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Week4 alteredmobilitydysphagia

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

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