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Basic guidelines for providing a safe caregiver and patient environment include the following:

• Always following standard precautions, including thorough

hand washing. Refer to Table 10-4 for a summary of infection prevention precautions, including contact, airborne, and droplet precautions.

•

Knowledge of the facility'S policy for accidental chemical, waste,

or sharps exposure, as well as emergency procedures for evacuation, fire, and natural disaster. Know how to contact the employee health service and hospital security.

•

Confirming the patient'S name before physical therapy intervention by interview or identification bracelet. Notify the nurse if a patient is missing an identification bracelet.

•

Reorienting a patient who is confused or disoriented. In general,

patients who are confused are assigned rooms closer to the nursing

station.

• Make recommendations to nursing for the use of bathroom

equipment (e.g., rub bench or raised toilet seat) if the patient has

functional limitations that may pose a safety risk.

• Elevating the height of the bed as needed to ensure proper body

mechanics when performing a bedside intervention (e.g., stretching

or bed mobility training).

• Leaving the bed or chair (e.g., stretcher chair) in the lowest position with wheels locked after physical therapy intervention is complete. Leave the top bed rails up for all patients.

• Always leaving the patient with the call bell or other communication devices within close reach. This includes eyeglasses and hearing aids.

• If applicable, using bed alarms so that the staff will know

whether a patient has arrempted to get our of bed alone.

• Keeping the patient's room as neat and clutter free as possible ro

minimize the risk of trips and falls. Pick up objects that have fallen

API'ENDIX 1-8: AClfrE CARE SETrlNG

751

on the noor. Secure electrical cords (e.g., for the bed or intravenous

pumps) out of the way. Keep small-sized equipment used for physical therapy intervention (e.g., cuff weights) in a drawer or closet.

Store assistive devices at the perimeter of the room when not in

use. Do not block the doorway or pathway to and from the

patient's bed.

• Providing enough light for the patient to move about the room

or read educational materials.

• Only using equipment (e.g., assistive devices, recliner chairs,

wheelchairs) that is in good working condition. If equipment is

unsafe, then label it as such and contact the appropriate personnel

to repair or discard it.

• Disposing of linens, dressings, and garbage according to the policies of the facility.

Latex Allergy

A la/ex allergy respollse is defined as "the State in which an individual experiences an immunoglobulin E (lgE)-mediated response to latex" from tactile, inhaled, or ingested exposure to natural rubber

latex. I Signs and symptoms of an allergic reaction ro latex may range

from swelling, itching, or redness of skin or mucous membranes to

anaphylaxis.'

Natural rubber latex can be found in a multitude of products and

equipment found in the acute care setting. Those products most commonly used by the physical therapist include gloves, stethoscopes, blood-pressure cuffs, Ambu bags, adhesive tape, electrode pads, and

hand grips on assistive devices. If a patient has an allergy or hypersensitivity to latex, then it is documented in the medical record, nursing cardex or report, and at the patient's bedside. Hospitals will provide a

special "latex-free kit," which consists of latex-free products for use

with the patient.

Health care providers, including physical therapists, may be at risk

for developing latex allergy from increased exposure to latex in the

work setting. If there is a suspected latex hypersensitivity or allergy,

then seek assistance from the employee health office or a primary care

physician.

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ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Use of Restraints

The use of a restraint may be indicated for the patient who (I) is

unconscious, (2) has altered mental status at risk for wandering or

pulling out lines and tubes, (3) is unsafely mobile, (4) is physically

aggressive, or (5) is so active or agitated that essential medical-surgical care cannor be complered.' The most common types of restraints in the acute care setting are wrist or ankle restraints, mitt restraints,

or a vest restraint. An order from a physician, which must be

updated approximately every 24-48 hours, is required to place a

restraint on a patient.

General guidelines most applicable to the physical therapist for the

usc of restraints include

• Usc a slipknot to secure a restraint rather than a square knot.

This ensures that the restraint can be rapidly untied in an emergency.

• Do not secure the restraint to a moveable object (e.g., the bed

rail), to an object that the patient is not lying or sitting on, or

within the patient's reach.

• Ensure that the restraint is secure but not too tight. Place twO

fingers between the restraint and the patient ro be sure circulation

is not impaired.

• Always replace restraints after a physical therapy session.

• Be sure the patient does nOt trip on the ties or "tails" of the

restraint during functional mobility training.

• Consult with the health care team to determine wherher a

patient needs to have restrainrs.

Effects of Prolonged Bed Rest

The effects of short- (days to weeks) or long-term (weeks to months)

bed rest can be deleterious and impact every organ system in the

body. For the purposes of this discussion, bed rest incor�orates immobilization, disuse, and recumbence with an end result of multisystem deconditioning. The physical therapist mUSt recognize that a patient

in the acute care serting is likely to have an alteration in physiology

(i.e., a traumatic or medical-surgical disease or dysfunction) superimposed on bed rest, a second abnormal physiologic state.'

APPENDIX I-B: AClITE CARE SETTlNG

753

Most patients on bed rest have been in the intensive care unit (ICU)

for many weeks with multisystem organ failure or hemodynamic

instability requiring sedation and mechanical ventilation. Other clinical situations classically associated with long-term bed rest include severe burns and multi-trauma, including the need for skeletal traction, spinal cord injury, or grade IV non-healing wounds of the lower extremity or sacrum. It is beyond the scope of this text to discuss in

detail the effects of prolonged bed rest; however, Table I-B.'1 lists these

major changes.

Clinical Tip

• MonitOr vital signs carefully, especially during mobilization out of bed for the first few times.

• Progressively raise the head of the bed before or during a

physical therapy session to allow blood pressure to regulate.

• A tilt table may be used if orthostatic hypotension persists

despite volume repletion, medication, or therapeutic exercise.

• Time frames for physical therapy goals will likely be

longer for the parient who has been on prolonged bed rest.

• Independent or family-assisted therapeutic exercise

should supplement formal physical therapy sessions for a

more timely recovery.

• Be aware of the psychosocial aspects of prolonged bed

rest. Sensory deprivation, boredom, depression, and a

sense of loss of control can occur.' These feelings may

manifest as emotional lability or irritability, and caregivers

may incorrectly perceive the patient to be uncooperative.

• As much as the patient wants to be off bed rest, the patient

will likely be fearful the first time out of bed, especially if the

patient has insight into his or her muscular weakness.

• Leave the patient with necessities or commonly used

objects (e.g., the call bell, telephone, reading matetial, beverages, tissues) within reach to minimize the patient's feelings of being confined to bed.

End-of-Life Issues

End-of-life issues are often complex moral, ethical, or legal dilemmas,

or a combination of these, regarding a patient'S vital physiologic func-

754

AClfTE CARE HANDBOOK FOR PHYSICAL ll-IERAI'ISTS

Table I-B.l. Systemic Effects of Prolonged Bed Rest

Body System

Effects

Cardiac

Increased heart rate at rest and with submaximal

exercise. Decreased stroke volume and left ventricular end-diastolic volume at rest. Decreased cardiac

output, Vo2max with submaximal and maximal

exercise.

Hematologic

Decreased [oral blood volume, red blood cell mass, and

plasma volume. Increased blood fibrinogen and risk

of venous thrombosis.

Respirarory

Increased respiratory rate, forced vital capaciry, and

total lung capacity (slight). Increased risk of

pulmonary embolism and possible ventilationperfusion mismatch.

Gastrointestinal

Decreased appetite, fluid intake, bowel motiliry, and

gastric secretion.

Genirourinary

Increased mineral excretion, calculus formation,

difficulty voiding, postvoid residuals, and overflow