PTEACS Comp Exam

What effects does immobility have on the integumentary system?

Pressure sores

Decreased sensation

Altered cognition

Decreased ability to move

How do we prevent pressure sores?

Positioning: decrease bony prominence pressure

Frequent position changes (assist every 2hrs, wheelchair users every 15-20 mins)

Clean environment

Nutrition

What effects does immobility have on the musculoskeletal system?

Osteopenia: lose up to 1% total bone mass weekly, 30-40% overall

Heterotopic ossification

Osteomyelitis

Skeletal deformity

Joint contractures (can occur after 5 days of immobilization)

Muscle (10-15% strength lost weekly, up to 50% in 3-5 weeks)

How do we prevent musculoskeletal effects due to immobility?

Encourage activity, exercise, weight bearing

Tilt table may be used to move towards upright position

Active exercise and patient movement

Regularly change position

Full passive ROM in joints

Change position every 2 hours

What effects does immobility have on the digestive system?

Poor appetite (decreased peristalsis, poor abdominal activation)

Constipation

Dehydration

What effects does immobility have on the urinary system?

Urinary incontinence

Bladder and urinary tract infections

Kidney and bladder stones

What effects does immobility have on the cardiovascular system?

Deep vein thrombosis

Pulmonary embolism

Orthostatic hypotension

What effects does immobility have on the respiratory system?

Pneumonia

Pulmonary embolism

How do we prevent immobility effects on the respiratory system?

Breathing exercises

Coughing exercises

Movement

What effects does immobility have on the nervous system?

Anxiety

Depression

Confusion

Insomnia

Intellectual ability lost

What is the purpose of positioning?

Prevents soft tissue injury, pressure, and joint contracture

Provides patient comfort

What are the common sites of contractures in supine?

Hip and knee flexors

Ankle plantar flexors

Shoulder extensors, adductors, and internal rotators

Hip external rotators

What are the common sites of contractures in prone?

Ankle plantar flexors

Shoulder extensors, adductors, and internal/external rotators

Neck rotators, left or right

What are the common sites of contractures in side-lying?

Hip and knee flexors

Hip adductors and internal rotators

Shoulder adductors and internal rotators

What are the common sites of contractures in sitting?

Hip and knee flexors

Hip adductors and internal rotators

Shoulder adductors, extensors, and internal rotators

Note: forearm, elbow, wrist, and finger contractures can develop, depending on the position used

What are the important considerations of preventive positioning?

Reduce pressure over bony prominence

Linen should be clean and free of folds or wrinkles beneath the patient

Maintain proper body alignment

Maximum duration in a position should not exceed 2 hours

If WC bound, patients should reposition themselves at 10-15 minute intervals

What are common sites of pressure sores in supine?

Back of head

Posterior calf

Sacrum

Scapulae

Heels

Spinous processes

Elbows

What are common sites of pressure sores in prone?

Dorsum foot/ankle

Knees

Thigh

Iliac Crest

Anterior Chest

Acromion Process

Cheek and ear

What are common sites of pressure sores in side-lying?

Greater trochanter

Medial and lateral condyles

Ears

Ribs

Malleolus

Acromion process

What are common sites of pressure sores in sitting?

Heels

Sacrum/Coccyx

Plantar foot

Scapula

Popliteal

Ischial tuberosities

What are special positioning considerations for transfemoral amputations?

Avoid prolonged hip flexion

Avoid elevation of residual limb (RL) for more than a few minutes

Limit sitting to 40 minutes of each hour

Avoid hip abduction

Maintain residual limb in extension

Ideal resting position: Supine w/ hip in neutral flexion and neutral abduction

What are special positioning considerations for transtibial amputations?

Avoid prolonged hip and knee flexion

Avoid elevation of RL (no more than a few minutes keeping knee in extension)

Limit sitting to 40 minutes of each hour

Maintain the RL in extension

Encourage periodic prone lying

Ideal resting position: Supine w/ hip in neutral flexion and knee in extension

What are special positioning considerations for hemiplegia?

Avoid prolonged shoulder adduction and internal rotation, elbow flexion, forearm pronation/supination, and wrist, finger, and thumb flexion/adduction

Avoid prolonged hip and knee flexion, hip adduction and external rotation, and ankle plantar flexion and inversion

What are special positioning considerations for Rheumatoid arthritis?

Avoid prolonged immobilization of involved joints

Protect bony prominences

Perform careful and gentle exercises several times a day

What are special positioning considerations for burns?

Avoid prolonged positions for affected joints

Avoid positions of comfort

Perform gentle, careful, and frequent exercises

What are special positioning considerations for total knee replacement?

Maintain the affected knee in extension

Neutral hip rotation

What are special positioning considerations for total hip replacement?

Avoid hip adduction past neutral

No excessive hip rotation: maintain neutral

Prevent hip flexion beyond 90 degrees

Define restraints

Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition

What is the purpose of restraints and key considerations?

When a patient is at risk of self-harm or harm to others, for protective positioning

Should only be used when less restrictive interventions have been tried and found to be ineffective

Must be prescribed by a Physician or other approved independent practitioner

A new order must be prescribed every 24 hours

Once a patient is placed in restraints, face to face evaluation must be completed by the ordering health care provider within 1-hour

What is the purpose of draping?

Provides modesty for the patient

Helps patient maintain appropriate body temperature

Provides access and exposure to areas to be treated while protecting other areas

Protects the patient's skin or clothing from being soiled or damaged

What are the 6 elements of the cycle of infection?

Infection

Susceptibility

Infectious agent

Reservoir

Exit

Transmission

What is the order for donning and doffing PPE?

Donning: Hand hygiene, gown, mask/respirator, goggles/face shield, gloves

Doffing: Gloves, gown, exit the room, perform hand hygiene, remove face shield/goggles, remove and discard facemask or respirator, perform hand hygiene

What PPE is required for contact transmission?

Gown and gloves

Ex: C. diff, MRSA, Herpes, wound infections, Vancomycin-resistant Enterococcus

What PPE is required for droplet transmission?

Mask, gown, gloves, and face shield

Ex: influenza, COVID-19, Pertussis, Mumps, Rubella, Meningitis

What PPE is required for airborne transmission?

Fit-tested N95 Mask, gown, gloves, and face shield

Ex: Tuberculosis, measles, Chickenpox

When completing hand rubbing, how long should you rub your hands for?

Until they dry or at least 15 seconds (whichever comes second)

When washing your hands, how long do you wash for?

40-60s

According to OSHA, what are the responsibilities of health care employees?

Use protective equipment and clothing

Dispose of wastes in proper containers

Dispose of sharps in proper sharp containers

Keep work and patient care areas clean

Wash hands immediately following removal of gloves

Immediately report exposure to a supervisor

According to OSHA, what are the responsibilities of health care facilities?

Educate employees

Provide safe and adequate protective garments

Educate on prevention of transmission

Provide proper disposal containers

Offer HBV vaccine

Provide follow-up care to employees exposed to communicable diseases

Define dependent assist

Patient requires total physical assistance from 1+ persons to accomplish the activity safely; special equipment or devices may be used

Define Max Assist

Patient performs 25-49% of activity; assistance is required to complete activity

Define Mod Assist

Patient performs 50-74% of activity; assistance is required to complete activity

Define Min Assist

Patient performs >/=75% of activity; assistance is required to complete activity

Define Contact Guard Assist

Caregiver is positioned close to the patient with his or her hands on the patient or a gait belt

Define Standby Assist

Patient can perform the activity w/o physical assistance, but therapist is WITHIN arm reach (w/o touching) to give verbal cues and in case loss of balance occurs

Define Supervision Assist

Patient can perform activity on their own, but therapist will in room (OUT of arms reach) to watch or give verbal cues

Define Modified Independent Assist

Patient may require verbal cues or uses assistive equipment or adaptive equipment (bed rail, grab bars, transfer board, furniture)

Define Independent Assist

Patient can perform a transfer without any type of verbal or manual assistance

What is Trendelenburg position? Why use it? What should we be aware of?

Position: Feet above the head

Why: Helps with circulation, oxygen to the head and allow gravity to pull the blood; helps with BP

Be Aware: Harder for respiration

What is Reverse Trendelenburg position? Why use it?

Position: Head up and feet down (angle)

Why: Help with breathing, lower extremity circulation, intracranial pressure, and eating/swallowing

What is Fowlers position? Why use it?

Position: trunk/head raised 45+ degrees

Why: help with eating, respiration, and comfort

What is Semi-Fowlers position? Why use it?

Position: trunk/head raised 15-45 degrees

Why: help with eating, respiration, and comfort

What are 4 general parameters for determining appropriate transfer?

Information gathered from the medical record review, the patient, or patient's family/caregiver

Physician's order

Assessment of the patient's ability to assist

Goals of treatment

What special precautions should be made for low back trauma or discomfort during transfers?

Avoid excessive lumbar rotation, trunk side bending, and trunk flexion

Logroll may be more comfortable than segmental

May be more comfortable with hip and knee flexion when side-lying or supine

What special precautions should be made for a spinal cord injury during transfers?

Avoid distraction and rotational forces

Protective positioning or restraints will be required when the patient is side-lying

Maintain contact with patient's trunk at all times sitting without back support

Osteoporosis may be present

Patient may experience syncope when transferring from supine to sitting

Be mindful of positioning LE and UE

What special precautions should be made for burns during transfers?

Avoid shear forces and direct pressure on area(s) of graft/burn

Instruct patient to elevate body/extremities when moving area(s) with graft/burn

What special precautions should be made for hemiplegia during transfers?

Avoid pulling on involved or weakened extremities to control/move patient

Many patients experience discomfort/pain when lying on or rolling over involved shoulder

Why complete transfers?

Prevents skin problems, weakness, and contractures

Acts a stepping stone to independent movement

Promotes function

What documentation is required for a transfer?

Type of transfer

Surfaces transferred to and from

Amount of time to complete transfer

Level of safety demonstrated

Level of consistency of performance

Equipment or devices used

What are the general transfer principles?

Predetermined patience mental and physical capabilities

Ensure suitable clothing and shoes

Mentally prepare sequence of activities

Apply safety belt or transfer sling

Teach components of transfer

Instructs slowly and concisely

Be alert for unusual events

Select, position, and secure necessary equipment

Reduce friction prior to moving

Consider the effects of gravity

Position yourself to guard, guide, direct, and protect

Apply basic principles of physics and body mechanics

Transfer toward the strong side

At conclusion: position patient for comfort, stability, and safety

If a patient has <3/5 BLE (B NWB or B amputation w/o prosthesis) and <3/5 UE. What transfer is used?

Sitting transfer

One person dependent lift transfer or 2-person dependent lift transfer

If a patient has <3/5 BLE (B NWB or B amputation w/o prosthesis) and >/=3/5 UE. What transfer is used?

Sitting Transfer

Start with sliding board transfer then, progress to lateral swing transfer once patient is proficient

If a patient has >/=3/5 at least one LE and 1 LE is affected. What transfer is used?

Standing transfer

Standing assisted pivot transfer (TKR standing pivot transfer with FWW)

What limb should be blocked in a standing assisted pivot transfer?

Affected LE at knee UNLESS NWB, knee incision, or amputation without prosthetic then block the strong limb

If a patient has >/=3/5 at least one LE and BLE affected. What transfer is used?

Standing dependent pivot transfer

Why use a standard foam cushion for a wheelchair?

Lowest cost and most economical cushion

Provides firm support and some comfort rather than seating directly on wheelchair seat upholstery

Seat upholstery can cause a slinging effect which has adverse positioning and pressure on the user

Solid foam cushion is best for those at low risk of developing pressure areas on their skin

Primarily used for support and positioning

Best to have a combination cushion such as gel or memory foam for comfort and pressure reduction

Why use gel for a wheelchair cushion?

Supportive and pliable

Shifts and moves w/ user but also keeps them in place especially when used in combination w/ foam

Gel and foam combination highly recommended for users w/ advanced stages of skin breakdown, as well as bariatric users

If higher risk for skin breakdown or already compromised skin, gel should be considered

Provides protection and weight distribution

Why use wedge/positioning cushion for a wheelchair?

Angled or wedge-shaped design that prevents leaning in particular direction

Customarily angled higher posteriorly and low anteriorly which prevents forward leaning or slouched posture

Ideal for individuals prone to slouching and run risk of dislodging their cushion

Prevents slumping and positioning that compromises posture

Why use a Roho cushion for a wheelchair?

Decrease amount of pressure on sitting area

Patented technology of interconnected neoprene air cells that increase and decrease in air volume to match an individual's contours

Well suited for patients w/ decreased sensation or for who may have developments of pressure areas on the skin

What are the key components and clinical implications for wheelchair fitting?

Proper fitting essential for comfort, function, skin integrity, posture, and propulsion efficiency

Poor fit can lead to pressure injuries, impaired circulation, pain, instability, and reduced mobility

When fitting a wheelchair: What is the goal of seat width?

Accommodate widest part of hips/thighs without excess space

When fitting a wheelchair: What if seat width is too narrow? Too wide?

Too narrow: Increase pressure over greater trochanters, Risk of skin breakdown, Restricts comfort and posture

Too wide: Difficulty reaching drive rims, Reduced propulsion efficiency, Poor maneuverability and control

When fitting a wheelchair: What is the goal and standard of seat depth?

Goal: support thighs w/o contacting the back of the knee

Standard: ~2 finger widths between seat edge and popliteal fold

When fitting a wheelchair: What if the seat depth is too deep? Too shallow?

Too deep: Pressure at popliteal fold, Impaired circulation, Increased risk of skin integrity issues

Too shallow: Feeling of instability or "falling out", Increased pressure on ischial tuberosities, Poor thigh and knee support, Decreased postural stability

When fitting a wheelchair: What is the goal of leg rest height/foot plate position?

Goal: Feet rest flat w/ thighs fully support

When fitting a wheelchair: What if the leg rest height/foot plate position is too short? Too high?

Leg rests too long (footplates too low): Feet push downward, Increased pressure on posterior femurs, Poor weight distribution

Footplates too high: Excessive knee flexion, Increased pressure on ischial tuberosities, Reduced comfort and posture

When fitting a wheelchair: What is the goal of armrest height?

Goal: Support arms while maintaining neutral scapular position

When fitting a wheelchair: What if the armrest height is too high? Too low?

Too high: Scapular elevation, Shoulder discomfort, Difficulty reaching drive rims

Too low: Scapular depression, Shoulder strain, Inadequate arm support

When fitting a wheelchair: What is the standard back upholstery height?

Just below the inferior angle of the scapula

When fitting a wheelchair: What if the back upholstery height is too high? Too low?

Too high: Interferes w/ arm motion, Limits effective wheelchair propulsion

Too low: Decreased trunk support, Reduced postural stability, Increased risk of fatigue and unsafe sitting

What is the standard wheelchair designed for?

Designed for people <200lb and limited use on rough surfaces

Not designed for vigorous functional activities

What is the sports wheelchair?

Low-profile, fixed frame, lightweight (15-24lb) chair w/ features such as low back, canted rear wheels, fixed or adjustable axles, and fixed or adjustable seat and backrest (Can be both or customized for various sports activities)

What is the externally powered wheelchair?

1+ deep-cycle batteries that provide stored electrical energy to 1+ belts that drive or propel the wheelchair

What is the semi- or fully-reclining wheelchair and when is it used?

When person needs to recline when in chair

Semi-reclining: recline ~30 degrees

Fully reclining: recline to horizontal

Elevating leg-rests and headrest extensions are necessary for these chairs

What is the Tilt-in-Space wheelchair?

Wheelchair can be adjusted to position the user at various angles and can be wheeled w/ user positioned at any angle

What are the floor --> wheelchair approaches? How are they named?

Front approach, back approach, and side approach

Named based on the wheelchair location to the one approaching

What are the purposes of assistive devices? (5)

Increase BOS (stability)

Reduce weight-bearing

Improve mobility

Compensate for deficits

Decrease pain

What are key characteristics of a walker? (4)

Most stable

Easy to use

Poor on stairs/uneven surfaces

Can have wheels or platform

What are key characteristics of axillary crutches? (3)

Can be used for all gait patterns

Require coordination

Risk of axillary nerve compression

What are key characteristics of forearm crutches (Lofstrand)? (3)

Less trunk stability

Require strong UE + trunk

Easier to handle

What are key characteristics of quad cane? (2)

Larger BOS than single point cane

Cannot use if NWB

What are key characteristics of Single Point Cane? (3)

Least support

Unilateral or bilateral use

Not for NWB

What are key characteristics for hemi-walkers? (2)

Most stable unilateral AD

Largest BOS for unilateral

What are general fitting rules for ADs?

Shoes ON

Ulnar styloid = handgrip height

Elbow flexion = 20-25 degrees

What happens if a device is too tall?

Shoulder elevation

Hunching

What happens if an AD is too short?

Leaning

Hip flexion

Dropped shoulders

What are different fitting rules for axillary crutches?

Have patient hold crutches 2-3 inches lateral and 4-6 inches anterior

Should be 2-3 fingers below axilla

What are different fitting rules for Lofstrand or forearm crutches?

Have patient hold crutches 2-3 inches lateral and 4-6 inches anterior

Forearm cuff should be 1-1.5 inches below olecranon

What are 4 general rules of gait training?

ALWAYS use gait belt

Educate on WB status

Follow precautions

Ensure patient compliance

Define NWB

No contact with ground