Med Surg Test 1- Objectives Flashcards
Explain the relationship between health, wellness, illness, and disease.
Health- the world health organization has defined health as a state of complete physical, mental, and social well-being and not merely as the absence of disease or infirmity.
Wellness- one end of the healthy spectrum. “health is an individuals level of wellness.”
Illness- often defined as sickness or deviation from a healthy state. The perception and response of the person to not being well.
Disease- refers to biologic or psychologic alteration that results in a malfunction of a body organ or system. It can be objectively documented through tests and measures.
- health=wellness; illness=death; medium in between where one can fluctuate between health & illness
Relate patient information given in a physical therapy evaluation to the following categories of health: biologic, psychological, spiritual, and sociologic
Health reflects a person’s biologic, psychological, spiritual, and sociologic health.
biologic- or physical state refers to the overall structure of the individuals body tissues and organs and to the biochemical interactions and functions within the body.
Psychologic- includes the individual’s mood, emotions, and personality.
Spiritual- the individual’s religious needs, which may be affected by illness or injury.
sociologic- interaction between the individual and the social environment.
Provide examples of common variables that can affect a person’s overall health
Genetic influence, cognitive ability coping strategies, gender, environment and lifestyle, geographic location, standard of living, culture, religion, health beliefs and practices, previous health experiences, support systems.
Describe the role of homeostasis in overall health and wellness
- Begins on a cellular level by receiving vital nutrition from the environment, then progresses to maintain overall equilibrium through all systems.
- can be a domino effect once one system gets out of whack, or once all function properly.
Decipher a given patient description and appropriately categorize it using the Nagi disablement model as the patient’s: pathology, impairment, functional limitation, or disability.
Disease or pathology- describes the underlying pathogenesis and abnormal cellular processes. (ex. osteoarthritis)
Impairments- Examples of impairment include reduced PROM/AROM, reduced muscle force, pain, swelling, anatomically short lower limb, excessive anterior glide of gh jt, decreased strength. Objectively measurable data.
Functional Limitations- restrict that person’s performance or specific actions (ex. inability to reach in cabinets, inability to climb stairs)
Disability- limitation of physical of mental function in a social context. (ex. inability to work, inability to feed self)
Decipher between the characteristics of restorative, wellness, maintenance, and preventative therapies
Physical Therapy interventions are considered restorative therapy. This indicates that there is a medical need for the intervention of a PT/PTA to restore the patients function.
Wellness clinics provide wellness therapy, prevention therapy, and maintenance therapy.
This is usually provided via exercise physiologists, personal trainers, nutritionists, athletic trainers, etc.
Explain the importance of studying wellness as it applies to your job as a PTA.
you as a health care professional should be able to answer questions related to general health issues and to be current on recent trends and concerns so that you can apply your knowledge to rehabilitate your patients to their fullest potential.
Provide examples of primary, secondary and tertiary disease prevention
Primary- removing or reducing risk factors. example- health fair screenings
Secondary- early detection of disease and employ preventative measures to avoid further complications. THIS IS WHAT WE DO!
Tertiary- aimed at limiting the impact of the established disease. Goal is to return person to highest possible level of function.
Describe the PTA’s role in promoting health and wellness
Understanding how to optimize a patient’s health and wellness allows the PT/PTA to customize interventions that will:
Enhance function
Improve overall fitness
Address comorbidities and prevent additional onsets.
PATIENT EDUCATION IS EXTREMELY IMPORTANT!
Discuss why EBP has become the major focus on health professionals
Increased focus on documentation, Increased healthcare costs, Increased focus on medical errors, Improving/changing technologies, Required by insurance to approve reimbursement
Explain the relationship between EBP and a PTA’s clinical experience.
“evidence-based physical therapy practice is ‘open and thoughtful clinical decision making’ about the physical therapy management of a patient/client that integrates the ‘best available evidence with clinical judgment’ and the patient/client’s preferences and values, and that further considers the larger social context in which physical therapy services are provided, to optimize patient/client outcomes and quality of life.”
Discuss the term “patient-centered care” and how EBP utilization facilitates this philosophy.
To integrate clinical expertise with current research findings (evidence) to facilitate the optimum outcome for your patient. EBP allows patient-centered choices for treatment interventions. “If there is a better way to practice, therapists should find it.”
Provide examples of practical barriers that inhibit the use of EBP in today’s workplace
67% of therapists that were surveyed stated that the biggest hurdle with utilizing EBP is finding time to do the research. Productivity issues are stifling the process. Almost 50% surveyed sited lack of confidence in ability to find, assess and apply the research.
Discuss the goals of EBP and why it is now such an emphasis in today’s healthcare model.
To navigate away from “anecdotal” practice. Become less of a “knobologist”. Provide sturdy ground for therapists to practice upon without the fear of repercussions. To again differentiate between a PT tech and PTA. To validate the need for physical therapy services due to our level expertise and skilled interventions.
Provide a summary of required characteristics of a PTA that wants to pursue the use of EBP.
Willingness to challenge the norm, ability to design appropriate research questions, knowledge of where to find relevant current information time,willingness to practice and apply new material.
List the 4 basic steps to implementing the EBP process.
Form a question, find clinical evidence related to the specific question and assess its relevance to the patient’s problem, apply the evidence to your patient’s treatment sessions, evaluate the outcome… did it work as well as you thought it would?
Explain why the use of EBP is considered a self-directed learning model.
As PTA’s we need to be able to know how to formulate effective research questions, where to locate relevant research, and to be skilled in analyzing the research once we’ve found it. EBP is a self-directed learning model because you get out of it what you put into it as far as the research goes.
Describe how the following concepts are related to EBP: awareness, consultation, judgment, creativity.
Awareness- knowing that evidence is out there somewhere and how to find it
Consultation- educating yourself and your patient on why you are choosing the interventions and their expected outcomes
Judgment- knowing how to analyze the data and make sound judgment as to if it will work for your patient’s problem
Creativity- how to apply the evidence presented in the study to what tools you have available for your patient
Compare and contrast the four phases of professional development.
Preservice Experiences - the level that you are at now. More book knowledge than hands on experience.
Novice Professional - the level you will be at graduation and for the next few years. Building your “patient database.”
Experienced Professional - after many years of experience. Able to pull from a “patient database” and form generalizations about patient populations
Expert Professional - forming questions looking for new possibilities. Performing own formal research studies
Differentiate between background and foreground questions.
Background questions- serve to find general information regarding a certain topic; textbooks, informational articles, support groups with internet resources , CDC website, etc. Helpful to be familiar with background information prior to formulating a foreground question.
Foreground questions- serve to find a specific relationship between information pertaining to a patient, pathology or intervention.
Recognize the difference between a peer reviewed article and non-peer reviewed article; include how each is applied to your profession as a PTA.
Peer review ensures that an article-and therefore the journal and the scholarship of the discipline as a whole-maintains a high standard of quality, accuracy, and academic integrity. When you consult peer-reviewed sources, you are tapping into a wealth of established, verified knowledge. Citing such sources in your assignments gives your work credibility and demonstrates that you’re familiar with the issues and trends in the field of study.
Describe the desired characteristics of a good research article.
- The study addresses the specific clinical question the physical therapist is trying to answer.
- The subjects in the study have characteristics that are similar to the patient/client about whom the physical therapist has a clinical question
- The study was published in a peer-reviewed medium (paper, electronic)
- The context of the study and/or the technique of interest are consistent with contemporary health care.
Describe the following research designs to allow recognition and understanding of the levels of bias with each: RCT, systematic reviews, quasi-experimental, observational, physiologic, case studies, narrative reviews, historical.
RCT- randomized controlled trials , or randomized clinical trials. Highest probability to reduce bias. (Experimental designs)
RCT divides its subjects into two or more groups and the researcher has control over how each is affected. (Control and experimental groups, etc.)
Single System Design RCT- only one person is studied, but receives both controlled and experimental conditions to compare results
Systematic reviews- cumulative study of multiple research reports to find an answer. Will have its own inclusion/exclusion criteria.
*Quasi-experimental designs - may not divide into subject groups, or may not randomize selection of groups.
*Observational / non-experimental designs - same as quasi-experimental but additionally does not include experimental manipulation of the subjects.
*often limited due to ethical issues
Physiologic studies- focus on cellular, physiological or anatomical effects. Do not incorporate e person into the research.
*Case studies- describe how one patient responded to an intervention.
*Narrative reviews- summarize prior research.
*Lack systematic approach to the topic
*Can be utilized to stimulate further research
Historical design - retrospective: looks at previous patients that have been discharged over a period of time. Prospective: looks at new patients over a period of time.
Based on EBP found in research, assess validity and effectiveness of interventions and outcomes presented.
Sample questions- Did investigators randomly assign subjects to group?
Were subjects masked to the subjects group assignment?
Was this a study with more than 1 group?
Were standardized person-level outcomes instruments used?
Define acute care.
“acute care, a pattern of health care in which a patient is treated for a brief but severe episode of illness, for the sequelae of an accident or other trauma, or during recovery from surgery. Acute care is usually given in a hospital by specialized personnel using complex and sophisticated technical equipment and materials, and it may involve intensive or emergency care. This pattern of care is often necessary for only a short time, unlike chronic care.”
Explain how and when physical therapy is initiated in acute care.
Once patient is medically stable
Orders for a PT evaluation
*Length of stay (LOS) is ↓, Earlier PT interventions required to decrease sequelae, EBP encouraging early mobility for improved outcomes, interventions must be highly effective, MUST have comprehensive understanding of patient’s pathology to prescribe effective treatments.
List and describe the 6 elements required for any physical therapy evaluation.
Examination = history, systems review, tests and measures Evaluation Diagnosis = medical and Physical Therapy Prognosis/Plan of Care Interventions Outcomes
List the normal metabolic panels for the following elements: acid/base ABG levels, sodium, potassium, chloride, phosphate, bicarbonate, partial pressure of oxygen (PaO₂), partial pressure of carbon dioxide (PaCO₂)
Acid/Base ABG levels: ph of 7.35-7.45 Sodium: › 147 mEq/L Potassium: › 5.5 mEq/L Chloride: 104-110 mEq/L Phosphate: 2.4-4.8 mg/dL Bicarbonate (HCO₃-) 22-28 mEq PaO₂ 80-100 mmHg PaCO₂ 35-45 mmHg
Describe the following conditions, including their etiology and clinical manifestations: respiratory acidosis, respiratory alkalosis, metabolic acidosis, metabolic alkalosis, hypernatremia, hyponatremia, hyperkalemia, hypokalemia, hypovolemia, hypervolemia
Respiratory Acidosis- Commonly caused by Chronic Obstructive Pulmonary Disease (COPD), thoracic trauma, drug overdose
Period of irritability & restlessness followed by lethargy, headache, muscle tremor/convulsions, vertigo, tachycardia, peripheral vasodilation, possible coma
pH ‹ 7.35; PaCO₂ › 45 mmHg (CO₂ retention!)
(acidic) (high CO₂)
Respiratory Alkalosis- Commonly caused by pain, fever, hyperthyroidism, meningitis, brain tumor, psychogenic, Dizziness, confusion, paresthesia, convulsions, coma, sweating
pH> 7.45; PaCO₂ 7.45; PaCO₂ ≥/ ≤normal ; HCO₃- > 27 mEq/L (basic) (? PaCO₂) (high bicarbonate)
Compare and contrast the components for the 7 mechanisms of cellular injury, including: ischemia, infectious agents, immune reactions, genetic factors, nutritional factors, physical/mechanical factors, and chemical factors.
- Ischemia- critical reduction of oxygen supply to the cell due to a blood supply that is less than the minimum required for homeostasis.
Can be:
hypoxia (partial loss of oxygen circulation) or
anoxia (complete loss of oxygen circulation) - Infectious Agents- Can be:
Bacterial: invade cells and release endotoxins and exotoxins that result in cell lysis and breakdown of the cell’s extracellular matrix. OR
Viral: can disrupt the integrity of the nucleus, or become encoded proteins that embed into the cell membrane and alter its permeability. Also can encode foreign proteins in the cell surface that set the immune system into action to destroy the now “foreign” cell. - Immune Reactions- allergies cause histamine reactions that can be mild or severe. Can cause anaphylactic shock, or full body allergic reaction
- Genetic Factors-
a) altered structure or # of chromosomes that include abnormalities. (Example: Down’s Syndrome)
b) single mutations that cause changes in
amount or function of cell proteins (Example: Sickle Cell Anemia
c) multiple mutations that interact with environmental factors to cause abnormalities (Example: Type 2 Diabetes) - Nutritional factors-
a) when a person’s diet lacks essential
nutrients, will disrupt homeostasis
(Example: lack of iron = anemia)
b) when a person’s diet has too many
nutrients, will disrupt homeostasis
(Example: increased iron = increased free radicals) - Physical / Mecahnical Factors- Direct or indirect trauma to the cells. Or exposure to extreme temperature changes, radiation, electricity.
(Example: Mechanical factors include repetitive stress injuries. ) - Chemical Factors- Two types of injury etiology
a) direct injury when exposed to the
chemical. (Example: mercury)
b) a metabolic transformation must occur to make the chemical toxic. Example: free
radical formation
(Example: Antioxidants neutralize the unstable oxygen radicals and thereby promote healthy tissues)
Describe the processes involved with the three stages of healing after soft tissue injury: inflammation, proliferation and maturation.
Three phases of healing: inflammation, proliferation, and maturation. *Each phase has 3-4 stages within itself.
The sequelae depend on injury site, injury etiology, current state of homeostasis, and level of recovery.
What is the inflammation phase?
Inflammation = the “itis” words Starts immediately after injury. Is a protective response Its purpose is to destroy, dilute, or isolate the affected cells. Lasts approximately 1 week.
4 Cardinal Signs Heat (calor) Redness/Erythema (rubor) Swelling/Edema (tumor) Pain (dolor)
“Complex sequence of interactive and overlapping events including: vascular, cellular, hemostatic and immune processes.”₂
- Vasoconstriction – to minimize blood loss; first 5-10 minutes after injury.
- Vasodilation – of the surrounding, noninjured tissue blood vessels. Stimulates release of chemical mediators.
- Clot formation- to stop the bleeding. Hageman Factor is the stimulus.
- Phagocytosis – by the neutrophils and macrophages
What is the proliferation phase?
Purpose is to cover the wound and add strength to the site of injury.
Involves epithelial cells and connective tissues.
Usually lasts approximately 20 days.
Epithelialization
Fibroplasia/collagen synthesis
Wound contracture
Neovascularization
- Epithelialization – re-establishment of the epidermis. Provides an initial protective barrier to prevent fluid and electrolyte loss
- Fibroplasia/Collagen Production – fibroblasts make collagen. Collagen is the most abundant protein in the body and provides increased strength to the tissues. Granulation tissue is red beefy dots, indicative of healing. The dots are new capillary growths
- Wound Contracture – pulls the edges of the wound together. Myofibroblasts similar to fibroblasts except also have properties of smooth muscle. “Picture Frame Theory”- a ring of myofibroblasts moves inward from the wound margin.
- Neovascularization – creation of new blood supply. (through development of granulation tissue)
What is the maturation phase?
Purpose is to change the size, shape and strength of the scar tissue.
Longest phase in the healing process.
Ultimate goal is to return to prior level of function.
Scar tissue on skin appears to fade from red/purple to white.
Chronic inflammation lasts for months or year
Three Stages:
1. Collagen Synthesis/Lysis Balance 2. Collagen Fiber Orientation 3. Healed Injury
Explain how the ”Picture Frame Theory” of healing affects wound closure; include what shapes heal most easily and quickly to most complicated and lengthy.
a ring of myofibroblasts moves inward from the wound margin.
*Shape makes a difference! Linear- heals fastest, followed by square or rectangle shape, and circles heal slowest.
Epithelial cells stay connected to their “parent” cells, causing the epidermis to move over the wound.
HOWEVER- can have contact inhibition if epithelial cells from one edge meet cells from another edge, then they stop moving.
Give examples of tissues that are capable of regeneration.
Epidermis Lining of intestine Bone marrow Liver Bone tissue May possibly regenerate if conditions are right: lung, skeletal muscle, peripheral nerves
Give examples of tissue that cannot regenerate.
CNS neurons Cardiac muscle Tendons Ligaments Cartilage
Explain the healing process for bone, including all 5 phases as outlined in your lecture
Hematoma formation- clotting with inflammation stage
Cellular proliferation- fibroblast activity and granulation tissue form a protective “splint”
Callous formation- hardening of the fibroblastic “splint”, not strong enough to bear weight.
Ossification (calcification)- osteoblasts replace fibroblasts
Remodeling- callus is reabsorbed and remodeled into strong bony material strong enough to bear weight.
Indicate the expected fracture healing times for children, adolescents and adults.
Children- 4-6 weeks
Adolescents- 6-8 weeks
Adults- 10-18 weeks
Factors include: type of fracture, location, blood supply, comorbidities, age, levels of health.
Explain the difference between open and closed reduction methods for stabilizing a fracture.
Open reduction- cuts into the skin, OPENS the tissue to get inside and insert rods/screws, etc.
Closed reduction- casting, splinting, etc. Skin in fractured area remains intact (CLOSED)
Describe the possible complications associated with fracture healing.
Muscle spasm may cause malunion Infection Ischemia Compartment Syndrome- Fat emboli Nerve damage Non-union Subject to osteoarthritis or stunted growth
Give examples of what therapeutic interventions are appropriate during the healing phase after a fracture.
Can do ther ex above and below fracture site. Do not mobilize a fractured joint!
Train patient in use of assistive device
Train patient in use of assistive equipment
Educate patient on condition and expected healing time/outcome
Reinforce precautions (WB, etc.)
Give examples of therapeutic interventions that are NOT appropriate during the healing phase after a fracture.
Mobilizing a fractured joint
Breaking weight bearing precautions
State the role of the immune system
To distinguish self from non-self. Wants to destroy “non-self.”
Differentiate between the following types of immunity: innate, acquired, passive and active. Give examples for each.
Two basic types of immunity: innate and acquired
a) Innate – the body’s first line of defense. Nonspecific responses to invaders. Same response every time. Lacks a memory. Gene specific.
Examples:
1. Skin 5. Stomach acids
2. Tears 6. Vaginal secretions
3. Ear wax 7. Acidic urine
4. Nasal hairs
Acquired – has specificity and memory.
Two types:
1. Active (Cell Mediated) –the antigen is introduced to the body via natural or artificial means. Long term effects.
a) natural – direct exposure through environment;
example: chicken pox. Once had them, will
not return.
b) artificial - vaccination; example: flu shot
2. Passive (Humoral)- the antibody is introduced to the body via natural or artificial means. Temporary effects.
a) natural – antibodies passed from mother to child
b) artificial – antibodies given via injection, example:
rabies shot after exposure.
Define antigen.
foreign body that does not have the characteristics of “self” cell surface markers. Each body’s “self” surface markers are unique like a handprint. Mine is not the same as yours. They may look the same, but when examined more, each has a different line pattern or characteristic that makes it unique.
Explain the significance of HLA’s.
(HLA’s) histocompatibility markers to identify as “self.”
Explain the role of an antibody (immunoglobulin) in the immune system.
proteins known as immunoglobulins that link to specific antigens and destroy them.
Distinguish between the roles of the 5 main types of immunoglobulins: IgM, IgG, IgD, IgE, IgA.
IgM- Initial immune response. Largest size. Activates the
complement system. Responsible for blood type matching
IgG- Found in blood. Crosses the placenta to protect newborns by
passive immunity. Activates the complement system.
IgA- Innate Immunity: found in saliva, mucus membranes, tears, etc. Defends external body surfaces.
IgD- Antigen receptor. Found on B-lymphocytes.
IgE- Eliminates parasitic invaders. Releases histamine. Normal response until becomes excessive due to allergies and causes anaphylactic shock. (Link the “E” to the role of epi-pens)
Describe the cellular make up of the immune system including: lymphocytes, T-lymphocytes,T-helper cells, B-lymphocytes, NK cells.
Lymphocytes- type of WBC produced by the marrow. Has capability to recognize and react to antigens.
Three Types:
T-lymphocyte – from stem cells in bone marrow to thymus for recognition of antigens on cell surfaces and within the cell. Has ability to directly destroy them. (Cell mediated immunity) Capable of reproduction to create an “army” of defense in the body. Effective against cells containing a virus, fungi, cancer, and transplanted tissues.
T-Helper cells- CD₄ molecules regulate all molecules in the immune system and release cytokines.
Killer T Cells- CD₈ molecules are cytotoxic
B-lymphocyte – from bone marrow cells to spleen and lymph tissues; produce antibodies. (Humoral immunity) Also has a memory component. Effective against bacteria, and viruses found outside of the cell. NK cells (Natural Killer Cells)- capable of killing cancer cells and viruses
Distinguish between the 4 types of immune system hypersensitivities.
Type I- Allergic Reactions. Due to IgE release.
Type II- Myasthenia Gravis. Cytotoxic reactions to “self.”
Type III- Lupus (SLE). Immune complexes that are not gotten rid of. Activates inflammatory response.
Type IV- Contact Dermatitis. Latex Alllergy. Cell Mediated Immunity.
Discuss the etiology, types of hypersensitivity, pathogenesis, prognosis, presentation and treatment for Myasthenia Gravis and Lupus.
Myasthenia Gravis- “Grave Muscular weakness” Prevalence: 5-20/100,000 Common symptoms can include: A drooping eyelid Blurred or double vision Slurred speech Difficulty chewing and swallowing Weakness in the arms and legs Chronic muscle fatigue Difficulty breathing
Antibody-antigen complex of IgG and anti-Ach antigen
Impaired reception of the ACh (acetylcholine) molecule at the neuromuscular connection. This reception is needed to stimulate an action potential to create a muscle contraction. An anti-Ach antibody either blocks the transmission site or may damage the receptor site membrane.
Possibly linked to thymus dysfunction. (organ responsible for T-Cell maturation.)
How to Detect Myasthenia Gravis
Three ways:
Immunologic testing- detects Anti-Ach receptor antibodies in blood serum
Pharmacologic testing- administer “Tensilon.” If condition improves, that proves condition was due to decreased Ach levels.
Electrophysiological testing- EMG
What is the prognosis for Myasthenia Gravis?
Typically will experience fluctuating remissions and exacerbations.
Slow, progressive disease
Severe flare up can be a medical emergency requiring intubation due to decreased synapses of respiratory muscles
What are the PT implications for Myasthenia Gravis?
Emphasize deep breathing techniques
Educate on energy conservation techniques
Good posture when eating and chin tuck when swallow
Avoid extreme temperatures
Avoid stress and strenuous activities
Monitor for osteoporosis due to corticosteroid medications
Light exercise with frequent rest breaks
What is the etiology of lupus?
Onset between ages 20-40.
Mainly in women
Most frequent in African American, Asian, Hispanic, or American Indian decent
Signified by a facial rash (Butterfly rash)
Auto-Antibodies circulate and destroy multiple systems in the body. Different for each patient. Minimum of 4 areas involved simultaneously.
Treated by anti-inflammatory medications and steroids
What are common lupus manifestations
- Arthralgia, without joint damage
- Butterfly rash
- Photosensitivity
- Hair loss
- Kidney damage *If you do not know a term listed
- Pleurisy here, look it up!
- Carditis
- Raynaud’s Phenomenon
- Mood swings
- Anemia
What is the prognosis for lupus?
Improved with early detection
Typically see cardiac involvement. Affects valves. Can also create occluded vessels, risk for MI
Increased risk for certain cancers, esp. lymphoma
Explain why tissue transplants are at risk for rejection
The HLA’s on the transplanted tissue do not match the “Self” HLA’s. Can initiate a rejection
To inhibit rejection, patients are on multiple immunosuppressant drugs.
Why? To decrease the Non-self reaction that would be naturally caused by the immune system.
What are the consequences? Patient at high risk for infection.
Distinguish between the following types of tissue transplant: allograft, xenograft, autograft, and isograft.
Allograft – transfer between same species
Isograft – transfer between identical twins
Autograft – transfer from own body
Xenograft – transfer from one species to another
Describe how to contract HIV, including risk factors associated with the disease.
Acquired by exchange of bodily fluids containing HIV. The infected fluid must gain access to the potential host’s bodily fluids. NOT acquired via casual contact.
Behavioral factors Unprotected sex (in any orifice) More than 6 partners in one year’s time Engaging in sexual conduct with a person who is known to be infected Prostitution Injection drug usage
How does HIV work?
HIV is considered a “retro virus.”
Contains reverse transcriptase. This is an enzyme that allows for copying of all the genetic information of the HIV virus and places it into the infected cell.
Explain the 3 stages of AIDS.
Early stage- virus is being replicated, patient may not have symptoms. Able to detect virus via blood tests. T-helper cells numbers are decreased.
Middle stage- patient begins to show symptoms. Many different possible clinical manifestations. Most common among all patients is fatigue and decreased ability to perform recreational activities.
Advanced Stages- Will have a neurologic component and begin to see signs of:
Dementia Mutism Incontinence Paraplegia Dermatological conditions Pain syndromes
Describe the role of physical therapy for a patient with HIV/AIDS.
Can administer drugs to slow the process, CANNOT eliminate the virus from the body.
Educate on prevention mechanisms
Research on further drugs and possible cures
Will spend most of time treating secondary conditions that arise due to being immune suppressed.
Discuss the six processes involved in the chain of transmission of a disease.
- Pathogenic Agent
- Reservoir
- Portal of Exit
- Mechanism of Transmission
- Portal of Entry
- A susceptible host
Pathogen – Defined as “any microorganism that has the capability to cause disease.”
Many varieties as to how a pathogen works and where they originate
Reservoir- defined as “an environment in which organism can live and multiply, such as an animal, plant, soil, food, or other organic substance or combination of substances.”
Portal of Exit – “The place from which the parasite leaves the reservoir.” The front door of the “Motel 6.”
Examples: urine, feces, blood, secretions, exudates
Mode of Transmission-
1. Direct or Indirect contact- touch the organism itself from person to person or touch something an infected person touched.
Portal of Entry – How the pathogen enters the new host. Examples: bites, ingestion, direct contact between open areas, inhalation
Host Susceptibility- Influenced by biological factors like Can also be sociological factors like lifestyle.
Differentiate between common contact precaution categories including : contact, airborne, droplet, and vehicle. Give examples of each type.
Airborne – tuberculosis, chicken pox, measles
Droplet – coughs, sneezes. Droplet fall within 3 feet of source.
Vehicle – transmitted through a common source like food, water, IV fluids
Clostridium Difficile
(Eeeewwwww….!!! Yuck!)
Highly contagious. Should be controllable with universal precautions.
Will have a specific smell to the feces
Pt will experience severe diarrhea. Makes effective PT treatments difficult.
Can be brought on by too many antibiotics
Identified by stool samples
Staphylococcus Aureus
Can be in blood, urine, feces, respiratory secretions, etc. Therefore many types of transmission. Always ask the nurse of check the chart to find out where it is located and how to appropriately avoid.
Cannot invade through intact skin. Normally resides on skin. Invades when skin is broken.
Creates open sore on skin and then invades deeper tissues.
Treated through antibiotics
MRSA
Methycillin Resistant Staphylococcus Aureus. Resistant to antibiotics. Difficult to get rid of.
Symptoms
Staph skin infections, including MRSA, generally start as small red bumps that resemble pimples, boils or spider bites. These can quickly turn into deep, painful abscesses that require surgical draining. Sometimes the bacteria remain confined to the skin. But they can also penetrate into the body, causing potentially life-threatening infections in bones, joints, surgical wounds, the bloodstream, heart valves and lungs.
Pulmonary TB
A chronic bacterial infection of the lungs. Acquired by inhalation of a dried droplet nucleus that contains the bacteria. (*Can live in dry sputum for weeks!) Actively affected patients or potentially infected patients will be in isolation. *Need to wear duck-bill mask. Preferably the patient will be in a specialized isolation room with one way ventilation. Usually involves a double door system.
Primary TB -usually asymptomatic. May have mild pulmonary infection with low fever. Patient has been exposed to the TB, but not actively symptomatic. Pathogen is phagocytosed and starts inflammatory response. Forms a granuloma which creates a tubercle, where caseation necrosis occurs. Can remain dormant, or become active when body’s immune system declines.
Secondary TB – pathogen becomes active. Body no longer able to fight it off. Productive cough > 3 weeks, weight loss, fever, night sweats, fatigue, malaise, anorexia
Hepatititis A,B,C,D,E, and G
Hepatitis- acute or chronic inflammation of the liver.
Type A- typically food or water related. Transmitted via poor hygiene after defecating. Fecal matter is ingested via the mouth. Usually gets on hand after wiping, not washing after, and then handling food. Or can be in not-treated water supplies in underdeveloped countries. Lasts 4-8 weeks, then self-destructs. Period of infectivity begins BEFORE active symptoms arise, therefore easily transmitted.
Type B- transmitted via skin puncture or mucosal contact. *100 x more infectious that HIV!!!
Considered an STD due to commonly transmitted via unprotected sexual intercourse.
Also, high risk among IDU’s
Type C- usually transmitted via blood transfusion or IUD.
Type D- only able to exist with HBV. Same symptoms as HBV. Cannot activate alone.
Type E- transmitted via contaminated water as with HAV.
Type G- transmitted parenterally. (Injection)
Necrotizing fasciitis
Otherwise known as the flesh-eating bacteria!
Progressively attacks underlying fascia until toxic shock is possible.
Immediate surgery with debridement and powerful antibiotics is best way to remove. Very difficult to remove all affected tissue due to rapid spread.
Affected body part will decay and die. Depending on rate of spread, can be fatal.
Necrotizing fasciitis (NF) is a rare, life-threatening, soft-tissue infection characterized by rapidly spreading inflammation and necrosis of the skin, subcutaneous fat, and fascia.[1] The incidence of NF in adults has been reported to be 0.40 cases per 100,000 population, while the incidence in children is 0.08 cases per 100,000 population.[2,3] Despite the uncommon nature of this condition, over the last decade, there has been a five-fold increase in the incidence of NF.[4] Although largely unexplained, the aging of the population and the increase in numbers of immunosuppressed individuals may be related. Rapid early intervention may prevent morbidity and mortality, but, left untreated, mortality rates as high as 73 percent have been reported.[1] Mortality varies with age, with increasing mortality seen in older age groups. For example, patients over 50 years of age have a mortality rate of 37 percent, while those over 60 years of age have a mortality rate of 62 percent.
Varicella Zoster Virus
Chicken Pox and Shingles
Primary VZV = “Chicken Pox”- transmitted by inhaling infected droplets or cross contamination from open sores.
Skin Rash is common outward sign of infection. However, is contagious up to 5 days prior to outbreak of rash. Incubation period of 10-21 days. “Dewdrop on a rose petal” describes the look og the rash. DON’T SCRATCH and spread the “dew”!
Herpes Zoster Virus
Secondary VZV = “Shingles” - Herpes zoster (reactivation of VZV)
Characterized by:
Skin eruption (shingles)
Unilateral maculopapular lesions followed by vesicular eruptions with dermatomal distribution (1-3 dermatomes is usual) that does not cross the midline
Facial nerve (7th cranial nerve) involvement (Ramsey-Hunt syndrome)
Pain from inflammation of sensory nerve ganglia
Lyme Disease
Definition
Lyme disease is a tick-borne illness that causes signs and symptoms ranging from rash, fever, chills and body aches to joint swelling, weakness and temporary paralysis. Lyme disease is caused by the bacterium Borrelia burgdorferi. Deer ticks, which feed on the blood of animals and humans, can harbor the disease and spread it when feeding.
You’re more likely to get Lyme disease if you live or spend time in the grassy and heavily wooded areas where ticks carrying the disease breed. It’s important to take common-sense precautions in areas where Lyme disease is prevalent. If treated with appropriate antibiotics in the early stages of the disease, you’ll most likely recover completely. However, some people have recurring or lingering symptoms long after the infection has cleared.
Discuss the various locations and actions of the glands of the endocrine system, including: Hypothalamus, pituitary, thyroid, parathyroid, adrenal, islets of pancreas, ovaries, testes
Hypothalamus Pituitary Thyroid Parathyroid Adrenals Islets of pancreas Ovaries Testes
Hypothalamus
Part of the diencephalon; linked to the pituitary gland. Sends message hormones to pituitary Regulates the ANS: Body temp Sexual behavior Appetite Fluid balance Arousal Emotions
Pituitary
Connected to the hypothalamus
“the master gland”- produces 6 hormones and stores 2. (GH, TSH, ACTH, prolactin, FSH, LH; stores ADH & oxytocin)
Targets the thyroid, reproductive organs and adrenal cortex.
Disorders of pituitary are linked to disorders of the hypothalamus due to their interaction.
Thyroid
Located just below the larynx, anterior to the trachea
Requires iodine to produce the thyroid hormones to regulate metabolism
Large blood supply
Able to store hormones for up to 30 days
Targets all major body systems
Also closely related to the pituitary gland and hypothalamus
Disorders of the thyroid are more common in females
Parathyroid
Four small glands located behind the thyroid
Regulates calcium and phosphate metabolism via the PTH.
NOT related to pituitary and hypothalamus
Targets the bone, kidneys and intestines
Adrenal
Located above the kidneys
Involved in: HR & BP regulation, salt and potassium levels, metabolic functions (processing of carbohydrates, proteins, and fats)
Targets the kidneys, gastrointestinal system, cardiovascular system, reproductive organs
Islets of Pancreas
Pancreas is located in right upper abdominal quadrant
Performs both hormonal and digestive functions
Responsible for glucose homeostasis; produces insulin
Targets all the major body systems
Defined as: chronic, systemic disorder that is triggered by hyperglycemia and incorrect metabolism of fats, carbohydrates, and proteins.
Caused by a defect in either the production or the processing of insulin.
Glucosuria. Excess glucose is not absorbed by kidneys, therefore excreted in urine.
Commonly affects heart, eyes, kidneys, nerves, and blood vessels.
type 1-IDDM- Insulin Dependent Diabetes Mellitus
Insulin Dependent Diabetes Mellitus
Insulin production and secretion is affected.
Pancreas produces insulin in the Islet of Langerhans.
Insulin is a hormone that transports glucose to the cell to be used for energy and storage of glycogen. Also stimulates protein synthesis and fat storage.
Common Complications: peripheral neuropathy, loss of sight (retinopathy), ulcers, disorders of the feet, amputation.
Important to check glucose levels regularly. Consult with physician regularly to monitor appropriate dosage. (Sliding scale). Inspect feet regularly. Take insulin regularly. Exercise regularly.
Clinical presentations: Frequent urination Thirst; dry mouth Insatiable Weight loss Blurred vision Weakness Fatigue Dizziness
Normal glucose is between 80-120 mg/dL.
Treatment: insulin injections, dietary modifications, regular exercise
Precautions: exercise causes blood glucose to drop. Do not exercise your patient before eating or just after an injection of insulin.
Hypoglycemic reaction: headache, weakness, irritability, loss of coordination, psychosis, shaking, tachycardia; give high carbohydrate foods such as orange juice, hard candy, honey
Diabetic Ketoacidosis (DKA)- severe insulin deficiency. Usually from an interruption in regular insulin administration schedule. Treat as a medical emergency. Presents as: High glucose levels (>300). Dehydration. Fruity-acidy breath smell. Weak pulse. Deep, rapid breathing. Mild nausea. Can lead to diabetic coma. Can be quick or gradual onset.
Explain Cushing’s Disease
Cushing’s Disease- (hypercortisolism) Secondary adrenal insufficiency. Excess release of ACTH (adrenocorticotropic hormone) from the pituitary gland. Causes abnormal stimulation of the adrenal gland. *Can happen after overdose of cortisols.
Clinical presentation: HTN, hyperglycemia, proximal muscle weakness, osteoporosis, protruding abdomen with obvious stretch marks, poor wound healing, “moon face.”
Explain Addison’s Disease
Addison’s Disease- Primary adrenal insufficiency. A problem with the adrenal gland itself in that it doesn’t release enough cortisol. Idiopathic and autoimmune. Used to be a complication after TB.
Risk factors: surgery, pregnancy, trauma, infection, profuse sweating
Explain Hypoparathyroidism
: causes hypocalcemia; low levels of PTH in blood;
Anxiety, Confusion, Seizures, Arrhythmias, Fatigue, Paresthesia, Hyperreflexia, Muscle spasms/tetany
Explain Hyperparathyroidism
: causes hypercalcemia; high levels of PTH in blood; causes calcium to leave bone and deposit in kidneys, tendons, etc.
Arrhythmias with forceful cardiac contractions, comas, lethargy, skeletal muscle weakness, constipation, vomiting, kidney stones, osteoporosis, arthralgia, tendonitis, hypercalcuria
May require surgical excision of parathyroid gland, drugs less effective
Explain Hashimoto’s Disease
“Chronic thyroiditis.” most common form of hypothyroidism. Women>men by 10:1 ratio. Autoimmune disease that destroys the function of and enlarges the thyroid gland. Pituitary gland secretes too much TSH.
Treatment: hormone replacement therapy to reduce release of TSH.
Explain Hypothyroidism
- deficiency of thyroid hormone that results in decreased overall metabolism. Either from 1) decreased thyroid size or hormone synthesis or 2) from decreased stimulation of the thyroid gland due to a pituitary or hypothalamic disorder.
Most common thyroid disorder.
Clinical Manifestations- fatigue, sensitivity to cold, fluid retention, forgetfulness, depression, dry skin, slowed pulse, tenosynovitis (CTS), muscle weakness and trigger points, goiter.
Possible detrimental effects: CAD, fibromyalgia, inflammatory arthritis
Treatment: hormone replacement therapy
Explain Graves’ Disease
- autoimmune condition; most common form of hyperthyroidism. (G/F pg 466) Autoantibodies circulate and stimulate hyper excretion of thyroid hormones. Increases the body’s sympathetic nervous system reaction, therefore increases metabolism and depletes the body’s needed absorbed nutrition.
Presents as: mild goiter, nervousness and mood swings, tremor, heat intolerance, weight loss with increased appetite, diaphoresis, diarrhea, heart palpitations, muscle weakness, flushed skin, rapid pulse, polyuria, amenorrhea.
Potential detrimental effects: a-fib, CHF, CAD, exopthalmos.
Treatment: radioactive iodine, surgery, anti-thyroid medicines.
Explain Hyperthyroidism
- thyroid secretes too much thyroid hormone. Increases body’s overall metabolism.
Explain Hypopituitarism
- short stature, delayed growth, delayed puberty. Decreased or absent release of GH from pituitary gland.
“dwarfism” (???…) tends to be more of a genetic link than pituitary link.
Explain Hyperpituitarism
- usually associated with GH release. Responsible for Gigantism (exagerated growth of long bones prior to adulthood) and Acromegaly (increased bone thickness and soft tissue hypertrophy as adults)
Explain Type 2 Diabetes
NIDDM: Non-Insulin Dependent Diabetes Mellitus. Adult onset diabetes. Typically >60 y/o.
Insulin is produced by the pancreas, but not effectively utilized by the body.
Commonly affects patients with obesity
(at least 80% of all patients are obese and sedentary)
Smoking is a huge risk factor for onset
Can occur in obese children
Insulin receptors are ineffective, therefore insulin does not accurately bring down glucose levels and help with metabolism.
Clinical presentation: excessive urination, thirst, blurred vision, weakness, fatigue. Can be asymptomatic.
Explain the Ovaries and Testes functions
Releases testosterone, progesterone, and estrogens
Affects growth & sexual maturity
Decipher between the three types of pain: acute, chronic and referred.
Acute- “Pain that is usually temporary and results from something specific, such as a surgery, an injury, or an infection.”
Chronic- “Pain that lasts beyond the term of an injury or painful stimulus. Can also refer to cancer pain, pain from a chronic or degenerative disease, and pain from an unidentified cause.”
Referred- Pain felt at a site different from the location of the injured or diseased part of the body. Referred pain is due to the fact that nerve signals from several areas of the body may “feed” the same nerve pathway leading to the spinal cord and brain
Explain the various etiologies that stimulate the perception of pain
Tissue inflammation Tissue infection Tissue ischemia Tissue necrosis Over-stretched tissue Chemical disturbance Burn
Explain the physiology of pain, including the roles of A-Delta, A-Beta and C fibers
Nociceptors- nerve endings activated by noxious stimuli
Two types: A-Delta and C fibers
A-Delta: small, myelinated fibers. (A=acute)
Quick onset; short duration.
Sharp/stabbing/prickling pains.
Located mainly superficially
C fibers: small, unmyelinated fibers. Slow onset, long lasting. Dull ache, tingling, burning pain. (C=chronic)
Located in deeper structures
Non-nociceptive:
A-Beta: larger, myelinated. FASTER than A-delta. Stretch, vibration and mechanoreceptors. In joints and skin
Explain how the physiology of pain affects the Gate Control Theory
since 1965.
A-Beta fibers are nonnociceptive. Travel faster than A-Delta and C fibers. Therefore stimulus of A-Beta can block transmission of A-Delta and C closing the “gate” to the brain.
One reason why massage works and trigger point release works. Also used for TENS
Describe how to objectify pain by using the various pain scales including: numerical, visual analog, non-verbal, and Oswestry Disability Scale.
Example Pain Scales
Numerical ratings: assign numbers to degrees of pain from no pain to excruciating pain.
Visual Analog Scale: (VAS) patient marks on a line the amount of pain perceived.
Nonverbal scales: pictorial faces exhibiting levels of perceived happiness. Good for conquering language barriers…
Oswestry Disability Score (New revised form)
Describe how the Limbic System can affect a patient’s outcomes in physical therapy
emotional center of body. Regulates autonomic nervous system. The brain’s mind-body-spirit connection. If the person isn’t in the right state of mind for therapy, you will not have as much progress with them.
Differentiate between sympathetic and parasympathetic nervous system responses
Sympathetic Nervous System: “fight or flight”
Located: thoracic and upper lumbar spinal cord segments
Function: Increases CV, neuromuscular, respiratory and neurologic function
Stimulated by: fear, excitement, anger, pain, etc.
Releases: Epinephrine- vasoconstrictor
Norepinephrine- vasoconstrictor
Cortisol- metabolism and body alertness
*Prolonged stimulation of SNS can be detrimental!
Parasympathetic Nervous System- opposes the SNS.
Located: midbrain, pons, medulla, and sacral spinal segments
Relaxation response.
Decreased CV, respiratory, neuromuscular and neurological responses.
Calming effects.
Describe commonly prescribed relaxation techniques
Guided imagery – decreases levels of cortisol
Desensitization – patient talks about fear; reaches new understanding; less fearful of stimulus.
Exercise
Reading
Recreational activity
Journaling
Explain the role of a PT/PTA and how mental health status can affect the outcome for patients.
Mental health status is one of the most important predictors of physical health.
The Role of the Therapist: PTA to promote positive thinking PTA to provide environment conducive to positive results Therapist’s perspective is key… Setting realistic goals Intervention strategies Motivation strategies
Explain Fibromyalgia
Chronic Muscle Pain
Specifically pain located within at least 11 predetermined trigger point areas.
Considered a systemic problem.
Etiology- multiple factors, depression, anxiety, trauma, hypothyroidism, viral infection
No specific diagnostic testing available.
Decreased circulation with activity
Increased use of accessory breathing muscles
Physiologically, muscles never rest.
Constant state of hyper excitation
Pathogenesis- 4 primary systems are involved:
- HPA = hypothalamic-pituitary-adrenal axis
- ANS = autonomic nervous system
- RHA = reproductive hormone axis
- Immune system
Explain Chronic Fatigue Syndrome
It is a SYNDROME. Not easily diagnosed by special tests.
Mostly seen in females
Typical onset age between 29-35
Patients who are “neurotic” and “introverted” are at high risk
Mostly a sociological and psychological disorder.
Starts with fever and general malaise. Muscle pain increases, as does forgetfulness.
Minimal energy exertion results in hallmark sign of the condition: post-exertional malaise, or overwhelming fatigue
To “diagnose” will rule out: Lyme Disease, thyroid condition, DM, MS, CA, depression and bipolar disorder
Educate patient on energy conservation, regular light exercise, stress reduction techniques, proper nutrition, proper posture, ergonomics
Explain Complex Regional Pain Syndrome
CRPS (RSD) Type 1- develops after trauma. Insidious c/o pain. Edema. Erythema. Movement disorders.
Sympathetic nervous system is out of whack! Exaggerated pain response. Constant state of arousal. No relief.
Treatment: variety of tactile cues, light PRE, gentle stretching, modalities, education
Differentiate between internal and external locus of control, and how it can affect therapy outcomes
Locus of control: Ability to control life conditions and events Internal: outcomes are self-determined External: outcomes are determined by others
*External leads to anxiety and skepticism in rehab
May require “cognitive restructuring.”
Explain Type A Personality
Type A
Domineering personality
Achievement-oriented and focused
Self-critical
Strong sense of urgency with time management
(Patience is NOT a virtue!)
**Strong evidence linked to risk of heart attack and coronary artery diseases.
Explain Type B Personality
Type B
Low level of competitiveness
Little to no sense of urgency with time management
(Patience IS a virtue)
“Stops to smell the roses”…
**Low risk of cardiac disease due to decreased stress levels
Explain Type C Personality
Type C Inhibited Introverted Emotionally constrained Wanting to please others more than self *Hypothesized at increased risk of disease due to bottling up of emotions.
Explain Type D Personality
Type D
Negative affect
Doom and gloom attitude toward disease
*At risk for poor rehab potential
No one is just one. We all have tendencies toward one more than other but usually a combination.
Explain how each of the three different types of coping strategies can be utilized to affect the outcome of physical therapy
Coping strategy categories:
Seeking vs. avoiding control and information
Expressing vs. repressing emotional reactions
Seeking vs. withdrawing social interaction
Differentiate between a malingerer and a symptom magnifier
Malingerer- a patient that continues to c/o pain even after stimulus has been removed. “Lingers” in symptomatic form or may have fabricated the symptoms in the first place. Defined as “intentional production of false or grossly exaggerated physical…symptoms, motivated by external incentives such as avoiding military duty, avoiding work, financial compensation, evading criminal prosecution, or obtaining drugs.”
Symptom Magnifier- “self-destructive, socially reinforced behavioral response pattern.” Patient focuses on symptoms and is unable to focus on rehab. Exaggerated reports of symptoms. Always 10/10.
Differentiate between the capabilities of a psychologist and a psychiatrist.
Psychiatrist-
Holds a medical doctor degree. (MD) Can prescribe medications.
Psychologist-
Holds a doctorate degree. (PhD) Cannot prescribe medicine independent from physchiatrist’s guidelines.
Both can counsel psychological disorders.
Describe the three classifications of depression: major, minor and bipolar.
Major depression- “a period of at least two weeks during in which there is either a depressed mood or loss of interest or pleasure in nearly all activities.” Can be isolated occurrence or fluctuating occurrence. Additionally will see at least 4 of these changes: appetite and weight fluctuation, sleep, concentration, guilty feelings, energy levels, suicide contemplation. Significant impairment in ADL functioning.
Organic depression- results from a biological change in the brain.
Bipolar disorder- many phases of mood changes throughout life. Mania= high energy outbursts. Depression= low energy, withdrawal from society
Explain Schizophrenia
- inability to interpret reality.
Commonly have delusions and hallucinations.
Inappropriate emotional responses.
Frequent alterations in mood.
Unknown etiology.
Usually appears in adolescence or adulthood.
“The Soloist”
Explain Anxiety disorders
- Panic attacks Post-traumatic Stress Disorder Obsessive Compulsive Disorder patient usually knows the emotions are irrational, but is unable to control them
Explain Somatiform disorders
-
Hypochondriacs- every symptom is something wrong with them. Psychosomatic dysfunction; perceived illness presents as physical illness.
Explain Anorexia Nervosa
- patient’s perception of self and body image is distorted to where he/she becomes obsessed with not gaining weight. Avoids food, compulsively exercises, some substance abuse such as laxatives and diuretics, vomits after eating to void all calories
Explain Bulimia Nervosa
- Same body image issues as above, but with compulsive overeating followed by forced voiding.
List common age related conditions that can affect psychological health
Dementia- lack of intellect after age 18.
Characterized by: progressive confusion, disorientation, memory loss, personality changes
Alzheimer’s Disease- Degeneration of limbic system and neuronal synapses.
Progressive from mild to moderate to severe.
Common causes of death: infection or falls
Medication available: Aricept
As patients age, their social network deteriorates. Friends/relatives in same generation start to die. Initiates depression in many individuals.
As patients age, they can’t perform tasks like they used to. May have some hypersensitivities to this issue…
As patients age, their comorbidities tend to increase and can cause depression issues
Understand and apply the implications of mental health issues to physical therapy practice
Patients will have difficulty focusing on PT goals until their emotional issues are resolved.
Patients who perceive themselves as an active part of the rehabilitation process will have better outcomes.
Patients with congenital impairments have a different perspective on rehabilitation than ones who have sustained a traumatic event
For the best outcomes with any patient:
Figure out what personally motivates your patient and use it appropriately
Encourage regularly
Positive vs. negative feedback
Empower your patients to feel that they are in control of their rehabilitation outcomes. **PATIENT EDUCATION!!!
