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S7- Special Populations > Week 12- Medical Management of The Complex Patient > Flashcards

Week 12- Medical Management of The Complex Patient Flashcards

1
Q

PART 1: THE CAREGIVER

A

PART 1: THE CAREGIVER

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2
Q

Caregivers:

  • The “______________”
  • ___% female, ___% spouses, ___% adult children.
  • __/__ of caregivers are the sole source of support.
A
  • “invisible workforce”
  • 60% female, 20% spouses, 50% adult children
  • 1/3
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3
Q

Where do PTs fit in with caregivers? (5)

A
  • Sharing expertise.
  • Providing education on safety and efficacy of a task.
  • Assisting with home modifications and equipment needs.
  • Finding community resources.
  • Learning from the caregiver.
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4
Q
  • What are some caregiver stressors? (4)

- What are the PT considerations for each?

A
  1. ) Physical Health
    - Assess home environment and abilities of caregiver.
  2. ) Psychological Health
    - Use caregiver burden scales or open conversation about stress levels.
  3. ) Social Well-being
    - Use caregiver burden scales or open conversation about stress levels.
  4. ) Economic Well-being
    - Access community resources.
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5
Q

How can we assess caregiver outcomes/stressors?

A

Caregiver Burden Scales

-16 specific to Dementia (more tan 35 available)

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6
Q

What are the dimensions of caregiver burden in Dementia? (3)

A
  • Direct impact of caregiving on caregivers’ lives
  • Guilt
  • Frustration/embarassment
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7
Q

What is the most widely used measure of caregiver burden that consists of 22 items assessing burdens associated with patient behavioral and functional impairments?

A

Zarit Burden Interview

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8
Q

What is caregiver burnout?

A

State of physical, emotional, and mental exhaustion and distress that may include depression, agony, anxiety, etc.

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9
Q

What are the signs of burnout syndrome? (3)

A
  • emotional exhaustion
  • depersonalization
  • reduction in personal fulfillment
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10
Q

Caregiver Burnout Effects:

  • Interferes with _______ of care.
  • Risk of mental/physical problems for the caregiver.
  • Early patient ____________.
  • Increased risk for ________.
A
  • -quality of care
  • early patient institutionalization
  • abuse
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11
Q

PART 2: MEDICALLY COMPLEX PATIENT

A

PART 2: MEDICALLY COMPLEX PATIENT

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12
Q

What all should we be looking for when performing a chart review of the medically complex patient? (7)

A
  • Summary of why patient came to ED
  • PMH
  • Past surgical history
  • Medications
  • Lab values
  • Diagnostics
  • Other provider notes
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13
Q

What should we assess for first and why?

A

Assess cognition first because this will drive the direction of communication and POC.

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14
Q

List of Common Pathological Conditions. (9)

A
  • Coronary Heart Disease (CHD)
  • Acute Coronary Syndrome (ACS)
  • Heart Failure (HF)
  • Pneumonia
  • UTI
  • Sepsis
  • Dizziness
  • Dehydration
  • Metabolic Syndrome
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15
Q

Coronary Heart Disease:

  • Elevated _____ and ____________.
  • Systolic HTN, if left untreated, can lead to what?
  • Increased arterial stiffness and ventricular wall thickening leads to vascular constriction. These changes lead to reduced EF and increased O2 demand ultimately resulting in _________.
  • When CHD progresses to cause ischemia, we get ____________. This is a severe imbalance of O2 demand and supply.
A
  • LDLs and total cholesterol
  • LV hypertrophy
  • ischemia
  • Acute Coronary Syndrome (ACS)
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16
Q

CHD Comorbidities. (4)

A
  • DM
  • CA
  • Atherosclerosis
  • Increased mortality
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17
Q

What is the gold standard diagnostic testing procedures for CHD? (2)

A
  • Graded Exercise Testing

- Cardiac Catheterization

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18
Q

What are some common medications used to treat CHD? (5)

A
  • Diuretics
  • Beta-blockers
  • Ca+ channel blockers
  • ACEi, ARBs
  • Statins
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19
Q

Heart Failure:

  • Involves a _____ dysfunction in which the metabolic needs are unmet.
  • What are the 1st and 2nd leading causes of HF?
  • What are the S/Sx? (4)
A
  • pump dysfunction
  • 1st = ischemic LV dysfunction d/t CAD, 2nd = HTN
  • Fatigue, SOB, decreased activity tolerance, mixed L/R S/Sx
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20
Q

HF Comorbidities. (3)

A
  • Valvular Disease
  • CAD
  • HCM
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21
Q

How do we test for HF?

A
  • Pitting edema
  • JVD
  • Adventitious breath sounds
  • Dyspnea
  • Orthopnea
  • Tachypnea
  • Desaturation
  • BNP values between 100-1000
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22
Q

What are some common medications used to treat HF? (4)

A
  • Diuretics
  • ARNIs
  • Antihypertensives
  • Digoxen
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23
Q

Describe the Pitting Edema Scale.

A 
1+ = 2mm depression with immediate rebound
2+ = 4mm depression with a few seconds to rebound
3+ = 6mm depression with 10-12s to rebound
4+ = 8mm depression with >20s to rebound
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24
Q

Cardiac Considerations:

  • Pulse Pressure = _____-_____
  • What pulse pressure is normal and what required medical attention?

-OH = ___mmHg drop in SBP, or ___mmHg drop with increased HR

  • HR = increase ___-___ bpm/MET
  • BP = increase ___-___mmHg
A
  • DBP-SBP
  • Normal = 40mmHg, >60 requires medical attention

-OH = 20mmHg drop in SBP, or 10mmHg drop with inc HR

  • 10-20bpm/MET
  • 10-12mmHg
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25
Q

Pneumonia:

  • ___ leading cause of death in community-dwelling older adults.
  • 2nd cause of nosocomial infections (behind _____)
  • ___________-ACQUIRED pneumonia accounts for 50% of cases of sepsis and has a 33% mortality rate.
A
  • 6th
  • behind UTIs
  • HOSPITAL-ACQUIRED pneumonia
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26
Q

What are some ways Pneumonia is diagnosed? (5)

A
  • Chest Xray
  • Positive findings of infitrates or consolidation
  • Elevated WBC count
  • Desaturation of SaO2 even at rest
  • Chest pain, pleuritis
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27
Q

What are some common medications used to treat Pneumonia? (2)

A
  • Antibiotics or antivirals

- Oxygen

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28
Q

List (5) ways to administer O2 and their LPM/FiO2 levels.

A

Nasal Cannula
-LPM = 1-6, FiO2 = 24-44%

Salter High Flow Nasal Cannula
-LPM = Up to 15, FiO2 = 54-75%

High Flow Nasal Cannula
-LPM = Up to 60, FiO2 = Up to 100%

Partial Rebreather Mask
-LPM = 6-10, FiO2 = 60-80%

Non-Rebreather Mask
-LPM = 10-15, FiO2 = 60-80%

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29
Q
  • At what FiO2 level is mechanical vent needed?

- Which O2 administration is most common?

A
  • 0.6 (60%)

- nasal cannula

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30
Q

Pulmonary Considerations:

  • Average respiratory rate = ___-___ breaths/min.
  • 1:1 insp/exp rate suggests _____ventilation, 1:3 suggests ______ventilation.
  • Observe expansion of chest wall in all directions.
  • Speech = ___-___ syllables/breath.
  • Error rate for pulse-ox up to 5-6%, what is the most accurate placement?
  • Auscultation: normal vs ________ sounds
A
  • 12-20 breaths/min
  • 1:1 suggests hyperventilation, 1:3 suggests hypoventilation
  • 12-15 syllables/breath
  • earlobe
  • adventitious
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31
Q

UTI:

  • Accounts for __/__ of infections in nursing home residents.
  • What is the primary cause of UTIs?
  • What is the BIGGEST change that occurs due to UTIs in OLDER ADULTS?
A
  • 1/3
  • urinary stasis (indwelling catheter may also cause)
  • ACUTE DELIRIUM
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32
Q

What is the primary cause of urinary stasis leading to UTI in older men vs older women?

A
  • Older women = decreased pelvic floor strength and estrogen levels
  • Older men = decreased bladder emptying d/t BPH
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33
Q
  • If we see a sudden onset of delirium, what are we thinking?
  • Is it easily treatable?
A
  • Infection (often UTI)

- Yes, antibiotics

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34
Q

Sepsis:

  • What is it?
  • Is the mortality rate low?
  • Leading cause of __________ and is the most expensive inpatient condition.
A
  • “Life-threatening organ dysfunction caused by a deregulated host response to infection.”
  • No, mortality rate of 51%!
  • Leading cause of hospitalization.
35
Q

Septic Shock:

  • What is it?
  • Mortality 4x greater when Septic Shock criteria met. What are these criteria? (2)
A

-Abnormal circulatory and cellular metabolism profound enough to significantly increase mortality.

  1. ) Persisting hypotension that requires vasopressors to maintain MAP at 65mmHg or greater.
  2. ) Blood lactate >2mmol/L despite volume resuscitation.
36
Q

Describe the pathophysiology of sepsis. (6)

A
  1. ) Sepsis differentiated from infection by a dysregulated host response that results in organ dysfunction.
  2. ) Loss of adaptive homeostasis in response to infection.
  3. ) High degree of mortality risk with organ dysfunction.
  4. ) Anti-inflammatory response fails to develop.
  5. ) Proinflammatory process becomes unregulated.
  6. ) Results in cascade of dysfunction.
37
Q

Sepsis S/Sx:

  • Lactate >___mg/dL
  • _____tensive
  • Fever >____ degrees
  • HR >___bpm
  • RR >___breaths/min
A
  • Lactate >18mg/dL
  • hypotensive
  • Fever >103 degrees
  • HR >90bpm
  • RR >20 breaths/min
38
Q

Clinical manifestations of Sepsis can occur in what systems? (6)

A
  • Cardiovascular
  • Pulmonary
  • CNS
  • Renal
  • GI
  • Hepatic
  • Hematologic
39
Q

Sepsis CV Clinical Manifestations. (5)

A
  • Hypotension
  • Tachycardia
  • Elevated CO (drops with septic shock)
  • Systemic vascular resistance drops with septic shock
  • Hypoperfusion exacerbated -> lactate accumulation
40
Q

Sepsis Pulmonary Clinical Manifestations. (4)

A
  • Tachypnea
  • Hypoxemia (vent:perf mismatch)
  • Respiratory alkalosis
  • Pulmonary edema and respiratory failure -> ARDS
41
Q

Sepsis CNS Clinical Manifestations. (3)

A
  • Altered mental status
  • Encephalopathy
  • Polyneuropathy
42
Q

Sepsis Renal Clinical Manifestations. (2)

A
  • Oliguria

- Azotemia

43
Q

Sepsis GI Clinical Manifestations. (2)

A
  • Impaired motility

- Stress ulceration

44
Q

Sepsis Hepatic Clinical Manifestations. (3)

A
  • Elevated serum transaminase
  • Hyperbilirubinemia
  • Final stages: hepatic insufficiency
45
Q

Sepsis Hematologic Clinical Manifestations. (4)

A
  • Leukocytosis
  • Multifactorial anemia
  • Thrombocytopenia and coagulation abnormalities
  • Disseminated intravascular coagulation (DIC) is a late-stage manifestation
46
Q

Sepsis Implications for PT:

  • Can we perform PT in ICU/acute care once stable?
  • Are patients able to safely respond to increased vascular and O2 demands on exam/treatment?
  • Patient status can fluctuate by the minute, therefore we must provide “________-dependent management”.
  • ______ and _______ of O2 must match.
A
  • Yes
  • Yes
  • response-dependent management
  • delivery and consumption
47
Q

How to Tell Vestibular from Cardiac Dizziness:

Vestibular:

  • _______ most common cause in older adults.
  • ______ is also common in older adults.

Cardiac:

  • ______ is more often the symptom of dizziness.
  • _____ and _______ to monitor cardiac function/blood flow.
A

Vestibular

  • Vertigo
  • BPPV

Cardiac

  • Syncope
  • ECG and Holter
48
Q

How do we rule in/out OH as a cause for dizziness?

A

Take positional BP

49
Q

What are some medications that can cause dizziness? (3)

A
  • Antihypertensives
  • Diuretics
  • Sedatives
50
Q

What are some things we can do to find the cause of dizziness? (6)

A
  • Ask the right questions!
  • Comorbidities (DM, cardiac)
  • Medication list
  • Vitals (positional BP)
  • Sensory assessment
  • Nutritional status
51
Q

Dehydration:

  • What are the (3) types of dehydration?
  • Why are older adults more susceptible to dehydration? (4)
  • What are the S/Sx of dehydration? (4)
A
  • Hypertonic, Isotonic, and Hypotonic Dehydration
  • Blunted thirst mechanism, reduced total body fluid, decreased renal function, physical/mental decline
  • Confusion, lethargy, rapid weight loss, functional decline
52
Q

Dehydration Risk Factors:

  • ________ age
  • _______ gender
  • BMI between ___-___
  • Dementia
  • Hx of CVA, UI, infections
  • Use of _______
  • ____pharmacy
  • Declining functional independence
A
  • advanced age
  • female
  • BMI 21-27
  • Use of steroids
  • polypharmacy
53
Q

______tonic Dehydration:

  • Water < Na+ loss
  • Closely monitor Na+ lab values

______tonic Dehydration:

  • Water > Na+ loss
  • Infection, hot temperatures

_____tonic Dehydration:

  • Water = Na+ loss
  • V/D
A
  • Hypotonic
  • Hypertonic
  • Isotonic
54
Q

Which type of dehydration is most common in older adults?

A

Hypotonic Dehydration

-Water < Na+ loss

55
Q

Dehydration Clinical S/Sx. (9)

A
  • Decreased cognitive/mental status
  • Dry mucosa
  • Decrease skin turgor
  • Tachycardia
  • Decrease BP
  • OH
  • Weight loss in short time
  • JVD
  • Decrease muscle strength, balance, function
56
Q

Metabolic Syndrome:

  • What is it?
  • Affects about ___% of the US population.
  • Also referred to as what?
  • “_______ ______”
  • Increased incidence of _____ and ___ events.
A
  • A cluster of conditions that increase the risk of heart disease, stroke, and diabetes.
  • 30%
  • Insulin Resistance Syndrome (IRS)
  • “Vicious Cycle”
  • T2DM and CV events
57
Q

What are the criteria for Metabolic Syndrome and how many must they have to be classified?

A
  1. ) Abdominal Obesity
  2. ) High Triglycerides
  3. ) Decreased HDLs
  4. ) Increased BP
  5. ) High fasting glucose

Must have 3+/5

58
Q

What is Frailty?

A

Multisystem presentation that creates loss of function and physiological homeostasis.

59
Q
  • What is the key HALLMARK OF FRAILTY?

- What is the role of the PT in treating the frail?

A
  • DECREASED PHYSIOLOGIC RESERVE

- Identify frailty and ensure patient receives necessary and appropriate services.

60
Q

What are the (5) phenotypes of frailty?

A
  • Unintentional weight loss
  • Self-reported exhaustion
  • Muscle weakness
  • Slow walking speed
  • Low physical activity
61
Q

What are the classifications of frailty based on how many phenotypes they have?

A
  • Not Frail = 0
  • Prefrail = 1-2
  • Frail = 3+
62
Q

What are some other tools we can utilize to diagnose frailty besides phenotypes?

A
  • Frailty Index
  • Frailty Index for Elders - Questionnaire
  • Gait Speed, Grip Strength, Repeated Chair Stands
  • Comprehensive Geriatric Assessment (CGA)
  • Frailty Index
  • TUG (>10s)
  • Gait speed (<0.8m/s)
  • Frailty Index for Elders (FIFE)
  • Phenotype of Frailty
  • Life Space
63
Q

Frailty Assessment Tools:

  • Gait Speed 20x more likely
  • Grip Strength
A
  • <0.65m/s
  • <25kg
  • <7x in 30s
64
Q

What are (3) other aspects of frailty?

A
  • Cognitive Frailty
  • Psychological Frailty
  • Social Frailty
65
Q

What are the 4 degrees of frailty and their measures on the following:

  • Gait Speed
  • 30s CRT
  • Floor transfers
A

Fit (not frail)

  • Gait = >1.0-1.2m/s
  • 30s CRT = 15 reps or more
  • Independent floor transfers

Mild Frailty

  • Gait = 0.8-1.2m/s
  • 30s CRT = 8-15 reps or more
  • Modified floor transfers

Moderate Frailty

  • Gait = 0.5-0.8m/s
  • 30s CRT = <8 reps
  • Assisted floor transfers

Severe Frailty

  • Gait = <0.5m/s
  • 30s CRT = Unable
  • Unalbe to floor transfer
66
Q

Describe how frailty affects response to stress. (Healthy vs Frailty)

A
  • In a healthy individual, you are at the top of independence. When you have a minor illness, your independence level only slightly drops.
  • When you are a FRAIL individual, you are at the lower end of independence. When you have a minor illness, you drop further into dependence.
67
Q

What is the difference between mobility disability and frailty?

A

Mobility disability may have a larger metabolic reserve vs frail persons.

68
Q

Pathophysiology of Frailty. (7)

A
  • Pro-inflammatory state
  • Blunted immune response
  • Autonomic dysfunction
  • Kidney dysfunction
  • Anemia
  • Malnutrition
  • Endocrine dysfunction
69
Q

Etiology of Frailty. (3)

A
  • Multifactorial (genetic, environmental, metabolic, lifestyle stressors)
  • Acute and chronic diseases (results in multisystem impairments across multiple physiologic systems)
  • Impaired homeostatic mechanisms
70
Q
  • Progressive __________ exercise is a key component for treating frailty.
  • ___ week programs can show significant gain.
  • _____-intensity effort is key.
A
  • resistance
  • 12 week program
  • high-intensity
71
Q

Frailty Exercise Parameters:

  • ___-___% 1RM
  • 8 reps for 1 set, working up to __ sets.
  • Are LE or UE exercises a priority?
A
  • 40-80% 1RM
  • 3 sets
  • LE
72
Q

Why is floor transfer training important? What can increased time on the floor lead to?

A

If stuck on floor, can cause rhabdomyolysis from compressed areas.

73
Q

What are some other interventions used to treat frailty? (3)

A
  • Nutrition
  • Hormone treatment
  • Pharmaceuticals
74
Q

Frailty Primary Prevention (Triple Aim):

  • Regular engagement in ____-____ physical activity.
  • _________ stimulating activities.
  • Healthy diet/supplementation as needed.
  • Ideal sleep.
  • Maintaining proper body ________.
  • __________ control (blood sugar, blood pressure, blood lipids).
A
  • mod-vig physical activity
  • cognitively stimulating
  • body weight
  • metabolic control
75
Q

Frailty Secondary Prevention (Triple Aim):

  • Use assessment too to identify key underlying deficits.
  • Implement a _________ approach. (med management, falls prevention, nutritional support, social/psych support, exercise program)
A

-multimodal

76
Q 
Osteoporosis:
-What is it?
How is it different from osteopenia?
-12.6% of adults over \_\_\_.
-What are the (2) types of osteoporosis?
A
  • Metabolic bone disorder resulting in decreased bone mass and density.
  • Osteopenia is a lesser form of osteoporosis
  • over 50
  • Primary (postmenopausal, idiopathic), Secondary (following disease condition)
77
Q

Osteoporosis Risk Factors:

  • ____-_______ (_______ deficiency)
  • Other hormonal factors
  • ______ lifestyle
  • Vitamin ___ deficiency
  • Smoking
  • Asian/caucasian
  • Excessive caffeine consumption
A
  • post-menopausal (estrogen deficiency)
  • sedentary lifestyle
  • Vitamin D deficiency
78
Q

What are T scores and how do they define osteoporosis?

A

-WHO diagnostic classification in postmenopausal women, men over 50. Cannot be applied to healthy and young population.

79
Q

What is the difference between T-scores and Z-scores?

A
  • T-scores are better at determining if you have osteoporosis.
  • Z-scores are better at assessing your 10-year risk for developing osteoporosis.
80
Q
  • Osteoporosis T-score = _____

- Osteopenia T-score = _____

A
  • Osteoporosis T-score = -2.5 or less

- Osteopenia T-score = -1 to -2.5

81
Q

Pharmacological Treatments for Osteoporosis. (7)

A
  • Vitamin D + calcium
  • Fluoride supplements
  • Bisphosphonates
  • Calcitonin
  • Injected human parathyroid hormone
  • Raloxifene
  • Other: surgery to reduce kyphosis/realign vertebrae
82
Q

What are some exercises to build bone/strength in Osteoporosis? (2)

A

Standing / WBing exercises
Strengthening, flexibility, and balance activities

***Dosage depends on bone loss and level of fitness

83
Q

What are some exercises to avoid in Osteoporosis? (3)

A
  • Trunk flexion and excessive rotation
  • High impact exercises
  • Joint mobilizations/manual percussion

S7- Special Populations (18 decks)

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