Assessment of the Critically Ill Patient in (.pptx

Dpt

1. ASSESSMENT OF THE CRITICALLY ILL PATIENT IN (ICU) Dr Ayesha Anwer Ali

2. INTRODUCTION Physiotherapy is an essential component in the management of patients admitted to the intensive care unit (ICU). Traditionally, the role of physiotherapy in the ICU was limited to respiratory management, but over the last decade rehabilitation and mobilization have become the priority for patients admitted to the ICU. Physiotherapists are, therefore, responsible for the prevention and treatment of deconditioning musculoskeletal function, as well as management of the respiratory system maintain lung volume, improve oxygenation and ventilation, optimize clearance of secretions) in critically ill patients.

3. ASSESSMENT OF THE CRITICALLY ILL PATIENT INCORPORATES THREE MAJOR CATEGORIES: 1- History   (including investigation of symptoms and review of systems) Systematically gathering past and present data related to why the patient needs physiotherapy should be incorporated in history taking along with the patient’s primary reason for hospitalization and admission to the ICU. History taking should include: General demographics (including religious and cultural beliefs, as well as any language barriers) General health status Presenting condition Previous medical and surgical history.

4. CONTD… list of patient’s current medications family history social history By inquiring about the patient’s history, the physiotherapist also becomes aware of the cognitive status of the patient (alert, unconscious, confused) which leads into the next category.

5. CONTD… 2- Systems Review  (multisystem assessment) refers to the assessment of: The anatomical and physiological status of the cardiovascular, respiratory, neurological, musculoskeletal, integumentary and renal systems The communication ability, language, cognition and learning style of the individual. The assessment of communication ability includes the level of consciousness and the orientation (i.e. person, place and time) of the patient as this will impact the physiotherapy intervention.

6. CONTD… 3- Tests and measures The physiotherapist will select specific tests and measures based on the information gathered from the history and systems review. In the ICU, tests and measures are limited to those necessary for establishing the patient’s level of functioning and those impacting the physiotherapist’s judgment of the diagnosis or treatment plan. These are often incorporated when assessing the multiple body systems and can include  spirometery  radiological examinations, sputum analysis, aerobic capacity and endurance, muscle performance (including grip strength, manual muscle testing), etc.

7. MULTI-SYSTEMS APPROACH TO ASSESSMENT: Cardiovascular system Assessment of the cardiovascular system should include heart/pulse rate, heart rhythm  (as evident on the electrocardiogram [ECG]) and quality, blood pressure, peripheral oedema  and perceived level of exertion at rest and with activity. It is important to also review the cardiac trends over the 12-24 hours preceding the physiotherapy assessment in order to establish a true picture of the patient. Circulation, ventilation and respiration are often assessed concurrently as cardiovascular and respiratory conditions present with similar signs and symptoms.

8. RESPIRATORY SYSTEM Bed rest, immobility and inflammation in critically ill patients lead to impaired ventilation, increased resistance of the airways and decreased compliance of the lungs, resulting in dysfunction of the respiratory system. These complications are even more pronounced in mechanically ventilated patients. The functioning of the respiratory system is best assessed by analyzing measures of oxygenation and ventilation, including oxygen saturation and arterial blood gases.  Evaluation of the respiratory system starts with simply observing how the patient breathes - expansion of the thorax, effort of breathing, breathing pattern and the symmetry of breathing. It is also important to note if the patient requires ventilator support and the level of support needed full or assisted and support.

9. NEUROLOGICAL SYSTEM ASSESSMENT of the neurological system includes various factors such as the level of consciousness generally measured using the Glasgow Coma Scale, pupils size, reactivity, and equality, tendon reflexes, muscle tone any spasticity or rigidity, skin sensation, cerebral perfusion pressure (CPP), intracranial pressure (ICP), and a review of any radiological imaging cranial computed tomography scan (CT) or magnetic resonance imaging [MRI]. A unilateral fixed dilated pupil is indicative of pressure on the oculomotor nerve and must be investigated urgently. Bilaterally fixed and dilated pupils point towards severe neurological impairment sustained severe ICP and cerebral oedema which is sensitive to hypoxia and often a sign of brainstem death. Any of these signs signal the urgent referral for a CT or MRI scan.

10. MUSCULOSKELETAL SYSTEM Prolonged bed rest leads to decreased skeletal muscle strength including diaphragm strength and poor endurance of patients. When combined with critical illness, it results in ICU-acquired weakness which has long-term repercussions for patients beyond discharge from the ICU. Assessment of the musculoskeletal system should, therefore, include the evaluation of a patient’s skeletal muscle properties muscle tone, active and passive joint range of motion. Assessment of functional tasks includes bed mobility rolling, supine to sit, sitting over the edge of the bed and out-of-bed mobility sitting-to-standing transfers, transfers from bed to chair, wheelchair transfers, commode transfers and ambulation on level surfaces and stairs.

11. INTEGUMENTARY SYSTEM Reviewing the integumentary system should incorporate the assessment of pliability i.e. texture, skin color, presence of scar tissue and skin integrity. Many factors such as medications for example corticosteroids, poor nutrition, prolonged bed rest and general age-related changes can lead to more fragile skin which is also more prone to breakdown. It is, therefore, essential to look for areas of skin breakdown, ecchymosis and pressure injuries as these can be potential sites for infection, causing poor patient outcomes and prolonged length of stay. Skin lesions can be prevented by frequently changing the position of the patient, especially with activities out of the bed.

12. RENAL SYSTEM Measurement of fluid balance including urine output is important as it affects the consistency of the patient’s secretions, as well as cardiac output. Dehydration can cause constant mucous plugging which in return can block the airway and result in patient distress. Fluid retention can be a sign of acute kidney injury which may require urgent medical attention. The physiotherapist may be the person to identify this sudden change and may need to call the attention of the ICU physician or the nurse. In assessing the renal system, it is important to note if the patient is catheterized or not, the type of catheter used and the length of catheterization, as this could potentially be a route of infection.

13. OTHER SYSTEMS TO CONSIDER INCLUDE THE: Gastro-intestinal system to ensure adequate nutritional support for optimal energy and prevention of muscle wasting protein supplements. Hematological and immunological systems - awareness of infection, the organism responsible for the infection and the risk of cross-infection between patients and to the ICU team.

14. ACUTE RESPIRATORY DISTRESS SYNDROME Acute respiratory distress syndrome (ARDS) occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs. The fluid keeps your lungs from filling with enough air, which means less oxygen reaches your bloodstream. This deprives your organs of the oxygen they need to function.

15. SYMPTOMS Severe shortness of breath Labored and unusually rapid breathing Low blood pressure Confusion and extreme tiredness

16. CAUSES

17. RISK FACTORS Inhaling vomit, smoke, chemical fumes, or water during a near drowning Injury from a blow, burn, or broken bone can lead to ARDS. A broken bone, for example, can lead to a fat embolism, a clot of fat that blocks an artery. Lung or heart surgery or being placed on a heart-lung bypass machine or ventilator Pancreatitis Reaction to medicines.

18. DIAGNOSIS Chest X-ray: A chest X-ray can reveal which parts of your lungs and how much of the lungs have fluid in them and whether your heart is enlarged. Computerized tomography (CT): A CT scan combines X-ray images taken from many different directions into cross-sectional views of internal organs.

19. TREATMENT OXYGEN Supplemental oxygen.  For milder symptoms or as a temporary measure, oxygen may be delivered through a mask that fits tightly over your nose and mouth. Mechanical ventilation.  Most people with (ARDS) will need the help of a machine to breathe. A mechanical ventilator pushes air into your lungs and forces some of the fluid out of the air sacs.

20. Medication Prevent and treat infections Relieve pain and discomfort Prevent blood clots in the legs and lungs Minimize gastric reflux Sedate

21. LIFESTYLE AND HOME REMEDIES: Quit smoking.  If you smoke, seek help to quit, and avoid secondhand smoke whenever possible. Get vaccinated.  The yearly flu (influenza) shot, as well as the pneumonia vaccine every five years, can reduce your risk of lung infections.

22. DISSEMINATED INTRAVASCULAR COAGULATION Disseminated intravascular coagulation (DIC) is a rare but serious condition that causes abnormal blood clotting throughout the body’s blood vessels. You may develop DIC if you have an infection or injury that affects the body’s normal blood clotting process.

23. DIC PROGRESSES THROUGH TWO STAGES: In  stage one,  overactive clotting leads to blood clots throughout the blood vessels. The clots can reduce or block blood flow, which can damage organs. In  stage two,  as DIC progresses, the overactive clotting uses up platelets and clotting factors that help the blood to clot and clotting factors, DIC leads to bleeding just beneath the skin, in the nose or mouth, or deep inside the body.

24. SYMPTOMS: Bleeding at wound sites or from the nose, gums, or mouth Blood in the stool or urine Bruising in small dots or larger patches on the body Chest pain Pain, redness, warmth, and swelling of the leg

25. CAUSES Sepsis: This is a body-wide response to infection that causes inflammation. Sepsis is the most common risk factor for DIC. Major damage to organs or tissues: This may be caused by of the liver, pancreatitis, severe injury, burns, or major surgery. Severe immune reactions: Your body may overreact because of a failed blood transfusion, rejection of an organ transplant, or a toxin such as snake venom. Serious pregnancy-related problems: These include the separating from the uterus before delivery, amniotic fluid entering the bloodstream, or serious bleeding during or after delivery.

26. TREATMENT Treatment for DIC depends on your symptoms and how serious they are. The main goals of treatment for DIC are to control clotting and bleeding and to treat the underlying cause. DIC may go away once the underlying cause is treated. In the meantime, your doctor may use medicines or procedures to help stop the bleeding. MEDICINE You may be given them as a pill, as an injection, or through an IV. Possible side effects include bleeding, especially if you are taking other medicines that also thin your blood, such as aspirin.

27. PHYSIOTHERAPY TECHNIQUES IN ICU The role of the respiratory physiotherapist is to assist in clearing the airways of the patients, and maintaining and improving the integrity of the respiratory system. Treatment interventions include: Positioning, Education, Manual and ventilator hyperinflation, Weaning from mechanical ventilation, Non-invasive ventilation, Percussion, vibration, suctioning, Respiratory muscle strengthening, Breathing exercises and mobilization.

28. REHABILITATION Early Mobilization with a focus on returning to functional activities helps in reducing hospital stay and minimize functional decline. A survey. suggests positive outcomes with physiotherapy implementation in ICU and also discusses the barriers by the physiotherapists in ICU.  A pilot RCT suggests early in-bed cycling with mechanically ventilated (MV) patients has positive outcomes. For patients at risk, start rehabilitation as early as clinically possible which should include: Measures to prevent avoidable physical and non-physical morbidity, Nutrition support An individualized, structured rehabilitation program with frequent follow-up reviews. The details of the structured rehabilitation program and the reviews should be collated and documented in the patient's clinical records.

29. IMPACT OF PHYSIOTHERAPY Early intervention by physiotherapists in the ICU helps: Reduce the patient's stay in the ICU and overall hospital stay. Prevent ICU related complications To improve function and quality of life in the long term