introduction to patient care acute care in pt. topic objectives discuss the basic guidelines for...

Introduction to Patient Care

ACUTE CARE IN PT

TOPIC OBJECTIVESDiscuss the basic guidelines for providing safe

caregiver and patient environment.Describe the ff:

Oxygen TherapyHemodynamic MonitoringIntracranial Pressure Monitoring

Enumerate the general PT considerations for the different acute care behaviors mentioned above.

Enumerate the general PT considerations with medical-surgical management devices.

TOPIC OBJECTIVES

Familiarize 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 SETTING

A unique environment with protocols and standards of practice and safety

Nature: to provide a 24-hour care

Patient safety is a TOP PRIORITY.

ACUTE CARE/HOSPITAL SETTING

Role of the PT: strive to keep the pt safe at all times

comply with hospital initiativesunderstand The Joint Commission’s annual National Patient Safety Goals.

BASIC GUIDELINES IN PROVIDING SAFE ENVIRONMENT

BASIC GUIDELINES

Knowledge of the facility’s 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 GUIDELINES

Always following Standard Precautions.

Confirm that you are with the correct patient prior to initiating PT intervention according to the facilities policy.

BASIC GUIDELINES

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).

BASIC GUIDELINES

Leave 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.

BASIC GUIDELINES

Keep the pt’s 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 pt’s bed.

BASIC GUIDELINES

Provide 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 GUIDELINES

Make 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 GUIDELINES

Dispose of linens, dressings, and garbage according to the policies of the facility.

OXYGEN THERAPY

OXYGEN THERAPY

O2 therapy is for hypoxemia.The goal of O2 therapy:

to treat and prevent hypoxemia, excessive work of breathing and excessive myocardial work

Variable vs Fixed performance

GENERAL PT CONSIDERATIONS

A 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.


Observe 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.


O2 system may need added humidification.

Provide extra length of O2 extension tubing if functional mobility will occur farther than 5-6ft from the bedside.


Ensure that portable O2 tanks are turned on and have sufficient levels of O2 before use. Have backup tanks available.

Observes masks for the accumulation of mucus or clogging. Clear or change the cannula or mask if needed.


Monitor the pt’s skin for potential breakdown due to pressure from the cannula or mask. Provide appropriate padding without interfering with the fit of the cannula or mask.


Document the type and amount of supplemental O2 used during PT intervention.

HEMODYNAMIC MONITORING


Provide information about the adequacy of a pt’s circulation, perfusion, and oxygenation of the tissues and organ systems.

GOAL: maintain the balance between oxygen demand and oxygen delivery

Invasive vs Noninvasive


Positioning: Raising the level of the phlebostatic axis relative to the transducer gives false high readings; in lowering it gives false low readings.


If a waveform changes during treatment, in the absence of clinical signs, reposition the patient or limb and reassess. If the waveform does not return to baseline, notify the nurse.

INTRACRANIAL PRESSURE MONITORING

ICP MONITORING

GOALS: For early identification of increased ICP prior to the occurrence of cerebral damage

To provide access for CSF sampling and/or drainage

To evaluate the effectiveness of medical-surgical treatment


Be aware of the ICP value and corresponding waveform on the monitor.

Sustained elevation in ICP > 5 minutes should be reported to the nurse.

Position the pt with the head of the bed at 30 degrees.


Be aware of the ff positions that can increase ICP:Lowered head of the bedTrendelenburg positionLateral neck flexionExtreme hip flexion


Be aware of the ff conditions that can increase ICP:Valsalva maneuverNoxious stimuliCoughingPainStressFrequent arousal from sleep

GENERAL PT CONSIDERATIONS WITH MEDICAL-SURGICAL MANAGEMENT DEVICES


Before entering a pt’s 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.


Note whether any particular precautions protecting the patient or the caregiver from specific pathogens are in place.


Practice standard precautions. The likelihood of encountering bodily fluids is increased in the acute care setting especially in ICU.


Discuss your planned intervention with the nurse. Scheduled procedures may take precedence over this intervention, or it may coordinate well with another planned procedure.


On entering the pt’s room, take inventory. Observe the pt’s appearance and

position. Systematically observe the pt,

and verify the presence of all documented lines.


On entering the pt’s 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.


Anticipate how your intervention may change the pt’s vital signs and how this will likely appear on the monitors. Be aware of which readings may change artificially owing to relative position change.


Using 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.


Ensure 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.


Discuss with the nurse whether any lines can be removed or temporarily disconnected from the pt before your treatment.


Most 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.


If available and appropriate , use a portable telemetry monitor when mobilizing a pt away from the bedside to maintain the continuity of the ECG.


On 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 pt’s status.

SPECIALIZED PATIENT CARE UNITS

CCU: Coronary/Cardiac Care Unit/ Critical Care Unit

ER/ED: Emergency Room/ Emergency Department

ICU: Intensive Care Unit/ Intermediate Care Unit

MICU: Medical Intensive Care Unit

SPECIALIZED PATIENT CARE UNITS

NICU: Neurologic Intensive Care Unit/ Neonatal Intensive Care Unit

OHRU: Open Heart Recovery Unit

PACU: Post Anesthesia Care Unit

SICU: Surgical Intensive Care Unit

INTENSIVE CARE UNIT

INTENSIVE CARE UNIT

A typical pt cubicle in an ICU is likely to have several types of equipment to:

1. monitor the physiologic state2. ventilate the pt3. provide intravenous therapy4. deliver oxygen5. remove fluids from the pt

INTENSIVE CARE UNIT

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

TREATMENT GUIDELINES IN AN ICU

1. Review the pt’s medical record before each treatment session, even when multiple sessions occur during the same day.

2. Request information about the pt’s current status from nursing personnel.


3. Wash your hands, and apply protective garments as necessary.

4. Observe the equipment or devices used to monitor the pt for current information about pt’s physiologic status.


5. Observe the type and location of the equipment or devices being used by the pt.

6. 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.


7. Evaluate or determine the pt’s present physical and mental status before initiating treatment.

8. Observe the pt and monitoring devices frequently; determine his/her response to the treatment; identify significant changes.


9. Notify nursing personnel of significant changes in his/her condition; document and record your activities and observations as necessary.

INTENSIVE CARE UNIT

When 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.

INTENSIVE CARE UNIT

GOAS OF TX: Minimize or prevent the adverse

effects of inactivity and immobility.

Assist pt to become functionally independent.

INTENSIVE CARE UNIT

Possible/Appropriate PT Interventions:PROME, AROMEProper positioningBed mobility training (transfer and

ambulation activities)PulmophysiotherapyWound care and managementPain management

PRECAUTIONS TO USE IN AN ICU

1. Avoid occlusion or excessive tension on all tubes, monitor leads, suction units, supplemental nutrition items, and oxygen service.


2. Observe and assess the pt before, during, and after treatment; determine objective and subjective response to treatment.


3. Modify or cease treatment if pt exhibits abnormal, unexpected, or undesired response/s to treatment.


4. Request assistance from nursing or RT if you identify changes in the function or performance of the pt support systems.


5. Note the appearance and odor of visible wounds and wound or urine drainage; observe the general appearance of the pt.


6. Request assistance, as necessary, to adjust or move equipment or reposition pt.


7. At 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.


7. At 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.

REFERENCESPaz, J.C. and West, M.P. (2009) Acute Care

Handbook for Physical Therapists. 3rd Edition. Missouri: Saunders Elsevier

Pierson, F. and Fairchild, S. (2008). Principles and Techniques of Patient Care, 4th Ed. Missouri: Saunders Elsevier

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