Gen Med 1

1. Layers of the skin – purpose and structures found in each layer

Stratum Corneum Dead Keratinocytes
Stratum Lucidum Melanocytes
Mature Keratinocytes
Stratum Granulosum
Langerhan's Cells
Stratum Spinosum Keratinocytes
New Keratinocytes
Stratum Basale
Merkel's Cells
Areolar connective tissue
Meissner's Corpuscles
Papillary Layer
Blood and lymph vessels
Free nerve endings
Collagen, elastin, reticular
Reticular Layer
fibers
Subcutaneous fat
Subcutaneous Pacinian Cells
Free nerve endings
Epidermis
Tough outer layer that protects deeper layers of epidermis
Produces melanin to prevent UV absorption
Produces Keratin to make the skin waterproof
Interacts with immune cells
Undergoes mitosis to continue skin cell development but to a
lesser degree than basal
The origin of skin skills, which undergoes mitosis, then moves ↑
Detects Touch
Dermis
Binds epidermis and dermis together
Detects light touch
Provides circulation and drainage
Detects heat and pain
Provides strength and resilience
Hypodermis
Provides insulation and shock absorption
Detects pressure
Detects cold

2. Bed mobility- push patient to opposite side of bed and always roll TOWARD you
a. Reposition patient in:
 Supine/sideling- every 2 hours
 Sitting- every 10 to 20 minutes  side lean, forward lean, sitting push up
b. Move in 3 sections: head and shoulders/ pelvis/ legs (when moving to side)
c. Cross opposite ankle on top to the side you are rolling to
d. When side lying sit, put hand on patients iliac crest for cue
e. Log roll prevent trunk rotation /side bending
 Put hands from top to down under to support knees
 Move UE and LE at same time
f. Supine long sit short sit is common in orthopedic/total joint replacements b/c patients
CANNOT roll
g. Pump ankles and take deep breaths to avoid orthostatic hypotension

3. Mobility/gait
a. For bariatric patient only time you DO NOT use supinated grip (use handshake position) for
sit to stand
b. Bobath dependent transfer PRONATED grip & patients head in OPPOSITE direction of way
you are going/moving them
c. Axillar crutches: 2 inches lateral and 4-6 inches anterior to foot
d. Sit stand with NO crutches: position stronger foot in the back (should be 4-6 inches from
chair) and affected foot in the front
 e. Assistive device stays with affected side and it is up with the good down with the bad
 ONE EXCEPTION: using a walker up the curb/stairs with a partial weight bearing
status up with bad, down with good
f. Walker does NOT stay with affected side when going up curb 5” or less for Full Weight
Bearing face curb forward place walker up on curb, then step up with unaffected
g. Walker going up curb backwards (6” or more) up with good, then move affected and walker
together
h. NO RAIL with walker make the heights of walker legs different, and go UP BACKWARD and
DOWN FORWARD
 Best method!!!!
i. WITH rail with walker fold walker, and use walker as a moveable rail LEAST STABLE

o Do NOT use wheeled walkers on the stairs

4. Differential Diagnosis and treatment of DM type I & II

  Type I (Ketosis Prone) Type 2 (Not Ketosis-Prone)

Age at onset Usually < 20 yr Usually > 40 yr
Proportion of all cases < 10% >90%
Type of onset Abrupt Gradual

Possible viral/autoimmune,
Etiologic Factors Obesity-associated insulin resistance
resulting in destruction of islet cells

HLA association Yes No

Insulin antibodies Yes No
Bodyweight at onset Normal or thin Majority are obese (80%)
Endogenous Insulin
Decreased (little or none) Variable (above or below norm)
Production
Ketoacidosis May occur Rare
Diet, oral hypoglycemic agents, exercise,
Treatment Insulin, diet, exercise
insulin, and weight control

5. Exercise guidelines with DM

a. Precautions:
  Hypoglycemia may occur during exercise or up to 24-48 hours after exercise because of an
inability to regulate insulin levels
 Provide snack (15 grams of carbohydrate) initially
1. During 15 grams of carbs every hour of intense activity
 Do not exercise if glucose is < 70 mg/dL
 Do not exercise if glucose is > 300mg/dL (fasting) or ketosis is present in urine test
 Do not exercise without eating at least 2 hours before exercise
 Do not exercise during peak insulin times
 Do not exercise without adequate hydration (16 oz before exercise)
 Do no exercise alone
 Do not exercise in extreme temperatures
 Do no exercise at night  can cause delayed hypoglycemia
 Do not inject short-acting insulin in exercising muscles or site close to exercising muscles as
insulin is absorbed more quickly (abdominal is preferred)
Exercise raises blood glucose levels by releasing stored glycogen
b. Cardiovascular Training (ACSM)
 Intensity: 50-80% of VO2 max or heart rate reserve (HRR)
 Frequency: 3-4 days/week
 Duration: 20-60 min
 Type 2 DM: 150 min of moderate to vigorous intensity aerobic exercise spread over at least 3
days
 Type 1: exercise has not been proven to increase glycemic control
c. Resistance Training (ACSM)
 Lower resistance: 40-60% of 1RM
 One set of exercises for major muscle groups with 10-15 reps (progress to 15-20)
 Minimum frequency 2 days/week; at least 48 hours between sessions
 Proper technique: minimize sustained gripping, static work, and Valsalva

6. Dressings – types and indications for use

Type Indication
Gauze May be used for any type of wound if properly applied and removed
Transparent Film Autolytic debridement, to reduce friction, superficial wounds with minimal drainage, secondary
dressing over foam or gauze
Hydrocolloids Partial - or full-thickness wounds with low to moderate drainage, including partially necrotic
wounds. Provide a moist environment and promote autolysis
Amorphous Dry eschar wounds, clean granulating wounds, exposed tendon and bone
Hydrogels Partial-thickness wounds with minimal drainage, or a secondary dressing on full-thickness wounds
Foams Partial - or full-thickness wounds with minimal to moderate drainage
Calcium Partial - and full-thickness wounds with large amounts of drainage, infected or noninfectred
Alginates wounds. Provide a moist wound environment to facilitate autolysis
Collagen Matrix Any recalcitrant wound to facilitate migration of collage
Topical Dressings Wounds requiring topical medications

7. Differential diagnosis of ulcers

Wound Characteristics
   Pressure Ulcer Arterial Wound Venous Wound Neuropathic Ulcer

Over Bones: Heels, Distal/LE Foot (plantar surface

LE
Sacrum, Occiput, Lower 1/3 leg 1st and 5th MT heads
Location Below Knee
Ischial tuberosity, Lateral Malleolus Phalanges
Medial Malleolus
greater trochanter Foot Dorsum, Toes
0.6-0.8  borderline
perfusion
ABI Normal: 1.0-1.3 ≤ 0.5 pain @ rest ≥ 0.8 is typical Unreliable
≤ 0.4 critical limb
ischemia
absent (distal to
Pulse Normal Normal Varies (no pedal)
wound)
+ to ++ (due to lack + or – (if in
Pain Variable Absent
of Oxygen) dependent position)
Wound Size Variable (small/deep) Small Large Variable
Wound Shape Round, triangular Round, punched out Irregular Round, oval
Variable (symmetrical:
Gradually Deeper Round or Oval w/
Wound Edge greater trochanter, Cliff/Stair step
toward center CALLOUS
irregular: coccyx)
Wound Depth Variable Shallow to Deep Shallow Often deep
Wound Bed & Variable (depends on Pale, Dry, Eschar Wet, Slough (Slow
Eschar to granulation
Appearance wound depth) (2°↓Circulation) Granulation)
Edema Minimal Minimal (localized) Mod to Large Localized
Mod to Large
Staining Absent Absent Hemosiderin stain Absent
(purple color)
Variable (based on
Exudate/Drainage Minimal Mod to Heavy Low to Mod
depth)

8. Hyperglycemia vs. hypoglycemia – signs & symptoms

Hyperglycemia Hypoglycemia
Diabetic Ketoacidosis (DKA)
Hyperosmolar, Hyperglycemic State (HHS) (type II) Insulin Shock (type II)
(Type I)
Gradual Onset Gradual Onset Sudden onset
Headache Extreme Thirst Pallor
Hyperventilation Kussmaul Polyuria leading to quickly ↓ urine output Perspiration
Fruity Odor to Breath Volume loss from polyuria → quickly to renal insufficiency Piloerection
Lethargy/confusion/coma Severe dehydration Palpations
Abdominal pain & distention Lethargy/confusion ↑HR
Dehydration Seizures Irritability/Nervousness
Polyuria  ketones in urine Coma Weakness
Flushed Face Blood Glucose > 600 mg/dl Hunger
Elevated temperature Arterial pH > 7.3 Shakiness
Blood Glucose > 300 mg/dl LACKS ketosis  NO ketones in blood Headache
Double/blurred vision
Arterial pH < 7.3
Dilated pupils
Thirst (extremely dry mouth)    Slurred Speech
 Illness and infection can lead   Fatigue
 to this
  Numbness of lips/tongue
    Confusion
    Convulsion/coma
Blood Glucose < 70 mg/dl
   
(too much insulin in blood)

9. OA vs. RA – differential diagnosis (S & S including joints)

  OA RA
Initially develops between ages 25-50 yr
Usually begins at age 40 yr
Onset Sudden onset over several weeks to months;
Gradual onset over many years; > 65 yr
intermittent exacerbations and remissions
Incidence 12% of US adults; 21 million 1-2% adults; 600,000 men/1.5 million women
Most common in men before age 45; after Women 3:1; but more disabling and severe when in
Gender
women men
Multifactorial; local biomechanical factors,
Etiology Unknown biochemistry, previous injury, inherited
predisposition
Begins in joints on one side of the body
Primarily: hips, knees, spine, hands, feet Symmetric simultaneous Joint Disturbance
Inflammation w redness, warmth, edema Can affect any joint; predilection for UE
Manifestations
(10% of cases) Inflammation almost always present
Brief morning stiffness that is decreased by Prolong morning stiffness lasting 1 hour or more
physical activity and movement
No systemic symptoms; possible associated System presentation with constitutional symptoms
S&S
trigger points (e.g. fatigue, malaise, weight loss, fever
Synovial fluid ↑ WBC and ↓ viscosity
Effusions rare, synovial fluid has ↓ WBC & ↑
ESR markedly increased
viscosity
Lab Values Rheumatoid factor usually present
ESR may be mildly to moderately increased
C-reactive protein, a true predictor of inflammation
Rheumatoid factor absent
present

 OA affects hands at PIP and DIP joint

o PIP: Bouchard node
o DIP: Heberden node

10.Hip precautions: maintain hip in abduction when sitting and sleeping abduction pillows

Approach Precautions
No hip flexion beyond 90°
Posterolateral No excessive IR
No hip adduction past neutral
Lateral No combined hip flexion beyond 90° with ADD, IR, or both
Anterolateral (more
common due to less
Hip extension and ER past 45° are to be avoided
dislocations than
posterior)
11.Surgery types (including hardware)
a. Total Hip Arthoplasty (THA)
 Replacement of both the femoral head and the acetabulum (metal & polyethylene)
1. Cemented
a. Reserved for individuals with decreased ability to regenerate bone
b. Allows early full weight bearing
2. Uncemented
a. Younger more active patients
b. WB per surgeon protocol
3. Bipolar prosthesis
a. Metallic acetabular cup and polyethylene liner
b. Used for revision when there is instability caused by osseous or muscular
insufficiency
12. Hip Exercise Progression
a. Post op day 1
 I. Take vitals first
 II. Supine exercises be happy with 10 reps!
1. Ankle pumps
2. Isometric glute and quad exercises
3. Short arch quad
4. Hip Abduction AAROM  do last because it is the toughest
a. Heel slides into abduction
5. Goniometer measurement/ sensation
6. ***Straight leg raises surgeon specific*****
 Get patient up
1. MMT
2. Walking (10-30 ft)
 In chair Long arc quads

b. Broken/fractured hip signs: hip shortens and ER

13.Garden Classification of Femoral Neck Fractures

a. Grade 1: incomplete, impacted fracture in valgus malalignment (generally stable)
b. Grade 2: nondisplaced fracture
c. Grade 3: incompletely displaced fracture in virus malalignment
d. Grade 4: Completely displaced fracture with no engagement of the two fragments
 More evident fracture in lateral view for grade 4
14.Fractures of Femur
a. Intracapsular fracture: within hip joint capsule including the femoral head, sub capital and femoral neck
(Use Garden scale to classify femoral neck fracture) require internal fixation or hemiarthroplasty
b. Extracapsular fracture: outside the hip joint capsule intertrochanteric or subtrochanteric fracture
requires open reduction internal fixation
c. Intertrochanteric fracture: occur between greater and lesser trochanter requires open reduction
internal fixation
d. Subtrochanteric fracture: below the lesser trochanter and end at a point 5 cm distally requires open
reduction internal fixation

15.Osteoporosis vs Osteopenia

 -1 or above T score= normal

 -1 to -2.5 T score on bone mineral density test= osteopenia
 -2.5 or lower T score= osteoporosis
 Calcium intake: 1000 for males 20-70 y/o, 1000 for females 20-50 y/o, 12000 for females 50
y/o to end of life, 1200 for males >70 y/o
 16. FIM

Complete independence Pt ambulate >150 ft without an 7 Points

assistive device

Modified independence Pt ambulate >150 ft with an assistive 6 points

device, orthosis, and/or prosthesis

Supervision Pt ambulate >150 ft with standby 5 points

supervision, cues, or coaxing

Minimal Assistance Pt performs 75% to 100% of effort to 4 points

go >150 ft

Moderate Assistance Pt performs 50% to 74% of effort to 3 points

go >150 ft

Maximum Assistance Pt performs 25% to 49% of effort to 2 points

go >50 ft

Total assistance or dependent Pt performs 0% to 24% of effort to go NO POINTS

>50 ft

17.Gait Cycle

Amputations Details:
 o Greater NRG required for gait
 10-60% increase in NRG for BKA
 60-120% increase in NRG for AKA
 200-300% increase in NRG for bilat AKA, hip disarticulation, hemipelvectomy
o Gait Speed
 10-40% slower for BKA
 40-55% slower for AKA
o NRG return in gait with prosthetics
 20% for SACH
 90% multi-axis foot
 240% for normal musculature
o Donning Prosthetic
 Liner is inverted all the way inside out and the base of the liner is placed on the distal stump
 Liner then rolled up onto the stump
 Place a sock of correct thickness over the liner
 Don the prosthesis
o Adjusting Sock Ply
 Decrease Sock ply due to residual limb volume increase
 Unable to don prosthesis, sock feels too tight, prosthesis seems taller, instability, stump
not fully in the socket, pressure resulting in discomfort in new areas, ill-fitting socket,
discomfort on tibial tubercle, too much sock
 Increase Sock ply due to residual limb volume decrease
 Socket feels too loose, prosthesis seems shorter, increased pressure/pain in the groin
region (AKA), increase pressure/pain on the patellar tendon area (BKA), increased
pressure/pain on the distal stump, increased pressure on bony areas, improper fitting
socket, pistoning
o Common reasons for falls
 Stance Phase
 Insufficient residual limb extension
 Incorrect timing or residual limb extension
 Prosthetic knee in flexion at initial contact/loading response
 Prosthetic knee axis anterior to TKA line
 Swing Phase
 Insufficient residual limb hip flexion
 Incorrect timing of residual limb flexion
 Stubbing prosthetic toe as a result of a >5-degree pelvic dip with sound limb stance

Lab Values
 Kidney GFR Rates
o Normal: 90 mL/min or more
o End stage Renal Disease (ERSD): less than 15 mL/ min
 Stage 5
 Arterial pH
o Normal: 7.35 to 7.45
 DKA occurs with pH <7.3
 Creatine
o Normal: 0.6 to 1.2 mg/dl
 Increased level indicates kidney disease
 Ketones
o Normal: <0.6 mmol/L
  >3.0 mmol indicates DKA
o
 Glucose Fasting (60 to 100)
o Normal Adult: 70 to 100 mg/dl
o Normal Adult over 60: 80 to 110 mg/dl
 >300 indicates DKA
 >200 indicates DM
 Glucose can increase after an MI (STEMI)
 Urine ACR
o Normal:<30 mg/gm
 A1C
o Normal: <5.7 %
o Prediabetes: 5.7-6.4%
o Diabetics: >6.5 % indicates DM

Ulcer Grading Scales

Wagner Ulcer Grading system: For Diabetic Ulcers

0- Preulcerative lesions; healed ulcers; presence of bony deformity

1- Superficial ulcer without subcutaneous tissue involvement
2- Penetration through the subcutaneous tissue; may expose bone, tendon, ligament or joint capsule
3- Osteitis, abscess, osteomyelitis
4- Gangrene of digit
5- Gangrene of foot requiring disarticulation (amputation)

Stages of Pressure Ulcers

1- Intact skin with nonblancahable redness of localized area usually over bony prominence
2- Partial thickness loss of fermis presenting as a shallow open ulcer with a red pink wound bed without slough;
may also show intact or open/ruptured blister; shiny or dry
3- Full thickness tissue loss; subcutaneous fat may be visible but NOT bone, tendon or muscle; may include
tunneling
4- Full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar present with undermining and
tunneling
Unstageable: full thickness tissue loss in which base of ulcer is covered by slough (yellow, tan, gray, green, brown)
and/or eschar (tan, brown, or black) in wound bed; at least a stage 3 or 4

Suspected Deep Tissue Injury: purple or maroon localized area of discolored intact skin or blood-filled blister

Braden Scale of Pressure Ulcers

6 subscales:
- Mobility
- Activity
- Sensory perception
- Moisture
- Nutrition
- Friction/shear
Score (1-4) each subscale if score is 18 (out of 23) and under, initiate pressure ulcer prevention and treatment
1- Completely limited
2- Very limited
3- Slightly limited
4- No impairment

Dressings

Dressing Description Examples Wounds to use on

Category

Absorptive Absorb copious amounts of fluid Foam

(infection)
Mepore

Calcium Alginates

Adherent -Adhere to wound Wide mesh gauze Arterial wound

(initially)
-May debride dead tissue

Non-adherent - Does not adhere to wound; Absorptive Venous wound (if

not infected)
- Useful for clean wounds that Foams
are re-epithelizing
Hydrocolloids
Pressure ulcer
Hydrogels stage 3
Impregnated gauze

Semi-permeable - Protect non-exudating wounds Poly-urethane films Diabetic Ulcer

from skin breakdown; (initially)

- Maintain most wound

environment (waterproof but
allow passage of water vapor);

- Well tolerated by sensitive skin

Occlusive - Impermeable to water and air Hydrocolloids

- Maintain hydration of wound Hydrogels

and encourages re-epithelization
Transparent films

Silicone gel sheets

Biological - Adhere to a wound bed and Collagens

either promotes healing or
Heterograft
prepares wound for permanent
closure Homograft

Amniotic membrane
 Biosynthetic - Similar to biological Biobrane

Collagen derivatives

Alginates

Composite - Combine physically distinct Telfa

agents into a multifunctional
Tegrederm
dressing (3 layers)

- Layer 1: semi-adherent that

(with absorbent
touches wound
pad)
- Layer 2: absorptive layer

that wicks drainage

- Layer 3: bacterial barrier

layer

K Levels
K 0: no potential for use of prosthesis (wheelchair bound)

K 1: potential for use of prosthesis for transfer or limited ambulation at fixed speed on level surfaces

K 2: potential to ambulate on low level environmental barriers: limited community ambulator

K 3: potential to ambulate with variable cadence: unlimited community ambulator

K 4: prosthetic needs that exceed basic ambulation, exhibiting high impact, stress, or high energy levels

Harris Hip Scale

10 domains with 4 items: max score = 100 points

 Pain
o 1 item
 Function- (ADLs)
o 7 items
 Absence of deformity
o 1 item
 ROM
o 2 items
Scoring:

 <70 is considered a poor result

 70-80 is considered fair
 80-90 is good
 90-100 is excellent

FIM
Complete independence Pt ambulate >150 ft without an 7 Points
assistive device

Modified independence Pt ambulate >150 ft with an assistive 6 points

device, orthosis, and/or prosthesis

Supervision Pt ambulate >150 ft with standby 5 points

supervision, cues, or coaxing

Minimal Assistance Pt performs 75% to 100% of effort to 4 points

go >150 ft

Moderate Assistance Pt performs 50% to 74% of effort to 3 points

go >150 ft

Maximum Assistance Pt performs 25% to 49% of effort to 2 points

go >50 ft

Total assistance or dependent Pt performs 0% to 24% of effort to go NO POINTS

>50 ft

Transfers
 Sliding boards:
 Hardwood basic: 250 lb weight limit
 Hardwood special notch wood: 250 lb weight limit
 Black plastic: 400 lb weight limit
 Beasy Board: 350 lb weight limit
 S shaped board with a disk/tract
 7-ply birch board: 400 lb weight limit

Exam 2
1. Ventilator Rehabilitation Contraindications
a. Do NOT exercise if:
i. FiO2 is > or equal to 60 %
ii. PEEP > or equal to 15
 iii. Tidal Volume < 325 mL
1. Normal: 500 mL
2. High levels indicate decreased venous return
iv. ICP > 15
v. BP instability despite vasopressors
vi. Uncontrolled arrythmias
2. Ventilator Complications
a. Infections
i. Ciliary function is impaired
ii. Ability to cough and clear sections is impaired
iii. Incidence of pneumonia increase after 72 hours
b. Barotrauma
i. Occur when airway pressure results in alveoli rupture
c. Tracheal Erosion
i. Pressure necrosis of the trachea by balloon cuff
3. ICU Lines & Purposes

Description Placement

ART Line Continuous monitoring of HR & BP, site to Radial or Femoral artery; contain
draw ABGs pressurized IV bag

FloTrac Calculates cardiac output, cardiac index, Attach to ART line

stroke volume, delivery of O2 to tissues

Central Venous Pressure Pressure of circulating fluid volume as Subclavian/jugular vein SVC sits
Line entering R atrium; vascular access for TPN, outside R atrium
repeated blood samples, admin blood/fluids
& chemo

Pulmonary Artery Line Multi-lumen catheter that monitors fluid Brachial/internal

(Swan Ganz) status “wet/dry” & monitors pressure in lungs jugular/femoral/subclavian vein R
and indirect L atrial pressure  balloon at atrium R Ventricle sit in Pulmonary
end “wedged” Artery

ECG Graphic representation of patient cardiac White on right

status
Snow over grass (white over green)

Smoke over fire (black over red)

Pulse Oximetry % of HGB saturated with O2 in arterial blood Finger, toe, nose, earlobe

Chest Tube Remove fluid (hemothorax) or air Placed in pleural space between 4th and
(pneumothorax) 5th intercostal
External Ventricular Device Control & monitor ICP by allowing for Placed in ventricle in brain
therapeutic CSF drainage

Extracorporeal membrane Directly oxygenates and removes CO2 from N/A

oxygenation blood artificial lung & bridge to transplant

Intraortic Balloon Pump Increase myocardial oxygen perfusion & Balloon sits in aorta
increase cardiac output (deflates in systole &
inflates in diastole)

Ventricular Assist Device Take over function of heart while waiting for
transplant

Nasogastric Tube Keep stomach empty after surgery to rest Nostril esophagus sit in stomach
bowel & can be used for delivering tube
feeding/meds (put in and take out materials)

PEG/PEJ Long term access for nutrition Abdominal wall sit in jejunum or
stomach

Peripherally Inserted Central Long term admin of TPN, meds, fluid Basilic/cephalic vein SVC Sit outside
Venous Catheter (PICC) R atrium

Mechanical Ventilation Positive Pressure breathing (normally we do Nose/mouth/trachea sit in main stem
negative pressure breathing)  volume bronchus
controlled, pressure controlled,
spontaneously controlled

Pressure Controlled I: E (1 to 2) set by operator breathing

Ventilation performed by machine

PEEP Prevent lungs from totally collapsing at end of

exhalation; allow alveoli to open up and come
into contact with blood (-5 mm is normal)

CPAP Increase pressure in throat so airway does

not collapse when exhaling

BiPap Allows more gas in and out of lungs without

normal muscular activity needed (two
pressure settings, one for inhale one for
exhale)
 4. CBC Values
Normal Value Increased & PT implications Decreased & PT implications
White Blood 5,000 to 10,000 Leukocytosis (>11,000 ul) Leukopenia (<4,000 ul)
Cells Fight ul (microliter) - Infection, leukemia, trauma, - Bone marrow failure,
infection and malignancy, pneumonia, tissue necrosis autoimmune disease,
indicate status of radiation/chemo
immune system - PT: may have fever, cautious with - PT: may have fever & may be on
excessive activity neutropenic precautions. If you
are sick or have cold sore, do not
see patient
Hemoglobin Males: 14 to 18 - Result from dehydration or Hypoxemic
transport O2 g/dl polycythemia - Anemia, blood loss during
throughout body - PT: headaches, dizziness, blurred surgery, dietary iron insufficiency
Females: 12 to vision, decrease in mental acuity , - Heart works harder to transport
16 g/dl sensory changes in distal extremities, adequate O2 by increasing CO
increase risk for stroke and thrombosis (cardiac output)
- PT: lightheadedness/ pass out,
tachycardic, increased fatigue,
decreased tolerance to upright,
avoiding excessive
strengthening/ endurance
training
Hematocrit % Males: 42 to Polycythemia - Anemia, hemodilution, blood
of total blood 52% - Chronic lung disease, heavy tobacco loss
volume that use - PT: lightheadedness/ pass out,
contains RBC- Females: 37 to - Impeded flow to tissues tachycardic, increased fatigue,
indicates 47% - PT: headaches, dizziness, blurred decreased tolerance to upright,
viscosity of blood vision, decrease in mental acuity, avoiding excessive
sensory changes in distal extremities, strengthening/ endurance
increase risk for stroke and thrombosis training
Platelets form 150,000 to Thrombocytosis (can result in thrombus) Thrombocytopenia (can result in
clots by forming 400,000 ul - Iron deficiency, neoplasm, renal failure hemorrhage)
platelet plugs (microliter) - Infection, drugs, chemo, HIV,
liver disease, disseminated
* can impact fall intravascular coagulopathy (DIC),
risks prosthetic heart valves
- PT: pt has increased bruising

5. CBC Exercise Guidelines- recommendations

a. WBC
i. <1,000 mm3  NO exercise; wear protective mask
ii. <5,000 mm3 with fever NO strenuous exercise
iii. >5,000 mm3 light exercise, progress to resistive exercisers as tolerated
b. Absolute Neutrophil Count (ANC)
i. 2,500 to 6,000 mm3  normal
ii. < 1500 mm3  neutropenic precautions
 c. Red Blood Cells
i. 4.5 to 5.3 million/mm3  normal
d. Hematocrit
i. <25%  NO exercise permitted
ii. 25 to 30%  light exercise permitted
iii. 30 to 32%  resistive exercise as tolerated
iv. > 5000 mm3  light exercise, progress to resistive exercisers as tolerated
e. Platelets & Exercise Guidelines for Thrombocytopenia
i. 150,000 and above exercise and activity without restriction (normal activity)
ii. 80,000 to 150,000  moderate resistance exercise, amb and ADLs
iii. 50,000 to 80,000  minimal resistance exercise, amb, and ADLs
iv. 50,000 and less  NO resistive exercise
v. 20,000 to 50,000  AROM, functional activity, light weights/ exercise
vi. 10,000 to 20,000  functional activity only
vii. 10,000 or less  consider cancelling PT, could maybe do AROM
f. Hemoglobin
i. < 8 g/dL  no exercise permitted OR light ROM & isometrics
ii. 8 to 10 g/dL  light exercise permitted, ADLs with assistance
iii. > 10 g/dL  resistive exercise permitted
g. Prothrombin time
i. > or = to 2.5 times reference range physical and occupational therapy contraindicated
h. INR (Anticoagulant therapy)
i. > or = to 2.5 to 3.0  consult with physician b/c it’s a red flag
ii. 4 to 5  may be allowed to participate in familiar exercise routine
iii. > 6  bed rest
6. BMP Values
Normal Value Increased & PT implications Decreased & PT implications

Sodium (Na+)  neve 135 to 145 mEq/L Hypernatremia Hyponatremia

conduction, muscle
- Can cause cells to - Can cause cells to shrink/swell
contraction, functioning of
cells shrink/swell (brain cells) (brain cells)

- Confusion, weakness, - Confusion, weakness,

intracranial hemorrhage intracranial hemorrhage

Chloride  indicates 95 to 105 mEq/L *Levels fluctuate with fluid *Levels fluctuate with fluid
hydration & acid/base status status status

*controlled by kidneys

BUN  related to metabolic 10 to 20 mg/dl - Renal impairment &

function of liver and potential need for dialysis
excretory function of kidneys
*excreted in urine as waste

*formed in liver & end

product of diet protein
breakdown

Potassium (K+)  impact 3.5 to 5.0 mEq/L Hyperkalemia Hypokalemia (worse)

neuromuscular function
- ECG changes, bradycardia,
asystole, nausea, diarrhea
- PT: hold PT until imbalance is
corrected
- Dangerous ventricular
arrythmias, cardiac irritability,
ST segment depression,
dizziness, hypotension,
decrease in force of contraction
of heart muscle

- PT: hold PT until imbalance is

corrected

Bicarbonate (HCO3)  assist 22 to 26 mEq/L

with acid/base balance

Creatinine serum (SCR)  0.6 to 1.2 mg/dl - Renal impairment &

product of normal muscle potential need for dialysis
metabolism

*regulated by the kidneys

Glucose  blood sugar level Adult: 70 to 100 mg/dl Hyperglycemia Hypoglycemia

- Acetone breath, - HA, shakiness, weakness,

dehydration, weak and rapid
Adult >60 y/o: 80 to pulse, stupor, coma
110 mg/dl
- PT: Blood sugar >300 can be
risk of DKA
irritability, cold sweats,
decreased muscle control
- PT: low activity tolerance &
over extension can cause
hypoglycemic reaction

Calcium 9 to 11 mg/dl

7. Coagulation Profile
Define Normal Therapeutic Range Critical levels
Range

Prothrombin Time (PT) - Time required for a 12 to 15 For anticoagulant -3 times control
fibrin clot to form when seconds therapy may be value
extrinsic pathway is 1.5 to 2 times the
stimulated reference range - Risk for
hemorrhage
- Blood comes into
 contact with tissue
thromboplastin

-Measure effectiveness
of oral anticoagulant
therapy
(coumadin/warfarin)

Partial Thromboplastin - Time required for a 32 to 70 For anticoagulant -3 times control

Time (PTT) fibrin clot to form when seconds therapy may be value
intrinsic pathway is 1.5 to 2 times the
- Risk for
stimulated reference range
hemorrhage
- Blood or lining of blood
vessel is damaged

- Monitors effectiveness
of Heparin therapy
(more immediate effect)

International - Ratio of prothrombin 0.9 to 1.1 Usually 2 to 3 times INR >3.5 is at an

Normalized Ratio (INR) time to the reference the normal range increased risk for
range of prothrombin (blood things due to bleeding
time heart valve or DVT)

8. DVT Exercise Guidelines

a. If thrombus is below knee continue with activity
b. If thrombus is above knee continue with activity if anticoagulation has been given
c. If one dose of lovenox has been given to patient OK for treatment
d. If patient has IVC Filter no restrictions for therapy
9. Bundles done 100% of time to reduce preventable condition
a. Ventilator Bundle
i. Head of Bed raised
ii. DVT Prophylaxis
iii. Appropriate sedation  sedation vacations
iv. Peptic ulcer disease prophylaxis
v. RN/ RT weaning protocol
vi. Subglottic suctioning
vii. Mouthcare
b. Central Line Bundle
i. Full sterile drape
ii. Hand hygiene
iii. CHG skin antiseptics
iv. Line location
v. Assess daily for need
vi. Remove as soon as no longer needed
 c. Surgical Site Infections
i. Correct antibiotics (ATB)
ii. At right time
iii. Only for 24 hours
iv. Done use razor for hair removal
v. Glucose control (Open heart procedures)
vi. Normothermia (colon procedure)
10.Infectious Disease
a. Acute care hospitals should have at least 0.8 to 1 FTE for every 100 to 115 occupied beds
b. Agencies Involved in Infection Control
i. Governmental
1. CDC
2. OSHA (Occupational Safety and Health Admin)
3. EPA
4. PHS (Public health service)
5. CMS
a. No payment for certain health care acquired events (as of 10/2008)
6. ODH (Ohio department of health)
ii. Non-Governmental (accredit hospitals)
1. Joint commission
2. APIC
3. Professional Associations
4. ACS, ABA, CARF
c. Standard Precautions Apply to ALL patients
i. Hand hygiene (WARD), gloves, gowns, masks, eye protection, environment, patient care
equipment, patient placement, linen, food trays trash
ii. Transmission based precautions are used with this contact, airborne, droplet
d. PPE
i. Don: Gown Mask/respirator Googles/ face shield Gloves
ii. Doff: Gloves Goggles/face shield Gown Respirator
e. Transmission Precautions
Contact Precaution Droplet Precaution (mask if Airborne Precaution (PAPR) <10-
(direct/indirect) within 3 ft patient)  >10-micron micron diameter
diameter

- MRSA/ VRE - COVID-19 - Pulmonary TB

- Major wounds/ abscess - Influenza - Chicken Pox (Varicella)

- Scabies/ lice - Pertussis (Whooping Cough) - Measles

- RSV in children - Mumps - Shingles

- C-diff - Invasive N. Meningitis - Smallpox

- Rubella
 - Invasive H. influenza - SARS

f. Bloodborne pathogen Facts

Epidemiology
Transmission mode
Body Fluids that Transmit Disease
S/S  majority of people have no
s/s so they do not know they are
infected
Hepatitis B/C viral infection that
invades liver
- Potentially life threatening
- Can live on surfaces at room temp for
7 days
- HBV= more common
- 1- 10% HBV will be chronically
infected
- Needlestick, contact with blood
through mucous membranes & non-
intact skin
- Blood, vaginal secretions, synovial
fluid, pericardial fluid, breast milk, any
fluid visibly contaminated with blood
- Fatigue, loss of appetite, mild fever,
aching muscles/ joints, nausea and
vomiting, diarrhea, jaundice, itching
skin, dark urine, light colored feces
- Will last 6 weeks to 6 months
HIV viral infection that attacks immune
system and causes AIDS
- Life threatening
- Not as infectious as HBV b/c less # HIV
in body fluids
- Very fragile; can be destroyed on an
environmental surface
- Semen, CSF, pleural fluids, peritoneal
fluid, saliva in dental procedures,
amniotic fluid
- Swollen lymph glands, recurrent fever,
night sweats, rapid weight loss for no
reason, constant fatigue, diarrhea &
decreased appetite, yeast infections or
blemishes of mouth, other opportunistic
infections (Kaposi’s sarcoma,
pneumocystis carinii pneumonia)

11.ABG’s
a. Compensated (fully): pH is normal, and BOTH PaCO2 and HCO3 are out of range
b. Partial compensated: pH is out of range (but moving toward normal range), and BOTH PaCO2
and HCO3 are out of range
c. Uncompensated: pH is out of range, and EITHER PaCO2 OR HCO3 are out of range
i. Increased PaCO2 makes plasma more acidic
ii. Increased HCO3- makes plasma less acidic (or more basic)
1. For every 10 point change in PaCO2 there should be a 0.08 change in pH in
opposite direction (inverse)
2. For every 10 point change in HCO3- there should be a 0.15 change in pH in the
same direction (direct)
d. Two systems CANNOT overcompensate (kidneys take longer to compensate 12 to 24 hrs.)
e. Whatever pH is match HCO3 & PaCO2 to determine metabolic versus respiratory
f. Usually reported as PaO2/PaCO2/pH/HCO3- followed by + or - which indicates BE
pH PaCo2 S/S Causes

Respiratory ↓ pH ↑ PaCo2 - Pulmonary (Dyspnea, - CNS Depression (TBI, narcotics, sedatives,

acidosis respiratory distress, shallow anesthesia)
respirations)
- Impaired respiratory muscle function (SCI, NM
- Neurological (HA, restlessness, disease)
(due to alveolar drowsiness, lethargy, confusion,
hypoventilation) - Pulmonary disorders (atelectasis, pneumonia,
 altered mental status, tremor, pneumothorax, pulmonary edema, bronchial
coma) obstruction, COPD)

- CV (Tachycardia, dysrhythmia, - Massive Pulmonary Embolus

hypertension, diaphoresis)
- Hypoventilation (pain, chest wall injury/deformity,
-Redness of skin rib fractures, abdominal distension, sleep apnea)

Respiratory ↑ pH ↓ PaCo2 - Neurological (light - Psychological (anxiety or fear)

alkalosis headedness, numbness/tingling,
confusion, inability to - Pain
concentrate, blurred vision)
- Increased metabolic demands (fever, sepsis,
(due to alveolar - CV: A-fib (palpitations, pregnancy)
hyperventilation) dysrhythmia, diaphoresis)
- Medications (respiratory stimulants)
- Misc. (dry mouth, tetanic
- CNS lesions
spasm of arms/legs)
- Cardiopulmonary (CHF, PE, asthma, ARDS,
- Watch for respiratory muscle
hypoxia)
fatigue hard breathing

Metabolic acidosis ↓ pH ↓ HCO3 - Pulmonary (Kussmaul - Renal failure, DM, DKA, anaerobic metabolism
respirations- deep, desperate (lactic acidosis), starvation, alcoholism, diarrhea,
breathing in attempt to ↑pH by ostomy drainage, parental nutrition (extended
removing CO2) need), salicylate intoxication (aspirin)

- Neurological (HA, restlessness,

drowsiness, lethargy, coma,
confusion)

- CV (Dysrhythmia)

- Misc.(warm & flushed skin)

Metabolic ↑ pH ↑ HCO3 - Neurological (dizziness, - Excess base (excess ingestion of antacids, excess
alkalosis lethargy, disorientation, use of bicarb, use of lactate in dialysis)
seizures, coma)
- Loss of acids (Vomiting, NG suction,
- Pulmonary (respiratory hypochloremia, hypokalemia, excess diuretics, high
depression- attempt to retain levels of aldosterone)
PaCO2 by ↓ pH)
- Banked blood transfusions
- Musculoskeletal (weakness,
muscle twitching, muscle - Cushing’s Syndrome (overactive adrenal gland)
cramps, tetany)

- GI (Nausea, vomiting)

12.Emotion/Spirituality
a. Spirituality: ultimate or immaterial reality
i. Association with transcending entity or dimension
ii. Deepest values and meanings by which people live (purpose of life)
 iii. Great diversity
b. Religion: collection of cultural systems, belief systems, and worldwide views that establish
symbols that relate to humanity and spirituality and sometimes moral values
i. Emphasize community development and institutionalization of shared beliefs/practices
ii. Overlaps with spirituality more organized
iii. Gives meaning to illness, pain and suffering
iv. Most apparent in critically ill patients
v. Unmet needs in psychosocial aspect more than physically
c. JCAHO requires spiritual assessment
i. Hospital must determine the patients denomination, beliefs, and what spiritual practice
is important to them
d. Gestures
i. Thumbs up
1. US good
2. Germany mean #1
3. Japan Means #5
4. Afghanistan insult
ii. Thumb & finger circle
1. US means ok
2. Japan means pay me
3. France means you’re worthless
4. Russia vulgar insult
13. Cultures
a. 5 Guidelines for Respectful Care
i. Understand spiritual needs, resources & preferences
ii. Follow expressed wishes
iii. Do not prescribe (prevent) new spiritual practices
iv. Understand ones spirituality
v. Integrity
b. Paradigms
i. Western guilt or innocence
ii. Muslim shame or honor
iii. Tribal fear or power
c. Christian
i. Values eternal life & life
ii. Struggle against death doesn’t always make sense
d. Jewish (E. European countries) Orthodox (most strict), Conservative, Reform (least strict)
i. Sanctity of life
ii. Israel is holy land
iii. English, Hebrew, Yiddish
iv. Sabbath is from sundown on Friday to sundown Saturday
1. Invite other families in for Friday evening Sabbath dinner
 v. Kosher diet
1. Prepared according to Jewish law under Rabbinical supervision
2. Eating unclean animals is forbidden
3. Blood and animal fats are taboo blood is synonymous with life
4. Do not mix meat with dairy
vi. Saving life overrides all religious obligations
vii. Men do not touch women, unless its their wife
1. Touch is only for hands-on care
viii. Very talkative and friendly
ix. Stoic and authoritative
x. Respect health care workers who show self confidence
xi. Appreciate family accommodation
xii. Jewish law must seek complete medical care
xiii. Donor transplants not acceptable but are to conserve and reform
xiv. Discourage cremation at death
1. Autopsy is permitted in less strict groups
xv. At death, soul returns to heaven and body returns to dust of earth
xvi. Patient is NOT touched by care provider of opposite sex
xvii. All body parts buried together including amputated
1. Entire body, tissue, organs, and blood need to be available for burial
xviii. Do not cross hands in postmortem care
xix. Unnecessary procedures are avoided during the Sabbath or other holy days
e. Muslim
i. Judgment day and life after death
ii. Encourages submission to will of God (Allah)
1. Believe in Allah, Mohammed and his prophet
iii. 5 daily prayers
iv. Zakat giving of alms to poor
v. Pilgrimage to Mecca is the goal of the faithful
vi. No pork or alcohol
1. Eat only Halal meat (type of Kosher)
vii. Limit eye contact, do not touch when talking
viii. Women cover entire body expect face and hands
ix. Do not force food when religiously forbidden
x. Abortion before 130 days
1. Fetus treated as discarded tissue
2. After 130 days treated as human being
xi. Fatalistic worldview to ‘inshallah’ (God willing)
xii. Some prohibit handshakes or any contact between genders
xiii. Confession of sins and begging forgiveness in presence of family before death
1. After death only relatives or priest may touch body
2. Body is bathed and clothed in white and buried within 24 hours
 xiv. Recite Islamic Creed (Koran) at death holy book
xv. Ramadan month of fasting from dawn to dusk
f. Hindu
i. Cyclic birth and reincarnation
ii. Everything determined by behavior in last life (status, condition, caste)
iii. Cow is sacred (no beef)
iv. Limit eye contact & do not touch while talking
v. Priest may tie thread around neck/wrist to signify blessing at death do NOT remove
1. Priest will pour water into mouth of body
2. Family will request to wash body
3. Eldest son responsible for funeral rites
vi. Do not force foods when religiously forbidden
g. Buddhist
i. Budhi means “to awaken”
ii. Buddha was born in 563 BC
iii. Principles of Buddhism Dhamma or Truth
iv. Balance between self-indulgence and self-modification
v. Moral life
vi. Mindful and aware of thought and actions
vii. Wisdom and understanding
viii. Calm and collected
ix. Tolerant and not concerned with labels
x. Elimination of suffering by reaching “Nirvana” or “Enlightenment”
xi. If eliminate all desire can eliminate suffering
1. Great # of reincarnations
xii. Animalistic approach in Far East to increase luck instead of involving in time-consuming
& demanding practices
xiii. 9 is a lucky number
xiv. Karma deeds good or bad, will be rewarded in kind
xv. ½ are vegetarian/near vegetarian
1. Nonviolence to animals
14. Emotional Status (need to meet emotional needs of patients)
a. Dysthymic disorder: low grade depression but lasts longer than depression
b. Major depression= most common mood disorder
i. Affects 1/3 internal medicine patients
ii. Risk increases over time (most episodes occur at age 25)
1. 2-3 more times likely in women
iii. Increased depression= decreased PT/ adherence
iv. Most commonly associated with suicide (50% associated with suicide)
v. Caffeine, alcohol and Marijuana can worsen this
c. Major Depression Symptoms
 i. Major depression: 5 or more of the following symptoms present during the same two-
week period and shows change from previous function (1 out of the 5 must be deep
sadness/emptiness OR apathy)
ii. Symptoms:
1. Deep sadness/emptiness
2. Apathy
3. Agitation or restlessness
4. Sleep disturbance
5. Weight/appetite disturbance
a. Loss/gain > or equal to 5 % in a month without trying
6. Lack of concentration
7. Feelings of excessive guilt or worthlessness
8. Morbid thoughts
9. Fatigue
iii. NMDA receptor agonist new antidepressant for treatment resistance depression
(TRD)
1. Resistant to at least 2 different antidepressants
2. Nasal spray at MD office and monitored for 2 hours after rapid effect
iv. Treatment
1. Exercise takes 1 week daily for symptoms to decrease
2. Deep breathing
3. Bright light therapy
4. Regular, restful sleep
5. Avoid negative thinking
6. Classical musical therapy
7. Daily spiritual exercises
v. Diets increasing depression= omega 3 fats, folic acid, vitamin B12, homocysteine, animal
protein intake/puberty
d. Frontal lobe (Prefrontal cortex) aka the control center/planning area of the brain for
decisions, behaviors, emotions & “crown” of the brain
i. Depression decreased frontal lobe blood flow and activity
ii. Alcohol reduce frontal lobe activity
1. Loss of abstract thinking can present up to 24 hours after last drink
2. Drinking less than legal limit weakens judgement 9x higher fatal accidents
iii. Nicotine affects frontal lobe
1. Decreases sleep, mental tasks, stress control, brain function depression
iv. Hypnosis short circuited frontal lobe
1. Loses thought activity (weak beta brain waves)
v. TV frequent switching of camera angles causes frontal lobe suppression
1. If angle is linear for 30 to 60 secs allow full frontal lobe involvement
2. Train yourself not to react
e. Smoking Cessation
 i. 5 A’s
1. Ask about use
2. Advise to quit
3. Assess willingness to make a quit
4. Assist in quit attempt
5. Arrange follow up
ii. 5 R’s for unwilling to quit
1. Relevance of quitting
2. Risks of use
3. Rewards of quitting
4. Roadblocks possible to quitting
5. Repetition of discussion
f. Exercising the Brain
i. # of neurons and # of connections can increase by stimulation
ii. Reading
iii. Learn foreign language
iv. Use imagination
v. Spiritual exercises (memorizing scripture)

15. Gen Med Therapeutic Exercise

a. FITT-P
i. Frequency, Intensity, Time or reps/sets, Type, Progression
b. 4 Major components
i. Aerobic Endurance, Strength/Muscle, Flexibility/ROM, Balance & agility
c. Aerobic Endurance start slow and progress gradually & warm up/ cool down
i. Monitor vitals regularly!
ii. Recumbent bikes, steppers, UE bikes, treadmills
iii. Assessing
1. 2, 6, 12-minute walk test (6= most common)
a. Monitor HR, BP, distance before & after
2. Take HR & perceived exertion at given exercise load
a. Allows teasing out of limiting factors
iv. Max HR
1. 220- age= low end (less fit patients)
2. 210- (0.5 x age)= high end (more fit patients)
v. Target HR
1. Standard [Max HR x Intensity Level (70 to 85%)]
2. Karvonen’s Method accommodates for baseline fitness and resting HR
(typically higher than standard Target HR)
a. [(Max HR- Resting HR) x 55-80%] + Resting HR
vi. Borg Scale & CR scale RPE
 1. Borg range from 6 to 19 (add 0 on to RPE to predict HR)
2. CR Scale range from 0 to 10
3. Goal for geriatric patients:
a. 3 to 6 on CR scale (newest) moderate to strong
b. 13-16 on Borg scale (oldest) somewhat hard to hard
vii. FITT-P for Aerobic Exercise
1. Frequency: most days
a. 3-5 times a week
b. 3 times for weight management/ heart disease
2. Intensity: 70-85% Max HR and/or use of perceived exertion
a. 40-50% for deconditioned patients ICU, bed bound
3. Time or sets/reps: 20 to 60 minutes
4. Type: repetitive movements of large muscle groups
5. Progression: 5-10 % per week, add some interval training to increase intensity,
increase time/distance first and then intensity
viii. Terminate exercise if:
1. Chest pain
2. Labored breathing
3. Systolic >220 mmHg
4. Diastolic >120 mmHg
5. BP falls
6. Patient c/o of dizziness, fainting, confusion
7. Unable to maintain HR in acceptable range
8. Abnormal ECG changes ST segment depression greater than 4 mm
d. Strength Training
i. Weight
1. Start lighter so you can lift 12-20 times for first 2-4 weeks
2. Use load you can lift 8-12 times with proper form with greatest effort on last rep
3. As long as you get failure you get strength benefits
ii. Progression
1. Double progressive program increase reps, then resistance
iii. Technique
1. Movement speed 6 seconds (2 sec lift, 4 sec lower)
2. Breathing inhale during lowering, exhale during lift
iv. FITT-P for Strength Training
1. Frequency: 2-3 nonconsecutive days per week
a. Repair/remodeling take 48 to 72 hours
2. Intensity: 60-80% 1 RM
3. Time or sets/reps: 8-12 reps for 1-3 reps
a. Begin with 1 set and progress to 2-3 sets
4. Type: isometric, isotonic, isokinetic, plyometric, free weight, machine, body
weight, tubing/band
 a. Manual resistance MMT
b. Mechanical resistance (machine, free weights, pulleys, T-band)
c. Body weight
5. Progression: start easy for first several weeks then increase after two
consecutive sessions of 12-15 reps, then increase weight so only can do 8-12
again
e. Flexibility
i. Commonly tight hamstrings, calves, hip flexors and chest
ii. Modes of stretching:
1. Manual Force applied by practitioner
2. Self independent
3. Mechanical device provides/assists with stretching
a. Dynasplint= constant continuous stretch
b. JAS brace= cyclic stretching patient controlled
iii. FITT-P for Flexibility
1. Frequency: 2 days a week minimum
a. Depends on tightness, severity, patient age
2. Intensity: low load (no pain)
3. Time: 30 to 60 sec in healthy person with musculoskeletal tightness
a. One vs multiple cycles
b. Longer time for contractures 20 minutes minimum
4. Type: slow and gradual
a. Ballistic more for young athletes
5. Progression: as tolerated without pain
f. Balance and Agility
i. Types of Balance
1. Static: static sitting or standing in a given sensory environment
a. Sensory environment: eyes open/eyes closed, foam surface, head turns
b. Base of support: wide, narrow, tandem, single leg stance
2. Anticipatory: involves person doing something they have done before
(functional activities)
a. Functional reaching (further, faster)
b. Ball toss/kick (further, faster, random direction)
c. Sit to stand (faster, lower height)
d. Lunges and quick steps
e. Turns (faster)
f. Obstacle course (faster, more challenge)
3. Reactive (hardest to do)
a. Reactive stepping
b. Slip/trip training
c. Tug of war
d. External perturbations
 ii. FITT-P for Balance and Agility
1. Frequency: 2 to 5 days a week
a. Greater than 50 hours for max benefits
2. Intensity: High, weight bearing with occasional loss of balance
3. Time: as tolerated with fatigue, tolerance, and overall goal of therapy
4. Type: anticipatory, reactive, static
5. Progression: as able with in fear and safety tolerance of patient
16. Fire Safety
a. Fire: chemical reaction where material is rapidly oxidized through chemical combustion process
i. Occur between oxygen in air and some sort of fuel
ii. Fire triangle used to understand elements of a fire Fuel, Heat and Oxygen
1. Oxygen fire needs oxygen to stay alight (21%= room oxygen)
a. Generates combustion
2. Fuel material for fire to start that is any kind of combustible material, including
paper, oils, wood, gases, fabrics, liquids, plastics and rubber
a. Characterized by its moisture, size, shape and quantity determines how
easy fuel will burn & temp it burns at
3. Heat must be present for ignition to take place & burn fuel
a. Flammable materials give off vapors that combust w/ heat
b. Responsible for spread & maintenance of fire remove moisture from
nearby fuel and allow it to travel and develop
b. R.A.C.E
i. Do this in event of fire emergency visible flames, visible smoke, smell of smoke or
burning, feeling unusual heat or other indications of fire
1. Rescue
a. Rescue or remove everyone (patients, visitors, staff, volunteers) in danger
immediately
b. Rescuing residents should be every health care workers primary concern
c. Direct people to safe zones, assist caregivers with patient lifting, move
patients from immediate danger
d. Use horizontal exits (away from area of danger) and designed refugee
areas
i. Adjacent smoke compartment on same floor
2. Alert (happen simultaneously with Rescue)
a. Notify co-workers and other personal or “Code Red”
b. Activate nearest fire alarm pull station
c. Call EMS
3. Confine
a. Fire, smoke and toxic combustion products must be confined to area
where it started
b. Close doors and windows to cut off flow of oxygen to fire enables first
responders time to arrive
c. Disconnect oxygen lines
 4. Extinguish/Evacuate
a. Fire extinguisher
b. Evacuate patients to nearest smoke compartment
i. Smoke compartment protected by smoke barrier doors
1. Prevent evacuation of building if possible
2. Contains medical gases and emergency power
c. Partial Evacuation: relocate to other areas of the building
i. Horizontal followed by vertical evacuation (vertical= another
level/floor)
d. Complete Patient Evacuation: complete evacuation from building due to
severity of building is endangered
i. Directions given by senior officer of fire department
e. Patient Removal: immediate danger patients moved first
i. Ambulatory patients accompanied or directed to smoke
compartment
ii. Non ambulatory patients should be moved using wheelchairs ot
stretchers to smoke compartment
f. Do not take patients past room of origin, take an outside route
g. Priority for relocating patients:
i. First patients who require staff directions and/or verbal
prompting only
ii. Second patients that require staff physical assistance
iii. Third patients that require full physical assistance by staff or
restricted to beds/gurneys
h. Never:
i. Fight fire larger than trash can
ii. Fight fire that has spread beyond its starting point
iii. Spend more than 1 min fighting fire
iv. Let fire block escape route
v. Turn your back on fire
ii. Keep fire doors closed unless going through them to contain spread of smoke/fire
c. P-A-S-S
i. Fire extinguisher can put out SMALL fires, reduce or knock fire down
ii. Acronym to operate fire extinguisher
1. Pull the pull pin at top
2. Aim at the flames where fuel is being combusted
3. Squeeze the handle while aiming at fire
4. Sweep from side to side at BASE until fire is extinguished
d. Things to remember:
i. Know location of at least 2 fire alarms
ii. Know location of fire extinguishers/ how to use them
iii. Know how to shut off oxygen and other compresses gasses quick
iv. Know where exits are and at least 2 evacuation routes
v. Know location of smoke compartments
vi. Never block exits, walkways, fire doors
 vii. Know what emergency numbers to call (police, public safety, security, switchboard)
viii. Know specific facility emergency plans and practice them

17. TBI Pathophysiology

a. Concussion: symptoms that are a rapid onset with spontaneous recovery in 7 to 10 days
i. Most common c/o after Headache
b. TBI: impairs brain functioning from an external force
i. Moderate TBI often results in structural damage (hemorrhage or contusion) most are
mild (which are harder to detect)
1. Epidural hematoma common with skull fracture
ii. Closed head injury NO skull fracture
iii. Altered level of consciousness can occur with focal head injuries lowest level is Coma
1. Coma: not obeying commands, not uttering words, not opening the eyes, or a
state of unresponsiveness
a. Indicates brain failure rarely lasts longer than 4 weeks
iv. Common c/o after brain injury head and neck pain
v. Often flaccid at onset and then develop to be spastic/ increased tone/ rigidity
vi. Over 10 mm mass shift is very detrimental to patient and less than 10 mm shift has
more of a better outcome secondary injury due to pressure

18. Glasgow Coma Scale (GCS)

a. Determine level of consciousness and gives baseline prognosis for ICU patient within 24 hours
of admission determine the type and amount of cueing appropriate for patient
i. “T” after score= patient is intubated
b. Scoring range from 3 to 15
 i. 90% less than or equal to 8 are in coma
ii. Greater than or equal to 9 are NOT in coma
iii. 8 is the critical score
iv. Less than or equal to 8 at 6 hours: 50% will die severe
v. 9-11 = moderate severity
vi. Greater than or = to 12 indicates minor injury
Glasgow Coma Scale (pg. 164 Paz)

GCS is a measure of LOC & responsiveness. To determine the overall score (E + M +

V). The GCS should be used to confirm the type and amount of cueing needed to
communicate with the pt, determine what time of day a patient is most capable of
participating in PT and delineating PT therapy goals.

Response Score

Eye Opening (E)

Spontaneous: eyes open w/o stimulation 4

To Speech: eyes open to voice 3

To pain: eyes open to noxious stimulus 2

Nil: eyes do not open despite variety of stimuli 1

Motor Response (M)

Obeys: follows commands 6

Localizes: purposeful attempt to move limb to stimulus 5

Withdraws: flexor withdrawal w/o localizing 4

Abnormal flexion: decorticate posturing to stimulus 3

Extensor response: decerebrate posturing to stimulus 2

Nil: no motor movement 1

Verbal Response (V)

Oriented: normal conversation 5

Confused conversation: vocalizes in sentences, incorrect

context 4

Inappropriate words: vocalizes with comprehensible words 3

Incomprehensible words: vocalizes with sound 2

No response: no vocalization 1

19. Rancho Scale

a. Assess cognitive recovery of brain injury patients
i. Often used in conjunction with GCS scale
ii. More meaningful info as patient emerges from the coma
iii. Lower score increased mortality
b. Scoring: Level 1 to 8 (8= best)
i. 2 levels were added last year as expansion of level 8
ii. Rancho Level 4 is a great candidate for inpatient rehab

Ranchos Los Amigos

I Unresponsive

II Generalized Response

III Localized Response

IV Confused; agitated

V Confused; non-agitated, inappropriate

VI Confused; appropriate

VII Automatic, appropriate

VIII Purposeful, appropriate: SBA

IX Purposeful, appropriate SBA on request

X Purposeful, appropriate: Mod I

20. Glasgow Outcome Scale (GOS) & GOS-E
a. Used to assess outcome after TBI predicts recovery of brain injury 1 year after accident
i. Utilized at 3, 6- and 12-months post injury
b. GOS-E is more sensitive & has less risk of intrarater reliability
c. GOS: 5 categories
i. Death (1)
ii. Vegetative State minimal responsiveness (2)
iii. Severe Disability Conscious but disabled; dependent on others for daily support (3)
iv. Moderate Disability disabled but independent: can work in sheltered setting (4)
v. Good Recovery resumption of normal life despite minor deficits (5)
d. GOS-E: 8 categories
i. Death
ii. Vegetative state
iii. Lower severe disability
iv. Upper severe disability
v. Lower moderate disability
vi. Upper moderate disability
vii. Lower good recovery
viii. Upper good recovery
21. Critical Care Pain Observational Tool (CPOT)
a. Assesses pain in ICU patients who are incapable of reporting their pain
i. Assess intubated or sedated patients (good reliability and validity)
b. Scoring out of 10points
i. Score of 2 or less= minimal to no pain
1. 0= awake and adequate patient
ii. Score of 2 or more= unacceptable pain level
c. Categories:
i. Facial Expression
ii. Body Movements
iii. Muscle tension
iv. Compliance with mechanical ventilator
v. Vocalization

22.ABCDEF Bundle
a. Well-rounded patient care and optimize recovery time multidisciplinary clinician
i. Reduce delirium, improve pain management and reduce long-term consequences of the
ICU
ii. Early mobility in ICU is essential decrease LOS, delirium and days on vent
iii. Helps prevent PICS
b. Acronym
i. A: Assess, prevent and manage pain
1. Use CPOT scale
ii. B: Both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT)
iii. C: Choice of analgesia and sedation
1. Defining depth of sedation and choosing right meds
iv. D: Delirium: assess, prevent and manage
v. E: Early mobility and exercise
 1. Should achieve max mobility and exercise  PT job
vi. F: Family engagement and empowerment
1. Involve family in patient care and recovery PT Job
23.CVA
a. Ischemic stroke occur when artery to the brain is blocked
i. Most commonly caused by narrowing of arteries (atherosclerosis) & then causes clots 
Thrombus or embolus clots
1. Thrombus
a. Large vessel MCA or carotid
b. Small vessel aka lacunar stroke
2. Embolus clot often starts in heart and gets dislodged (often dislodged from A-
fib)
ii. Infarct obstruction of blood supply to tissue/organ caused by thrombus/embolus
iii. Most strokes are ischemic strokes
1. Treatment: Allow hypertension in brain so it can deliver O2 to brain tissue to
prevent more tissue death  limit secondary effects
2. tPA  must be given within 4.5 hours of symptom onset
a. Risk of hemorrhaging no PT immediately after
b. Watch BP control for 24 hours closely after injection
3. Endovascular thrombectomy lyse/remove extensive thrombus via catheter
a. Complete within 8 hours of symptom onset
4. 20% atherosclerotic, 20% embolism/thrombi, 25% lacunar strokes, 30%
cryptogenic
iv. Modifiable Risk factors
1. Mediterranean diet
a. High consumption of olive oil & low consumption of saturated fats
i. Low amounts of fish, dairy, red meat, alcohol lots of plants!
2. Most modifiable risk factor is Hypertension (160/95)
a. reducing diastolic BP by 5-6 mmHg
v. Constraint Induced therapy avoids allowing patient to compensate by constraining
unaffected limb
1. Neural plasticity
 vi. Symptoms of Middle Cerebral Artery Stroke:
1. Contralateral paresis (hemiparesis) of face, arm and leg (leg least affected)
a. Damage to primary motor cortex and internal capsule
2. Contralateral sensory impairment of the face, arm, and leg (pain, temp, touch,
vibration, position, two-point discrimination, stereognosis)
a. Damage to primary sensory cortex and internal capsule
3. Brocas aphasia (motor speech disorder; expressive-aphasia-telegraphic-halting
speech)
a. Damage to Brocas control area in dominant hemisphere (usually L)
4. Wernicke’s/ receptive aphasia (fluent by often jargon speech, poor
comprehension)
a. Damage to Wernicke’s cortical area in dominant hemisphere (usually L)
5. Perceptual problems such as unilateral neglect, apraxia’s, depth perception
problems, spatial relation difficulties
a. Damage to parietal sensory association cortex
6. Contralateral homonymous hemianopsia (complete neglect of entire side visual
field)
a. Damage to optic radiation in internal capsule
7. Loss of conjugate gaze to opposite side
a. Damage to frontal eye fields or their descending tracts
8. Contralateral ataxia of limbs (sensory ataxia)
a. Damage to parietal lobe
vii. Other issues:
1. Shoulder-hand syndrome results from humeral subluxation
a. Use GivMohr Sling to prevent this
24.Middle Cerebral Artery
a. Largest branch of internal carotid & most common site of emboli
i. Circle of Willis can make up for issues with one sided damage
b. Supplies:
i. Lateral surface of frontal, parietal and temporal lobes [cortical surface]
ii. Internal capsule and basal ganglia (deep branches)
c. Affects/ Controls:
i. communication; language interpretation; and perception and interpretation of space,
sensation, form, and voluntary movement
25.TIA
a. Precursor to a stroke (symptoms last less than 1 hour)
i. 10-15% will have CVA within 90 days; 5% will have CVA within 2 days
b. Caused by a focal disturbance of brain or retinal ischemia
1. Commonly caused by carotid or vertebrobasilar disease
1. Treat: Carotid Endarterectomy
a. Surgery that removes plaque buildup from inside a carotid artery in the
neck to restore normal blood flow to prevent a stroke
26. Hyperlipidemia
 a. Abnormally high cholesterol in blood that can cause build up on the walls of the blood vessels
and form plaque atherosclerosis
i. Usually determined after a heart attack or stroke
1. Can be genetic
ii. Normal Values:
1. Total cholesterol
a. <200  Recommended
b. 200 – 239  Borderline high; moderate risk
c. > 240  Higher risk
2. HDLs (want high HDL)
a. <40  Desirable
b. > 60  Represents a negative risk factor; the higher the number, the
better
3. LDLs (want low LDL)
a. <70  recommended target value if at very high risk for heart disease
b. <100  recommended if heart disease or diabetes is present
c. <130  Recommended if two or more risk factors are present
d. <160  Recommended if one or no risk factors are present
e. 160- 189  High
f. > 189  Very high
4. Triglycerides
a. <150  Recommended
b. < 100  Desirable
c. 150-199  Moderate risk
d. 200-499  High risk
e. > 499  Very high risk
f. > 1,000  At risk for pancreatitis
27.NIH Stroke Scale
a. Measure symptom severity associated with cerebral infarcts after acute stroke
i. Provide quantitative measure
ii. Taken at immediate symptom onset in ER
b. 11 items:
i. Level of consciousness, best gaze, visual fields, facial palsy, limb ataxia, sensory, best
language, dysarthria, extinction, inattention, motor leg, motor arm
c. Scoring
i. 0: No stroke symptoms
ii. 1-4: Minor stroke
iii. 5-15: Moderate Stroke
iv. 16-20: Moderate to severe stroke
v. 21-42: Severe stroke

28. AM-PAC 6 Clicks (Activity Measure for Post-Acute Care)

 a. Assess basic mobility and helps with prediction in discharge planning
i. Completed at every visit with PT/OT
ii. Can help determine G code based off % of impairment
b. Scoring (out of 24)
i. Total score: 17 or less /24  patient is NOT safe to d/c home (d/c to inpatient/SNF)
ii. Assist Levels
1. 1- total dependent/ assist
2. 2- max or mod assist
3. 3- min assist, contact guard assist, supervision)
4. 4- independent
29.ICIQ-SF (International Consultation of Incontinence Questionnaire)
a. Evaluate the frequency, severity and impact on quality of life of urinary incontinence
b. 4 question items out of 6 frequency, amount of leakage, overall impact, self-diagnostic
c. Scoring out of 21
i. Higher the score, the more incontinent
1. Slight = 1-5
2. Moderate = 6-12
3. Severe = 13-18
4. Very Severe = 19-21
30.Pushers Syndrome push toward hemiparetic side with WHOLE body
a. Visual and vestibular perception is OK
b. Opposite posture of normal stroke patients normal stroke patients lean to strong side to
compensate for hemiparetic deficits
c. During gait will show extreme LE extension on hemiparetic side (and abduction)
d. Brain will compensate within 6 months
31.Stroke symptoms
a. BEFAST Acronym
i. B: Balance
ii. E: Eyes
iii. F: Face (droop)
iv. A: Arm (weakness)
v. S: Speech (slurring)
vi. T: Time (to call 911)

32. Spinal Stenosis (narrowing within bones of spine)

a. Can lead to neurogenic claudication (inflammation of nerves)
 b. Can dislodge blood clot to brain and cause stroke
i. Can also occlude vertebral artery and cause atherosclerosis

33. Right Versus Left Sided Stroke S/S

a. Right Typically produce perceptual deficits (unilateral neglect, agnosia, apraxia, spatial
disorganization)
b. Left Typically produce speech and language impairments Aphasia

Left Brain Injury Right Brain Injury (“Rowdy”)

R-sided hemiplegia/paresis L-sided hemiplegia/paresis

R-sided hemisensory loss L-sided hemisensory loss

Speech and language impairments (dominant Visual-perceptual impairments: L-sided unilateral neglect,
hemisphere/r-handed individuals): non-fluent agnosia, visuospatial impairments, disturbances of body
(Broca’s/expressive) aphasia, fluent (Wernicke’s/receptive) image and body scheme
aphasia, global aphasia

Difficulty planning and sequencing movements Difficulty sustaining a movement

Slow, cautious behavioral style Quick, impulsive behavioral style

Disorganized problem-solving Difficulty grasping the overall organization or pattern,

problem-solving and synthesizing information

Often very aware of impairments, anxious about poor Often unaware of impairments, poor judgment, inability to
performance self-correct; increased safety risk

Difficulty with processing delays; highly distractible Rigidity of thought, difficulty with abstract reasoning

Difficulty with expression of positive emotions Difficulty with perception of emotions, expression or
negative emotions

Difficulty processing verbal cues, verbal commands Difficulty processing visual cues

Memory impairments, typically related to language Memory impairments, typically related to spatial-
perceptual information

Apraxia is common; difficulty planning and sequencing Fluctuations ion performance

movements (ideational, ideomotor)

Deficits in either hemisphere:

- Visual field Deficits homonymous hemianopsia

- Emotional Lability, apathy, irritability, low frustration levels, anxiety, depression

- Cognitive confusion, short attention span, loss of memory, executive functions

34.Inpatient Rehab Qualifications
a. Must have 2 out of 3 therapies needed (ST, OT, PT)
b. Must complete 3 hours of therapy 6 days a week
c. 60% must have:
i. Stroke, SCI, amputation, major trauma, burn, hip fracture, 3 arthritic conditions (Joint
replacement of both knee/hip, BMI >50, Age >85 y/o)
 Gen Med 2
1. Myelodysplastic Syndrome
a. Define: dysplasia in greater than or equal to 10% of any myeloid linages or cytogenetics
i. High morbidity and mortality with bone marrow transplant
2. Leukemia
a. Malignant neoplasm of the blood-forming cells that replaces normal bone marrow with a malignant
clone of lymphocytic or myelogenous cells
b. Medical emergency if WBC >100,000 ul which can cause cerebral hemorrhage& avascular necrosis due
to leukostasis
c. 3 common signs: anemia, thrombocytopenia, infection
d. Heterogenous= ALL & AML

e. Acute Myelogenous Leukemia: more than 20% of blasts in the bone marrow & most common in adults
i. Chromosome 5/7 affected in tx related AML
ii. Mostly develop from unknown reasons
iii. Myeloid stem cells differentiate into granulocytes, monocytes, erythrocytes, and platelets
iv. NO CNS involvement
v. Cell divides without regulation and fails to undergo apoptosis
vi. Auer rods are seen on peripheral blood smear
vii. Splenomegaly in 50% patients
viii. Use FAB Classification system based on cell morphology & staining (8 subtypes)
 ix. Acute promyelocytic leukemia (latter translocation better prognosis
x. Lower survival rate than ALL  5 to 10% survival rate after 5 years of treatment
1. Worse prognosis than ALL
xi. Common first treatment= chemotherapy
1. Induction chemo to consolidation chemo (more aggressive)
f. Acute Lymphoblastic Leukemia: more than 25% of blasts in bone marrow & most common in children
i. Leukemic cells with <45 chromosomes poor prognosis
1. Good prognosis if > 50 chromosomes
ii. Inability to differentiate and mature cells
iii. Spread to extramedullary sites testicles and ovaries
iv. HAS CNS involvement
1. Can diagnose ALL from Lumbar puncture collecting CSF
v. Bone & joint pain or hemorrhage into joint first common s/s in children
1. Arthralgia and arthritis in 60% kids
vi. Common presentation hepatosplenomegaly, lymphadenopathy, and enlarged thymus
1. Result in difficulty breathing and UE swelling due to increased pressure on bronchus
vii. Tumor lysis syndrome at diagnosis
viii. NO Auer rods on peripheral blood smear
ix. 98% of children and 85% of adults achieve a complete remission following remission-induced
therapy
1. ½ of adults relapse resulting in 30 to 40% cure rate
3. Serpiginous= indicative of avascular necrosis (osteonecrosis)
4. Band cell count Immature form of neutrophils
a. Normal: 3-5 %
i. Higher than 10% indicates sepsis
5. Cancer
a. Stages
i. 0= precancerous
ii. 1= early stage (small invasive mass or tumor, no spread to lymph nodes/tissues)
iii. 2= localized (cancer affects nearby lymph nodes/tissues, mass grown in size)
iv. 3= regional spread (cancer spread to distant lymph nodes away from mass, mass grown in size)
v. 4= distant spread (cancer spread to tissues/organs beyond origin)
b. Grading Tumor; Nodes; Metasets
i. T: 0-4 ; N: 0-4 ; M: 0-1
c. Signs & symptoms due to tumor growth/ invasion of tissue & biopsy is best diagnostic tool
i. Persistent cough/ hoarseness without a known cause
ii. Skin changes
 1. Hyperpigmentation (darker-looking skin)
2. Jaundice (yellow skin and eyes)
3. Erythema (reddened skin)
4. Pruritus (itching)
5. Excessive hair growth
d. Treatment:
i. Delay/modify rehab until chemo SE are reduced/alleviated
ii. Patients are at increased risk for fracture
iii. Monitor vitals and lab values before, during and after exercise
1. Hemoglobin/hematocrit (RBC), white blood cell count, platelet count, and INR
iv. Neutropenic precautions < 1,000 mm3 neutrophils
1. No live plants in patients room
2. More hand washing and increase time of washing hands
3. Reverse protective isolation do not want to bring infection into patients room
v. Do no use heat
vi. Time frame for goals will be longer
vii. Need to prevent pulmonary complications deep breathing exercises
viii. Radiation: eradicate tumor cells
1. Brachytherapy/ Internal (plant seeds) or external (most common due to localization)
2. Use PET scan (Positron Emission Tomography)
3. Radiation induced malignancies leukemias, breast cancer, sarcoma
4. Site specific toxicities
5. Decreased skin distensibility decreased ROM
ix. Chemotherapy (antineoplastic therapy): inhibits various signaling pathways systemically
1. Can cure or reduce tumor size pre & post op
2. Affects patients appetite/ ability to absorb nutrients inhibit strength/conditioning
3. Be on lookout for neutropenia/ neutropenic precautions infection/sepsis
x. Bone Marrow Transplant
1. Complete chemo before procedure to wipe out cells
2. Only completed if conventional treatment failed
3. Complication graft versus host disease (reject transplant)
4. Gentle exercise program for 5-week hospital stay
5. Caution when temperature is > 99.5
 6. Lab Values
a. Liver blood tests/panel
i. Decreased liver function increased risk for infection due to liver regulating coagulation &
producing albumin
1. People who exercise regularly/ have muscular trauma can have abnormal values
2. Indicates inflammation of liver
Normal Values Abnormal Value Indications

Gamma glutamyl transferase (GGT) 5 to 38 U/L Increased levels indicate injury to liver

AST (Transamine) 8 to 20 U/L Increased in liver damage; released by

liver when damage occurs to liver
cells; increased with primary muscle
disease (myopathy)
ALT (Transamine) 5 to 35 U/L Increased in liver damage; released by
liver when damage occurs to liver
cells; increased with primary muscle
disease (myopathy)
LDH 45 to 90 U/L Increased in liver damage; released by
liver when damage occurs to liver
cells; increased with primary muscle
disease (myopathy); Increased with
metastatic disease osteosarcoma
Alkaline Phosphatase (ALP) 30 to 85 U/L Increased with liver tumor; biliary
obstruction; rheumatoid arthritis;
hyperparathyroidism; Paget disease of
none

b. Thyroid tests (necessary for growth & development)

i. Elevated TSH with decreased T4 indicates thyroid disease
1. Depressed TSH indicated pituitary disease
 ii. TSH Normal: 0.35 to 5.5 uIu/L
iii. T4 (Thyroxine) Normal: 4.5 to 11.5 ug/dL
c. Autoimmune diseases
i. ESR (test inflammatory disorders by RBC sinking)
1. More severe inflammation faster sedimentation rate & higher ESR
2. Normal adult men: 0-17 mm/hr
3. Normal adult women: 1-25 mm/hr
4. Pregnant women: 44-114 mm/hr
ii. C reactive Protein (CRP) indicator of systemic inflammation
1. Elevated (above 3 mg/L) indicates risk for MI, and stroke, HTN, DM and restenosis
after angioplasty
2. Values
a. Low risk: <1.0 mg/L
b. Average Risk: 1.3 mg/L
c. High Risk: >3 mg/L
iii. Creating Phosphokinase (CPK) released after cell injury/death
1. Normal CPK: 55 to 71 IU
2. CK-MB most common (cardiac muscle injury or death, diagnose MI and size)
a. Normal CK-MB: 0-3%
3. High levels= stress or injury to heart/ other muscles
iv. Amylase (involves pancreas)
1. Normal: 30 to 220 U/L
7. Autoimmune Diseases

Hashimotos Graves’ Disease Systemic lupus MS RA Sjogren’s

Thyroiditis erythematosus Syndrome
Chronic Most common Affect skin and Sclerotic plaques Autoimmune Chronic arthritis
inflammation of form of multiple organ in CNS with disease that affecting several
thyroid due to hyperthyroidism systems (heart, multiple lesions affects synovial organs (moisture
destruction of with over kidneys, CNS) in brain/spinal tissue and joints producing glands
gland by function of entire cord such as mouth
lymphocyte thyroid gland (demyelination) and eyes)
infiltration
↓ T3 and T4 & ↑ ↑ T4 & ↓ TSH Symmetrical Fatigue, optic Fatigue, weight Dry eyes &
TSH arthralgias and neuritis, sensory loss, weakness, mouth, dry
polyarthritis, changes, general diffuse throat, dryness in
rashes of the skin spasticity, muscle musculoskeletal organs,
weakness, ataxia, pain inflammation of
bowel/bladder salivary gland
symptoms
Goiter/ Symmetrical Diagnosis: CBC, Diagnosis: MRI to Diagnosis: Diagnosis: Slit
enlargement of goiter, Heat ESR, Urinalysis, see lesions on Rheumatoid lamp test,
gland, Fatigue, intolerance, Skin biopsy spinal cord/brain, factor present in Schirmer test,
dry skin, cold bulging eyes, CSF analysis, blood (> 20), ↑ blood tests, lip
intolerance weight loss blood test, ESR, ↑CRP, ↑ biopsy
McDonald ACPA, EULAR
Criteria for MS Classification
diagnosis (> 2 Criteria of RA (>
attacks) 6/10)
Affects women Affects women Affects women Affects women Affects women
more (10:1) more (4:1) more (2.5 :1) more (3:1) more (9:1)
Leads to Thyroid ** Need to rule Slow/ insidious
hypothyroidism Stimulating out other progression
Immunoglobin diagnoses**
(TSI) is +

8. Hypertension
a. Systolic >140 and Diastolic >90 on 2 separate occasions 2 weeks apart
i. Arterioles regulate BP
1. Determined by blood flow (cardiac output) & peripheral vascular resistance
b. Increased risk with age (> 55 years) due to loss of elasticity of arteries & African American ethnicity
i. Most important risk factor in CVD
c. Primary HTN: Idiopathic cause (90-95%)
d. Secondary HTN: Known cause (5-10%)  CKD is most common cause
e. Malignant HTN: Diastolic >125 mmHg
f. Isolated Systolic HTN: Increase systolic BP independent of Diastolic
i. Systolic HTN= Most common in older adults
1. Goal for older adults (65 and older) 150/90
g. Orthostatic HTN: Decrease systolic >20 mmHg and diastolic >10 mmHg
i. Increase concomitant pulse of < 15 bpm
ii. Use tilt table for potential treatment
h. Frequently asymptomatic (if symptomatic: HA, vertigo, flushed face, nocturnal urinary frequency)
i. Aging systolic BP increases through life & diastolic increases until 50-60 yrs old
i. Due to less compliant arteries
j. Treatment:
i. DASH diet Low sodium diet; High intake of fruits, vegetables, and low-fat dairy foods; Reduce
BP in healthy and high BP people
ii. Diuretics= first choice
k. Contraindications to Exercise:
i. Resting: SBP > 200 mmHg ; DBP >110 mmHg
ii. Low risk adults: SBP > 250 mmHg ; DBP >115 mmHg
iii. Cardiac patients: ↓ SBP >10 mmHg ; DBP >110 mmHg

Systolic BP (mmHg) Diastolic BP (mmHg)

Normal Adult <120 <80
Normal Infant 80 40
Normal Teen 115 70
Normal Children 100 60
Prehypertension 120 to 139 80 to 89
Stage 1 hypertension 140 to 159 90 to 99
Stage 2 hypertension >160 >100
Infant hypertension 90 60
Children hypertension 120 180
Teenager hypertension 130 180

9. Coronary Artery Disease (disease due to insufficient blood supply)

a. Atherosclerosis (thickening of arterial wall) is most common form of arteriosclerosis (thickening/loss
elasticity artery walls)
i. Nonatherosclerotic causes are uncommon Kawasaki disease, coronary embolism, metabolic
syndrome, insulin resistance, trauma, arteritis, radiotherapy, connective tissue disorder
b. Cigarette smoking  leading preventable cause  # 1 reason for morbidity/mortality
 i. Quitting smoking will reduce their risk by ½ after 1 year and equalize their risk of CAD to that of
a nonsmoker in 15 years
c. Risk factors

i. >200 cholesterol and 2x riskier if >240 cholesterol and ratio of total cholesterol to HDL
ii. is more than 4.5
iii. Blacks= 3x more likely
iv. Pulse pressure <60 mm Hg for men

d. Inflammation plays major role in CAD & presence of CRP in blood

e. Atherosclerosis (damage occurs in arterial wall not the “hole” of vessel)
i. Begin with injury to endothelial lining of artery due to HTN, harmful substances, wear/tear
ii. Penetration of lipoproteins that produce fatty streaks
iii. Coronary artery lesion forms and grows outward maintaining the opening of the lumen (positive
remodeling)
1. Blood clot can form
iv. Plaque (atheroma) begins to build up pressing inward to lumen which obstructs the blood flow
causing possible rupture and MI/stroke
f. Symptoms may not be present until lumen of coronary artery narrows by 75%
g. Largely preventable disease (control LDLs)
h. Diagnosed by coronary angiography (angiogram or arteriogram; inject dye into arteries)
i. Treatment  PTCA, CABG, and coronary stents
10. Hyperlipidemia
a. Abnormally high cholesterol in blood that can cause build up on the walls of the blood vessels and form
plaque atherosclerosis
i. Usually determined after a heart attack or stroke
1. Can be genetic
ii. Normal Values:
 1. Total cholesterol
a. <200  Recommended
b. 200 – 239  Borderline high; moderate risk
c.> 240  Higher risk
2. HDLs (want high HDL)
a. <40  Desirable
b. > 60  Represents a negative risk factor; the higher the number, the better
3. LDLs (want low LDL)
a. <70  recommended target value if at very high risk for heart disease
b. <100  recommended if heart disease or diabetes is present
c. <130  Recommended if two or more risk factors are present
d. <160  Recommended if one or no risk factors are present
e. 160- 189  High
f. > 189  Very high
4. Triglycerides
a. <150  Recommended
b. < 100  Desirable
c. 150-199  Moderate risk
d. 200-499  High risk
e. > 499  Very high risk
f. > 1,000  At risk for pancreatitis
11. Myocardial Infarction (development of ischemia with resultant necrosis of myocardial tissue)
a. Leading cause of death in adult American population
b. Left ventricle is most common site of infarction because it has greatest workload LAD thrombosis
c. Prognosis determined by size, location, damage, early complications and long-term prognostic
outcomes
d. Same risk factors as CAD (see above)  especially angina pectoris
e. 80 to 90% caused by coronary thrombus from preexisting atherosclerotic stenosis
i. Plaque is most likely to rupture because it is vulnerable to mechanical forces ruptures due to
occlusion by a clot
ii. Soft, smaller, and usually undetected plaques rupture and cause sudden death (large detectable
plaques= most stable)
1. Not all rupturing of plaque results in an MI
f. Smokers have 2x as many MI as nonsmokers & sudden cardiac death occurs 2-4 x more frequently
g. Occur more frequently in the early morning hours (due to increase catecholamines) & increased
incidence between Thanksgiving and New Year’s Day for everyone
h. Upper respiratory tract illnesses, periodontal disease and acute respiratory infections increase MI risk
i. Flu vaccine decreases risk for MI
i. Ratio of waist to hip measurement BEST indication of heart attack risk
j. Myocardial ischemia/reperfusion involves 3 major components: molecular oxygen, cellular blood
elements (especially neutrophils) and activated complement system
Zone of Infarction - Necrotic tissue of myocardium that has been completely
deprived of oxygen
- Leukocytes remove dead cells and collagen forms scar (6-8
weeks)
- Remaining heart cells enlarge to compensate
Zone of hypoxic - Area of less damaged tissue (returns within 2 to 3 weeks
injury normally)
 Zone of ischemia - Adjacent to zone of hypoxic injury
- Ischemia causes changes to ECG wave
- ST segment and T waves gradually return
- Abnormal Q waves persist
k. Myocardium cannot contract/pump with loss of nutrients and O2 lead to heart failure
l. Most common symptom sudden sensation of pressure (center of chest pain with occasional radiation
of pain to arms, throat, neck, back and jaw) that is constant and lasts 30 mins up to hours without relief
by medications (nitro) or rest
i. Can occur with SOB, pallor, profuse perspiration, cool/clammy skin, dizziness, nausea
ii. Similar to angina pectoris but MORE severe
iii. More common on Left side
m. Symptoms do not always follow classic pattern especially in women:
i. Most common symptoms in women SOB and chronic unexplained fatigue
1. Women more likely to have unrelated/unusual chest pain: aching, heaviness or
weakness in one or both arms, heat and flushing sensation, racing heart
2. Atypical symptoms in women: continuous pain in the midthoracic spine or interscapular
area, neck and shoulder pain, R biceps pain, stomach or abdominal pain, nausea and
vomiting without chest pain, unexplained intense anxiety, dizziness, breathlessness,
heart burn that is relieved by antacids
n. Silent attacks painless infarction without acute symptoms (nonwhites, over 75 yrs, smokers, Diabetics)
i. Nausea and vomiting may occur first from reflex stimulation (fever within first 24 hours too)
o. Most common complication of acute MI arrythmias (caused by ischemia, hypoxia, lactic acidosis,
electrolyte imbalance, drug toxicity)
p. Many people with acute MI have atypical symptoms
i. ½ of all people with typical symptoms do NOT have acute MI
q. Diagnosis:
i. Biomechanical markershormones released by organs under dress and can indicate
inflammation of arteries, lack of O2, damage to collagen matrix and toxic free radical damage
1. Troponin levels GOLD standard for diagnosing/ predicting an MI (levels increase with
more heart damage & as day goes on)
a. Normal Troponin Level: < 3.1 ug/ml
ii. Scintigraph studies show areas of necrotic myocardium and diminished perfusion when ECG
cannot
iii. ECG asses ability of heart walls to contract and relax
1. Transesophageal echocardiography (TEE)
iv. MRI
v. EchoGen contrast agent that infiltrates ONLY healthy heart muscle (not damaged)
r. Treatment: reestablish flow of blood in blocked coronary arteries
i. Meds for pain, limit infarct size, reduce vasoconstriction, prevent thrombus formation
1. tPA (within 70 mins) and Heparin therapy
ii. Reperfusion therapy need to admin within 1 hour but not used often due to delayed ER visits
iii. Angioplasty, atherectomy, angiogenesis, tissue engineering, stem cell transplant, cardiac
rehabilitation, low fat diet with intensive exercise training
12. Congestive Heart Failure (inadequate valve or myocardium performance in which heart cannot pump
sufficient blood to supply body’s need)
a. 4 types:
 i. Systolic failure contractile failure of myocardium
ii. Failure with preserved ejection fraction (diastolic failure) increased filling pressures are
required to maintain adequate CO despite normal contractile function
iii. Left sided failure left ventricle can no longer maintain CO
1. Aka Congestive Heart Failure
iv. Right sided failure right ventricle fails secondary to left sided heart failure or pulmonary
disease (inadequately pumps blood to lungs)
b. Predictor of survival measure swings in HR in one 24-hour period (40 to 50% die suddenly)
i. Pulse pressure= best measure of BP for predicting mortality
c. Common complication of ischemia (MI) and hypertensive heart disease (HTN= most prevalent cause of
CHF)
i. Common for MI survivors to get CHF due to damaged heart muscle
d. Most common cause of hospitalizations in people over 65 y/o
i. More common in women
e. Neurohormonal compensatory phases when heart fails to propel blood forward (effective short term)
i. First compensatory phase enlargement of pumping chambers to hold greater volumes of
blood (ventricular dilation)
1. Congestion occurs into lungs causing SOB & can lead to fluid accumulation/flooding in
lung tissue spaces and progressive edema
2. R ventricle continues to pump more blood into lungs
ii. Second compensatory phase sympathetic nervous stimulation to increase stimulation of
heart muscle to pump more often
1. Increases HR and muscle mass ventricular hypertrophy & need for more O 2
2. Person gets angina from coronary arteries not meeting O 2 demand
iii. Third compensatory phase renin angiotensin aldosterone system
1. Kidneys retain water and Na+ to increase blood volume  cause tissue edema
a. Diaphoresis, cool skin, tachycardia, cardiac arrythmias, reduced urine excretion
f. Common symptom wet cough with nothing coming up (due to pulmonary edema)
g. Medical Managementsee chart above
i. Get good measurement of I & O’s from catheter
h. PT Treatment:
i. Resistive training in LE
ii. Light weights for UE  more taxing for CV patients
iii. Endurance training
iv. Airway clearance
v. Breathing techniques diaphragmatic breathing, pursed lips breathing

13. Left versus Right Heart Failure

a. Left sided heart failure cause pulmonary edema OR disturbance in respiratory control mechanisms
i. Occurs due to pulmonary congestion
ii. Can cause R ventricular failure can then cause dependent edema due to congestion
1. Biventricular heart failure (NOT the same thing as cor pulmonale)

b. Right sided heart failure causes peripheral edema AND venous congestion of organs (mostly LE)
i. Early sign dependent edema in feet/ankles
ii. Jugular venous distension result of fluid overload into jugular veins
1. See pulsations in neck at 45 degree angle
2. Use R internal jugular vein b/c left may be falsely elevated

Clinical Manifestations of Heart Failure

Left Ventricular Failure (CHF) Right Ventricular Failure

 Progressive dyspnea (exertional
Dependent edema (ankle or pretibial 1st)
first)

Paroxysmal nocturnal dyspnea

Jugular Venous Distension (JVD)
(PND) suffocation @ night

Orthopnea Abdominal pain and distention

Productive Spasmodic Cough Weight gain

Pulmonary Edema RUQ Pain (liver congestion)

Extreme Breathlessness Cardiac cirrhosis

Anxiety Ascites

Frothy pink sputum Jaundice

Nasal flaring Anorexia, nausea

Accessory muscle use Cyanosis (nail beds)

Rales/ Crackles Psychological disturbances

Tachypnea  

Diaphoresis  

Cerebral Hypoxia  

Irritability  

Restlessness  

Confusion  

Impaired memory  

Sleep Disturbances  

Fatigue, exercise intolerance  

Muscle weakness  

Renal Changes (reduced formation

of urine & increased peripheral  
vascular resistance)

14. Cor Pulmonale/ Pulmonary Heart Disease (enlargement of R ventricle secondary to pulmonary HTN
often caused by hypoxia that occurs in diseases of the thorax, lungs & pulmonary circulation)
a. Primary causes pulmonary vascular disease & respiratory disease (COPD)
i. Can be caused by restrictive (lower life expectancy) OR obstructive lung disease
b. Excludes R sided heart dysfunction secondary to L sided heart failure, vascular dysfunction &
congenital heart disease
c. Occurs late during course of COPD/irreversible diseases (poor prognosis: 2-5 yrs)
i. Occurs when pulmonary embolus blocks 60 to 75% of pulmonary circulation
 1. Can also occur with mechanical ventilation (PEEP)
d. Develops due to sustained elevation in pulmonary arterial HTN due to vasoconstriction, abnormal
vascular structural remodeling or vessel obliteration
i. Causes R ventricular hypertrophy long term
e. Common symptoms chronic productive cough, exertional dyspnea, wheezing respirations, easy
fatiguability, weakness
f. Signs of cor pulmonale exercise induced peripheral cyanosis, clubbing, distended neck veins, bilateral
dependent edema
g. Treatment goal is to reduce workload of R ventricle to lower pulmonary artery pressure
i. O2 admin, salt/fluid restriction, diuretics, treat underlying pulmonary disease while relieving
hypoxemia and acidosis, surgical removal of emboli if big enough, heart lung transplant in late
stages

15. Digoxin can alter EKG segment

a. Lower ST segment ; Flatten/invert T wave; Shortening of QT segment

16. Heart sounds

Jugular Venous - Back up of fluid into venous system from R sided heart failure
Distension (JVD) - Observe pulsations at internal jugular neck region at 45° (R side) higher than 3-5 cm
above sternum or absent pulsations indicates JVD (normal= 3 to 5 cm)
Bruits - Accelerated blood flow velocity and flow disturbance due to obstruction (stenosis)
- Whooshing sound over carotid artery
Murmur - Regurgitation of blood flow through valves (abnormal blood flow)
- Heard over specific valve  whooshing/swishing sounds during heartbeat
- Caused by aortic stenosis and mitral regurgitation
Pleural Friction Rub - Indicate inflammation of pericardium (crack/leather snapping sound each heartbeat)
- Heard over 3/4th intercostal & anterior axillary line
- 1 systolic, 2 diastolic sounds (extra sound)
S3 Gallop - Low frequency, brief vibration occurring in early diastole at end of rapid ventricular
filling (Ventricular sound)
- 30° left lateral position while palpating/listening to the apical impulse
S4 Gallop - Occur before S1 and ALWAYS indicate heart disease (L ventricular failure)

17. EKG (electrical impulses of the heart & indicates the hearts function)
a. Conduction pathway
i. P wave atrial depolarization (contraction)
ii. Junctional Node (AV node) delay conduction 1/10 second from atria
iii. PR segment ejection of blood into ventricles & filling (atrial kick)
1. Longest duration
iv. QRS complex ventricular depolarization (contraction) & atrial repolarization (relaxation)
1. Highest amplitude
v. ST segment initiation of ventricular repolarization (flat line)
vi. T wave ventricular repolarization
b. Pathologies
i. Significant Q wave sign of previous or current myocardial infarction
1. Absence of electrical activity & takes hours/days to develop
ii. Inverted T wave suggest myocardial ischemia
c. Infarctions
i. STEMI (ST Elevation MI) TOTAL occlusion of a major artery (coronary artery commonly)
1. Abnormal Q wave (in 24 to 48 hours)
2. ST segment elevation
 ii. Non-STEMI (Non-ST Elevation MI) PARTIAL occlusion of major artery (coronary artery
commonly)
1. Normal Q wave
2. ST depression OR inverted T wave
d. Cardiac Index= Cardiac output/ body surface area (mass)

18. Heart Procedures

Procedure Indications PT Implication
Radiofrequenc - Low-power high frequency alternating - SVT, atrial - Leg used for access must
y Ablation current to destroy cardiac tissue fibrillation, atrial remain straight and
(Catheter - Uses heat for energy flutter, and certain immobile for 3-4 hours
ablation) - Remove/ isolate ectopic foci to reduce types of ventricular after procedure if vein
rhythm disturbance fibrillation was used if artery was
- Use leg for access used: 4-6 hours
Cryoballoon - Catheter inserted into femoral vein in groin - Atrial fibrillation
ablation and threaded to heart
-Balloon inflates and releases liquid nitrogen in
pulmonary veins to immobilize area causing
irregular heartbeat (left atrium)
- Use cold (cryotherapy) to freeze problematic
cells & restrict them from electrically
conducting their signals
Surgical Aortic - Open heart (median sternotomy) procedure - Severe/ chronic - Has sternal precautions
Valve -Remove diseased valve and replace with aortic stenosis - Teach sit to stand
Replacement mechanical (man-made & last longer) or without using arms
(SAVR) biological valve (animal/human tissue & last 10
to 20 years)
Transcatheter - Minimally invasive NON open-heart surgery - Severe/ chronic - No sternal precautions
Aortic Valve procedure aortic stenosis & - PT is essential before
Replacement - Catheter inserted through artery in groin people who cannot surgery
(TAVR) (transfemoral artery) have open heart
- Delivers replacement valve to valve site surgery
through catheter

19. Cardiac Catheterization

a. Invasive procedure that can be used in diagnostic and therapeutic techniques to visualize chambers,
valves, coronary arteries, great vessels, cardiac pressures & volumes to evaluate cardiac function (EF &
CO)
i. Used diagnostically for angiography, PTCA, electrophysiologic studies, cardiac muscle biopsy
ii. Used as intervention to increase blood flow to heart angioplasty (open artery with balloon
and push plaque away) & stenting
b. Classified as R or L side
i. Right sided entry through sheath into vein (subclavian vein)
1. Evaluates R side of heart and can continuously hemodynamically monitor patients
ii. Left sided entry through sheath into artery (femoral artery)
1. Evaluates aorta, coronary arteries and L side heart
a. Can also enter through radial artery has no restrictions here
c. PT Implications
i. Bed rest 4-6 hours for venous access OR 6-8 hours for arterial access
ii. Sheaths removed 4-6 hours after procedure and constant pressure needs to occur over site for
20 mins constantly
 iii. Extremity should be immobile with sandbag over access site to provide constant pressure and
reduce vascular complications (bleeding)
iv. Defer PT during precaution parameters
1. May need to complete bronchopulmonary hygiene with patient if there is a risk
2. May need to educate patient on functional mobility if anxious
v. Normal mobility can progress to patients impairment level after precautionary period

20. Coronary Artery Bypass Graft (CABG)

a. Procedure performed when coronary artery has been completely occluded or it cannot be corrected by
PTCA, coronary atherectomy, or stenting
i. Take portion of vein or artery from leg, chest, or arm and graft onto coronary artery
1. Commonly used saphenous vein, radial artery, brachial artery, left & right internal
mammary artery
ii. Provides alternative route for blood to reach the heart & decrease risk of infarction
iii. Commonly performed through median sternotomy (direct access to all important CV structures)
1. Caudally from inferior suprasternal notch to below xiphoid process and split sternum
longitudinally
iv. Off-pump bypass graft (partial sternotomy) has been increasing use to decrease death in women
& it is less invasive
1. Operate on beating heart and do NOT use bypass machine
v. Bypass machine temporality takes over function of the heart and lungs during surgery,
maintaining the circulation of blood and oxygen content of the body
1. Venous blood is drained, oxygenated and returned to body with pump
2. Patient is weaned off machine after surgery
vi. Patient feelings after CABG:
1. May feel depressed, helpless & fearful for 3 months, but after 6 months tell physician
a. Millions micro emboli released when bypass pump on
2. May also gain 5-10 lbs of fluid weight gain due to swelling
3. May have hot/cold flashes use blankets
4.
b. Dysrhythmias after CABG
i. Atrial fibrillation  most common (30 to 40%)
1. Related to moving the heart during surgery or Valsalva maneuver
ii. Premature ventricular contractions okay if <6 per minute
iii. Ventricular tachycardia rare, may need cardioversion, hold PT one day
c. PT Implications
i. Be aware of post op poor pulmonary function
ii. Place hand on patient chest and ask patient to cough if asynchronous movement of chest
occurs then patient requires sternal precautions b/c it indicates an unstable chest
iii. Takes 4-6 weeks for heart to recover from heart attack
1. Takes 6 weeks for sternum to heal
iv. Should walk and exercise everyday (beginning with ¼ mile) & resume ADLs
1. Exercise 2 times a day & ass 1-2 lbs as tolerated  stationary bike with no resistance
v. 2 flights of stairs/day for first week increase tolerance
vi. Sternal precautions (reduce sternal dehiscence possibility)
1. Implemented for 8 weeks
2. Scar mobilization is permissible after incision is healed
3. People at risk for sternal dehiscence DM, severe osteoporosis, women with larger
breasts, bariatric patients
4. Can resume sexual actives in 4 to 6 weeks
 Do not lift >10 lbs (gallon
of milk= 8 ½ pounds)
No pushing/pulling up in
bed, open windows and
jars
No scapular adduction
No UE resistive exercises
No UE flexion and
abduction past 90
degrees
Minimal use of arms for
supine sit transfers
Cough with splinting (use
heart pillow)
No driving motorized
vehicles (car accidents)
for 1 month
Do not sit in front seat of
a car & only be in car for
short distances
Avoid shoulder horizontal
abduction with extreme
ER
Avoid unilateral
movements and forces
bilateral encouraged
Do not strain during
activity or bowel
movement
Can NEVER shovel snow
again
Do not swim or use hot
tub for 2 months
Avoid hot/cold temps &
getting overly tired (pace
yourself & rest 2x/day)
Cannot return to work for
8 weeks
Cannot mow lawn for 8
weeks

21. Jackson Pratt (JP) Drain suction drain to empty excess fluid (blood) from body after surgery to increase
healing)
a. Lies over superior surface of liver
b. Gradually removed after surgery as drainage decreases but commonly left in up to 1 week after surgery
c. PT implication milk the drain (drag index finger and thumb over it) to prevent clotting in tube
22. Cardiomegaly enlarged heart due to hypertension, CAD, heart valve disease, cardiomyopathy, MI, infections
of the heart
a. Seen in CHF patients
23. Uncoiled Aorta mild enlargement and straightening of the aorta that can indicate atherosclerosis

24. Angina (symptom of ischemia that is a consequence of an imbalance between cardiac workload and oxygen
supply to tissue)
a. Exertional angina (chronic stable angina) occur at predicted levels of physical/emotional stress and
respond promptly to Nitro
i. Pain occurs during exertion due to increased O2 demands on heart
ii. No pain at rest & location, duration, intensity, and frequency of chest pain are consistent over
60 days
b. Dyspnea can cause angina shortness of breath or breathlessness due to impaired L ventricle
c. Males versus Females:
i. Males experience angina as first sign of CAD and it occurs more often than in females
ii. Females ½ of all females experience angina and remain asymptomatic or present with atypical
symptoms in the remaining cases
1. Many describe pain similar to unstable angina do not experience angina until
advanced stages of MI
2. More difficult to recognize MI symptoms
3. More likely to occur during rest, sleep, or periods of mental stress
25. Cardiac Rehab
a. Decrease mortality by 45%
b. Least likely to participate older ladies
c. Involved most after a CABG procedure
d. Medicare Continuous ECG monitoring & physician supervision
i. MI, CABG, PCI, Valve, or transplant within 12 months, stable angina or heart failure
ii. Physician approved & renewed every 30 days
e. Phases:
i. Heart Surgery to Rehab
1. Average hospital stay 2 to 4 days
a. Average OR time 4 hours or less
i.
Go right to ICU after OR
2. Line management after surgery
a. Chest tubes removed first (1 pleural and 2 mediastinal)
i. Assisted during surgery with lung re-expansion and drainage of fluids
away from chest cavity
ii. Pleural tube most painful limit shoulder elevation to 90 degrees
iii.May stay in if drain > 100 cc/ 8 hours or air leak (chair and walking cause
dumping)
b. Swanz Ganz removed second (monitored fluid status, temp, and cardiac output)
c. ART line removed third (continuous monitor of BP and easy ABG blood draw
site)
d. Foley catheter removed last
e. Central IV line remains in
3. After extubated (3 to 4 hours after procedure) get patient up in chair twice and walk
around unit (about 50 feet) once
a. Lines have to be at level of heart when moving patient
4. ICU to Step down unit Activity begins to increase & PT is ordered here
a. Patients are very tired; eat in bedside chair for all meals
b. Have oxygen, IV pole & monitor
c. Day 0: Walk in hallway with nurse for each post op day
d. Respiratory therapy deep breathing and coughing to assist with lung
expansion and prevent pneumonia
i. Incentive spirometry (every 2 hours, 10 deep breaths)
1. Prevents pneumonia and atelectasis
2. Complete 2-5 times a day for one month
ii. Cough technique with heart pillow (every 2 hours)
iii. Chest percussion & drainage
iv. Wean Oxygen according to O2 sat
e. Dietitian
i. Decrease cholesterol, triglycerides, saturated fat intakes &trans fatty
acids
ii. Nutrition classes on TV
iii. Decrease sodium intake 2-4 gms/day
iv. Increase fiber, protein (lean meats) & Vitamin C
5. Insulin IV drip for 24-48 hours, Calcium and Magnesium immediately post op
ii. Phase 1- hospital after intervention, surgery or MI
1. Focus education, physical activity (sitting, standing, walking, some stretching &
breathing) and psychological issues
2. Strictly supervised with PT and Nurses working together
3. Education on transfers, gait training, s/s DVT
4. Monitor vitals closely
5. Clean incision 2x a day with liquid soap and water (no washcloth)
 6. Wear ted hose all day (not at night) for 2 weeks to increase venous return and prevent
blood clots
7. Acute Period:
a. Passive ROM (1.5 METs)
b. Upper extremity ROM (1.7 METs)
c. May raise arm to shoulder above 90 degrees
d. Do not lift objects over head
e. Lower extremity ROM (2 METs)
f. Use protective chair posture (↓ CO by 10%)
g.
Bedside commode (3.6 METs) versus bedpan (4.7 METs)
8. Subacute Period:
a. Activities or exercises of intensity (3-4 METs)
b. Stair climbing (3-4 steps)
c. Nu step machine (2-4 METs)
d. Walking (regular slow walk) = 2-3 METs
e.Continue ROM gradually increasing speed and duration
9. Exercises:
a. Day 1:
i. Ankle pumps & LE exercises to increase circulation
1. Marching
ii. Bilateral movements encouraged post-op Day 1
1. Bilateral arm flexion to at least 120 (functional) with PLB
2. Bilateral shoulder abduction
iii. Arm circles
iv. 5 reps of sitting of arm & leg exercises stressing PLB with chest
expansion (deep breathing)
1. Spirometer need 10 breaths/min to prevent atelectasis &
pneumonia
v. Inspiration through nose with arm flexion and abduction overhead
1. Expiration through mouth as patient lowers arms
b. Day 2:
i. 10 to 15 reps of standing
c. Day 3:
i. 20 reps standing because d/c
10. Physician follow ups Family doctor and cardiologist (7-10 days); surgeon (4 weeks)
iii. Phase 2- outpatient referral after patient has seen MD in the office
1. Continue monitoring ECG and education
2. Identify risk factors & lifestyle changes to ↓ further risk of CAD (see risk factors above)
3. Focus on Aerobic & strengthening exercises and functional goals
iv. Phase 3- Maintenance program
1. Monitor BP periodically, independent exercise, self-pay
26. Cardiac Patient Exercise Guidelines for Discontinuing or Modifying Exercise
i. Symptoms:
1. New onset or easily provoked anginal chest pain
2. Increasing episodes, intensity, or duration of angina (unstable angina)
3. Discomfort in the upper body including chest, arm, neck or jaw; chest pain unrelated to
chest incision
 4. Fainting, light-headedness, dizziness
5. Sudden, severe dyspnea
6. Profuse sweating
7. Severe fatigue or muscle pain
8. Nausea or vomiting
9. Back pain during exercise
10. Bone or join pain or discomfort during or after exercise
11. Severe leg claudication
ii. Clinical Signs:
1. Pallor; peripheral cyanosis; cold, moist skin
2. Staggering gait, ataxia
3. Confusion or blank stare in response to inquires
4. Resting HR > 130 bpm or <40 bpm
5. > 6 arrythmias (irregular heartbeats; palpitations) per hour
6. Frequent premature ventricular contractions
7. Uncontrolled DM (blood glucose > 250 mg/dL)
8. Oxygen saturation < 90% (98% is normal); some variability (individual and geographic)
9. Acute infection or fever > 37.8 degrees Celsius (100 degrees Fahrenheit)
10. Persistent drainage or change in drainage from any incision
11. Increased swelling, tenderness, and redness around any incision site
12. Inability to converse during activity
13. Blood pressure abnormalities
a. Fall in systolic BP with increase in workload; specifically, a decrease of 10 mmHg
or more below any previously recorded BP accompanied by other signs or
symptoms
b. Rise in systolic BP above 250 mmHg or diastolic BP above 115 mmHg
14. Signs of CNS involvement (confusion or delirium, cognitive decline, encephalopathy,
seizure, stroke)
iii. Other:
1. Person indicated need or desire to stop & recent myocardial infarction within 48 hours
27. Cardiac Common Meds
Med Classifications/ Name How they work Examples

ASA (Acetylsalicylic Acid) ↓ swelling, thins blood, ↓ Aspirin

workload of heart, pain reliever

Vitamin with Iron ↑ RBC, may cause constipation

Stool Softener Pain meds & vitamins may cause

constipation, avoids Valsalva
maneuver

Pain medications Can cause respiratory depression, Percocet (oxy+tylenol), Tylenol,

dizziness, constipation Morphine, OxyContin, Marcaine
pump for thoracotomy

Diuretics ↓ swelling and edema, ↓ BP, ↑ Lasix, Hydrochlorothiazide

urination, ↓ potassium

Calcium channel blockers ↓ BP, relax smooth muscle, anti- Norvasc, Cardizem, Verapamil (SR)
anginal
 Beta Blockers ↓ HR, ↓ BP, ↓ myocardial Atenolol, Lopressor/Toprol XL,
oxygen consumption Coreg

ACE inhibitors ↓ BP, ↓ sodium retention, use in Capoten, Vasotec, Altace, Prinivil
CHF (caution with renal pts)

Nitroglycerin (sit down when ↓ pain, chest discomfort, &

taking it & protect from air and heaviness (indicates lack of O2 to
light) heart); good for 3 months

Coumadin (used in chronic A-fib) Blood thinner & prevent clots;

used with mechanical valves

Amiodarone Antiarrhythmic, long ½ life;

caution with Iodine allergy; 1/3
CABG pts go into A-fib

28. Heart Rhythms (each block on graph is 1 second, look at 6 second blocks to compare distances)
a. 30 large boxes= 6 seconds

Normal Sinus Distance between waves is same

Rhythm

** Has pre ventricular

contraction (PVC) at end due
to blockage

Sinus Bradycardia Slow heartrate

Junctional Inverted P wave P wave is

Tachycardia coming from junction NOT sinus

Bigeminy Repeated rhythms heart beats,

one long and one shorter

2nd degree type 2 Occasional non-conducted P

block waves with prolonged PR
intervals.

Sinus tachycardia/ Fast heartrate b/c atria beat too

atrial tachycardia quick
3rd degree block Complete heart blockage
(most dangerous)

Atrial flutter Atria beats too quick

Wenckebach 2nd P to QRS ratio

degree type 1

Atrial fibrillation - No P wave fires too fast

- Atria beat out of coordination

with ventricles

29. Left & Right Ventricular Assist Device (used as a bridge to transplant)
a. People with decreased Cardiac Output and Ejection Fraction pushes blood through heart with
continuous flow and reduced pulsability
b. Valve-less system
c. For Congestive Heart Failure patients
d. Up to 10 L/min output (normal= 4-7 L/min)
e. Assessing
i. No pulses; BP is unreliable; MAP at best use doppler; O 2 sat inaccurate
ii. Look at capillary refill, skin temp, color and moisture, nailbed, lip color, mental status, dizziness,
loss of consciousness
iii. Only accurate thing ECG
f. Considerations ability to tolerate anticoagulation; nonreversible end organ failure; BSA & BMI
g. Restrictions No excessive jumping or contact sports; no exposure to MRI; avoid static discharge
(vacuum, touch TV or computer); no immersion in water; no external chest compressions; no pregnancy

30. Life Vest protection for patient while bridge period to ICD placement
a. Removed when showering; alarms to warn patient of impeding shock; alarms louder for others around
patient for impeding shock
b. May be removed for CPR

31. Heart Transplant same physical restrictions as CABG

a. Vital signs different than CABG Higher resting HR; slower increase in HR with exercise; return to
baseline HR takes longer
i. Exercise tolerance is MORE important than vital sign response
b. Cannot have angina

32. ACSM Risk Stratification for Cardiac Rehabilitation

Low risk No significant left ventricular dystrophy (E.F. > 50%); No resting or exercise-induced myocardial
ischemia manifested as angina &/or ST seg displacement; No resting or exercise-induced complex
arrhythmias; Uncomplicated MI, CABG, PTCA, PCI; Functional capacity > 6 METs on graded exercise test
3 or more weeks after clinical event
Intermediat Mild/mod ↓ left ventricular function (E.F 31% - 49%); Functional capacity < 5METs on graded exercise
e Risk test 3 or more weeks after clinical event; Failure to comply with exercise intensity prescription;
Exercise-induced myocardial ischemia (1-2 mm ST- seg dep) or reversible ischemia defects (ECG or
nuclear radiography)

High Risk Severely depressed left vent function ( E.F. < 30%); Complex ventricular arrhythmias at rest or
(can still do appearing or increasing with exercise; Decrease in systolic BP of > 15 mm HG during exercise or failure
cardiac to rise with increasing exercise workloads; Survivor of sudden cardiac death; MI complicated by CHF,
rehab go cardiogenic shock, and/or complex vent arrhythmias; Severe coronary artery disease and marked
slow) exercise-induced myocardial ischemia (>2mm ST-segment depression)

33. Purewick Catheter noninvasive external catheter for incontinent women that is connected to a low-pressure
suction unit to wick drainage away from body into a canister
a. Facilitates early indwelling catheter removal and decreases risk for UTI from Foley catheter
b. Replaced every 8 to 12 hours & needs to me removed when walking a patient (only for in bed use)

34. Pursed Lip Breathing (PLB) technique when air is inhaled slowly (4 seconds) through nose and exhaled
slowly (6 seconds) through pursed lips
a. Splint the opening of airways by creating a back pressure (resistance) prevent collapse of airways
i. Better gas exchange
b. Active exhalation
c. Beneficial for slowing RR in CHF patients & provide positive end expiratory pressure in COPD patients

35. Pacemaker device implanted to create an action potential to manage certain arrythmias (lasts 5-10 years)
a. Indications:
i. HR too slow (sinus bradycardia)
ii. HR fails to increase appropriately with exercise (chronotropic incompetence)
iii. Electric pathway is blocked resulting in atrioventricular delays or bundle branch blocks
b. Can be used temporarily to control arrythmias after CABG (removed 1-3 days after surgery)
c. PT implication:
i. Patient comes out of procedure with a sling for first week & no shoulder AROM above 90
degrees on ipsilateral side for 4 weeks
ii. Important to understand rate modulation (ability to modulate HR based on activity/demands)
1. Not all pacemakers have this can affect exercise modalities
a. No rate modulator: low-level activity with small increases in metabolic demand
i. Training SBP= (SBP max- SPB rest)(intensity- usually 60% to 80%)
b. Modulator: need to consider type of modulation used (activity, motion, QT
sensors)
i. Know upper limit of rate modulator monitor BP here
36. Ejection Fraction(EF) amount of blood the ventricles eject
a. < 20% and Cardiac index < 2 L/min/m2 = transplantation candidate
b. Completed through echocardiogram
c. Normal: 60 to 75%
i. Decreased EF indicates ventricular failure

37. Holter Monitor24 or 48-hour ECG analysis recorded and analyzed later to detect arrythmias/symptoms during
patients daily activitiy

38. Preeclampsia vs Gestational Hypertension

Preeclampsia (more serious) begin after 20 weeks Gestational HTN begin after 20 weeks

>140 systolic & >90 diastolic on 2 diff occasions 6 BP over 140/90 & can lead to preeclampsia
hours apart

Proteinuria No proteinuria (rules out preeclampsia)

Blood vessels to placenta do not develop/work Significant elevations in total peripheral resistance &
properly (more narrow which limits blood flow) reduction in renal blood flow

HELLP syndrome, changes in vision, decreased urine Edema, small amounts of urine, vision changes, HA
output, swelling, thrombocytopenia, SOB that does not go away, upper R abdomen pain

Treatment: delivery of baby Treatment: delivery of baby

Diagnosed: blood tests, urine analysis, fetal Diagnosed: BP readings, urine analysis, blood clotting
ultrasound, nonstress tests to see amount of amniotic tests
fluid

39. Cardiopulmonary function declines at faster rate than musculoskeletal function for bed rest patients

40. Borg RPE scale (rate perceived exertion during physical training and rehabilitation)
a. Range from 6 to 20
b. Preferred method of prescribing exercise insanity to cardiac patients
i. No greater than 13/20 on scale for cardiac patients
c. Target range for cardiac patients is 11-13 in post-operative phase
d. Modified Borg can be visual faces OR number scale to rate pain
i. Terminate/ modify treatment when patient has SOB (at least 5/10)

41. Dyspnea on Exertion Scale (American Thoracic Society Dyspnea scale)

 42. Pitting Edema Scale (observable swelling)
a. Edema can occur due to R sided H failure, trauma, obstruction, & insufficiency
i. Can see edema ANYWHERE on body (not just distal to knee)

43. Wheelchair ramp 1:12 ramp slope ratio ADA Guidelines (4.8 degrees slope or one foot of wheelchair ramp for
each inch of rise)

44. Common Surgeries

Hysterectomy - Removal of uterus which may or may not include the cervix & - Use inspirometer following surgery
supporting ligaments (ovaries & fallopian tubes not removed) because pain in abdomen makes it
harder for people to breathe
- Indications: cancer of uterus or cervix or ovaries; endometriosis;
chronic pelvic pain; abnormal vaginal bleeding - Estrogen levels decline much faster

Cholecystectom - Surgical removal of gall bladder - Use inspirometer following surgery

y because pain in abdomen makes it
- Indications: gall stones, gall bladder inflammation/ pancreas harder for people to breathe
inflammation due to gall bladder
- Watch for continued pain

Appendectomy - Surgical removal of vermiform appendix - Use inspirometer following surgery

because pain in abdomen makes it
- Indication: appendicitis harder for people to breathe

- Watch for bleeding, infection & injury

to nearby organs

45. Respiratory Tracts

a. Upper nose (heats and moisturizes), pharynx, larynx
b. Lower trachea (bifurcates at angle of Louis into R and L mainstem bronchus); cartilage rings; bronchi;
bronchioles; terminal bronchioles; respiratory bronchioles; alveoli
i. R bronchus/ lung shorter and wider; 3 branches
ii. L bronchus/ lung longer and narrower; 2 branches
46. Respiration
a. Lungs:
i. Apex 1 inch above middle 1/3 clavicle
ii. Base concave resting on convexity of diaphragm
b. Muscles Used:
i. Primary diaphragm (C3,4,5)
ii. Accessory
 1. Expiratory internal intercostals & abdominal muscles
2. Inspiratory external intercostals; SCM; scalenes; trapezius; pectoralis muscles
c. Ventilation vs Respiration (you need ventilation for respiration)
i. Ventilation movement of air into and out of lungs
ii. Respiration gas exchange across alveolar capillary membrane
1. Automatic: medullary respiratory system in brainstem (rhythmicity) & pneumotaxic
center in pons (rate/depth)
2. Voluntary: cerebral cortex
3. Chemical control arterial levels of CO2 , H+ & O2
a. Need ↑ CO2 to breathe (very ↑ in COPD)
b. Carotid/aortic bodies detect rise & fall in chemicals (send to respiratory center)
d. Mechanics of Breathing: (pressure gradient drives breathing)
i. Inspiration
1. Alveolar pressure is < atmospheric pressure
2. Diaphragm lowers
3. Rib cage elevates
ii. Expiration (passive)
1. Alveolar pressure > atmospheric pressure (drives air out of lungs)
2. Diaphragm relaxes and elevates
3. Rib cage lowers
iii. Ratio of 1:2 (Inspiration to expiration)= normal
1. COPD patients 1:4 is normal
iv. Gas Exchange
1. O2 carried to tissues
a. Hemoglobin & dissolved in plasma
2. CO2 transported away from tissues
a. Bicarbonate, dissolved in plasma, bound to Hemoglobin chemically
e. Auscultation
i. Patient sit up &breathe slow and deep with open mouth with diaphragm of stethoscope directly
on skin & apply in a systemic fashion (anterior posterior lateral)
1. Start in upper R corner of anterior and posterior chest
2. Common errors interpret chest hair as adventitious lung sounds & auscultating only in
convenient areas
f. Voice Sounds (through stethoscope)
i. Normal air filled lung tissue filters voice sounds resulting in significant reduction in intensity
and clarity
ii. Bronchophony increase in intensity and clarity of vocal response (pneumonia)
iii. Egophony “e-e-e” will be heard as “a-a-a” (pleural effusion/pneumonia)
iv. Whispered Pectoriloquy whispered words “1-2-3” come out clear over consolidated areas

g. Pulmonary Function Tests reveals location and abnormalities in airways, alveoli and pulmonary
vascular bed early when physical examination and x-rays are normal
i. Determines:
1. Obstructive versus restrictive disease
2. Separating airway disease from issues with elasticity
3. Central versus peripheral causes of breathing disorders
ii. Static lung volumes; dynamic breathing tests; physiological tests
iii. Time based Test FeV1/ FVC
1. Forced expiratory volume in one second / forced vital capacity
iv. Physiologic test maximum inspiratory pressure (manometer)

h. Lung Mechanics:
 i. Forced Vital Capacity maximal volume of air that can forcefully be expired after normal
inspiration to total lung capacity
1. Normally equal to vital capacity
2. COPD diagnosed when < 0.70
ii. Forced expiratory volume in 1 second volume of air expired in 1 second
1. Indicates how open respiratory channels are and resistance to exhalation
2. COPD diagnosed when < 0.70

i. Spirometer- Lung Volume & Capacities

i. Spirometer measures movement of air in and out of lungs
1. Only measures changes that occur with breathing NOT actual volume in lungs
2. Measures the following below
Define Normal Values

Tidal Volume (VT) -Normal relaxed breathing Male: 500 ml

-Amount inspired with normal breath Female: 400 to 500 ml

Residual Volume (RV) Volume of air left in lungs after exhalation to Male: 3.1 L
prevent the lungs from collapsing (N/He present)
aka wind knocked out of you Female: 1.9 L

Expiratory Reserve Volume Volume of air maximally exhaled after normal Male: 1.2 L
(ERV) Tidal Volume (beyond normal exhalation)
Female: 0.8 L

Inspiratory Reserve Volume -Volume of air maximally inhaled after normal Male: 1.2 L
(IRV) Tidal Volume (beyond normal inspiration)
Female: 1.0 L
- Maximal volume of air that can be expired
after normal inspiration

Total Lung Capacity (TLC) -Volume of air remaining in lungs after maximal
inspiration

-All lung volumes added together

TLC= VT + RV + ERV +IRV

Vital Capacity (VC) Maximum air one can exhale after maximum
inspiration

VC= VT + IRV + ERV

Inspiratory Capacity (IC) - Largest volume of air that can be inhaled from a
resting expiratory volume

IC= VT + IRV

Functional Residual - Volume of lungs when muscles of inspiration

Capacity (FRC) are relaxed

- Volume before normal tidal

inspiration/expiration
 FRC= ERV + RV

47. Flutter mucus clearancedevice that alters exhaled airflow to increase sputum production, lung function,
prevent lung collapse & pneumonia, and improve oxygenation in CF or bronchiectasis patients (oscillatory
positive expiratory pressure)
a. Exhale 10 breaths into device followed by 2 large exhaled volumes & cough to clear secretion
i. Repeat until secretions are cleared from lungs
b. Angle device 30 degrees
c. 4-6 times a day

48. Breathing sounds (clear to auscultation aka CTA means patient has normal breathing sounds)
a. Normal Sounds

Description Location

Bronchial/ - High pitched sounds with an expiratory component = or - Heard over trachea/ bronchioles
Tracheal slightly longer than inspiratory component

- High pitch; loud intensity

Bronchovesicular - Moderate pitch and intensity with = inspiratory and - Heard around upper part of sternum
expiratory component & between scapulae posteriorly /
bronchioles

Vesicular - Lower pitch and intensity - Heard over lung parenchyma

(alveoli)
- Heard primarily during inspiration & minimally during
expiration

b. Adventitious Sounds (Abnormal)

Define Commonly heard

Diminished - Intensity of sound created by turbulent - Shallow breathing; obstructed airway (mucous);
flow through bronchi are reduced hyperinflated airways (COPD); pleural effusion; obesity

Bronchial - Replace normal vesicular sound when - Atelectasis; Pneumonia/consolidation

Breath Sounds lung tissue decreases in density

- Same sound different location

Wheezes - Vibrations of the wall of narrowed or - Asthma; COPD; bronchospasm; mucosal edema; foreign
compressed airway passes through at a object
high velocity

- High pitched continuous lung sound

- Heard over lung parenchyma (alveoli)

Rhonchi - Low pitched continuous coarse wheeze - Pneumonia & increased secretions
that may be produced by a sputum flap
vibrating in the airstream

Crackles (Rales) - Produced by movement of excessive - Pulmonary edema (CHF); atelectasis; pneumonia;
secretions or fluid in the airways as air fibrosis; COPD
passes through OR when collapsed
airways pop open during inspiration and
expiration

- Discontinuous

Stridor - Loud, high pitched sound
- Heard without stethoscope
- Heard over larynx and trachea
- Airway obstruction (choking); croup; recent extubation
(tube removal);
- Caused by inflammation

- Heard during inspiration and expiration

Pleural Friction - Creaking/grating sound that occurs - Pleurisy

Rub when pleural surfaces are inflamed &
roughened edges rub together during
breathing

49. Lung Diseases

a. Obstructive defect in the flow of air OUT of the lungs
i. COPD (emphysema & chronic bronchitis), asthma, cystic fibrosis
ii. Chronic inflammation of peripheral airways
iii. Excessive mucus production
iv. Bronchospasm
v. Hyperinflation & air trapping
vi. FeV1 is lower because unable to expire (60%)
vii. Increased Residual Volume
viii. Increased Functional Residual Capacity
b. Restrictive defect in the flow of air INTO the lungs with lung expansion decreased
i. ARDS often developed from a trigger (sepsis) with increased fluid in alveoli because
membrane becomes permeable & lungs become stiff
ii. FeV1 is normal or greater than normal (80%)
iii. Decreased Residual Volume
iv. Decreased Functional Residual Capacity
Emphysema (more severe
COPD)
-Enlarged/inflamed air
spaces beyond terminal
bronchiole with loss of
elasticity, airway collapse &
gas trapping
- Loss of capillaries (causes
pulmonary HTN & cor
pulmonale)
3 types:
- Centrilobular: uneven
damage to bronchioles &
upper lung (most
common)
- Panlobular: even damage
to air spaces of acinus/
lower lung (alpha 1 ↓ pts)
- Paraseptal (panacinar):
damages alveoli
Caused by changes in lung
tissue (↓ elastin which
enlarges the acini)
↑ work of breathing due to
hypoxemia; use accessory
muscles for ventilation;
Barrel chest
Exertional dyspnea that
progresses to dyspnea at
rest; thin build; tachypnea;
anxiety (3x); cough is
uncommon
Chronic Bronchitis Asthma Cystic Fibrosis
(COPD)
- Productive cough for 3 - Inflammation & increased Genetic disease with
months per year (winter reactivity of smooth muscle excessive mucus
months usually) for 2 of airways to various stimuli production
years in a row (triggers)
- Most common chronic
disease of childhood (before
age of 5 dx)
- Inherited disorder
- Inflammation & scarring 2 types: Benefit heavily from chest
of bronchial lining that percussion
obstructs airflow to/from - Extrinsic (ONLY
allergies/atopy) IgE
the lungs causes
wheezing antibodies; 70% of children
- Intrinsic (non-allergies/
- Caused by mucus
production and swelling independent of atopy)
secondary to chronic
infections; adult onset
↑ mucus production & Chronic airway inflammation
#/ size of mucus and intermittent/short lived
producing glands attacks of bronchospasm
caused by airway
hyperresponsiveness to
allergens or irritants can
lead to COPD long term
↓ PaO2  polycythemia Dry unproductive cough in
(overproduce RBC), ↑ beginning, chest tightness,
hematocrit, ↑ Bicarb, tachypnea, tachycardia,
cyanosis & peripheral fatigue, anxious,
edema causes cor agitated/restlessness; wet
pulmonale and thicker cough as it
becomes more productive
Persistent cough & ↓ SpO2 can occur fast;
sputum production accessory muscle respiration;
(worse in morning/night) pale and moist skin;
prolonged expiration;
wheezing; Barrel chest;
elevated shoulders
Treat: cessation of
smoking; PLB;
diaphragmatic breathing;
lung transplant;
supplemental O2; infusion
of alpha 1 antitrypsin
Treat: spirometry & Treat: education &
bronchodilators & prevention; B agonist
antibiotics/steroids receptor (intermittent);
metered dose inhaler (mild);
corticosteroids (moderate to
severe)

Risk Factors: SMOKING & Risk Factor: SMOKING Risk Factors: early exposure
heredity (alpha antitrypsin to pets & infections,
1 deficit)

50. Lung Compliance and Elasticity (opposites, so ↑ in one while other ↓)

a. Compliance: how easily the lungs or chest wall stretch/expand
i. Compliance= change in volume/ change in pressure
b. Elasticity: lung or chest wall resistance to stretch; ability of lungs to recoil
i. Elasticity= change in pressure/change in volume
c. Diseases:
i. Emphysema ↓ elasticity and ↑ compliance
ii. Pulmonary fibrosis ↑ elasticity and ↓ compliance
51. COVID-19
a. Bind to ACE 2 enzymes (found in lungs and cells that line a blood vessel)
b. Binding to ACE 2 prevents vasodilation & allows for more Angiotensin II to be produced
i. Increases HTN, vascular permeability, pulmonary edema ARDS
ii. Leads to oxidative stress & hypoxemia
1. Damages endothelial cells inflammation release Von Willebrand factor platelet
aggregation intraarterial thrombosis

52. Physical Examination Inspection of Pulmonary patients

a. Face:
i. Flaring of nostrils common in respiratory distress
 ii. Cyanosis of mouth or mucosa of mouth
b. Neck
i. Tracheal position center of neck below suprasternal notch
1. Shifting occurs toward atelectasis and fibrosis & away from pneumothorax, pleural
effusion, consolidation or lung tumor
ii. Jugular Venous Pressure (JVP) volume of venous pressure in R side of heart
1. Increases with R heart failure (cor pulmonale)
c. Fingers:
i. Clubbing thickening and widening of terminal phalanges of fingers and toes & cause loss of
angle between nail and nail bed
1. Early clubbing= 180 degree and nail base feels spongy to palpation
a. Normal: 160 degrees
2. Schamroth method diamond shape seen between nails is NO clubbing
3. Seen in issues with tissue perfusion CF, COPD, pulmonary fibrosis, congenital heart
disease, lung abscess, lung cancer, & bronchiectasis
4. Caused by pulmonary disease and hypoxia
5. Does not always indicate lung disease heart disease, PVD, liver/GI issues
d. Chest
i. Configuration (Normal)
1. Rib angles < 90 degrees
2. Vertebral attachments at 45 degrees
3. A-P diameter ½ transverse diameter
ii. Barrel Chest A-P diameter increases, ribs lose their 45 degrees & angle of slope (become
horizontal)
1. Present in COPD
e. Breathing (observe when patient is unaware of inspection)
i. RR (normal is 12-20 breaths/min)
ii. Rhythm
iii. No PT if Spo2 < 90 %
iv. Pattern
v. I:E Ratio= 1:2
vi. Symmetry
vii. Sequence of chest wall movement
viii. Accessory muscle use patient uses SCM, traps and scalenes to breathe
ix. Ease of phonation
x. Can be influenced by: pain; emotion; body temp; sleep; body position; activity level; presence of
pulmonary, cardiovascular, metabolic or CNS disease

53. Postural Drainage and Percussion & Airway Clearance

a. Postural Drainage and Percussion patient is placed in specific positions to allow gravity to facilitate
removal of pulmonary secretions out of bronchopulmonary segment and toward large airways and then
percussion is applied
i. Need physicians orders to complete
ii. Technique clapping on chest wall using cupped hands that vibrates lung & shakes secretions
1. Percuss 2 mins/segment & 5-10 mins per lobe
a. After percussing ask patient to take in deep breath in, and when exhaling
push down on patients percussing area and vibrate (shake) them to let
pulmonary secretions free from lung parenchyma
i. Complete 1-2 times of each segment following percussion
1. Then have patient sit up and cough & observe vitals
2. ~ 60 percussions/minute
3. Preform every 4 to 6 hours
iii. Contraindications
1. ICP > 20 mmHg
2. Unstable spinal injury
3. Recent spinal surgery
4. Active hemoptysis (cough up blood)
5. Empyema
6. Bronchopleural fistula (mucus)
7. Pulmonary edema associated with CHF
8. Large pleural effusions
9. Pulmonary embolus (can cause decreased O 2 sat)
10. Rub fractures
11. Aged, confused or anxious patient who cannot tolerate position changes

iv. Positions see below

b. Airway Clearance
i. 4 phases of productive cough
1. Full inspiration
2. Closure of the glottis with increasing intrathoracic pressure
3. Abdominal contraction
4. Rapid expulsion of air
ii. PEP Therapy flow resistor device that patient exhales against 15-20x
1. Create back pressure in airways to open small airways & alveoli
 2. Huff cough (forced exhale with mouth open) at end of each cycle to bring up mucus
3. Can replace chest percussion
iii. Chest Vest forced exhalation technique of 1-2 Huff coughs from mid to low lung volume,
followed by period of relaxed & controlled diaphragmatic breathing
1. Changes position of equal pressure point in airway stabilizes airway to ↑ clearance
iv. Active Cycle of Breathing (ACB) combination of 3 breathing techniques to ↑ aeration to
alveoli & ↑ secretion clearance
1. Breathing Control normal diaphragmatic breathing
2. Thoracic Expansion deep diaphragmatic breathing
3. Huff Cough forceful exhale with mouth open
v. Autogenic Drainage controlled breathing at 3 different lung volumes to ↑ secretion without
wheezing
1. Low lung volume unstick mucus deep in lungs
2. Mid lung volume collect mucus loosened in stage 1
3. High lung volume expel mucus

54. Diaphragmatic Breathing

a. Purpose help breathing capacity & decrease work of breathing by training and strengthening
diaphragm/abdominal muscles
b. Procedure breathe in through nose letting abdomen come out as far as it can & breathe out through
pursed lips while pressing abdomen firmly inward and upward
i. Put patient hand on abdomen to feel it protrude in & out

55. Treatment Pulmonary patients energy conservation; general strength/ endurance of UE and LE; stretching
overworked and tight musculature; postural activities; diaphragmatic breathing; prone positioning to improve O 2

56. Laminectomy spinal surgery to relieve pressure on neural structures by removing one or more lamina or
bony protrusions/spurs
a. Gives access to spinal cord
b. Indication spinal stenosis
c. Log roll precautions after surgery

57. Bariatric Patient ambulate every 2-6 hours post op & every 2-4 hours while awake
a. Terminate exercise if:
i. Increase in systolic BP of 20 mmHg or more
ii. Decrease diastolic BP of 20 mmHg or more
iii. HR increase or decrease by more than 20 bpm
iv. Severe dyspnea or paradoxical breathing
v. Dizziness
vi. Excessive sweating
vii. Patient report of feeling faint
b. May hear abnormal breathing patterns with auscultation d/t increased adipose tissue
c. Active breathing exercises and airway clearance should be performed

58. Oxygen (must be ordered by MD)

a. Supports combustion & not flammable caused by oil, grease & petroleum-based products (Vaseline)
b. Medicare Guidelines to qualify for O2:
i. PaO2 of 55
ii. SpO2 of 88%
c. Indications:
i. Hypoxemia
1. PaO2 <60 mmHg
 2. SpO2 <90 %
ii. Severe trauma
iii. Acute MI (decrease hearts workload)
iv. Short term therapy following anesthesia
d. Precautions/Complications
i. O2 induced hypoventilation PaO2 > 60 mmHg and can cause ventilatory depression in COPD
ii. Absorption atelectasis  prolonged exposure causes washout of nitrogen from lungs & cause
micro-atelectasis (neonates)
iii. Oxygen toxicity high exposure can result in consolidation, thickening of capillary beds,
formation of hyaline membranes and fibrosis, edema & atelectasis (neonates)
iv. Retinopathy of Prematurity (ROP)  vasoconstriction of retina which can lead to retinal
detachment & blindness
e. Storage
i. Central storage large liquid cylinder outside hospital & heated to gaseous state (green port)
ii. Cylinders tanks that store O2 in gaseous state
1. Older naming:
a. D smaller, portable
b.H larger, stationary
2. Newer naming (# represents cubic feet of tank):
a. M4 smaller, portable, lighter weight
b. M9 larger but smaller than D (old name)
3. Color coding:
a. Yellow air
b. Green Oxygen
4. Moving cylinders 50 to 2,200 psi pressure
a. Leave valve caps in place when moving; don’t lift cylinder by cap; use cart
behind you when amb; don’t use Vaseline; do not exceed > 54 degrees C
5. Storing cylinders: cool, dry & well-ventilated area (away from flammable areas with no
smoking signs)
6. Regulators: reduce pressure in medical gas cylinder (50 to 2200 psi)
a. PISS (Pin Index Safety System)
7. Flowmeters (Thorpe Tube): tapered tube with small end at bottom and large end at top
a. High flow rate= higher the pressure is below float & float will be suspended at
higher level
b. Read by middle of steel ball for O2 patient is getting
c. Knob that turns O2 on
8. Cracking the tank ¼ counterclockwise opens & ¼ clockwise closes
9. Cylinder valve open & turn ¼ clockwise
10. Bleeding tank relieves pressure in regulator before removal
f. Liquid Oxygen (gaseous O2 cooled into liquid)
i. Store at 297 degrees Fahrenheit
ii. More compact, less refills & lower pressures (1 cubic foot of liquid= 860 ft of gaseous O2)
1. 20 psi pressure
iii. Primary bulk source of hospital O2
iv. Portable tanks= 5 to 15 pounds (empty to full)
1. Low flow rate= last several hours
v. Remove moisture from liquid O2 tank & store/ carry container upright
g. Oxygen Concentrators (electronic device using specialized filters to eliminate other gases from room
and concentrate O2 to patient)
i. Home use
 ii. Tank is <10 psi pressure
iii. Inaccurate in Liter flows > 2-3 L

59. Oxygen Delivery Devices

a. Low flow O2 enriches gas as part of patients inspiratory flow needs
i. Patient requires administration of a limited amount of 100% O2 mixed with room air
ii. Rely on nasal/oral/pharynx as reservoir
iii. O2 amount delivered somewhat variable by RR And TV
iv. Devices:
1. Nasal cannula (most common) Increase by 4% each L
a. 1L = 24%; 2 L= 28%; etc
2. Simple O2 mask
a. FIO2 35 to 55% with 5 to 8 L/min flow
b. Used following surgical procures
3. Partial Rebreather Mask
a. FiO2 60% with 6-12 L/min flow
b.Enough to keep bag from collapsing during inhalation
4. Nonrebreather Mask
a. FiO2 100% with 6-12 L/min flow
b. Enough to keep bag from collapsing during inhalation
b. High flow provides all of total inspiratory flow required by patient
i. Inspired gas is provided by device (precise amount of O2)
ii. RR and TV will NOT affect delivered FiO2
iii. Devices:
1. Venturi Mask jet mixing & mixes O2 and ambient air
a. Deliver specific FiO2
b. Precise amount of O2 desired
2. High Flow Nasal Cannula uses air/O2 blender & heated humidifier
a. Precise amount of FiO2 delivered
3. Ventilator dial in precise % of O2
60. Pulsatile Lavage
a. Benefits improved safety; improved comfort; portable; decreased change of periwound maceration;
treat tunnels and undermining; treat if WP is not available; treat if WP is contraindicated
i. WP contraindicationsunresponsiveness, cardiopulmonary compromise, venous insufficiency,
fever, incontinence
b. Drawbacks cross contamination of bacteria from patient to patient OR from 1 wound to another
wound due to aerosolization
i. Need to terminally clean after each use
c. Precautions insensate patients; patients taking anticoagulants; wound with tunnels and/or
undermining
d. Cautions to stop treatment patient complains of increased pain; patient unable to tolerate treatment
because of pain
e. Stop/ call Physician patient has arterial bleeder; bleeding has not stopped after 10 min of pressure;
abscess is opened; joint is disarticulated
61. Heart Rate
a. Pulse blood created by contraction of LEFT ventricle
i. Use 3 fingers to take pulse
b. Normal HRs:
Age Avg bpm Normal limits
Newborn 125 70 to 190

12 yr male 85 65-105

12 yr female 90 70-110

18 yr male 70 50-90

18 yr female 75 55-95

Athlete 50-60 50-100

Adult 75 60-80

Aging 75 60-100

c. Pulse Ox use earlobe or forehead for monitoring during exercise

d. Force of Pulse scale
i. 0= absent
ii. 1+= diminished (weak, thready)
iii. 2+= normal
iv. 3+= moderately increased
v. 4+= markedly increased (bounding)
e. HR situations
i. Dehydration ↑ HR due to ↓ plasma volume & ↓ stroke volume to maintain CO
ii. Anxiety ↑ HR
iii. Irregular rhythm monitor on EKG
iv. Beta blockers blunted HR so use RPE scale
1. Rely on hypoglycemic signs sweating, hunger, fatigue, poor concentration
62. Respiratory Rates
a. 10-12 low for older adult

Age Breaths/Min

Birth- 3 mo 35-55

1-3 yr 20-30

3-6 yr 20-26

6-10 yr 15-25

10-16 yr 12-30

18 yr 12-20

63. Blood Pressure (taken on one arm unless pulse is significantly decreased, presence of IV, dialysis shunt,
lymphedema)
a. Stethoscope:
i. Large diaphragm high pitched sounds (lung & normal heart)
 ii. Small bell low pitched sounds (abnormal heart S3 and S4)
b. Sphygmomanometer mercury manometer is most accurate & aneroid manometer is more portable
i. Check calibration!
ii. Thigh cuffs for obese arms
c. Arm cuff size bladder length should be 80% of arm circumference & bladder width should be 40% of
arm circumference
d. Korotkoff sounds
i. First Korotkoff sound systolic BP
ii. 4th phase diastolic BP muffled sound as releasing pressure
1. Record this sound during exercise, amb & activity
iii. 5 phase diastolic BP diastolic BP
th

1. Sound disappears
iv. Normal sequence for 120/80 BP:

120 mmHg 1st Korotkoff sound Silence to snapping (faint tapping)

107 mmHg 2nd Korotkoff sound Snapping to murmur (swishing)
Potential auscultation gap
90 mmHg 3rd Korotkoff sound Murmur to thumping (distinct tapping)
85 mmHg 4th Korotkoff sound Thumping to muffling
th
80 mmHg 5 Korotkoff sound Muffling to silence

e. Brachial Artery BP Instructions:

i. Sitting/lying with arm relaxed at heart level (or will get lower reading)
ii. Place cuff 2.5 cm above antecubital crease
iii. Palpate radial pulse & inflate till no longer palpable and note inflation value
iv. Palpate brachial pulse (medial aspect of antecubital fossa) & place stethoscope there
v. Inflate cuff 20-30 mmHg beyond cuff inflation before
1. Avoids auscultatory gap that occurs during 2nd Korotkoff sound and can be caused by
arterial stiffness
vi. Deflate cuff at ~ 3 mmHg/sec
1. Continue until 4th (rarely) or 5th (typical) Korotkoff diastolic BP is obtained
f. General BP Guidelines:
i. Diastolic BP in young & athletes ↓ slightly with dynamic exercise
1. < 10 mmHg increase/decrease DBP is normal
2. Secondary to total peripheral resistance
ii. Diastolic BP should not vary in older/aging individuals
1. Will vary in CAD, CABG, HTN & compensated CHF
iii. After 15 minutes of exercise cessation BP should return to normal
iv. Alter duration & intensity based on BP

64. Heart Auscultation

a. Place bell (small end) on area of heart
i. Areas to auscultate aortic, pulmonic, tricuspid (LLSB) and mitral areas (apex) using diaphragm
& bell
b. Heart Sounds
i. Normal: S1, S2 (lub dub)
1. Lub is louder
2. S1= ventricular systole (closure of AV valves- tricuspid, mitral)
3. S2= ventricular diastole (closure of semilunar valves- pulmonary, aortic)
ii. Abnormal
1. S3 (apex) occurs immediately after S2 in early ventricular diastole
 a. Ventricle forced to dilate more than normal
b. CHF
c.SLOSH’-ing-in (S1 S2 S3)
2. S4 (apex) immediately after S1 in late ventricular diastole during atrial kick
a. Hypertensive, coronary heart disease, MI, CABG
b. a-STIFF’-wall (S4 S1 S2)
3. Murmur regurgitation/backward flow through the valves
a. Mitral regurgitation, aortic stenosis
4. Pericardial friction rub heart rubs against an inflamed pericardium or lung pleura
a. Pericarditis
65. Ankle Brachial (Pressure) Index
a. Procedure (complete bilaterally)
i. Patient should be supine
ii. Measure brachial systolic BP first
1. Use brachial pulse
2. 8 MHz at 30 to 45 degrees (superficial vessels) and move to 5 MHz (deeper vessels)
iii. Measure ankle systolic pressure second
1. Place cuff above malleoli
2. Use dorsalis pedis OR posterior tibial pulse
iv. When sound returns that’s the BP reading you want
b. Sounds
i. Higher the pitch= greater the blood flow velocity toward or away from the probe
c. ABI= highest pressure in ankle/ highest pressure in arm
i. 0.95- 1.20 normal
ii. < 0.95 arterial disease
iii. < 0.6  contraindication for compression bandages
iv. > 0.5 and < 0.95  intermittent claudication
v. < 0.5  severe arterial disease (gangrene, ischemic ulceration, rest pain)
1. Rest pain is <0.5
2. Gangrene/ischemia is <0.2
d. Problems and errors can arise if:
i. Cuff is repeatedly inflated or inflated long periods
1. Causes ankle pressure to fall
ii. Cuff is not placed at ankle (too far superior)
1. Ankle SBP is not measured & pressure recorded is usually higher than correct #
iii. Pulse is irregular OR cuff is deflated too rapidly
1. SBP may be misread
iv. Vessels are calcified (associated with DM), legs are too large, fatty or edematous, cuff is too
small, or legs are dependent
1. Falsely high readings (> 1.3)
v. Central systolic pressure may influence ‘normal’ range for ABI
1. Falsely negative reading
66. Orthotic Spinal and Trauma Care
a. Insurance/cost
i. Inclusive of the cost of the device is the:
1. Consultation visit
2. Interim fitting visit(s)
3. Final fitting visit
4. Follow up visits(s)
ii. Any adjustments in the following 90 days from delivery on devices we fabricate are NOT charged
b. Cervical Orthoses (CO)
 i. Soft collars
1. Inexpensive
2. Comfortable
3. Promote muscle relaxation
4. Reminder of ROM
5. Restricts less then 10% of flexion and extension
6. Sometimes used post fusion
ii. Semi Rigid Collars: Philadelphia, Aspen, Miami J
1. Reduce cervical motion more than soft collars
2. Post-op use for immobilization, protection, and reminder of biomechanics
3. Used for stable cervical fractures
a. Minimal of non-displaced fractures
c. Cervicothoracic (CTO)
i. Provides more rigid control in all planes
ii. Used for post-operative and fracture situations when greater control is needed
1. Higher level fracture (T5 or higher)
iii. CTO-Halo
1. Indications
a. C1/C2 fractures (hangman’s and odontoid)
b. Post-op fusion, tumor, resection, infection of unstable spine
c.Unstable fractures/noncompliant patient
2. 90-99% restriction of movement in all planes
3. Pins must be re-torqued every 24-48 hours
a. Pins must be cleaned daily
d. Thoracolumbosacral (TLSO)
i. TLSO-Body Jacket
1. Indications
a. Unstable spinal fractures
b. Post-op stability
c. Instability
d. OA
e. Patient anatomy
2. Contraindications
a. Severe respiratory problems
b. Design dependent on age, etc.
3. Total contact
4. Rigid vs. Flexfoam
a. Flexfoam has give in front for breathing
5. Immobilization
a. Flexion/extension
b. Rotation
c. Lateral bending
ii. TLSO-Hyperextension
1. Causes hyperextension of the spine
2. Indications
a. T12-L1 anterior compression fractures
iii. TLSO
1. Indications
 a. Stable compression fractures
b. Postural support
c. Comfort
d. Decrease kyphosis
iv. Lumbosacral (LSO)
1. LSO-Body Jacket
a. Rigid lumbo-sacral orthosis
b. Lower level/lower profile
c. If control for L5-S1, best way to immobilize this area is to add a leg extension
d. Indications
i. Spinal fractures, post-op, instability of lumbar spine
2. BOB-Boston Overlap Brace
a. Rigid support of the lumbosacral region in all 3 planes
b. Indications
i. Instability of the spine of L2 to L5
ii. Spinal. Fractures
iii. Disc herniation
iv. Spondylolisthesis
v. LBP
v. Lumbar
1. Corset
a. Elastic or canvas material
b. Mild control of the lumbar spine in all 3 planes
c. Indications
i. LBP
ii. Transverse/spinous process fracture
iii. DDD
iv.
Post-op support
2. Sleeq AP+LSO
a. Lumbar support
b. Indications
i. LBP
ii. Post-op use
67. Scoliosis Treatment
a. Less than 25-degree curve
i. Observation
b. 25-45-degree curve
i. Orthotic management
ii. May vary with pt age
c. Greater than 50-degree curve, skeletal maturity or failed orthotic management
i. Surgery
68. Early Mobilization ICU Program
a. Team members
i. PT
ii. OT
 iii. RN
iv. Respiratory Therapist
b. Criteria
i. FiO2 less than or equal to 50%
ii. PEEP less than or equal to 5
iii. RASS/CAM scores
iv. Other standards that other pts are held to
v. JUDGEMENT
c. RASS Scale
i. Level of consciousness assessment
ii. +4= combative
iii. +3= very agitated
iv. +2= agitated
v. +1= restless
vi. 0= alert and calm
vii. -1= drowsy
viii. -2=light sedation
ix. -3=moderation sedation
x. -4=deep sedation
xi. -5= unarousable
d. CAM Scoring
i. Cognition of patient (delirium or not
e. Contraindications to initiate therapy
i. MAP <65mm Hg
ii. HR <60, >120
iii. RR <10, >32
iv. Pulse oximetry <90%
v. PEEP >5
vi. Patient agitation requiring increased sedation in last 30 mins
vii. Insecure airway device or difficult airway
viii. Lab values, medical imagining, actively undergoing a procedure
ix. CVVHD machine
69. Blood test values
a. D-Dimer
i. Provides highly specific measurement of the amount of fibrin degradation
ii. High sensitivity but not specific
iii. High levels indicate thromboembolic problems DVT, pulmonary embolism, thrombosis of
malignancy
1. Accurately identifies patients with DVT
iv. Negative D-Dimer test low likelihood of having DVT
1. False negatives are not uncommon for pulmonary emboli negative D-Dimer does not
rule out possibility of a PE
2. 99% negative predictive value for DVT in pts 60-80 y/o
3. 21%-30%? negative predictive value for DVT in pts > 80 y/o
b. Heparin Anti-Xa
i. Low molecular weight Heparin Normal: 0.5 to 1.2
ii. Unfractionated Heparin Normal: 0.3- 0.7
70. TKA
a. Want 90 degrees flexion in 5 days
i. Will ER their leg to get relief, PREVENT THIS
ii. 65 degrees flexion same day after surgery is what is common for people to come out with
b. Day of surgery
i. Get outta bed and walk 15-20 feet
c. D/C day after surgery (POD 1)
 d. TKA lose lots of blood and can cause anemia
i. Use tourniquets to prevent blood loss
71. Wells Clinical Prediction Tool:
a. a validated clinical model for estimating pre-test probability of DVT
b. Scoring:
i. < 1 Well score can reliably rule out possibility of DVT in trauma patients
ii. -2 to 0 points: low probability for DVT
iii. 1-2 points: moderate probability for DVT
iv. 3-8 points: high probability for DVT
72. KOOS vs. WOMAC
a. KOOS
i. higher the score= less knee problems
b. WOMAC
i. Higher the score= worse pain, stiffness, and functional limitations
73. Types of Urinary/Fecal Incontinence

a.
b. Types of fecal incontinence: Muscle, nerve, constipation, diarrhea, rectal prolapse, recto seal