By E. Jose. Louisiana State University at Shreveport. 2018.
A of rewards order toradol 10mg on line,143 and emotional responses to stim- much more extensive activation was found in uli144 can be used to compare normal subjects these regions on the right in patients with TBI to people who remain disabled by the typical for the 1-back to 2-back comparison 10 mg toradol sale, although sequelae of TBI (see Chapter 11) order toradol 10mg amex. Both groups had a lying hypothesis is that patients process infor- similar magnitude of task-related increase in mation less efficiently after TBI discount 10 mg toradol amex. In addition buy discount toradol 10 mg on-line, activation when the 0-back and 2-back were the effects of repetition and priming on mem- compared. Functional imaging, then, revealed ory processing can be monitored by functional a difference in the ability of the TBI subjects imaging, which may aid the development of to modulate or allocate resources with an in- cognitive rehabilitation approaches. The clin- ical symptoms of the patients suggested diffi- MULTIPLE SCLEROSIS culties in the maintenance and manipulation of verbal information. A study of patients who The partial remissions after exacerbations of were recovering from more severe TBI used multiple sclerosis (MS) and the progression the paced auditory serial addition test to assess over long periods of time lead to the specula- working memory (see Chapter 7). Compared tion that partial restitution and substitution to healthy subjects, the patients made more er- may evolve from lesion-induced and practice- rors and the pattern of cerebral activations was related network and representational plasticity, more dispersed and lateralized to the right improved axonal conduction,146 remyelination, frontal lobe. By the same logic, exhaus- impaired network may require larger or more tion of reorganizational plasticity as the burden widespread network activity to successfully of axonal lesions grows may contribute to func- carry out cognitive tasks. Another PET activation study examined one An fMRI study employed simultaneous flex- of the consequences of diffuse axonal injury. Perseverative errors were higher ipsilateral activation accompanied significantly and inversely related to metabo- greater functional impairment in patients com- lism in the right, but not the left dorsolateral pared to controls. This re- weighted MRI lesion load of MS plaques, the lationship was independent of any individual center of the activation shifted posteriorly in differences in global brain metabolism, general the sensorimotor representation contralateral cognitive ability, or overall performance on the to the hand that moved, especially as the vol- test. No relationship was found between per- ume of the MS lesions increased within the severative errors and the presence of prefrontal corticospinal projection. Functional imaging tests of tion moved approximately 8 mm, from the pos- this frontal-subcortical circuit, then, may help terior wall of the precentral gyrus to the ante- clinicians measure the impact of diffuse axonal rior wall of the postcentral gyrus in 15 of 24 injury in frontal white matter and serve as phys- subjects. As in the studies of patients with iologic markers for the evaluation of cognitive stroke described earlier, this posterior migra- and pharmacologic interventions aimed at tion may point to a greater representational modulating the circuit. A study of 176 Neuroscientific Foundations for Rehabilitation patients with primary progressive MS who had sentational changes as assessed by TMS, MEG, normal function of an upper extremity also re- PET, and fMRI. Transcranial magnetic stimu- vealed a different pattern of cortical activation lation reveals a lower threshold, greater num- than healthy control subjects during flexion- ber of stimulation sites, and higher evoked am- extension movements of the unaffected plitude for the muscles most proximal to the hand. In addition, functional imaging TRAINING-INDUCED has revealed evidence for motor reorganization REORGANIZATION after a single bout of MS148a and adaptive changes during a sustained attention task in pa- Although the number of pilot studies of pa- tients who performed normally. Nine patients with CADASIL, for The ideal serial study compares perform- example, were more likely to have bilateral ance-related activations before, during, and af- S1M1 activations on an fMRI task of hand tap- ter completion of training. For example, if a by MR spectroscopy, the ipsilateral activation patient practices repetitive functional use of the increased. Fatigue may be and may include preforming the hand in the associated with impaired functionality between shape of the item to be grasped. The success of cortical and subcortical components of a net- training ought to be measured by tools that are work in patients with MS (see Chapter 12). Thus, disruption of corticosubcorti- achieve an important behavioral milestone or cal circuits is associated with central fatigue. Color Figure 3–8 (in separate color insert) shows the consequences of this strategy. Learning- Peripheral Nerve Transection dependent plasticity is a function of the inten- sity, duration, and specificity of what is prac- Experimental studies in monkeys that had a ticed (see Chapters 1 and 2). This investigational strategy allows the muscle was smaller than in the unaffected clinician to study patients at any point in time hand. Behavioral outcomes for the upper ex- after onset of a persisting impairment and dis- tremity significantly improved with training. The critical component is the need for The gains were associated with an expansion of a well-defined and testable rehabilitative in- the scalp areas that evoked a thumb muscle re- tervention. Indeed, after one day of therapy, stim- gators to use functional neuroimaging as a ulation sites over the infarcted hemisphere physiologic marker of the adequacy of inter- changed from about 40% less than those on the ventions for rehabilitation. For example, a poor resentational plasticity suggests that much la- performance in discriminating the size of ob- tent function of the hand had been present. A jects with the recovering hand after a striato- prior study by the same investigators found a capsular infarct correlated with low rCBF in significant decline in the number of activation the contralateral sensorimotor cortex at rest sites for the unaffected hand after therapy, but and bilateral activation during the task. Functional gains in terms of ac- after a CNS or PNS lesion augments the ac- tive use of the affected arm were stable over tivity in local and remote regions.
Frequently purchase 10 mg toradol mastercard, however discount toradol 10mg overnight delivery, organizations need to be a little more spe- cific than structures toradol 10 mg discount, processes 10mg toradol, and outcomes order 10mg toradol with visa. In this case, most organizations turn to either their strategic plan or the literature. Equity The Joint Commission (1993) has also identified the following dimensions of clinical performance that could be used to categorize indicators: • Appropriateness • Availability • Continuity • Effectiveness • Efficacy • Efficiency • Respect and caring • Safety • Timeliness Irrespective of the method used, it is critical that an organization decide which concepts, types, or categories of indicators it wishes to meas- ure. If consensus around this issue is not reached, the rest of the journey will be a mere random walk through the data. Milestone 3 Once an organization has decided on the types of indicators it wishes to track, the next step in the journey is to identify specific indicators. A helpful com- parison to clarify these two milestones is the analogy of finding your seat 98 The Healthcare Quality Book at a baseball game. Milestone 3, on the other hand, focuses on the spe- cific row and seat you have been assigned (e. Imagine that your organization has identified patient safety as one of its strategic objectives. This seems like a perfectly good thing to monitor, but patient safety cannot be directly measured because it is a concept. You need to specify, therefore, (1) what aspect of patient safety you intend to measure and (2) the actual indicators. Note that even within the broad category of patient safety, we need to identify what aspect (i. Within patient safety, for exam- ple, you could focus on medication errors, patient falls, wrong-site sur- geries, missed/delayed diagnoses, or blood product errors. This example uses medication errors as the selected aspect of patient safety. The decision as to which indicator is selected (from the list shown in Figure 5. If you phrase the question in terms of the absolute volume of an activity you might be interested in tracking, a simple count of the number of medication errors might be sufficient. If, on the other hand, you are inter- ested in a relative measure, you would be better off measuring the per- centage of medication errors or the indicator most frequently used, the medication error rate. When it comes to indicator selection, there are more options than most people realize. The challenge is to be very specific about what section, row, and seat you have selected. Milestone 4 The real work of indicator development begins when you hit milestone 4— developing an operational definition of the specific indicator. This activity requires inquisitive minds (left-brained people are often good at develop- ing operational definitions) and patience. They are not only essential to good measurement but also critical to suc- cessful communication between individuals. Medication Errors Concept and Specific What specific indicators could we track? Indicators • Number of medication orders that had an error • Total number of errors caught each day • Percent of orders with an error • Medication error rate • Number of wasted IVs • Percent of administration errors Which specific indicator will you select? Basically, an operational definition is a description, in quantifiable terms, of what to measure and the specific steps needed to measure it con- sistently. A good operational definition • Gives communicable meaning to a concept or an idea; • Is clear and unambiguous; • Specifies the measurement method, procedures, and equipment (when appropriate); • Provides decision-making criteria when necessary; and • Enables consistency in data collection. Remember, however, that operational definitions are not universal truths. A good operational definition represents, therefore, a statement of consensus by those respon- sible for tracking the indicator. Note also that the operational definition may need to be modified at some future point, which is not unusual. When this is done, it will be necessary to note when the definition was changed, as this could have a dramatic effect on the results. If you are part of a multihospital system or plan on com- paring provider outcomes, each provider must define the indicator in the same way. For example, CMS released data on nursing homes to the pub- lic in 2002. Lack of consistency in the operational definitions used by CMS poses the risk of not having apples and oranges when comparisons are made; fruit salad will be the result!
Maximum recom- maximum 4 g/d 4–11 mo purchase 10mg toradol mastercard, 80 mg; mended dose for adults 1–2 y order 10 mg toradol visa, 120 mg; 2–3 y purchase toradol 10mg on line, is 4 g/d buy 10mg toradol overnight delivery, from all 160 mg; 4–5 y buy cheap toradol 10mg, 240 mg; sources. Parents and 6–8 y, 320 mg; 9–10 y, caregivers should ask 400 mg; 11 y, 480 mg. Rectal suppository 650 mg Rectal suppository: age q4–6h, maximum of under 3 y, consult 6 in 24 h physician; age 3–6 y, 120 mg q4–6h, maxi- mum, 720 mg in 24 h; age 6–12 y, 325 mg q4–6h, maximum 2. RA: PO 150–200 mg/d in two, three or four divided doses (continued) 106 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Drugs at a Glance: Analgesic, Antipyretic, Anti-inﬂammatory Drugs (continued) Routes and Dosage Ranges Generic/Trade Name Indications for Use Adults Children Comments Ankylosing spondylitis AS: PO 100–125 mg/d in Diclofenac sodium is (AS) four or ﬁve divided available in 25-, 50-, Pain, dysmenorrhea doses (eg, 25 mg four and 75-mg delayed- or ﬁve times daily) release tablets and a Pain, dysmenorrhea: 100-mg extended- (diclofenac potassium release (XR) tablet. It only) PO 50 mg three is not recommended times daily for acute pain or dys- menorrhea. Diﬂunisal (Dolobid) Osteoarthritis OA, RA: PO 500– Not recommended for use Rheumatoid arthritis 1000 mg/d, in two in children <12 years of Pain divided doses, in- age creased to a maximum of 1500 mg/d if necessary Pain: PO 500–1000 mg initially, then 250– 500 mg q8–12h Etodolac (Lodine, Osteoarthritis OA, RA: PO 600– Dosage not established Available in immediate- Lodine XL) Rheumatoid arthritis 1200 mg/d in two to release and extended- Pain four divided doses release (XL) tablets of Pain: PO 200–400 mg various strengths. The q6–8h immediate-release Maximum according to forms should be used weight: 1200 mg/d for to treat acute pain. Bursitis to a maximum of three doses Acute painful shoulder 150–200 mg/d, if Acute gout necessary Closure of patent ductus arteriosus (IV only) CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 107 Drugs at a Glance: Analgesic, Antipyretic, Anti-inﬂammatory Drugs (continued) Routes and Dosage Ranges Generic/Trade Name Indications for Use Adults Children Comments Acute gouty arthritis, acute painful shoulder, PO 75–150 mg/d in three or four divided doses until pain and inﬂammation are con- trolled (eg, 3–5 d for gout; 7–14 d for painful shoulder), then discon- tinued Ketoprofen (Orudis, Pain Pain, dysmenorrhea: PO Do not give to children Extended-release cap- Oruvail) Dysmenorrhea 25–50 mg q6–8h PRN <16 years unless di- sules are available as Osteoarthritis OA, RA: PO 150–300 mg/d rected by a physician. Note that the doses names do not contain Sustained-release (Oruvail any letters (eg, SR, XL) SR), 200 mg once daily that indicate long-acting Maximum, 300 mg/d for dosage forms. IM 15 mg q6h to a maximum of 60 mg/d Meloxicam (Mobic) Osteoarthritis PO 7. Oral sion, and in immediate- Ankylosing spondylitis symptoms subside suspension (125 mg/ and delayed-release Pain Maximum, 1250 mg/d 5 mL) twice daily ac- formulations Dysmenorrhea Naproxen sodium: Pain, cording to weight: Bursitis dysmenorrhea, acute 13 kg (29 lb), 2. Pirox- ative safety of these drugs, there have been a few cases re- icam has a half-life of about 50 hours. The long half-lives ported in which hypertension was acutely worsened by the allow the drugs to be given once daily, but optimal efﬁcacy drugs (blood pressure returned to previous levels when the may not occur for 1 to 2 weeks. Formulations a COX-2 inhibitor had a small increase in the incidence of are delayed or extended-release and onset of action is there- myocardial infarction and stroke due to thrombosis, compared fore delayed. Peak action occurs in about 2 hours and effects with clients receiving a nonselective NSAID (naproxen) or last 12 to 15 hours. Diclofenac has a serum half- (97%) and its serum half-life is about 11 hours. A glandins associated with pain and inflammation without small amount is excreted unchanged in the urine. Rofecoxib blocking those associated with protective effects on gastric (Vioxx) acts within 45 minutes and peaks in 2 to 3 hours. Thus, they produce less gastric irritation than aspirin is 87% protein bound and has a half-life of 17 hours. In addition, they are not associated with metabolized in the liver and excreted in urine and feces. CHAPTER 7 ANALGESIC–ANTIPYRETIC–ANTI-INFLAMMATORY AND RELATED DRUGS 109 Acetaminophen (also called APAP, an abbreviation for Drugs at a Glance: Drugs for Gout N-Acetyl-P-Aminophenol) is a nonprescription drug com- monly used as an aspirin substitute because it does not cause Routes and Dosage Ranges Generic/ nausea, vomiting, or GI bleeding, and it does not interfere Trade Name Adults Children with blood clotting. It is equal to aspirin in analgesic and antipyretic effects, but it lacks anti-inﬂammatory activity. Allopurinol Mild gout, PO 200– Secondary Acetaminophen is well absorbed with oral administra- (Zyloprim) 400 mg/d hyperuricemia tion and peak plasma concentrations are reached within 30 Severe gout, PO from anticancer 400–600 mg/d drugs: <6 y, to 120 minutes. Hyperuricemia in PO 150 mg/d; Acetaminophen is metabolized in the liver; approximately clients with renal 6–10 y, PO 300 mg/d 94% is excreted in the urine as inactive glucuronate and sul- insufﬁciency, fate conjugates. Approximately 4% is metabolized to a toxic PO 100–200 mg/d metabolite, which is normally inactivated by conjugation with Secondary hyper- uricemia from anti- glutathione and excreted in urine. With usual therapeutic cancer drugs, doses, a sufﬁcient amount of glutathione is available in the PO 100–200 mg/d; liver to detoxify acetaminophen. In acute or chronic overdose maximum 800 mg/d situations, however, the supply of glutathione may become de- Colchicine Acute attacks, PO Dosage not established pleted. The probable mechanism for in- 3-d interval between creased risk of hepatotoxicity in this population is that ethanol courses of therapy induces drug-metabolizing enzymes in the liver. Allopurinol (Zyloprim) is used to prevent or treat hyper- uricemia, which occurs with gout and with antineoplastic drug therapy. Probenecid may precipitate acute gout until zyme called xanthine oxidase. Allopurinol prevents formation serum uric acid levels are within the normal range; concomitant of uric acid by inhibiting xanthine oxidase. It is especially use- administration of colchicine prevents this effect.
For treatment purchase toradol 10mg online, oral or IV drugs may be The azole antifungals may cause hepatotoxicity; hepatitis given at the onset of fever and neutropenia discount 10mg toradol fast delivery, when fever per- occasionally occurs with all of the drugs discount toradol 10 mg without a prescription. Hepatic aminotrans- sists or recurs in a neutropenic client despite appropriate anti- ferases (ALT order 10mg toradol with visa, AST) and serum bilirubin should be checked be- microbial therapy buy 10 mg toradol mastercard, or when maintenance therapy is needed fore drug use, after several weeks of drug use, and every 1 to after acute treatment of coccidioidomycosis, cryptococcosis, 2 months during long-term therapy. These infections often relapse if antifungal elevations in ALT and AST may occur. Clients must be closely monitored for ALT increase to more than 3 times the normal range, the azole adverse effects of antifungal drugs. With ﬂuconazole, hepatic dysfunction may range from mild Use in Renal Impairment elevations in ALT and AST to clinical hepatitis, cholestasis, he- patic failure, and death. Fatal hepatic damage has occurred pri- Amphotericin B deoxycholate (Fungizone), the conven- marily in clients with serious underlying conditions, such as tional formulation, is nephrotoxic. Renal impairment occurs AIDS or malignancy, and with multiple concomitant medica- in most clients (up to 80%) within the ﬁrst 2 weeks of therapy tions. Itraconazole is relatively contraindicated in clients with but usually subsides with dosage reduction or drug discontin- increased liver enzymes, active liver disease, or a history of uation. It should be given only if ex- mendations to decrease nephrotoxicity include hydrating pected beneﬁts outweigh risks of liver injury. If the BUN exceeds 40 mg/dL or the serum cre- including toxic hepatitis. Terbinafine has egy is to give a lipid formulation (eg, Abelcet, AmBisome, or been associated with a few cases of liver failure, and its Amphotec), which is less nephrotoxic. For clients who already clearance is reduced by 50% in clients with hepatic cirrho- have renal impairment or other risk factors for development of sis. Its use is not recommended for patients with chronic or renal impairment, a lipid formulation is indicated. Renal func- active liver disease and liver function tests should be done tion should still be monitored frequently. Hepatotoxicity has Caspofungin does not require dosage reduction for renal been reported in patients with and without preexisting liver impairment and is not removed by hemodialysis. For clients with a creatinine clearance (CrCl) above 50 mL/minute, full dosage may be given. For those with CrCl of 50 mL/minute Use in Critical Illness or less, dosage should be reduced by one-half. However, for clients receiving hemodialysis, an extra dose may be needed Amphotericin B, ﬂuconazole, and itraconazole are the drugs because 3 hours of hemodialysis lowers plasma drug levels by most often used for serious fungal infections. Itraconazole can be given to clients with penetrates tissues well, except for CSF, and only small amounts mild to moderate renal impairment but is contraindicated in are excreted in urine. With prolonged administration, the those with a CrCl of 30 mL/minute or less. Lipid formulations may be preferred in crit- Flucytosine is excreted renally and may accumulate in ically ill clients because of less nephrotoxicity. Accumulation may increase BUN and penetrates tissues well, including CSF. Although IV admin- serum creatinine and lead to renal failure unless dosage istration may be necessary in many critically ill clients, the 610 SECTION 6 DRUGS USED TO TREAT INFECTIONS drug is well absorbed when administered orally or by naso- may be teaching correct usage and encouraging clients to per- gastric tube. Signiﬁcantly impaired renal function may require sist with the long-term treatment usually required. With IV reduced dose and impaired hepatic function may require dis- antifungal drugs for serious infections, the home care nurse continuation. When itraconazole is used in critically ill may need to assist in managing the environment, administer- clients, a loading dose of 200 mg 3 times daily (600 mg/day) ing the drug, and monitoring for adverse effects. In addition, air conditioning and air ﬁl- Antifungal drugs may be taken at home by a variety of routes. NURSING Antifungal Drugs ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. To regulate ﬂow accurately (3) Use a separate intravenous (IV) line if possible; if nec- essary to use an existing line, ﬂush with 5% dextrose in water before and after each infusion. The oral solution is oral solution on an empty stomach and ask the client to used to treat oropharyngeal and esophageal candidiasis, and cor- swish the medication around in the mouth, then swallow the rect administration enhances contact with mucosal lesions. Antacids and other drugs that suppress give with antacids or other gastric acid suppressants.
The Bobath sling raises sal and volar resting splints that extend up the the humeral head via a foam rubber roll under forearm and across the wrist have been found the axilla buy toradol 10mg mastercard. Recent fingers in abduction to produce a similar in- designs for items from wheelchairs to utensils hibitory effect per the Johnstone approach generic toradol 10mg without prescription, al- create a positive buy toradol 10 mg fast delivery, even a sporty and aesthetically though the technique was not efficacious as a pleasing character generic toradol 10mg. Thus toradol 10 mg otc, the choice of a splint often de- manufacturers, including Apple and IBM, have pends more on personal experience. Measur- development programs for people with special ing cost-effectiveness is difficult. Cellular phones and hand-held messag- The hemicuff and Bobath slings are often ing and Internet devices give relatively immo- used to reduce shoulder subluxation as a pro- bile people powerful links for communicating phylactic measure to avoid pain. Adjustable with significant others and business associates fabric shoulder straps pull the cloth cuff around and enlarge their safety net. Adaptive Aids for Daily Living Feeding Communication Utensil: thickened or palm handle; cuff holder Cellular phone, hand-held Internet device Dish: scoop; food guard; suction holder Universal infrared transmitter controller Cup: no spill covers; holders; straws Computer Workstation Finger foods Slip-on typing aid Bathing Environmental controls Shower seat, transfer bench Communication: spoken words; voice synthesis; Washing: mit, long handle scrub brush, hose voice recognition for printing Safety: grab bars; tub rails Interface adaptations: keyboard, microswitch, voice activation Dressing Miscellaneous Velcro closures: shoes, pants One-handed jar opener Button hook, zipper pull Door knob extension Low closet rods Book holder, page turner Long handle comb, hair brush Holder for cutting with loop scissor or knife Toileting Long-reach jaw grabbers Toilet safety rails; raised seat Standing frames Commode Sports and Hobbies Mobility Needle holder for one-handed knitting Prefabricated ramps Action Life Glove: double tunnel loops hold Stair lifts pool cue, fishing rod, gym equipment Wheelchairs Strong Arm fishing rod holder Transfer devices and ceiling-mounted track lifts Automobile and van: lifts, hand controls, specialty designs 234 Common Practices Across Disorders some especially functional, off-the-shelf items. DuPont Institute A wide variety of portable communication regularly publish evaluations of computer de- devices are available commercially for the pa- vices and software for communication. Some software can learn to pre- clude robotic manipulators, mobile robots, ma- dict the next word and list words and word end- nipulations of a virtual reality environment, and ings often chosen by the user. Portable comput- that can convert a muscle or eye movement or ers can be controlled with small one-handed a cerebral biosignal into a control signal for a keyboards or microswitches that move a cursor computer are available (e. As aids become even if that is only a twitch of the frontalis mus- more sophisticated, designers and manufactur- cle. Patients can operate on-screen keyboards ers will have to consider the varied needs of with a mouse under ultrasonic or infrared head the disabled person, otherwise clever products control, by blowing into a straw, and by voice in search of a use will result. With additional interfaces, these controls can access telephones, lights, alarms, WHEELCHAIRS intercoms, and other home and work electronic equipment. These devices are of particular Over 2 million people in the United States use value to the patient with quadriparesis from wheelchairs. Head controllers that al- wheelchair was designed by Everest and Jen- low a quadriplegic patient to control the nings in 1939 and commercial battery-run wheel- pointer or mouse cursor of a computer with chairs did not appear until the 1950s. Although slight head movements allow such people to the technology allowed such devices to have been work productively. Most systems work by pro- developed much sooner, even the inventors portional gain of neck movements (HeadMas- called their wheelchairs invalid chairs, suggest- ter Plus, Prentke Romich Corp, Wooster OH; ing that anyone who needed a wheelchair was Tracker 2000, Madentec Ltd, Edmonton, not independent or bright enough to manuever Canada). Veterans Administration, funding for a disabled person to have a lightweight, well- agencies such as the U. Wheelchair Prescription Parameters Frame Leg and footrest Material Height; adjustment from edge of seat Weight Fixed, removable, swing-away; straps Seat Wheels Height, width, depth, angle Materials—alloys, plastic Sling or cushioned; inserts Tires—width, tread; pneumatic or solid Cushion—elastic foam,viscoelastic foam, air or Angulation viscous fluid filled, alternating pressure Handrims Back Front casters Height; fixed or reclining; head rest Brakes—locking, backsliding Flexible, custom molded; foam or gel inserts Anti-tip bars Arms Power supply; control system Height—fixed or adjustable Fixed, removable, swing-away Arm troughs; clear plastic lap board; power controls The Rehabilitation Team 235 Chairs range from the depot type that oth- A powered wheelchair run by a joystick, sip- ers push, lightweight ones for self-propelling, and-puff, chin, or voice-command controller ultra lightweight chairs for highly active peo- may be ideal for a quadriparetic patient who ple, and sports chairs for rapid mobility and has cerebral palsy or a cervical cord injury, but turns on a tennis or basketball court. In gen- would be hazardous for a patient with hemi- eral, an ultra lightweight wheelchair is more inattention or poor judgment. Electric pow- durable and adjustable than a lightweight chair ered wheelchairs have electromechanical for active people. Sensors that paretic person who needs an electric wheel- avoid obstacles and tracking technology that chair system. Hybrid wheelchairs Many models of different weights and materi- (Yamaha) are becoming available. Wheelchair clin- the rim activates an electric hub motor for a ics in rehabilitation facilities bring in repre- boost, especially up hills. This remarkable vehicle includes comfort, trunk and thigh support, skin and gyroscopes for balance, has a 4-wheel rotating pressure point protection, type of transfers into base to maneuver over curbs, stands the user the chair, ease of propulsion, transportability, upright, and ascends and descends stairs. Some pation about changes related to progression of paraparetic patients, particularly those with impairments. For example, the hemiplegic pa- multiple sclerosis or diseases of the motor unit tient may require a seat set low enough to al- such as postpolio, find that scooters allow them low one leg to help propel the chair. Patients must be able to young person will develop wheelchair skills transfer easily and have good trunk and upper over time that require fewer safety features, al- extremity motor control. Some lightweight low the wheel axle to set forward for greater scooters can be taken apart in 3 pieces. A maneuverabilty, and improve pushrim biome- portable phone in the home and a cellular chanics. Training in best biomechanics for phone for the community provide great con- wheelchair use and in strength and endurance venience and measures of safety to the patient exercises may help reduce injuries. On- ies estimate that two-thirds of manual users going studies in ergonomics, engineering, com- suffer arm pain and many develop compression puterized safety and control devices, and ma- neuropathies.
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