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71 Cards in this Set
- Front
- Back
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Levels of Communication- 4
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Intrapersonal
What we absorb from our environment which ultimately forms a thought/idea Interpersonal One on one Small group discussion Team/Family meetings Interprofessional/Interdisciplinary meetings Organizational communication Intradepartmental/Interdepartmental meetings Egos, personal agendas, professional differences |
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Attentive/Active Listening
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Evaluating the patient’s tone of voice
Observing non-verbal cues Listening for the main theme of the message Focusing on content rather than delivery Provide verbal feedback to clarify understanding |
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teach back
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Teach-back in verbal communication improves patient understanding and outcomes
“Just so I make sure I explain things well, can you tell me what we covered today for your home exercises?” |
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kleinmans questions
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Kleinman's Questions:
1. What do you think caused the problem? 2. Why do you think it happened when it did? 3. What do you think your sickness does to you? How does it work? 4. How severe is your sickness? Will it have a short course? 5. What kind of treatment do you think you should receive? 6. What are the most important results you hope to receive from this treatment? 7. What are the chief problems your sickness has caused for you? 8. What do you fear most about your sickness? |
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pain
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Unpleasant sensory and emotional experience
actual or potential tissue damage described in terms of such damage.” |
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cause of pain
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Perception or identification of stimuli as painful
Subjective sensation Expectations, past experience, anxiety, suggestions Affective – own emotional factors Behavioral – how one expresses or controls pain Cognitive – one’s beliefs about pain Activation of specific types of nerve fibers – due to mechanical, thermal, & chemical energy |
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Nociceptors
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Pain specific nerve endings in the periphery
Fire in response to potential tissue damage Found in skin and musculoskeletal (MS) system Consist of free nerve endings Activates afferent nerves Aδ and C fibers Transmit signal to the central nervous system |
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Aδ fibers
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Respond to mechanical & thermal stimulation
Carry intense pain quickly, short duration Withdrawal reflexes Myelinated,fast & big(relative the C fibers) |
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C fibers
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Respond to chemical, mechanical & thermal stimuli
Carry long-term throbbing & chronic pain messages Unmyelinated, slower & small |
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Non-nociceptors
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nerves that don’t transmit pain
Large-diameter Aß fibers Inhibit the effects of firing by Aδ & C fibers ‘close the gate’ via activation of the Substantia gelatinosa (SG). This inhibits ascending response at the spinal cord level |
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nociceptors vs. non-nociceptors
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Nociceptors
Aδ and C fibers Transmit pain Open the ‘gate’ Small diameter non nociceptors Aß fibers Don’t transmit pain Close the ‘gate’ Large diameter |
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Ascending (afferent) pathway
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Ascending (afferent) pathway
Transmit impulses from the periphery to the brain 1st order neurons Sensory receptors to the dorsal horn of the spinal cord 2nd order neurons Dorsal horn along the Spinothalamic tract to thalamus 3rd order neurons Thalamus to the specific brain centers (cerebral cortex) |
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1st order neurons
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1st order neurons
Sensory receptors to the dorsal horn of the spinal cord |
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2nd order neurons
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2nd order neurons
Dorsal horn along the Spinothalamic tract to thalamus |
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3rd order neurons
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3rd order neurons
Thalamus to the specific brain centers (cerebral cortex) |
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Descending (efferent) pathways
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Descending (efferent) pathways
Transmit impulses from the brain to the periphery (spinal cord) Controls intensity and frequency of ascending tract cell firing Can inhibit the ascending tract via interneurons in the dorsal horn Cognitive & emotional factors can inhibit or enhance this activity Relaxation, meditation, imagery, etc. |
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neurotransmitters
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Neurotransmitters
Chemical substances used to communicate between neurons Examples: dopamine, serotonin, norepinephrine, gamma-aminobutyric acid (GABA) Released with nerve impulses & bind/activate a specific sensory receptor Can either be excitatory or inhibitory |
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sensory receptors: 4 types and what they do
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Mechanoreceptors
Touch, light/deep pressure Thermo receptors Hot and cold Proprioceptors Change in length or tension Nociceptors Painful stimuli |
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nerve endings
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Nerve Endings
Termination of a nerve fiber in a structure Can be sensory or motor |
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peripheral mechanisms that modulate pain
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Peripheral mechanisms that modulate pain
Inflammatory response Inflammatory mediators ↑ peripheral nociception Sensitization of nociceptors Repeated stimuli ↓threshold to stimulation Allodynia: non-painful stimuli can be perceived as painful Peripheral nerve injury If nerve regeneration is blocked, neuromas form Neuromas are sensitive to mechanical stimuli |
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inflamatory response does what to nociceptors
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Peripheral mechanisms that modulate pain
Inflammatory response Inflammatory mediators ↑ peripheral nociception |
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sensitization of nociceptors
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Sensitization of nociceptors
Repeated stimuli ↓threshold to stimulation Allodynia: non-painful stimuli can be perceived as painful |
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peripheral nerve injury
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Peripheral nerve injury
If nerve regeneration is blocked, neuromas form Neuromas are sensitive to mechanical stimuli |
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pain theories
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1874 – Intensive (summation) theory
1895 – Specificity theory 1895 – Strong’s theory 1943 – Central Summation theory 1940’s – 4th Theory of pain 1965 – Gate control theory Central Biasing theory Endogenous Opiate theory |
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intensive summation theory
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Excessive stimulation of the sense of touch
Based on intensity Further classified to add central summation |
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Specificity Theory
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Function of the amount of physical damage alone
Sensation is specific to physical location of stimulus Lead to ‘cutting out’ pain |
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Strong’s Theory
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Noxious stimulus and psychic reaction or displeasure provoked by the sensation
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Central Summation Theory
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Intense stimulation due to nerve/tissue damage activated fibers that projected into spinal cord
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4th Theory of Pain
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Expanded on Strong’s theory
2 components of pain Perception of pain Reaction to it 2 individuals could have the same stimulus and react differently. Agree?? |
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Gate Control Theory (Melzack & Wall)
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Pain can be modulated through alternative input to the nervous system
Dorsal horn acts like a gate that can increase or decrease the flow of nerve impulses from peripheral fibers --> spinal cord cells --> brain Large-fiber(1st order neurons) inputs close the gate Small-fiber(1st order neurons) inputs open the gate |
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Gate Control Theory
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SG (2nd order neuron) acts as the gate
Pain also controlled by descending influences from the brain They can inhibit nociceptors directly or indirectly |
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Gate Control Theory
Activating non-nociceptive fibers can The relative rate of firing of the C and Aß fibers determines |
Activating non-nociceptive fibers can interfere with signals from pain fibers, thus inhibiting pain.
The relative rate of firing of the C and Aß fibers determines the response of the projected neuron response |
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Stimulation of Aß nerves can--------- pain
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Stimulation of Aß nerves can inhibit pain
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Non-painful stimulus can ------------transmission of the noxious stimulus
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Non-painful stimulus can block the transmission of the noxious stimulus
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gate theory pain interventions
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Interventions:
Massage Ice/heat Electrical stimulation (e-stim) Skin-to-Skin (Kangaroo Care in NICU) |
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Central Biasing Theory
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Higher centers(cerebral Cortex) can control the perception of and response to pain
It can determine which stimulus is ignored over time Closes the gate and blocks pain transmission PT Intervention: E-stim |
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Endogenous Opiate Theory
A stimulus causes the release of -------from the local sites in the --------from the -------into the----------- this causes decrease in pain by blocking the-------------- fibers pt intervention- |
A stimulus causes the release of encephalin from the local sites in the CNS and ß-endorphin from the pituitary gland into the spinal fluid
This causes a decrease in pain by blocking the Aδ & C fibers PT intervention: TENS for 30+ mins. |
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Clinical Presentation of Pain
PAIN |
Observation
Pain behaviors Description (Subjective) Pattern: Onset & Duration Area: location Intensity: level Nature: Description/type |
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know ransford pain drawing and
visual analog scale for pain other pain questionaires: 4 |
McGill Pain Questionnaire
Assess overall intensity of pain experience Dallas Pain Questionnaire Assess amount of chronic spinal pain affecting different aspects of life Oswestry Low Back Disability Questionnaire Assess person’s perceived disability Brief Pain Inventory (BPI) Assess intensity of pain and degree to which it interrupts function |
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Passive modalities
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Passive modalities
Heat, cold, manual therapy, e-stim |
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indirect treatments
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Indirect treatment
Address physical impairments Decreased ROM, deceased strength, muscle imbalance, tissue restriction, inflammation, poor posture Therapeutic exercise Increase strength and ROM but also circulation |
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goals of pain management
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Reduce pain
Eliminate pain Control acute pain Manage chronic pain Prevent further injury |
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Vital signs:
Temperature, pulse rate, RR, BP newborn |
Temp:98.6-99.8
Pulse: 120-160 RR: 30-80 BP: 80/40 |
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Vital signs:
Temperature, pulse rate, RR, BP 3 y/o |
Temp:98.5-99.5
Pulse: 80-125 RR: 20-30 BP: 98/64 |
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Vital signs:
Temperature, pulse rate, RR, BP 10 y/o |
Temp:97.5-98.8
Pulse: 70-110 RR: 16-22 BP: 110/58 |
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Vital signs:
Temperature, pulse rate, RR, BP 16 y/o |
Temp:97.6-98.8
Pulse: 55-100 RR: 15-20 BP: 80/40 |
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Vital signs:
Temperature, pulse rate, RR, BP adult |
Temp:96.8-99.5
Pulse: 60-100 RR: 12-20 BP: 80/40 |
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Vital signs:
Temperature, pulse rate, RR, BP geriatric |
Temp:96.5-97.5
Pulse: 60-100 RR: 15-20 BP: 120/80 to 160/95 |
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yellow flags- bp hypotension
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Yellow flag: Dizziness; syncope (fainting); lack of concentration; blurred vision; nausea; cold, clammy, pale skin; rapid, shallow breathing; fatigue; depression
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Review of Systems vs. Scan Exam
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Systems Review
Quick investigation of each system Quick investigation of each system Not diagnostic-R/O further examination/referral (comprehensive exam as a doctoring profession) Impairments indicate further tests & measures to diagnose source of pain/dysfunction Scan Exam Investigate an area of the body (e.g. spine, extremity) Investigate an area of the body (e.g. spine, extremity) Diagnostic-R/O symptoms that are referred from one body part to another (e.g. serious pathology, differential diagnosis) Special tests & measures to differentially diagnose source of pain/dysfunction |
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Review of systems- Musculoskeletal
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impairments search
ROM Strength Symmetry of movements (posture) Observe for signs of pain or impairments Perform known provocative assessments last |
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Break test-Isometric Strength Tests
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Assess strength of primary muscle groups & check for more severe neurological problems at the same time
Test one muscle group for each MYOTOME (each spinal nerve root level) Stabilize proximal joint(s) & provide force distally without crossing the joint Test the joint in mid range if possible Use proper verbal/tactile cues Give progressive resistance up to max using proper force & form Be repeatable / reliable |
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Upper Quadrant Myotome Levels
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C2 – Neck Flexion
C3 – Cervical side-bending C4 – Shoulder elevation (upper traps) C5 – Shoulder abduction (deltoids) C6 – Elbow flexion (biceps) & wrist extension C7 – Elbow extension (triceps) & wrist flexion C8 – Finger flexion, thumb extension or abduction T1 – Finger abduction & adduction (dorsal & palmer interossei) |
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Lower Quadrant Myotome Levels
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L2 – Hip Flexion (Iliopsoas)
L3 – Knee Extension (Quadriceps) L4 – Ankle Dorsiflexion & inversion (Anterior Tib) L5 – Toe Extension (Extensor Hallicus Longus), extensor digitorum (heel walk), gluteus medius S1 –Hip extension (gluteus maximus), Ankle plantar flexion with ankle eversion (walk on toes gastroc-soleus & peroneals) |
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spinal tract sensory
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Sensory
Spinothalamic – non-discriminatory sensation (pain, temp) Dorsal column – discriminatory sensation / localization |
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spinal tract motor
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Motor
Corticospinal - major Reticulospinal Vestibulspinal |
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sensory receptors
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Cutaneous
Deep Sensory Muscle Joint Thermoreceptors Nociceptors |
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Neurosensory- Motor Dysfunction-
CNS PNS |
CNS
Stroke Traumatic brain injury Spinal cord injury Parkinson’s disease PNS Trauma “Pinched nerve” Spinal nerve root Carpal tunnel syndrome Diabetic neuropathy |
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neurovascular screening- 5 P's
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Pain- persistent pain not relieved by pain medication and slowly worsening
Pulses-absent pulses indicative of decreased blood flow Parathesia- assessment of sensation via light touch near and distant to affected area. Paralysis- movement is assessed by having patient flex and extend each joint Pallor- condition that is result of decreased hemoglobin and is visible in skin and mucosa. Assessed by checking the temperature of limb and noting color |
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Sensory Examination
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Preliminary Tests
Arousal Attention span Orientation Cognition Memory Hearing and visual acuity |
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Cognition- fund of knowledge
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Fund of knowledge
Factual information; “In which state is Boston?” |
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Cognition
calculation ability |
Calculation ability
Simple math (addition, subtraction, multiplication, division) |
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Cognition-proverb interpretation
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Proverb interpretation (culturally dependent????)
Example: “a rolling stone gathers no moss” Alternative / problem solve “if Sally is taller than Johanna, and Johanna is taller than Bob, who is taller Bob or Sally?” |
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Rating of Coordination
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4 – normal
3 – minimal impairment 2 – moderate impairment (slow, awkward) 1 – severe impairment (unable to complete) 0 – unable to attempt / impossible |
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Finger-to-nose
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If impaired Dyssynergia
“impaired coordination of muscular contractions / movement” (i.e. sequence is impaired) |
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Pronation / supination
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If impaired Dysdiadochokinesia
“Impaired ability to perform rapid alternative movements” |
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Slide heel-on-shin
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If impaired Dysmetria
“impaired ability to judge the distance or range of movement” |
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Deep Tendon Reflexes
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Reflex “involuntary, predictable and specific response”
DTR elicited from stimulation of stretch sensitive afferents MUST test both sides Technique is VERY important |
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Edema
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Palpation/pitting scale
1+ indentation barely detectable 2+ slight indentation visible when skin is depressed returns to normal in 15 s. 3+ deeper indentation occurs when pressed and returns to normal in 30 s. 4+ indentation lasts for more than 30 s. |
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Tests for DVT
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Homan’s sign – “quick and dirty” test
Passively DF ankle with knee extended and squeeze gastroc / + pain Cuff Test – better BP around calf and inflate to 40 mmHg / + pain Best Doppler US Venography Imaging |
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Proprioception-
kinesthesia=- |
Proprioception-awareness of position
kinesthesia=-awareness of movement |
