Intro to Management of Patients in the Acute Care Setting Flashcards
how is acute care defined?
pts are not stable enough to receive care at an outpatient clinic
what is acute care?
a level health care in which a pt is treated for a brief but severe episode of illness
what is typically the entry point of care for acute care?
the ED or by another physician for a planned procedure or treatment
what is hemodynamic stability?
a medical term that describes a person’s stable blood flow, BP, and HR
t/f: anything that leads to inadequate blood flow to vital organs leads to hemodynamic instability
true
what causes homeostatic imbalance?
imbalance of ions, water, or electrolytes
what are the most common diagnoses for inpatient stay?
livebirth, septicemia, HF, pneumonia, OA, DM complications, acute MI, dysrythmias, COPD excerbation
what is septicemia?
a bacterial infection of the blood
very serious life threatening response to infection
pts get very sick very quickly
total organ failure
what is observational status?
well defined set of specific clinically appropriate services, which include ongoing short-term Rx, assessment, and reassessment b4 a decision can be made regarding whether pts will require further Rx as hospital pts or if they’re able to be discharged from the hospital
how long is observation status typically?
<24 hours
how long can some rare and exceptional cases be in observation status?
> 48 hours
what is the purpose of observation status?
to monitor a pt to determine if they need to be admitted
what is the Affordable Care Act’s Hospital Readmissions Reduction Program?
CMS began reducing Medicare payments to inpatient hospitals deemed to have excessive pt readmissions w/in 30 days of d/c
if pts are classified as outpatients under observation status, their return to the hospital within 30 days isn’t considered readmission
t/f: Medicare is incentivized to to overturn hospital decisions to admit individuals as inpatients, which is more costly to the healthcare system than outpatient admission
true
Medicare considers observation what kind of service and is covered under what part of Medicare
outpatient covered under Medicare part B
t/f: Medicare part B services have both deductibles and cost-sharing for beneficiaries which means that the cost to the patient of an observation stay is more variable than a traditional inpatient
true
does time spent in observation status count towards the 3 day inpatient stay requirement for Medicare SNF coverage
nope
will Medicare pay for medically necessary post-acute care in a SNF without a 3 day inpatient stay?
nope
what is unique about the acute care setting?
there is medical team trained and experienced in identifying and treating instabilities at REST
the therapist needs to be skilled in identifying physiological responses both AT REST and WITH MOVT
t/f: stability can quickly change with movt
true
what is involved in sound clinical decision making?
be observant
integrate info
predict the pt’s expected level of improvement to determine goals, d/c needs, and rehab prognosis
be aware of your limitations and ask for help when needed
create a comprehensive PT care plan that’s individualized and focused on the pt and caregiver’s goals and circumstances
choose optimal dose-specific interventions
t/f: we should do as much the pt can do and push to fatigue as long as they’re stable
true
we should adjust intervention choices and dosage based on what?
the pt’s response and d/c needs
what are some important skills for entry level PTs in acute care?
you need to know what you know and don’t know
you need to look at the big picture but be able to break down problems into component parts to manage pt’s care
what is the purpose of documentation in acute care?
to ensure quality pt care, facilitate communication among healthcare providers, and meet legal and reimbursement requirements
what is the importance of documentation in acute care?
proper documentation supports continuity of care, justifies medical necessity, and aids in risk management
t/f: adherence to specific documentation guidelines is set by Medicare and private insurers
true
what fxnal outcome/progress measure is often used in acute care?
6 Clicks
how soon should documentation be done in acute care?
right away!!!
what are the requirements in documentation for Medicare and insurance?
date and duration of treatment
specific interventions and their medical necessity
fxnal outcomes and progress measures
timely submission
use of approved terminology and coding
regular reviews and updates of the POC
what is involved in justification for medical necessity?
clear articulation of why PT services are required
documentation of fxnal limitations and their impacts on daily activities, potential for fxnal improvement through PT interventions, and skilled nature of the provided services
establishment of measurable fxn based goals
regular reassessment and documentation of progress toward goals
explanation of any changes in the treatment plan or lack of progress
what needs to be documented for justification of medical necessity?
fxnal limitations and their impacts on daily activities
potential for fxnal improvement through PT interventions
skilled nature of the provided services
what are the best practices for acute care PT documentation?
be concise yet comprehensive
use objective, measurable terms
avoid repetitive or irrelevant info
document in real-time or as soon as possible after treatment
ensure legibility and proper use of abbreviations
regularly review and update documentation practices
participate in ongoing education about documentation requirements
communication in acute care involves communication bw who?
bw healthcare workers and the pt/family/caregiver
what is the #1 reason for mistakes made in acute care?
poor communication
what is involved in communication in acute care?
verbal and nonverbals
listening skills
team communication
documentation
reporting
t/f: professional demeanor and interpersonal communication precedes clinical skills?
true
what phrase at the end of statements should we avoid?
“okay?”
what is SBAR?
Situation
Background
Assessment
Recommendations
what is included in the situation part of SBAR?
what’s the situation you’re calling about
ID self, unit, patient, room #
briefly state the problem, what it is, when it happened or how it started, and how severe
what is included in the background part of SBAR?
pt background info related to the situation could include:
admitting dx and date of admission
most recent VSs
screen/exam results (provide date and time the test was done and results of previous tests for comparison)
other clinical info (response to intervention)
code status
what is included in the assessment part of SBAR?
what is your assessment of the situation
what you found and think is going on
what is included in the recommendation part of SBAR?
what is your recommendation or what does the pt want
ie. hold off on treatment, clarify orders, or request consult
what is a unique challenge when working with sick patients?
it is unlikely they will take in much info you tell them
t/f: effective communication leads to better pt outcomes and satisfaction
true
what are some key communication strategies?
active listening
clear and simple language
empathy and compassion
how can we actively listen?
pay full attention to pts
use nonverbal cues to show engagement
how do we use clear and simple language?
avoid medical jargon
use analogies to explain complex concepts
how do we show empathy and compassion?
acknowledge pts’s pain and concerns
use a calm and reassuring tone
how do you adapt communication for patient needs?
assess pt’s cognitive status and adjust accordingly
consider cultural and linguistic differences
use visual aids or written instructions when appropriate
involve the family members or caregivers when necessary
utilize teach-back method to ensure understanding
prioritize clear, empathetic communication
adapt strategies to individual pt needs
what are common barriers to communication?
pain and discomfort
medication effects
anxiety or fear
language differences
what are some strategies for overcoming communication barriers?
use pain scales and body language interpretation
schedule therapy sessions around medication timing
practice patience and offer reassurance
utilize interpreter services when needed
what is involved in discharge planning?
determine destination, level of support, need for continuity of care in post-acute setting, and critically assess pt safety (cognition and fxn)
determine optimal equipment needs
synthesize the pt’s life context
assess the expectations and desires of stakeholders
understand regulations imposed by the healthcare systems and payers
what are the different destination settings for discharge?
rehab, outpatient, home, sub-acute, or other additional services and follow up needs
what factors are involved in determining optimal equipment needs for discharge?
reasonable and necessary available funding
individual circumstances
what is included in the synthesis of the pt’s life context in discharge planning?
their pre-hospitalization status
age
suitability of home environment
caregiver support
follow-up/transportation needs
risk factors for re-hospitalization
economic resources
who is involved in the assessment of the expectations and desires of the stakeholder for discharge planning?
the pt, family, caregiver, medical services, and surgical services
if the patient will not achieve pre-hospital or acceptable level of function prior to discharge, is medically complex, and requires extended stay specialty hospital, where will they be discharged to?
LTACH
if the patient will not achieve pre-hospital or acceptable level of function prior to discharge, is not medically complex or requiring extended stay specialty hospital, and could get significantly better in inpatient rehab/can tolerate 3 hours of therapy (OT/PT/SLP) per day/has a significant advantage with regards to medical safety, timeframe, or ultimate level of goal achieved, where will they be discharged to?
IRF
if the patient will not achieve pre-hospital or acceptable level of function prior to discharge, is not medically complex or requiring extended stay specialty hospital, and could get significantly better in inpatient rehab/can tolerate 3 hours of therapy (OT/PT/SLP) per day/has a significant advantage with regards to medical safety, timeframe, or ultimate level of goal achieved, and has no skilled nursing or medical needs only/could not reach rehab goals in a less resource intensive environment, where will they be discharged to?
IRF
if the patient will not achieved pre-hospital or acceptable level of function prior to discharge, is not medically complex or requiring extended stay specialty hospital, and could get significantly better in inpatient rehab/can tolerate 3 hours of therapy (OT/PT/SLP) per day/has a significant advantage with regards to medical safety, timeframe, or ultimate level of goal achieved, and has skilled nursing or medical needs only/could reach rehab goals in a less resource intensive environment, where will they be discharged to?
SNF
can a pt progress from LTACH to home?
yes
can a pt progress from SNF to IRF?
yes
if the patient will be able to achieve pre-hospital or acceptable level of function prior to discharge, where will they be discharged to?
home
what services may be involved in home health?
PT/OT
day hospital
community re-entry
outpatient rehab services
will your patient get rehab coverage if you document them as supervision or contact guard?
not likely
if you feel the need to stand close by your patient, what level of assistance should they be documented as?
min A
if you document that your pt walked >100 feet, will they get rehab coverage?
likely not
if your pt walks a total of 120 feet but needs rest breaks, how should you document it so they can get rehab coverage?
document the time walking in chunks breaking it up when they needed rest breaks
if a pt is not medically complex for admission to acute rehab, where may they be appropriate to d/c to?
IRF
if a pt didn’t use an AD b4 admission, but now does, what should you document?
their baseline fxn prior to admission
if someone may otherwise be a good candidate for IRF but cannot handle 3 hours of therapy per day, where may they d/c to?
SNF
t/f: we should not refer to SNF as a nursing home
true
t/f: SNF is a temporary place to get better and go home once you are more independent and safe to go home
true
how do we decide on interventions for acute care pts?
breakdown activities and fix what you can while assessing mobility
think about what you can do to make them qualify for rehab
ID what is preventing them from accomplishing the task independently
why is it important to get to know the typical d/c and recovery length post-op for certain surgeries?
bc we have to assess their rehab potential on day one and they will not look their best day one post-op so it may skew our interpretation of their rehab potential
what items are included in a safety checklist?
check for behavioral issues
check VS from the nurse
nonslip socks and gait belt
bring in all equipment w/you
hand washing and gloves as needed
inform the nurse when you’re done
move barriers
lock chair
safe positioning
turn bed alarm back on
make sure call bell is on and w/in reach
check for correct use of equipment
ADs
before entering the pt’s room, what things should we do to ensure safety?
SBAR with nursing or other medical staff as needed
coordinate w/the team on timing of treatment, consider meds, equipment, and personnel availability to optimize effectiveness
make sure PT is indicated and there is an appropriate referral
review medical hx
if a pt doesn’t have an appropriate referral for PT, what should we do?
ask nursing, case manager, or physician why there’s no referral
what is involved in the medical review b4 entering a pt’s room?
note if PT is indicated based off the prior and/or current medical and surgical hx
note meds that may impact mental status, wakefulness, and ability to follow commands
note meds that may impact HR and BP responses
determine the prior LOF and activity tolerance (use AHA HF classification scale, Borg RPE, MRC breathlessness scale, etc)
during the exam/interventions, what things should we do to ensure safety?
observe, evaluate, and modify the environment
protect lines and tubes
observe, evaluate, and modify your approach and rxns to the pt
monitor hemodynamic status
monitor the physiological response of other systems
t/f: we should always step away and come back to pts who are not cooperating
false, sometimes the pt needs a good push to get up and moving, but other times you need to step ways for the day or a few minutes then come back
what is involved in observing, evaluating, and modifying the environment?
the space to treat (remember you are entering someone else’s space)
lines, tubes, and monitors
how do we protect lines and tubes?
keep lines and tubes in front of you and the pt where you can see them
keep Foley catheter and chest tubes below waist level
must be able to manage lines and guard the pt appropriately
always be able to look at your pt’s face
what is involved in observing, evaluating, and modifying your approach and rxns to the pt?
physical appearance
mood, affect, emotions, level of cooperation
consider the impact of illness or medical procedures, and meds on pt’s mobility, weakness, incision, trauma, pain, and equipment needs
why is observing mood, affect, emotions, and level of cooperation important in safety?
it determines how they feel about mobilization, any concerns they have, and their readiness
what do we monitor to know the pt’s hemodynamic status?
monitor VSs of the pt and symptoms throughout
if the pt is not awake and alert, follows simple commands, and has stable mental status, is the pt appropriate for therapy?
probably not
if the pt is awake and alert, follows simple commands, and has stable mental status, but is not cardiovascularly stable, is the pt appropriate for therapy?
maybe not
if the pt is awake and alert, follows simple commands, and has stable mental status, is cardiovascularly stable, but is not stable in pulmonary values, is the pt appropriate for therapy?
maybe not
if the pt is awake and alert, follows simple commands, and has stable mental status, is cardiovascularly stable, is stable in pulmonary values, but doesn’t have safe lab values, is the pt appropriate for therapy?
maybe not
if the pt is awake and alert, follows simple commands, and has stable mental status, is cardiovascularly stable, is stable in pulmonary values, and has safe lab values, is the pt appropriate for therapy?
probably
what is acceptable HR range?
> 50, <150 bpm
what is stable heart rhythm?
AFib under 100 bpm
acceptable PVCs
no recent VT
what is acceptable BP range?
resting MAP >65, <120 mmHg
SBP >80, <200 mmHg
what makes a pt cardiovascularly stable?
acceptable HR and rhythm
acceptable BP
absence of chest pain or pressure
absence of recent DVT/PE
surgical precautions being followed
what makes a pt pulmonarily stable?
resting pulse ox >88%
RR<35 breaths/min
acceptable breathing pattern
no observable respiratory distress
no SOB at rest
acceptable O2 delivery
appropriate mechanical ventilation
appropriate ABGs
what is appropriate O2 levels?
> 88%
what is acceptable RR?
<35 breaths/min
what is appropriate hemoglobin levels?
> 7g/dL w/o CV disease and no signs of bleeding
> 8-10 if known CV disease
what is appropriate hematocrit levels?
> 25%
what is appropriate platelet count?
> 20,000 cells/mm^2
what should we consider when WBC counts are <5,000 cells/mm^2?
limit pt exposure to possible infection risks
what should we consider when WBC counts are >10,000 cells/mm^2?
consider active infection (febrile vs afebrile)
what are acceptable potassium levels?
3.5-5.3 mEg/dL
what are acceptable sodium levels?
135-148 mEg/dL
what are acceptable calcium levels?
8.5-10.5 mg/dL
what are acceptable magnesium levels?
1.8-2.7 mg/dL
what are acceptable glucose levels?
> 60 mg/dL, <300 mg/dL
what lab values should be obtained for cardiac conditions?
troponins, CPK, and BNP
what lab values should be obtained for renal disease?
creatinine
what lab values should be obtained for hepatic disease?
LFT
what lab values should be obtained to determine if nutrition status is acceptable?
albumin and pre-albumin
what orthopedic conditions should be considered for making a decision on the appropriateness of PT in acute care?
WB restrictions
stable spine
what integumentary considerations should be taken into account when making a decision on the appropriateness of PT in acute care?
skin grafts-see if ROM and WB restrictions are restricting mobility
vacuum drainage system
what are the red flags in pt responses to treatment?
CV-SBP/MAP falls, new onset VT
pulmonary-desaturation <85%
subjective responses-chest pain
^^^ may indicate life threatening change
what are the yellow flags in pt responses to treatment?
CV-excessive HR or BP increase
pulmonary->5% decrease in SpO2, excessive DOE/fatigue
MSK change
what are green flags in pt responses to treatment?
all appropriate responses
if we see red flags in pt responses to treatment, what may we do?
discontinue PT immediately–> return to resting position–> monitor pt closely until they stabilize–>consider need for assistance
discuss with the medical and nursing team
if we see yellow flags in pt responses to treatment, what may we do?
decrease the intensity of the PT session
if condition stabilizes, continue with PT
if condition worsens, discontinue PT, return to resting position, monitor closely until pt stabilizes, consider need for assistance
if we see green flags in pt responses to treatment, what do we do?
continue with PT and consider increasing the intensity, duration, and frequency of treatment
what is included in a complete blood count (CBC)?
WBCs
platelets
RBCs
hemoglobin
hematocrit
what does a complete blood count tell us?
concentration of WBCs, RBCs, platelets as well as the concentration of hemoglobin and hematocrit w/in a blood sample
info regarding an individual’s overall health
differential dx for a variety of diseases and conditions
why do we want WBC counts?
to ID presence of infection and conditions that cause inflammation, allergic rxns, and cancers of the blood and lymphatic system
t/f: flutuations in WBC occur at any age
true
fluctuations in WBCs are most common in what population?
infants
what is the reference range for WBCs in newborns?
9,000-30,000
what is the reference range for WBCs in a child younger than 2 yo?
6,200-17,000
what is the reference range for WBCs in a child older than 2 and adults?
5,000-10,000
what are possible critical values for WBCs?
<2,500
> 30,000
what is an absolute neutrophil count (ANC)?
total neutrophil/granulocytes present in the blood
what is leukocytosis?
upward trending WBCs
what are some causes of leukocytosis (upward trending WBCs)?
infection, inflammation, bone marrow disease, immune system disorder, severe stress/pain
what is the presentation of someone with leukocytosis (upward trending WBCs)?
fever, fatigue, bleeding, bruising, frequent infections
what are the clinical implications of leukocytosis (upward trending WBCs)?
closely monitor s/s
consider timing of PT due to early morning low level and late afternoon high peak
what is leukopenia?
downward trending WBCs
what are some causes of leukopenia (downward trending WBCs)?
chemo, radiation, marrow infiltrative diseases, infections, dietary deficiencies, autoimmune disease
what is the presentation of someone with leukopenia (downward trending WBCs)?
frequent/persistent infections, inflammation/ulcers in and around the mouth, headache, stiff neck, sore throat, fever/chills, night sweats
what are the clinical implications of leukopenia (downtrending WBCs)?
refer to facility guidlines
monitor s/s of infection
monitor fatigue (Borg and RPE)
educate on fatigue
provide falls prevention screening
why do we want platelet counts?
platelets help stop bleeding by forming a clot
what is the reference range for platelets in a pre-mature infant?
100,000-300,000
what is the reference range for platelets in a newborn?
150,000-300,000
what is the reference range for platelets in an infant?
200,000-400,000
what is the reference range for platelets in a child/adult?
150,000-400,000
what are the possible critical values for platelets?
<50,000
> 1 million
what is thrombocytosis and thrombocythemia?
upward trending platelets
what are some causes of thrombocytosis and thrombocythemia (upward trending platelets)?
cancer, polycythemia Vera, splenectomy, acute/chronic inflammation, strenuous exercise, iron-deficiency anemia
what is the presentation of someone with thrombocytosis and thrombocythemia (upward trending platelets)?
headache, dizziness, weakness, chest pain, tingling in hands and feet
what are the clinical implications of thrombocytosis and thrombocythemia (upward trending platelets)?
screen for VTE
monitor s/s of VTE
collaborate to weight risks vs benefits of PT with abnormal findings
what is thrombocytopenia?
downward trending platelets
what are the causes of thrombocytopenia (downward trending platelets)?
hemorrhage/blood loss, damage to developing blood cells, chemo, radiation, and various diseases that lead to decreased platelet counts
what is the presentation of someone with thrombocytopenia (downward trending platelets)?
petechiae (rash like dots), ecchymosis, oral bleeding, hematoma, epitaxis (nose bleed)
what are the clinical implications of thrombocytopenia (downward trending platelets)?
education of fall risk strategies
monitor fatigue (Borg and RPE)
why do we want RBC count?
they transport O2 to the tissues throughout the body and use it to produce energy
what cells contain hemoglobin?
RBCs
what is the reference range for RBCs in a newborn?
4.8-7.1
what is the reference range for RBCs in a 2-8 week old?
4-6
what is the reference range for RBCs in a 2-6 month old?
3.5-5.5
what is the reference range for RBCs in a 6 month-1 year old?
3.5-5.2
what is the reference range for RBCs in a 1-18 year old?
4-5.5
what is the reference range for RBCs in a male adult?
4.7-6.1
what is the reference range for RBCs in a female adult?
4.2-5.4
what is erythrocytosis?
upward trending RBCs
what are some causes of erythrocytosis (upward trending RBCs)?
high altitude, dehydration, cor pulmonale, pulmonary fibrosis, severe COPD, polycythemia Vera, meds, congenital heart disease
what is the presentation of someone with erythrocytosis (upward trending RBCs)?
weakness, fatigue, headaches, lightheadedness, dyspnea
what are the clinical implications of erythrocytosis (upward trending RBCs)?
monitor fatigue (Borg and RPE)
screen for VTE
monitor s/s of VTE
what are the causes of anemia (downtrending RBCs)?
hemorrhage, bone marrow suppression, oncologic condition, hemoglobinopathy, renal disease, pregnancy, dietary deficiency, prosthetic valves, over hydration
what is the presentation of someone with anemia (downtrending RBCs)?
OH, weakness, fatigue, dyspnea on exertion, pallor, dizziness, chest pain, leg cramps with exercise
what are the clinical implications of anemia (downtrending RBCs)?
monitor VSs and cardiac rhythm
monitor fatigue (Borg and RPE)
monitor for leg cramps
assess and monitor for cognitive impairments
provide falls prevention screening and intervention
what is hemoglobin?
the main component of RBCs that transport O2 and CO2
what is the reference range for hemoglobin in a newborn?
14-24
what is the reference range for hemoglobin in a 0-2 week old?
12-20
what is the reference range for hemoglobin in a 2-6 month old?
10-17
what is the reference range for hemoglobin in a 1-6 year old?
9.5-14
what is the reference range for hemoglobin in a 6-18 year old?
10-15.5
what is the reference range for hemoglobin in an adult male?
14-18
what is the reference range for hemoglobin in an adult female?
12-16
what is the reference range for hemoglobin in a pregnant female?
> 11
t/f: values for hemoglobin in older adults will be slightly decreased
true
what are the possible critical values for hemoglobin?
<5
> 20
what is polycythemia?
upward trending hemoglobin
what are some causes of polycythemia (upward trending hemoglobin)?
severe dehydration, high altitude, smoking, congenital heart disease, chronic pulmonary disorder, HF
what is the presentation of someone with polycythemia (upward trending hemoglobin)?
fatigue, headache, dizziness, visual changes, TIA, bruising, bleeding, dysrhythmia
what are the clinical implications of polycythemia (upward trending hemoglobin)?
monitor VS and cardiac rhythm
provide falls prevention screening
implement activity pacing strategies to reduce load and prevent undue stress on the CV system
if hemoglobin is at or below ___, we hold PT
7
what should we do if hemoglobin levels are close to 7?
use symptom based approach
when would we hold PT for hemoglobin above 7?
if they are post-op with high prior levels and now a sudden drop due to surgery
if someone lives around 7 for hemoglobin levels, what should we do?
monitor for s/s
t/f: we should look for signs of active bleeding if hemoglobin is downtrending
true
what are some causes of anemia (downward trending hemoglobin)?
hemorrhage/blood loss, vit B12 and iron deficiency, bone marrow suppression, oncologic conditions, metabolic disorders, various diseases than can impact RBC production, meds
what is the presentation of someone with anemia (downward trending hemoglobin)?
pallor, tachycardia, OH, dysrhythmias, impaired endurance and activity tolerance
what are the clinical implications of anemia (downward trending hemoglobin)?
collaborate to weigh risks vs benefits of PT
timing of transfusions b4 PT
monitor VS (esp SpO2) to predict tissue perfusion
monitor pts with pre-existing cerebrovascular, cardiac, or renal conditions for tissue perfusion
provide falls prevention screen
implement activity pacing strategies
monitor fatigue (Borg and RPE)
what are some signs of decreased tissue perfusion to watch for with pts with anemia?
discoloration, poor peripheral pulses, decreased temperature, and angina
what is hematocrit?
the % RBCs in total blood volume
what may abnormal hematocrit levels indicate?
blood loss or fluid imbalance
what is the reference range for hematocrit for a newborn?
44-64%
what is the reference range for hematocrit for a 2-8 week old
39-59%
what is the reference range for hematocrit for a 2-6 month old?
35-50%
what is the reference range for hematocrit for a 6 month-1 year old?
29-43%
what is the reference range for hematocrit for a 1-6 year old?
30-40%
what is the reference range for hematocrit for a 6-18 year old?
32-44%
what is the reference range for hematocrit for an adult male?
42-52%
what is the reference range for hematocrit for an adult female?
37-47%
what is the reference range for hematocrit for a pregnant female?
> 33%
t/f: the values for hematocrit in older adults may be slightly decreased
true
what are the possible critical values for hematocrit?
<15%
> 60%
what are some causes of polycythemia (upward trending hematocrit)?
severe dehydration, congenital heart disease, polycythemia Vera, erythrocytosis, burns, eclampsia, high altitude, hypoxia due to chronic pulmonary conditions (COPD, HF)
what is the presentation of someone with polycythemia (upward trending hematocrit)?
fatigue, headache, dizziness, visual changes, TIA, dysrhythmia, bruising, bleeding
what are the clinical implications for polycythemia (upward trending hematocrit)?
screen for VTE
what are the causes of anemia (down trending hematocrit)?
hemorrhage, leukemia, bone marrow failure, multiple myeloma, dietary deficiency, pregnancy, hyperthyroidism, cirrhosis, rheumatoid arthritis, hemolytic rxn, hemoglobinopathy, prosthetic valve, renal disease, lymphoma
what is the presentation of someone with anemia (downward trending hematocrit)?
OH, dizziness, headache, pallor, cold hands/feet, angina, dysrrhythmia, dyspnea
what are the clinical implications of anemia (down trending hematocrit)?
assess and monitor VS (esp SpO2)
provide falls prevention screening and invention
monitor OH
what is the definition of acute care PT?
specialized area of PT practice in hospital settings
what is the focus of acute care PT?
treating pts w/acute medical conditions or recovering from surgery
what is the goal of acute care PT?
improve fxnal mobility and d/c planning
what are the different acute care PT settings?
ICUs
EDs
med-surg units
specialty units (cardiac, Neuro, Ortho)
post anesthesia care units (PACUs)
what is the role of the PT in acute care?
early mobilization and rehab
pain management
respiratory care and chest PT
wound care and edamame management
pt and family education
d/c planning and recommendations
what are the challenges of acute care PT?
time constraints
pt acuity and medically instability
limited space and equipment
infection control protocol
coordinating w/multiple healthcare professionals
rapidly changing pt status
what are the parts for the pt exam and assessment in acute care?
chart review and medical hx
physical exam (resp assessment and Neuro screening)
fxnal mobility assessment
pain evaluation
what are the key components of an acute care assessment?
if the pt has surgical precautions, instruct them on appropriate techniques 1st, then assess their ability while providing verbal cues
if no surgical precautions, assess their ability w/o instruction or cuing
only provide physical assistance if necessary
t/f: we should be providing min A for assessment of pt mobility
false, provide no help at first to assess what they can do themselves
what are the key components of intervention in acute care?
priority is on fxn and mobility
bed mobility, transfers, gait training
mobility is both a(n) ____ and a(n) ____
assessment, intervention
t/f: when assessing mobility, we are looking at the quality of movt
true
how is mobility both an intervention and assessment?
we first assess the quality of a pt’s movt and if it is impaired, we use it as an intervention
what is part of the CVP screen?
HR, RR, BP, edema, and temp
what is part of the neuromuscular screen?
gross movt, maintaining positions, gait, changing body positions, transferring oneself
what is part of the MSK screen?
gross symmetry, ROM, strength, and height/weight
what is part of the integ screening?
pliability, presence of scar formation, skin color, skin integrity
what is part of the screen of communication ability, affect, cognition, and language?
level of arousal
if we get a (+) CVP screen, what are some interventions we can use?
aerobic capacity, endurance, anthropomorphic s (edema)
if we get a (+) NM screen, what are some interventions we can use?
assistive and adaptive devices, balance
if we get a (+) MSK screen, what are some interventions we can use?
assistive and adaptive devices, jt mobility, muscles power
if we get a (+) integ screen, what are some interventions we can use?
wound assessment
if we get a (+) pain screen, what are some interventions we can use?
check meds, anxiety reducing interventions, deeping breathing, splinting w/movt
what is the focus of the exam in acute care?
fxn, safety, and d/c planning
what are key to CDM and d/c planning in acute care?
outcome measures
what are the categories of tests and measures in acute care?
aerobic capacity and endurance
anthropomorphic characteristics
assistive and adaptive devices
balance
circulation
cranial and peripheral nerves integrity and reflex integrity
environmental factors
gait
integ integrity
jt integrity, mobility, and ROM
mental fxns
mobility, self-care, and domestic life
motor fxn
muscles performance
pain
posture
skeletal integrity
ventilation and respiration
what are common tests and measures for the acute care setting?
AM-PAC “6 Clicks”
gait speed
6MWT
2MWT
5xSTS
30s chair rise
TUG
SPPB
what is the AM-PAC “6 Clicks” good for predicting?
d/c decisions (whether a person can go home or not, not WHERE they will go if not home)
higher 6 Clicks indicates what?
d/c home
lower 6 Clicks indicates what?
no d/c home
a 6 Clicks score of ____ or less indicates a pt is not appropriate to d/c home
16
what is the cutoff score for community ambulation gait speed?
0.8m/s
what gait speed distinguishes bw dependent mobility and independent mobility in the hospital for older adults?
.35 m/s
t/f: there is an association bw gait speed and hospital readmission
true
gait speeds below ____ were strongly predictive of 30-day hospital readmissions in older adults
0.8 m/s
what can be used to ID high risk pts prior to d/c?
gait speed
what is the inpatient MCID for gait speed?
0.05-0.10 m/s
if a pt has a slow gait speed, what do we do? (important for the practical)
fall risk assessment using standardized tools
review for hospital readmission risk factors and collaborate with healthcare professionals
implement strength and fxnal training focusing on the LE strength
add endurance training w/progressive intensity
provide task-specific gait training w/attention to mechanics and AD use
refer to specialists if medical comorbidities are contributing to the slow gait speed
educate the pts and caregivers on mobility maintenance and home exercises
conduct a home environment assessment to ensure safety and reduce fall risk
what is the 6MWT a test of?
it is a submaximal test of aerobic capacity/endurance
can O2 or ADs be used in a 6MWT?
yup!
what are reasons to stop a 6MWT?
chest pain, intolerable dyspnea, leg cramps, staggering, diaphoresis, and pale/ashen appearance
what are the predictive values of the 6MWT?
hospital readmissions and surgical outcomes
for pts with COPD, <___m in the 6MWT predicts risk of rehospitalization w/in 30 days of d/c
350
the 6MWT predicts surgical outcomes in what population?
frail older adults or pts w/chronic diseases
t/f: lower distances in the 6MWT prior to surgery may predict risk for complications
true
for pts undergoing lung surgery, <____m b4 surgery on the 6MWT was associated with higher risk of post-op complications
400
if you have a pt with a specific dx and you are doing a 6 MWT, what are you going to do to find out the MCID for safe d/c?
look it up
what is the 2MWT a measure of?
gait speed and aerobic capacity in pts who’re unable to complete the 6MWT
t/f: in pts with COPD, the 2MWT was shown to correlate to the 6MWT and lower performance on the 2MWT was associated with increased risk of hospital readministration and poorer long term outcomes
true
t/f: HF pts demonstrated that poor performance on the 2MWT correlated w/increased risk of recovering from acute conditions
true
what is the MCID for the 2MWT for pts recovering from acute conditions?
10-30m
what is the MDC for the 2MWT depending on the clinical condition?
20-50m
what is the commonly reported MDC for the 2MWT when recovering from surgery, stroke, or cardiac events?
30m
what does the 5xSTS measure?
LE strength, balance control, fall risk, exercise capacity
a slower 5xSTS is linked to what?
increased fall risk, slow gait speed, and deficits in other ADLs for community-dwelling older adults
the 5xSTS is a valid tool for predicting what?
d/c outcomes and hospital readmission risk, particularly in older adults and pts with COPD, HF, and fraility
a 5xSTS time of >___s indicated delayed d/c and higher readmission rates in various populations
15
what the normal range for 5xSTS in 60-69 year olds?
11.4s +/-2.1s
what the normal range for 5xSTS in 70-79 year olds?
12.6s +/-2.9s
what the normal range for 5xSTS in 80-89 year olds?
14.8s +/-5s
the 30s chair rise is a useful measure for what?
LE strength and fxnal capacity
the 30s chair rise is useful to measure LE strength and fxnal capacity, which are key in predicting what?
fxnal decline
post-op recovery
d/c home or rehab
hospital readmission, esp in older adults and those with chronic diseases
a 30s chair rise of <_____ reps indicates a higher risk for complications and a delayed or difficult d/c process
8-12
how can we use the 30s chair rise for d/c planning?
a fxnal assessment to evaluate whether pts have regained enough strength and mobility for safe d/c
how can we use the 30s chair rise to predict hospital readmissions?
to ID pts at risk for complications due to insufficient fxnal recovery in pts with HF and post-op
what is the difference in using the 30s chair rise or the 5xSTS?
we should use the 30s chair rise to measure endurance and overall LE fxn for those who can’t complete the 5xSTS
we should use the 5xSTS to assess power and fxnal LE strength
what is the MCID for the 30s chair rise?
2-3 reps
what is the MDC for the 30s chair rise?
1-2 reps
what is the MCID for the 5xSTS?
2.5-4 sec
what is the MDC for the 5xSTS?
1.5-2 sec
what pts had the highest fall rate with the TUG?
pts unable to do to the TUG due to non-physical disability
behind those unable to to the TUG due to non-physical disability, who had the second highest fall rate with the TUG?
those with physical disability
who has the lowest fall rate with the TUG?
those able to do the TUG
t/f: acutely unwell, immobile pts w/dementia and delirium were not at excessive risk of falls with the TUG
true
in acute care, the value of the TUG lies in what?
the inability to complete the test rather than the time recorded
a TUG of >__s indicates high fall risk
14
what does the TUG measure?
mobility, balance, and fxnal independence
what can the TUG predict?
falls, d/c home, and hospital readmission
TUG score of >_____s indicates higher chances of requiring extended care, delayed d/c, or d/c to SNF
14-20
in pts s/p hip fx, the TUG was a good predictor of what?
whether the pt would be d/c home or require further rehab
TUG performance at d/c for older hospitalized adults was a strong predictor of what?
d/c destination
what is the MDC of the TUG?
4-5 sec
what is the MCID of the TUG?
1-2 sec
3 components of the SPPB (short physical performance battery)?
ability to stand for 10 sec w/feet in 3 dif positions (side to side together, semi-tandem, tadem)
time to rise from a chair 5x
2 timed trials of a 3m or 4m walk
what is the min and max score of the SPPB?
min=0, max=12
t/f: the SPPB is a valid and reliable tool that can support d/c planning and hospital readmission prediction
true
what population is the SPPB for?
older adults and those at risk for fraility or fxnal decline
what do lower SPPB scores indicate?
higher hospital readmission rates and increased mortality
SPPB score of less than or equal to ___ predicts hospital readmission w/in 30 days
9
what is the MCID for the SPPB?
1-2 points
what is the MDC for the SPPB?
0.5-1 point
what are common interventions in acute care?
bed mobility
transfer training
gait training w/AD
airway clearance techniques
positioning and pressure relief
therapeutic exercises
fxnal mobility training
what are functional mobility training interventions?
rolling
scooting
supine to/from sit
sit to/from stand
transfers bw surfaces
pressure relief
locomotor training
gait training w/ or w/o AD
stair training
WC mobility and management
what are the purposes of dose-specific interventions in acute care?
prevention of hospital-associated deconditioning
maintenance of muscles strength and mobility
reduction of post-d/c disability
improvement in CVP impairments
enhanced recovery and shortened hospital stay
low to moderate intensity exercise is good for what?
counteracting deconditioning w/o overstressing the pt
who is appropriate for higher intensity exercise?
those with higher baseline fitness
what is moderate intensity exercise good for?
greater improvements in muscle strength and fxnal mobility
enhancement of CV fitness
reduction in risk of hospital-assisted complications
how often should pts exercise?
ideally, daily or near-daily
t/f: more frequent PT sessions are associated with better outcomes, reduced hospital stay, and minimized risk of long term disability
true
what s/s would indicate that we should terminate treatment?
dizziness not resolved w/in 60 sec of obtaining upright
nausea
blurred vision
dilated pupils
inc in HR of 20-30 bpm over baseline
change in SBP of 30mmHg or DBP of 10 mmHg
anginal pain
SOB
diaphoresis
Dec in HR from resting values
what is the definition of fall risk?
an event which results in a person coming out rest inadvertently on the ground or floor or other lower level, even if controlled
what are the risk factors for falls?
prior fall, DM, visual disturbances, poor balance, age, polypharmacy, incontinence, anyone relying on an AD for ambulation
why would a pt be put in restraints?
risk of harm to self or others (ie pulling tubes)
what are restraints?
any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a pt to move their arms, legs, body, or head freely
a med/drug when it’s used as a restriction to manage the pt’s behavior or restrict the pt’s freedom of movt and isn;t a standard Rx or dosage for the pt’s condition
can we take off restraints for PT?
yes, but keep in mind that they were there for a reason and the team should be consulted as needed
