Session 6 Lab Guide - Student PDF

Session 6 Lab Guide =================== Learning Goal: Safely and effectively utilize foundational intervention strategies when working with non-complex patients #### Course Goal \#6: **Position** and drape patient appropriately Part 1: Direction Case- PT and PTA =================================...

Session 6 Lab Guide =================== Learning Goal: Safely and effectively utilize foundational intervention strategies when working with non-complex patients #### Course Goal \#6: **Position** and drape patient appropriately Part 1: Direction Case- PT and PTA ================================== ### PATIENT INFORMATION Pt. is a 63 y.o. female dx with TBI 2^0^ to MVA. She is comatose. She is in the ICU in stable condition. PT evaluation shows she is unresponsive. PROM to all extremities showed full range with no limitations. Strength and functional movements were not examined. No discoloration or disruption of the integumentary system was noted. #### #### **[INSTRUCTIONS]** Besides long-term positioning, your short-term goals for the patient were to maintain full ROM in all extremities to prevent contractures to optimize future function. The PT met with the PTA to briefly discuss the patient's diagnosis and intervention. In addition, the PTA was reminded that even though the patient is comatose, the assumption is that the patient can hear and understand; therefore, explanation and continued verbal communication are essential. The PTA was instructed to perform daily gentle PROM to all joints of BUE and BLE. If there was a change in patient status the PTA was instructed to contact the PT. The PTA performed daily PROM to the hip, knee, ankle, toes, shoulder, elbow, wrist, and fingers. #### DAY 5: Five days after the initial evaluation the PTA entered the patient's room and was greeted by the patient who was oriented to person, place, and time. The PTA introduced himself and explained the intervention that would be performed that day. The PTA performed the PROM regimen for the patient. Full range was achieved at all joints. During the treatment, the PTA observed that the patient was assisting the therapist during some of the movement and was moving all four extremities actively during the intervention. The patient commented that her arms felt heavy and weak, and she feels uncoordinated, but at least she did not have any pain. At the completion of the session, the PTA decided to contact the PT about the change of status in the patient. - As a PT, given this information, how would you progress the patient at this point? What type of ROM would you perform? Why? #### DAY 6: The PT accompanied the PTA to the patient's room and found that the patient was sitting up in a chair. The patient said she was feeling a little confused and was having difficulty remembering everyone's name. Upon completion of an upper quarter and lower quarter screening examination, the PT determined that the patient had gross muscle strength of 3/5 and her range of motions was WNL throughout all 4 extremities. Incoordination was noted. The PT decided to modify the patient's goals to include achievement of full strength of the upper and lower extremities. The PT provided instructions to the PTA on how to progress the patient's exercise program. - What instructions would you give the PTA if you were the PT? Why? #### Day 9: The patient was transferred to a rehabilitation center. The patient was oriented to person, place and time; however she commented that she has difficulty following commands and remembering instructions. Upon examination the PT notes she has full ROM throughout BUEs and BLEs. Her strength was 3+/5 throughout BUEs and BLEs. She had difficulty with all ADLs including dressing and grooming because she has significant incoordination, particularly in BUEs. You decide she needs help relearning how to perform her ADLS. You plan to work with a PTA. - What type of ROM would you perform at this point? Why? Part 2: Long Term Positioning ============================= Overview of Long Term Positioning --------------------------------- - Indications: LT positioning is utilized for patients who are unable to move themselves out of a position or who are unable to move in bed - Blanching Test is potentially problematic - Considerations: - **SAFETY** - **COMFORT** - **PREVENTION** - Construction worker female with solid fillSafety Considerations: - Patients must change positions every 2 hours or every 15 minutes if in sitting - Monitor for skin breakdown, ensure that pressure is minimized in areas of common concern - The patient must be positioned in the middle of the bed if supine, sidelying, or prone - If in sitting must have feet supported and if in a w/c then brakes must be locked - Patient needs a means to call for help (ensure it is in a place they can reach) Long Term Positioning Practice ------------------------------ ### Supine +-----------------------------------+-----------------------------------+ | **Positioning Objective** | **How to Achieve it** | +===================================+===================================+ | **Safety** | - Means to **call for | | | assistance** | | | | | | - **No active feeding tube** | | | | | | - **Elevate HOB if difficulty | | | breathing** | +-----------------------------------+-----------------------------------+ | **Preventing Pressure Ulcers** | - Head cushion with normal | | | **spinal alignment** to | | | relieve the occiput | | | | | | - Special Cushion to relieve | | | the **scapulae** | | | | | | - Special Cushion to relieve | | | the **sacrum** | | | | | | - Pillow under **lower legs** | | | to relieve pressure on heels | | | but **prevent knee | | | hyperextension** | +-----------------------------------+-----------------------------------+ | **Normal Spinal Alignment** | - Small **pillow under head** | | | | | | - **Shoulders and hips | | | parallel** | | | | | | - **Legs neutral rotation; | | | support on lateral thigh (if | | | necessary)** | | | | | | - **Hips in neutral | | | flexion/extension** | +-----------------------------------+-----------------------------------+ | **Preventing Contractures &** | - Arms **abducted** | | | | | **Edema** | - **Arms and hands supported; | | | hands open** | | | | | | - **Hips neutral; knees | | | extended (not hyper | | | extended); ankles | | | dorsiflexed** | +-----------------------------------+-----------------------------------+ KEY CONSIDERATIONS for Long Term Positioning in Supine ------------------------------------------------------ - Reposition **every 2 hours** - Key difference between ST and LT: hips and knees fully extended or only slightly flexed, ensure the knees aren't hyperextended - Remove all pressure from the heels, suspending them slightly above the surface of the bed, place a pillow under the calves (NOT under the heels) just enough to float the heels above the bed - To relieve pressure from the sacrum do pressure relief or do sidelying toward supine (book calls it ¾ supine) -- don't just place another towel under the sacrum because that is just raising the surface without decreasing pressure - If there is UE involvement then want to support the UE with pillows to prevent edema, towel roll for the hand to prevent fisting - IF Pt has LE Amputations: Do not let the residual limb hang off the EOB, do not place a pillow under the thigh or knee in supine, do not place a pillow under the low back, do not flex knees for long periods or cross legs, do keep hips in neutral, knee extended ### Sitting +-----------------------------------+-----------------------------------+ | **Positioning Objective** | **How to Achieve it** | +===================================+===================================+ | **Safety** | - Means to **call for | | | assistance** | | | | | | - **Upright; hips slightly | | | flexed; trunk slightly | | | reclined** | | | | | | - **Lateral trunk and arm | | | supports** | +-----------------------------------+-----------------------------------+ | **Preventing Pressure Ulcers** | - Centered in chair with hips | | | back | | | | | | - Weight evenly distributed | | | | | | - Knees slightly higher than | | | hips | | | | | | - Cushion between knees as | | | needed | | | | | | - Appropriate seat cushion | +-----------------------------------+-----------------------------------+ | **Normal Spinal Alignment** | - Hips centered and back in the | | | chair | | | | | | - **Shoulders over the hips** | | | | | | - **Trunk , head and hip | | | support as needed** | | | | | | - **Lumbar support** | | | | | | - **Knees slightly higher than | | | hips** | +-----------------------------------+-----------------------------------+ | **Preventing Contractures &** | - Arms slightly abducted and | | | supported on the armrest | | **Edema** | | | | - Elbows partially extended; | | | hands open at/above heart; | | | heels cushioned and back on | | | foot rest; LE elevated as | | | needed; padding contact | | | points as needed | +-----------------------------------+-----------------------------------+ ### KEY CONSIDERATIONS for Long Term Positioning in Sitting - Needs more frequent repositioning -- **every 15 minutes** - Support normal spinal curves but watch out for large lumbar rolls - Hips flexed \~ 90 degrees or slightly more with pelvis positioned in the back of the chair - If pt has hemiplegia may need to support involved UE ### Prone +-----------------------------------+-----------------------------------+ | **Positioning Objective** | **How to Achieve it** | +===================================+===================================+ | **Safety** | - Clear airway (**turn head**) | | | | | | - Means to **call for | | | assistance** | +-----------------------------------+-----------------------------------+ | **Preventing Pressure Ulcers** | - Head cushion with normal | | | **spinal alignment** | | | | | | - Special Cushion to relieve | | | pressure on the **anterior | | | shoulder** | | | | | | - Special Cushion to relieve | | | pressure on the **iliac | | | crests** | | | | | | - Additional cushioning to | | | relieve pressure on the | | | **knees** (particularly for | | | patients with hip flex | | | contractures) | | | | | | - Pillow under **lower legs** | | | to relieve pressure on dorsum | | | of feet and toes | +-----------------------------------+-----------------------------------+ | **Normal Spinal Alignment** | - Small **pillow under abdomen | | | & hips** | | | | | | - **Arms overhead or at side** | +-----------------------------------+-----------------------------------+ | **Preventing Contractures &** | - Arms **abducted** | | | | | **Edema** | - **Arms and hands supported** | | | | | | - **Prone often used to prevent | | | hip flex contractures\*** | +-----------------------------------+-----------------------------------+ ### KEY CONSIDERATIONS for Long Term Positioning in Prone - Least common choice but currently it is used in COVID care so it is being used more often. It is also a very useful position for pt's with an SCI to decrease pressure on their sacrum and to promote hip extension stretching - Ensure that the pt has a clear airway and access to a call bell in the direction they are looking - If promoting hip extension ensure that there is not a large pillow under the hips - Ensure that that feet are supported and the toes are floating - Arms should be abducted but elbows can be flexed or extended based on pt comfort ### Sidelying #### toward supine #### toward prone +-----------------------------------+-----------------------------------+ | **Positioning Objective** | **How to Achieve it** | +===================================+===================================+ | **Safety** | - Clear airway (**turn head**) | | | | | | - Means to **call for | | | assistance** | +-----------------------------------+-----------------------------------+ | **Preventing Pressure Ulcers** | - Head cushion with normal | | | **spinal alignment** | | | | | | - Cushion to relieve pressure | | | on the **anterior shoulder** | | | | | | - Trunk rotated **slightly | | | forward or back** with pillow | | | support | | | | | | - Underside arm slightly | | | forward (dec. axillary | | | compression) | | | | | | - Underside hip slightly | | | **forward or back** (dec. | | | greater trochanter pressure) | | | | | | - Pillow between knees and | | | ankles | +-----------------------------------+-----------------------------------+ | **Normal Spinal Alignment** | - **Pt. centered in the bed** | | | | | | - Small **pillow under head** | | | | | | - **Underside leg straight, top | | | leg flexed** | +-----------------------------------+-----------------------------------+ | **Preventing Contractures &** | - Upper arm **abducted** | | | | | **Edema** | - **Elbow extended** | | | | | | - **Hand open, resting at or | | | above heart level** | +-----------------------------------+-----------------------------------+ ### KEY CONSIDERATIONS for Long Term Positioning in Sidelying - If rotated forward (TOWARD PRONE) place pillow in front of the pt and place the superior arm on the pillow in a flexed or extended position - If rotated backward (TOWARD SUPINE) bring the inferior shoulder forward, place a pillow behind the pt, and place the superior arm on a pillow in a slight flexed but nearly extended position - Prevent hand edema of uppermost arm by propping it so it isn't in a dependent position (keep arm and hand at or above the heart) - Underside leg straight and top leg flexed - If pt has hemiplegia then want to ensure good support of the involved UE - Be careful with positioning on the affected side- if positioned on this side position the affected shoulder slightly forward with elbow straight if possible and wrist in neutral and hand open- because of decreased sensation will want to check the pt after 5 minutes to ensure that they are tolerating the position (check for redness, warmth, etc) Summary ======= +-----------------------------------+-----------------------------------+ | **[Short-Term | **[Long-Term | | Positioning]** | Positioning]** | +===================================+===================================+ | **Key Points to Remember:** | **Key Points to Remember:** | | | | | **Short-term consider: SAFETY, | **Long-term consider: SAFETY, | | COMFORT, AND ACCESS** | COMFORT, PREVENTION** | +-----------------------------------+-----------------------------------+ | **[Short Term Positioning | **[Long Term Positioning | | Checklist]** | Checklist]** | | | | | - Patient **safety** | - Clear airway | | | | | - Good spinal alignment | - Good spinal alignment | | | | | - **Accessibility** of | - Minimized pressure over bony | | necessary areas of the body | prominences | | | | | - Trunk and extremities | - Minimized gravity creating | | supported for **comfort** | shearing forces | | | | | - Positioned well within the | - Cushioned support surfaces | | **environment** (line of | | | sight, communication, etc.) | - Immobile extremities elevated | | | | | - **Special needs** | - Joint and soft-tissue | | accommodated | contractures prevented | | | | | - Has a **means to | - Trunk and extremities | | communicate** or call for | supported and stabilized | | help | | | | - Long-term functional | | | positions | | | | | | - Positioned to optimize | | | interaction with the | | | environment (line of sight, | | | communication, etc.) | | | | | | - Special needs accommodated | | | | | | - Safety | | | | | | - Normal spinal alignment | | | | | | - Prevent pressure ulcers | | | | | | - Prevent edema and | | | contractures | +-----------------------------------+-----------------------------------+ [\ ] Part 3: DOCUMENTATION--- SOAP Note Practice =========================================== WHERE? WHAT? Example of Information Provided In This Section -------- ------------------------------------------------------- S O A P Read the following excerpts and decide which portion corresponds to S, O, A, or P. S: [ ] O: [ ] A: [ ] P: [ ] S: [ ] O: [ ] A: [ ] P: [ ] **Try It Out: WRITE YOUR OWN SOAP NOTE.** **Be as concise as you can, use abbreviations where possible and cut out information that may not be relevant.** Pt noted feeling "better" today but after last session he said that his hip hurt more. He thinks that the pain was because of the standing. He asked the nurse for ice and he brought the ice and after he iced his hip he felt better. His hip didn't hurt when he was sleeping. Pt reports that he really likes watching the Price Is Right and that when he was at home he would watch it with his cat. Pt told pt they would review the THA precautions, get out of bed and transfer to the toilet. Pt said ok and that he was eager to be able to get out of bed on his own. Pt very forgetful, he kept asking what he wasn't supposed to do. PT had to tell him many times the THA precautions. PT provided pt with a sign with the precautions written out with pictures. Pt needed Min A for supine -\> sit -\> stand, mostly for maintenance of L hip precautions. Pt needed Min A while walking with his rolling walker x100', with frequent v.c. to slow down and keep walker on floor. Pt is a 76 y.o. male who had a left total hip replacement. Pt is unsafe and at high risk for hip dislocation or fall when unattended, as he lives alone he will need assistance so it would be best if he was transferred to a long term care facility. Pt lives in NW DC. His strength and endurance are limited which is causing him to have difficulty walking longer distances. He will benefit from cont daily PT to work on strengthening, balance, and maintaining precautions during movement. Will discuss discharge plan with case manager, this therapist recommends a long term care facility. If home discharge planned, will need to train caregiver(s) in precautions and assisting/guarding pt. LT Positioning Summary Questions ================================ 1. Name 3 areas at greatest risk for decubiti in: - Sitting - Supine - Sidelying 2. What is the difference between LT and ST positioning in supine? Why? 3. What are 4 major considerations whenever positioning a patient long term in any position? 4. What is one way to ensure safety? 5. How do you determine whether a device is considered a restraint or not? 6. Name 3 typical contractures in UE? LE? 7. Pt with a BKA is at greatest risk for which contractures? 8. Why is it important to keep the HOB \