Acute Care Midterm

Lectures 1-6

APTA minimal entry-level requirements

sound clinical decision making, safety, skills, D/C planning, communication

acute care primary concern

medical status

acute care PT

bedside tx, dx vary, tx time 15-60 mins; focused on mobility, general strengthening, balance, endurance, DME recommendations and d/c planning

inpatient rehab/acute rehab primary concern

functional status

inpatient rehab/acute rehab

tx in gym, dx more specific, tx minimum 180mins/day (requires 2 disciplines); tx focused on independence in mobility, strengthening, neuro re-ed, balance, condition, education for pt/family/caregivers; LOS 10-14 days

acute care discharge goal

most appropriate, least restrictive (home health v SNF v inpt rehab)

inpatient rehab/acute rehab discharge goal

must anticipate d/c back to community within 3-4 weeks

subacute rehab/SNF

tx in gym, dx variable (less strict); tx time varies (often 30min-1hr/day); LOS longer than inpatient rehab (up to 100 days under Medicare A)

subacute rehab/SNF discharge goal

back to community

continuum of care

acute → inpatient rehab → subacute rehab→ home health → outpatient

acute care PT skills

* bed mobility
* pathophysiology
* pharmacology
* imaging
* gait training
* transfer training
* ROM
* strength
* education
* evaluation
* assistive devices/equipment
* teamwork
* D/C planning
* FLEXIBILITY

acute care PT evaluations

* look at function (history, PLOF)
* gross evaluation of strength, ROM, mobility (transfers, bed, ambulation, sensation)
* goals (short)
* D/C planning

upper and lower quarter screens

brief evaluation of (B) strength, ROM, sensation, and DTR; efficient way to grossly examine neuromuscular status (guides PT where to do more in depth/specific testing)

acute care goals

* functional
* timeframe (1-3 days, 3-5 days, 7 days)
* realistic

acute care POC

BID, QD, 3-5x/week (2x/day, everyday); level of care (skilled vs maintenance; inform pt and nursing

treatment sessions

functional activities (bed mobility, transfers, gait, stairs), strengthening, ROM, balance

acute care equipment

assistive devices, stand aids (SAL), hoyer lift, TBand, cones, stairs

how is productivity measured

by total number of patients or units (often lower than other settings due to time required to review charts, speak with other team members, travel between floors, etc

early mobilization

initiating mobility when pt is minimally able to participate; emphasis is on progressive mobility as pt’s medical status allows

cardiovascular consequences of immobility

* ↓ CO and max SV
* ↓ exercise tolerance
* ↓ orthostatic tolerance
* venous pooling

hematologic consequences of immobility

* ↓ blood volume
* ↓ red blood cells
* ↑ risk of DVT

MSK consequences of immobility

muscle atrophy, bone demineralization

pulmonary consequences of immobility

* ↓ lung capacity
* ↓ respiratory muscle strength
* ↑ risk of pneumonia/pulmonary emboli

metabolic/endocrine consequences of immobility

* ↑ insulin resistance
* ↑ urinary excretion of electrolytes and minerals
* ↑incidence of kidney stones

psychiatric consequences of immobility

* ↑ anxiety, delirium, depression, agitation

effects of early mobilization

decrease LOS, adverse events, improved functional outcomes

is early mobilization safe?

only 2-4% had “untoward” events (physiological responses, line removal)

early mobilization additional benefits

pressure relief, lung expansion, regaining night/day cycle, improve alertness during day to promote sleep at night

who is appropriate for early mobilization?

can follow minimal commands, hemodynamically stable, receiving adequate oxygenation

CV appropriate pts for early mob

* HR> 50 and

pulmonary appropriate pts for early mob

* RR < 35 breaths/min
* SpO2 >90%

when to terminate session?

* SpO2

Johns Hopkins Activity and Promotion Program (JH-AMP)

created to simplify implementation of early mobilization programs for facilities; increase compliance of all staff with mobility equipment and goals

barriers to early mobility

fear, limited staffing, coordination among disciplines

AMPAC 6- Clicks

most commonly used measure in acute care; 6 questions, can be used to predict discharge destination

AMPAC 6-Clicks questions

asks if difficulty with task of turning in bed, sit to stand, supine to sit (unable, a lot, a little, none) and if assistance needed with transfers, gait in hospital room, ascend 3-5 stairs (total, a lot, a little, none)

AMPAC 6-Clicks scoring

range from 5-24 (higher score means more functional

MDC for AMPAC (MDIC not reported)

4\.7 for individuals 18-65

7\.36 for individuals over 65

Greenville Early Mobility Scale (GEMS)

created by PTs to aid acute care nurses in assigned pts a level of mobility (in bed activity, edge of bed activity, standing activity, independent activity)

Short Performance Physical Battery (SPPB)

evaluates LE function in older adults (5 items, max score of 12); score

SPPB assessment

balance (static, semi-tandem, tandem stance), gait speed (2 trials of 3/4 meters), sit to stand (repeated)

Edmonton Frail Scale (EFS)

potential scores of 0-17; higher score= higher rate of frailty

Berg Balance Scale (BBS)

STS, stand unsupported, unsupported sitting, transfer, stand unsupported EC/feet together, reaching, pick object up off floor, trunk rotation, turn 360°, toe taps, tandem stance, SLS

4 square step test

assess dynamic balance, coordination, and stepping in all directions

5 time sit to stand test

quick measure of functional LE strength and movement strategies; pt stand with arms crossed from standard chair five times

2 and 6 minute walk tests

assess aerobic capacity and endurance; pt is asked to walk greatest distance over 2 or 6 mins (assistive devices allowed)

10 meter walk test

assesses gait speed, pt is asked to walk 10m at comfortable or fast paced; 2/3 trials with 2m acceleration and deceleration zones

most common types of lines

intravenous, drains, catheters, telemetry, respiratory support, feeding

intravenous therapy (IV)

* common form of fluid and medication delivery
* delivered directly to venous system which allows meds/fluids to move rapidly through body
* peripheral cannula, central line, peripheral inserted central catheter (PICC)

peripheral cannula (IV)

most common type of IV, short catheter inserted into peripheral vein; connected to an infusion line during delivery of meds or fluids; between doses, flushed to prevent clotting, capped with a lock

central line

catheter with tip inserted into large vein

central line advantages

* delivers meds that would irritate peripheral vein
* meds reach heart immediately
* multiple meds can be delivered at once and distributed rapidly
* able to measure central venous pressure through line

central line disadvantages

* higher risk of infection and emboli
* increased difficulty with insertion (need specially trained clinician)

peripheral inserted central catheter (PICC)

used when IV access needed for a prolonged period or material to be infused would damage central line; inserted with ultrasound guidance, placement confirmed with x-ray

PICC advantages

* can have multiple compartments (lumen)
* safer to insert than central line
* with proper hygiene, can remain in place for months

PICC disadvantages

* requires better protection than peripheral cannula
* inserted through smaller peripheral vein, so meds take a less predictable route to vena cava in comparison to central line

drains

commonly used to drain pus, blood, or other fluids away from wound; post-surgery, but don’t necessarily result in faster healing time; can be active or passive

active drains

maintained under suction (high or low)

passive drains

no suction, drain functions by means of pressure differentials (gravity or overflow)

drain types

JP drain, hemovac, wound vac, chest tube

JP drain

jackson-pratt or bulb drain; pulls excess fluid out of body; consists of flexible plastic bulb connected to internal tube; primarily used after abdominal surgeries

hemovac

circular drain with tube inserted directly to body to drain excess fluids; drain is compressed and as it slowly expands, pulls fluid out with a gentle suction

wound vac

negative pressure wound therapy; promotes faster tissue granulation; used for large surgical, trauma, and non-healing wounds

chest tube

(passive) flexible tube inserted into pleural space via 4th intercostal space; used to drain hemothorax, pneumothorax, pleural effusion, empyema

urinary catheters

tube placed in bladder to drain urine (indwelling/Foley, condom, intermittent)

telemetry

continuous monitoring of HR and rhythm; may be attached to monitor on wall or portable and monitored remotely

respiratory support

required due to hypoxemia; level of invasiveness increases as level of support required increases

respiratory support

nasal cannula, non-rebreather mask, ventimask, biPAP, CPAP, ventilator

nasal cannula

supplemental oxygen mixed with room air (RA), usually 1-6L per min (max is 8lpm), mouth breathing does NOT indicate that patient is not receiving supplemental O2

non-rebreather mask

delivers high concentrations of O2 than nasal cannula; 1L O2 reservoir bag that connects to external O2 source; typically deliver O2 at 60-80% rates at a flow rate of 10-15 lpm

ventimask

delivers supplemental O2 at a precise concentration; different valves that allow for varying ratios of RA to O2; considered a high flow system

BiPAP machine (bi-level positive air pressure)

non-invasive ventilation that helps keep upper airways open by constant flow of air through face mask

ventilator

mechanically assists or replaces breathing; considered invasive due to tube penetrating mouth or skin (endotracheal tube or tracheostomy tube)

feeding tubes

nasogatric (NG) tube and PEG tubes

NG tube

runs from nasal passage to stomach; temporary; passage for fluids, nutrition, and medications (may be 100% or supplementary); only connected during feedings

complete blood count (CBC)

common test to asses general health; monitor disease progression/regression and impact of tx interventions

what is included in a CBC?

RBC, hemoglobin, hematocrit, WBC, platelet count

red blood cell count (RBC)

number of RBCs in a sample; used to dx anemia (and other conditions); also includes %%mean corpuscular volume (MVC%%- average size of RBCs), %%mean corpuscular hemoglobin (MCB%%- average amount of hemoglobin inside RBCs), and %%red cell distribution width (RCDW%%- measurement of variation in size of RBCs)

low RBC sx

* fatigue
* SOB
* dizziness
* increased HR
* headaches
* pale skin

high RBC sx

* fatigue
* SOB
* joint pain
* tenderness
* itching skin
* sleep disturbances

hemoglobin

protein in RBcs that carry O2; male 14-17, female 12-16; low indicates anemia, bleeding, chronic kidney disease, low iron, leukemia; high indicates cor pulmonale (right sided HF), pulmonary fibrosis

hemoglobin cut-off for PT

Hgb 7.1-7.9

activity orders must be clarified with primary MD (vitals documental pre-, para- and post- tx)

Hgb

no PT with certain exceptions (i.e. pts who decline blood transfusions for religious reasons)

hematocrit (Hct, “crit”)

the percentage of volume of whole blood that is made up of RBCs

normal hematocrit

male: 40-50

female: 36-44

hematocrit cut-off

if pt receiving blood transfusion:

hold from PT until transfusion is complete

WBC count

used to screen for disease, infection or allergic reaction

high WBC value

* viral/bacterial infection
* inflammation
* physical trauma
* burns
* immune disorder (lupus, RA)
* leukemia
* lymphoma
* thyroid disorders

platelet count

(fragments of cytoplasm created in bone marrow, clump from blood vessel injury) normal range 150,000-450,000 platelets per mcL

high platelet count

(thrombocytosis) spontaneous blood clots, caused by abnormal cells in bone marrow causing increased platelet production

low platelet count

(thrombocytopenia) frequent bleeding (nose, GI tract, gums), easy bruising, causes may include meds, cancers (leukemia, lymphoma), chemotherapy, kidney infection/dysfunction, alcohol intake

comprehensive metabolic panel (CMP)

measures 14 different substances in blood, detects chemical balance/imbalance and metabolism (glucose, calcium, sodium, etc.)

CMP is used to check for:

* liver and kidney health
* blood sugar levels
* blood protein levels
* acid and base balance
* fluid and electrolyte balance
* metabolism

liver function test

(liver panel/hepatic panel) group of tests to assess function of liver, dx or monitor diseases of the liver

abnormal liver function test results may indicate:

* acute or chronic liver damage
* bile duct obstruction
* liver inflammation (ETOH abuse, immune response)
* tumor
* trauma (fall, MVA)

urinalysis

urine sample test for kidney function (liver disease or diabetes as well); color, acidity, protein, glucose, WBCs, bilirubin, blood

electrolyte panel

measures balance of fluid and electrolytes that includes sodium, chloride, potassium, bicarbonate

hypokalemia causes

excessive loss of K+ through urine, diarrhea, vomiting, excessive sweating