Exam 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) Insulin Shock
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 Type II 
Dilated pupils
Thirst (extremely dry mouth)    Slurred Speech
  Illness and infection can lead
  Fatigue
to this
Type I   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 Hip extension and ER past 45° are to be avoided
common due to less
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
 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
 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
prepares wound for permanent Heterograft
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 10-15
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. 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(ECMO) 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)
 3. 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 - Anemia, blood loss during
transport O2 g/dl polycythemia surgery, dietary iron insufficiency
throughout body - PT: headaches, dizziness, blurred - Heart works harder to transport
Females: 12 to vision, decrease in mental acuity , adequate O2 by increasing CO
16 g/dl sensory changes in distal extremities, (cardiac output)
increase risk for stroke and thrombosis - 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

4. CBC Exercise Guidelines

a. WBC
i. <5,000 mm3 with fever NO strenuous exercise
ii. >5,000 mm3 light exercise, progress to resistive exercisers as tolerated
b. Hematocrit
i. <25%  NO exercise permitted
ii. 25 to 30%  light exercise permitted
iii. 30 to 32%  resistive exercise as tolerated
c. Platelets
 i. 150,000 and above exercise and activity without restriction
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 and functional activity
vi. 10,000 to 20,000  functional activity only
vii. 10,000 or less  consider cancelling PT
5. 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) 
product of normal muscle
metabolism
*regulated by the kidneys
Glucose  blood sugar level
Calcium
6. Coagulation Profile
Prothrombin Time (PT)
Partial Thromboplastin
Time (PTT)
0.6 to 1.2 mg/dl - Renal impairment &
potential need for dialysis
Adult: 70 to 100 mg/dl Hyperglycemia Hypoglycemia
- Acetone breath, - HA, shakiness, weakness,
dehydration, weak and rapid irritability, cold sweats,
Adult >60 y/o: 80 to pulse, stupor, coma decreased muscle control
110 mg/dl
- PT: Blood sugar >300 can be - PT: low activity tolerance &
risk of DKA over extension can cause
hypoglycemic reaction
9 to 11 mg/dl
Define Normal Therapeutic Range Critical levels
Range
- 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)
- Time required for a 32 to 70 For anticoagulant -3 times control
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)

7. 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
8. 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)
9. 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 - SARS

- Invasive H. influenza

f. Bloodborne pathogen Facts

Epidemiology
Transmission mode
Body Fluids that Transmit Disease
S/S  majority of people have no
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,
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,
 s/s so they do not know they are
infected
aching muscles/ joints, nausea and
vomiting, diarrhea, jaundice, itching
skin, dark urine, light colored feces
- Will last 6 weeks to 6 months
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)

10.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
respirations)
- Neurological (HA, restlessness,
(due to alveolar drowsiness, lethargy, confusion,
hypoventilation) altered mental status, tremor,
coma)
- CV (Tachycardia, dysrhythmia,
hypertension, diaphoresis)
anesthesia)
- Impaired respiratory muscle function (SCI, NM
disease)
- Pulmonary disorders (atelectasis, pneumonia,
pneumothorax, pulmonary edema, bronchial
obstruction, COPD)
- Massive Pulmonary Embolus

-Redness of skin - Hypoventilation (pain, chest wall injury/deformity,

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)

11.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
12. 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
13. 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)

14. 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. 220- (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
15. 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

16. 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

17. 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

18. 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

19. 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
ii. Vegetative State minimal responsiveness
iii. Severe Disability Conscious but disabled; dependent on others for daily support
iv. Moderate Disability disabled but independent: can work in sheltered setting
v. Good Recovery resumption of normal life despite minor deficits
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

20. 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
21.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
22.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,
where the cell death occurs
iii. Penumbra area surrounding the infarct that can be compensated by inflammation
and secondary changes
iv. Most strokes are ischemic strokes
v. Stroke #1 cause of long-term disability in the world
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
vi. 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
vii. Constraint Induced therapy avoids allowing patient to compensate by constraining
unaffected limb
1. Neural plasticity

viii. 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
ix. Other issues:
1. Shoulder-hand syndrome results from humeral subluxation
a. Use GivMohr Sling to prevent this
23.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
24.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
25. 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
26.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

27. 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
28.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
29.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
30.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)

31. 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

32. 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 (Broca’s) agnosia, visuospatial impairments, disturbances of body
aphasia, fluent (Wernicke’s) aphasia, global aphasia image and body scheme

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

33.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)
34.Gait patterns with AD
a. Four-point pattern – bilateral amb aids (R AD, L LE, L AD, R LE)
 i. Modified four-point pattern – one amb aid held on strong, unaffected side (AD, affected LE,
unaffected LE)
b. Two Point pattern – bilateral amb aids (R AD & L LE, then L AD & R LE)
i. Modified two-point pattern – one amb aid held on strong, unaffected side(AD & affected LE
simultaneously, then unaffected LE)
c. Three point pattern – bilateral amb aids (AD & affected LE, then unaffected LE using a step to or step
through)
i. Modified three-point pattern – one amb aid held on strong, unaffected side(both ADs
simultaneously along with PWB affected LE, then unaffected LE)
35.

Good spontaneous
No Spontaneous Some Spontaneous Independent with
breathing: RR > 10
Breathing - Total Breathing: RR < 10 Weak Spontaneous Breathing: (RR < ventilation and able
but inspiratory
Ventilator Inspiratory efforts: VT < 6 10) Good effort: VT > 10 ml/kg to physiologically
effort still weak: VT
Dependence mL/kg support self
< 10 mL/kg

Continuous
Synchronous
Assist Pressure
Assisted Intermittent
Control Mode Control Support Positive Extubated
Ventilation Mandatory
Mode Ventilation Airway
Ventilation
Pressure