What to Study for Your Acute Care Fieldwork

As an OT student starting any fieldwork, it is important to walk into your clinical setting with an idea of the expectations of the setting. That’s exactly what we will cover in this post.

Before you start your acute care fieldwork, the first thing you want to do is to contact your clinical instructor (CI) and ask questions about the types of diagnoses you’ll see and what materials they recommend you should study/review before starting.

Acute care therapists spend most of their time “on the floor,” so it could be more difficult to call and get in touch with your CI. Find out their preferred method of communication – it might be email or text. The communication method should be clarified before you arrive on your first day in case you need help finding your way around.

A Brief Intro To Acute Care

Acute care is a fast-paced setting that requires therapists to be flexible as the condition and location of the patient changes often. Patients may getting an x-ray, swallow study, MRI or another procedure like surgery or dialysis.

It is a good idea to bring a small notepad or a piece of paper to take notes throughout the day, as you may not have time to be able to pause to type a note after each treatment.

Therapists in the acute setting will be part of the multi-disciplinary team that is responsible for the care of this patient. This means you will be playing an active role and communicating with all team members: nurses, doctors, physical therapists, and social workers – so be prepared.

Social workers (also called case managers) will often rely on therapists (both PT and OT) to make recommendations for the patient’s post-acute care. Often, therapists will recommend equipment such as a walker, shower bench, or bedside commode.

Therapists will also provide insight into the appropriate level of care: swing-bed, outpatient rehab, home health, or long-term care/skilled nursing facility. Be sure to review each of these post-acute settings.

Become Familiar With Medical Terminology

Being familiar with the most common medical terminology is especially important when reviewing a patient’s past medical history. Seeing a list of letters (like DM, HTN, GERD, CABG) provides important information about a patient, and seeing all the unfamiliar acronyms may be a little scary at first.

Review Lab Values

Patients are admitted to acute care for management of medical conditions – so, it is important to make sure that your patient is medically stable before entering the room. If you are unable to access lab values in the patient’s electronic medical record, be sure to speak with their nurse or your CI.

Many hospitals will have their own lab values “cheat sheet” for you to carry with you. You’ll want to have that with you at all times to ensure your patient is medically appropriate for therapy.

You can study the most important lab values before you get started, including (but not limited to) H&H, troponin, and glucose here (via Physiopedia). 

Review Contact Precautions

Patients are placed in isolation for a number of reasons based on their diagnosis, and there are different types of precautions based on what is happening with the patient.

Often, there will be something on the patient’s door to identify whether the patient is contact/droplet/airborne precautions, with a quick review of what these mean.

The most common include:

• Contact: Wear gloves and gown when in contact with the individual, surfaces, or objects within their environment
• Airborne: In addition to standard precautions (always practicing hand hygiene and wearing gloves), you will wear a fitted N95 respirator and possible gown and eye coverings when in the same space of the patient
• Droplet Precautions: In addition to standard precautions, you will wear a surgical mask when within 3 feet of the patient

Source: Infection Control and Prevention – Transmission-based Precautions (DHS)

Review Typical Assessments

You will see and use quite a few assessments in the acute care setting. The most common assessments include vital signs, pain scales, upper extremity ROM, and manual muscle testing.

You will also use balance assessments, cognitive assessments and ADL assessments regularly.

For an in-depth article all about the acute care assessments you will see and use, be sure to check out our article, Top Occupational Therapy Assessments in Acute Care.

Typical Diagnoses Seen in Acute Care

Acute care provides the additional challenge/opportunity to see a variety of diagnoses. Some of the more common acute care diagnoses for which therapy may be consulted are orthopedic patients, stroke, cardiac surgery, spinal surgery, or respiratory failure. These are the basics for what you’ll want to know for each diagnosis.

Orthopedic Patients

Patients with an orthopedic diagnosis can be either elective or the result of a trauma such as a fall, or car accident. The onset of injury can greatly affect their recovery. Patients with an elective surgery will often expect therapy and be more willing to participate. Traumatic orthopedic patients will often have other factors, including pain and a new, or at least amplified, fear of falling, which may limit their willingness to participate. Therapy is equally important for both populations.

Review weight bearing status and precautions along with the accompanying acronyms: NWB, TTWB, 50% WB, WBAT.

Review posterior hip precautions and types of equipment in a “hip kit” and use of each device.

Posterior Hip Precautions include:

• No hip flexion more than 90 degrees
• No Twisting
• Do not cross legs
• Do not turn knees inward or together

Some surgeons have their own specific protocol for orthopedic recovery; be sure to consult with your clinical instructor as you begin treating this population.

Neuro Patients (Stroke/Brain Injury)

Patients in acute care that are admitted with a neurological insult or stroke present in an especially sensitive time for the patient and the family as everyone adjusts and search for answers. Even neurological insults in the same area of the brain can present completely different in each patient, but expect possible changes in sensory, motor, visual, and cognition.

While the evaluating OT will assess many body systems upon initial evaluation, stay aware throughout their entire stay, reporting any changes to the patient’s nurse as they occur.

Review signs of aspiration: as OTs we often work with feeding and are in the position to see if the patient has any trouble with swallowing. OT is qualified to address swallowing and can make diet recommendations, but depending on the setting – this may be more of a speech therapist’s responsibility. If this is the case for your setting, communicate any concerns to the patient’s speech therapist.

Respiratory: monitor O2 saturation; use a pulse oximeter – and be able to identify types of respiratory devices: nasal cannula, high flow nasal cannula, BiPAP, intubation. This is relevant to any patient with increased oxygen needs.

Cardiac Patients 

Along with the above respiratory precautions, you will also want to monitor heart rate and blood pressure with activity, particularly if the patient has any trouble with orthostatic hypotension or complains of being dizzy when getting up.

Sternal Precautions: If your cardiac patient had heart surgery, these precautions are especially important when considering UE exercises or when pushing up from a chair with armrests. This puts both of your arms out to the side and behind your back.

• Do not lift more than 5 to 8 pounds.
• Do not push or pull with your arms.
• Do not reach behind your back or reach both arms out to the side.
• Do not reach both arms overhead.

Energy Conservation Techniques: With both cardiac and respiratory patients, you will also want to become familiar with energy conservation techniques. These include teaching your patient to pace themselves, prioritize their tasks and plan their day while taking rest breaks as needed.

A few other examples include educating your patient on adaptive equipment, task delegation, and adaptive techniques such as seated ADLs. For more on teaching your patients energy conservation techniques, be sure to check out our ECT article here.

Respiratory/Pulmonary Patients

Patients admitted for respiratory conditions such as COPD exacerbation, asthma, pneumonia, or acute hypoxic respiratory failure will also benefit from the above-mentioned energy conservation techniques. They will often need to have O2 monitoring throughout therapy to ensure their O2 sats don’t drop much lower than 90%.

If your hospital doesn’t have in-room vital sign monitoring, I highly recommend you bring your own pulse oximeter. These can be purchased from Amazon fairly cheaply.

Spinal Patients

Patients can be admitted for elective or non-elective spinal surgeries, or with non-operative spinal fractures. They will typically have the following precautions:

No BLT’s (No Bending, Lifting or Twisting):

• No bending forward past 90 degrees
• No lifting over 5 or 10 pounds, depending on the doctor’s orders
• No twisting the trunk during any activities

Log Rolling: In addition to educating your patient on the BLT’s, you’ll also instruct the patient to use the log rolling method during bed mobility tasks to avoid twisting the spine. This may take some repetition as patients forget this one more often than not and may end up twisting when getting out of bed.

If the patient is provided a brace, they must always wear it when out of bed until the doctor states otherwise.

A hip kit is also very helpful to patients with spinal precautions to help them complete lower body dressing while adhering to their spinal precautions.

Spinal Cord Injuries

If you will be at a higher level trauma hospital, you may also encounter patients with a new spinal cord injury. You can familiarize yourself ahead of time on the different levels of spinal cord injury and what you can do to address these acute injuries functionally.

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These topics are just a basic jumping off point for what you should study in preparation for your acute care fieldwork. For more in-depth acute care information, we also highly recommend you frequently utilize the all-encompassing Occupational Therapy in Acute Care textbook, as well as check out our e-book below for acute care intervention ideas:

What did we miss? What else would you recommend OT students study for their acute care fieldwork? Please let us know in the comments below!

This article was co-written by Leah Hawks, OTR/L and Sarah Stromsdorfer, OTR/L.