PTA Acute Care - 1st Practical Flashcards
what are indications for IPC?
- chronic venous insufficiency (CVI)
- amputations
- traumatic edema (chronic)
what are contraindications for IPC?
- arterial insufficiency
- infections in the treatment area
- thrombi
- edema in patients with cardiac dysfunction (such as CHF pitting edema)
- edema in patients with kidney dysfuncion
- obstructed lymphatic channels
- increased risk of metastasis in patients with cancer
- acute pulmonary edema
- congestive heart failure (see #4)
- acute fracture
- edema immediately after a traumatic injury
what is equipment needed for BP?
sphygmomanometer stethoscope cotton ball alchol watch with second hand
what is anterior bony landmark for 1st rib?
clavicle
what is anterior bony landmark for 2nd rib?
sternal angle
what is anterior bony landmark for 6th rib?
xiphoid process
what is posterior bony landmark for T3/4th rib?
root of the spine of the scapula
describe positions of dyspnea
1.
what are Indications for use of Postural Drainage?
to facilitate clearance of excessive secretions in patients with:
- pneumonia
- increased secretions pre- or post-operatively
- exacerbation of chronic lung disease with history of excessive secretions
- severe respiratory muscle weakness or paralysis
- comatose patient
what are Contraindications for use of Postural Drainage?
- gross hemoptysis (due to severe lung contusion)
- untreated pneumothorax
- severe pulmonary edema
- aneurysm or obstruction in main vessels
- shock
list Contraindications to Trendelenburg position:
- congestive heart failure
- severe arrhythmias, hypotension, or hypertension
- acute myocardial infarction
- following recent head injury, some neurosurgery and some eye surgeries except if drugs to reduce intracranial pressure are being given and are effective
- if there is regurgitation of gastric juices i.e. esophageal reflux, hiatal hernia (stomach through diaphragm)
list Precautions to Percussions and/or Vibration/Shaking
- do not percuss over an incision or recent skin graft
- conditions prone to hemorrhage, i.e. platelets less than 50,000 per cu. mm.
- percussion may be performed over rib fratures and flail chest only by an experienced PT. no vibration.
- conditions which cause fragile bones, i/e/ osteoporosis, rickets.
- pulmonary embolus
Postural Drainage, Upper, Apical
pt position: seated, leaning posteriorly 30 degrees, pillow behind back
PTA position: behind pt, likely standing
percussion/vibration: superior, between clavicle and scapula
Postural Drainage, Upper, Posterior
pt position: seated, leaning anteriorly 30 degrees, leaning on table, on pillows, arms on table, scapulas protracted
PTA position: behind patient, standing
percussion/vibration: over upper back, between scapulas, not on spine
Postural Drainage, Upper, Anterior
pt position: table at 0-degrees, supine, pillow under knees (and heels off table)
PTA position: to the side, if only doing one side
percussion/vibration: between clavicle and nipple
Postural Drainage, Middle
pt position: table at 30-degrees, side-lying 1/4 turn from supine, pillow behind back, knee pillow
PTA position: beside, heel of hand on mid-axillary line between 4th and 6th rib, under breast tissue
percussion/vibration: lateral and slightly inferior to breast; maybe quick stretch on each vibration or cue to ‘breathe into my hand’
Postural Drainage, Lower, Posterior Basal
pt position: table at 45-degrees, prone, pillow under pelvis and ankles
PTA position: to the side
percussion/vibration: over lower ribs
Postural Drainage, Lower, Lateral Basal
pt position: table at 45-degrees, side-lying 1/4 turn from prone, knee pillows, hug pillow
PTA position: to the side
percussion/vibration: over lower lateral ribs
Postural Drainage, Lower, Superior
pt position: table at 0-degrees, prone with 2 pillows under pelvis, pillow under ankle
PTA position: to the side
percussion/vibration: just below the scapula
describe the Bifurcation of the Trachea
find the sternal angle, explain that trachea bifurcates into left and right behind it.
describe location of the Upper Lobe of the lung
midclavicular, anterior, protrudes upward behind the 1st rib, down to 4th rib, follow 4th rib to mid axillary line, then upward to T4 posterior. on left, is a bit lower anterior
describe location of Middle Lobe of the lung
midclavicular, anterior, from 4th to 6th rib (level of xiphoid process), around to mid axillary line
describe location of Lingula of the lung
similar to middle lobe, from cardiac notch to intersection of transverse and oblique fissure
describe location of Lower Lobe of the lung
6th rib midclavicular to 8th rib midaxillary to 10th rib posteriorly
visual inspection: general
level of consciousness confused? comfortable? in pain? respiratory distress? body build? (obese, thin, cachetic)
what are the signs of respiratory distress
- Rapid, shallow breathing (dyspnea)
- Intercostals retraction
- Grunting sounds
- Flaring of the nostrils
- crackles, rhonchi, wheezes
visual inspection: positioning
is patient - tripod? leaning to one side? conducive to recovery? shoulders protracted?
visual inspection: face
color
nostrils- flaring?
visual inspection: neck
jugular distention
SCM engaged or hypertrophied
mediastinal shift
visual inspection: chest
configuration - pigeon, funnel, barrel
scars - which can limit excursion
breathing pattern - belly, shoulders (apical), shallow, tachycardia (hypoxia)
visual inspection: cough and phonation?
SOB with speech - raspy, volume
productive cough - sputum
cough spasm
what do we look for in sputum?
color (clear, white, brown, yellow)
consistency
odor
amount
visual inspection: appearance of extremities
digital clubbing - prolong hypoxia
cyanosis of nail beds
edema
visual inspection: lines attached to patient
intravenous line oxygen tube feeding tube or nasogastric tube urinary catheter drainage tubes EKG lines ear or finger probe leading to oximeter
pulmonary palpation: symmetry of chest wall movements
upper lobes - pump handle, fingers over clavicle, palms on anterior just inferior to clavicle, thumbs open in L shape
middle chest - bucket handle, line up on xiphoid process, palms lateral
lower chest - piston or caliper, posterior, line up at T10
pulmonary palpation: vocal fremitus
edge of 5th metacarpal along medial border of lungs
4 levels
have patient say 99
decreased sound will mean air is trapped
increased sound will mean secretions in airway
list of pulmonary assessments
visual inspection vital signs palpation vocal fremitus mediate percussion auscultation chest expansion measurements ROM/strength activity evaluation
auscultation, how
listen to lung sounds with stethoscope
skin or gown
“s” pattern, 5 levels
breath sounds may be decreased, absent or extra (adventitious)
auscultation, why
identify areas of lungs in which congestion exists
identify areas whereby airflow is obstructed or absent
determine effectiveness of airway clearance technique
chest expansion measurements
for each, pt will breath in/out 3 times while therapist measures excursion with tape measure
upper: level of sternal angle, high in axilla
middle: level of xiphoid process
lower: level 9th rib (three fingers breadth lower than xiphoid process)
what might you find with ROM/strength assessment?
- ROM is often limited in chest and UEs and in need of stretching
- weakness may be apparent in ventilator muscles
- weakness may be present in extremity muscles due to inactivity , prolonged steroid use, poor nutrition, etc.
purpose of mobilization exercises
- to combine upper extremity and trunk movements with deep breathing
- used to maintain or improve mobility of the thorax and shoulder
- may improve ventilation stretch tight areas; and facilitate mobilization
- to get patient to coordinate breathing with movement
some arm and trunk mobilization exercises from sitting
- backstroke
- hands on shoulder, elbow circles
- shrug and hold, relax
- exhale and bend to right with left arm overhead; inhale as come back to straight; other side
- exhale and bend to floor, inhale as sit up, opening arms wide
some arm and trunk mobilization exercises from standing
- clasp hands, swing, right, left, all around; other side
2. exhale and bend to right with left arm overhead; inhale as come back to straight; other side
percussion is done for how long?
3-5 minutes
vibration is done for how long?
5-7 times
name normal breath sounds
vesicular
bronchovesicular
bronchial
name abnormal breath sounds
bronchial
decreased
absent
name adventitious breath sounds
crackles (rales)
wheezes (rhonchi)
pleural ribs
stridors
crackles (rales) is a possible sign of:
fine:
atelectatsis
interstitial pulmonary fibrosis
coarse:
retained secretions
wheezes (rhonchi) is a possible sign of:
high or medium pitch:
bronchospasm (asthma)
cardiogenic pulmonary edema
COPD
low pitch:
retained secretions in large airways
pleural ribs is a sign of:
pleurisy (inflamed pleura rub together during breathing)
stridors is a sign of
obstruction of upper airway
is sign of airway distress and needs immediate attention.
equipment for coughing
2 towels
sputum cup
pillow (for splinting)
progression in instruct coughing
- turn head, inhale, two coughs
- find diaphragm, turn head, inhale, two coughs
- find diaphragm, turn head, inhale, two coughs with up and in pressure
- find diaphragm, turn head, inhale, two coughs with up and in pressure while leaning forward
- find diaphragm, turn head, inhale, two coughs with up and in pressure with therapists hands on while leaning forward
explain huffing
- open mouth to O shape
- breathe out as if trying to fog up a mirror really fast
- in and up on diaphragm, breathe out as if trying to fog up a mirror really fast
why use huffing
history of CVA history of Aneurysm coughing hurts too much coughing causes spasms incision
why use diaphragmatic breathing
to increase ventilation and promote basal lung expansion
contraindication to diaphragmatic breathing
COPD
explain diaphragmatic breathing to the patient
- comfortable, relaxed, gravity-dependent position, such as semi-Fowler’s
- relax neck and shoulder muscles
- find diaphragm - put hand just under ribs and sniff, sniff. feel that - that’s the diaphragm. you want that muscle to go out and in while your upper chest stays quiet or still
- with your hand on your diaphragm, breathe in through nose and out through mouth
- want to see that hand moving out and in. you can put your other hand on your upper chest to focus - bottom hand moves out and in, top hand moves hardly at all.
- do this 3-4 times, then rest, so you don’t get light-headed.
measure leg length
- bilateral
- supine, legs parallel and perpendicular to line connecting ASIS, feet 15-20 cm apart
- measure between inferior portion ASIS and inferior edge of medial malleolus
- measure between inferior portion ASIS and inferior edge of lateral malleolus
- repeat other leg
- compare.
measure extremity girth
- position patient supine
- palpate bony prominence as reference point, mark it with skin pencil
- make marks in 10 cm increments above and below the reference point
- measure in cm, record
- measure again after treatment
what to expect in practical
- read and understand scenario
- know what treatment is appropriate
- take vitals
- assess and measure
- treat
- re-assess and measure
- document in SOAP
perform volumetric measurement
- prepare and position patient (no open wounds)
- fill volumeter, collect and discard overflow
- position graduate cylinder
- slowly immerse extremity, collect displaced water
- measure and record displaced water
use IPC
- position patient supine, 30 degree elevation of leg
- take BP and HR
- measure girth
- apply stocking carefully, no wrinkles
- set up machine
- apply air boot
- set inflation time and deflation time in 3 to 1 ratio
- set pressure, inflate starts
- leave pt with call bell. treatment is 1 hours
- inspect skin
- measure and record girth
- wrap extremity in compression
- take vitals
why use the 6-minute Walk Test?
to measure endurance and exercise capacity in individuals with cardiac and pulmonary pathology
-can monitor decline or evaluate improvement
perform 6MWT
- set up two chairs a known distance apart
- get resting vitals of pt
- pt walks between two chairs for 6 minutes
- therapist takes vitals during - HR and pulse
- take vitals at finish
Borg scale for RPD
Rate of Perceived Dyspnea
0 nothing at all 0.5 very, very slight (just notiecable) 1 very slight 2 slight 3 moderate 4 somewhat severe 5 severe 6 7 very severe 8 9 very, very severe (almost maximal) 10 maximal
segmental breathing: three segments
apical expansion
lateral basal expansion
posterior basal expansion
perform apical expansion
- patient sitting (or supine hook-lying)
- place hands as close to horizontal as possible below clavicle
- ask pt to breath normally out and in (3 times is good)
- just prior to inspiration, quick stretch In and Down
explain to teacher why doing segmental expansion
doing a quick stretch to the muscles of inspiration to get them to kick in to draw ribcage up, to get more expansion, to draw in more air
explain to pt why doing segmental expansion
giving the breathing muscles an extra cue to kick in to expand ribcage to make room for lungs to draw in more air
perform lateral basal expansion
- pt sitting or hook-lying
- line thumbs up on xiphoid process, wrap hands around lateral chest wall, parallel to ribs
- ask pt to breath normally out and in (3 times is good)
- just prior to inspiration, quick stretch In and Down
pt performs lateral basal expansion at home
with a sheet or hands
when to use Segmental Expansion
pneumonia
and
perform posterior basal expansion
- pt leans forward over pillow, bent at hips or is just sitting
- place hands inferior to scapulae, really hang on to the ribs
- ask pt to breath normally out and in (3 times is good)
- just prior to inspiration, quick stretch In and Down
when to use Paced Breathing
- to decrease work of breathing and relieve dyspnea during activity
- used with activity
instruct Paced Breathing
- breathe in through nose on count of one
- breathe out through mouth on count of two
- do with with activity
what is Active Cycle Breathing Technique
pattern of breathing maneuvers
cyclic-repetition of three phases
1. breathing control - 5-10 seconds of diaphragmatic or paced breathing
2. thoracic expansion - 3-4 times of deep breath in - hold 3 seconds - breathe out. breathe through mouth.
3. repeat 1 and 2 3 to 4 times, as necessary
4. forced expiration - cough or huff
5. follow with breathing control for 5-10 seconds
when to use Active Cycle Breathing Technique
as home exercise program to remove secretions
describe Borg Scale of RPE
Rate of Perceived Exertion
6 No exertion at all 7 Extremely light (7.5) 8 9 Very light 10 11 Fairly Light 12 13 Somewhat hard 14 15 Hard 16 17 Very hard 18 19 Extremely hard 20 Maximal exertion
What is the Target Exercise Range on the Borg RPE scale?
12 - 16
light - almost very hard
