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81 Cards in this Set
- Front
- Back
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Hemorrhage
Ruptured Berry aneurysm: |
endovascular coil placement/clipping
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Hemorrhage
Arteriovenous malformation: |
embolization/surgical resection/radiation
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Hemorrhage
Hypertensive hemorrhage: |
conservative
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Hemorrhage
Hemorrhage due to amyloid angiopathy: |
conservative
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how to treat
Lacunar infarction: |
risk factor management (HTN, DM, smoking) + atheroma prophylaxis (ACEi/ARB, statin) + Aggrenox
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what are risk factors for stroke?
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HTN
diabetes smoking previous stroke |
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how to treat:
Large vessel distribution infarction Artery to artery thromboembolism: |
risk factor management + atheroma prophylaxis + Aggrenox ± carotid endarterectomy
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how to treat:
Large vessel distribution infarction Systemic embolism: |
chronic anticoagulation
Cardiac pathology Clotting diathesis |
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Features of Large Vessel Infarcts
what happens if in Left Hemisphere?(4) |
1. Aphasia
2. Apraxia - loss of the ability to execute or carry out learned purposeful movements, despite having the desire and the physical ability to perform the movements. 3. Impaired calculation 4. Heightened emotionality |
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Features of Large Vessel Infarcts
what happens if in Right Hemisphere?(5) |
1. Hemispatial neglect
2. Anosognosia - condition in which a person who suffers disability seems unaware of or denies the existence of his or her disability 3. Anosodiaphoria - condition in which a person who suffers disability due to brain injury seems indifferent to the existence of their handicap. 4. Flattened affect - a lack of emotional reactivity on the part of an individual. 5. Visuospatial dysfunction |
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Features of Large Vessel Infarcts
Posterior circulation (3) |
1. Lateral medullary infarction
2. Top of the basilar infarction 3. Basilar thrombosis |
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Features of Lacunar Infarcts
1. Normal higher ___ function 2. No ___ 3. Normal ___ 4. Electroencephalographic features 5. Characteristic clinical syndrome (3) |
1. cortical
2. hemianopia 3. graphesthesia 4. 5. -Pure sensory stroke -Ataxic hemiparesis -Sensorimotor stroke |
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Characteristic clinical syndrome
-Pure sensory stroke -Ataxic hemiparesis -Sensorimotor stroke Features of ___ Infarcts |
Lacunar Infarcts
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Infarction
1. Large Vessel (3) 2. Lacunar |
1. Artery to artery embolism;
2. cardiogenic embolism; 3. systemic clotting diathesis |
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Top-down model for Neurological Rehabilitation
1. Participation = ___ 2. Activity = ___ 3. Body structure/function = ___ 4. Health condition = ___ |
1. Roles - Employer/employee, Community service/volunteer, Hobbies/past-times/social activities, Retirement plans, Wife/Husband/Daughter/Son/Father/Mother
2. Skills - The ability to achieve a desired outcome with consistency, flexibility, efficiency (physical and cognitive). The outcome of therapy is the development of skill. What skills do they need to return to that role? Walk, run, jump, roll, crawl, climb, ascend/descend stairs. get out of bed, sit in a chair/out of chair, push/pull/lift/grasp, pick up/carry objects, bend over/stoop down, use a keyboard, drive 3. Resources - what resources do they need to acquire those skills? muscle strength, ROM, coordination, cognition, sensation, speech/language 4. Recovery |
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___ is the ability to achieve a desired outcome with
-consistency -flexibility -efficiency (physical and cognitive) the outcome of therapy is the development of ___ |
Skill
Skill |
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"Independence" does not mean that you are ___
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skilled
"independent" does not mean our jobs are over |
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Implications of a Top-Down Model
intervention is derived from ___ 1. What is the individual's ___? 2. What ___ do they need to return to that (answer from 1)? 3. What ___ do they need to acquire those (answer from 2)? |
who the person IS
1. Role (participation) 2. Skills (activity) 3. Resources (body structure/function) |
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Primary Impairments in ___
Changes in muscle strength (paralysis or weakness) Changes in muscle tone (hypotonicity/hypertonicity) Changes in muscle activation (inappropriate timing of firing, difficulty sequencing, inappropriate initiation) Changes in sensation (awareness/interpretation) |
Resources (Body Structure/Function)
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Primary Impairments in ___
Visual Cognition Emotion Perception Depression Speech/language |
Resources (Body Structure/Function)
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Primary Impairments in ___
Orthopedic changes in alignment and mobility Changes in muscle and soft tissue length Pain Edema |
Resources (Body Structure/Function)
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Risk Factors for Stroke ___
1. Family history 2. Race 3. Age 4. Gender 5. Previous stroke or ___ 6. ___ fibrillation 7. ___ valve abnormalities 8. ___ disease |
non-modifiable
5. Heart attack 6. Atrial fibrillation 7. Cardiac valve abnormalities 8. Coronary artery disease |
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risk factors for stroke
___ Hypertension Diabetes High cholesterol Obesity Decreased physical activity Cigarette smoking Cocaine use Heavy alcohol consumption |
modifiable
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Stroke Warning Signs
1. sudden ___, unilaterally 2. sudden ___, speaking/understanding 3. sudden trouble ___ in one/both eyes 4. sudden trouble walking, ___, or coordination 5. sudden severe ___ with no known cause |
1. numbness/weakness
2. confusion 3. seeing 4. dizziness, loss of balance 5. headache |
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Acute Care Hospital
Length of stay: ___ days; until medically stable What is the role of PT? 1. Determination of further ___ 2. Coordination/communication with other ___ 3. Positioning 4. Getting the patient ___ 5. Patient/family ___ |
2-7 days
Role of physical therapy: 1. services 2. health care professionals 3. 4. upright 5. education |
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Admission to Inpatient Rehabilitation?
1. Medical ___ 2. Ability to sit upright for ___ 3. Ability to actively participate in ___ 4. Presence of a ___ 5. Limitations in ___ area/domain |
1. stability
2. one hour 3. rehabilitation 4. functional deficit 5. more than one |
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Acute Inpatient Rehabilitation
Length of stay: ___ days Role of physical therapy 1. Patient/family ___ 2. ___ training (gait, stairs, transfers, bed mobility) 3. Identification of ___ needed to return to role 4. Restitution of ___ as they relate to skills (resources) 5. Determination of Durable ___ (WC, orthotic device, assistive device |
7-21 days
1. education 2. Mobility 3. skills 4. impairments 5. Medical Equipment |
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Sub-Acute Inpatient Rehabilitation
Length of stay: ___ days Role of physical therapy 1. Patient/family ___ 2. Positioning 3. ___, especially shoulder and ankle; prevention of ___ 4. Getting patient ___ 5. ___ endurance 6. ___ training |
14-28 days
1. education 2. 3. ROM; contractures 4. upright 5. Sitting 6. Mobility |
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Long-Term Care Facility
Length of stay: ___ Role of physical therapy 1. Education of ___ 2. Patient/family education 3. Patient ___ of bed 4. Sitting/standing ___ 5. Monitor ___, especially shoulder and ankle; prevention of ___ |
indefinite
1. facility staff 2. 3. upright/out 4. endurance 5. ROM; contractures |
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Home Health
Length: ___ weeks Role of physical therapy 1. Evaluate patient’s ability to ___ 2. Evaluate potential ___ to ensure safe negotiation of home 3. Practice tasks in ___ 4. ___ development/return to independence 5. Patient/family education |
4-6 weeks
1. negotiate home 2. hazzards/make recommendations 3. real-life situation 4. Skill 5. |
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Outpatient Rehabilitation
Length: ___ weeks Role of physical therapy 1. Endurance 2. ___ training – adaptive environments 3. ___ development/return to independence 4. Patient/family education |
3-6 weeks
1. 2. Gait 3. Skill 4. |
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Timing of Stroke Rehabilitation
rehabilitation therapy should start as early as possible, once ___ is reached strong correlation between early admission to stroke rehabilitation and ___ |
medical stability
improved functional outcomes |
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Intensity of Rehabilitation
1. ___ answer to this 2. “more is better” – ___ 3. positive benefits associated with ___ treatment intensities, not always maintained over time 4. more important question – ___ of the intervention |
1. not a definitive
2. maybe/maybe not 3. greater 4. nature |
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Predicting Stroke Recovery
Will everyone recover the same? Can I predict how a patient will do? What factors contribute to stroke recovery? |
cool
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Levels of Stroke Severity
1. The most powerful predictor of functional recovery is ___ 2. ___ also a predictor of functional recovery, but not in and of itself (recover at a slower rate). |
1. initial stroke severity
2. Age |
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Levels of Stroke Severity
___ Band – early (5-7 days post-onset) FIM score > 80; ___ stroke |
Upper Band
mild stroke |
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Levels of Stroke Severity
___ Band – early (5-7 days post-onset) FIM score 40 – 80; ___ stroke |
Middle Band
moderately severe stroke |
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Levels of Stroke Severity
___ Band – early (5-7 days post-onset) FIM score < 40; ___ stroke |
Lower Band
severe stroke |
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___ Index
Range: ___ Feeding Bathing Grooming Bladder control Bowel control Walking/wheelchair Stair climbing Chair/bed transfers Dressing toileting |
Barthel
0-100 |
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Predicting Stroke Recovery
(“Stage ___”) 1. ___ (no movement or associated rx only) 2. bowel/bladder ___ 3. severe sensory ___ 4. severe perceptual/motor deficits 5. moderate to severe ___ deficits 6. impaired ___ balance 7. major ___ 8. Barthel Index ___ 9. Burden of care: ___ |
“Stage 1”
1. hemiplegia 2. incontinence 3. deficits 4. 5. cognitive 6. sitting 7. comorbidities 8. < 60 9. caregiver will provide majority of assistance |
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Predicting Stroke Recovery
(“Stage ___”) 1. hemiplegia (associated rx only, minimal voluntary movement, movements only within ___) 2. ___ incontinence 3. moderate ___ deficits 4. mild ___ deficits 5. impaired ___ balance 6. major comorbidities 7. Barthel Index ___ 8. Burden of care: ___ |
“Stage 2”
1. synergy pattern 2. bladder 3. cognitive 4. sensory 5. standing 6. 7. at least 60 8. caregiver will provide partial assistance |
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Predicting Stroke Recovery
(“Stage ___”) 1. hemiplegia (movements ___ patterns) 2. continent of bowel/bladder 3. ___ sensory deficits 4. mild or no cognitive deficits 5. good ___ balance 6. limited number of comorbidities 7. Barthel Index ___ 8. Burden of care: ___ |
“Stage 3”
1. out of synergy 2. 3. mild or no 4. 5. standing 6. 7. > 60 8. caregiver will need to provide little to no assistance |
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Predicting Stroke Recovery
(“Stage ___”) 1. slight ___ (individual joint movements possible) 2. continent of bowel/bladder 3. no ___ deficits 4. ___ balance 5. limited number of comorbidities 6. Burden of care: ___ |
“Stage 4”
1. hemiparesis 2. 3. sensory 4. good 5. 6. none |
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Acute Care Hospital
Length of stay: ___ days; until medically stable Role of physical therapy: Determination of further services (___) Coordination/communication with other health care professionals Positioning Getting the patient upright Patient/family education |
2-7
Discharge planning |
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Role of the Acute Care Physical Therapist
Responsibilities: Discharge Planning Communication and Coordination with other disciplines Assessment of patient Patient and family education Prevention of secondary impairments Interventions |
neat!
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Discharge Planning
Ultimately we are preparing the patient for the next level of care |
Sometimes, physicians consult PT specifically for discharge recommendations:
Meaning, is the patient safe to discharge home today? Must use your evaluative skills, communication skills with the patient and family, and coordination with other services to make your clinical decision. |
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Admission to Inpatient Rehabilitation?
1. Medical stability 2. Ability to sit upright for one hour (Tolerate therapy ___) 3. Ability to actively participate in rehabilitation (Follow a ___ command) 4. Presence of a ___ 5. Limitations in ___ area/domain |
1.
2. 3hrs/day 3. 2-3 step 4. functional deficit 5. more than one |
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Guidelines for Discharge
Subacute Rehabilitation 1. Require ___ disciplines 2. Unable to ___ therapy for 3hrs/day 3. Tolerate ___ 4. Decreased participation 5. Difficulty/Unable to follow commands (Low level of ___) 6. Unable to return ___, caregiver ___ |
1. 2/3
2. tolerate 3. 1-2hrs/day 4. 5. consciousness 6. home alone; unable to provide assistance |
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Guidelines for Discharge
Home 1. Deficit in ___disciplines 2. Supportive family available to assist after discharge 3. ___ Assessment = Assess basic cognitive function and IADL assessment |
1. 1 out of 3
2. 3. Occupational Therapy |
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Guidelines for Discharge
Home Home health versus Outpatient? Outpatient 1. Achieving ___ distances with gait 2. Ability to receive ___ to clinic Home health 3. Provided to patients considered ___ once discharged. 4. May have assistance at home, but ___ in mobility and family training needed for safety with mobility. |
1. community
2. transportation 3. home bound 4. dependent |
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Who’s part of the Team?
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PATIENT
Family Case Manager Nurses Physician Assistant/Nurse Practitioner Physicians Occupational Therapist Speech Language Pathologist Respiratory Therapist Nutrition Dietician Psychologists Social Worker Clergy |
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Methods of Communication
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Direct, verbal communication
Computer documented evaluations and progress notes Multi-disciplinary team meetings Paper chart Plan of Care Specific to Shands hospital |
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Ultimate Goal of a Team Approach?
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Addressing the Patient as a whole
Providing the patient with the available needed resources Minimizing risk for the patient Reduce barriers Providing Quality care Safe and effective discharge |
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Medical Information: Etiology
Hemorrhagic (3) - hemorrhage/blood leaks into brain tissue |
Subdural Hematoma
Subarachnoid Hemorrhage Intracranial Hemorrhage |
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Medical Information: Etiology
Ischemic - clot stops blood supply to an area of the brain |
Embolus
Thrombus |
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This is a ___
Temporary state of ___ to an area of the brain. Stroke-like symptoms for less than 24 hrs, usually ___ hours. Can be a warning sign that a true ___ may happen. |
Transient Ischemic Attack
reduced blood flow 1-2 hours stroke |
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Assessment: Acute Care Approach
Reviewing the medical information What ___ was involved? Which ___ of the brain? What ___ may you expect to observe? |
blood vessel
side impairments |
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Assessment: Acute Care Approach
Considerations for patients post-stroke Fatigue Difficulty with ___ Challenge with following ___ 1st time out of bed may be with you!! |
communication
commands |
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Assessment: Acute Care Approach
Assessment begins as soon as you look at the patient and environment What lines are connected to the patient? What is the physical position of the patient? Is family present? Is the cute nurse/murse single? |
cool!
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Assessment: Acute care Approach
Approach to an acute care evaluation is different! Key areas to assess: 1. Arousal, alertness, attention 2. Communication 3. Active movement of the ___ side 4. Gross mobility 5. Prior level of function/Social support/Home environment |
1.
2. 3. paretic 4. 5. |
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Key areas to assess
how to assess: Arousal, alertness, attention |
Introduce yourself using voice, gesture
Does the patient acknowledge your presence? Can they shake your hand? If they don’t shake your hand, could they if you asked them to? |
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Key areas to assess
how to assess: Communication |
Does the patient verbally/nonverbally respond?
Do they present with aphasia? |
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Key areas to assess
how to assess: Active movement |
Do they spontaneously or purposefully move their paretic side?
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Key areas to assess
how to assess: Gross mobility |
How do they present in bed?
Can they readjust their position if you ask? |
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Key areas to assess
how to assess: Prior level of function/Social Support/Home environment |
Can the patient give you an accurate history?
May need to seek family for these answers Important for discharge recommendation |
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Tests and Measures:
Active and Passive ROM Muscle strength Manual Muscle Test? Sensation: ___ Dermatomes Domains: Light touch, deep pressure, proprioception May be unable to formally test Unexpected pain/pressure/touch |
Not dermatomes!
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Tests and Measures
Acute care mobility measure |
FIM - Initial evaluation and discharge
Type of assistive device |
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Tests and Measures
Activity Tolerance |
Vital signs: pre and post activity
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Tests and Measures
Balance |
Berg Balance Scale
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Tests and Measures
Gait analysis |
10 meter walk test for gait speed
impairments? |
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Patient and Family Education
What is the role of the patient in their care? Is the family involved? Extremes -What do you think the family may be doing? Education -Therapeutic exercises/ROM -Positioning -Precautions -Risk of secondary impairments -Importance of engaging patient’s attention from paretic side Methods of education |
great!
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Prevention of secondary impairments
what secondary impairments are you trying to prevent? 1. Deep Vein Thrombosis 2. Skin ___ (Positioning) 3. Loss of ROM/Joint ___ (Joints most at risk: ___,___) 4. Shoulder pain/Subluxation 5. Falls 6. ___ complications 7. ___ from prolonged bed rest |
1.
2. breakdown 3. contracture; ankle, shoulder 4. 5. 6. Respiratory 7. Deconditioning |
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Secondary Impairments
Loss of ROM/Joint contracture which joints are at most risk?(2) |
1. ankle
2. shoulder |
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Acute Care Intervention
Positioning |
Can be therapeutic and assist in preventing secondary complications.
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Acute Care Intervention
Gross mobility tasks |
Bed mobility
Sitting and Standing Balance Transfers Gait/Stairs |
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Acute Care Intervention
Mobility tasks in conjunction with ADL’s |
Example: Standing balance while brushing teeth
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Acute Care Intervention
Goals of intervention in Acute Care with patients post-stroke (2) |
1. Prevent secondary complications
2. Improve the patient's level of function that allows for a safe discharge to the next level of care. |
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Nutrition and diet can be a major factor in skin ___. Inadequate nutrition can lead to ___.
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breakdown
poor healing |
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The ___ is important to discuss concerns with the patient and family regarding financial assistance, lack of social support when the patient is discharged, and other needs that may be met in the community.
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social worker
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The ___ is someone with a nursing background that now coordinates the discharge and financial planning of the patient while hospitalized. This person will become very close to you in that they have to know your recommendations for discharge to get that process started by contacting insurance companies and facilities.
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Case manager
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Severely impaired: aneurysm rupture; low levels of consciousness, ICU care, may be on ventilator, several lines, stable enough to initiate therapy (with an activity order for oob), impaired sitting balance, risk for 2ndary impairments, total assist.
Moderately impaired: Most typical we treat and try to prepare for inpatient rehab. May see deficits in gross motor ability, cognition, strength, dual tasking, but can usually tolerate upright treatment sessions, 1-3 hrs/day. Mildly impaired: TIA; mild gait deficit, may benefit from AD to safely d/c home and f/u with OPPT. Work on balance, fall risk assessment, higher level mobility such as stairs, minor incoordination. |
awesome!
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