I am so sorry for the late post. I had a family emergency to tend to today, but don’t worry, this will be worth the read!!
Today I had the opportunity to treat a patient in the neuro ICU. We had a lecture on the ICU last week, as well as went into the simulation lab to experience all of the lines, tubes and ventilators we would have to work around during a treatment in the ICU. Once I graduate and am licensed, I want to work in the neuro setting, however, I am not sure if I want to work in inpatient or outpatient. I always thought I would hate acute care because I am not a big fan of hospitals, but today was an eye opener. I actually enjoyed treating in the ICU!
When we went into the patient’s room, she was disoriented, confused and would not open her eyes. She really had not done much, other than bed mobility since evaluation due to her being uncooperative, disoriented, and confused. We decided to be more aggressive. Due to her flaccidity and conscious state, we decided to sit her edge of bed (to get her weight-bearing – I will talk about this in a moment) and do some exercises and range of motion. As soon as we sat her at the edge of the bed, she became much more oriented, was able to respond to commands, and her eyes were wide open. This coincides with what I have learned in my neuroscience 2 & 3 classes as well as a presentation I attended at CSM, “Disorders of Consciousness” by Patrice Perrin and Kelly Betts.
Here are a few questions I will be answering: Why did this patient become more aroused, oriented, and able to follow commands? Why did we place her edge of bed? How did we position her post-treatment and why did we positioned her that way?
So, let’s talk about it.
Why did this patient become more aroused, oriented, and able to follow commands?
Getting a patient vertical, no matter the level of consciousness, stimulates the reticular activating system (RAS) in the brain. The reticular activating system is located in your brainstem and plays a role in your arousal and alertness. When a person is placed upright (vertical), somatosensory information is transported up the spinal cord, to the brainstem, where the RAS is stimulated. This input is sent through the thalamus, which picks out the important information (like a filter) and stimulates the cerebral cortex, which in return, causes the person to become more alert. WHOA! In other words, if you are sleepy GET VERTICAL!
Why did we place her edge of bed?
Placing this patient seated at the edge of the bed gets the patient vertical and puts the patient in weight-bearing. Weight-bearing has been shown to activate a co-contraction around the joint of flaccid muscles and decrease tone around a joint in spastic muscles. Since our patient was flaccid, our goal was co-contraction. Weight bearing is also task specific. What I mean by task specific is, it is something she will have to/want to do to function once she is out of the hospital. She may want to sit in a chair to comb her hair, get dressed, or watch TV. To help you further understand, if you want to get better at walking you’re not going to lay supine and do straight leg raises, you’re going to walk! Same for this patient. We want to get her better at sitting, so we sat.
How did we position her post-treatment and why did we positioned her that way?
After we completed our treatment, we left the patient lying supine with the head of the bed raised slightly. We placed a foam at her feet to prevent plantarflexion contractures from occurring. Since this patient was flaccid, we did not have to worry about eliciting a plantar grasp reflex. We placed a towel roll between her knees to keep her from adducting, as the was severely adducted when we entered the room. We placed her flaccid upper extremity in scaption with slight elbow flexion with her forearm pronated, wrist in neutral, and hand and fingers open with palm down to promote weight-bearingthrough her hand. This patient had left-sided neglect, so a towel roll was placed under the right side of her pillow to prevent her from rolling her head to the right and to try to initiate head movement and gazing to the left.
I would like to thank Dr. Patrice Perrin and Dr. Kelly Betts at Tirr Memorial Hermann for the amazing lecture at CSM as well as Dr. Suzanne Tinsley from LSUHSC – Shreveport for sharing her wealth of knowledge. I am so thankful to have a professor as knowledgeable as her.