Anand - COVID ITU rehab Flashcards
What are Anand’s details?
70 year old man who caught COVID 29 days previously and has been on ITU for 3 weeks with respiratory failure. Tracheostomy intubated and ventilated – weaning on spontaneous mode.
What’s Anand’s past medical history?
Hypertensive and hypothyroid
What’s Anands drug history?
losartan potassium and levothyroxine previously; currently on renal levels of dopamine and sedation medication.
What’s Anand’s history of present condition?
Unsure of virus exposure source, but 28 days ago he became symptomatic with a high fever. He was tested positive for COVID-19 in hospital 7 days after this, when his respiratory symptoms deteriorated. His symptoms included, nausea and vomiting, an unproductive cough, and reduced taste and smell. He was taken to ITU around 24 hours after his admission to hospital with respiratory failure.
What’s Anand’s social history?
Lives alone in a flat, his wife died of cancer 3 years ago. Son and two daughters live nearby.
Has a lady friend/companion who cooks for him, whom he met at the local temple.
What do you see on examination of Anand?
Weaning from ventilation, minimal sedation.
Becoming more alert – intermittently cooperative with treatment
GCS = 11 on minimal sedation (eyes open to verbal stimulation = 3 verbal, confused = 4 and motor, normal flexion = 4)
Ventilated via a trachy tube on spont, rate of 16 breaths per minute, PEEP of 5cmsH2O, FiO2 0.40, PS 12. SpO2 is 94%
ABGs last taken 6 hours ago: pH =7.35, pCO2 =5.5 kPa, pO2 =10 kPa, HCO3 =28 mmol/L
Cardiovascularly stable HR 80bpm & BP 110/70
Temperature 37.5 0C
Nursing staff have reported an increase in thick yellow secretions on suction.
CXR shows some patchy shadowing at bases
Neurological assessment – CT shows several small cerebral infarcts, presenting physically with low tone/diminished reflexes R and L, grossly deconditioned, muscle wasting apparent upper and lower limbs, with muscle power generally graded at 2 – 3 and fatigues quickly which makes testing difficult.
What would you include in your subjective assessment of Anand?
-Expect responses to be minimal & do not complete a full assessment as he is critically ill, and this may confuse and exhaust him more
-Check for signs of stroke / TIA during subjective e.g., Slurred speech, face drop, cognition levels, intellectual deterioration
What would you include in your objective assessment of Anand?
-GCS
-ABG’s
-Auscultation
-Palpation
-Neurological assessment and neuro-integrity test - test reflexes and record them.
-Chest x-ray
-Rapid shallow breathing index
How would you manage Secretions and why?
Closed Suctioning & percussion
why: Has yellow secretions in lungs
-Perform percussion before suctioning to mobilise secretions ahead of removal via suctioning
-Suction to remove secretions to prevent infection
-Want to suction as he has unproductive cough and is confused so may not be able to cooperate with a more active treatment
-Closed suction as he’s acutely ill and will be spending a lot of time in ICU- so will have to be suctioned multiple times.
Supine position
What evidence supports Closed Suctioning & percussion?
Suctioning: a review of current research recommendations (Day et al., 2002)
https://www.sciencedirect.com/science/article/pii/S0964339702000046
How would you manage Muscle Wasting and why?
Neuro Deficit: Abnormal / diminished reflex’s, low tone.
PNF for lower limb
LL D1
Ask them to do it with you
Passively
3-5 days pw
do it to maximum effort of patient
heart rate should go up
sats should stay the same
Adjunct:
Active-assisted / PROM in bed I.e., lift your arm up
why: -Working through ROM of muscle and joints during PNF passively when he is unable to cooperate. When able to cooperate with treatment can add resistance to work on strength and improve neuro plasticity.
-We are doing PNF as he is grossly deconditioned, muscle wasting apparent and has a muscle power grade of 2/3. PNF will also improve the motor neural pathways in his brain- aiming to prevent loss of motor movements caused by his cerebral infarcts.
- PNF uses biarticular movement patterns to promote functional muscle involvement, helping to prepare for mobilising around the ward at a later stage.
-Motivation by asking him to do it with you & always helps to be hands on
- Utilising verbal cues
What evidence supports PNF for lower limb - LL D1 ?
https://assets.cureus.com/uploads/case_report/pdf/119856/20221209-5388-18m8ueb.pdf
Kazi, F., Dadgal, R. and Salphale, V. (2022) “Impact of proprioceptive neuromuscular facilitation technique for early rehabilitation to restore motor impairments in a classic case of left middle cerebral artery stroke,” Cureus [Preprint]. Available at: https://doi.org/10.7759/cureus.31222.
How would you manage Low oxygen in Anand’s case and why?
Positioning
why: -Ensuring skin integrity protection; regularly repositioning
-Sitting allows better interaction with the environment and is a better position for functional activities
-Repositioning can help to mobilise secretions for clearance and therefore allow for better gaseous exchange within the lungs which will improve his oxygen levels. (Regularly- every 2hrs)
Alternative position: prone as this assist to move secretions from peripherals
What evidence supports positioning?
https://www.ajol.info/index.php/ebnr/article/view/219526/207164#:~:text=The%20correct%20positioning%20of%20patients,on%20the%20V%2FQ%20matching.
Helen: need to reconsider as V/Q matching is different with ventilation. Think more about secretion drainage and function
What Multi disciplinary team members would be involved in Anand’s care
Nurses or HCA’s: repositioning regularly to promote skin integrity & avoid pressure sores
Anaesthetist: Delivery of medication
Pharmacist: check there are no clashes in medication
Speech and language specialist: assess swallowing to avoid risk of aspiration (cerebral infarctions put him at risk of full stroke and aspiration / dysphagia). Also starting to become more conscious therefore will need an assessment for eating / drinking / speaking.
Dietician / nutritionist: oversee nutritional requirements and TNP
Cleaning staff: clean environment / infection prevention
MDT: ICU diary – important to humanize patient’s care & fill in the ‘gap’ in their life that they may experience
