GAIT TRAINING For Educational Purposes Only

Document Sample
GAIT TRAINING For Educational Purposes Only Powered By Docstoc
					                                 GAIT TRAINING

                       For Educational Purposes Only

    1. DEFINITION:

        •   Gait – Is a manner of walking.
        •   Training – Is to educate
        •   Normal Gait Ambulation
        •   Gait Cycle

    2. BASIC COMPONENT OF GAIT CYCLE:

    A) Stance Phase
          1. Heel Strike
          2. Foot Flat
          3. Mid Stance
          4. Heel off
          5. Toe off

    B) Swing Phase
          1. Acceleration
          2. Mid Swing
          3. Deceleration

    -   Stance Phase: Limb in contact with the ground, ( weight bearing phase )
    -   Swing Phase: Foot on the air, for limb advance.
    -   Single Support: One limb in contact on the floor.
    -   Double Support: Two limb are in contact on the floor.
    -   Step Length: Distance reference foot of the opposite foot (15 inches apart)
    -   Stride length: Distance reference foot to the opposite foot to the reference foot.
        (30 inches apart.)
    -   Cadence: The number of step.

3   THE ABNORMAL GAIT PATTERNS:
      b) Antalgic Gait – A painful Gait to the Hips and Knee.
      c) Arthrogenic Gait – Stiffness of the Hips and Knee.
      d) Ataxic Gait – Poor of sensation and coordination, and Poor of balance.
      e) Gluteus Medius Gait – Contra Lateral and Ipsi Lateral
      f) Gluteus Maximus Gait – Back ward lurch of the trunk ( muscle hips
         extension)
      g) Hemiplegic or Hemiparetic Gait – Weak half of the body ( most commonly
         seen to Stroke Patient)
   h) Quadriceps Gait – Weak anterior thigh response to a knee extension (
      commonly seen to Polio Patient)
   i) Equinus Gait – Foot is inverted and planter flexed.
   j) Parkinsonian Gait – Shuffling short rapid step ( A.K.A festinating and
      shuffling Gait)
   k) Scissoring Gait – Spastic Gait Most commonly seen in cerebral palsy clients)
   l) Short leg Gait – Trunk is lurched toward the affected.




                   RANGE OF MOTION (ROM)
DEFINITION:
  The normal extend of movement on a joint.
  Full motion possible.


TYPES OF RANGE OF MOTION EXERCISE (ROME)
  Passive ROME (PROME) with the caregiver assistant.
  Active ROME (AROME) a client may not need the care giver to assist him/her.
  Active assistive ROME (AAROME) care giver and the client are participated.

   INDICATION AND GOALS OF ROME

PROME
1. For comatose, Paralyzed, Bed rest, Presence of inflammation, and Painful
2. Increase complications of immobilization.
3. Maintain joint and soft tissue integrity.
4. Minimize the affects of the formation of contractures.
5. Assist in circulation and vascular dynamics.
6. Maintain mechanical elasticity of the muscles.
7. Enhance synovial movement for cartilage nutrition and diffusion of .materials on
   the joint.
8. Decrease or inhibit pain.
9. Surgery.

AAROME AND AROME
1. Same goals of PROME.
2. Maintain physiologic elasticity and contractility of the participating muscle.
3. Provide sensory feed back from contracting muscles.
4. Provide stimulus for bone and soft tissue integrity.
5. Increase circulation.
6. Develop coordination and motor skills for functional activities.
GUIDELINES: ASSISTING OF RANGE OF MOTION (ROM)

1. Do not start ROME exercise until you have receive specific instruction. For your
    particular client.
2. Never take the client beyond the point of pain. Pain is a warning sign. And should
    not headed. Report client to your supervisor.
3. Report the supervisor if the client does not do the exercises when you are not in
    the house.
4. Report to the supervisor if the client finding the exercise harder than to do than
    easier.
5. Use the flat part of your hand and fingers to hold the client’s body parts, do not
    grip with your finger tips. Some people are sensitive to pressure. Some people are
    ticklish.
6. If you forgot what to do think on your own body and how it works.
7. Talk to client and explain what is being done and why, even if the person does not
    understand, the tone of your voice and the touch of your hands can help you
    communicate.
8. Better communication great improves your chances for Client cooperation.
9. Do each exercise three to five times or as you have been instructed.
10. Fallow a logical sequence during the exercise so that each joint and muscle is
    exercise. For example. Start from the head and down to the feet.
11. Be gentle never bend or straighten a body part father than it will go
12. Slow steady movement of a tight muscle will help the muscle to relax and so
    increase the joint range.
13. Include the family or caregivers in the activity so they can learn and continue the
    exercises when you are not there.

PROCEDURES FOR APPLYING RANGE OF MOTION TECHNIQUE
1. Wash your hands.
2. Explain to the client that you are going to help him exercise muscle and joint.
3. Ask visitors to leave, if appropriate.
4. Offer the client bed or urinal.
5. Drape the client for modesty.
6. Raise the bed to the highest horizontal position, if possible.
7. Lower the side rail on the side you are working, if possible. Move the client close
    to you.
8. Proceed with the exercises as you have been instructed.
9. Make the client comfortable.
10. Wash your hands.
11. Chart that you have completed the exercises. Also note anything you observed
    about the client during the procedure.
        ROME IN DEFFRENT JOINTS OF THE BODY
   NECK: flexion, extension, lateral / side – flexion to R & L, rotation to R & L
   SHOULDER: flexion, extension, abduction, adduction, internal / medial rotation,
   external / lateral rotation.
   ELBOW: flexion, extension.
   FOREARM: pronation, supination.
   WRIST: flexion, extension, radial deviation / flexion, ulnar deviation, flexion.
   THUMB: flexion, extension, abduction, adduction, opposition
   FINGERS: flexion, extension, abduction, adduction.
   HIP: flexion, extension, abduction, adduction, internal / medial rotation, external
   lateral rotation.
   KNEE: flexion, extension.
   ANKLE: plantar flexion, dorsalisflexion, inversion, eversion.
   TOE: flexion, extension, abduction, adduction.
   TRUNK: flexion, extension, lateral / side flexion, to R & L rotation to R & L.



                  GAIT TRAINING PROGRAM
A) Pre ambulation Mat Program.
       The four stages of motor control.
       • MOBILITY: in corporate the initiation of movement technique.
       • STABILITY: characterized the ability to maintain a posture against
          gravity.
       • CONTROLLED MOBILITY: the ability to maintain the postural control
          during shifting movement.
       • SKILL: is a considered as a highest characterized by discrete motor
          controlled super imposed on stability on more central position of the body
          resisted movement.

THE GOAL OF PREAMBULATION EXERCISE PROGRAM:
1. Improve strength.
2. Improve or maintain Range of Motion.
3. Improve Coordination.
4. Facilitate proprioceptive feed back.
5. Instruct the patient in handling and moving in accordance to his disability.
6. Develop postural ability in sitting and standing.
7. Develop mobility functioning perceive by the ability to move.
8. Develop control mobility function in movement transitions such as rolling and
    moving from supine coming to standing position.
9. Improve trunk and pelvis control.
10. Develop static and dynamic balance control including righting in equilibrium and
    projective reactions.
11. Deep breathing and chest mobility.

   Things to remember when teaching mat activities to an individual.
   Give an explanation of the activities
   Demonstrate them the exercises
   Participate by stabilizing or guarding
   Correct errors in performance

   Activities in Pre ambulation Mat programs.
1. ROLLING: may be initial starting point of pre ambulation mat program.
   Rolling activities progresses from log rolling to segment rolling.
   • Log rolling – produce movement of the entire trunk as a unit.
   • Segment rolling – progression from log rolling, either the lower or the upper
      segment of the trunk moves independently while other segment is stability.
   • Position supine – arms raised to vertical position, hands clasped together.
   • Action – use the pendulum chopping action of arms to initiate rolling
   • Functional carry over – develop coordination and strength necessary for
      changing bed position.

2. BRIDGER (PELVIC LIFTER).
   • Position – supine hips and knee flexed elbows close to trunk and forearms
     perpendicular to mat.
   • Action – hyperextend back lifting hips off mat
   • Functional carry over – transfer off and on a bed pan, in and out of braces, and
     dressing activities.

3. PRONE MOVER ( for moving into a prone position)
   • Position 1 – prone on elbow, it provides weight bearing on the elbow and the
     forearms, which facilitate proximal stability needed as perquisite for using the
     upper extremities in weight bearing.
   • Action – Shift weight from elbow to elbow pulling body forward and pushing
     body backward.
   • Position 2 – prone on hand this position is considered intermediate step
     between prone on elbows to the hands and wrist.
   • Functional carry over – develop coordination and strength for moving prone
     position.

4. PRONE PUSH UP.
   • Prone position – prone hands in line shoulder
   • Action – straighten elbow lifting trunk from mat
   • Functional carry over – getting up from the floor with crutches and braces.
5. QUADRUPED POSITION.
   • Position – hand inline with shoulder
   • Action – push on hands straighten elbow, tuck chin, round back and align hips
     over the knees.
     a) Hip sawyer
     b) Camel cat
     c) Forward and backward reacher
   • Functional carry over – useful in facilitating initial control of the muscle of
     the lower trunk and hips

6. SITTING.
   • Position 1– short sitting, the patient knees and hips are flexed with the feet flat
      on the floor.
   • Position 2 – long sitting the patient hips are flexed and the knee are extended
      on the supporting surface.
   • Functional carry over – this position can be use effectively to develop valance,
      trunk control, and weight bearing on the upper extremities.
      a) Sit-up
      b) Leg – mover
      c) Sitting push – up
      d) Trunk twister and hip raiser
      e) Sitting balance

7. KNEELING
   • Position – erect position with weight on both knees
   • Action – weight shifting, forward, backward, and sideward
   • Functional carry over – useful for establishing lower trunk and pelvic control.


8. MODIFIED PLANTIGRADE
   • Is an early weight bearing posture that can be use in preparation for erect
     standing and walking.
   • Action – this pattern required during gait, combines hip flexion with knee
     extension and ankle dorsalis flexion.
   • Functional carry over – an important precursor walking.

9. STANDING
      - Activities are not most initiated in the parallel bars.
   • Position – head up, pelvis forward and rolled under trunk, feet part
     approximately 4 inches.
   • Action – head erect and shoulder relaxed with shoulder balance direct over the
     ankle.
                   PARALLEL BAR ACTIVITIES
   1) Weight Shifter
   2) Coordination Exercises
      a) Four count coordinator
      b) Six count coordinator
      c) Hip hiker
      d) Leg swinger

   3.    Gait Training
        a) Four point gait drill
        b) Drag to gait drill
        c) Swing to gait drill
        d) Swing through gait drill
        e) Sideward gait drill

   4. Moving from sitting to standing and reverse with assistive device
      a) From wheel chair to standing position
      b) From standing to wheel chair
      c) From standing to straight chair without arms
      d) From straight chair without arms to standing

   5. Standing balance and weight shifting activities with assistive device.
   6. Use of assistive device (selected gait patterns) for forward progression
      and turning.

        1. ASSISTIVE DEVICE – permit some patient who can not ambulate
           without assistive to ambulate safety.
        2. The three major Indications for using assistive device.
              Structural deformity or loss, injury or diseases which decrease the
              ability to bear weight on the lower extremities.
              Muscle weakness or paralysis of the trunk or lower extremities.
              Inadequate balance. – common seen to Elderly.


USE OF ASSISTIVE DEVICES
    Assistive devices are design to improve a person stability
    Help the patient to compensate for the decreased balance, strength or
    coordination or decreased ability to bear weight on one or both lower
    extremities.
    Reduce pain during ambulation.
PARALLEL BARS.
- Advantage: most balance
- Disadvantage: limit mobility
     Use when maximal stability and support are required
     Gait pattern are initiated in a parallel bar.
     The bars severely limit mobility.

ADVANCE PARALLEL BAR ACTIVITIES
  1) Walking side ward (side walking )
  2) Walking backward
  3) Braiding
  4) Resisted a ambulation activities

WALKER
  Use when maximal patient stability and support along with mobility and required.
  Various style are available and most have four support legs, feet and some may
  have two or more wheels and can be adjustable for proper fit.
  Light weight some can be folded for storage.

Disadvantage
   Slower
   Difficult to store or transport
   Difficult or impossible to use on a stair
   Reduce speed of walking
   Difficult to perform a normal gait patterns
   Difficult to use in narrow or crowded place or area.

PICK UP WALKER
• Types
- Adjustable
- Folding or non-folding
- Reciprocal
- Stair climbing

•   Advantage
-   Provide stability with both lower limb and weakness.

•   Disadvantage
-   Require use of both hands
-   Does not fit through all passages
-   Questionable stair climbing ability
WALKER WITH CASTER

•   Feature
-   Come with seat attached
-   Can be ordered with breaks

•   Advantage
-   Provide stability for both lower and upper limb involvement and balance

•   Disadvantage
-   Cumbersome can not fit through all passages
-   Unable to use on stairs
-   Caster lock do not stabilize walker well enough.

RECIPROCAL WALKER

•   Feature
-   The left side of a walker and the right lower limb move forward together.

•   Advantage
-   Allow for a two point gait
-   Provide for greater stability than a cane
-   Permits fast gait

•   Disadvantage
-   Cumbersome and cannot be used on stair.

USING THE WALKER
- Walking with walker
1. Left the walker and place it at a comfortable distance in front you with all four of
   its leg on the floor. This distance is usually equal to an arms length.
2. Move your operative leg toward the walker first. Then take a step with your good
   leg bringing slightly ahead of the operative leg, if you had a surgery on both side
   does not matter which leg you use to begin walking.
3. Do not take a big step that place you to close to the walker at all times. If you are
   too close you may be lose balance.
4. Hold your head up and look straight ahead. It is tempting to watch your feet but
   more tiring and you may run into something.
SITTING WITH A WALKER
1) Slowly back up to the chair, bed or toilet until you feel it against the back of your
   leg.
2) Slowly lower your self on to the seat by letting forward and keeping your
   operative leg out stretched in front of you. Go slowly so that you do not “plop” in
   to the chair.
3) Let go of the walker and reach back for the bed, chair arms or toilet seat, while
   sliding your operative leg forward.
4) If you have had both joints replace, place both hands on the chair arms, bed or
   commode seat as noted above lower your self to the seat and gradually walk, both
   legs forward. Again do not “plop”.

WALKER
• Parts
  -     Back up right
  -     Front up right
  -     Horizontal bar
  -     Hand grip
  -     Rubber tip
  -     Side bar.

CRUTCHES
• Use for a person who need less stability or support.
• Allow greater selection of a gait patterns and speed.
• Good stability and support.
• Most are composed of wood or aluminum and can be easily adjusted for proper
  fit.
• Relatively easily stored and transported.
• Can be use in narrow areas for stairs.

GENERAL ADVANTAGE
• Less stable than a walker
• Required good standing balance
• Elderly patient may feel insecure with them
• An – proper use can cause paralysis in arms.

AXILLARY CRUTCHES
• Construction
- metal and wood
- adjustable or non – adjustable.
• Advantage
- lateral stability
-   an expensive if made of wood
-   fits stairs



•   Disadvantage
-   cumbersome
-   tendency to put pressure on the armpit
-   especially when going upstairs

FOREARM CRUTCHES
• Types
- German
- Loft stand
- Canadian
- Lumex ortho

•   Advantage
-   Hand grip gives more support
-   May release grip without dropping crutches
-   Less cumbersome
-   Fit stairs.
•   Disadvantage
-   Cuff difficult to remove
-   Require better control than other types
-   More expensive than wooden axillary

PLATFORM CRUTCHES
• Advantage
- use for patient with amputation
- those who can not bear weight or wrist or hands
- usually with arthritic patients
- patients who cannot extend the elbow

AXILLARY CRUTCHES

•   Axillary bar
•   Hand grip
•   Double up right
•   Single upright
•   Rubber tip
    1. 2 distance from the Axilla to the axillary bar
    2. the hand grip must be level with your hips
    3. the distal and must be 2 inches lateral and 6 inches anterior
FOREARMS CRUTCHES
• Forearm cuff
• Single upright
• Hand grip
• Rubber tip
  1. The forearm must be 1 -1.5 inches away from the elbow
  2. The hand grip must be 2 inches lateral and 6 inches anterior.

CANE (unstable)
• Use to compensate for impaired balance or to improve stability
• More functional on stairs and narrow confined areas
• Can be transported more easily than the crutches or a walker

•   General advantage
    o Provide very limited stability because of its small base support
    o Two cane do not provides sufficient stability to perform other gait patterns.

STANDARD CANE
• Types
  o crook handle
  o metal or wooden
  o adjustable or none – adjustable

•   Advantage
    o wood cane is expensive
    o fit stairs

•   Disadvantages
    o point of support is in front of hand
    o small base of support, no arm support

LUMEX – ORTHO CANE
- Molded hand grip
- Adjustable.

•   Advantage:
    o Point of support direct below hand
    o Fit stairs

•   Disadvantage:
    o Small base of support.
    o No arm support.
QUADRAPED CANE
- Bases available in several sizes
- Adjustable

•   Advantage
    o Wide base support.

•   Disadvantage
    o Point of support not centered
    o Large size does not fit stairs.
    o Difficult to carry stairs while using handrail.

WALK CANE
• Advantage:
  o Wide base support.
  o Greater stability than quadruped cane.

•   Disadvantage:
    o Cumbersome.
    o Large size does not fit up stairs
    o Difficult to carry up stairs while using handrail.



                    WHEEL CHAIR

Fit properly to provide function, comfort stability and safety and protection of the
body structure.

Seat high and / Leg length
A) 2 -3 Finger lengthwise between the back of the back of the patients and thigh and
    the seat upholstery.
B) Foot plate is at list 2 inches above the floor.

Seat depth
A) Hand parallel to the floor, there must be a distance of 3 – 4 fingers between t
     he front edge and the back of the knee.

Seat width
A) You should be able to slide each hand between patient hips and clothing guard
     with minimal contact.

Back High
A) With the hand vertical to the floor, you should be able to the place the width of
   the finger between the top of the back upholstery and floor of the armpit.

Arm Rest High
A) When a elbow rest on the armrest there must be distance of 4 inches from the
   back post.
B) Shoulder must be level.
C) Trunk should be straight.

Adverse effects of improper fit.
A) If the sit is too high.
   o Insufficient trunk support (can cause scoliosis)
   o Difficulty positioning the knee beneath a table or desk.
   o Difficulty propelling the wheelchair.

B) If the seat is too low.
   o Difficulty performing transfer.
   o Improper weight distribution.
   o If foot plate are lowered to compensate for the low seat decreased mobility
       and unsafe of chair.

   Seat dept
   o Lessen trunk stability
   o Increase weight bearing of the sit bone due to lock support from the thigh.
   o Poor balance due to reduced base of support.

   Seat too long.
   o Increased pressure ulcer in the area of the back of the knee.

   Seat width:
   o Difficulty in propelling the chair.
   o Difficulty performing transfers.
   o Difficulty moving through narrow hallways or doorways.
   o Postural deviations.
   o Difficulty in changing position.
   o Exercise pressure to the hips bone.
   o Difficulty wearing bulky outer garments.

   Back high
A) If the back is too high
   o Difficulty propelling the chair
   o Difficulty in performing the standing transfers.
   o Accessive irritation to the skin over the shoulder beads
   o Difficulty with balance.
B) If the back is too low.
   o Decreased trunk stability or postural deviation.

   Arm rest
   A) Arm rest is to high
      o Difficulty propelling the chair
      o Difficulty performing the standing transfer
      o Postural deviation.
      o Limited use of arm rest due to discomfort.

   Leg length
   A) If the foot plate is too low
      o Increase pressure to the end of the back of thigh.
      o Decrease function and ensure mobility.

   B) If the Foot plate is too low.
      o Increase pressure to the sit bone.
      o Difficult positioning the chair beneath the table or desk
      o Decrease trunk stability due to lock of support.

COMMPOSNET AND FEATURE

1. WHEEL CHAIR
   a) Toggle locks
   b) Lever or ratchet lock.
   c) Auxiliary lock for a reclining back chair.
   d) Caster lock.

2. BODY RESTRAINTS
   a) Lap waste belt
   b) Chest belt

3. WHEELS AND TIRES
   a) Caster wheel.
   b) Drive or rear wheel.

4. ARM REST
   a) Fixed arm rests
   b) Remove reversible arm rests
   c) Desk cut out or armrests
   d) Adjustable armrest
        5.     FRONT RIGGING, LEG REST AND FOOTN REST COMPONENTS
               a) Fixed
               b) Swing away/ removable leg rest
               c) Elevating leg rest
               d) Foot rest is also known as a foot plate.
Note:

        Can are not use for restricted weight bearing.
        Orthostatic – Is decreasing a blood pressure due to sudden standing position.
        Gait belt – Is use to put on around the waste of the patient during transferring
        from the assistive devices.
        Postero lateral position – Is standing slightly in front of the patient and lightly the
        side is common when assisting a client walking on the stairs.



                                  TRANSFERS

        Definition: Movement a person or a client from place to another.
        Must be specific safe and efficient.

        Types:
         •     Independent transfer
         •     Sime – independent transfer.
         •     Dependent transfers.

             Method of transfer:
             •   Standing
             •   Sitting
             •   Lying or recumbent

    Basic guidelines:
    A) Before transfer
         1. Asses the client capabilities and limitations.
         2. Explain and demonstrate the transfer procedure to the client.
         3. Client must be properly clothed for the transfer.
         4. Surface where transfer is to be done must be firm, stable and immobilize.
         5. Secure the necessary assistive devices or guarding equipments.

    B)        During transfer.
              6. Care provider must assume the proper stance or posture.
       7. Stand where the client can be protected from falling.
       8. Allow the client to see the direction he / she moving.
       9. Allow the client to use whatever function he / she has.

 C)    After transfer
       10. Make sure client is secure in the new surface area.
       11. Transfer must not be tiring to both client and care giver.



                          ELDERLY
DEFINITION OF TERMS:

1. Geriatric
      Come from a Greek word GERAS meaning Old Age
      Ia tri kos meaning healing.
      Medical specialty which includes a Physiology, Pathology, Diagnosis
      management and treatment of disease of the elderly person.

2. Gerontology
      Come from a Greek word GERON meaning Old Man.
      LOGOS meaning discourage study of Old Age,
      Study of all aspect of aging process including biology (Psychology and
      Sociological factors.

3. Aging
      A process of gradual changes in the structure and function which occurs with
      the passage if time and does not results from diseases or trauma and cause in
      increasing probality of death.
      It is typically accompanied by gradual but progressive physiologic changes
      and increase of acute chronic illness.

4. Ageism
      Prejudice or discrimination against older people.

5. Eugeric Aging
      “Eu” means well
      “Eus” means good
      Natural death, no vices no disease.

6. Chronological Age
        Number of years a person lived.

7. Frail Elderly
         Use to describe at he elderly individual who has a significant physiological
         and functional impairment whatever the age.




8. Primary Aging
      Apparently Universal Changes that occurs with aging independent of the
      disease and environmental affects.

9. Secondary Aging
      Includes lifestyle and environmental consequences and disease as part if the
      aging syndrome.

10. Successful Aging
       Characterized by minimal or physiologic losses in a particular organ system
       and would comprise a relatively small subset of the totally normal aging
       population.

11. Usual Aging

CATEGORIZING THE AGING POPULATION
• 55 – 64 y/o the older population
• 65 – 74 y/o the elderly
• 75 – 85 y/o the aged
• 85 years old up the extreme aged
• Age 60 -70 young old
• Age 75 – 85 the middle old
• Age 85 & up the old – old

MYTHS OF AGING
  Two Aspects of Decline of Intelligence
  o   Fluid Intelligence
  o   Crystal Intelligence

 Fluid Intelligence
- Decrease in some aspect due to decrease rate if central information progressing.
An intelligence performance is measure by
   o Time cognative performance task.
   o Associating memory.
   o Logical reasoning
   o Abstract thinking

    Crystal Intelligence
-    Still contact with age
-    Intellectual performance is measure by task of verbal abilities in vocabulary
     information and comprehension is preserved.
-    The ability to learn is preserved but at the slower rate.

1. The myth that most elderly lived in the institution in contrast with the reality that
   only about 5% do.
2. The common motion that the elderly are not interested in sexual activity is
   certainly not universally true.
3. The older people become sick and dependent.
4. The population mis – conceptions that people suffer progressive decline in
   intelligence as they age.


                    NORMAL CHANGES OF AGING

    Body Composition
     Gradual loss spine
     Lean tissue and increase in fat especially in the abdomen.
     Loss of lean tissue reflects loss of muscle mass.
     o     total body muscle mass
     o      muscle sectional area
     o     limb muscle volume
     o     muscle fiber size and area

     Body fat increase to 30% of body weight at age of 80 and 15% at the age of 30.
     Bone mineral is lost.
     Peak bone density occurs at 30s and 40s and thereafter gradually declines.

    Postural Changes of Aging
     Progressive anterior thrust of the head.
     Extension of the cervical spine.
     Straightening of lumbar spine
     UE: shoulder extention, scapular retraction, elbow flexion, ulnar deviation, finger
     flexion ( upper extremities).
     LE: hip and knee flexion, decrease ankle dorsil flexion (lower extremities).
     Ambulation: decrease ability to balance on one leg with eye either close or open.
     Decrease righting reflexes.
     Progressive widening of standing base.

    Motor Sign
     Tendency to tremor.
     Dysmetria – (impaired ability to calculate distances).
     Dysdiadochokinesia – (inability to do rapid alternative movement).
     Thinning of palmar muscles.
     Increase muscle tone LE > UE proximal > distal
     Diminished muscle strength: LE > UE proximal > distal
     One common functional complaint of the elderly is difficulty arising from the
     chair or toilet seat. Patients are typically more functional if seated in a chair with
     firm seats supporting their knees and hips at 90° with their feet flat on the floor.
     The chair should have arms rest.

    Sensory Sign and Reflex Sign
     Diminished vibratory sense distally, legs > arms.
     Possible change in proprioception.
     Diminished or absent ankle jerk.
     Some reduction in knee, biceps and riceps reflexes.

 Phychosocial Changes
  Emotional
- Reflex of meaningless of life, put success and failure into prespective.
- Sense of wisdom, knowledge and self reliance of being able to cope with
  whatever comes along.

     Motor or Religious
-    May become more spiritually oriented.
-    Value system changes from material orientation to amore value, oriented out look.

Nervous System
   Progressive loss of number neuron in the brain and spinal cord.
    Loss of total bulk of brain.
   Myelin sheath is decreased resulting to slow speed of nerve impulse and
   conduction, slowed reaction of time
   Decrease blood flow to the brain.
   Change in sleep patterns
   Behavioral changes: lessened adaptability diminished emotional responses,
   decrease short term memory confusion, disorientation, narrowed interest.

Care Giver Responsibility.
   Promotes independence in daily activities.
   Allow ample time for completion of task.
   Use sleeping medication with caution.
   Provide adequate warmth.
   Maintain social functioning by providing recreational and diversion activities
   Orient to reality to prevent and treat confusion and disorientation.
Cardiovascular System (changes)
   Derease pumping of the heart.
   Narrowing of the arteries result to shortening in circulation of the blood.
   Stiffening of the heart valve.
   Myocardial hypertrophy.
   Coronary blood flow decreases.
   Decrease cardiac out put and maximum heart rate.
   It is the amount of blood running out by each side of the heart in one min.
   Decrease endurance
   Arteriosclerosis and edema.(hardening of the heart).
   Increase systolic pressure.
   Orthostatic hypertension.

CARE GIVER RESPONSIBILITY
  Minimize edema and fatigue with rest period and elevation
  Encourage exercise as tolerated.
  Teach energy conservation method in daily activities.
  Teach client in changing position to avoid falls

Musculoskeletal changes
  A trophy (decrease of the bone and muscle) with decrease of strength ability.
  Bone more porous and lighter through calcium losses.
  Enlarge and stiff joints.
  Reduce range of motion.
  Stooped posture.

Respiratory system (changes)
   Lung Tissue be come elastic.
   Decrease the number of alveoli 300 millions.
   Degenerative the rib cage and conjunction of the weakening of the muscle.
   Impaired ventilation and diffusion.
- Ventilation: mass exchange of gasses to front the body.
- Diffusion: the transport of gas to the blood.
   Increased residual volume and functional residual capacity.
- Residual: is the amount of air that remain in your lungs (after expiration) and
   (after resting expiration)
   Reduced vital and lung capacity, it is measured by maximum inspiration fallowed
   by expiration.
   It is a total amount of air that is contain in the lung after lung inspiration.
   Reduced cough.
   Impaired pulmonary circulation.

Gastro Intestinal System (Changes)
   Loss of teeth common (32)
   Increase saliva which results to difficulty in swallowing.
   Reduce peristalsis and decreased excretory efficiency.
   Reduce gastric mobility and secretion due to astrophy of the stomach and
   intestine.
   Decrease gastric acid.
   Decrease liver size.
   Impaired metabolism.
   Decrease appetite.
   Constipation, diarrhea and flatulence common problem.

 Urinary system female and male. And urinary changes.
      Decrease kidney function.
      Decrease strength of ureter, bladder and urethra.
      Bladder capacity decreased.
      Urinary frequency.
      Retention.
      Dysria and noctria. (dysria difficulty in urination, noctria urinary frequency at
      night.
      Incontinence.
      Enlargement of prostate in male.

 Reproductive system changes.
     Female
     • Decrease production of estrogen, progesterone at menopose.
     • Artrophy and drying of vaginal canal.
     • Infertility.

       Male.
       • Impair ability to achieve full penile erection.
       • Decrease level of androgen.
    CARE GIVER RESPONSIBILTY
         Provide encouragement and discuss modification in sexual expression as
         necessary.
         Rest before and after sexual activity.

    Integumentary System

           Skin – derma and epidermis.
           Hair – loss of pigment / decrease of hair follicles, thinning.
           Nail – dry thick and brittle.

 CARE GIVER RESPONSIBILITY
• Observed and assess the skin frequently.
• Use lanoline lotion.
• Protect the skin again trauma.
• Avoid over exposure to sun.
• Maintain adequate hydration.
• Keep skin clean, dry, lubricated and pressure free.
• Provide adequate humidity and heat in environment.
• Lower bath water temperature to 100 / 105 F, test water temperature first.
• Johnson 5 .5 pH balance soap.
• Avoid hard sponge bath, loofah instead of warm cloth.
• Decrease frequency of complete bath.
• Canadian setting 2-3x a week.

    Integumentary Changes
•     Thinning, wrinkling, loss of elasticity, dryness.
•     Atropy of elastic fiber, sagging breast.
•     Decreased subcutaneous tissue.
•     Decreased perspiration and sebum.
•     Decreased moisture content, epidermal renewal and blood supply.
•     Flocking of skin, itchiness.
•     Fish scale, skin due to lock of vitamin A.
•     Increased sensitivity to cold.
•     Frangile easily injured.

 Special Senses
  Vision
• Emmetropia – normal vision
•   Hyperopia
•   Myopia
•   Astigmatism
•   Major eye problem
•   Presbyopia
•   Cataracts
•   Glaucoma
•   Retinal detachment.

    CARE GIVER RESPONSIBILITY
•   Let client use prescribed eyeglasses.
•   Avoid sudden lightning changes.
•   Work in areas with adequate light.
•   Provide increased illumination without glare.
•   Provide safe environment by orienting client to the surrounding and removing
    potential hazard.
•   Use sunglasses out doors.
•   Use large print book.
•   Avoid night driving.
•   Use contrasting color – coding.
•   Use of touch as a form of communication.

    Changes in Vision.
•   Small and irregular pupil
•   Diminished of visual activity.
•   Reduction of visual fields
•   Reduced accumondation to light changes.
•   Decreased ability to distinguished color.
•   Emetropia./ hyperopin / myopin.
    Hearing
    Presbycusis

•   Types of hearing.
o   Conductive hearing loss.
o   Sensory hearing loss.
o   Mixed

    CARE GIVER RESPONSIBILTY
•   Early recognize and treatment of hearing impairment to avoid isolation and
    paranoid ideation.
•   Look directly in the of the person when speaking and speak clearly and slowly,
    low pitched voice is heard best.
•   Write messages.
•   Use special expressions and gestures in communicating.
•   Encourage the use of hearing aid.
•   Decreased background noise.




    Changes in hearing.
•   Decreased hearing activity.
•   Neurons in ears decreased with aging and the blood supply diminished in the
    body. Aging changing may cause in loss of hearing difficulty.
•   Presbyscusis.

    Type of hearing Loss.
•   Conductive hearing loss – conducting of sound.
•   Sensorineural - nerve.
•   Mixed

    Endocrine System

    CARE GIVER RESPONSIBILITY
•   Assess for endocrine deficiency condition such as diabetes mellitus and
    Hypothyrodism.

    Endocrine Changes
    Decreased function of pituitary, thyroid, adrenal cortex, pancreas, parathyroid,
    and ganads
    Gradual decrease in glucoses tolerance to reduced sensitivity of tissue to due
    metabolic affects of insulin / or insulin resistance.
    Contribution of obesity and physical activity increase incidence of DM and may
    benefit for weight loss and regular exercise to control.
                          DEMENTIA
    DEFINITION:
    Progressive deterioration of intellect, behavior, and personality as a consequence
    of diffuse disease of the cerebral hemispheres, maximally affecting cerebral
    cortex and hippocampus.
    Dementia may occur of any age but more common in the elderly.
    Dementia is a symptom of disease rather than single – disease entirely.

    Possible causes:
1. Alzheimer
2. Neurodegenerative
3. Infectious
4. Normal pressure Hydrocephalus
5. Nutrition
6. Metabolic
7. Chronic inflammatory
8. Trauma
9. Tumor
10. Drugs
11. Multiple sclerosis
12. Alcohol
13. Depression
14. Delirium

    Dementia is not a normal part of Aging, some early warning of dementia include.

•   Resent memory loss that effect job skills.
•   Difficulty with familiar task.
•   Problem with language, forgetting simple word.
•   Getting loss in familiar places.
•   Personality changes.
•   Poor or decreased judgment.
•   Lost interest of life.
               ALZHEIMER’S DISEASE
What is Alzheimer’s Disease
(AHLZ – high – merz) disease that progressive brain disorder that gradually
destroyed a person memory and ability to learn, reason make judgment
communicate and carry out daily activities, as Alzheimer’s progresses, individuals
may also experience changes in personality and behavior, such as a Axienty,
suspeciousness of agitation, as well delusion or hallunation.
 Irreversible – can not cure.
Igitation – they have fear.
Idiophatic – cause by Alzheimer’s
Chronic – long term damage.
Dementia – 60 %
Dysphagia – difficulty in swallowing.
Anomia – difficulty speech.
Echopraxia – repeated word.

Causes
Alzheimer’s disease has known a single cause, but in the last 15 years scientist
have learned a great dual about factors that may play a role.
Scientist regards two abnormal microscopic structures called “plaque” and
“tangle” as Alzheimer’s hall mark amyloid plaque (AM – uh – loyd plaks) and
chump of protein that accumulate out side the brain’s nerves cells. The tangle are
twisted strands of another protein that form inside cells.

Warning and Signs of Alzheimer’s

1. Memory loss – forgetting recently learned information is one of the most
   common early signs of dementia. A person begins to forget more often and is
   un – able to recall the information later.
   • What is normal? Forgetting names or appointment occasionally.

2   Difficulty in performing familiar task – people with dementia often find it
    hard to plan or complete everyday task. Individuals may lose track of the steps
    involved in preparing a meal, placing a telephone cell or playing a game.
    • What is normal? occasionally forgetting, why you may came into room, or
        what your plan to say or do.
3. Problem with language – people with Alzheimer’s disease often forget simple
   words, making their speech or writing hard to understand. They may be an –
   able to find the tooth brash, for example and instead ask for thing for may
   mouth.
   • What is normal? Sometime having trouble finding the right word.


5. Disorientation to time and place – people with Alzheimer’s disease can be
   come lost in their own neighborhood, the forger where they are and how they
   go there, not known how to get back home.
   • What normal? Forgetting the day of the week or where you were going.

6. Poor decrease judgment – those with Alzheimer’s may dress in –
   appropriately wearing several layers on a warm day or little clothing in cold.
   They may show poor judgment like going away large some of money of a
   little marketers.
   • What is normal? Making questionable or debatable decision from to time
        to time.

7. Problem with abstracts thinking – some one with Alzheimer’s disease may
   unusual difficulty performing complex metal task. Like forgetting what
   numbers are for and how they should be used.
   • What is normal? Finding challenging to balance check book.

8. Misplacing things – A person with Alzheimer’s disease put things in unusual
   places, an Iron in the freezer of a wrist watch in sugar bowl.
   • What is normal? Misplacing keys or wallet temporally.

9. Change mood or behavior – some one with Alzheimer’s disease may show
   rapid mood swing from calm to tears to anger for no apparent reasons.
   • What is normal? Occasionally feeling sad and moody.

10. Change personality – the personality of people with dementia can change
    dramatically, they may become extremely confused, suspicious, fearful,
    dependent on a family member.
    • What is normal? People personalities do change some what with age.
    11. Loss of initiative – a person with Alzheimer’s disease may become very
        passive sitting in front of the TV for hours, sleeping more than unusual or not
        wanting to do unusual.
        • What is normal? Some line feeling weary of work or social obligations.

    Stage of Alzheimer’s Disease:

        Stage 1: No impairment (Normal function)
•   Individual experience no memory problem and none are evident to a health care
    professional during a medical.

    Stage 2: very mild cognitive decline (may be normal age – related changes or
    earliest signs of Alzheimer’s disease).
•   Individuals may feel as if they have memory lapses, specially in forgetting a
    familiar words or name or the location of keys, eyeglasses, or other everyday
    objects. But these problems are not evident during medical examination or
    apparent to friends, or family and co – workers.

   Stage 3: (mild cognitive decline)
  (Early stage Alzheimer’s can be diagnosed in some, but not all individuals with
  these symptoms)
o Friends and family or co – workers begins to notice deficiencies. Problem with
  memory or concentration may be measurable in clinical testing or discernible
  during a detail medical interview. Common difficulties include.
• Word or name – finding problem noticeable to family or close associate.
• Decrease ability to remember names when introduced to new people.
• Performance issues in social work setting noticeable to family, friends or co –
  workers.
• Reading passage are retaining materials.
• Losing or misplacing a valuable object.
• Decline in ability to plan or organize.

  Stage 4: (moderate cognitive decline)
  (Mild early Stage Alzheimer’s disease)
o At this stage a careful medical interview detects clear – cut deficiencies in the
  fallowing areas.
• Decrease knowledge of resent occasions or current event.
•   Impair ability to perform challenging mental arithmetic – for example, to count
    backward from 100 by 7s.
•   Decrease capacity to performed complex task, such as a marketing, planning
    dinner for guests or paying bills and managing finance.
•   Reduced memory of personal history.
•   The affected individual may seem subdued and withdrawn, especially in socially
    or mentally challenging situation.

  Stage 5: Moderate severe cognitive decline
  (Moderate or mild stage Alzheimer’s disease)
o Major gaps in memory and deficits in cognitive function emerge. Some assistance
  with day to day activities becomes essential. At this stage, individuals may:
• Be unable during a medical interview to recall such important details as their
  current address, their telephone number or the college or high school from which
  they graduated.
• Become confused about they are or about the date, the day of the week, or season.
• Have trouble with less challenging mental arithmetic; for example, counting
  backward 40 by or from 20. by 2s.
• Need help choosing proper clothing for the season or the occasion.
• Usually retain substantial knowledge about themselves and know their own and
  the names of their spouse or children.
• Usually require no assistance with eating or using the toilet.

   Stage 6: Severe cognitive decline
(Moderately severe or mild –stage Alzheimer’s disease)
o Memory difficulties continue to worsen, significant personality changes may
   emerge and effected individuals need extensive help with customary daily
   activities. At the stage, individuals may.

•   Lose most awareness of recent experiences and events as well as of their
    surroundings.
•   Recollect their personal history imperfectly, although they generally recall their
    own name.
•   Occasionally forget the name of their spouse or primary caregiver but generally
    can distinguish familiar from unfamiliar faces.
•   Need help getting dressed properly; without supervision, may make such errors as
    putting pajamas over day time clothes or shoes on wrong feet..
•   Need help with handling details of toileting (flushing toilet, wiping and disposing
    of tissue properly).
•   Heave increasing episodes of urinary or fecal incontinence.
•   Experience significant personality changes and behavioral symptoms, including
    suspiciousness and delusions (for example, believing that their caregiver is an
    impostors); hallunations (seeing or hearing things that are not really there); or
    compulsive, repetitive behavior such as hand wringing or tissue shredding.
•   Tend to wander and become lost.
       Stage 7: very severe cognitive decline
       (Severe or late – stage Alzheimer’s disease)

   o This is the stage of the disease when individuals lose the ability to responsed to
     their environment, the ability to speak and, ultimately, the ability to control
     movement.

   •   Frequently individuals lose their capacity for recognizable speech, although words
       or phrases may occasionally be uttered.
   •   Individuals need help with eating and toileting assistance then the ability to sit
       without support, the ability smile, and the ability to hold their head up. Reflexes
       become abnormal and muscles grow rigid. Swallowing is impaired.

       10 warning signs of Alzheimer’s
       1. MEMORY LOSS
       2. DIFFICULTY PERFORMING FAMILIAR TASK
       3. PROBLEMS WITH LANGUAGE
       4. DISORIENTATION TO TIME AND PLACE
       5. POOR OR DECREASE JUDGEMENT
       6. PROBLEMS WITH ABSTRACTS THINKING
       7. MISPLACING THINGS
       8. CHANGES IN MOOD OR BEHAVIOR
       9. CHANGES IN PERSONALITY
       10. LOSS OF INITIATIVE

THE DIFFERENCE BETWEENALZHEIMER’S AND NORMAL AGE
RELATED MEMORY CHANGES


Some with alzheimer’s diseases               Some one with normal age related
symptoms                                      memory changes

Forgets entire experience                    Forget part of a experience


Rarely remember later                        Often remember later

Is gradually unable to fallow written        Is usually able to follow written / spoken
spoken direction.                            directions
Is gradually unable to use note as reminder   Is usually able to use notes as reminder

Is gradually unable to care for self          Is usually able to care for self




   Dispelling Myth about Alzheimer’s
   Myth 1: Alzheimer’s loss is natural part of aging.
   Myth 2: Alzheimer’s disease is not fatal.
   Myth 3: Drinking out of aluminum cans or cooking in aluminum pots and pans can
   lead to Alzheimer’s disease.
   Myth4: Aspartame causes memory loss.
   Myth5: there are therapies available to stop the progression of Alzheimer’s disease.

   CLINICAL COURSE

   DAMAGE TO THE LIMBICSYSTEM.
   • People will act tearful and anxiously
   • They may act depressed and suspicious
   • They certainly terrified and frustrated.
   • They may have verbal out burse.
   • They are agitated.
   • They angage in seemingly purposeless activity, wandering to and from trying to
     make sense of what is happening to them.
   • They are unable to retain the meaning of written words after reading.
   • They misplace objects and then become suspicious that others may thinking
     things then, or hiding them.
   • They may be sexually active.

   DAMAGE SPEADS TO THE PARIENTAL AREA
   • They easily become disoriented and lost.
   • They begins to loss the ability to recognize familiar sensory stimuli, a condition
     called agnosia.
   • They have problem identifying objects in terms of function.
   • They begins to have problems identifying people – especially those of different
     generation, or people they do not see often (visual agnosia).
   • They may experience imaginary visual imagines (hallunation).
   • One in ten people with dementia will have grand or petit mal seizures.
   • They loss the ability to concentrate or focus,
   • As aspartial perception declines, they begins to lose the ability to locate certain
     parts of the body.
•   Deteriorating hand skills often makes it difficult for them to carry out activities of
    daily living..
•   They begins to experience deterioration in speech organization.
•   They have difficulty with syntax (the rule governing the arrangement of words in
    speech)
•   They have problems in touch interpretation (tactile agnosia); they cannot identify
    an object unless they can see it

DAMAGE TO THE TEMPORAL LOBE
• They forget name even those of close as family members.
• They have problem finding the right words what mean , and may say “no for
  “yes” or “ purse” for “nurse”
• They ask question repeatedly, and seeking information, they can not retain.
• They can not string ideas together, and may lose they train of thoughts and mind
  sentence.
• They may develop Broca’s Apasia.
• They repeat the same meaningless sound or word over and over, echo sounds
  (echoprasia) or speak gibberish or “words salad” that is difficult to understand ( a
  symptoms of Wemeck’s Aphasia): I don’t want to bump my self. I found my self.
  I was gone. I have to back again. It is the same thing. I cant figure…….”
• They may have total expressive or receptive Aphasia.
• Repeated ask for assistance with time orientation.
• Have decrease knowledge in current events.
• Cannot remember personal history accurately.
• Begins to have problems performing complex task that require sequencing use of
  equipment or supplies or involvement with people.

DAMAGE TO THE OCCIPITAL LOVE
• The loose their peripheral vision.
• They loose their ability to look up and their gaze is directed downward.
• They loose their ability to focus on, truck moving object.
• They become very obsessive and may repeat the motion over, and over again.
• They often have delusion that their spouse/wife is unfaithful or that “ This is not
  my house”.
• Their agitation increase.
• They engage “rummaging” activity, which can be very disruptive to other but can
  provide them many hours of pleasing activity.
• As axienty level scalate, they wonder Occasionally about making threats to people
  they encounter or verbal outburst.
• They are disoriented in the three spheres: time, place, and person.
• They may be personality changes, which under the stress can lead to “violent
  behavior” or catastrophic reactions.
•    There is loose of mark power.
•   They loose the ability to read.
•   They may experience nausea or general feeling of malaise.
•   They begin to suffer for cognitive abulia: they can not hold an idea long enough
    to complete an intended action.

DAMAGE TO MOTOR AREA
• The person have problem initiating and fallowing through with the movement.
• Dysphagia – difficulty in swallowing food.
• Gait, posture and motor planning are affected.
• They may be symptoms of rigidity due to decrease in amount of the the
  neurotransmitter dopamine often to the description of neuroleptic drugs.
• Muscle weakness.
• Balance is compromised.
• People may experience hyperkinesis.
• Their may be muscle cramping.
• Persons may show hypermetamorphasis (fascination with small objects).
• In the later stage person may curl into fetal position.

DAMAGE TO THE OCCIPITAL LOBE CONTINUES
• There are increase visual impairment.
• They begin to suffer from mind blindness, and are not able to distinguish night
  and day.

DAMAGE TO THE LIMBIC SYSTEM CONTINUE
• Person may feel old deep in their bones, or be comfortably hot.
• Thirst can be extreme.
• They have enomous appetite, partly because due to memory loss, they do not
  remember when they last ate.
• They are unaware of recent event and their surroundings.

    DAMAGE TO PREFRONTAL AREA
•   They can not fallow direction.
•   Visual changes continue and now include visual field neglect.
•   The fallowing problem are common.
    1. Wandering.
    2. Soundowing.
       3. Hallucinations – is seeing hearing or feeling something is not really there.
       4. Delusion – false belief.
       5. Castrophic Reaction – extreme response.
       6. Agitation and Restlessness.
       7. Agitation and Combativeness.
       8. Screaming.
       9. Abnormal Sexual behavior.
       10. Repetitive Behavior.

Care for the Person with Alzheimer’s Disease and Dementia.
   (Environment)
       Fallow established routines.
       Avoid changing room or roommates.
       Place picture signs, on rooms bathrooms, dining rooms, and other areas.
       Keeps personal items where the person can see them.
       Stay within the person sight to the extent possible.
       Place memory aid where the person can see them.
       Keep noise level low.
       Play music and show movies from the person past.
       Keeps task and activates simple.

   Communication:
     Approach the person in a calm, and quiet manner.
     Fallow the rules in communication.
     Practice measure to promotes communication.
     Provide simple explanation of all procedure and activities.
     Give consistent response.

   Safety
      Remove harmful, sharp, and breakable object from the environment this includes
      knife, scissors, glass, dishes. Razors and tools.
      Provide plastic eating and drinking utensils. This helps prevent breakage and cuts.
      Place safety plugs and electrical outlets.
      Keep cords and electrical outlets in out of reach.
      Sore personal items in a safe place (shampoo, deodorant, lotion and others).
      Keep childproof caps on medicine containers and house holds cleaners.
      Store household cleaner and medicines in locked storage areas.
      Store dangerous equipment and tools in a safe place.
      Removes knobs from stove, or place childproof cover on the knobs.
      Removes dangerous appliances and power tools from the home.
      Removes firearms from the home.
      Store keys to the cars or other motors vehicles in a safe place.
      Supervise the person who smokes.
      Store cigarettes or cigars pipes, matches and other smoking materials in a safe
      place.
      Practice safety measure to prevent falls.
   Practice safety measure to prevent fires.
   Practice safety measure to prevent burns.
   Practice safety measure to prevent poisoning.




Wandering:
  Make sure doors and windows are securely locked.
  Make sure doors alarm are turned on, the alarm turn off when the doors opened.
  Make sure the person wear ID or bracelet at all times.
  Exercise the person as ordered. Restraints require a doctor’s order. They also tend
  to increase confusion and disorientation.
  Do not argue to the person who wants to leave. Remember that the person does
  not understand what you are saying.
  Go with the person who insists on going out side. Make sure she / or he properly
  dressed. Guide the persons inside after a few minutes.
  Let the person wander in enclosed area provided.

Soundowing:
   Provide calm, quiet setting late in the day, treatment and activities early in the
   day.
   Do not restrain the patient.
   Encourage exercise and activity early in the day.
   Make sure the patient has eaten. Hunger can increase restlessness.
   Promote urinary and bowel elimination. A full bladder or constipation can
   increase restlessness.
   Do not try to reason with the person. Remember he / or she can not understand
   what your saying.
   Do not tell the person to tell you what is bothering him or her. The erson ability to
   communicate is impaired. He / or she does not understand what you are asking.
   The person can not think or speak clearly.
   Dim light and play soft music to help calm the patient.

Hallunation and Delusions
    Do not ague with the persons. She / or he does not understand what are you
   saying.
   Reassure the person. Tell him or/ her that you provide protection from harm.
   Distract the person with some item or activity.
   Use touch to calm and reassure the person.

   Basic Needs
   Provide the person food and fluid needs. Provide finger foods, cuts foods and
   pour liquids as needs.
   Provide good skincare. Keep the person free of urine and feces.
   Promote exercise and activity during the day, this help reduce wandering and
   soundowing behaviors. The persons may sleep better.
   Reduce the person intake of coffee, tea and cola drinks. This contains caffeine.
   Caffeine is a stimulant. It can increased the person restlessness confusion and
   agitation.
   Provide quiet. Restful setting, soft music is better in the evening than loud
   television programs. Play music during care activities such as bathing and during
   meals.
   Promote personal hygiene. Do not force the person into shower or tub. People
   with Alzheimer’s Disease often afraid of bathing. Try bathing the person when he
   or she calm. Use the bathing method preferred by the person ( tub bath, shower
   and bed bath) provide for privacy and keep person warm. Do not rust the person.
   Provide oral hygiene.
   Have any equipment ready for any procedure ahead of time. This reduces the
   amount of time the person is involved in care measures.
   Observed for sign and symptoms of other disorder of diseases.
   Protect the persons from infection.

           CARE GIVER RESPONSIBILITIES FOR ALZHEIMER

Communication
• Speak directly to your patient, looking at them to ensure that he or /she has heard
  you.
• Speak slowly and in a calm tone of voice.
• Use short sentences with one idea at a time. Instead of asking of the patient what
  he or/ she wants, which can confuse her. Use declarative sentences like, “its time
  to eat now.”
• Try not to discus a topics that patient can no longer remember. Encourage to talk
  an familiar things and time.
• Eliminate distraction, such as noise activities when speaking. It may be difficult
  for the patient to sort things out.

Daily grooming
• Have every thing you need prior to starting. This reduce distractions. Make sure
   that the room is warm enough.
• Fill tub with one only a few inches of water. Make sure to check the temperature
   of the water.
• Avoid using of bath oils or any additive that will make the surface of the slippery.
• Break activity in to steps. Try this approach; “Here’s the washcloth, wash your
   arm.
• Be calm and gentle, but firm, avoid distraction or discussion. It is best to focus on
   the task on hands.
• NEVER URRY.
• Check for skin rushes or sores. Consider using cornstarch instead of powder.
• Place a towel over the shoulder of the shoulders of the bather for warm and sense
   of privacy.
•   Be flexible….. if loved one refuses to step on the tub. Consider a sponge bath in
    the bed room.




Dressing
• Lay or hang all cloths in the order they should be put on.
• Use number of magazine picture to label clothing drawers.
• Don’t task for choice preferences.
• Remove seldom use clothing to reduce choices. Never hurry your patient.
• Use simple garments. Velcro can replace many fasteners. Cardigan sweaters are
   easier to use and pull on sweater. Jogging out fits are both fashionable and easy to
   put on.
• Place brushes and in combs and clear view.
• Clothing can be come hazard if does not fit properly. Be sure that the clothes
   being worn will not trip your patient.

Mealtime
• Serve one food at a time so your Alzheimer’s wont have to decide which one to
  eat first.
• Use a bowl instead of a plate to prevent spills.
• To minimize frustration cut food into a bite size or piece.
• Has your Alzheimer’s patient forgotten how to use fork? Watching you
  demonstrate the may bring the skills back, if not offer if not offer the patient a
  spoon, or consider serving nutritious finger foods.
• Giving your patient a smaller spoon will encourage him to or / her to take smaller
  bites and avoid choking and digestion problems.
• A plastic aprons and tablecloth will make clean up simpler.
• Avoid very hot beverages to avoid the scalding.

Sleeping problem
• Avoids day time naps if the patient is not sleeping through the night.
• Make sure of excess energy by getting some exercise every day.
• Consult the patient doctors about any medications that might cause sleeplessness,
    and before giving your patient any kind of over – the counter sleeping aid.
• Avoid caffeine in all forms, if possible.
• Make sure your patient has used the bathroom before going to bed.
• Try to keep a consistent time and normal routine for going to bed.

Sundowning
• A nap or some quite time in the afternoon if doesn’t interfere with sleeping at
   night.
• An early dinner or late afternoon snack.
•   Good lightning inside the house to compensate for the decrease of sunlight
    outside.
•   Schedule more difficult activities, such as a baths. Earlier in the day.



Toileting
• Establishing a regular schedule for taking the Alzheimer’s patients to the
   bathroom. Start with two hours intervals – as well as first thing in the morning
   and afternoon naps. Adjust intervals as necessary.
• Put nightlight in the bedroom. Corridor and bathroom.
• Paint the bathroom door a bright color or put an eye – catching sign on it.
• Try to protective bedding and adult diapers a (nurse can help you select these
   product).
• You will probably need to plan on using adult diapers for your patient at some
   point during the illness.

Wandering
• Have your patient wear an ID bracelet that indicates that this is a memory
  impaired” person. A name and phone number should be appeared on this ID.
• Notify the neighbors that you care for memory impaired person. Explain what is
  to be done if they ever see your patient out alone.
• Reflected tape can be place on clothing. Can make this your patient a little visible
  to others. ID should be worn by all Alzheimer’s patient. Name tags sewn or
  ironed on to clothing can provide a name and phone number.
• Some individuals won’t leave anywhere without certain personal items like sun
  glasses, shoes, their purse, etc. use this knowledge to your advantage by placing
  these items in secure place known only to you.
• If your patient does wander off. Call the police immediately. Having recent photo
  (and video, if possible) and a description of the patient ready for the police will
  save time. Most importantly, when your patient does return home, great him/her
  with love and affection.

Catastrophic behavior
• Remained calm and quietly remove the patient from the upsetting position.
• Remember that hostile behavior can result from feeling frustrated with
   limitations, misunderstanding what’s going on in the environment, or simply
   forgetting the appropriate behavior.
• Try to determine what causes this reaction. Is there a pattern?
• Avoid ageing or reasoning and provide a kind word or touch.
• Consult your patient physician. Irritability and hostility can be a direct result of
   some physical pain that the patient is unable to describe.
           CREATING A SAFE HOME ENVIRONMENT

Bathroom
• Place a bath mat or adhesive strip on tub and on shawer.
• Install grabs bars in tub.
• Install a chair or shower.
• Install sturdy grab bars around the toilet facilities.
• Install raise toilet seats.
• Use a hand – held shower nozzle.
• Use a padlock or childproof latches on cabinets containing medicine, cleaning
   fluids and other dangerous products.
• Cover the faucet in the tub with a soft material like sponge to help prevent injury
   if the patient falls in the tub.
• Color code faucet handles, red for hot blue for cold.
• Put a sign on the outside of the door identifying the bathroom.

Kitchen
• Removes knobs from the stove.
• Use a padlock or childproof latches on cabinet that contained cleaning supplied or
   other hazardous materials.
• Looks up knives, scissors, and other potentially dangerous utensils.
• Keep a fire extinguisher in the kitchen.
• Keeps handle pots and pans facing toward the back of the stove.
• Place emergency numbers on the refrigerator.
• Remove area rug in front of the sink or under the table.

Stairs
• Mark the top and bottom of the stairs with bright yellow tape.
• Install gates at the top and bottom of the stairs.
• Install a handrail on both side of the stairs (if possible).

Window and doors (specially important for patients who wander).
• Install child proof doorknobs. Install look high on the doors, out of the reach of
  the patients. You can also install a lock that can only be opened with a key.
  Secure lock from opposite side of the door so they can not be unscrewed by the
  patients.
• Use double lock or two step lock.
•   Use alarm mats in front of the door. Install portable alarms on doors, or place
    bells on next doors.
•   Disguise the door by painting it by the same color as the wall and hanging a
    scenic picture on it.
•   Put sign and or picture on doors describing room (bathroom, closet, bedroom,
    etc.)
•   Disarm automatic garage door opener.
•   Install lock on windows.
•   Give a spare key to a neighbor or hide one out side incase your patient lock you
    out

Fire burn, and electrical shock safety
• Purchase a fire extinguisher and smoke detectors for each level of the home
   (including the basement).
• Put a smoke detector in the patient bedroom.
• Determine a fire emergency exit route and practice using with your patient.
• Post the fire emergency number in prominent place.
• Keep hot water below temperature below 120 degrees.
• Keep lighter and matches locked up.
• Avoid of the use of portable heaters.
• Guard radiators.
• Avoid running electrical cords in open spaces where patient can reach them.
• Place child proof covers over plugs.

Personal safety
• Get an ID bracelet to your patient that would notify rescuers, local police, or
   medical staff and other of the patient’s condition in the event of an emergency.
• Keep a recent photo or video of your patient hand.
• Place iron – on labels with your patent’s name, address and phone number in
   clothing to aid in identification incase your patient get loss.
• Arrange furniture so your patient can move around easily.
• Remove or firmly tape down the scatter rugs, area rugs moveable carpets.
• Purchase rubber soled shoes or slippers for your loved one to avoid falls.
• Keep working flash light by your bed.
• Use night light, specially for your patient to avoid the bathroom at night.
• Remove firearms and weapon from your home.
• Lock up over the counter medicines, prescription medicines and cleaning fluids.
• Keep alcohol in a lock cabinet and away from your patient.
• If necessary, build a wheel chair rump.
• Use bed rail or place a comforter or pillow on the floor around the patient bed.
• Hide car keys and, if necessary, disconnect the car battery if patient is not allowed
   to drive but still want to.
• If patient hallucinates or is bothered by his / her reflection , cover or remove
   mirrors.
•   Keep medical records on hand at all time.




                           STROKES

DEFINITION:
        (Infraction) loss of blood supply to the brain / or entire body.

ETIOLOGY:
        Atherosclerosis.
     1. Thrombus – Not traveling
     2. Embolus – Is traveling
     3. Hemorrhage

RISK FACTORS:
        Major risk factors.
     1. Age – is the main risk factors
     2. Hypertension – most travel risk factors.
     3. Cardiac Disease - risk of stroke double with coronary.
     4. Previous stroke.

            Minor risk factors.
       1.   Cigarette smoking – because of the nicotine found on the cigarette.
       2.   Sedentary life time
       3.   Hypercholesterol – eating fatty food.
       4.   Oral contraceptive.

           Sign and symptoms.
       1. Paresis and plegia – weakness and paralysis.
       2. Sensation – presence of numbness.
       3. Visual – the side of the body is affected, and the right eye is loss of
           visions.
       4. Motor faction –
       5. decrease (ROM) range of motion exercise – contracture and deformity
           resulting immobilization.
       6. Atrophy – decrease the size.
       7. Pain form immobilization of support of joints.
       8. Associated reaction.
       9. In coordination.
       10. Apraxia
       11. Difficulty in ADL – daily activities. (Like walking)
  12. Speech and language
  - Apaxia: loss of speech
             Fluent – speech is smooth but has a grammatical errors.
             Non – fluent – flow in speech slow and vocabulary is limited.
             Global combination of fluent and non – fluent.
  13. Cognitive and behavioral changes.
             Anxious
             Depress that last to 7/8 months and occurs 6 months to 2 years
         after the incident.
             Emotional lability.
             Impatient, impulsive, over dependent, apathetic.
             Patient can not remember instruction for a new task given only 30
         seconds.

  14. Dementia
      “Characterized by”
              General decline in the higher brain function.
              Faulty judgement.
              Impair consciousness
              Poor memory
              Diminished communication
              Behavioral alternation.
  15. Occurrence of seizure
  16. Bowel and bladder dysfunction – incontinence, infection through catheter.
      – urinary or bowel in - control.
  17. Orofacial

              Dysphagia
              Drooling.
              Difficulty digesting food.
              Aspiration
              Asymmetry of facial expression
              Other use NGT

       CGR
  1.   Regulate the Blood Pressure
  2.   Diet
  3.   Cessation of smoking
  4.   Control associated disease
  5.   Use assistive device.
  6.   Functional activities.
  7.   Reward system.
  8.   Encourage the use of the affected side.

CARE OF THE PERSON WITH STROKE / CVA/ BRAIN
ATTACT
     1. The lateral position is used to prevent aspiration.
     2. Coughing and deep breathing are encourage.
     3. The best is keep in semi – fowler position.
     4. Turning and repositioning are done every two hours.
     5. Food and fluids are met.
     6. Elastic stocking are ordered to prevent thrombi (blood clot) in the legs.
     7. Range of motion exercise is performed to prevent contractures.
     8. A catheter must be inserted or bladder training program may be started.
     9. A bowel – training program may be necessary.
     10. Safety precaution is practiced. Check about the nurse by the use of bed
         rails.
     11. Assistant is given to safe care activities. The person’s encourage to do
         much as possible.
     12. Communication method are established. Question are limited to those that
         have “yes” or “no” answers. Speak slowly. Allow the persons time to
         responds.
     13. Good skin care is given to prevent pressure ulcers.
     14. Speech therapy, physical therapy, and occupational therapy, are ordered.
         Assistive devices are used as necessary.
     15. Emotional support and encouragement are given. Praise is given even the
         slightest accomplishment.

PROPER BED POSITIONING
   The room should be maximize patient awareness of the hemiplegic side.
   Common position that should be promoted include.

     Lying in the supine position.
     The head and trunk should be positioned in midline or flexed slightly toward
     the sound side to elongate muscles on the hemiplegic side.
     Small pillow or towel under the scapula will assist in scapular protation.
     The arms can rest on supporting pillow, extend and abduction, with wrist and
     finger extension.
     The pelvis is also protected (on a small, pillow or towel roll) with the leg in
     neutral position relative to rotation.
     The affected knee is position with a small towel roll to prevent
     hyperextension.

     Lying on the sound side
     The trunk should be straight.
     Small pillow under the rib cage can be used to elongated the hemiplegic side.
     The affected shoulder is protected with the arm well forward on a supporting
     pillow, with the elbow extend and the forearm in neutral supinated.
     The pelvis is protected and the affected leg flexed at the knee with the limp

     Lying the affected side
     The trunk should be straight.
           The affected shoulder underneath is position well forward with the elbow
           extended and forearm supinated.
           The affected leg is position in hip extension with the knee flexion. An
           alternate position has slight hip and knee flexion with pelvic protraction.
           The affected leg is position in flexion on a supporting pillow.

           Sitting (in a bed or a wheelchair)
           The patient should sit upright with trunk and head in midline alignment
           Symmetical weight bearing in both buttock should be encouraged.
           The leg should be in neutral with respect to rotation.
           When sitting in bed, pillows may be needed to bring the trunk to upright
           position.
       When sitting in a chair, the hips and knees should be positioned in 90 degrees of
       flexion, with weight bearing on the posterior thighs and with the feet flat.
       In a bed, the arm can be supported in a pillow or adjustable table, while in a
       wheelchair an arm board or lapboard can be used. The scapula should again be
       protected with wrist and finger extended in a functional open position.

NEUROLOGICAL DEFICITS OF STROKE: MANIFESTATIONS
AND CAREGIVER IMPLICATION.

                                                                Caregiver Implications
   Neurologic Deficits               Manifestation               Patient teaching
                                                                 Applications
VISUAL FIELD DEFICITS
Homonymous hemianopsia          Unaware of persons or             Place objects within the
                                objects o side of visual loss     patients intact field of
                                Neglect on one side of the        vision.
                                body.                             Approach the patient from
                                Difficulty judging distance       side of his intact field of
                                                                  vision.
                                                                  Teach are remind the
                                                                  patient to urn his head in
                                                                  the direction of visual to
                                                                  compensate for loss of
                                                                  visual field.
                                                                  Encourage the use of eye
                                                                  glasses if available.
                                                                  When teaching the patient,
                                                                  do so within patient intact
                                                                  visual field.
Loss of peripheral vision       Difficult seeing at night.        Place object in the patient
                                Unaware of objects or the         center of vision.
                                borders of objects.               Encourage the use of cane
                                                                  or other object to identify
                                               in the periphery of the
                                               visual field.
                                               Avoid night driving or any
                                               other risky activity in the
                                               darkness


Diplopia         Double vision                 Explain to the patient the
                                               location of an object when
                                               placing near the patient.
                                               Consistently place patients
                                               care items in the same
                                               location.
MOTOR DEDICITS   Weakness of the face, arm,    Place objects within the
Hemiparesis      and leg on the same side      patient’s reach on the non
                 (due to lesion in the         affected side.
                 opposite hemispher)           Instruct the patient to
                                               exercise and increase the
                                               strength on the affected
                                               side.
Hemiplegic       Paralysis of the face, arm,   Encourage the patient to
                 and leg on the same side      provide a range of motion
                 (due to a lesion in the       exercise to affected side.
                 opposite hemisphere)          Encourage neutral body
                                               alignment.
                                               Exercise an affected limb
                                               to      increase     mobility
                                               strength and use.
Ataxia           Staggering unsteady gait      Support patient during the
                 Unable to keep feet           initial ambulating phase.
                 together needs a broad        Provide supportive device
                 base to stand.                for ambulating.
                                               Instruct the patient not to
                                               walk without assistance or
                                               supportive device.
Dysarthria       Inability to form words       Provide the patient with
                                               alternative method of
                                               communicating.
                                               Allow        the       patient
                                               sufficient time to respond
                                               to verbal communication.
                                               Support the patient and
                                               family       to      alleviate
                                               frustration     related     to
                                               difficulty                  in
                                               communicating.
Dysphagia                   Difficulty in swallowing      Assist the patient with
                                                          meals.
                                                          Place     food    on     the
                                                          unaffected side of the
                                                          mouth.
                                                          Allow ample time to eat.
SENSOTY DEFICITS            Numbness and tingling of      Instruct the patient to
Parenthesia (occur on the   the body parts                avoid using this body part
side opposite lesion)       Difficulty          with      as the dominant limb.
                            proprioception                Provide range of motion
                                                          exercise to affected areas
                                                          and     apply     corrected
                                                          devices as needed.
                                                          Place patient care items
                                                          toward an affected side.
VERBAL DEFICITS             Unable to form words that     Encourage      patient    to
Expressive aphasia          are understandable, may be    repeat sound of the
                            able to speak a single word   alphabet.
                            response
Receptive aphasia           Unable to comprehend the      Speak slowly and clearly
                            spoken word; is able to       to assist the patient in
                            speak but may not make        forming the sound.
                            sense.
Global aphasia              Combination       of   both   Speak clearly and simple
                            receptive and expressive      sentences use gesture or
                            aphasia.                      pictures when able.
COGNITIVE DEFICITS          Short and long – term of      Reorient patient time,
                            memory loss.                  place      and      situation
                            Decrease attention span.      frequently.
                            Impaired      ability    to   Use verbal and auditory
                            concentrate.                  cues to orient patient.
                            Poor abstract reasoning.      Provide familiar objects
                            Altered judgment.             (family     photo     graphs
                                                          favorite objects)
                                                          Use non complicated
                                                          language with the patient.
                                                          Match visual task with a
                                                          verbal cue; holding a tooth
                                                          brush; stimulate brushing
                                                          teeth with saying I would
                                                          like you to brush your
                                                          teeth now.
                                                          Minimize          distracting
                                                          noises and views when
                                                          teaching the patient.
                                                          Repeat      and    reinforce
                                                  instruction frequently.
                                                  Ask question concerning
                                                  abstract reasoning and
                                                  judgments         that    are
                                                  appropriate to the patient
                                                  educational and cultural
                                                  back round such as how
                                                  apple and orange alike?
                                                  What should you do if
                                                  there is a fire?
EMOTIONAL DEFICITS   Loss of self control         Support patient during
                     Emotional lability           uncontrollable outburst.
                     Decrease tolerance to         Discuss with the patient
                     stressful situations.        and family the outburst are
                     Depression                   due to the disease process.
                     Withdrawal                   Encourage        patient   to
                     Fear, hostility and anger.   participate in – group
                     Feeling of isolation.        activity.
                                                  Provide stimulation for the
                                                  patient.
                                                  Control stressful situation
                                                  if possible.
                                                  Provide          a       safe
                                                  environment.
                                                  Encourage        patient   to
                                                  express        feeling     of
                                                  frustrations related to
                                                  disease process
                 PARKINSON’S DISEASE


INTRODUCTION
     Chronic, progressive disease of the nervous system. A.K.A “Paralysis
     Agitans”
     Characterized pathologically by degeneration of pigmented and other
     brain stem nuclei, particularly the Substantia Nigra.
     Primary biomechanical defect is loss of strial dopamine. Resulting from
     the degeneration of a dopamine – producing cells in the substantia nigra.

Note:
Chronic – is long term
Progressive – getting worse.
Dopamine – nuerotransmiter.

EPEDEMIOLOGY
     Occurs in about 1% of the population older than 55 years of age and
     becomes increasingly common with the advancing age, reaching
     proportions by age 85 years. The main age of onset is between 58 years
     and 62 years of age, with the minority of cases having their onset between
     the ages of 50 and 79.

ETIOLOGY
     Idiopathic Parkinsonism
          Etiology is unknown.
          Include “True Parkinson’s Disease” or “Paralysis Angitan”
          Was first was firs described by James Parkinson in 1817.
          It is the most common form.

       Infectious Parkinsonism
            Occurs to individual exposed to industrial poisons and chemical
            (manganese, carbon disulfide, carbon monoxide, cyanide, and
            methanol). The most common of this toxin is manganese, which
            represent a serious occupational hazard to miners.
           Pharmacologic Parkinsonism
                Various drug can produced Parkinsonian symptoms as side affects
                notably such as nueroleptics and powerful tranquilizers as
                chlorpromazine, haloperidol, and thioridazine, blood pressure
                medications containing reserpine.

           Methabolic Causes
               Due to disorders of calcium methabolism that result in basal ganglia
               calcifation. Hypopathyroidism is an example.

           Atypical Parkinsonism (Multiple System Atrophy)
                Degenerative disease of the nervous system can affect the substatia
                nigra and produced parkinsonian signs and symptoms along with
                others neurologic sign.
                Include striatonigral degeneration (SND). Shy – Drager Syndrome,
                Progressive Supranuclear Palsy (PSPO) Olivopontocerebellar
                Atrophy (OPCA), cortical – basal ganglionic degeneration, and
                diffuse Lewy body disease.
                Many of this condition is rare and affected relatively small number
                of individuals.

    Clinical sign
    1.Rigidity – may be defined as an increase to resistant to passive motion and
           affected all striated muscle
-   Cogwheel Rigidity: is a jerkey, ratchet – like response to passive movement as a
    muscle alternately tense and relaxes.
-   Lead – pipe Rigidity: it is constant, uniform resistance to passive movement
    without fluctuation.

    2.Bradykenesia
-   Means slowness of movement
    *Akinesia*
-   Severe form inability to move.
-   Accounts for many of the disabling characteristics of Parkinson Disease.
    3.Treamors
-   Most common symptoms and initial complain.
-   Characteristic of resting type (typical present at rest and disappears with voluntary
    movement).
-   Has frequentcy of 3-6 Hz and 4-7 oscillations per second.
-   Begin at typical “pill rolling” movement of the index of the finger and thumb.
-   Suppressed when the patient is relaxed and unoccupied.
-   Aggravated with fatigue, stress, movement of the opposite limb, emotional
    tension, and excitement.

    4.Postural Instability
-   Balance reactions are impaired or absent. Patient typically have trouble in
    maintaining upright balance, walking or turning around.
-   When balance is loss, patient falls easily due to loss of reactive process needed to
    adjust posture and regain equilibrium, frequent injury is the result.
-   May be a result of degeneration of the globus pallidus.


    OTHER CLINCAL SIGN AND SYMPTOMS
    1. Kinesia Paradoxia
       - Patient’s in – ability to make a rapid movement when experiencing a surge
       of emotional energy.
    2. Micro graphia
       - Small cramped handwriting.
    3. Sialorrhia
       - Excessive drolling: the muscle is not working
    4. Festinating gait
       - A.K.A “shuffling gait” Small stepped shuffling gait with absence of arm
         swing.
       - Patient’s is lens forward and takes increasingly faster steps to catch the
         displacement of the center of gravity. (COG)
       - Propulsive gait : a forward accelerating quality of gait.
       - Lateral propulsion: tendency to fall on the side.
       - Retropulsion: tendency to fall backwards.
       - En Block Movement: loss of normal heel toe gait pattern with difficulty in
         turning.
    5. Bradyphrenia – slow in thinking
       - slowness of thought process
       - Accompanied by lock of concentration and attention




 6.    Masked Facie
       - A.K.A “exprssionless face” Mask like, with reduced eye blinking.
       - Blepharoclonus: fluttering of close eyelids
       - Blepharospasm: involuntary closure of the eyelids.
 7.    Dysphagia
       - Difficulty in chewing food and swallowing, resulting from cranial nerve
         dysfunction. Present in 50% of patient’s
 8.    Dysartia
       - Disturbed speech.
 9.    Hypophonia
       - Decreased volume of speech secondary to rigidity and bradykinesia of the
         speech musculature
       - Speech is slurred and monotonous
 10.   Mutism
       - Patient speak in whispers
 11.   Myerson’s sign
       - A sustained blink response produced after repetitive over the bridge of the
         nose.
       - Exaggerated glabellar reflex.

 SECONDARY IMPAIRMENTS OR COMPLICATION
 1. Muscle atrophy and weakness.
 2. Loss of flexibility and contracture formation.
 3. Deformities (Kyphosis – most common postural deformity)
 4. Osteoporosis
 5. Cardiopulmonary changes (Phuemonia – one of the leading causes of death)
 6. Nutritional changes.
 7. Decubitus ulcer.
 8. Seborrheic dermatitis.

  TREATMENT
- There is known cure for Parkinson’s disease.
- There are method of management includes:
         Pharmacology
         Rehabilitation
         Nuerosurgical Procedure
A) Pharmacological
     • Dopamine – does not cross the blood brain barrier.
     • L – dopa (Carbidopa).

              Preferred treatment for Parkinson’s disease.
              Administered orally with carbidopa: combination of this two is marketed
              as o be sinimet.
              Crosses the blood brain barrier and is decarboxynated in the brain to
              dopamine.
              L – dopa and sinimet proved to be affective in reducing tremor.
              Does not stop progression of the disorder.
              Common early side effects are nausea, vomiting, and hypertension.
              May cause “on and off Phenomenon” characterized by episodes of
              freezing or bradykinesia.


B) Rehabilitation
             Relaxation exercise to decrease rigidity.
             ROM exercise, stretching maneuvers
             Mat Activities.
             PNF technique.
             Frenkel’s Exercise.

C) Nuerosurgical
            Unsuccessful in relieving Parkinsonian symptoms.



                       Multiple Sclerosis (Blood clot)

   •   Great crippler or young adult.
   •   The disease is characterized by demyelinating (hardened tissue in autopsy) lesion
       as a plagues that are scattered throughout the central nervous system.
   •   Demyelination impairs nueral transmission and causes nerves to fatigue rapidly
       and myelin sheath is replaced by scar.
  •   Symptoms is vary and is usually symmetrical.
  •   Cause: Unknown; infection, hereditary.
  •   Female > male.
  •   Age is onset is 15 – 45 years old.
  •   Common in temperate climates.
  •   There are fluctuating periods of symptom free (remission) and symptom flare up
      (exacerbation)

  Charcoat’s triad
      1. Scanning speech.
      2. Intention tremor
      3. Nystagmus – rhythmic jerking movement of the eye.

  Sign and symptoms.
     1. Global dementia.
     2. Dysphagia which may cause choking – (difficulty in swallowing)
     3. Dysartia – (difficulty in forming words).
     4. Blurred or double vision (Diplopia) eye patch.
     5. Easy fatigability – refreshed in early morning, client feel fatigue and
         exhausted by early afternoon then up again by late afternoon.
  - Significant cause of disability.
  - Loss of energy may limit tolerance to exercise.
     6. Psychological changes
     7. Hypersensitive to heat.
     8. Weakness and paralysis of the limb.
     9. Spasticity.
     10. Poor balance and coordination.
     11. Staggering gait.
     12. Dragging gait.
     13. Ataxia – uncoordinated movement and may influence egait, posture and
         patterns of movement.
     14. Numbness or pins and needles.
     15. Poor bowel and bladder controls.


CGR
      1. For sensory deficits:
         - Topping promotes awareness for those who are unable to shift position
            because of the weakness and spasticity.
         - Keep skin clean and dry.
         - Fallow a good diet and drink plenty of fluids.
         - Inspect skin regularly.
         - Provide regular pressure relief.

      2. Pain:
         - LBP is a common complain.
    -   May benefit in pool therapy.
    -   Stretching or exercise may relief pain.
    -   Postural retraining.
    -   Adaptive seating devices.

3   Spasticity:
    - Self stretching.
    - Pool therapy.
    - Cold pack.
    - Mat activities.
    - Relaxation technique.

4   Paresis and fatigue:
    - Resistive training sequence may be appropriate.
    - Achieve greatest number of goals with fewest exercises.
    - Functional Activities.
    - Exercising to the point of fatigue is contraindicated.
    - Exercise in hot environment is avoided.
    - Air conditioned place is advisable.
    - Teach energy conservation techniques.
    - Time out should be instituted.
    - Activity should be balance at rest.

5. Ataxia
   - Postural stability focusing holding in a number of different weight bearing
      antigravity posture (prone on elbow, sitting quadraped, kneeling,
      plantigrade, and standing).
   - Joint approximation.

6. Gait
   - Patient have weal calf and tights muscles particularly hip abductors which
      leads to difficulty fin foot clearance.
   - Ambulatory assistance.
   - Standing and walking activities should stress safety adequate transfer with
      trunk rotation with stable base of support and controlled progression.

7. Functional Impairments
   - Develop problem solving skills
   - Appropriate compensatory techniques.
   - Energy conservation.
   - Toilet grabs bars, raised seat and dressing hooks.

8. Respiratory problem
   - Breathing exercises.
   - Shallow respiration may continue to speech difficulty and re current
      respiratory infection.
       -   Muscle for respiration may be weak, ataxic or spastic.




       -   Resistive breathing.
       -   Effective coughing.
       -   Postural training.

   9. Feeding and Nutrition issues
      - May benefit eat in the morning.
      - Eating multiple small meals.
      - Using ice cube or water Popsicle or tongue and straw can stimulate
         sucking reflexes and saliva production.
      - Dietary counseling on the proper consistency of food.
      - Proper sitting posture, head control, eye – hand coordination and voluntary
         control of muscle chewing.

   10. Psychosocial issues.
       - Assist the individual and family in understanding the disease.

 Exacerbating factors – effect is immediate and dramatic.
  1. Change in health status – stress, viral or bacterial infection, disease of major
     organs, pregnancy.
  2. Heat – climate, treatment modalities, fever, internal heat, prolonged exercise.
  3. Exhaustion, dehydration, malnutrition and sleep deprivation.

 Additional stress on the already compromised nervous system.
 Prognosis – 22 – 25 years old cause by respiratory and urinary infection.
 No cure.



            CARDIO VASCULAR PROBLEM

                      HYPERTENTION

Definition:
       High blood pressure

Type:
   1. Primary or essential HPN.
   2. Secondary HPN.
Risk factors:
   1. Non- modifiable.
   2. Modifiable.

Sign and symptoms:
   1. Occipital headache.
   2. Vertigo (dizziness).
   3. Flushed face.
   4. Spontaneous epistaxis.
   5. Visions changes.
   6. Ringing of ears.
   7. Noctumal urinary frequency.
   8. Personality changes: forgetful, irritable and confused.

CGR:
  1. To encourage compliance with anti-hypertensive therapy, suggest establishing
     a daily routine for taking medication.
  2. Advice to stop smoking and alcohol.
  3. Suggest stress – reductions groups.
  4. Dietary changes – avoid high sodium foods (pickles, potato chips, canned
     soups, cold cuts) caffeine, table salt, foods high in cholesterol and saturated
     fat.
  5. Exercise program (aerobics) to improved cardiac status, reduced obesity, and
     serum cholesterol level.
  6. Continue monitor BP.
  7. Provide positive reinforcement and psychosocial support.



                  ANGINA PECTORIES

 DEFINITION:
   Vessels are lined with atherosclerotic plaque.
   Acute chest pain, (Nitroglycerine).
   Imbalance Cardiac workload and oxygen supply myocardial tissues.

 Sign and symptoms:
    Difficult to recognize in woman symptoms less reliable.

     1.    Placing a clenched fist against the sterum.
     2.    Gripping viselike feeling of pain or pressure behind the breast bone.
     3.    Squeezing, burning, pressing, chocking, aching and bursting.
     4.    Pain that may radiate to the neck, jaw, back, shoulder, or arms most often
           the left arm.
     5.    Pain usually last 3-5 min. and relieved by rest or nitroglycerine.
   6.    Tooth ached.
   7.    Burning Indigestion.
   8.    Dyspnea ( Shortness of breath).
   9.    Nausea.
   10.   Belching – to expel gas to the mouth to the stomach.


Nitroglycerine:
   To increase oxygen to the heart, decrease symptoms of the angina.
   Trade name Nitrocotine.

Types of Angina:
1. Chronic stable angina; level of psychical and emotional, stress, response to rest
   nitroglycerine.
2. Resting angina: rest in supine position, exercise is relieved by rest.
3. Unstable angina: Abrupt changes intensity and symptoms.
4. Noctumal angina:
5. Atypcal angina: visual symptoms (headache, tooth ache) subside with rest.
6. New – onset: developed for the first time, for the last 60 days.
7. Prinzemetal – symptoms similar to attifecal cause by coronary artery, occurs at
   rest and in the morning.
8. Variant: common under 50 years old.

Cause of angina is coronary arteries.

   Definition:

   Active chest pain.
   Result from imbalance between cardiac workload and oxygen supply to
   nyucardial disease.
   Vessels are lined with atreosclerotic. Plague.
                MYOCARDIAL IMFRACTION
Definition:
     Heat attack.
     Reduce blood flow to the coronary artery which causes myocardial.
     A sudden decrease I coronary perfusion or an increase of myocardial oxygen
     (ischemia).
     Clot and plague.

Epidemiology:
1. Common in men equalizes after women.
2. North America / Western Europe, is a common cause of death.
3. Result from a cardiac damage or complication.

Risk Factors:
1. Age related changes cardiovascular system.
2. Eating large meal.
3. Physical exertion.

Predisposing Factors:

Sign and symptom.
1. Severe substernal chest pain or squeezing pressure.
2. Pain possibly radiating down both arms.
3. Feeling of indigestion.
4. Angina lasting for 30 minutes or more.
5. Angina unrelieved by rest or nitroglycerine.
6. Nausea.
7. Pain infarct relieved by a change in position.
8. Sudden dimness or loss of vision or loss of speech.
9. Pallor.
10. Diaphoresis (heavy perspiration).
11. Shortness of breath Weakness numbness and feeling of faintnes.
CGR:

  1. Check blood pressure from time to time.

  2. Avoid situation that may precipitate attacks.

  3. Organize patient care and activities to minimize uninterrupted rest periods.

  4. Provide low cholesterol, low sodium diet, without caffeinated beverages
     (dietitian)

  5.   Provide stool softener to prevent staining during defecation (valsalva).

  6. Allow the patient to use a commode and provide as much privacy as possible.

  7. Assist in ROM exercises.

  8. Teach client ankle pumping exercise.

  9. Provide emotional support and help reduce stress and anxiety.

  10. En courage the Patient to participate in cardiac rehabilitation program.

  11. Counsel the patient to resume sexual activity progressively. Don’t over look this
      aspect of care with older adult. Most of the older adult are sexually active and
      may not feel comfortable asking about this topic. The patient may take
      nitroglycerine before sexual intercourse to prevent chest pain from the increased
      activity.

  12. Instruct the patient to report any chest pain.

  13. If appropriate, stress need to stop smoking.

  14. If necessary, refer the client to smoking cessation program.
           CHRONIC OBSTRUCTIVE POLMONARY DISEASE

Definition:
   Refers to a number of disorder that affect movement of air in and out of the lungs.
   Bronchitis emphasima asthimal chronic outflow limitation.

Predisposing Factors:
1. Cigarette smoking: exacerbate COPD, inducing bronchospasm.
2. Air pollution: mucosal edema in turn increase air way resistance.
3. Occupational exposure to irritating dust or gases.
4. Heredity: antitrypsia (enzyme) protect the lungs.
5. Infection.
6. Allergies.
7. Aging.
8. Harmful drug and chemicals.



                  ACUTE BRONCHITIES
Definition:
   Inflammation of the trachea and bronchi tracheobronchial tree that is self limiting
   and short duration.
   Result form chemical irritation (smoke, fume, and gas).
   Also from viral infection such as a influenza, measles chicken pox or whooping
   cough.


                  CHRONIC BRONCHITIS
Definition:
   Condition associated with prolonged exposure to non – specific bronchial irritant.
   Accompanied by mucus hypersecreation and by structural changes in the bronchi.
Sign and Symptoms:
   Cyanosis

Phatologic changes
   This irritation is result of cigarette, dusts, pollution.
1. Increase the number of mucus – producing cells in the lining of the bronchial tree.
2. Decrease the number and action of the ciliate epethelial cells that mobilize
   secretions.
3. Narrowing of the airways because of chronic inflammation of the bronchial tree.



                          EMPHESEMA
Definition:
   May develop in person after a long history of chronic bronchitis in which the
   alveolar wall are destroyed which read to permanent over distention of the air
   spaces.

Clinical Sign and Symptoms:
1. Dyspnea.
2. Cough.
3. the client is often thin.
4. Tachypnea with prolonged expiration.
5. Use of accessory muscle.
6. Leaning forward when breathing.
7. Barrel chest and increased expiratory effort. The client is known as a pink puffer.
8. Orthopnea only able to breathe in upright position.
9. Purse – lip breathing.

Prognosis:
   As the disease progress, there is a loss of surface area available for gas exchage.
   In the final stage, cardiac complications especially enlargement and dilation of the
   right ventricle develop.

Treatment :
   Cession of smoking.
   To improve oxygen and decrease carbon dioxide.
   Improve pulmonary function.
                       ASTHMA
Definition:
   Shortness of breath.

Respiratory symptoms are cause by:
1. Hypersensitivity to irritants such as pollutants or allergens.
2. Psychological stress.
3. Cold air.
4. Exercise
5. Drug use.

   Pathophysiology:
1. Extrinsic bronchial asthma (or allergic asthma).
2. Intrinsic bronchial asthma (non allergic).

   In both forms the airway is hypereactive. Once the airway is spasm, mucus plug
   the airway, trapping distal air. hyperventilation occurs as the lung attempts to
   responds to increased volume and pressure.

Sign and symptoms:
1. Symptoms worse at night.
2. Dyspnea.
3. Prepare to seat upright or lean forward using accessory muscle for respiration.
4. At the beginning at the attack there’s a sensation of chest constriction, wheezing
   non- productive coughing prolonged expiration.
5. Tachycardia and tachypnea.

Treatment and prognosis:
1. Affect of asthma is reversible with treatment.
2. Environmental control.
3. Pharmachologic therapy for air flow obstruction (bronchodilators) and in
    flammation.
4. Immunotherapy.
5. Maintain Hydration.
6. Provide high calorie, rich in protein diet to promote health and healing.
7. Encourage daily activity.
8. Vibration.
  9. Teach coughing and deep breathing.




INFLAMMATION AND INFECTIOUS DISEASE

                          PNEUMONIA
  Causes:
  1. Aspiration of food fluids or vomitus.
  2. Inhalation of toxic chemical, dust or gases.
  3. Bacterial or viral infection.

  Hacking productive coughing (rust- colored or green, purulent sputum)

  CGR:
  1. Assist in taking medication.
  2. Rest and supportive treatment.
  3. Maintain hydration.


                        TUBERCULOSIS
  Definition:
     PTB

  Sign and symptoms:
  1. Weight loss and loss of appetite.
  2. Feeling sick.
  3. Fever.
  4. Sweating specially at night.
  5. Chest pain.
  6. Coughing.
  7. Coughing up blood.
  8. Unexplained pain in any body.
  9. Cyanosis.

  How tuberculosis is diagnose?
    Physician can only make diagnosis of tuberculosis, active or inactive after an skin
    test or X-ray and or as sputum sample is take.
    Usually once the diagnosis of tuberculosis is made, close contacts of the infected
    person are also tested.

  Treatment:
  1. Medication is always prescribed and taken for a long time.
2. Isolation of the client.

CGR:
1. Maintain a routine in the house, and encourage the client to maintain thes regime
   set up by the physician and in teaching the family the truth about the disease.
2. Proper diet encourage eating though there is no appetite.
3. Encourage fluid intake.
4. Explain to the family that the disease is under treatment, the change in contracting
   the disease is past.


                              ARTHRITIS
Definition:
   Inflammatory of the joint.
   Inflammatory or non-inflammatory of the joint.

Joint structure that may be involve:
a) Synovium.
b) Cartilage.
c) Tendons
d) Capsule.
e) Bone.
f) Surrounding muscle.


CLASSIFICATION:

1. Inflammatory connective Tissue Disease.
- Example: Rheumatoid Arthritis Dermatomyositis Juvenile Rheumatoid Arthritis.

2. Inflammatory Crystal – Induced Disease.
- Example: Gout Psuedogout.

3. Inflammation Induced by Infection Agent.
- Example: Bacterial, Viral, Tuberculous and fungal arthritis.

4. Seronegative Spondyloarthropathies.
- Example: Ankylosing Spondylitis, Psoriatic Arthritis Reiter Disease and ABD.
                        OSTEOARTHRITIS
Definition:
     A form of arthritis associated with bone and cartilage degeneration: seen most
     often in aging people.

Most commonly Involved Joint.
1. Fingers.
2. Feet.
3. Knees.
4. Hips.
5. Spine.


CAUSE AND RISK FACTORS:
  Stress of the joint cause of the activity and aging almost all people average of 50
  years old have osteoarthritis and injury to the bone.

Special Consideration for Aging:

   Years of weight bearing and work cause wear and tear of the bones, ligaments,
   and joints.
   The total weight and density of the bones decreases.

Sign and symptoms:

   Pain – is often present at rest.
   Morning stiffness – fallowing a period of rest.
   Enlarge of joints.
   Most common involve the weight – bearing joints (hips an knees), and the
   cervical and lumbar spine and distal interphalangeal joints of the fingers and the
   carpometacarpal joint of the thumb.
   Crepitus.
   Stiffness.
   Progressive weakness of muscles.
   Impairment of joint position sense may occurs.
Care Giver Responsibility:

1. To relieve pain, apply heat to painful and stiffness joints for 20 minutes 2 – 3
   times a day, Use:
- Hot towels.
- Hot tubs.
- Electric heating pads.
- Deep heating ointments or lotion.
- Whrilpool spa.

2. If osteoarthritis of neck cause pain in the arm, suggest wearing soft and
   immobilizing collar.
3. Use corset for back pain.
4. Massage muscle around painful joints.
5. Have the client sleep of their back with mattress or waterbed.
6. Give patient reliever as prescribed by physician.




                  RHEUMATOID ARTHRITIS
Definition:
   An realness characterized by joint disease that involved the muscle and membrane
   lining of the joint and cartilage 2 or 3 X” more common in woman it usually
   beginning between the age of 30/40 years old. Body parts that involved.

1. Cartilage.
2. Synovile membrane.
3. Muscle and ligament.

Sign and symptoms:
1. Effusions and swelling of the joints: which cause aching and Yimited motion.
2. Pain motions: increase temperature of the affected joints.
3. Slight increase of temperature.
4. Onset is usually in the smaller joints of the hands and feet, most commonly in the
   proximal interpharangeal joint. Usually symptoms are bilateral.
5. Deformities and may ankylose or become sublux.
6. Asymmetry in muscle pull adds to deforming forces.
7. Persons fatigue easily and requires additional rest during periods of flare up in
   order not to stress the joints.


     CARE GIVER RESPONSIBILITY:
1.   Have your client wear a soft fabric to prevent unexpected neck muscle strain.
2.   Apply moist heat. Let client take hot shower twice a day and let the water beat on
     your client neck and shoulder for 10 – 20 minutes.
3.   Improved your client posture.
4.   Sleep without the pillow or cervical pillow.
5.   Client education.
6.   Range of motion exercise.
7.   Advice use of supportive (splints) to prevent deformities and or assistive
     equipment to minimize stress.
8.   Stretch muscles.


                            FALLS
Definition:
   Falls on the stairs or / chairs.

   Environmental factors: weather unfamiliar surroundings.
1. Out doors.
2. Indoors.
3. Psychological factors:

     The persons may experience low self esteem or fear of falling again, of being
     unable to perform ADL or of social rejection, which is turn may lead to
     depression and withdrawal.
     The reaction of family members after a fall is can also affect an older person’s
     outlook, they may become over protective, trying to limit older person’s activities
     or making decisions for him.

        Life style: alcoholism.
        Poor hearing and visuals.
        Gait and balance changes.
        Foot disorder.
        Medications.
        Medical devices.
        Restrains.
        Shoe style.


CAE GIVER RESPONSIBILITY:
1.   Home safety: lighting, flooring clutters.
2.   Use of hearing aid and eyeglasses.
3.   Gait training use assistive device, proper foot wear, strengthening exercises.
4.   Trimming of nails.



                        FRACTURE
Definition:
   Any break in the continuinity of the bone.

1. Complete fracture: the broken bone is completely separated.
2. Incomplete (green stick) fracture: broken base is not completely separated.
3. Commuted fracture: there are two or more fragment at the fracture site.
4. Open compound fracture: fracture bone has broken the skin.
5. Clouse fracture: including stress fracture the fracture bone has not broken the
   skin.
6. Compression fracture: the break occurs dues to extend pressure on the bone.
7. Impacted fracture: the broken end have been driven into each other.
8. Anulsion fracture: force has been applied to strong tendons causing it to pull on
   and break off portion of bone.

Sign and symptoms:
1. Pain and swelling at the fracture site.
2. Tenderness close to the fracture.
3. Painless and deformity.
4. Loss of pulse bellow the fracture usually on the lower extremity.
5. Numbness, tingling, or paralysis, below the fracture. (rare).
6. Bleeding or brushing at the site.
7. Weakness an in ability to bear weight.


CAUSE AND RISK FACTORS:
1. Injury of direct trauma.
2. Osteoporosis.
3. Falls.
4. Tumors of the bone or bone marrow.
5. Motor vehicular accident.

CARE GIVER MANAGEMENT:
1. Seek emergency first aid care.
2. Special exercise to maintain muscle tone.
3. Take vitamin C and zinc supplement to promote bone healing.
4. Suggest using assistive or supportive devices for ambulation.
                           OSTEOPOROSIS
     Definition:
        Hardening of the bone with increase density and destruction of the bone marrow.
        It is a rare inherited disease. Also called (marble bone, ivory bone).
        Advance cases may lead to severe anemia, blindness and bone fracture.

     Etiology:
     1. Primary Osteoporosis.
     - Ediopathic
            Type I Postmenopausal.
            Type II senile – affect woman ages 70/85 years old.
     2. Secondary Osteoporosis.

     CLINICAL PICTURE:
        Effect soft immobilization and physical inactivity.

            Loss of muscle and bone.
            Decrease bone density.
            Disrupts calcium metabolism.

        Weight bearing and physical activity both act mechanical stimuli for bone growth
        and remodeling.

     CARE GIVER RESPONSIBILITY:
1.    Care for fragile skeleton.
     a) Avoid lifting heavy load and exercise involving strenuous bending.
     b) Deep breathing. Extension exercise.
     c) Stretching of chest.
     d) Back extension.
     e) Abdominal strengthening.
2.    Maintenance of flexibility, coordination and fitness. WB exercise.
3.    Proper mechanics.
4.    Dietary measure.
     a) 1000mg of calcium daily for premenopause- 8oz of milk.
     b) 1500mg of calcium daily for menopause.
     c) Other source of calcium: shrimp, tofu, broccoli green turnips, ice cream, cheese,
         yoghurt sardines, salmon.
5.    Prevention of fall – use of AD and maintain strength.
6.    Avoidance of immobilization – can do swimming or water exercise.
7. Role of estrogen.
   a) Major role.
   b) May be prescribe within 2 years after menopause.
          Smoking anti – estrogen effect.

OTHER MEDICAL PROBEM


                          DIABETIS MELETUS

  Definition:
     Chronic disorder cause by deficient Insulin action in the body.


  RISK AND FACTORS;
  1. Being over 40 years old.
  2. Being obese.
  3. Family History.
  4. Fat baby > 9 lbs.

  -    CHO – 50/60 %
  -    CHON – 10/20 %
  -    FAT – 20/30%

  CLASIFICATION:
  1. Type I/ IDDM- little or no insulin produced; 10% children and young adult, lack
     or destruction of pancreatic cells. 10% of diabetic patients.
  2. Type II/ NIDDM- insulin production is not being utilized properly over 40 years
     old; 90% (non – obese is 60/90 %)

  SIGN AND SYMPTOMS:
  1. 3 P’s (polyuria, polydypsia, polyphagia)
  2. Weight loss in the presence of polyphagia, improper fat metabolism and
     breakdown of fat store)
  3. Hyperglycemia – increase blood glucose level > 140mg/dl.
  4. Glycosuria.
  5. Fatigue/ weakness.
  6. Blurred visions.


      Liver serve as a storage of glucose, which is use mater by tissue like, skeletal
      muscle and fats. When insulin function is impaired, glucose is not taken up or
      removed by this tissues it continue to accumulate in the blood because glucose has
      not been deposited into the liver, liver synthesize more glucose and release it into
      the circulation.
CARE GIVER RESPONSIBILITY:
1. You’ll need precise records, of vital sign, weight, fluid intake, urine output, and
    caloric intake.
2. Administered insulin or an – oral antidiabetic drug prescribe.
3. Monitor for acute complication of diabetic therapy specially hypolglycimia (slow
    cerebration, dizziness, weakness, pallor, tachycardia, diaphories, seizures and
    coma) which require you to give the clients carbohydrates in the form of fuits
    juice, candy or honey.
4. Watch of sign for diabetic neuropathy (numbness or pain in the hands or feet, foot
    drop, diarrhea constipations and erectile dysfuctions).
5. Provide meticulous skin care especially in the feet and legs.
6. Encourage the patient to verbalized his feeling about diabetic and its affects his
    lifestyle and life expentancy.
7. Help the patient developed a new coping strategies.
8. Stress importance of carefully following the prescribed treatment plan: diet.
    Medication exercise. Prevention, recognize and treat.
9. May use AD.
10. Proper foot care, wash feet daily.
11. Encourage having annual eye examination for early detection of diabetic
    neuropathy.
12. Watch the client diet.



AIDS (ACQUIREDIMMUNE DEFICIENCY SYNDROME)
RISK FACTORS:
   If you are an IV who share the needle.
   You receive blood or blood product before 1978.
   You have a several sexual partners and do not use comdoms.
   You do not know your sexual partners well.
   Any of your sexual partners have had “unprotected” SEX since 1978.

FORMS OF AIDS.

A) AIDS Carrier.
- The only sign of disease to these people may be positive blood test. Some carrier
never show active sign of the disease. How ever they can not transmits the disease.

B) AIDS Related conditions
- Some people may be healthy for years after a positive blood test and then show
   related symptoms.

C) AIDS
-   The disease may appear years after the first positive test and year after AIDS
    related condition have appeared and been treated.




CARE GIVER RESPOSIBILITY
1. Demonstrate standard precaution while caring for the AIDS client but use it with
   precaution so that client will not feel that you are afraid.
2. Provide companionship.
3. Give prescribe medications.
4. Not and report all changes.


                         CANCER
Definition:
   A malignant tumor of any type.
   Cancer smears: cells obtain by swabbing tissue which may contain extruded
   (detached) cancer cells, such cancer that smears glass slide and examined under
   the microscope.

FACTORS THAT MAY AFFECRED THE COURSE OF THE DISEASE.
  Location of the tumors.
  Type of the tumors.
  When the cancer was is discovered.
  Type of treatment is available.
  General health of the client.


POSIBLE CAUSE OF CANCER:
  Chemical.
  Pollution.
  Heredity.
  Vital infections
  Radiation
  Smoking.
  Hormones.

Symptoms of cancer
   Abnormal bleeding or diarrhea.
   Thickening of the lump.
   Un ulcer which remain opened.
   Severe anemia.
   Persistent cough of hormones.
   Urinary difficulties.

   Persistent digestive disturbances.
   Difficulty in swallowing.

   Metastasis – spread of cells cancer from one area to another.
   Biopsy – examination of tissue taken from the body and examining it under a
   microscopes to be able to classified it. An – cancerous (malignant) or benign ( not
   malignant).

MEDICAL MANAGEMENT
  Varies from client to client
  May undergo surgery.
  Radiation therapy.
  Chemotherapy.
  Orcombination.

CARE GIVER RESPOSIBILITY:
1. Give the best care you can give. Give both physical and motional support.
2. Encourage the family members to visit your client and be supportive.
3. Fallow the principle of good personal care.
4. Fallowing the instruction of the therapies within the limits of the client
5. Encourage the client take part in his care.
6. Do not give a false hopes, but do not assume he/ she will die unless you have been
   told this.
7. Help the family member deal with this diagnosis by letting them take part in
   client’s care if they wish to.
8. Encourage them to talk to some one who can help them accept this diagnosis.


                       NEOPLASTIC DESORDER

CLASIFICATION:
A). Benign Neoplasia:
    - Cells adhere to each other and the growth remains circumscribed.
    - Generally not life threatening unless they occurs in restricted area.
    - Classified according to tissue involved.

B). Malignant Neoplasia /Cancer.
    - Involved all body organs.
    - May spread or metastasize by direct extension, lymphatic spread and
      hematologic spread.

   Grading and staging of cancer.
   - A method use to described the tomurs.
   -   Include the extend of the tumor, size, involvement of regional nodes and
       metastatic development.
   -   Grading: classified the cellural aspect of the cancer.
   -   Staging: classifies the clinical aspect of the cancer.
       o T – designates a primary tumor.
       o N – designates lymp node involvement.
       o M – designate metastasis.
       o 0 to 4 to any of the above letters designates degree involvement
       o TIS – designates carcinoma in situ.

Factors that influence cancer development.
   1.     Environmental factors:
      a. chemical carcinogen – industrial chemical , drugs and tobacco.
      b. Physical carcinogen – lonizing radiation, ultraviolet radiation, chronic
          irritation and trauma.
      c. Viral carcinogen
   2. Dietary factors: high fat and low fiber diets; high animal fat intake;
      preservatives, contaminants, additives; and nitrates.
   3. Genetic predisposition.
   4. Age.
   5. Immune functions.

Prevention’
      Avoid of known or potential carcinogen and avoidance or modification of the
      factors associated with the development of cancer.
      Warning and sign:
          C – change in bowel or bladder habits
          A – any sore that doest not heal.
          U – unusual bleeding or discharge.
          T – thickening or lump in breast or elsewhere.
          I – Indigestion.
          – obvious change in wart or mole.
          N – nagging cough or hoarseness

Early Detection:
• Breast self examination.
• Testicular self examination.
• Stool for occult blood.
• Sigmoidoscopy.
• Skin inspection.
• Mammography

Diagnostic test:
   Depend on the primary or metastatic sites of cancer.
   Biopsy.
     Definitive means of diagnosing cancer.
     Provide histologic proof of malignancy.
     Involves surgical incision of a small piece of tissue for microscopic examination.
     Frozen section or permanent paraffin section.



     Treatment Modalities
     A. Surgery.
         - Use to diagnose, stage and treat cancer.
1.   Prophylactic surgery – removal or the organ at risk or with premalignant codition.
2.   Curative Surgery – all gross and microscopic tumor is either removed or
     destroyed.
3.   Control / Cytoreductive surgery – a debulking procedure.
-    Increases the chance that other therapies will be successful.
4.   Pallative Surgery - performed to improved quality of life.
5.   Reconstructive or rehabilitative surgery – performed to improved quality of life
     by restoring maximal function and appearance.
         - Side affects:
         o Loss or loss of function of specific body part.
         o Reduced function as a result of organs loss.
         o Scarring or disfigurement.
         o Grieving about altered body image or impose change in lifestyle.



Chemotherapy:
    Kills of inhibits reproduction of neoplastic cells.
    Affects both healthy and cancerous cells.
    Combination therapy is usually use.
    May be combined with others treatments such as a surgery or radiation therapy.

Side Effects:
     Alopecia.
     Nausea, Vomiting.
     Muscositis
     Skin changes.
     Immunosuppression.
     Anemia, Thrombocytopenia

C. Radiation Therapy
     Destroy cancer cells with minimal exposure of normal cells to the damaging
     effects to radiation
     Effective on tissues direct on the path of radiation.
     Side effects; vary according to the site of treatment.
     o Skin changes
o Alopecia
o Altered task sensation
2 almost common types.




1. Teletherapy – beam radiation
   o Actual radiation source is external to the client.
   o Doest not emit radiation, doest not post hazard to any one client
      education.
        1. Wash area with water or water and mild soap using hands rather
            than wash clothes, rinse soap thoroughly.
        2. Do not remove radiation marking from the skin.
        3. Use no powders, ointment, lotion, or creams on the area unless
            prescribed.
        4. Wear soft clothing over the area, avoiding belts. Buckles straps,
            on any clothing that binds or rubs the skin.
        5. Avoid sun and heat exposure.
        6. Monitor moist desquamation, if it occurs, cleanse the area with
            warm water and path dry apply antibiotic ointment or steroid
            cream as prescribed and expose the site to air.
2. Brachytherapy
      Radiation source come into direct contact with tumor tissues for a
      specific time.
      Patients emits radiation and post hazard.
      2 kinds.
      1. Unsealed radiation source; oral or IV route, or installation into
          body cavities.
          o Excrete is radioactive and harmful within 48 hours.

      2. Sealed radiation source; radiation source implanted within the
           tumor target tissues.
           o Clients emits radiation while implant is in place but excrete is
               not radioactive.
Care of client
o Place patient in private room with private bath..
o Place caution sign in client door.
o Limit time to ½ hour per care per shift.
o Wear dosimeter film badge to measure radiation exposure.
o Wear lead shield to reduce the transmission of radiation.
o A nurse should never care for > 1 client with radiation implant at one
   time.
o Pregnant nurse or visitor and children < 16 years old are not allowed.
o Limits visitors to ½ hour per day and 6 feet away.
o Save bed linens until source is removed.
Diagnose Radiation source.
o Do not touch with bare hands.
o Use long handled forceps to place the source in lead a container, kept in
   client’s room and call the physician.