Debbie Petersen, RN, MSN Sandra Bond, RN, BSN. Objectives Understanding why prevention is key to the...
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Transcript of Debbie Petersen, RN, MSN Sandra Bond, RN, BSN. Objectives Understanding why prevention is key to the...
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