Transcript Interventions to prevent - Spalding Rehabilitation Hospital

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
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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
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Immobility
Neuropathic Disease
Arterial Inflow Disease
End stage Renal Disease
Systemic Infection
Wound Care Complications
Interventions to prevent
 Early Intervention
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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