Pearls in Rehab Hospitals and Nursing Homes for Pysicisans

By: Maged Taman

Here is some pearls to rehab and nursing home doctors:


1- In most hospitals rehab doctors need to see the patient in 24 hours in nursing homes 48 hours.
2- Patients tend to fall in first day in rehab were patient saftey may not be assessed well yet. It is important to assesss fall risk early in admission so patient can have appropriate saftey measures.
3- Saftey measure against fall are: Tab sitter, raising side rails of bed and seat belt. Ensure as well that patient recognise how to use the call button for nurses.
4- Patient who need to be sent acute, has to be sent to the same hospital he came from unless his condition is serious enough to require the closest and appropriate hospital.
5- Patient can commonly have US Doppler study to role out DVT , simple x-rays and blood work in same nursing home..
5- Follow up imaging studies are done in same hospital patient has the original study done as CT, MRI...
6- Before writing a new medicines always check patient allergies.
7- Be careful about cross allergies ASA and NSAID's, PCN and cephalosporins. ACEI's and ARB's.
8- PRN orders need to specify what the PRN for: pain, heart burn....
9- Avoid narcotics, sedatives and muscles relaxants in the elderly if possible can cause confusion, falls and aspirations. When needed start low and slow with meds.
10- Most meds Q AM or P AM, Q 12h , or Q 8 hours. Diabetics meds with meals, Insulin R 1/2h before meals, humalog or novalog 15 minutes with or even after meals.
11- Insulin sliding scale is premeal. Patients on oral anti diabetics may do BS bid before breakfast and supper many of them would not need sliding scale but adjusting the oral antidiabetic.
12- Patients in insulin need 2-5 check of BS a day. When use sliding insulin use it only before meals giving regular or short acting insulin at night may cause hypoglyecemia overnight.
13- Intensity of checking blood sugar depends on its variability. In type 2 DM check BS BID for 3 days. If BS are good then may check BS less often.
14- Commonly remind patients of low blood sugar symptoms (shakiness, sweating, mental staus change....).
15- Always check every patient have DVT prophylaxis arixtra, heparin, lovenox or coumdin. Additionally high thigh TEDs and IPC boots may help. The latter can both be used for people who we can not be anticoagulated, we have to document why we can not anti coagulate.
16- For patients can not be anticoagulated and will likely to be immobile IVC filter is commonly done before patient sent to rehab.
17- Patients after orthopedic surgery who are in coumdin are give arixtra 2.5 mg sq`daily or lovenox 40 mg sq daily until INR is > 1.8.
18- Low Blood pressure common in early admission second to deconditioning and low oral intake. Be sure no sepsis: fever, high WBC's, patient looks sick...
19- Encourage PO Fluids unless fluid overload, patient who can not get enough oral fluid IV fluids may be needed commonly IV NS given overnight about 750 to 1000 cc over night, so IV pump does not interrupt morning rehab. Then assess daily need of IV fluids.
20 Aviod hypotonic fluids since patient commonly have pain, pain meds, thiazides and other factors that predispose to SIADH and cause hyponatermia.
21- People who would need IV fluids are those ususally lost fluids due to vomiting, diarrhea or overdiuersis and started to show symptoms and signs of dehydration (low BP, tachycardia, dry mouth, fatigued, washed out, high BUN/Cr ratio >20 .
22- Low BP is common early in rehab admission related to pain meds, anemia and decrease oral intake. Commonly patient would need to hold some of BP meds. A good way to do that is to hold BP meds for systolic BP <110 .="."> 180 and heart rate <55>110 for most of patients.
23- Write parameters to therapists to hold therapy if BP < 100 or > 180 and heart rate <55 or="or">110 for most patients.
24- Use parameters to hold betablochers, dig, some calcium channels hold for HR <60 .="." br="br">25-Minimize blood work if not needed.
26- Treat bacturia if symptomatic, fever, high WBC's... Consider many times not to treat if asymptomatic.
27-Risk of C.diff after antibiotics in hospitals is quite high. It is not uncommon to come from other hospital with undiagnosed c.diff.
28- For C. diff flagyl 500 mg po q 8h for 10 dayswork very well, those with severe C.diff or resistance oral vancomycin 125-250 mg PO QID x 10-14 days.
29- Pain control though varies between patients, 1-2 percocet or vicodin q 8 am and q noon time works well. When try Oxycontin better try 10 mg PO one time in day time.
30- Patients with GI upset or mental status changes second to narcotics may do O.K on tramadol (ultram) 25 mg PO q 4-6h.
31- The best way to round in patiens is to round first with nurses. They will give the problems of the day, change in condition, eating, urine, bowel functions, saftey and skin integrity.
32- When you round with a nurse open the med sheet it will give you the meds patient to reviwe quickly. It has the blood pressure, heart rate and blood sugars. For example the patient reported to be weaker to day: the med sheet may suggest to you low BP, low BS, Slow heart rate, low K or high K due to one of meds, low Na, high calcium, over-diuersis due to one of the meds also.
33- For a full note write meds, labs, tackle our acute and chronic medical condition. Do that at least once week will allow you to pick any significant thing early. You may choose to indicate that you revwied all meds and labs to save your time without writing them.
34- When write antibiotics write start date and stop date.
35- Do not role out MI in the floor if you think patient needs to be rolled out send back to hospital he came from.
36- When seeing a patient after hip or knee surgery mild erythema, bruise, warmthness, serosageouns discharge, and swellings are quite common and normal findings. For infection Look for purulent or semi purulent drainage, pockets of swellings with significant tenderness, fever and leukocytosis. Marking area of redness and follow up is helpful. You may do culture if the drainge is suspicious. Surgeons usually like to see the patient before starting antibiotics.
37- Removing staples or sutures can be done after 10-14 days after surgery or as specified by surgeon. When remove staples remove 1/2 of them usually every other staple. You may then remove the rest in few days. Before removing staples be sure there is total healing and gaps beteen the healing wound edjes. Apply stri-strips after staples removed.
38- Do not remove Staples or sutures of amputation stump, surgeons like to do that. Many times it take more than 3 weeks before can remove the sutures or staples.
39- For 1 st stage decubitus (red skin) use granulex spray bid it toughs the skin and make it less prone to get sloughed. For stage two (partial skin thickness) allevyn dressing Q 72 h which is slef adhesive. Can use silvadene if infected. Anticoat or iodflex are more effective when drainage is more and infection is likely. They serve both as absorabant and antibacterial/ They are usually covered with allevyn dressing.
40- For copsious drainage both infected or strile wound vacc provide excellent suction of drainage and approximation of the wound edjes. It is commonly put in contionus suction unless draiange is slowing down can use intermitten suction.
41- For decubitus in feet to hang above pillow, may use allevyn cup or Leonard boot. If it gets worse or diabetic consult podiatry.
42- For heel blister or eschar depridement is mostly not needed. The heel gets more painful and more prone to infection after depridement. The blister usually collapse and exchar falls off.
43- For worsening wounds or decubiti refer patient to a wound center.
44- Most common skin problems we encountered in rehab and nursing home are fungal rashes, decubiti, folliculitis, drug eruptions and seborrheic dermatitis.
45- Fungal rashes are treated with:
46- Folloculitis is treated with:
47- Seborrheic dermatitis is treated with:
48- Women in antibiotics may develop yeast vaginitis (vaginal itch and/or discharge) It is treated with diflucan 150 mg PO x 1 +/- vaginal anti fungal cream if needed.
49- Check with nurses bowel movements constipation can cause urine retention, hemorrhoids, if severe Ogilvie ' syndrome (acute colonic pseudo=obstruction may occur and cause cecal perforation). Regular BM's in rehab or nursing patients are indication of good effort of the doctor and nurses.
50- Common therapy for consitpation:
51- After surgery consider incentive spirometer Q 15 minutes for patients who has lung disease or coughing. Ventolin inhaler with spacer or nebulizer BID, QID or QID prn to consider.
52- Respect low O2 sat many times it is your first clue to a serious pulmonary embolism. So the later could occur with normal O2 sat. Chest pain, SOB, new arrhythmia......are other manifestations of PE.
53 numbness or sciatic pain may respond well to neurintin or lyrica. Star with small dose some times low doses 100 mg PO tid with the first or 25 mg PO qhs with the second may be cough.
54- When evaluate your patients recognize those with sensitive stomach or who get drugged easily by medicines. consider lower doses of medicine.
55- Ear wax treatment instill 5-10 drops of dobrax bid for 4 days then clean or ear wash.
56- Lidoderm patch is effective in many musculoskeletal conditions. However avoid in open areas or hot areas like post op TKR, THR and so forth. Use q 8am to q 8pm or q 8am to q 8pm (12 hours a day only) according to patient pain more at night or day time maximum 3 patches per day. Bengay tid is effective as well hot pack or ice pack. Ice pack can be used over lidoderm but hot pack can increae the absorption of the lidoderm so remove it before applying hot pack.
57- Ice pack works well in headaches bruises and orthopedic surgeries. It is also effective when trying to stop epistaxis.
58- Recognize dry weight and teach cardiac, hepatic and renal patients this concept. It is the weight at which patient has no shortness of breath and no leg or trace edema and no signs of being dry as thirsty, feeling dry, washed out or orthostatic. Patient usually can recognize at what weight he achieve this status. He has to try to keep it by increasing or decreasing lasix according to the deviation from dry weight.
59- Fluid challenge is a term used to describe given fluids to patients with low BP or elevated creatinine to see if it will improve the situation.
60- Patient with quite low BP have to have IV normal saline wide open. Other measures like IV dopamine should be considered as well.
61- Skin rash due to drugs stop the medicine. For itch hydrocotrisone 2.5% cream bid Zyrtec 5-10 mg PO qd for few days and atarax 25 mg po tid itch.
62- Do not forget to write patient eye drops. Glucoma can get worse if drops are omitted.
63- For bed sores be sure the patient position is changed every tow hours. To lie on side as much as he can. Change to air mattress. Frequent inspection of the decubitus daily or every other day.
64- Change patient bed position in bed when necessary: for shortness of breath or aspiration sit patient up all time. For low BP telendlenburg position.
65- When you put IV: put tourniquet, see and palpate the vien, recognize the anatomy of the vien the size, how deep and what is its direction. Commonly you need to hold the arm as well the skin.
66- 90% of K we ingest is excreted through the kidney. K is elevate in the blood if patient has kidney failure or patient is taking medicine that cause the kidney not to get rid of K as ACE inhibitors, ARB's, K sparing diuretics.
67- Cit C 500 mg po bid and zinc sulfate 220 mg (have 50 mg elemental zinc) po daily may enhance heeling. Nutrion and bloos sugar contol are essential for wound healing.
68- Most common skin problems in rehab are fungal rashes, decubiti, folliculitis, drug eruptions and seborrheic dermatitis.
53- Vaginitis (vaginal itch and/or discharge) is not uncommon in women after antibiotics. diflucan 150 mg PO x 1 +/- vaginal anti fungal cream.
54- Check with nurses bowel movements constipation can cause urine retention, hemorrhoids, if severe Ogilvie ' syndrome (acute colonic pseudo=obstruction may occur and cause cecal perforation).
55- After surgery consider incentive spirometer for patients who has lung disease or coughing. Ventolin inhaler with spacer or nebulizer BID, QID or QID prn to consider. Many times inhalers would be the best to get rid of secretions particularly in patients with airway disease. Mucinex 1 tab Q 12 h will lossen secretions and allow expectotarions.
56- Respect low O2 sat many times it is your first clue to a serious pulmonary embolism. So the later could occur with normal O2 sat. Chest pain, SOB, new arrhythmia particularly supraventricualr......are other manifestations of PE.
57- numbness or sciatic pain may respond well to neurintin or lyrica. Star with small dose some times low doses 100 mg PO tid with the first or 25 mg PO qhs with the second may be cough.
58- When evaluate your patients recognize those with sensitive stomach or who get drugged easily by medicines. consider lower doses of medicine.
59- Ear wax is not uncommon in eldely. For treatment instill of Dobrax 5-10 drops bid for 4 days then clean or ear wash.
60- Be sure the patient is not fall risk, if have him close to nurse station. Lab belt and tab sitter as indicated. Let the family now.
61- Lidoderm patch is effective in many musculoskeletal conditions. However avoid in open areas or hot areas like post op TKR, THR and so forth. Use q 8am to q 8pm or q 8am to q 8pm (12 hours a day only) according to patient pain more at night or day time maximum 3 per day. Bengay tid is effective as well hot pack. Ice pack works well in headaches bruises and orthopedic surgeries. You can use ice over lidoderm patch but not hot pack since it can increase its absorption.
62- Recognize dry weight which is the weight when patient is dry of edema meanwhile has no symptoms of overdiuresis . Teach cardiac, hepatic and renal patients this concept. It is the weight at which patient has no shortness of breath and no leg or trace edema and no signs of being dry as thirsty, feeling dry mouth, washed out or orthostatic. Patient usually can recognize at what weight he achieve this status. He has to try to keep it by increasing or decreasing lasix to keep the dry weight.
63- Fluid challenge is a term used to describe given fluids to patients with low BP, low urine output or elevated creatinine to see if it will improve the situation.
64- Patient with quite low BP have to have IV normal saline wide open. Other measures like IV dopamine should be considered as well.
65- For skin rash due to drugs stop the medicine. For itch hydrocotrisone 2.5% cream BID + Sarna anti-itch + Zyrtec 5-10 mg PO qd for few days and atarax 25 mg po tid itch.
66- Do not forget to write patient eye drops. Patients in glucoma drops if missed can have worsened vision.
67- For bed sores be sure the patient position is changed every two hours. To lie on side as much as he can. Change to air mattress. Frequent inspection of the decubitus daily or 2-3 days according to decubitus and dressing used.
68- Change patient bed position: for shortness of breath or aspiration sit patient up all time. For low BP telendlenburg position.
69- When you put IV: put tourniquet, see and palpate the vien, recognize the anatomy of the vien the size, how deep and what is its direction. Commonly you need to hold the arm as well the skin.
70- 90% of K we ingest is excreted through the kidney. K is elevated in the blood if patient has kidney failure or patient is taking medicine that cause the kidney not to be able to get rid of K as ACE inhibitors, ARB's, K sparing diuretics.
71- If K is elevate by 1 mg/dl give 30 gm PO kayxalate and repeat K or chem 7. For K more than 6 you need to do EKG and evaluate particularly for change in T wave becomes prominant.
72- Fever 101 and chills do BC x 2 urine culture and give one gram of rocephin. Most times it is UTI. Some patient can go to urosepsis. Ask nurse to check vitals q 2h or according to BP and HR.
73- Recognize well when to send patient back to another hospital since unnecessary transfer exahust every one patient spend long hours in ER, family has to attend to and the other hospitals doctors spend time to find what is wrong. Many times you can wait and see how patients does. It is better to explain to the family this fine line of finding something and exhasting the patient in another hospital. If you do not feel comfort just send the patient.
74- If you suspect DVT or PE give a dose of arixtra or lovenox before send the patient to be evaluated for these conditions if not already in these medicines.
75- On discharge mention patient neuro condition if was admitted for neurological problems. FIM score in admission and discharge can give better idea of patient progress.
76- Make the nurses lives and yours easy ask nurses when the do the dressing changes to let you know so you see it with them at the same time of dressing change.
77- Dysphagia is assessed by speech therapist who usually determine the need for MBS (modified barium swallow) and the type of diet or its change.
78- For Dysphagia Diet can be or advance to : NPO------level 1 (puree)----level 2 (ground/mashed)----level 3 (soft,bite size)---mechanical soft----regular.
79- For dysphagia: Liquids can be or advance to: NPO---pudding------honey----nectar-----thin. Patients in pudding or honey may need IV fluids daily to meet fluids requirments, less so with nectar. Patients in thick fluids usually need their laxis held.
80- Other aspiration percausions: OOB all meals, chin tuck, head turn to right or left, rehab dinning, crush meds in applesauce or pudding, HOB 30 degrees all times, no straws.
81- Patients with dysphagia who cough after meals need close observation. Some particualrly with underlying airway disease may benfit from vent-neubilize of Duoneb nepulizer after meals.