Foundations of Interventions Unit 3 Study Guide PDF

Unit 3: Let's Get Our Patients Moving [Aerobic Exercise] - ATP Production - ATP - An energy bearing molecule composed of carbon, hydrogen, nitrogen, oxygen, and phosphorous atoms - Used in all cellular actions requiring energy - Muscle cells have l...

Unit 3: Let's Get Our Patients Moving [Aerobic Exercise] - ATP Production - ATP - An energy bearing molecule composed of carbon, hydrogen, nitrogen, oxygen, and phosphorous atoms - Used in all cellular actions requiring energy - Muscle cells have limited capacity to store ATP - Cells continuously create ATP at a rate equal to ATP use - Biological Energy Systems - Three basic energy systems exist in muscle cells to replenish ATP - Phosphagen system - Glycolysis - Oxidative system - Energy and Work - Anaerobic energy sources - Short, explosive events - Requires max effort less than 2 min - Phosphocreatine breakdown and glycolysis provide rapid sources of ATP - Aerobic energy sources - Prolonged (max/submax) exercise - Supplied by aerobic metabolism of carbohydrates and fats in mitochondria of muscle - Immediate energy sources - Anaerobic - ATP/Phosphocreatine - Max work, 1-5 seconds - Short-term energy sources - Anaerobic - Glycolysis (breakdown of CHO) - Max work, \2 minutes and all submax work - Cardiorespiratory Fitness (CRF) - The ability of the circulatory and respiratory systems to supply oxygen to the muscles to perform dynamic physical activity - Measured by Oxygen Uptake (VO2) - VO2 = CO (cardiac output) x (a-V)O2 difference - CO = HR x SV - How much blood your heart can pump in a minute - SV = how much blood is ejected at each contraction - (a-V)O2 difference - How much oxygen is going from arteries to venous supply - VO2 - How much oxygen you're able to take in and deliver to your working muscles - Measure of the volume of oxygen that is used by your body to convert the energy from the food you eat into the energy molecules (ATP) - VO2 = mL/kg/min (relative) - Takes into account individual's body weight - VO2 = L/min (absolute) - Energy Expenditure - Activities are categorized as light, moderate, or heavy depending on the energy cost - Energy cost is impacted by body mass and mechanical efficiency - Compute energy expenditure from the amount of oxygen consumed during the activity - MET = metabolic equivalent - The O2 consumed per kilogram of body weight per minute - 1 MET = energy expended/O2 consumed at rest - 1 MET = 3.5 mL O2/kg per min = resting metabolic rate - Classification of Activities - Light Work - 2 METS - Walking, cooking - Moderate Work - 3-6 METS - Heavy (Vigorous) Work - \>6.0 METS - Impact of Endurance Training - Increased reliance on fat as a fuel, sparing carbohydrate - Decreased time to submaximal steady state - Increased ventricle size, VO2 max, SV, and O2 extraction - Training effects specific to trained muscles - VO2 max can be maintained through intense exercise, when duration and frequency are reduced - Skeletal Muscle - Converts chemical energy of ATP from carbs and fats into mechanical work - Sarcomeres: fundamental units of muscle contraction - Contain thick filament myosin and thin filament actin - Bound by connective tissue called the Z line - Muscle Fiber Types and Performance - Type I (slow oxidative) - Slow contraction, low force, resist fatigue - Aerobic - Type IIa (fast oxidative glycolytic) - Fast contraction, high force, resist fatigue - Both anaerobic and aerobic - Type IIx (fast glycolytic) - Fast contraction, high force, easily fatigue - Anaerobic: Phosphocreatine breakdown and glycolysis - Genetics, Sex, Training - Distribution is highly variable and strongly influenced by genetics - Training doesn't convert fast-twitch fibers to slow-twitch and vice versa - Training increases mitochondrial number and capillary density (oxidative capacity) - Cardiovascular Responses to Acute Exercise - Increases blood flow to working muscle - Involves altered heart function, peripheral circulatory adaptations - Heart rate - Increases - Stroke volume - Increases - Cardiac output - Increases - Blood pressure - Blood flow - Blood - Respiratory Response to Exercise - Respiratory changes needed to - Supply the increased amount of oxygen needed - Expire excess carbon dioxide produced - Changes Include - Increased - Respiratory rate - Gas exchange - Tidal volume - Neuromuscular Responses Providing Increased Oxygen to Muscles - Increased blood flow to the working muscles → increased CO2 → Increase O2 extraction from the blood to tissue - Art of Exercise Prescription - The proper dose of activity is dependent on the desired effect or goals of the individual client - The dose of exercise needed for achieving better health differs from that needed to achieve peak performance - Exercise Dose (FITT-VP) - Frequency of Exercise - Number of training sessions conducted per day or per week - Depends on the interaction of exercise intensity and duration, training status of the athlete and specific sport season - Intensity of Exercise - Combination of moderate and/or vigorous intensity exercise - Adaptations in the body are specific to the intensity of the training session - High-intensity aerobic exercise increases cardiovascular and respiratory function and allows for improved oxygen delivery to the working muscles - Increasing exercise intensity is beneficial for skeletal muscle adaptations by affecting muscle fiber recruitment - Prescribing Intensity - Heart rate reserve, RPE, % Vo2 max - Heart Rate - Karvonen method - Percentage of maximal heart rate method - RPE - Ratings of perceived exertion - Subjective rating of how hard one may be working - RPE range of 11-16 is recommended to improve cardiorespiratory fitness - Usually ranges from 6-20 - For typical healthy individuals prescribe - 60-80% of VO2 max - 75-90% of HR max - Time (duration) of Exercise - Length of time of the training session - Longer the exercise duration, the lower the exercise intensity - Type of Exercise - All types of exercise are beneficial as long as they are of sufficient intensity and duration - Rhythmic, continuous exercise that involves major muscle groups is the most typical - Volume of Exercise: product of frequency x intensity x time - Made up of the time, frequency and intensity of the program - Progression: transitioning from easier to harder exercise over time - Progression of an aerobic endurance program involves increasing the frequency, intensity, and duration which shouldn't increase by more than 10% each week - Guidelines for Increasing CRF - Encourage screening, regular participation, and variety - Use a program that focuses on progression - Increase duration or frequency before increasing intensity - Recommendations for Achieving Health, Fitness, and Performance Goals - Health - Lower risk of heart problems - 40-59% HRR - 5-7 days per wk - Accumulate \> 150 min per wk - 30 min most days - Fitness - Cardiovascular fitness - 60-80% HRR - 3-5 days per wk - 20-60 min per session - About 3 mi - 3 times per wk - Performance - Running performance - \>80% HRR - 7+ times per wk - \>60 min per session - About 50-90 mi per wk - Types of Aerobic Endurance Training Programs - Long, slow distance training - Training distance greater than race distance - Intensities equivalent to 70% of VO2 max - Adaptations from this exercise include - Enhances the body's ability to clear lactate - Causes an eventual shift of Type IIx fibers to Type I fibers - Pace/tempo training - Intensity at or slightly above competition intensity, corresponding to the lactate threshold - Steady pace/tempo training - 20-30 minutes of continuous training at the lactate threshold - Intermittent pace/tempo training - Series of shorter intervals with brief recovery periods - Interval training - Exercise at an intensity close to Vo2 max for intervals of 3-5 min - Allows athletes to train at intensities close to VO2 max for a greater amount of time - Increases VO2 max and enhances anaerobic metabolism - HIIT - Uses repeated high-intensity bouts interspersed with brief recovery periods - Need to spend several minutes above 90-95% VO2 max for optimal stimulus - May be effective for improving running economy and running speed - Fartlek training - Easy running combined with hills or short, fast bursts - Can be adapted for cycling and swimming - Benefits include - Enhanced VO2 max - Increased lactate threshold - Improved running economy and fuel utilization - Exercise Program - Purposes - Increase levels of fitness for healthy individuals - Slow the decrease in functional capacity with age - Recondition those who have been ill or who have chronic disease - Three Components to ALL Exercise Programs - Warm-Up Period - Lag time between onset of activity and body responses - Increases muscle temperature, contraction, rate of nerve conduction, and extraction of oxygen from blood - Should be 10 minutes of total body movement - Aerobic Exercise Period - Cool Down Period - Prevent pooling of blood in the extremities - Increases venous return to the heart - May help prevent myocardial ischemia, arrhythmias and other cardiac complications - Enhances recovery by removing waste products and replenishing energy stores - Should improve performance gradually and progressively [Ambulation] - Ambulation - Process of assisting the patient who is walking but not providing direct education to overcome a gait deviation - Gait training - Denotes a therapeutic intervention designed to improve some aspect of the patient's gait - Weight Bearing (WB) Terminology - WB Restriction - NWB (non-weight-bearing) - Foot doesn't touch the ground - TTWB (toe-touch) - Foot contacts ground for balance only - PWB (partial weight bearing) - Percentage of body weight (usually 20%-50%) - NOT a WB Restriction - WBAT (weight bearing as tolerated) - Limited only patient tolerance - FWB (full WB) - No restriction; 100% WB allowed - Monitoring WB - Bathroom scales - Having patient shift weight from one scale to the other provides feedback about static WB - Two scales more accurately mimic static WB - Limb-load monitor (LLM) - Audible feedback to patient and clinician regarding WB during gait is provided - Sensitivity can be adjusted to according to patient's WB restrictions - DO NOT USE YOUR FINGERS TO TEACH WB RESTRICTIONS - Choosing an Assistive Device - Consider the patient, environment, and task to be performed - The degree of support required - The degree of stability required - Assistive devices are typically used to facilitate gait by - Increasing support - By providing additional support of load - Increasing stability - By increasing your patient's BoS - Devices: Most Supportive to Least Supportive - Parallel bars - Indications - Greatest stability provided and can serve as a transition toward greater mobility - Advantages - Stability - Enables you to focus on a particular gait deviation or specific gait objective - Disadvantages - Lack of portability - Walker - Indications - Functional mobility is desired but a wide BoS is needed - Can be used for balance - Can be used to partially unweight a limb - Rolling walkers provide wide BoS, greater speed, and less energy cost, but at the expense of some stability - Advantages - Four points of contact on the floor and a wide BoS - Box shape provides stability and a sense of security lightweight - Provide stability and unloading of LE - UE platforms can be attached - Disadvantages - Awkward in small spaces - Unsafe on stairs - Abnormal gait (no arm swing, halting, slow gait) - Standard Walkers - Pick up walkers require more energy to use than rolling walkers - Glides or tennis balls attached to feet increase ease of advancement - Bilateral axillary crutches - Bilateral forearm crutches - Hemi walker or Walk Cane - Cane - Large Base Quad Cane - Cane - Small Base Quad Cane - Cane - Single-Point Straight Cane - Choosing the Correct Device - NWB, TTWB, PWB - Parallel bars (in the clinic) - Standard walker - More stable - Crutches (axillary or loftstrand) - WBAT - Unilateral or bilateral devices - Any devices are appropriate - The Goal - Your goal as a therapist is to use the least restrictive device (LRD) - LRD = the most functional with the least risk - Energy Costs of Assistive Devices from Least to Most - Canes - Crutches - Wheeled/rolling walker - Standard walker - Device Specific Fitting Techniques - Parallel Bars - Function - Most stability, used for gait retraining or when pt needs lots of assistance - Fit - Level of greater trochanter, ulnar styloid process, wrist crease - 2" clearance between the bars and greater trochanter - Bars must be secure before ambulating - Walkers - Patient Population - People with severe balance issues, NWB, TTWB, PWB - Function - Balance - Decrease WB if standard walker (non-weight bearing, partial weight-bearing, toe touch weight bearing) - No wheeled walkers with WB restrictions - Fit - Walker grips should be at the level of greater trochanter, ulnar styloid process, wrist crease - Walker should be 5-6" in front of them (anterior to the hips) with 20-0 degrees of elbow flexion - A walker that is - Too short = facilitates a flexed posture - Too tall = limits the function of elbow flexors and shoulder depressors - Confirming the Fit - Check the angle of the elbow - Re-confirm once patient is walking - Forearm Trough that can add to the Rolling Walker - Used for some sort of WB status in their wrist/not able to use their hands - Fit the walker the same way but might need to adjust the wrist so that you can get a 90 degree angle with that - Can be used s/p CVA for more wrist stability - Wheeler Walkers - No WB restrictions - Cardiopulmonary patients or geriatrics - Axillary Crutches - Patient Population - NWB, TTWB, PWB - Functions - Balance - Increased BOS - Decreased WB - More mobility - Fit - Proximal stability of the crutches comes from placement of the axillary bar against the rib cage - Too short = unstable as the patient can't control the upper part of the crutches between the upper arm - Too tall = continuous pressure can cause nerve and vascular damage - Can adjust the overall height or the handgrip - Adjusting overall height - Calculate 77% of your patient's height - Subtract 16" from an adult patient's height - In supine, measure from the axillary fold to a spot 6-8" lateral to the bottom of the heel - In sitting, assume an ATNR (asymmetrical tonic neck reflex) position with one elbow at 90 degrees and the other fully extended - Measure from the olecranon process of the flexed elbow to the long finger of the opposite hand - Measure two finger difference between the axilla and the axillary pad - Adjust the handgrip position - In supine, measure from the bottom of the heel to the greater trochanter or from the axillary fold to the greater trochanter - In standing, shoulders relaxed, arms at sides, handgrip should be at the level of the greater trochanter, ulnar styloid, wrist crease - Confirming the Fit - In a relaxed standing position with the crutch tips placed 2" lateral and 6" anterior to the small toe there should be 2-3 finger width between the axilla pads and the elbows should be at a 20-30 degree angle - Forearm Crutches - Functions - Same as axillary crutches except less stable - Allows for greater mobility and is more cosmetic - Often used in the US for long-term use - Fit - Forearm crutches can be adjusted proximally to alter the cuff position and distally to alter the crutch height - Length adjustment - As with axillary crutches - Cuff adjustment - Top of cuff should be 1-1.5" distal to the olecranon process or elbow crease - The width of the cuff can also be adjusted so it makes partial contact with the forearm but is not binding; it should not drop off the arm during gait - Canes - Function - Increase BOS for balance - Particularly helpful in decreasing the forces at the hop - ONLY USE FOR WBAT or FWB - Fit - Length of the cane = distance from heel to greater trochanter, ulnar styloid process, wrist crease - Can be measured in supine or standing - Ideal measurement is from wrist crease to floor with patient standing - Front tip of cane should be 6" anterior to the lateral border of the toes and the pt's hand on the handle, the elbow should be at a 20-30 degree angle - Hemi Walker and Quad Cane - Function - Improve balance with a wider BOS - Used in a neuro population when need greater stability but unable to use both arms on a standard walker (CVA) - ONLY USE FOR WBAT or FWB - Fit - Height of the hemi-walker grips should be at greater trochanter, ulnar styloid process, wrist-crease - Typically used for people with CVA - Gait Patterns - Selection of gait pattern is based on patient's - Balance - Coordination - Muscle function - WB status - Differ significantly in their - BOS - Speed - Energy consumption - Gait Patterns for Crutches - Safety - Weight should be through the hands not the axillas - Maintain a wide BOS - DO NOT let pt rest with their feet parallel to the crutches - Hold axillary bar snuggly against chest - Hold head up and look forward - Use small steps to turn - Gait Patterns Available Using Crutches - WB Restrictions - Three point - Two ADs are advanced followed by one LE - 3 pts of contact at all times - Move the more involved LE with the crutches so crutches can take the weight - Normal heel toe pattern to prevent tightness from developing - Function - Used with unilateral NWB - Modified three point is used with any PWB, TTWB, WBAT - Cue - Crutches and R Foot Step To/Step Through - No Weight on the L - Step To - LE in swing phase is advanced only to the level of the ADs - Easiest pattern to learn - Requires less balance and coordination - Requires less hip, knee, and ankle ROM - Function - Typically for weakness in BLE - GENERALIZED WEAKNESS - Step Through - LE in swing phase is advanced beyond level of ADs - A more normal gait pattern; more efficient - Function - Typically for weakness in BLE - Gait Re-Training, Balance, and Coordination - Used with neuro population Two point - AD and opposite LE advance together - One or two canes, crutches, or a hemi walker - Less stable than four point - 2 pts of contact at all times - Used for balance incoordination or bilateral muscle weakness - Cues - L Crutch, R Foot, R Crutch and L Foot - Four point - 1 crutch, opposite foot - Used for progressing one part of the body - Most stable - Used for balance, incoordination or bilateral muscle weakness - Cues - L Crutch, R Foot, R Crutch, L Foot - SCI ambulation with B long leg braces - Most likely using lofstrand crutches but may use axillary - Both legs move together in a swing motion - Swing to - Both crutches advanced simultaneously followed by simultaneous advancement of LEs to level of ADs - Function - Typically for weakness in BLE - Swing Through [Foundations of Resistance Training ] - Components of muscular fitness - Strength = max amount of force generated during a specific movement - Force = mass x acceleration - Hypertrophy = an increase in the size of a muscle - Power = rate of performing work; the product of force and velocity - Local muscular endurance = ability of the muscle groups involved in a movement to sustain contraction - Types of Strength - Max strength = highest force the neuromuscular system can generate during a max voluntary contraction - Strength endurance = force production in repetitive fashion over extended periods of time - Absolute strength = amount of force generation irrespective of body weight - Example: Squatting 500 pounds - Relative strength = ratio between max strength and body weight - Example: 2 people are squatting 500 pounds, 1 person is 100 pounds and the other is 200 pounds, the 100 pound lifter has higher relative strength - Power - Work = product of a given force acting through a given distance - Power = the rate of work production (work/force x velocity) - Can't have a high level of power unless you are strong initially - Principles of Training - Individuality - Not all people are created equal - Emphasizes the idea that genetics affects performance and each person has variations in metabolism, cell growth rates, etc - Specificity - Exercise adaptations specific to mode and intensity of training - Overload - Increase demands on body to make further improvements - Muscles must be loaded beyond normal loading for improvement - Variation - Systematically changes one or more variables to keep training challenging - Intensity, volume, and/or mode - Increasing volume, decreases intensity - Decreasing volume, increases intensity - Reversibility - Use it or lose it - Training → improved strength and endurance - Detraining reverses gains - Types of Muscular Contractions - Concentric = shortening of a muscle when force is applied - Eccentric = force of the object may be greater than the force generated by the muscle (muscle lengthening) - Isometric = muscle is generating force but muscle length stays the same - Isokinetic = a contraction where a constant speed is maintained - Resistance Training Programs - Exercise order - Large muscle groups before small - Multijoint before single joint - High intensity before low intensity - Rest periods based on experience - Novice, intermediate lifters: 2 to 3 min between sets - Advanced lifters: 1 to 2 minutes between sets - Training Frequency - Number of training sessions completed in a given time period - Training Load and Repetitions - The heavier the load, the lower the number of repetitions that can be performed - Commonly seen as a 1 RM - 2 for 2 rule - f the individual can perform two or more repetitions over the assigned repetition goal in the last set in two consecutive workouts for a specific exercise, need to add weight - General Resistance Exercise Recommendations - Frequency - Each major muscle group should be trained 2 days/wk - Intensity - 60-70% 1RM performed for 8-12 reps is encouraged for muscular fitness - - Strength Development - Novice - 60-70% 1RM, 1-3 sets/8-12 reps, slow/moderate, 2-3 sessions/week - Intermediate - 70-80% 1RM, 1-3 sets/6-12 reps, slow/moderate, 3-4 sessions/week - Advanced - 80-100% 1RM, 1-3 sets/1-12 reps, slow/moderate, 4-6 sessions/week - Muscle Hypertrophy - Novice - 70-80% 1RM, 1-3 sets/8-12 reps, slow/moderate, 2-3 sessions/week - Intermediate - 70-85% 1RM, 1-3 sets/6-12 reps, slow/moderate, 4 sessions/week - Advanced - 70-100% 1RM, 3-6 sets/1-12 reps, slow/moderate, 4-6 sessions/week - Muscle Power - Novice - 0-60% 1RM, 1-3 sets/3-6 reps, moderate, 2-3 sessions/week - Intermediate - 0-60% 1RM, 1-3 sets/3-6 reps, fast, 3-4 sessions/week - Advanced - 85-10% 1RM, 3-6 sets/1-6 reps, fast, 4-5 sessions/week - Muscular Endurance - Novice - Light load, 1-3 sets/10-15 reps, slow/moderate, 2-3 sessions/week - Intermediate - Light load, 1-3 sets/10-15 reps, slow/moderate, 3-4 sessions/week - Advanced - 30-80% 1RM, 10-25 reps, slow/moderate, 4-6 sessions/week - General Exercise Precautions - Valsalva maneuver - Substitute motions - Overtraining/overwork - Pathological fracture - Exercise-induced muscle soreness - Exercise Contraindications - Pain - Inflammation - Severe cardiopulmonary disease - Resistance Training Across the Lifespan - RT in children - Each child should understand the benefits and risks associated with training - Exercise should be safe and free of hazards - Children don't grow at a constant rate, substantiated interindividual differences in physical development at any given chronological age - Should have some form of resistance training in their 60 minutes of activity a day - Misconception that RT will stunt growth in kids - RT in older adults - RT is a way to combat muscle strength loss and muscle mass loss to improve overall strength - 70-85% 1RM for RT strength, 40-60% 1RM for RT power - Avoid the idea of doing reps to failure for older adults as it could increase joint stress in older populations - Safety in Exercise - Know a patient's health history and current health status - Provide a safe environment - Warm up and cool down - Ensure the patient is performing the exercises correctly - Stability to Mobility continuum moving from less mobile to more mobile - Capacity for mobility stability controlled mobility skill - RT Regimes - PRE: progressive resistance exercises - External load is applied to a contracting muscle by weight or weight machine that is incrementally progressed - Determined by: repetition max - Improvements in strength is primarily the result of physiological adapations - Increase weight 5-10% when all prescribed repetitions and sets are completed without - Pain - Movement compensations - Extreme fatigue - Circuit training - Pre-established sequence of continuous exercise with stations targeting different muscle groups - Higher reps, lower resistance and minimal rest between sets and stations - Order is important - Alternating between upper, lower and core - Alternate between push and pull - Large groups before small groups - Multi joint before isolated muscle group - Isokinetics - Used in later stages of rehabilitation/testing - Task specific training - Limited transference of training - Usually 1-2 sets of 8-10 reps of agonist/antagonist muscle action at different velocities - Plyometric Training - Method of conditioning designed to allow the muscle to reach maximal force in the shortest possible time - Quick, powerful jumping or hopping movements - Maximal concentric contraction is stronger when it is preceded by an eccentric contraction of the same muscle - How it Works - Purpose is to increase the power of subsequent movements by using - Natural elastic components of muscle - The stretch reflex - Stretch Shortening Cycle - Combination of natural elastic components of muscle and the stretch reflex - Facilitates a maximal increase in muscle recruitment over a minimal amount of time - Emphasizes power and coordination - Three Phases - Eccentric - Stretch of the agonist muscle - Elastic energy is stored in the series elastic component - Muscle spindles are stimulated - Amortization - Pause between eccentric and concentric phase - Type 1a afferent nerves synapse with alpha motor neurons - Alpha motor neurons transmit signals to agonist muscle group - Concentric - Shortening of agonist muscle fibers - Elastic energy is released from the series elastic component - Alpha motor neurons stimulate the agonist muscle group - The Stretch Reflex - Stretch on the muscle and then a subsequent concentric contraction - Used towards end stages of rehab because you need higher levels of strength to perform - Use this usually to get back to sport - [Acute Care Lab] - Equipment - Chest Tubes - Drain excess fluid from the lungs placed in pleural space - Feeding Tubes - NG Tube - Nasal gastric taped to the face used for helping in feeding for children - Don't pull on the tube when moving the pt - PEG Tube - Surgically placed - Don't pull on the tube when moving them - Cautions and Precautions for Managing Patients with Feeding Tubes - Keep HOB \> 30 degrees while feeding and up to one hour after to prevent regurgitation and aspiration - Avoid left sidelying because this position hinders the stomach from emptying - Ventilators - Maintain HOB \>30 degrees and don't provide slack on the line for the ventilator - Nasal Cannula - Do not remove the device used to administer O2 without permission - Never shut off O2 flow from the wall outlet or tank - Make sure there are no kinks in tubing and person is not lying or sitting on tubing - Don't allow the tubing to touch the floor - Report signs and symptoms of respiratory distress - IV - Be careful not to pull on the needle, catheter or IV bag and protect when moving the patient - If a problem occurs with the flow of fluid an alarm sounds alerting the nurse - If the insertion of the needle is near a joint, flexion of the joint may occlude the flow - Avoid pressure proximal to the IV site - PICC line - Lasts longer than IV - Line goes from art to heart - Similar precautions to IV - Make sure it doesn't pull - Urinary Elimination - Foley catheter: through urethra to bladder - Condom catheter: may loosen easily - Hanging bag or leg bag - Keep drainage bag below the bladder - Attach bag to the bed frame, never attach to the side rail - Do not allow bag or tubing to touch floor - Report leaks to nurse - Ask nurse or assistance to empty a full bag before working with the patient - Bowel Elimination Ostomy - Opening in the body - Colostomy: opening between colon and abdominal wall - Ileostomy: opening between ileum and abdominal wall - Avoid pressure or tension on the pouches - Don't place belt over pouch or right under it - Plan ahead with tubes and lines - Maintain slack and control of all lines - Set up environment - Always check with nursing or the medical team