The Evaluation of Persons with Brain Injury Flashcards
the pt presentation with CVA can vary based on what factors?
cause of stroke
area of infarct
setting
what are the 2 types of stroke?
ischemic and hemorrhagic
which stroke is more common?
ischemic stroke
what is the most common area of infarct?
MCA (middle cerebral artery)
a stroke of the cerebellum will result in what deficits?
coordination deficits
what is the focus of acute/subacute CVA care?
medical stability (hemodynamics, respiratory fxn)
in acute/subacute stroke rehab, which is more common, flaccid or spastic hemiplegia?
flaccid hemiplegia
what are the characteristics of chronic CVA care?
stable but CV impaired
spastic hemiplegia
loss of fractionated movement
what is normal CBF?
60
what is the threshold for synaptic transmission for CBF?
20
what is the CBF levels indicative of irreversible damage?
12
what is the CBF range for reversible damage/suboptimal fxn?
12-20
what is the CBF range for adequate function?
20-60
why will a pt’s BP be kept high post CVA?
to increase perfusion
what is the penumbra?
the area of vulnerability around the dead tissue post CVA that is silent, not dead from a lack of blood flow
with adequate restoration of perfusion, it can be reversed
what are the characteristics of a left hemisphere lesion?
difficulty communicating
difficulty processing info in a sequential, linear manner
cautious, anxious, and disorganized when trying new tasks
realistic in appraisal of problems
what are the characteristics of a right hemisphere lesion?
difficulty in spatial-perceptual tasks
overestimation of their abilities (decreased awareness of limitations)
may have L neglect and even pusher
geographically challenged
what are common s/s following a stroke?
impaired motor control (flaccidity vs spasticity, decreased activation on the involved side, decreased contralateral strength)
impaired sensation and proprioception
limited ability to ambulate
limited postural stability
limited fxnal mobility
limited ability to perform self-care and ADLs
what are some less common, lesion-specific s/s following a stroke?
impaired language and communication
dysphagia (deep and posterior, more severe)
impaired cognition/memory
impaired behavioral control and judgement
visual/perceptual deficits ; unilateral neglect
apraxia (sequencing issue)-premotor injury
limbic: fear, emotional lability, depression
impaired B/B control
pain (MSK, neuro)
sleep disturbances
is the issue post CVA more so strength or activation of muscles?
activation of muscles
what is the first step in treatment post CVA?
postural alignment!!!
what are the primary impairments in CVA?
changes in muscle tone, muscle activation, muscle strength, and sensation
what are the muscle tones that can result from CVA?
flaccidity, hypotonicity, and spasticity
what are the deficits in muscle activation that can result from CVA?
poor initiation, muscle sequencing, timing, or firing
what are the deficits in muscle strength that can result from CVA?
flaccid paralysis or weakness, contralateral weakness
what are the deficits in sensation that can result from CVA?
varying degrees of light touch, nociception, static, and dynamic position sense
what secondary impairments can result from CVA?
changes in postural alignment, stability, and/or mobility
atypical movement synergies
clinical hypertonicity
changes in muscle and soft tissue length
pain, edema, skin integrity, vascular integrity (DVT)
what is clinical hypertonicity?
not spasticity, but movement related phenomenon where more movement and effort leads to increased tone
what are composite impairments that can result from CVA?
functional movement deficits
undesirable functional compensations and learned non-use
pain
in the hours to days following CVA, what happens?
flaccid hemiplegia
electrical silence
when does the most significant recovery occur post CVA?
the 1st 6 months
what are the key components of interventions post-CVA?
make the interventions skilled, task-specific, goal directed
how long post CVA can pts generally make improvements?
2-3 years
t/f: interventions have to be salient to the pt
true
what % recover to near complete fxning?
10%
what % recover fxnally with mild impairment?
25%
what % experience moderate to severe impairments?
40%
what % require placement and 24 hrs care?
10%
what % die as a result of CVA?
15%
t/f: early intervention yields more potent results
true
what is one of the main determinants of synaptogenesis?
training, specifically experience-induced or fxn-induced cortical reorganization
t/f: the cortex has the capacity to change structure and fxn during training and enriched environments
true
t/f: the anatomy of the damage, time since damage, age of pt, and amount of therapy received influences changes that can be made
true
t/f: the secondary motor areas become more fxnally relevant w/damage to the primary motor cortex, but can’t fully compensate
true
what is involved in acute care d/c planning?
chart review, labs/imaging/meds/social hx, MD orders, nursing report, AIDET, systems review, and fxnal assessment
what is involved in d/c planning for chronic CVA?
observation, AIDET, interviewing, HPI/imaging, meds, social/PLOF, ROS, systems review, examination
what do we want to know in acute CVA care?
date, type, location
current med stability, parameters
initial presenting symptoms and severity
timing of medical intervention
hx of management to date
trajectory of recovery
presence of complications
current vs previous status, prognosis
optimal d/c setting given status and supports
what do we want to know in chronic CVA care?
date, type, and location
current presenting symptoms and severity; summary of progression
medical interventions, w/complications
what type of Rx (medical, PT, OT, SLP) has pt received
desired goals
limiting factors
what social info is critical to obtain or ask for?
social hx and level of function
what are the screenings in acute CVA care?
medical stability
alertness
cognition and ability to follow commands
communication
perception
sensory and motor fxn
postural control and functional status
if a pt has HTN (>165/95mmHg) what is their risk for stroke?
6x increased risk
if a pt has heart disease, what is their risk for stroke?
2-6x increased risk
if a pt has A-fib, what is their risk for stroke?
increased risk of ischemic stroke, DVT, edema
what is the risk for a pt that has HF w/ or w/o reduced ejection fraction (EF)?
reduced exercise tolerance
if a pt has DM, what is their risk for stroke?
3-6x increased risk
what are the 5 components of metabolic syndrome?
increased waist circumference, increased BP, decreased HDL, increased triglycerides, increased fasting glucose
if a pt with metabolic syndrome has all 5 components present, what is their stroke risk?
5 fold stroke risk
what CV conditions increase risk for stroke?
HTN, heart disease, A-fib, HF
what endocrine disorders increase stroke risk?
DM, metabolic syndrome, obesity, and hypothyroidism
what neurologic conditions increase stroke risk?
hx of stroke, TIA, tumor, or brain injury
sleep fxns
cognitive decline (is dementia)
behavioral/psychological changes
what pulmonary conditions increase stroke risk?
smoking
what are precautions for CVA in acute care?
b4 seeing the pts, obtain and follow the physician’s orders regarding bed rest, activity, and vital signs parameters
pre-plan your sequence and equipment, assistance needs, and safety plan
monitor vital signs for all individuals
implement fall precautions
monitor pt’s pain and fatigue
plan ahead in regards to neglect and impulsivity
monitor for PT vulnerability (potential abuse)
pts with flaccid hemiplegia may be at risk for what?
shoulder pain and dysfunction
what critical evaluation limitations can greatly impact your eval?
beginning postural alignment
alertness, cognition, communication
behavior, attention, judgement, motivation
perception, neglect
motor sequencing and planning issues (apraxia)
what should be done at the start of a CVA intervention?
postural adjustments (esp the pelvis)
what is included in the neuro section of the systems review?
signs of seizures or hydrocephalus
screen of CNs
swallowing fxns
mentation
communication
behavior
motor fxns
executive fxns
what are the 5 breathing patterns to be aware of?
eupnea
bradypnea
biot’s respirations
cheyne-strokes respirations
apnea
what is eupnea?
normal respiration w/ equal rate and depth
12-20 breaths/min
what is bradypnea?
slow respirations
<10 breaths/min
what are Biot’s respirations?
irregular respiration of variable depth (usually shallow), alternating w/periods of apnea
what are Cheyne-Strokes respirations?
gradual increase in depth of respiration followed by gradual decrease and then a periods of apnea
what is apnea?
absence of breathing
why does hemorrhagic CVA pose concern for respiration?
the bleed can expand and shift structures and put pressure on the BS (respiratory and vital fxns)
why would acute CVA BP be higher?
doctors often set it higher to increase perfusion
anyone with dysphagia should have what vital sign monitored?
temperature
what are s/s to watch for aspiration and swallowing dysfunction?
excessive drooling, wet/gurgly voice, frequent coughing/choking
poor oral food management, pocketing of food
what are the interventions for aspiration/swallowing dysfunctions?
referral to SLP
positioning for meals
precautions pertaining to oral intake should be implemented where indicated
monitor and inform
what is the primary auditory cortex responsible for?
auditory discrimination