Acute Care and ICU

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Acute Care
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Acute Care
Acute care is an inpatient hospital setting for individuals with a critical medical condition. These patients may have experienced a sudden decline in their medical and functional status due to a traumatic event, a worsening of a progressive disease, or the onset of a new condition.
Purpose of Acute Care
The primary goal of acute care is to stabilize the patient's medical status and address any threats to his or her life and loss of function. Research provides strong support for early mobilization of patients in acute hospital and critical care settings.
What is the role of OT in Acute Care?
Occupational therapy plays an important role in facilitating early mobilization, restoring function, preventing further decline, and coordinating care, including transition and discharge planning
Chart Review
Orders
Precautions
Physicians Notes
Nursing Notes
Imaging
Lab Values
Medications
Current and past medical history
Home Situation
Orders
Are they present?
What is it for?
-Evaluate and treat
-Splinting
-ROM
-Equipment
-Discharge pending
Precautions
-WB
-Hip
-Activity/timeline
-Surgical/procedural
Weight Bearing Precautions
Weight Bearing As Tolerated (WBAT)
Partial Weight Bearing (PWB)
Touchdown weight bearing (TDWB)
Non weight bearing (NWB)
Fall Precautions
Safety Alarms
Identification for risk
(i.e. socks, bracelet, signage)
Level of assist for transfers and ambulation
Posterior
No hip flexion beyond 90*
No hip adduction past neutral
No hip internal rotation
Anterior
No hip extension
No hip external rotation
Trochanteric
No active hip abduction
Physician's NotesDetermine if patient is appropriate for the day -Changes in medical status Planned procedures and possible precautions -(i.e. surgeries, lumbar puncture) Changes in goals of care -(i.e. Comfort Measures, de-escalation of care,)Consult Notes-Primary team is the group of physicians that are primarily responsible for patient -Consult services are those that the primary team ask to assist with overall treatment plan ---Reading the consult services notes is also helpful in gaining necessary information.Nursing NotesBedside nurse documents an intimate report of the details of patient care. -Mental status -Mobility occurrences -Family interactions -Responses to medicationImagingVenous duplex scans (Doppler) -Used to locate DVT (deep vein thrombosis) or PE (pulmonary embolus) Computed tomography (CT) scan -Used to locate of fractures, masses, and fluid retention Magnetic resonance imaging (MRI) -Provides in depth images of tissues and organsLab ValuesComplete Blood Count (CBC) -White blood cell count -Red blood cell count -Platelets -Hemoglobin -Hematocrit International Normalized Ratio (INR) Arterial Blood Gases (ABG)White Blood Cell CountIndicates immune system status, infection, or inflammation Normal range 5,000-11,000 Abnormal Values -Leukocytosis: >11,000 -Leukopenia:<5,000 Critical Values: <2,000 or >30,000LeukopeniaBone marrow disorders, specific anemias, HIV infection, autoimmune diseases, radiation or chemotherapy, drugs, alcoholism, or diabetesLeukocytosisCaused by bacterial infection, inflammation, leukemia, malignancy, trauma, drugs, hemorrhage, stress, burns, dehydration, pneumonia, tissue injury, or tissue necrosis.<500/mm3:Extremely dangerous, possibly fatal< 1000/mm3:Defer Therapy< 4,000/mm3:Neutropenic precautions observed. -Strict handwashing -Gown, gloves, mask, disinfecting equipment brought into the room.<5,000/mm3 with fever:Consider deferring therapy, as patients are at increased risk of infection> 5,000/mm3:Light or resistive exercises as tolerated11,000/mm3:with fever: use caution with exerciseRed Blood CellsIndicates the number of red blood cells in blood and their ability to transport oxygen and nutrients throughout the body Normal Range -Males: 4.5-5.3 mcl -Females: 4.1-5.1 mclAbnormal ValuesMales: > 5.72 mcl Females: > 5.03 mcl Anemia: Decreased red blood cells Polycythemia: Increased red blood cellsAnemia can be caused by blood loss, destruction of red blood cells, decreased production of red blood cells, chemotherapy, leukemia, multiple myeloma, systemic lupus erythematosus.Anemic patients may have decreased endurance and activity tolerance. They may experience weakness, fatigue, dizziness, dyspnea on exertion, palpitations, and tachycardia -If patient requires transfusion, check facility's policy on treatment while being transfused.Polycythemia can be caused by dehydration, severe diarrhea, chronic heart disease, poison, pulmonary fibroses.Patients with polycythemia are at an increased risk for stroke and thrombosis. They may experience headache, dizziness, blurred vision, mental status changes, and sensory disturbances in hands and feet.Platelets are responsible for clotting blood Normal Range: 150,000- 400,000 Abnormal ValuesThrombocytosis : > 1 million Thrombocytopenia: <150,000 Critical Value: < 20,000Thrombocytosis may be caused byinflammation, infection, iron deficiency, renal failure, cancer, splenectomy, trauma, acute blood loss, or heart disease.Thrombocytopenia may be caused byviral or bacterial infections, nutritional deficiency, drugs, radiation and chemotherapy, bone marrow disease, HIV, coagulation disorders, and liver disease.Thrombocytopenia -patient are at risk forbleeding easily from mucosal surfaces, including gums, nose, GI tract, respiratory tract, and uterus -There is also increase risk for bruising and bleeding under skin, and post surgical bleedingLow hemoglobin causes the heart towork harder to ensure sufficient oxygen can be transported to the rest of the body.Hemoglobin less than8g/dl may require a transfusionhemoglobin between8-10 g/dl requires close monitoring with light exercise due to possible decreased activity toleranceResistive exercise is appropriate with hemoglobin more than10 g/dlThe purpose of hematocrit is tomeasure the percentage of red blood cells in total blood volume.normal hematocrit levelsMales: 37%-49% Females: 36%-46% Abnormal Values: < 25% Critical Values; <20% or >60%Increased hematocrit levels may be caused bypolycythemia, acclimation to high altitudes, heavy cigarette smoking, chronic lung disease, or congenital heart defect.Decreased hematocrit may be caused byanemia; blood loss, or iron, folic acid, and B12 deficiencies.Symptoms of low hematocrit includeweakness, fatigue, tachycardia, dyspnea on exertion, and heart palpitations and decreased activity tolerance, requiring close monitoring of vitals and rest breaks.Hematocrit lab levels< 20% Can result in cardiac failure or death < 25% Defer Therapy 25%-30% ADLs and light exercise as tolerated 30% Add resistive exercise > 60% Associated with spontaneous blood clottingInternational Normalized Ratio (INR) developed to help measure coagulationNormal Range: 0.9-1.1 Abnormal Range: >3.5 Critical Value: >5 Increased INR >3.5 are at an increased risk for bleeding. Extreme caution is needed to prevent falling or injury.Arterial Blood Gas analysis assessescardiopulmonary function, oxygen and carbon dioxide in the blood, and acid-base regulation.It is collected from the arterial system and looks at the values ofpH Partial pressure of carbon dioxide (PaCO2) Partial pressure of oxygen (PaO2) Bicarbonate (HC03) Oxygen saturation (SpO2)pH measures acid-base balance of the bloodNormal Range: 7.35-7.45 Abnormal Values: Acidosis: < 7.35 Alkalosis: > 7.45 Seriously impaired cell function: <7.2 or >7.55 Critical Values <7.20 or >7.0 <6.8 or >7.8 incompatible with lifePaCO2 and pH have an inverse relationship-When PaCO2 increases, pH decreases, leading to respiratory acidosis with symptoms including diaphoresis, tachycardia, confusion, headache, lethargy. -When pH increases and PaCO2 decreases, the result is respiratory alkalosis with symptoms including light headedness, muscle twitching, cardiac arrhythmia, anxiety, agitation, and paresthesiaPaCO2 measures how much carbon dioxide is dissolved in blood.Normal Range: 35-45 mmHg Critical Values: <20 or >70 mmHg PaCO2 is affected by pulmonary function.Bicarbonate measuresthe amount of bicarbonate dissolved in the blood. Bicarbonate is important to keep acid-base balance and works to keep pH within normal limits Normal Range: 22-26 Critical Values: <10 or >40Increased bicarbonate is associated withmetabolic alkalosis that can result in restlessness, confusion, agitation, and nausea.Decreased bicarbonate is associated withwith metabolic acidosis that can result in headache, lethargy, nausea, convulsions, muscle twitchingPartial Pressure of oxygen measures the pressure of oxygen dissolved in the bloodNormal Range: 80-100 mmHg Abnormal Value: Hypoxemia : < 80mmHg Critical Value: < 40mmHgSigns of hypoxemia includemental status changes, tachycardia, light headedness, which can progress to incoordination , restlessness, cardiac arrhythmias, and cardiac arrestMedications can have side effectsUpset stomach Change in heart rate or rhythm Dizziness Change in vision Change in level of alertness Change in appetite Change in metabolism Important to monitor blood pressure, respiratory rate, heart rate, and oxygen saturationHome situationHome Layout Presence/Absence of Stairs Assistance available and needed for ADLs and homemaking tasks Bathroom Setup Assistive DevicesSequential compression deviceDevice that provide a sequential pattern of compression from ankle to knee or mid thigh. The use of SCDs has been found to decrease the occurrence of DVT in the lower extremityAnti-Embolism stocking reducethe incidence of DVT and to promote increased blood flow in the legs by compression of the deep venous system.Heart RateNormal 60-100 beats per minute Abnormal Bradycardia: <60 Tachycardia: >100Blood PressureNormal Systolic: 90-120 mmHg Diastolic: 60-80 mmHg Abnormal Hypotension: <90 systolic Prehypertension: 120-140/80-89 Stage 1 hypertension: 140-159/90-99 Stage 2 hypertension: >160/100 Mean Arterial Pressure Normal: 70-110mmHgPulse Oximeter Oxygen SaturationMeasures the percentage of hemoglobin that is bound to oxygen or carbon monoxide Normal value is 95-100%Respiratory ratenormal: 12-20 breaths per minPeripheral IVPurpose Used to administer drugs, fluids, blood transfusion and to obtain venous blood. Location Inserted on peripheral vessel Typically located in hand or forearm Key Points Infiltration occurs when IV fluid travels to tissues instead of vein. Usually lasts 3-5 daysPeripherally Inserted central catheterLess invasive and can be left in for longer time Long, slender, small, flexible tube inserted into a peripheral vein and advanced to a large vein in the chest Upper arm is area of choiceJVACsLow pressure vacuum unit Used to collect exudate or blood Must be activated to work! Must stay compressed at all times Usually pinned to the patient's gown to prevent being pulled onJPsBulblike Typically breast & abdominal surgeries Used to collect exudate or blood In order to work must stay compressed at all times Usually pinned to patients gown so that it doesn't get pulledTemporary Dialysis CatheterPurpose Short term hemodialysis Provides direct access to vein Location Femoral, jugular, or subclavian Key Points Larger bore and less flexible Can potentially kink In place for less than 14 days, usuallyWounds VacsWounds vacs can be found on any part of the body They are used to rid a wound bed of any drainage Wound Vacs cannot be disconnected from the patient but can run on battery powerHemodynamicsthe study of the forces that influence the circulation of bloodPulmonary Artery Catheterdetermine hemodynamic status at bedsideArterial SheathPurpose It reduces the local, continuous and repetitive trauma from the catheter rubbing in the arterial wall during catheter manipulation. Location Indwelling sheath is placed in the artery usually in IR or cath lab Key Points Strict bedrest as long as sheath remains in place and for several hours after it is removed Larger bore catheter, not flexible.NGs, OGs, and CorPaksThe tips of the nasogastric (NG) and oral gastric (OG) sits in the stomach CorPak tips are in the small bowel Utilized for feeding, medication administration, and at times, bowel decompression Feeding must be turned off or placed on hold if the patient's head goes below 30 degreesChest Tubes-Used for treatment of a collapsed lung (pneumothorax), blood in pleural space (hemothorax), or to drain fluid in pleural space. -Tip of the chest tube sits in the pleural space between the lung and chest cavity -The chest tube is attached to either wall suction or water-seal which is contained in the atrium -The physician decides what setting is most appropriate for the patientStandard nasal cannulais used up to 6LHigh Flow nasal cannula is used6-15 lTherapy considerations for supplemental oxygen devicesWhen increasing O2, you must switch to high flow nasal cannula if over 6L in order to deliver the right concentration.Face maskis used for a minimum of 5L but can offer oxygen concentrations from 35-50%CapnographyCapnography measures the amount of expired CO2. -CO2 levels indicate the adequacy of ventilation. -Capnography monitoring provides a real-time, early indication of patient deteriorationThe nonrebreather maskThis mask offers 60-80% oxygen concentration. Allows patient to only breathe oxygen directed from the bag into the mask. A one-way valve directs oxygen from a reservoir bag into the mask upon inhalation. A second one-way valve allows gas to exit into the atmosphere when the patient exhales. Therapy considerations: Nonrebreather is a significant oxygen requirement. As a result, participation in therapy is not likely appropriate.Venturi MaskContains a Venturi device that can be set at the desired flow of oxygen and FiO2 Therapy considerations: This device can be used with an oxygen tank.Trach shield provides oxygen via the tracheostomyAn AP Neb (featured in photo on right) can be used to set desired flow of oxygen and FiO2. LPM of O2 is featured above and percentage of FiO2 is featured below. Therapy considerations: AP Neb requires conversion to Venturi in order to be used with oxygen tank. Verify if patient is on supplemental oxygen or humidified air only.BoltIntracranial pressure monitoring uses a device, placed inside the head, which senses the pressure inside the skull and sends its measurements to a recording device.An EVD is a device that relieveselevated intracranial pressure and hydrocephalus when the normal flow of cerebrospinal fluid around the brain is obstructed. It is used to drain fluid from the ventricles of the brain and keep them decompressed, as well as to monitor intracranial pressure. RN needs to clampEndotracheal TubePurpose Used for short term mechanical ventilation Location Oral or Nasal Key Points Note the location of ETT before and after activity At lip or at teethTracheostomyPurpose Used for long term ventilation Allows for improved comfort and oral hygiene Potential for speech and oral nutrition Reduced need for sedation Improved weaning from vent Key Points It takes 5-7 days for fibrosis (well defined track between the trachea and the skin) to formPassy-Muir ValveKey Points It is a one way valve Some patients may not be able to tolerate increased activity with valve in place Tracheostomy cuff must be deflated before valve is placed otherwise patient could suffocate.VentilatorsEndo-Tracheal tube that sits in the trachea and allows for gas exchange (this can also include tracheostomy, or nasal-tracheal tube)