Midterm Flashcards
what is blood pressure
force exerted by circulating blood on the walls of blood vessels
systolic blood pressure
blood pressure when the heart (ventricles) is contracting in a BP reading
diastolic blood pressure
the time when the heart is in a period of relaxation and dialation
stroke volume
amount of blood ejected into the aorta with each heartbeat
heart rate
of heart beats per minute
peripheral resistance
the resistance factors in the circulatory systems that affects the ease of blood flow
- tone of BVs
- viscosity of blood
- increase in peripheral resistance = increase in cardiac output and vice versa
normal BP
120/80
hypotension
90 or less/60 or less
pre hypertension
130-139/85-89
stage 1 hypertension (mild)
140-159/90-99
stage 2 hypertension (moderate)
160-179/100-109
stage 3 hypertension (severe)
180-209/110-119
stage 4 hypertension (very severe)
210+/120+
pulse pressure
the difference between the systolic and diastolic pressures. Palpated as a rhythmical throbbing over an artery, normally assessed at the wrist or neck
when taking BP, which artery is the stethoscope on
brachial artery
false high BP reading causes
- Narrow cuff size
- Wrapping cuff loosely or unevenly
- Recording BP immediately after a meal, cigarette, exercise or if bladder is full
- Deflating cuff too slowly
- “White coat” syndrome- fear of doctors
false low reading
- Having a person’s arm above their heart
- Diminished hearing of health professional
false high or low reading
- defective equipment
- Performing the technique too quickly or without attention to detail
baroreceptors and location
- Receptors within BV walls that sense pressure changes.
- Locations: Carotid sinus - in the neck at the point where the carotid of the aorta, large veins, pulmonary BV and the heart
chemoreceptors and location
- Monitor the concentration of O2, CO₂ and H in the blood Located in the carotid sinus and the heart
- Influence breathing rate
- May change vascular tone through communication with the vasomotor centers of the brain
how does the autonomic nervous system affect BF
- Short term influences on BP- HR and peripheral resistance
- Parasympathetic stimulates the vagus nerve decreasing HR Sympathetic stimulation increases BP
how does the central nervous system affect blood flow
Prevents ischemia of brain tissue in extreme cases of insufficient causing massive vasoconstriction to raise BP
Renin-Angiotensin-Aldosterone mechanism
- Utilize salt retention or excretion to influence BP
- Renin, a kidney enzyme, released with sympathetic NS firing causes vasoconstriction, salt and water retention, invreasing BP
how do hormones affect blood flow
Influence vasoconstriction
- ex. Renal prostaglandins & vasopressin
Renal body-fluid pressure
Maintains BP over long term via water and salt excretion through the kidneys.
hypertension
elevation of blood pressure above normal for a prolonged period of time
hypertension is diagnosed if
systolic pressure is 140+ and diastolic is 90+ for 2-3 consecutive visits
target hypertension organs
heart
kidneys
CNS
arteries
how is the heart affected by hypertension
angina pectoris
acute myocardial infarction
acute pulmonary edema
congestive heart failure
how are the kidneys affected by hypertension
atherosclerosis plaques on renal arteries cause decrease flow to kidneys causing tissue damage and decrease function
damage to nephrons results in systemic fluid retension
excessive release of renin, results in vasoconstriction, water and salt retention, edema, increase blood volume and pressure
nocturia
failure
how is the CNS affected by hypertenion
transient ischemic attacks (mini strokes)
strokes
how are the arteries affected by hypertension
dissecting aneurysms
artherothrombotic obstruction
risk factors of hypertension
45 and above family history smokers - double risk diabetics races if darker skin men > women until menopause then equal pregnancy people with high stress levels high sodium high alcohol oral contraceptives obesity and/or physical activity
what is hypertension associated with
heart disease myocardial infaction angina pectoris left vent hypertrophy transient ischemic attacks and stroke diabetes metabolic disorders adrenal tumors
primary hypertension
idiopathic or essential
silent long term condition that is not associated with an underlying condition
about 90-95% of hypertension is essential
sign and symptoms of primary hypertension
- “silent killer” there are no symptoms. life expentancy decreases as blood pressure increases and specific organs at risk of damage
- if any: dizziness, headache, nausea, blurred vision, fatigue, lethargy, nose bleeds, mild edema, nocturia, exertional dyspnea
complications of primary hypertension
-chronic, slow progressive damage to vital organs
-aneurysm formation and rupture
-atherosclerosis
hyalinization (thickening) of capillary walls in an attempt to reinforce their strength leads to poor tissue health and slowed healing time
-death in 20-40 years: 60% due to chronic congestive heart failure; 30% due to cerebral haemorrhage; 10% due to kidney/liver/lung failure
secondary hypertension
occurs secondary to another condition, such as kidney disease, vascular disease or adrenal dysfunction (often a tumor) eclampsia & pre-eclampsia (pregnancy induced hypertension
signs and symptoms of secondary hypetension
nosebleeds severe headaches double vision considerable edema nausea/vomiting personality changes severe tinnitus convulsions emotional changes coma
complications of secondary hypertension
- death in a few days to a few years
- usually due to kidney failure, cerebral hemorrhage or acute congestive heart failure
- damage to blood vessels: thrombosis, aneurysm, embolism
- onion skinning: repeated scarring of vessel walls resulting in increased hypertension due to a decreased lumen and elasticity
- if hypertension is untreated it leads to pathological changes in BV
- atherosclerosis, stroke, heart attacks, peripheral heart disease
medications for hypertension
reccomended when BP is above 140/90 over 3-6 month period
- diuretics
- angiotensin-converting enzyme inhibitors
- beta-blockers
- calcium channel blockers
- vasodilator drugs
congestive heart failure
hearts inability to pump sufficient blood supply the bodys needs
what may CHF be secondary to
heart disease, chronic high BP, valvular disease, viral infection, alcoholism and other conditions that stress the heart
Hypotension:
A decrease in the systolic/diastolic BP below normal (95/60)
Orthostatic postural hypotension
An excessive fall in BP on assuming an upright position (a drop of 20mmHG in systolic or 10mmHG in diastolic pressure) This is not a disease but a manifestation of abnormal BP regulation due to variety of causes
Varicose Veins
Distended or dilated, abnormally large, elongated and bulging veins leading to venous insufficiency
Thrombophlebitis
Inflammation of a superficial or deep vein that leads to the formation of a thrombus (blood clot which is attached to the wall of a blood vessel)
Venous stasis
slow blood flow in the veins
Which 3 factors can affect systolic blood pressure?
- Stroke volume
- Speed of ejection
- Elasticity in the walls of the BV
Which 3 factors can affect diastolic blood pressure?
- Elasticity in the walls of the BV
- Competency of the aortic valve
- Resistance of the arterioles
What effect will stimulation of the vagus nerve have on heart rate?
parasympathetic stimulates the vagus nerve decreasing heart rate
Persistent hypertension increases the risk of which medical problems?
increases the risk of stroke, heart attack, heart failure and arterial aneurysm, and is a leading cause of chronic renal failure.
how do dieuretics help lower BP
reduce sympathetic NS effects on vascular smooth muscle (decreases edema but may lead to heart arrhythmias)
how does Angiotensin-converting enzyme (ACE) inhibitors help lower BP
reduce vasoconstriction
how do beta blockers help reduce BP
inhibit the action of the sympathetic NS on vascular smooth muscle causing vasoconstriction
how do calcium channel blockers lower BP
reduce tone in venous and arterial smooth muscle and reduce cardiac output by inhibiting movement of calcium into cardiac and smooth muscle
how do vasodilator drugs lower BP
to decrease peripheral resistance through relaxation of the smooth muscle of the arterioles (but may produce tachycardia (rapid heartbeat) and contribute to salt and fluid retention)
Describe what happens in terms of blood volume with congestive heart failure:
Usually about 2/3rd’s of the blood volume in the heart is ejected with ventricular contraction this volume becomes progressively less (as low as 1/4 to 1/5) during heart failure, the remaining fluid causes dilation of the faulty ventricle and passive congestion of the organs proximal to it
What tissues will become congested with right ventricular heart failure?
Liver and limb congestion
What tissues will become congested with left ventricular heart failure?
lung congestion
class 1 CHF
no limitation is experienced in activates; there are no symptoms from ordinary activities
class 2 CHF
slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion
class 3 CHF
marked limitation of any activity; the patient is comfortable only at rest
class 4
any physical activity brings on discomfort and symptoms occur at rest
Why should full body MLD be avoided in a client with severe hypertension or CHF?
MLD with heart conditions because MT increases the flow of lymph towards the heart increasing congestion around the heart
What effect does petrissage have on arterial pressure?
causes initial increase followed by a decrease in pressure from peripheral vasodilation
what are the sx and sx of left ventricular CHF
- pulmonary congestion and edema
- dyspnea (laboured/difficult breathing) orthopenea (advanced dyspnea) and/or paroxysmal nocturnal dyspnea
- pulmonary edema
- hacking cough with frothy, bloody sputum
- tissue hypoxia
- decrease tolerance for exercise
- cerebral hypoxia
what are the sx and sx of right ventricular CHF
- edema distal to heart, including lower limbs (beginning with the ankles, sacral area and posterior thighs), liver, peritoneal cavity - chronic and pitted edema may develop
- impaired liver function
- enlarged spleen
- abdominal pain, intestinal problems, anorexia
- distension of jugular veins (upon standing)
- ***breathing less affected
Which types of techniques should be avoided in the treatment of someone with hypertension or CHF? Give examples.
- Prolonged painful techniques avoided because they increase the sympathetic nervous system firing therefore increase blood pressure
- Limit the number of painful techniques incorporated and the limit location
- Intersperse painful technique with soothing techniques
- Avoid vigorous stimulating techniques – cupping, hacking & pounding
- Avoid prolonged rotation of the neck during neck treatments as it could occlude BF
- Avoid simultaneous bilateral neck treatment (treat one side at a time)
- Avoid using repetitive long broad techniques (ex. Effleurage)
- Avoid repetitive full ROM, especially involving the limbs
- Avoid full body MLD
- Avoid full-body or extreme hydrotherapy applications
- Avoid Hydrotherapy applications to the chest, back and neck
Which types of techniques should be used in the treatment of someone with hypertension or CHF? Give examples.
- The goal is to decrease SNS firing
- Decrease pain and stress with soothing techniques
- Slow relaxed breathing
which positions should be avoided in someone with hypertension or CHF?
- avoid prolonged elevation of arms or legs above the heart (careful of pillow use)
- be careful of prone position because heart is lower than body part being treated and has to work harder
- avoid abdominal pillowing
which positions should be used in someone with HT or CHF
two or more pillows under the head and shoulders
which stages of uncontrolled hypertesion are completely CI’d for MT
very severe HT that is uncontrolled
if cx has controlled, very severe HT, what would be the position(s) to use for a back treatment
seated or side lying L side up
which essential oils may raise BP
hypertensive oils: rosemary, sage, thyme, camphor & hyssop
vasoconstriction oils: cypress, geranium & rosemary
how can you approach treatment of a limb when treating somebody with moderate HT or higher
begin on most distal part of the limb, using short segmental techniques and work proximally ending with the trunk treatment
list warnings of cardiac distress
increase HR rapid pulse labored breathing sweating or clamminess of skin extreme fascial flushing tissue bogginess and edema post massage
home care for cx with hypertension
- relaxation techniques (slow relaxed breathing, yoga, meditation)
- gentle modified exercising (mild to moderate levels of aerobic exercise walking, swimming), stretch and strengthen regime
- improve diet, address other risk actors as necessary
- essential oils - to facilitate decreased sympathetic NS firing
- marjoram, ylang ylang, lavender, lemon
define vasovagal syncope
sudden fainting due to hypotension induced by a nervous system response to abrupt emotional stress, pain or trauma
what is the function of valves in systemic veins
prevent back flow
what can result if systemic veins are incompetent
varicose veins
which vein is most affected with varicose
great saphenous
sx of varicose veins
- enlarged and bulging veins
- bluish veins appear lumpy
- can become tortuous
- more prominent when standing
- can be asymptomatic or cause dull achy px
- edema round ankles and lower legs
- itchiness on or around affected veins
- heavy, fatigued feeling in legs (making wlaking difficult); weakening of calf mm
- nocturnal leg cramps in calf mms
- sin over varicosities may appear shiny, bluish brown
special test for DVT
homans
What are your treatment goals for someone with varicose veins?
- Decrease and prevent fibrosis from edema and/or scar tissue adhesions through fascial and friction techniques surrounding but not on affected veins. These techniques must be modified or may be completely CI’d if client is using anticoagulants or if tissue is too fragile
- Increase ROM of affected joints, increase muscle strength, encourage drainage, and maintain joint health through active and passive movements, low-grade joint play and isometric or isotonic exercises for each affected joint o Passive and active movements of the joints in the lower limbs (hip, knee, ankle)
What is the recommended homecare for somebody with varicose veins?
- Encourage client to check with MD re: possible use of Support stockings or wraps
- Educate client on wearing looser clothing at the waist
- Avoiding prolonged periods of sitting or standing or crossing legs, avoid heavy lifting
- Sleep with feet elevated
- Care is taken not to scratch the skin over the varicosities as it may bleed and may cause an ulceration
- Maintain good foot care and frequently monitor limbs for signs of dermatitis, poor healing cuts and ulcers
- Standing in a cold foot bath, walking on the spot in cold water may assist swelling (dry thoroughly and wear warm socks)
- Light exercise such as walking to increase circulation
- Self-massage to the legs using cypress essential oil (avoid during pregnancy) to promote venous health
- AF ROM such as drawing the alphabet with ankles to increase circulation and mobility
- Elevate legs at least 3 times a day for about 10 minutes especially if they are on their feet for long periods of time
Which techniques are CI’s when client is taking anticoagulant drugs? Why
modify depth of pressure to prevent bruising
What does the alphabet have to do with homecare for a patient with varicose veins?
AF ROM such as drawing the alphabet with ankles to increase circulation and maintain ROM
What are the causes of thrombophlebitis?
- Venous stasis (slow blood flow in the veins)
- Increase in blood coagulation (blood clotting)
- Injury to the wall of the blood vessel
- Contributing factors:
• Age (40+) but especially elderly
• Fracture of lower limb
• Prolonged immobilization
• Cardiac failure, stroke or heart disease
• Anesthesia or surgery (esp. Hip replacements, hip fractures, knee surgery, prostate surgery, gynelogical surgery, neurosurgery, and caesarean section)
• Trauma (esp. Lower limbs and pelvis) and burn victims (pulmonary embolism)
• Previous history of venous disorder, especially thromboembolism (blood clot that moves)
• Pregnancy or postpartum
• Oral contraceptives
• Diabetes mellitus
• Cancer (esp. lung and pancreatic cancers- increased risk of clotting) - Clotting disorders
What is the most common place for thrombophlebitis to occur?
legs
What are the symptoms of thrombophlebitis?
• Symptoms resemble the inflammatory process
o Heat
o Redness
o Swelling (usually distal to clot)
o Deep muscle pain
o Fever
o General malaise, pain and discomfort, described as localized, deep, aching, cramping, and throbbing *usually worsens upon activity
*degree of clot determines degree of symptoms
• Can be asymptomatic in some people (30-50%)
Why are Deep Vein Thrombosis more severe than superficial vein thrombosis?
if it breaks free (embolus-a mobile clot) and travels to the lungs there is quite a high risk of a pulmonary embolism (can be fatal
What are the signs and symptoms of a pulmonary embolism?
- Extreme distress
- Dyspnea (shortness/ difficulty breathing)
- Sharp localized chest and sternal (posterior) pain
- General chest discomfort
- Distension of veins of neck
- Person may collapse or go into shock
What are the CIs for a client that has DVT or suspected DVT?
- If DVT is suspected, DO NOT perform a local massage or massage to the affected limb
- With a femoral fracture both legs are contraindicated
- As a precaution, post-surgery, massage to the legs is CI’ed if there is leg cramping
- If there is an acute DVT, Active and Passive ROM’s are CI’ed
What are the signs & symptoms of a DVT?
- Most common signs are those of the inflammatory process
- Redness, heat, swelling, deep mm pain, fever and general malaise
- Pain described as localized, deep, aching, cramping and throbbing, and exacerbated by activity like walking
- Swelling distal to occlusion
define raynauds disease
Arterial spasms and symptoms are similar to Raynaud’s Phenomenon except there is no underlying related conditions and the blood vessels appear normal
What are the presenting signs/symptoms of Raynaud’s Disease?
Tips of extremities are:
-White, blue, red – color change is TRIPHASIC (pallor caused by arteriole vasospasm, followed by cyanosis due to lack of circulation and anaerobic metabolism then redness- rubor) or BIPHASIC color change (pallor to Rubor or cyanosis to Rubor)
-color changes do generally not progress past the metacarpophalangeal joints of the hands; thumb is rarely affected
-shiny
-paresthesia-numbness and tingling during attack is common
-red and feel burning or throbbing as returning to normal feeling
o possible risk of gangrene
Extremities may have Slight edema
what can trigger an attack with raynauds disease
- Cold (most common) :In severe cases, an affected person may trigger an episode of Raynaud’s simply passing by an air conditioning vent, picking up a glass of water or walking by refrigerated areas in grocery stores
- Emotional stress: Anger or anxiety can stimulate the sympathetic nervous system including a vasospasm in the extremities
In which types of occupations would you expect to see a higher prevalence of Raynaud’s Disease? Give examples
- Occupations which use vibrating tools such as chainsaws and pneumatic devices can affect anywhere from up 40-90% of workers (construction, logging, mining)
- Up to 50% of food prep workers (butchers, fish mongers, kitchen prep) exposed to chronically cold environments have been found to have Raynaud’s
describe triphastic color change with raynauds
- pallor caused by arteriole vasospasm,
- followed by cyanosis due to lack of circulation and anaerobic metabolism then
- redness- rubor)
describe biphastic color change with raynauds
pallor to rubor OR
cyanosis to rubor
define raynauds phenomenon
peripheral vascular disorder affecting BV outside the heart and
What are the underlying conditions that Raynaud’s Phenomenon can be caused by?
- Obstructive arterial disease
ex: OAD aka peripheral vascular disease
- arteriosclerosis
- TOS and other compression
syndromes
- beugers disease - Connective tissue disorder
ex: systemic scleroderma
- lupus
- RA - Drug side effects: beta blocers, decongestants, methysergide, ergotemine tartate (vasoconstriction found in migraine meds)
- other: vibration injuries/trauma, neurogenic lesions, myoedema, pulmonary hypertension, previous vessel injury
continuous exposure to hot, cold or vibration
symptoms of raynauds phenomenon
- Episodic vasospasm of arteries and arterioles that supply blood to the extremities, primarily the hands and feet; less often the nose, ears and on rare occasions the tongue
- Change in color and sensory symptoms, trophic changes of the skin
o brittle nails, hyperkeratosis (thickening, peeling)
o in rare cases ulcers andg angrene
o Ulcers may result in chronic infection - Eventual tissue dystrophy (decrease nutrition therefore abnormal development)
o Increasing the risk of thrombosis and arthritis of the affected digits
o Muscle atrophy
Which digits are affected with Raynaud’s Disease or Phenomenon?
- the thumb is rarely affected. Color changes don’t progress past the MCP joints
What are the Cis when treating someone with Raynaud’s?
- Cold hydro on affected areas
- Extreme temps – heat may damage dystrophic tissue
- Stimulating and painful techniques
- Deep frictioning around affected area and poor tissue health
- frictioning
- Do not let limbs hang off table during treatment as it obstructs circulation
Which special tests can be used when assessing somebody with Raynaud’s? Explain each and how they would give you more information about the client’s condition.
- Allen’s Test – testing for radial or ulnar arterial occlusions
How to perform: The client is asked to open and close the hand several times as quickly as possible and then squeeze the hand tightly. Therapists thumb and index finger are place over the radial and ulnar arteries, compressing them. The client then opens the hand while pressure is maintained over the arteries. Release pressure for one artery and observe, test other artery similarly.
Positive sign: if circulation does not return to the hand in the area of radial or ulnar arteries - Nail bed compression test:
How to perform: Apply pressure to a client’s nail bed (hand or foot) while supporting the hand or foot. Release pressure after 2-4 seconds and look for the color to return to pink
Positive if: it takes longer than 2 seconds to return to pink
Indicates: a slow peripheral vascular response possibly indicating peripheral vascular disease.
Which hydrotherapy is appropriate for somebody with Raynaud’s?
contrast: 3 warm to 1 cool
3: 1
Which essential oils can be beneficial for somebody with Raynaud’s? Which effect will they have on the client?
- Essential oils, lemon and ginger, used to promote circulation.
- Blend 25 drops with 50ml oil
key difference is raynauds disease and phenomenon
disease:
- affects young women
- idopathic
- wrist pulses present and normal
- none to minimal trophic tissue change
phenomenon
- affects men and women equally
- secondary to another condition
- ulnar and radial pulses may be obstructed
- severe trophic changes (gangrene, thrombosis)
how many lobes and fissures does each lung have
left:
2 lobes
1 fissure
right:
3 lobes
2 fissureswhere are the locations of the fissures in the left lung
fissure runs obliquely from 5th rib anteriorly to T3 posteriorly
where are the fissures located in the right lung
- Fissure – between upper and middle lobes, runs obliquely from 3th rib anteriorly to T3 posteriorly
- Fissure – between smaller middle and lower lobes, runs obliquely from 6th rib anteriorly to rib 5 at the lateral scapular border
What is the function of the upper respiratory tract?
Air flows through nasal cavity and pharynx where it is filtered, warmed, and humidified
What is the function of the lower respiratory tract?
Air is transported to the alveoli where gas exchange takes place
Ventilation:
Air exchange from atmosphere to alveoli
Respiration
Blood transport and exchange of gases at the alveolar capillary level
Resting inhalation:
10-12 breaths/minute; 12-20
- Diaphragm – contracts and flattens
- External intercostals – lifting the ribs
- Scalenes – elevate first two ribs, increasingly active with deep or forced breathing
forced inhalation
50 breaths / minute
- Diaphragm – descends at least 3-4 intercostal spaces
- Sternocleidomastoids – lift sternum when head and neck are upright or hyperextended not flexed
- Subclavius – elevates 1st rib when clavicle is fixed
- Upper trapezius – elevate shoulders and indirectly the ribcage with laboured breathing
- Levator costarum – lift the ribs posteriorly and superiorly
- Serratus posterior superior - raise the 2nd- 5th ribs
- Latissimus dorsi – raises 9th – 12th ribs
- Pectoralis major – raises sternum and 2nd – 6th ribs
- Pectoralis minor – lifts 3rd – 5th ribs
relaxed expiration
Passive process – diaphragm, external intercostals and scalenes relax, ribs drop
Forced Expiration:
Coughing
- Internal intercostals – pull ribs downward
- Rectus abdominus, internal and external obliques, transverse abdominus and quadratus lumborum
dyspnea
laboured, distressed breathing as a result of shortness of breath
tachypnea
- rapid, shallow breathing; decreased tidal volume but increased rate) may be severe
Apical breathing:
upper chest breathing
beginning with the trachea and ending with the alveoli, describe the airways as they branch from largest most superior structure to the smallest most inferior structure
trachea L&R main brochi lobar bronchi segmental bronchi terminal bronchioles respiratory bronchioles alveoli
Describe the position of the relaxed diaphragm:
When relaxed the left dome is at the level of rib 5 while the right is slightly higher at the intercostal space between rib 4 and 5
Define chronic bronchitis
- Condition that results in the production of purulent sputum for at least 3 months in a row over 2 consecutive years
sx and sx of chronic bronchitis
- Chronic productive cough – worse in the morning, evening & winter months
- 2 sources of bronchial mucus:
▪ Bronchial glands - enlargement
▪ Epithelial goblet cells lining bronchial walls – increase in the number of cells - Decrease in the number of ciliated epithelial cells that mobilize and remove mucus
- Shortness of breath
- Airways become chronically inflamed from ongoing irritation, leading to edema and thickening (hyperplasia) of the walls, obstructing airways
- Obstruction in the airways
- Difficulty expiring, wheezing
- Decreased expiratory airflow rates and prolonged expiration (>4 sec.)
- worse in the morning
- Dyspnea – laboured, distressed breathing
- Recurrent respiratory infection develop
- Apical breathing – upper chest breathing
sx and sx of long term chronic bronchitis
- Less tolerance for physical activity as disease progresses
- Given name of “blue bloaters” or “non-fighter” Cyanosis
- Peripheral edema
- Retain weight
- Decrease in cardiovascular health
- Eventual pulmonary hypertension leading to right ventricular failure
- Poor tissue health due to poor gas exchange
- Low oxygen
- Clubbed fingers – ends of fingers become bulbous
- Decrease in thoracic mobility
- Barrel chest
Define acute bronchitis
• acute inflammation of the tracheobronchial tree, generally self-limited with eventual healing and return to function
sx and sx of acute bronchitis
• Usually proceeded by cold or flu
• Chills, fever, back and muscle pain, sore throat
• Onset of cough signals onset of bronchitis
• Cough is initially dry and non-productive becoming productive after a few days
o Cough worse when patient lying down
• Cold air and smoke increases cough
• Sputum is suggestive of bacterial infection
• Persistent fevers suggests pneumonia
• Dyspnea may be noticed secondary to airway obstruction
Define simple chronic bronchitis:
mild, persistent cough with clear sputum
Define mucopurulent bronchitis
thick, yellowish sputum due to bacterial infection
Define obstructive bronchitis
structural damage due to continual infection, inflammation, and coughing
What is the nickname for someone with chronic bronchitis? Why do they have this nickname?
Blue bloaters due to cyanosis and peripheral edema
What are the contraindications when treating someone with chronic bronchitis?
- Fever, infection which indicate contagious disease. Refer client to M.D. for diagnosis to rule out Pneumonia and other respiratory conditions.
- Osteoporosis is a precaution due to heavy tapotement in the treatment.
- Some medications may alter the client’s sensation to pain.
- People with severe asthma may have to have their treatment intensely altered.
- Some positions and treatment depth may have to be altered in people with circulatory complications.
- No over stimulating a debilitated client
- No joint play with hypermobility or rib subluxation
- No postural drainage:
o If there is blood in sputum (hemoptysis)
o Cardiovascular instability
o Severe Pulmonary edema or Pulmonary embolism
o Severe Hypertension or Hypotension o Chronic congestive heart failure
o Recent neurosurgery
o Shortly after client eats
o Postural dyspnea (when head is below heart – hips elevated) - No exhausting a client – with overtreatment or prolonged painful techniques
- No Thyme essential oil for pregnant clients or hypertension
- No increase in daily H2O if cardiac or renal disorders
What are the primary muscles of respiration?
diaphragm and external intercostals
What are the secondary muscles of respiration?
scalene, SCM, upper trapezius, pectoralis major and minor, abdominals, quadrates lumborum, serratus anterior
In which muscles might you see trigger point development, tenderness, or hypertonicity in a client with a respiratory disorder?
The secondary and primary respiration muscles listed above along with postural muscles
Which areas of the body should you assess when doing AF ROM for a client with a respiratory disorder?
check cervical, thoracic spine and GH
decrease ROM especially is t/s
Which areas of the body should you assess when doing PR ROM for a client with a respiratory disorder?
include static and motion palpation of the C/S and T/S
check cervical, thoracic spine and GH
decrease in ROM especially T/S
Which areas of the body should you assess when doing AR ROM for a client with a respiratory disorder?
Check abdominal and GH
Maybe a decrease in strength
mediate percussion test
Tests for: Lung density, mucus congestion in specific lobes or hyperinflation. Help locate affected lobes for postural drainage
• Procedure: Client prone then supine; place middle finger of non-dominant hang along intercostal space, with the 1st and 2nd fingers of dominant tap firmly on the other finger. Repeat tapping over various aspects of the thorax. Sound varies depending on underlying tissues
• Positive: for congestion if sound is duller (sound IS duller over solid areas- heart and abdomen); positive for hyperinflated lungs if sound is more resonant
vocal (tactile) fremitus test
Tests for: areas of bronchial congestion
- Procedure: client prone, place hands (using the balls of the fingers) symmetrically on the thorax, instructing client to repeat “ninety- nine” causing thorax to vibrate in a palpable manner, assessing various areas over the lungs and bronchi. Start over the apices of the lung and palpate from one side to the other. The vibrations should feel equal. Normal Fremitus is most prominent between the scapulae posteriorly and the sternum anteriorly. There is normal decrease in Fremitus as you progress down the thoracic cage as more tissue impedes sound transmission.
▪ Repeat with client supine, avoiding nipples
- Positive: if vibrations are:
▪ decreased or absent - air is trapped, obstructing airway such as obstructed bronchus, pneumothorax or emphysema
▪ Increased – in presence of secretion in the airway occurs with compression of the lung tissue such as in lobar pneumonia.
anterior and lateral spinous challenge test
Anterior - Place your thumbs over an individual spinous process, applying slow pressure in an anterior direction. Assess C/S in supine & T/S & L/S in prone
- Lateral – Place thumbs together on the lateral border of the spine and apply slow contra-lateral pressure to an individual spinous process
Levator Costarum fixation test:
- Tests for: assess mm length – levator costarum restriction
- Procedure: client prone, locate affected rib (rib palpation test), have client rotate head to unaffected side, stabilize SP of vertebra superior with pressure that is directed anterior and toward unaffected side. With palm of other hand apply pressure to the posterior angle of the rib in an inferolateral direction.
- Positive: leathery end feel and reported tenderness from client
first rib mobility test
Tests for: assess mobility of 1st rib
- Procedure: client seated, instruct client to fully rotate head to unaffected side then flex forward as far as possible
- Positive: limited flexion – but scalene hypertonicity and facial restrictions may also cause hypomobility
what is postural drainage
Gravity drains the mucus into the main bronchi where it can be more easily expectorated
what position would you use to drain the upper lobes
prone, raise hips to 30-45˚ - pillows built into a wedge under hips
what position would you use to drain the middle right lobe
¼ turn from supine with affected side higher supported by pillows under right thorax & knees
what position would be used to drain the lower lobes
mostly affecting bedridden clients - seated position, pillows piled up in lap and on table to support thorax
What is diaphragmatic breathing?
reduces the work involved in breathing and alleviates dyspnea. It potentially eliminates accessory mm. activity and decreases respiratory rate
segmental breathing
increases thoracic excursion in hypomobile patients
What is pursed-lip breathing?
decreases respiratory rate and increases tidal volume (amount of air entering and leaving the lungs) even during exercise
What are the treatment goals for chronic bronchitis?
- Decrease stress & decrease sympathic NS firing
- Encourage diaphragmatic breathing
- Decrease facial restrictions
- Stretch shortened muscles, decrease hypertonicity & decrease TP
- Decrease pain
- Mobilize thorax
- Thin and remove secretions
- Improve circulation to overused structures
Which type of hydro is most appropriate for someone with chronic bronchitis? Where would you apply the hydro?
Facial steam – 5 min. prior to massage
▪ Eucalyptus, benzoin (a bronchodilator) & frankincense (also slows & deepens respiration) are expectorants; pine, benzoin, tea tree, eucalyptus and juniper are beneficial for cleaning mucus and have antibacterial properties
▪ Steams may be done before or during the treatment. – 5 drops added to bowl of hot water
o Hot compress over lower intercostals
o Hot compress over pectorals prior to fascial treatment
Describe how you would instruct your client with chronic bronchitis to mobilize the thorax for homecare?
Client seated, inhales and bends thorax away from restricted side, makes a fist and pushes it into affected side of stretched thorax; on exhalation client then bends to affected side to mobilize ribs inferiorly
ashtma
Chronic inflammatory disorder Characterized by episodes of acute bronchospasms (airway narrowing/obstruction) and mucus production triggered by exposure to various stimuli
Is remission of asthma more common in children or adults?
children
Describe extrinsic asthma:
irritating substances from outside the body
- hypersensitivity reaction in which histamine causes vasodilation, increasing cell permeability and excess mucus production, when exposed to an irritant
- Irritating agents – pollens, animal dander, foods, cigarette smoke and emotional upset – skin tests are positive
- Most childhood asthma’s
Describe intrinsic asthma:
characterized by a lack of clearly defined precipitating factors – idiopathic
- Genetic predisposition; Factors within the body may cause an attack:
o respiratory infection, emotional or physical stress
o Weather changes, bronchial irritants such as air pollution, gastro-esophageal reflux and workplace irritants – skin tests are negative
whats happening during an acute asthma attack
expiration becomes prolonged due to airway obstruction
• Amount of air that can be exhaled forcefully with each breath decreases
• Air that can’t be exhaled becomes trapped in the lungs – hyperinflation
• Anteroposterior dimension of the thorax increases & there is limited rib movement on inhalation
• Diaphragm becomes flattened due to hyperinflation
• Person must work hard to exhale- recruiting accessory mm. of respiration
• Unproductive cough during attack that becomes productive afterwards
• Audible wheezing on inhalation & exhalation
• Anxious and possibly sweating, most comfortable sitting upright
• Dyspnea (distressed, laboured breathing as a result of shortness of breath) or tachypnea (rapid, shallow breathing; decreased tital volume but increased rate) may be severe
what happens during a severe asthma attack
Requires immediate emergency medical attention:
- Person can’t complete sentence in one -Respiration is > 25 breaths/minute
- Pulse is > 110 BPM
- Life-threatening indicators: cyanosis, feeble respiratory effort, exhaustion, confusion, coma
- “Status asthmaticus” = attack lasts > 24hrs., leading to dehydration and exhaustion with potentially fatal results
CI’s of treating asthma
- NO treatment during an acute attack - Hydro, postural drainage or massage
- No over stimulating a debilitated client
- Careful not to exhaust a client - Avoid stimulating work if stress or physical exertion is a trigger
- No triggers of attacks (ex. scents) in the treatment room, ensure room is dust free & clean
- Avoid excessive heat or cold in hydrotherapy if it is a trigger and avoid completely during an attack
- No joint play over xiphoid and floating ribs
- No tapotement over bony prominences, floating ribs, breast tissue
- Be careful with clients who are on steroids as it may weaken tissues
- Long-term steroid use may lead to osteoporosis
- Avoid increase in H20 if client has cardiac or renal disorders
- Postural drainage is contraindicated with severe hemoptysis (copious amounts of blood in sputum), severe pulmonary edema, congestive heart failure, pulmonary embolism, severe hypertension or hypotension, recent myocardial infarction and recent neurosurgery o No postural drainage if client just ate
- Be aware of location of inhaler and have it available in case of attack
Which treatment position should be avoided for someone with severe asthma?
Avoid time in supine, if any at all
Describe the rib recoil technique described in your notes:
- Therapist palpates rib for hypomobile segment
o Therapist places one thumb on posterior angle of fixed rib and the other thumb moves medially onto the nearest, superior Spinous Process
o The therapist applies a contralateral pressure on the SP away from the rib to stretch levator costarum
o Therapist keeps hand placement as client takes a deep breath in, on exhalation the therapist gently releases the SP and rib, allowing for elastic recoil to mobilize levator costarum.
What are some common postural changes in somebody with a respiratory disorder? (How will they present, in other words.)
- Elevated shoulders, barrel chest, anterior head carriage, hyperkyphosis
- Prolonged exhalation, possibly pursed-lip breathing
- Thin and fatigued looking
- Prominent accessory muscles of respiration
- Client may lean on elbows on table so shoulders are elevated to assist breathing
- Skin is rosy and pink - AKA “Pink puffers”
- Bluish appearance (“blue bloaters”- indicates chronic bronchitis)
- Clubbed fingers
define COPD
Describes a spectrum of diseases, most frequently some combination of emphysema and chronic bronchitis; also includes Cystic Fibrosis (CF)
define emphysema
- A condition in which the alveoli of the lungs becomes fibrous and inelastic
Describe what happens with the alveoli with emphysema:
- Alveoli merge with each other and decrease the surface area, limiting the exchange of oxygen and carbon dioxide
List the signs and symptoms of emphysema:
Dyspnea – difficulty breathing
• Pain with breathing; Difficulty breathing on exertion
• Bubbles, rasps when breathing
• Wheezing, prolonged expiration (slow and forced) and physical inactivity
• Breathlessness
• Decrease in diaphragmatic breathing
• May or may not have a productive cough – present if combined with chronic bronchitis or other respiratory infection
• Little interest in eating
• Loss of general muscle tone due to decreased activity
• Barrel chest, hyperkyphosis, anterior head carriage
• Ribs and mm. of respiration are constantly engaged
• Diaphragm is flattened and accessory mm. are overused
• Lung congestion - Hyperinflation
• Hypoxia leads to over ventilation o AKA “Pink puffers” – pink complexion, shortness of breath
• Thin build
What is the nickname for somebody with emphysema? Why?
“Pink puffers” – pink complexion, shortness of breath
Supine and prone. Treat in semi reclined or seated
Supine and prone. Treat in semi reclined or seated
describe barrel chest
increased anteroposterior thoracic dimensions
sinusitis
acute or chronic recurrent inflammation of the mucous membranes in the paranasal sinuses
sinus headache
a painful headache that often accompanies a sinusitis where the location and quality are defined by the location of maximum sinus irritation
frontal sinus
appear by age 7 years; vary in size from 5mm to larger hollows
drain into the top of the nasal cavity
ethmoid sinuses
appear between 2&8 years; variable number of small cells
drain into lateral nasal cavity
sphenoid sinus
appear after 2 years; relatively large
drain into posterior nasal cavity
maxillary sinus
present at birth; largest
drain superiorly into the nasal cavity
frontal sinus headache
located in the frontal area above the eyes
ethmoidal sinus headache
causes by both a frontal headache that is describes as “splitting” and pain behind the eyes
sphenoidal sinus headache
is less well localized causing in both the frontal and occipital area
maxillary sinus headache
causes pain in the maxillary area under the eyes, a frontal headache and often a toothache
sinus
air filled continuations of the nasal passages, lined with mucous membrane
predisposing factors of sinusitis
deviation of the nasal septum
dairy and wheat products
upper molar abscess
homecare for sinusitis
facial steams (up to 5/day), vaporizers or nasal rinse
cold compress to the face and warm compress to posterior cervical area
educate client on properly blowing their nose one side at a time, keeping the other nostril closed
- do not blow too hard; may spread infection to eustachian tubes
- do not blow both sides at the same time as it partially closes off the passage
AF ROM for cspine and jaw as self care
strengthening for the neck and upper back
teach full diaphramatic breathing
self massage to face and neck
referral to MD, dentist or ENT specialist; naturopath can helo strengthen the immune system
what are the special tests used to asses sinusitis
trans illumination of the sinuses
perform test in a dark room using flashlight
maxillary: instruct cx to place light against roof of mouth
- normal: bright red glow on anterior aspect of cx cheek
frontal: close eyes and hold light against medial aspect of cx cheek
- normal: red glow on the forehad over vertical part of the sinus
positive result: a blocked or infected sinus does not trans illuminate
check the AF ROM of the cspine (leave forward flexion to the last as it may induce px) and TMJ looking for restricted or guarding movement/assymteries
have cx bend forward or flex their head. cx will feel increased pressure in the face and sinuses and increased px in the sinuses, frontal bone, cheeks, ears or teeth. if the cx is able to breath through the nose, have them press a finger against one nostril and then the other while inhaling to see if one side is more congested
what are the hydro modalities for sinusitis
fascial steams:
- 5 mins
- tissues and waste basket close by
- 4-5 drops of essential oil in hot water (tea tree/thyme is antiseptic to treat infection, lavender for px refied & decrease swelling, eucalyptus/pine to unclog mucous)
- cold compress over cheeks, forehead and eyes can reduce inflammation
- hot towels around nexk can reduce muscle tension and can hold a few drops of essential oils to promote drainage
CI’s of sinusitis
fever
local MLD with acute infection
refer to MD or dentist if sinusitis is chronic, recurrent or dental infection is present
avoi placing client in face cradle if sinuses are swollen and tender
work within the clients pain tolerance, especially over sinuses
what is DDD
degeneration of the annulus fibrosis of an intervertebral disc. with age, a slow degeneration is normal. resulting is px, tearing, scarring and clefts
where is DDD most common
C/S and L/S
what does the nucleus gel change into with DDD
a fibrous structure (H2O decreases and collagen increases)
with DDD; overall height of the disc _______ and disc space _______. leading to what?
height decrease and disc space narrows leading to nerve root irritation
is DDD more common in men or women?
men
in DDD _______ portion of the annulus compresses and bulge as a result of the ________
posterior, lumbar lordosis
__________ portion of the disc weaken first (DDD)
posteriorlateral
what combination of spinal movements increase stress on posterolateral portions of the annulus fibers?
diagonal combinations. flexion with rotation
disc prolapse
bulging of the nucleus pulposus against the posterolateral layers of the annulus fibrosis.
outer layers remain intact
disc herniation
tearing of both the inner and outer layers of the annulus fibrosis causing the nucleus pulposus to bulge directly into the intervertebral layer
extrusion (disc herniation)
annulus fibrosis is pierced, allowing nucleus to enter epidural space
sequestration (Disc herniation)
fragments of the nucleus and the annulus are found outside the disc
men:women ratio for disc herniation
3:2
what joints account for 98% of all low back and low back disc injuries
L4-L5 or L5-S1
what is the laymens term for disc herniation
slipped disc
what are aggravating movements/positions for each area of DDD or each type
posterior lumbar: sitting
anterior lumbar: standing and walking
posterior cervical: carrying heavy objects like a bag
anterior cervical: swallowing
what diagnostic tool is used to determine DDD
xray
if cx has nerve root impingement from DDD/disc herniation, what myotomes would be affected
C5: shoulder AB C6: elbow flexion, wrist extension C7: elbow extension, wrist flexion C8: thumb abduction T1: finger adduction L4: ankle DF L5: big toe extension S1: PF
types of disc herniation
prolapse: bulging of NP against posterolateral layers of AF. tearing of inner AF layers lead to weakening, but the outer layers remain intact
herniation: tearing of both inner and outer layer of AF causing NP to bulge directly into the intervertebral space
extrusion: annulus fibrosis is pierced, allowing nucleus to enter epidural space
sequestration: fragments of nucleus & annulus are found outside disc
prognosis for DDD & herniation
DDD:
better if sx are recent and sudden onset
gradual onset with mm weakness and atrophy have poorer prognosis
few weeks of sx, asymptomatic period, flareups onset by overuse or poor posture
Acute herniation
asymptomatic periods interspeed with acute episodes of disc bulging for no apparent reasons
c-spine prognosis is good, most severe sx diminish in a few days, full healing in a few months
L-spine up to 8 weeks to heal in most cases
special tests used to disc herniation
kemps or spurlings: may produce local px if facet joint is inflamed or radiating px if nerve is impinged or compressed due to degeneration of the disc
valsalva: may be positive with cervical/lumbar herniation
ULTT may be positive with cervical disc herniation
slump and SLR test may be positice with lumbar disc herniation
what would you test for if there is nerve root involvement with disc herniation
myotomes, dermatomes and deep tendon reflexes
what sx and sx will cx with nerve root involvement show in disc herniation
motor weakness, dermatomal sensory changes such as parathesia or sensation loss
for DDD/OA name the assessments/ROM you would use to asses a cx
- asses length and tone of surrounding muscles
- asses ROM of joints affected by DDD and/or OA
(another card will tell what to specifically test for these)
what would you expect to happen with AF ROM and PR ROM with OA/DDD
AF rom will be decreased
PR ROM will have more available range with an end-capsular end feel
ROM and how joints are affected in acute herniation
posterior or posterolateral herniation contained by annular fibers: movement can decrease symptoms
- flexion is decreased and symptoms peripheralize - extension is decreased and symptoms centralize - complete annular rupture & sequestered nucleus: movement cannot relieve symptoms as hydrostatic disc mechanism is no longer intact
movement toward pain increase pain= possible nerve root involvement or herniation is later to the nerve root or inside the vetebral joints
movement away from pain= possible FJ involvement or herniation is medial to the nerve root or musculature or articular in origin
ROM and how joints are affected in DDD
extension is more restricted in the c-spine & L-spine
stiffness is likely
possible pain
end-feel likely capsular
AR ROM - possible weakness; depending on stage of degeneration
what mechanism of injury can cause disc herniation
chronic overloading the disc leading to annular fiber micro tearing & migration of the nucleus
contributing factors for DDD
postural dysfunction - anterior head carriage, improper back support
muscle imbalances leading to asymmetrical loading; lack of flexibity
occupational deviation leading to excessive rotation
poor blood supply to the disc
fixation (fusion) of the spine will lead to degeneration changes especially above and below the sites of fixation
- joints above and below a fixation will make up for the loss of movement and become hypermobile causing excessive wear and tear on the spine
direct trauma such as a fall or whiplash or lift and twist injuries
biomechanical changes
- asymmetrically shaped facet joints
- hypo or hypermobile FJ
what exercises can be used for a client with DDD with hyperlordosis vs flat back
hyperlordosis
begin tx with fascial, TP therapy and GSM to hip flexors: rec fem, IT band, Iliopsoas, TFL
joint mobs to hypomobile SI joints
position prone to treat lumbar erector spinae group, QL and glutes (fascial, TP therapy and GSM)
joint mobs to hypomobile vertebrae
- long axis traction to lumbar
stretch shortened mm: hip flexors
flat back
stretch shortened mm: hamstrigns (fascial,GSM, PIR)
stimulate stretched/lengthened mm: hip flexors, lumbar extensors (brisk stimulating work)
decrease posterior pelvic tilt
- passive hip extension combined with submaximal isometric contraction of the quads
