Prevention of complications - Spalding Rehabilitation Hospital by hcj

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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




                                                                 Patient
      STAFF
                                                         Wash hands before leavin
h hands before/after pt.
                                                                  room
      contact                                         Gown/Mask when leaving ro
                                                      if necessary
 n/Gloves when in
act with body fluids                                  Meals and therapy in room i
                                                      draining wound/incontinent;
k when in room- if                                    check with nurse
ssary-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

								
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