Critical Care Flashcards
Systems based approach to assessment on Critical care/ICU:
DATA BASE SUBJECTIVE (General Observation) RESPIRATORY SYSTEM: Airway Breathing CVS: Circulation CNS: Disability RENAL SYSTEM MSK: Exposure Bloods
Information gathering and general observation helps to establish:
Indications and contraindications to physiotherapy
Need to be assessing:
before/during and after any intervention to:
- To Establish if the patient has got a physiotherapy related problem
- To Determine if the patient is stable enough for selected treatment
- To Identify any deterioration and ensure appropriate action: always document next to patient to ensure no adverse change in condition and if so manage appropriately.
In database we look for:
PC/HPC/PMH/DH/SH and subjective questions/information from Notes/Staff
In subjective we assess for:
Emotional status/symptoms/pain/fatigue/specific problems
Some information can be ascertained from the nursing staff: 1) Ask nursing staff how the patient is today 2) What has happened since the last PT treatment 3)Are there any limitations to movement/handling (lines, IABP, high SCI) 4) What are the physiological parameters the medical team are working towards (Obs)
In RESPIRATORY SYSTEM we assess for
Airway & Breathing:
- Mode of ventilation/method of delivery/(ETT/Tracheostomy/Facemask) ventilator settings/oxygen delivered/mode of delivery and use of any home oxygen
(LTOT-Long Term Oxygen Therapy)/SP02/RR/ABGS/CXR/
- Previous pulmonary function tests
- Auscultation / palpation/ cough/ sputum/breathlessness/cyanosis/work and pattern of breathing Chest wall shape and expansion
In CVS we assess for:
Circulation:
- HR/Rhythm/BP and MAP/CVP/temperature/invasive cardiac monitoring (pacemaker, defibrillator)
- Ensure vigilance for signs of deterioration/loss of stability: pre, during and post treatment
In CNS we assess for:
Disability:
- Level of consciousness AVPU or GCS. Common causes of unconsciousness include profound hypoxia, hypercapnia, cerebral hypoperfusion, or the recent administration of sedatives or analgesic drugs
- Sedation score (RAS score- see over page*) if sedated (kidney failure more sedated)
- Pain score & route of analgesia- oral or intravenous (IV)
- Intra Cranial Pressure (ICP): ICP bolts?
In RENAL SYSTEM we assess for:
- Fluid input: Infusions N.B.be aware of what the drugs do as they may affect treatment options
- Fluid Output: NGTube/drains/Urine
Renal results E.G. Urea and Creatinine levels in the blood: kidneys maintain the blood creatinine and urea levels within a normal range therefore Urea and creatinine are therefore good indicators of a normal functioning kidney and an increase in the blood are indications of kidney dysfunction.
In MSK we assess for:
Exposure:
- Muscle charting/grading.
- Bony injury/fixation: #, orthopaedic surgery
- Be mindful of Skin condition: refer to tissue viability nurses
- Ex tolerance & any limitation E.G due to an injury: Is ex tol RE. MSK or C/R (O2 levels and reserve)
- Baseline i.e. PMH that may result in functional limitations /use of aids
In Bloods we assess for:
- Any other relevant Blood tests E.G. C-Reactive Protein (CRP) and White Cell Count (WCC) for signs of inflammation or infection. CRP is an acute phase reactant, a protein made by the liver that is released into the blood within a few hours after tissue injury, the start of an infection or other inflammation
- Liver function
- Clotting, i.e. platelet level and clotting times: mobilisation consideration RE: risk of bleed
General Observation includes:
- Face/colour/expression: hypoxemic (pale, clammy, cyanosis), hypercapnic, pain (facial expression)
- Position/posture/comfort
- Equipment/Attachments/drip/drains
- Skin/wounds
- Peripheries/oedema/cyanosis: unveil clothes to check, pitting oedema?, oedema - are they urinating
Common monitoring equipment in ITU includes:
- ECG (Electrocardiogram)
- Central Venous Pressure catheter (CVP)/Central lines/Jugular Venous Pressure (JVP) lines
- Arterial line (A-Line)
- Saturation Probes
- Swan Ganz Catheter/Pulmonary artery catheter
- ICP Bolts
- Intra-Aortic balloon pumps (IABP)
- Continuous Veno-Venous hemofiltration (CVVH)
- External-Ventricular Drain (EVD)
(Ventilator)
ECG measures:
Measures heart rate and rhythm. Normal values HR 50-100bpm. <50bpm (bradycardic), >100bpm (tachycardic). Always look at the HR and Rhythm before commencing treatment to establish a baseline (warning signs)
HR and rhythm are affected by:
- Physiotherapy: suctioning causes arrythmias
- Hypoxia: ischaemia of heart
- Electrolyte imbalance: seen as fluid imbalance
- Myocardial ischaemia
- Anxiety: ITU environment/treatment may cause tachycardia.
Central Venous Pressure catheter (CVP)/Central lines/Jugular Venous Pressure (JVP) lines is:
A catheter line inserted into the subclavian or internal jugular vein. Usually blue line to represent venous system.
Central Venous Pressure catheter (CVP) measures:
the amount of fluid volume and is an indicator of the hearts ability to cope with this volume. Normal values 3 – 15cmH2O. >15cmH2O = venous congestion secondary to fluid retention (heart failure?), <3cmH2O = dehydration secondary to major bleed?
CVP catheter monitoring will guide:
fluid therapy, provide state of filling of vasculature on the R side of the heart, can be used for blood sampling, enteral feeding, drug administration (compromises true value seen; drugs need to be switched off).
Arterial line (A-Line) taken from:
major artery (Radial, femoral, brachial, dorsalis pedis). Red lines to represent arterial system
A-Line measures:
constant (to the minute) measure of blood pressure - vital in critically ill, especially if taking meds affecting BP. Normal values for BP 120:80 mmHg (hypertension is >145/95 & <90/60 is hypotension) and ABG’s: PaCO2 4.7-6 kPa, PaO2 10-14 kPa, HCO3 22-26 mmol-1, pH 7.35-7.45, BE +/- 2.
- Gives access for arterial blood sampling - vital in critically ill with life-threatening conditions
Precautions for A-lines for physiotherapy include:
- Radial: monitor when sitting up - think hand placement, i.e. hold hand or bum shuffle)
- Femoral: movement is restricted. Always documented
- Dorsalis Pedis: Last place if body is septic. Common in paeds
Complications that can occur from A-Lines are:
Ischaemia if it occludes: heparin (blood thinner) is given
Bleeding if it becomes dislodged: secondary excessive bleeding due to heparin
Therefore always needs to be visible
Site of potential infection
Saturation probes measure:
oxygen levels from a patients finger, toe or ear. Normal values >95%, 88-92% COPD.
Swan Ganz Catheter/Pulmonary artery catheter are:
inserted via a central vein through the right side of the heart into the pulmonary artery.
- Usually for patients undergone cardiac surgery or have cardiac issues.
- Usually yellow and differentiates into blue and red to represent arterial and venous system
Swan Ganz Catheter measure:
cardiac output, stroke volume and ventricular load. Hints cardiovascular instability and guides assessment and treatment (more careful).
ICP Bolts measures:
Intracranial Pressure (ICP) & Cerebral Perfusion Pressure (CPP). CPP = MAP – ICP. Normal values of Mean Arterial Pressure (MAP) 90 mmHg (mean pressure of systolic and diastolic pressure), ICP 0-15 mmHg (critical value >20mmHg), CPP >70 mmHg (critical value < 50 mmHg).
ICP Bolts provides:
information on pressure build up in brain and how that will impact brain’s ability to perfuse. Usually seen in head injuries
Intra-Aortic balloon pumps (IABP) are:
Placed in thoracic aorta and balloon inflates during diastole increases aortic pressure during diastole and increases coronary blood flow. Balloon deflates prior to and during left ventricular contraction reducing aortic pressure and afterload. Usually in cardiothoracic unit. Hints CVS instability, requires gas so must be careful to not kink the line
Precautions for IABP with Physiotherapy is:
Tends to be sited femorally guiding treatment when sitting up ensuring not occluding line
Continuous Veno-Venous hemofiltration (CVVH) is a:
Dialysis catheter for short-term treatment of renal failure. Inserted into a main vein. Two separate lines: one takes blood to a machine and through a filter it removes fluid/replaces with correct volume of fluid (electrolytes); other takes blood back.
Precautions for CVVH with Physiotherapy include:
Be aware to not occlude lines during assessment and treatment
External-Ventricular Drain (EVD) is:
Inserted into ventricles of brain to reduce fluid reducing ICP. Seen in brain injury patients neurological units
Precautions for EVD with Physiotherapy include:
Be aware when positioning patients as it works on gravity so need to ensure it stays at correct level (not too much fluid is leaking out or vice versa)
Primary role of physiotherapy in critical care includes:
PT is an essential part of short and long term management of the critically ill
We are primarily involved in three main areas: 1) Management of respiratory problems including intubation avoidance and weaning from ventilation
2) Emotional problems and communication.
3) Deconditioning and related complications
- Optimisation of neurological status: CVA/TBI hemiplegic shoulder
- Communicate with MDT members
Other MDT members in critical care include:
Dieticians, Pharmacists, Psychology, Healthcare, Support Workers, OT, Medics, Nurses, SALT
Extended role of Physiotherapy in critical care:
Weaning/liberating patients from mechanical ventilation
Extubating/decannulation (removal of tracheostomy)
Troubleshooting mechanical ventilation problems
A-lines for ABGs
OMs
- The Chelsea Critical Care Physical Assessment Tool (CPAX) = measure physical morbidity in the general adult critical care population. Score of 50
- Manchester Mobility Score:
1 in bed interventions: Passive Movements, Active exercise, chair position in bed
2 Sit on edge of bed
3 Hoisted to chair (incl. standing Hoist)
4 Standing practice
5 Transfers with assistance
6 Mobilising with or without assistance
7 Mobilising > 30m
A Agitated
U Unwell
Other problems that arise from critical care
Nearly all severely ill patients will suffer some form of anxiety, distress or agitation during their stay in ICU . Anxiety and stress in critically ill patients is almost always multifactorial:
Sleep deprivation , sensory overload , anxiety felt by the patient due to their insight of the situation, delirium, adverse drug effects, pain and inability to communicate with the ICU team may all contribute to the patient’s distress.
Patients can develop Psychological, emotional and psychiatric problems, and cognitive dysfunction. Many go on to develop serious psychological problems including (PTSD) following their admission.
Relatives and staff may also be stressed by Critical Care.
Recovery, especially from the psychological impact of Critical Care, can take time and often continues into the community setting.
What to remember when assessing and treating patients in critical care:
Simple measures such as providing compassionate and considerate care are essential.
