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Acute PT Overview
Acute Care PT: An Overview, some of the slides
| Question | Answer |
|---|---|
| Roles of the Acute Care PT | Communicate/co-treat with other members of therapy team Assessment is vital to d/c planning for the pt Initiates mvmt & fxnal activity pt can tolerate First therspist to see pt after something that impacted ability to fxn |
| More roles of the acute care PT | Must possess broad knowledge base of many diagnoses Understand contraindications/precautions associated w/ dx Knowledge of lab values Knowledge of monitoring devices being used |
| Critical Care Environment | Pts are dependent on outside means & care of others to meet basic physiologic needs Require close supervision, monitoring, & care & have medically complex needs |
| PT's primary goal in the critical care environment | Initiate mvmt & prevent complications associated with immobility |
| Normal Vital Signs: HR, O2 Sat, BP, Respiratory Rate | HR: 60-100 bpm O2 sat: 90-100%, <85- notify nurse ASAP BP: 100-140 systolic/70-90 diastolic (some pts may need increased BP for more circulation) RR: 12-20 breaths/min |
| Indications for Discontinuing or Modifying Activity (vital signs) | HR: <40 or >130 O2 sat: <85% BP: >220 systolic or >110 diastolic Decrease in systolic 10+ mmHg with increased activity; increased diastolic- disruption in peripheral blood flow, could be in shock Blood sugar >300 |
| Oxygen Delivery Methods | Cannula- in the nose Oximizer- reservoir of O2 under the nose Mask BiPAP- maintains pressure to keep airway open Endotracheal tube- used for ventilator to assist respiration |
| SaO2 monitoring | % hemoglobin saturation Measured via pulse oximetry |
| PaO2 monitoring | Partial pressure of arterial O2 Measured via arterial blood gases |
| Pulse Oximetry | Non-invasive way of monitoring % hemoglobin saturated with O2; Keep >90% unless otherwise specified Nail polish, skin pigmentation, low tissue perfusion, vasoconstriction, anemia can affect readings |
| Cardiac Monitoring | All ICU pts have heart monitors; Select pts have portable heart monitors connected to monitoring station; Monitors: heart rhythm, need for med changes, response to mvmt, exercise, disease process |
| Cardiac Arrhythmias | Look at rate & rhythm on EKG Rhythm: regular/irregular? patterns to the irregularity? extra beats? Rate: too fast (tachy) HR >100; too slow (brady) HR <60 |
| Normal Sinus Rhythm | Regular rhythm P wave for every QRS complex Rate 60-100 |
| Atrial Fibrillation | Irregular rhythm No discernable p-wave Narrow QRS complex Has a saw-tooth pattern These pts fatique quickly won't tolerate activity |
| Dead (Ventricular) Rhythms | Asystole (flat line) Ventricular fibrillation (irregular pattern) Pulseless ventricular tachycardia PEA (pulseless electrical activity): Any rhythm without a pulse |
| Monitoring Your Patient: Tubes & Lines | Understand purpose of the tube or line Understand barriers & precautions created by the physical presence of the tube/line |
| Central Venous Lines (CVL's) | Tip of CVL is in superior vena cava Used for: irritating meds, large-volume blood products, vasoactive meds, rapid fluid infusion, TPN (total parenteral nutrition), Measurement of central venous pressure (pressure of R atrium) |
| Types of CVL's | PICC- peripherally inserted central catheter Triple lumen Tunneled Port-a-cath |
| PICC (Peripherally Inserted Central Catheter) | Inserted through peripheral vein & advanced toward the heart until the tip lies in the superior vena cava Don't take BP on the side of the PICC |
| Triple Lumen Catheter | Threaded thru jugular or subclavian vein Short-term catheter for rapid fluid infusion & certain meds Can be used to measure central venous pressure |
| Tunneled Central Venous Lines | Used for long-term IV access: chemo, antibiotics, IV fluids Usually threaded under skin, then through jugular or subclavian vein to the superior vena cava |
| Port-a-Cath | Long-term implantable vascular access device Accessed through the skin Often used for chemo |
| PT Implications of Central Venous Lines | Don't pull them out! If dislodged, apply pressure at site. Decrease in CVP may indicate decrease in circulating blood volume. CVP, line will be hooked up to monitor, a transducer, & pressure bag. Mobility will be limited by length of lines. |
| Arterial Line | Used for constant BP monitoring Can draw arterial blood from lines for blood gas monitoring Usually inserted in wrist (radial a) or groin (femoral a) Limit ROM at wrist/groin on that side; with femoral line, can't get pt up out of bed |
| Epidural Catheter | Pain mgmt Small catheter usually placed mid to low thoracic spine Make sure it's taped & dressing secure Locked infusion pump Don't lay these patients flat, could affect breathing! Epidural could also affect leg strength. |
| PCA Pump | Pt-controlled analgesia Pt self-administers IV pain meds at pre-determined intervals Pump "locks out" if it's not time yet Gives pt more control over pain |
| External Ventricular Device (EVD)/Ventriculostomy | Decreases CSF pressure Tip of drain positioned in lowest part of 4th ventricle Temporary; laser has to be lined up with tragus (tragus lined up with bottom of 4th ventricle) Know whether or not EVD can be clamped, must clamp before PT |
| Chest Tubes & Indications | Mediastinal/Pleural Post-thoracic trauma, cardiothoracic surgery, injury/disease causing increased fluid/air in lungs, pneumo-/hemothorax, empyema, metastatic cancer Know where chest tube is (gait belt); see blue water (good seal, bubbles=poor seal) |
| PT Implications for Chest Tubes | Avoid pulling/kinking tube Keep drainage container upright, below chest level Chest tube hooked up to wall suction/set to water seal Suction tubes may limit mobility with pt Hooked to suction, be sure to ask RN if it can be disconnected for PT |
| 3 Compartments of Chest Tubes | Water seal, suction chamber, collection chamber Continuous air bubbles in the water seal chamber indicative of air leak |
| Drains | Can be placed in variety of areas Drain fluids by creating suction (pulling) in tube PT implications: Don't pull on drain; secure drain to pt gown; make sure suction is maintained |
| Nasogastric Tubes | Decompression or feeding Inserted thru nose Tip ends in stomach/small intestine Decompression- hooked up to wall suction Avoid pulling/dislodgement Tubing may limit tx if NG hooked up to suction |
| Feeding Tubes | May be N-G or percutaneous Pt may be getting bolus or continuous feedings If percutaneous, monitor site (watch gait belt!) Keep head of bed up at least 30-45 deg while feeding is occurring |
| Rectal Tube | Works like catheter, but in rectum Often used if pt immobile & has constant loose stools Helps protect pt from skin breakdown Don't pull on/dislodge tube while moving pt |
| Ostomies | Small/lg intestine brought outside body where stoma is created to provide pathway for waste May be permanent or temp, depending on surgery Ostomy pouch attached to skin to catch contents of bowel Ileostomy: paste-like/loose stool Colostomy: thicker st |
| Hemoglobin Values | O2-carrying component of RBC Normal: F (12-16) M (14-18) Abnormal: Critical <5, check if <9 Decrease: fatigue, weakness, dyspnea; monitor for dizziness/light-headedness |
| Platelets | Normal: 150,000-400,000/mL Abnormal: thrombocytopenia <100,000 affects clotting; critical: <1000 |
| WBC | Immune system status. Low WBC- pt/PT wear mask during tx Normal: 4.8-10.8 K/uL Abnormal: decrease (leukopenia): immune system/bone marrow diseases/chemo or radiation; Increase (leukocytosis): malignancies, infection, trauma S/sx: Fever, wkness, aches |
| Absolute Neutrophil Count (ANC) | Immune system status; body's 1st line of defense in acute infection Normal: 1900-7000 Abnormal: Low WBC precautions if <1000 Implications: Pt & caregivers need masks, no live plants/flowers, no visitors with cold/flu-like s/sx & no children <12 |
| INR (International Normalized Ratio) | Blood clotting ability, monitors Coumadin therapy Normal: 0.9-1.2 Abnormal: Pt. may be on bedrest if INR is >5 Implications: May postpone therapy with abnormally high levels due to increase bleeding risk |
| Blood Glucose | Normal: 70-100 mg/dL Abnormal: Critical <30 or >600 Hold exercise if glucose <60 or >300 |
| Slide 52 Picture | HgB= hemoglobin (very important) Hct= hematocrit BUN= blood urea nitrogen Creatinine= kidney fxn, kidneys should be getting rid of it HCO3= bicarbonate (respiration) low HCO3, body tries to compensate for high CO2 |
| The Bariatric Patient: BMI Review | <25 = normal 25-30 = overweight >/=30: obese >/=45: morbidly obese |
| Medical Complications of Obesity | Pulmonary disease; Diabetes: CVA; Cataracts; CAD; Pancreatitis; Cancer; Phlebitis; Gout; Skin; OA; Gynecologic abnormalities; Non-alcoholic fatty liver disease |
| What is Fornier's Gangrene? | Infection in groin, always occurs in males |
| Treatment Concerns with Bariatric Patient | Need for bariatric equipment Need for more staff to assist with mobility Staff/pt injuries More medical complications Longer length of stay D/c planning difficulties |
| Communication with Patients & Families | Be sensitive to new dx/abilities Consider culture Consider level of education/understanding Find what motivates your pt Develop goals/PoC together Involve caregivers Provide education |
| Communication with Physicians | Know when to call (order clarification, with concerns re: medical status, when requested) Do homework, be prepared Be visible Build relationships |
| Communication with Nurses | Great source of info Concerns/questions about medical status Report back-share info Be visible Build relationships |
| Communication with other staff | Team with other disciplines Share info Be visible Build relationships |
| D/c Planning- one of the most important roles acute care PT plays is in DC planning | Help team determine pt's d/c needs & appropriate next level of care Beginning at initial eval, we recommend where pt should go & what they will need PT needs to find out detailed info about pt's home, prior level of fxn, & support the system |
| D/C Planning- what to consider | PLOF; How independent do you expect pt to be; Home support system; Pt's restrictions/limitations; Pt home set-up; Any ongoing medical needs; Equipment needed at home |
| Discharge Options | IP Rehab SNF Long-Term Acute Care Hospital (LTACH) Nursing home Assisted Living Home Health OP Therapy |
| IP Rehab | Pt requires intensive rehab at least 3 hours/day, 5 days/week PT/OT/ST Must be expected to achieve fxnal significant improvement over reasonable period of time Goals focus on max level of independent fxn 50% pts must be Medicare; 60% must have CMS 13 |
| SNF | 1-3 hrs/day 5 days/week 3 midnights as IP in acute care prior to xfer Skilled nursing care must be required at least daily |
| LTACH | Medical/respiratory needs dominate reason for admission Must require medical, respiratory, & skilled nursing Pts. expected to be there @ least 24 days Sickest pts. Vent pts, complex wound/infection pts |
| Home Health | Requires cares, but not level of rehab/SNF May receive nursing, therapy, behavioral health Must be homebound (medical trips/church allowed) "Leaving home requires considerable & taxing effort" Will they be safe at home most of the day? |
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