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TreaTmenT STraTegieSinThe

acuTe careof STroke SurvivorS

ByJanDavis,MS,OTR/L

VideoRegistrationNo.___________________________________

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Tableof conTenTS

How to Use this Learning Module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Behavioral Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Program Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Introduction to Acute Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

SAFE Guidelines for Optimal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

ICF: The International Classication of Functioning, Disability & Health . . . . . . .17

Six Elements in the Continuum of Acute Care . . . . . . . . . . . . . . . . . . . . . .21

I.ReviewMedicalInformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

II.ObservethePatientandtheEnvironment. . . . . . . . . . . . . . . . . . . . . . . . . . 23III.InitiatePatientContact. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26IV.AssessBodyFunctionsandBodyStructures. . . . . . . . . . . . . . . . . . . . . . . . 28V.AssessFunctionalActivities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31VI.Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Guidelines to Intervention in the Acute Care Setting . . . . . . . . . . . . . . . . . .39

SafetyDuringIntervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40ExamplesofICFComponents,Domains&Categories. . . . . . . . . . . . . . . . . . . . . 42ExamplesofTherapeuticIntervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43DeterminingaPlanofIntervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44BasicHandlingPrinciples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

CommunicatingEffectivelywithYourPatient . . . . . . . . . . . . . . . . . . . . . . . . . . 50ManagingYourTime. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51ModifyingYourPlanofIntervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52ImprovingPatientComfort. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53PreventingShoulderPain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ImprovingAwarenessoftheInvolvedSide. . . . . . . . . . . . . . . . . . . . . . . . . . . 55AwakeningtheLethargicPatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56UtilizingPassiveHandling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57IncreasingSittingToleranceandChairSelection . . . . . . . . . . . . . . . . . . . . . . . . 59ReturningthePatienttoBed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Ideas for Therapeutic Intervention: Bedside . . . . . . . . . . . . . . . . . . . . . . .63

FacilitationofLowerExtremityControl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63ScapularMobilizationinElevation/Depression,Protraction/Retraction,UpwardRotation/DownwardRotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65ReachingforObjectsfromtheBedsideTable. . . . . . . . . . . . . . . . . . . . . . . . . . 67BedMobility:BridgingandScootinginBed. . . . . . . . . . . . . . . . . . . . . . . . . . . 68BedMobility:RollingwithMaximumAssistance. . . . . . . . . . . . . . . . . . . . . . . . . 70SidelyingtoSittingwithMaximumAssistance. . . . . . . . . . . . . . . . . . . . . . . . . . 72

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Ideas for Therapeutic Intervention: Sitting at the Edge of the Bed . . . . . . . . . . .75

Mobility:ScootingtotheEdgeoftheBed. . . . . . . . . . . . . . . . . . . . . . . . . . . . 75WeightbearingThroughtheInvolvedUpperExtremity. . . . . . . . . . . . . . . . . . . . . 77FacilitationofTrunkControlwithLateralWeightshifts. . . . . . . . . . . . . . . . . . . . . . 79SittingtoSidelyingwithModerateAssistance. . . . . . . . . . . . . . . . . . . . . . . . . . 81

Ideas for Therapeutic Intervention: Sitting in a Chair . . . . . . . . . . . . . . . . . .83FacilitationofKneeExtension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83GroomingandHygieneattheSink. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Dressing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87Mobility:FacilitationofSittoStand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Ideas for Therapeutic Intervention: Standing . . . . . . . . . . . . . . . . . . . . . .91

FacilitationofReachingWhileStanding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91FacilitationofTrunkandLowerExtremityControlDuringGrooming. . . . . . . . . . . . . . 93

The Intensive Care Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

IntroductiontotheICU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

ManagingEquipmentintheICU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Discharge Planning and Recommendations . . . . . . . . . . . . . . . . . . . . . . .99

Family Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Practice Labs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

BedMobility:ScootingSidetoSide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104BedMobility:RollingfromSupinetoSidelying . . . . . . . . . . . . . . . . . . . . . . . . .107BedMobility:SidelyingtoSitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109BedMobility:SittingtoSidelying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Mobility:SittoStandNormalMovement . . . . . . . . . . . . . . . . . . . . . . . . . . . .113

Mobility:SittoStandwithModerateAssistance. . . . . . . . . . . . . . . . . . . . . . . . .115Mobility:SittoStandwithMaximumAssistance. . . . . . . . . . . . . . . . . . . . . . . . .117Mobility:SittoStandwithTwoPersonAssist . . . . . . . . . . . . . . . . . . . . . . . . . .119ScapularMobilization:ElevationandDepression. . . . . . . . . . . . . . . . . . . . . . . .121ScapularMobilization:ProtractionandRetraction. . . . . . . . . . . . . . . . . . . . . . . .122ScapularMobilization:UpwardRotationandDownwardRotation . . . . . . . . . . . . . . .123

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

CEU Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

WorksheetAssignment1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133WorksheetAssignment2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135

WorksheetAssignment3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137WorksheetAssignment4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139WorksheetAssignment5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141WorksheetAssignment6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143WorksheetAssignment7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145

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guidelineS To inTervenTion

inThe acuTe care SeTTing

Inordertooptimizeeachtreatmentsession,thetherapistmustdevelopsharpobservationskillsandcompetent handling skills and must know how and when to make modications during intervention. The safe

and therapeutic plan of intervention must be specic to each stroke survivor, determined by their medical

condition and by the problem areas identied during the assessment.

Thischapterincludesimportantinformationthatwillhelpyoutobeassuccessfulaspossibleasyouinitiate

interventionintheacutecaresetting.Thechapterbeginswithgeneraltherapeuticguidelinesandcontinues

with helpful tips for time management, planning your intervention strategy, making modications, improving

patientcomfortandgeneralhandlingmethodsrelatedtoactivities(mobilityandself-care)andbodyfunctions

andstructures(facilitationoftrunkandlimbcontrol)fromtheICFmodel.

Afterreadingthisentirechapter,turntoDisc2andobservetherapiststreatingfourpatientsintheacutecare

hospital:Mary,Calvin,EllanoraandBen.Youwillneedtocompleteaworksheetassignmentforeachpatient.

You can nd the worksheets in the chapter CEU Requirements. Take out the worksheets and follow along.

Aftercompletingthischapter,turntothenextchapter:IdeasforTherapeuticInterventionintheAcuteCare Setting. It includes specic treatment ideas that are organized according to the typical progression of

interventionbeginningwithsuggestionsforworkingbedsidewiththepatientinbed,sittingattheedgeofthe

bed,sittinginachairandendingwithstanding.Manyofthesesuggestionsareillustratedduringthetreatment

videosofMary,Calvin,Ellanora,andBen.

Remember,duringinterventionsafetyisthenumberoneconcernandthereforeitiscriticalthatthefour

componentsoftheSAFEguidelinescontinuetodirectyourpatientcare.

Calvin Ellanora

Mary Ben

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Safety During InterventionThemedicalconditionofanacutestrokesurvivorcanbelifethreateningandchangehourbyhour.Whether

treatingintheIntensiveCareUnitorintheacutecareunit,itisessentialthatyoustaycurrentwithall

informationrelatedtothepatientsmedicalcondition,suchasrecenttestresults,vitalsignsandmedications.

Beawareofcontraindicationsrelatedtothehealthconditionandanynecessaryprecautions.Ifyourpatients

vitalsignsarebeingmonitoredcontinually,notethereadingsforheartrate,bloodpressureandoxygen

saturationbeforebeginningyourtreatment.

Symptoms of Acute Distress

Isthepatientcoldorpale?

Isperspirationontheforeheadvisible?

Doesthepatientcomplainoflight-headedness,dizzinessor

vertigo?

Isthepatientnauseated?

Aretherechangesinrespirationorisbreathinglabored?

Doesthepatienthaveaglazedlookorablankstare?

Isthepatientagitated,panickedorfearful?

If Symptoms of Acute Distress are ObservedIfyounoticeanysymptomsofacutedistressorachangeinyour

patientsvitalsigns,stopyourtherapyandreturnyourpatienttoa

restingposition(sittingonthebedorchairorlyingdowninbed).

Observeandassessyourpatient.Dothesymptomsresolve?Ifso,

proceedwithcaution.Ifnot,trytodeterminethestimulithatcaused

thechangeinvitalsignsordistress.Wasitachangeinyourpatients

positionoreffortrequired?

Ifyouobserveanyofthefollowing,contactanurseimmediately:

blood(instooloremesis)

seizures

lossofconsciousness

Always consult the nursing staff if you have questions or are unsure of anything.

Sternal PrecautionsAlwayscheckwiththenurseandfollowtheguidelinesandprotocols

establishedatyourfacilitybeforeworkingwithapatientwithsternalprecautions.

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Aspiration Precautions

Acute stroke survivors may have difculty swallowing, which could lead

toaspiration.Aspirationcanbeextremelyseriousandlifethreatening.

Patientsdisplayingsymptomsofaspirationshouldbeevaluatedbya

speech-languagepathologist.

Symptoms of Aspiration

coughing

clearingthethroat

awetorgurglyvoice

shortnessofbreath

wateringeyes

Inaddition,thefollowingstandardproceduresforaspirationprecautionsshouldbefollowed:

Elevatetheheadofthebedtothemostuprightpositionandusepillowstohavethepatientsittingat

90 during meals. Maintain this position for a minimum of 30 minutes following each meal. If safetyallows,havethepatientsitinachairforbettingalignmentandpositionofthepelvis,trunkandhead

duringmeals.

Elevate the head of the bed to 30 during NG tube feedings. If you are preparing to boost or scoot a

patient up in bed, put the tube feeding on hold and lower the bed to a at position. Once the patient

hasbeenscootedupinbed,returnthetubefeedingpumptorun,orhavethenurseassist.

Duringoralhygiene,minimizetheliquidsinthemouth.Dependingonthelevelofrisk,useasuction

toothbrush or a damp oral care sponge to take excess uid out of the mouth. For patients who are

atlessrisk,havethemleanforward(tothebasinorsink)andaskthemtotakesmallsipsofwaterto

rinsetheirmouthtominimizethepotentialforaspiration.

Always check the specic procedures for aspiration precautions at your hospital.

IV Inltration

Stroke survivors may require an IV for uids and medications during

the rst few days post stroke. The placement of the IV needle varies

frompatienttopatient,butitisusuallyplacedinthehand,wristorarm.

When an IV is in place, inltration sometimes occurs. The two most

obvious symptoms of inltration are swelling around the needle site

orasmallamountofbloodintheline.Notifythenurseifyouobserve

eithersymptomduringtherapy.Askthenursingstafftoconsider

changingthelocationoftheIV.

SwellingcanlimitpassiveandactiveROM(especiallyonthedorsumofthehand)andshouldbeminimized.

Theswellingusuallyresolveswithinafewdays,butelevationofthelimbabovethecardiaclevelcanbe

helpful.ReplacingtheIValongthewristormoreproximalcanallowforbetteruseoftheinvolvedhandduring

therapy.

For specic information on equipment and monitors used in the hospital setting, turn to the chapter on the

Intensive Care Unit.References: 19, 20, 21, 22

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Determining a Plan of InterventionYour plan of intervention generally reects your patients level of functioning and the impairments of body

functions and structures identied during the initial assessment. As you determine your plan of intervention,

severalfactorsmustbetakenintoconsiderationinordertocreateasafeandtherapeutictreatmentsession.

Consider the patients medical conditionWhatlimitations,ifany,arethererelatedtoyourpatientsdiagnosisandsubsequentmedicalcondition?

Arethereanymedicationsthatmayaffectyourpatientssafetyduringmobilityorself-care?Shouldoxygen

saturationorbloodpressurebemonitoredduringyourtreatmentsession?Reviewyourpatientsmedical

recordandaskyourpatientsnurseifadditionalinformationisneededregardingthemedicalcondition.

Consider the patients tolerance to activityYourpatientslevelofenduranceandtolerancetoactivityareextremelyimportantwhendeterminingyourplan

ofintervention.Whetheryourpatienthasalowtoleranceorappearstohaveafairlygoodtolerancetoactivity,

carefullyprioritizeyourtreatmentgoalsforeachsession.Maximizetheirlevelofparticipationrelatedtoyour

establishedgoalsbyprovidingassistancewithtaskcomponentsthathavealowerpriority.

Determine the length of the treatment sessionThelengthofthesessionmaybedeterminedbyyourpatientstolerancetoactivity,oritmaybedeterminedby

yourpatientsschedule.Sincetheaveragelengthofstayintheacutecarehospitalisapproximately4-5days

forstroke,manymembersoftheteamwillbetryingtoscheduletimewithyourpatient.Yoursessionmaybe

cutshortbyyourpatientsschedulewithotherteammembers.

Select therapeutic methods that decrease impairment of body functions and structuresImpairmentsofbodyfunctionsandstructuressuchasdecreasedROM,motorfunction,sensoryimpairment,

cognitive decits and visual impairment can signicantly impede mobility, dressing, grooming and hygiene.

Interventionthatreducesimpairmentcanfacilitateyourpatientsabilitytofunction.Carefullyselecttherapeutic

methods that are specically designed to decrease your patients areas of impairment. Teach your patient and

theirfamilyhowtoprotectbodystructuresinordertominimizefuturecomplicationsthatcouldpreventpotential

functionalrecovery.

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UsedwithpermissionfromThomasLandPublishers,

Topics in Stroke Rehabilitation.

References: 14

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Use functional activities whenever possibleUrgentdischargeplanningandshortlengthofstayincreasestheneedforfunctionalactivitiestobeincluded

duringeverytreatmentsession.Thetrainingoffunctionalactivitiessuchasdressing,groomingandhygiene,

bedmobilityandtransfersarepracticedsothetherapistcanmakesaferecommendationstotheteam,the

patientandfamilymembersfordischarge.

Theuseoffunctionalactivitiescanalsoaddressimpairmentofbodyfunctionsandstructures.Enrichedenvironmentsareinherentintheactivitiesofmobilityandself-careandprovideamulti-dimensionalapproach

totreatmentrequiringthesimultaneousskillsofmotorcontrol,cognition,visualperception,sensationand

motorplanning.Rehabilitationsciencesupportstheuseoffunctionaltaskstakenfromreal-lifesituationsto

improveperformanceinstrokesurvivors.

Whenutilizingfunctionalactivitiesduringintervention,determineyourprimaryobjectiveforthattreatment

sessionandstructureyourplanaccordingly.Forexample,isyourprimaryobjectivefunctionalindependenceor

facilitationofmotorcontrol?

Consider the following during task selection:

Selectataskthatrequiresthesamemovementyouaretryingtofacilitate. Selectataskthatusessimple,commonobjects.

Selectataskthatrequiresrepetition.

Selectataskthathaslight,easymovements.

Selectataskthatrequiresproblemsolving.

Selectataskthatdoesnotrequireprecision.

Selectataskthatismeaningfultoyourpatient.

For more in-depth information on choosing specic functional tasks, view the course Functional

Treatment Ideas and Strategies in Adult Hemiplegia.

References: 11, 12, 14, 23, 24, 25, 26, 27, 28, 29

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Tips for Using Items in the Hospital Room

Treatinginthehospitalroomcanbeachallengeastherapeutic

equipmentandspaceareoftenlimited.Abitofcreativitymaybe

neededtohelptherapistsbemorefunctional.Eachhospitalroomis

slightlydifferent,butmosttherapistscanusethefollowingtipsintheir

acutecaresetting.

Mosttherapistsplanfunctionalactivitiesusingthesink,thebathroom

andthebedsidetable.However,whenlookingfortaskstofacilitate

movementandfunction,alsoconsiderthefollowing.

Use owers, plants, balloons, or get well cards from loved ones.

Theseitemsaremeaningfulandpurposefultothepatient.

Theycanbeusedforcommunication,visualtrackingorupper

extremityfunction.

Booksandmagazinescangiveyouanideaofareasofinterest.

Itemsonthebedsidetablemayprovideinterestingand

functionalideas.Whenworkinginstanding,putthebedside

tableagainstthewallforbetterstability.

Usethehospitalmenuandhaveyourpatientpreparefor

mealtime.

Thewindowandwindowsillcanbeusedwhenstandingyour

patient.Havethemlookoutthewindowandpointtothings.Or,

havethemcleanthewindowsorpullthecurtains.

Ahospitalbedraisedtoitshighestpositioncanprovideastable

supportforyourpatientinstanding.Haveyourpatientfacethe

bedandchangethepillowcasesormakethebed.

Aregularchair(nexttothebed)canbeusedfortransfertrainingandfunctionalmobility.Turnthechairaroundanduse

thebackofthechairasastablesupportduringstanding.

Acommodechairwithlockingwheelscanbeausefulpiece

ofequipmentwhenawheelchairisnotavailable.Withthelid

down,itcanbeusedtohelppatientssitforshortperiodsof

timeinfrontofthesinktodogroomingandhygiene.

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Basic Handling Principles

Position yourself for safetyConsiderthetask,thepositionofthepatientandthepatientslevel

offunctionwhendetermininghowbesttobepositionedduring

intervention.Whenworkingbedside,withthepatientinsupineor

sidelying,positionyourselfontheinvolvedsidetohelpincrease

awarenessofthatside.

Whenworkingwithpatientsinsittingorstandingrequiringhandson

assistance,positionyourselfonthepatientsinvolvedsideordirectlyin

frontofthepatientandmaintainclosecontact.Contactsupporthelps

yourpatientfeelsafe.

Have equipment and supplies readyBepreparedwithanyequipmentyouwillneedbeforebeginningyour

treatmentsession.Itcanbeunsafetoleaveyourpatientssideonceyourpatientisinasittingposition.Havethegaitbelt,caneorwalker

withinreachforambulation.Placethecomb,brush,basin,washcloth,

toothbrushandtoothpasteonthebedsidetableforgroomingand

hygiene.Getanyclothingorbathrobesfromtheclosetfordressingand

placethemwithinreach.

Establish a good starting positionWhetheryouworkwithyourpatientbedside,insittingorinstanding,

establishagoodstartingposition.Insupine,trytoachieveapositionof

symmetrywiththetrunk,headandlimbs.

Insitting,theproperpositionofthepelvisallowsformoredynamictrunkcontrol.Facilitatethepelvisoutofaposteriorpelvictilt.Trytoachieve

equalweightbearingoverbothhips.Activatetrunkextensionandhead

righting.

Provide a good base of supportProvide a rm, stable surface when working with a patient in sitting.

Ifyourpatientissittingattheedgeofthehospitalbed,modifythe

environment if necessary. Lower the bed and position the feet at on

the oor. Provide a stool or chair, as needed. If your patient is on a very

softmattress,tryusingaslidingboardpaddedwithblanketstoprovide

a rmer base of support. If your patient is positioned on an air mattress,

maximize the pressure or deate the air to provide a more stable

support.Ifpossible,transferyourpatienttoachairforbettersupport.

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References: 11, 30

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Assist as necessaryHowmuchyouassistandhowmuchyouletyourpatienttryanactivity

ontheirownwillbedeterminedbythegoalofthetreatmentsession

andtheneedtomaintainasafeenvironment.Iftheprimarygoalofthe

sessionistodetermineapatientsfunctionalstatus,assistasnecessary

forsafety.Ifthegoalofthetreatmentsessionistofacilitatetrunkand

limbcontrolandimprovefunctionaloutcomes,giveassistanceasneededtoencourage,facilitateanddevelopcontrolledmovements.

Whenmovingapatientorhelpingapatientchangeposition,placeyour

hands rmly on the trunk or pelvis. Never pull on the involved arm.

Observe your patients responseYourpatientmaytirequickly.Observefacialexpression,respiration,skincolorandtemperature.Providesafe

opportunitiesforyourpatienttorestbeforetheybecomedistressed.Yourpatientcanrestinachairoryoucan

supportyourpatientwhilesittingattheedgeofthebed.

Facilitate more efcient movementsConsiderthepositionofthepatient,theenvironmentandfacilitationmethodsusedwhentryingtoachieveefcient and controlled movements. If your patient is unable to move a limb against gravity, change the

positionofthepatienttoallowforagravity-eliminatedpositionofthelimb.Checktoseeifenvironmental

factors inhibit efcient movement. The friction or weight of the bedding or clothing can make movement of the

limb difcult for patients. Change the position of the task to facilitate better movement or try different handling

methodstofacilitatemorecontrolledmovements.

Motivating factorsPatient participation during therapeutic intervention can signicantly improve when the task makes sense or

ispurposefultothepatient.Motivatingfactorscanvaryfrompatienttopatient.Somepatientsenjoyactivities

andparticipatemorewhenagameorcompetitionisinvolved.Otherpatientsrespondwellwhentasksrelate

sociallytofamilyorfriends.

Schedulingdressing,groomingandhygieneattheappropriatetimeofthedaycangivepurposetothese

tasks.Havepatientsgetpreparedforvisitorsbybrushingtheirhair,shavingorputtingonmake-up.

Forexmple,onephysicaltherapisthadaruleforherhigherlevelpatients:beforeleavingtheroomtowalk

downthehallway,herpatientshadtogototheircloset,donarobeandbrushtheirhair.Anothertherapist

emphasizedtheneedtopracticesafebed-to-commodetransfersasamotivationtohavingthecatheter

removed.

References: 31, 32, 33, 34

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Incorporate the involved upper extremity into functional activitiesMakeeveryattempttoincorporatethepatientsinvolvedupperextremityintotasksinordertomaximize

thepotentialforrecovery.Therearethreewaysanonfunctionalupperextremitycanbeincorporatedinto

functionaltasks.

1. Youcanguidethepatientshand,placingyourhandovertheirs.

2. Youcanputthepatientsupperextremityinaweightbearingor

stabilizingposition.

3. Youcanhavethepatientusebothhandstogether,bilaterally.

Formoredetailedinformationonutilizingtheinvolvedupperextremityintofunctionaltasks,viewthe

courseFunctional Treatment Ideas and Strategies in Adult Hemiplegia.

References: 14, 30, 31, 35, 36

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Modifying Your Plan of InterventionTheunexpectedcanoccurduringanytreatmentsessionandyourpatientrespondsinawayyouhadnot

anticipated.Allofasuddenyourpatientisntfeelingwell.Yourpatientbecomeslight-headedornauseousor

fatiguesetsin.Perhapsyourpatienthassuddenlybecomebelligerentorimpulsive.Yourplanofintervention

needs to be modied. What do you do?

Whenthetreatmentdoesntgoasplanned,modifyyoursessionbasedonsafety.

Herearethreerecommendations:

1. Discontinue treatment. Your safety or the patients safety is

compromised.

Stopandreturnyourpatienttoasafeposition.Ifyouare

standingortransferringyourpatient,returnthemtothechairor

bedforsafety,andthenreassessyoursituation.Iftheeventis

relatedtotheirmedicalcondition,notifythenurseimmediately.

2. Continue treatment, if safety is not a concern.

Eventhoughyourpatientisperformingataskinawayyouhad

notanticipated,youdetermineyourpatientissafeandchoose

nottointerruptyourpatient.Afteryourpatienthascompleted

thetask,oraportionofit,youcanthenexplaintoyourpatient

yourpreferenceforthewaythetaskshouldhavebeendoneor

could be modied in the future.

3. Stop, make modications and then continue.

Askyourpatienttowaitforamoment.Ifyoudidntgetthe

responseyouwanted,determinehowthesessioncouldbe

modied for better results. Sharp observations, critical thinking

andclinicalreasoninghelpdeterminehowyouwillmodifyyour

treatment. Modications may include a change in:

thepositionofyourpatient

yourhandlingmethods

theamountofassistanceyougive

thetaskorthecomplexityofthetask theenvironment

And nally, always be prepared with a back up plan. If Plan A doesnt work, be ready with Plan B. In fact,

haveideasforplansC,DandE,too!

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Weightbearing Through theInvolved Upper Extremity

ICF Component: BodyFunctions

Domain: Neuromusculoskeletalandmovementrelatedfunctions

Therapeutic BenetsMaintainsROMofthewristandhandbymaintaininglengthofconnectivetissuestructures.Providessensory

informationandimprovesawarenessoftheinvolvedside.Facilitatesdynamictrunkcontrolinlateralweight

shifts.

Combinethisactivitywithfunctionaltaskssuchaswashingthefaceorcombinghair.

Precautions

IVlocatedinthedorsumofthehand.Wristpaincausedbymalalignmentofthecarpals.

Swollenhandorpainfulshoulder.

Sternalprecautions.

Starting PositionHaveyourpatientsittingattheedgeofthebedwiththefeetwellsupported.

Handling

1. Sitnexttoorinfrontofyourpatient.

2. Positiontheinvolvedhandonyourfemur,justaboveyourknee(thisallowsyoutofeeltheamountofweightyourpatientis

actuallyputtingintotheinvolvedupperextremity).

3. Placeyourhandbehindtheinvolvedelbow,givingaslight

amountofextensionandexternalrotationofthearm.

4. Askyourpatienttoshifttowardtheinvolvedside,puttingweight

throughthearmandintothehand.

5. Observetheangleofthewrist.Becarefulnottoallowextremeextensionofthewrist.

6. Holdthepositionforafewseconds,thenallowyourpatienttoshiftbacktomidline.

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TipsGivingapurposetothisactivityencouragesgreaterweightshifttoward

theinvolvedsideandintotheinvolvedupperextremity.Haveyour

patientreachforahairbrush,washclothoranyotherpurposefulobject.

A white washcloth placed on a white sheet can be difcult for your

patienttosee.Enhancetheenvironmentbyusingobjectswith

contrastingcolorsorchangetheplacementoftheobject.

Modications/VariationsPrecautions,suchasplacementoftheIVorswellingofthehand,may

preventweightbearingthroughthehand.Ifthisisthecase,modifythis

taskbyhavingyourpatientbearweightthroughtheforearm,instead.

Common MistakesDonotallowyourpatienttohangonthejointasthiscancausemalalignmentandoverstretchingofthejoint

capsule.Besurethattheshoulder(glenohumeraljoint)isingoodalignmentasyourpatientshiftsweightover

theinvolvedupperextremity.

Formoreindepthinformationonfacilitationofweightbearingthroughtheupperextremity,viewthe

courseFunctional Treatment Ideas and Strategies in Adult Hemiplegia.

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Mobility: Facilitation of Sit to Stand

ICF Component: Activities

Domain: Mobility

Therapeutic BenetsTheabilitytomovefromsittingtostandingpreparesthepatientfor

ambulationandenablesthepatienttomanageclothesduringdressing

andaftertoileting.

PrecautionsHipprecautionsduetosurgery,fractures/injuryorarthritis.

Starting PositionBeginwiththepatientsittinginachairorattheedgeofthebed.Havethepatientwearshoesandsocksor

non-skidslippers.

Handling

1. Standontheinvolvedside,nexttoyourpatient.

2. Position your patients feet at on the oor, parallel and about

shoulderwidthapart.

3. Makesurethedistal1/3ofthefemurisunsupported.Haveyour

patientscootforward,ifnecessary.

4. Positionthefeetbehindtheknees.Remember,thetallerthe

patient,thefurtherbackthefeetshouldbepositioned.Tip:As

youbringyourpatientforward,observethelessinvolvedfoot.

Ifyourpatientrepositionsthestrongfoot,positiontheinvolved

footsymmetrically.

5. Askyourpatienttoplacetheirhandsontheirthighsorclasp

themtogether.Thishelpsyourpatienttobemoreawareofthe

involvedarmandmovemoresymmetrically.

6. Positionyourselfsothatyourshoulderisbehindandincontact

withyourpatientsinvolvedshoulder.Thiswillhelpcueyour

patienttocomeforwardand,atthesametime,keepyour

patientfrompushingbackintoextension.

7. Placeyourhandaroundyourpatient,ontothelessinvolvedhip.

Yourforearmwillbealongyourpatientslumbarspine.

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8. Place your other hand rmly on the femur, just above (not on)

theinvolvedknee.Giveyourpatientacuetobringthefemur

forwardandputweightintotheinvolvedfoot.

9. Cueyourpatienttocomeforwardattheshoulderandatthe

hips,justuntilthehipsleavethechair.Asthehipsclearthe

chair,dontgiveanymoreforwardinformation.

10. Asyourpatientstands,slideyourhandalongthefemurand

place your hands rmly on the illiac crests of the pelvis.

11. Moveyourbodyclosertoyourpatient,makingcontactalong

theinvolvedhip.

TipsPatientswholearntostandupbyshiftingtheirweightforward(insteadofusingagrabbarorpushingoffthe

armrestsofthechair)willeventuallybecomemoreindependentwithself-careskills.However,ifyourpatient

needsequipmentathomeforsafety,makesurethattheyhaveit.

Avoidpullingyourpatientupbytheinvolvedarm,insteadsupportyourpatientatthetrunk.Traumatic

impingementtotheshouldercanbecomepainfulandtakeweeksormonthstoheal.

Common MistakesSome patients may have difculty coming forward to stand up. Give more cues to the patient from the

shoulder,hipsandfemurtoshiftthepatientsweightforwardinordertostandup.Asyourpatientstandsup,

watch the toes. If the toes come up from the oor, the patients weight is too far back.

Thefeetarenotinthecorrectposition(notfarenoughbehindtheknees).Remember:thetallerthepatientand

thelowerthesurface,thefurtherthefeetshouldbepositionedbehindtheknees.

Ifyourpatientavoidsputtingweightontotheinvolvedfoot,makesuretheinvolvedfootisplacedparallelwith

thelessinvolvedfoot.Manystrokesurvivorsstaggertheirfeet,placingtheinvolvedfootinfrontoftheless

involvedfoot(avoidingweightshifttotheinvolvedside).

This therapeutic method is demonstrated in the chapter Practice Labs.

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Copyright2007-2009InternationalClinicalEducators,Inc. TheIntensiveCareUnit(ICU)

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The inTenSive care uniT

The following information is presented on Disc 3.

Introduction to the ICUTheinitialassessmentandearlyinterventionofastrokesurvivor

oftenbeginsintheintensivecareunit(ICU).Tobeeffectiveinthe

ICUrequiresbothknowledgeandskill.Apatientsunstablemedical

conditioncanchangeyourplansonadaily,orevenanhourly,basis.

The rst time working in the ICU environment can be overwhelming.

Yourpatientisveryillandtheroomisfullofcomplicatedandunfamiliar

equipment.Thenumerouslinescanappearasatangledweb.

TherapistsshouldfeelsafewhenworkingintheICU.Anurseisalwaysnearbyandthemonitorswillsoundanalarmifthereisanyproblem.

Whenanalarmgoesoff,trytodeterminewhy.

Ifitsamechanicalissue,correctitandproceed.

Ifitsrelatedtoachangeinyourpatientsstatus,followpropermedicalguidelines.

Alwaysworkwithintheparametersofpropermedicalguidelines.Donthesitatetoconsultwithyour

nursestoclarifyanyquestionsyoumayhave.

Thetherapeuticmethodsusedfortheassessmentandintervention

ofastrokesurvivorintheICUarebasicallythesameasdescribed

throughoutthislearningmodule.Youmayhavemoreequipmentordifferentmonitorstodealwith,butyoucanusealloftheprevious

treatmentideas.Followallmedicalguidelinesandprotocolsinyour

ICU.

Monitoryourpatientsvitalsignsatthebeginningofyoursession

todetermineabaseline.PatientsintheICUmayexperiencea

hypersensitivitytovisual,tactileorauditorystimulation.Besensitive

andmakeadjustmentsasnecessary.

Letyourpatientknowwhatyouaredoingintheroom.Movetheirpersonalitemscarefullyandrespectfully.

Yourpatientsroomistheirpersonalspaceandtheirhomeforthetimebeing.

Whenpreparingtochangethepositionofyourpatient(intoasittingpositionoratransfer),manydecisions

mustbemadepriortomovingyourpatient.Forexample,whenpreparingyourpatientforsittingattheedgeof

thebed,whichsideisbest?Thedecisionisoftenbasedonthelengthandlocationofthelines.

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Managing Equipment in the ICUBecomefamiliarwiththeactualequipmentusedinyourICUasyoursmaybeslightlydifferent.Eachhospital

hasitsownprotocolsandprecautionsrelatedtoequipmentintheICU.

Manageandorganizethelines.Ageneralrulebeforemovingapatient:

Youarelimitedbyyourshortestline.Enhancetheenvironment.

CondensingalllinestooneIVpolemakesiteasierforyoutomove

allofthelinesnecessarybeforesitting,standingortransferringyour

patient.Withpracticeyouwillfeelmorecomfortabledoingthis.

VentilatorAventilatormaybeattachedtothetracheostomytubeor

endotracheostomytube.Bemindfulnottoletthecondensationinthetubingrollbackintoyourpatientsairway.Dontliftthetubesabovethe

sitewherethetracheostomyentersthebody(atthestomaormouth).

Trynottotwistormovethetubingnearthetracheostomysiteormouth

asitcausesyourpatienttocough.Assurethereisnotuggingorpulling.

Remembertovisualizeorwalkthroughyourtreatmenttodetermine

line-lengthneedspriortomovingyourpatient.

Suction CatheterWhen patients have difculty with swallowing or clearing secretions in

theirmouth,asuctioncathetercanbeused.Itcanalsobeusedaround

thestomaofatracheostomy.Becautiouswhenusingatonsil-tip

suctioncatheterasapatientwhoisnotalertmightbitedownonitor,if

it goes too far back in the throat, you might trigger a gag reex.

VentriculostomyIfyourpatientisonaventriculostomy,itisextremelyimportanttoask

thenursewhatisandisntallowedduringyourtreatmentsession.

Beforechangingtheheightofthebed,raisingtheheadofthebedor

movingyourpatient,theventriculostomyneedstobeclampedbythenurse.Manageormoveanylinethatisinsertedintotheskullorspine

withextremecare.

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EKG Telemetry MonitorInspectyourpatientschestandnotewheretheEKGleadsareplaced.

Followalllinesfromorigintoinsertion.Notebaselinereadingsofthe

cardiacmonitorbeforebeginningtherapy.

Foley CatheterUsecareanddonotallowacathetertubetotugorpullduringtherapy.

Alwaysmonitorthelocationofthecatheterbeforechangingapatients

positioninbedortransferringfromthebedtoachair.

Foley Catheter with Temperature SensorApatientscoretemperaturecanbemonitoredonacontinualbasis

withasensorattachedtoaprobefromtheFoleycatheter.Oftenthetemperaturelinecanbedetachedduringtreatment,onceabaseline

hasbeennoted.Besuretoreattachthetemperaturesensorattheend

ofyourtreatmentsession.

Pulse OximeterOxygensaturationismeasuredwiththepulseoximeter.Itisusually

attached to a nger, but can also be attached to your patients ear,

foreheadortoe.Itreadshowmuchoxygenisonthehematocrit

molecule.

Discusswiththenursewhatisanacceptableoxygensaturationlevelfor

yourpatient.Observethemonitortoestablishabaseline.Typicallytheoxygensaturationlevelshouldbeabove92.Ifthesaturationleveldrops

below90,stopyourtreatment,haveyourpatientliedownandallow

yourpatienttorest.Checkwiththenursetodetermineiftheoxygencanbeincreased.

Central LineBeextremelycarefulworkingwithpatientswhohaveacentrallinebecausethelinesarehardertoreplace

whendislodged(usuallydoneintheoperatingroomwithaphysician).Assurethatthereisnotuggingorpulling

onthecentralline.Visualizeorwalkthroughyourtreatmenttodeterminethelengthofthelineneededpriorto

movingyourpatient.

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Copyright2007-2009InternationalClinicalEducators,Inc. PracticeLabs

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Practice Lab

Bed Mobility: Sidelying to Sitting

The following guidelines may need to be modied if your patient has secondary complications or medical

conditionsinterfere.

Starting PositionThepatientislyinginbedontheinvolvedside.

Handling1. Placeyourpatientslowerarmbetweenyourhumerusand

trunk.Maintainthissupport.

2. Slideyourhandunderthescapulaandbringtheinvolvedarm

into protraction and forward exion, as close to 90 as possible.

3. Bring the upper trunk into exion, closer to the edge of the bed.

Thiswillbebetterforyourbackandwillalsokeepyourpatient

frompushingbackintoextension.

4. Bring the hips and knees into as much exion as your patient

cancomfortablytolerate.Thiswillhelptoinhibitextensionof

thelowerextremitiesandshortenthelevers,makingiteasier

tocontrolthetallerpatients.

5. Standinfrontofyourpatientwithawidebaseofsupport.

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6. Assistyourpatienttoreachacrosswiththelessinvolvedarm

andaskthemtopushupfromthebed.Thishandplacement

alsohelpskeepthemforwardanddiscouragesthemfrom

fallingbackontothebed.

7. Slideyourpatientsfeetoffofthebed,keepingyourleginfront

oftheirfeet.Dontallowtheirlegstofallasthiscancausestressatthehip.

8. Placeonehandonyourpatientsilliaccrest,bringingthepelvis

downandslightlyback.Thisfacilitatestrunkactivityontheless

involvedside.

9. Atthesametime,shiftyourweightfromoneleg(positioned

towardtheheadofthebed)totheotherleg(positionedtoward

thefootofthebed).Thislungeencouragesuseofyourlegs

insteadofyourback.

10. Bringyourpatientsuppertrunkuprightintoasittingposition,

continuallysupportingtheinvolvedupperextremity.

TipsConsiderthefollowingpriortosittingyourpatientattheedgeofthebed.

abilitytofollowdirections

levelofalertness

sensationandfunctionofthelessinvolvedside

lowerextremityROM

Inaddition,checkforanyindicationofpain.

Common MistakesDontforgettoslidethefeetoffthebed(step#7)beforecomingtoasittingposition.Facilitationofthepelvis

(step#8)andthelungeweightshift(step#9)areextremelyimportantsothatyoudontuseyourbacktoliftthe

patient.

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