Question

MS. LEE PRESENTS TO YOUR CLINIC FOR A NEW PATIENT EVALUATION. SHE IS A 75 YEAR-OLD WOMAN WITH AN HISTORY OF ATRIAL FIBRILLIATION, DIABETES, CAD AND GLAUCOMA. HER DAUGHTER COMES WITH HER TO THE FIRST APPOINTMENT AND TELLS YOU SHE WAS RECENTLY IN THE EMERGENCY DEPARTMENT AFTER STUMBLING AND FALLING ONTO HER LEFT SIDE. HER X-RAY DID NOT SHOW ANY FRACTURES AND SHE WAS DISCHARGED HOME. ON FURTHER QUESTIONING MS. LEE REPORTS THAT SHE FELL EARLY IN THE MORNING WHEN SHE WAS GETTING UP TO GO TO THE BATHROOM. SHE THINKS SHE TRIPPED ON THE EDGE OF THE RUG. SHE WAS ABLE TO GET UP ON HER OWN, BUT HAS HAD PAIN IN HER LEFT KNEE SINCE. SHE HAD BEEN FEELING LIKE HER USUAL SELF BEFORE THE FALL AND DENIES ANY RECENT FEVER, CHILLS, COUGH DYSPNEA,URINARY OR GI COMPLAINTS. SHE DID NOT HIT HER HEAD OR LOSE CONSCIOUSNESS. SHE DID NOT HAVE ANY CHEST PAIN, PALPITATATIONS OR DIZZINESS PRIOR TO THE FALL. SHE LIVES ALONE.HER DAUGHTER LIVES NEAR AND HELPS HER WITH HER MEDICATIONS. SHE TESTS HER BLOOD SUGER EACH MORNING AND IT HAS BEEN 120-200MG/DL. SHE OCCASIONALLY FEELS LIGHTHEADEDFIRST THING IN THE MORNING WHEN SHE GETS OOB, BUT SHE HAS NOT HAD ANY OF THOSE SYMPTOMS THROUGHOUT THE DAY. SHE DENIES ALCOLHOL USE.

PHYSICAL EXAM

BP 134/78 LYING, 126/72 STANDING

HR 78 IRREGULAR

TRACE EDEMA IN BOTH LOWER EXTREMITIES

BILATERAL KNEE CREPITUS, BUT FULL ROM

3/10 PAIN LEFT KNEE

DIFFICULTY GETTING OUT OF CHAIR 9NEEDS TO ROCK SEVERAL TIMES)

IT TAKES HER 15 SECONDS TO WALK 10 FEET AND SIT BACK DOWN

SHE SWAYS AND CANNOT HOLD HER POSTURE WITH ONE FOOT IN FRONT OF THE OTHER.

SHE TELLS YOU SHE WANTS TO EXERCISE BUT DOES NOT KNOW THE BEST WAY TO DO SO.

MEDCATIONS

ASPIRIN 81MG DAILY

GLUCOPHAGE 100MG TWICE DAILY

METOPROLOL 50 MG TWICE DAILY

ATORVASTIN 20MG DAILY

SITAGLIPTIN 50MG DAILY

DIPHENHTDRAMINE 25MG AS NEED AT NIGHT FOR SLEEP

QUESTIONS

1. LIST MS. LEE’S RISK FACTORS FOR FALLING
2. HOW DO YOU TEST GAIT?
3. WHAT IS A GOOD BALANCE TEST? DESCRIBE HOW IT IS PERFORMED.
4. DESCRIBE THE PROCEDURE FOR CHECKING ORTHOSTATIC BP.
5. WHY IS IT IMPORTANT TO CHECK ORTHOSTATIC BP IN THIS PATIENT.
6. HOW CAN YOU ASSESS WHETHER SHE IS READY TO HEAR YOUR ADVISE ABOUT FALL PREVENTION.
7. LIST 3 PRIORITY NURSING DX FOR MS. LEE

Answer 1

Qn1 Risk factors for fall

1. Older age

2 Use of drug such as Metoprolol ,Atorvastatin ,SIitagliptin,Diphenhtdramine which can cause the side effect of dizziness and lightheadness etc .

3 The disease conditions such as Atrial fibrilation,And glaucoma

Qn2 When you dothe GAIT analysis the it is wise for a therapist to see the patient from the three body plane ie from the front,back and the side.First see the gait cycle.In right gait cycle we focus on the right leg during the full stride.I t starts from the initial contact of one foot and ends with initial contact of another foot

Stride includes the initial contact of the one foot end with the  the initial contact of the same foot

first will see the two phases of the gait cycle,first one is the stance phase it occupies the 60%of the full gait cycle and the swing phase wich accounts for the 40% of the gait cycle.

In Stance phase the right foot is always in contact with the floor so it is known as the stance phase.And in the swing phase the right leg swings.

During the stance phase the right leg has to complete different tasks .During heel strike the leg has to accept the body weight.So it is known as loading response.And it makes the 10% of the gait cycle.

The loading cycle ends once the contralateral foot lift from the ground.After the load response untill the point of heel off it is known as mid-stance.By this 30% of the full gate cycle.

The heel of the right foot starts to lift when the contralateral leg has initial contact with the floor.This is known as terminal stance.By thgis 50% of the gait cycle has completed.

While the contralateral leg proceeding to make full contct with the floor the the right leg lifts off from the ground.This is known as the pre-swing phase and reached 60% of the gait cycle.So the stance phase has completed and now has t check the swing phase.In this the only thing is thye right leg enhancement untill the next heel strike.The swing phase is subdevided into the initial swing (from toe off untill the feet are adjecent) and mid-swing it lasts till the tibia is vertical.By this 87% of the gait cycle has completed.The last period known as the treminal period ends with the heel strike of the right leg.

By using Njmegen orthopedic gait analysis form ,which is a check list to assess certain aspects of  body during gait and it is important to compare the two sides.Ask the patient to walk in his/her normal pace.The general thing is to assess whwter there is any shortened stance phase or not.This is one of the normal deviation from the normal gait.Check the trunk whether the trunck is anterior or posterior nto the hips or any lateral flexion is present.Next look at the pelvis for the posterior roptation in excessive.At the hips check for the amount of extension whether it is reduced.Do the same thing for the knee.Also assess the knee for the knee flexion movement and check whether it is absent.

Check for the normal plantar flexion which which might be reduced.Lastly assess the internal or external rotation of the leg.

Example of a videotaped gait analysis check list is added below

Identify a patient that may benefit from a videotaped observational gait analysis session.

Evaluate the patient first with a history, a physical examination, and radiographs as needed, and ensure that no contraindications exist for the patient to perform on a treadmill.

Discuss the procedure with the patient, and schedule the session.

Ensure that all equipment is available and working properly and that the room has adequate lighting.

Obtain consent from the patient for the session.

Reinterview and examine the patient before starting the session, and ask the patient about any changes since the office visit that could affect the session.

Place retroflective tape on bony landmarks.

Perform a static evaluation of the patient with and without shoes.

Perform a dynamic evaluation of the patient on a treadmill with and without shoes as per taping session protocol.

Review the tape, and record results on an available data collection form.

Interpret the data either manually or with the aid of computer software.

Identify any deficiencies that are found in the data interpretation.

Devise a therapeutic plan to resolve deficiencies and implement a plan.

Arrange for follow up and possible repeat videotaped observational gait analysis session to monitor the progress of therapy.

Qn 4.Videonystagmography (VNG) balance test

A VNG may be done by a primary health care provider or one of the following types of specialists:

• An audiologist, a health care provider who specializes in diagnosing, treating, and managing hearing loss
• An otolaryngologist (ENT), a doctor specializing in treating diseases and conditions of the ears, nose, and throat
• A neurologist, a doctor specializing in diagnosing and treating disorders of the brain and nervous system

During a VNG test, you will sit in a dark room and wear special goggles. The goggles have a camera that records eye movements. There are three main parts to a VNG:

• Ocular testing. During this part of the VNG, you will watch and follow moving and nonmoving dots on a light bar.
• Positional testing. During this part, your provider will move your head and body in different positions. Your provider will check if this movement causes nystagmus.
• Caloric testing. During this part, warm and cool water or air will be put in each ear. When cold water or air enters the inner ear, it should cause nystagmus. The eyes should then move away from the cold water in that ear and slowly back. When warm water or air is put in the ear, the eyes should move slowly toward that ear and slowly back. If the eyes don't respond in these ways, it may mean there is damage to the nerves of the inner ear. Your provider will also check to see if one ear responds differently from the other. If one ear is damaged, the response will be weaker than the other, or there may be no response at all. Qn 4 Have patient lie in bed with the head flat for a minimum of 3 minutes, and preferably 5 minutes. Measure the blood pressure and the pulse while the patient is supine. Instruct patient to sit for 1 minute. Ask patient about dizziness, weakness, or visual changes associated with position change.
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