Anda di halaman 1dari 20

Dr. B.L.

Kapur Memorial Hospital


Department of Physiotherapy and Rehabilitation
PHYSIOTHERAPY GUIDELINE FOR PHYSIOTHERAPIST

Critical Care Medicine

Approved By: Dr. Mridul Kaushik Head Medical Services Reviewed & Edited By: Head of Department Department of Internal Medicine/Critical care medicine

Prepared By: Dr. Dharam Pani Pandey PT (HOD Dept. Of PT and Rehabilitation) Dr. Sonia Talreja PT Senior Physiotherapist Dr. Vashali Bhardwaj PT Senior Physiotherapist Dr. Ashima Naval PT Attending Physiotherapist

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

Goal and Aim of Physiotherapy in Critical Care


Prophylactic Maintain/improve bronchial hygiene Prevent Atelectasis Minimize/Prevent deconditioning Effect of Immobilization Prevent Pressure Sore Optimize V/Q Matching Prevent Proteolysis o Degradation of Protein from muscle fibre mediated by enzyme Protease Optimize Neuromuscular Physiology o Sensory Motor Stimulation

Therapeutic Remove / Mobilize Retained Secretions Decrease Work of Breathing Correct Abnormal Breathing Pattern Enhance Mucociliary Mechanism Improve Physical/Functional Activity Tolerance Improve Muscular Strength/Endurance Assist In Weaning of Patient from Ventilator Improve Heamodynamic

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

Planning PT Intervention & Goal Setting Specific Measurable Achievable Realistic Timed

Common Physiotherapy Intervention Positioning Postural Drainage Chest Wall Manipulations Airway Clearance Techniques Endo Tracheal Suctioning Neurophysiological Facilitation Lung Volume Expansion Techniques Early Mobilizations

Positioning Physiological Effects Upright Positioning o Improves Lung Volumes o Decreases WOB Lateral o Improves V/ Q match o Airway Clearance Prone o Improves V / Q matching o Redistribute Edema o Increase FRC Head Down Tilt o Airway Clearance o Reduces CO2 Concentration

Postural Drainage
3

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

11 Positions / 14 Segments o o o o Enhances peripheral Airway Clearance Increases Functional Residual Capacity Improves V / Q matching Increases Lung Thoracic Compliance

Chest Wall Manipulations (Improve Mucociliary Motion) o Percussion Frequency 100 480 cycles /minute o Vibration 10 to 20 Hz o Rib shaking and Springing

Manual Hyper Inflation Effect


o Slow deep inspiration: Recruits collateral ventilation thus promoting mobilization of secretions Enhances interdependence to aid reexpansion of atelectatic segments Improves gaseous exchange Assesses and potentially improves compliance. o Inspiratory hold(atfullinspiration): Further utilizes collateral ventilation and interdependence as at higher volume therefore maximizes pressure distribution. o Fast expiratory release: Mimics a forced expiration(huff or cough) Stimulates a cough.

Active Cycle of Breathing Technique Relaxed breathing >>>>>>>Deep breaths (2-5)>>>>>>>> Relaxed breathing >>>>>>>> Huffs Neurophysiological Facilitation(NPF) Promoting response of neuromuscular mechanism through proprioceptors, Mechanoreceptors. o Cutaneous and proprioceptive stimulation reflexly increases the depth of breathing . INDICATIONS: Non alert patients such as those who are drowsy postoperatively.
4

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

Those with neurological conditions. Partially breathing patient on ventilator, especially if they are unable to turn.
Lung Volume Expansion Therapy o Breathing Exercises o Deep Breathing Exercises o Segmental Breathing o Diaphragmatic Breathing Exercises o Costal Breathing o Pursed Lip Breathing o SMI (Sustained Maximum Inspiration) o PNF Techniques Bilateral D2 Symmetrical Flexion Pattern

Endo Tracheal Suctioning Suctioningisdescribedasthemechanicalaspirationofpulmonarysecretionsfromapatientwithanartificial airwayinposition.(AARC)

Early mobilisation o Improves Respiratory Function o Optimizes V / Q Match o Increases Lung Volumes o Improves Airway Clearance o Reduces Adverse Effects of Immobilisation o Increases Level of Conscious o Somatosensory Stimulation o Increases Functional Independence o Preventing ICU Syndrome o Prevent antigravity muscle Proteolysis

o Prevent ICU Induced Polyneuropathy Myopathy Pyschosis Evidence in Practice (Physiotherapy in ICU) Strong Evidence PT for Atelectasis Prone position ARDS Side lying Unilateral Lung Disease Continuous Rotational Therapy Multi Modality PT Early Mobilization
5

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

Moderate Evidence MHShort term Effect Conventional PTShort Term Effect Postural Drainage PT In Pneumonia Remember : A hammer in a carpenters hand is not always used to pull out a nail Therapist working in the ICU should be aware about the entire setup and should consider the advantages and disadvantages of the various techniques in order to optimize the outcome.

Therapeutic Consideration as per various vital parameters, Lab values and monitoring A) Vital Signs a. Obtain parameters from order entry i. Heart rate (HR): 50-120, avoid 20 bpm increase in HR ii. Systolic blood pressure: 90-150, avoid 20mmHg increase in blood pressure (BP) iii. Oxygen saturation: >90% iv. Respiratory rate (RR): <30 resting do if special recommendation or it may be the congestion it self May need to clarify specific parameters with doctor consultant. B) Lab Values: May need specific clarification for activity orders per consultant a. Complete Blood Count (CBC) i. Hematocrit (Hct): normal= 40-54 for males, 36-48 females ii. White Blood Cells (WBC): normal 4,000-10,000 for males and females iii. Red Blood Cells (RBC): normal 4.5-6.4 for men, 3.9-6.0 for women iv. Hemoglobin (Hgb): normal 13.5-18 for men, 11.5-16.4 for women v. May need to hold treatment, or consult ICU Incharge consultant. If there is a significant decreased in levels from previous day, or: 1. Hct <20 2. Hgb <8 b. Platelet count: normal= 150,000-450,000 i. <10,000= functional activity only ii. 10-20,000= ambulation, functional mobility, therapeutic active exercise (including no resistive exercises, AROM and isometric exercises allowed), stationary bike (without resistance) iii. 20-50,000 all of the above, may increase resistance of exercise to 2 kg iv. 50-150,000 continue progression of program. Resistance must remain <2 kg
6

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

c. Normal Values for Blood Gases i. pH: measures blood acidity, 7.35-7.45 ii. PaCo2: partial pressure of carbon dioxide dissolved in arterial blood (related to pulmonary function), 35-45 mmHg iii. HCO2: amount of bicarbonate or alkaline substance dissolved in blood (related to metabolic function), 22-26 mHg/L iv. PaO2: partial pressure of oxygen dissolved in arterial blood, 80-100 mmHg v. O2 sat: percentage of oxygen carried by hemoglobin, 95-98% d. International normalized ratio (INR): normal value 1.0-2.0, therapeutic range 2.0-3.0. Obtain activity orders from consultant. if INR >3.0, or <1.0. Hold PT with INR >4.0 C) Monitoring a. Electrocardiographic recording- ECG i. Noninvasive, continuous monitoring of heart rate ii. Telemetry unit will be located next to the patients bed iii. Position telemetry unit in view for both therapist and nursing during treatment iv. Hold treatment with new cardiac arrhythmia, HR >150, ventricular dysrhythmias, or heart blocks (2 and 3 degree) b. Pulse Oximetry i. Noninvasive, continuous monitoring of oxygen saturation ii. Detects alternating intensity of oxygenation iii. Will find probe on finger or ear. Probe must be maintained on patient during treatment c. Hemodynamic Monitoring i. Invasive monitoring of cardiovascular status ii. May use arterial lines, central venous pressure (CVP) lines, pulmonary artery lines or intra-aortic balloon pump (IABP) iii. Please see below listed precautions for each line d. Temperature i. Monitoring of patients core temperature with rectal line or manual assessment with temperature probe ii. Be cautious of rectal line with mobility as this is easily dislodged D) Lines, Tubes, Drains: Prior to initiating treatment, take note of each line and tube to avoid dislodging during mobility. Ask for the appropriate assistance when necessary, and check with nurse about lines/tubes that may be disconnected prior to treatment. Specific precautions and contrainidications. a. Arterial Lines i. Direct arterial puncture for monitoring of blood pressure and central access to arterial blood gases ii. Generally uses radial artery or femoral artery
7
13 nd rd

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

iii. Do not flex involved limb at site of insertion. May see flat board attached to wrist if radial line is used iv. If femoral artery is used, patient generally is on bed rest, and no hip flexion allowed on involved side b. Central Venous Pressure (CVP) i. Invasive, measures the blood pressure in the large veins of the body ii. Monitors venous pressures by an indwelling catheter and a pressure manometer iii. No range of motion (ROM) restrictions iv. Allows venous blood sampling, medication administration, nutrition or transfusions v. Could be part of a triple lumen catheter vi. Normal values in the right atrium are 0-8mmHg c. Intraaortic Balloon Pump (IABP) i. No PT intervention except for positioning and splinting ii. Involved hip must remain in extension, and immobile iii. Patients with IABP are usually unstable, and not appropriate for therapeutic exercise programs. Specific orders may be placed by doctor for exercise of the uninvolved extremity. d. Pulmonary Artery (PA, or Swan-Ganz) line i. Invasive monitoring, usually for patients that may be hemodynamically unstable ii. Usually, patients are on bed rest and are not appropriate for PT, except for splinting and positioning iii. If there are questions, staff members should discuss with their supervisor Physiotherapist and ICU Doctor in charge prior to initiating treatment iv. If the patient is stable with the PA line, specific orders need to be provided by the consultant., and occasionally include bed to chair and therapeutic exercise v. Avoid ROM and therapeutic exercise to ipsilateral shoulder secondary to risk for dislodging or causing arrhythmias with line movement vi. Patients may have a locked PA line, which prevents movement of the line. Clarify with nurse prior to treatment. Ipsilateral shoulder may be flexed 90 degrees and functional use of bilateral UE is allowed e. Ventriculoperitoneal Shunt (VPS): i. Patients are generally on bed rest for 24 hours with head of bed flat ii. Gradual elevation of HOB and out of bed activity orders will be generally be ordered by consultant. on post op day 1 f. External Ventricular Drainage System (EVD): i Consultant.order is required for all out of bed mobility. Nurse must clamp the EVD prior to initiating mobility, and generally do not clamp >30min ii. Head of bed usually kept elevated 30 degrees iii. Do not adjust the height of the bed since it will change the relationship between the level of the patients ventricular system and the external drain. The external auditory meatus or tragus is the anatomical reference for the correct drain alignment.
8

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

iv. Normal intracranial pressure (ICP) range is 4-15mmHg. A monitor may alarm at 20 mmHg v. Avoid activities that may increase ICP including: 1. flat supine and trendelenberg positioning 2. pain 3. agitation 4. extreme hip flexion 5. extreme lateral neck flexion 6. valsalva maneuver 7. coughing 8. isometric exercises g. Lumbar Drain i. Consultant. order required for all out of bed mobility. Nurse must clamp drain prior to mobility, and generally do not clamp >30min ii. Alignment is the same for EVD, nurse must realign device level once returned to static position h. Epidural Catheter i. Must check in chart/flow sheet, or with nurse to determine level of epidural catheter ii. Patients with a lumbar epidural will have impaired circulation/sensory/motor function at all levels for B/L LE, therefore, out of bed mobility is contraindicated until 4-6 hours following a capped, or stopped epidural. iii. Patients with a thoracic epidural, usually s/p abdominal or thoracic surgery should have intact circulation/sensory/motor above and below level of epidural 1. Always assess circulation/sensory/motor function prior to initiating out of bed activity. If circulation/sensory/motor function is impaired, do not progress to weight bearing activities. 2. May progress to ambulation if circulation/sensory/motor function is intact i. Feeding Tubes i. Types include: nasogastric tube (NG tube), gastrostromy tube (G-tube or PEG) and jejunostomy tube (J-tube, PEJ) ii. Provides short to long term nutrition iii. Caution with line placement during mobility iv. Place feeding tube on hold when patient is lying flat j. Hemofiltration (CVVH, plasmophoresis, HD) i. Continuous venovenous hemofiltration (CVVH) vs. Hemodialysis (HD, non-continuous) ii. Filter system used to remove fluid and solutes to clean the blood iii. Plasmophoresis used to separate plasma from blood solute to remove unwarranted antibodies within the blood iv. Usually through femoral line- see precautions listed above for femoral line in lines, tubes, drains section Hold PT or may done on specific order or if it is deemed required k. Vacuum Assisted Sponge Dressing (VAC)
9

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

i. Do not disconnect VAC sponge without specific order from consultant. Occasionally, the VAC sponge may be clamped prior to ambulation, and nurse will assist with this. ii. The VAC sponge power source will switch to battery automatically when unplugged from the outlet source.

l. Chest Tube (CT) i. Patient must remain on suction at all times, unless specified by consultant. Can also be placed on water seal, H2O seal per consultant order. Speak with an experienced therapist, or ask for assistance from nurse for transferring patient from wall suction to portable suction for mobility as necessary. ii. Defer PT after CT removal until chest x-ray (CXR) follow-up, unless therapist received specific order from consultant iii. In those cases, monitor O2 sats throughout intervention, and discontinue therapy if O2 <90% m. Ventricular Assistive Devices (VAD) i. LVAD (left VAD), RVAD ( right VAD), BiVad ii. Provides circulatory support to one or both ventricles of the heart iii. Most often used in situations in which the IABP fails, intraoperative cardiac emergency warrants, bridge to transplant, or life-prolonging circulatory assistance n. Temporary pacemaker (external pacemaker) A. Two types: i. Epicardial wires placed during cardiac surgery 1. No UE ROM limitation as the wires are transthoracic ii. Transvenous pacing wires 1. No ROM assessment of thorax to the involved shoulder as the wires are placed through juglar or subclavian line iii. If a patient is 100% dependent on pacing wires, mobility and PT are contraindicated secondary to cardiac instability iv. If the patient is on a back-up mode, clarify activity parameters. Use caution to avoid dislodging the wires during mobility v. After the epicardial wires are discontinued, and there are no signs of cardiac tamponade: vi. Patient may be out of bed with nurse in room after one hour of bedrest vii. Patient may participate in PT on post-op day after two hours viii. Patients may initiate or resume stair training after four hours j) Semi permanent pacer i. Generally used as a bridge to permanent pacing for patients who are not medically appropriate for permanent pacemaker ii. Clarify activity orders with consultant and electrophysiologist prior to initiating treatment iii. Pacer is sutured subcutaneously, therefore, mobility and ipsilateral shoulder ROM is generally allowed as tolerated

10

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

E) Ensure patient has had stable ECG for 24 hours prior to initiating treatment. The use of the following medications, usually through intravenous (IV) drips, indicates that the patient is hemodynamically unstable. Assess timing of intervention in regard to the patients medication schedule and assess appropriateness for PT when a new medication is added. a. Nitric Oxide (NO) i. Need specific activity orders for these patients ii. Must maintain correct ratio of NO/FiO2, therefore do not adjuct FiO2 during treatment iii. Consult doctor as needed b. Dopamine i. PT intervention allowed if dose <5 (renal dose) ii. Must have specific activity orders if dosage is >5 mcg/kg Consult ICU Incharge For assistance regarding Medicine. i. Hold all PT intervention except positioning and splinting when the following medications are used: i. IV nitroglycerin (NTG) ii. Streptokinase iii. Nipride of Nitroprusside (SNP) iv. Epinephrine (epi) v. Norepinephrine vi. Neosynephrine (neo) or Phenylephrine vii. Lidocaine F) Deep Vein Thrombosis (DVT) a. Signs/Symptoms of DVT in the extremity include: i. Pain and swelling distal to the thrombus ii. Localized redness and warmth iii. Low grade fever iv. Dull ache or tightness in the region of the DVT b. Positive Homans Sign: pain in calf with forced dorsiflexion c. Hold PT until cleared by consultant. Diagnostic testing included UE/LE noninvasive study (LENIS/UENIS) d. Avoid PT until the patient is therapeutic on anticoagulation medication, usually within 24-72 hours. e. Patient may need an inferior vena cava (IVC) filter placed if there is a high risk for pulmonary embolism (PE) i. Placed on bed rest for 6 hours following the procedure ii. PT may resume once activity orders are advanced. G) Pulmonary Embolism a. Signs/Symptoms may include: i. Tachycardia ii. Possible chest pain iii. Rapid onset of tachypnea iv. Anxiety
11

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

v. Lightheadedness vi. Dysrhythmia vii. Hypotension viii. Decreased oxygen saturation b. Complications of a DVT are a medical emergency. Notify nurse immediately. H) Blood Transfusion a. Usually hold PT until blood transfusion is completed. Exceptions may include positioning interventions, or specific orders from consultant. Speak with an experienced therapist and consultant prior to initiating treatment. b. One unit of blood takes approximately 3-4 hours to transfuse c. Most adverse reactions to blood transfusions occur within first 15 minutes of the transfusion. Vitals signs are taken every 15-30 min by nursing staff d. Observe for the following signs/symptoms of possible allergic or adverse reaction to the transfusion: i. Low grade fever ii. Chills iii. Myalgias iv. Hypotension v. Tachypnea vi. Emesis vii. Headache viii. Flushed skin ix. Anxiety x. Tachycardia xi. Severe cough xii. Diarrhea I) Specific Testing a. Rule Out (R/O) myocardial infarction (MI) Protocol i. Consultant determines R/O. Usually three sets (one every eight hours) of cardiac enzymes (CK-MB and Tn-I) and ECGs ii. Strict bed rest and defer PT until R/O is complete iii. If the patient rules in for a new MI, new activity orders must be obtained from consultant prior to proceeding with PT intervention. b. Cardiac Catheterization i. Generally activity orders are as followed: 1. Left heart cath: bed rest x 6-8 hours with involved LE straight. Patients may have knee immobilizer donned to prevent hip flexion 2. Right heart cath: no restrictions, consider patients tolerance to anesthesia 3. Can be used for diagnostic and/or interventional purposes when a stent is deemed appropriate for a non-patent vessel. c. Cerebral Angiography i. Patients are on bed rest for 6-8 hours, with involved hip and knee immobilized ii. Defer therapy until activity orders are advanced iii. Used for diagnosis and possible treatment of carotid artherosclerotic lesions
12

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

d. Lumbar Puncture i. Patients are on bed rest for 4-6 hours following procedure ii. Short term complications, and indications to hold PT until pt is stable or cleared by consultant for out of bed activity include: headache, backache, bleeding at needle site, CSF leak, voiding difficulty and fever iii. Used for diagnostic purposes and for short term relief of hydrocephalus e. Myelography i. Depending on type of dye used, patients may be on bed rest with specific out of bed instructions ii. Short term complications, and/or indications to hold PT for additional time, include: headache, back spasm, fever, nausea or vomiting iii. Used for diagnostic purposes for imaging of spinal column Considerations for Appropriateness of Treatment: A) Mechanical Ventilation a. Types of intubation include: endotracheal (ETT, short term), nasotracheal (NTT, short term) or tracheostomy tube (long term, chronic) b. A cuff is inflated around the tube to ensure that the air is being delivered directly to the lungs i. If a cuff leak is suspected, the pt may be able to phonate or make audible sounds from mouth. Nursing should be notified immediately c. Modes vary depending on the needs of the patient and will be determined by the consultant and ICU incharge. Control mode is the most dependent level, and progresses to intermittent mandatory ventilation (SIMV), pressure support volume (PSV) and continuous positive airway pressure (CPAP), until extubation. d. Be cautious with progressing activity during weaning period as patient may be less tolerant to exercise as the demand on respiratory system increases. Signs of distress may include: autonomic changes, paradoxical breathing, tachypnea, agitation, panic, diaphoresis, cyanosis, angina and arrhythmias. e. Patients who require prolonged ventilatory support are at risk for developing respiratory muscle atrophy, skin breakdown, contractures and deconditioning. B) Pharmacology a. Common agents used in the ICU settings include paralytic, sedatives and analgesics. Cardiovascular medications previously mentioned in the Lines, Tubes and Drains section above. i. Narcotics are used for the analgesic effect. Side effects may include: hypotension, gastric hypomobility, and respiratory depression. Examples: morphine, fentanyl ii. Benzodiazepines are used to promote amnesia to pain. Known for anticonvulsant and muscle relaxant properties. Side effects include delayed recovery secondary to accumulation of the drug in fat, and high potential for physiological and psychological dependence. Examples: diazepam, midazolam, lorazepam iii. Barbituates are used for sedation, and tend to heighten pain intensity/awareness. Side effects may include cardiovascular depression, cerebrovascular
13

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

vasoconstrictors and high potential for physiological and psychological dependence. Example: phenobartbital iv. Neuromuscular paralytic agents are used to decrease or stop muscular contractions. Indicated in surgical interventions, endotracheal intubation, intractable convulsive activity, and/or prevention of increased intracranial pressures for patients with head injuries. Side effects may include: unrecognizable signs of distress, skin breakdown, and abnormal histamine responses causing hypotension and bronchospasm. Examples include: pancuronium, doxacurium, vecuronium C) Effects of Anesthesia a. Many patients in the ICU are status post surgical intervention and in the recovery phase, and have a recent history of an anaesthesia. b. General effects include: i. Neurological: decrease cortical and autonomic function ii. Cardiovascular: potential for arrhythmias, decreased BP, decreased myocardial contractility and peripheral vascular resistance iii. Respiratory: decreased arterial oxygenation, decreased surfactant, decreased airway reflex c. Most common post-op complications include: i. Neurological: delayed arousal, agitation, altered consciousness, cerebral edema, seizure, stroke, peripheral muscle weakness ii. Cardiovascular: hypotension, hypertension, dysrhythmia, MI, DVT, PE iii. Respiratory: airway obstruction, hypoxemia, hypercapnia, pulmonary edema iv. General: acute renal failure, urine retention, abdominal distention, hypothermia, sepsis, hyperglycemia, fluid imbalance, acid-base disorders D) Communication Barriers a. Patients may have difficulty with communication secondary to tubes obstructing their vocal cords (i.e: ventilation), pharmacologic intervention, neurological or musculoskeletal impairments b. Factors influencing effective communication include: level of arousal, physical limitations, visual impairments, speech/language impairments, letter/number recognition, and ability to recognize familiar pictures c. Alternative forms of communication may include: visual cues, such as a communication board (OT can assist with introducing this device), nod yes/no, hand signaling, sign language with appropriately trained professional, and passemuir valve to allow the trached patient to speak through a one way valve expiring air to pass through the larynx. Speech and Swallowing will need to be consulted for introduction and training to the valve. d. All alternative forms of communication need to be assessed for accuracy and reliability prior to use. E) Effects of Prolonged Bed Rest a. Musculoskeletal:
14

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

i. Muscle: muscle atrophy, decreased strength and endurance, potential contractures, weakened myotendinous junctions and tendon and ligament insertion on bone ii. Bone: osteoporosis iii. Joints: cartilage degeneration, synovial atrophy and ankylosis b. Cardiovascular iv. At rest: increased heart rate, decreased stroke volume, decreased cardiac size and volume v. With exercise: increased heart rate with submaximal exercise, decreased VO2 maximum, decreased stroke volume, decreased cardiac output vi. In general: increased risk for venous thrombosis, decreased blood cell flow or increased blood viscosity c. Neuromuscular vii. Orthostatic intolerance e. Fluid Balance i. Decreased volume, including total blood volume, decreased red blood cell mass and loss of mineral and plasma protein f. Skin i. Potential for skin breakdown secondary to prolonged pressure over bony prominences and decreased mobility F) Potential Neuropathy and Myopathy Related to Critical Illness a. Critical illness polyneuropathy may be a common complication which presents 7 or more days following onset of severe sepsis. I. Pt will most likely require mechanical ventilation. II. Will have limb muscle weakness/atrophy, reduced or absent deep tendon reflexes, loss of peripheral sensation to light and sharp touch. Cranial nerves usually intact. III. Recovery of patients with mild to moderate injury will take weeks to months. Some residual nerve dysfunction noted several years post onset. b. Critical illness myopathy is also associated with sepsis and multi-organ dysfunction. Muscles may be damaged through direct effects of toxins or via inflammatory mediators. I. Nerve and muscle injury may occur sequentially. II. Normal deep tendon reflexes, normal sensation, diaphragmatic weakness and spared facial muscles G) Acid-Base Metabolic Disorders a. Respiratory Acidosis- CO2 retention i. May result from hypoventilation, ventilation/perfusion mismatch, CNS injury, or airway obstruction ii. Signs may include: diaphoresis, headache, tachycardia, agitation, cyanosis, lethargy, ventricular fibrillation iii. Lab values: pH <7.35, PaCo2 >45 mmHg, HCO2 >26 mmHg/L
15

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

b. Respiratory Alkalosis- CO2 excretion i. May result from hyperventilation, or respiratory stimulation ii. Signs may include: rapid deep respirations, light-headedness, muscle twitching, anxiety and fear, parasthesias, cardiac arrhythmias iii. Lab values: pH : 7.45, PaCO2 <35 mmHg, HCO2 >26 mmHg/L c. Metabolic Acidosis- HCO2 loss or acid retention i. May result from renal disease, excessive production of organic acid due to endocrine disorder, decreased excretion of acids due to hepatic disease ii. Signs may include: rapid, deep respirations, headache, lethargy, drowsiness, nauseas, vomiting, coma, cardiac arrhythmias iii. Lab values: pH <7.35, HCO2 <22mmHg/L d. Metabolic Alkalosis- HCO2 retention or acid loss i. May result from loss of HCL (prolonged vomiting or gastric suctioning), loss of K (diuresis), or excessive alkali ingestion ii. Signs may include: slow shallow breathing, hypertonic muscles, restlessness, twitching, confusion, irritability, apathy, tetany, convulsions, coma, cardiac arrhythmias e. Rehab implications i. Metabolic disorders requiring medical intervention to reverse states ii. Patient may be less able to participate in therapy, or treatment session must be tapered to the patients needs and tolerance. Avoid changing the percentage of FiO2 without notifying nurse or consultant as this will shift the patients acid-base balance. Examination: 1) Chart Review A. HPI & PMH Onset and duration of symptoms and reason for admission to hospital Presence of disability and functional limitations prior to admission Prior medical/surgical history Systems review B. HC Previous and ongoing medical and/or surgical treatment, date of procedures and any postop complications Pertinent laboratory and diagnostic tests Cardiac and pulmonary status, including need for medical intervention for stability and use of ventilatory support C. Medications Type of medications, side effects and rehab implications. Please see the listed contraindications/precautions 2) Social History Home environment and current/potential barriers to returning home Family/caregiver support system available Family, professional, social and community roles Patients goals and expectations of returning to previous life roles 3) Physical Examination

16

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

Select the appropriate examination measurements depending on patients diagnosis and ability to participate in therapy. Patients may be limited in ability to communicate/participate secondary to medication or ventilation dependence. Please see above section on considerations for additional information. Vital Signs (HR, BP, RR, SpO2) and subjective response to intervention Skin Integrity: areas for potential skin breakdown, temperature, edema and any surgical incisions Pain Respiratory Pattern Sensation ROM Strength and Motor Function Tone Balance Endurance Postural Alignment Mobility Positioning 4) Cognitive-Perceptual and Psychological Considerations Mental Status o Level of alertness, orientation, and ability to follow commands o Safety Awareness Psychological Considerations o Assess patients coping mechanisms to altered functional status Teaching/Learning Considerations o Patients goals, motivators and learning style o Patients ability to comprehend and apply information Evaluation / Assessment: The primary goal for inpatient physiotherapy for a patient with a critical illness requiring intensive care is to maximize functional independence while minimizing impairments as a result of the illness and hospital admission. Potential impairments may include but are not limited to impaired cognition, ROM, endurance, strength, skin integrity, respiratory capacity, balance, and patient knowledge regarding exercise progression during and after their acute hospital course. The predicted optimal level of improvement for these patients is to return to their previous level of function in their homes, community and work environments and resume their previous life roles. The timeframe for optimal recovery is widely variable impairments and functional impairments that may result from multi-organ dysfunction and disorders of the central and peripheral nervous system. This prognosis may need to be modified due to any of the following factors: presence of co-morbidities, complications or secondary impairments, decreased cognitive status, barriers to returning to previous living environment and any other factors that may influence the patients ability to achieve functional independence. Collaboration with the critical care team is essential in forming the PT prognosis as the consultant and nurse can provide valuable information on the expectations for the patients medical recovery. Age specific considerations in this population include all the normal physiological changes that occur with aging. Look for more details. The physiotherapist will consider all of the patients impairments whether they are disease or age based and will determine a comprehensive assessment, prognosis and rehabilitation plan for each patient.

17

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

Individual and measurable goals should be formulated for each patient, taking into consideration the patients medical, physical and cognitive status and their own goals for recovery. Suggested goals (1-6 weeks) may include: 1) Maximize functional mobility 2) Normalize tone and motor function 3) Minimize abnormal movement patterns 4) AROM UE/LE, as appropriate 5) Strength grossly >3/5 throughout bilateral UE/LE, as appropriate 6) Improve patients ability to participate in guided exercise 7) Maintain stable vital signs 8) Prevent loss of ROM and function by proper positioning and splinting 9) Maximize safety awareness with all functional mobility Treatment Planning / Interventions Established problem list and Plan of treatment Established Protocol This section is intended to capture the most commonly used interventions for this ICU patients. It is not intended to be either inclusive or exclusive of appropriate interventions. Intervention Initiate physiotherapy intervention, as appropriate, given the patients medical status, precautions and activity orders as indicated by the physicians orders. Refer to the above listed precautions/contraindications and additional information. 1. Functional Mobility Bed mobility, rolling, bridging, and supine sit activities. Transfer training, ( bed chair, wheelchair, commode) use of adapted equipment as appropriate 2. Balance Training Sitting and standing activities as appropriate 3. Gait Training Pre-gait activities. Assistive device prescription as indicated. Progress to stair navigation, as appropriate, prior to d/c to home 4. Positioning Techniques Initiate program to maintain ROM and skin integrity, and prevent deformities secondary to prolonged bedrest 5. Facilitation of normal movement patterns 6. Therapeutic exercise program 7. Endurance training 8. Lower extremity splinting and bracing

Patient/Family Education 1. Discuss realistic expectations regarding function, appropriate level of assist that the patient requires from family and their anticipated rehab progression
18

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

2. Provide emotional support to the patient and their family as needed 3. Instruct the patient on safe activity progression, applicable precautions (i.e. craniotomy precautions) 4. Instruct the patient and family members in the following and assess their understanding via return demonstration: Therapeutic exercise and endurance program Safe mobility techniques to encourage maximal independence Frequency & Duration Patients will have follow-up physiotherapy treatments based on individual need. The frequency of treatment for each patient will be determined by the acuity of his or her impairments and functional limitations. Recommendations and referrals to other providers Discuss the patients needs for additional services with the primary team. A patient may benefit from the following services if appropriate: 1. Occupational Therapy: If a patient presents with impairments that affect his or her ability to perform activities of daily living independently and/or who may have adaptive equipment needs. Occupational therapy should be consulted for any patient with a new onset of cognitive impairments. 2. Speech and Swallowing: If a patient presents with impairments that affect his or her ability to swallow difficulty and/or a new communication impairment. 3. Care Coordination: If a patient has a complicated discharge situation and the care coordination team is not involved. 4. Social Work: If a patient has a complicated social history and pt and/or family require additional support or counselling. Re-evaluation / assessment Reassessment will occur under the following circumstances: within 10 days from the previous assessment, all physical therapy goals are met, significant change in medical status occurs, prior to discharge from services or facility, and/or failure to respond to physical therapy interventions. Discharge Planning Discharge planning will occur on an individual basis depending on the patients medical, physical and social needs. Discharge planning is a coordinated effort that occurs with the physician, care coordinator, nurse, physical and occupational therapists, the patient and his or her family. status, but the acuity of the patients needs is less. Physiotherapy will remain involved on the step-down ward, and further assist with discharge planning. If the patient continues to have significant impairments and functional limitations and/or complicated medical needs at the time of discharge from the acute hospital, he/she may be discharged to an acute or sub-acute rehabilitation facility, skilled nursing facility), or extended care facility. The patient will continue to progress towards their physiotherapy goals at the alternate inpatient facility. If the patient has met all inpatient physiotherapy goals and is medically stable, he/she may be discharged to home with or without services. Consider the following resources for continued therapy: Home PT Outpatient PT for patients who have a high level of function but continue to have specific impairments Outpatient Occupational Therapy Cognitive Clinic Adult Day Programs References
1. APTA Guide to Physical Therapy Practice, Second Edition. Physical Therapy 81: (1); 2001. 2. Ambrosino, N, Clini E, et. al. Supported Arm Training in Patients Recently Weaned from Mechanical Ventilation. Chest. 2005. 128: 2511-2520. 3. Arnall, D. Paralytics. PT Magazine. 1996. 4(1): 13,18. 4. BWH Department of Rehabilitation Services Guidelines for frequency of physical therapy patient care in the acute-care hospital setting. 5. Campbell, A, Dicker, R, et. al. Effects of Tidal Volume on Work of Breathing During Lung-Protective Ventilation in Patients with Acute Lung Injury and Acute Respiratory Distress Syndrome. Crit Care Med. 2006. 34(1):8-14.

19

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist

6. Criner, G, Gaughan, J, et. al. Impact of Whole-Bosy Rehabilitation in Patients Receiving Chronic Mechanical Ventilation. Crit Care Med. 2005. 33(10): 2259-2265. 7. Fenzi, F, Latronico, N. Critical Illness Myopathy and Neuropathy. Lancet. 1996. 347: 1579-1581. 8. Ghasemi, Z, Martin, T. The Role of the Physical Therapist in the Intensive Care Unit. PT 9. Greenleaf, JE. Intensive Exercise Training During Bed Rest Attenuates Deconditioning. American College of Sports Medicine. 207-215. 1997 10. Hansen-Flaschen, J. Neuromuscular Disorders of Critical Illness. 11. Lewis CB, Bottomley JM. Geriatric Physical Therapy: A Clinical Approach. E. Norwark, CT: Prentice Hall, 1994. 12. Nava, S. Rehabilitation of Patients Admitted to a Respiratory Intensive Care Unit. Arch Phys Med Rehabil. 1998. 79: 849-854. 13. Paz JC, West MP. Acute Care Handbook for Physical Therapists, Second Edition. Boston: Butterworth-Heinmann. 2002. 14. Polich S, Faynor SM. Interpreting Lab test Values. PT Magazine. 1996;76-88. 15. Stiller, K. Physiotherapy in Intensive Care Towards an Evidence-Based Practice. Chest. 2000, 118:1801-1813. 16. Wheeler, AP. Sedation, Analgesia, and Paralytics in the Intensive Care Unit. Chest. 1993; 104:566-77.

20

Department of Physiotherapy and Rehabilitation, Dr. BLKapur Memorial Hospital, Intensive Care Unit, Guideline for Physiotherapist