8): cause respiratory paralysis or cardiac arrest
- Symptoms typically related to abnormalities in muscular or cardiac function
Hypermagnesemia
- excessive level of magnesium in blood (Norm: 1.5-2.5)
- relatively rare since the kidneys are able to eliminate excess magnesium by rapidly reducing its tubular absorption.
- Most often caused by renal failure.
- Symptoms: hypotension and respiratory depression
Hypernatremia
- excessive level of sodium in blood (Norm: 135-145)
- Occurs when there is a net water loss or a sodium gain and reflects too little water in relation to total body sodium and potassium.
- Most often caused b impaired thirst or restricted access to water and can be facilitated by pathologic conditions with increased fluid loss
- Primary symptoms is thirst .
Neck ROM norms
Neck Flexion range - 0-45 deg
Neck Extension range - 0-65 deg
Neck Rotation range - 0-60 deg
Neck Lateral Flexion range - 0-35 deg
Shoulder ROM norms
Shoulder Flexion range - 180 deg
GHJ Flexion/Elevation range - 120 deg
GHJ Extension range - 60 deg
Shoulder ABD range - 180 deg
GHJ ABD range - 90 - 120 deg
Shoulder Horizontal ADD range - 135 deg
Shoulder Horizontal ABD range - 45 deg
Shoulder IR range - 70 - 90 deg
Shoulder ER range - 90 deg
Elbow ROM norms
Elbow flexion range - 150 deg
Elbow Extension range - Ext: 0 deg, hyper-Ext: 15 deg
Elbow Pronation range - 80 - 90 deg
Elbow Supination range - 80 - 90 deg
Wrist ROM norms
Wrist flexion range - 80 deg
Wrist extension range - 70 deg
Wrist Ulnar deviation range - 30 deg
Wrist Radial deviation range - 20 deg
Finger ROM norms
DIP flexion: 90 deg
DIP extension: 10 deg
PIP Flexion: 0-100 deg
MCP Flexion: 0-90 deg
MCP Extension: 0-45 deg
Thumb ROM norms
CMC flexion: 0-50 deg
IP flexion: 0-80 deg
Hip ROM norms
Hip Flexion range - 0-120 deg
Hip Extension range - 0-30 deg
Hip ABD range - 0-45 deg
Hip ADD range - 0-30 deg
Hip IR range - 0-45 deg
Hip ER range - 0-45 deg
Knee ROM norms
Knee Flexion range - 0-135 deg
Knee Extension range - 135-0 deg
Ankle ROM norms
Ankle PF range - 0-50 deg (talocrural)
Ankle DF range - 0-20 deg (talocrural)
Ankle Inversion range - 0-30 to 35 deg (midtarsal/transverse tarsal)
Ankle Eversion- 0- (15-20) deg (midtarsal/transverse tarsal)
Subtalar Inversion/Eversion - 0-5 deg
Thoracic and Lumbar Spine ROM norms
Flexion: 0-80 deg
Extension: 0-25 deg
Sidebending (Lateral Flexion): 0-35 deg
Rotation: 0-45 deg
Stop exercise red flags for BP:
systolic >250 mm Hg.
diastolic >115 mm Hg.
systolic drop >10 mm Hg from baseline.
failure of the systolic pressure to increase with increasing workload.
Stages of Hypertension:
Normal: <120/80mmHg
Elevated: 120-129/80mmHg
Stage 1: systolic 130-139 OR diastolic 80-89
Stage 2: systolic atleast 140 OR diastolic atleast 90mmHg
Hypertensive crisis: systolic over 180 and/or diastolic over 120
Normal respirations in adults:
12-20
Normal temperature
98.6 deg F OR 37C (measured rectally)
SpO2 norm
95-100
Need O2 if 88 or below
Medicare guideline for admin of O2
88%
PROM dosage
5-12 repetitions
~5-10 sec per cycle
3-5 time/wk
UE PNF D1 Flexion
UE PNF D1 Extension
LE PNF D2 Flexion
LE PNF D2 Extension
Goals of PNF?
Initiate Motion
Learn a Motion
Change Rate of Motion
Increase Strength
Increase Stability
Increase coordination and control
Increase endurance
Increase Range of Motion
Relaxation
Decrease Pain
To promote functional movement, inhibition, strengthening, and relaxation of muscles.
Afterdischarge
Relation to PNF
The effect of stimulus continues after the stimulus stops. Increase strength and duration of a stimulus will cause a larger afterdischarge.
Temporal summation
In relation to PNF
A succession of weak stimuli occurring within a short period of time will combine to create excitation.
Spacial Summation:
In relation to PNF
Weak stimuli applied simultaneously to different parts of the body reinforce each other and summate to cause excitation.
Irradiation
In relation to PNF
A spreading and increased strength of a response. The response can be excitation or inhibition (the absence of contraction). i.e. as the body puts forth effort, other body parts participate to assist (push hard with one leg, the other leg starts pushing too)
OR another definition:
Spread of energy from agonist to complimentary agonists and antagonists within a pattern. aka overflow
Successive induction (inductions means stimulation):
In relation to PNF
An increased excitation of an agonist muscle follows stimulation of the antagonist (techniques involving reversals make use of this property- slow reversal)
Reciprocal Inhibition:
In relation to PNF
When one set of muscles contracts, the antagonistic muscles are inhibited. This is essential for coordinated movement. Relaxation techniques make use of this property.
Traction and Approximation with PNF
Traction (elongation of muscles), facilitates a pull back. To enhance isotonic movement. Should be applied through the entire range.
Approximation (stabilization) facilitates a push back – promotes weight bearing. Increases proprioception with each.
Stimulates joint receptors and facilitates isometric contractions around the joint.
Including a quick stretch with PNF does what
Facilitates the muscle that is being stretched and other synergists to contract with it. You stimulate muscles by giving a quick stretch in the opposite direction. (This is a reflex that can be over-riden in normal people but need to watch for in people with neurological dysfunction- ankle plantarflexors)
Facilitates the muscles ability to contract with greater force
Rhythmic Initiation
Technique of PNF
Used when a pt is unable to initiate a specific movement
From PROM – AAROM – AROM.
May be used to instruct on proper sequencing.
Slow Reversal
Technique of PNF
Rhythmic concentric contraction of all components of the agonist and antagonist patterns
Slow reversal hold - same but ISOM at end range
Resistance should allow as much ROM as possible while still eliciting maximal motor response.
Good for endurance
Repeated contractions
Technique of PNF
Used to increase contraction by eliciting the stretch reflex repeatedly through ROM
A quick stretch is applied to the whole synergistic group
Do a quick stretch at any point of the moton to elicit contraction. Do this when the pt is fatiguing and has not completed the full ROM.
Timing for Emphasis
Technique of PNF
Used to increase the contraction of a component of a movement pattern
Typically only applied to one muscle after ISOM of the stronger muscles iin the pattern
A quick stretch is applied to one component of the synergistic group (only to the weak component)
Agonist Reversal
Technique of PNF
Both concentric and eccentric contractions of the same movement
Can be performed through a specific range or throughout the whole range if more control is needed.
Combination of Isotonics
Technique of PNF
Combines the concentric, eccentric, and isometric/staiblizing contractions
Start in position where pt has the most strength or best coordination
Concentric contraction – ISOM – eccentric with no relaxation between contractions.
Rhythmic Stabilization
Used to promote stability of a body part in specific range
Muscle demands must be very slow and specific
MMT Grade 5
Normal
Ability to complete full ROM (AG) & tolerate maximal resistance
MMT Grade 4:
Good
Able to complete full ROM (AG) & tolerate moderate resistance
MMT Grade 3
Fair
Moves through full ROM (AG) without resistance
MMT Grade 3+
Fair+ can complete full ROM (AG) and pt. can hold end position against Mild resistance or ½ range with mod resistance
MMT Grade 2:
Poor
Muscle moves through full ROM (GE)
MMT Grade 1:
Trace
PT can palate muscle contraction or visually observe tendon move, there is no structural movement as result of the contractile activity
MMT Grade 0
Completely absent upon palpation or visual inspection
Beaus’s Lines
Visual: indented transverse lines across the nail
May result from: Trauma Raynaud’s disease (decreased blood flow to fingers) Psoriasis Infection around nail plate
Clubbing
bulbous swelling of fingertips with loss of the normal angle b/w the nail bed & skin
Nails appear bluish-gray =cyanotic
Nails are boggy -spongy
Develops gradually
Associated with; longstanding hypoxia; Congenital heart defects; Cardiopulmonary diseases
Lindsay’s nails (half-and-half nails)
distal portion of nail turns red, pink, or brown
Distinct line of demarcation b/w the two halves
Present in renal failure
Onycholysis
detachment of nail from nail bed
Associated with Trauma; Fungal infections; Psoriasis; Overactive thyroid gland
Mee’s lines
transverse white lines across the breadth of the nail
Associated with systemic disease: Renal failure; Hodgkin’s disease; Malaria; Sickle cell anemia; Associated with arsenic poisoning
Pitting of the fingernails
Tiny punctate depressions in the nail
Caused by systemic diseases: Reiter’s syndrome (reactive arthritis); Psoriasis; eczema
Splinter hemorrhages:
tiny hemorrhages that create reddish lines of blood under the nails
Looks like a “splinter”
Associated with bacterial endocarditis and trauma
McGill Pain Questionnaire
- pain assessment questionnaire with 70 questions in 4 sections
- most widely used pain assessment scale
- 4 sections: draw where it hurts, choose one word to describe pain, describe pain pattern and relieving factors, and rate the intensity
Visual analog scale
- 10-15cm line and the pt marks their perceived level of pain on the line
- scale can be highly sensitive if small increments such as millimeters are used to measure the pts point of pain on the scale.
Wong Baker
The Wong-Baker Faces Pain Rating Scale was created to assist children three years of age and older to communicate about their pain. The scale uses a series of faces and verbal descriptors to categorize the severity of pain. A score of 0 would indicate “No hurt.”
Delayed Three point gait pattern with AD
- Crutches advanced first followed by the involved
lower extremity; then uninvolved lower extremity. - Indicated when patient requires increased stability
and slower movement.
Delayed Three point gait pattern with AD
- Crutches advanced first followed by the involved
lower extremity; then uninvolved lower extremity. - Indicated when patient requires increased stability
and slower movement.
Four point gait pattern with AD
- One crutch is advanced forward, followed by the con-
tralateral lower extremity, then the second crutch is
advanced forward, followed by that contralateral limb. - Used with bilateral lower extremity involvement.
Four point gait pattern with AD
- One crutch is advanced forward, followed by the con-
tralateral lower extremity, then the second crutch is
advanced forward, followed by that contralateral limb. - Used with bilateral lower extremity involvement.
Swing through gait pattern
- Crutches advanced first, and lower extremities swing
forward to meet the crutches. - Used on non-weight-bearing status or bilateral lower
extremity involvement.
Swing-to gait pattern with AD
- Crutches advanced first, and lower extremities swing
forward to meet the crutches. - Used on non-weight-bearing status or bilateral lower
extremity involvement.
Total Cholesterol number
<200 mg/dL = desirable
200-239 mg/dL = Borderline
>240 mg/dL = High
LDL cholesterol number
< 100 mg/dL = Optimal
100-129 mg/dL = Near optimal
130-159 mg/dL= Borderline
160-189 mg/dL = High
> 190 mg/dL =Very high
HDL Cholesterol numbers
< 40 mg/dL = Low
260 mg/dL = High
Triglycerides
< 150 mg/dL = Desirable
150-199 mg/dL = Borderline
200-499 mg/dL = High
≥ 500 mg/dL = Very high
When taking a BP with someone that has a fairly established one what is the appropriate amount to inflate the cuff?
- Use the known systolic measurement as the baseline value.
*The blood pressure cuff should then be inflated to 15-25 mm Hg above the baseline value.
- If the patient’s blood pressure is unknown, the therapist can estimate the baseline value by determining the amount of pressure needed to occlude the radial artery (i.e., the pressure at which the artery becomes occluded).
- For a patient with a known systolic blood pressure of 140 mm Hg, the cuff should be inflated to 155-165 mm Hg. 160 mm Hg would fall within this range.
What is a dynamometer measured in?
Kg
Nasogastric tube (NG tube)
- plastic tube inserted through a nostril that extends into the stomach.
- Used for short-term liquid feeding, medication administration or to remove gas from the stomach.
- The position of the tube in the nostril and back of the throat can inhibit a cough and be irritating for the patient.
Gastric tube (G tube)
- tube inserted through a small incision in the abdomen into the stomach.
- Used for long-term feeding in the presence of difficulty with swallowing due to an anatomic or neurologic disorder or to avoid the risk of aspiration.
Jejunostomy tube (J tube)
- Inserted through endoscopy into the jejunum via the abdominal wall.
- The tube can be used for long-term feeding for patients that are unable to receive food by mouth
Intravenous system (IV) feeding
- Consists of a sterile fluid source, a pumo, a clamp, and a catheter to insert into a vein (Fig. 8-30).
- Can be used to infuse fluids, electrolytes, nutrients, and medication.
- Most commonly inserted into superficial veins such as the basilic, cephalic or antecubital.
- Permit nutrients to be introduced when the gastrointestinal tract is not able to digest and absorb food.
Arterial line
- Monitoring device consisting of a catheter that is inserted into an artery and attached to an electronic monitoring system.
- Measure blood pressure or to obtain blood samples.
- The device is considered to be more accurate than traditional measures of blood pressure and does not require repeated needle punctures.
- If an arterial line is displaced, a therapist should apply direct pressure to limit blood loss and call for assistance
Central venous pressure catheter
- Used for measuring pressures in the right atrium or the superior vena cava by means of an indwelling venous catheter and a pressure manometer.
- Used to evaluate the right ventricular function, right atrial filing pressure, and circulating blood volume.
- The use of the catheter significantly reduces the need for repeated venipuncture.
indwelling right atrial catheter (Hickman)
- Inserted through the cephalic or internal jugular vein and threaded into the superior vena cava
and right atrium. - The catheter is used for long-term administration of substances into the venous system such as chemotherapeutic agents, total parentaeral nutrition, and antibiotics
Intracranial pressure monitor
- Measures the pressure exerted and the against the skull using pressure sensing devices placed inside the skull.
- Excessive pressure can be produced by a closed head injury, cerebral hemorrhage, overproduction of cerebrospinal fluid, or brain tumor.
- Types of intracranial pressure monitors include epidural sensory, subarachnoid bolt, and intraventricular catheter.
Pulmonary artery catheter (Swan-Ganz catheter)
- Soft, flexible catheter that is inserted through a vein into the pulmonary artery. Sticks out of neck
- Provide continuous measurements of pulmonary artery pressure (R atrium, ventricle, and pulmonary artery). – diagnostic
- Should avoid excessive movement of the head, neck, and extremities to avoid disrupting the line at the insertion site.
Peripheral IV
inserted into the peripheral vein. For meds to be directly administered
Central IV
- Delivers meds that could irritate the blood vessel lining
- Superior vena cava and into the ehart
- Med, chemo, parenteral nutrition (glucose)
peripherally inserted central catheter (PICC)
- a central line that is inserted at a peripheral point and used for prolonged periods (>2 weeks)
- Chemo, antibiotics, parenteral nutrition
Types of skeletal Traction: Balanced Suspension
- Pins, screws, and wires to be surgically inserted into bone for the purpose of applying a traction force using an externally applied weight.
- Comminuted femur fractures.
- Requires prolonged immobilization and therefore increases the incidence of secondary complications such as contractures or skin breakdown.
Chest tube
- placed in the pleural space around lungs
- to remove air or fluid from pleural space
- Keep unit below level of lungs
- watch for signs of pleural effusion (SOB, difficulty breathing, etc)
Nasal Cannula
- 1-6 L/min of O2
- O2 concentration is 28-44% (the norm is 21%)
Oxygen Mask
- 6-10 L/min of O2
- O2 concentration is 60%
Oxygen Mask with non-rebreather
- 6-15 L/min
- O2 concentration is 100%
Types of skeletal Traction: External fixation
- Holes are drilled into uninjured areas of bone surrounding the fracture.
- The fracture is then set in the desired anatomical configuration using specialized wires, pins, bolts, and screws.
- An external frame is used to maintain the bony fragments in the desired alignment (Fig. 8-31).
- External fixation enhances stability and allows for earlier mobility while maintaining the desired alignment.
Types of skeletal Traction: Internal Fixation
- Surgical procedure that attempts to promote the healing process of bone without appliances being applied external to the skin.
- Metal plates, rods, wires, screws, and nails.
- Comminuted or displaced fractures.
- The procedure provides needed stability to healing joints which allows earlier mobility and less postoperative complications.
Which of the following is used for the delivery of fluids, nutrients, and medications?
- Nasogastric tube
- Gastric tube
- Jejunostomy tube
- Intravenous system
Intravenous system
Which are used for long term feeding?
- Nasogastric tube
- Gastric tube
- Jejunostomy tube
- Intravenous system
- Gastric tube
- Jejunostomy tube
Which type of mechanical ventilation is commonly used with pts that require long term support?
- pressure cycled
- volume cycled
- mechanical cycled
- volume cycled
What is the most likely method to obtain a sample of synovial fluid for analysis?
Arthrocentesis
Arthrocentesis refers to a technique using a sterile needle to remove fluid from a joint. The obtained fluid is often sent to a laboratory for further analysis.
What is the most likely method to obtain a sample of synovial fluid for analysis?
Arthrocentesis
Arthrocentesis refers to a technique using a sterile needle to remove fluid from a joint. The obtained fluid is often sent to a laboratory for further analysis.
Which medical device would be used to remove fluid from the pleural space after surgery?
- central venous line
- chest tube
- intraventricular catheter
- vascular access port
chest tube
A chest tube is a flexible plastic tube that is inserted through an incision into the side of the chest. The tube uses a suction system to remove air, fluid or pus from the intrathoracic space.
Which type of feeding equipment is most likely to inhibit a cough?
- gastric tube
- gastrojejunal tube
- jejunostomy tube
- nasogastric tube
nasogastric tube
A nasogastric tube is a plastic tube inserted through the nose and extends into the stomach. The position of the tube in the nostril and back of the throat can inhibit a cough and be irritating for the patient. The remaining options all extend through the abdominal wall.
Which medical device is used for long-term administration of substances into the venous system such as chemotherapeutic agents, total parenteral nutrition, and antibiotics?
- arterial line
- intracranial pressure monitor
- pulmonary artery (Swan-Ganz) catheter
- indwelling right atrial (Hickman) catheter
indwelling right atrial (Hickman) catheter
An indwelling right atrial catheter is inserted through the cephalic or internal jugular vein and threaded into the superior vena cava and right atrium.
What is the max output for a nasal cannula
6 liters per minute
A nasal cannula consists of tubing extending approximately one centimeter into each of the patient’s nostrils. The maximum oxygen output is 6 liters per minute.
A patient who has had an endotracheal tube inserted will have the most difficulty with which activity?
- talking
- suctioning
- bedside exercises
- ambulation
talking
An endotracheal tube is inserted into a patient’s airway to allow the delivery of gas from a mechanical ventilator. The tube allows for suctioning to still occur, although significantly affects the patient’s ability to verbally communicate. A patient who is using a ventilator can still perform low-level exercise and ambulation.
A central venous pressure catheter measures pressures in which heart chamber?
right atrium
A central venous pressure catheter is an intravenous tube that is used to measure pressures in the right atrium or superior vena cava. This information is used to determine how well the right ventricle is functioning.
Which of the following functions can be performed with an arterial line?
- obtain blood samples
- administer medications
- administer nutrition
- insert a coronary stent
obtain blood samples
An arterial line is a catheter that is inserted into an artery, typically the radial, dorsal, pedal, axillary, brachial or femoral artery. The device is used to continuously measure blood pressure or to obtain blood samples.
Which of the following is a possible complication with use of an intravenous line?
- myocardial infarction
- stroke
- pulmonary embolism
- seizure
pulmonary embolism
A disrupted or loose intravenous (IV) line connection may result in the development of an air embolus. These emboli can be life-threatening if they make their way to the heart or lungs. Other complications with use of an IV line include phlebitis, infection, thrombosis, and local hematoma.
Which of the following is most commonly used in a hospital setting for short-term feeding?
- percutaneous endoscopic gastrostomy
- percutaneous endoscopic jejunostomy
- nasogastric tube
- total parenteral nutrition
nasogastric tube
A nasogastric tube is a plastic tube inserted through a nostril that extends into the stomach. The device is commonly used for short-term liquid feeding, medication administration or to remove gas from the stomach.
Which ventilator setting delivers a constant tidal volume?
- computer-assisted control ventilation
- mechanical control ventilation
- pressure control ventilation
- volume control ventilation
volume control ventilation
With volume control ventilation (VCV), the ventilator controls the inspiratory flow. The ventilator is set to deliver a constant tidal volume utilizing whatever pressure is required to reach the necessary value.
Which patient would be the most appropriate candidate for nasogastric feeding?
- patient with dysfunctional gag reflex
- patient with gastroesophageal reflux
- patient with high risk for aspiration
- patient in a coma
patient in a coma
A nasogastric tube is a plastic tube inserted through a nostril that extends into the stomach. The device is commonly used for liquid feeding, medication administration, and to remove gas from the stomach. Common candidates for nasogastric feeding include comatose patients, patients with neck or facial injuries, premature infants, and patients on a mechanical ventilator.
What is the most common method of patient-controlled analgesia?
- epidural
- transdermal
- regional
- intravenous
intravenous
Intravenous patient-controlled analgesia (PCA) is the simplest and most common form of PCA. This form of PCA occurs by inserting a needle into a peripheral vein that connects to a catheter or intravenous line.
How many inches should be added to the widest aspect of the user’s buttocks when determining the seat width of a wheelchair?
two inches
What is the standard back height of a standard w/c?
16 inches
How many inches above the seat should the top of the armrest be positioned in a standard wheelchair?
9 inches
If the back height of a patient’s wheelchair is too high, what complication will most likely occur?
- decreased trunk stability
- increased difficulty with propelling the wheelchair
- skin irritation to the nape of the neck
- increased difficulty with pressure relief activities
increased difficulty with propelling the wheelchair
If the back of a wheelchair is too high, the patient may experience difficulty propelling the wheelchair since the shoulders and scapulae will not be able to move as easily. Other complications include excessive irritation to the skin over the inferior angles of the scapulae and difficulty with balance secondary to forward inclination of the trunk.
Why is a slight anterior pelvic tilt important when positioning a patient in a wheelchair?
allows for weight bearing on the ischial tuberosities
A slight anterior pelvic in sitting allows for weight bearing on the ischial tuberosities. The ischial tuberosities refer to the bony broadening on the posterior portion of the superior ramus of the ischium.
What to do as the pt if they are fallling backwards in w/c?
tuck the chin toward the chest
When falling backwards in a wheelchair, the patient should tuck their chin towards their chest and maintain a semiflexed trunk position to avoid hitting their head against the floor. One hand should grasp the opposite armrest to prevent the thighs from moving backwards during the fall, and the other hand should reach forward.
What is the safest way for a patient in a wheelchair to descend a curb?
- self-propel the chair off the curb while facing forward
- self-propel the chair off the curb while facing backward
- have an assistant control the chair off the curb while facing forward
- have an assistant control the chair off the curb while facing backward
have an assistant control the chair off the curb while facing backward
When descending a curb, it is safest for the patient to have someone assist them off the curb. Though the patient can descend the curb either facing forward or backward, it is safest for the patient if it is performed backward. If the assistant loses control of the wheelchair in this position, they are still positioned behind the chair to prevent the patient from falling off the curb.
Compared to wheelchair propulsion on a level surface, propulsion while ascending a ramp is characterized by:
- longer, slower strokes
- shorter, faster strokes
- longer, faster strokes
- shorter, slower strokes
shorter, faster strokes
When ascending a ramp in a wheelchair, the strokes should be shorter and faster than the strokes incorporated on level surfaces. The individual should also lean forward with cervical spine and trunk flexion to prevent backward tipping.
A patient with a C6 complete spinal cord injury should control their wheelchair descent on a ramp by:
- squeezing the rims with their hands
- applying a downward pressure on the rims
- applying a medially directed pressure to the rims
- placing the feet in contact with the ramp
applying a medially directed pressure to the rims
A patient with a C6 complete spinal cord injury would lack innervation of the triceps and finger flexors. For this reason applying a medially directed force to the rims is the safest and most appropriate method to control the decent of a wheelchair on a ramp
What is the low pressure alarm of a mechanical ventilator most commonly associated with?
leak in the ventilator circuit
