Fisioterapi Kardiovaskuler Pulmonal 2 Pertemuan 7

(1)

Intensive

care unit

Physical

therapy

by:

Slamet

Sumarno.

(2)

Fisioterapi ICU

Intensive Care Unit = Perawatan intensif.

ICU umumnya rawat kond kritis Cardiorespirasi

dan banyak menggunakan alat bantu serta

ditangani secara team.

Siapa yang harus di rawat di ICU.

?

 Gejala gagal nafas (krirtis pernafasan).

 Indikasi memerlukan alat bantu pernafasan.

 _{Tidak stabilnya pernafasan .}

 Kritis trauma capitis.

(3)

Gagal nafas.

Pengertian.

Gagal nafas diartikan sebagai kegagalan

pertukaran gas dlm paru yg ditandai

dengan turunnya kadar oksigen di arteri

(hipoksimia) atau naiknya kadar

karbondiaksida (hiperkarbia) atau

kombinasi keduanya.

(4)

Kriteria diagnosa gagal nafas.

PaO2 <

60mmHg,

PaCO2 > 49

mmHg tanpa

gangguan

alkalosis

metabolik primer

(Muhadi,OE Tampubolon, 1989)

(5)

Pemeriksaan lab Gas Darah

(6)

Etiologi Gagal nafas.

Penyakit akut atau kronik kembali akut.

Acut dan Acut on chonic respiratory failure

(hipersekresi, spasme bronkus, edema

mukosa).

Spasme bronkus pada: Asma, bronkitis

kronik yg berkembang menjadi emfisema

(7)

Lanjutan.

1.

1. Otak: Neoplasma, Epilepsi, Hematoma _{Otak: Neoplasma, Epilepsi, Hematoma}

subdural, Keracunan morfin dan CVA.

2.

2. Susunan neuromuskular: Miastenia gravis, _{Susunan neuromuskular: Miastenia gravis,}

Polyneuritis, Analgesia spinal tinggi,

kelumpuhan otot respirasi.

3.

3. Dinding thorak, diapragma: Trauma thorak._{Dinding thorak, diapragma: Trauma thorak.}

4.

4. Paru: Asma, infeksi paru, Aspirasi, pneumonia, _{Paru: Asma, infeksi paru, Aspirasi, pneumonia,}

edema paru.

5.

5. kardiovaskuler: Gagal jantung, emboli paru._{kardiovaskuler: Gagal jantung, emboli paru.}

6.

(8)

Komplikasi rawat ICU.



_{Peningkatan resiko infeksi nosocomial}

_

atelectasis



_Mechanics

_ventilasi

_pasien

_yang

memungkinkan terjadi penurunan FRC dan

CL , V/Q nya tidak sebanding۬



_{immobilisasi pada pasien dengan penyakit}

kritis yang menderita muscle deconditioning,

peningkatan resiko DVT, pressure sore

FRC=fungsional reserve capacity. CL = lung capacity

(9)

Problem

Koknetif

gerak

sikap

(10)

Physiotherapy Assessment

Cognition, motivation, patients own goals

Previous level of function & independence

Posture, movement, strength, balance, pain

Functional ability; sitting, standing, transferring,

walking, turning, reaching, bed mobility, stairs,

getting up from floor, arm & hand function,

exercise tolerance

Use of Objective measures

(11)

Physiotherapy programme

Exercises to address specific problems,

e.g. loss of joint movement, muscle

weakness, balance problem.

Functional activity, in a safe, supervised

environment, to improve performance and

confidence

Provision of and practise using appropriate

mobility aids

(12)

Problematik

umum

1. Gangguan pernafasan.

2. Gangguan Jantung dan sirkulasi.

3. Gangguan Hormonal dan bufer.

4. Gangguan sistem syaraf.

(13)

PROBLEM PERNAFASAN.

Oleh karena:

1.

Gangguan systen neurologi.

_{Gangguan systen neurologi.}

2.

Gangguan Sangkar thorak.

_{Gangguan Sangkar thorak.}

3.

Gangguan jalan nafas / obtruktif.

_{Gangguan jalan nafas / obtruktif.}

4.

Gangguan pleurae.

_{Gangguan pleurae.}

5.

Gangguan perfusi / restriktif.

_{Gangguan perfusi / restriktif.}

6.

Gangguan system sirkulasi pulmonal.

7.

(14)

Tujuan Fisioterapi ICU

• meningkatkan/mempertahankan

A.fungsi cardiopulmonari:

1. Posisioning.

2. Membuka jalan nafas.

3. Oksigen terapi.

4. Meningkatkan ventilasi.

5. Fasilitasi dan stimulasi breathing.

4 a. mekanik ventilasi

(15)

B. Fungsi Musculoskeletal

1. Joint function / movement

2. Performance kerja otot.

3. Balance, coordination, komunikasi

(16)

C. Fungsi Neuromuskular.

1.

Sensasi,

_Sensasi,

2.

stimulasi,

_stimulasi,

3.

Inhibisi.

_Inhibisi.

D.

D. Edukasi .

Edukasi .

E.

E. Mencapai goul

Mencapai goul

(harapan)

.

F.

(17)

PROSES FISIOTERAPI

Assessment /reassessment

Mesurment. / remesurment

Analysis of fndings Intervensi/Implementation

of treatment / modifkasi

Problems

identifiation

Planning of treatment

(18)

Evidence Based Practice

Falls – strength & Balance training

NSF, NICE, CSP Guidelines

Locally developed guidelines; walking

aids, falls prevention education leaflets,

group exercise, resistance training for

osteoporosis

(19)

Evidence

Based

Medicine (EBM)

“

Menggunakan segala pertimbangan

bukti ilmiah (evidence) yang sahih yang

diketahui hingga kini untuk menentukan

pengobatan pada penderita yang

sedang kita hadapi”.

Merupakan penjabaran bukti ilmiah

lebih lanjut setelah obat dipasarkan dan

seiring dengan pengobatan rasional.

(20)

Lima tahap evidence based

Memformulasikan pertanyaan tentang masalah

fisioterapi yang dihadapi

Menelusuri bukti-bukti terbaik yang tersedia

untuk mengatasi masalah tersebut

Mengkaji bukti, validitas dan keseuaiannya

dengan kondisi praktek

Menerapkan hasil kajian

Mengevaluasi penerapannya (kinerjanya)

(21)

Assessment FT Kritis Di ICU

Baca status riwayat dan keadaan sekarang.

1.

Posisi pasien:

Sudah memudahkan proses pernafasan. Sudah membantu

sirkulasi. Sudah menguntungkan bila terjadi kekakuan. Sudah

mencegah dekubitus. Sudah memudahkan / memfasilitasi pernafasan dan

(22)

2. Kenali alat dan monitor yg ada

a.

a. Sounde. Tentukan ukuran soude yang masuk _{Sounde. Tentukan ukuran soude yang masuk}

oesophagus.

b.

b. Thrachea tube : tentukan ukuran panjang yang _{Thrachea tube : tentukan ukuran panjang yang}

masuk thrachea. 18, 19, 20, 21, 22 dst

biasanya dewasa 22 cm.

c.

c. Tentukan apakah monitor EKG berfungsi _{Tentukan apakah monitor EKG berfungsi}

dengan baik ( terutama elektrode yg terpasang

pada dada dan tangan atau kaki biola ada.

d.

d. Tentukan ventilator berfungsi dengan baik, _{Tentukan ventilator berfungsi dengan baik,}

menggunakan inhalasi atau tidak,

e.

(23)

Sistem assesment / mesurment.

1.

Fungsi tingkat kesadaran.

_{Fungsi tingkat kesadaran.}

2.

Vital sign.

_{Vital sign.}

3.

Fungsi jalan nafas dan paru

_{Fungsi jalan nafas dan paru}

4.

Fungsi jantung dan sirkulasi.

_{Fungsi jantung dan sirkulasi.}

5.

Fungsi sangkar torak : sendi, otot dan tl

_{Fungsi sangkar torak : sendi, otot dan tl}

6.

(24)

Kesadaran.

1.

1. Kompos mentis_{Kompos mentis} : bereaksi sgr dgn orientasi sempurna._{: bereaksi sgr dgn orientasi sempurna.}

2.

2. ApatisApatis:: terlihat mengantuk tetapi mudah dibangunkan, terlihat mengantuk tetapi mudah dibangunkan, reaksi penglihatan, pendengaran dan perabaan

reaksi penglihatan, pendengaran dan perabaan

normal.

3.

3. SomnolenSomnolen: dapat dibangunkan bila dirangsang, dapat : dapat dibangunkan bila dirangsang, dapat disuruh dan menjawab pertanyaan bila rangsangan

disuruh dan menjawab pertanyaan bila rangsangan

berhenti penderita tidur lagi.

4.

4. Sopor:Sopor: dapat dibangunkan bila dirangsang dengan dapat dibangunkan bila dirangsang dengan keras dan terus menerus.

keras dan terus menerus.

5.

5. Soporcoma:Soporcoma: reflek motoris terjadi hanya bila reflek motoris terjadi hanya bila dirangsang dengan rangsangan nyeri.

dirangsang dengan rangsangan nyeri.

6.

6. Coma:_Coma: tidak ada reflek motoris sekalipun dengan _{tidak ada reflek motoris sekalipun dengan}

rangsang nyeri.

(25)

PEMERIKSAAN KESADARAN

Coma Scala dari

3-15).

15).

1.

1. Kompos mentis : bereaksi segera dengan orientasi Kompos mentis : bereaksi segera dengan orientasi sempurna. (15)

sempurna. (15)

2.

2. Apatis: terlihat mengantuk tetapi mudah Apatis: terlihat mengantuk tetapi mudah

dibangunkan, reaksi penglihatan, pendengaran dan

perabaan normal. (14-15)

3.

3. Somnolen: dapat dibangunkan bila dirangsang, Somnolen: dapat dibangunkan bila dirangsang, dapat disuruh dan menjawab pertanyaan bila

dapat disuruh dan menjawab pertanyaan bila

rangsangan berhenti penderita tidur lagi. (12-14)

4.

4. Sopor: dapat dibangunkan bila dirangsang dengan Sopor: dapat dibangunkan bila dirangsang dengan keras dan terus menerus.(8-11)

keras dan terus menerus.(8-11)

5.

5. Soporcoma: reflek motoris terjadi hanya bila Soporcoma: reflek motoris terjadi hanya bila dirangsang dengan rangsangan nyeri. 7-8

dirangsang dengan rangsangan nyeri. 7-8

6.

6. Coma: tidak ada reflek motoris sekalipun dengan Coma: tidak ada reflek motoris sekalipun dengan rangsang nyeri. (3-7)

(26)

Glasgow coma scale

Eye Opening E Spontan 4

Dng Perintah 3

Dng rangsang nyeri 2 no response 1

Tidak ada respon 1

E + M + V = 3 to 15

(27)

MATA (EYE=E=4.

Tehnik. Baca nama pasien dipapan

nama pasien.

4. Spontan membuka mata.

3. Dipanggil namanya buka mata.

2. Diberi rangsang nyeri buka mata.

1. Rangsang nyeri tidak buka mata.

(28)

Respon pupil thd cahaya

Normal = 5

Lambat= 4

Respon tidak sama = 3

Besar tidak sama = 2

Tidak ada respon = 1

(29)

Cerebral perfusion presure (CPP)

Tekanan kritis yang adequate blood supply

terhadap otak dan mencegah acidosis, hypoxia

dan kerusakan.

Otak harus diipertahankan kontinusitas

tranportsai oksigennya dan tekanan darahnya

secara otomatis regulasi, range of blood presure

over tidak efektif dan dapat menimbulkan nyeri

kepala.

CPP = mean arterial presure (MAP) minus

intracranial presure (ICP).

Normal value > 70mmHg.

Critical value < 50 mmHg.

(30)

Intracranial presure.

TIK =Tekanan intra cranial normal berkisar 1-15

mmHg, yg berfluktuasi dng perubahan: BP, RR

pola nafas, batuk, mengejan.

TIK tergantung dari 3 unsur:

1). Jarinagn otak 80-87%. 1). Jarinagn otak 80-87%.

2). Cairan serebrospinal (CSS)9-10%) dan 2). Cairan serebrospinal (CSS)9-10%) dan

3). Darah yg ada dlm pembuluh darah otak 3). Darah yg ada dlm pembuluh darah otak (1-10%).

(1-10%).

Bila TIK > 16 mmHg dapat mengancam jiwa

pasien.

(31)

Reflek saraf cranial

Semua ada= 5

Bulu mata tidak ada= 4

Kornea tidak ada = 3

Doll’s tidak ada =2

Karina (semua) tidak ada= 1

(32)

Kejang (skor terbaru).

Kejang tidak ada = 5

Kejang fokal = 4

Umum , intermiten = 3

Umum kontinue = 2

Flaksid = 1

(33)

Nafas spontan

Hiperventilasi central = 3

Iregular/hipoventilasi = 2

Apnu = 1

Toatal skor = 35 terburuk = 7

(34)

Kejang (skor terbaru).

Kejang tidak ada = 5

Kejang fokal = 4

Umum , intermiten = 3

Umum kontinue = 2

Flaksid = 1

(35)

Nafas spontan

Normal = 5

Periodik =4

Hiperventilasi central = 3

Iregular/hipoventilasi = 2

Apnu = 1

Toatal skor = 35 terburuk = 7

(36)

Pain Stimulus

 _{NAIL BED COMPRESSION}_{NAIL BED COMPRESSION}

 fine ree ssrree ith焐 h焐rsb _{fine ree ssrree ith焐 h焐rsb}

 N=(+)Crers焐tng atn_{N=(+)Crers焐tng atn}

 _{STERNAL RUB}_{STERNAL RUB}

 DSP_DSP

 rse knrckle ove re _{rse knrckle ove re}

she renrs as tf “gretndtng a

tll” fore 5 se c.

 N=20-30 se c. Poshrretng _{N=20-30 se c. Poshrretng}

(tnthtal ree achton)

 Wath fore ah le ash 30 _{Wath fore ah le ash 30}

se conds

 TRAPEZIUS SQUEEZE

 rstng h焐rsb & 2

finge res, greas 2 tnc焐e s of h焐e srscle & h焐e n hitsh

SUPRAORBITAL PRESSURE

 rse h焐rsb

(37)

O

xygenation

_xygenation

Assess respiratory status. Assess respiratory status.

Maintain patent airway & adequate ventilation. Maintain patent airway & adequate ventilation.

(38)

Oxygenation

 Re shle ssne ss/ trerethab tlthy_{Re shle ssne ss/ trerethab tlthy}

 Pe ret 焐e real cyanosts_{Pe ret 焐e real cyanosts}

 Use of acce ssorey srscle s of _{Use of acce ssorey srscle s of}

ree s treahton

 Ala Nase faretng_{Ala Nase faretng}  Angtna_Angtna

 Tac焐ycaredta_{Tac焐ycaredta}  Tac焐y ne a_{Tac焐y ne a}

 GIT/ Re nal Dysfrnchton (Lahe sx)_{GIT/ Re nal Dysfrnchton (Lahe sx)}  Dx/ Lab ree srlhs: Dx/ Lab ree srlhs:

Prlse Oxtse hrey

(39)

M

otor Function

_{otor Function}

Assess integration of consciousness &

voluntary movement.

Look for purposeful or non-purposeful

response.

Also assess muscle tone, size, strength.

Observe for symmetric, spontaneous

movement of arms & legs…

(40)

Ab n=

syc焐ohreo tc drergs,

ne rreologtc dtsorede res

(Parektnson’s, MS, ore HC)

ahreo 焐y, aree sts, le gta,

facctdthy, s ashtcthy, retgtdthy

= sohore ne rreon ore srscle

dtse ase

rnree s onstve clte nhs

–焐e st le gta_{焐e st le gta} - corehtcos tnal - corehtcos tnal hreach

hreach dasage dasage

–de corehtcahe de corehtcahe - r - r e re e re corehtcos tnal

corehtcos tnal hreach dasage

hreach dasage

–de ce ree b reahe _{de ce ree b reahe} – b reatnshe s – b reatnshe s

0 No conhreachtonNo conhreachton 1

1 Sltg焐h conhreachtonSltg焐h conhreachton 2

2 Frll asstve ROMFrll asstve ROM 3

3 Frll ROMFrll ROM 4

4 Frll ROM agatnsh Frll ROM agatnsh sose ree stshance

sose ree stshance

5

5 Frll ROM agatnsh Frll ROM agatnsh frll ree stshance

(41)

P

upils

_upils

Assess for size,

shape & reaction to

light.

– Breatnshe s_{Breatnshe s}

– Mtdb reatn_{Mtdb reatn}

Pr tllarey

Asse ssse nh

– Stze _Stze

– Re achton_{Re achton}

– S焐a e …_{S焐a e …}

 _{N= 1.5-6ss (3.5 avg.)}_{N= 1.5-6ss (3.5 avg.)}

– Antsocoreta_Antsocoreta

– N_N=17%;=17%;

– Ab n_{Ab n}=He rentahton…=He rentahton…

Pupillary Size

(42)

Pupillary Reaction

– N_N==

BRTL

Dtree ch Conse nsral Ltg焐h

ree s onse

Ht rs

Ht rs – cannoh srshatn– cannoh srshatn

- conshretch h焐e n ree dtlahe s _{conshretch h焐e n ree dtlahe s}

ith焐 ltg焐h on

– I stlahe real_{I stlahe real}

Ab n=(+)le ston/ b reatn

– early CN III compressionearly CN III compression NRTL/ Fixed

NRTL/ Fixed

–Fixed Dilated_{Fixed Dilated}= = _ ICP, ICP,

Prolonged diffuse hypoxia,

Atropine

–Pinpoint pupil_{Pinpoint pupil} = Narcotics = Narcotics (Morphine, Demerol), Long

(Morphine, Demerol), Long

Acting analgesia (Fentanyl)

(43)

Pupillary Shape

- _{osh freonhal}_{osh freonhal}

/ anhe retore

O

cular Movement

_{cular Movement}

Assess for deviation to

one side.

Also assess voluntary &

(44)

S

igns

_igns

Assess V/S.

Observe for significant trends.

Look for Cushing’s reflex:



PR,



RR,

Widened Pulse Pressure…

(45)

U

rinary

_rinary

Output

Assess for increased output, possible S/S of

impaired water regulation.

Also assess for electrolyte imbalance,

especially hyponatremia…

Oliguria ( below 30 cc)…

(46)

(47)

E

mergency

_mergency

Evaluate assessment findings to determine

whether emergency exists.

If so report findings to doctor STAT…

(48)

Test for attention, concentration &

calculation.



Ask ho cornh Ask ho cornh

b ackiared freos 100,

srb hreachtng b y

se ve n e ac焐 htse

(”100, 93, 86…”).



N=Can cornh b ack N=Can cornh b ack tnho h焐e 50s ith焐tn

tnho h焐e 50s ith焐tn

one stnrhe …

(49)

Memory Memory

Test for short-term memory

 Name 3 unrelated objects Name 3 unrelated objects (e.g. car, garbage can, alarm (e.g. car, garbage can, alarm clock) then ask for these clock) then ask for these words again for within a few words again for within a few minutes



Ask client’s mother’s Ask client’s mother’s maiden name.

maiden name.

Memory Loss

Memory Loss – abnormal – abnormal & signal disease, infection

& signal disease, infection

or temporal lobe trauma…

(50)

Logic, Judgment, Reasoning & Logic, Judgment, Reasoning &

decision-making ability decision-making ability

 Test for Logic & JudgmentTest for Logic & Judgment

 Ask “What would you do if you were inside a burning Ask “What would you do if you were inside a burning building?”

building?”

 N=sound judgment. N=sound judgment.

 Abn=Frontal Lobe damage, dementia, psychosis, mental Abn=Frontal Lobe damage, dementia, psychosis, mental retardation.

retardation.

 Test for reasoning & decision-making abilityTest for reasoning & decision-making ability answering questions appropriately

answering questions appropriately

 Ask the meaning of a proverb such as “A stitch in time saves Ask the meaning of a proverb such as “A stitch in time saves nine.”

nine.”

(51)

Emotional Stability, Speech &

Language



Emotional StabilityEmotional Stability



Moods, Feeling, Thought processMoods, Feeling, Thought process

Speech & Language



Voice quality, Articulation, Content, ComprehensionVoice quality, Articulation, Content, Comprehension

 N=Spontaneous & well paced speech; logical contentN=Spontaneous & well paced speech; logical content



Ask to read a sentence form age-& education-appropriate Ask to read a sentence form age-& education-appropriate material; write name or simple sentence.

material; write name or simple sentence.



Abn=Aphasia (speech), dysarthria (articulation & rate), Abn=Aphasia (speech), dysarthria (articulation & rate),

dysphonia ( voice), apraxia (conversion of thought into motor

sound), agraphia ( writing), alexia (written language

comprehension)…

(52)

Cerebellar function

Gait

_{Ask to walk a straight heel-to-toe line.}_{Ask to walk a straight heel-to-toe line.}

– Abn=staggering, shuffling, tiptoe walking, foot _{Abn=staggering, shuffling, tiptoe walking, foot}

slap, leg drag.

– Uncoordinated gait & loss of balance_{Uncoordinated gait & loss of balance} = =

motor, sensory, vestibular or cerebellar

dysfunction.

– Cerebellar ataxia_{Cerebellar ataxia} – unsteady gait with legs – unsteady gait with legs spread wide.

spread wide.

– Scissors gait_{Scissors gait} – short, stiff steps with thighs – short, stiff steps with thighs overlapping.

overlapping.

– Foot drop - lifts knee high then slaps foot down_{Foot drop - lifts knee high then slaps foot down}

– Parkinsonian shuffle_{Parkinsonian shuffle} – accompanied by stooped – accompanied by stooped posture

posture

– Spastic paralysis_{Spastic paralysis} - arms flexed & held to the - arms flexed & held to the body, client “throws” each leg forward…

(53)

Cerebellar function

Cerebellar function BalanceBalance

Romberg’s test

– arms at sides, feet together, arms at sides, feet together,

– eyes closed for 20 seconds. _{eyes closed for 20 seconds.}

– Watch for loss of balance._{Watch for loss of balance.}

– Stand close enough to prevent falling. _{Stand close enough to prevent falling.}

N=slight swaying.

Abn

– loss of balance_{loss of balance}

– (+) Romberg_{(+) Romberg}

cerebellar ataxia, alcohol intoxication, MS,

impaired visual functioning, or loss of

proprioception.

Test for coordination, muscle strength, & cerebellar function

Test for coordination, muscle strength, & cerebellar function – Ask to stand on 1 foot & do a shallow knee-bend, or hop,. Ask to stand on 1 foot & do a shallow knee-bend, or hop,.

Abn= Cerebellar dysfunction or lack of physical

fitness…

(54)

Cerebellar function

(Rapid alternating movements

(Rapid alternating movements; ; Accuracy of movement

Accuracy of movement; Balance; Gait); Balance; Gait)

Rapid Alternating Movement (RAM) of the hands & fingers

Rapid Alternating Movement (RAM) of the hands & fingers - -

– assesses coordination & dexterity. Pat knees with the palms, then flip assesses coordination & dexterity. Pat knees with the palms, then flip & do so with the back of the hands, first slowly then faster.

& do so with the back of the hands, first slowly then faster.

– N=smooth & bilateral movementN=smooth & bilateral movement

– Abn=slow, awkward movement= cerebellar dysfunction_{Abn=slow, awkward movement= cerebellar dysfunction}

Ask to touch thumb to each finger from index to 5

Ask to touch thumb to each finger from index to 5thth finger & back finger & back

again, slowly at first then faster. Repeat on the other hand. again, slowly at first then faster. Repeat on the other hand.

Abn=Dyssenergy (lack of coordinated muscle movement) =upper neuron Abn=Dyssenergy (lack of coordinated muscle movement) =upper neuron weakness, cerebellar disease, EP dysfunction.

weakness, cerebellar disease, EP dysfunction.

Finger-to-nose coordination test

– Ask to touch index finger to nose then to the examiner’s outstretched _{Ask to touch index finger to nose then to the examiner’s outstretched} vertical finger to different points.

vertical finger to different points.

Abn=Dyssnergy, Dysmetria (misjudgment of distance, speed & Abn=Dyssnergy, Dysmetria (misjudgment of distance, speed & force of movement = cerebellar dysfunction…

(55)

Sensory function

_{Superficial Pain & Touch Sensation}_{Superficial Pain & Touch Sensation}

– test distal points on arms & legstest distal points on arms & legs

– Eyes closed.Eyes closed.

– Examine Arms, Legs & Abdomen. _{Examine Arms, Legs & Abdomen.}

– Assess sensitivity to light touch with a wisp of cotton (distal to _{Assess sensitivity to light touch with a wisp of cotton (distal to}

proximal).

– Ask to say “now” when each sensation is felt.Ask to say “now” when each sensation is felt.

Sharp object (opened paper clip). Ask whether she feels a sharp or

dull sensation.

Temperature sensitivity

- 2 test tubes (1 filled with hot & 1 with cold water, along the

same routes.

Abn=Peripheral nerve problem: paresthesia &

impairment in touch sensation (Anesthesia, Hypoanesthesia).

Pain sensitivity

Pain sensitivity – analgesia, hypalgesia, – analgesia, hypalgesia, hyperalgesia…

(56)

Proprioception, Vibratory sensation

 Proprioception_{Proprioception} – (tested on great toe & hands) – sense motion, – (tested on great toe & hands) – sense motion, position, & vibration

position, & vibration

– Hands (sides of index finger between thumb & index finger). Hands (sides of index finger between thumb & index finger). Eyes closed. Move finger up or down. Ask client to describe

Eyes closed. Move finger up or down. Ask client to describe

direction. Repeat on other hand & in both great toes. If (+) abn

proceed to next proximal joint.

Abn=peripheral neuropathy or lesion in the posterior spinal

column, sensory cortex, or thalamus.

 Vibratory sensation_{Vibratory sensation} – stem of vibrating tuning fork against client’s – stem of vibrating tuning fork against client’s distal finger or great toe. Ask to say “now” if vibration is felt. Proceed

distal finger or great toe. Ask to say “now” if vibration is felt. Proceed

to next proximal joint if abn…

(57)

Cortical sensation Cortical sensation

(stereognosis, graphesthesia, 2-point

discrimination)

Stereognosis

Stereognosis – recognizing objects by feel. – recognizing objects by feel.

– Eyes closed. Identify familiar objects (e.g. key). Repeat on other hand Eyes closed. Identify familiar objects (e.g. key). Repeat on other hand with different object.

with different object.

Abn=Astereognosis = parietal lobe problems

Graphesthesia

Graphesthesia – identify shapes, numbers, or letters traced on the skin. – identify shapes, numbers, or letters traced on the skin.

– Eyes closed. Use blunt object such as closed paper clip to draw shape, Eyes closed. Use blunt object such as closed paper clip to draw shape, letter or number on the palm. Repeat on the other palm.

letter or number on the palm. Repeat on the other palm.

Abn=Graphanesthesia = parietal lobe problems.

2-point discrimination

2-point discrimination – touching 2 identical sharp objects (e.g. Opened – touching 2 identical sharp objects (e.g. Opened paper clips) to the skin in close proximity, while eyes closed.

paper clips) to the skin in close proximity, while eyes closed.

– Ask whether she feels 1 or 2 points, noting distance between 2 points. _{Ask whether she feels 1 or 2 points, noting distance between 2 points.}

Repeat test on arms, legs, face & abdomen, decreasing the actual

distance between the points until client feels 2 points as one.

N=distance-2 to 20 mm.

Abn=parietal lobe problem…

(58)

Superficial /Cutaneous Reflexes

– T8-T10 spinal nerves - controls upper abdominal muscles_{T8-T10 spinal nerves - controls upper abdominal muscles}

– T10-T12 – lower abdominalsT10-T12 – lower abdominals Dorsal Recumbent.

Dorsal Recumbent.

Blunt tipped object (cotton swab).

Scratch each abdominal quadrant lightly (lateral to midline,

high to low)

– N=muscle contraction & slight shift of umbilicus _{N=muscle contraction & slight shift of umbilicus}

towards the stimulus.

Plantar Reflex (Babinski)

– controlled by L4 & L5, S1 & S2controlled by L4 & L5, S1 & S2

Stroke foot sole with the handle of a reflex hammer. Run

the edge along the outer heel up to the ball of the foot.

Repeat on the other foot.

– N=toe flexion (except in infant)_{N=toe flexion (except in infant)}

Abn=Dorsiflexion of big Toe, Fanning of Little

Toes (except in infant) Pyramidal Tract / Upper

Motor Neuron Damage…

(59)

Superficial /Cutaneous Reflexes

Cremasteric, Anal

Cree sashe retc Re fe x

Cree sashe retc Re fe x - _{T12 – L2}_{T12 – L2}

- _{Fore ge nthorretnarey cos latnhs only tn se n.}_{Fore ge nthorretnarey cos latnhs only tn se n.}

- Ltg焐hly shreoke h焐e tnne re h焐tg焐_{Ltg焐hly shreoke h焐e tnne re h焐tg焐}

N=screohal e le vahton on h焐e shtsrlahe d stde

Anal Re fe x

Anal Re fe x - _S3-S5_S3-S5

- Ge nhly horc焐tng areornd h焐e anrs ith焐 a cohhon _{Ge nhly horc焐tng areornd h焐e anrs ith焐 a cohhon}

siab ore glove d finge re

N=conhreachton of ree chal s 焐tnche re…

(60)

Deep Tendon Reflexes

Biceps, Triceps, Patellar, Achilles,

Brachioradialis

Re qrtree s reachtce & a ree laxe d clte nh.

Sthhtng ith焐 fe e h dangltng. Easte re tf

rse d ith焐 dtshreachtons.

Potnhe d 焐asse re – ssall he ndons

Flah e nd – larege re he ndons

he sh fore ankle clonrs(re焐yh焐stc

conhreachton).

– N=(-)Patn & tnvolrnharey sove se nhN=(-)Patn & tnvolrnharey sove se nh

– Ab n= Clonrs=sohore ne rreon Ab n= Clonrs=sohore ne rreon dysfrnchton

dysfrnchton

l _{Deep Tendon Reflexes}_{Deep Tendon Reflexes}

(DTR) GRADING

DTR GRADEDTR GRADE ResponseResponse

3+ Slightly increasedSlightly increased 4+

(61)

Jenis intervensi FT ICU

1.

Posisioning.

_Posisioning.

2.

Oksigen terapi

3.

Stimulasi/ fasilitasi dan inhibisi.

4.

Breathing.

5.

Chest FT.

_{Chest FT.}

6.

Inhalasi.

_Inhalasi.

7.

Mobilisasi/ ambulasi

_{Mobilisasi/ ambulasi}

8.

(62)

Chest Fisioterapi

1. P D.

2. Topotement / klepping

3. Breathing

4. Coughing/huffing.

5. assisted coughing hafing.

Chest PT dapat dilakukah pre medikasi dengan:

stimulasi, inhalasi, rileksasi dll

Post chest PT dpt dilakukan: mobilisasi ambulasi

dan tranvers.

(63)

_Inhalasi.

 Chest fisioterapi.

 Mobilisasi

 Ambulasi



Educasi

(64)

Retained seiretions

Partially oiilude

Uneven distribution of ventilation

V/Q mismatihing

Hypoxemia

Complete oiilude

Shunting blood

V_/Q_

(65)

Postural drainage position (PD)

Posisi dengan meluruskan segmen

bronchi dengan gravitasi , jadi sekresi

diakumulasi pada segmen

bronchopulmonari bergerak ke arah central

dan dikeluarkan dengan batuk , dan

dengan mudah meludah

(66)

(67)

(68)

Upper lobe

1.

1. Half supine lying = Atas depan R/L._{Half supine lying = Atas depan R/L.}

2.

2. Half prone lying = Atas belakang R/L_{Half prone lying = Atas belakang R/L}

3.

3. Half supine lying R up = Atas depan R_{Half supine lying R up = Atas depan R}

4.

4. Half Supine lying L up = Atas depan L_{Half Supine lying L up = Atas depan L}

5.

5. Half prone lying R up = Atas belakang R_{Half prone lying R up = Atas belakang R}

6.

6. Half prone lying L up = Atas belakang L_{Half prone lying L up = Atas belakang L}

7.

7. Half Right side lying = Atas samping kiri_{Half Right side lying = Atas samping kiri}

8.

(69)

(70)

(71)

Pe rekrst dan Vtb reast

= Manipulasi eksternal dari area toraks yang berfungsi untuk mobilisasi untuk membantu proses sekresi.

Perkusi : Tepukan yang iepat, iupping

( dengan tangan berbentuk mangkok ) dari bagian eksternal thorax, seiara langsung tepat diatas saluran segmen paru .

Mekanika perkusi : Gelombang mekanik dari energi yang dihasilkan diperiaya akan

(72)

(73)

(74)

(75)

Vibrasi : Gerakan yang

menyebabkan

getaran dilakukan secara manual dari gerakan menekan langsung pada

area ribs dan soft fissure dada

normal bergerak selama exhalasi (pengeluaran

(76)

(77)

(78)

(79)

(80)

(81)

Pada ICU bedside

-Baca status dengan teliti dan perhatikan a . Vital Sign monitor.

b. ventilation parameter

c. Alat-alat medis lain : EKG, Infus, Sounde dll - Mengaplikasikan teknik FT yang tepat

- Closed observation and continuously monitored selama Rx

- Mengassesment kembali pada akhir Rx - Sebelum meninggalkan pasien, FT harus memastikan bahwa semua alarm sudah di aktifkan, VS stabil, pasien merasa aman dan nyaman.

(82)

Hal-hal yang menjadi pertimbangan untuk FT. pada ICU Closed observation and continuously monitoring

- patient ‘s ability to tolerate PT Rx

- ventilated patient / penerunan tingkat kesadaran / jeleknya gag (sumbatan) reflex aspiration

- perawatan yang tepat minimize cross-infection

- peningkatan tekanan aliran darah

- tingginya PAP

- arrhythmia

- vital sign

- level of ICP

(83)

ICU: Mempunyai masalah komplek.

Dikerjakan secara team.

FT harus ingat perasaan dan rasa takut pasien yang dapat membuat mereka tidak natural terhadap

lingkungannya

- ketidakmampuan untuk bicara

- loss of perception of time

(84)

Thank

you

For

Your

(85)

THANK YOU

FOR

LISTENING !

GOOD DAY !

and

T焐e

END !

What are the

3 objects

shown a

while ago?

Any

(86)

(87)

(88)

(89)

: Postural Drainage dengan perkusi dan vibrasi memfasilitasi pergerakan sekresi

: Perkusi sendiri dapat menyebabkan :

•FEV₁

•menyebabkan hypoxemia

tetapi efek negatifnya dapat dicegah jika breathing

exercises tergabung ke dalam program Rx

(90)

Selama perkusi dan vibrasi FT harus observasi ekspresi wajah pasien karena nyeri atau tidak nyaman

Konsekuensi nyeri :

- muscle splinting

- meningkatkan kerja pernapasan

- konsumsi O2 meningkat

(91)

Breathing exercises (BE)

Otot2 ventilasi`terdiri dari otot diaphragma dan otot intercostal, bertindak sebagai “pump muscles” yang berfungsi menggerakan tulang thorax, menyebabkan intrathoracic pressure, lalu hasilnya aliran udara masuk ke paru2,

Otot larynx and pharynx bertindak sebagai “valves

(92)

(93)

Inspirasi Aktif

 Expansi paru-paru pada 3 bagian :

- antero – posterior - transverse

- longitudinal

 Pump handle movement terjadi pada upper ribs

 Bucket handle movement terjadi pada lower ribs

(94)

(95)

Teknik Pembuangan Sekresi

Suction (penyedotan)

Batuk

(96)

(97)

Pola-pola BE

- Diaphragmatic BE

- Costal BE (thoracic expansion exercise) - Pursed lips breathing (PLB)

- Sustained maximal inspiration (SMI)

(98)

Collateral ventilation

- Channels of Martin (interbronchiolar channel)