UW Physical Therapy

1. UW Physical Therapy July 22, 2008 Ellen Robinson, PT, A.T.C. Harborview Medical Center

2. Objectives Acute Care case simulation Medical Record Review Physical Therapy Examination Treatment Progression Discharge Planning

3. History What do you need to know? Demographics Social history and habits Living environment PLOF Medication

4. MD Orders What do they want you to do? What is the consult for? Specific therapy orders or protocols? Activity orders? Precautions (medical and therapeutic)?

5. Procedures Diagnostic Radiology, CT, MRI, EMG Surgical Type, location How will surgical sites affect function? How will surgical sites affect physiology?

6. Lab Values PO2/PCo2/Ph/HCO3 Na/CL/BUN/Glucose K/HcO2/CR\

7. EMR vs Paper Charting

8. Finding Information

9. Writing Notes

10. PT Examination Use of The Guide Mental Preparation Visual Preparation Make NO assumptions Discharge Planning � on the first day!

11. PT Examination �Red Flag� technique Systems review Screen CV/Pulm, M/S, Integ, Neuromusc, cognition, affect, language communication, Focus on the areas that are sending signals Call in assist as needed MD, RN, OT, SLP, TR, Psych, SW

12. Case One 50 y/o female involved in MCC. Pt suffered a crush injury to her R LE and tib plateau fx LLE. R foot was not salvageable and pt underwent R BKA and also ORIF to L tib plateau. Pt has a plaster cast on her R LE stump and a L HKB. PT consult: �for strengthening and mobility� Consider the following: Precautions? Evaluation expectations? Possible Impairments? Barriers? Therapy interventions? Discharge planning?

16. Case Two 18 y/o male s/p 30 ft fall off scaffolding at his job as a construction worker. Pt suffered rib fx 1-9 on R side, R PTX/HTX and R mid-shaft humerus fx, and splenic lac. Pt had an exploratory laparotomy with a splenectomy and a IMN to his R UE. Pt has 2 R sided CTs to suction. PT consult: �for ambulation� Consider the following: Precautions? Evaluation expectations? Possible Impairments? Barriers? Therapy interventions? Discharge planning?

19. Nerve considerations

20. HTX/PTX PTX � air in thorax HTX � �heme� blood Air or blood leaks from into the space between the lung and the chest wall. Dark side of chest is filled with air that is outside the lung tissue

21. Chest Tubes Inserted to drain blood, fluid, or air and allow full expansion of the lungs. Tube is placed in the pleural space - between the ribs (sutured in) and connected to a bottle or canister with sterile water. Suction is attached to the system to encourage drainage. The chest tube remains in place until the X-rays show that all the blood, fluid, or air has drained from the chest and lung re-expanded

22. Chest assessment

23. Case Three 37 y/o male involved in a MVC who suffered a TBI with EDH to R FTP lobe. Pt also suffered a R acetab fx. Pt s/p R craniectomy with evacuation. Pt is in the ICU with an ICPM, a ventric, and DFT on his R LE. PT consult: �for ROM and positioning� Consider the following: Precautions? Evaluation expectations? Possible Impairments? Barriers? Therapy interventions?

25. ICPM/Ventriculostomy

26. Skeletal Traction

27. Positioning

28. Case Three � Part II Patient is now out of the ICU on the general acute care ward. Pt is s/p ORIF of his R acetab fx via posterior approach. PT consult: �Mobilize patient TTWB R LE, 60 deg HFP R LE� Consider the following: Pre mobility assessment? Mobilization strategies and progression? Discharge Planning?

29. Acetabular Fracture

30. ORIF

31. Mobilization

32. Case Four 21 y/o female s/p fall from horse and trampled. Pt with open book pelvic fx and grade IV liver laceration. Pt s/p ex fix of ant pelvis and perc pinning of B/L SIJ. Pt s/p exp lap with liver packing. Post op, pt suffered acute respiratory failure and acute renal failure. Pt in ICU on a rotobed with an ETT for MV, a central line, and an A-line. PT consult: �for ROM and positioning� Consider the following: Precautions? Evaluation expectations? Possible Impairments? Barriers? Therapy interventions?

33. Intensive Care Unit

34. Organ Injury Solid Organ Injuries Grade I-V for severity Consider what organ is in where and how it might impact treatment? Blood values, nutrition, exercise tolerance?

35. Pelvic Fracture

36. Pelvic Fixation

37. Nerve Injury Red Flag LE exam Distal function Sensory assessment

38. The Fifth Limb (the trunk)

39. Case Four � Part II Patient is out of ICU on the acute care ward, with a tracheotomy and a trach tent in place. Pt on 40% O2. Pt is 8 weeks post her initial accident. PT consult: �strengthening and mobility� Consider the following: Pre mobility assessment? Mobilization strategies and progression? Discharge Planning?

40. Oxygenation RA = 21% 1 Liter O2 = 4% 5L O2 = 20% +21% = 41% 40% Face mask ~= 5L

41. Tracheostomy tubes Selection of sizes varies among MD�s Guidelines include patient�s weight & general anatomy. Can be cuffless or cuffed Myth: People cannot talk with trachs. Myth: People cannot eat with trachs. Myth: Trachs are permanent.

42. Cuffed vs Cuffless

43. Mobilization Options

44. Moveo (Trees)

45. Moveo (Trees)

46. Endurance Training Consider use of upper body and lower body ergometers for more aerobic activities Light resistance to begin, increase time and resistance as tol.

47. Other Issues Impacting Recovery Prolonged intubation, long term ventilation may lead to Critical Illness (aka ALI, ARDS, SIRS): CIM/CIP � critical illness syndromes Swallowing impairments Communication impairments Cognitive Impairments Emotional Impairments

48. Red Flags/Indicators for Swallowing Evaluations Hoarse voice�Indicates laryngeal involvement s/p extubation. Weak or wet, gurgley voice. Coughing or vocal wetness after swallowing food/liquid. Poor ability to manage own secretions�drooling, coughing on saliva, wet voice baseline, requiring suctioning. -You as a PT are in the room with the patient looking at the patients whole presentation, here are some signs that would help you determine if a patient would need a swallow evaluation prior to PO intake. -You as a PT are in the room with the patient looking at the patients whole presentation, here are some signs that would help you determine if a patient would need a swallow evaluation prior to PO intake.

49. Intubation Trauma Patients s/p extubation that are aphonic or present with hoarse whisper quality may have laryngeal involvement. If aphonia or hoarse vocal quality (dysphonia) does not improve in 7-10 days following extubation consider an Otolaryngology consult If true vocal fold paresis/paralysis present, temporary vs. more long-term interventions may be indicated to decrease risk of aspiration complications, improve cough strength and/or improve quality.

50. Cognitive function after ARDS 100% of ARDS survivors at discharge and 78% at 1 year show some degree of cognitive abnormality (Hopkins) For most, this is in �executive function� skills Attention/concentration Speed of processing Memory Executive function

51. Etiology of Cognitive Impairments Pathogenesis of the cognitive problems is not well understood, but is likely multi-factorial and the subject of ongoing discussion/research. Possible etiologies include: Prolonged hypoxemia Toxic or metabolic effects from sepsis Combination of hypoxemia & sepsis may result in more severe impairments than either alone Gas emboli to the CNS which results in decreased tissue oxygenation Result of psychological state associated with stress of prolonged critical illness

52. Emotional Impairments Anxiety - (consider situation) Depression - Feelings of hopelessness, Crying, Indecisiveness, Restlessness, Decreased initiation PTSD � (consider situation) Withdrawal from medication?

53. Case Five 45 y/o male s/p logging accident in which a tree fell on him at work. Pt suffered C6/7 fracture/dislocation and complete SCI. Pt underwent cervical fusion C4-T1 and is in a CTO (Minerva) brace for stabilization. �PT consult for SCI� Consider the following: Precautions? Evaluation expectations? Possible Impairments? Barriers? Therapy interventions? Discharge planning?

54. Spine injuries Anterior Middle Posterior Treatment will depend on which columns are unstable

55. Fixation

56. Spine Injury

57. Rehabilitation Consider level of injury as how it relates to function Predict Outcomes based on level of injury Develop treatment plan based on predicted outcomes

58. Other Systems Consideration Neurological � � - autonomic dysfunction, spasticity Pulmonary: � � - Assisted coughing, positioning, suctioning Cardiovascular: Monitoring vital signs� � Bradycardia may occur due to parasympathetic response Pt may have low SBP from loss of sympathetics and muscle pump Integumentary Turn Q2 Basic positioning principles for bony prominences Brace monitoring for decubiti GI/GU � �- Bowel and Bladder program: Undetected GI/GU dysfunction in vertebral fractures

59. Early Mobilization

60. Enhancing patient success Utilize extra hands as needed (RN, therapy aides, family member) to begin mobility training as soon as possible Be flexible when setting rehab goals and scheduling therapy sessions to allow for the patient�s changing needs, stamina, and medical status Continuity of care from ICU to Acute

61. Physical Therapists �In the course of a single day, a PT working in acute care may act not only as a care provider, but also as a consultant, a researcher, an educator and an advocate� Feburary 2006 � PT Magazine

62. Questions?

63. Resources http://www.gentili.net/fracturemain1.asp http://www.wheelessonline.com https://depts.washington.edu/hmctraum/ http://sci.washington.edu/ lnrobin@u.washington.edu