2.5 Early Mobilization of the Critically Ill Flashcards
Dastardly Duo
Idiopathic Pulmonary Fibrosis &
Pulmonary HTN
How can PT can improve respiratory status?
PNA we can help mobilize secretions
COPD we can do pursed-lip breathing, buffering using lungs
Body positioning - pleural effusion, atelectasis, deep breathing
Upright allows more air to open alveoli!
How can PT can compromise respiratory status?
Think O2 dissociation curve and patients S&S
What are the 9 steps of O2 transport?
1) FiO2 (21% room)
2) Airways
3) Lungs and chest wall
- alveolar ventilation
4) Diffusion O2
5) Perfusion of lungs
- gravity dependent
6) Myocardial function
- preload, afterload
7) Peripheral circulation
8) Tissue extraction and use of O2
9) Return of partially desaturated blood and CO2 to lungs
Our role as PTs & 9-steps of O2 transport:
Define where the dysfunction is and then determine:
1) can we intervene at that level to improve O2 transportation or
2) can we try to impact it indirectly from the peripheral levels?
What do we look for in the indirect history for neurocognitive?
Wake up, open eyes, move arms, and legs during sedation holiday?
Anxious, aggravated, ventilatory asynchrony?
Known trauma?
Bleed? Active or progressing?
We should look at ECG and vitals over how long?
8 hours, last 24 hours
What happens with a high CVP?
Normal is 2-8mmHg, with a high it will be harder to get the blood back into the heart, decreases preload!
Venous pressure should be?
40 mmHg
Indirect hx:
Is the patient on oxygen?
Is this the baseline? Where are they stable with O2? What the change of baseline is with O2?
Over the past 8 hours check sats!!
Respiratory reserve ratio?
PaO2/FiO2
100/21 = 4.76L (normal RRR)
What is the desired goal by physician of RRR?
3L or 300
Although if below, still work them, but be very careful and take vitals and read pts S&S!
STILL TREAT! But what is the intensity? Manipulate to be safe!
When would you not treat the critically ill patient?
No! If the patient is trying really hard to breathe uncontrolled at rest. Do not treat. Collar with team members until vitals improve! Exercise will drop the pts O2 even more!
Should anyone be exercising if their resting heart rate is above their HRmax???!
NO!
Will deep breathing be effective in a patient that has compromised CO2 (hypercapnic), decreased lung compliance, resistance?
This will cause harder work!! Leads to compromise health status! Shallow, rapid will be preferred in restrictive alveolar process!
Need BiPAP!
What 2 considerations of CP?
1) Cardiovascular reserve?
2) Respiratory reserve?
How often should we re-assess before we intervene?
24 hours!
How will BiPAP help in someone that is very compromised and works hard to breathe?
It will breathe for her and allow her muscles to relax. Stop her form producing CO2! Before intubating!
If patient is moving in the right direction…when will you treat though?
Think Stiller!
Cardiovascular reserve, stiller says <50% but very conservative… treat with caution.
Respiratory reserve, if still similar from 1st session, don’t treat pt?, not stabilized yet! Collar with team how we can safely mobilize them!
What is normal pulmonary artery pressure?
Rest: 14mmHg
If 25 at rest or >30 during exercise it’s too high!
What score on the MRC is considered critical illness weakness?
48/60
Hypothesis of Key Impairments
Diminished aerobic capacity due to poor gas exchange form fibrotic lung tissue, and increased strain on the R heart from pulmonary HTN.
Slowed gait speeds to compensate for aerobic capacity decline.
Muscular system atrophy.
Risk for mobility status decline impacting QoL.
How can we impact critically ill patient’s O2 saturation?
Alter environment - give her O2 support. Increase utilization of O2 from peripheral muscular system. Train muscular strength to move O2 to peripheral tissues. Less stress on her already taxed respiratory system. Activities will become easier for her.
How long should the patient sit on EOB before you stand them up?
10 minutes!
Able to lift legs in bed…
Do standing tolerance. Sit down and reassess…
Interval training
Trying to build up volumes of exercises with lower intensity…Keeping below 4/10 of SOB
Restrictive diseases…how can we treat?
Find the cause!
Can the underlying cause be changed?
It no treat indirectly!
Why do we ask you to breathe slow? Behind the mucus?
*NOT IN THIS CASE
To build up pressure behind it in alveoli, collateral ventilation. Push it up…
