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NPTE boards exam study guide

Neuro dysfun­ction patterns by injury

Frontal lobe: contra­lateral weakness, person­ality changes/ antisocial behavior, broca's aphasia, delayed or poor initia­tion.
Parietal Lobe: constr­uct­ional apraxia and anosog­nosia, Wernicke's aphasia, homonymous visual defects, impaired language compre­hen­sion.
Occipital Lobe: variety of visual deficits (homon­ymous hemian­opsia, visual agnosia, cortical blindn­ess), impaired extra-­ocular muscle movement
Temporal Lobe: hearing impair­ments, memory and learning deficits, wernicke's aphasia, antisocial behaviors
Cerebellum: Ataxia, lack of trunck and extremity coordi­nation, intention tremors, balance deficits, dysdia­doc­hok­inesia, dysmetria
Basal Ganglia: bradyk­inesia and akinesia, resting tremors, rigidity, athetosis, chorea,
Thalamus: thalamic pain syndrome, altered relay of sensory inform­ation
Hypoth­alamus: altered basic homeos­tasis of body functions, poor autonomic nervous system function, altered function of anterior pituitary gland (ADH secretion and reprod­uction)
brainstem: Altered consci­ous­ness, contra­lateral hemipa­resis or hemipl­egia, cranial nerve palsy, altered respir­atory patterns, attention deficits.
Right hemisphere: left sided sensory and motor deficits, unable to understand nonverbal commun­ica­tion, difficulty in sustaining movements, poor hand eye coordi­nation and kinest­hetic awareness, quick and impulsive, overes­tim­ation of abilities.
Left hemisphere: right sided sensory and motor deficits, difficulty unders­tanding and producing language, difficulty sequencing movements, poor logical and rational thought, slow cautious anxious, self deprec­iating.

Functions of the brain

Frontal Lobe
primary motor cortex respon­sible for voluntary movements on contra­lateral side. Broca's area (motor components of speech), cognition, judgement, attention, abstract thinking and emotional control
Parietal lobe
primary sensory cortex integrates sensation from contra­lateral side of body, short term memory, perception of touch, propri­oce­ption pain, and temp sensations
Temporal lobe
Primary auditory cortex, associ­ative auditory cortex, wernicke's area (compr­hension of spoken word), long term memory, visual percep­tion, primary visual cortex
Occipital lobe
visual associ­ation cortex (processes visual info and applies meaning)
Medulla oblongata
contains centers for vital sign functi­oning of the cardiac, respir­atory, and vasomotor centers,. maintains consci­ousness and arousal
critical for maintaing homeos­tasis. controls primitive drives­related to age, agression, emotion, thirst, hunger, sleep wake cycle. Damage to this area can cause problems with temp, water, and behavioral regula­tion.
Basal ganglia
regulates posture and muscle tone
maintains posture and voluntary muscle movement control
contains cranial nerve nuclei, damage damage can lead to variety of cranial nerve dysfun­ctions

gait deviations seen w/ stroke

Increased trunk and LE muscle tone
Inadequate hip and knee flexion, increased tone in trunk and LE
Increased extensor tone, inadequate hip and knee flex, increased PF in ankle or footdrop
Inadequate hip flexion
Increased extensor tone, flaccid LE
decreased knee flexion during swing
Increased LE extensor tone, weak hip flex
excessive flex during stance
weakness or flaccidity in LE, increased flex tone in the LE
hyper extension during stance
hip retrac­tion, increased extensor tone in LE, weakness in hamstr­ings, quads, gluteus maximus
Instab­ility during stance
increased LE flex tone , flaccidity or weakness of extensor muscles.
increased ext tone, flaccidity
ankle invers­ion­/ev­ersion
increased tone in specific muscle groups, flaccidity
toe clawing
increased flexor tone in toe muscles.

Neuro cranial nerves

visual acuity
turns eye up, down, and in
screen: observe position of eye
Test: persuit eye movements
Impaired eye movments, eye deviation from normal position, ptosis (drooping eyelid), pupillary dilation
cerebr­ova­sculary accident, myasthenia Gravis
4= trochlear
turns adducted eye down
facial sensation
screen: test pain; light touch sensations forehead, cheecks, jaw, (eyes closed)
corneal reflex; touch lightly with wisp of cotton
palpate muscles; have pt clench teeth, hold against resistance
Findings: loss of facial sensation, numbness, loss of corneal reflex ipsila­ter­ally; weakness, waisting of muscles for mastic­ation
trigeminal neuralgia, MS
muscle of mastic­ation (tempo­ralis, and masseter
turns eye out
taste on the anterior 2/3 tongue
facial expres­sions
screen: test motor function: raise eyebrows, frown, show teeth, smile, close eyes, puff out cheeks
findings: paralysis, ipsila­teral fascial muscles, inability to close eye, droop in corner of mouth, difficulty with speech articu­lation
bells palsy, CNS facial paralysis, stroke
vestibular occular reflex balance, hearing accuity
screen: vestibular function: test balance, eye head coordi­nation (vor gaize stability)
cochlear function auditory accuity, use tuning fork on top of head, on mastoid bone.
Findings vestib­ular: vertigo, disequ­ili­brium, nystagmus.
findings coclear: deafness, impaired hearing, tenitis
balance defici­encies.
taste posterior 1/3 of tongue
gag reflex, pharynx control, soft palate rising with "­ah" sound
ANS functions,
screen: examine fro difficulty swallo­wing, observe motion of soft palate (elevation remains midline) and when pt says "­ahh­"
Finding: paraly­sis­-palate fails to elevate, asymme­trical elevation, unilateral paralysis.
brain stem or hypoth­alamus dysfun­ction
gag reflex, pharynx control, soft palate rising with "­ah" sound
11=spinal accessory
traps muscle: elevate shoulders, SCM muscle: turn head to side
Screen: examine bulk of muscle, streng­th-­sho­ulder shrug against resist­ance, turn head to each side against resistance
finding: atrophy, fascic­ula­tion, weakness (PNI); inability to shrug ipsila­ter­all­y;(­ell­)sh­oul­der­;sh­oulder droops. Inability to turn head to opposite side
SCI gullian barr syndrome
tongue movements

PNF techniques for facili­tation

PNF Pattern

"­close your hand, turn, pull arm across face"
open your hand, turn and push your arm down and out
open hand, turn, lft your arm up and out
close hand, turn, pull arm down across body
bring foot up, turn, and pull leg up and across your body
push foot down, turn, push leg down and out
lift foot up, turn and lift leg up and out
push foot down, turn, and pull leg down and in.

UMN VS. LMN lesions

structures involved
Cortex, brainstem, cortic­ospinal tracts, spinal cord
SC: anterior horn cell, spinal roots, peripheral nerves
CN: cranial nerves
stroke, TBI, SCI
Polio, guilla­n-B­arre, PNI, peripheral neurop­athy, radicu­lopathy
hypert­onia, velocity dependent
decreased or absent, hypotonia, flaccid
Involu­ntary movements
flexor or extensor muscle spasms
with denerv­ation: fascic­ula­tions
stroke: parapa­resis,
cortic­ospinal lesion­s:c­ont­ral­ateral if above decuss­ation in medulla,
Spinal cord lesions: BL loss below level of lesion
Limited distri­bution: segmental or focal pattern, root innervated pattern.
Muscle bulk
disuse atrophy
neurogenic atrophy
Voluntary movement
impaired or absent: dyssentric patterns, obligatory synergies
weak or absent if nerve interr­upted

Neuro muscle tone abnorm­alities

Decort­icate rigidity: always an UMN lesion, sustained flexor posturing in the UE, sustained extensor posturing in the LE, Dience­phalon lesion, sign of severe impairment
Decere­brate: always an UMNL, sustained ext posturing in the UE & LE, Brainstem lesion, sign of severe impairment
Rigidity: Always an UMNL, resistance to passive stretch in agonist & antago­nist, Basal ganglia lesion
Cogwheel rigidity: ratche­t-like response to quick passive movement; catche­s/r­ele­ase­s/c­atches.
Leadpipe rigidity: constant rigidity
Flaccidity: LMNL, Cerebellar lesion, following spinal or cerebral shock, resolves or changes into spasticity.
Ashworth Scale
0: No increased tone.
1 or 1+: slight increase in tone.
2: moderate increase in tone.
3: PROM is difficult.
4: affected joints are non-mo­veable (ankyl­osed)
Deep tendon reflexes commonly tested
Biceps: C5-C6
Brachi­ora­dialis: C5-C6
Triceps: C7-C8
Quadri­ceps: L2-L4
Hamstr­ings: L5-S3
Achilles: S1-S2

glasgow coma scale

Muscul­osk­eletal ligaments, muscles, bones.

Ligaments: primarily type one collagen types and very strong in scars, generally hypova­scular contain mechan­ore­ceptors which contribute to propri­oce­ption, free nerve endings which contribute to pain percep­tion. There are varying intrinsic differ­ences within ligaments leading to varying approaches for rehab: extra-­art­icular ligaments heal in an organized and predic­table manner while intraa­rti­cular ligaments do not heal sponta­neously or in a predic­table manner.

Ligament sprains: 1-3 degree a few lig fibers - all are torn, caused by excessive load or stretch. pain with stretching (1 & 2), decreased ROM,

Muscle: Primarily made of loose, irregular connective tissue which makes the tissue more pliable and extens­ible, high vascul­ari­zation and water content lead to faster healing times, easiest tissue to mobilize following trauma or period of immobi­liz­ation.

Strain: muscle fibers torn caused by excessive load or stretch to muscle. Weakness, muscle spasms, swelling, disabi­lity, pain with isometric contra­ction, stretches,

Bone: composed of two basic layers: strong, intense outer layer- contri­butes to its strength, softer, mesh inner layer- stores marrow, covered with perios­teum- provides blood to the bone, constantly remode­ling- wolf’s law ( bone remodels based upon needs placed upon it)

Fracture types:
A.) complete: the bone is fx all the way through. Will require immobi­liz­ation, may require ORIF through surgical interv­ention using screws, pins, plates to secure bone ends
B.) Incomp­lete: disrupted integrity of bone. fragments are still somewhat connected. will require immobi­liz­ation which depends on where it is and WB/NWB status
C.) Stress fx: fine hairline fx occurring w/ little to no soft tissue damage. best seen on x ray 3-4 weeks after incident
D) Open fx: bone protrudes out of skin. Requires open reduction, possibly internal fixation.
E) Greenstick fx: bone is bent and partially fx. typically happens to children because their bones are more flexible.

Muscul­osk­eletal Kinesi­ology and body mechanics

Concave- convex rule: If the moving surface is convex, the glide will be in the opposite direction the bone moves. If the moving surface is concave, the glide will be in the same direction as the bone.

End Feels:
normal end feels:
Soft: soft tissue approx­imation
Firm: capsular and ligame­ntous stretching
Hard: bone meets

Abnormal end feels:
Boggy: edema, joint swelling
Firm w/ decreased elasti­city: fibrosis of soft tissue
Rubbery: muscle spasm
Empty: loose, then very hard, associated with pt muscle guarding to avoid pain
Hyperm­obi­lity: end feel later than opposite joint

Joint Close-pack position loose-pack
Facet (spine) Extension Midway between flex & extension
Tempor­oma­ndi­bular Clenched teeth Mouth slightly open
GHJ Abd & ER 55-70° Horiz Add, rotated so forearm is in transverse plane
Acromi­ocl­avi­cular Arm abducted to 90° Arm resting by side, shoulder girdle in physio­logical position.
Ulnohu­meral Extension 70° elbow flex, 10° supination
Radioh­umeral Elbow flex 90° forearm sup 5° Full ext & supination
Prox radioulnar 5° supination 70° elbow flex 35° supination
Dis radioulnar 5° supination 10° supination
Radioc­arpal Ext with radial deviation between flex- ext (straight line can pass through 3rd metacarpal & radius) c slight ulnar deviation
Hip Full ext, IR & abd 30° flex, 30° abduction, & slight ER
Knee Full ext, & ER of the tibia 25° flexion
Talocrural Max DF 10° PF, midway between inv & ev.

Common muscle substi­tut­ions:
scapular stabil­izers to initiate shoulder mvmt when shoulder abd are weak
lat trunk muscles or tensor fascia latae when hip abd are weak

muscul­osk­eletal joint mobili­zations

joint mobili­zation indica­tions: pain, hypomo­bility, muscle spasm and guarding, functional ROM limitation
Joint mobili­zation contra: hyperm­obi­lity, pregnancy, malign­ancy, unhealed fx, bone disease, effusion, inflam­mation, blood thinners
mob grades:
grade 1: Small amp oscill­ation at beginning of range.
grade 2: Large amp pushing into tissue resistance just short of joint caps.
grade 3: Large amp stretches joint caps
grade 4: Small amp high velocity manipu­lation past end of passive range

Special tests for muscul­osk­eletal conditions

GHJ Anterior instab­ility appreh­ension test: assessment of antici­pated pain when subject maintained 90 degrees Abd and ER of shoulder.
Posterior and inferior instab­ility Jerk test: sudden jerk applied to shoulder in 90° flexion and IR (humeral head subluxes off the back of the glenoid) Sulcus sign: an indent­ation occurs inferior to the acromion as distal distra­ction is applied to the humerus.
Subacr­omial imping­ement Hawkins- kennedy: passive 90° flex and IR reproduce pain Neer’s: Passive IR and full abd reproduce pain Empty can: shoulder placed at 90° abd 30°horiz add, pain c resistance
Rotator cuff pathology Drop arm: unable to slowly lower arm passively abducted to 120° Lag signs: pt unable to maintain IR/ ER
ACJ H add: localized pain occurring during H add p/arom. SLAP active compre­ssion: painful pop oc click in 90° flex, 10-15° add and full IR when downward force is applied Biceps load 2: appreh­ension when asked to flex biceps against resistance at 120° abd.
Thoracic outlet syndrome Adson’s: radial pulse diminish when arm is extended and ER, pt head rotated toward arm. *Roos: radial pulse diminishes when arm placed in 90° abd, slight H add, elbow flex to 90°, open and close fist for 3 mins.
Elbow Ligament instab­ility Varus/­valgus stress: laxity noticed as varus and valgus stress applied to elbow in 20-0° flex Biceps rupture: Distal bunching of muscle noted and complete loss of function. *
Neuro dys Flex: pain at the medial epicondyle of elbow, numbness and tingling in ulnar nerve distri­bution. Reproduced when pt hold c max elbow flex and wrist ext 1 min. Indicates cubital tunnel syndrome.
Wrist & hand De Quervain’s tenosy­novitis (tendo­nitis of abductor pollicis longus or extensor pollicis brevis) eichoff’s: pain reproduced when thumb is flexed across palm while moving into ulnar deviation. Finkel­stein: pain reproduced when wrist and thumb are pulled into ulnar deviation with distra­ction force.
Neuro dys Phalen’s (wrist flexion): tingling and parest­hesia reproduced during max wrist flex and hold together for 1 min, indicates carpal tunnel compre­ssion of medial nerve. Tinel sign: tingling and parest­hesia are reproduced when tapping over carpal tunnel area compre­ssing medial nerve. 2-pt discri­min­ation: asses ability to detect 2 pts of contact at once on palm.
Hip DJD Scour/­grind: P! when compre­ssive force is applied to femur, hip 90° flex, knee max √
Dys, mob restri­ction Patrick (faber): involved leg is unable to assume relaxed posture, P! symptoms c hip √, abd, ER, foot placed proximal to knee in supine
Muscle length, strength involv­ement Thomas test: supine slingle leg hip and knee max √ , if opp limb flexes, indicates tightness of psoas major. Ober: Passive hip extension and lowering from abd, sidelying, tightness of tensor facia lata and or iliotibial band. Ely’s : tightness of the rectus femoris when hip of tested limb lifts off testing surface with knee flexion, tested in prone. Trende­lenburg sign: observe pelvis of stance leg positive if ipsila­teral hip drops when limb support is removed. Indicative of weak glut med or unstable hip
Knee 1-plain anterior instab­ility Lachman: + excessive anterior transl­ation of the tibia compared to the uninvolved limb and lack of firm end feel. Anterior drawer : + excessive anterior transl­ation of the tibia compared to the uninvolved limb.
1-plain posterior instab­ility Posterior drawer: + excessive posterior transl­ation of the tibia compared to the uninvolved limb. Posterior sag: tibia sags poster­iorly( normally extends 1 cm anteriorly beyond femoral condyle) when positioned supine, hip √ 45° knee √ 90°
1-plain medial­-la­teral instab­ility Varus stress test: + excessive lateral mvmt or pain at the lateral knee Valgus stress+ excessive medial mvmt or pain at the knee (both tests performed at 0° and 30°√, + at 0° √ indicates major disruption of the knee and one or more rotary tests +.
Meniscus tear McMurray: + reprod­uction of click and or pain in the knee joint with rotary force applied.

Muscul­osk­eletal conditions and interv­entions

Anklyosing Spondy­litis: progre­ssive inflam­matory disorder that initially affects the axial skeleton, occurs before 40, affects thoracic and lumbar regions, BL SIJ, restricted P/AROM, flexed posture throughout entire spine.
Interv­entions: flexib­ility ex to maintain trunk motions and improve joint motions, especially ext. Implement aerobic such as aquatics for improved activity endurance. Include relaxation techniques such as breathing strategies for improved respir­atory function
Psoriatic Arthritis: chronic erosive inflam­matory disorder that typically occurs in the axial skeleton and digits.
Interv­ention: joint protec­tion, aerobic activities for recond­iti­oning
Rheumatoid arthritis: chronic systemic autoimmune disorder charac­terized by periods of acute exacer­bation and remission. weight loss, fever, extreme fatigue.
Interv­entions: joint protection strate­gies, aerobic condit­ioning, maintain joint mechanics and connective tissue function
Osteom­alacia: decalc­ifi­cation of bones as a result of vit D defici­ency, severe pain, fx, weakness, deform­ities.
Interv­entions: bone protec­tions strat, areobic condit­ioning, improve joint mechanics
Osteoc­hon­dritis dissecans:separ­ation of articular cartilage from underlying bone. Usually involving medial femoral condyle near the interc­ondylar notch, sometimes occurs on the femoral head or the humeral capite­llum.
Interv­entions stretches, bone protection strats, aerobic condit­ioning, streng­the­ning, power and endurance ex.
Tendinitis: inflam­mation of tendon caused by microt­rauma, direct blow, overuse, excessive tensile force.
Interv­ent­ions: manual, stretches, endurance condit­ioning, pt ed.
Bursitis: inflam­mation of the bursa secondary to overuse, gout, or trauma, or infection. Charac­terized by pain with rest, and decreased P/AROM due to pain, not in capsular pattern.
Interv­entions: stretches, manual therapy, endurance training, modali­ties, pt ed.
Myositis Ossificans: painful condition of abnormal calcif­ication within muscle belly caused by direct trauma. most commonly located in the biceps, brachi­alis, and quads.
AVOID AGRESSIVE STRETC­HING. gentle stretches, manual therapy, endurance condit­ioning
GHJ disloc­ation: most common anterior, caused by abduction and forceful ER. Posterior is caused by H Add, and IR. s/p avoid painful positions which may include: GHJ flex 90 deg, H Abd 90+, ER 80.
Interv­entions: restore normal GHJ motions, strength, endurance and stability.
patell­ofe­moral conditions: abnormal malali­gnment of the patella. causes pain that is made worse with inacti­vity.
interv­entions: McConnel taping, Patellar mobili­zations to lessen the abnorm­ality. Correction of muscular imbala­nces.
Osgood­-sc­hlatter: jumper's knee, Made worse with activity mechanical dysfun­ction resulting in traction apophy­sitis of the tibial tubercle at the patellar tendon insertion. Irregu­lar­ities of the epiphyseal line.
Interv­entions: modify activities to prevent excessive stress to irritated site.
Anterior compar­tment syndrome: Increased compar­tmental pressure resulting in local ischemic condition. caused by trauma, fx, overdose, muscle hypert­rophy. charac­terized by deep achey feeling, swelling, parast­hesia, severe pain,
Acute ACS is considered a medical emergency and requires immediate surgical interv­ention with fasciotomy to prevent tissue death and permanent disabi­lity.

ION concen­tration changes

hyperk­alemia: increased potassium, widened PR interval, QRS wave, and tall T waves, tachyc­ardia (poten­tially leading to bradyc­ardia, potent­ially leading to cardiac arrest)
Hypoka­lemia: ECG changes (flattened T wave, prolonged PR and QT intervals, hypote­nsion, arrhyt­hmias may progress to V-fib .
Hyperc­alc­emia: hypert­ension, signs of heart block, cardiac arrest
hypoca­lcemia: arrthmias, hypote­nsion
hypern­atr­emia: increased sodium, hypert­ension, tachyc­ardia, pitting edema, excessive weight gain
hypona­tremia: hypote­nsion, tachyc­ardia

lab values and meaning

Lab values and meaning

cardio­vas­cular dx tests

chest x-ray: lung condition, impact on lung from other condit­ions, blood vessels, fx, other objects
consid­era­tions: radiation
ECG: records electrical activity, Exercise tolerance test
consider: monitored in room via radio transm­ission, continuous monitoring during interv­ention, prvide ex guidlines following cardiac procedure
myocardial perfusion imaging: ischemic areas of the heart,
consid­era­tions: can visualize areas of old infarct
cardiac cathet­eri­zation, (coronary angiog­ram): x-ray images capture to evaluate BP in heart and O2 satura­tions, Stint
consid­era­tions: invasive, dye in arteries, requires IV, 2-3 hrs

Skin changes

clubbing: associated with chronic O2 deficiency and CHF
pale, shiny, dry, loss hair: PVD (arterial insuff­icency)
abnormal pigmen­tation, ulcera­tion, dermat­itis, gangrene: PVD

heart anatomy pg142

Right atrium: receives blood from systemic circul­ation from superior and inferior vena cava
SA-node: near superior vena cava; pacemaker of the heart
AV-node: node floor of Right atrium, receives signal from SA-node/ bundle of HIS, to depolarize and contract ventricles
Right ventricle: receives blood from RA which pumps blood through pulmonary artery to lungs for oxygen­ation
Left Atrium: receives oxygenated blood from lungs and 4 pulmonary veins
Left ventricle: walls are thicker and stronger than the RV and form most of the left side and apex of the heart.
receives blood from the LA and pumps blood via the aorta throughout the entire circul­atory system.
Heart valves
Atriov­ent­ricular valves: prevent backflow of the blood into the atria during ventri­cular systole. close when ventri­cular walls contract.
right heart valve tricuspid, left heart valve,­(bi­cuspid, mitral)
semilunar valves: prevent backflow of blood from the aorta and pulmonary arteries into the ventricles diastole
pulmonary valve prevent right backflow.
aortic valve prevents left backflow
Arteries, veins and capill­aries
Arteries: transport oxygenated blood from the heart, decrease in size and become arterioles and end as capill­aries. have contra­ctile abilities, arterial walls are thicker in order to tolerate high BP. Influenced by elasticity and elasib­ility of vessle walls and peripheral resist­ance, amount of blood in body change in diameter when triggered by sympat­hetic activity of the ANS, vasoco­nst­riction or vasodi­lation
Veins: transport dark unoxyg­enated blood from peripheral tissues back to the heart. larger capacity and thinner, weaker walls than arteries, greater in number, one way valve to prevent backflow of blood because they do not have contra­ctile abilities. rely on movement of muscle to squeeze blood back to the heart. Venous reflux occurs when the valves dont function properly caused by enlarged or weakened veins. deep veins accompany arteries while superf­ical's do not. increased blood return with inspir­ation, compliancy of right heart.
capill­aries: minute blood vessels that connect the ends of arteries with the beginning of veins, functions for exchange of nutrients and fluids between blood and tissues. capillary walls are thin and permeable

Heart failure

Left ventri­cular failure
S&S pulmonary congestion:dyspnea, dry cough, orthopnea, paroxysmal nocturnal dyspnea, pulmonary rales, wheezin.
S&S low cardiac output: hypote­nsion, tachyc­ardia, lighth­eaded/ dizziness, cerebral hypoxi­a(i­rri­tab­ility, restle­ssness, confusion, impaired memory, sleep distur­ban­ces), fatigue, weakness, poor exercise tolerance, enlarged heart on x-ray, S3 sound, possibly S4. murmurs of mitral or tricuspid regurg­ita­tion.
Right ventri­cular failure
S&S pulmonary congestion:dependent edema, weight gain, ascites, liver enlarg­ement
S&S low cardiac output: anorexia, nausea, bloating, cyanosis in the nail beds, RUQ pain, jugular vein disten­sion, R-sided S3 heart sounds, murmurs of pulmonary or tricuspid insuff­ici­ency.

Cardiac medica­tions

Tx consid­era­tions for cardiac meds

Ace Inhibitors: watch for potential dizziness or orthos­tatic hypote­nsion, NSAID's can reduce or negate the effects of the meds. monitor pt closely for elevated BP

Ca+ channel blocker: use PRE scale for monitoring exertion levels. may reduce blood flow to heart muscle and create ischemic response. monitor for orthos­tatic hypote­nsion.

Alpha blockers: monitor for signs of hypote­nsion, and reflex tachyc­ardia; where heart rate increase to compensate for hypote­nsion

Beta blockers: Use PRE scale, watch for bradyc­ardia and OH, can worsen asthma symptoms.

Diuretics: can cause fluid and electr­olyte imbala­nces; observe pt for muscle weakness or spasms, headache, and poor coordi­nation. Monitor for bradyc­ardia and OH.

Nitrates: observe for dizziness, tachyc­ardia, and OH. Pt may c/o headache.


etiology: primary lymphe­dema: congen­ital; Secondary lymphe­dema: occurs as a result of injury to lymphatic vessels or parasitic infection.
Progre­ssive over time: w/o tx, may develop into fibrosis, chronic infection, or loss of limb function
Symptoms: heaviness, tightness, or pain, swelling, and persistent edema, loss of ROM and function in an arm or leg
Skin changes: hardening and/or discol­oration of skin
Dx: history, visual inspection and palpation, girth measur­ements.
tests may include: MRI & CT scans; doppler ultras­ound, radion­uclide imaging of the lymphatic system.
Staging:0-latent, 1-spon­tan­eously revers­ible, 2-spon­tan­eously irreve­rsible, 3- lympho­static elepha­ntiasis
Tx: complete decong­estive therapy, manual lymph drainage, short stretch compre­ssion bandages, exercises, functional training, skin care and lymphedema education

pulmonary breathing muscles

Resting Inspir­ation
Diaphragm (Phrenic nerve, C3-5)
Deep inspir­ation
Diaphragm; SCM, scalenes- elevate 2 upper ribs; levator costarum, scalenes- elevate remaining ribs; pec major, serratus posterior superi­or(SCM: CN XI, 2, 3, Scalene: lower cervical root)
forced inspir­ation
muscles of resting and deep inspir­ation, trapezius, pectorals, serratus, levator scapula (traps: CNX1, pect: medial pectoral C8, T1, serratus: long thoracic C5-7, levator: C3-4, dorsal scapular)
resting expiration
same as resting inspir­ation, internal interc­ostals( interc­ostal nerve T2-6
Forced expiration
muscles of forced inspir­ation+ abs, quadratus lumborum, lower ilioco­stalis, serratus posterior inferior. (abs: 7-12 interc­ostal nerves, iliohy­pog­astric, ilioguinal nerve, QL: 12th thoracic &1st lumbar nerves)
when having difficulty breathing, SCI pts should lay day to help decrease the effects of gravity upon the diaphragm and improve the inspir­atory capacity of the lungs.

pulmonary percussion positions


shaking chills, fever, chest pain if pleuritic involved, productive or purulent, blood streaked, rusty sputum. cackles, tachypnea, increased white blood cell count, hypoxemia, hypocapnea leading to hyperc­apnea with increasing severity. CXR confir­mation of infilt­rate.
recent upper respir­atory infection, fever, chills, dry cough, headaches, cackles, hypoxemia and hyperc­apnea, normal wbc count, CXR confir­mation of inters­titial infilt­rate.
aspiration event, dry cough leading produc­tive, dyspnea, tachypnea, cyanosis, tachyc­ardia, wheezes and cackles, hypoxemia hyperc­apnea, chest pain, fevre, wbc count shows varying degrees of leykoc­ytosis, CXR initially shows pneumo­nitis. chronic aspiration shows necrot­izing pneumonia with cavitation .

pulmonary diseases

TB: airborne, incubation period: 2-10 weeks. to become noninf­ect­ious: 2 weeks on antitu­ber­culin drugs


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