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Altered Mobility, Dysphagia, Altered Communication, Social Isolation Weeks 4 & 5
Objectives <ul><li>Discuss impaired mobility across the lifespan </li></ul><ul><li>Discuss strategies to reduce its effect...
Stroke <ul><li>More than 50,000 Canadians stroke annually </li></ul><ul><li>Annual cost of care is $2.7 billion  </li></ul...
Stroke Review <ul><li>Interrupted arterial blood flow to a part of the brain  </li></ul><ul><li>2 major categories:  </li>...
Stroke: Pathophysiology <ul><li>Interrupted blood flow to the brain due to: </li></ul><ul><ul><li>Impaired cerebral autore...
Pathophysiology: Hemorrhagic <ul><li>Ruptured artery leads to bleeding over brain surface (occurs during activity) </li></...
Risk Factors For Ischemic and Hemorrhagic Stroke <ul><li>Non-modifiable: </li></ul><ul><ul><li>Advanced age (over age 55) ...
Clinical Manifestations: <ul><li>Any of the following: </li></ul><ul><li>Numbness or weakness of the face, arm, or leg (es...
Left Brain Stroke  Right Brain Stroke <ul><li>Parlyzed left side </li></ul><ul><li>Left-sided neglect </li></ul><ul><li>Sp...
Stroke: Diagnostic Studies <ul><li>Done to confirm the stroke and identify the likely cause  </li></ul><ul><li>CT, CTA, CT...
Key Aspects of Management <ul><li>Ischemic: </li></ul><ul><li>For TIA/mild stroke:  </li></ul><ul><ul><li>Atrial fib: coum...
Collaborative Rehabilitation Care <ul><li>Assessment: </li></ul><ul><li>Primary assessment is focused on cardiac and respi...
Stroke: Intervention <ul><li>Respiratory System: </li></ul><ul><li>Risk for atelactasis and pneumonia </li></ul><ul><ul><l...
Stroke: Intervention <ul><li>Neurological System: </li></ul><ul><li>Monitored for changes such as extension of the stroke,...
Stroke: Intervention <ul><li>Cardiovascular System: </li></ul><ul><li>Cardiac efficiency can be compromised by fluid reten...
Stroke: Intervention <ul><li>Musculoskeletal System: </li></ul><ul><li>Goal is to maintain optimal function by preventing ...
Stroke: Intervention <ul><li>Integumentary System: </li></ul><ul><li>Particularly susceptible to breakdown related to loss...
Stroke: Intervention <ul><li>Gastrointestinal System: </li></ul><ul><li>Try to avoid constipation </li></ul><ul><li>Use of...
Stroke: Intervention <ul><li>Urinary System: </li></ul><ul><li>Poor bladder control, resulting in incontinence </li></ul><...
Stroke: Intervention <ul><li>Nutrition: </li></ul><ul><li>Use of IV therapy to maintain fluid and electrolyte balance as w...
Stroke: Intervention <ul><li>Communication: </li></ul><ul><li>Assess the ability to speak and understand </li></ul><ul><li...
Stroke: Intervention <ul><li>Sensory-Perceptual Alterations: </li></ul><ul><li>Homonymous hemianopsia is a common problem ...
Sexuality: Interventions <ul><li>Sexuality assessment should be an automatic part of assessment for clients with chronic i...
Assessing Sexual Needs <ul><li>Helpful Techniques for Assessing </li></ul><ul><ul><li>Bridging Questions e.g. Has anyone t...
Stroke Prevention <ul><li>Antithrombics </li></ul><ul><ul><li>ASA </li></ul></ul><ul><ul><li>Clopidrogrel (Plavix) </li></...
Prevention of Complications <ul><li>In the Rehab Setting: </li></ul><ul><li>Aspiration, Pneumonia </li></ul><ul><li>Depres...
Prevention of Complications In Rehab <ul><li>Other complications: </li></ul><ul><li>Spasticity </li></ul><ul><li>Bowel and...
Altered Mobility: Problems and Issues <ul><li>What does age have to do with mobility? </li></ul><ul><ul><li>declining phys...
Altered Mobility: Problems and Issues <ul><li>What kinds of musculoskeletal disorders may result in altered mobility? </li...
Altered Mobility: Problems and Issues <ul><li>What kinds of lifestyle related issues may result in altered mobility? </li>...
Altered Mobility: Problems and Issues <ul><li>Why might Diabetes cause altered mobility? </li></ul><ul><ul><li>common caus...
Altered Mobility: Problems and Issues <ul><li>What effects would sensory impairment have on mobility? </li></ul><ul><ul><l...
Altered Mobility: Problems and Issues <ul><li>How does pain effect mobility? </li></ul><ul><ul><li>Can make simple tasks d...
Effects of Immobility <ul><li>**Most profound effects occur with bedrest!! </li></ul><ul><ul><li>Cardiovascular System </l...
Effects of Immobility <ul><li>**Most profound effects occur with bedrest!! </li></ul><ul><ul><li>Cardiovascular System </l...
Effects of Immobility <ul><li>**Most profound effects occur with bedrest!! </li></ul><ul><li>What happens to the Respirato...
Effects of Immobility <ul><li>What happens to the Musculoskeletal System? </li></ul><ul><ul><li>increased joint stiffness ...
Effects of Immobility <ul><li>**Most profound effects occur with bedrest!! </li></ul><ul><li>What about your bones?  </li>...
Effects of Immobility <ul><li>**Most profound effects occur with bedrest!! </li></ul><ul><li>What happens in the GI System...
Effects of Immobility <ul><li>What happens in the Neurological System? </li></ul><ul><ul><li>decreased sensory stimulation...
Altered Mobility: Interventions <ul><li>Physical activity </li></ul><ul><li>Adequate nutrition </li></ul><ul><li>Pain cont...
Altered Mobility: Interventions <ul><li>Physical Activity </li></ul><ul><ul><li>Benefits: enhances musculoskeletal strengt...
Altered Mobility: Interventions <ul><li>Adequate Nutrition </li></ul><ul><ul><li>Canada’s Food Guide </li></ul></ul><ul><u...
Altered Mobility: Interventions <ul><li>Pain control </li></ul><ul><ul><li>adequate pain control necessary </li></ul></ul>...
Altered Mobility: Interventions <ul><li>Aids for Sensory Impairment  </li></ul><ul><ul><li>Low-vision rehabilitation </li>...
Altered Mobility: Interventions <ul><li>Psychosocial Interventions </li></ul><ul><ul><li>Empowerment </li></ul></ul><ul><u...
Altered Mobility: Interventions <ul><li>Management of Equipment </li></ul><ul><ul><li>Devices for mobility </li></ul></ul>...
Cerebral Palsy <ul><li>What is Cerebral Palsy? </li></ul><ul><ul><li>A group of permanent disorders of the development of ...
Cerebral Palsy <ul><li>Etiology: Prenatal brain abnormalities </li></ul><ul><ul><li>80% are caused by unknown brain abnorm...
Interdisciplinary Management of CP <ul><li>Key disciplines involved and their role: </li></ul><ul><ul><li>OT: help with as...
Cerebral Palsy <ul><li>Nursing Care </li></ul><ul><ul><li>Goal </li></ul></ul><ul><ul><li>Nursing attitudes </li></ul></ul...
Goals of Therapy <ul><li>To establish locomotion, communication, and self-help skills </li></ul><ul><li>To gain optimal ap...
Therapeutic Management <ul><li>Ankle foot braces may be worn </li></ul><ul><li>Orthopedic surgery to correct spastic defor...
Nursing Care Management <ul><li>Assist the family in devising and modifying equipment and activities </li></ul><ul><li>Med...
Social Isolation <ul><li>Solitude: voluntarily chosen time alone </li></ul><ul><li>Involuntary social isolation occurs whe...
Social Isolation <ul><li>Social isolation without choice is loneliness </li></ul><ul><li>Loneliness: the distressing, depr...
Social Isolation <ul><li>Satisfactory social lives are determined by the  quality and reciprocity, not quantity and freque...
Social Isolation <ul><li>Social contact is a main component of human comfort </li></ul><ul><li>Living without social conta...
Social Isolation <ul><li>What the literature tells us: </li></ul><ul><li>Functional limitations in ADLs hinder independenc...
Social Isolation <ul><li>Assessment: </li></ul><ul><li>Objective: ask questions </li></ul><ul><li>Subjective: find out the...
Social Isolation <ul><li>Intervention: </li></ul><ul><li>Peer counseling </li></ul><ul><li>Support groups </li></ul><ul><l...
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Week4 alteredmobilitydysphagia

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  • Each stroke costs an average of $27,500 to the acute care system
  • Transcript of "Week4 alteredmobilitydysphagia"

    1. 1. Altered Mobility, Dysphagia, Altered Communication, Social Isolation Weeks 4 & 5
    2. 2. Objectives <ul><li>Discuss impaired mobility across the lifespan </li></ul><ul><li>Discuss strategies to reduce its effects </li></ul><ul><li>Concept and characteristics of social isolation </li></ul><ul><li>Discuss relevant interventions for social isolation </li></ul><ul><li>Manifestations and interdisciplinary management of cerebral palsy </li></ul><ul><li>Interdisciplinary management of CP </li></ul>
    3. 3. Stroke <ul><li>More than 50,000 Canadians stroke annually </li></ul><ul><li>Annual cost of care is $2.7 billion </li></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, p 1600) </li></ul><ul><li>The leading cause of death and disability in adults </li></ul><ul><li>About 15% of sufferers die and about 30% are left with moderate-severe disability </li></ul><ul><li>(Heart and Stroke Foundation, 2007) </li></ul>
    4. 4. Stroke Review <ul><li>Interrupted arterial blood flow to a part of the brain </li></ul><ul><li>2 major categories: </li></ul><ul><ul><li>ischemic (80%), in which vascular occlusion and significant hypoperfusion occur </li></ul></ul><ul><ul><li>hemorrhagic (20%), in which there is extravasation of blood into the brain </li></ul></ul><ul><li>(Heart and Stroke Foundation, 2007) </li></ul>
    5. 5. Stroke: Pathophysiology <ul><li>Interrupted blood flow to the brain due to: </li></ul><ul><ul><li>Impaired cerebral autoregulation </li></ul></ul><ul><ul><li>Increased cerebral arterial carbon dioxide levels increase cerebral blood flow </li></ul></ul><ul><ul><li>Blood pressure, cardiac output, and blood viscosity affect cerebral blood flow </li></ul></ul><ul><ul><li>Decreased cerebral blood flow may result in compensatory collateral circulation development </li></ul></ul><ul><ul><li>Atherosclerosis </li></ul></ul><ul><ul><ul><li>Ischemic cascade </li></ul></ul></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, pp 1601-1602) </li></ul>
    6. 6. Pathophysiology: Hemorrhagic <ul><li>Ruptured artery leads to bleeding over brain surface (occurs during activity) </li></ul><ul><li>Hemorrhagic stroke can be subdivided into: </li></ul><ul><ul><li>Intracerebral hemorrhage </li></ul></ul><ul><ul><ul><li>Caused mainly by uncontrolled hypertension </li></ul></ul></ul><ul><ul><ul><li>Prognosis is poor </li></ul></ul></ul><ul><ul><li>Subarachnoid hemorrhage </li></ul></ul><ul><ul><ul><li>Intracranial bleeding into CSF-filled space </li></ul></ul></ul><ul><ul><ul><li>Caused mainly by rupture of a cerebral aneurysm </li></ul></ul></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, p 1604) </li></ul>
    7. 7. Risk Factors For Ischemic and Hemorrhagic Stroke <ul><li>Non-modifiable: </li></ul><ul><ul><li>Advanced age (over age 55) </li></ul></ul><ul><ul><li>Gender (men) </li></ul></ul><ul><ul><li>Race </li></ul></ul><ul><ul><li>Genetic factors </li></ul></ul><ul><li>Modifiable: </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Heart disease, atrial fib </li></ul></ul><ul><ul><li>Hyperlipidemia </li></ul></ul><ul><ul><li>Hypercoagulability </li></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Oral Contraceptives </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Physical inactivity </li></ul></ul><ul><ul><li>Excessive alcohol </li></ul></ul>
    8. 8. Clinical Manifestations: <ul><li>Any of the following: </li></ul><ul><li>Numbness or weakness of the face, arm, or leg (especially on one side) </li></ul><ul><li>Confusion or change in mental status </li></ul><ul><li>Trouble speaking or understanding speech </li></ul><ul><li>Visual disturbances </li></ul><ul><li>Difficulty walking, dizziness, or loss of balance or coordination </li></ul><ul><li>Sudden severe headache </li></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, p 1605) </li></ul>
    9. 9. Left Brain Stroke Right Brain Stroke <ul><li>Parlyzed left side </li></ul><ul><li>Left-sided neglect </li></ul><ul><li>Spatial-perceptual deficits </li></ul><ul><li>Tends to deny or minimize problems </li></ul><ul><li>Rapid performance, short attention span </li></ul><ul><li>Impulsive, safety problems </li></ul><ul><li>Impaired judgement </li></ul><ul><li>Impaired time concepts </li></ul><ul><li>Paralyzed right side </li></ul><ul><li>Impaired speech/language aphasias </li></ul><ul><li>Impaired right/left discrimination </li></ul><ul><li>Slow performance, cautious </li></ul><ul><li>Aware of deficits: depression, anxiety </li></ul><ul><li>Impaired comprehension related to language, math </li></ul>(Lewis, Heitkemper, & Dirksen, 2010, p 1606)
    10. 10. Stroke: Diagnostic Studies <ul><li>Done to confirm the stroke and identify the likely cause </li></ul><ul><li>CT, CTA, CTP, MRI, MRA, DWI </li></ul><ul><li>See Table 59-4 Stroke p 1607 </li></ul>
    11. 11. Key Aspects of Management <ul><li>Ischemic: </li></ul><ul><li>For TIA/mild stroke: </li></ul><ul><ul><li>Atrial fib: coumadin or aspirin </li></ul></ul><ul><ul><li>aspirin, plavix </li></ul></ul><ul><li>Thrombolytic therapy: t-PA (within 3hrs) </li></ul><ul><li>Anticoagulant therapy </li></ul><ul><li>Prevent/treat complications </li></ul><ul><li>Hemorrhagic: </li></ul><ul><li>Allow the brain to recover (elevating head of bed) </li></ul><ul><li>Prevent/minimize rebleeding (surgery) </li></ul><ul><li>Prevent/treat complications </li></ul>
    12. 12. Collaborative Rehabilitation Care <ul><li>Assessment: </li></ul><ul><li>Primary assessment is focused on cardiac and respiratory status and neurological assessment </li></ul><ul><li>Goals include attaining and/or maintaining: </li></ul><ul><li>A stable or improve LOC </li></ul><ul><li>Maximum physical functioning </li></ul><ul><li>Maximum self-care abilities and skills </li></ul><ul><li>Stable body functions (e.g. bladder control) </li></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, p 1612) </li></ul><ul><li>Communication abilities </li></ul><ul><li>Adequate nutrition </li></ul><ul><li>Avoid complications of stroke </li></ul><ul><li>Maintain effective personal and family coping </li></ul>
    13. 13. Stroke: Intervention <ul><li>Respiratory System: </li></ul><ul><li>Risk for atelactasis and pneumonia </li></ul><ul><ul><li>Advanced age and immobility </li></ul></ul><ul><li>Risk for aspiration pneumonia </li></ul><ul><ul><li>Impaired consciousness or dysphagia </li></ul></ul><ul><li>Risk for airway obstruction </li></ul><ul><ul><li>Problems with chewing and swallowing, food pocketing, and the tongue falling back </li></ul></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, p 1615) </li></ul>
    14. 14. Stroke: Intervention <ul><li>Neurological System: </li></ul><ul><li>Monitored for changes such as extension of the stroke, increased ICP, vasospasm, or recovery from stroke symptoms </li></ul><ul><li>Can use the GCS, NIHSS and the CNS </li></ul><ul><li>Vital signs are also closely monitored and documented when using any neurological assessment tool </li></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, p 1615) </li></ul>
    15. 15. Stroke: Intervention <ul><li>Cardiovascular System: </li></ul><ul><li>Cardiac efficiency can be compromised by fluid retention, overhydration, dehydration, and blood pressure variations </li></ul><ul><li>Closely monitor IV therapy, intake and output, vitals, cardiac rhythms, adjusting fluid intake, lung sounds, and heart sounds </li></ul><ul><li>Risk for DVT </li></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, p 1616) </li></ul>
    16. 16. Stroke: Intervention <ul><li>Musculoskeletal System: </li></ul><ul><li>Goal is to maintain optimal function by preventing joint contractures and muscular atrophy </li></ul><ul><li>ROM exercises and positioning </li></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, p 1616) </li></ul>
    17. 17. Stroke: Intervention <ul><li>Integumentary System: </li></ul><ul><li>Particularly susceptible to breakdown related to loss of sensation, decreased circulation, and immobility </li></ul>
    18. 18. Stroke: Intervention <ul><li>Gastrointestinal System: </li></ul><ul><li>Try to avoid constipation </li></ul><ul><li>Use of stool softeners </li></ul><ul><li>Check for impaction </li></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, p 1616) </li></ul>
    19. 19. Stroke: Intervention <ul><li>Urinary System: </li></ul><ul><li>Poor bladder control, resulting in incontinence </li></ul><ul><li>Promote normal bladder function </li></ul><ul><li>Avoid use of in-dwelling catheters </li></ul><ul><li>Use of bladder retraining programs </li></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, p 1616) </li></ul>
    20. 20. Stroke: Intervention <ul><li>Nutrition: </li></ul><ul><li>Use of IV therapy to maintain fluid and electrolyte balance as well as administer drugs </li></ul><ul><li>Use of enteral feeds and parenteral feeds </li></ul><ul><li>Gag reflex assessment </li></ul><ul><li>Screen for swallowing ability </li></ul><ul><li>Positioning before, during and after feedings </li></ul><ul><li>Feeding techniques and precautions </li></ul><ul><li>Modified diet and monitoring during meals </li></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, p 1617) </li></ul>
    21. 21. Stroke: Intervention <ul><li>Communication: </li></ul><ul><li>Assess the ability to speak and understand </li></ul><ul><li>See table 59-9 p 1617 </li></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, p 1617) </li></ul>
    22. 22. Stroke: Intervention <ul><li>Sensory-Perceptual Alterations: </li></ul><ul><li>Homonymous hemianopsia is a common problem </li></ul><ul><li>Initially – arrange the environment within the client’s perceptual field </li></ul><ul><li>Later – client learns to consciously attend or scan the neglected side </li></ul><ul><li>Attend to safety risks by anticipating potential hazards and providing protection from injury </li></ul><ul><li>Other visual problems – diplopia, loss of corneal reflex and phosis </li></ul><ul><li>(Lewis, Heitkemper, & Dirksen, 2010, p 1617) </li></ul>
    23. 23. Sexuality: Interventions <ul><li>Sexuality assessment should be an automatic part of assessment for clients with chronic illness </li></ul><ul><li>Need for privacy & confidentiality is the same </li></ul><ul><li>Need to incorporate cultural, age, gender sensitivity when discussing </li></ul>
    24. 24. Assessing Sexual Needs <ul><li>Helpful Techniques for Assessing </li></ul><ul><ul><li>Bridging Questions e.g. Has anyone talked to you about your stroke & how it may affect your ability to have sex? </li></ul></ul><ul><ul><li>Unloading—(a topic) e.g. Many men have had problems with their ability to have an erection. Have you experienced this problem since your surgery? </li></ul></ul>
    25. 25. Stroke Prevention <ul><li>Antithrombics </li></ul><ul><ul><li>ASA </li></ul></ul><ul><ul><li>Clopidrogrel (Plavix) </li></ul></ul><ul><ul><li>Dipyridamole (Aggrenox) </li></ul></ul><ul><ul><li>Ticlopidine (Ticlid) </li></ul></ul><ul><ul><li>Warfarin (Coumadin) </li></ul></ul><ul><li>(Heart and Stroke Foundation, 2007) </li></ul>Statin Agents Atorvastatin (Lipitor) Ffluvastatin (Lescol) Lovastatin (Mevacor) Simvastatin (Zocor) Pravastatin (Pravachol) ACE Inhibitors Lotensin Capoten Vasotec Monopril Altace
    26. 26. Prevention of Complications <ul><li>In the Rehab Setting: </li></ul><ul><li>Aspiration, Pneumonia </li></ul><ul><li>Depression </li></ul><ul><li>Falls </li></ul><ul><li>DVT </li></ul><ul><li>Pressure Ulcer </li></ul><ul><li>UTI </li></ul><ul><li>Msk pain </li></ul><ul><li>Malnutrition </li></ul><ul><li>Seizure </li></ul>(Heart and Stroke Foundation, 2007) <ul><li>In the Acute Care Setting: </li></ul><ul><li>Hemorrhagic transformation </li></ul><ul><li>Cerebral edema </li></ul><ul><li>Stroke reoccurrence </li></ul><ul><li>dysphagia </li></ul>
    27. 27. Prevention of Complications In Rehab <ul><li>Other complications: </li></ul><ul><li>Spasticity </li></ul><ul><li>Bowel and Bladder incontinence </li></ul><ul><li>Constipation </li></ul><ul><li>Shoulder subluxation </li></ul>
    28. 28. Altered Mobility: Problems and Issues <ul><li>What does age have to do with mobility? </li></ul><ul><ul><li>declining physical ability associated with age </li></ul></ul><ul><li>Why? </li></ul><ul><ul><li>D/T less muscle fibers (this reduces muscle strength and endurance) </li></ul></ul><ul><ul><li>bone and cartilage changes (lose ability to function) </li></ul></ul><ul><ul><li>deteriorating cartilage surfaces </li></ul></ul><ul><ul><li>calcium loss </li></ul></ul><ul><ul><li>More stiffness, less joint mobility and strength (due to collagen fibers growing) </li></ul></ul>
    29. 29. Altered Mobility: Problems and Issues <ul><li>What kinds of musculoskeletal disorders may result in altered mobility? </li></ul><ul><ul><li>joint disease </li></ul></ul><ul><ul><li>musculoskeletal deformities </li></ul></ul><ul><ul><li>osteoporosis </li></ul></ul><ul><ul><li>fractures </li></ul></ul><ul><ul><li>podiatric problems –bunions, calluses (cause pain and reluctance/inability to walk) </li></ul></ul><ul><ul><li>osteoarthritis –most common form of degenerative joint disease </li></ul></ul><ul><ul><li>rheumatoid arthritis –more profoundly impairs mobility </li></ul></ul><ul><ul><li>Osteo and Rheumatoid –37 million </li></ul></ul><ul><ul><li>200,000 hip fractures / yr </li></ul></ul>
    30. 30. Altered Mobility: Problems and Issues <ul><li>What kinds of lifestyle related issues may result in altered mobility? </li></ul><ul><ul><li>more sedentary lifestyle with aging -> muscle atrophy, loss of flexibility, loss of endurance </li></ul></ul><ul><ul><li>This disuse disability perpetuates further reduction of activity </li></ul></ul><ul><ul><ul><li>And sets up a vicious cycle of disuse and declining function </li></ul></ul></ul><ul><ul><li>Smoking, obesity and alcohol linked to disorders assoc. with disability/impaired mobility </li></ul></ul><ul><li>What psychosocial factors may effect mobility? </li></ul><ul><ul><li>personal, family or culture –may foster dependence </li></ul></ul><ul><ul><li>decreased socialization -> inactivity, altered mobility, social isolatoin </li></ul></ul><ul><ul><li>decreased mobility <-> depression </li></ul></ul>
    31. 31. Altered Mobility: Problems and Issues <ul><li>Why might Diabetes cause altered mobility? </li></ul><ul><ul><li>common cause of foot deformity and lower extremity amputation </li></ul></ul><ul><ul><li>retinopathy -> vision loss </li></ul></ul><ul><ul><li>neuropathy -> decreased sensation </li></ul></ul><ul><ul><li>degenerative changes in the bones </li></ul></ul><ul><li>-all lead to altered mobility </li></ul><ul><li>What kinds of cardiovascular problems may result in altered mobility? </li></ul><ul><li>CAD -> angina, MI, congestive heart failure ->decreased mobility, fatigue </li></ul><ul><li>PVD -> claudication –pain, decreased mobility </li></ul><ul><li>Both CAD and PVD lower strength and endurance then lower activity level </li></ul>
    32. 32. Altered Mobility: Problems and Issues <ul><li>What effects would sensory impairment have on mobility? </li></ul><ul><ul><li>Visual </li></ul></ul><ul><li>-> falls and accidents </li></ul><ul><li>->fear of falls and self restriction </li></ul><ul><li>-> inappropriate restrictions in institutions </li></ul><ul><ul><li>Hearing </li></ul></ul><ul><li>->accidents </li></ul><ul><li>What about iatrogenic effects? </li></ul><ul><ul><li>prescribed meds -> Side effects </li></ul></ul><ul><ul><li>narcotics, sedatives, hypnotics -> drowsiness and ataxia </li></ul></ul><ul><ul><li>antipyschotics -> muscle rigidity </li></ul></ul>
    33. 33. Altered Mobility: Problems and Issues <ul><li>How does pain effect mobility? </li></ul><ul><ul><li>Can make simple tasks difficult </li></ul></ul><ul><ul><li>Depletes energy </li></ul></ul><ul><ul><li>Pt reluctant to move </li></ul></ul><ul><ul><li>Pain, anxiety and immobility cycle </li></ul></ul><ul><li>What about environment? </li></ul><ul><ul><li>slick floors </li></ul></ul><ul><ul><li>pathway obstructions </li></ul></ul><ul><ul><li>architectural barriers –lengthy stairways, narrow corridors, high curbs and steps, inaccessible or fast moving transit, steep ramps, limited bathroom space </li></ul></ul>
    34. 34. Effects of Immobility <ul><li>**Most profound effects occur with bedrest!! </li></ul><ul><ul><li>Cardiovascular System </li></ul></ul><ul><ul><li>Respiratory System </li></ul></ul><ul><ul><li>Musculoskeletal </li></ul></ul><ul><ul><li>Bone </li></ul></ul><ul><ul><li>Skin </li></ul></ul><ul><ul><li>Metabolic System </li></ul></ul><ul><ul><li>GI System </li></ul></ul><ul><ul><li>Genitourinary System </li></ul></ul><ul><ul><li>Neurological – Psychological and Social </li></ul></ul>
    35. 35. Effects of Immobility <ul><li>**Most profound effects occur with bedrest!! </li></ul><ul><ul><li>Cardiovascular System </li></ul></ul><ul><ul><li>Cardiac muscle atrophies </li></ul></ul><ul><ul><li>resting heart rate increases </li></ul></ul><ul><ul><li>(venous stasis) decreased skeletal muscle pumping action -> pooling and thrombosis </li></ul></ul><ul><ul><li>4 days BR -> increased risk for thromobis </li></ul></ul><ul><ul><li>story in news of a small boy that got a blood clot in his leg from spending 11 hours in a crouched position doing video games </li></ul></ul><ul><ul><li>also an issue with those that are flying or sitting for long periods </li></ul></ul><ul><ul><li>DVT -> pulmonary embolus </li></ul></ul>
    36. 36. Effects of Immobility <ul><li>**Most profound effects occur with bedrest!! </li></ul><ul><li>What happens to the Respiratory System? </li></ul><ul><ul><li>supine position –diaphragm displaced (cephalad) </li></ul></ul><ul><ul><li>increased respiratory effort (fewer deep breaths) </li></ul></ul><ul><ul><li>hypoventilation -> decreased PO2 & atalectasis (collapse of alveoli, mediastinal shift towards area of atalectasis, fever, dyspnea) </li></ul></ul><ul><ul><li>cough less effective </li></ul></ul><ul><ul><li>secretion pooling -> pneumonia (secretions rich in nutrients for bugs to grow) </li></ul></ul>
    37. 37. Effects of Immobility <ul><li>What happens to the Musculoskeletal System? </li></ul><ul><ul><li>increased joint stiffness </li></ul></ul><ul><ul><li>decreased ROM </li></ul></ul><ul><ul><li>with immobilization -> muscle fibers shorten (lowers ROM) </li></ul></ul><ul><ul><li>loss of skeletal muscle mass -> 7 – 14% after 4 weeks </li></ul></ul><ul><ul><li>skeletal muscle atrophy –rapid within 7 days </li></ul></ul><ul><ul><li>strength loss greatest in legs </li></ul></ul><ul><ul><li>need 1 week of rehab / 1 week of immobilization (longer for elderly) </li></ul></ul>
    38. 38. Effects of Immobility <ul><li>**Most profound effects occur with bedrest!! </li></ul><ul><li>What about your bones? </li></ul><ul><ul><li>decrease in wt. Bearing -> increased calcium excretion </li></ul></ul><ul><ul><li>bone loss begins in 7 days </li></ul></ul><ul><ul><li>directly r/t length of immobilization </li></ul></ul><ul><ul><li>compounded with age </li></ul></ul><ul><ul><li>-> osteoarthritic bone fractures </li></ul></ul><ul><ul><li>Need to get them weight bearing to increase calcium absorption </li></ul></ul><ul><li>How about the skin? </li></ul><ul><ul><li>pressure ulcers </li></ul></ul><ul><ul><li>Less capillary blood flow </li></ul></ul><ul><li>What are the metabolic effects? </li></ul><ul><ul><li>immobility reduces energy requirements of cell </li></ul></ul><ul><ul><li>bedrest -> impaired glucose tolerance </li></ul></ul><ul><ul><li>Negative nitrogen balance within 7 days r/t muscle loss -> highest after 14 days </li></ul></ul>
    39. 39. Effects of Immobility <ul><li>**Most profound effects occur with bedrest!! </li></ul><ul><li>What happens in the GI System? </li></ul><ul><ul><li>Altered: ingestion, digestion and/or elimination </li></ul></ul><ul><ul><li>decreased colonic motility and lack of gravity -> constipation and illeus </li></ul></ul><ul><ul><li>Decreased colonic activity and metabolic rates -> reducing appetite </li></ul></ul><ul><ul><li>Poor nutrition=interference with digestion and cellular metabolism </li></ul></ul><ul><li>How about the Genitourinary System? </li></ul><ul><ul><li>increased risk of UTI and calculi formation </li></ul></ul><ul><ul><li>Urine drains via gravity </li></ul></ul><ul><ul><li>with B.R. drainage from renal calyces impaired -> urinary stasis -> infection </li></ul></ul><ul><ul><li>allows for precipitation of calcium crystals -> calculi </li></ul></ul>
    40. 40. Effects of Immobility <ul><li>What happens in the Neurological System? </li></ul><ul><ul><li>decreased sensory stimulation </li></ul></ul><ul><li> auditory and visual alterations -> time and spatial distortions </li></ul><ul><li>How does immobility effect social needs? </li></ul><ul><ul><li>decreased social interaction </li></ul></ul><ul><li>How about the Psychological effects? </li></ul><ul><ul><li>anxiety, hostility, depression, neurosis </li></ul></ul><ul><ul><li>poor sleep </li></ul></ul><ul><ul><li>effects self esteem </li></ul></ul><ul><ul><li>increased dependence on family </li></ul></ul><ul><ul><li>may lead to helpless behaviour </li></ul></ul>
    41. 41. Altered Mobility: Interventions <ul><li>Physical activity </li></ul><ul><li>Adequate nutrition </li></ul><ul><li>Pain control </li></ul><ul><li>Aids for Sensory Impairment </li></ul><ul><li>Psychosocial Interventions </li></ul><ul><li>Management of Equipment </li></ul><ul><li>Reducing Environmental Barriers </li></ul><ul><li>Cultural Influences </li></ul>
    42. 42. Altered Mobility: Interventions <ul><li>Physical Activity </li></ul><ul><ul><li>Benefits: enhances musculoskeletal strength </li></ul></ul><ul><ul><li>The Bedridden Client: major goal is to maximize mobility </li></ul></ul><ul><ul><li>Exercise: </li></ul></ul><ul><ul><ul><li>Flexibility Training </li></ul></ul></ul><ul><ul><ul><li>Resistance/Strength Training </li></ul></ul></ul><ul><ul><ul><li>Endurance/Aerobic Training </li></ul></ul></ul><ul><ul><ul><li>Balance Training </li></ul></ul></ul>
    43. 43. Altered Mobility: Interventions <ul><li>Adequate Nutrition </li></ul><ul><ul><li>Canada’s Food Guide </li></ul></ul><ul><ul><li>Adequate carbohydrate and protein needed to </li></ul></ul><ul><ul><ul><ul><li>reduce negative nitrogen balance </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Maintain tissue repair </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Support exercise performance </li></ul></ul></ul></ul><ul><ul><li>Need to supplement </li></ul></ul><ul><ul><ul><ul><li>Micronutrients, vitamins and minerals </li></ul></ul></ul></ul><ul><ul><li>calcium -> reduce bone loss </li></ul></ul><ul><ul><ul><li>800 mg –young to middle age </li></ul></ul></ul><ul><ul><ul><li>1000 mg –postmenopausal women on hormone replacements </li></ul></ul></ul><ul><ul><ul><li>1500 mg for all men and women over 65 and younger women not receiving hormone replacements </li></ul></ul></ul><ul><ul><li>hydration –1500 ml/day </li></ul></ul><ul><ul><ul><li>Prevents dehydration, decreases urinary stasis, maintains electrolyte balance, blood viscosity, pulmonary secretion viscosity </li></ul></ul></ul>
    44. 44. Altered Mobility: Interventions <ul><li>Pain control </li></ul><ul><ul><li>adequate pain control necessary </li></ul></ul><ul><ul><li>Nonnarcotic analgesics: acetaminophen, salicylates, NSAID’s </li></ul></ul><ul><ul><li>Narcotics for more severe pain: morphine, codiene, fentanyl </li></ul></ul><ul><ul><li>steroids </li></ul></ul><ul><ul><li>Complementary forms of pain control: </li></ul></ul><ul><ul><ul><li>comfort –relaxation </li></ul></ul></ul><ul><ul><ul><li>massage </li></ul></ul></ul><ul><ul><ul><li>biofeedback </li></ul></ul></ul><ul><ul><ul><li>acupuncture </li></ul></ul></ul><ul><ul><ul><li>imagery </li></ul></ul></ul><ul><ul><ul><li>heat / cold </li></ul></ul></ul>
    45. 45. Altered Mobility: Interventions <ul><li>Aids for Sensory Impairment </li></ul><ul><ul><li>Low-vision rehabilitation </li></ul></ul><ul><ul><li>improved lighting </li></ul></ul><ul><ul><li>make sure they wear their glasses if they need them </li></ul></ul><ul><ul><li>steps with coloured edges </li></ul></ul><ul><ul><li>enlarged lettering </li></ul></ul><ul><ul><li>things in same place </li></ul></ul><ul><ul><li>raised lettering (Braille) </li></ul></ul><ul><ul><li>books on tape </li></ul></ul><ul><ul><li>enlarged print </li></ul></ul><ul><ul><li>Tactile or auditory </li></ul></ul><ul><ul><li>visual cues </li></ul></ul><ul><ul><li>facing when talking </li></ul></ul><ul><ul><li>speech slow and well enunciated </li></ul></ul><ul><ul><ul><li>simple terms </li></ul></ul></ul><ul><ul><ul><li>short sentences </li></ul></ul></ul><ul><ul><li>telecommunication devices </li></ul></ul>
    46. 46. Altered Mobility: Interventions <ul><li>Psychosocial Interventions </li></ul><ul><ul><li>Empowerment </li></ul></ul><ul><ul><li>Encourage social activity </li></ul></ul><ul><ul><li>Support for ct’s social network </li></ul></ul><ul><ul><li>Respite time </li></ul></ul>
    47. 47. Altered Mobility: Interventions <ul><li>Management of Equipment </li></ul><ul><ul><li>Devices for mobility </li></ul></ul><ul><ul><li>Devices for hygiene </li></ul></ul><ul><ul><li>Devices for adaptation of homes </li></ul></ul><ul><li>Reducing Environmental Barriers </li></ul>
    48. 48. Cerebral Palsy <ul><li>What is Cerebral Palsy? </li></ul><ul><ul><li>A group of permanent disorders of the development of movement and posture, causing activity limitation, </li></ul></ul><ul><ul><li>Theses are attributed to nonprogressive disturbances that occurred in the developing fetal and infant brain </li></ul></ul><ul><li>What are the clinical manifestations? </li></ul><ul><ul><li>Abnormal muscle tone and coordination (motor disorders) </li></ul></ul><ul><ul><li>Disturbances of sensation, perception, communication, cognition, and behaviour, and epilepsy </li></ul></ul><ul><ul><li>Manifested by contractures, hemiplegia, and quadriplegia </li></ul></ul><ul><ul><li>It is nonprogressive and may be accompanied by perceptual problems, language deficits, and intellectual impairment </li></ul></ul><ul><li>What is the pathophysiology behind the disease? </li></ul><ul><ul><li>Now know it most commonly results from existing pre-natal brain abnormalities </li></ul></ul><ul><ul><li>Results from pre-natal, perinatal, or post-natal problems -> brain damage (limited -> extensive) </li></ul></ul><ul><ul><li>Neurologic lesions occur -> their precise location is difficult to establish </li></ul></ul>
    49. 49. Cerebral Palsy <ul><li>Etiology: Prenatal brain abnormalities </li></ul><ul><ul><li>80% are caused by unknown brain abnormalities </li></ul></ul><ul><ul><li>Intrauterine exposure to chorioamnionitis </li></ul></ul><ul><ul><li>12% of infants born prior to 36 weeks </li></ul></ul><ul><ul><li>Periventricular leukomalacia </li></ul></ul><ul><ul><li>Result of shaken baby syndrome </li></ul></ul>
    50. 50. Interdisciplinary Management of CP <ul><li>Key disciplines involved and their role: </li></ul><ul><ul><li>OT: help with assistive devices required e.g. ankle-foot orthoses (AFOs; braces) </li></ul></ul><ul><ul><li>Doctor: pharmacologic and surgical mgt </li></ul></ul><ul><ul><li>PT: help with physical therapy needs </li></ul></ul><ul><ul><li>Speech Pathologist: speech training, swallowing </li></ul></ul><ul><ul><li>Dentist: regular visits and prophylaxis to prevent hyperplasia </li></ul></ul>
    51. 51. Cerebral Palsy <ul><li>Nursing Care </li></ul><ul><ul><li>Goal </li></ul></ul><ul><ul><li>Nursing attitudes </li></ul></ul><ul><ul><li>Mechanical Aids </li></ul></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><li>Exercises </li></ul></ul><ul><ul><li>Surgery </li></ul></ul><ul><ul><li>Family Support </li></ul></ul><ul><li>(see Nursing Care plan: pp 1722-1723) </li></ul>
    52. 52. Goals of Therapy <ul><li>To establish locomotion, communication, and self-help skills </li></ul><ul><li>To gain optimal appearance and integration of motor functions </li></ul><ul><li>To correct associated defects as effectively as possible </li></ul><ul><li>To provide educational opportunities adapted to the child’s capabilities </li></ul><ul><li>To promote socialization experiences </li></ul>
    53. 53. Therapeutic Management <ul><li>Ankle foot braces may be worn </li></ul><ul><li>Orthopedic surgery to correct spastic deformities </li></ul><ul><li>Pharmacologic agents to treat pain related to spasms and seizures </li></ul><ul><li>Botulinum A injections </li></ul><ul><li>Dental hygiene </li></ul><ul><li>Physical/occupational therapy </li></ul>
    54. 54. Nursing Care Management <ul><li>Assist the family in devising and modifying equipment and activities </li></ul><ul><li>Medication administration </li></ul><ul><li>Safety precautions </li></ul><ul><li>Recreational activities </li></ul><ul><li>Support family </li></ul>
    55. 55. Social Isolation <ul><li>Solitude: voluntarily chosen time alone </li></ul><ul><li>Involuntary social isolation occurs when demands for social contact or communication exceeds the human or situation capability of others </li></ul><ul><li>(Holley, 2007) </li></ul>
    56. 56. Social Isolation <ul><li>Social isolation without choice is loneliness </li></ul><ul><li>Loneliness: the distressing, depressing, dehumanizing, detached feelings people have when there is an emptiness in their life due to an unfulfilled social or emotional life </li></ul><ul><li>(Holley, 2007) </li></ul>
    57. 57. Social Isolation <ul><li>Satisfactory social lives are determined by the quality and reciprocity, not quantity and frequency of contacts </li></ul><ul><li>Many chronically ill people suffer from social isolation </li></ul><ul><li>(Holley, 2007) </li></ul>
    58. 58. Social Isolation <ul><li>Social contact is a main component of human comfort </li></ul><ul><li>Living without social contacts and comfort can have serious consequences for a person’s health and life </li></ul><ul><li>(Holley, 2007) </li></ul>
    59. 59. Social Isolation <ul><li>What the literature tells us: </li></ul><ul><li>Functional limitations in ADLs hinder independence </li></ul><ul><li>Neurological disorders that change personality can alter interaction ability </li></ul><ul><li>Loss of social roles </li></ul><ul><li>Difficulty finding transportation </li></ul><ul><li>Social isolation experienced by caregivers </li></ul><ul><li>(Holley, 2007) </li></ul>
    60. 60. Social Isolation <ul><li>Assessment: </li></ul><ul><li>Objective: ask questions </li></ul><ul><li>Subjective: find out the client’s perception of their social situation </li></ul><ul><li>(Holley, 2007) </li></ul>
    61. 61. Social Isolation <ul><li>Intervention: </li></ul><ul><li>Peer counseling </li></ul><ul><li>Support groups </li></ul><ul><li>Rebuilding family networks </li></ul><ul><li>Enhancing spirituality </li></ul><ul><li>Internet support </li></ul><ul><li>Therapeutic use of self </li></ul><ul><li>(Holley, 2007) </li></ul>
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