Acute care in pt

Introduction to Patient CareAcute care in ptTOPIC OBJECTIVESDiscuss the basic guidelines for providing safe caregiver and patient environment.Describe the ff:Oxygen TherapyHemodynamic MonitoringIntracranial Pressure MonitoringEnumerate the general PT considerations for the different acute care behaviors mentioned above.Enumerate the general PT considerations with medical-surgical management devices.TOPIC OBJECTIVESFamiliarize with the different specialized pt care units.In an Intensive Care Unit environment:Enumerate the several types of equipment.Enumerate the guidelines in treating a pt.Enumerate the precautions to observe.Enumerate the appropriate PT interventions.ACUTE CARE/HOSPITAL SETTINGA unique environment with protocols and standards of practice and safety Nature: to provide a 24-hour carePatient safety is a TOP PRIORITY.ACUTE CARE/HOSPITAL SETTINGRole of the PT: strive to keep the pt safe at all timescomply with hospital initiativesunderstand The Joint Commissions annual National Patient Safety Goals. The Joint CommissionAn independent, not-for-profit organization, The Joint Commission accredits and certifies more than 19,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organizations commitment to meeting certain performance standards.Our Mission: To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.Vision Statement:All people always experience the safest, highest quality, best-value health care across all settings.

National Patient Safety Goals (NPSGs)In 2002, The Joint Commission established its National Patient Safety Goals (NPSGs) program; the first set of NPSGs was effective January 1, 2003. The NPSGs were established to help accredited organizations address specific areas of concern in regards to patient safety.Development of the GoalsA panel of widely recognized patient safety experts advise The Joint Commission on the development and updating of NPSGs. This panel, called the Patient Safety Advisory Group, is composed of nurses, physicians, pharmacists, risk managers, clinical engineers and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of health care settings.

5Basic guidelines in providing safe environment Both for the caregiver and patient.6BASIC GUIDELINESKnowledge of the facilitys policy for accidental chemical, waste, or sharps exposure, as well as emergency procedures for evacuation, fire, and natural disaster. Know how to contact the employee health service and hospital security.

BASIC GUIDELINESAlways following Standard Precautions.Confirm that you are with the correct patient prior to initiating PT intervention according to the facilities policy.

BASIC GUIDELINESElevate the height of the bed as needed to ensure proper body mechanics when performing a bedside intervention (e.g. stretching or bed mobility training).

Elevate the height of the bed as needed to ensure proper body mechanics when performing a bedside intervention (e.g. stretching or bed mobility training).9BASIC GUIDELINESLeave the bed or chair in the lowest position with wheels locked.Leave the top bed rails up for all patients.Only use equipment that is in good working condition.

10BASIC GUIDELINESKeep the pts room as neat and as clutter free as possible to minimize risk of trips and falls.Pick up objects on the floorSecure electrical cordsKeep small-sized equipment used for PTStore assistive devices when not in useDo not block the doorway or pathway to and fro the pts bed. BASIC GUIDELINESProvide enough light for the patient to move about the room or read educational materials. Always leave the pt with the call bell or other communication devices within close reach like eyeglasses and hearing aids. BASIC GUIDELINESMake recommendations to nursing for the use of bathroom equipment (e.g. tub bench or raised toilet seat) if the pt has functional limitations that may pose a safety risk. BASIC GUIDELINESDispose of linens, dressings, and garbage according to the policies of the facility. OXYGEN THERAPYThe purpose of this is to:Describe the various type of medical-surgical equipment commonly used in the acute care setting, including O2 therapy and noninvasive monitoring and management devicesProvide a framework for the safe use of such equipment during PT intervention.15OXYGEN THERAPYO2 therapy is for hypoxemia.The goal of O2 therapy:to treat and prevent hypoxemia, excessive work of breathing and excessive myocardial workVariable vs Fixed performance

The general indication of O2 therapy is hypoxemia. Hypoxemia is considered to be present when the arterial oxyhemoglobin saturation (SaO2) is less than 90%, corresponding to an arterial blood O2 partial pressure (PaO2) of less than 60 mmHg. The goal of O2 therapy is to treat and prevent hypoxemia, excessive work of breathing and excessive myocardial work by increasing PaO2.

How does O2 therapy work? O2 moves across the alveolar-capillary membrane by diffusion, the physiologic mechanism by which gas moves across a membrane from a region of higher to lower pressure and is driven by the partial pressure gradient of O2 between alveolar air (PaO2) and pulmonary capillary blood. To improve diffusion, a rise in PaO2 can be attained by increasing the fraction of inspired O2 (FiO2) with supplemental O2.

Variable performance depends on pts TV and RR, and the type, fit, and placement of the cannula or mask. Fixed performance delivers a specific FiO2 despite the pts respiratory rate and pattern. 16GENERAL PT CONSIDERATIONSA green label designates the O2 supply on hospital walls. Supply of pressurized air is designated by a yellow label. Significant supplemental O2 requirement indicates respiratory compromise which may indicate the need to modify or defer PT. GENERAL PT CONSIDERATIONSObserve pts for clinical signs of hypoxemia: SOB, use of accessory mm of breathing, confusion, pallor, or cyanosis. Ensure all connections are intact, O2 is flowing as indicated and cannula or mask is properly positioned. GENERAL PT CONSIDERATIONSO2 system may need added humidification. Provide extra length of O2 extension tubing if functional mobility will occur farther than 5-6ft from the bedside.

Supplemental O2 may be drying to the nasal mucosa and lead to nosebleeds. But added humidification is not used with partial non-rebreather mask because it interferes with O2 delivery and is not used when oxygen flow is 5 minutes should be reported to the nurse.Position the pt with the head of the bed at 30 degrees.Position with head of the bed at 30 degrees maximizes venous blood flow from the brain to help decrease ICP. 30GENERAL PT CONSIDERATIONSBe aware of the ff positions that can increase ICP:Lowered head of the bedTrendelenburg positionLateral neck flexionExtreme hip flexionPosition with head of the bed at 30 degrees maximizes venous blood flow from the brain to help decrease ICP. 31GENERAL PT CONSIDERATIONSBe aware of the ff conditions that can increase ICP:Valsalva maneuverNoxious stimuliCoughingPainStressFrequent arousal from sleep32GENERAL PT CONSIDERATIONS WITH MEDICAL-SURGICAL MANAGEMENT DEVICESGENERAL PT CONSIDERATIONSBefore entering a pts room, review the medical record, particularly new orders, recent progress notes, and test results. Review graphic sheets for vital signs, noting trends or variations from the norms.GENERAL PT CONSIDERATIONSNote whether any particular precautions protecting the patient or the caregiver from specific pathogens are in place. GENERAL PT CONSIDERATIONSPractice standard precautions. The likelihood of encountering bodily fluids is increased in the acute care setting especially in ICU.GENERAL PT CONSIDERATIONSDiscuss your planned intervention with the nurse. Scheduled procedures may take precedence over this intervention, or it may coordinate well with another planned procedure. GENERAL PT CONSIDERATIONSOn entering the pts room, take inventory. Observe the pts appearance and position. Systematically observe the pt, and verify the presence of all documented lines. GENERAL PT CONSIDERATIONSOn entering the pts room, take inventory. Develop a consistent method of surveying the room: left to right, top of bed to bottom of bed: to ensure that all lines and equipment are observed and considered in your treatment plan. Take note of all the readings on the monitor before intervention.GENERAL PT CONSIDERATIONSAnticipate how your intervention may change the pts vital signs and how this will likely appear on the monitors. Be aware of which readings may change artificially owing to relative position change. GENERAL PT CONSIDERATIONSUsing appropriate precautions, gently trace each line from the pt to its course. Ask for assistance, if needed, to untangle any lines or to free any lines that might be under the pt. GENERAL PT CONSIDERATIONSEnsure that there is no tension on each line before attempting to move the pt. Never attempt to free a line that cannot be completely visualized!Ask for appropriate assistance when mobilizing the pt. GENERAL PT CONSIDERATIONSDiscuss with the nurse whether any lines can be removed or temporarily disconnected from the pt before your treatment.GENERAL PT CONSIDERATIONSMost invasive monitoring systems have two alarm controls: one to silence or discontinue the alarm for a few minutes, and another to disable or turn off the alarm. Do not silence an alarm without permission from the nurse! It is not recommended that the PT disable an alarm. GENERAL PT CONSIDERATIONSIf available and appropriate , use a portable telemetry monitor when mobilizing a pt away from the bedside to maintain the continuity of the ECG. GENERAL PT CONSIDERATIONSOn completion of your treatment, ensure that all appropriate alarms are turned on and that the pt is positioned with the appropriate safety and communication measures in place. Notify the nurse of any change in the pts status. SPECIALIZED PATIENT CARE UNITSCCU: Coronary/Cardiac Care Unit/ Critical Care UnitER/ED: Emergency Room/ Emergency DepartmentICU: Intensive Care Unit/ Intermediate Care UnitMICU: Medical Intensive Care UnitSPECIALIZED PATIENT CARE UNITSNICU: Neurologic Intensive Care Unit/ Neonatal Intensive Care UnitOHRU: Open Heart Recovery UnitPACU: Post Anesthesia Care UnitSICU: Surgical Intensive Care Unit INTENSIVE CARE UNIT

INTENSIVE CARE UNITA typical pt cubicle in an ICU is likely to have several types of equipment to:monitor the physiologic stateventilate the ptprovide intravenous therapydeliver oxygenremove fluids from the pt

INTENSIVE CARE UNITEquipments you may find in an ICU:IV linesArterial monitoring linesDrainage tubesOxygen /Respiratory supportCardiac monitoring devices

TREATMENT GUIDELINES IN AN ICUReview the pts medical record before each treatment session, even when multiple sessions occur during the same day. Request information about the pts current status from nursing personnel.Review the pts medical record before each treatment session, even when multiple sessions occur during the same day. Request information about the pts current status (i.e. physical activity level, mental capacity, or alertness) from nursing personnel.

52TREATMENT GUIDELINES IN AN ICUWash your hands, and apply protective garments as necessary.Observe the equipment or devices used to monitor the pt for current information about pts physiologic status. 53TREATMENT GUIDELINES IN AN ICUObserve the type and location of the equipment or devices being used by the pt.Identify the location of all tubes , monitor lead connections, IV line connections and insertion sites, and pt-controlled analgesia; maintain all tubes & leads free of occlusion and tension. Observe the type and location of the equipment or devices being used by the pt (e.g. ventilator, IV line, oxygen, urinary catheter, supplemental nutrition, suction).Identify the location of all tubes , monitor lead connections, IV line connections and insertion sites, and pt-controlled analgesia; maintain all tubes & leads free of occlusion and tension.

54TREATMENT GUIDELINES IN AN ICUEvaluate or determine the pts present physical and mental status before initiating treatment.Observe the pt and monitoring devices frequently; determine his/her response to the treatment; identify significant changes.Evaluate or determine the pts present physical and mental status before initiating treatment.Observe the pt and monitoring devices frequently; determine his/her response to the treatment; identify significant changes.

55TREATMENT GUIDELINES IN AN ICUNotify nursing personnel of significant changes in his/her condition; document and record your activities and observations as necessary. 56INTENSIVE CARE UNITWhen the pt is acutely ill, it will be necessary to:Reduce the intensity of the tx.Give shorter tx sessions.Give fewer exercise repetitions.Demand less for active participation from the pt if necessary.

57INTENSIVE CARE UNIT GOAS OF TX: Minimize or prevent the adverse effects of inactivity and immobility.Assist pt to become functionally independent.58INTENSIVE CARE UNIT Possible/Appropriate PT Interventions:PROME, AROMEProper positioningBed mobility training (transfer and ambulation activities)PulmophysiotherapyWound care and managementPain management

59PRECAUTIONS TO USE IN AN ICUAvoid occlusion or excessive tension on all tubes, monitor leads, suction units, supplemental nutrition items, and oxygen service. 60PRECAUTIONS TO USE IN AN ICUObserve and assess the pt before, during, and after treatment; determine objective and subjective response to treatment. 61PRECAUTIONS TO USE IN AN ICUModify or cease treatment if pt exhibits abnormal, unexpected, or undesired response/s to treatment.Modify or cease treatment if pt exhibits abnormal, unexpected, or undesired response/s to treatment (e.g., changes in VS, breathing pattern, indication of increased pain, reduced mental awareness or alertness.

62PRECAUTIONS TO USE IN AN ICURequest assistance from nursing or RT if you identify changes in the function or performance of the pt support systems. Request assistance from nursing or RT if you identify changes in the function or performance of the pt support systems (e.g., IV line, monitors, ventilation, supplemental nutrition, or drainage devices). 63PRECAUTIONS TO USE IN AN ICUNote the appearance and odor of visible wounds and wound or urine drainage; observe the general appearance of the pt. 64PRECAUTIONS TO USE IN AN ICURequest assistance, as necessary, to adjust or move equipment or reposition pt. 65PRECAUTIONS TO USE IN AN ICUAt the conclusion of treatment:Be certain that the pt is properly positioned.Elevate or replace side rails on the bed.Position the bedside table so it is accessible to the pt.

66PRECAUTIONS TO USE IN AN ICUAt the conclusion of treatment:Position other personal items so they are accessible.Inform the pt of the location of the nurse call device; position it so it is accessible.

67REFERENCESPaz, J.C. and West, M.P. (2009) Acute Care Handbook for Physical Therapists. 3rd Edition. Missouri: Saunders ElsevierPierson, F. and Fairchild, S. (2008). Principles and Techniques of Patient Care, 4th Ed. Missouri: Saunders Elsevier