1
Q
What are the different ways in which a patient can enter the acute care setting?
A
- Emergency care
- Urgent care
- Short-term stabilization
- Pre-hospital care
- Critical care
- Trauma care and acute care surgery
2
Q
What is acute care?
A
• “include all promotive, preventive, curative, rehabilitative or palliative actions, whether oriented
towards individuals or populations, whose primary
purpose is to improve health and whose effectiveness largely depends on time-sensitive and, frequently, rapid intervention.”
• “includes the health system components, or care delivery platforms, used to treat sudden, often unexpected, urgent or emergent episodes of injury and
illness that can lead to death or disability without rapid intervention.”
3
Q
What are the units found in acute care?
A
- General medical
- Specialty inpatient services
- Surgical: may be general surgery or individual units determined by type of surgery (ortho, cardiopulmonary, general)
- Combined “med/surg”
- Obstetrics/gynecology (ob/gyn)
- Post-anesthesia care unit (PACU)
- Pre-operative unit
- Emergency department (ED): usually the point of entry to the system by most patients
4
Q
What are the characteristics of general care, acute care?
A
Highest patient to nurse ratio
5
Q
What are the characteristics of intensive care, acute care?
A
- May be general ICU or divided into specialties (i.e., trauma, cardio, neuro, pediatric, neonatal)
- Lowest patient to nurse ratio
6
Q
What are the characteristics of transitional units, acute care?
A
- “Step down” units that bridge between ICU & general medical care
- Patient to nurse ratios between ICU and general care
7
Q
What are the acute care team members?
A
• Hospitalist
• Specialty physician (ortho, neuro, cardio, pulmo, nephro, etc)
• Nurse (usually RN, but sometimes LVN/LPN): primary, charge, managers/directors,
house supervisor
• Rehab team: PT/OT/ST
• Case Managers (usually an RN, but includes social workers)
• Respiratory therapy (RT)
• Pharmacist (RPh)
• Patient care technician/certified nursing assistant (PCT/CNA)
• Chaplain
• Others as needed (hospice care, dialysis nurse, ostomy nurse, etc)
8
Q
What is SBAR?
A
Situational briefing guide for staff & provider communication re changes in pt status or needs for non-emergent events, related issues, events in unit, the lab, or within health team.
9
Q
What are the components of SBAR?
A
- Situation: What’s going on with the patient?
- Background: What’s the clinical background or context
- Assessment: What do I think the problem is?
- Recommendations: What do I think needs to be done for the patient?
• Does not become part of the medical record
10
Q
What are the characteristics of the written form of communication used in the acute care setting?
A
• Medical record: “If you don’t document, it didn’t happen!” - Reading them can be a different story (see example in readings of a physician history and physical) • SBAR
11
Q
What are the characteristics of the verbal form of communication used in the acute care setting?
A
- Multi-disciplinary rounds
- Professional-to-professional
- Team huddles
12
Q
What are the characteristics of communication in the acute care setting?
A
• Critical for patient safety and medical error prevention!
- Poor communication also contributes to increased length of stay, excessive resource
utilization, poor patient/family satisfaction, and employee turnover
• Necessary for discharge planning: “discharge
planning begins on hospital day one!”
• Facilitates efficient and effective transitions of care
between hospital providers
• Patient privacy of utmost importance! HIPAA!
13
Q
What do Multidisciplinary Rounds consist of?
A
Consists of entire healthcare team and/or representatives
14
Q
What are the characteristics of Multidisciplinary Rounds?
A
- Meet on daily basis
* Patient-centered
15
Q
What do Multidisciplinary Rounds focus on?
A
- Open and collaborative communication
- Decision making
- Information sharing
- Care planning
- Patient safety issues
- Cost and quality of care issues
- Setting daily goals of care
- Communicating with patients and/or family members
16
Q
What are the components of safety in acute care?
A
- Imperative to create and maintain a safe environment and plan of care
- Establish appropriateness of care
- Assemble required assistance and items (equipment, AD, PPE, other personnel)
- Two patient identifiers (name, DOB verification– look at wrist band)
- COMMUNICATION!!
17
Q
What are the components of establishing appropriateness of care in the safety of an acute care setting?
A
- Verify orders and other precautions (WB, surgical, etc)
- Chart review to determine preliminary precaution list and plan (look at lab values, nursing notes, H&P/MD progress notes)
- VITALS!!!!!
- Key discussions with other providers– esp. nursing and MD
- Anticipate difficulties or challenges in patient mobility or status, and plan accordingly
18
Q
What are some common safety situations common in acute care (but also present in skilled nursing and inpatient rehab?
A
- Various mattress types (can change bed mob. strategies)
- Bed and chair alarms
- Call lights/bells
- Presence of various lines, tubes, & monitors
- No undergarments or presence of a brief/adult diaper
- Need for specialized lifting equipment (Hoyer lift, sit-to-stand lift, overhead lift)
19
Q
What are the precautions to take with patients in an acute care setting?
A
• Infection control (see other lecture) • Eating/drinking precautions - NPO (can't have anything by mouth) - Swallow precautions - Fluid restrictions - Fluid monitoring (input output) • Falls precautions • 1-on-1 supervision (may be for safety, suicide prec., swallow prec.)
20
Q
What is the 1st thing to do before any thing begin in the acute care setting?
A
Before anything begins, ALWAYS check with the nurse about any new developments or information on the patient that may not have been in your
chart review!
21
Q
What are the subjective information to get in an acute care exam?
A
- PLOF and work/school/activities— FALL HX!!!
- Caregiver support and availability
- Home situation and barriers– esp. stairs to enter home and whether home 1-2 stories; where is the main bedroom & is there a full bath on 1st floor?
- Availability of assistive devices
- Patient/caregiver’s d/c plans (may not match up with your assessment, though)
22
Q
When should the vitals of an acute care patient be assessed?
A
Before, multiple times during if needed, after activity. Remember pain is another
important part of vitals assessment!
23
Q
What is a key to remember when doing test and measures?
A
Recognize that you may not need to do ALL, and some may require adjustments to normal exam technique or may need a more functional assessment
24
Q
What are the tests and measures that can be done in an acute care setting?
A
• Cognition • Speech/language ability • General appearance • CVP • MSK– may not be able to perform traditional positions for ROM/strength; look at functional mobility • Neuro– as appropriate for the patient condition: screen vs full exam • Integumentary • Pain • Functional mobility • Standardized measures
25
How do we choose functional measures appropriate for acute
| care use?
* Applicable to the patient
* Practical for use in acute care (time, cost, feasibility)
* Assistance with d/c planning and pt. safety
* Acceptability of test to the individual (tolerance for test, positioning)
* Appropriateness of test for application to the pathology or health condition, body function or status, activity, or participation
26
What are the general functional mobility and endurance functional measures that are appropriate for acute care use?
* Functional tests (AMPAC 6-Clicks)
* Cardiovascular endurance (6MWT, 2MWT, 400m walk test, 2 min step test)
* Walking Speed
* RPE during functional activities
27
What are the balance & falls functional measures that are appropriate for acute care use?
* TUG
* Berg
* Forward Reach
* Single limb support
* ABC
28
What are the functional strength functional measures that are appropriate for acute care use?
```
• Chair rise test (quad strength)
- 30 sec, timed 5 reps
• Arm curl
• Supine hip extension
• Heel rise
• Toe tap
```
29
What is the role of n acute care PT?
• Not to necessarily completely resolve the patient’s issues but rather to determine what is needed to d/c safely to the next level of care, whether that is home or to another post-acute facility
• To assist in preventing further functional decline, discourage bed rest as much as is
possible
• To prepare the patient for further care and progressions needed after hospitalization,
whether that is a HEP, family education and training, info re the role of subsequent therapy settings, or other recommendations
• To initiate new movement patterns and/or use of assistive devices needed as a result of
the patient’s surgery, medical condition, or recent functional losses
• To EDUCATE, EDUCATE, EDUCATE
- You are often the “translator” between the MD and pt/family!
- Multiple opportunities to educate other healthcare providers on many issues
(safety, transfers, body mechanics, role of PT, etc)
30
What are the characteristics of discharge planning?
• Begins on DAY ONE!!
• Communicate to the hospital team (likely the case manager or hospitalist) immediately
• It’s okay to be a little unsure– better to overestimate care and be prepared than project a lower level of care & have to scramble last minute for d/c disposition
• Consider pt/family resources and projected level of assistance: do these match?
• Use functional measures to help you in justifying d/c recommendations
• Recommend equipment needs– what needs to be arranged by hospital? What
must pt/family secure? How many of these needs are essential for d/c?
• Remember, insurance, finances, and care arrangements can be MESSY!
31
What are the characteristics of discharge disposition: Home w/no further therapy needed?
Pt. may not even need therapy in the hospital or have no other needs after initial treatments
32
What are the characteristics of discharge disposition: Home w/home health PT?
* “Homebound” status
* Does the patient need supervision or assistance?
* Pt’s own home/apartment, family or caregiver home, assisted-living facility?
33
What are the characteristics of discharge disposition: Home w/referral to outpatient therapy?
* Can the pt drive?
* What kind of assistance still needed?
* Oftentimes, a significant gap exists between hospital d/c & start of care in OP–HEP/education critical!
34
What are the characteristics of discharge disposition: Post-acute facility placement?
* Inpatient rehab (IRF)
* Skilled nursing (SNF)
* Long-term acute care (LTAC)
* Long-term care facility/nursing home
35
What is the criteria 1 for a patient to be Home health homebound upon discharge?
• Criterion 1: The patient must either:
• Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence.
OR
• Have a condition such that leaving his or her home is medically contraindicated.
If the patient meets one of the Criteria 1 conditions, then the patient must ALSO meet
both additional requirements defined in Criteria 2.
36
What is the criteria 2 for a patient to be Home health homebound upon discharge?
* There must exist a normal inability to leave home; and
| * Leaving home must require a considerable and taxing effort
37
What are the patients that go to an Assisted Living Facility upon discharge?
Patients who need housing, support services, and health care
38
What are the Services/Amenities (Facility dependent) provided at an Assisted Living Facility?
* 3 Meals/day in common dining area
* Housekeeping
* Transportation
* Laundry services
* Exercise/Wellness programs
* Social/Recreational activities
* Social/recreational activities
* Assistance w/ADLs
* Medication assistance
* Rehabilitation services (HH vs OP)
* Emergency call systems
39
What are the patients that go to an Inpatient Rehabilitation Facility upon discharge?
Patient who needs intensive rehabilitation services
• Must be able to tolerate 3 hours of therapy services 5-7 days/wk
- Includes PT, OT, ST (must have AT LEAST two disciplines on board)
40
What are the characteristics of an Inpatient Rehabilitation Facility?
* Length of stay determined by diagnosis: typically 10-12 days
* Rehabilitation is the main focus, medically stable
* No qualifying length of stay required in acute care hospital
* Patients can even be referred from and admitted straight from home or ED
* “60% rule” for Medicare patients
41
What are the patients that go to a Skilled Nursing Facility upon discharge?
Patient who needs daily skilled care under the direction of skilled nursing or rehabilitation staff for a hospital related medical condition
• Rehabilitation services
• Nursing services (IV injections etc.)
• Activities
42
What are the characteristics of a Skilled Nursing Facility
* Billed under Part A Medicare for those 65+, otherwise private insurance
* Requires 3 midnight stay in acute care hospital (for Medicare)
* Length of stay up to 100 days
* Can be within a long-term care facility or a free-standing facility (often combined with inpatient rehabilitation services)
43
What are the patients that go to a Long-term Acute Care Hospital upon discharge?
Patients with multiple co-morbidities who need a long stay of hospital care
• Still need daily medical management by a physician
44
What are the characteristics of a Long-term Acute Care Hospital?
```
• Average LOS >25 days
• Provide: (These are facility dependent)
- Ventilator Weaning
- IV Antibiotics
- Dialysis
- Rehabilitation services
- Wound Care services
```
45
What is the external ventricular drain (EVD)?
A small tube surgically inserted into the ventricles of the brain, which drains cerebrospinal fluid (CSF) The tube is connected to a device that measures the amount of this fluid
46
When is an external ventricular drain (EVD) used?
When the ICP is elevated, and the drain may be clamped for short periods of time and should only be done by nursing unless your facility regulations allow other providers after significant training.
47
What must be position of the bed be when using an external ventricular drain (EVD)?
The head of the bed must be elevated to a specific level the bed should be locked out to prevent accidental movement of head of bed. Head must be at 30 deg when the drain is open
48
Why must the bed be in a certain position when using an external ventricular drain (EVD)?
Because of the specific calibration, function of the drain, and accuracy in measurement. Unless the drain is clamped, the head of the bed may not be changed, and patients should not be mobilized.
49
Why should you alway check with the nurse prior to working with a patient that has an external ventricular drain (EVD)?
They will need to close drain prior to mobilization.
50
What is the function of the external ventricular drain (EVD)?
Monitors and alleviates swelling and increased pressures in the ventricles of the brain
51
Where are the locations that a "central" central line can be?
- Subclavian
- Internal jugular
- External jugular
52
Where are the locations that a "peripheral" central line can be?
- Basilic
- Cephalic
- Femoral
53
What are the functions of a central line?
Used to deliver meds, nutrition, dialysis, blood draws
54
What are the characteristics of a central line?
- Usually patients can be disconnected from any tubing connected to IV pole (other than during dialysis) to allow easier mobilization with less lines to manage.
- Usually the port is covered with a thin clear dressing, always use gloves when handling these patients to prevent infection.
- You should never disconnect any of these lines as nursing will need to flush and clamp to prevent claudication in the line. - Commonly known as a hep lock
55
Where are IVs inserted and what are they used for?
IV’s are inserted into veins and are used to deliver medications and fluids.
56
What are the characteristics of an arterial line IV?
- Arterial line are placed in the artery they are quite painful for the patient during insertion and any wiggling of the line is painful.
- Arterial lines are place to limit arterial punctures for blood gas draws and can be used to directly measure pressure.
- Ask nurses which lines can be disconnected (Hep lock) prior to mobilization sometimes, they can which make ambulating patient easier
57
What should you do if you pull out an IV line?
- Cover site with clean linen, gauze ect ASAP, calmly apply pressure
- Don’t walk away from patient calmly have them sit down.
- Notify Nurse
58
Where is a Pulmonary Artery Pressure Monitors also called swan-ganz catheters inserted?
Directly into pulmonary artery at the right side of the heart
59
What is the function of the Pulmonary Artery Pressure Monitor?
Measures heart function pressure
60
What is a major component of managing a patient with a Pulmonary Artery Pressure Monitor?
ALWAYS CHECK WITH NURSING PRIOR TO MOBILIZATION
61
What is pulmonary hypertension?
When the pressure in the pulmonary artery is greater than 25 mm Hg at rest or 30 mmHg during physical activity
62
When will a patient be placed on an oxygen max or rebreather?
If the patient is on more than 4 L
63
When will a patient be placed on a nasal cannula and what are the characteristics?
For up to 6L. Is extremely drying to nose tissues and it is common to have nose bleeds.
- This is especially concerning when the patient is on a blood thinner like heprin, coumadin, or a low molecular weight heprin such as levenox.
64
What is a saline reservoir used for in the administration of oxygen?
To assist with moistening environment, increased comfort for patient O2
65
What are the characteristics of a saline reservoir?
- Many home health patients will be d/c home without the sterile saline reservoir, never add tap water to the reservoir. - If you are working with a patient who is a mouth breather use mask or if you are working with mouth breather who has nasal cannula, OK to put it in their mouth after wiping with an alcohol wipe.
66
What is a CPAP and BIPAP usually prescribed for?
- Usually prescribed for sleep apnea but it can also assist with pts with COPD, high level spinal cord, or patients with ALS for respiratory support.
- Also used to decrease work of respiratory muscles so you might find them in ICU after a patient has been extubated from the ventilator.
67
What does a BIPAP allow for?
Bipap allows for 2 levels for inhalation and exhalation good for pts with COPD as they might need more help getting the air out, and less inspiratory pressures.
68
What is telemetry and how is it achieved?
The monitoring of the heart EKG without being directly tethered to the EKG machine. Achieved through a 5 lead device
69
What should be done before working with a patient with a telemetry (tele patient) and why?
Be sure you notify tech prior to working with patients to avoid perceived emergency situation
70
What is an impella?
A device inserted into the left side of the heart to temporarily assist the heart to pump.
71
What are the medical devices used to help the heart pump during a Percutaneous coronary intervention (PCI)?
The Impella heart pump and IABP
72
What is a Percutaneous coronary intervention (PCI)?
A non-surgical procedure used to treat narrowing (stenosis) of the coronary arteries of the heart found in coronary artery disease
73
What does an impella heart pump and IABP do?
- Both devices push blood from the left ventricle to the aorta with each heartbeat.
- Both devices increase blood flow to your coronary arteries and the rest of your body during the PCI procedure
Intra aortic pump is timed with the beating of the heart deflating in systole and inflates in diastole to increase blood flow to coronary arteries.
74
What does a ventricular assist device do?
- Increases cardiac circulation in heart failure patients, it can support either right, left, or both sided heart failure and can be worn as an outpatient
- Assists with increasing pressure for circulating blood
75
What are the characteristics of a ventricular assist device?
It can be use temporary or full time long term awaiting heart transplant.
76
What does a Pt controlled analgesic, or PCA pump allow for?
Allows the patient to control the delivery of pain medication through IV.
77
What are the characteristics of a Pt controlled analgesic, or PCA pump?
- The nurse sets the maximal medication units and Dosing controlled by the device so the patient cannot overdose.
- There is Conflicting evidence for use in literature
78
What is the function of a nasogastric or NG tube?
- Can be used as a drain through connection with wall suction or it can be used for short term delivery of nutrition
79
What are the characteristics of a nasogastric or NG tube?
- When working patients who have an NG tube you must keep the head of the bed at 45 degrees or greater to prevent aspiration.
- Do Check with nursing to see if the patient can be d/c prior to working with them.
80
What are the ways to administer of TPN- total parenteral nutrition?
- Central line: vena cava
- Bypass GI tract
- Glucose, protein, vitamin, minerals, lipids
81
What are the ways to administer PPN- partial parenteral nutrition?
- Peripheral vein lines
| - Amino acids, dextrose, lipids
82
What are the characteristics of the ways to administer total/partial parenteral nutrition?
- These interventions are used for longer term nutrition delivery for very sick or burn pts, as they bypasses GI tract.
- This can be for GI rest, decrease the work of the GI system, or quicker delivery of nutrients directly into the blood stream.
- TPN provides minerals, glucose and lipids and is delivered via central line while PPN is inserted into peripheral veins
83
What is a hemovac drain used for after surgery?
Used to drain excessive fluid, blood from a surgical sight.
84
What are the characteristics of a hemovac drain?
Do not open collection device; if opens in advertally let nursing know so they can reestablish suction.
85
What type of patients have a G- tubes/J tubes?
When working with patient who have swallowing problems, as long term solution for delivery of nutrition with patients that cant swallow: such as GB, CVA, TBI
86
What are the characteristics of a G- tubes/J tubes?
- These lines do not have the restrictions of an NG and patient can be supine on a flat surface.
- These lines can be surgically removed if the patient regains the ability to swallow.
- The G tube on the top looks infected and I would notify the nurse of this redness
87
What is the function of a chest tube?
- To re-inflate a collapsed lung through the creation of negative pressure in the chest cavity
- Also used to remove blood during pleural effusion, or pus from empyema.
88
What are the characteristics of the setup of a chest tube?
- These devices are usually attached to the wall with suction.
- The middle chamber of the collection device of a traditional chest drainage system is the water seal.
89
What is the main purpose of the water seal found in a chest pump?
The main purpose of the water seal is to allow air to exit from the pleural space on exhalation and prevent air from entering the pleural cavity or mediastinum on inhalation to assist in the re-inflation of the lung.
90
What does bubbling in the water seal chamber of a chest pump mean?
Air Leak.
91
What are the characteristics of a chest tube?
- You should always check with nursing to be sure but usually these patients can be disconnected from wall suction for mobilization.
- NEVER roll the patient onto the side with the chest tube it can kink the line and be very painful for the patient. If they cant be disconnected from the wall suction you can work with them sitting as the edge of the bed, standing, marching in place, transfers are all very appropriate interventions.
- Be aware of where the line is, how taunt is is and be sure to keep reservoir below the level of tube entry as raising it may allow the collected fluid to re-enter the chest wall causing infection.
92
What are the characteristics of a balloon?
- Balloon holds device in bladder
- Be sure and take catheter bag with you so it does not get pulled out
- You can empty the bag prior to mobilization as long as you let nursing know the amount empty
- Keep collection bag lower than bladder to prevent re-entry of urine into bladder
- Can cause bladder infection
93
What are the characteristics of fecal tubes?
- The patients diet is adjust to allow the feces to be a nectar thick consistency.
- This device is a great help to nursing but more importantly it keeps the patients skin dry and clean as urine and fecal matter will quickly break down the integrity of skin.
- They are also used to keep sacral wounds clean and dry to allow for healing.
94
What are wound vacs used for?
Used to assist in wound or surgical incision healing.
95
What are the characteristics of a wound vac?
- Foam and clear drapes are used with suction allowing for any drainage to be pulled away from healing wound.
- Use unit has a battery pack allowing the patient to move and walk with this portable pack.
- An alarm if suction is broken, movement may break suction.
- Usually using a gloved hand to smooth around the dressing will recreate the suction. Or you may need to apply more drapes (they have an adhesive backing) to secure the dressing to allow for appropriate suction. If the unit continues to alarm Let nursing know if they are responsible.
- Always Use gloves when working with these patients as the drainage may be infectious.
96
What is a Peripheral Compression pump used for?
Used as a prophylactic to prevent DVT and are common after surgery
97
What are the characteristics of a Peripheral Compression pump?
- Always take the time to remove and check the skin underneath.
**Lazy therapists just disconnect but leave on
98
What are the characteristics of a general anesthesia?
- Propofol is one of the most commonly used intravenous drugs employed to induce and maintain general anesthesia.
- The patient is unconscious with no awareness and no sensation.
- Generally a majority of the effects are gone within 24 hours however, complete resolution of these medications can take week(s).
99
What are the characteristics of a regional anesthesia?
- The patient is awake, usually the patient is given additional drugs to decrease awareness examples are spinal or epidurals.
- Epidural medications fall into a class of drugs called local anesthetics, such as bupivacaine, chloroprocaine, or lidocaine.
- They are often delivered in combination with opioids or narcotics such as fental in order to decrease the required dose of local anesthetic.
100
What are the characteristics of a local/peripheral anesthesia?
- Injected into tissue to temporally numb the area like in dental procedures using the same medications used for epidurals.
- The physician may add epinephrine, clonidine, dexamethasone, tramadol, or sodium bicarbonate to increase effectiveness
101
What are the characteristics of a conscious sedation?
– midazolam and propofol are the most commonly used sedatives, whereas fentanyl is the most frequently administered analgesic to help relax and block pain while the patient remains awake but not able to speak and wont remember much about procedure: colonoscopy, breast biopsy, minor surgical procedures
102
What are the side effects of general anesthesia?
- Nausea (most common)
- Vomitting (most common)
- Sore throat
- Confusion
- Muscles aches
- Itching
- Hypothermia
103
What are some tips a PT should employ when working with a patient that has received a general anesthesia?
- Moving the patient slowly, cueing for deep breathing helps but one should always be ready have a emesis basin or trash can close by.
- Another helpful tip is having a cold damp wash cloth to place on the patients face.
- Another tip is to carry a packaged alcohol wipe if the pt begins to get nauseous open the package and place the pad under the patient nose and have them breath deeply
104
What causes a sore throat in patients after a general anesthesia?
From intubation
105
Why is confusion generally worse in older patients after general anesthesia?
Their decrease metabolism and any kidney/liver pathology makes it difficult to clear the medications.
106
What are some complaints that a patient might have and what should be done?
- If the patient c/o being itchy notify nursing they often have standing order for Benadryl.
- Pts may also complain about being cold refusing to get out of bed. You can use a warm bath blanket to drape over shoulders or promise then deliver lots of warm blankets once you are done with therapy.
107
What are some complications seen in patients after general anesthesia?
- Delirium
- Cognitive dysfunction
- Malignant hyperthermia
There are some serious and long lasting serious complications of anesthesia. It’s more common in older people
108
What are the effects of anesthesia on the cardiovascular system?
- Hypotension
- Hypertension
- Dysrhythmias
- Increased risk for MI
- DVT
109
What are the effects of anesthesia on the respiratory system?
- Hypoventilation
- Decreased ventilation drive
- Aspiration
- PE
110
What are the effects of anesthesia on the psychomotor function?
- Time to regain consciousness
- Delirium
- Personality changes
- Memory loss
111
What are the things to do before ambulation with a patient after anesthesia?
- Take a set of vitals before beginning, just because a patient does not c/o dizziness does not mean that they may have orthostatic hypotension. Take vitals in every position after 1-2 min BEFORE you begin ambulation
- On initial evaluation especially, take time to allow for transition of patients position.
- Encourage deep breathing, if they have an incentive spirometer at bedside have the patient demonstrate its use (suck don’t blow) in supine before sitting bedside, in sitting EOB before ambulating
- Remind pts to take deep breaths when ambulating many times they will hold their breath in anticipation or because of pain.
- Risks of DVT, as the wells decision rules delineates an increase risk with surgery. ALWAYS take the time to look at the patients lower leg, pull ted hose down and inspect for warmth, redness, and swelling.
- Report any unilateral symptoms immediately to the nurse.
- If the patient is on prophylactics (for 7 days post op) Apixaban, dabigatran, rivaroxaban, edoxaban, and betrixaban are alternatives to warfarin ask the nurse when the first dose was given. It takes 3 days for warfarin to become therapeutic, however low weight molecular heparin becomes effective in 2 hours.
112
What are some low molecular weight heparins?
Lovenox and Xeralto are brand names other meds with parin at the end of it (Bemiparin. Certoparin. Dalteparin. Enoxaparin. Nadroparin. Parnaparin. Reviparin. Tinzaparin.) are all low molecular weight heparins.
113
What incision site has the highest rate of pulmonary complications?
Chest and abdominal surgery (thoracic and upper abdominal)
114
Why do patients with chest/abdominal incisions have the highest rate of pulmonary complications?
Do not breath deeply because of perceived or actual pain leading to a wide range of pulmonary complications
115
What should we always do with patient incision sites?
We should always include assessment of inspiration volumes (incentive spirometer) cough (be sure and use splinted cough techniques) and complete interventions that encourage deep breathing and movement.
116
What are the other factors for a pulmonary complication?
- Age > 60yrs
- Decreased mobility
- Malnourishment
- Past respiratory disease
- Prolonged procedure
- Expected intubations
117
What are the pulmonary complications seen in an abdominal/thoracic surgery?
- Incision pain
- Weakness secondary to fasting
- Sedation
- Poor pain control
- Infrequent position change
- Increased airway secretions
- Decreased diaphragmatic excursion
- Rib cage and lung expansion.
118
What can cause diaphragmatic dysfunction in patients with an abdominal/thoracic surgery?
Occur from decreased phrenic nerve output which occurs secondary to pain especially in upright positions, from reflexes arising from the periphery (chest wall and/or peritoneum), which could inhibit the phrenic nerve output
119
What does decreased volume in a patient with an abdominal/thoracic surgery mean?
Decrease volume means decreased pressure which means less pressure in alveoli which can cause atelectasis
120
Diaphragmatic breathing can reduce ____ and should be instructed on every post op pt with and abdominal or thoracic incision.
Diaphragmatic breathing can reduce *atelectasis* and should be instructed on every post op pt with and abdominal or thoracic incision.
121
What does the inability to eat after surgery do?
Effects surfactant levels which decreased ability to lower surface tension
122
What can infrequent position change lead to?
Atelectasis. So educating our patients to move despite pain should be encouraged, as patients to always get out of bed for meals and to use the bathroom, nursing staff can bring a bedside commode rather than bedpan
**Sometime nursing staff with just use a bedpan because it is easier and does not require the supervision of the patient. Educating patient on the importance of requesting to get OOB for toileting is always best as gravity can help with bowel and bladder elimination whereas the bedpan does not facilitate evacuation**
123
What are the things that a PT should do when working with a post op patient?
- Assess cough
* teach splinted coughing
* teach airway clearance
- Teach diaphragmatic breathing
- Teach incentive spirometry
- Teach infrequent position changes
*Education on the importance of the above and should be done with every post op patient on every visit
124
What are the observation/assessment things to do for a post op patient?
- Look for edema
- Assess for DVT
- Look at incision if possible or at least look for drainage
- Assess for orientation and the ability to follow commands
- Involve family if possible but if they are going to get in the way, give them permission to take a break
125
When should an incision be looked at?
Before and AFTER mobilization
126
What are the pain management techniques for post op patients?
• Communicate with nursing
- Pain med schedule
- Maximize scheduling of PT
• Use splinting
- Pillow
- Abdominal binder
• Educate patient about routine pain meds
- Don't get behind
- Address fear of addiction
- Tell the patient your goal is to minimize their pain while completing needed task
• Use deep breathing as a tool to decrease pain
127
What should be done if a patient is within 30 mins of pain med dose?
Come back 30 mins after, and communicate with the patient that they are close to receiving another dose of medications and you will return at the height of its effectiveness. This simple conversation reinforces with the patient that you are doing everything possible to decrease their pain
128
What kind of activities should a PT start a post op patient with?
Start with activities that will:
- Promote confidence in the PT
- Don't hurt
- Give your patient some control
- Promote upright posture
129
How do you consider the incision in a post op patient?
- Avoid stretching or stressing the incision
| - Avoid unilateral stress especially with abdominal and thoracic incisions
130
What are the normal values of white blood cells?
4,500-10,000/mcL
131
What is Leukocytosis?
When the WBC is >11,000 as a result of a bacteria infection, stress/trauma, allergy, smoking, pneumonia, or a neoplasm
132
What is Leukopenia?
A <5,000 due to bone marrow failure (aplastic anemia), radiation & chemo, HIV, viral diseases
133
What are the guidelines for PT in regards to WBC?
* <5,000 with fever hold PT
| * >5,000 light exercise, progress as tolerated
134
What is the most common cause of leukocytosis?
Most common cause of
| leukocytosis, usually due to bacterial infection
135
What is eosinophilia due to?
Allergic reaction or asthma.
136
What is lymphocytosis due to?
Viral infections and chronic bacterial
137
What is normal RBC?
* 4.7-6.1x10^6/uL (Male)
| * 4.2-5.4x10^6/uL (Female)
138
What are the possible causes for a decrease in RBC?
Anemia, cancer, blood loss,
| malnutrition
139
What are the possible causes for an increase in RBC?
Dehydration, Right HF, COPD and smoking
140
_____ is an indicator of severity of anemia or polycythemia
*Hemoglobin (HgB)* is an indicator of severity of anemia or polycythemia
141
What is the normal range of Hemoglobin (HgB)?
* Male: 14-17Gm/dL
| * Female: 12-16Gm/dL
142
What are the possible causes for a decrease in Hemoglobin (HgB)?
Anemia, surgery, iron and B12
| deficiency
143
What are the possible causes for an increase in Hemoglobin (HgB)?
COPD, altitude
144
What kind of exercise should be done if a patient's hemoglobin (HgB) is less than 8gm/dL?
Essential daily activities only, hold therapy
145
What kind of exercise should be done if a patient's hemoglobin (HgB) is greater than 8gm/dL?
Ambulation permitted.
146
What kind of exercise should be done if a patient's hemoglobin (HgB) is between 8-10gm/dL?
```
Stairs, light aerobics,
light weights (1-2lbs).
```
147
What kind of exercise should be done if a patient's hemoglobin (HgB) is greater than 10gm/dL?
Resistive exercise permitted
148
What is hematocrit (Hct)?
Percent by volume of RBC in a whole blood sample
149
What is the normal range for hematocrit (Hct)?
- Male: 43-49%
| - Female 38-44%
150
What are the possible causes for a decrease in hematocrit (Hct)?
Anemia, fluid overload, bleeding
151
What are the possible causes for an increase in hematocrit (Hct)?
Heart defects, severe dehydration, hypoxia, smoking
152
What kind of exercise should be done if a patient's hematocrit (Hct) is below 25%?
Essential daily activities only, hold therapy
153
What kind of exercise should be done if a patient's hematocrit (Hct) is between 25-35%?
Therapy permitted, ambulation and stairs permitted, light
| aerobics, light weights (1-2 lbs)
154
What kind of exercise should be done if a patient's hematocrit (Hct) is greater than 35%?
Resistance and moderate
| aerobic exercises.
155
What are platelets (PLT)?
Cells in blood who function to stop bleeding, produced in bone marrow.
156
What is the normal range for platelets?
150-350,00/uL
157
What is thrombocytosis and what causes it?
When the platelets is >450,00, caused by iron deficiency, cancer, infection and inflammation
158
What is thrombocytopenia and what causes it?
When the platelets is <150,000 caused by liver disease, aplastic anemia, viral
infection (HIV/AIDS chicken pox), radiation and Chemo
159
What kind of exercise should be done if a patient's platelet is < 10,000 and /or temperature >
100.5 degrees?
No therapeutic
| exercise/Hold therapy
160
What kind of exercise should be done if a patient's platelet is between 10,000-20,000?
Therapy permitted, Therapeutic exercise/bike without resistance
161
What kind of exercise should be done if a patient's platelet is > 20,000?
Therapeutic exercise/bike with or without resistance
162
What are coagulability tests used for?
Used to monitor anticoagulation therapy
| • Post orthopedic surgery, cardiac surgery/stenting, Afib, DVT
163
What is coagulability test: Prothrombin Time (PT) used for?
Used to assess the function of the extrinsic pathway (fast system)
164
What are the characteristics of the extrinsic pathway?
Activated by trauma to tissue, causing blood to escape from the vascular system, initiated by release of tissue factor
165
What does the prothrombin time (PT) screen for?
Bleeding abnormalities, measures the time it takes for the liquid portion (plasma) of your blood to clot
166
What are the normal ranges for a prothrombin time (PT)?
11-12.5sec
• Values 1-2 times normal range is “Therapeutic”
• Values 2-3 times normal range is “risk of bleeding"
Need to use judgment, facility guidelines and context
167
What is the partial thromboplastin time (aPTT) used for?
Used to assess the function of the intrinsic pathway (slow system)
168
What are the characteristics of the intrinsic pathway?
Activated factors in the blood (factor XII)
169
What does the partial thromboplastin time (aPTT) test screen for?
Bleeding abnormalities, measures the time it takes for your blood to clot.
• aPTT “activated PTT”, addition of an activator which speeds up clotting time and results in a
narrower reference range, considered a more sensitive than PTT, essentially the same thing
170
What is the normal range for a partial thromboplastin time (aPTT) test?
30-40sec
171
Why may a person need to hold exercise in reference to the partial thromboplastin time (aPTT) test?
Values 1-2 times normal range is may need to hold exercise due to risk of spontaneous
bleeding.
172
What is the standardized technique to correct variations in Prothrombin Time (PT) between labs?
International Normalized Ratio (INR)
173
The International Normalized Ratio (INR) is used to monitor ___
Coumadin (Warfarin) therapy.
174
How is the INR calculated?
(PTtest)/(PTnormal)
Ptnormal usually 12-13
175
What is the normal range for the INR?
0.9-1.1
176
What does it mean when the INR is greater than 3?
Risk for bleeding
177
What are the therapeutic ranges of the INR?
* Afib/DVT/PE: 2-3
| * Valve replacement: 2.5-3.5
178
What kind of exercise should be done when the INR is less than 4.0?
PT indicated, light exercise,
hold progressions until INR at
therapeutic levels
179
What kind of exercise should be done when the INR is greater than 5.0?
Hold exercise, however can
| perform PT evaluation in room
180
What kind of exercise should be done when the INR is greater than 6.0?
PT contraindicated, 2 days
| bed rest likely, possibly transfers OOB to chair only
181
What is the interpretation of the wells score DVT?
• Score >2.0 — High (probability 53%])
• Score 1.0 to 2.0 — Moderate
(probability 17%)
• Score <2.0 — Low (probability 5%)
182
____ may be used to rule in/out DVT
*D-Dimer* may be used to rule in/out DVT
183
What is indicated in Moderate to High risk DVT?
A vascular ultrasound is indicated
184
What are the components of the Wells Score PE (Pulmonary Embolism)?
* Clinically suspected DVT — 3.0 points
* Alternative diagnosis is less likely than PE — 3.0pts
* Tachycardia (heart rate > 100) — 1.5 pts
* Immobilization (≥ 3d)/surgery in previous four weeks — 1.5 pts
* History of DVT or PE — 1.5 pts
* Hemoptysis — 1.0 pts
* Malignancy (with treatment within 6 months) or palliative — 1.0 pts
185
What is the interpretation of the Wells Score PE?
* Score >6.0 — High (probability 59%])
* Score 2.0 to 6.0 — Moderate (probability 29%)
* Score <2.0 — Low (probability 15%)
* Score > 4 — PE likely. Consider diagnostic imaging.
* Score 4 or less — PE unlikely. Consider Ddimer to rule out PE
186
What is a Disseminated Intravascular Coagulopathy (DIC)?
Serious disorder in which the proteins/factors that control blood clotting become over active.
187
What causes Disseminated Intravascular Coagulopathy (DIC)?
Severe trauma, liver failure, transfusion failure, sepsis, venom poisoning, cancer.
188
What are the characteristics of Disseminated Intravascular Coagulopathy (DIC)?
• Small blood clots form in the blood vessels, can block vessels that supply organs
such as the liver, brain, or kidneys, leading to organ failure.
• Over time, the clotting factors in the blood are consumed or "used up." resulting in a high risk of serious bleeding, even from a minor injury or without injury.
189
When is a D-dimer test ordered?
When a DVT or PE is suspected and to confirm DIC
190
What does the D-dimer test measure?
Measures levels of degradation of fibrin products in the body
191
What is a positive D-dimer test?
Values >500ug/L
192
What does the basic metabolic panel (BMP) include?
- Sodium
- Potassium
- Glucose
- Chloride
- Bicarbonate
- Blood Urea Nitrate (BUN)
- Creatnine
Used to assess the function of the endocrine system
193
What is the function of sodium?
Regulates fluid volume and important for nerve conduction
194
What do increases in sodium result in?
Increases fluid retention, fluid volume and blood pressure
195
What is the normal range of sodium?
135-145mEq/L
196
What is hyponatremia and what are its possible causes?
Low Na+
- Causes: diuretics, chronic vomiting/diarrhea, dehydration (Hypovolemic) and over-hydration (hypervolemeic), HF and cirrhosis (euvolemic)
197
What are the signs and symptoms of hyponatremia?
Confusion, weakness, cramps/spasms, HA, convulsions, irritability
198
What happens when the amount of sodium in fluids outside cells drops?
Water moves into the cells to balance, brain cells especially sensitive to swelling, can be fatal.
199
What type of patients mostly get hypernatremia?
Most often hypovolemic, common in elderly who don’t drink water
200
What are the symptoms of hypernatremia?
Swelling, increased thirst, lack of urination, cramps/spasms, weakness
201
What is the function of potassium?
Affects the excitability of the heart, muscle and nerves.
| • Abnormal values either way can cause cardiac arrhythmias
202
Potassium is normally excreted in ___
Potassium is normally excreted in *urine*
203
What is the normal range of potassium?
3.5-5.0mEg/L
204
What causes hypokalemia?
NG suctioning, diuretics, diarrhea, Cushing's syndrome
205
What causes hyperkalemia?
Severe cell destruction (ie trauma) redistributes K+ from intra to extracellular fluid.
206
What are the signs and symptoms of hypokalemia?
Flattened Twave, arrhythmias, clammy skin, muscle tetany, weakness, abdominal distension (low ab tone) & respiratory failure (resp muscle weakness)
207
What are the signs and symptoms of hyperkalemia?
Flaccid paralysis, Peaked Twaves, shortened Q-Twave interval
208
What is the function of chloride?
Works with sodium, potassium and bicarbonate to regulate acid-base balance
• Typically mirrors values of sodium
209
What are the normal ranges of chloride?
95-105mEg/L
210
What are the causes of hyperchloremia?
Dehydration, kidney disease
211
What are the signs and symptoms of hyperchloremia?
Does not often cause symptoms, can cause metabolic acidosis
212
What are the causes of hypochloremia?
NG suction, diarrhea, cystic fibrosis vomiting, usually occurs with metabolic alkalosis,
213
What are the signs and symptoms of hypochloremia?
There are no signs or symptoms specific for hypochloremia as it rarely occurs in isolation
214
What are the normal values of Bicarbonate (HCO3-)?
22-26mEq/L
215
What is the function of Bicarbonate (HCO3-)?
Critical in maintaining acid-base balance, mediated by kidneys
216
What is respiratory acidosis?
Reduction in alveolar ventilation, results in increased CO2 in blood, body compensates by producing more HCO3- to balance
217
What is respiratory alkalosis?
Elevation in the frequency of alveolar ventilation, results in less CO2 in blood, body compensates by producing less HCO3- to balance
218
What are the characteristics of Blood Urea Nitrate (BUN)?
* Urea is synthesized in the liver from ammonia derived from the metabolism of protein in the body and gut.
* It is filtered and reabsorbed by the kidney; reabsorption is inversely related to the rate of urine flow.
219
What is normal Blood Urea Nitrate (BUN)?
10 to 20 mg/dL
220
What do increases in Blood Urea Nitrate (BUN) cause?
Kidney disease and dysfunction, Excessive protein intake, excessive tissue
destruction (burns, fever, corticosteroid therapy), heart failure, dehydration, shock,
GI bleeds
221
What do decreases in Blood Urea Nitrate (BUN) cause?
Low-protein diets, muscle wasting, starvation, liver failure, cirrhosis, high urine flow.
222
What is creatinine?
Waste product of muscle metabolism of creatine
223
What are the characteristics of creatinine?
* Creatinine production in most people is relatively constant and related to muscle mass, averaging 20-25 mg/kg in men and 15-20 mg/kg in women.
* Creatinine is then filtered but not reabsorbed in the kidneys.
224
What could elevations of creatinine indicate?
Kidney issues, dehydration and rhabdomyolysis
225
What is the BUN: Creatinine ratio used for?
Used to determine the cause of acute kidney injury or dehydration
226
What is the principle behind the BUN: Creatinine ratio?
The principle behind this ratio is the fact that both urea (BUN) and creatinine are freely filtered by the glomerulus
• Urea reabsorbed by the tubules can be regulated (increased or decreased)
• Creatinine reabsorption remains the same (minimal reabsorption)
227
What is the normal BUN: Creatinine ratio?
10:1
228
What does a BUN: Creatinine ratio of 10 to 20:1 mean?
Likely due to kidney dysfunction.
229
What does a BUN: Creatinine ratio of greater than 20:1 mean?
Likely due to dehydration.
230
What is the normal range of glucose?
70-100 mg/dL (non-diabetic)
231
What can cause elevated levels of glucose?
Eating, post surgery, stress lack of insulin or insulin sensitivity
232
What can cause reduced levels of glucose?
Exercise and fasting
233
What is hypoglycemia?
Glucose <70mg/dL
234
What are the signs and symptoms of hypoglycemia?
Clammy skin/sweating, shaking, delirium, vision changes, HA, tachycardia, weakness,
lightheadedness, LOC, seizures
235
What is hyperglycemia?
Glucose >100mg/dL
236
What are the signs and symptoms of hyperglycemia?
Frequent urination, Increased thirst, nausea, vomitting, abdominal pain, and severe fatigue
237
What can the failure to correct hyperglycemia (>240md/L) result in?
Life threatening ketoacidosis
238
What are the signs and symptoms of ketoacidosis?
Nausea, vomiting, dry mouth , fruity breath
239
What should be done in terms of exercise and glucose?
<70mg/L consider giving patient a carbohydrate snack before exercise
240
When is exercise typically contraindicated in terms of glucose?
>250mg/L exercise typically contraindicated
241
Why is glucose contraindicated when glucose is >250mg/L?
Initial minutes of exercise results glucose levels increase, due to suppression of insulin
production and release of glycogen to feed muscles, if patient is already in a severe
hyperglycemic state it’s indicative that glucose is not absorbing well.
• Thus exercise could make hyperglycemia worse!
242
What are the characteristics of Glycated Hemoglobin (HbA1C)?
* Based on the attachment of glucose to HgB contained within RBC
* RBCs live for about 3 months, thus the A1C test reflects the average of a person’s blood glucose levels over the past 3 months
243
What is the normal range for Glycated Hemoglobin (HbA1C)?
4-6%
244
What is the pre-diabetic range for Glycated Hemoglobin (HbA1C)?
6-6.5%
245
What is the diabetic range for Glycated Hemoglobin (HbA1C)?
>6.5% (well controlled DM is considered at least <7%
246
What is the function of Magnesium?
Mg2+ along with Ca2+ are crucial for normal neuromuscular activity.
247
What are the normal value of Magnesium?
0.7–1 mmol/L
248
What causes Hypomagnesemia?
Malabsorption; protracted vomiting, diarrhea, or intestinal drainage; defective renal tubular reabsorption, Cyclosporine
249
What are the signs and symptoms of hypomagnesemia?
- Generalized alterations in NM function (tetany, tremor, seizures, weakness, ataxia)
- Depression
- Irritability
- Delirium
- Sinus tachycardia
- Supraventricular tachycardias, and ventricular arrhythmias
- Prolonged PR or QT intervals - T-wave flattening or inversion.
250
What causes hypermagnesemia?
Typically occurs due to renal insufficiency, normally kidneys excrete large amounts (250 mmol/d), soft tissue injury
251
What are the signs and symptoms of hypermagnesemia?
* >2 mmol/L vasodilation and neuromuscular blockade,
| * >4mmol/L nausea, lethargy, weakness, respiratory failure, paralysis, coma, hypoactive tendon reflexes
252
What is the function of calcium?
Plays a critical role in regulating normal cellular function and signaling:
• Neuromuscular signaling, cardiac contractility, hormone secretion, and blood coagulation
253
What are the normal ranges of calcium?
8.5-10.5 mg/dl
254
What causes hypocalcemia?
Most often due to impaired Parathyroid hormone (PTH) or vitamin D production
255
What are the signs and symptoms of hypocalcemia?
Often asymptomatic in mild & chronic cases, mod to severe: seizure, muscle spasm, bronchospasm, laryngospasm, paresthesia & prolonged QT interval.
256
What causes hypercalcemia?
Excessive PTH production, Hyperthyroidism and malignancy
257
What are the signs and symptoms of mild hypercalcemia?
(11–11.5 mg/dL) often asymptomatic
258
What are the signs and symptoms of severe hypercalcemia?
(>12–13 mg/dL) especially acute: lethargy, stupor, coma, bradycardia, AV block, and short QT interval
259
What are the levels of Cardiac Troponin (cTn)?
<0.1-0.4 ng/ml
260
What are the characteristics of cardiac specific troponin isoforms?
• Cardiac Troponin I (cTnI): Inhibitory subunit,
• Cardiac Troponin T (cTnT): Tropomyosin-binding subunit
• Elevations detectable as early as 2 hrs after MI but not reliably
elevated in all patients until 6 to 12 hrs.
261
What are the characteristics of CPK-MB: Cardiac specific isoenzyme of creatine kinase?
• Normal values 0-0.04 ng/ml
• Elevation within 4 to 8 hrs after coronary artery occlusion,
peak between 12 and 24 hours, and return to normal between 3 and 4 days
262
What must be done in regrads to cardiac troponin and myocardial infarctions?
- MUST RULE OUT OTHER CAUSES OF ELEVATION TO
DIAGNOSE AS MI
- IF MI DIAGNOSED MUST WAIT FOR 2 CONSECUTIVE
DOWNTRENDING VALUES BEFORE INITIATING PT
263
What does BNP indicate?
Cardiac ventricular stretch/over-stretch, termed as such
| because it was initially discovered in the brains of animals.
264
What is the primary physiological action of BNP?
Primary physiological action is to reduce arterial pressure by decreasing blood volume
(diuresis) and systemic vascular resistance.
265
What do levels of BNP <100 pg/mL indicate?
No heart failure
266
What do levels of BNP 100-300 pg/mL indicate?
Heart failure is present.
267
What do levels of BNP 300-600 pg/mL indicate?
Mild heart failure
268
What do levels of BNP >600 pg/mL indicate?
Moderate to severe heart failure.
269
What is albumin a measurement of?
Measurement of circulating protein
270
What is normal albumin?
3.5-4.8U/L
271
What do high amounts of albumin indicate?
Dehydration
272
What do low amounts of albumin indicate?
Poor liver or kidney function.
273
What does Glomerular Filtration Rate (GFR) reflect?
Reflects kidney function
274
What is normal Glomerular Filtration Rate (GFR)?
> 90 mL/min
275
What is the expected decrease in GFR with age?
Approximately 1 mL/min/year after age 35
Acute care
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