Debbie Petersen, RN, MSNSandra Bond, RN, BSN

ObjectivesUnderstanding why prevention is key to the

success and management of a rehabilitation patient.

Understanding key interventions to assist the rehabilitation patient who has complications.

Understanding why complications directly impact progress and discharge to home.

Catheter Associated Urinary Tract Infections (CAUTI) Why Prevent

Never EventPain/lethargySepsisPermanent damageIncreased LOSUse of antibioticsQuality Measure- considered a Hospital

Acquired Condition (HAC)

Catheter Associated Urinary Tract Infections (CAUTI) Interventions to preventHand washingInsert foley catheter using aseptic technique

and sterile equipmentClosed System

No leg bag Sample thru sampling port only after

cleansing with disinfectant and using sterile syringe

Smallest catheter possible to minimize urethral trauma

Catheter Associated Urinary Tract Infections (CAUTI) Interventions to prevent

Limited use of Foley cathetersExternal cathetersIntermittent catheterizationTimed voiding scheduleRemove as soon as possible

Maintain unobstructed urinary flowProperly secured to prevent urethral tractionCDC Guideline for Prevention of Catheter

Associated Urinary Tract InfectionsMonitor CAUTIs Identify problems and areas for

improvement

Catheter Associated Urinary Tract Infections (CAUTI) Barriers to progress and discharge homeLethargy- unable to participate and benefit

from therapyLong term antibioticsLong term damage to urinary tract

IncontinencePain with voidingObstruction

Deep Vein Thrombosis/Pulmonary EmbolusWhy PreventPainTherapy limited for a period of timeRisk for further complications

Pulmonary Embolus-In 90% of the cases of PE the thrombosis originates in the deep veins of the legs www.dvt.org

Death- 80% of the PEs occur without signs and 2/3 of the deaths occur within 30 minute www.dvt.org s

Anticoagulant medications- Long term up to 3 months

IVC filter- procedure riskVessel Wall damage

Deep Vein Thrombosis/Pulmonary EmbolusInterventions to preventInitial assessment to identify risk

MobilityType of surgery/injury/disease processAgeBMIProlonged bed restHistory of DVT/PE

Deep Vein Thrombosis/Pulmonary EmbolusInterventions to preventAppropriate intervention

Pharmacological prophylaxis Already on- stay on same/change Need to start

Heparin Coumadin LMW heparin: Lovenox Other pharmacological intervention: Dextran; Aspirin

Contraindicated GI bleed/hemorrhage Recent surgery Bleeding disorder History of HIT

Deep Vein Thrombosis/Pulmonary EmbolusInterventions to preventOther methods of prophylaxis

SCDsFoot pumpsTEDs- knee hi is preferred

MobilityExercises while in bed/sittingEARLY detection

Deep Vein Thrombosis/Pulmonary EmbolusInterventions to preventDaily assessment for:

Calf tendernessPositive Homans’ sign- resistance in the

calf/popliteal area with dorsiflexionSwellingIncreased LE painDyspneaPleurtitic chest painCoughHemoptysis

Deep Vein Thrombosis/Pulmonary EmbolusInterventions to preventEarly diagnosis with any Signs and symptoms

UltrasoundD-DimerV/Q scan; Spiral CT

Start intervention timely if DVT identifiedIV Heparin gtt

Transfer to acute care if PE identified

Deep Vein Thrombosis/Pulmonary EmbolusBarriers to Discharge HomeDelay in progress due to Medical Hold or

acute care admissionLong Term medications that require ongoing

managementPotential for surgical intervention

ContracturesWhy PreventLimits functionPainPermanent shortening of a muscleDeformityJoints immobileSwellingPoor circulationPressure ulcersDifficult transfers

ContracturesInterventions to PreventResults from unmoved jointsPrevention begins on the day of the injuryPrevention is critical- muscle not used loses

10-15% of its strength each week (Contractures; The Research and Training Center on Independent Living)

At least daily Range of Motion movements of each muscle

ContracturesInterventions to PreventProlonged stretch to reverse or “treat” a

developing contractureSerial castingSplintingHeat helps

Proper postureGood back supportProper joint positioning

ContracturesInterventions to PreventIf spasticity is a problem include weight

bearing exercise to strengthen the musclesAvoid skin breakdownSurgery to lengthen tendons but will not

lengthen the thickest part of the muscle

ContracturesBarriers to discharge homeIncreased difficulty with transfersIncreased difficulty with all careDecreased independence

InfectionsInfections that most impact the rehabilitation

patientMRSAC-DiffPneumoniaWoundUTI and CAUTICLABSISepsisCRE

InfectionsWhy preventPainLethargyLimits participation in therapyAntibiotic treatmentIncreased LOS

InfectionsInterventions to preventHand washingPPEIsolationMRSA surveillanceEarly identificationPatient/Family education

VISITORS

1CHECK with the NURSE before entering the room

2NO Children in the room

3Wash hands before leaving the room

STAFF

Wash hands before/after pt.

contact

Gown/Gloves when in contact with body fluids

Mask when in room- if necessary-check with nurse

Patient

Wash hands before leaving room

Gown/Mask when leaving room if necessary

Meals and therapy in room if draining wound/incontinent; check with nurse

InfectionsInterventions to preventAseptic technique

Wound careFoley cathetersCentral Line care

Good perineal careQuickly identify signs and symptoms of sepsis

ConfusionFeverTachycardiaLow blood pressure

InfectionsBarriers to Discharge homeIncreased LOSLong Term IV AntibioticsDecreased strengthDecrease Independence

Wound Care ComplicationsWhy Prevent

Decreased MobilityPainIncrease LOSIncreased FatigueIncrease Morbidity and Mortality

Wound Care ComplicationsInterventions to prevent

Early recognition- assess skin frequently Immobility Neuropathic Disease Arterial Inflow Disease End stage Renal Disease Systemic Infection

Wound Care ComplicationsInterventions to prevent

Early Intervention Positioning every 2 hours Prevent friction injury Get patient out of bed as soon as possible Float heels Perform range of motion exercises Keep skin dry, decrease moistureDevices such as heel boots, air mattress

Wound Care ComplicationsInterventions to prevent

Infection Control Medical Management

Nutritional Management High Protein foods will promote healing Adequate Hydration

Wound Care ComplicationsBarriers to progress and discharge homeWound complications can result in delay of

patient getting home.Wound vacuum can result in Skilled Facility

PlacementPain Increase LOSLong Term IV Antibiotic Use

HypotensionHypotension is defined as abnormally low

blood pressureCauses

DehydrationBeta BlockersDecreased Cardiac OutputDiureticsHemorrhage

HypotensionWhy Prevent

ComplicationsDecrease ImmobilityDizzinessSeizuresFainting

HypotensionInterventions to prevent

Increase fluid intakeIV fluidsTilt TableMedical Management

HypotensionBarriers to progress and discharge home Increased LOS Inability to participate in therapy treatments Increase fatigue Decreased strength

Central Line Catheters ComplicationsWhy Prevent (What to Prevent)

Migration of Catheter Tip into the heartPinch-off Syndrome

The anatomic, mechanical compression of a catheter as it passes between the clavicle and first rib at the costoclavicular space

OcclusionsInfections

Increased LOSIncrease incidence in severe medical

complications

Center Line Catheters Complications

Pinch-Off Syndrome

Image from Oncology Nursing Society, Access Device Guidelines, 2011

Central Line Catheters ComplicationsInterventions to prevent

MigrationNon-invasive: Patient repositionInvasive: Remove catheter, Surgical reposition

port, fluoroscopic catheter guidance.Pinch-off Syndrome

Surgical Intervention – Removal of Catheter

Central Line Catheters ComplicationsInterventions to prevent

OcclusionsAdequate flushes with normal saline and

locking with low dose heparin solution routinely and after catheter use.

Oral low-dose warfarin has been shown to decrease the rate of catheter related thrombosis but may increase the patient’s risk of bleeding (Currently this is not recommended.

Routine locking with thrombolytics such as high-dose heparin and tissue plasminogen activator (tPA) requires more research.

Fibrin TailFibrin tail with “initial” attachment on the outside of catheter, allowing for “trap door” effect and demonstration of partial withdraw occlusion; ability to flush easily but no blood return when attempting to aspirate

Central Line Catheters ComplicationsInterventions to prevent

OcclusionsFlush the catheter with normal saline gently

using the push-pull method.Reposition the patient.Ask the patient to cough and deep breathPerform tPA treatmentPerform fibrin sheath removal in interventional

radiology.

Central Line Catheters ComplicationsInterventions to prevent

InfectionsFrequent hand washing before and after all Catheter

care.Routine surveillance for infectionPatient and caregiver educationAdministration of pre-placement antibiotic is not

effective in preventing catheter-related infections (CDC, 2007)

Co-morbid diseases such as diabetes or chronic obstructive pulmonary disease or those on corticosteroid therapy can be predispose a patient to infection.

Treatment includes IV antibotics and catheter removal.

Central Line CathetersBarriers to Discharge

Invasive Medical TreatmentIV antibioticsPainIncrease LOS

Constipation

Constipation is defined at going longer than three days without a bowel movement.

Constipation is a preventable side effect of medication and immobility.

Constipation Why Prevent

Causes Medicines (Narcotics, Antidepressants, or iron

pills)Spinal Cord InjuryImmobilityDehydration

Neurological Conditions (Parkinson’s Disease) Complications

PainIncreased ImmobilityLoss of Appetite

Constipation Interventions to Prevent

Diet and Lifestyle ChangesHigh-Fiber DietRegular exerciseAdequate fluid intake

LaxativesFiber Supplements, Stimulants, Lubricants,

Stool softeners, Osmotics, Saline laxatives Procedures

Manual ProceduresSurgical Procedures

Constipation Barriers to Discharge

Increase LOSPain

SummaryComplications can result in multiple Length

of Stay delays for rehabilitation patients.Early Recognition and Early Intervention can

reduced overall impact of a complication.

Thank You

Questions