Management of Severe-Mod Deficits Flashcards
Neuro ICU Must Do’s
Mobilize patient ASAP
Check for orders in medical chart
Talk with nursing
Will likely need multiple people
What should you monitor in neuro ICU?
Intracranial pressure
Hemodynamics
Vitals
How to set up environment in neuro ICU
Prediction of patient’s mobility/ability
Consider medical constraints- lines/drains/monitors
Common barriers to mobility - intrinsic to patient
Elevated ICP
Neurological storming
Unstable hemodynamics
Absence of Bone Flap
Pain
Decreased arousal
Impaired cognition
Physical impairments
Obesity
Unstable spine
Surgical precautions
what is neurological storming
hypothalamic stimulation of sympathetic nervous system and adrenal glands causing increase in corticosteroids and catecholamines- symptoms include altered LOC, increased posturing, dystonia, HTN, hyperthermia, tachycardia, tachypnea, diaphoresis, and agitation
Common barriers to mobility - extrinsic
External Ventricular drains that cannot be clamped
Lines/Tubes
Staffing/resources
Fear/Uncertainty/Safety/Knowledge
Adequate Equipment
Inappropriate or absence of activity orders
Timing of PT consults
things to consider when mobilizing s/p stroke
Severity and Type
Timing
Interventions received- tPA, evacuation, thromectomy
Hemodynamic parameters
Neuroimaging
Discussion with MD/RN
Close monitoring with activity
things to consider when mobilizing s/p TBI
Severity of injury
Presence of skull/facial fractures- CSF leaking
Intracranial Pressure parameters
Neurologic Storming
Bone Flap/Helmut
Daily Assessments
Avoid any injury
– People moving patients need appropriate training
— UEs
— Safety
Emphasis to maximize active involvement
Neurologic factors to consider for positioning needs
– Normalize tone
– Decrease influence of pathologic reflexes
– Facilitation to midline
– Interaction with environment
– Awareness of body and body part
Musculoskeletal factors to consider for positioning needs
prevent ROM issues
Physiologic factors to consider for positioning needs
Prevent skin irritation/breakdown
— Ability to move
— Sensation
— Visual/Perceptual
— Bony prominences
— Be good about bowel/bladder management and hygeine
Minimize medical problems
— NG or PEG tube – 30 degrees HOB elevated to decrease risk of aspiration
— ICP pressure monitor
features of UMN lesion
deficits in motor behavior, weakness, slowness of movement, loss of dexterity, fatiguability
Positive features of UMN lesion
exaggerations of normal phenomena or release phenomena
Tone, exaggerated tendon jerk, clonus
Flexor withdrawal, extensor or flexor spasms
adaptive features of UMN lesion
Physiological, mechanical, and functional changes in muscle and other soft tissue
Adaptive Motor Behavior
Abnormal Posturing- immobility, disuse changes to soft tissue, adaptations in resting length of muscles
Abnormal Patterns of movement- synergy, difficulty controlling muscles, difficulty in timing, imbalance in strengths
Exaggerated Reflexes - STNR
Flexion of neck elicits flexion of UE, Extension LE
Extension of neck elicits extension of UE, flexion LE
Exaggerated Reflexes - ATNR
Extension to side facing, flexion to side not facing
Exaggerated Reflexes - Tonic Lumbar
Rotation to R- elicits flexion RUE, extension RLE, extension LUE, flexion LLE
How do exaggerated reflexes impact us?
- initial conditions
- positioning in bed and chair
What is spasticity and when should you manage it?
- velocity dependent resistance to passive movement
- Need to manage when it limits person’s ability to move, move fully, or for therapist to move person
Prevent noxious stimuli – both internal and external
Internal stimuli- pain, pressure sores, agitation, constipation,
incontinence
External stimuli- positioning in bed or wheelchair
Prevent consequences of spasticity
Tightness
Contracture
Sores
Physical management of spasticity
Range of motion to maintain or increase muscle length
Slow sustain traction to improve mobility and reduce pain; consider joint mobilization Grade 1 and 2
Prolonged stretch- Evokes a higher threshold response
Stimulus- slowly applied, maintained stretch to inhibit or dampen muscle contraction and tone
Exteroceptive Stimulation for Management of Spasticity
Neutral warmth- applied for 10-20 minutes- useful for managing high arousal and increased sympathetic activity, impact tone/spasticity
Generalized inhibition of ton
Wrapping body or parts with warm towel
Monitor for overheating- patient will not be able to tell you-cognition/communication
Techniques for using a stimulus to dampen muscle contraction and tone
Manual contacts
Inhibitory splinting/casting – dynamic splinting, tone inhibiting serial casting
WEIGHT BEARING- weightbearing normalizes tone
— Sitting with limbs supported
— Standing Frame- long prolonged stretch; great tool for lower level patient- get prolonged stretch, get upright for attention/engagment
Pharmacologic Management of Spasticity
Second line of defense or adjunct to physical management
Need to understand if patient has more general or focal spasticity
Generalized spasticity
- extensor spasms
- oral medication
Focal Spasticity
clenched hand, PF contracture unresponsive to
physical management and oral medication
Phenol block – washes general area
Botox (more expensive)- more precise
Surgery for Spasticity Management
Surgery- last option
Last resort when all other attempts to manage have failed
Could be neurologic- insertion of baclofen pump
Could be musculoskeletal- tendon lengthening
How to Manage agitation
Activate parasympathetic division of autonomic nervous system
Calming effect for a high arousal patient
- Neutral warmth
- Rocking
- Stroking paraspinals
- Maintained touch/support
Cognitive Dysfunction Ranchos Level II/III
Elicit response to sensory input
Elicit specific response
Increase ability to focus and sustain attention
Consider ability to track object, reach for object
Utilize for functional activities –> Rolling: having them reaching for picture across body for example
Cognitive Dysfunction Ranchos Level IV
Decrease intensity, duration, and frequency of agitation
Increase attention to environmental stimuli
Try to engage in movement – try to move uncontrolled and non-purposeful movement →controlled and purposeful movement
Principles of treatment- limit external stimuli
Consistency in place, staff, time if possible
Structure patient/therapist interaction
Explanation of activities/goals
Communication- calm, clear, concise
Give choices as able
Response to inappropriate behavior
Behavior contract
Cognitive Dysfunction Ranchos Levels V and VI
Rancho Levels 5 and 6
Decrease confusion
Improve orientation- A&O x 4
Improve cognitive processes
- Attention, selective attention, attention span
- Recent memory
- Categorization/Organization
Incorporate cognitive function into functional activities
Where should activities be performed for Ranchos Level V and VI
Treatment should occur in actual setting patient will perform
Poor carryover of an activity
What should be provided for Ranchos level V and VI
Written instructions/Pictures
Cognitive Dysfunction Levels 7 and 8
Adapt activities to more complex tasks, environments
Consider carryover
Removal of structure
Interactions
essential elements of rolling
Rotation and flexion of neck
Hip and knee flexion
Flexion of shoulder and protraction of shoulder girdle
Rotation in trunk
significant impairments of rolling
Extremity hypertonicity
Loss of Trunk Control
Extremity Weakness
Loss of alignment due to muscle shortening
Pain
undesirable compensatory patterns
Grabbing and pulling with unaffected arm
Use of excessive hypertonicity in arm/leg
Learned disuse of hemiparetic limbs
movement elements of sidelying to sitting
Lateral flexion of the trunk
Extended arm- weightbearing through forearm
Body weight taken over hip
essential elements of sidelying to sitting
Lateral flexion of neck
Lateral flexion of trunk
Legs lifted and lowered over side of bed
significant impairments that interfere with sidelying to sitting
Weakness of trunk and extremities
Loss of alignment
Inability to accept weight through extremities
Hypertonicity of extremities
undesirable compensatory patterns for sidelying to sitting
Sitting straight up
Use unaffected arm to pull body up and out of bed
Patient hooks leg under affected leg to lift both over bed
