PT Fundamentals Week 5 - Notes

Infection Control & Safety

• Goal: Minimize contamination to prevent infection spread.
• Cleanliness: State of minimized infectious organisms.
• Soiled: Indicates presence of pathogens or potential exposure.
• Healthcare-Associated Infection (HAI): Infections acquired in a healthcare setting.
• Nosocomial Infections: Infections acquired in a hospital.
• CDC Estimate: 1 in 31 patients in the U.S. has at least one HAI.

Isolation Precautions: Standard

• Hand Hygiene: Use soap and water or hand sanitizer.
• Five Moments of Hand Hygiene: Before entering patient room, before clean procedures, after body fluid exposure risk, after touching a patient, after touching patient's surroundings.
• Personal Protective Equipment (PPE): Includes gloves, gown, mask, goggles/eye shields, and face shields.
• PPE Donning: Typically done outside the patient room before entering.
• PPE Doffing: Typically done inside the room before leaving.
• Respiratory Hygiene: Cover mouth and nose when coughing/sneezing, cough into sleeve or elbow, practice hand hygiene after respiratory secretions, wear a face mask if respiratory secretions are present.
• Clinical Attire: Bare Below the Elbows (BBE) policy reduces indirect contact infection.
• Footwear: Closed-toe, low heels, nonskid soles.
• Biohazard Containers: Specialized handling and disposal of items that have come into contact with bodily fluids or suspected infectious materials.

Isolation Precautions: Transmission-Based

• Purpose: Reduce risk of transmission of pathogens.
• Types: Contact, droplet, airborne, and novel respiratory precautions.
• Factors Determining Precautions: Mode of transmission, PPE required, donning/doffing location, order of donning/doffing, and patient transportation requirements.

Contact Precautions

• Purpose: Reduce risk of transmission through physical contact.
• Indications: Patients with known or suspected infections that represent an increased risk for contact transmission (e.g., MRSA, VRE, diarrheal illnesses, open wounds, RSV).
• PPE Usage: Gloves and gown.

Droplet Precautions

• Purpose: Reduce risk of transmitting infectious agents via respiratory droplets.
• Examples: Bacterial pneumonia, bacterial meningitis, viral influenza, mumps, rubella.
• Indications: Patients known or suspected to be infected with pathogens transmitted by respiratory droplets (e.g., mumps, influenza, streptococcus, meningitis, measles, pneumonia).
• PPE Usage: Mask and either goggles or face shield.

Airborne Precautions

• Purpose: Reduce risk of transmitting infectious agents through airborne transmission.
• Examples: Rubella, measles, varicella-zoster virus (chickenpox/shingles), legionella infection, tuberculosis.
• Indications: Patients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., tuberculosis, measles, chickenpox, disseminated herpes zoster).
• PPE Usage: Fit-tested NIOSH-approved N95 or higher-level respirator.
• Patient Placement: Airborne Infection Isolation Room (AIIR) with positive or negative air pressure.

Droplet vs. Airborne Particles

• Distance: Airborne particles travel farther than droplets.
• Factors Influencing Distance: Speed and force of expulsion, density of secretions, environmental factors (temperature and humidity).
• Surface Viability: Microorganisms in respiratory droplets can land on surfaces and remain viable for extended periods.

Novel Respiratory Precautions

• SARS-CoV-2 (COVID-19): Mainly transmitted through contact and droplet but can also spread through airborne transmission.

Laboratory Values

• Purpose: Determine or detect medical conditions, monitor treatments or chronic conditions.
• Review Considerations: Baseline values, trends, rate of change, additional testing, clinical context (acute or chronic conditions, time of day, medications, recent nutrition/hydration status).
• Risk vs. Benefit: Determine appropriate plan of care, anticipate physiological changes with abnormal values, assess risk of adverse events against benefit of PT intervention.
• Critical Values: Values outside normal range that may pose an immediate health risk.
• Age Considerations: Physiological differences in children, adults, and older adults.
• Race and Culture Considerations: Genetic heterogeneity can lead to variability in lab results.
• Sex and Gender Considerations: Use transitioned gender to determine reference value if hormone therapy is being received. If not, biological sex is used to determine reference value.

Complete Blood Count (CBC)

• Components: White blood cells (WBC), red blood cells (RBC), hemoglobin (HGB), hematocrit (HCT), platelets (PLT).

White Blood Cells (Leukocytes)

• Function: Provide protection against infectious diseases, identify infection, inflammation, blood/lymphatic system cancers, and allergens.
• Leukocytosis: WBC count trending upwards.
• Causes: Infection, inflammation, bone marrow disease, immune system disorder, severe stress.

Red Blood Cells (Erythrocytes)

• Function: Provide protection against infectious diseases, identify internal bleeding, pulmonary conditions, cardiac conditions, and cancer.
• Erythrocytosis: RBC count trending upwards.
• Causes: High altitude, dehydration, cor pulmonale, pulmonary fibrosis, thalassemia trait, severe COPD, polycythemia vera, medications, congenital heart disease.
• Anemia: RBC count trending downwards.
• Causes: Hemorrhage, bone marrow suppression, oncologic conditions, hemoglobinopathy, renal disease, pregnancy, dietary deficiency, prosthetic valves, overhydration.

Hemoglobin (HGB)

• Polycythemia: HGB trending upwards.
• Causes: Severe dehydration, high altitude, smoking, congenital heart disease, chronic pulmonary disorders, heart failure.
• Anemia: HGB trending downwards.
• Causes: Hemorrhage, vitamin B-12 and iron deficiency, bone marrow suppression, oncologic conditions, metabolic disorders, medications.

Hematocrit (HCT)

• Polycythemia: HCT trending upwards.
• Causes: Severe dehydration, congenital heart disease, polycythemia vera, erythrocytosis, burns, eclampsia, living at high altitudes, hypoxia due to chronic pulmonary conditions (COPD, heart failure).
• Anemia: HCT trending downwards.
• Causes: Hemorrhage, leukemia, bone marrow failure, multiple myeloma, dietary deficiency, pregnancy, hyperthyroidism, cirrhosis, rheumatoid arthritis, hemolytic reaction, hemoglobinopathy, prosthetic valve, renal disease, lymphoma.

Platelets (PLT)

• Function: Support damaged blood vessels, control bleeding, aid in recovery from surgeries, fight cancer, and manage chronic diseases.
• Thrombocytosis & Thrombocythemia: Platelets trending upwards.
• Causes: Cancer, polycythemia vera, splenectomy, acute/chronic inflammation, strenuous exercise, iron-deficiency anemia.
• Thrombocytopenia: Platelets trending downwards.
• Causes: Hemorrhage, damage to developing blood cells, various diseases leading to reduced platelet count.

Electrolytes and Glucose

• Impact of Electrolyte Changes: Alter neuronal, cardiac, and skeletal muscle excitability, potentially leading to arrhythmias, weakness, spasms, and tremors.

Sodium (Na)

• Function: Determinant of extracellular fluid volume (hypervolemia) or decreased fluid/dehydration (hypovolemia).
• Hypernatremia: Sodium trending upwards.
• Causes: Hypovolemia, sodium overload, endocrine disorders.
• Hyponatremia: Sodium trending downwards.
• Causes: Hypervolemia, hypovolemia, severe fluid loss, dehydration, diuretics, renal or hepatic disease, gastrointestinal disorders, hypotonic IV administration.

Referral and Fall Prevention

• Consider referring patients to other providers as needed.
• Provide fall prevention screening and intervention as needed due to increased fall risk.
• Monitor for orthostatic hypotension.
• Educate patients/caregivers on recognizing orthostatic hypotension symptoms, avoiding quick postural changes, and monitoring blood pressure in the presence of orthostasis or dizziness.
• Consider seizure precautions.

Potassium

• Essential for the function of excitable cells, including nerve, muscle, and cardiac tissues.
• Reference values:
  • Newborn: 3.9-5.9 mEq/L
  • Infant: 4.1-5.3 mEq/L
  • Child: 3.4-4.7 mEq/L
  • Adult/Elderly: 3.5-5.0 mEq/L

Hyperkalemia (Potassium Trending Upwards)

• Causes:

  • Excess potassium supplementation
  • Renal failure
  • Metabolic acidosis
  • Diabetic acidosis
  • Blood transfusion

• Clinical implications:

  • Collaborate with the interprofessional team in the presence of critical hyperkalemia.
  • Patients with levels > 5 mEq/L are at increased risk for dysrhythmia and acute cardiac events: monitor cardiac rhythm, vital signs, and symptoms closely, considering possible decreased activity tolerance.
  • Assess and monitor for an acute decline in muscle strength and performance, which may occur in an ascending pattern and progress to flaccid paralysis.

Hypokalemia (Potassium Trending Downwards)

• Causes:

  • Fluid overload
  • Renal dysfunction
  • Gastrointestinal disorders
  • Diuretics
  • Alcoholism
  • Hormonal and endocrine disorders
  • Cystic fibrosis

• Clinical implications:

  • Collaborate with the interprofessional team in the presence of critical hypokalemia.
  • Patients with levels < 2.5 mEq/L are at increased risk for dysrhythmia and acute cardiac events: monitor cardiac rhythm, vital signs, and symptoms closely, considering possible decreased activity tolerance.
  • Assess and monitor for an acute decline in muscle strength and performance, which may occur in an ascending pattern and progress to flaccid paralysis.

Calcium

• Reference values (mg/dL):
  • Infant < 10 days old: 7.6-10.4
  • Infant 10 days old - 2 years: 9-10.6
  • Child > 2 years: 8.8-10.8
  • Adult: 9-10.5

Hypercalcemia (Calcium Trending Upwards)

• Causes:

  • Excessive release of calcium into the blood
  • Dehydration
  • Endocrine and hormonal disorders
  • Gastrointestinal disorders
  • Excessive vitamin D supplements/antacids
  • Cancer
  • Immobilization

• Clinical implications:

  • Assess and monitor cardiac rhythm, vital signs, and symptoms closely. Patients at risk for cardiac events may have decreased activity tolerance.
  • Assess and monitor for an acute decline in muscle strength and performance.
  • Patients undergoing cancer treatment are at risk for hypercalcemia. Alert the interprofessional team if there are concerning signs or symptoms, as this is deemed an oncologic emergency.
  • Consider seizure precautions.

Hypocalcemia (Calcium Trending Downwards)

• Causes:

  • Chronic kidney disease
  • Sepsis
  • Malnutrition
  • Malabsorption
  • Pancreatitis
  • Laxative use

• Clinical implications:

  • Monitor cardiac rhythm, vital signs, and symptoms closely, considering possible decreased activity tolerance.
  • Assess and monitor for an acute decline in muscle strength and performance.
  • Cognitive and sensory impairments may decrease independence and safety and increase fall risk. Consider referral to other providers as appropriate.
  • Long-term deficiency can lead to cataracts and impaired vision. Consider associated fall risk.
  • For patients with osteopenia, utilize safe handling precautions (hand placement, minimize torque, maintain alignment due to increased fracture risk).
  • Consider seizure precautions.

Glucose

• Reference values (mg/dL):
  • Premature infant: 20-60
  • Neonate: 30-60
  • Child < 2 years: 60-100
  • Child > 2 years to adult:
    • Fasting (no caloric intake for at least 8 hours): 70-110
    • Casual (any time of day regardless of food intake): ≤ 200
  • Adult: 74-106
  • Older adult:
    • 60-90 years: 82-115
    • > 90 years: 75-121

Hyperglycemia (Blood Sugar Trending Upwards)

• Causes:

  • Diabetes mellitus
  • Acute stress response (general anesthesia, stroke, MI, strenuous exercise, burns)
  • Cushing syndrome
  • Cystic fibrosis
  • Chronic kidney disease
  • IV fluids
  • Acute pancreatitis
  • Medications

• Implications:

  • Due to the increased risk of hyperglycemia, monitor glucose levels in patients receiving immunosuppressants following organ transplantation, as well as with patients who are initiating or altering antiretroviral therapy.
  • Assess for peripheral arterial disease prior to initiation of compression or sharp debridement.
  • Assess integumentary system for edema, skin lesions, and wounds.
  • Assess for loss of protective sensation.
  • Educate regarding appropriate footwear and foot self-care.

Hypoglycemia (Blood Sugar Trending Downwards)

• Causes:

  • Excess insulin
  • Hypopituitarism
  • Hypothyroidism
  • Addison's disease
  • Malnutrition
  • Alcoholism

• Clinical implications:

  • Consult with the interprofessional team if blood glucose < 100 mg/dL prior to physical therapy intervention. May need to ingest 15-30g of fast-acting carbohydrate prior to activity.
  • Educate patient/caregiver to monitor blood glucose before, during, and after exercise. May also include strategies to prevent, detect, and treat hypoglycemia.
  • Monitor blood glucose prior to the activity as some patients may experience hypoglycemia unawareness.
  • Provide fall prevention screening and intervention as indicated due to increased fall risk.

Coagulation and Bleeding Profiles

• Partial Thromboplastin Time (PTT): Measures the time plasma will clot when exposed to clotting factors. Monitor heparin therapy.
• International Normalized Ratio (INR): International standard prothrombin time test. When INR is above normal, causes may include: alcohol, anticoagulation therapy, liver disease, bile duct obstruction, vitamin K factor deficiency.
• Prothrombin Time (PT): Measures the time for clot to form; determines efficacy of anticoagulant Coumadin (Warfarin). Prolonged prothrombin time can be caused by: alcohol, anticoagulation therapy, liver disease, bile duct obstruction, vitamin K deficiency, inherited factor VII deficiency, disseminated intravascular coagulation, inherited deficiency of prothrombin, fibrinogen, factor V, factor X, acquired inhibitor of prothrombin, fibrinogen, factor V, factor X.
• D-Dimer: A protein the body makes to break down thrombi. Blood test checks for blood-clotting issues. Initial screening test to diagnose patients who have signs or symptoms of venous thromboembolism. Bleeding is a pathological cause of elevated D-dimer levels. Other causes include: thrombosis, trauma, pregnancy, renal and liver disease, malignancy and its treatment, vascular disorders, infections, inflammation (COVID-19).
  • Reference values are < 250 ng/mL or < 0.4 mcg/mL.

Presentation of Positive PTT, PT, INR, or D-Dimer

• Increased bleeding tendency
• Bruising
• Oozing from wounds
• Mucosal bleeding

Clinical Implications of Positive PTT, PT, INR, or D-Dimer

• Provide fall prevention screening and intervention as needed due to increased risk of injury with falls.
• Apply prolonged pressure to the site if bleeding occurs.
• Examine skin for bruising, petechiae, or blood in urine.
• Bruising may result from blood pressure cuff or other medical devices.
• Monitor for changes in neurological condition due to increased risk of intracranial bleeding.
• Educate the patient that falls or contact sports may increase trauma-induced bleeding risk.
• Collaborate with the interprofessional team if levels are outside the therapeutic range to determine safe exercise prescription and intensity of activity.

Long-Term Positioning

• Safety: Maintain open airways, avoid falls, select a position within patient's medical and physical limitations.
• Prevention: Pressure injuries, contractures, edema, protect joint tissues.
• Intervention: Achieve optimal physiological function, promoting compensatory function.
• Patient quality of life: Promote functional independence and social interaction.

Modified Side-Lying Position

• Alternative to the supine position for those at risk of developing pressure injuries.
• Upper body is rotated (not fully side-lying), and the pelvis is rotated upward off the bed surface.
• Requires extra pillows or wedges to maintain position.

Supine Position

• Arm elevated on a pillow to potentially prevent edema.
• Sheet roll to elevate the calcaneus and protect heels (may use heel protectors).

Long-Term Positioning Checklist

• Clear airway
• Good spinal alignment
• Minimized pressure over bony prominences
• Minimized shearing forces created by gravity
• Cushioned support surfaces to minimize pressure
• Elevated immobile extremities
• Prevention of joint and soft tissue contractures
• Support and stability provided for trunk and extremities
• Facilitation of maximum long-term function
• Optimized interaction with the environment (line of sight, communication, etc.)
• Special needs accommodated

Fowler's Position

• One of the most common positions for patients resting in hospital beds or recliners.
• Long-term positioning can compromise ROM and tissue integrity, potentially causing contractures.
• Semi-reclined position with the patient's knees usually somewhat flexed for comfort.
• The head of the bed (HOB) is elevated to about 45 degrees to 60 degrees, with high Fowler's position closer to 80 degrees or 90 degrees.
• Comfortable position that allows patients to participate in their environment (eat lunch, interact with others).
• Increases pressure on the sacrum.
• Over time, the patient can slide down in bed due to gravity, causing friction and shearing forces that increase the risk of developing a pressure injury.
• Educate patients, caregivers, and the nursing team on rotating the patient's position frequently.
• Create a long-term positioning plan to create a daily schedule.

High Fowler's Position vs. Low Fowler's Position

• Increasing the head of the bed beyond 30 degrees can increase the risk of skin breakdown due to friction.
• Low Fowler's position with less pulling forces decreases the risk of a shearing injury.

Contractures

• Limitations in joint motion caused by adaptive shortening in ligaments, tendons, and muscles.
• Loss of joint motion may become permanent.
• Muscle weakness can develop along with contracture development.
• When one muscle group is placed in its shortened range, the opposite (antagonist) muscle group becomes overlengthened for the same prolonged period.
• Contractures tend to occur in positions of comfort, most often in flexion.

Sites of Common Contracture Development

• Supine: Shoulder flexion, elbow flexion, wrist and hand flexion, hip flexion, hip adduction, knee flexion, and ankle plantarflexion.
• Sidelying: Shoulder flexion, shoulder adduction, scapular protraction, elbow flexion, wrist and hand flexion, hip flexion, hip adduction, knee flexion, and ankle plantarflexion.
• Sitting: Shoulder flexion, elbow flexion, wrist and hand flexion, hip flexion, hip adduction, knee flexion, and ankle plantarflexion.

Location-Specific Contractures and Positioning to Counteract Them

• Head and Neck:
  • Contracture and Adaptive Shortening Positions: Forward head with upper cervical hyperextension and increased lower cervical flexion; decreased cervical rotation.
  • Positioning to Counter Contractures: Position the head in the same frontal plane as the shoulders, approximating normal cervical lordosis; alternate right and left cervical rotation positions.
• Shoulder Girdle:
  • Contracture and Adaptive Shortening Positions: Scapular protraction with glenohumeral adduction and internal rotation ("rounded shoulders").
  • Positioning to Counter Contractures: Neutral scapulae with glenohumeral abduction and external rotation; arm up over the head.
• Elbow:
  • Contracture and Adaptive Shortening Positions: Flexion.
  • Positioning to Counter Contractures: Elbow extended.
• Wrist and Hand:
  • Contracture and Adaptive Shortening Positions: Flexion.
  • Positioning to Counter Contractures: Wrist in a neutral position with the hand lying open; an object in the hand to maintain an open position and counteract a fisted hand position.
• Hips and Knees:
  • Contracture and Adaptive Shortening Positions: Hip and knee flexion. Hip and adductin or hip adduction with external rotation and knee flexion ("frog leg").
  • Positioning to Counter Contractures: Hip extension and knee extension (not hyperextension). Moderate hip abduction with knee extension; possibly bolster or towel roll on the lateral aspect of the thighs to prevent hip external rotation.
• Ankle and Foot:
  • Contracture and Adaptive Shortening Positions: Ankle plantarflexion.
  • Positioning to Counter Contractures: Ankle neutral or dorsiflexed, possibly with aid of a positioning device.

Pressure Injuries

• Localized injury to the skin caused by unrelieved pressure.
• Can also be caused by pressure with shearing forces.
• Estimated 60,000 patients in U.S. hospitals die yearly due to complications.
• Estimated cost of managing one full-thickness injury is as high as $127,000.

Biomechanical Factors of Pressure Injuries

• Load: Patient's body weight.
• Pressure: Surface area that the load is distributed.
• Time: High loading over a short period can lead to injury, and low loading over a long enough time can also lead to tissue damage.

Shear and Friction in Pressure Injuries

• Moving patients in bed by pulling or sliding them can create increased friction against the outermost layer of the skin and cause shearing forces between the layers of the skin.
• The weight of the patient's body weight can compound pressure injuries.

Patient Susceptibility to Pressure Injuries

• Head
• Shoulders
• Hips
• Buttocks

Conditions that Increase Susceptibility to Pressure Injuries

• Inability to move independently
• Impaired circulation
• Pathologically low blood pressure
• Absent or impaired sensation
• Bladder or bowel incontinence
• Muscle atrophy
• Postural impairments (e.g., kyphosis)
• Fragile or friable skin
• History of skin breakdown
• Nutritional deficiencies
• Cachexia (a metabolic syndrome resulting in severe weight loss including muscle wasting)
• Impaired cognitive ability
• Use of medical devices such as splints, braces, endotracheal tubes, urinary catheters, and antiembolic stockings
• Use of physical or chemical restraints
• Use of medications that affect mobility or awareness
• Cigarette smoking

High-Risk Areas for Skin Breakdown

• Sacrum and coccyx: The bony prominences make it prone to pressure.
• Heels: Due to the potential for compression in the supine position.
• Elbows: Prone to pressure from lying face down on pillows.
• Lateral malleoli: Due to their proximity to the bed surface.
• Scapulae: The bony prominence of the shoulder blade.
• Trochanters: The bony prominence of the hip.
• Greater trochanters: The bumpy protuberance on the outside of the hip.
• Knees: Prone to pressure if kept in flexion for long periods.

Promoting Cardiopulmonary Health

Orthostatic Hypotension

• Decrease in BP at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing up.
• Syncope with a change in position.

Edema

• Any immobile extremity in a dependent position (below the level of the heart) is at risk for edema.
• Positioning extremities higher than the heart helps prevent and alleviate swelling in the hands and feet.

DVT

• Immobility can cause blood to become stagnant and develop into a thrombus.
• Indications of venous thrombosis may include localized pain, warmth, redness, and swelling.
• The main risk factor associated with DVT is immobility.

Blood Pressure

• BP can determine the intensity of planned activity.
• Due to prolonged immobility, patients may have abnormal BP responses to activity.
• Monitoring BP can indicate a patient's ability to tolerate additional activity.

Positioning Devices

• Alleviate pressure on an area: Heel suspension boot.
• Prevent contraindicated motion: Abduction pillow.
• Provide additional protection or cushioning for vulnerable areas: Bony prominences.

Physical Restraints

• Devices, material, or manual methods that limit the ability to move the arms, legs, body, or head freely.
• Commonly used during or immediately after a surgical procedure to ensure a patient's safety.
• In rare situations, nonsurgical patients may be restrained to prevent them from moving in ways that could be harmful to themselves or others.

Test your knowledge on infection control practices and personal protective equipment (PPE) in healthcare settings. This quiz covers topics such as respiratory hygiene, contact precautions, and hand hygiene protocols. Understand the various precautions necessary to prevent the spread of infection in clinical environments.