1. Treatment Considerations

2. Medically Complex Patients
Physical therapy treatments for medically complex patients tend to start at a very basic level of intensity and frequency. The intensity progression is determined by the patient’s response to treatment and overall medical stability. In order to do this safely and effectively, a PTA must be familiar with many factors that may indicate a change of status.
In order to effectively carry out the plan of care (POC) with a medically complex patient, you must take the time to discuss the current status with the supervising physical therapist. It is essential to work closely with the nursing staff and other members of the team due to the fact that the status of these patients can change very quickly. While not always possible, it is always best practice to talk directly with the patient’s nurse prior to initiation of treatment and upon completion of the session.

3. Advancement of Activities
Picture of patient in bed
Advancement of exercises and mobility activities with the medically complex patient is likely to be much slower than with a general acute patient. Patients may advance forward one day and then relapse the next day. Early phases of therapy often focus on preventative measures that would complicate long-term functional recovery such as contracture prevention, decubitus ulcer prevention, basic lower and upper extremity exercises, and bed mobility. Ongoing caregiver education and reinforcement of precautions is essential in each of these categories to reduce the risk of preventable secondary conditions. There may be opportunities to recruit a family member to assist in heel cord stretches, positioning techniques, and a basic supine exercise program.

4. Therapeutic Progression
Picture of patient in wheelchair
Therapeutic progression of activities include sitting at the edge of the bed for static and dynamic balance control, transfer training, wheelchair mobility activities, static and dynamic standing balance, and possibly gait training. The PT/PTA team will work closely to progress the patient in a safe and effective manner. The key to any successful therapy plan is careful monitoring of the patient’s tolerance with subjective and objective information. Vital signs such as blood pressure, respiration rate, and oxygen saturation should be monitored before and after each treatment.

5. Level of Arousal and Cognitive Status
Confused patient
Another important treatment consideration is a patient’s level of arousal and cognitive status. If a medical condition or medications are impairing a patient’s ability to actively be engaged in the treatment, this will impact the intensity of services. Activities such as cognitive orientation, positioning, tone management and passive stretches are appropriate for an obtunded or lethargic patient. Remember that the best motor learning occurs when the patient is in an alert state. Sometimes therapy interventions such as supine to sitting at the edge of the bed will provide enough sensory stimulation to increase a patient’s level of arousal and enhance the benefit from the activity.

6. Homeostasis Something like this, to represent balance
Homeostasis involves a series of complicated chemical balances involving all body cells. Maintaining homeostasis determines overall health. The medically complex patient’s status is assessed, in part, by blood chemistry or blood lab values. These special lab tests provide objective data about the body’s organ function. This information is used to determine medical stability and direct medical care, including the appropriateness of physical therapy.

7. Scenario
This can go with the following slide—I just couldn’t fit it all on one.
Review the scenario and use the information provided to answer the questions about this patient. Focus on blood glucose, red and white blood cell counts, as well as kidney, pulmonary and cardiac chemistry.

8. Scenario A less cheerful elderly man would be more appropriate
Medical Record
Physician documentation:
New orders: Supplemental O2 to maintain PO2 at ≥ 92%, repeat CBC labs in the morning
Nursing documentation:
Patient anxious, requesting medication for abdominal cramps, declining meals.
Respiratory documentation:
Episode of PO2 at 82% at 6:00 am, unresolved with pursed lip breathing, supplemental O2 provided at 2 l/min via nasal cannula. PO2 achieved 94% within 10 min.
AM blood lab values:
Red blood cells (RBC) 22 mL/kg, white blood cells (WBC) 9.8 x 10³, hematocrit (Hct) 30%, hemoglobin (Hgb) 8 gm/dl
Blood glucose:
135 mg/dl
BUN:
24 mg/100ml
Creatinine:
1.3 mg/100ml
M. Sanderson is a 65 year old male who has a 25 year history of diabetes mellitus, a 20 year history of asthma and 5 years s/p colorectal cancer which was treated with large bowel resection and chemotherapy. He was admitted to the acute care setting 5 days ago due to a GI bleed. PT services were initiated one day ago with an evaluation and instruction of supine bilateral LE exercises and bed mobility activities. He tolerated sitting at the edge of the bed for 10 minutes, but c/o being dizzy and nauseous.
You are seeing this patient on the second day of therapy to perform active exercises, attempt sitting at the edge of the bed, and initiate transfer training to a bedside chair if the patient can tolerate the activity. Prior to meeting the patient you review the information in the patient’s medical record.
A less cheerful elderly man would be more appropriate

9. Question 1
Based on the patient information, your best initial course of action is to:
Chart that the patient is not appropriate for PT services at this time due to a change in condition.
Discuss the above information with the supervising PT before beginning treatment.
Proceed with the POC of supine exercises, mobility and sitting activities at the edge of the bed.
Progress the POC to transfer training to a bedside chair.
Initiate sitting activities and transfer training before the patient fatigues.
Feedback:
The patient has had a change in condition due to her respiratory status. Additionally, the A.M. labs would reflect that activity should be limited to essential ADLS, not out of bed activity, so talking to the supervising PT is your best option.

10. Question 2
If the supervising PT states that it is OK to proceed with the POC while monitoring the patient’s O2 saturations and tolerance to activity, which of the following would be the best beginning treatment intervention?
Passive ROM of both lower extremities.
Hamstring and heel cord stretches to patient’s tolerance.
Active supine exercises, avoiding isometrics.
Resisted lower extremity exercises to patient’s tolerance.
Initiate sitting activities and transfer training before the patient fatigues.
Feedback:
Active supine exercises are appropriate because they are within the POC, and are the safest initial activity to perform with this patient.

11. Question 3
Based on the patient information, what is the most likely cause of the patient’s new symptoms and lab values?
Unresolved GI bleed.
Colorectal metastasis to the lungs.
Uncontrolled blood sugars.
Nosocomial bacterial infection.
Acute kidney failure
Feedback:
An unresolved GI bleed is likely because the patient’s lab values reveal that she continues to lose red blood cells.

12. Mr. Sanderson now has an oral temperature of 101/5 and the AM lab values have changed as follows:
Medical Record
Blood lab values:
Red blood cells (RBC) 26 mL/kg, white blood cells (WBC) 12.8 x 10³, hematocrit (Hct) 45%, hemoglobin (Hgb) 12 gm/dl
Blood glucose:
125 mg/dl
BUN:
39 mg/100ml
Creatinine:
8.2 mg/100ml

13. Question 4
What is the most likely cause of the patient’s new symptoms and lab values?
Colorectal metastasis to the lungs.
Unresolved GI bleed.
Uncontrolled blood sugars.
Acute kidney failure
Nosocomial bacterial infection
Feedback:
The information points to a bacterial infection because the patients RBC, Hct and Hgb are normalizing but the WBC is high and the patient has a temperature, both indicators of an infection that she did not have prior to admission.

14. Summary
Treatment considerations for each patient within the inpatient setting require ongoing critical thinking skills of both the PT and the PTA. Data is gathered by both patient observation/assessment and objective measure. Treatment interventions are then selected based on the patients’ needs and tolerance to activities.