Acute Care

Patient Safety - Basic Guidelines

• Reduce the risk of health-care associated infections

• Familiarity with alarm systems (code call buttons, staff assist, etc.)

• Confirmation of the correct patient to treat

• Proper body mechanics during patient treatment

• Use equipment in good working condition

• Keep the patient’s room clean and clutter free

• Provide recommendations for the nursing staff

Fall - Definition

• Defined as an event that results in a person coming to rest inadvertently on the ground/floor/other lower level

• Patients may be conscious or unconscious

• One of the more common adverse effects and accounts for increased

• personnel needs, length of stay, cost, morbidity and mortality, especially of older adults

• Fall risk assessment (advanced age, medications, visual acuity, muscle strength, functional abilities)

Medical conditions associated with falls

neurologic, orthopedic, cognitive, postural/orthostatic hypotension

Morbidity vs Mortality

• Mortality = state of being dead / frequency of being dead

• Morbidity = disease prevalence

Latex Allergy

• Either allergic to the natural rubber in latex, or the chemicals used to produce latex

• Includes gloves, stethoscopes, cuffs, airway and IV tubing, electrodes, etc.

Restraint Definition

• Any manual method, physical, or mechanical device that reduces patient movements especially the extremities

• Examples: wrist/ankle restraints, mitt restraints, vest restraints, enclosure bed

Restraints - Indication

For patients who are at risk for self-harm or harm to others

Restraints - downsides

• increased agitation

• nerve or muscle damage

• alterations in skin integrity

Intensive Care Setting

• It is a place of intensive medical-surgical care for patients who require continuous monitoring, usually in conjunction with other therapies or medical interventions such as vasoactive medications, sedation, circulatory assist devices, and mechanical ventilation

• May be PICU, CICU, SICU, MICU depending on patient distribution

ICU - Intensive Care Setting

Patients are faced with environmental stressors such as physical restrictions, sleep deprivation, unfamiliar medical equipment, crowding, excessive lighting, odors, noises, and touch associated with procedures.

ICU - Psychological Stressors

diminished dignity and self-esteem, powerlessness, loss of autonomy, vulnerability, boredom, pain, fear, anxiety, isolation, uncertainty about the future, and spiritual distress

ICU Delirium or ICU Syndrome

increased with emergency surgery, polytrauma, organ failure, metabolic acidosis, coma, dementia, or advanced age

B-Type Natriuretic Peptide - Rationale

Assesses the biomarkers of heart failure, including natriuretic peptides

B-Type Natriuretic Peptide - Interpretation

• Normal Levels - 100pg/mL,

• Values above 500 are usually considered to be positive of heart failure, correlations between BMP and peak oxygen uptake

Blood urea nitrogen, plasma creatinine levels, urine output - Rationale

Assesses kidney function

N BUN values

6-30 mg/dL

N Creatinine Values

0.6-2.0 mg/dL

Oliguria values

<400 mL of urine in 24 hours

Anuria Values

<100mL of urine in 24 hours

Hemoglobin and hematocrit levels - Rationale

Assesses the oxygen carrying capacity within the system

N hemoglobin values

• 12-14 gm/mL of blood (males)

• 14-16 gm/100mL (women)

N Hematocrit values

• 45% men

• 45% women

Creatine Kinase - Myocardial band CK-MB index Rationale

• Creatine Kinase MB Subunit is an isoenzyme, is released into the blood and elevates with acute MI

Creatine Kinase - Myocardial band CK-MB index Values

• Normal level 0-3%

• Minor cardiac dysfunction 5%

• Major cardiac dysfunction 10%

• Peak levels 14-36 hours post MI

Troponin I - Rationale

• Most frequently used marker to assess the presence of an acute MI Troponin I

• isotype found in the myocardium and is therefore 100% cardiac specific

Troponin I - Values

• N levels 0-0.2 mcg/mL

• Minor cardiac dysfunction 5 mcg/mL

• Major cardiac dysfuntion 10 mcg/mL

• Peak level 24-36 hours post MI

C-Reactive protein - Rationale

• Measures the amount of protein in the blood that signals acute inflammation

• For a more sensitive test = high- sensitivity C-reactive protein assay is available to check for risk of Hemodialysis

C-Reactive protein - Values

hs-CRP <1.0 mg/L = low risk

hi-CRP 1-3 mg/L = average risk

hi-CRP 3 mg/L = high risk

Electrolyte Assessment - Rationale

Appraise the levels of potassium, calcium, and magnesium to allow for normal electrical condition throughthe heart

Electrolyte Assessment - Interpretation

• Hypokalemia - <3.5 mEq/L produces arrythmias with flattened T waves and depressed ST segments, as well as B LE muscle cramping

• Hypocalcemia and hypomagnesemia have the potential to increase ventricular ectopy within the heart

Effects of Hypokalemia

• produces arrythmias with flattened T waves and depressed ST segments

• B LE muscle cramping

Effects of Hypocalcemia and hypomagnesemia

potential to increase ventricular ectopy within the heart

Systemic Effects of Prolonged Bed Rest - Cardiac

• Increased heart rate at rest and with submaximal exercise

• Decreased stroke volume, VO2 Max, Left ventricular volume, and cardiac output

• Myocardial thinning

• Orthostatic hypotension

Systemic Effects of Prolonged Bed Rest - Hematologic

• Decreased total blood volume, red blood cell mass, and plasma volume

• Increased hematocrit

• Venous stasis, hypercoagulability, blood vessel damage

Systemic Effects of Prolonged Bed Rest - Respiratory

• Decreased lung volumes and capacities, (FRC, FVC, FEV1)

• Decreased mucocilliary clearance

• Increased risk of pneumonia, atelectasis, and pulmonary embolism

• Decreased arterial oxygen saturation

Systemic Effects of Prolonged Bed Rest - GI

• Decreased appetite, fluid intake, bowel motility, and gastric bicarbonate secretion

• GERD

• Difficulty swallowing

Systemic Effects of Prolonged Bed Rest - Genitourinary

• Increased mineral excretion, kidney stones, difficulty voiding, and urinary retention

• Increased risk of urinary tract infection

Systemic Effects of Prolonged Bed Rest - Endocrine

• Altered temperature and sweating responses, circadian rhythm, regulation of hormones, increased cortisol and glucose intolerance

• Decreased overall metabolism

Systemic Effects of Prolonged Bed Rest - MSK

• Increased muscle weakness (especially antigravity muscles), atrophy, decreased muscle endurance, risk of contracture,

• weakened myotendinous junction

• Disuse osteoporosis

• Degeneration of cartilage, synovial atrophy, and ankylosis

Systemic Effects of Prolonged Bed Rest - Neurologic

• Sensory and social deprivation

• Decreased dopamine, noradrenaline, and serotonin levels

• Depression, restlessness, insomnia

• Decreased balance, coordination, and visual acuity

• Increased risk of compression neuropathy

• Reduced pain threshold

Systemic Effects of Prolonged Bed Rest - Integumentary

pressure injury formation

Systemic Effects of Prolonged Bed Rest - Immune

• Increased risk of reactivation of latent viruses

• Reduced immune response and immunity

Systemic Effects of Prolonged Bed Rest - Psychological

• Impaired self worth and self esteem

• Increased risk of delirium, depression, and post-traumatic stress syndrome

Systemic Effects of Prolonged Bed Rest - Body composition

• Increased sodium, potassium, calcium, phosphorus, and nitrogen loss

• Increased body fat and decreased lean body mass

• Fluid shift from legs to abdomen/thorax/head, diuresis

PT Considerations

• Be aware of the psychosocial aspects of prolonged bed rest including sensory deprivation, boredom, depression, and sense of loss of control

• Expect fear when patients get out of the bed for the first time especially if they are aware of their impairments

• Leave necessities and commonly used items near the patient to minimize the feeling of confinement

• Use chair alarm systems or restraints, if ordered, to minimize the risk of falls and other untoward incidents

Infectious Diseases - Antibody

Highly specific protein that is manufactured in response to antigens and defends against subsequent infection

Infectious Diseases - Antigen

Agent that is capable of producing antibodies when introduced into a body of a susceptible person

Infectious Diseases - Communicable

The ability of an infective organism to be transmitted from person to person, either directly or indirectly

Infectious Diseases - Health Care Associated Infection

Localized or systemic condition resulting from an adverse reaction to the presence of an infectious agents(s) or its toxin(s); there must be no evidence that the infection was present or incubating at the time of admission to the acute care setting

Infectious Diseases - Immunocompromised

An immune system that is incapable of a normal response to pathogenic organisms and tissue damage

Infectious Diseases - Immunodeficiency

The prevention or diminution of the immune response, as by drugs or radiation

Infectious Diseases - Immunosuppression

The prevention or diminution of the immune response, as by drugs or radiation

Infectious Diseases - Nosocomial Infection

Infection acquired in the hospital setting; note that this has been replaced by the term HAI

Infectious Diseases - Opportunistic

An infectious process that develops in immunosuppressed individuals (Opportunistic infections normally do not develop in individuals with intact immune systems.)

Infectious Diseases - Subclinical Infection

A disease or condition that does not produce clinical symptoms, or the period before the appearance of disease specific symptoms

Factors Affecting the Immune System

• Pregnancy

• Preexisting infections

• Malignancies (Hodgkin’s disease, acute or chronic leukemia, nonlymphoid malignancy, or myeloma)

• Stress (emotional or surgical-anesthesia)

• Malnutrition

• Age

• Chronic diseases

• Lymph node dissection

• Immunosuppressive treatment (corticosteroids, chemotherapy or radiation therapy)

• Indwelling lines and tubes

Corticosteroid Use - Immunosuppressive

• Reduction of WBC activity to the site of infection or injury

• Decrease T cell proliferation

  • Weakens adaptive immunity

• Impaired antigen presentation

  • Macrophages and dendritic cells are less effective in recognizing pathogens

Corticosteroid Use - Susceptibility to Infections

• Tuberculosis and herpes

Corticosteroid Use - Wound healing

• Delayed

• inhibition of fibroblast activity

Summary of Precautions to Prevent Infection - Standard

• Wash hands before and after each patient contact. Wear a different set of gloves with each patient.

• Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (e.g., wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient).

Summary of Precautions to Prevent Infection - Airborne

• A respirator (preferable) or mask is required in situations in which contagious pathogens can be transmitted by airborne droplet nuclei, which can stay in the air for more than an hour and can travel >10 feet because of their small size (<5 μm).

• The preferred placement for patients who require Airborne Precautions is in an airborne infection isolation room (AIIR).

• An AIIR is a single-patient room that is equipped with special air handling and ventilation capacity (e.g., negative pressure)

Summary of Precautions to Prevent Infection - Droplet

• A mask or face shield, or both, are required when large-particle (>5 μm in size) droplet transmission (usually 3 ft or less) is likely.

• Droplets can be generated from coughing, sneezing, and talking.

• Spatial separation of ≥3 feet and drawing the curtain between patient beds is especially important for patients in multi-bed rooms

• Healthcare personnel should wear a mask (a respirator is not necessary) for close contact with infectious patients, and the mask is generally donned upon room entry

Summary of Precautions to Prevent Infection - Contact

• Gown and gloves are required when pathogens are transmitted bydirect person-to-person contact or person-to-object contact.

• It is important to use disposable or dedicated patient-care equipment (e.g., gait belt), don PPE upon room entry, and discard it before exiting the patient room.

• Patients on Contact Precautions who must be transported outside of the room should have the infected or colonized areas of the patient’s body covered or contained.

Contact (enteric)

• Agents spread by direct or indirect contact

• Example agents: MRSA, Gram-negative bacterial infections, Clostridium difficile

• Hand hygiene (Chlorhexidine soap), gloves, gown

• Mask not required

Droplet

• Agents spread through mucous membranes and respiratory secretions

• Example agents: Mumps, Neisseria meningitidis

• Hand hygiene, mask

• Patient must wear surgicalmask when out of room

Airborne

• Agents that remain infectious and suspended in the air over long distances

• Example agents: Varicella virus, Rubeola virus, Mycobacterium tuberculosis, SARS-COV-2

• Hand hygiene, fit-tested N95

• Patient must wear surgical mask when out of the room

Antibiotic Reisstant Infections are due to?

Due to inappropriate antibiotic use in healthcare institutions and hospitals

Antiobiotic Resistant Infections - Multidrug-resistant

At least one agent in three or more antimicrobial categories

Antiobiotic Resistant Infections - Extensively Drug Resistant

At least one agent in all but two or fewer categories

antibiotic resistant infections – pandrug resistant

Non-susceptibility to all agents in all antimicrobial categories

Antibiotic resistant infections – examples

• methicillin resistant staphylococcus (MRSA)

• Multidrug resistant microbacterium tuberculosis (MDR – TB)

• Vancomycin resistant enterococcus (VRE)

• Extended spectrum beta lactamass (ESBL) bacteria

  • Escherichia Coli and Klensiella pneumoniae

• Multidrug resistant pseudomonas aeroginosa

• Multi drug resistant Acinetobacter baumanni (MDRAB)

• Clostridoides difficile (C. Diff)

1. Proper hand washing technique

Hand washing with soap and water is the best method to remove pathogens, including highly contagious pathogens (e.g. Norovirus, C. Diff,) from your hands

1. What your hands with clean, running water (warm or cold), and apply soap

2. Lather your hands by rubbing them together with the soap. Be sure to lather the back of your hands, between your fingers, and under your nails.

3. Scrub your hands for at least 20 seconds. Some pathogens such as norovirus, require a longer time at least 60 seconds to remove stool contamination from hands

4. Rinse your hands well under running water (stool contaminated norovirus hands should be rinsed for at least 20 seconds)

5. Dry your hands using a clean, disposable tower, or air dry them.

Hand washing - if soap and water are not available

If soap and water are not available, use an alcohol based hand sanitizer that contains at least 60% alcohol. (continue to rub the sanitizer overall hand and finger surfaces until dry). Alcohol based hand sanitizers can quickly reduce the number of pathogens, but do not remove all pathogen types e.g. Norovirus, C. Difficile spores

Medical surgical equipment

• Medical surgical equipment is used in all areas of the hospital. Some type types of equipment are used only in specialty areas, such as the intensive care unit.

• The presence of certain types of equipment in a patient’s room can provide the physical therapist with a preliminary idea of the patient’s general medical condition and the appropriateness of therapeutic physical therapy intervention, prophylactic physical therapy intervention, or both

Oxygen therapy

• The general indication is hypoxemia

• Increase O2 levels in the blood and alveoli to improve oxygenation

• Hypoxemia

  • SaO2 <90% (Some cases <88%)

  • Arterial blood O2 partial pressure is <60 mmHG

Oxygen therapy indications

severe trauma, shock, acute myocardial infarction, surgery, carbon monoxide/cyanide

Variable Oxygen Delivery for SBA - FiO2

• Fraction of inspired oxygen

• The concentration of oxygen in the gas mixture.

• The gas mixture in room air has a fraction of inspired oxygen of 21%, meaning that the oxygen concentration in room air is 21%.

FiO2 - COPD

<88%

FiO2 - MI or stroke

Min <93%

Variable oxygen delivery For SBA - Nasal Canula

• Delivers supplemental O2 mixed with RA (21%), usually 1–6 lpm

• Fio2 - 24 to 44%

Variable oxygen delivery for SBA – open face tent

• Provides humidified, supplemental O2 mixed with RA

• Can also be used for nebulized medications

• Fio2 - 30 to 55

Variable oxygen delivery for SBA – Closed face mask

• Delivers supplemental O2 mixed with RA

• Mask capacity is limited but does allow for the collection of O2 about the nose and mouth

• Fio2 - 40 to 60%

Variable oxygen delivery for SBA – Transtracheal oxygen catheter

• Used for long-term O2 therapy

• Indicated when there are complications with or suboptimal nasal cannula use, nocturnal hypoxemia despite nasal cannula

Variable Oxygen Delivery for SBA - Tracheostomy mask or collar

• Provides supplemental, humidified O2 or air at a tracheostomy site

• Fio2 - 28 to 100%

Variable Oxygen Delivery for SBA - Partial non-rebreather mask

• Mix of supplemental O2 and RA

• Provides a high FiO2 to the patient while conserving the O2 supply

• Two-way valves in the mask allow for RA inhalation in addition to supplemental O2.

• Fio2 - 40 to 60%

Variable Oxygen Delivery for SBA - non-rebreather mask

• Provides the patient with the highest concentration of supplemental

• O2 available via a face mask in a variable-performance system

• One way valves control inflow of supplemental O2 and outflow of exhaled air so that the patient is only breathing the supplied O2

• FiO2 - 60-80%

Fixed Performance Oxygen Delivery - Air entrapment Mask

• Provides a specific concentration of supplemental O2 using color- coded diluter pieces to ensure accurate FiO2 delivery

• Fio2 - 24 to 50%

Fixed Performance Oxygen Delivery - BiPAP

• Bilevel Positive Airway Pressure

• Pressure-supported, noninvasive ventilation that provides positive inspiratory and end-expiratory pressure

• May be used to avoid intubation and mechanical ventilation

• Often used in the hospital or home setting for the management of obstructive sleep apnea

• Fio2 - 21 to 100%

Non-Invasive Medical Monitoring - Telemetry

Continuous monitoring of heart rate and rhythm and respiratory rate (ECG)

Non-Invasive Medical Monitoring - Pulse Oximeter

A noninvasive, transcutaneous method of monitoring the percentage of hemoglobin saturated with O2 in arterial blood

Invasive Medical Monitoring - Arterial Line

Direct and continuous monitoring of systolic, diastolic, and MAP; source for repeated arterial blood gas

Medical surgical management devices - AV fistula / graft

Provides access for long term hemodialysis

Invasive Medical Monitoring - Central Venous Catheter

• Indicated for a patient with significant fluid volume deficit and is used as a guide to overall fluid balance

• Measurement of CVP is a direct reflection of right heart function

• Also provides vascular access for parenteral nutrition, large fluid volumes, or noxious medication

Medical surgical management devices - Chest tube

• Removes and prevents the reentry of air or fluid from the pleural or mediastinal space and provides negative intrapleural pressure

• Used to treat pneumothorax, hemothorax, pleural effusion

Medical surgical management devices - Nasogastric Tube

For feeding, gastric decompression and keeping the stomach empty after surgery

Medical surgical management devices - Nebulizer

Delivers aerosolized water or medications to the respiratory tract, lungs, throat, or nose

Medical surgical management devices - Percutaneous endoscopic gastronomy / jejunostomy

Provides long-term access for nourishment to patients who are

• unable to tolerate food by mouth

• or have a nasoenteral obstruction,

• or for a patient with confusion/ agitation at risk for nasoenteral tube dislodgement

Medical surgical management devices - Peripheral IV Line

• Provides temporary access for delivery of medications, fluids, electrolytes, nutrients, or blood product transfusions

• It cannot be used to draw blood

Medical surgical management devices - Peripherally inserted central catheter

• Provides IV access for administration of total parenteral nutrition (TPN), medications, fluid, blood products, or chemotherapy.

• Generally placed for midterm access (weeks to months)

Medical surgical management devices - Sequential compression devices

• Provides intermittent pressure to the lower extremities via gradual and sequential inflation and deflation of the air-filled sleeves

• Promotes venous return and prevents deep vein thrombosis (DVT) and venous thromboembolism (VTE) secondary to prolonged or postoperative bed rest or inactivity