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Newsletter Archive

Case Management

What Is Case Management?
Case Management is system, for delivering health care to people who have had catastrophic or high cost medical conditions with cost containment through out the recovery process. The American Nurses Association described it as; ?A system of health care delivery designed to facilitate achievement of expected outcomes within an appropriate length of stay.? Others have identified Case Management as a system in where the needs of a patient are identified.

Who are case managers?
Case managers are healthcare professionals, whose role is to advise the patient and their family about the services required throughout the recovery process. A case manager has training, which helps her/him to identify the needs of a patient with catastrophic injuries, work-related injuries, chronic illnesses, health-related illnesses and psychological illnesses. Through assessments, planning, and coordination, the Case Manager seeks to meet the individual?s unique health care needs with cost effective outcomes.

What do case manager do?
Case managers arrange the many services required for patient autonomy. They visit with the patient and their family outlining the goals and expected outcomes of care. They use a multidisciplinary approach, to identify the members of healthcare team who can provide services to the patient. They ensure continuity of care. A case manager is the patient / physician liaison. A case manager will conduct research, identify therapies, arrange for home health, locate medical devices, and make physician referrals, all in the best interest of the patient. A case manager is the patient?s advocate.

What are the goals of a Case Manager?
The goal of the Case Manager is to enhance the quality life of the patient, while promoting quality and cost-effective health care. A case manager is a valuable resource, which promotes autonomy, achieving positive patient outcomes.

Contributed by Bonnie Rupke RN CLNC, Rupke & Associates LLC, PO Box 615, Hays, KS 67061, Phone/Fax (785) 625-4464.

Cerebral Palsy

What is Cerebral Palsy?
Cerebral palsy is an incurable disorder affecting children. Defined as "Non-progressive disorders of movement and posture resulting from damage to the brain." The damage to the brain can and usually occurs during fetal development. Damage to the brain can also occur before, during, shortly after birth or during infancy. As one might think, "these disorders are not caused by problems in the muscles or nerves" These disorders are caused by inadequate "Development or damage" to areas of the brain that control movement and posture.

What causes cerebral palsy?
Unlike many other disorders, cerebral palsy has no one single cause. In over 90% of the cases the damage occurs before birth. Hypoxia (lack of oxygen to the brain) while in utero is the most common cause. Other causes include infections spread from mother to the unborn fetus and kernicterus which results from an excess of bilirubin (bile pigment) in babies with hemolytic disease of the newborn. Head trauma during the birthing process leading to decreased oxygen levels in the infant can cause cerebral palsy. Cerebral palsy can also occur after the child is born. Encephalitis or meningitis (infection of the brain or its protective covering) are other causes. These occur after birth.

Can cerebral palsy be prevented?
Yes, like many other disorders there are some preventative measures one can take or do. A measles vaccination for women who are planning to conceive a child can help. Avoiding exposure to x-ray during pregnancy. Regular prenatal visits are encouraged. It is standard care for a mother to be tested for the Rh factor in their blood while pregnant. Phototherapy (light therapy) is available for babies who are jaundiced after birth due to high bilirubin levels in the blood. These are a few programs which are directed toward the prevention of prematurity of an infant. Safeguarding infants after birth is also a preventative measure. All of the measures listed can help to prevent cerebral palsy however, children will be born with cerebral palsy even with all safeguards in place.

Are there different types of cerebral palsy?
Yes. Doctors classify cerebral palsy in three different categories depending in the movement disturbance. the first is known as spastic cerebral palsy. 70-80% of children diagnosed fall under this category. The muscles of children affected by this disorder are "stiffly and permanently contracted." The next category is known as athetoid or diskinetic cerebral palsy. Only 10-20% of children diagnosed fall into this category. Athetoid or diskinetic cerebral palsy is characterized by uncontrolled, slow writhing movements. Although this disorder affects mainly the hands, feet, arms and legs; the muscles of the face and tongue can be affected as well. The third category is called ataxic cerebral palsy. This rare form affects a small 5-10% of children diagnosed. One diagnosed with this form of cerebral palsy will have a poor sense of balance and depth perception. Finally patients with cerebral palsy may also have what is know as mixed forms. This is characterized by a combination of two are more of the three categories.

How do physicians diagnose cerebral palsy?
Cerebral palsy, no matter the category cannot always be diagnosed right away. Clinical signs and symptoms of cerebral palsy do not always appear right away. However, it can be diagnosed by testing the infants motor skills, muscle tone, reflexes and by the infants ability or lack theory to reach various developmental milestones. Ruling out other developmental disorders is also very important. Physicians can also use CT (computerized tomography) scans and MRI (magnetic resonance imaging) scans to detect brain damage or brain underdevelopment. Ultrasonography can also be used on infants before the bones of the skull have time to harden and close. Overall the diagnose of cerebral palsy can be a tricky one.

What are the treatments option for cerebral palsy?
Management is a better word than treatment. Not only are there medications, surgeries, and braces than can be in a treatment regimen, but many other resources can be used as well. Much support will be needed from many outside sources, also i.e., family friends, teachers, therapist, etc. Therapy, whether it be physical, occupational, speech, etc. will all play a very important role in the child achieving his/her highest developmental potential. Contributed by: Bonnie J. Rupke, RN, CLNC Rupke and Associates, LLC P.O. Box 615 Hays, Kansas 67601 P/F 785.625.4464

What is an upper extremity amputation?

What is an above-elbow and below-elbow amputation?
Surgical removal of the arm above or below the elbow can occur due to any of the following reasons: peripheral vascular disease, trauma, infection, tumors, nerve injury, and/or congenital anomalies. The location of the injury is directly related to the amount of the limb affected. Limb length and joint salvage are directly related to the functional outcome of the extremity. For optimal function of the remaining arm (referred to as the stump), it is important that the muscle groups be positioned tightly and securely over the transected bone ends during the surgery.

What happens after the surgical procedure?
After the surgical procedure a rigid dressing is used to decrease pain and swelling at the amputation site. It is very important at this time that a life care planner is involved in your recovery process. A Life Care Planner is a person who is trained to plan the patient?s future needs which may include medication, rehabilitation, prosthetic devices, functionally adaptive tools for daily living, and vocational rehabilitation. During the patient?s hospital stay complications related to the removal of a limb can occur. These complications include hematoma(s), infections, necrosis, contractures, neuromas, phantom pain, and terminal overgrowth (in children).

Be creative ? there are choices
A person who has an amputation must be creative. They may be missing a limb (in some cases two) but there are still ways to complete activities of daily living such as eating, bathing, and dressing. A person with an amputation can learn to drive, wash dishes, and use a shovel. Creativity is the key to learn to do things for oneself. In today?s world there are also choices to be made about prosthetic devices. It is possible to do many activities, which once seemed impossible. Technology has introduced body-powered prostheses. This type of device attaches to ones body with straps and cables. As the person moves once part of their body the prosthesis moves. The body-powered prosthesis uses a hook rather than artificial fingers. This enables the person to pick up smaller objects There are also electrical prostheses. This type of devise allows muscles in the arm to operate the electric motors, thus allowing the hand to open and close. The electrical devise looks and feels more like a real arm, but they are not as resistant and will require more frequent maintenance. There are also prosthetic devices, which look natural. The tone of the skin is created to match your own skin tones. This type of devise is called a cosmetic prosthesis. The limb looks and feels like a real arm but the hands do not move. The real purpose of a cosmetic arm is to look natural. Contributed by Bonnie Rupke RN CLNC, Rupke & Associates LLC, PO Box 615, Hays, KS 67061, Phone/Fax (785) 625-4464.

Pressure Sores

What is a pressure sore/ulcer?
The phrase, pressure sore/ulcer, is defined as "an area of skin and tissue that becomes injured or broken down". Also known as bed sores or decubitus, pressure ulcers occur in both the acute hospital settings, as well as in nursing homes and home care settings. Pressure ulcers are an unfortunate and almost always preventable condition too often seen in the medical profession.

What causes a pressure sore/ulcer?
Pressure ulcers occur in a variety of patients, but more commonly occur in those who are bedridden or wheelchair bound. Because of their inability to move or change position frequently, constant pressure on capillaries (tiny blood vessels) causes the capillaries to close. Without oxygen and nourishment supplied by the capillaries, the surrounding tissue (skin, fascia, muscle, etc.) begins to breakdown and necrose (die). Friction (rubbing of skin surface), shearing (dragging skin across a surface), and maceration (exposure to fluids for extended time causing the skin to break down, i.e., urine, stool, or drainage from wound) are also known causes of pressure ulcers.

What are the different stages referred to when describing a pressure sore/ulcer?
There are four stages defining the severity of an ulcer. Stage I: The beginning of a pressure ulcer noted as "reddened area on intact skin that, when pressed, is non-blanchable (does not turn white) Stage II: Partial thickness skin loss is noted by blisters and/or forms an open sore/shallow crater. Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue (just underneath the skin) that may extend down to, but not through, underlying fascia (fibrous membrane covering, supporting, and separting muscles). Stage IV: Full thickness skin loss with full destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, i.e. tendon or joint capsule.

What is the treatment for pressure sores/ulcers?
Treatment will vary depending on the stage of the pressure ulcer. Key factors in treatment is providing tissue load management, which refers to the distribution of pressure, friction, and shear of tissue. Staying off the ulcer is essential. Frequent respositioning, no less than every 2 hours and may require the assistance of a low-air-loss/air fluidized mattress/bed for tissue load management. Proper nutritional support is likewise essential. Initial care of pressure ulcer involves debridement (the removal of damaged/dead tissue), wound cleansing, application of dressings, and possible adjunct therapy. Some case will require surgical repair. In all cases, specific wound care strategies should be consistent with overall patient goals. Contribution by Bonnie Rupke, RN, CLNC and US Department of Health and Human Services, Clinical Practice Guidelines.

Spinal Cord Injuries: Tetraplegia / Quadriplegia

What is quadriplegia/tetraplegia?
Many of us have heard of the word or even know someone who is a quadraplegic. This is an old term, which is still commonly used for a person who is unable to move the upper or lower body. Though quadriplegia is a familiar and commonly used term, "tetraplegia" is the accurate word to be used for this condition. The definition of tetraplegia/quadriplegia is the inability to move ones arms and legs. This is a result of a spinal cord injury (SPI) to the top of the spine or backbone. The closer the injury is to the brain or the higher the injury is on the spinal column will determine how much movement and sensation will be altered or lost and what parts of the body below the injury will be affected. Injury to the cervical vertebrae can be divided into three groups. Injury to the 1st ? 3rd cervical vertebrae (C1- C3) is referred to as a high cervical injury. With this type of injury respiratory support is usually required. Injury to the 4th ? 6th cervical (C4 ? C6) or mid cervical injury can require respiratory support initially. Injury to the 7th cervical vertebra (C1) or 1st thoracic vertebra (T1) is referred to as a low cervical cord injury and requires no respiratory support. A person who has suffered a cervical injury is not able to move his arms or legs or will have minimal/restricted movement/control of upper extremities. ?52% of spinal cord injuries is paralysis of both the upper and lower parts of the body,? according to the Spinal Cord Injury Center.

The who, what, when, where and why of tetraplegia?
There are approximately 150,000 people in America who are tetraplegic due to motor vehicle accidents, gunshot wounds, motor cycle accidents, falls and diving incidents. There are more male than female tetraplegics. The common age is between 20 and 40 years of age. The most common site for a cervical spine injury occurs between C5 and C7. The most common cause of death is respiratory aliments.

The Life Care Planners Role
A cervical spine injury is catastrophic. Treatment of this type of injury begins at the scene of the accident. This type of injury costs insurance companies millions of dollars each year. The average hospital stay immediately after the injury is 15 days at a cost of $140,000. This is followed by an average of 44 days in a rehabilitation unit. The average yearly expense for medical care and living expense for a High tetraplegic (C1-C4) is $572,178 the first year with subsequent years costing $102, 491. The average yearly expense for medical care and living expense for a low tetraplegic (C5-C8) is $369,488 with each subsequent year costing $41, 983. The estimated lifetime costs for a 25 year-old with a high tetraplegic (C1-C4) is $2,185,665 and for a low tetraplegic (C5-C8) is $1,235,481. The role of a life care planner is projecting expected medical/non-medical necessities. Therefore planning the expectant needs of a tetraplegic is a valuable tool in the healthcare continuum. The statistical figures of this article came from the Spinal Cord Injury Contributed by Bonnie Rupke RN CLNC, Rupke & Associates LLC, PO Box 615, Hays, KS 67061, Phone/Fax (785)625-4464

Spinal Cord Injuries: Paraplegia

What Is Paraplegia?
When the spinal cord is injured or completely severed at the first through eighth thoracic vertebrae(T1 ? T 8), an individual may experience no sensation or movement below the injured area; this is paraplegia. Though the hands may not be affected, the person does lose the ability to move or feel the lower part of his/her body. The person usually has poor truck mobility. Additionally, internal organs including the stomach and the lower back and legs are affected. It is estimated that approximately 11,000 new cases will occur this year alone. It is also estimated that 183,000 ? 203,000 people already have spinal cord injuries. The paraplegic can accrue costs in excess of $193,000 the first year, with subsequent needs for the rest of their life ranging to over half a million dollars.

What can cause paraplegia?
Motor vehicle or motorcycle accidents are the leading cause of injury to the spinal cord/nerves. Violent acts, such as gunshot wounds and stabbing also cause spinal cord injuries. There are non-injury causes too including spinal tumors, scoliosis (lateral deviation in the normally straight vertical line of the spine) or spina bifida (a developmental anomaly characterized by defective closure of the bony encasement of the spinal cord through which the spinal cord and meninges may or may not protrude).

Life Expectancy
A person who has the injury occuring at a younger age will have a greater life expectancy than that of a person who has the injury in the later years of life. People with paraplegia are more likely to develop lung infections such as pneumonia or viral pneumonia.

The function of a Life Care Planner
Long-term medical care can be both emotionally and financially devastating for a patient and their family. A Life Care Planner is a person who is specially trained to predict the future medical needs of the injured party. Life Care Planners are advocates for the individual with a spinal cord injury in that they focus on the tasks the person is not able to do in normal day-to-day functions by his/herself and endeavour to develop a plan how to restore as much function/independence as possible. A life care plan is needed from the day of the injury to the life expectancy of the individual. The intent of the life care plan is to meet the daily medical, psychosocial, educational, equipment, caregiver, housing and vocational needs of the patient. Contributed by Bonnie Rupke RN CLNC, Rupke & Associates LLC, PO Box 615, Hays, KS 67601, Phone/Fax (785) 625-4464

What is a stroke?

A stroke, also known as cerebral vascular accident (CVA), occurs when blood flow to the brain is stopped. Miller and Keane provide the definition: "Rupture or blockage of a blood vessel in the brain, depriving parts of the brain of blood supple, resulting in loss of consciousness, paralysis or other symptoms depending on the site and extent of brain damage."

Who can suffer from a stroke?
According to the National Stroke Association (NSA) ? strokes occur in people of all ages. It?s a common misconception, yet every year thousands of children suffer from strokes, though rare, it is estimated that about ?1,000 infants are year suffer a stroke during the newborn period or before birth ? plus anywhere from 3,000 to 5,000 from are one month to 18 years.? Babies and Strokes ? How to Treat the Smallest Victims by Lauran Neergaard

Statistical Facts
? Every second, 32,000 neurons ? brain cells ?die; that?s 1.9 million a minute ? Your brain loses 14 billion synapses, the vital intersections between neurons ? An oxygen ?starved brain ages about 3.6 years each hour ? The average stroke involves 54 milliliters of brain tissue ? about 3 cubic inches ? and takes 10 hours to evolve

Symptoms of a stroke
It is critical that people recognize the clinical symptoms of a stroke. In adults the symptoms seen could be: ? Sudden numbness or weakness of face are or leg ? Sudden confusion ? trouble speaking or understanding ? Sudden trouble seeing in one or both eyes ? Sudden trouble walking, dizziness, loss of balance or coordination ? Sudden severe headache. In infants and children a stroke can have the same symptoms. Those symptoms include one-sided weakness, loss of speech and, in babies, seizures.

Debilitating effects
The residual effects of a stroke can be debilitating. There are the visual signs, which can involve anything from a drooping mouth and or eye to paralysis on one or both sides of the body. Research shows that babies can suffer enough damage to the brain that the there will be permanent motor and cognitive disabilities. It is estimated that between 10 and 25 percent of pediatric stroke sufferers die. The information used in this article came from,, and,2933,177858,00.html Contributed by Bonnie Rupke RN, LNC, BGS, Rupke & Associates LLC, PO Box 615, Hays, KS 67061, Phone/Fax (785) 625-4464

Amputations: Lower Extremity

What is an Amputation?
An amputation is the removal of a limb. This happens through a surgical procedure or when an external body part (limb) is torn from the body after an accident. An amputation can also occur when a limb has been crushed or when there is impaired circulation to that extremity. Here is the United States the most common cause of amputation of the lower extremity are disease (70%), trauma (22%) congenital birth defects (4%) and tumors (4%).

Lower Extremity Amputations
When circulation is lost or severely diminished, a surgical procedure known as a below the knee amputation (BKA) may occur. The removal of a limb above the knee is know as an above the knee amputation (AKA). The singular reason for the removal of a lower extremity is ischemia from arterial occlusion. Other contributing factors may include infection, neuropathy, gangrene, and cutaneous ulceration. Peripheral Vascular Disease (PVD) is the number one systemic disease responsible for circulation compromise to a lower extremity.

The Role of the Life Care Planner
Issues of simple mobility and self-care are the initial problems that most amputees face. There is a greater chance of rehabilitation for the person who has a BKA over an above the knee amputation (AKA). Participation in a comprehensive rehabilitation program, identifying the prosthetic device(s) needed, will help the amputee return to life?s daily activities. This is where the Life Care Planner becomes involved. The life care planner will assure a team approach to the amputee?s recovery. The patient?s physician and therapists will develop a rehabilitation program based on the individual needs of the patient. If there are home care needs, the Life Care Planner will identify those needs. Your Life Care Planner will also make sure any emotional needs are met. Patient and family education is needed to deal with psychological trauma related to the amputation and prevent further complications.

Statistical Facts about Below the Knee Amputations
Statistical Facts about Below the Knee Amputations ? Eighty-five (85 %) percent of amputations, which occur to a lower extremity, occur due to peripheral vascular disease. ? Between forty five ? eighty three percent (45-83 %) of all BKA occur in diabetic patients. ? Fifty (50) percent of diabetics who have BKA will develop serious complications in the alternate limb. These information and statistics were found at

It is estimated that there are 350,000 amputees living in the United States with and estimated 135,000 new amputations occurring each year.

Contributed by Bonnie Rupke RN CLNC, Rupke & Associates LLC, PO Box 615, Hays, KS 67061, Phone/Fax (785) 625-4464.

Spinal Cord Injuries

Outline of the Spinal Column
There are 7 cervical vertebrae, labeled C1 ? C7. There are 12 vertebra in the thoracic spine labeled T1 ? T 12 and 5 vertebrae in the lumbar spine, labeled L1 ? L5. The 5 sacral vertebrae, labeled S1 - S5 are generally fused in adults forming the sacrum. The 4 rudimentary coccygeal vertebrae fuse to form the coccyx. The higher the injury on the spinal column the more affected the person will be.

Leading Causes of Injury to the Spinal Column
Over 10,000 people experience spinal cord injuries each year. There are over 200,000 people with paralysis of arms, legs or both due to injuries. The leading cause of injury to the spinal nerves occurs from motor vehicle accidents. Acts of violence, falls and sports injury are other methods where spinal cord injuries can occur. Depending on the site of injury a person can experience partial or permanent loss of their upper and/or lower extremities. Incomplete injury can be seen with symptoms as moderate to severe back pain made worse by movement, numbness, tingling, weakness or bowel/bladder dysfunction. Complete spinal cord injuries mean that the spinal cord has absolutely no function below the affected area. This can be seen with total loss of function of the upper and/or lower extremities. Severed or degenerated nerve processes in the cord cannot recover. The damage is permanent.

Role of the Case Manager
Due to the complex nature of these cases the role of a case manager is crucial. The case manager, with the collaborative process of assessment and planning facilitates options and services the meet the variety of needs of the client. The case managers goal is to obtain optimum value for both the client and the reimbursement agency while dealing with and providing adequate rehabilitation and prevention of long term complications the injured person may face. Contributed by: Bonnie J. Rupke, RN, CLNC, Rupke and Associates, LLC P.O. Box 615 Hays, Kansas 67601 P/F 785.625.4464