multi d midterm Flashcards
purpose of the guide to physical therapist practice
describes practice
describes setting and role
terminology
clinical making process
reviews interventions
describes outcome measures
biopsychosocial model
complete
not merely the absence of disease or infirmity
define acute
very serious or dangerous, requiring serious attention or action
acute care today
advancements and improvements in life support
rehab services now treating seriously injured
treatment goals
prevent adverse effects of PI
prevent contractures
improve general conditioning
prevent pressure ulcers
return pt to pre-hospital level
special considerations for acute care
monitor vitals
compression devices
encourage mobility
homework
isolation for infection
tubes
safety
define disability
inability or restricted ability to perform actions
define health condition
pathology
disorder
disease
injury
trauma
congenital anamaly
define PT diagnosis
how the condition causes disability
what is an activity?
task or action done by an individual
what is participation?
involvement in life situation
what are contextual factors?
personal and environmental factors may be positive or negative
may facilitate or impede functioning/recovery
what all does a review of systems include?
cardiopulm
endocrine
EENT
GI
neuro
reproductive
hematologic/lymphatic
integ
psych
msk
PT systems review
hands on
cardiopulm
integ
msk
neuro
what are tests and measures used for?
help establish diag, prog, treatment plan
what interventions to use
PT evaluation
putting it all together
diag
problem list
prog
goals
plan of care
define PT diagnosis
ID discrepancies between the pt’s level of function and what is desired
determine capacity of pt to achieve that level
define prognosis
optimal level of improvement
listing of goals
define problem list
impairments of body structure or function
activity limitations
participations restrictions
risks and causes of a hip fracture
osteoporosis
age over 60
any increase of fall risk
any increase in bone weakness
weakness in hip muscles due to PI
three types of hip fracture
intracapsular - break in capsule
intertrochanteric - between lesser and greater troch
subtrochanteric - within 5 cm below lesser trochanter
types of pelvic fracture
lateral compression
AP compression
vertical shear
favorable factors contributing to bone healing
early mobilization
early weight bearing
maintenance of fracture reduction
younger age
good nutrition
minimal soft tissue damage
patient compliance
presence of growth hormone
normal body weight
supportive environment
good general strength
unfavorable factors contributing to bone healing
tobacco use
comorbidities
vitamin deficiency
osteoporosis
infection
irradiated bone (exposed to radiation)
severe soft tissue damage
distraction of fracture fragments
multiple fracture fragments
disruption of vascular supply to bone
corticosteroid use
prognosis of total joint arthroplasty
fairly consistent positive outcomes with brief hospitalization
significant post op rehab in multiple levels of care
Total hip arthroplasty precautions (posterior)
no hip flexion greater than 90 deg
no hip adduction past midline
no hip internal rotation past neutral
Total hip arthroplasty precautions (anterior)
no hip extension past neutral
no active hip abduction
no hip external rotation past neutral
TKA recommendation
no twisting of LW in WB position
no sitting with legs crossed
avoid low soft chairs
do not forcefully bend operated knee
do not kneel on operated knee
use of walker as needed
total shoulder or rotator cuff repair
NWB and immobilized constantly unless PROM
no abduction or extension past neutral
AROM of elbow, wrist, hand
outpatient 5 times per week for 4 weeks is common
main causes of amputation
LE - vascular disease
UE - trauma
pain management focus in amputation
residual limb
phantom limb
musculoskeletal
residual limb and prosthesis focus in amputation
hygiene
fitting of prothesis
various types and uses
psychosocial focus in amputation
bereavement of lost limb
depression management
changes in social life
societal perceptions
daily needed focus in amputation
transportation
couple relationships
activities, return to work, sports
fall prevention
pt management for amputations
education
- positioning for edema control
- positioning to avoid contractures
benefits of early ROM, strength, mobility training
discussion of pain management, phantom pain
most common neck/back pain diagnosis requiring hospitalization
spinal nerve compression related to disk
compression fracture
what can a PT do for neck/back pain diagnosis
relieve, stabilize, strengthen, educate
NO bending, lifting, twisting of spine
describe a discectomy
removal of disc fragments that compress spinal nerve root
describe a laminectomy
removal of part of lamina to depress spinal canal
describe a fusion
use of instrumentation and/or bone grafting to stabilize vertebral segments
describe a vertebroplasty
injection of bone cement to stabilize a vertebra with a compression fracture
describe a kyphoplasty
insert inflatable balloon to restore height prior to injection of bone cement
what type of exercise is best for a spinal surgery pt?
walking
describe an acute care setting
inpatient with unstable medical conditions
24 hrs/day highly skilled services
PT role in discharge from acute care
reducing length of stay
communication with whole team
what are considered post acute care?
IRF
SNF
LTACH
inpatient rehabilitation facility
relatively medically stable
min 3 hours of therapy a day
must need 2/3 therapies
sees physician once a week
average length of stay for IRF
12-14 days
13 diagnostic categories that must make 60% of IRF pts
stroke
SCI
congenital deformity
amputation
major multiple trauma
fracture of femur
brain injury
neurological disorders
burns
arthritis
joint inflammation
severe OA
bilateral knee or hip replacement
skilled nursing facilites
require medical services
at least 1 hour of therapy a day
one service
sees physician every 30 days
average LOS for SNF
around 30 days
what is the discharge % from SNF to home
45%
long term acute care hospital
very close medical supervision, but considered stable
might get PT
example of who needs LTACH
cannot get off a ventilator
ongoing dialysis
intensive respiratory care
multiple IV meds
burn care
average LOS in LTACH
greater than 25 days
what is the discharge % from LTACH to home
27%
assisted living with respite care and home health services
temporary
private pay for respite
can perform in home setting but just not their normal home due to architectural barriers
home health care
delivered in home setting
must be homebound
could be eligible for several weeks
45-60 min sessions
outpatient therapy
ambulatory care environments
broad range of clinical problems
varying complexity
least expensive
2-3x / week for 4-12 weeks
long term care facilities
varying levels of supervised living arrangements
unable to safely manage independent living
“nursing home”
may not have regular PT
physician sees pts as needed
clinical test of sensory interaction on balance (CTSIB)
- normal, eyes open
- normal, eyes closed
- normal, conflict dome
- foam, eyes open
- foam, eyes closed
- foam, conflict dome
timed for 30 seconds each
cut off score for CITSIB
< 260 seconds for all 6 condition
specificity of CTSIB
90%
berg balance scale
14 items that assess sitting and standing balance
each item scored 0-4
< 47 indicating patient is a fall risk
stats on berg balance
sensitivity = 94.4%
MCID = 13.5, 15 for goals
cut off score: <47
dynamic gait index (DGI)
assess ability to modify balance while walking in presence of external demands
timed up and go (TUG)
stands up, walks 3 meters, turn around and sit back down
timer starts once clinician says go
what is the cutoff for fall risk in the TUG?
> 13.5 seconds
what is the average MCID for TUG?
3.4 seconds
four square step test (FSST)
use canes to make the square
once clockwise then once clockwise
both feet touch each square
“try to complete as fast as possible and face forward the entire time”
cut off scores for FSST
> 15 seconds is at risk for falls
function in sitting test (FIST)
for those who cannot walk to evaluate sitting balance
seated balance
14 items scored 0-4
cut off for FIST
<41.5 cannot go home
30 second sit to stand
hand crossed over chest
feet flat on floor
on go rise to full standing and sit back down
MCD and MCID for 30SSS
MDC = 2.96
MCID = 2.0 or 2.6 so take larger number
use ~3 for both
5X sit to stand test
time until the fifth full up
cutoff for fall risk for 5XSST
> 12 seconds - needs assessment for fall risk
15 seconds - recurrent falls
mini best
14 items
10-15 minutes
anticipatory section:
~ sit to stant
~ rise to toes
~ stand on one leg
reative postural control:
~ stepping correction forward
~ stepping correction backward
~stepping correction lateral
sensory orientation:
~ CTSIB
~ eyes closed on incline
dynamic gait:
~ change in gait speed
~ walk with head turns
~ walk with pivot turns
~ step over obstacles
~ TUG with dual task
MCID for mini best
4 points out of 28
6 min walk test
start timing once pt starts walking
do not walk with the pt
after 30 meters turn around to make another lap
what is a small meaningful change for 6 min walk test?
20 meter improvement
what is a large meaningful change for 6 min walk test?
40 meter improvement
timed 10 meter walk (gait speed)
2 meters acceleration
6 meters fast walking
2 meters deceleration
timed 10 meter walk test cut off scores
less than .8 m/s is at risk for sarcopenia and frailty
greater than 1 m/s are likely to be independent
greater than 1.2 m/s is a normal ambulator
2 minute step test
measure .5 the distance between iliac crest/patella
only count how many times the right knee reached the required height
primary indications for cardiac rehab
acute coronary syndrome
MI
CABG
heart or lung transplant
heart valve repair
heart failure
cardiac rehab phase 1
referral when pt is medically stable
education
self care eval
low level exercise
goals of inpatient CR
prevent another event
recover from event
evaluate response to self care and ambulation
increase knowledge
what to monitor during ambulation and ADL eval
hemodynamic, symptomatic and ECG response
need to know every change
benefits of early mobilization in CR
improves HR, arterial BP, myocardial O2 uptake
improves peripheral circulation, pulmonary ventilation, ANS
expected outcomes of CR
prevent harmful effects of bed rest
walk 5-10 min continuously or 1000 feet 4x/day
1 flight of stairs independently
know safe limits for exercise
recognize abnormal S&S
promote more rapid and safe return to ADLs
prepare for home
modifiable risk factors for cardiac disease
smoking
hypertension
hypercholesterolemia
PI
diabetes
obesity
on meds for a risk factor
discontinue exercise in CR if any of the following happen
outside of max HR ranges
resting HR > 120
post op > 30 bpm above resting
post MI > 20 bpm above
DBP >/equal to 110mmHg and/or SBP > 210mmHG
decrease in SBP > 10mmHg or increase in > 40 mmHG in response to exercise
contraindications for CR
unstable angina
resting SBP > 200 mmHg or resting D > 110 mmHg
orthostatic BP drop > 20 mmHg with sympotms
4 ways to diagnose orthostatic hypotension
SBP decrease of 20 mmHg or more
DBP decrease of 10 mmHg or more
SBP decreases under 90 mmHg
HR increase of 10 bpm or more
most common cause of right heart failure
left heart failure
chronic stable angina
predictable episodes
controllable (lower exercise, nitro)
could be known or unknown
unstable angina
unpredictable
poor alleviation efforts
requires immediate medical attention
angina scale
1: mildly, barely noticeable
2: somewhat strong
3: moderately severe, very uncomfortable
4: very severe, most intense pain ever experienced
claudication scale
1: initial pain, minimal
2: moderate discomfort or pain; attention diverted
3: intense pain; attention cannot be diverted
4: excruciating and unbearable pain
can exercise up to grade 3
pulse 4 point scale
0: absent
1+: palpable, thready and weak, easily obliterated
2+: normal, easily identified, not easily obliterated
3+: increased, moderate pressure of obliteration
4+: full, bounding, cannot obliterate
acute coronary syndrome
myocardial oxygen deprivation causing angina and potentially tissue ischemia
treatments: PTCA, stent, CABG
percutaneous coronary interventions (PCI)
PTCA
stent
atherectomy
PTCA
balloon to squish plaque out of the way
often done with stent placement
CABG
single through quadruple
valve disease
over time pumping dysfunction
sternotomy precautions
sternal precautions
no pushing, pulling, lifting over 8-10 lbs
no raising arms above the shoulder
no arms behind the back
do not push up from a chair
do not carry children, pets, groceries
what do inefficiencies from arrhythmias lead to?
heart having to work harder for the same output
S&S of chronic heart failure
weight gain
dyspnea
orthopnea
paroxysmal nocturnal dyspnea
tachypnea
cough
fatigue
cyanotic extremities
peripheral edema
decreased activity tolerance
when does a pt need supplemental oxygen?
<88% on room air
nasal canula rates
1-6
above 4 causes dryness
INR
time for blood to clot
troponin
will be elevated in MI
BNP
identify CHF when over 100
d-dimer
blood clot breakdown
identify embolism/DVT
goals of PT in the ICU
prevention of secondary complications
promote weening from ventilators
optimize oxygenation
restoration of function
decrease length of stay
improve progression of mobility
improve QOL
when do PTs communicate to interdisciplinary team in ICU?
daily prior to intervention
risks of under sedation
ventilator asynchrony
increased O2 consumption
inadvertent removal of devices, IV’s, catheters
PTSD
risks of over sedation
pneumonia/lung injury
neuromuscular dysfunction
delirium
critical illness polyneuropathy/mypathy
overlapping syndromes of diffuse, symmetric, flaccid muscle weakness occurring in critically ill pts
occurrence of ICU delirium
60-80% of ventilated pts
20-50% non-ventilated pts
ICU delirium management
pain, agitation, delirium
sedation vacation
discontinue asap
initiate mobility asap
minimize sleep disruption
national institute of health stroke scale
0-42 scoring
lower score is better
tells how severe, not the location
<5: 80% discharged to home
richmond agitation scale
combative - unarousable
figure out how to adapt treatment
glasgow coma scale
used before entering room to check pt status
PT focus in pt skills
communicate plan
access # of people to assist
obtain safety devices
vital signs
plan to return to safe position
explain plan
proceed and reassess for tolerance
aterial line
access in arterial system
central venous pressure catheter
large vein access
indwelling right arterial catheter (hickman)
right atrium
intravenous system
superficial vein access
pulmonary arter catheter
access to pulmonary artery via a vein
intracranial pressure monitor
against skull
precautions from access and pressure monitors
discuss POC with nurses
do not disconnect without permission
nasogastric tube
nostril to stomach
gastrostomy tube PEG
to stomach
jejuonstomy tube PEJ
to jejunum
IV (nutrition)
for fluids, meds, electrolytes
nutrition precautions
not in flat if receiving
external catheter
male: condom
female: purewick (suction)
foley catheter
indwelling for continuous drainage
suprapubic catheter
surgically inserted
urinary catheter precautions
bag below bladder
purewick may be removed
gaitbelt not over insertion of suprapubic
cardiac leads
stickers
battery or wall
chest tube
incision in chest
suction or water seal
cardiac lines precautions
maintain continuous monitoring
chest tube canister below insertion point
gait belt above chest tube insertion point
