strength training of the quadriceps and the hip, weight bearing and functional activities, as well as improving ambulation and transfers, to return this patient to his prior level of function. It is unlikely that this patient will return home until the delirium is gone. As previously mentioned, hip replacements can be either cement- ed or non-cemented. As non-cemented total hip replacements were originally developed to improve the length of time that the prosthesis would stay in place, it is most common for a hip replacement in an elderly patient to be cemented, because the prosthesis is not expected to need to remain in place for as long. This type of surgery will allow for immediate weight bearing, and typically the patient complains of less pain. A non-cemented hip, however, will be non-weight bearing for several weeks following the surgery. This can further complicate the rehabilitation process, as gait training is significantly more dif- ficult with non-weight bearing restrictions. As already discussed, the patient is most likely to return to the prior level of function if weight bearing activities are included in the rehabilitation pro- gram. When a patient is non-weight bearing, the focus of therapy is on maintaining weight bearing precautions with transfers and gait, and also improving LE strength and balance in a single leg stance. to improve her independence on the stairs. The patient, however, is adamant about going home. With this in mind, what recommendations can the physical therapist make to give this patient the support she needs to be successful at home? This patient will need assistance to get into her house, so she will need to arrange for a friend or family member to help. She will need a roller walker and an elevated toilet seat. She will need to talk to her sister about doing the cooking for the next few days or weeks. She will also need to figure out how to get the laundry done. If her sister is not able to do it, she can arrange for a laundry service to pick up and do her laundry, or hire a home health aide to come in a few hours a week to assist with light cleaning, shop- ping, laundry and bathing. All equipment needs and arrange- ments for assistance from friends and family should be arranged prior to discharge from the hospital. With this level of support at home, the only remaining concern is the patient losing her balance when turning corners. Before the patient leaves the hospital, additional education can be provided by the therapist to provide strategies for walker placement to re- duce this risk. It should also be recommended that the patient receives either outpatient or home health physical therapy to focus on helping her to return to her prior level of function. Providing a patient with a written home exercise program will also assist her in maintaining the gains she made in the hospital. These specific recommenda- tions should allow for the patient to return home safely. Contrast this example in which the therapist and team educates the patient in the importance of receiving follow up care in an inpatient rehab facility; yet when the patient expresses instead that she is going home, the team allows her to return home but simply states that it is “against medical advice.” The team then provides no other recommendations to her. This patient is much more likely to fall under these circumstances - perhaps as soon as she tries to go up the stairs without help to get into her house. The therapists and physicians may feel as if they have given the patient the best advice, but as it wasn’t followed it didn’t benefit the patient. This illustrates the importance of including the patient in the discharge planning process so the best recommendations for each individual patient are made.
erative stress (Robinson & Eiseman, 2008). There are three types of delirium: Hyperactive, hypoactive and mixed delirium. The most common form (in 79 percent of delirium cases) is hypoac- tive delirium and presents with lethargy and decreased alertness. Hyperactive delirium is rare, but will present with agitation, com- bativeness, and restlessness. Mixed delirium is present nearly 21 percent of the time. According to Robinson & Eisemen, patients with mixed delirium can have characteristics of both hyperactiv- ity and hypoactivity. This will obviously impair this patient’s safety with ambulation and transfers which will delay the ability for this patient to return home. The physical therapist has an important role in identifying delirium as a problem and also in treating it. There are many different ap- proaches in addressing it. Specific to therapy, the options include daily ambulation and ROM performed at a regular time each day, as well as regular orientation to person, time and place (Robinson & Eiseman, 2008). In this case study, the patient’s family is present. An important part of therapy will be educating the family not only to help the patient become oriented, but also to provide important verbal and tactile cues for his safety. The patient should be educat- ed on the hip precautions, but the family should receive this educa- tion, too, so frequent reminders to the patient can be given. While this limitation has been addressed, the focus on therapy can be on Discharge planning The goal of returning a patient to his/her prior level of function (or even a functional level that would allow the patient to return home) is not always possible during an acute stay. In many hos- pital systems, the medical team will request recommendations from the therapy staff for appropriate discharge settings. There is no standardized recommendation for the most appropriate discharge location; however, there are some important consider- ations: The primary considerations are the goals of the patients, and - by extension - their families. The prior level of function of the patient is also an important con - sideration. A patient who was dependent with mobility prior to sur- gery is unlikely to become mobile and function at a higher level after surgery. It is important to ask the patient what they need to be able to do to go home. Are there stairs? Handrails? Will the patient have assistance, or will he or she be alone? A patient that will have assistance and who is able to walk short distances in the hospital with an assistive device and/or stand by assist may be able to go home directly from the hospital. However, the same patient at the same level of function may need to go to a rehab or skilled unit if there are several stairs to get into the home or if the patient will be going home alone. Each recommendation should be carefully considered; recommending fewer services than the patient needs may increase the risk of a fall upon discharge. Consider the following for how discharge recommendations by the physical therapist can affect the patient in this example: An 86 year old woman has been in the hospital for three days after an ORIF of her right hip. She lives in her family home with her 82 year old sister. There are three stairs with one rail to get into the house. The laundry is in the basement. Prior to this hip fracture, the patient was doing both her own laundry and her sis- ter’s laundry. The patient and her sister took turns cooking. It is the goal of the patient to return home directly from the hospital. She has been walking 150 feet in the hospital with a roller walker with SBA. The patient does well when walking straight, but oc- casionally is unsteady when turning corners. The patient has been able to self-correct without falls. The patient requires min assist to ascend three stairs with one rail. She has 4-/5 strength in the right knee, 5/5 strength in the right ankle, and 3/5 strength in the right hip. The patient is modified independent with transfers, requiring an elevated seat and handrails on the toilet. Discharge options have been discussed with the patient, and the consensus of the rehab team is to recommend a short inpatient rehab stay to im- prove high level balance, to reduce risk of falls when turning, and
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Book Code: PTCA2624
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