acute care medical/surgical management & discharge planning

in acute care, what is a PTs role regarding pain?

- to teach functional mobility with pain (not to alleviate)

*document pain every session and response to functional activities/interventions

oral agents - given for how much pain, how often, & how long they take to work

- mild --> severe pain

- intermittent or scheduled

- slowest to work (~20 mins)

IV agents - given for how much pain, how often, & how long they take to work

- moderate --> severe pain

- intermittent or break through doses

- work rapidly

patient controlled analgesia (via IV) & patient controlled epidural analgesia - given for how much pain & how often

- moderate --> severe pain

- can constant does or dependent on pt pushing a button

common side effects of strong analgesics

- dizziness/lightheadedness

- nausea

- drowsiness/sleepiness

- orthostatic hypotension

patient controlled epidural analgesia (PCEA) is associated with an increased risk for

orthostatic hypotension

true or false: PCA and PCEA can be disconnected for mobility

false

true or false: PTs cannot press the PCA/PCEA button for the patient

true

how does pain affect breathing after surgery?

- limited diaphragm descent

- limited bucket handle movement

- reliance on upper chest breathing

- cough suppression

- shallow breathing because of incision

what is the result of a breathing changes due to pain after surgery?

- retained secretions (and increased risk of atelectasis and infection)

- limited acitivty tolerance

the primary intervention of respiratory complications is

mobility

indications for airway clearance techniques

- impaired mucociliary transport

- excessive pulmonary secretions

- an ineffective or absent cough

*impaired airway clearance

what are simple forms of airway clearance?

- deep breathing

- coughing techniques

- mobility

safety considerations for airway clearance techniques

- should be performed at least 30 mins prior to or after meal/tube feeding

- optimize pain control prior to

- consider use of inhaled bronchodilators prior to intervention

- monitor vital signs throughout

- monitor patient tolerance and response to treatment

if a pt has shallow breathing, guarding, fear of pain with coughing (rib fx, surgery, chest tube) - what are PT priorities? what techniques should you use?

- PT priorities: improve ventilation, prevent atelectasis, making coughing tolerable

- techniques: incentive spirometer, splinted cough, diaphragmatic breathing, positioning/mobility

*pain control first, slow and controlled

how to use incentive spirometer?

long slow breath to get down to alveoli at bottom of lungs (usually 10x/hr)

what is a splinted cough?

pillow is used to apply gentle pressure to the painful area (surgical incision, rib fx)

what is diaphragmatic breathing?

facilitates outward motion of the abdominal wall while reducing upper rib cage motion during inspiration

*needs to be taught in multiple positions

if a pt can cough but it's ineffective, is fatigued, has poor technique, secretions not clearing - what are PT priorities? what techniques should you use?

- PT priorities: improve cough mechanics, reduce fatigue, mobilize secretions

- techniques: teach cough technique, huff cough/FET, ACBT

what are the stages of an effective cough?

1. large volume inhalation (trunk extension)

2. closure of glottis

3. contraction of abdominals (trunk flexion)

4. forceful expulsion of air

why is it important to do an inspiratory hold while doing stages of an effective cough/optimizing a cough?

because it builds pressure

what are the benefits of a Huff Cough (forced expiratory technique/FET)

- less painful

- less fatiguing

- helps stabilize collapsible bronchiole walls

- air gets behind mucus

what is the active cycle of breathing (ACBT)

1. breathing control 5-10 seconds (relaxed)

2. 3-4 thoracic expansion exercises (deep breathing)

3. breathing control 5-10 seconds (relaxed)

4. 3-4 thoracic expansion exercises (deep breathing)

5. breathing control 5-10 seconds (relaxed)

6. 2 huff coughs

*repeat

if a pt has dyspnea (high RR, anxiety, poor breathing pattern, hypoxemia) - what are PT priorities? what techniques should you use?

- PT priorities: reduced WOB, improve efficiency, support activity tolerance

- techniques: pursed-lip breathing, diaphragmatic breathing, breathing control

SOB vs dyspnea

- SOB is an observation

- dyspnea is percieved difficulty of breathing (ask the pt)

what is pursed-lip breathing?

***only used for dyspnea relief

- for every 1 second of inhalation, 2 seconds of exhalation

if a pt has weak/absent cough due to a neurological condition (SCI, ALS, prolonged vent use)- what are PT priorities? what techniques should you use?

- PT priorities: augment expiratory force, prevent secretion retention, reduce respiratory complications

- techniques: manually assisted cough, mechanically assisted cough

manually assisted cough

instruct the person to take a deep breath and deliver manual assistance as they cough

*timing of person and caregiver is key

mechanically assisted cough

devices that apply mechanical forces to the body or intermittent pressure changes to the airway to assist with coughing

risk factors for VTE formation

- Virchow's Triad (vascular stasis, endothelial injury, hypercoagulability)

- elevated risk for 5-6 weeks after surgery

complications of DVT

- PE

- post thrombotic syndrome (PTS)

what is PTS? sxs? long-term outcomes?

- permanent damage to valves in veins --> blood reflux

- chronic sxs: aching pain, intractable edema, limb heaviness, leg ulcers

- long-term outcomes: impaired functional mobility, poor QoL, increased healthcare costs

complications of PE

- death

- chronic thromboembolic pulmonary HTN (CTPH)

preventative measures of VTE

- LE exercises (prevent vascular stasis)

- ambulation

- hydration

- mechanical compression

- medication referral

UE DVT is associated with

cancer and use of PICC lines

signs and sxs of UE DVT

swelling, pain, edema, cyanosis, dilation of superficial veins

what are IVC filters?

- catch clots before they reach lungs

- used for people who can't be anticoagulated (oncology pts or if meds don't work)

when is compression use recommended?

- when a person is at high-risk

- sxs of PTS (pain and swelling) are present

ineffective discharge planning can increase risk of:

- falls

- readmissions

- caregiver burden

- institutionalization

PT, OT, SLP role in discharge? who has the ultimate decision?

- make recommendations

- pt, medical provider, insurance

PT-driven vs System-Driven discharge planning

PT-driven:*

- PLOF

- current functional status

- safety and fall risk

- ability to participate in therapy, learn, and carry over

- pt goals and preferences

- available assistance/support

System-driven:*

- insurance coverage and authorization

- facility acceptance criteria

- bed availability

- diagnosis-based coverage regulations

- LOS pressures

why are there discharge pressures from the hospital?

- hospitals are paid using diagnostic-related groups (DRGs)

- no matter how long pt stays, hospital gets a fixed rate

how does PT reduce hospital readmissions

- PT/OT during hospitalization

- early home-based PT

- when PT discharge recommendations are followed

what dischage destinations can PTs recommend?

- home

- inpatient/acute rehab

- SNF

pt can go home w/o services if

they're at PLOF and have no new need for assistance

pt can go home with OP PT if

- pt is not at PLOF

- has no new need for assistance

- can leave the home safely

pt can go home with home PT if

- pt is not at their PLOF

- either has no new need for assistance or has need for assistance with help available

- is homebound

what does it mean for someone to be homebound

- require the assistance of another person or an AD to leave the home

- OR leaving home is contraindicated or unsafe

- leaving the home requires considerable and taxing effort

(exceptions made for medical appts, religious services, special occasions)

t/f: the fact that nobody is able to drive the pt to OP PT is a reason that qualifies them as homebound

false