Fisioterapi Kardiovaskuler Pulmonal 2 Pertemuan 7

  

Intensive

Intensive

  

care unit

care unit

Physical

Physical

  

therapy

therapy

by:

by:

  Slamet Slamet Sumarno.

  

Sumarno. Fisioterapi ICU Fisioterapi ICU Intensive Care Unit = Perawatan intensif.

  ICU umumnya rawat kond kritis Cardiorespirasi dan banyak menggunakan alat bantu serta ditangani secara team.

  Siapa yang harus di rawat di ICU.

  ?

   Gejala gagal nafas (krirtis pernafasan).  Indikasi memerlukan alat bantu pernafasan.  Tidak stabilnya pernafasan .  Kritis trauma capitis.  Kondisi yg memerlukan perawat intensive.

  

Gagal nafas.

  Gagal nafas.

  Pengertian.

  Pengertian.

  Gagal nafas diartikan sebagai kegagalan Gagal nafas diartikan sebagai kegagalan pertukaran gas dlm paru yg ditandai pertukaran gas dlm paru yg ditandai dengan turunnya kadar oksigen di arteri dengan turunnya kadar oksigen di arteri

  (hipoksimia) atau naiknya kadar (hipoksimia) atau naiknya kadar karbondiaksida (hiperkarbia) atau karbondiaksida (hiperkarbia) atau kombinasi keduanya. kombinasi keduanya. Kriteria diagnosa gagal nafas.

  Kriteria diagnosa gagal nafas.

  PaO2 < PaO2 <

  60mmHg, 60mmHg,

  PaCO2 > 49 PaCO2 > 49 mmHg tanpa mmHg tanpa gangguan gangguan alkalosis alkalosis metabolik primer metabolik primer

  (Muhadi,OE Tampubolon, 1989) (Muhadi,OE Tampubolon, 1989)

  

Pemeriksaan lab Gas Darah

Pemeriksaan lab Gas Darah

  Asidosis acut respiratory Asidosis acut respiratory acidosis acidosis a 7.1 metabolik acidosis a 7.1 metabolik acidosis r 7.2 chronic respiratory r 7.2 chronic respiratory t 7.3 acidosis t 7.3 acidosis e 7.4 e 7.4 r 7.5 metabolik alkalosis r 7.5 metabolik alkalosis

  I 7.6 respiratory alkalosis I 7.6 respiratory alkalosis

  7.7 2 4 6 8 10 12 7.7 2 4 6 8 10 12

  Alkalosis PH= 7,35-7,4 PCO2= 5-6 kpa Alkalosis PH= 7,35-7,4 PCO2= 5-6 kpa

  

Pemeriksaan lab Gas Darah

Pemeriksaan lab Gas Darah

  

Etiologi Gagal nafas.

  

Etiologi Gagal nafas.

  Penyakit akut atau kronik kembali akut.

  Penyakit akut atau kronik kembali akut.

  Acut dan Acut on chonic respiratory failure Acut dan Acut on chonic respiratory failure

  (hipersekresi, spasme bronkus, edema (hipersekresi, spasme bronkus, edema mukosa). mukosa).

  Spasme bronkus pada: Asma, bronkitis Spasme bronkus pada: Asma, bronkitis kronik yg berkembang menjadi emfisema kronik yg berkembang menjadi emfisema

  

Lanjutan.

  Dinding thorak, diapragma: Trauma thorak.

  6. Pasca bedah: laparatomi dll

  6.

  kardiovaskuler: Gagal jantung, emboli paru. kardiovaskuler: Gagal jantung, emboli paru.

  5.

  5.

  Paru: Asma, infeksi paru, Aspirasi, pneumonia, edema paru. edema paru.

  4. Paru: Asma, infeksi paru, Aspirasi, pneumonia,

  4.

  3. Dinding thorak, diapragma: Trauma thorak.

  

Lanjutan.

  3.

  Polyneuritis, Analgesia spinal tinggi, kelumpuhan otot respirasi. kelumpuhan otot respirasi.

  Susunan neuromuskular: Miastenia gravis, Polyneuritis, Analgesia spinal tinggi,

  2. Susunan neuromuskular: Miastenia gravis,

  2.

  Otak: Neoplasma, Epilepsi, Hematoma subdural, Keracunan morfin dan CVA. subdural, Keracunan morfin dan CVA.

  1. Otak: Neoplasma, Epilepsi, Hematoma

  1.

  Pasca bedah: laparatomi dll

  

Komplikasi rawat ICU.

   Peningkatan resiko infeksi nosocomial  atelectasis  Mechanics ventilasi pasien yang memungkinkan terjadi penurunan FRC dan CL , V/Q nya tidak sebanding۬

  

 immobilisasi pada pasien dengan penyakit

kritis yang menderita muscle deconditioning, peningkatan resiko DVT, pressure sore FRC=fungsional reserve capacity.

  Problem Problem

Koknetif

  gerak sikap Manusia Physiotherapy Assessment Physiotherapy Assessment

  Cognition, motivation, patients own goals Cognition, motivation, patients own goals

  Previous level of function & independence Previous level of function & independence

  Posture, movement, strength, balance, pain Posture, movement, strength, balance, pain

  Functional ability; sitting, standing, transferring, Functional ability; sitting, standing, transferring, walking, turning, reaching, bed mobility, stairs, walking, turning, reaching, bed mobility, stairs, getting up from floor, arm & hand function, getting up from floor, arm & hand function, exercise tolerance exercise tolerance

  Use of Objective measures Use of Objective measures

  Physiotherapy programme Physiotherapy programme

  Exercises to address specific problems, Exercises to address specific problems, e.g. loss of joint movement, muscle e.g. loss of joint movement, muscle weakness, balance problem. weakness, balance problem.

  Functional activity, in a safe, supervised Functional activity, in a safe, supervised environment, to improve performance and environment, to improve performance and confidence confidence

  Provision of and practise using appropriate Provision of and practise using appropriate mobility aids mobility aids

Problematik umum

  1. Gangguan pernafasan.

  2. Gangguan Jantung dan sirkulasi.

  3. Gangguan Hormonal dan bufer.

  4. Gangguan sistem syaraf.

  

5. Kecerdasan menangkap perintah.

  6. Ganguan perilaku.

  PROBLEM PERNAFASAN. PROBLEM PERNAFASAN.

  4. Gangguan pleurae.

  7.

  Gangguan system sirkulasi pulmonal.

  6. Gangguan system sirkulasi pulmonal.

  6.

  Gangguan perfusi / restriktif.

  5. Gangguan perfusi / restriktif.

  5.

  Gangguan pleurae.

  4.

  Oleh karena: Oleh karena: 1.

  Gangguan jalan nafas / obtruktif.

  3. Gangguan jalan nafas / obtruktif.

  3.

  Gangguan Sangkar thorak.

  2. Gangguan Sangkar thorak.

  2.

  Gangguan systen neurologi.

  1. Gangguan systen neurologi.

  7. Gabungan satu sampai enam Gabungan satu sampai enam

  Tujuan Fisioterapi ICU Tujuan Fisioterapi ICU

• meningkatkan/mempertahankan

  A.fungsi cardiopulmonari: 1. Posisioning.

  2. Membuka jalan nafas.

  3. Oksigen terapi.

  4. Meningkatkan ventilasi.

  5. Fasilitasi dan stimulasi breathing. 4 a. mekanik ventilasi

B. Fungsi Musculoskeletal

  1. Joint function / movement 2. Performance kerja otot.

  3. Balance, coordination, komunikasi

  4. Performance fisik : ambulation / ADL

  C. Fungsi Neuromuskular.

  Edukasi .

  Evaluasi .

  F.

  F.

  .

  (harapan) (harapan) .

  Mencapai goul Mencapai goul

  E.

  E.

  Edukasi .

  C. Fungsi Neuromuskular.

  D.

  D.

  Inhibisi.

  3. Inhibisi.

  stimulasi, stimulasi, 3.

  2.

  Sensasi, 2.

  1. Sensasi,

  1.

  Evaluasi .

  PROSES FISIOTERAPI PROSES FISIOTERAPI

Assessment /reassessment Mesurment. / remesurment

  Analysis of fndings Intervensi/Implementation of treatment / modifkasi Problems identifiation

  Planning of treatment Evidence Based Practice Evidence Based Practice

  Falls – strength & Balance training Falls – strength & Balance training

  NSF, NICE, CSP Guidelines NSF, NICE, CSP Guidelines

  Locally developed guidelines; walking Locally developed guidelines; walking aids, falls prevention education leaflets, aids, falls prevention education leaflets, group exercise, resistance training for group exercise, resistance training for osteoporosis osteoporosis Evidence Evidence

  Based Based

  Medicine (EBM) Medicine (EBM)

  “ “

  Menggunakan segala pertimbangan Menggunakan segala pertimbangan bukti ilmiah (evidence) yang sahih yang bukti ilmiah (evidence) yang sahih yang diketahui hingga kini untuk menentukan diketahui hingga kini untuk menentukan pengobatan pada penderita yang pengobatan pada penderita yang sedang kita hadapi”. sedang kita hadapi”.

  Merupakan penjabaran bukti ilmiah Merupakan penjabaran bukti ilmiah lebih lanjut setelah obat dipasarkan dan lebih lanjut setelah obat dipasarkan dan seiring dengan pengobatan rasional. seiring dengan pengobatan rasional.

  Lima tahap evidence based Lima tahap evidence based

  Memformulasikan pertanyaan tentang masalah Memformulasikan pertanyaan tentang masalah fisioterapi yang dihadapi fisioterapi yang dihadapi

  Menelusuri bukti-bukti terbaik yang tersedia Menelusuri bukti-bukti terbaik yang tersedia untuk mengatasi masalah tersebut untuk mengatasi masalah tersebut

  Mengkaji bukti, validitas dan keseuaiannya Mengkaji bukti, validitas dan keseuaiannya dengan kondisi praktek dengan kondisi praktek

  Menerapkan hasil kajian Menerapkan hasil kajian

  Mengevaluasi penerapannya (kinerjanya) Mengevaluasi penerapannya (kinerjanya)

  

Assessment FT Kritis Di ICU

Assessment FT Kritis Di ICU

Baca status riwayat dan keadaan sekarang.

  Sudah membantu sirkulasi. Sudah menguntungkan bila terjadi kekakuan. Sudah mencegah dekubitus. Sudah memudahkan / memfasilitasi pernafasan dan

  

2. Kenali alat dan monitor yg ada

  

2. Kenali alat dan monitor yg ada

a.

  a.

  Sounde. Tentukan ukuran soude yang masuk Sounde. Tentukan ukuran soude yang masuk oesophagus. oesophagus.

  b.

  b.

  Thrachea tube : tentukan ukuran panjang yang Thrachea tube : tentukan ukuran panjang yang masuk thrachea. 18, 19, 20, 21, 22 dst masuk thrachea. 18, 19, 20, 21, 22 dst biasanya dewasa 22 cm. biasanya dewasa 22 cm.

  c.

  c.

  Tentukan apakah monitor EKG berfungsi Tentukan apakah monitor EKG berfungsi dengan baik ( terutama elektrode yg terpasang dengan baik ( terutama elektrode yg terpasang pada dada dan tangan atau kaki biola ada. pada dada dan tangan atau kaki biola ada.

  d.

  d.

  Tentukan ventilator berfungsi dengan baik, Tentukan ventilator berfungsi dengan baik, menggunakan inhalasi atau tidak, menggunakan inhalasi atau tidak, e.

  e.

  Monitor Vital sign.

  Monitor Vital sign.

  

Sistem assesment / mesurment.

  

Sistem assesment / mesurment.

  1.

  1. Fungsi tingkat kesadaran.

  Fungsi tingkat kesadaran.

  2.

  2. Vital sign.

  Vital sign.

  3.

  3. Fungsi jalan nafas dan paru Fungsi jalan nafas dan paru 4.

  4. Fungsi jantung dan sirkulasi.

  Fungsi jantung dan sirkulasi.

  5.

  5. Fungsi sangkar torak : sendi, otot dan tl Fungsi sangkar torak : sendi, otot dan tl 6.

  6. Fungsi umum: sendi, otot, gerak Fungsi umum: sendi, otot, gerak

  

Kesadaran.

  3. Somnolen Somnolen

  6.

  5. Soporcoma: Soporcoma: reflek motoris terjadi hanya bila reflek motoris terjadi hanya bila dirangsang dengan rangsangan nyeri. dirangsang dengan rangsangan nyeri.

  5.

  4. Sopor: Sopor: dapat dibangunkan bila dirangsang dengan dapat dibangunkan bila dirangsang dengan keras dan terus menerus. keras dan terus menerus.

  4.

  : dapat dibangunkan bila dirangsang, dapat : dapat dibangunkan bila dirangsang, dapat disuruh dan menjawab pertanyaan bila rangsangan disuruh dan menjawab pertanyaan bila rangsangan berhenti penderita tidur lagi. berhenti penderita tidur lagi.

  3.

  

Kesadaran.

  : : terlihat mengantuk tetapi mudah dibangunkan, terlihat mengantuk tetapi mudah dibangunkan, reaksi penglihatan, pendengaran dan perabaan reaksi penglihatan, pendengaran dan perabaan normal. normal.

  2. Apatis Apatis

  2.

  : bereaksi sgr dgn orientasi sempurna.

  1. Kompos mentis Kompos mentis : bereaksi sgr dgn orientasi sempurna.

  1.

  6. Coma: Coma: tidak ada reflek motoris sekalipun dengan tidak ada reflek motoris sekalipun dengan rangsang nyeri. rangsang nyeri.

  

PEMERIKSAAN KESADARAN

PEMERIKSAAN KESADARAN

STEP STEP PROSEDURE PROSEDURE

  A. KESADARAN

  A. KESADARAN Tingkat kesadaran. Tingkat kesadaran.

• Kompos mentis
• Kompos mentis (GCS=15) E4M6 V5.

  (GCS=15) E4M6 V5.

• Somnolen
• Somnolen

  (GCS=12-14) (GCS=12-14)

• Sopor (GCS=8-11) -Sopor (GCS=8-11) -Coma (GCS=3-7).
• Coma (GCS=3-7).

  GCS: Glascow GCS: Glascow Coma Scala dari 3-

  1.

  1. Kompos mentis : bereaksi segera dengan orientasi Kompos mentis : bereaksi segera dengan orientasi sempurna. (15) sempurna. (15) 2.

  2. Apatis: terlihat mengantuk tetapi mudah Apatis: terlihat mengantuk tetapi mudah dibangunkan, reaksi penglihatan, pendengaran dan dibangunkan, reaksi penglihatan, pendengaran dan

perabaan normal. (14-15)

perabaan normal. (14-15)

3.

  3. Somnolen: dapat dibangunkan bila dirangsang, Somnolen: dapat dibangunkan bila dirangsang, dapat disuruh dan menjawab pertanyaan bila dapat disuruh dan menjawab pertanyaan bila rangsangan berhenti penderita tidur lagi. (12-14) rangsangan berhenti penderita tidur lagi. (12-14) 4.

  4. Sopor: dapat dibangunkan bila dirangsang dengan Sopor: dapat dibangunkan bila dirangsang dengan keras dan terus menerus.(8-11) keras dan terus menerus.(8-11) 5.

  5. Soporcoma: reflek motoris terjadi hanya bila Soporcoma: reflek motoris terjadi hanya bila dirangsang dengan rangsangan nyeri. 7-8 dirangsang dengan rangsangan nyeri. 7-8 6.

  6. Coma: tidak ada reflek motoris sekalipun dengan Coma: tidak ada reflek motoris sekalipun dengan

  

Glasgow coma scale

Glasgow coma scale

Eye Opening E

V

Response M

  Spontan

  4 Dng Perintah

  3 Dng rangsang nyeri

  2 no response

  1 Best Motor

  Terhadap perintah: Menurut perintah

  6 Rangsang nyeri: Melokalisasi nyeri 5 flexion-menarik baik 4 flexion-abnormal 3 extension

  2 Best Verbal Response

  orientasi dan berbicara 5 disoriented dan berbicara MATA (EYE=E=4.

  4 Kata-kata tak sesuai

  3 Suara tak bermakna

  2 Tidak ada respon 1

  MATA (EYE=E=4.

  E4= Spontan membuka E4= Spontan membuka mata. mata.

  E3= Terhadap suara E3= Terhadap suara membuka mata. membuka mata.

  E2= Terhadap nyeri E2= Terhadap nyeri membuka mata. membuka mata.

  E1= terhadap segala jenis E1= terhadap segala jenis rangsang Menutup rangsang Menutup mata mata

  Tehnik. Baca nama pasien dipapan Tehnik. Baca nama pasien dipapan nama pasien. nama pasien.

  4. Spontan membuka mata.

  4. Spontan membuka mata.

  3. Dipanggil namanya buka mata.

  3. Dipanggil namanya buka mata.

  2. Diberi rangsang nyeri buka mata.

  2. Diberi rangsang nyeri buka mata.

  1. Rangsang nyeri tidak buka mata.

  1. Rangsang nyeri tidak buka mata. Respon pupil thd cahaya Respon pupil thd cahaya

  Normal = 5 Normal = 5

  Lambat= 4 Lambat= 4

  Respon tidak sama = 3 Respon tidak sama = 3

  Besar tidak sama = 2 Besar tidak sama = 2

  Tidak ada respon = 1 Tidak ada respon = 1 Cerebral perfusion presure (CPP) Cerebral perfusion presure (CPP)

  Tekanan kritis yang adequate blood supply Tekanan kritis yang adequate blood supply

terhadap otak dan mencegah acidosis, hypoxia

terhadap otak dan mencegah acidosis, hypoxia

dan kerusakan. dan kerusakan.

  Otak harus diipertahankan kontinusitas Otak harus diipertahankan kontinusitas tranportsai oksigennya dan tekanan darahnya tranportsai oksigennya dan tekanan darahnya

secara otomatis regulasi, range of blood presure

secara otomatis regulasi, range of blood presure

over tidak efektif dan dapat menimbulkan nyeri over tidak efektif dan dapat menimbulkan nyeri kepala. kepala.

  CPP = mean arterial presure (MAP) minus CPP = mean arterial presure (MAP) minus intracranial presure (ICP). intracranial presure (ICP).

  Normal value > 70mmHg.

  Normal value > 70mmHg.

  Critical value < 50 mmHg.

  Critical value < 50 mmHg.

  Intracranial presure.

  Intracranial presure.

  TIK =Tekanan intra cranial normal berkisar 1-15 TIK =Tekanan intra cranial normal berkisar 1-15 mmHg, yg berfluktuasi dng perubahan: BP, RR mmHg, yg berfluktuasi dng perubahan: BP, RR pola nafas, batuk, mengejan. pola nafas, batuk, mengejan.

  TIK tergantung dari 3 unsur: TIK tergantung dari 3 unsur: 1). Jarinagn otak 80-87%.

  1). Jarinagn otak 80-87%.

  2). Cairan serebrospinal (CSS)9-10%) dan 2). Cairan serebrospinal (CSS)9-10%) dan

  3). Darah yg ada dlm pembuluh darah otak 3). Darah yg ada dlm pembuluh darah otak (1-10%).

  (1-10%).

  Bila TIK > 16 mmHg dapat mengancam jiwa pasien. pasien.

Bila TIK > 16 mmHg dapat mengancam jiwa

  Reflek saraf cranial Reflek saraf cranial

  Semua ada= 5 Semua ada= 5

  Bulu mata tidak ada= 4 Bulu mata tidak ada= 4

  Kornea tidak ada = 3 Kornea tidak ada = 3

  Doll’s tidak ada =2 Doll’s tidak ada =2

  Karina (semua) tidak ada= 1 Karina (semua) tidak ada= 1

  Kejang (skor terbaru).

  Kejang (skor terbaru).

  Kejang tidak ada = 5 Kejang tidak ada = 5

  Kejang fokal = 4 Kejang fokal = 4

  Umum , intermiten = 3 Umum , intermiten = 3

  Umum kontinue = 2 Umum kontinue = 2

  Flaksid = 1 Flaksid = 1

  Nafas spontan Nafas spontan

  Normal = 5 Normal = 5

  Periodik =4 Periodik =4

  Hiperventilasi central = 3 Hiperventilasi central = 3

  Iregular/hipoventilasi = 2 Iregular/hipoventilasi = 2

  Apnu = 1 Apnu = 1

  Toatal skor = 35 terburuk = 7 Toatal skor = 35 terburuk = 7 Terdiri dari: 1. GSC=15.

  Terdiri dari: 1. GSC=15.

  2. Pupil= 5

  2. Pupil= 5

  3. Kejang (skor terbaru)=5

  3. Kejang (skor terbaru)=5

  4. Reflek saraf cranial=5

  4. Reflek saraf cranial=5

  5. Nafas spontan=5

  5. Nafas spontan=5 Kejang (skor terbaru).

  Kejang (skor terbaru).

  Kejang tidak ada = 5 Kejang tidak ada = 5

  Kejang fokal = 4 Kejang fokal = 4

  Umum , intermiten = 3 Umum , intermiten = 3

  Umum kontinue = 2 Umum kontinue = 2

  Flaksid = 1 Flaksid = 1

  Nafas spontan Nafas spontan

  Normal = 5 Normal = 5

  Periodik =4 Periodik =4

  Hiperventilasi central = 3 Hiperventilasi central = 3

  Iregular/hipoventilasi = 2 Iregular/hipoventilasi = 2

  Apnu = 1 Apnu = 1

  Toatal skor = 35 terburuk = 7 Toatal skor = 35 terburuk = 7

  Pain Stimulus Pain Stimulus

  

NAIL BED COMPRESSION

  

  fine ree ssrree ith焐 h焐rsb

  fine ree ssrree ith焐 h焐rsb

  ove re e nctl on h焐e b ase

  ove re e nctl on h焐e b ase

  

TRAPEZIUS SQUEEZE

  

   rstng h焐rsb & 2 finge res, greas 2 tnc焐e s of h焐e srscle & h焐e n hitsh

  of h焐e crhtcle

Te sh b tlahe really

N=(+)Crers焐tng atn

   rse h焐rsb  C/I: Creantal freachrree

  

  

  of h焐e crhtcle 

STERNAL RUB

DSP

  (tnthtal ree achton) 

  (tnthtal ree achton)

  

  she renrs as tf “gretndtng a tll” fore 5 se c. tll” fore 5 se c.

  rse knrckle ove re rse knrckle ove re she renrs as tf “gretndtng a

  

  

N=20-30 se c. Poshrretng

Wath fore ah le ash 30 Wath fore ah le ash 30

O O xygenation xygenation Assess respiratory status. Assess respiratory status

  

Maintain patent airway & adequate ventilation.

  

Maintain patent airway & adequate ventilation.

  Watch for S/S of hypoxia & hypercapnia… Watch for S/S of hypoxia & hypercapnia…

Nohe fore S/S of Nohe fore S/S of Hy oxta/ Hy oxta/ 焐y oxe sta 焐y oxe sta

  Oxygenation Oxygenation

• (-) S onhane ors ree s treahton

  ree s treahton ree s treahton

  (-) S onhane ors ree s treahton

• Re shle ssne ss/ trerethab tlthy

Re shle ssne ss/ trerethab tlthy

• Pe ret 焐e real cyanosts

Pe ret 焐e real cyanosts

• Use of acce ssorey srscle s of

Use of acce ssorey srscle s of

• Ala Nase faretng

Ala Nase faretng

• Angtna

Angtna

• Tac焐ycaredta

Tac焐ycaredta

• Tac焐y ne a

Tac焐y ne a

• GIT/ Re nal Dysfrnchton (Lahe sx)

GIT/ Re nal Dysfrnchton (Lahe sx)

• Dx/ Lab ree srlhs:

Dx/ Lab ree srlhs:

Prlse Oxtse hrey

  Ca nogrea 焐y

  Ca nogrea 焐y

M M otor Function otor Function

  

Assess integration of consciousness &

Assess integration of consciousness &

voluntary movement. voluntary movement.

  

Look for purposeful or non-purposeful

response. response. Also assess muscle tone, size, strength. Also assess muscle tone, size, strength. Observe for symmetric, spontaneous Observe for symmetric, spontaneous movement of arms & legs… movement of arms & legs…

Look for purposeful or non-purposeful

  Ab n= Ab n= htcs, hree sores htcs, hree sores = shree ss, long he res rse of = shree ss, long he res rse of syc焐ohreo tc drergs, syc焐ohreo tc drergs, ne rreologtc dtsorede res ne rreologtc dtsorede res MUSCLE STRENGTH

MUSCLE STRENGTH

  (Parektnson’s, MS, ore HC) (Parektnson’s, MS, ore HC)

GRADING

  ahreo 焐y, aree sts, le gta, ahreo 焐y, aree sts, le gta, Greade De scret hton

Greade De scret hton

  facctdthy, s ashtcthy, retgtdthy facctdthy, s ashtcthy, retgtdthy = sohore ne rreon ore srscle = sohore ne rreon ore srscle No conhreachton

No conhreachton

  dtse ase dtse ase

  1 Sltg焐h conhreachton

  1 Sltg焐h conhreachton

  2 Frll asstve ROM

  2 Frll asstve ROM

  rnree s onstve clte nhs rnree s onstve clte nhs

• – 3 Frll ROM

  焐e st le gta - corehtcos tnal

  3 Frll ROM

  焐e st le gta - corehtcos tnal hreach hreach dasage dasage

  4 Frll ROM agatnsh

  4 Frll ROM agatnsh

• – de corehtcahe de corehtcahe - r - r e re e re

  sose ree stshance

  sose ree stshance

  corehtcos tnal corehtcos tnal

  5 Frll ROM agatnsh

  5 Frll ROM agatnsh

  hreach dasage hreach dasage frll ree stshance frll ree stshance

• – de ce ree b reahe – b reatnshe s

  de ce ree b reahe – b reatnshe s dasage dasage

  Conhreolle d b y: Conhreolle d b y:

P P upils upils

• – CN-III

CN-III

• – Breatnshe s

Breatnshe s

  Assess for size, Assess for size, shape & reaction to shape & reaction to light. light.

• – Mtdb reatn

Mtdb reatn Pr tllarey Pr tllarey Asse ssse nh Asse ssse nh

  Observe for ptosis… Observe for ptosis…

• – Stze

Stze

• – Re achton

Re achton

  Pupillary Size Pupillary Size

• – S焐a e …

S焐a e …

   N= 1.5-6ss (3.5 avg.) N= 1.5-6ss (3.5 avg.)

• – Antsocoreta Antsocoreta
• – N N =17%; =17%;

  Pupillary Reaction Pupillary Reaction

• – N =

N =

BRTL

  

Dtree ch Conse nsral Ltg焐h

Dtree ch Conse nsral Ltg焐h

  ree s onse ree s onse Ht rs – cannoh srshatn

Ht rs – cannoh srshatn

• conshretch h焐e n ree dtlahe s

  conshretch h焐e n ree dtlahe s

• – early CN III compression – early CN III compression ith焐 ltg焐h on

  ith焐 ltg焐h on

NRTL/ Fixed NRTL/ Fixed

• – Btlahe real Ht rs

Btlahe real Ht rs

  Fixed Dilated – =

   ICP,

  Fixed Dilated =

   ICP,

   

  Prolonged diffuse hypoxia,

  Prolonged diffuse hypoxia,

Ab n= Se tzrree

  Atropine Atropine

Me ntngthts

• – Pinpoint pupil

  Pinpoint pupil = Narcotics

• – = Narcotics

I stlahe real

  (Morphine, Demerol), Long

  (Morphine, Demerol), Long

Ab n=(+)le ston/ b reatn

  Acting analgesia (Fentanyl)

  Acting analgesia (Fentanyl)

  hrsore

  hrsore

N

ICP

  Assess for deviation to Assess for deviation to one side. one side.

  Pupillary Shape Pupillary Shape

  =Rornd

  =Rornd

  =oval –

  =oval – 

Ab n

  

  (15-20ssHg) (15-20ssHg)

• osh freonhal

  he s oreal

  he s oreal

  le stons le stons

• Conhrstons Conhrstons …

  … O O cular Movement cular Movement

  Also assess voluntary & Also assess voluntary & spontaneous spontaneous movement… movement…

  EOM – controlled by CN EOM – controlled by CN

  / anhe retore

  osh freonhal

  / anhe retore

  S S igns igns Assess V/S.

  Assess V/S.

  Observe for significant trends.

  Observe for significant trends.

  Look for Cushing’s reflex: Look for Cushing’s reflex:

   

  PR, PR,

   

  RR, RR,

  Widened Pulse Pressure… Widened Pulse Pressure…

U U rinary rinary Output Output

  Assess for increased output, possible S/S of Assess for increased output, possible S/S of impaired water regulation. impaired water regulation.

  Also assess for electrolyte imbalance, Also assess for electrolyte imbalance, especially hyponatremia… especially hyponatremia…

  Oliguria ( below 30 cc)… Oliguria ( below 30 cc)…

R R eflexes eflexes

• – Pons

Pons

• – Me drlla

Me drlla Gag/ Corg焐 Gag/ Corg焐

• – Me drlla

Me drlla

  gag

  CN X…

  Corene al Corene al

  reflex… reflex…

  corneal

  or or gag

  of of corneal

  loss

  & & loss

  babinski

  Assess for Assess for pathologic pathologic reflexes, reflexes, especially especially babinski

• – CN IX

CN IX

• – CN X…

E E mergency mergency

  Evaluate assessment findings to determine Evaluate assessment findings to determine whether emergency exists. whether emergency exists.

  If so report findings to doctor STAT… If so report findings to doctor STAT…

  Test for attention, concentration & Test for attention, concentration & calculation. calculation.

Ask ho cornh Ask ho cornh b ackiared freos 100, b ackiared freos 100, srb hreachtng b y srb hreachtng b y se ve n e ac焐 htse se ve n e ac焐 htse (”100, 93, 86…”). (”100, 93, 86…”)

  

   N=Can cornh b ack N=Can cornh b ack tnho h焐e 50s ith焐tn tnho h焐e 50s ith焐tn one stnrhe … one stnrhe …

Memory Memory Test for short-term memory Test for short-term memory

  

Name 3 unrelated objects Name 3 unrelated objects (e.g. car, garbage can, alarm (e.g. car, garbage can, alarm clock) then ask for these clock) then ask for these words again for within a few words again for within a few minutes minutes Test for long term Test for long term memory memory

   Ask client’s mother’s Ask client’s mother’s maiden name. maiden name. Memory Loss Memory Loss – abnormal – abnormal & signal disease, infection & signal disease, infection or temporal lobe trauma…

Logic, Judgment, Reasoning & Logic, Judgment, Reasoning & decision-making ability decision-making ability Test for Logic & Judgment Test for Logic & Judgment

  

Ask “What would you do if you were inside a burning Ask “What would you do if you were inside a burning

   building?” building?”  N=sound judgment. N=sound judgment.

   Abn=Frontal Lobe damage, dementia, psychosis, mental

Abn=Frontal Lobe damage, dementia, psychosis, mental retardation. retardation. Test for reasoning & decision-making ability Test for reasoning & decision-making ability

   answering questions appropriately answering questions appropriately Ask the meaning of a proverb such as “A stitch in time saves Ask the meaning of a proverb such as “A stitch in time saves  nine.” nine.”

   Abn=low intellect, dementia, schizophrenia… Abn=low intellect, dementia, schizophrenia…

Emotional Stability, Speech & Emotional Stability, Speech & Language Language

   Emotional Stability Emotional Stability

   Moods, Feeling, Thought process

  Moods, Feeling, Thought process Speech & Language

  Speech & Language 

  

Voice quality, Articulation, Content, Comprehension

Voice quality, Articulation, Content, Comprehension

   N=Spontaneous & well paced speech; logical content

  N=Spontaneous & well paced speech; logical content 

  Ask to read a sentence form age-& education-appropriate Ask to read a sentence form age-& education-appropriate material; write name or simple sentence. material; write name or simple sentence.

   Abn=Aphasia (speech), dysarthria (articulation & rate),

  Abn=Aphasia (speech), dysarthria (articulation & rate), dysphonia ( voice), apraxia (conversion of thought into motor dysphonia ( voice), apraxia (conversion of thought into motor

   Ask to walk a straight heel-to-toe line.

  

Cerebellar function

Cerebellar function

Gait Gait

Ask to walk a straight heel-to-toe line

• – Abn=staggering, shuffling, tiptoe walking, foot

Abn=staggering, shuffling, tiptoe walking, foot slap, leg drag. slap, leg drag

• – Uncoordinated gait & loss of balance Uncoordinated gait & loss of balance = = motor, sensory, vestibular or cerebellar motor, sensory, vestibular or cerebellar dysfunction. dysfunction.
• – Cerebellar ataxia

Cerebellar ataxia – unsteady gait with legs – unsteady gait with legs spread wide. spread wide

• – Scissors gait

Scissors gait – short, stiff steps with thighs – short, stiff steps with thighs overlapping. overlapping

• – Foot drop - lifts knee high then slaps foot down

Foot drop - lifts knee high then slaps foot down

• – Parkinsonian shuffle

  Parkinsonian shuffle – accompanied by stooped – accompanied by stooped posture posture

Cerebellar function Cerebellar function Balance Balance Romberg’s test Romberg’s test

• – arms at sides, feet together,
• – eyes closed for 20 seconds.
• – Watch for loss of balance.

  arms at sides, feet together,

  eyes closed for 20 seconds.

  Watch for loss of balance.

• – Stand close enough to prevent falling.

Stand close enough to prevent falling. N=slight swaying. N=slight swaying. Abn Abn

• – loss of balance
• – (+) Romberg
• – Ask to stand on 1 foot & do a shallow knee-bend, or hop,. Ask to stand on 1 foot & do a shallow knee-bend, or hop,.

  loss of balance

  (+) Romberg

  cerebellar ataxia, alcohol intoxication, MS,

  cerebellar ataxia, alcohol intoxication, MS,

  impaired visual functioning, or loss of

  impaired visual functioning, or loss of proprioception. proprioception.

  

Test for coordination, muscle strength, & cerebellar function

Test for coordination, muscle strength, & cerebellar function

Cerebellar function Cerebellar function

  (Rapid alternating movements (Rapid alternating movements

  ; ;

  Accuracy of movement Accuracy of movement

  ; Balance; Gait) ; Balance; Gait)

  Rapid Alternating Movement (RAM) of the hands & fingers Rapid Alternating Movement (RAM) of the hands & fingers - -

• – assesses coordination & dexterity. Pat knees with the palms, then flip

  assesses coordination & dexterity. Pat knees with the palms, then flip & do so with the back of the hands, first slowly then faster. & do so with the back of the hands, first slowly then faster.

• – N=smooth & bilateral movement

  N=smooth & bilateral movement

• – Abn=slow, awkward movement= cerebellar dysfunction

  Abn=slow, awkward movement= cerebellar dysfunction Ask to touch thumb to each finger from index to 5 Ask to touch thumb to each finger from index to 5 ^{th th} finger & back finger & back again, slowly at first then faster. Repeat on the other hand. again, slowly at first then faster. Repeat on the other hand.

Abn=Dyssenergy (lack of coordinated muscle movement) =upper neuron

  

Abn=Dyssenergy (lack of coordinated muscle movement) =upper neuron

weakness, cerebellar disease, EP dysfunction. weakness, cerebellar disease, EP dysfunction. Finger-to-nose coordination test Finger-to-nose coordination test

• – Ask to touch index finger to nose then to the examiner’s outstretched

  Ask to touch index finger to nose then to the examiner’s outstretched vertical finger to different points. vertical finger to different points. Abn=Dyssnergy, Dysmetria (misjudgment of distance, speed & Abn=Dyssnergy, Dysmetria (misjudgment of distance, speed &

  

Sensory function

Sensory function

   Superficial Pain & Touch Sensation

  Superficial Pain & Touch Sensation

• – test distal points on arms & legs

  test distal points on arms & legs – Eyes closed. Eyes closed.

• – Examine Arms, Legs & Abdomen. Examine Arms, Legs & Abdomen.
• – Assess sensitivity to light touch with a wisp of cotton (distal to Assess sensitivity to light touch with a wisp of cotton (distal to proximal).

  proximal).

• – Ask to say “now” when each sensation is felt.

  Ask to say “now” when each sensation is felt.

  Sharp object (opened paper clip). Ask whether she feels a sharp or

  Sharp object (opened paper clip). Ask whether she feels a sharp or dull sensation. dull sensation.

  Temperature sensitivity

  Temperature sensitivity

• - 2 test tubes (1 filled with hot & 1 with cold water, along the
• - 2 test tubes (1 filled with hot & 1 with cold water, along the same routes. same routes.

  Abn=Peripheral nerve problem: paresthesia &

  Abn=Peripheral nerve problem: paresthesia & impairment in touch sensation (Anesthesia, Hypoanesthesia). impairment in touch sensation (Anesthesia, Hypoanesthesia).

Proprioception, Vibratory sensation Proprioception, Vibratory sensation

• Proprioception

  Proprioception

• – (tested on great toe & hands) – sense motion,
• – (tested on great toe & hands) – sense motion,

  position, & vibration position, & vibration

• – Hands (sides of index finger between thumb & index finger).

  Hands (sides of index finger between thumb & index finger).

  Eyes closed. Move finger up or down. Ask client to describe Eyes closed. Move finger up or down. Ask client to describe direction. Repeat on other hand & in both great toes. If (+) abn direction. Repeat on other hand & in both great toes. If (+) abn proceed to next proximal joint. proceed to next proximal joint.

  Abn=peripheral neuropathy or lesion in the posterior spinal Abn=peripheral neuropathy or lesion in the posterior spinal column, sensory cortex, or thalamus. column, sensory cortex, or thalamus.

• Vibratory sensation

  Vibratory sensation

• – stem of vibrating tuning fork against client’s
• – stem of vibrating tuning fork against client’s

  distal finger or great toe. Ask to say “now” if vibration is felt. Proceed distal finger or great toe. Ask to say “now” if vibration is felt. Proceed to next proximal joint if abn… to next proximal joint if abn…

Cortical sensation Cortical sensation (stereognosis, graphesthesia, 2-point (stereognosis, graphesthesia, 2-point discrimination) discrimination)

  Stereognosis

  Stereognosis – recognizing objects by feel. – recognizing objects by feel.

• – Eyes closed. Identify familiar objects (e.g. key). Repeat on other hand

  Eyes closed. Identify familiar objects (e.g. key). Repeat on other hand with different object. with different object.

  Abn=Astereognosis = parietal lobe problems

  Abn=Astereognosis = parietal lobe problems

  Graphesthesia

• – Eyes closed. Use blunt object such as closed paper clip to draw shape,

  Eyes closed. Use blunt object such as closed paper clip to draw shape, letter or number on the palm. Repeat on the other palm. letter or number on the palm. Repeat on the other palm.

  Abn=Graphanesthesia = parietal lobe problems.

  Abn=Graphanesthesia = parietal lobe problems.

• – touching 2 identical sharp objects (e.g. Opened paper clips) to the skin in close proximity, while eyes closed. paper clips) to the skin in close proximity, while eyes closed.
> – touching 2 identical sharp objects (e.g. Opened
• – Ask whether she feels 1 or 2 points, noting distance between 2 points.

  2-point discrimination

  2-point discrimination

  Ask whether she feels 1 or 2 points, noting distance between 2 points.

  Repeat test on arms, legs, face & abdomen, decreasing the actual