Acute Care Flashcards
What is unique about the patient population in Acute Care?
- Patients potentially medically fragile
- May have gone through a life changing event
- High stress for patient and for family
What is different about an Acute Care environment?
- Variety of Acute Care settings
- Patient may be connected to equipment or monitoring
- Interdisciplinary approach
How might the exam be different than an outpatient setting?
- Need to know medical status at that moment (lab values, precautions, etc)
- Consideration for high stress situations for patient and care givers
- Rapid changes in status
- Discharge often takes place prior to full recovery
How might the exam be the same?
- ICF model- patient centered
- Past medical history
- Thorough systems review
- Prioritize impairments
- Assess – Treat– Reassess
- Address Fear
- Deciding when it is appropriate to treat and when to refer
Health Care Continuum (Most Intensive to Least Intensive)
Most Intensive
- ICU Medical/Surgical
- Rehab Unit (hospital), Subacute Unit (SNF)
- Home Care, Assistive Living
- Outpatient Clinic, Urgent Care
- Independent HEP
Least Intensive
Intensive Care Units =
Highest Risk Settings
(Intensive Monitoring – medically fragile
Cognitive & behavioral assessment
Treatment is bedside)
Ex: NICU, CCU, Transplant ICU
NICU stands for (2)
Neurological ICU
Neonatal ICU
CCU stands for
Coronary Care Unit
Surgical Acute Care
Step down from ICU
More medically stable / less fragile
Rehab progression functionally oriented
Treatment at bedside or in the PT inpatient gym setting
Ex: Total knee surgery. Looking at what they need to do next to be able to function.
Who would assess Dysphagia?
Speech Language Pathologist
Who would assess CN and DTR?
PT, Physician, OT
Who would assess cognitive and perceptual functions?
PT, Psychologist, OT, Neurologist
Who would assess safety in locomotion for DC to home
PT
Who would assess capacity to bathe and dress self
OT
Who would assess BP and Hr at regular intervals?
Nurse
How should you prepare to see a patient in an Acute Care setting?
- Chart review (Current lab values, why they are here, family factors)
- Informed consent/Advanced directives
- Consultation with IDT(interdisciplinary team)/ nurse
- Mental review of considerations for or contraindications to treatment
- Develop a flexible plan
Contraindications for Treatment - Acute Care
Priorities for PTs and GUIDELINES for Tx:
Hgb: < 8 no exercise
8-10 light exercise for essential ADLs
> 10 no restrictions/ exercise to tolerance
Na+: hypernatremia associated with dehydration and changes in mental status
Glucose: 250 – caution
> 300 danger for ketoacidosis
< 70 hypoglycemia / dizzy, faint, pale
INR and PTT: Prothrombin time: high = risk for bleeding
Vital signs
O2 Saturation: check expectation based on pt. hx
Ketoacidosis
Body cannot process the blood glucose that is there
When coming into a room what should you be observing?
Patient: Are they in pain, are they comfortable, how do they interact with environment
Family: How they interact with patient, what is the mood
Lines and Tubes: Are any under sheets?
Equipment: Walker?
Clues: Tell you how they have been up to this point
Informally assess environment while you:
- Introduce self
- Mutually determine treatment goals for today/ get informed consent
- Engage in small talk
What is a phrase you can say so as to not rush too fast into things without properly assessing your environment?
“Thanks for your patience while I safely organize everything before we start to work.”
What do we need to consider with medical restrictions/precautions?
Is aware of medical precautions
E.g., fractures and soft tissue injury from trauma
Notices any braces or restraints
Notices & ensures safety of tubes and lines
Draining out of patient? (positioned below)
Infusing into the patient? (positioned above)
Requires patient in head-up position?
What are some requirements for Ethical and legal use for restraints?
- deemed medically essential
- use least restrictive option
- re-ordered every 24 hours
- 1-pull release
Tubes for draining out fluids
- Suction – NG/ secretions
- Chest tubes
- Wound drains
- Catheters
- Shunts
Tubes for infusing fluids
- IVs
- Tube feedings
- Blood transfusions
Monitoring devices:
- Arterial line/ Swan- Ganz line
- Central venous lines – CVP and PICC lines
- Pulse oximeter
- Intracranial pressure line
Breathing devices:
- Oxygen masks/ nebulizer
- Ventilator/ respirator
Patient Energy is Precious. What is important as a PT to do?
Do NOT repeat tests if other’s results are clear & re-testing…
- Would not provide additional info or help clarify current status
- Would be detrimental to patient status
DO perform tests needed for PT specific goals
- focus on components to reach goals
Systems Review and Screening
Mental status:
Alert and Oriented x 4?
CV/P:
BP, HR, Respirations, vascular flow, edema;
Status: at rest / with position change/ with activity?
Integument:
Skin intact? Color? Post-surgery or post-injury:
Status of wound and healing? Sensation intact?
Musculoskeletal:
A or PROM limits? Weakness? Strength screen?
Neurological:
Weakness? Incoordination? Imbalance? Cranial nerve deficits? Sensory loss?
How should you select tests?
Completed systems review
- Observation and chart review
Prioritize testing
What tests will give you the most information needed at that moment?
Minimize position changes for patients with pain or low endurance
- Preplan your examination
Functional Assessment - Acute
Method used, level of success, assist needed, indicators of safety
Bed mobility
Transfers (All in reverse as well)
Sit to Supine
Sit to Stand
Bed to Chair
Gait
In acute care what is your intervention?
FUNCTIONAL MOBILITY
Levels of Physical Assistance
Stand By Assistance (SBA)- PT does not touch or provide assistance but is close in proximity for safety
Contact Guard Assistance (CGA): PT needs to have 1-2 hands lightly touching pt to help steady pt; no other physical assistance
Min-Max assist chart
Need to know
Considerations for total/max assistance
Integumentary
Skin breakdown from pressure
Consider a different mattress or assistance with changing positions
Cardiopulmonary
Pulmonary function in supine
Consider raising the head of the bed
Musculoskeletal
3-4% strength loss per day in the first week
Consider PROM or AAROM to maintain motion
Neuromuscular
Cognition, mental status
ALWAYS! ALWAYS! ALWAYS! Treat your patient with respect and explain what you are doing and why. You can not judge someone’s intelligence or comprehension based on verbal communication or a diagnosis.
Determining Discharge Destination
Very short lengths of stay in acute care
May be asked to make a judgment with limited info
“What’s the next safe step?”
Outcome measures help us determine functional outcomes. Helps determine discharge.
Options at Discharge
- Discharge directly to home
- Transitional Options - Going Home Shortly
- Inpatient Rehabilitation
- Inpatient care facilities
Discharge directly to home
Independent (with or without equipment or changes to the home)
With support: physical assist of family/ in-home care providers
May include home-based therapy services if patient is “homebound”
Transitional options - going home shortly
Transitional care unit
“Swing bed” at regional facility
Short term placement in skilled nursing facility (SNF)
Inpatient rehab unit ->
Inpatient Rehabilitation
Dedicated IP Rehab Unit Commission on Accreditation of Rehab Facilities (CARF)
Must have functional goals that require intensive rehab
Must tolerate 3 hours of PT, OT or SLP (combined) per day
DC plan established…to home or other community residential setting
Inpatient Care Facilities
Assisted Living
Mostly independent with some assist
Ex: Bathroom safety
Skilled Nursing Facility
Slower pace than inpatient rehabilitation
Potential for improvement
Monitor levels, make medical decisions
Extended Care Facility
Higher level of assistance required
Not expected to return home
When assessing discharge decision making what do we look for?
- Medically stable
- Is patient safe to function at home safely
- Expected to gain safety from home with prescribed adjustment
- Expected to gain safety for home within days
