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Download Interventions to prevent - Spalding Rehabilitation Hospital
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Debbie Petersen, RN, MSN Sandra Bond, RN, BSN Objectives Understanding 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 Event Pain/lethargy Sepsis Permanent damage Increased LOS Use of antibiotics Quality Measure- considered a Hospital Acquired Condition (HAC) Catheter Associated Urinary Tract Infections (CAUTI) Interventions to prevent Hand washing Insert foley catheter using aseptic technique and sterile equipment Closed 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 catheters External catheters Intermittent catheterization Timed voiding schedule Remove as soon as possible Maintain unobstructed urinary flow Properly secured to prevent urethral traction CDC Guideline for Prevention of Catheter Associated Urinary Tract Infections Monitor CAUTIs Identify problems and areas for improvement Catheter Associated Urinary Tract Infections (CAUTI) Barriers to progress and discharge home Lethargy- unable to participate and benefit from therapy Long term antibiotics Long term damage to urinary tract Incontinence Pain with voiding Obstruction Deep Vein Thrombosis/Pulmonary Embolus Why Prevent Pain Therapy limited for a period of time Risk 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 risk Vessel Wall damage Deep Vein Thrombosis/Pulmonary Embolus Interventions to prevent Initial assessment to identify risk Mobility Type of surgery/injury/disease process Age BMI Prolonged bed rest History of DVT/PE Deep Vein Thrombosis/Pulmonary Embolus Interventions to prevent Appropriate 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 Embolus Interventions to prevent Other methods of prophylaxis SCDs Foot pumps TEDs- knee hi is preferred Mobility Exercises while in bed/sitting EARLY detection Deep Vein Thrombosis/Pulmonary Embolus Interventions to prevent Daily assessment for: Calf tenderness Positive Homans’ sign- resistance in the calf/popliteal area with dorsiflexion Swelling Increased LE pain Dyspnea Pleurtitic chest pain Cough Hemoptysis Deep Vein Thrombosis/Pulmonary Embolus Interventions to prevent Early diagnosis with any Signs and symptoms Ultrasound D-Dimer V/Q scan; Spiral CT Start intervention timely if DVT identified IV Heparin gtt Transfer to acute care if PE identified Deep Vein Thrombosis/Pulmonary Embolus Barriers to Discharge Home Delay in progress due to Medical Hold or acute care admission Long Term medications that require ongoing management Potential for surgical intervention Contractures Why Prevent Limits function Pain Permanent shortening of a muscle Deformity Joints immobile Swelling Poor circulation Pressure ulcers Difficult transfers Contractures Interventions to Prevent Results from unmoved joints Prevention begins on the day of the injury Prevention 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 Contractures Interventions to Prevent Prolonged stretch to reverse or “treat” a developing contracture Serial casting Splinting Heat helps Proper posture Good back support Proper joint positioning Contractures Interventions to Prevent If spasticity is a problem include weight bearing exercise to strengthen the muscles Avoid skin breakdown Surgery to lengthen tendons but will not lengthen the thickest part of the muscle Contractures Barriers to discharge home Increased difficulty with transfers Increased difficulty with all care Decreased independence Infections Infections that most impact the rehabilitation patient MRSA C-Diff Pneumonia Wound UTI and CAUTI CLABSI Sepsis CRE Infections Why prevent Pain Lethargy Limits participation in therapy Antibiotic treatment Increased LOS Infections Interventions to prevent Hand washing PPE Isolation MRSA surveillance Early identification Patient/Family education VISITORS 1CHECK with the NURSE before entering the room 2NO Children in the room 3Wash hands before leaving the room STAFF h hands before/after pt. contact n/Gloves when in act with body fluids k when in room- if ssary-check with nurse Patient Wash hands before leavin room Gown/Mask when leaving ro if necessary Meals and therapy in room i draining wound/incontinent; check with nurse Infections Interventions to prevent Aseptic technique Wound care Foley catheters Central Line care Good perineal care Quickly identify signs and symptoms of sepsis Confusion Fever Tachycardia Low blood pressure Infections Barriers to Discharge home Increased LOS Long Term IV Antibiotics Decreased strength Decrease Independence Wound Care Complications Why Prevent Decreased Mobility Pain Increase LOS Increased Fatigue Increase Morbidity and Mortality Wound Care Complications Interventions to prevent Early recognition- assess skin frequently Immobility Neuropathic Disease Arterial Inflow Disease End stage Renal Disease Systemic Infection Wound Care Complications Interventions 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 moisture Devices such as heel boots, air mattress Wound Care Complications Interventions to prevent Infection Control Medical Management Nutritional Management High Protein foods will promote healing Adequate Hydration Wound Care Complications Barriers to progress and discharge home Wound complications can result in delay of patient getting home. Wound vacuum can result in Skilled Facility Placement Pain Increase LOS Long Term IV Antibiotic Use Hypotension Hypotension is defined as abnormally low blood pressure Causes Dehydration Beta Blockers Decreased Cardiac Output Diuretics Hemorrhage Hypotension Why Prevent Complications Decrease Immobility Dizziness Seizures Fainting Hypotension Interventions to prevent Increase fluid intake IV fluids Tilt Table Medical Management Hypotension Barriers to progress and discharge home Increased LOS Inability to participate in therapy treatments Increase fatigue Decreased strength Central Line Catheters Complications Why Prevent (What to Prevent) Migration of Catheter Tip into the heart Pinch-off Syndrome The anatomic, mechanical compression of a catheter as it passes between the clavicle and first rib at the costoclavicular space Occlusions Infections Increased LOS Increase incidence in severe medical complications Center Line Catheters Complications Pinch-Off Syndrome Image from Oncology Nursing Society, Access Device Guidelines, 2011 Central Line Catheters Complications Interventions to prevent Migration Non-invasive: Patient reposition Invasive: Remove catheter, Surgical reposition port, fluoroscopic catheter guidance. Pinch-off Syndrome Surgical Intervention – Removal of Catheter Central Line Catheters Complications Interventions to prevent Occlusions Adequate 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 Tail Fibrin 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 Complications Interventions to prevent Occlusions Flush the catheter with normal saline gently using the push-pull method. Reposition the patient. Ask the patient to cough and deep breath Perform tPA treatment Perform fibrin sheath removal in interventional radiology. Central Line Catheters Complications Interventions to prevent Infections Frequent hand washing before and after all Catheter care. Routine surveillance for infection Patient and caregiver education Administration 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 Catheters Barriers to Discharge Invasive Medical Treatment IV antibiotics Pain Increase 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 Injury Immobility Dehydration Neurological Conditions (Parkinson’s Disease) Complications Pain Increased Immobility Loss of Appetite Constipation Interventions to Prevent Diet and Lifestyle Changes High-Fiber Diet Regular exercise Adequate fluid intake Laxatives Fiber Supplements, Stimulants, Lubricants, Stool softeners, Osmotics, Saline laxatives Procedures Manual Procedures Surgical Procedures Constipation Barriers to Discharge Increase LOS Pain Summary Complications 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
