Hospital D/C and Short Term Rehab Flashcards
List Possible Discharge Dispositions
- discharged to Home
- Home with VNA services
- Short Term Rehabilitation
- Long Term Acute Care
- Hospice facilities
Patients who need part time nursing services or rehabilitative services and cannot get out of the house to go to clinic, provider, outpatient facilities.
type of d/c
Hospital to HOME with VNACare
possible reasons pt could be d/c to
Hospital to HOME with VNA Care
- Consider a patient post op from TKR
- Cancer patient with PE and starting on Lovenox for the 1st time
- Afib patient starting on coumadin
- New Tube Feeds
how long can pts recieve VNA
Patients can receive VNA until you meet the goals which are set forth by the PT/OTs/RNs
define Skilled Nursing Facility(SNF)
criteria?
no longer need acute care but not ready to go home
Criteria:
- •Must have a 3-day qualifying hospital stay within 30 days of going to a SNF
- •Few days to several weeks
An elderly patient requiring continued IV antibiotics but unable to take care of themselves at home.
Skilled Nursing Facility(SNF
You must be able to take part in 2-3 hours of therapy a day, this is crucial to meet the goals
Acute Rehabilitation/ Short Term(STR
criteria for Hospice Care
Only true criteria is
- a diagnosis of a terminal illness
- life prognosis <6 months.
If patient lives past 6 month, eligible to renew benefit
Long Term Acute Care(LTAC)
define & give an example of a pt who may qualify
Condition has stabilized, but require greater care than what can be given at home, STR, or SNF
- Medicare designated level of acute care
Possibly on a Ventilator long term.
Alc withdrawl syndrome:
Can occur as early as ______ after Alcohol cessation
peaks after ____days
but can persist up to____days after alcohol cessation
•Can occur as early as 6 hours after Alcohol cessation,
peaks after 2-3 days,
but can persist up to 7 days after alcohol cessation
Pathophysiology of Alcohol Withdrawal
NORMALLY:
- (GABA) - inhibitory neurotransmitter
- (NMDA) - excitatory neurotransmitter
ETOH
↑ effects of GABA = ↓ excitability (downregulation og GABA recpetors)
↓ NMDA neuroreceptors = ↑ upregulation of the receptors
Abrupt cessation of ETOH = brain hyper excitability,
- because receptors previously inhibited (NMDA) are no longer inhibited
Gamma-amino-butyric acid (GABA) - _____ neurotransmitter
N-methyl-D-aspartate (NMDA) - ______ neurotransmitter
Gamma-amino-butyric acid (GABA) - inhibitory neurotransmitter
N-methyl-D-aspartate (NMDA) - excitatory neurotransmitter
si/sx of alcohol withdrawl
Alcohol Cessation = Days 0-1
Days 2-3
Days 5-7
Alcohol Cessation = Days 0-1
- Anxiety
- Headache
- Palpitations
- Insomnia
- GI Upset
Days 2-3
Seizures = As early as 2 hrs after last drink
- Generalized Tonic Clonic Convulsions
Hallucinations: Visual, Auditory & Tactile
Delirium Tremens= Peaks on Days 5-7
- Agitation
- Disorientation
- Tachycardia & Hypertension
- Diaphoresis
- Fever
indications for inpatient management of alc withdrawl syndrome
- Abnormal Lab Results
- Lack of social supports
- Comorbid illnesses such as DM, CHF, COPD
- High risk of DTs
- Long term intake of large amounts of alcohol
- Serious psychiatric conditions
- SI or HI
- Severe alcohol withdrawal symptoms
- Urine drug screen positive for other substances
Tools for Predicting Severity of Alc withdrawl syndrome
(PAWS)
- Part A – threshold criterion (ex. last drink, BAH at time of admission)
- Part B – patient interview
- Part C – physiologic (ex. BAL, ANS activity)
Clinical Institute Withdrawal Assessment for Alcohol
(CIWA-Ar)
Validated 10 item assessment tool that can be used to quantify the severity of etoh withdrawal
- Scores <8 = mild withdrawal
- Scores of 9-15 = moderate withdrawal
- Score >15 = severe withdrawal and increased risk of DTs and Seizures
Goals of Care for Patient in Alcohol Withdrawal
- “To provide a safe withdrawal from the drugs of dependence and enable patient to become drug free”
- “To provide withdrawal that is humane and thus protects the patient’s dignity”
- “To prepare the patient for ongoing treatment of their dependence on alcohol and drugs
basic tx of alc withdrawl
Correct abnormalities in fluid levels, electrolytes, nutrition “Banana Bag”
- IV fluids if excessive diaphoresis, vomiting
- MVI
- Thiamine, give before Glucose to prevent Wernicke’s encephalopathy
complciations of alc withdrawl syndrome
Wernicke’s Encephalopathy
- due to Thiamine deficiency - reversible
- Ocular findings (ophthalmoplegia), Cerebellar dysfunction, Confusion
Korsakoff’s is a late manifestation of WE,
- amnestic syndrome, not reversible
- Can progress to severe psychosis
2 tx regimes for alc withdraw syndrome
Symptom Triggered: CIWA every hr to assess need for medication
Administer q1hr if CIWA 8-10
- •Librium 50-100mg
- •Valium 10-20mg
- •Ativan 2-4mg
Shown to be less Medication over admission but requires Staff to be trained
Fixed Regimen: PRN based on CIWA <8
Administer the regimen q 6 hours
- Chlordiazepoxide (Librium)
- Diazepam (Valium)
- Lorazepam (Ativan)
Pharmacologic Treatment of Alc Withdrawal
Uses therapeutics which are cross-tolerant with alcohol
Benzodiazepines –safe and effective, prevent seizures and delirium
- BZDs can cause delirium in higher doses, such as Lorazepam >20mg / day
Phenobarbital is coming into favor (less medication overall vs diazepam)
- Give loading dose and ↓q 30 mins
- Barbiturates have dual activity: Simultaneously enhance GABA activity and suppress glutamatergic activity.
- Matched to the pathophysiology of alcohol withdrawal
- BZDs ONLY ↓excitability
Diazepam and Chlordiazepoxide are long-acting agents,
- withdrawal may be smoother, less rebound symptoms
Lorazepam is immediate acting, good efficacy (available IM)
- better for trouble with metabolizing,
- Avoid in elderly, liver failure.
MOA of Phenobarbital
tx of?
Alc withdrawl syndrome
Barbiturates have dual activity: Simultaneously enhance GABA activity and suppress glutamatergic activity.
- Which is matched to the pathophysiology of alcohol withdrawal
Indications for use of Long-acting agents in alc withdrawl syndrome
list the long acting agents
Diazepam and Chlordiazepoxide
•withdrawal may be smoother, less rebound symptoms
drug for alc withdrawl syndrome that is immediate acting
CI??
Lorazepam- better for trouble with metabolizing,
Avoid in elderly, liver failure.
Adjuvant tx of alc withdrawl syndrome
Haldol –good for treating agitation and hallucinations
- BUT it lowers the seizure threshold.
Atenolol –Helps with VS, consider with CAD when may not tolerate the strain on the system.
Clonidine can also be effective on the ANS symptoms
Phenytoin can be considered if underlying withdrawal symptoms
List components of Discharge Summary
Patient information –Full name, address, date of birth, gender, SSN or other health information number
Primary physician/s and health care team –
Admission and discharge details –
- Date of admission
- si/sx exhibited during admission
- referral type
- hospital name or type
- date of discharge
- discharge method
- date of death (if the patient died)
Clinical care plan –List of medical and/or surgical care interventions given to the patient
- diagnoses
- medical alerts
- allergies, hypersensitivities
- Diet
- patient’s functional state
- immunization status, infection status, etc.
Medications –List of all medications given to the patient, also what new medications added, what doses have been changed.
Continuing care plan –Health teachings (diet and therapy recommendations)
- follow-up outpatient visit daily schedule
- required physician actions
Admission and discharge details should include
- Date of admission
- si/sx exhibited during admission
- referral type
- hospital name or type
- date of discharge
- discharge method OR date of death (if the patient died)
after death of a pt you should??
Interview the RN, the team with the patient. Especially if unexpected
Ask family if an autopsy is desired –
Determine if organ donation (RN will call)
Be empathetic with family –
Explain the pronouncement to the family
what is included with the death Pronouncement
Identify the patient ( 2 identifiers)
general appearance/ PE of the body
- no reaction to verbal or tactile stimuli
- no pupillary light reflex (should be fixed and dilated)
- carotid pulse, no heart sounds
- breath sounds, no respirations
date of death and time of pronouncement
Note that family, coroner, and organ bank was notified
if the family accepts autopsy
the attending physician was notified
Physical exam of a death should include what findings?
no reaction to verbal or tactile stimuli
no pupillary light reflex (should be fixed and dilated)
carotid pulse, no heart sounds
breath sounds, no respirations
Discuss the difference in discharge summaries of a pt who dies
Discharge date = date expired or date of death
Discharge Dx= cause of death
what is a death certificate
what does it include?
Legal documentation that named person is dead
- Information may be used by the government, public health agencies, researchers to prevent further mortality.
- Prior to COVID the person who completed the death certificate was the physician treating the patient or a medical examiner
Includes:
- information about the cause of death
- place of death
- circumstances of death
pt can be transferred to an acute rehab on ___ day of hospital admisssion
day 3
Preparing Patient for Acute Rehab Transfer
Reconcile medications: home, pain & anticoags
- Wound Care
- PT/OT
- DVT Prevention
- FU with PCP, Orthopedist & Cardiologist
Paperwork for transfer
Dictate or electronically prepare a discharge summary
Summary of hospitalization ‘What happened’, surgery preformed, include dates
WT bearing status, precautions, activity
Wound care, staples out?
Lab trends, lab needs
Tolerance of activity, PT/OT
Med reconciliation
DVT prevention
FU visits (PCP, Ortho, Cardiologist)
Notify if…
- Temp > 100.5
- red/pus from wound
- pain not controlled by meds
- calf pain or swelling
acute rehab has a Time-limited with the goal of:
- improving functioning
- discharging home
explain the typical day of a pt with in an acute care rehab
therapy?
expectations?
3-5 hours of therapy every day, with a mix of physical, occupational, and other acute therapies, such as respiratory therapy or speech
- Seen by medical team every day to mark progress and make recommendations for continuation of rehabilitation.
Acute patients are expected to make fast progress and move up a level out of acute rehab
focus of acute care rehab
- Strength =Walking, standing from sit, lifting/pushing/pulling
- Balance =Functional, dynamic
•ADL’s and self-care= Bathing/hygiene, getting dressed
•Meal prep
Med for alc withdrawl - good for treating agitation and hallucinations
adverse effects?
Haldol –good for treating agitation and hallucinations
•BUT it lowers the seizure threshold.
med for alc withdrawl consider with CAD when may not tolerate the strain on the system
•Atenolol –Helps with VS
med for alc withdrawl that is effective on the ANS symptoms
Clonidine
med for alc withdrawl that is considered if underlying withdrawal symptoms
Phenytoin
explain hor tx of withdrawl and dependence are addressed in AUD
Tx of withdrawal THEN alcohol dependence.
Inpatient Rehab - manage w/drawl si/sx
Outpatient programs – address alc dependence
- Cognitive behavioral
- Family therapy
