PCM 2 Unit 2 Entry Lvl Practitioner in Acute Care Flashcards
What is needed for Clincial Decision Making?
- Self awareness of abilities and limitations
- Observant of patient, environment
- Ability to integrate and synthesize information from multiple resources
- Predict and anticipate patient presentation and needs
- Screen medical record for appropriateness of PT services
- Clearly communicate in verbal and written documentation clinical decision making
- Select appropriate examination and intervention
What are the Expected Clinical Decisions made by Acute Care PTs?
- Patient saftey
–Intervention selection
–Readiness for mobility
–Method of executing of mobility - Need for continued therapy and additional consultations withing acute and post discharge
- Need to withhold or discontinue physical therapy services
- Problem solving to reduce or elimate barriers to the patient acccessing care within the acute setting and in post acute care after discharge
- Appropriateness of delegating POC to PTA
- Anticipate patients needs and resources for further care
Clinical Decision Making
What takes place in the Examination?
- Review of the medical record
- Communication of relevant information and interpretation with support staff re: patient condition
- Select appropriate examination screens and measure
- Communicate with the patient
- Observe of situation, enviornment and patient current condition
Clincal Decision Making
What takes place in the Plan of Care?
- ICF model: current condition medically, tolerance of activity, level of assistance
- Anticipation of needs/prognosis upon discharge
- Access to resource/insurance limitation
- Need for continued therapy post discharge
- GOALS
- Intervention selection
Clinical Decision Making
What takes place in the Discharge Planning?
This begins with the end in mind
This begins on day of initial evaluation
- Cognition and safety awareness
- Level of support
- Home environment
- Need for durable medical equipement
- Recognize regulations imposed by healthcare systems and insurance companies
- Assess and consider expectations and desires of stakeholders
- Coordinate and communicate with the interprofessional team to ensure patient recives resouce and placement upon discharge
What are some communication considerations?
- Style and delivery
–Verbal and non-verbal components
–Medical literacy
–Cultural needs
–Language barriers - Clarity of clinical decisions with supportive data
–Verbal
–Written - Use of strategies to improve patient safety, reduce errors
–Situation, background, assessment and recommendations
–Huddles - Maintain professional and respectful dialogue during crucial conversations
How can we, the PTs, ensure the safety of the patient?
- Thorough review of medical record (PMH, lab values, meds, fall risk, systems review), with this determining the appropriateness of initiating PT
- Consideration and anticipation of mobility affecting medical stability, and medication affect on physiological response to activity
- Application of PPE (Personal Protective Equipment)
- Ensure safe environment
- Identify lines, tubing, and equipement along with specific precautions
- Knowledge of ventilator equipment and the impact of patient mobility and POC, prognosis and discharge plane
- Recognize need for additional assistance and collaboration from interprofessional team within the treatment session
With Patient Management, what should PT document?
- Defensible documentation that expresses clinical decison making with sound rationale
- Communicate to the interprofessional team through written documentation needs for patient care management
- Report accurately all aspects of the patient encounter including medical status, safety, parameters of the intervention, and patient response
With Braces and Orthotics in Acute Care, what may we see in the Medical Chart prior to seeing the patient?
- Activity Orders
- Precautions
-Weight Bearing: LE/UE
-Sternal
-Spinal
-Fall Risk
Head Braces/Orthosis
What is the Soft Shell Helmet? What is one major consideration associated with the soft shell helmet?
- This is a helmet of foam material and requires wearing after having a craniectomy or a resection of any part of the skull
- Both adults and children can be prescribed this, and often times the activity order will be written only out of bed with helmet donned
- One major consideration when a patient is wearing this, is if there is a wound present on the top of their scalp, this can cause increase risk of infection. Sometimes gauze of a washcloth may be placed on the top of the head to create some elevation and space between the helmet and skull
What are the Risks and Benefits of Immobilization and Mobilization of brases of the Cervical Spine?
For surgical management,its often performed to allow the patient to get out of bed earlier, reducing hospitalization time and avoiding physical or psychological deterioration from bed rest
Cervical Orthoses
When would a patient wear a Soft Collar?
- This is for Minimal Control
With injuries such as: Whiplash, Cervical weakness
What is a Rigid SOMI Collar? What are they affective at restricting? When are they used?
SOMI stands for: Sterno Occipital Mandibular Immobilizer
- These are for Moderate Control
These include:
-Philadelphia, Apen Collar, Miami J Collar
- The Miami J and Apen Collar can accomodate a tracheostomy
- The SOMI devices are effective at restricting flexion between C1 and C5 and proviodes mandibular support during change in position. also limits extension, lateral flexion, and rotation
- These are often on the neck after traction to stabilize a cervical fracture. They are used during the transitional period for 4 to 6 weeks before unresticted movement is allowed. Sometimes they are used after removing the maximal rigid Halo brace
With Cervical Orthoses, what are the 2 orthoses used for Maximum Control?
- Minerva and Halo
With Max. Control Cervical Orthoses, What is the Minerva Orthosis? When is this donned?
- The Minerva is non-invasive and has 3 points of control to further reduce motion. Point of control are at the Mandible, the occiput and forehead.
- There is also a custom molded body jacket that helps encase the chin and a posterior skill portion that is extending to the costal margin or pelvis
- Its been reported to have better stabilization than a Halo, execpt for injuries at C1 and C2
- This is donned following cervical Fx
With Max Control Cervical Orthoses, What is the Halo? What is a contraindiation for this? When is this donned on a patient?
- This is an Invasive orthoses, it is fixed to the skull with 4 pins/screws piercing through the skin to the skull and the outer layer of the periosteum is penetrated.
- Its attached to a super structure that is used for attachment and stabilization to that thoracic vest. That vest must fit very intimately with the patient
- If there is movement of the vest, it can translate movement of the C-Spine, which is a contraindication
- It creates increased mass at the head and the neck, and it tends to create a leaning forward of the trunk
- So these patient will need mobility re-training to control the extra mass that is at the top of their head, so they may need a cane or other ADs and then readapt post-halo
- This is donned following facet subluxations and dislocations that have been reduced with traction
There may be infection from the pins, skin irritation, nerve damage. They may also develop TMJ dysfunction and possibly dysphagia
What is a Cash Extension Brace?
This is a Thoracic Orthosis
- This is donned following a compression fracture, this prevents further flexion and further damage
With the Thoracic Spine, what is the Jewett?
- A brace that restricts flexion and encourages hyperextension
- Limits rotation and sidebend to some degree
- Improper adjustment could lead to pressure on throat or genitals in sitting
With the Thoracic Spine, what is the Knight Taylor?
- This is a brace that has a rigid frame worn posteriorly
Thoracic Movement
- Unrestricted rotation and intermediate restriction of flexion, extension and sidebend
Lumbar Movement
- Rotation restricted intermediately other planes effectively restricted
Lumbosacral Movement
- No flexion/extension restrictio, rotation intermediate, Side bend effective
What is a Molded Thoracolumbosacral Orthosis?
This is an orthotic often reffered to as a shell
- This provides Maximal stability to trunk
- Limits all planes of motions
- A Thigh Extension (aka hip spica) can be attached to also restrict hip flexion mobility if the lower lumbar spine needs immobilizing (below L5)
- Also Shoulder Outriggers or Cervical Extension can be attacted if the upper thoracic or lower cervical need immobilizing
What is a Thoraco-Lumbar-Sacral Orthoses (TLSO)?
This can be used by patients with scoliosis
- Although they do not correct the deformity, they prevent them from getting worse (To correct scoliotic deformities, surgery is required)
- The braces have adjustable straps to create a three-point counter force to try to create stability to work toward preventing further curvatures
What is a TLSO: Bivalved Plastic body Jacket? With this orthosis, what can and cannot be done with rehab?
- This is very common to patients with SCI in the T- and L-Spine.
- This type of orthosis will allow for skin inspection and bathing
- It immobilizes to allow for the earlier rehab post-SCI to occur
- These patients will likely have spinal precautions, which will make rehab more challenging but still feasible
- When the Lumbar spine is affected and needs immobilizing, there can be no hamstring stretch or hip flexion past 90
- We can still perform UE PROM and AROM symmetrically
What are the different Lumbo-Sacral Orthosis and when are they used?
Lumbo-Sacral braces can be both soft and rigid
- Soft Corset: For LBP, Post-Op lsp fusion, to improve body mechanics, to help weak muscles maintain stability)
- Rigid: This can be used post-op fusion, spondylolisthesis. Also this can be used to prevent side bending and flexion and extension between the lumbo-sacral components
What is a Hip Abduction Orthosis used for?
This is used for Total Hip Revisions or to ensure hip percautions arent broken (may be needed for those patients with dementia)
What are Some Percautions after Hip Replacements?
No Hip IR, Hip Add, and no Flexion of the hip and trunk past 90° (Posterior Hip Replacement)
When would a patient use Knee Immobilizers or Long Leg Extension Braces?
These are often prescribed to patients after having a Total Knee surgery (they are typically recovering from a nerve block and the trauma of the surgery itself), these patients are more susceptible for buckling of the knee when attempting to place weight as tolerated
- For the first day or two, the activity order may require the brace when initiating mobility out of bed into weight bearing positions after surgery
When are Short Leg Walking Boots Utilized?
For advanced management of fractures of the foot or ankle (May be encountered in acute care, must check activity orders and WB status, an AD is typically used with this)
What is the use of the Pressure Relieving Ankle Foot Orthosis (aka PRAFO boot)?
This is provide pressure relief to the heel
- This also helps reduce the risk of losing ROM since it places the foot in a relatively 90° angle to help maintian neutral position
What is the Forefoot Off Loading Shoe?
These shoes are indicated for patients whom have had amputations of the toes or they present with wounds and ulcers around the forefoot area
- The most common health condition associated with these complications is Diabetes Mellitus (DM)
When is the Simple Arm Sling used?
This is for weight bearing percautions or when they have placed certain ports and lines, as well as subluxation management
What is the purpose of the Resting Hand Splint?
This is often prescribed by OT to assist with management of hypertonicity, especially is the hand is posturing in a flexed manner that places risk for hygienic problems as well as severe shortening of the flexor tendons
Why is working within an Interprofessional Team important?
- Limits adverse events
- Improves patient outcomes
- Decreases length of stay
- Improves patient satisfaction
- Optimizes health care workers performance and job satisfaction
- Reduces hospital costs
What is the Role of the Physician and Specialists?
The primary physician is bringing all the information together and leading the patient’s care. Physiatrist, Nephrologists, Neurologists, Cardiologists, Neurologists, Oncologists, etc
What is the Role of the Physician Assistant or Nurse Practitioner?
Work directly under the physician to execute medical plan of care. Accessible to therapists for communication about the patient’s care.
What is the Role of the Nurse?
The minute-by-minute healthcare provider. Seek information from the nurse upon entering the room and provide relevant communication to the nurse after completing a session.
- Responsible for dispersing medication, managing daily needs for the patient related to bodily functions, position changes, dressing changes, etc.
What is the Role of the Certified Nursing Assistant?
Supports nursing staff by taking the patient’s vital signs, setting up meals, providing drinks, assisting with position changes, toileting, and linen changes.
What is the Role of the PT?
Evaluate and develop a plan of care with the patient to enhance independence with safe mobility and discharge to the next level of care.
What is the Role of the OT?
Evaluate and develop a plan of care with the patient to improve independence with activities of daily living, cognition, and feeding in order to safely discharge to the next level of care. Consult with OT’s regarding potential cotreatment to enhance patient mobility outcomes
What is the Role of the SLP?
Evaluate and develop a plan of care to improve breath Control, cognition, swallowing and feeding. Experts in movement control of the mouth so the patients can swallow food safely. Determine the safest consistency of food and drink for the patient and progress or regress as needed. Consult with this SLP regarding communication style, strategies, and food or drink restrictions.
What is the Role of the Social Worker/Case Manager?
Coordinate discharge planning, establish insurance coverage and approval, order equipment for the home environment, and help secure resources to access within the community.
What is the Role of the Recreational Therapist?
Rec therapists evaluate the holistic abilities of a patient and incorporates the patient’s specific interests into therapeutic activities. They encourage and promote physical, emotional, and social well-being by finding what the patient is interested in and then adapting that activity to meet the needs of the patient.
What is the Role of the Psychologist/Neuropsychologist?
The Psychologist role on the team is to address coping with the condition or illness, behavior management, and improving emotional and mental health. They serve not only the patient but also the family. Neuropsychologists have further specialty training in neuroscience and may be more specifically trained to work with patients who have suffered from neurological trauma such as TBI.
What is the Role of the Pharmacist?
The pharmacist manages the prescribed medications and considers adverse interactions that may occur with poly-pharmacy.
What is the Role of the Clergy/Spiritualist?
Clergy or spiritualists provide the patient with prayer and spiritual support while in the hospital.
What is the Role of the Respiratory Therapist?
Execute a plan of care designed to manage the respiratory system with a patient. Provide patient support while on a ventilator by adjusting settings, providing breathing treatments, suctioning services for airway clearance, and assisting with cough production.
What is the Role of the Dietician/Nutritionist?
Dieticians and nutritionists provide patients with meal plans that align with their health condition such as ensuring enough caloric intake, limit certain foods such as salt or sugar, and ensure no foods are provided that could counteract or be contraindicated with medications.
