Intensive Intensive care unit care unit Physical Physical therapytherapy

by:by:Slamet Slamet

Sumarno.Sumarno.

Fisioterapi ICUFisioterapi ICUIntensive 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. Kondisi yg memerlukan perawat intensive.

Gagal nafas.Gagal nafas.

Pengertian.Pengertian.

Gagal nafas diartikan sebagai kegagalan Gagal nafas diartikan sebagai kegagalan pertukaran gas dlm paru yg ditandai pertukaran gas dlm paru yg ditandai dengan turunnya kadar oksigen di arteri dengan turunnya kadar oksigen di arteri (hipoksimia) atau naiknya kadar (hipoksimia) atau naiknya kadar karbondiaksida (hiperkarbia) atau karbondiaksida (hiperkarbia) atau kombinasi keduanya.kombinasi keduanya.

Kriteria diagnosa gagal nafas.Kriteria diagnosa gagal nafas.

PaO2 < PaO2 < 60mmHg, 60mmHg, PaCO2 > 49 PaCO2 > 49 mmHg tanpa mmHg tanpa gangguan gangguan alkalosis alkalosis metabolik primermetabolik primer

(Muhadi,OE Tampubolon, 1989)(Muhadi,OE Tampubolon, 1989)

Pemeriksaan lab Gas DarahPemeriksaan lab Gas Darah

Asidosis acut respiratory acidosisAsidosis acut respiratory acidosis a 7.1 metabolik acidosis a 7.1 metabolik acidosis r 7.2 chronic respiratoryr 7.2 chronic respiratory t 7.3 acidosist 7.3 acidosis e 7.4e 7.4 r 7.5 metabolik alkalosisr 7.5 metabolik alkalosis I 7.6 respiratory alkalosisI 7.6 respiratory alkalosis 7.7 2 4 6 8 10 12 7.7 2 4 6 8 10 12 Alkalosis PH= 7,35-7,4 PCO2= 5-6 kpaAlkalosis PH= 7,35-7,4 PCO2= 5-6 kpa

Etiologi Gagal nafas.Etiologi Gagal nafas.

Penyakit akut atau kronik kembali akut.Penyakit akut atau kronik kembali akut.

Acut dan Acut on chonic respiratory failureAcut dan Acut on chonic respiratory failure

(hipersekresi, spasme bronkus, edema (hipersekresi, spasme bronkus, edema mukosa).mukosa).

Spasme bronkus pada: Asma, bronkitis Spasme bronkus pada: Asma, bronkitis kronik yg berkembang menjadi emfisemakronik yg berkembang menjadi emfisema

Lanjutan.Lanjutan.

1.1. Otak: Neoplasma, Epilepsi, Hematoma Otak: Neoplasma, Epilepsi, Hematoma subdural, Keracunan morfin dan CVA.subdural, Keracunan morfin dan CVA.

2.2. Susunan neuromuskular: Miastenia gravis, Susunan neuromuskular: Miastenia gravis, Polyneuritis, Analgesia spinal tinggi, Polyneuritis, Analgesia spinal tinggi, kelumpuhan otot respirasi.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.edema paru.5.5. kardiovaskuler: Gagal jantung, emboli paru.kardiovaskuler: Gagal jantung, emboli paru.6.6. Pasca bedah: laparatomi dllPasca bedah: laparatomi dll

Komplikasi rawat ICU.

Peningkatan resiko infeksi nosocomial atelectasis

Mechanics ventilasi pasien yang memungkinkan terjadi penurunan FRC dan CL , V/Q nya tidak sebanding ۬

immobilisasi pada pasien dengan penyakit kritis yang menderita muscle deconditioning, peningkatan resiko DVT, pressure sore

ProblemProblem

Koknetif

gerak sikap

Manusia

Problematik umum

1. Gangguan pernafasan.2. Gangguan Jantung dan

sirkulasi.3. Gangguan Hormonal dan

bufer.4. Gangguan sistem syaraf.5. Kecerdasan menangkap

perintah.6. Ganguan perilaku.

PROBLEM PERNAFASAN.PROBLEM PERNAFASAN.Oleh karena:Oleh karena:

1.1. Gangguan systen neurologi.Gangguan systen neurologi.

2.2. Gangguan Sangkar thorak.Gangguan Sangkar thorak.

3.3. Gangguan jalan nafas / obtruktif.Gangguan jalan nafas / obtruktif.

4.4. Gangguan pleurae.Gangguan pleurae.

5.5. Gangguan perfusi / restriktif.Gangguan perfusi / restriktif.

6.6. Gangguan system sirkulasi pulmonal.Gangguan system sirkulasi pulmonal.

7.7. Gabungan satu sampai enamGabungan satu sampai enam

Tujuan Fisioterapi ICUTujuan 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 b. Breathing exercises

B. Fungsi Musculoskeletal

1. Joint function / movement

2. Performance kerja otot.

3. Balance, coordination, komunikasi

4. Performance fisik : ambulation / ADL

C. Fungsi Neuromuskular.C. Fungsi Neuromuskular.

1.1. Sensasi, Sensasi,

2.2. stimulasi, stimulasi,

3.3. Inhibisi.Inhibisi.

D. D. Edukasi .Edukasi .

E. E. Mencapai goul Mencapai goul (harapan)(harapan)..

F.F. Evaluasi .Evaluasi .

PROSES FISIOTERAPIPROSES FISIOTERAPI

Assessment /reassessment Mesurment. / remesurment

Analysis of findings Intervensi/Implementation of treatment / modifikasi

Problems identification

Planning of treatment

Diagnosa fisioterapi

Evidence Evidence BasedBased Medicine (EBM) Medicine (EBM)

““Menggunakan segala pertimbangan Menggunakan segala pertimbangan bukti ilmiah (evidence) yang sahih yang bukti ilmiah (evidence) yang sahih yang diketahui hingga kini untuk menentukan diketahui hingga kini untuk menentukan pengobatan pada penderita yang pengobatan pada penderita yang sedang kita hadapi”.sedang kita hadapi”.

Merupakan penjabaran bukti ilmiah Merupakan penjabaran bukti ilmiah lebih lanjut setelah obat dipasarkan dan lebih lanjut setelah obat dipasarkan dan seiring dengan pengobatan rasional.seiring dengan pengobatan rasional.

Lima tahap evidence basedLima tahap evidence based

Memformulasikan pertanyaan tentang masalah Memformulasikan pertanyaan tentang masalah fisioterapi yang dihadapi fisioterapi yang dihadapi

Menelusuri bukti-bukti terbaik yang tersedia Menelusuri bukti-bukti terbaik yang tersedia untuk mengatasi masalah tersebut untuk mengatasi masalah tersebut

Mengkaji bukti, validitas dan keseuaiannya Mengkaji bukti, validitas dan keseuaiannya dengan kondisi praktek dengan kondisi praktek

Menerapkan hasil kajian Menerapkan hasil kajian

Mengevaluasi penerapannya (kinerjanya) Mengevaluasi penerapannya (kinerjanya)

Assessment FT Kritis Di ICUAssessment 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 gerak fungsional.

2. Kenali alat dan monitor yg ada2. Kenali alat dan monitor yg adaa.a. Sounde. Tentukan ukuran soude yang masuk Sounde. Tentukan ukuran soude yang masuk

oesophagus.oesophagus.b.b. Thrachea tube : tentukan ukuran panjang yang Thrachea tube : tentukan ukuran panjang yang

masuk thrachea. 18, 19, 20, 21, 22 dst masuk thrachea. 18, 19, 20, 21, 22 dst biasanya dewasa 22 cm.biasanya dewasa 22 cm.

c.c. Tentukan apakah monitor EKG berfungsi Tentukan apakah monitor EKG berfungsi dengan baik ( terutama elektrode yg terpasang dengan baik ( terutama elektrode yg terpasang pada dada dan tangan atau kaki biola ada.pada dada dan tangan atau kaki biola ada.

d.d. Tentukan ventilator berfungsi dengan baik, Tentukan ventilator berfungsi dengan baik, menggunakan inhalasi atau tidak, menggunakan inhalasi atau tidak,

e.e. Monitor Vital sign.Monitor Vital sign.

Assesment / mesurment.Assesment / mesurment.

Vital sign.Vital sign.

Fungsi tingkat kesadaran.Fungsi tingkat kesadaran.

Fungsi jalan nafas dan paruFungsi jalan nafas dan paru

Fungsi jantung dan sirkulasi.Fungsi jantung dan sirkulasi.

Fungsi sangkar torak : sendi, otot dan tlFungsi sangkar torak : sendi, otot dan tl

Fungsi umum: sendi, otot, gerak Fungsi umum: sendi, otot, gerak

Kesadaran.Kesadaran.

Kesadaran diobsevasi dari mata.Kesadaran diobsevasi dari mata.1.1. Tidak mampu membuka mata.Tidak mampu membuka mata.2.2. Mampu membuka mata dengan Mampu membuka mata dengan

rangsang sentuhan nyeri.rangsang sentuhan nyeri.3.3. Membuka mata dengan rangsang lebih Membuka mata dengan rangsang lebih

keras.keras.4.4. Membuka mata dengan rangsang ringan Membuka mata dengan rangsang ringan

dan lama (spontan)dan lama (spontan)

Glasgow coma scaleGlasgow coma scale

Eye Opening E

spontaneous 4

to speech 3

to pain 2

no response 1

Best Motor Response

M

To Verbal Command:

obeys 6

To Painful Stimulus:

localizes pain 5

flexion-withdrawal 4

flexion-abnormal 3

extension 2

no response 1

Best Verbal Response

V

oriented and converses

5

disoriented and converses

4

inappropriate words

3

incomprehensible sounds

2

no response 1

E + M + V = 3 to 15E + M + V = 3 to 15

GLASGOW COMA SCALEGLASGOW COMA SCALE

DescriptionDescription SpontaneouslySpontaneously

To SpeechTo Speech

To PainTo Pain

Do not OpenDo not Open

OrientedOriented

ConfusedConfused

Inappropriate SpeechInappropriate Speech

Unintelligible speechUnintelligible speech

No verbalizationNo verbalization

Obeys CommandObeys Command

Localizes PainLocalizes Pain

Withdraws from painWithdraws from pain

Abnormal FlexionAbnormal Flexion

Abnormal ExtensionAbnormal Extension

No Motor ResponseNo Motor Response

SubscaleSubscale

EYE OPENINGEYE OPENING

(E)(E)

VERBAL VERBAL RESPONSERESPONSE

(V)(V)

MOTOR MOTOR RESPONSERESPONSE

(M)(M)

ScoreScore44

33

22

11

55

44

33

22

11

66

55

44

33

22

11

* Clients who are unable to cooperate can be evaluated using this scale

Best Score = 15Worse = 3

Scoring E4 V5 M6ES - Eyes swollen

Untestable = (+) dressingETTRParesisPlegiaTractionCast

FORMS OF FORMS OF STIMULISTIMULI

VVERBALERBALVOICEVOICESHOUTSHOUT

TTACTILEACTILETOUCHTOUCHTAP/ SHAKETAP/ SHAKE

PPAINAINSUPERFICIALSUPERFICIALDEEPDEEP

LOCLOC

VVerbalerbal TTactile actile PPainain

ConsciousConscious (+) (+) (+) (+) (+) (+)

LethargicLethargic (+) (+) (+) (+) * (+) (+) *

StuporousStuporous (-) (-) (-) (+) (-) (+)

ComatoseComatose (-) (-) (-) (-) (-) (-)

Respon pupil thd cahayaRespon pupil thd cahaya

Normal = 5Normal = 5

Lambat= 4Lambat= 4

Respon tidak sama = 3Respon tidak sama = 3

Besar tidak sama = 2Besar tidak sama = 2

Tidak ada respon = 1Tidak ada respon = 1

Reflek saraf cranialReflek saraf cranial

Semua ada= 5Semua ada= 5

Bulu mata tidak ada= 4Bulu mata tidak ada= 4

Kornea tidak ada = 3Kornea tidak ada = 3

Doll’s tidak ada =2Doll’s tidak ada =2

Karina (semua) tidak ada= 1Karina (semua) tidak ada= 1

Kejang (skor terbaru).Kejang (skor terbaru).

Kejang tidak ada = 5Kejang tidak ada = 5

Kejang fokal = 4Kejang fokal = 4

Umum , intermiten = 3Umum , intermiten = 3

Umum kontinue = 2Umum kontinue = 2

Flaksid = 1Flaksid = 1

Nafas spontanNafas spontan

Normal = 5Normal = 5

Periodik =4Periodik =4

Hiperventilasi central = 3Hiperventilasi central = 3

Iregular/hipoventilasi = 2Iregular/hipoventilasi = 2

Apnu = 1Apnu = 1

Toatal skor = 35 terburuk = 7Toatal skor = 35 terburuk = 7

Pain StimulusPain Stimulus

NAIL BED COMPRESSIONNAIL BED COMPRESSION fine pressure with thumb fine pressure with thumb

over pencil on the base over pencil on the base of the cuticleof the cuticle

Test bilaterallyTest bilaterally N=(+)Crushing painN=(+)Crushing pain

STERNAL RUBSTERNAL RUB DSPDSP use knuckle over use knuckle over

sternum as if “grinding a sternum as if “grinding a pill” for 5 sec.pill” for 5 sec.

N=20-30 sec. Posturing N=20-30 sec. Posturing (initial reaction)(initial reaction)

Wait for at least 30 Wait for at least 30 secondsseconds

TRAPEZIUS SQUEEZE using thumb & 2 fingers, grasp 2 inches of the muscle & then twist

SUPRAORBITAL PRESSURE use thumb C/I: Cranial fracture

OOxygenationxygenation

Assess respiratory status. Assess respiratory status.

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

Watch for S/S of hypoxia & hypercapnia…Watch for S/S of hypoxia & hypercapnia…

OxygenationOxygenationNote for S/S ofNote for S/S of Hypoxia/ Hypoxia/ hypoxemiahypoxemia

(-) Spontaneous respiration(-) Spontaneous respiration Restlessness/ irritabilityRestlessness/ irritability Peripheral cyanosisPeripheral cyanosis Use of accessory muscles of Use of accessory muscles of

respirationrespiration Ala Nase flaringAla Nase flaring AnginaAngina TachycardiaTachycardia TachypneaTachypnea GIT/ Renal Dysfunction (Late sx)GIT/ Renal Dysfunction (Late sx) Dx/ Lab results: Dx/ Lab results:

Pulse OximetryPulse Oximetry

CapnographyCapnography

ABGABG

Hematology (hct; hgb)…Hematology (hct; hgb)…

MMotor Functionotor Function

Assess integration of consciousness & Assess integration of consciousness & voluntary movement. voluntary movement.

Look for purposeful or non-purposeful Look for purposeful or non-purposeful response. response.

Also assess muscle tone, size, strength. Also assess muscle tone, size, strength. Observe for symmetric, spontaneous Observe for symmetric, spontaneous

movement of arms & legs…movement of arms & legs…

Abn= Abn=

tics, tremorstics, tremors

= stress, long term = stress, long term use of psychotropic drugs, use of psychotropic drugs, neurologic disorders neurologic disorders (Parkinson’s, MS, or HC)(Parkinson’s, MS, or HC)

atrophy, paresis, atrophy, paresis, plegia, flaccidity, spasticity, plegia, flaccidity, spasticity, rigidityrigidity = motor neuron or = motor neuron or muscle diseasemuscle disease

unresponsive clientsunresponsive clients–hemiplegiahemiplegia - corticospinal - corticospinal tract tract damagedamage–decorticatedecorticate - upper - upper corticospinal corticospinal tract tract damagedamage–decerebratedecerebrate – brainstem – brainstem damagedamage

MUSCLE STRENGTH MUSCLE STRENGTH GRADINGGRADING

GradeGrade Description Description

00 No contractionNo contraction

11 Slight contractionSlight contraction

22 Full passive ROMFull passive ROM

33 Full ROMFull ROM

44 Full ROM against Full ROM against some resistancesome resistance

55 Full ROM against Full ROM against full resistancefull resistance

PPupilsupilsAssess for size, Assess for size,

shape & reaction to shape & reaction to light. light.

Observe for ptosis…Observe for ptosis…

Controlled by: Controlled by: – CN-III CN-III – BrainstemBrainstem– MidbrainMidbrain

Pupillary Pupillary AssessmentAssessment– SizeSize– ReactionReaction– Shape…Shape…

N= 1.5-6mm (3.5 avg.)N= 1.5-6mm (3.5 avg.)– AnisocoriaAnisocoria– NN=17%;=17%;

– AbnAbn=Herniation…=Herniation…

Pupillary SizePupillary Size

Pupillary ReactionPupillary Reaction– NN==

BRTLBRTL

Direct Consensual Light Direct Consensual Light responseresponse

Hippus Hippus – cannot sustain– cannot sustain- constrict then redilates constrict then redilates

with light onwith light on

– BilateralBilateral Hippus Hippus

Abn= Seizure, Abn= Seizure, MeningitisMeningitis

– IpsilateralIpsilateral

Abn=(+)lesion/ brain Abn=(+)lesion/ brain tumortumor

AbnAbn= = SRTLSRTL

– – early CN III compressionearly CN III compression

NRTL/ FixedNRTL/ Fixed–Fixed DilatedFixed Dilated= = ICP, ICP, Prolonged diffuse hypoxia, Prolonged diffuse hypoxia, AtropineAtropine

–Pinpoint pupilPinpoint pupil = Narcotics = Narcotics (Morphine, Demerol), Long (Morphine, Demerol), Long Acting analgesia (Fentanyl)Acting analgesia (Fentanyl)

Pupillary ShapePupillary Shape

NN=Round=Round

AbnAbn=oval – =oval – ICP ICP (15-20mmHg)(15-20mmHg)

- post frontal post frontal / anterior / anterior temporal temporal lesionslesions

- ContusionsContusions……

OOcular Movementcular Movement

Assess for deviation to Assess for deviation to one side. one side.

Also assess voluntary & Also assess voluntary & spontaneous spontaneous movement…movement…

EOM – controlled by CN EOM – controlled by CN – III, IV, VI…III, IV, VI…

SSignsigns

Assess V/S. Assess V/S.

Observe for significant trends. Observe for significant trends.

Look for Cushing’s reflex: Look for Cushing’s reflex:

PR, PR,

RR, RR,

Widened Pulse Pressure…Widened Pulse Pressure…

UUrinary rinary OutputOutput

Assess for increased output, possible S/S of Assess for increased output, possible S/S of impaired water regulation. impaired water regulation.

Also assess for electrolyte imbalance, Also assess for electrolyte imbalance, especially hyponatremia…especially hyponatremia…

Oliguria ( below 30 cc)…Oliguria ( below 30 cc)…

RReflexeseflexes

Assess for Assess for pathologic pathologic reflexes, reflexes,

especially especially babinskibabinski & &

lossloss of of corneal corneal or or gag gag

reflex…reflex…

Corneal Corneal – PonsPons– MedullaMedulla

Gag/ CoughGag/ Cough– MedullaMedulla– CN IX CN IX – CN X…CN X…

EEmergencymergency

Evaluate assessment findings to determine Evaluate assessment findings to determine whether emergency exists. whether emergency exists.

If so report findings to doctor STAT…If so report findings to doctor STAT…

Test for attention, concentration & Test for attention, concentration & calculation.calculation.

Ask to count Ask to count backward from 100, backward from 100, subtracting by subtracting by seven each time seven each time (”100, 93, 86…”). (”100, 93, 86…”).

N=Can count back N=Can count back into the 50s within into the 50s within one minute…one minute…

MemoryMemory

Test for short-term memoryTest for short-term memory

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

Test for long term memoryTest for long term memory

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

Memory LossMemory Loss – abnormal – abnormal & signal disease, infection & signal disease, infection or temporal lobe trauma…or temporal lobe trauma…

Logic, Judgment, Reasoning & Logic, Judgment, Reasoning & decision-making abilitydecision-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 appropriatelyanswering questions appropriately

Ask the meaning of a proverb such as “A stitch in time Ask the meaning of a proverb such as “A stitch in time saves nine.”saves nine.” Abn=low intellect, dementia, schizophrenia…Abn=low intellect, dementia, schizophrenia…

Emotional Stability, Speech & Emotional Stability, Speech & LanguageLanguage

Emotional StabilityEmotional Stability

Moods, Feeling, Thought processMoods, Feeling, Thought process

Speech & LanguageSpeech & 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 dysphonia ( voice), apraxia (conversion of thought into motor sound), agraphia ( writing), alexia (written language sound), agraphia ( writing), alexia (written language comprehension)…comprehension)…

Cerebellar functionCerebellar function GaitGait

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. slap, leg drag. – Uncoordinated gait & loss of balanceUncoordinated gait & loss of balance = =

motor, sensory, vestibular or cerebellar motor, sensory, vestibular or cerebellar dysfunction.dysfunction.

– Cerebellar ataxiaCerebellar ataxia – unsteady gait with legs – unsteady gait with legs spread wide.spread wide.

– Scissors gaitScissors gait – short, stiff steps with thighs – short, stiff steps with thighs overlapping.overlapping.

– Foot drop - lifts knee high then slaps foot downFoot drop - lifts knee high then slaps foot down– Parkinsonian shuffleParkinsonian shuffle – accompanied by stooped – accompanied by stooped

postureposture– Spastic paralysisSpastic paralysis - arms flexed & held to the - arms flexed & held to the

body, client “throws” each leg forward…body, client “throws” each leg forward…

Cerebellar functionCerebellar function BalanceBalance

Romberg’s testRomberg’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. N=slight swaying.

AbnAbn– loss of balanceloss of balance

– (+) Romberg(+) Romberg

cerebellar ataxia, alcohol intoxication, MS, cerebellar ataxia, alcohol intoxication, MS, impaired visual functioning, or loss of impaired visual functioning, or loss of proprioception.proprioception.

Test for coordination, muscle strength, & cerebellar functionTest 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 Abn= Cerebellar dysfunction or lack of physical fitness…fitness…

Cerebellar functionCerebellar function (Rapid alternating movements(Rapid alternating movements; ;

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

Rapid Alternating Movement (RAM) of the hands & fingersRapid 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 dysfunctionAbn=slow, awkward movement= cerebellar dysfunction

Ask to touch thumb to each finger from index to 5Ask to touch thumb to each finger from index to 5 thth 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) Abn=Dyssenergy (lack of coordinated muscle movement) =upper neuron weakness, cerebellar disease, EP dysfunction.=upper neuron weakness, cerebellar disease, EP dysfunction.

Finger-to-nose coordination testFinger-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…force of movement = cerebellar dysfunction…

Sensory functionSensory functionSuperficial Pain & Touch SensationSuperficial 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). 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 Sharp object (opened paper clip). Ask whether she feels a sharp or dull sensation.dull sensation.

Temperature sensitivityTemperature sensitivity

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

Abn=Peripheral nerve problem: paresthesia & impairment in Abn=Peripheral nerve problem: paresthesia & impairment in touch sensation (Anesthesia, Hypoanesthesia). touch sensation (Anesthesia, Hypoanesthesia).

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

Proprioception, Vibratory sensationProprioception, Vibratory sensation

ProprioceptionProprioception – (tested on great toe & hands) – sense motion, – (tested on great toe & hands) – sense motion, position, & vibrationposition, & 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 direction. Repeat on other hand & in both great toes. If (+) abn proceed to next proximal joint. proceed to next proximal joint.

Abn=peripheral neuropathy or lesion in the posterior spinal Abn=peripheral neuropathy or lesion in the posterior spinal column, sensory cortex, or thalamus. column, sensory cortex, or thalamus.

Vibratory sensationVibratory 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…to next proximal joint if abn…

Cortical sensation Cortical sensation (stereognosis, graphesthesia, 2-point (stereognosis, graphesthesia, 2-point

discrimination)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 problemsAbn=Astereognosis = parietal lobe problems

GraphesthesiaGraphesthesia – 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.Abn=Graphanesthesia = parietal lobe problems.

2-point discrimination2-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 Repeat test on arms, legs, face & abdomen, decreasing the actual distance between the points until client feels 2 points as one. distance between the points until client feels 2 points as one.

N=distance-2 to 20 mm. N=distance-2 to 20 mm.

Abn=parietal lobe problem…Abn=parietal lobe problem…

Superficial /Cutaneous ReflexesSuperficial /Cutaneous ReflexesAbdominal, PlantarAbdominal, Plantar

Abdominal ReflexAbdominal Reflex

– T8-T10 spinal nerves - controls upper abdominal musclesT8-T10 spinal nerves - controls upper abdominal muscles

– T10-T12 – lower abdominalsT10-T12 – lower abdominals

Dorsal Recumbent. Dorsal Recumbent.

Blunt tipped object (cotton swab). Blunt tipped object (cotton swab).

Scratch each abdominal quadrant lightly (lateral to midline, Scratch each abdominal quadrant lightly (lateral to midline, high to low) high to low)

– N=muscle contraction & slight shift of umbilicus N=muscle contraction & slight shift of umbilicus towards the stimulus.towards the stimulus.

Plantar Reflex (Babinski)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 Stroke foot sole with the handle of a reflex hammer. Run the edge along the outer heel up to the ball of the foot. the edge along the outer heel up to the ball of the foot. Repeat on the other 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 Abn=Dorsiflexion of big Toe, Fanning of Little Toes (except in infant) Pyramidal Tract / Upper Toes (except in infant) Pyramidal Tract / Upper Motor Neuron Damage…Motor Neuron Damage…

Superficial /Cutaneous ReflexesSuperficial /Cutaneous Reflexes Cremasteric, AnalCremasteric, Anal

Cremasteric ReflexCremasteric Reflex- T12 – L2T12 – L2- For genitourinary complaints only in men.For genitourinary complaints only in men.

- Lightly stroke the inner thighLightly stroke the inner thigh

N=scrotal elevation on the stimulated sideN=scrotal elevation on the stimulated side

Anal ReflexAnal Reflex- S3-S5S3-S5

- Gently touching around the anus with a cotton Gently touching around the anus with a cotton swab or gloved fingerswab or gloved finger

N=contraction of rectal sphincter…N=contraction of rectal sphincter…

Deep Tendon Reflexes Deep Tendon Reflexes Biceps, Triceps, Patellar, Achilles, Biceps, Triceps, Patellar, Achilles,

BrachioradialisBrachioradialisRequires practice & a relaxed client. Requires practice & a relaxed client. Sitting with feet dangling. Easier if Sitting with feet dangling. Easier if used with distractions.used with distractions.

Pointed hammer – small tendonsPointed hammer – small tendons

Flat end – larger tendonsFlat end – larger tendons

Compare bilateral responsesCompare bilateral responses

If any of the DTRs are hyperactive = If any of the DTRs are hyperactive = test for ankle clonus(rhythmic test for ankle clonus(rhythmic contraction).contraction).

Lift 1 of the client’s legs & support Lift 1 of the client’s legs & support the flexed knee with non-dominant the flexed knee with non-dominant hand. Grasp the foot & quickly hand. Grasp the foot & quickly dorsiflex the toes. dorsiflex the toes.

– N=(-)Pain & involuntary movementN=(-)Pain & involuntary movement– Abn= Clonus=motor neuron Abn= Clonus=motor neuron

dysfunctiondysfunction

DTR GRADINGDTR GRADING

DTR GRADEDTR GRADE ResponseResponse

00 Absent reflexAbsent reflex

1+1+ DiminishedDiminished

2+2+ NormalNormal

3+3+ Slightly Slightly increasedincreased

4+4+ HyperactiveHyperactive

Jenis intervensi FT ICUJenis intervensi FT ICU

1.1. Posisioning.Posisioning.2.2. Oksigen terapiOksigen terapi3.3. Stimulasi/ fasilitasi dan inhibisi.Stimulasi/ fasilitasi dan inhibisi.4.4. Breathing.Breathing.5.5. Chest FT.Chest FT.6.6. Inhalasi.Inhalasi.7.7. Mobilisasi/ ambulasiMobilisasi/ ambulasi8.8. Edukasi.Edukasi.

Chest FisioterapiChest Fisioterapi

1. P D.1. P D.

2. Topotement / klepping 2. Topotement / klepping

3. Breathing3. Breathing

4. Coughing/huffing.4. Coughing/huffing.

5. assisted coughing hafing.5. assisted coughing hafing.

Chest PT dapat dilakukah pre medikasi dengan: Chest PT dapat dilakukah pre medikasi dengan: stimulasi, inhalasi, rileksasi dllstimulasi, inhalasi, rileksasi dll

Post chest PT dpt dilakukan: mobilisasi ambulasi Post chest PT dpt dilakukan: mobilisasi ambulasi dan tranvers.dan tranvers.

Inhalasi.

Chest fisioterapi.

Mobilisasi

Ambulasi

Educasi

Pembersihan Jalan Napas

Retained secretions

Partially occlude

Uneven distribution of ventilation

V/Q mismatching

Hypoxemia

Complete occlude

Shunting blood

V/Q mismatching

Postural drainage position (PD)Postural drainage position (PD)

Posisi dengan meluruskan segmen Posisi dengan meluruskan segmen bronchi dengan gravitasi , jadi sekresi bronchi dengan gravitasi , jadi sekresi diakumulasi pada segmen diakumulasi pada segmen bronchopulmonari bergerak ke arah central bronchopulmonari bergerak ke arah central dan dikeluarkan dengan batuk , dan dan dikeluarkan dengan batuk , dan dengan mudah meludahdengan mudah meludah

Posisi paru atasPosisi paru atas

Upper lobeUpper 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/LHalf prone lying = Atas belakang R/L

3.3. Half supine lying R up = Atas depan RHalf supine lying R up = Atas depan R

4.4. Half Supine lying L up = Atas depan LHalf Supine lying L up = Atas depan L

5.5. Half prone lying R up = Atas belakang RHalf prone lying R up = Atas belakang R

6.6. Half prone lying L up = Atas belakang LHalf prone lying L up = Atas belakang L

7.7. Half Right side lying = Atas samping kiriHalf Right side lying = Atas samping kiri

8.8. Half Left side lying = Atas samping kanan.Half Left side lying = Atas samping kanan.

Paru bagian tengahParu bagian tengah

Paru bagian bawahParu bagian bawah

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

Perkusi : Tepukan yang cepat, cupping ( dengan tangan berbentuk mangkok ) dari bagian eksternal thorax, secara langsung tepat diatas saluran segmen paru .

Mekanika perkusi : Gelombang mekanik dari energi yang dihasilkan dipercaya akan ditransmisi sepanjang dinding paru untuk menghilangkan mukus dari saluran jalan napas ( Gelombang berkisar 4 – 5 Hz ).

Percusi

Breathing

Coughing/huffing /fibrasi/ konpresi

Vibrasi : Gerakan yang menyebabkan getaran dilakukan secara manual dari gerakan menekan langsung pada area ribs dan soft fissure dada normal bergerak selama exhalasi (pengeluaran napas)

Bantuan / latihan batuk/ huffing.

Pasien dengan trachea cubeDilakukan suction

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.

Summary

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

- tingkat kesadaran , sedation dll.

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

- suffer from chronic sleep deprivation

Thank you

For

Your attention

THANK YOU FOR LISTENING !

GOOD DAY !

and

The END !

What are the 3 objects shown a while ago?

Any questions ?

: 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

Kombinasi (penggabungan) treatment FT

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

- bronkospasme

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 (katup)” yang membantu mengatur dan menjaga aliran udara

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

abdominal berpindah ke downward (ke bawah)

Teknik Pembuangan Sekresi

Suction (penyedotan)

Batuk

Huffing. dll.

Pola-pola BE

- Diaphragmatic BE

- Costal BE (thoracic expansion exercise)

- Pursed lips breathing (PLB)

- Sustained maximal inspiration (SMI)

- Deep BE etc.

Collateral ventilation- Channels of Martin (interbronchiolar channel)

- Channels of Lambert (bronchiole-alveolar channel)

- Pore of Kohn (interalveolar channel)