General Medicine and Neuro Flashcards
what is the joint commission?
the accreditation of many healthcare facilities that sets the standards for quality of care
who surveys accredited hospitals every 3 years?
the joint commission
t/f: the joint commission can show up randomly during a specified 3 month period every 3 years for inspection of hospitals
true
what are some national patient safety goals that are pertinent to PT?
ID the pt correctly
use alarms safely
prevent infection
reduce risk for suicide
how do we ID pts correctly?
use at least 2 pt identifiers (name and DOB)
t/f: room and location can be used as pt identifiers to confirm ID
false, room/location do not count
t/f: we need to ensure that alarms on medical equipment are heard and responded to
true
how do we prevent infection?
hand hygiene
how do we reduce risk for suicide?
any equipment brought in must be brought out with suicide watch
we are often the ones to pick up on suicide risk, so we must communicate this with the team
what are some complications of hospital admission?
acquired infectious disease
delirium
disuse atrophy
decreased CV reserve and endurance
hospital acquired pneumonia
falls
what is the #1 way ppl get hurt in the hospital?
falls
what is delirium?
acute onset of severe confusion
rapid changes in brain fxn
t/f: delirium is a cluster of symptoms resulting from another disease/clinical process
true
is delirium constant or transient?
transient
is delirium treatable?
yes!
what are the diagnostic criteria for delirium?
disturbance in attention and awareness develops acutely and tends to fluctuate in severity
at least one additional disturbance in cognition
disturbances that aren’t better explained by pre-existing dementia
disturbances that don’t occur in the context of a severely reduced level of arousal or coma (ie coming out of anesthesia)
evidence of an underlying organic causes
t/f: the a pt with dementia can have delirium on top of it
true
how can we differentiate if cognitive deficits are the dementia or delirium in a pt with dementia?
get an idea of the pt’s baseline cognition from family members
does delirium or dementia have an acute onset?
delirium
does delirium or dementia have chronic decline?
dementia
is delirium or dementia persistant?
dementia
is delirium or dementia fluctuating?
delirium
does delirium or dementia primarily affect attention?
delirium
does delirium or dementia affect any cognitive domain?
dementia
is dementia or delirium more age independent
delirium
is dementia or delirium a neurodegenerative disease associated w/aging?
dementia
what are the risk factors for delirium?
age >70
male
dementia
meds (polypharmacy)
acute illness
infection
exacerbation of chronic illness
what are some causes of delirium?
illicit drugs, dehydration, detox, deficiencies, discomfort
electrolytes, elimination abnormalities, environment
lungs (hypoxia), liver, lack of sleep, long ED stay
infection, iatrogenic events, infarction
restraints, restricted mobility, renal failure
injury, impaired sensory input, intoxication
UTI, unfamiliar environment
metabolic abnormalities, metastasis to brain, meds
t/f: anytime you take someone out of their typical living environment and put them somewhere different, they are at risk for delirium
true
a stay in the ED longer than ______ b4 getting on the hospital floor is a risk for delirium
12 hours
what are iatrogenic events?
harm caused by medical interventions
how do restraints create a cycle of delirium?
pts are put in restraints bc delirium makes them a danger to themselves and others but then being in restraints creates further risk for delirium
what are some prevention strategies for delirium?
address contributing factors
re-orient them
promote circadian rhythm
encourage the presence of familiar care-givers
how can we re-orient pts to prevent delirium?
when they get A&O questions wrong, correct them
how can we orient pts to day time?
open windows
turn on lights
do activities
how can we orient pts to night time?
turn off screens
turn off lights
close windows
t/f: infectious disease can be the reason for admission or acquired during admission
true
how can infectious diseases be acquired during admission?
pt to pt
provider to pt
pt to provider to pt
what factors can increase risk for infectious disease?
longer LOS
surgery
invasive procedures
wounds
immune status
comorbidities
age
why do invasive procedures put a pt at risk for infectious disease?
bc it bypasses the body’s natural mechanisms for fighting infection (skin, resp, Foley)
what comorbidity especially puts a pt at risk for infectious disease?
DM
t/f: increased age puts pts at risk for infectious disease
true
what is the reference range for WBCs?
5,000-10,000
what is leukocytosis?
increased in WBCs
what is leukopenia?
decrease in WBCs
when would we look at a pt’s absolute neutrophil count (ANC)?
when they are very compromised
what are the causes of leukocytosis?
infection
inflammation
bone marrow disease
immune system disorder
severe stress/pain
how would a pt with leokocytosis present?
fever
fatigue
bleeding
bruising
frequent infections
t/f: high WBCs are not usually dangerous unless >100,000
true
pts with WBCs >100,000 are at risk for complications in what systems?
cardiac
pulmonary
renal
neuro
when would high WBCs be a good thing?
when a pt has a known infection, it can tell us their body is fighting the infection
can tell us that a pt has an infection b4 they have any outward signs
what are the causes of leukopenia?
chemo
radiation
marrow infiltrative diseases
infections
dietary deficiency
autoimmune disease
how would a pt with leukopenia present?
frequent/persistant infections
inflammation/ulcers in/around the mouth
headache
stiff neck
sore throat
fever/chills
night sweats
t/f: pts with leukopenia may be on neutropenic precautions
true
what are the clinical implications of leukopenia?
neutropenic precautions
monitor s/s of infection
monitor fatigue using RPE
there is an increased falls risk
leukopenia is typically associated with _________ or __________
bone marrow cancer; chemo/radiation
what are the most numerous WBCs and 1st line to fight an infection?
neutrophils
what is an absolute neutrophil count (ANC)?
the total neutrophil granulocytes present in the blood
ANC <______ indicates severe immunocompromised and increased risk of infection
1,000
ANC of <_____ indicates the highest risk for infection
500
ANC of _______ indicates moderate risk for infection
500-1000
ANC of >_____ indicates low risk for infection
1000
t/f: there are universal standards for neutropenic precautions
false, they vary
what are the environmental precautions for neutropenic precautions?
no plants/flowers
damp dust only
no room manintanence
no foods that can’t be washed (ie. berries)
what are the equipment precautions with neutropenic precautions?
must be dust free
disinfect w/disinfectant wipes bw pts
t/f: the door should be kept closed with neutropenic precautions
true
what are the transportation precautions for neutropenic precautions?
transport for essential purposes only
have the pt wear N95 respiratory if severely immunocompromised
t/f: if a pt is on neutropenic precautions all ppl recovering from respiratory illness must wear a mask
true
when entering/leaving the room of a pt on neutropenic precautions, what should we do?
use waterless foam of wash hands
if gloves are not needed, why should we not use them?
bc they make it less likely that we will follow hand hygiene
when should we use gloves?
when there is a chance of coming in contact with bodily fluids
what are standard precautions/universal precautions?
precautions used for all pts in the hospital
hand hygiene
clean pt care areas and equipment
handle laundry carefully
proper handling of sharps
treat all body fluids as if there were infected
wear gloves when reasonable suspicion of coming in contact with bodily fluids
when are contact precautions used?
for infectious disease spread by direct or indirect contact
MRSA, CRE, C.diff
what are contact precautions?
private room/others with the same infection
gloves and gown (removed b4 leaving the room)
limit transportation
single use equipment where possible
when are droplet precautions used?
for infectious diseases that create particles that can be spread in the air but don’t travel far (no more than 3 feet)
spread by coughing, sneezing, vomiting
flu, RSV, adenovirus
what are droplet precautions?
private room/others with the same infection
surgical mask
limit pt transport
when are airborne precautions used?
for infectious diseases that create extremely small particles that remain suspended in the air
varicella (chicken pox)
zoster
COVID-19
tuberculosis
t/f: all PT must be done in the pt’s room with airborne precautions
true
who is not allowed in the room with a pt with varicella/zoster?
pregnant people
what are airborne precautions?
private room (neg air pressure)
door closed
N95 respirator
limited pt transport
restrict entry of susceptible ppl
what is the purpose of negative air pressure?
to prevent air from getting out of the room when the door is opened
what neuro health conditions are treated in the hospital?
stroke
TIA
TBI
neuromuscular diseases (PD, MS, GBS, ALS, myasthenia gravis, chronic idiopathic demyelinating polyradiculoneuropathy)
why do we want a CT scan taken within 30 minutes and read within 45 minutes of arrival for a stroke?
to determine if it is hemorrhagic or ischemic bc they are treated differently
if a CT scan shows an ischemic stroke, what can be given?
fibrinolytic therapy
when should fibrinolytic therapy be given?
within an hour of arrival and 3 hours of symptoms onset
what is the most common stroke we will see?
ischemic stroke
what causes an ischemic stroke?
blockage of blood flow (embolic, thrombotic, atherosclerotic) causing tissue damage
what is the core infarct of a stroke?
an area of irreparable damage
what is the penumbra?
the area around the corner infarct that has low blood flow at high risk for cell death
what is the focus of treatment of stroke in the first 24 hours?
preserving stability of cells within the penumbra
what are the medical interventions for ischemic stroke?
intravenous thrombolysis
mechanical thrombectomy
assess for course of emboli
what is intravenous thrombolysis?
tPA (an IV med given to breakdown a blood clot)
what is mechanical thrombectomy?
a catheter threaded into the cerebral artery and clasps the clot to remove it
how do we assess for the source of an emboli?
do an EKG for a-fib
do an echocardiogram (US of the heart) for vegetations (buildup of bacteria with collagen fibers laid around it that can become an emboli) on heart valves and endocardium
carotid US for carotid stenosis
how is endocarditis treated?
with IV antibiotics for 6 weeks then may need to go undergo open heart surgery for valve replacement
> 70% occlusion of the carotid indicates need for what?
carotid endarterectomy
carotid artery stenting
what are the PT considerations with ischemic stroke?
typically 24 hours bed rest
early mobilization leads to better fxnal outcomes
BP may be purposefully higher to increase perfusion of brain tissue
why are ischemic stroke pts typically put on 24 hour bed rest following the event?
to prevent hypotension w/upright positioning that would lead to hypo-perfusion of the brain
what is permissive HTN?
purposefully high BP to promote cerebral blood flow and preserve as much brain tissue as possible
permissive HTN keeps BP around what?
220/120 mmHg
how long are BP control meds paused with permissive HTN?
24-48 hours
what is the purpose of permissive HTN?
to maintain cerebral perfusion
t/f: after 24-48 hours of permissive HTN BP is returned to normal immediately
false, BP should very slowly be brought back down, not all at once
how should we treat pts in PT with permissive HTN?
use a symptom based approach and monitor their response to activity
what is a hemorrhagic stroke?
abnormal bleeding of cerebral vessels
what are the different types of bleeds in hemorrhagic stroke?
intracerebral hemorrhage (ICH)
subdural hemorrhage (SDH)
subarachnoid hemorrhage (SAH)
in which type of stroke is there tissue damage in the area distal to the bleed and other tissues due to buildup of pressure?
in a hemorrhagic stroke
pts with a hemorrhagic stroke are typically admitted to the ICU for what medical management needs?
ICP monitoring and management
airway protection
BP management
surgery
what is the BP goals post hemorrhagic stroke?
SBP <140 mmHg
what kinds of surgeries may be done for hemorrhagic stroke?
hematoma evacuation
decompressive hemicraniectomy
clipping
endovascular coiling
what is a clipping surgery for hemorrhagic stroke?
clipping off an aneurysm causing weakness in the vessels to it can’t rupture can cause further bleeding
what is endovascular coiling for hemorrhagic stroke?
when wire is coiled into an aneurysm to prevent blood from entering it and causing a rupture and further bleeding
what are the PT considerations for hemorrhagic stroke?
strict BP control (SBP <140 mmHg)
HOB elevated >30 deg
why should the HOB be elevated >30 deg post hemorrhagic stroke?
to prevent a sudden rush of blood to the brain where there is an area of weakness that could rupture and cause further bleeding
what are the general stroke considerations in acute care?
shoulder protection (educate pt and family)
dysphagia (reinforce SLP recommendations)
if SLP confirms dysphagia in a pt post stroke, where should the HOB be?
elevated to >30 deg to prevent aspiration
what outcome measures are used in acute care for stroke?
Orpington prognositic scale (OPS)
postural assessment scale for stroke (PASS)
stroke rehab assessment of movt (STREAM)
what does a higher OPS score mean?
more impaired
what does an OPS score of <3.2 mean?
high likelihood of returning home
what does an OPS score of 3.2-5.2 mean?
respond better to rehab
what does an OPS score of >5.2 mean?
typically dependent w/increased risk of institutionalization
what are the subcategories of the PASS?
maintaining a posture
changing a posture
what activities are involved in a PASS?
sitting w/o support
standing w/support
standing w/o support
standing on nonparetic leg
standing on paretic leg
supine to paretic side
supine to nonparetic side
supine to sitting EOB
sitting EOB to supine
sitting to standing
standing to sitting
standing, picking up a pencil from the floor
to predict ambulatory ability at 30 days post stroke, the PASS maintaining posture score must be >___, the changing posture score must be >_____, and the total PASS score must be >_____
3, 8, 12
what are the 3 subsections of the STREAM?
upper limb mov’t
lower limb mov’t
basic mobility
what does BE FAST stand for?
Balance
Eyes (blurred vision)
Face (drooping)
Arms (weakness)
Speech (slurred)
Time
what are the indications for intracranial surgery?
elevated ICP
brain biopsy need
hemorrhage evacuation
aneurysm embolization (coils)
brain tumor removal
AVM repair
what is a Burr hole?
a small hole made in the cranium w/specialized drill to evacuate hematoma, clot, intracranial pressure management, brain biopsy, or to place a stereotactic device
what is a craniotomy?
surgical opening in the skull to provide access to the brain to remove a tumor, clip an aneurysm, or repair damage to the cerebrum
what is a craniectomy?
similar to a craniotomy except the bone flap is removed to decompress the brain tissue or fight infection
t/f: the bone bank is stored in the lining of the stomach following a craniectomy
true
what is a cranioplasty?
replacing the bone flap the was excised during a craniectomy
t/f: the bone replacement in a cranioplasty may be the og bone, a graft, or acrylic material
true
what are the craniotomy precautions? (used for all brain surgeries)
HOB > 30 deg
avoid valsalva
no head below level of shoulders
what precaution is taken following a craniectomy?
protective helmet is to be worn for mobility
why are pts very symptomatic following acoustic neuroma removal?
bc of the resultant edma and trauma to the area
what are some other considerations post intracranial surgery?
light sensitivity
visual disturbances
sensory overload/concentration issues
why do visual disturbances sometimes occur following intracranial surgery?
bc edema tends to buildup around the optic nerve
bc pts post intracranial surgery may have sensory overload/concentration issues, what should we do during our treatment?
split up treatment and education
provide written instruction bc not much of what is said to the pt will be taken in
what are the indications for spinal surgery?
unstable spine
cauda equina syndrome
tumor decompression
spinal stenosis
disc herniation
nerve root compression
spinal deformity
what is a discectomy?
excision of protruding disc material done via laminectomy or microdiscectomy
what is a laminectomy?
excision of post vertebral arch to access disc for a discectomy
what is a microdiscectomy?
incision made in the inf aspect of the lamina to extract disc material
what is a foraminotomy?
surgical enlargement of the intervertebral foramen to remove stenosis
what is a spinal fusion?
bone graft placed to join and fuse adjacent segments
may or may not use fixation
what is a posterolateral lumbar fusion (PLF)?
excision of lamina and other structures to place bone grafts to fuse adjacent segments
what is a posterior lumbar interbody fusion (PLIF)?
similar to PLF except it also replaces the disc w/an intervertebral body cage
what is an anterior lumbar interbody fusion (ALIF)?
similar to PLIF except via an anterior approach
retroperitoneal incision for lumbar spine
what is a vertebroplasty?
IR guided injection of cement into a vertebral body to repair a compression fx
what are the lumbar spine precautions?
no lifting >10lbs
no spine flexion
so spine rotation
avoid sitting >30 min
fusions may require braces
what are the lumbar bracing options?
lumbar spine orthosis (LSO)
thoracic and lumbar spine orthosis (TLSO)
t/f: lumbar spine braces should be loose enough for two fingers to slide bw the brace and skin but tight enough that you cant twist them
true
what are the spinal bracing considerations?
appropriate fit
independent in donning/doffing
skin protection
wearing schedule
when is a clamshell TLSO used?
for more extensive fusions or unstable spines
what are the cervical spine precautions?
no lifting >10 lbs
no spine flexion
no spine rotation
fusions may require braces
t/f: cervical collars are often worn all the time (including to bed), esp for fusions
true
when switching cervical collars for showering, how should it be done?
remove only the front or back at a time
t/f: cervical collars should be snug w/the head in neutral
true
