Competency Exam 3 Flashcards

Question

What are the trophic symptoms of CRPS?

Answer 1

* Skin may change color with activity or while at rest. Colors can range from blue, purple, red, white, and mottled combinations of all the colors * Brawny skin * Skin can be dull or shiny * Hair is sparse and coarse * Nails may be rigid

Answer 2

* Temperature of extremity may vary widely adn suddenly from very cold (usually skin is blue) to very hot (usually skin is red) * Poor tolerance of cold temperature (especially water)

Answer 3

* Muscle atrophy and shortening -- may note contractures in advanced cases * may have dystonia * weakness * tremors * resting position -- usually guarded with fingers flexed or in a lumbrical ro half-flexed position with elbow flexed

Answer 4

Pain * Unrelenting, severe pain that is out of proportion in relation to injury * Avoids moving, protects extremitiy, hypersenstive to touch Edema * initially thick, pitting, and significant

Answer 5

Treating Physicians * Neurologists * pain specialists * Orthopedists Medication * Cymbalta * Neurontin * NSAIDS & cortiocsteroids for pain and inflamation * Bone-loss medications * Sympathetic nerve-blocking medication (injection of anesthetic) Surgical interventions * ablative sympathectomy * Sympathetic nerve blocks either at the brachial plexus (for UE) or the lumbar plexus (for LE) * Intrathecal pain pumps Spinal cord stimulation * insertion of tiny electrodes along spinal cord. A small electrical current delivered to the spinal cord sometimes results in pain relief * Electrical impulses applied to nerve endings to decrease pain Transcutaneous electrical nerve stimulation * electrical impulses applied to nerve endings to decrease pain Biofeedback * learning to become more aware of body to relieve pain

Answer 6

Psychosocial * Be gentle with physical examinations because they may be very painful * Patients may be leery and fearful of medical professionals if the symptoms have been undiagnosed for a long time. Many patients have already been referred to psychaiatry for drug-seeking behaviros and for symptoms being "only in their head" * Patients expect the therapists to minimize teh pain and force unrealistic activities Therapy that sets the stage for future intervention * Weight bearing -- may only include placing the hand flat on a smooth warm surface such as his or her own leg or a wooden tabletop * Functional use -- most patients cannot tolerate using the limb for long periods. Performance of tasks with the affected limb is also what causes the most pain. Helping the patient to understand this conundrum will prove helpful to the rehabilitation process * Sensory reeducation -- using normal desensitization strategies (e.g. rubbing with different textures, contrast baths, putting hand in dry beans) Contraindications * Immobilization is contraindicated and contributes to teh disease process. Splinting is contraindicated; however, it may be indicated in some instances (e.g., unstable fractures when patient is not a candidate for surgical intervention) and immobilization is unavoidable * Manual therapy is very painful adn should not be attemtped in the early stages of intervention * icing * heat modalities may decrease pain; however, they must be used with caution becasue of decreased sensation Discharge recommendations * Outpatient therapy with therapist experienced in treating CRPS * Outpatient workup with physician experienced in treating complex regional pain syndrome * Aquatic therapy in a warm pool may reduce pain

Answer 7

Acute (1-3 months) * usually can repsond to treatment if diagnosed early * pain is only at site of injury * swellign and increased sensitivity to touch * skin is warm and red * osteoporosis begins at 3 to 4 weeks Description * pain (burning, irritating light touch) * redness of joints * pain due to movement * early stage hand may be pale * sweat may drip from digit

Answer 8

Sub-acute (within 1 year) * pain becomes more diffuse, swelling becomes more thick and hard * Skin becomes dry, nails brittle, grooved, stiffness is pronounced around joints * May see atrophy of finger tips (pencil pointing appearance) * Osteoporosis will now be pronounced Description * pain * edema (brawny and hard) * doesn't respond anymore * decreased sweating

Answer 9

Chronic (can last longer than 2 years) * Several months to many years * pain may diminish * deformities are now more fixed (clawing, etc) * Atrophy of muslces is very pronounced * Skin loses creases and becomes dry and cool * extreme osteoporosis Description * fibrosis with joint contracture, thickening of structures of joints * "dead hand" - pale, blue, atrophy, skeletal profound osteoporosis --\> very difficult to reverse * Men more likely than women * UE more than LE * diathesis = person is labile, dependent, low pain tolerance NOT MALINGERING

Answer 10

* Diagnose early * contact MD immediately * edema reduction * AROM Encourage functional use * Sensory desensitization/re-education * Patient education * WEIGHT BEARING: scrubbing on all fours; carrying a heavy bag * Education * Psychosocial * Coping skills training * significantly affects patient's life and family * Anxiety, loss of job, frustration because of misdiagnosis or missed diagnosis * Reduce pain: TENS or desnesitization --\> working in different particles * Massages (retrograde) * elevation * compression wrap * Contrast bath * Splint, continual passive range of motion machine * biofeedback * ultrasound * usually don't sling because it encourages protective posturing * gentle stretch * decrease caffine

Answer 11

* dry superficial thermal phsycial agent that transfers heat to soft tissues by agitation of heated air in cellux particles * contains fine particles of cellus (ground up corn cobs that are about the size of grains of sand) * the benefit is that patients can perform AROM while undergoing treatment (a good prepartory activity before occupation-based activity) Contraindication * tissue healing * severe circulatory obstruction * systemic infectious diseases (overheat body - fever) * open wound or sutures * severely impaired sensation * malignancy

Answer 12

* Occupational Profile * Accurate medical history * Hand dominance * Mechanism of injury (neurological or orthopedic) * General Inspection * Can the hand be placed in functional position? * What is the U/E posture? * What is the hand posture? * White towel on table --\> place injured hand on towel and non-injured hand to compare * Observe and compare to contralateral side * Color -bruising, change in vasculation, inflammation -- pale, red, blue * Shape - arches of hand - flattened (weakness, atrophic, deinnervation * skin creases - swelling * atrophy - thenar and hypothenar (if flat then hadn is deinnervated) * edema * vascularity - cool (loss of vascularity) hot (inflammation) * skin texture - waxy, scaly, calloused, chapped * deformities - joint sublux or misalignment, look for nail bed to be parallel * lesions - scars, abrasions, burns, wounds - is there any drainage from wound? color? amount? odor? measure wound and location, classify by color (black, yellow, red)

Answer 13

1. Boutoniere - an imbalanced digital position of PIP flexion and DIP hyperextnsion. The deformity is due to volar displacement of the central slip 2. Swan neck - presents as MP flexion, PIP hyperextension, and DIP flexion. 3. Mallet deformity - disruption of the terminal extensor tendon and manifests itself as DIP extensor lag. 4. Intrinsic minus - position of MP hyperextension and PIP flexion associated with muscle imbalance in ulnar-innervated structures.

Answer 14

* muscle bulk * muscle tone * skin temperature * nodes Approach the hand gently, palpate every area client complains of symptoms and looks suspicious wear gloves - keep everything clean

Answer 15

* pain - visual analog scale * Sensory - sterognosis, proprioception, vibration, kinesthesia, tactile location, light touch * Goniometric measurement (AROM, PROM, TAM & TPM) * TAM - total active motion - sum of composite digital flexion and extension of AROM * TPM - total passive motion - sum of composite digital flexion and extension of PROM * Normal TAM & TPM are 270 degrees * To calculate add the measurements for flexion of the MP, PIP, and DIP joints. Then subtract the combined deficits in extension for those joints. * Observe for tenodesis, digit alignment * MMT, Grip and Pinch * Coordination (Minnesota Rate of Manipulation Test, Box and Block test, purdue pegboard test, nine-hole peg test, jebsen test of hand function, TEMPA) * Edema (circumferential and volumeter)

Answer 16

* Finkelstein's test: pain in the 1st dorsal compartment is positive for tenosynovitis * make a fist with thumb tucked into fist. ulnarly deviate fist. * if positive teach patient to avoid wrist deviation, especially in conjunction with pincihign. Provide built-up handles. If splinting, use a forearm-based thumb spica * Median N compression tests * Phalen's test - maintaining the wrist in flexion for 60 seconds. done with extended elbows to avoid confusing these findings with a positive elbow flexion test. Positive if numbness and tingling in median distribusion * Tinel's test - tap/percussion over median nerve - positive if tingling or electric shock occurs * Both of these test indicate median n compression and are accompanied by thenar atrophy and night pain * Grind Test - test of CMC degenerative joint change - grind CMC into trapezium with rotation * Allen's test - test for arterial blood flow * occlude radial and median nerve and have patient pump fist. Release one and watch it flush. If hand doesn't flush the artery is occluded * if they have arterial insufficiency it leaves the hand pale adn cool * if they have venus insufficiency it leaves the hand blue (cyanotic) * **Don't elevate hand with vascular occlusions.**

Answer 17

Strength increases when muscle is stressed to the extent that additinoal motor units are recruited muscles must be stressed to the point of fatigue muscle will only gain strength within the ROM exercised Isometric, isotonic assistive, isotonic active, isotonic active resistived exercises * isometric - exercise in which a weak muscle is isometrically contracted to its maximal force 10 times with rest periods between each contraction * muscle grade: trace (0) the force of contraction is not sufficient to move teh part * Procedures: provide a stimulating environment; explain procedures; instruct the patient to contract the weak muscle ("hold"). External resistance appplied by teh therapist may help the patient isolate teh contraction ot the weak muscle or muscle group; patient holds contraction at maximum effort as long as possible while breathing normally; repeat 10 times with a rest between each contraction; increase duration of maximal contraction as patient improves; *maximal isometric contraction is contraindicated for patietns with cardiac disease* * Isotonic Assistive (Active Assistive ROM) - Exercise in which a weak muscle is concentrically or eccentrically contracted through as much ROM as patient can achieve; therapist adn/or external device provides assitance to complete motion * Muscle Grade: Poor minus (2-), fair minus (3 - ); though muscle can move only through partial available range in either a gravity-eliminated or against-gravity plane * Procedures: Provide a stimulating environment; explain procedures; for a 2- muscle, position limb to move in a gravity-eliminated plane; for a 3- muscle, position the limb to move against gravity; patient moves weak muscle through as much range as possible; therapist provides external force to complete motion; although this seems similar to PROM, it differs because patient actively attempts to contract weak muscle * Isotonic Active (AROM) - patient contracts muscle to move part though full ROM * Muscle grade: Poor (2), Fair (3), Muscle can move through full available range in either gravity-elminated * Procedures: Provide a stimulating environment; explain procedures; for a 2 muscle, position the limb to move in a gravity-eliminated plane; for a 3 muscle, position the limb to move against gravity; patient moves weak muscle through full available ROM; patient repeats motion for 3 sets of 10 repetitions with rest break between sets * Isotonic Active Resistive (Active Resistive ROM) - Patient contracts muscle to move part through full available ROM against resistance * Muscle grade: Poor plus (2+), Fair (3), Fair plus (3+), Good (4), Good plus (4+) * Procedures: provide a stimulating environment; explain procedures; for a 2+ or 3 muscle, position limb to move in gravity-eliminated plan; for a 3+ or above muscle, position limb to mvoe against gravity; therapsits determines appropriate amount of resistance depending on the strengthening used, teh 10-RM is established, which is teh maximum weight a person can lift through 10 repetitions with smooth controlled movement. If teh simplified protocol is used, the 1 - RM is established, which is the maximal amount of weight the patient can lift one time in a smooth controlled movement; Patient moves weak muscle through full available ROM against resistance; If the DeLorme protocol is used, the patient does 3 sets of 10 reps with varying resistance and rest breaks between sets. If teh simplified protocol is used, the patient does 4 sets of 10 reps at a set weight with rest breaks between sets.

Answer 18

* Passive stretching: Slow and gentle stretch to the point of maximal stretch in direction of teh line of pull; a few degrees beyond point of discomfort and hold for 15-30 seconds * Safety precautions: (1) Inflammation weakens the structure of collagen tissues; therefore, those tissues must be stretched cautiously with slow, gentle motion; (2) Sensory loss prevents the patietn from monitoring pain; thus, the therapist must pay particular attention to the tension of the tissues beign stretched; (3) Overstretching must be avoided becasue it causes internal bleeding and subsequent scar formation that may eventually ossify. Overstretching can lead to heterotopic ossification; (4) Resistance can be provided by weights either held in patient's hand or strapped around the moving part. Resistance can also be provided by tools and materials of activity. The greater the resistance taht is provided, the more aggressive teh stretch will be, so the therapist must take care that the stretch is slow and gentle * Manual Stretching Methods * Provide a relaxing environment for the patient * Describe manual stretching, noting that it involves tolerable pain * Use motions identical to motions used in ROM evaluation * Stabilize the bone proximal and distal to the joint that is to be moved to avoid any compensatory movement * Move the bone smoothly, slowly, and gently to teh point of maximal stretch (mild discomfort indicated verbally or facially by the patient) * Make sure the movement is in the line of pull of the muscle * Encourage the patient to assist in moving the limb if possible * Hold the limb at the point of maximal stretch for 15-30 seconds * Relief of discomfort should immediately follow the release of stretch * If the patient complains of residual pain, future stretches should be performed more slowly and with less force * Active stretching - place client in actiivty that encourages the desired motion. Use contract-relax technique of isometric contraction of the tight muscle for 3 to 10 seconds followed by passive stretch * Contract-relax involves a maximal isometric contraction of the tight muscle, usually performed at teh point of limiation. The muscle is contracted maximally for approx. 3-10 seconds against resistance provided by the therapists and then relaxed. During the relaxation phase, the therapist moves the part in the direction opposite to the contraction and holds it.

Answer 19

* Use moderately fatiguing activity for increasingly longer periods with intervals of rest * Increase the number of repetitions of a specific motion or time on task for this to be effective

Answer 20

* Contrast baths: 2 basins of water (100 degree H20 & 50 degree H20) place hand in warm water for 3 mins followed by 1 min in cold water for 4 or 5 cycles * Compression: * Coban wrap distal to proximal - wear during activity * Isotoner glove for short term. replace every 4 days * Position in elevation * hold extremity above heart and perform overheat fist 10 minutes on the hour - if they have good vascularity * retrograde massage - massage gently but firmlyfrom finger tips to heart

Answer 21

* Compression * coban wrap * isotoner glove * Scar massage * use soft pencil eraser followed by massage cream * Remodel scar tissue usign elastomer and gel pad under pressure * contraindication: open wound

Answer 22

Digital Tendon Gliding * Individual tendon glides are specific active exercises to promote independent function of structures * Purpose is to reduce soft tissue adhesions * Three types * Differential flexor tendon gliding exercies at the wrist * Median nerve gliding exercises * ulnar nerve gliding exercises * go to start position between each movement 10x several times a day Blocking Exercise * Stablization is provided to adjacent joints to facilitate tendon excursion at a specific joint * Blocking is applied by either the therapist, patient or blocking tool or splint * exercise comfortably into the end range to remodel the tissue. Teach them to do the exercises frequently adn slowly, holding at the comfortable end range for 3-5 seconds Place and Hold * Place the hand by passive or active assisted motion to end range followed by contraction to hold the position * Release teh assisting hadn while the patient tries to sustain teh position in a pain-free way * Use when PROM exceeds AROM * Purpose is to promote passive glide with less stress on the tissue * can be effective in combo with blocking exercises

Answer 23

* Prevent stiff hand by simultaneously managing edema and inflammation * Full, gentle arcs of motion * Gentle passive motion * buddy straps * static splic during acute, inflammatory stage Avoid aggressive PROM. It is okay to coax tissues to lengthen within their available comfortable range, but always respect teh feeling of tissue resistance, and do not exceed it.

Answer 24

* If indicated, splint to rest the injury * Active pain free motion in conjunction with splint * Redesign workspace and modify activities * Lateral epicondylitis: Velcro elbow cuff with gel insert below extensor wad. Support wrist at neutral during the night [resting splint] * Medial epicondylitis: eliminate resisted flexion and pronation. Velcro elbow cuff with gel insert below the flexor wad. Support wrist at neutral during the night. * use good ergonomics must change activity that caused it * after teh inflammation subsides, upgrade intervention to restore normal function through gradual mobilization balanced with rest. * Pain must be avoided * Instruct in tendon gliding exercises in a pain-free range appropriate to teh particular strutures involved. * Progress from isometric exercises with gentle contractions of involved structures to isotonic exercises * Gradually introduce low-load, high-rep strengthening in short arcs of motion. * Increase teh arc of motion and modify proximal positions to be more challenging if appropriate for work simulation. * Instruct in gentle flexibility exercises in a pain-free range. * Aerobic exercises and proximal conditioning are essential * How to evaluate * start with a cervical screening to look for proximal causes of distal symptoms * compare both extremities * asses for pain that may be local or diffuse, swelling, sensory changes, and loss of function. * identify the activity causing the pain * ergonomic risk factors for tendinitis include forceful, rapid, repetitive movement

Answer 25

* Tendinosis involving abductor pollicis longus and extensor pollicis brevis at the first dorsal compartment * use teh comfort cool thumb splint or long thumb spica with teh IP free * Avoid wrist deviation and pinch motions * modifiy work tasks and use built up handles * rest the hand and prevent excess thumb motion Can be tested by finkelstein's test (hand in fist and ulnar deviate the wrist - positive if there is exquisite pain with passive wrist ulnar devation while flexing thumb)

Answer 26

Median nerve compression/Capal Tunnel Syndrome (CTS) * Neutral splinting at the wrist * Median nerve glide exercise 10x several times a day * Modify activity demands to prevent extreemes of forearm rotation, wrist flexion, sustained pinch and grip * change person's pattern of hadn use - ergonomic recommendation Ulnar Nerve Compression/Cubital Tunnel Syndrome * Ulnar nerve glide exercises 10 x several times a day * Modify activty demands to prevent pressure on elbow * Pad or cushion the elbow in bed at night

Answer 27

* Desensitization for hypersensitivity - unresolved n laceration for neuroma treatment * Splint to protect a surgical repair of nerve - after surgery repair * Teach client to compensate for lost protective sensation * Identify the splint for * Median nerve: **low median (laceration at the wrist)** - hand-based thumb abduction splint to maintain balance, to substitute for lost thumb opposition, and to rpevent overstretching of denervated muscles; **high median (laceration near or at the elbow) -** hand-based thumb abduction splint * Ulnar Nerve: **low ulnar nerve (laceration at the wrist level)** - aims to prevent overstretching of the denervated ring and small finger intrinsics. An MP blocking splint that maintains slight MP flexion and prevents MP extension is recommended; **high unlar never (laceration at or proximal to the elbow)** - same as low ulnar nerve * Radial Nerve: **low radial nerve (laceration at deep motor branch)** - splinting to promote tenodesis for functional pinch, grip and release; **high radial nerve (laceration caused by humeral fractures)** - restores tensodesis and may be useful for many months during teh wait for reinnervation which occurs at approx 1 inch per month. Wrist extention splint (wrist cock-up)

Answer 28

Median nerve - ape hand ulnar nerve - claw hand radial nerve - wrist drop

Answer 29

* Injury can be minor or superficial * Mallet finger (Zones I and II) and Boutonnier (Zones III & IV) * Surgical repair of extensor tendon * splint to protect repair by limiting flexion * do NOT flex, maintain extension * Splint must be worn 24/7 until complete healing is achieved

Answer 30

* Postoperative splinting to protect repaired structures * minimize formation of adhesions through controlloed motion of passive flexion - active extension within protective dorsal splint * At night strap fingers to the dorsal hood * DON'T put hand in extension keep flexed * Fabricated splint with dorsal splint * move so they don't have adhesion but not so much they pop are repair

Answer 31

3 Thumb 5 Hand (Carpal tunnel is at zone IV)

Answer 32

7 Hand 5 Thumb (Carpal Tunnel is Zone 7) (injuries at zones I and II leads to a mallet deformity) (injuries at zones III and IV of hand lead to a boutoniere deformity) (injuries at zones V and VI of hand may be treated with immobilization or by controlled early motion) (injury in zone VII is likely to resutl in restrictions due to development of adhesions)

Answer 33

* Moderate temperatures * Gentle active motion through full arc of motion * evaluation rather than dependent posture * avoid forceful pinch * avoid abrasive materials * repetitions without strain * intervals of rest * short duration, repeated throughout the day * meaningful and contextually relevant * Avoid: ironing, scrubbing, sewing, needle point, knitting, sawaing * Good exercises: wiping a counter, dusting with dust mitt, card games (holding or card holder), brushing teeth/ADLs, flower arranging, sponge or finger paint, finger weaving, washing windows

Answer 34

S - Supraspinatus I - Infraspinatus T - Teres minor S- Subscapularis

Answer 35

Neer Impingement - Forced forward flexion witht eh shoulder internally rotated. If teh patient expresses pain, teh sign is positive, indicating compression and/or inflammation of teh supraspinatus and/or long head of the biceps Hawkins Test - Shoulder and elbow are flexed to 90 follwed by forced internal rotation. If teh patient expresses pain, the test is positve, indicating compression and/or inflammation of the supraspinatus and long head of the biceps Empty can test: Shoulder elvation to 45 and internal rotation (thumb facing down). Therapist applies resistance to abduction (downward force). Positive sign is weakness or pain. This test indicates a tear of teh supraspinatus tendon. Repeat the same test at 90. If pain is only experienced at 90 position, suspect bursitis Drop arm test : Patient's arm is postiioned in 90 degrees of abduction. The patietn slowly lowers his or her arm to the side. The test is positive if the patient drops the arm to teh side, indicating a supraspinatus tear Biceps speed's test: Shoulder flexed to 90, forearm supinated, and elbow extended. Resistance is applied to flexion (downward force using a long lever arm). Positive sign is pain over bicipital grove

Answer 36

Rotator cuff injury * Post-operative therapy * regaining full ROM, scapula and rotator cuff strengthening, practicing activies of daily living, and occuaptional tasks * immediately begin with PROM/AAROM for the next 4-6 wks * pendulum exercises, passive shoulder elevation, adn internal/external rotation int eh adducted of slightly abducted position * ice pack should be used befoe, during,a nd after exercise to decrease paina dn swelling * During this time, the patient should be instructed in one-handed techniqeus to perform activites of daily living. * At 4-6 wks the patient progresses to AROM. Begin in gravity-lessened positons and progess to against gravity movements * Engage the patient in light ADLs * Avoid compensatory movments such as hikign the scapula or lateral bending of the trunk * When performing against gravity ADLs, progress from waist level to above shoulder level * Strengthenign cna be initiated at 6 wks to prepare for functional activities * begin with isometric exercises for the rotator cuff adn scapula stabilization exercises * Eight wks post surgery, the patient progresses to isotonic exercises usign theraband and free weights * ADLs above shoulder level should be emphasized, includign cooking and laundry. * At 12 wks, the patient can begin resistive occupational tasks. * Pain-free occuaptional functioning * Non-surgical treatment * educating the patient on activity modification. * Patient should be instructed to avoid above shoulder level activities until pain subsides * Sleeping postures should also be addressed. * avoid sleepign with the arm above teh shoulder level or in an adducted and internally rotated position * combined adduction adn internal rotation for long periods of time can future compromise blood supply of the supraspinatus * exercise shoudl fous on pain-free ROM * Begin with PROM and as pain decreases progress ot AROM * Strengthing should include isometric exercises for the rotator cuff and scapula musculature

Answer 37

* Myocardial infarction * Congestive heart failure * Coronary artery disease (CAD) * Cardiomyopathies (disease of caridac muscle) * Angina * Valvular heart disease * Aortic aneurysm * Arrhythmias

Answer 38

Prventable or modifiable * high cholesterol * cigarette smoking * diet high in saturated fat and calories * excess alcohol consumption * high blood pressure or hypertension * throbogenic risk factors (e.g., elvated plasma fibrinogen) * diabetes mellitus or hyperglycemia * beign overweight, obsity * left ventricular hypertrophy * physical inactivity and sendentary lifestyle * psychosocial factors and emotinoal stress (ie., anxiety, depression, personality traits and disorders) Not Correctable * heredity -- gamily history of heart disease before age 55 in men adn age 65 in women * Age -- older than 60 * Gender -- men have a higher incidence of heart disease * AFter menopause in women * Personal history of coronary artery disease (e.g., stroke or peripheral vascular disease)

Answer 39

* Active signs and symptoms of MI (e.g., nausea, shortness of breath, light-headedness, chest pain) * Acut MI (\<1 day or 2 days after MI) * Active infection * Acute mycarditis or pericarditis * Digoxin toxicity * uncontrolled arrhythmias * uncontrolled diabetes, * severe CHF * Recent pulmonary embolism * Abnormal vital signs and blood counts (O₂saturation \< 85 %, respiration rate \> 45 breaths per minute, hemobglobin \< 8 g/dL or hematocrit \<26%)

Answer 40

* Increase in weight of 2-5 pounds or more over several days * inability to sleep * persistent dry hacking cough * shortness of breath with normal activity * swelling in ankles or feet * fatigue

Answer 41

* cornoary artery bypass graft (CABG) * Angioplasty * Ablation * pacemakers * Cardioversion * Medications: * beta blockers, ACE inhibitors, platelet inhibitors, anticoagulant therapy

Answer 42

Patients are discouraged from engaging in activities that expand the chest or pull the sternum apart. Generally, patients are restricted to lifting no more than 5-10 lbs. Patients are discouraged from using their upper extremities and ecnouraged to use the stronger muscles of their lower extremities when going from a sitting to a standing psotion. Patients are also encouraged to splint or brace their chest when coughing

Answer 43

Sternal precautions * General * any movements that require asynchronous movement between the two sides of the chest, any excessive shoulder flexion, rotation, abduction, or lifting more than 5-10 pounds are discouraged for the first 5-6 weeks. Consult the phsyican or facility policy for specific precautions and restrictions. * Bed Mobility and ambulation precautions * scooting up in bed: bend knees with feet flat on the bed adn push off the bed with legs extended to scoot up. Do not push or pull with arms on bed rails * Rolling side to side: Bend hips and knees and roll to teh side, with the trunk following * Supine to sitting: Roll onto side, drop legs off the bed, and then push up using elbow. The other hand holds onto the bedrail for support only. Patients may be assisted by supporting their upper back adn moving the hips toward the edge of the bed. * Do no pull on patients' arms when assiting them into an upright postion * Use the bed controls to raise the head of the bed to assist the patient into an upright position. However, once the patient is sitting on the edge of the bed, flatten the bed back to provide a level seat surface * Transferring to a low seat surface should be avoided because of tendency to push with the arms when coming to a stand * Hand-held assitance may be preferable to the ptaient when an assistive device for ambulation because some patients cannot control the amount of pressure exerted through a walker or other ambuation device * Activities of Daily living * Engage in normal ADLs but minimize excessive shoulder movemnts (e.g., shoulder retraction, shoulder abduction) * Avoid holding arms above teh head for sustained periods (e.g., washing hair) * Avoid excessive chest expansion movemnts with U/B dressing (e.g., when donnign or doffing a shirt or fastening a back-closing bra) * Avoid U/B twisting. When reaching for an object (e.g., the telephone), the patient should turn teh dirction of the obect instead of twisting an arm back behind himself or herself to reach for it * Minimaize shoulder extnsion and rotation movements when engaging in toileting hygiene * Avoid bending over to don lower-body clothing to minimize inadvertent breath holding when bendign forward. Cross one leg over teh other to access feet for L/B ADLs, or consider the use of assitive devices (e.g., readcher, dressing stick) * Do not lift more than 10 lbs, including grocery bags, children, pets, or trash bags * Avoid one-sided pusing, pulling, or lfiting (e.g., opending heavy doors, vaccuming) * AVoid heavy pushign or pulling wtih both arms (e.g., moving furniture) * Avoid driving or riding in the front seat of a car. An accidnet may resutl in forceful movemnt or pressure on teh sternotomy site * Avoid straining, for example, openign tight jras, straining during bowel movements, or activities that may cause breath holding (e.g., valsalva effect) * Exercise * Patients may partiicpate in full active range of motion exercise but should not exceed 90 degrees of shoulder flexion with presence of a muscle flap * Patricipants should not participate in resistive exercise, includign use of a thera-band or light weights, until cleared by physician (usually contrainidcated the first 4-6 weeks) * Avoid pushing and pulling activities * Sternal clicking is a feeling of shifting or snapping of the sternum and indicates instability. Any arm motion that causes clicking, expecially shoulder abduction, should be avoided. Signs and symptoms of exercise intolerance * chest pain or pain reffered to the teeth, jaw, ear, or arm * excessive fatigue * shortness of breath * lightheadedness or dizziness * nausea or vomiting * unusal weight gain of 3-5 lbs in a 1 - 3 day period General precautions * monitor vital signs before, during, and after therapy * Be aware of any signs of exercise intolerance or cardiac distress, including complaints of * dizziness * light-headedness * SOB * heart palpitations * chest pain described as pressure, burning, or heaviness * indigestion, nausea, or vomiting * sweating * confusion * anixiety or fear * changes in blood pressure (BP; \> 20 mm HG) or heart rate (HR: \> 20 bpm over resting heart rate) * Early activity helps prevent cardiopulmonary complications * Avoid valsalva maneuvers or effects. Holding teh breath casues an incrase in intrathoracic pressure, which decreases venous return, slows heart rate, and increases BP * Modify activity requirements per patient tolerance. Gradually grade activities, slowly progressing the patient * Durign teh first few weeks after a MI, HRs should not exceed 20-30 beats per minute over teh RHR * If the patinet's HR is more than 125 bpm with minimal effort, contact the physican * Heart transplant patients ahve a higher-than-normal RHR (e.g., 90-110 bpm) and require a longer warm-up and cool-down period than patients who have had other cardiac surgeries. * Patients on betablockers ahve lower HR and BP responses; therefore, therapsits must be attentive to otehr symptoms of distres (e.g., shortness of breath, fatigue, complaints of chest pain) * U/E exercises tend to increase HR and BP at a faster rate than do L/E exercises * Patients with a hsitory of hypertension may have an exaggerated response to exercise, even if is more than 180 over 90, notify the physican * If you are treating a ptient with a percutaneous transluminal cornoary angioplasty and angina begins, notify medical staff immediately * Patients are usually on bedrest precautions for several hours after a cardiac catheterization or angioplasty procedure

Answer 44

Cardiac rehab is often divided into phases that involve monitored exercise, nutritional counseling, support and edducation about lefestyle changes to reduce risks of heart problems The goals of cardiac rehab are to regain strength, to prevent condition from worsening adn to reduce risk of future heart problems

Answer 45

1. Anatomy of the heart and circulatory system 2. Mechanisms of damage to the heart; for example, narrowing of teh coronary arteries 3. Medical terminology so clients understand technical information regarding their recovery 4. Signs of disease and when to seek emergency care 5. Safe levels of exercise 6. How to prevent further disease by controlloing risk factors 7. Stress management 8. Medications 9. Energy Conservation and Work simplification

Answer 46

* Sit for as many activities as possible * Allow yourself more tiem for each activity * Consider the best time of day for each activity * Eliminate unnecessary tasks (e.g., air dryign teh dishes instead of hand drying) * Take frequent rests. Rest before getting too tired or overfatigued * Balance rest and activty * Prepalan activities: Try daily schedules, weekly schedules, or both so activities can be evenly spread out * Store things that are used often at a level comfortable to reach to avoid excessive reaching, bending, or stretching * Avoid lifting and carrying heavy objects * When engaging in activities, use both arms (hands) in smooth, flowing motions. Avoid jerky movements * Remember to use pursed-lip breathing during activities that may increase your shortness of breath. Pursed-lip breathing is breathing in through the nose and out thought gently pursed lips (i.e., smell the roses and blow out the birthday candles)

Answer 47

* Minimize steps in a task. Consider waht you are going to do next * Use labor-saving equipment that is easy to handle and operate * Avoid overreaching and bending by arranging equipment and materials in your work area within easy reach * Slide objects, do not lift and carry * Use carts with wheels to substitute for carrying or lifting * use good posture and body mechanics * Use proper breathing techniques when performing any task * Perform a task in teh proper sequence. Repeating the same methods will increase skill and make movments more efficient and ecnoomical. For example, if you normally put on a shirt before you pants, keep that sequence consistent. Do not don pants before you shirt, deviating from your normal routine * Combine steps when possible (e.g., don underwear and slacks over feet at the same time before pulling both up over hips) * Minimize trips between points. Gather all necessary items before moving between different rooms or locations * If available, use store scooters or wheelchairs for shopping instead of walking the aisles * Consider hiring someone to assist with certain activities, such as lawn care, maintenance, cooking, or cleaning

Answer 48

* Plan your schedule to allow time to engage in the task and also take rest periods * Work at a slowed, rhythmic, relaxed speed; work to music if necessary * Pace yourself * Spread heavy adn light tasks throughout the day or week, doing heavy tasks when you have the most energy * Set priorities * Eliminate unnecessary tasks * Delegate jobs when appropriate * Plan frequent periods for rest and relaxation (both mentally and physically)

Answer 49

* Sit when able and at a proper work height. A good work height is when you do not have to reach or bend excessively * Avoid clutter in work areas * Optimally position needed materials and equipment closer together * Organize all work areas by keepign all supplies for an activity or task stored together. use organizing equipment (e.g., lazy susan, stacking shelves, bins) * Ensure work areas have good lighting and ventilation

Answer 50

* Sit when possible * Have one designated area where all supplies are organized (e.g., razor, toothbrush, makeup, other toiletries) * Consider a short, easier-to-care-for haircut * Wash hair while in the shower * Have hair done by a professional, or ask family members to help out * Support elbows on a counter or table top when tasks take 5 minutes or longer * Never force, bear down, or hold your breath when having a bowel movement. Take deep breaths in through your nose and push gently as you blow out thorugh pursed lips

Answer 51

* Sit on a shower or tub chair or stool when showering or bathing * Sit to dress, undress, bathe, adn dry * Use a long-handled bath sponge or hand towel to wash back and feet * Use lukewarm water to reduce steam if you have difficulty with shortness of breath, or decrease the amount of steam by turning on the cold water first and then adding hot water slowly. * Use a shower hose extension (i.e., hand-held shower) to increase control over direction of spray * Install grab bars and nonslip strips to prevent falls * Organize shampoo, conditioner, and soap in an easy-to-reach place in the shower or bathtub * Have a towel and robe easily accessible. Use a towel or terry-cloth robe to pat yourself dry (or wear a terry-cloth robe until dry) instead of vigorously drying yourself off with a towel * If oxygen is prescribed, it should be worn while in the shower or bath * Avoid overexertion by taking rest breaks

Answer 52

* Designate a dressing area where all cothes can be reached easily * Before starting, gather all clothes and shoes together * Remeber breathign techniques--exhale while bending over or raising arms up * Wear loose-fitting, lightweight, comfortable clothing. Use suspenders if belts are too restrsicting * sit to dress * compelte lower-body dressing before upper-body dressing * eliminate bending as much as possible to minimize SOB. Consider using adaptive equipment to minimize bending * bring feet up toward body (e.g., can prop on stool) rather than bending down * minimize bending by crossing one leg over teh otehr while sitting ot put on socks, underwear, pants, or shoes * pull underwear and pants to knees while sitting, then stand one time to pull both items of clothing up over the hips * Put on slip-on shoes using a long-handled shoehorn * Try to use clothing that opens in the front, preferably with zippers, hook-and-loop fasteners, or buttons. Shirts that open from the front do not require neck flexion, which can constrict the lungs, making breathing slightly more labored, similaryly, use a front-closing bra

Answer 53

* use a cart with wheels to move items from the fridge to the sink or counter * use the coutner space for sliding heavy objects rather than carryign them * keep frequently used itms and ingredients within easy reach; store items where they will be used. For example, keep canned goods near the electric can opener, and keep pots and pans near the stove * Keep heavier items where they can be slid back and forth rather than lifting and carrying. Store lighter items higher up * Use electric appliances to make the work easier and quicker. For example, use a blender, electric can opener, electric knife or microwave oven * Stabilize or set objects down on teh counter or table rather than holdign them * Use lightweightt utensils and cookware * Distribute the weight of heavy pots or trays over tow hands rather than using one. Use oven mitts for handling hot items * Angle a mirror over the stove to see into the pots from a seated position * use dishes that can go from preparation to oven to dinner table * Eat on paper plates or reuse dishes directly from the dishwasher * Inquire whether the grocery store delivers or whether Meals on Wheels is available in your area

Answer 54

* cook large quantities, and freeze individual protions for later * prepare part of the meal ahead of time * use recipes taht require short preparation time and little effort * Gather all necessary items before beginning meal preparation * Sit to prepare items and mix ingredients * make one-pot meals * use ready-made foods to eliminate preparation time * Avoid peelign and other preparations. use packaged fresh vegetables or frozen products * serve food directly from baking dish

Answer 55

* Rest after emals before starting to clean up * have everyone clear their own place setting * use a utility cart to transport items * let dishes soak to eliminate scrubbing * sit to wash dishes or use a dishwasher * let dishes air dry * use lightweight cloths or sponges rather than heavy terry cloth rags

Answer 56

* Clean a different room each day * Use a lightweight vacuum or power broom * Use long-handled dusters and cleaning attachments * sit to dust * use a mop or a dustpan with an extended handle to clean up spills on the floor * Use a dust mitt rather than gripping a dust rag * Break up chores over the whole week, doing a little each day * Keep cleaning supplies in the room in which you use them * Allow cleaning agents (foamy spray) time to do their work so that less scrubbing is required

Answer 57

* store bed linen near the bedroom * use fitted sheets * make as much of the bed as possilbe while still lying in it, or sit on the edge of teh bed and scoot up as the covers are straightened * use the clock method. start at one end of the bed, and slowly make the bed as you move around it to the other side * Use a lightweight spread or comforter * consider changing the sheets less often to conserve energy * Share the taks with another person to reduce reaching

Answer 58

* If laundry area is downstairs or at teh opposite end of the home, put soiled clothes in a large laundry bag and throw it downstairs or drag it to the washer * Use a scoop for a dry detergent rather than lifting the whole box. put liquid in a pump container * use a wheeled cart to move clothes * make more frequent trips with lighter baskets of laundry rather than carrying heavy but less frequent loads * sit to iron, sort clothes, pretreat stains, or fold laundry * Transfer wet clothes into the dryer a few items at a time * Use a long-handled reacher to remove clothes from the back of teh washing machine * remove clothes from the dryer immediately after cycle to avoid wrinkles * Get help to fold large items such as sheets * Buy clothes that are easy to wash and require little to no ironing * If you need to iron, try a travel iron, which weighs less than 2 pounds * When ironing, slide the iron rather than lifting it * Do not do all the laundry chores in 1 day. Spread the tasks out over several days

Answer 59

* Phase 1: inpatient - cardiovascular risk factors and signs and symptoms of MI * Home Program Phase: HEP, focus on surgical incision care, increased activity, exercised program would be low intensity * Phase 2: Outpatient - cardiac telimetry (holter monitor - measures cardiovascular activityadn vital signs, increase rsistance and time spent in exercise, continued education concerning risk factors, * goals: increase aerobic activity, increase strength and endurance, monitor own HR and activity level, learn stretch and strengthening exercises (tied to occupation) * Phase 3: Maintenance - (ongoing community exercise program) - Long term lifestyle changes, generally community facilities, heart healthy habits, decreased future cardiac events

Answer 60

an individualized program of education and exercise classes that teaches a client about his/her lungs, how to exercise with less shortness of breath, and how to "live and breathe" with lung disease

Answer 61

* COPD (bronchitis, emphysema, asthma) * Lung transplant [pre&post] * pneumonia * sarcoidosis - unknown cause -\> inflammation constantly - immune cells cluster and form lumps called granulomas * pulmonary hypertension - abnorm increase of BP in arteries of the lungs --\> causes R side of heart to work harder than normal * Intersititial Pulmonary fibrosis - scarring and thickening of lung tissue * Cystic fibrosis - obstructive condition

Answer 62

* Muscle weakness/disuse atrophy * SOA - dysapnia * hypertension * depression * anxiety - fearful * decreased mobility * decreased functional performance * excuses for not participating

Answer 63

* SOA during ADL, IADL, work and leisure * none * mild * moderate * sever * Anxiety with SOA * Self-management of SOA - typically they hold their breath, forcing the exhalation, short gasping breaths, raising, shoulders, or throw back head (all uneffective) * Respiratory medication/equipment

Answer 64

1. Take the number 220 2. subtract the patient's age 3. the difference is that patient's MAHR 4. To establish his or her exercise heart range, muliply the MAHR by 50-85% to obtain the heart rate for exercise

Answer 65

* enhance the ability to perform daily living tasks * reduce hospitalizations and the use of medical resources * increase exercise tolerance adn performance * relieve the symptoms or respiratory disease * improve the emotional well-being of those who have anxiety, depression, lack of self esteem * educate about pulmonary disease and its managment * increase the possibilty of returning to work * increase survival in some participants

Answer 66

* Proper body mechanics * breathing exercises * energy conservation/work simplification * Adaptive equipment * HEP * Stress management/relaxation techniques No work with arms over head Try to teach that you exhale during strenuous part of motion. Ex: exhale as vacuum is pushed out and inhale as it comes back Precautions: Do NOT bend at waist (need reachers, long shoehorn, do NOT take steamy shower without Oxygen

Answer 67

Breathe in through your nose With lips pursed, exhale air slowly Try to take twice as much time to exhale as it did to inhale

Answer 68

Sit in a relaxed position preferably with feet elevated place you hand on your abdomen As you inhale through your nose, try to feel your stomach push out as you lungs fill with oxygen Next, feel your stomach go down as you slowly breathe out through pursed lips Continue to repeat this process until you become comfortable doing it Stop the diaphragmatic breathing if you become light headed or fatigued

Answer 69

* HR, Borg perceived rate of exertion, oxygen stats afer each activity * Amount of cueing required for PLB (min, mod, max) * Amount of cueing required for pacing (min, mod, max) * Amount of cueing required for breath hold (min, mod, max) * Carry over in home environment * motivation level

Answer 70

1. wrap blood pressure cuff 1 to 1.5 inches above the antecubital space 2. the cuff should be wrapped smoothign and firmly around teh arm 3. The bladder of the cuff should cover 80% of teh arm circumference 4. palpate teh brachial pulse on teh medial aspect of teh arm 5. place the stethoscope over the pulse 6. close the valve ont eh inflation ball 7. inflate teh cuff 20 mm Hg greater than the point where you heard the pulse obliterated 8. Slowly open the valve on the inflation ball so the mercury or arrow drops at the rate of 2-3 mm per second 9. The first sound heard is teh systolic pressure; make a note of that number 10. continue to listen until the pulse starts to muffle and finally disappears 11. the point at which the pulse disappears is the diastolic pressure; make a note of that number 12. Be sure to listen for 20 mm Hg longer to make sure you heard the exact last pulsation 13. Completely deflate the cuff and remove from the patient To be considered normal, blood pressure must be under 140/90 at rest. Systolic blood pressure should rise with exercise. Diastolic blood pressure should stay teh same or drop slightly. With exercise, diastolic blood pressure should not increase more than 10 mm of Hg compared with resting. The blood pressure response of patients with a history of high blood pressure is likely to be exaggerated with exercise

Answer 71

1. Locate indentation on lateral side of wrist about 1/2 inch proximal to the wrist crease 2. Palpate the radial artery with teh index and middle finger 3. Count the number of pulsations for 10 seconds 4. Multiply that number by 6 to determine the number of beats per minute 5. Notice if the pulse is regular or irregular 6. Also note any "skipped" or early beats A normal heart rate range a rest is between 60-100 bpm. Someone who is very fit, such as a runner, may have a heart rate in the 40s or 50s. After open heart surgery, a patient often has a heart rate in teh low 100s. Durign exercise inteh first 2 wks of convalescence, teh heart rate should not increase more than 20 bpm above resting for a patient with an MI and about 30 bpm for a patient after surgery. (Note that these are relative guidelines and not absolute). It is not uncommon for patients who have valve repair or replacement to develop a rapid heart rhythm called atrial fibrillation. This rhythm is usually controlled with medication or by cardioversion. If the patient's HR is uncontrolled and is 120 bpm or higher at rest, exercise is contrainindicated.

Answer 72

A pulse oximeter is a non-invasive test to determine teh amount of oxygen int he blood. A probe is wraped aroudn a fingertip. A light shines through the finger, and the amount of light reachign teh otehr side indicates the amount of oxygen in th blood. Hemoglobin is red, and the more hemoglobin in the blood, the less light is able to penetrate the fingertip. The oximeter can occasionally give false readings. If the patient is anemic, wears nail poish, or has poor circulation, the pusle oximetry may be inaccurate. Often the oximetry machine will also determine the patient's pulse. If teh palpated pusle and oximetry machine pulse match, it is likely that hte oxygen saturation will be accurate.

Answer 73

Grooming * Prop elbows on countertop (supporting upper extremities) when washign face, brushing teeth, combing hair, or shavign. Organize all utensils ahead of time * Dressing * Avoid tight clothing, which restricts trunk-chest expansion * Incorporate abdominal and pursed-lip breathing into dressin groutine * Sit to dress and avoid unnecessary steps (e.g., don underwear and patns at the same time to avoid standing and sitting multiple times to pull garments up over hips) * Use adaptive equipment when warranted (e.g., long-handled reacher, long-handled shoe horn, elastic laces, sock aid, or dressing stick) * Bathing * Sit to bathe * use adaptive equipment (e.g., long-handled sponge for bathing, bath chair, hand-help shower, warpping a wash cloth over a long-handled sponge to dry feet) * Dry self off by donning a terry cloth robe or draping a large towel aroudn body patting self dry * Avoid hot water for bathing and showering because steam and huminity may make it more difficult to breathe. Steam may also be minimized by leaving the door open or using a ventilation fan * meal preparation * Sit whenever possible * Use an exhaust fan for fumes, which may interfere with breathing * Organize all materiasl ahead of time

Answer 74

* Monitor vital signs before, during, and after activity because they reflect the patient's cardiopulmonary function * Note any signs of cyanosis, pallor, clubbing of fingers and toes, use of accessory muscles, or signs of abnormal breathing patterns * Modify activities if oxygen saturation levels fall below 90% (or other parameters set by medical staff) * Ensure patients maintain good oral care: The body has several normal defenses against respiratory infection, including cough and saliva, which removes plaque and microorganisms fromt eh mouth. Good oral care is essential for reducing bacterial colonization, which can lead to HAP. Oral hygiene includes brushing teeth and tongue and usign an antiseptic mouth rinse. Some patients may be prescribed a special mouth rinse * Adhere to all aspriation and swallowing precautions posted in patients' chart or in their room * Encourage oral suctioning when needed. Notify nursing when patients require tracheotomy suctioning * Adhere to infection control protocols, includign good hand hygiene and disinfecting equipment. This adherence is especially important for patients with a compromised pulmonary or immune system * Work with patients with the head of the bed elevated (30 - 45 degrees) or in an upright position * Promote engagement in activity. Immobility is detrimental to good respiratory function. * Avoid resistve exercise with thoracotomy or sternotomy patietns. Check with the physician because patients may have a lifting restriction for the first 4-6 weeks after surgery * Patients who are being discharged with oxygen satruation levels lower than 88% with activity may require home oxygen therapy. Notify medical staff, because home oxygen thearpy must be prescribed by a physician * Supplemental or increased oxygen may be used to prevent hypoxia; however, do not adjust oxygen levels with patient who are hypercapnic unless first consulting with medical staff

Answer 75

Visualization * Start with a short (5 min) time frame, and gradually increase the time to 15-20 min. Arrange for the client to be undistrubed and positioned comfortably laying in bed or sitting in a chair. Have the client close his or her eyes and cue him or her to breathe slowly and deeply. Have the client think of a place that is calm and peaceful * Suggested scenario: "You are lying on a warm, sandy beach. Feel the gentle breezes touching your skin, hear the ocean as it meets the shore, smell the saltwater in the air. Feel the sand running through your fingers. Listen to the waves coming in and out, in and out... Feel your body sinking into the warm sand...Feel the warthm of the sun and see the beautiful colors of the sunset...Imagine the ocean washing your worries away, leaving you feeling cleansed and relaxed. Spend a few minutes savoring the peacefulness of this place...all its sounds, smells, textures, and sights. Slow your breathing with the movement of the waves, and let your muscles relax and feel heavy. Let the waves carry away any tension. When you are ready, take a deep breath and, as you exhale, slowly open your eyes." Muscle relaxation * Start with a short (5 min) timeframe, and gradually increase the time to 15-20 min. Arrange for the client to be undisturbed and positioned comfortably. Instruct the client to close his or her eyes and take 3 deep breaths, breathing in through the nose and out through the mouth. Focus on breathing out more than on breathing in. Cue the client to return to breathing if the mind is wandering or he or she has difficulty focusing. * Suggested scenario: "Close your eyes. Tighten the muscles in your face, scrunch them up, and then let you face and mouth smooth out and relax. Relax your brow. Let you head and neck relax deeper into the pillow, sinking into it. Now tight the muscles in your shoulders and arms. Hold it....and then let your shoulders and arms relax. Make a tight fist with your hands, hold it... and then open you hands letting them relax by your sides. Sink deeper into the pillow. Your body is feeling heavy. Take a deep breath and let it out. Breathe out the tension. Now tighten the muscles in your stomach and back, hold it... and then let your stomach and back relax. Let your body sink into the bed [or chair]. Now tighten your buttocks, hold it...and then let the tension go out of your pelvis and buttocks. Take a deep breath and let it out. Tighten the muscles in your thighs and legs, hold it...and then let your thighs and knees relax. Now tighten the muscles in your ankles, feet, and toes, hold it... and then relax. Your body is getting heavy and warm. Stay in teh position for a few minutes feeling comfortable and relaxed. When you are ready, slowly open your eyes adn stretch." Simple deep breathing * Have the client sit quietly with his or her shoulders relaxed. cue the client to breathe out slowly through gently pursed lips for a count of 3-5. Then cue teh client to pause for 1-2 counts, neither inhaling nor exhaling. cue to inhale slowly, through the nose, if possible, while expanding the belly for a count of 2. Then exhale slowly again. Ideally, the client should work up to exhaling the breath twice as long as inhaling the breath.

Answer 76

* Avoid a tight grasp * Avoid pressure on the back of your fingers * avoid pressure on the side of your fingers * avoid prolonged periods of holding your hand in the same position

Answer 77

* Use the largest and strongest joint possible to do a task * scoop objects insead of lifting * Modify tasks or use special equipment * electric can opener * jar openers * slide objects on counter instead of lifting * Use light weight tools * Use tools with built up handles * Use foam to build up handles on utensil * Take frequent rest breaks * respect your pain!

Answer 78

OA (degeneratvie joint disease - non-inflammatory) * very specific goniometric measure of A/PROM * pain level * joint * edema * heat * DO NOT DO MMT, POG, & pinch * ADL/functional mobility and sensory RA (systemic autoimmune disease - inflammatory) * A/PROM in each joint * MAYBE Do MMT, POG, pinch * ADL * functional mobility * describe deformities

Answer 79

* knees * hips * spine * low back * fingers: CMC, PIP, DIP

Answer 80

* joint pain/tenderness that worsens over time * joint stiffness, loss of movement * crepitus * nodes (bony knobs) around some joints * one joint or several

Answer 81

* cartilage surface becomes worn * large sections of cartilage wear away * ends of bone thicken due to formation of new bone and cartilage * osteophytes: bone spurs * joint loses normal shape and mechanical structure

Answer 82

* Joints are: * warm * swollen * painful * red * Flu-like symptoms * fever * loss of appetite * weight loss * fatigue * morning stiffness * remissions and exacerbations cause unknown, but genetic predisposition

Answer 83

* Inflammation of synovial membrane * enzymes destroy tissue, bone, cartilage, and soft tissue * ligaments, tendons, and muscles weaken * unstable joints, dislocation, deformity, pain

Answer 84

Immune system response * triggering event: tissue irritation or damage * rush of white blood cells: release of enzymes * increased fluid and cells in joint * digestive enzymes digest bacteria, but also cartilage, bone, ligament

Answer 85

The 1st part of any motion is compression which increases pain in RA * reduce resistance --\> light weight --\> more reps but want to presever muscle strength

Answer 86

In stages - treatments is dependent on stage 1) Acute 2) Subacture 3) chronic

Answer 87

Goals * decrease inflammation * decrease pain * preserve function * prevent deformity Drug therapy * NSAIDs, corticosteroids * Slow acting (disease modifying) drugs * Cytotoxic medications Pain management Surgery: joint replacement Joint rest: * joint protection * Energy conservation * splinting \*Treatment precaution: gentle/pain free ROM in acute stages but ASAP range to end range (when pain allows) to preserve ROM

Answer 88

1. Respect pain as a signal to sotp the activity 2. maintain muscle strength and joint ROM 3. use each joint in its most stable anatomical and functional plane 4. Avoid positions of deformity adn forces in their direction 5. use the largest, storngest joints available for the job 6. ensure correct patterns of movement 7. avoid staying in one position for long periods 8. avoid starting an activity that cannot be stopped immediately if it proves to be beyond capability 9. Balance rest and activity 10. reduce the force 11. Fatigue management

Answer 89

* Acute phase: use PROM to get at least 1 complete ROM exercise per day -\> prevent contratures * Sub acute: full ROM to regain any lost motion -\> gentle end range stretch

Answer 90

* Exercise daily when stiffness and pain are teh least * Take a warm shower or apply heat and/or cold before or after exercise * perform gentle ROM exercise in teh evening to reduce morning stiffness and in the morning to limber up prior to arising * Modify exercise (decrease frequency or adapt movement) to avoid increasing joing pain eitehr during or after the exercise. Pain following exercise is a guide to reduce the number of repetitions * Use self-assitive techniques, such as wand exercises, to perform gentle stretching * Reduce number of repetitions when teh joint is actively inflamed

Answer 91

PROM - AROM

Answer 92

1. Tense muscles with no observable movement --\> hold for 5 on/ relax for 5 off 2. Chest press: palm on palm --\> press for 5 on/relax 5 off --\> 5 reps as they can increase time increments 3. Against wall press flat hand against wall --\> 5 on/5 off; 5 reps

Answer 93

* ulnar deviation * finger flexion

Answer 94

Self-care * Button hook, dressing stick (various lengths can be used for dressing as well as reach for dsitant items), sock cone, reacher, long-handled sponge, extended handle for managing toilet paper, long-handled comb, electric toothbrush, pump toothpaste dispensers Meal prep * rolling cart, knob turner for stove, built-up handles on cooking utensils, knives withright-angled handles, electric can opener, jar opener, spring-level scissors, cutting board with spikes to stabilize food, electric chopper, high kitchen stool, high stool on roller such as EZ Stand Moble Stool Home maintenance * long-handled dustpan, bucket on rollers, reachers to pull itmes out of areas and from floor Work and school * luggage cart, rolling cart, backpack, fanny pack, computer forearm-wrist rest, adapted key holder, built-up handle for writing implements, telephone headset, adapted hand toos, electric stapler and pencil sharpener, car door opener Leisure * Adapted gardening tools, rolling stool for gardening, card holder, reading rack, embroidery hoop holder, rolling golf cart, knob turner jar opener, pealer, built-up handles, kitchen grip/pot holder carry with flat hands, suction cup cutting board, dagger grasp, dycem mat --\> never want to see them grip anything, if stirring use dagger grasp, ergonomic pots, mixers with flathand versus grip

Answer 95

* lightweight, durable, compact, attractive in appearance * mulipurpose use to prevent need to search for multiple devices * Simplicity of operation * Reduce stress to all multilinked joints involved in operative the device * suitable for teh individual patient's gadget tolerance * In accord with the self-image of the user

Answer 96

* limited knowledge of teh disease and its progression * Limited kknowledge and skill to modify activities at home or in the community to protect joints and conserve energy * Limited ability to manage a full day, balancing between rest and activity * joint limitations and deformities * limited strength * limited knowledge of use of splints * limited knowledge on how to adapt or modify the environment * limited sense of self-efficacy to redesign lifestyle

Answer 97

* degnerative disk disease: occurs as disk ages adn loses its resilency * herniated, ruptured or bulging disk - the difference b/w herniation and bulging is teh degree- inflammation that hearts the nerve root * Spinal stenosis - narrowing of spinal canal - compresses nerve roots - pain, weakness, sensory loss, incontinence * Sponylolisthesis * Vertebral fractures (5 categories) - mechanical injuries (4), age-osteoporsis

Answer 98

* laminectomy * diskectomy * spinal fusion - limited ROM - precautions Post surgical precautions * OT's role to educate

Answer 99

* Body mechanic - client's * log roll - to keep back in close alignment * posterior pelvic tilt - protect lumbar * Functional mobility * can't sit in soft recliner chair - need firm higher chair, raised commode, symmetrical weight bearing --\> elevated foot (4-6 inches) in standing --\> puts them in posterior pelvic tilt * ADLs

Answer 100

* Hip Arthroplasty * Posterior Hip Replacement * Anterior Hip Replacement * Minimally Invasisve Hip Replacement * Hip Resurfacing - less extensive replacement - typically use it with younger people * Revision Total hip Arthoplasty - if you outlive hip replacement PHR and AHP are different because of approach and the precautions are different (if in doubt go with most restrictive precautions until clarified)

Answer 101

PHR * No hip flexion beyond 90 * No hip adduction past neutral * No hip internal rotation AHR * No hip extension * No hip external rotation Trochanteric * No active hip abduction

Answer 102

Progressively severe osteoarthritis in the hip joint * progressive chornic pain * impairment of daily function including walking, climbing stairs, and rising from a sitting position * altered gait Osteoporosis Fractures Disease (osteomyelitis)

Answer 103

Open-Reduction internal fixation (ORIF) screws and plates * more agressive way to fix bone structure * goals * need to get patient up and moving * begin functional activities * prevent DVT * prevent inactivity * has w/b restrictions, NWB --\> walk with walker * joint motion is as tolerated * equipment * walker * elevated commode seat or BSC * tub bench * bars in bathroom Hemi-arthoplasty * head and neck of the femur removed and replaced with metal prosthesis * used if the bones aren't properly aligned or if the bones have been damaged

Answer 104

* Deep Vein thrombosis * blood in large veins of the leg forms blood clots * swelling, warm to touch, painful * risk of pumonary embolism * Prevention: pressure garments, medications (blood thinners) * Infection - if infection occurs you have to start all over to irradicate infection * Dislocation - mostly occurs getting in and out of car * Greatest risk just after surgery because tissues have not healed around joint * Loosening of metal or cement * THRs evetnally fail: 12-15 years of service

Answer 105

Cemented - cement anchors the component to the bone - Weight-bearing status: WBAT * Pros * Full weight bearing immediately after surgery * faster rehabilitation * Cons * Risk of bone resorption causing bone loss around the acetabulum and the femur * Risk of femoral component lossening becasue of fatigue fractures (cracks) in the cement over time * Recommended population * Older patients (\> 70) * Patients with RA * Younger patients with compromised health or poor bone quality or desnity * Osteoporosis, soft femur bone does not bond well to porous metal Cementless - metal shell is held in place by teh tightness of the fit or by using screws to hold the metal shell into place; surface of metal pats is porus and looks like coral; bone can grow into the metal pores and lock the implant into place without the use of cement; Weight bearing status: NWB or PWB; requires growth of porous bone for stability during WB * Pros * Excellent long-term outcomes * Not subject to cement failures * Easier to revise when component fails * Cons * Longer healing time because of dependence on new bone growth for stability * Higher incidence of mild thigh pain when large cementless stems are used * requires protected weight bearing (with walker or crutches) * more expensive implants * More technically demanding to implant * Recommended population * Younger, more active patients (\<60) * Patients with good bone quality * Patients with juvenile inflammatory arthritis * Patients undergoing more complicated revsiions

Answer 106

6-8 weeks to allow soft tissues to heal for stability ORIF typically does nto require hip precautions but W/B precautions Must teach using multiple methods, handout, practice, demonstration Avoid: Flexion (beyond 90, some surgeons say 70), internal rotation (toes point up), adduction (avoid hyperextension) Equipment needed: reacher, sock aid, walker, long-handled shoe horn, long-handled sponge, bath bench, abducted wedge, elevate commode seat, grab bars, TED hose (more than 1 pair), good tred shoes, may need elastic shoe laces, trapeze (depending on mobility), great big garbage bag for car transfers

Answer 107

causes and complications: same as THR Sx: pain with WB, swelling, decreased ROM

Answer 108

* For elective surgery * baseline of information * severity and location of pain * functional abilities * strength and available motion of hip * Equipment and access needs * hip precautions * practice exercises * WB status

Answer 109

1. same or early next day 2. if they follow precautions, fall risk, functional mobility, transfers, BADLs, positioning 3. any of teh above that are problematic

Answer 110

* Open or compound: skin and soft tissues are damaged, broken ends protrude through skin * closed or simple: skin and soft tissue not involved * pathological: bone had been weakened by disease (osteoporosis, tumors, osteomyelitis) * comminuted: three or more fragments * greenstick: one side of bone is broken; the other side bends (children) * Impacted: one fragment is driven into the other * Displaced: anatomical alignment not preserved * Colles: distal radius

Answer 111

Immobilization * Stabilization and Healing * Actively use joints above and below stabilization * Early Consolidation (6-12 wks) OR * Mobility, Stability, W/B, and skill * Clinical Union * Move limb against gravity PROM & AROM to full arc Mobilization * Healing - not casted if it isn't a severe fx. Fx is protected but not cased adn can begin mobilization * Controlled AROM OR controlled PROM Gravity eliminated * Clinical union (3-4 wks) - key indicator, woven bone around fx, becomes harder and 2 parts move as 1 movent milestone in Fx healing * move limb against gravity PROM and AROM to full arc

Answer 112

Delayed union: bone is slow to heal Nonunion: bone stops healing short of a firm union Malunion: bone heals but alignment is off Complex Regional Pain Syndrome Nerve damage

Answer 113

Healing time dependent on: * Age * site and type of break * intial displacement of bone * blood supply to fragments * health of client before injury * client compliance with treatmetn In general: * UE spiral fracture: 6-8 wks * UE transverse: 12 wks * LE spiral: 12-16 wks * LE transverse: 24-30 wks

Answer 114

used for stable fracture used when muscular forces will not displace fracture requires no surgery immobilization in cast sets bone w/o opening wound

Answer 115

Internal fixation: nail, pin, screw, rod, or plate * used with irreducible fractures; when early motion is essential; with fractures with high incidence of non-union (ORIF) External fixation * used with unstable fractures; numerous bone fragments; requires traction; requires early mobilization open wound and use nail, pin, screw, and rod to set Fx Keeping penetration pins clean to prevent infection

Answer 116

Precautions: * immobilized as instructed by Dr * Education: edema, tingling, pain, burning, (could be ischemia), color (blue) * Elevation above heart level After repair * D/C splint at physicans discretion * active, early gentle AROM * PROM contraindicated keep arm elevated above heart while sleeping/watching TV

Answer 117

Dressing/Bathing Toileting Functional Mobility Precautions-Sleepign or Sexual Activity Education

Answer 118

Rotator cuff injury Fractures-Proximal Humerus * Rib Fractures Total Shoulder Arthroplasty

Answer 119

Subscapularis, supraspinatus, infraspinatus, and teres minor * usually supraspinatus (70% of patients) is what is torn Can be partial or complete Symptoms * Pain and tenderness in shoulder, especially when reaching overhead, reaching behind back, lifting, pulling or sleeping on the affected side * ER weakness/pain * Pain worse at night * Can't abduct the arm * Atrophy Confirmed with MRI

Answer 120

ADLs * Dressing/Bathing * Functional Mobility * Toileting * Sleeping Discharge Information

Answer 121

One of the most painful forms of arthritis Occurs when too much uric acid builds up in body Build up of uric acid can lead to * Sharp uric acid-crystal deposits in joints * deposits of uric acid * kidney stones Gout attack: can be brought on by stressful events, alcohol or drugs, or another illness Gout can cause: pain, swelling, redness, heat, stiffness in joints

Answer 122

Buildup of too much uric acid in the body Uric acid comes from teh breakdown of purines Purines are found in all of the body's tissu Uric acid dissolves in blood and is filtered by kidneys High uric acid levels = hyperuricemia Uric acid can build up when * the body increases the amount of uric acid it makes * The kidneys do not get rid of enough uric acid * A person eats too many foods high in purines

Answer 123

Have family members with disease male overweight excessive alcohol intake diet rich in foods containing purines enzyme defect organ transplant exposure to lead medications vitamin niacin

Answer 124

Hyperuricemia uric acid crystals in joint fluid more than one attack of acute arthritis arthritis that develops in 1 day attack of arthritis in only one joint

Answer 125

RA, Lupus, Fibromyalgia, Scleroderma OT may: Assess, educate, educate, educate

Answer 126

Mental functions Sensory functions including vision, hearing, vestibular, taste, smell, propioceptive, touch, pain, temperature and pressure Neuromusculoskeletal including joint mobility and muscle power, tone and endurance Cardiovascular and respiratory functions muscle power decreases as age increases even if in good shape Have increased difficulty maintaining homeostasis especially after exertion

Answer 127

Decrease in * problem solving * executive functioning declines * abstract reasoning/flexibilty in reasoning * Ability to learn is intact but slowed (very logical) * Memory/short term recall * Memory processing * Attention - easily distractible Is it a cognitive decline or sensory decline * make sure perceived cognition changes aren't in reality hearing or vision problems May start evaluation with sensory tests

Answer 128

Poor sensation/interpreting sensory information Vision * 70 years older - 18 % have severe visual problems * 55 years most people need some sort of corrective lenses * good lighting * Cataracts most common vision problem related to normal aging process * Presbyopia - progressive reduction of eyes' ability to focus. loss of elasticity of lens Hearing * 47% men, 30% women 65+ years have severe hearing loss * conductive - outer ear * sensorineural - age associated - less treatable because it is in the inner ear * wax build-up Taste and Smell * Thresholds for taste and smell increase with age * Decreased smell = food becomes tasteless * Sense of thirst may also decrease with age * Safety * nutritional status may be compromised * detect harmful odors * natural gas, spoiled food, smoke Tactile Changes * Number and sensitivity of touch and pressure receptors may decrease with age vision is the first system to show a normal decline begining in 20s hearing: have trouble tuning out background noise and localizing sound - speak in a louder tone of voice without shouting 70's need between 2-10x the potency in order to distinguish smell estimated regular time to eat meals in teh morning set 8 glasses of H20 - must be gone by end of day exercise --\> stimulates environment/senses take compensatory approach

Answer 129

Vestibular righting response diminishes impaired ability to maintain balance Biggest risk of loss of vestibular function? FALLS * 33% of older adults fall each year, 15% have serious injury, hip fracture * Mortality rate after a hip fracture is 50% * 65 and older, falls are teh leading cause of injury death. They also are the most common cause of nonfatal injuries and hospital admissions for trauma - national crisis - healthy people 2020

Answer 130

Sacropenia - age related loss of muscle mass, strength, and function Muscles * size and number of muscle fibers decrease * increase in fatty and connective tissue, decreased strength, flexibility and endurance Joints * joint function declines steadily after 20 years * ligaments/tendons prone to injury * loss viscosity, synovial fluid * cartilage cracks, frays, does not regenerate Bones * progressive loss of mineral content, results in loss of bone mass and density * Diet, exercise, gender influence

Answer 131

Loss of efficiency with age, every component of the cardiovascular system is affected by aging Elastic tissues decrease while fibrous tissue increases Airways made of smooth muscle constrict Diaphragm flattens Chest wall becomes barrel shaped and less compliant 50% of those 65+ have high BP

Answer 132

Pathological changes * Parkinson's disease * CVA * Osteoporosis - severe low bone density * Osteopenia - mild thinning dx 1st * Emphysema * Myocardial Infarction * Diabetes * Depression/anxiety older adults usually have comorbidities

Answer 133

Posture - postural sway --\> sway quite a bit before body corrects Gross/Fine motor coordination Dexterity Strength Endurance Reaction speed Activities: ADLs, IADLs, work, leisure, driving, the loss of roles and the addition of new roles Fall risk and risk for incontience --\> leading causes for admission into SNF

Answer 134

Adaptation: * remedial approach does not result in full restoration of client's skills/abilities * maximize independence/safety * environmental adpatations - grab bars, reduce clutter * Compensatory strategies - different sequence of tasks, may need pictures of sequencing task, use of alarms to cue activity Remediation - \* try first then make up difference with adaptation * to restore an impaired capacity/ability - HEP

Answer 135

AARP Home Fit Guide Purpose: To help people remain in their home as long as possible Recommendation to keep the home in top form for comfort, safety, and livability * Universal design * Home safety * Emergency exit plan * home maintenance * energy tips * references

Answer 136

Client's "go to" resource within the home Individualize Start developing day 1 Collaborate * medication safety * general tips * kitchen safety * emergency exit plans/ smoke detector maintainence schedules * oxygen safety Large font, easy to understand

Answer 137

You will be teaching exercises in a HEP, & you need to do it right! Follow a researched based model * fit in 10 1) Balance exercises * prevent falls * some balance exercises build up leg muscles, others focus on stability * side leg raises, toe stands * heel-to-toe walking, stork pose (standing on one foodt, hands out to side) * 2+ days a week for the muscle building exercises * Stability exercises should be performed daily in most cases 2) Endurance Exercises * Improve heart, lung, and circulatory system * Improves stamina for daily actitives * walking, jogging, dancing, playing tennis, water aerobics, pushing a lawn mower * choose an activity they enjoy (stay client centered) * 3 or more tiems per week * Warm up, cool down 3) Strength training * isometric, isotonic * Progressive resistance exercise - push muscles beyond what they are used to perofrming * All major muscle goups (legs, hips, back, abdomen, chest, shoulders, arms) * Strenght training 2-3 days a week, with "rest"days in between * Begin with weights you have, lift 10 times with moderate difficulty, if you can do over 12 reps then start with heavier weight * After two weeks, you should reassess * May incrase weight 1-3 lbs every 2 weeks * May need different sized weight for different exercises * \*\*Note: there is an increased risk of injury and improper form when using household items as weights 4) Stretching exercises * Flexibility = more freedome of movement, increase ROM, circulation, releives stress * injury and fall prevention * shoulder/upper arm stretch, calf stretch and thigh stretch * After endurance and strengthening exercises, if performing only stretching exercises, warm up first

Answer 138

National Institute on Aging and US Department of Health and Human Services recommends 4 types of exercise for the full health benefit of physical activity * Balance * Endurance * Strength training * Stretching Minimum of 150 minutes (2 hrs 30min) a week (30 mins/day for 5 days) Strive to increase to 300 mins (5 hrs) a week (1 hr/day for 5 days) Moderate intensity exercise

Answer 139

Often they have low expectations about what they can do Must exercise to be healthy and independent Split it up into 10 min increments It helps to make it a part of their daily routine * "After you put the coffee on, do 10 min of exercise before breakfast" Grade, Grade, Grade! * Start off walking 10 mins, then slowly add more time * increase frequency, intensity, and duration

Answer 140

* place items used frequently in visible locations * Use simple, one-step instructions * maintain habitual activities as much as posible; simplify as needed * obtain a bracelet identifying the person as memory imparied in case of wandering * Encourage physical activity during the day to improve nighttime sleep * Provdie activities that stimulate memory (for example, bakign or music that the person used to enjoy) * Avoid excessively crowded or unfamiliar surroundings that might lead to catastrophic reactions * Contact the local Alzheimer's assocaition for resoruce lists and support groups *

Answer 141

* Reduce clutter * label drawers and cabinets by their contents; for individuals who have dementia or other serious cognitive deficits, pictures may beeasier to understand than words * Use color, texture, and lighting changes to provide location cues, such as changes from carpet to tile signaling the move from dining area to hallway * Use times as reminers for specitfic functions * Put safety off switches on stoves and furnances

Answer 142

* use high-tone colors and low-gloss finishes to improve visual acuity and depth perception * Incorporate devices to icnrease magnification ro enlarge print, contrasting colors, adn dependence on other sensory systmes such as touch * Maintain a consistent environment to allow the visually impaired individual to functino more effectively * Write with felt-tipped pends and in bold print to help improve visibility * Access optometrists, opthalmotolgist, and staff at sight centers or Society for the blind for helpful input * provide high-intensity, low-glare light; avoid fluorescent lights; and put glare-reducing screens over televeisons and windows * Teach compensatory techniques to individuals who have reduced peripheral vision or who have only peripheral vision

Answer 143

* refer for a thorough evaluation from a speech pathologist, audilogist, or otolaryngologist * Speak slwoly adn clearly and use a deep voice with someone who has high-frequency loss; do not shout * Make sure the individual can see you when you speak * write messages if necessary * Select activities for which verbal interaction may not be essential, such as bowling, swimming, chekcers, and walks * Check the hearing aids are fitted and used properly and that batteriest are fresh; remember that these aids do not restore normal hearing and may not help everyone with eharing impairment * use visual cues, such as flashing lights, to get the client's attention

Answer 144

* Make sure the environment is free of hazards such as slippery floors, poorly marked stairs, adn architectural barriers * adjust teh height of chairs, beds, dressers, clothes, and toilet seats, and provide a bath chair if needed; ensure that grab bars are within easy reach * provide task-oriented treatment in the individuals' environment; numerous repetitions enchance learning, and simulated activities may not be easily transferred to real situations * In institutional settings, keep in mind OBRA regulations that mandate reduced used of restraints. careful evaltuation of seating can eliminate teh need for restrains; for example, a chiar that is higher in front than in back can make it more difficult to rise, adn well-fitted charis can enhance balance

Answer 145

* make sure taht the bathroom is physically accessible. Add grab bars and non-skid mats * mark teh bathroom clearly. use large, clear words, pictures, and color coding if necessary * reduce liquid intake prior to bedtime * institute regular reminders to use the bathroom * Use behavior modification techniques to assist elders to notice full bladders

Answer 146

Defined as "clinically severe obseity or extreme obesity" Body mass index of 35+ with a high-risk comorbidity/ 40+ with no high-risk comorbidity Approximately 1/3 of adult American's over age 20 are obese Rise could be attributed to childhood-related issues, poor understanding of proper diet, lack of exercise, and technolgoly related inactivity

Answer 147

* Diabetes * Renal failure * Cardiovascular disease (HTN, PVD, heart attack) * Arthritis * Pulmonary disease (asthma, sleep apnea) * Neurological disease (stroke, CTS) * Vascular disorders * Psychological disorders (anxiety, substance abuse, eating disorders, body schema disorders, depression) * Endocrine disorders (cancer, fetal abnormalities, male hypogandism [deminished activity of testes]) \*\*These conditions are typically the reason for hospital admission and why you as an OT would be working with the bariatric client

Answer 148

The role of OT is to help individuals with obestity chagne their lifestyle, engage in meaniful activites, and manage their weight Forcus on health promotion, disease prevention, remediation, adaptation, and maintenance OT's use an individualized, client-centered approach to identify barriers to performance of meaningful and necessary activities Training in ADL's is necessary to address prevention of with-related medical issues that arise, due in part, to the inability for self-care Acute care OT's frequently work with pt's with obestity as a comorbidity. Can work with pt's who've had bariatric surgery (rare; usually only if there are complications) OT should focus on conceptual strategies such as EC, work simplification, injury prevention, BADL's and IADL's Patient-Centered Intervention * D/C planning * dressing * toileting * hygiene * functional mobility * perforance skills * psycholsocial/lifestyle changes * home management * community access Care-giver Centered issues * transfer techniques * bariatric equipment in hospital * precautions specific to bariatric patients * advocacy for the morbidly obese patient to maximize QOL look at patterns of behavior - reengage in activities What is preventing them from engaging in meaningful occupations

Answer 149

Dressing * UB and LB * Clothign resources to improve self-image * Equipment: Reacher, Sock aid, Shoe horn, Cuff and collar extenders * Pants and Undergarments Procedures * Use a reacher to puton pants and underwear. Grabt the waistband adn thread the patns over your foot. Once you can reach teh waistband, repeat the process to putpants over teh otehr foot. Put both undergraments and pants on over you feet, then stand and pull them up at teh saem time. Sit down to dress * Socks: use a sock aid to put on socks. If your foot is frequently damp, wide, or swollen, use a soft or wide sock aid. If feet are damp, sprinkle powder int eh sock aid to make teh foot slide easier * Slide teh sock on with the bottom of teh sock on teh rounded part * Pull the sock tight aginst the end, stop at teh rope knots * put your toe into the opened sock adn point down * pull on both ropes with equal strength until teh sock is all teh way on * Teh sock aid will come out of teh sock once it is over the heal * Cuffs and Collars * If cuffs and collars are too small, use extenders * Shoes * If you ahve trouble reaching yoru shoes to put them on or tie them, several optiosn include wearing slip-ons, shoes with VElcro fasteners, or shoes with elastic shoelaces. The elastic shoeslaces can be tied before putting them on, making the shoes into slip-ons. Use a long-handled shoehorn to get your shoes on * Clothing * Many resources are available to purchase clothign in larger sizes * Hygiene: good hygiene is important to avoid body odors, and maintaining healthy skin is also critical for hygiene and health. Some hints for a good cleaning regimin follow * bacteria produce odor and irritation and grow in warm, dark, moist places, such as skin folds. Of these three conditions, the only one that can be controlled is teh amount of moisture in teh skin folds * Odors can develop anywhere skin touches kin, not just in the groin and underarm areas, especially under the stomach, behind the knees, in the navel, and under the breasts * Use a germicidal soap to assist in eliminating the bacteria, then rinse thoroughly so that soap residue will not lead to irritation * Dry thoroughly, especially between all skin folds. You may want to consider usign a hair dryer on a low, cool setting to assit in teh drying process. Do not use a hot dryer, which can burn skin * To best clean teh navel, use a cotton swab and hydrogen peroxide. Again, dry thoroughly * Avoid cornstarch-based powders, use Sween cream. If this cream is not available, an acceptable option would be a noncaking cornstarch powder * Check your skin on a weekly basis, especially skin folds. If needed, ask a family member or friend to check areas you cannot see, or use a mirror * Clothing choices can also contribute to moisture control: cotton absorbs moisture, and polyester locks it in; wearing properly fitting cotton underwear is important. Consider wearing a pnay liner or pad to absorb excess moisture; tight clothes can cause skin irritiation adn should be avoided; * Freshen up during the day, usign baby wipes to control odor if needed * Mitchum antiperspirant is especially made for people who sweat a lot * Bathing: Hard to reach areas can make washing more difficult. Here are a few suggestions * use a long-handled sponge for areas taht are hard to reach, such as your back adn legs * sit to make reaching these areas easier and to save energy * If steppinginto teh tub is getting difficult, use a transfer tub bench. The bench has two legs outside teh tub, adn two inside. Sit on teh end, slide back, and swing your legs fo the edge. If you are having trouble getting yoru legs over teh edge, use a sheet to help by putting it around teh food and pulling yoru leg over the edge of the tub. A shower seat is anotehr option for those who are able to step into teh tub or who have a shower stall but want to sit down * Check the weight limit on the bath seat before buying. Most benches avaialbe in sotres have a limit of 250-300 pounds. Benches rated for higher weights can be bouth from medical supply stores. The manufactura provides this information * Use hand-held shower sprayer to help rinse all areas * Place items on a shelf so they can be easily reached in teh shower * Clean the shower sponge by either putting it in the dishwasher or boiling it for about 5 minutes at least once a weak * Toileting: Reaching to cleanse after going to the bathroom can be very difficult. Several ideas for maintaining good hygiene follow * Use a toilet aid to hold toilet paper or flushable wet wipes to extend you reach * A toilet aid is a set of tons. Put the end of the toilet paper between the tongs to hold the paper; then wrap teh toilet paper aroudn teh tongs. Once you are done wiping, pull the tons aapart so that the toilet paper can fall in the toilet. Carry a small wide-mouthed bottle filled with bleach water in which teh toilet aid will fit. The toilet aid can bthen be cleaned after ever use * Wet wipes might allo for quicker cleaning * A portable bidet fixture can be installed on your toilet to further cleanse this hard-to reach area. Most porable bidets fasten to the sink faucet, with a hose extending to teh toilet. When teh water is turned on, it squirts up, providing a refreshing cleaning. A squeeze bottle can also be used * If teh patient is have trouble getting up from the toilet, place a bedside commone over the toilet (without the pail), providign a higher seat and armrest, or use an elevated toilet seat with an oblong opening * Home management: Cooking can be tiring and provides opportunities for injury. HEre are some suggestions * sit while preparing food * to improve reach, install pullout shelving, use a reacher, adn adjust work heights to avoid fatiguing or painful positions. One way to do this is to palce a cutting board on top of a pulled out drawer near the sink so that you can easily cut food while seated * To sit in front of a cabinet that does not have room for your feet, open the cabinet doors and move things around to give your feet room * To reduce teh weight of tiems taht you need to carry, use lighter items such as aluminum pans rather than cast iron or use a rolling cart to transport items * Gather all work supplies and ingredients before starting yoru food preparation * For easy meal prpearation, make a double batch of food and freeze the extra portions * Home management: Cleaning can be one of the most tiring and painful activities poeple do. The follow are several ways to make cleaning easier * For low areas, use long-handled tools, such as mop, to clean tubs and long-handled dusters, and long-handled dustpans so that you do not have to stoop * Use a reacher to pick up items on the floor * use a heavy-duty footstool to reach high items. Check for weight limits * Sit to iron, wash dishes, adn fold clothes * Use a utility or gourmet cart to carry things * Time-saving strategies can also decrease fatigue. Keep cleaning supplies on each floor of your home; spread out the cleaning by doing one room each day instead of a marathon cleaning session on Saturaday morning. This method will also make weekends more enjoyable, leaving more time for active leisure pursuits; keep the house clutter free, reducing the time needed to clean the house because you will not have to straighten before cleaning; to reduce the time spent making beds, straighten the sheets and blankets by pulling them tight before you get out of bed. Once you get out of the bed, make each side completely before switching sides * Make a list of 10 min chores that you have been putting off. post it on the fridge or by the phone. When you have 10 free minutes, go to the list. this makes the to-do list less overwhelming * Home management: preventing injury is key to maintaining an active lifestyle. Apply the following strategies when lifting or moving things * when trying to pick up an item, whether small or large or heavy or light: keep your back straight, and squat instead of bending over; lock your arms around the item before picking it up; use teh strength in your legs instead of your arms; rather than twist, turn your body all the way around, if at all possible, push do no pull, items; and ask for help if something is too heavy * Mobility in the community: community access is very important for maintaining an active lifestyle * if getting your leg into the car is difficult, use a leg lifter * Scooters can be purchased for personal use * standard seat belts are often too small. obtain seatbelt extenders * Mobility in your home * bed mobility: getting out of bed can be hard if yoru stomach muscles are weak or you have had surgery. Use the log roll method: Step 1: turn on your side. Step 2: swing your legs over the edge of the bed. Step 3 push up on your arms * widening the doors: if doors need to be widened, either have the door jams removed, or install offset or swing-away door hinges, widening teh opening by about 2 inches * Getting out of a chair: getting out of a chair that is too narrow or low can be hard. Use the following steps to get out of a chair: Step1: scoot forward to the edge of the chair. Step 2: bring your feet as close to the chair as possible and lean forward. Step 3: Push off with your arms to stand up. If you cannot get up from your favorite chair, put it on risers. The high the chair, the easier it is to get out of. If you have a choice of chairs, sit in the highest. The next best option is a wide chair with armrests. check the weight rating of all chairs with the manufacturer before buying * Performance skills * general strengthening * maximize activity tolerance * therapeutic exercise/reconditioning * injury prevention * Psychosocial and lifestyle restructuring * exercise and conditioning programs: swimming, biking, and walking are good ideas * leisure activities * coordinating diet, exercise, and personal goals * Include family in these discussions * Caregivers need to be educated on: * Safe usage of DME * Proper positioning * Precaustion taken for bariatric client; especially those who have just had surgery * have risks due to generalized weakness * how to encourage a positive attitude and well-balanced nutrious meals

Answer 150

Must establish trust with the patient. Time spend in prepartory strategies and rapport building will be invaluable Bed mobility * use trapeze bars on beds to assist with bed mobility Bed controls * most hill-rom beds can be positioing into full bed-chair position. Before the bed is placed in teh chair position, remove teh footboard. Then the bed can be lowered all teh way to the floor; allowign teh patient to stnd up from a chair position * Keep teh head of teh bed up * When scoot a patietn up in teh bed, put the bed in Trendelenburg psoition to go downhill Out of bed functional mobility * Use extra-long gait belts when transferring patients who are obese * Instruct the patietn to perofrm multiple repetitions of kene extension when seated on the edge of teh bed to ensure at least basic strenght. Perform a manual muscle tes. Be aware that the patinet's functional strength relative to weight may still be inadequate to sustain a functional stand. Once standing, encourage the patient to weight-shift back adn forth before moving away fromt eh bed. Only once sufficient strenght to ambulate has been established should mobility or transfers occur * If unsure about sustainable strenght, have someone follow with a chair o rremove teh footboard from teh bed and ambulate around the bed. the first suggestion is the safest; however it is not always feasible * Sliding boards are often unsafe for the bariateric patient * Common mechanical lift systems: Sling lifts (Hoyer) - most commonly used device. The sling must be rated for patient's weight; Stand-and-rise systems (Sara lift) - difficult to use if teh patient's legs are excessivly large; however, it allows teh patient to bear weight on his or her own legs for standing tasks. Ceiling-mounted lifts (Arjo) - permanently mounted in one room and therefore nota vailable to the genreal hospital population * stretcher chair or lateral transfer devices (Barton) - usually reclines flat, allowing for level lateral transfers. Once the patient is on teh chair, it is then moved into the chair position. Cuation with any gaps between teh surfaces * Air mattress sliders, slide glide transfer devices, or sliding sheets (Airpal) - reduces friction during lateral supine transfer between level surfaces * Caution with any gaps between the surfaces

Answer 151

Weight limits on DME - use equipment that is rated for higher weights Toilets- discuss with your facilities management department the weight limits of floor versus wall-mounted toilets. Most wall-mounted toilets have a weight limit of approximately 400 lbs. These toilest can fall off the wall Do not be cajoled into getting the patietn to teh bedside commode quickly if the patient has not been out of bed. Establishing mobility status when the patient is in a rush to go to the bathroom is hazardous Incision precautions * consider using an abdominal binder. Two or three can be combined to fit the girth appropriately. It is also possible to cut off a section of the binder so that it fits teh trunk appropriately * Reaching down to address IADLs or BADLs may increase stress on incisions and cause dehiscence. Consider using long-handled adaptive devices Generalized weakness can increase potential for falls. Strength relative to size may not be sufficient for safe mobility

Answer 152

Dressing * reacher * sock aid * shoe horn * cuff and collar extenders Toileting * bidet * toilet aid * reacher * bariatric bedpan Hygiene * long sponge brush * hand-held shower head * long mirror * Hair dryer (cool setting for drying skin folds) * Non-cornstarch based powders * Bariatric tub bench Functional mobility * leg lifter * bed risers/ chair risers * offset door hinges * removal of door jams * bariatric wheelchair Community Mobility * set belt extenders * small steering wheels * Scooters Lifts * hoyer lifts: most common; battery-operated or manual * Overhead lift systems * Stand and rise * some lifts can hold up to 1,000 lbs D/C * bariatric bed, bathroom equipment, mobility devices, and lift equipment for the home

Answer 153

* immobilization/mobilization * align (post fx) * protect * support * correct or prevent deformities * substitute for weak or absent muscles * rest (resting splint at night) * increase ROM * Limit or block joint motion (after surgical repair) * increase function * provide resistance or exercise * inhibit tone (TBI or CP)

Answer 154

Arches * for function - preserve the natural shape of hand * longitudinal arch - finger tip to wrist * distal transverse - rounded gives power to grip * proximal transverse - bowel of hand Creases * for full movement * once injury or splint crosses a crease --\> decreased ROM Bony landmarks * skin integrity

Answer 155

Arches of the hadn must be supported * longitudinal * distal transverse (metacarpal arch) * Proximal transverse (carpal arch) * dual obliquity (radial aspect longer and higher) * fingers flex toward scaphoid * digital creases * distal palmar crease * thenar crease * wrist crease * bony prominences on dorsum of hand and wrist

Answer 156

1. DIP crease 2. PIP crease 3. MCP crease 4. Distal palmar crease 5. Proximal palmar crease 6. Thenar creases 7. Distal wrist crease 8. proximal wrsit crease A hand-based splint must stay distal to the wrist crease

Answer 157

Ulnar styloid - can flair splint to avoid MPs on dorsum - avoid splinting tight over MPs

Answer 158

Disperse pressure * widen and long preferred over short and narrow * contour over pressure points * padding may increase pressure - instead put padding on while fabricating splint then remove for wear * The smaller the surface area the stronger the force * A red mark for more than several minutes indicates the need to revise the splint * If client complains of temperature change, tingling, pain, burning, puffy swollen, discolored skin then must refabricate splint * repetitive stress on splint requires a decrease in pressure in certain areas Mechanical advantage * lever arm lenght * forearm trough = 2/3 length of forearm and 1/2 the depth 3 point pressure * 3 individual inear forces in which the middle force is directed in an opposite direction from the other 2 forces * Directs strap placement

Answer 159

1. Consider client occupations: Goal is to facilitate return to occupation; not to wear a splint. A means to an end. 2. Consider length of time splint witll be worn: Thermoplastic is temporary of a few months. permanent are high temp 3. Low profile and good appearances: close fit to arm and hand. Color preferences, no makrs, instruct on cleaning splint 4. Allow for optimum function: do not immobilize or restrict joints needlessly - least amount of restriction 5. Allow for sensation: any body part covered no longer has sensation 6. Allow for ease of application: Don and doff without difficulty. Consider position of straps

Answer 160

Pressure areas * wear 20-30 mintues before leaving - don't let them leave before reviewing teh effects of the splint on arm so it may be fixed * check for pressure areas (red marks, identations); particularly over bony prominences Edema : too toight, monitor circulatoin Sensation * monitor temp of plastic before applying * be cautious of pressure areas

Answer 161

wrtten and oral * purpose of splint * how to don/doff (they need to demonstrate) * wearing schedule * cleaning * pain/redness/numbness * precautions * contact information

Answer 162

Low temperature (135-180 degrees F) * EZE form - resting and wrist cock-up Each material has different feel and quality based on characteristics * Variety of brands * color, perforation, thickness * heating time * working time

Answer 163

Memory * ability to return to original preheated size and shape Drapability : not a very ridid splint * conforms to underlying shape easily Elasticity * Stretch Bonding * Self-adherence Flexibility: something that will be worn at work or all day * tolerates repeated stress Rigidity * Strong and resistant to force

Answer 164

Make pattern cut material heat materia fit to client finish edges strapping check for safety and comfort education

Answer 165

Static: to rest or position the joint Dynamic: to provide controlled movement

Answer 166

Resting hand * resting pan * volar wrist/ hand immobilization Wrist cock-up * volar wrist immobilization Hand based thumb spica: immobilizes the CMC and MP of thumb * Short opponens * CMC palmar abduction * Short thumb spica

Answer 167

Immobilizes fingers, thumb, wrist * can be any length, dorsal or volar, hard or soft, can cover any combination of joints Purposes * Immobilization * Position in functional alignment * Decrease/slow further deformity Diagnosis that may require it * RA, burns, crush injury

Answer 168

functional position * 15 to 30 degrees of wrist extension * slight ulnar deviation * 15 - 20 degrees MCP flexion * 10 degrees PIP and DIP flexion * palmar abduction of thumb (preserve web space) * Extention of MP and IP of thumb Position for immobilization (intrinsic plus) * 30 - 40 degrees of wrist extension * 70 - 90 degrees of MP flexion * PIP and DIP extension

Answer 169

Immobilizes wrist in 0 to 20 degrees of extension pt should have ful MCP and PIP mobility Commonly volar, maybe dorsal or bivalve

Answer 170

Application usually * decreases pain or inflammation * provides support * enhances digital function * prevent wrist deformity * minimizes pressure on median nerve * minimizes tension on involved structure Good for RA and median nerve compression

Answer 171

CTS Radial nerve palsy Tendonitis Wrist Synovitis RA Wrist fractures

Answer 172

hand or forearm based immobilizes thumb arthritis, fractures, ligament disruption, de Quervains very commonly made short length easier to tolerate

Answer 173

Brings thumb into radial abduction Typically used with patients who exhibit mild to moderate tone, which pulls the thumb into the palm. usually is not effective with patients who exhibit high tone

Answer 174

Wrist cock-up in neutral position At night and during activities median tendon gliding exercises, avoid flexion, forearm rotation, pinching and prolonged grasp, ergonomic modifications to activities that exacerbate problem and rest

Answer 175

figure of 8

Answer 176

CMCs, thumb, wrist, MCP wrist and thumb immobilization leave IP free - thumb spica splint

Answer 177

De Quiervans or OA thumb spica During activities compensatory strategies to prevent reinjury, PROM, resting, built-up handles, dagger grip, modify to avoid pinch/grip, ice

Answer 178

Dorsal blocking splint 24/7 Protected ROM of IP, No wrist or thumb extension

Answer 179

finger and wrist flexion antideformity splint - wrist ext 30, MP 60 - 90 flex, IPs 0, thumb b/w palmar abd and opp antideformity (intrinsic plus) to prevent claw deformity and contractures

Answer 180

ADLs noting breathing pattern, pulse oximetry and vitals, signs and symptoms of distress, anxiety and depression, COPM, Borg RPE increased understanding of disease, increased activity tolerance, prioritizing occupations, controlled breathing EC/WS, proper body mechanics, problem solving and coping skills, education on avoiding environmental toxins and minimizing risk of infection, assessing equipment and recommending home modifications, offering emotional support for breathing disorder-related anxiety, increased ability to engage in leisure skills, instructing patients coordinating breathing with movements

Answer 181

1. Sternal precautions, exercise intolerance (HR, BP O2, pain), lowest MET levels, avoid valsava maneuver * sternal precautions : expand chest, no more than 5-10 lbs lifting, use LE to stand, brace chest when coughing 2. HR, BP, PRE, Bedside ADL, COPM, visual analog, ROM, Beck depression, work tolerance, activity card sort --\> educate which are within his MET levels 3. Resumption of ADLs, early mobilization, psych support, simple disease education, issues regarding recovery, activity tolerance, cardiopulmonary function, EC, environment modification, task simplification, pacing, ROM, proper body mechanics, AE 4. Family education, awareness of nutritional restriction, wt checks, use time in Phase I to prepare him for Home program, care of surgical incision, understand signs/sx risk factors and activity intolerance 5. MET activity and exercise guidelines, WS pacing, temp precautiosn, social activity, sexuality, signs and symptoms of exercise intolerance and for discussion of risk factors, stress management, medication management, incision care, HO to remind of education (precautions, MET levels), nutrition plan

Answer 182

Med surveillance and assessment of an individuals cardiovascular response to exercise, limit the physiological and psychological effects of heart disease, instruct on risk factors for heart disease and how to reduce their impact, max pscyhosocial and vocational status, take a careful Hx to determine risk stratification based on teh bpatient's ejection fraction, hospital course, HR and BP, Sx and/or possible EKG, MAHR, BPRE scale, exercise goals (b/w 5-6 METS), moitor depression, breating techniques, time management, self-monitoring, strengthening, ROM, proper body mechanics, breathing, EC/WS, HEP, stress management/relaxation

Answer 183

goal setting for risk management, informal disease education, group support encouraging heart healthy habits, leisure exploration, exercise

Competency Exam 3 Flashcards

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