Hospital D/C and Short Term Rehab Flashcards by alexandra silvonic

List Possible Discharge Dispositions

discharged to Home
Home with VNA services
Short Term Rehabilitation
Long Term Acute Care
Hospice facilities

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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

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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

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how long can pts recieve VNA

Patients can receive VNA until you meet the goals which are set forth by the PT/OTs/RNs

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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

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An elderly patient requiring continued IV antibiotics but unable to take care of themselves at home.

Skilled Nursing Facility(SNF

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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 da**y, 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 l**owers 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