Discharge, Pain Management, and Tests + Measures

Adaptive vs Maladaptive Pain

Adaptive: protective mechanisms where individual reacts to painful stimuli

Maladaptive: interferes with normal physio processes leading to further impairments

Acute vs Chronic vs Breakthrough Pain

Acute: follows injury, dissipates with healing, ie a warning

Chronic: no useful function and persists beyond normal healing timeline, undertreatment of acute pain facilitates this development (changes how CNS perceives impulses) → allodynia

Breakthrough: transient increase in pain which occurs against a background of persistent pain that has been controlled

Sedatives

Benzodiazepines (-pams) to calm (anxiety and sleep), sedate (anxiety), and hypnotic (produce sleepiness)

Premedication for surgery/procedure

Adverse: drowsiness, cannot learn new info, hangover, elderly are sensitive, exacerbate pulmonary issues (COPD, apnea)

General Anesthesia

Analgesia (conscious with amnesia + decreased pain awareness), unconsciousness, amnesia, SM relaxation, inhibition of sensory and autonomic reflexes

Surgical anesthesia - unconsciousness, no pain reflexes, regular respiration and BP

Medullary depression - severe respiratory and CV suppression

Lingering Post op effects (sedation, confusion, weakness)

IV Anesthetics

Propofol (diprivan) - rapid anesthesia and recovery

Ketamine (ketalar) - conscious but catatonic, analegesic, and amnesia

Local Anesthesia

Sensory transmission blocked from CNS (topical, injection around spinal cord (persists after; check sensory and motor function), transdermal using ionto/phonophoresis)

Analgesics

Non-opioid: acetaminophen (mild-mod pain, reduces fever, serious liver toxicity with OD), NSAIDs (aspirin, ibuprofen, naproxen) (heartburn, nausea, diarrhea, constipation)

Opioid: inhibits synaptic transmission in pain path of CNS (alters perception of pain) (sedative, euphoria, respiratory depression, orthostatic hypotension, GI distress, constipation)

Arousal, Attention, Cognition

DOB, reason for admission, A&Ox4

Repeat my name and discipline for short term

Repeat number sequences for immediate recall

Past personal info for long-term memory

GCS and mini-mental exam

Aerobic capacity and endurance

Vital sign (VS response)

RPE from OMs, bed mobility, STS, ambulation, toileting

Circulation

Edema (1-4+)

Pulse: 3+ bounding, 2+ normal (obliterated by strong pressure), 1+ weak (obliterated by slight pressure), 0 (absent)

MSK and Neuro

MSK: MMT, functional tests (transfers, stairs, self care)

Neuro: CN, DTR, sensation, joint position

Integumentary

Sensation

Incisions

Exam of bony prominences and pressure points for non-blanchable erythema

Indwelling lines (bruising, infection, infiltration, phlebitis)

Skin for hydration, marks, moles, rashes

GCS Scale

Mild head injury 13-15

Moderate 9-12

Severe <8

EVM 456

Gait, Locomotion, Balance

Gait for initiation, rhythm, cadence, stance, step length, speed, distance, posture, trunk (assess safety with AD; can they afford it)

Locomotion with 6MWT and TUG

Balance in sitting, standing, static, dynamic, BBS, FRT

Restraints

Any method (physical/mechanical/chemical) that reduces ability of pt to move body freelyor longer, requiring periodic review and reassessment by a qualified professional.

Non-violet/destructive actions to promote medical healing

Seclusion of violent behavior to manage safety of staff, others, or pt

Prolonged: violent restrain for 12 hours/7 consecutive days

Non-physical restrains

Family presence

Distraction

Personal comfort

Bed and chair exit alarms

Low bed with floor cushions

Wedge cushions and roll guards

Side Rails (only 3)

De-escalation techniques (good listener, comm skills, prevention strategies, interventions)

Physical Restrains

Side rails (all 4)

Mittens

Enclosure Bed

Limb and vest restraint

Locked restraints (most)

Harmful Effects of Restraints

Pressure ulcers

Bruises, lacerations, contractures

Vascular, nerve, nosocomial injuries

Cognitive and functional disability

Incontinence

Increased severity of injury with falls, wkness, immobility, isolation

IN ICU: HTN, tachycardia, anxiety, agitation, delirium

Discharge Planning

Goal: to enhance pt’s QOL, matching their needs, improve efficiency of care and reduce readmission

Begins at admittance and ends when pt leaves setting (requires need for post-hospital services and likelihood of capacity for self care)

Timely with comms between multiple disciplines/pt and authorization

Patient Adherence with continuity, location, and treatments essential for successful transitions to home or other settings. It involves assessing patient needs, coordinating resources, and ensuring understanding of discharge instructions.

Discharge Recommendation Summary

Referrals for additional services

Recommendation for follow-up PT

Family and caregiver training

Equipment provided

HEP

Did they achieve their goals? (ROM, stg, mobility, ability to ambulate, pain)

Considerations for DC Recommednation

Function (impairments, loss of bodily function, self care, mobility, domestic life, cognition, severity/duration of problem, prognosis)

Pt’s wants and needs

Ability to participate

Context of life (support and ability to live safely with modifications)

Healthcare regulation (insurance, length of stay, number of days available, dx restraints)

Home

Can pt get out of home on their own (transfers, gait, balance)

Quality of movement

Home Health

pt must be homebound (taxing effort to leave home), can go to doctors, adult day care or religion

Can have assistance at home

Must be under care of physician or req PT/OT/SLP/nursing care

Cannot get to outpatient

Outpatient

pt can safely go home with/out family support

May include PT/OT/SLP/Wound care

Inpatient Rehabilitation Facility (IRF) acute care

Must have at least two (PT/OT/SLP)

Daily MD visits (CVA, SCI, Amputation, multiple traumas, femur fx, TBI, Neuro, burns, TKA/THA with >85, BMI >50, bilateral)

Therapy is 6-7d/wk, 3hrs total per day

Can be denied if walks 200’ or more CGA/SBA, patient is independent, no support post DC, not contracted with all insurance

Long Term Acute Care Hospital (LTACH)

Continued hospital level of care, complex medical condition, complex wound/burn, mechanical vent weaning

Two or more medically active conditions that req >3 interventions (IV fluids, meds, TPN, blood products)

Daily MD evals

>6.5 hrs of skilled nursing and/or >3 respiuratory interventions per day

PT 5d/wk for 20-30d (individualuized)

Skilled Nursing Facility (SNF)

Can go with 1 therapy needs, extensive wound care or iv antibiotics (do not do Cx treatment)

PT is 5-7d/wk but cannot tolerate 3hr/d

Palliative Care

Not for end of life needs, improves QOL, provides relief from symptoms and stress of illness

Can be at home or in facility

Hospice

Inpatient (comfort and end of life, 3d covered)

Home with hospice (recommend equipment, family training, hospice nurse 2x/wk)

SNF with hospice (family wants pt to get stronger before going home with hospice support)