Care plan for patients with locked-in syndrome

We present a case and a Care Plan of a patient with Locked-in Syndrome. This is a disease of vascular origin, s characterised by a severe paralysis of the whole body, but not of the mind, as the intellectual faculties remain intact. We emphasise the importance of the development on the part of the professionals who take care of these patients and their communicative abilities, as they are essential in their treatment, for the satisfaction of the patients, their families and the professionals themselves. Communicating with these patients is a major challenge for professionals, who have to make use of their creative and communicative skills, which are essential for treatment to the satisfaction of patients themselves, their families and the professionals. We must also take into account the family involvement in the patient care. The union between the family and the patient is of vital importance in establishing a trusting relationship. During the development of our nursing duties, we must not forget the training the main caregiver must acquire to satisfy the main needs of the relative in the hospital, and at home in the future. Working together with the family is very important at all times, identifying the primary caregiver--although the support received by all is beneficial--and setting a series of common objectives to evaluate the progress of the case. It is about partnership: patient, family and professionals, must all establish a communication system adapted to each case by paying attention to the signals that the patient sends, and making use of an appropriate scale to interpret them suitably.     

全程健康教育对重度子宫内膜异位症患者术后应用GnRH-α副反应的影响

子宫内膜异位症（EM）是生育期妇女的常见病，其患病率呈逐年升高趋势。近年来的研究表明，应用促性腺激素释放激素激动剂（GnRH-α）可有效治疗EM，但其低雌激素引起的类似绝经期症状，如潮热、阴道干燥等副反应影响了患者坚持用药。绝经期症状的发生，不仅有生理因素，且与社会心理因素密切相关。我院对重度子宫内膜异位症患者术后应用GnRH-α治疗，在预防复发的同时，实施全程健康教育，取得良好效果，现报道如下。     

新护理模式下肿瘤患者康复的心理干预

恶性肿瘤是威胁人类生命安全最严重的疾病之一,近20年来发病率呈上升趋势,死亡率居高不下.由于肿瘤本身及治疗的复杂性,仅用手术、放疗、化疗、生物治疗很难满足人们对现代医学的需要.如何让肿瘤患者在康复过程中减轻其躯体痛苦和心理压力,从而提高患者的生活质量和生存年限,不仅是所有医护工作者所追求的,也是人类社会文明发展进步的体现.正是基于新医学模式的影响,在积极治疗肿瘤患者的同时,加以相应的心理护理和心理干预就起着越来越重要的作用.笔者对我国近年来的有关在肿瘤康复过程中的心理护理和心理干预问题综述如下.     

Early smooth horizontal eye movement: a favorable prognostic sign in patients with locked-in syndrome

Locked-in Syndrome (LIS) is a rare clinical entity consisting of quadriplegia, paralysis of lower cranial nerves, mutism, and bilateral paresis of horizontal gaze. The prognosis is usually poor. Most patients who do survive have severe residual impairment or develop chronic LIS. Review of the literature shows that recovery has been reported but not systematically studied, particularly with respect to early prognostic signs. We report a case of LIS with bilateral pontine infarctions shown by MRI. Severe neurological deficits included quadriplegia, paresis of horizontal gaze, facial paralysis, and bulbar palsy. Horizontal eye movements were present and smooth by the second week after onset. The patient had almost full functional motor recovery within four months, after a comprehensive rehabilitation program. Fourteen other reported cases of LIS with full recovery had documented recovery of lateral gaze in the early stage. In addition, smooth horizontal gaze is the most frequent activity in incomplete LIS. Early recovery of horizontal eye movement may indicate that the brain lesion is limited and may be a good prognostic sign in LIS.     

Management of pathologic laughter and crying in patients with locked-in syndrome: a report of 4 cases

Sacco S, Sarà M, Pistoia F, Conson M, Albertini G, Carolei A. Management of pathologic laughter and crying in patients with locked-in syndrome: a report of 4 cases.Emotional lability and pathologic laughter and crying (PLC) have been frequently mentioned in patients with locked-in syndrome (LIS) without giving any detail about the clinical characteristics and possible consequences in terms of symptoms burden, functional impact, and recovery. In the present report, we describe our approach and management of 4 patients with LIS and PLC. PLC caused discomfort to the patients and hindered the different components of their rehabilitation program, limiting communication, the execution of swallowing testing and training, and the improvement of any residual motor function. PLC was unrelated to depression, did not ameliorate after pharmacologic treatment, and improved with cognitive-behavior treatment. Our findings suggest that, in LIS patients, laughter and crying alterations do not represent symptoms of a mood disorder but are the result of the same pontine lesion that causes LIS. In relation to the complex pathway regulating laughter and crying, we hypothesized that, in patients with LIS, PLC may be the result of a direct damage to the pontine center or of an alteration in the ponto-cerebellar pathway linking emotional behavior to contextual information. Presence of PLC in patients with LIS severely affects their intelligent adaptation to the environment. Direct explanation to the patients of the origin of PLC may be helpful as a cognitive-behavior treatment, with resulting benefits to the entire rehabilitation program.     

综合康复治疗脑卒中后肩手综合征的疗效观察

目的 观察综合康复治疗对脑卒中后肩手综合征患者的治疗效果。方法 采用综合康复措施治疗56例脑卒中后肩手综合征患者，治疗方法包括正确体位摆放、避免腕屈曲、关节注射、压迫性向心缠绕、冰疗、主动和被动运动、电针、超短波及药物治疗等，治疗时间为4周。治疗前、后采用Fugl-Meyer量表和目测类比评分法（VAS）对患者上肢关节被动运动范围、上肢和腕手关节的运动功能、疼痛及水肿程度进行评定。结果 56例患者经过为期4周的综合康复治疗后，其病情均有明显改善，共显效35例（62．5％），有效2l例（37．5％）；治疗后患侧上肢关节被动运动范围、上肢及腕手关节的运动功能均较治疗前有显著改善（均P〈0．05），上肢疼痛和水肿程度亦均较治疗前有明显下降（均P〈0．05）。结论 综合康复治疗对脑卒中后肩手综合征患者具有较好疗效。     

Two cases of rehabilitation in Ehler-Danlos syndrome]

PURPOSE: Ehlers-Danlos syndrome is rare and little known. It comprises a heterogeneous group of heritable connective tissue disorders characterized by articular hypermobility, skin extensibility and tissue fragility. Diagnosis may be difficult and often delayed. CASE REPORT: Here we describe 2 cases of women with Ehlers-Danlos syndrome. The first had scoliosis with back pain and joint hypermobility. The second presented with hypermobility and joint dislocation, which increased during pregnancy. In these 2 cases, rehabilitation management produced clinical improvement. DISCUSSION: Orthopaedic complications such joint pain, joint swelling, joint dislocation, back pain, with walking and hand function disability are the main problems in Ehlers-Danos syndrome. Surgery may be necessary to correct dislocated joints but is often not sufficient to resolve the handicap, and physical therapy has an important place in management. CONCLUSION: Ehlers-Danlos syndrome is an evolving disease that can lead to great impairment. Thus, physicians must be aware of this syndrome to offer the best management, with the appropriate use of orthotic devices, specific strengthening routines, education in proper body mechanics and assistive devices, to prevent joint dislocation and subluxations responsible for pain and handicap.     

Mortality and complications of the locked-in syndrome

The locked-in syndrome is a severe disability consisting of quadriplegia and anarthria with preserved consciousness. No large series of cases have been reported and very few cases of long-term survival have been described. We present a follow-up of 27 patients "locked-in" for more than one year. Twenty-four were still alive up to 12.5 years after onset, with a mean survival of 4.9 years. Significant recovery was noted in only a few patients. Seventeen patients lived at home at the time of study. Eight were never hospitalized after the initial event. Gastrostomy and tracheostomy tubes and indwelling catheters were eventually removed from many patients. Electronic devices were used by ten patients to facilitate communication. We conclude that rehabilitation and medical care must be planned carefully, given the length of survival shown in this group.     

Vertebral artery dissection resulting in locked-in syndrome.

A 30 year-old man admitted to the hospital two weeks following a motor vehicle accident developed "locked-in" syndrome resulting from traumatic vertebral artery dissection. Aggressive nursing interventions during the acute and early recovery periods were implemented with the hope that both physical and emotional deficits might be alleviated. Although the prognosis for this type of injury is often poor, this patient has improved steadily over a 16-month period.     

A novel spelling system for locked-in syndrome patients using only eye contact

Abstract

Purpose: We developed and evaluated a novel spelling system for patients with locked-in syndrome: patients with tetraplegia, not able to talk, and only able to blink their eyes. Method: A new communication grid was compared with existing non-technical communication methods for practical daily use. The means of the number of decision steps to reach a full sentence were compared testing 10 sentences relevant in daily care. These 10 sentences together encompass all letters of the alphabet. Results: The new communication grid is organised alphabetically in 4 columns and 2 main rows, with each row subdivided in three rows. The first column contains vowels while the other columns contain consonants. Letters in each column are alphabetically ordered. When spelling a sentence the conversation partner counts the columns, until the patient indicates by an upward eye movement that the column contains the intended letter. Hereafter, the patient indicates by looking straight ahead or by looking down, whether the intended letter is in the upper or in the lower main row, respectively. The conversation partner will then read out the letters until the patient indicates the intended letter. Compared to other spelling systems, this system requires only vertical eye movement, is easier to memorise, and faster in use. The comparison of means of decision steps to reach the 10 full sentences for different communication grids shows that using the new communication grid is approximately one-third to three times faster than the existing spelling systems (p?=?0.005). Conclusion: This new grid is a valuable communication tool, especially in situations, such as bathing, getting dressed or out of house activities where no devices are available.

• Implications for Rehabilitation

• Communication with patients with locked-in syndrome is a complicated and strenuous task.

• Communication methods, such as the alphabet board and brain-computer interfaces, are time consuming or too sophisticated to use in daily life tasks.

• This communication grid is fast, easy to use and memorise and requires only vertical eye movement.

     

The hyperdense basilar artery sign: a case of locked-in syndrome

Background

Locked-in syndrome, although a notoriously famous clinical entity, the rarity of the condition coupled with the variability of clinical features on acute presentation represents a potential diagnostic pitfall for the emergency physician.

Case

A previously healthy 25-year-old female was brought to our Emergency Department after being found unresponsive. On examination, she was conscious and alert with a Glasgow Coma Score of 9; on neurological examination, the patient was quadriplegic and unable to speak but was able to move her eyes and blink. Non-contrast brain computed tomography (CT) revealed a hyperdense basilar artery, and CT cerebral angiography confirmed basilar artery thrombosis.

Conclusion

This case highlights the need for a high index of suspicion to make a diagnosis of locked-in syndrome in the Emergency Department, especially in young patients with no apparent risk factors for an ischemic stroke. The hyperdense basilar artery sign is one of the earliest signs on non-contrast CT imaging and may be the only clue to guide further management in a patient with basilar artery occlusion.

     

Long-term survival, prognosis, and life-care planning for 29 patients with chronic locked-in syndrome.

We present a life-table analysis of a cohort of 29 locked-in syndrome (LIS) patients followed for a minimum of five years, and we report on the status of the chronic LIS patient. Twenty-nine LIS patients who remained locked-in for more than one year were identified. Inpatient charts were reviewed for demographic, medical, and functional data. Telephone followup was obtained to examine medical complications after discharge, survival, neurologic recovery, care issues, and permanent disposition. A life-table analysis was performed on survival data. Cerebrovascular disease was the most common cause of LIS. Survival ranged from 2.02 to 18.15 years. Twenty of the 26 patients available for five-year followup survived; hence, five-year survival was 81%. An alternative method of communication and emotional stress for the patient's caregiver was the key issue in patient care. Most patients were cared for in their own homes. Although minimal late neurologic recovery occurs in chronic LIS, survival may, nonetheless, be prolonged with adequate supportive care. Modern computerized technology offers LIS patients the ability to interact with their environment. This information may assist physicians in making ethical and long-term care decisions with the patient rather than for the patient with LIS.     

The postpericardiotomy syndrome as a cause of pleurisy in rehabilitation patients

Pleuritic chest pain in patients on a rehabilitation unit may be caused by several conditions. We report 2 cases of postpericardiotomy syndrome (PPS) as a cause of pleuritic pain. PPS occurs in 10% to 40% of patients who have coronary bypass or valve replacement surgery. The syndrome is characterized by fever, chest pain, and a pericardial or pleural friction rub. Its etiology is believed to be viral or immunologic. The syndrome can be a diagnostic challenge, and an increase in length of hospitalization because of it has been documented. Identified risk factors for PPS include age, use of prednisone, and a history of pericarditis. A higher incidence has been reported from May through July. Many patients undergo a battery of expensive procedures before PPS is diagnosed. The pain is sharp, associated with deep inspiration, and changes with position. Pleural effusions may be present and tend to occur bilaterally. Pericardial effusions are a documented complication. A pericardial or pleural rub may be present and is often transient. Serial auscultation is important. Laboratory work provides clues with a mild leukocytosis and an elevated erythrocyte sedimentation rate. However, this does not provide the definitive diagnosis. Cardiac enzymes are not reliably related to the syndrome. An electrocardiogram will show changes similar to those associated with pericarditis. The patient may have a fever, but it is rarely higher than 102.5 degrees F. Complications include pericardial effusions, arrhythmias, premature bypass graft closure, and cardiac tamponade. Treatment consists of a 10-day course of nonsteroidal anti-inflammatory drugs.     

全程康复护理干预对脑卒中偏瘫患者的效果观察

目的规范留置导尿管及其护理过程,降低留置导尿管患者的感染率。方法将73例留置导尿患者按住院号单、双分为对照组（38例）和实验组（35例）,对照组按无菌操作原则置尿管,置管后以常规方法进行护理;实验组应用六西格玛改进模式及失效模式测量、分析留置导尿管感染主要原因,改进置管及置管后护理操作流程。在留置导尿的3,5,7,14d对2组进行细菌采样记录。结果实验组第5、7天尿道口有菌率明显低于对照组（P〈0．05）;2组中段尿、尿袋接口处有菌率比较,差异无统计学意义（均P〉0．05）。结论应用六西格玛方法系统分析的留置导尿管感染原因准确,采取的控制感染措施有效,能有效降低留置导尿管感染风险,对降低留置导尿管感染率有效可行。     

全程康复护理干预对脑卒中偏瘫患者的效果观察

目的 探讨护理人员对脑卒中偏瘫患者实施全程康复护理干预的效果,为今后护理干预提供指导和依据.方法 92例脑卒中偏瘫患者分为实验组和对照组各46例,2组患者均给予常规神经内科治疗和护理.实验组实施全程康复护理干预包括评估,康复护理教育和指导,出院前后持续教育和随访.分别在住院后1周内和干预后3个月进行复查,包括血三酰甘油(TG)、总胆同醇(TC)和同型半胱氨酸(Hcy)指标值及日常生活能力(ADL)和生理/心理健康的测评.结果 与对照组相比较,实验组患者TC、TG、Hcy水平均明显下降.实验组患者干预后的生理健康和心理健康领域得分高于干预前.对照组患者干预后生理健康领域得分高于干预前,但心理健康领域得分的变化无差异.结论 全程康复护理干预能够有效地降低脑卒中患者的TC、TG、Hcy水平;有效地提高脑卒中偏瘫患者的日常生活能力和生活质量.