PTE 763: exam 3

NICU, medical complications with premies, motor and cognitive delays, aging and dementia, TBIs, and meningitis

what populations use the neonatal intensive care unit (NICU)?

used for newborns who are born prematurely, have a low birth weight, or have serious health conditions like breathing trouble, heart problems, infections, or birth defects

how long is the ideal pregnancy?

38-40 weeks (up to 36 weeks is okay tho)

a pregnancy duration of ___ or less is dangerous because the _____ are the last organs to develop around this time. 

26 weeks; lungs

the APGAR neonate assessment is used to grade newborns immediately after birth to assess their health and determine if they need immediate medical assistance. what does the assessment look at?

Appearance, Pulse, Grimace, Activity, and Respiration

APGAR scale

what’s the indications of a low and high APGAR score?

low: poor health; medical issue occurring

high: good health; congrats!

what types of monitors are found throughout the NICU for continuous medical management?

• temperature monitor

• EKG and respiration

• pulse oximeter

• dynamap (measures BP and HR)

• arterial lines (measures PCO2 and PO2)

• apnea monitor

what types of monitors are found throughout the NICU for ventilation and oxygen administration?

• extracorporeal membraneous oxygenation (ECMO)

• high frequency ventilators

• ventilator endotracheal tube

• tracheostomy

• nasal canula

• oxyhood

nutrition is a huge concern for premies due to their lack of endurance for traditional feeding. what are some methods to provide nutrition for premies?

• parenteral (central venous catheter)

• gavage tube feeding (via oro or nasal)

• gastrostomy

premies may suffer from GERD. what is that?

Gastroesophageal Reflux Disease: happens when stomach acid flows back up into the esophagus and causes heartburn.

how should a caretaker position a patient suffering from GERD?

either 1) in prone with apnea monitor 2) supine with head elevated or 3) left sidelying

explain why a patient suffering from GERD should avoid right sidelying.

due to the shape and curve of the esophagus into the stomach, the acid has a tendency to flow back up easier. here’s a picture to show this:

a therapist is going to the NICU to assess a new premie born at 30 weeks. what should she include in her PT initial evaluation process?

the neonate’s environment and medical state while assessing the integumentary, musculoskeletal, and neuromuscular systems

list the newborn assessments of neurobehavioral function.

• neurological assessment of the preterm and full-term newborn infant (Dubowitz)

• neonatal behavioral assessment scale (NBAS)

• assessment of preterm infant behavior (APIB)

• neonatal intensive care unti network neurobehavioral scale (NNN)

• newborn behavioral observation system (NBO)

• newborn individualized developmental care and assessment program (NIDCAP)

• neurobehavioral assessment of preterm infant

list the newborn assessments of motor function.

• test of infant motor performance (TIMP)

• general movements assessment (GMA)

a therapist visits a premie who was born at 34 weeks old. the baby is improving and upon entering the NICU room, the therapist notices the baby is alert, cooing, and relaxing. what is the baby’s presentation?

expressing signals of comfort :)

a therapist visits a premie who was born at 29 weeks old. the baby is having a rough day as his GERD is flaring up today. he is sucking his fists that are held tightly together while wiggling around his isolette. what is the baby’s presentation?

expressing signals of self calming

a therapist visits a premie who was born at 26 weeks old. the baby is not progressing well and struggling through the session. she is fussy with a grimace-look on her face and is hyper-alert while reaching out to anyone near. what is the baby’s presentation?

expressing signals of distress :(

the therapist revisits the premie born at 26 weeks old the next day, but finds the baby is still struggling. she arches her back and flails her limbs at any touch and spits up near the end of the 20 minutes therapy session. what is the baby’s presentation?

still expressing signals of distress :(

what are important aspects to include in the developmental care of premies?

• reduce light and noise

• cluster care with limited interruptions during sleep

• encourage parent participation using kangaroo care

• manage pain

how should a therapist handle a premie during a therapy session?

• position baby with limbs and head in midline with limbs flexed close to body

• massage in the form of firm touch

• graded movement experience timed with infant’s readiness for social engagment

therapy treatments for _______ premies include cluster care, avoiding overstimulation, smooth and supported handling, positioning in prone, and placing pressure on feet. 

hypertonic

therapy treatments for _______ premies include arousing, applying firm tactile input, stimulating the vestibular system, maintaining upright position for head control, and add unimodal/graded sensory stimulation.

hypotonic

what are some predictive variables of developmental problems?

• time of onset of labor (pre-term and post-term)

• body size of infant (too big or too small)

• risks associated with multiple gestation (twins, triplets, etc.)

• late fetal heart declerations 

• premature rupture of membranes 

• breeching

• meconium aspiration (baby inhales his/her first stool passed in womb into their lungs)

what are the two pulmonary syndromes that are common with an under-developed pulmonary system?

1. RDS: respiratory distress syndrome

2. BPD: bronchopulmonary dysplasia

ischemia of an under-developed pulmonary system can lead to:

• selective neuronal necrosis

• focal ischemia brain necrosis and cavitation

• parasagittal cerebral injury

• PVL: periventricular leukomalacia

• ROP: retinopathy of prematurity

• NEC: necrotizing enterocolitis

ischemia of an under-developed nervous system can lead to __________ __________.

periventricular leukomalacia (PVL)

PVL diagnosed from an under-developed nervous system can lead to:

• seizure disorders

• cognitive impairments

• visual and auditory deficits

• atonic quadriplegia CP

• athetoid CP

• spastic quadriplegia, hemiplegia, and diplegia CP

what is retinopathy of prematurity (ROP)?

an eye disease in premature babies where abnormal blood vessels grow in the retina (hyperpoliferative neovascular response) leading to swelling and possible detachment of the retina

what is necrotizing enterocolitis (NEC)?

inflammation of the bowel (gut proper) that causes the death of mucosal cells which leads to a decrease production in mucus and an increase risk of proteolytic damage

what is hyperbilirubinemia?

occurs in newborns due to the breakdown of red blood cells and the immature liver's inability to process bilirubin efficiently; baby’s skin is yellowish

which common complications of newborns are the number one reasons for the baby’s referral into the foster care system?

fetal alcohol syndrome (FAS) and neonatal abstinence syndrome 

how does an individual qualify for the American Association of Intellectual and Developmental Disabilities (AAIDD)?

must have a disability characterized by significant limitations in both intellectual functioning and adaptive behaviors (conceptual, social, and practical skills)

define developmental disability.

a severe, chronic disability that is attributable to a physical or mental disability that is likely to continue throughout the person’s life and results in clear functional limitations in 3 or more areas of life activities

• usually diagnosed within first year of life

what is the DSM-V’s criteria to qualify as a developmental disabled individual?

1. score significantly sub-average intellectual functioning

2. concurrent deficits or impairments in present adaptive functioning in at least 2 areas

3. onset before 18 years of age

the score of ___ on an individually administered IQ test indicates sub-average intellectual functioning.

70 or below

list the IQ score ranges associated with mild, moderate, serve, and profound intellectual disability.

mild: 70-50

moderate: 49-40

severe: 39-20

profound: less than 20

the DSM-V’s criteria to qualify as a developmental disabled individual specifies an individual must be impaired in 2 adaptive functioning areas. name some examples of such.

communication, self-care, home living, social skills, self-direction, work, leisure, health, safety, and finances

infants may receive an assessment of intellectual function via sensorimotor-based evaluations. what is it a valid predictor of?

severe cognitive delay at that age

infants may receive an assessment of intellectual function via informational processing capacity. describe this assessment.

it is motor and language free assessment that observes how quickly children get bored of a task via monitoring their HR and time spent on task

• higher intelligence = bored quicker

list the assessments of intellectual function for children with motor and cognitive impairments.

• stanford-binet intelligence scale- IV or wechsler intelligence scale for children- III

• columbia mental maturity scale for CP

• raven’s progressive matrices

• leiter international performance sclae for language delayed

• kaufman assessment battery for children

which of the assessments of intellectual function for children allows for IQ measurement without using speech? (quiz question)

• raven’s progressive matrices

• leiter international performance sclae for language delayed

• kaufman assessment battery for children

list the assessments of adaptive behavior for children with motor and cognitive impairments.

• PEDI

• aamr adaptive behavior scale-school (ABS-S2)

• vineland adaptive behavior scales (VABS-II)

which assessments of adaptive behavior assess children with down syndrome and other cognitive issues?

• aamr adaptive behavior scale-school (ABS-S2)

• vineland adaptive behavior scales (VABS-II)

list the measuring outcomes used for children with motor and cognitive impairments.

• goal attainment scale (GAS)

• canadian occupational performance measure (COPM)

• single-subject research method

what is the ecological assessment of children with motor and cognitive impairments?

an assessment that determines the domains (home, community, vocational, recreation, and lesion) to be included in the child’s program

• looks at environments and sub-environments of these domains

T or F: it is important to consider current and future environments the child will be exposed to when creating an ecological assessment.

T

T or F: when evaluating a child with motor and cognitive impairments, partial participation or partial completion of a task is an acceptable outcome.

T

what aspects should be included when focusing on long-term goals for children with motor and cognitive impairments?

• development of self-determination (freedom, control, support system)

• employment or vocation

• group home or extended care facility 

list the PT interventions commonly used in children with motor and cognitive impairments.

• errorless learning

• differential reinforcement

• minimize erros

• instructed in natural environments

• positive behavioral program

• practice!! 

what in the world is “errorless learning”?

an instructional strategy that minimizes errors by using prompts to ensure the learner provides the correct response. below is the progression:

• instructional cueing

• stimulus prompts

• respond prompts

• prompts fading

what is the difference between gradual decline vs pathological decline?

gradual: the slow, subtle changes in thinking and memory that are a normal part of aging

pathological: the more severe and accelerated decline caused by a disease which significantly impairs daily functioning

the nervous system declines at a rate of __ each year after the age of 30.

1%

neurotransmitter decline is noted in aging adults and plays a crucial role in their decline. describe the changes associated with the decline of acetylcholine, serotonin, norepinephrine, and dopamine.

acetylcholine: memory los

serotonin: mood, sleep, cognition changes

norepinephrine: diminished motor learning

dopamine: preclinical PD and worsening executive function and working memory

T or F: typical neuromuscular changes in aging individuals include the degeneration of motor components. 

F; motor and sensory

the mid-thoracic preganglionic cell bodies decline at a rate of __ per decade resulting in a less efficient sympathetic nervous system (SNS).

8%

a therapist is treating an elderly patient for stability after a some falls. at the beginning of the session, the patient complains of lightheadedness and dizziness upon standing. he states this is a common occurrence and believes is the reason for his falls. why?

he has impaired regulation of his blood pressure (due to degeneration of SNS)

T or F: older individuals typically experience a decline in both bimanual and multi-joint coordination.

T

while watching two older professors walking, a DPT student notices they walk slow with small careful steps and the older man has to turn his full torso to talk to the older woman (decreased rotation). testing knowledge of the gait pattern, the student notices the older woman walks flat-footed with less heel strike and push off. is this typical or atypical?

typical gait for elderly!

what is the dementia?

a chronic disorder of mental processes due to brain disease or injury

• usually caused by neurodegenerative or cerebrovascular incidents

to qualify for the diagnosis of dementia, an older individual must have at least 3/5 deficits. what are the 5 deficits?

1. language

2. memory

3. emotion

4. cognition

5. visuospatial

dementia is considered a _____ disease.

global

can a person with dementia learn motor skills?

yes because the cerebellum and basal ganglion are less affected areas of the brain

T or F: depression is considered dementia and is among the reversible dementias.

T

what is delirium?

a transient change (acute onset) in mental status with fluctuating symptoms

• consciousness is affected

which has a better prognosis: dementia or delirium?

delirium

___-_______ delirium is the most common form.

post-anesthetic

why do older patients usually experience post-anesthetic delirium more than younger patients?

older = nervous system capacity is lower and metabolism is slower which increases the time to achieve the general anesthetic drug’s ½ life

what is alzheimers?

a progressive brain disorder that causes memory loss, confusion, and other cognitive decline

• most common form of dementia

what two characteristics develop within a brain of an individual suffering from alzheimers?

1. neurofibrillary tangles

2. amyloid plaques

where does alzheimers affect first within the brain?

hippocampus and pre-frontal cortex

what is normal pressure hydrocephalus (NPH)?

a condition where there is an excessive buildup of cerebrospinal fluid (CSF) in the brain's ventricles

• gradual buildup/slow process

T or F: normal pressure hydrocephalus has easily identifiable signs and symptoms.

F; signs and symptoms are often mistaken for aging causing others to overlook the possibility of NPH

what’s the triad that makes up signs and symptoms of NPH?

global deficits seen in gait disturbances, impaired cognition, and incontinence

what is the difference between a traumatic (TBI) and non-traumatic brain injury (NTBI)?

traumatic: an injury to the brain caused by an external physical force, such as a fall, MVA, or sports injury

non-traumatic: a type of brain damage that is caused by internal factors that disrupt brain function like stroke or tumors

a 20 year old male patient presents to the ER clinic following a MVA. he presents with a huge open gash across his forehead, bruising along his L cheek, a stiff neck, and is unconscious. what do these signs indicate?

indicate a head injury duh

____ _______ is blood or CSF leaking from the nose and/or ears and is indicative of a head injury.

nasal discharge

what are the mechanisms of injury related to TBIs?

• injuries to face and/or neck causing damage to brain’s blood supply

• direct impact injury

• coup-countercoup injury

• penetrating objects

• acceleration/deceleration injuries

describe what happens to the brain in a coup-countercoup injury.

brain is injured at site of impact, then bounces back and hits site opposite from impact → damage on both sides

unequal acceleration/deceleration injuries occur from high velocity incidents that result in the tearing of vessels and axonal shearing. what are some deficits that may be observed in a patient following this type of injury?

widespread globa deficits including memory, cognition, and balance issues

what is diffuse axonal injury?

a type of TBI that occurs when the brain experiences sudden acceleration or deceleration forces, causing widespread damage to the axons throughout the brain

• caused via MVAs, blasting injuries from combat, etc.

what are the primary damages seen following a TBI?

epidural and subdural hematomas

what’s the difference between epidural and subdural hematomas?

epidural: tearing of meningeal vessels resulting in blood collecting between skull and dura; fast onset

subdural: tearing of veins to superior sagittal sinus resulting in blood collecting between dura and arachnoid; slow onset

a patient comes into the ER at midnight following a rough football tackle incident. his mom states this occurred early in the night at his high school football game and since then her son has been vomiting, confused, and fatigued. the ER nurse rushes him to get a CT scan. why?

the ER nurse suspects an epidural hematoma (increased intracranial pressure)

increased intracranial pressure and ______ _____ are common secondary damages observed following a TBI.

cerebral hypoxia (or ischemia)

a therapist is seeing a patient from another therapist’s schedule. he was advised that this patient suffered from a huge hematoma in the L frontotemporal lobe and experiences bilateral UE motor and sensory deficits along with speech deficits. why?

the L frontotemporal hematoma shifted the brain towards the R causing the R side to be squished = affected both sides

what is an intracranial hemorrhage?

bleeding that occurs within the skull that causes hypoxia, increased pressure, and distortion to the brain tissue

• leads to cell death within minutes from the ischemia, edema, necrosis, and/or toxic effects of the blood on neural tissue

what are the four grades of hemorrhage?

1. minimal bleed without significant findings

2. bleeding moves into ventricles; no significant findings

3. dilation of ventricles from bleeding; some neurological signs and symptoms

4. bleeding into white matter; severe neurological signs and symptoms

T or F: seizures are most common right after injury from the increased pressure and again between 6-24 months after injury from the scarring with any brain bleeding incident.

T

a TBI patient attending an inpatient rehabilitation therapy session suddenly begins convulsing. his eyelids are fluttering with horizontal jerking of his eyes and his jaw is moving in a chewing-like motion. what is happening?

seizure

abnormal posturing like decorticate and decerebrate can be noted following a TBI. explain both postures.

what are some examples of physiological changes following a TBI?

• monoplegia or hemiplegia

• initially flaccid → spastic or rigid

• motor disturbances of timing, sequencing, and coordination

• return of primitive reflexes

• cranial nerve involvement

• changes in consciousness/coma

what are some examples of cognitive and behavioral changes following a TBI?

• irritability and impulsivity

• uncontrolled emotions and inappropriate behaviors

• memory loss

• problems with attention and concentration

• perseveration

• reduce problem-solving skills

• depression

what are the main pharmacological interventions given to patients suffering a TBI?

drugs that decrease intracranial pressure (ICP) and drugs taht control blood pressure

what is the Glasgow Coma Scale (GCS)?

a neurological assessment tool used to objectively rate a person's level of consciousness on a scale of 3 to 15

• mild concussion = score 13-15

• moderate concussion = score 9-12

• severe concussion = score 3-8

Glasgow Coma Scale

an EMS personnel assesses an individual who loss consciousness after hitting her head on a car’s dash in a MVA. she opened her eye’s in response to him asking her questions but she responded with inappropriate words. the EMS personnel then tested her motor response to which she moved away from a painful stimulus. what is her GCS score?

3 + 3 + 5 = 11

an EMS personnel assesses an individual who loss consciousness after colliding head-first into the boards during his hockey game. he opened his eyes immediately upon regaining consciousness yet was confused at how he ended up off the ice. the EMS personnel then tested his motor response to which he moved away from a painful stimulus but he couldn’t obey commands due to his confusion. what is his GCS score?

4 + 4 + 5 = 13

what are the Ranchos Los Amigos levels?

a 10-point scale used to assess cognitive and behavioral recovery in patients after a traumatic brain injury

Ranchos Los Amigos