Lecture 4 Crutches, Canes, Walkers

LECTURE 4 CRUTCHES, CANES, WALKERS • major area of human function is locomotion so they test these even though not a major emphasis in school! - area to test PT teaching & risk reduction Crutches: • How do you measure crutches?! ** need to know for risk reduction -> so you don’t ! cause nerve damage! a) length of crutch = 2-3 finger-widths below anterior ! axillary fold to a point lateral to & slightly in front of the foot! -> many questions ask where you measure from/to (so for ! crutches, if they ask anything measuring from axilla to ! foot -> rule out, they’re wrong instructions for length)! b) hand grip = can be adjusted up & down; when properly ! placed, should be apx. 30 degrees elbow flexion • How to teach crutch gaits (4 kinds):! ** names are pretty obvious w/ a few exceptions! a) 2-point! - move a crutch and opposite foot together followed ! by other crutch & opposite foot! - moving 2 things together! b) 3-point! - moving 2 crutches & the bad leg together! - moving 3 things together! c) 4-point! - moving everything separately! - move any crutch, then opposite foot, followed by ! next crutch then other foot! - very slow but very stable! d) Swing-through! - for non-weight bearing injuries (ex. amputations)! - plant crutches and swing the injured limb through ! (never touches down) • When do they use them?! - ask yourself “how many legs are affected?”! - even for even, odd for odd! * even point gaits when a weakness is evenly ! distributed (i.e. even # of legs messed up)! - 2-point = mild problems (bilateral)! - 4-point = severe problems (severe, bilateral ! weaknesses)! - 3-point = only odd one, when only 1 leg is affected • Ex. Early stages of rheumatoid arthritis = 2-point! Ex. Left, above the knee amputation = swing-through! Ex. First day post-op right knee replacement, partial weight-! bearing allowed = 3-point! Ex. Advanced stages of ALS = 4-point! Ex. Left hip replacement, 2nd day post-op, non weight-bearing ! = swing-through! Ex. Bilateral total knee replacement, 1st day post-op, weight-! bearing allowed = 4-point! Ex. Bilateral total knee replacement, 3 weeks post-op = 2 point • Going up & down stairs:! - up with the good, down with bad! - crutches move with the bad leg! Cains: • hold the cain on the strong side! - a lot of people use it the wrong way Walkers: • pick it up, set it down, walk to it • if they must tie their belongings to the walker, tie it at the sides, not the front! - boards doesn’t like things on the front (even tho most ! people do that anyways; they don’t like wheels or tennis ! ball on the bottom either) DELUSIONS, HALLUCINATIONS, & ILLUSIONS (Psych)! Neurosis Non-Psychotic vs. Psychosis • Hint: the first thing you have to do to get a psych questions correct is decide: “Is my PT non-psychotic or psychotic?”! = this will determine treatment, goals, prognosis, ! medication, length of stay, legalities…everything Definition Treatment/ Techniques Symptoms NON-PSYCHOTIC Has insight & is reality-based! - even w/ emotional ! distress/illness, ! mental/behavioral ! disorder! - recognize what the ! problem is and how ! it affects their life PSYCHOTIC Has no insight & is not reality-based - don’t think/know their sick! - think everyone else has ! the problem but not them ! (blame anyone else)! - even if they say they’re ! sick but then they say the ! martians made them sick ! they don’t have insight - good therapeutic ! - good therapeutic ! communication (like ! communication does not ! any PT that displays ! work because they are ! good comm. skills)! not rational! ** there’s nothing ! - need unique, specific ! special that you need strategies to do/know compared to any med-surge, paeds, or OB PT don’t have delusions, DELUSIONS, hallucinations, or HALLUCINATION, illusions ILLUSIONS! - only in psychotic PT’s! - as soon as they get any ! of these they’ve crossed ! the line to being psychotic Psychotic Symptoms: • a) Delusions! = false, fixed, idea or belief; no sensory component ! (all in the brain, thinking it)! i. Paranoid Delusions -> people are out to harm me! - ex. the mafia are out to get me! ii. Grandiose Delusions -> you are superior or you ! are the world’s smartest/greatest person! - ex. thinking you are Christ, Genghis Khan! iii. Somatic Delusions -> about a body part! - ex. x-ray vision; there are worms in my body • b) Hallucinations! = a false, fixed, sensory experience (purely sensory); ! 5 senses so 5 for (1 for each sense)! i. Auditory -> hearing things that aren’t there (primarily ! voices telling you to hurt yourself); most common! ii. Visual -> seeing; 2nd most common! iii. Tactile -> feeling things; 3rd most common! iv. Gustatory -> tasting things that are not there! v. Olfactory -> smelling things that are not there! *** last 2 are relatively rare • c) Illusions! = misinterpretation of reality; sensory experience! - difference from hallucination -> with an illusion there ! is a referent in reality! -> referent = something in reality to which a person ! refers when they say something (they just ! misinterpret it) • ex. PT says: “I hear demon voices” -> hallucination! ex. PT overhears nurses & MD’s laughing & talking at the nurse’s ! station & says: “Listen, I hear demon voices” -> illusion (there ! is a referent)! ex. person staring at a wall & says: “I see a bomb” -> hallucination! ex. person looks at fire extinguisher on the wall and says: “I see a ! bomb” -> illusion (referent) • Hint: On the test, they will tell you that there is something there thus, you can differentiate between a hallucination & an illusion. How do you deal with these Psychotic Symptoms? • first thing you ask after determining if PT is psychotic: What is their problem?! —> what kind of psychosis do they have?! • 3 Types of Psychosis:! 1. Functional Psychosis! - can function in everyday life (i.e. have jobs, a ! marriage, etc.)! - 4 diseases: Schizo Schizo Major Manics! i. Schizophrenia! ii. Schizoaffective Disorder! iii. Major Depression (if it’s major, test will say)! iv. Manic (Acute)! -> so bi-polar is functional, only psychotic ! during manic phase! - these PT’s have the potential to learn reality ! (because no damage)! -> may need meds or set boundaries for structure! -> nurse role = teach reality (4 steps)! a) acknowledge feeling -> “I see you’re angry; ! “You seem upset”, “Tell me how you are feeling”, ! often uses the word feeling or shows a feeling! b) PRESENT REALITY -> “I know that those voices ! are real to you but I don’t hear them” or telling ! them what is real (“I’m a nurse & this is a hospital”)! c) set a limit -> “That topic/behavior is off-limits”, ! “We are not going to talk about that right now”, ! “Stop talking about that”! d) enforce the limit -> “I see you’re too ill to stay ! reality based so our convo is over” (ending the ! conversation NOT taking away a privilege [i.e. ! punishment]; continuing to talk may enforce the ! non-reality)! *** on the test, they won’t ask these specific steps but ! instead, will ask “how should the nurse respond…”! *** try to pick the more positive statements (i.e. what ! they can have/do, not what they can’t); if between ! 2 statements go w/ the positive one! • 2. Psychosis of Dementia! - psychosis because of actual damage to the brain! * in Functional Dementia, there is no brain damage; ! it’s just messed up chemicals! - include PT’s w/ Alzeimer’s, psychosis after a stroke, ! organic brain syndrome; anything w/ “senile” or ! “dementia”! - cannot learn reality! -> major difference from functional (which is why ! you have to determine type of psychosis)! -> nurse role:! a) acknowledge feeling! b) REDIRECT them -> from something they can’t ! do to something they can do! ** you don’t set-limits because it’s mean! ** NOT APPROPRIATE to present reality to these ! PT’s when they are experiencing psychotic ! symptoms (BUT don’t confuse this w/ reality ! orientation)! -> important to remember that forgetting things (like ! where they are or what room they’re in - PT’s w/ ! dementia/Alzheimers) is NOT psychosis! ** when they start having delusions, hallucinations or ! illusions, then they are psychotic! -> reality orientation = telling them person, place, ! and time (ALWAYS APPROPRIATE w/ ! DEMENTIA) - this deals w/ memory! ! 3. Psychotic Delirium! = a temporary, sudden, dramatic, episodic, ! secondary loss of reality; usually due to some ! chemical imbalance in the body! * different because it’s temporary and very acute! -> include PT’s that are short-term psychotic because ! of something else causing the psychosis! - ex. a drug reaction, high on uppers or withdrawing ! from downers (delirium tremens), cocaine overdose, ! post-op psychosis (withdrawing from a downer), ICU ! psychosis (sensory deprivation), UTI (or any occult ! infection), thyroid storm, adrenal crisis! - good thing is it’s temporary so focus is removing ! the underlying cause & keeping them safe! -> nurse role:! a) acknowledge feeling! b) REASSURE them: it’s temp. & they’ll be safe! ** don’t present reality -> they won’t get it! ** don’t redirect -> not going to work! • Personality Disorders are different:! A = antisocial! B = borderline! N = narcissistic! ** very sick personality disorders! ** may be good to use Functional Psychosis ! techniques because you set limits Other Psychotic Symptoms: • Loosening of Association! = your thoughts aren’t wrapped too tight, all over the map! a) Flight of Ideas! - coherent phrases but the phrases are not ! connected (not coherent together)! b) Word Salad! - sicker, can’t even make a coherent phrase! -> babble random words! c) Neologism! - making up imaginary words • Narrowed Self Concept! = when a psychotic refuses to leave their room or ! change their clothes! - functional psychotic! - #1 reason is because their definition of self is ! narrowed -> defined self based on 2 things:! i. Where they are! ii. What they are wearing! *** so they don’t know who they are unless they are ! wearing those exact clothes in that exact room! - as the nurse, don’t make them change or leave the ! room (will cause escalating panic because they will ! lose their concept of self)! * use the Functional Psychosis techniques • Ideas of Reference! = think everyone is talking about you! - ex. see someone on the news and get upset ! because you think they are talking about you! - can have both paranoia & ideas of reference ! (paranoia if also think they are going to harm you)