ADL Lecture Lab Six

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ADL Lecture Lab Six

• SPECIAL CARE ENVIRONMENTS
• INFECTION CONTROL
• ARCHITECTURAL BARRIERS
• V.Southard PT MS GCS

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Specialized Patient Care Units

• CCU
• ER
• ICU
• MICU
• NICU
• OHRU
• SICU

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Important Considerations

• 1. Let the nurse know that you are there.
• 2. Ask for report.
• 3. Review Medical record.
• 4. Treat Pt. Sessions will be shorter.
• 5. Position Pt. Exactly as you found him.

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Positions in bed

• 1. Fowler
• 2. Trendelenburg
• Always be sure to check that no tubes have kinks
  or are on stretch.

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Life support

• Mechanical ventilators
• Volume cycled long term support. Volumes
  inspired are predetermined by pt. needs,
  exhalation is passive.
• Pressure cycled Predetermined maximum pressure
  of gas is delivered during inspiration,
  exhalation is passive. Flow rate differs from
  one respiration to the next.
• Negative Pressure Rare. Iron Lung

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Airway Placements

• Endotracheal tube provides a clear airway
  through the nasal, oral, or other passage to
  lungs.
• Allows suction of bronchial tree.
• Pt. cannot talk.
• Discomfort(throat) when removed.

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Monitors

• Common parameters monitored
• Cardiac vital signs
• ABGs
• Intracranial pressure
• Pulmonary art. Press (PAP)
• CVP
• Arterial press (A line)

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EKG

• Information re. BP, HR, RR
• Safe limits are usually set in the unit

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Oximeter

• Photoelectric info regarding O2 saturation of the
  blood.
• Positioned on pts finger.
• Also gives HR
• Normal 95-98

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Swan-Ganz catheter

• IV tube placed from int jugular or femoral
  vein?basilic or subclavian vein?pulmonary artery.
• Provides info regarding Pul art pressures,
  detects changes in pts CV status.
• Normal values for R atrial press(0-4 mmHg), PAP
  20-30mmHg systolic and 10-15mmHg diastolic PCWP,
  4-12 mmHg.
• Exercise may have to be restricted at the
  shoulder/hip with these in place

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Intracranial Pressure Monitor

• Measures the pressure exerted against the skull
  by brain tissue, blood, CSF
• Indicated in Closed head injury, Cerebral
  hemorrhage, Brain tumor, overproduction of CSF.
• Normal is 4-15 mmHg

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CVP Catheter

• Measures pressures in the R atrium or the
  Superior Vena Cava. Therefore it measures the
  filling pressure of the R ventricle

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A Line

• Arterial line usually found in the radial,
  dorsal, femoral artery.
• Continuous measurement of BP.
• Allows venue to obtain blood samples

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Hickman (Right Atrial Catheter)

• Passes from the cephalic or int. jugular
  vein?superior vena cava?R atrium.
• Used for meds and drawing blood.

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Feeding Devices

• Nasogastric Tube (NG) nostril?stomach
• 1. Removes gas/fluids
• 2. Eval digestive function/activity
• 3. Administer meds
• 4. Feed pt.
• 5. Allows for tx of upper GI tract
• 6. Obtain gastric specimens

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Gastric tube

• Plastic tube inserted via incision into the
  stomach.
• Functions are similar to NG tube.
• Avoid removing the tube during exercise.

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IV feeds, TPN, Hyperalimentation

• Large amounts of nutrients are infused.
• Allows for attainment of appropriate metabolic
  states.
• Catheter is inserted directly into the subclavian
  vein or jugular?subclavian.
• May be sutured into place.
• Loose connections can result in an air embolus
  that is potentially life threatening.

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IV

• Usually placed in a superficial vein.
• Possible complications include infiltration,
  phlebitis, cellulitis, thrombosis, local
  hematoma, sepsis, pul.thromboembolus,air embolus,
  catheter fragment embolus.
• Avoid disruption, disconnection,or occlusion. Do
  not apply a BP cuff above the IV on that side.
  Ambulate with that arm holding the pole so the
  infusion site will be at heart level or the blood
  will go out of the tube.

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Oxygen

• Purpose provide and maintain adequate O2 in
  blood. Delivered via Nasal cannula or Mask, Trach

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Chest Tubes

• Removes air, blood, pus from pts. Chest or
  pleural cavity.
• Are attached to wall/bottle suction.

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Traction

• Purpose to align fx sites, distend soft tissue
  decrease m spasm or contractures and immobilize
  pt.
• Types
• 1. Skin
• 2. Skeletal
• 3. Constant
• 4. Intermittant

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Traction

• Balanced suspension Used for comminuted femoral
  fractures
• Proximal splint under the femur(Thomas)
• Distal splint beneath the tibia(Pearson
  attachment)
• A Pin or wire is placed through the tibia
  providing traction to the distal femur.
• Exercise the other extremities and same side
  ankle. Prevent pressure complications.
• Internal/External fixators have replaced this
  method.

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Skull Traction

• Examples include Crutchfield, Gardner-Wells,
  Vinke, or Barton tongs.
• Tongs are put into small holes in the skull to
  promote healing for fracture dislocations of the
  C spine.
• Exercise be careful at the shoulders, certain m
  attachments can place stress at the fracture
  site.
• Precautions Assure the wts. are hanging
  freely.Avoid removing or releasing wts.during
  treatment. Dont bump into wts. Note skin
  condition around the pin

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External Fixation

• Stabilization and traction using a frame.
  Examples Haynes, Hoffman, Halo, Anderson.
• Frames hold the pins that are inserted into the
  bone fragments. Superior development of
  mobility.
• Weight bearing on an extremity with an external
  fixator is contraindicated.

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Internal Fixation

• Hardware within the bone. Screws, bone
  plates,wires nails, intramedullary rods. Shorter
  immobilization.
• Exercise to joints proximal/distal should be
  initiated. Activity for the m crossing the
  fracture varies according to fracture and
  fixation.
• Ambulation following LE ORIF is commenced usually
  the 1st day post op. Weight bearing status is
  determined by the fracture and type of fixation.

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PCA

• Pt delivers a small dose of pain meds by
  squeezing a pump as frequently as every 6
  minutes.
• NO more than the predetermined dose can be
  delivered.

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Dialysis

• ESRD
• Shunt is implanted in the forearm. Do Not take
  BPs on that side.

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Infection Control

• Goal of infection control stop microorganisms
  from growing and spreading to decrease disease
  processes.

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Requirements of a Microorganism for spread

• 1. Host
• 2. Means of Exit
• 3. Transmission from one person to another
• 4. Portal of Entry
• 5. Susceptible recipient (host)
• In general, microorganisms grow best in a dark,
  warm environment

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Infection Control

• Def interruption or establishment of a barrier
  to prevent spread.
• Examples of barriers
• 1. Proper hand washing
• 2. Gloves
• 3. Protective clothing
• 4. Proper removal/disposal of contaminated waste
• 5. Isolation techniques

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More definitions

• Medical asepsis the reduction of the of
  pathogens in an area so that the concentration,
  influence or capacity to create an infection is
  reduced by either a persons immune system or use
  of meds designed to kill the remaining pathogenic
  microbes.

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Hand Washing

• Most effective means of infection control.
• Done before and after pt.care.
• Used to remove/reduce the number of pathogenic
  organisms on the skin of the hands, wrists,
  forearms.
• Nosocomial infections.
• Friction is the most important element.

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Isolation

• Strict Isolation
• Contact Isolation
• Respitory Isolation
• Usually the facility you work at has a policy to
  follow.
• Colored cards designate the type of isolation
  being used.

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Wearing Protective Garments

• There will be a staging area outside of the pt.s
  room.
• The gloves and sleeves of the gown are considered
  the most contaminated.
• Sequence of application for protective isolation
  is hat, mask, gown, and gloves.
• See illustration in the chapter p.284

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Removing Contaminated Garments

• Order of removal gown, gloves,mask,and hat.
• Consider the furniture in the patients room
  contaminated
• Consider the linen contaminated, therefore avoid
  touching these areas with any part of your body
  that is unprotected

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Sterile fields

• Purpose is to maintain a sterile area and prevent
  contamination of objects within.
• Base is usually a sterile towel.
• Your responsibility is
• 1. Know whats sterile
• 2. What is not sterile
• 3. Separate the two
• 4. If the field becomes contaminated, start over.

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Standard Precautions

• Treat all patients as though they have HIV.
• There will be no doubts or second guessing.
• Used to be referred to as Universal Precautions

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Disinfection, Decontamination, Disposal

• Sharps in sharp box
• Wash hands immed, even when you wore gloves.
• Soiled linens in leak proof bags.
• Protective clothing
• Soiled dressings in Red bag

• Infected waste products in special drains to a
  sanitary sewer.
• Clean up spills immed. Use household bleach 110
• Follow OSHA regs

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Decontamination

• Defined as the removal, inactivation or
  destruction of blood borne pathogens

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Sterilization

• Destroys microbes including spores.
• Examples
• STEAM UNDER PRESSURE
• AUTOCLAVE
• ETHYLENE OXIDE
• EPA STERILANT 6-10 HRS.

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Disinfection

• 1. High level
• Kills all microbes excepts of bacterial
  spores.
• Hot water pasteurization 80-100C for 30
• Or 30-45in EPA Sterilant
• Uses Endotracheal tubes

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Disinfection

• 2. Intermediate Level
• Destroys most viruses, fungi, vegetative
  bacteria, TB. No Spores
• Hard surface germicides with chlorine I.e. bleach

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Disinfection

• 3. Low Level Disinfection
• Destroys most bacteria. Some viruses and fungi.
  Not TB or spores. Routine housekeeping cleaners
  that remove soil in absence of visible blood.

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Environmental Disinfection

• Applies to PT equipment such as mats, transfer
  boards, floors.
• All items must be cleansed before disinfection.

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Disposal

• Clean and dispose as your facility dictates.

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Incidents and Emergencies

• When do incidents occur?
• What types of pts. require closer attention?

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Prevention of injuries

• Maintain a safe environment.
• Promote safety for all pts and yourself

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Bandaging

• Figure of eight
• Recurrent
• Spiral

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Shock

• Pale, moist skin, shallow and irregular
  breathing, dilated pupils, weak, rapid pulse
  sweating dizziness/nausea syncope.
• Take vitals, place pt supine head sl lower than
  body. Control bleeding.
• Keep warm and quiet.
• Get help

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Seizures

• Place pt in a safe location, position on side
• Monitor rate and resp quality
• Have pt. Rest.
• Get help as necessary

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Heat Exhaustion

• Get pt out of the sun. Place in well ventilated
  area. Loosen clothes, monitor vitals.
• Apply cold compresses and give water if pt. is
  conscious
• Observe for shock
• If symptoms persist, get him help

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Heat stroke

• Get help, position as in heat exhaustion

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Autonomic Dysreflexia

• Sit pt up as much as possible.
• Relieve noxious stimulus. check catheter, and
  urine retention bag.
• Monitor vitals, get help.

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Assessing Architectual Barriers

• External Environment
• Entrances
• Exits
• Parking
• Sidewalks
• Paths

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Transportation

• Car transfers

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Ramps for W/C Access

• Grade no than 1 foot per 10 feet or 1 foot of
  height for every 10-12 feet long.
• Should have at least 1 handrail
• Nonskid surface

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Inside the house

• How is the furniture placed?
• How is the furniture?
• Location o the lights?
• Scatter rugs?
• Check for a smoke alarm.
• Electrical Appliances, Access.

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Floors

• Scatter rugs
• Lg area rugs
• Type of flooring and condition
• Carpet- worn /sculpted
• Waxed floors
• Thresholds

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Kitchen

• High storage
• Low ovens
• Accessibility of major appliances

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Bathroom

• Door wide enough?
• Tub accessible/deep
• Toilet too low?
• Towel racks are not grab bars!

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Other concerns

• Width of hallway
• Single steps
• Sharp corners
• Loose railings
• Clutter
• Excessive furniture
• Electrical cords

• Toys
• Phone cords
• Pets
• Electrical cords
• Long sleeved gowns
• Slippers

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We can fix this!

• Cover sharp edges
• Build up chairs
• Raise/lower beds
• Lock wheeled beds/place against wall
• Adapt a room downstairs until safe on steps
• Add night lights
• Use at least 60 watt bulbs
• No cords crossing paths

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Cont

• Cordless phones
• 2 sided tape beneath scatter rug or remove it
• Plastic runners over sculpted carpet tacked down
• High stool in kitchen,wheeled carts to move stuff
  around
• Frequently used items conveniently placed
• Remove any door that restricts movement
• Use w/c with removable arms, they are narrower