Early mobility: intensive care unit and acute care Flashcards
Demonstrate an understanding of the ABCDEF Bundle for Early Mobilization in the Intensive Care Unit (ICU)
Examine the typical progression of exercise/activity for early mobility in the ICU
Identify safe handling equipment used to mobilize patients in the ICU
what is the adverse effects of bed rest
muscle atrophy
malnutrition
reduced bone density (6 months)
pressure injury/vascular compromise
delirium
reduction in the heart and lung function
high risk of pulmonary complications
Muscle breakdowns begin how fast in ICU/ac
Muscle breakdown begins within 24 hours of AC/ICU admission and declines rapidly during the first week
associated with weakness throughout a 24-month follow-up
AC/ICU acquired weakness
Rapid onset of symptoms: 24 hours
Resolve slowly
Pervasive weakness
Polyneuropathy
Difficulty liberating from mechanical ventilator (ICU)
the diaphragm muscle atrophies after how long a ventilator
18 hours
what is the one intervention that hemps with long term physical function?
Early activity seems to be the only treatment yet shown to improve long-term physical function of survivors of critical illness
what does the research show about early mobilization of patients with respiratory failure?
Mobility therapy delivered early in the course of acute respiratory failure was shown to be:
Feasible
Safe
Cost effective
Associated with:
Decreased ICU and hospital LOS
Decreased duration of mechanical ventilation and days with delirium
Increased return to independent functional status at hospital discharge
what does the ABCDEF bundle do for patients in the ICU?
Geared towards reducing symptoms of pain, agitation, and delirium (PAD) that are common with ICU stays
what is the ABCDEF bundle?
A: Awakening trials and PAIN Assessment
B: Spontaneous Breathing trials
C: Choice of Analgesic and Sedation
D: Delirium assessment, prevention, and management
E: Early mobilization and Exercise
F: Family participation
what are the benefits of ICU liberation
Reduction in duration of mechanical ventilation
Reduced ICU & hospital length of stay (LOS)
Increased ability to ambulate at hospital discharge
Reduction in Post Intensive Care Syndrome (PICS)
what is post intensive care syndrome (PICS)?
ICU acquired weakness
Long-term cognitive impairment
Depression
Post-traumatic stress disorder
Additionally:
Personal and societal costs
Family/caregiver burden
what is the definition of early mobilization in the ICU
Early” defined as initial physiologic stabilization, continuing throughout ICU stay
Initiating patient mobilization within 48 hours of patient admission to the ICU through:
ICU cultural shift toward mobility as necessity not optional
Practice patterns of all ICU personnel emphasizing teamwork with mobilization
Optimizing the ICU environment to allow for patient mobility
Multidisciplinary teamwork
Safe patient handling equipment
Proper wake/sleep cycles
Minimal sedation
who might all be apart of early mobilization in the ICU?
Physician advocate
Nursing champions
Respiratory therapy
Physical therapy
Occupational therapy
Mobility aides
Case manager/social worker
what depth should ICU patients be sedated at for best outcomes?
Light levels of sedation associated with improved clinical outcomes shorter duration of mechanical ventilation and a shorter ICU length of stay
Recommend routinely using either daily sedation interruption or targeting light level of sedation in patients requiring mechanical ventilation
what is the spontaneous awakening trial?
A patient is considered “awake” if able to perform 3 of the following 4 tasks:
Opens eyes in response to voice
Uses eyes to follow the health care provider on request
Squeezes a hand upon request
Stick out the tongue upon request
what are the levels of the Richmond agitation sedation scale (+4 to -5)
+4 Combative Overtly combative, violent, immediate danger to staff
+3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive
+2 Agitated Frequent non-purposeful movement, fights ventilator
+1 Restless Anxious but movements not aggressive vigorous
0 Alert and calm
-1 Drowsy Not fully alert, but has sustained awakening (eye-opening/eye contact) to voice (>10 seconds)
-2 Light sedation Briefly awakens with eye contact to voice (<10 seconds)
-3 Moderate sedation Movement or eye opening to voice (but no eye contact)
-4 Deep sedation No response to voice, but movement or eye opening to physical stimulation
-5 Unarousable No response to voice or physical stimulation
how do you perform a spontaneous breathing trial (SBT)
Start (0400-0500)
Place head of bed > 40º unless on full spine precautions
PSV 5 and PEEP 5 both measures of positive ventilation pressure
Terminate wean if any of the following threshold values are observed and return to previous ventilator settings:
Pulse < 60 or > 130
Sustained RR > 38
Systolic Blood Pressure > 180 or < 90 mmHg
SpO2 < 88% despite increasing FIO2 to 50% or higher
Significant change in respiratory pattern, diaphoresis, or paradoxical breathing pattern
what are the cognitive changes related to the ICU stay
25 to 40% of patients with new onset cognitive changes
Impaired learning and short-term memory
Executive function
Attention
Contributing factors
Hypoxemia
Variable glucose control
Delirium/sedation
Sepsis
explain the pathway through the confusion assessment method for the icu?
slide 26
what prevents delirium?
Performing early mobilization of adult patients in the ICU & AC whenever feasible to reduce the incidence and duration of delirium is recommended
what does the E stand for in ABCDEF and what does it require?
Requires investment by the team
Involves actively getting patients off sedation, out of bed as soon as possible, and ambulatory while still intubated
what’s the red reason for exclusion from early mobolization?
Significant doses of increasing vasopressors for hemodynamic stability (maintain MAP> 60)
what are the exclusion guidelines for early mobility?
Significant doses of increasing vasopressors for hemodynamic stability (maintain MAP> 60)
FiO2 80% or .8 and/or PEEP >12
Acutely worsening respiratory failure
Neuromuscular paralytics
Acute evolving neurological or cardiac event with re-assessment for mobility every 24 hours
RASS less than -3 or greater than +2
Unstable spine or extremity fractures
Open abdomen, at risk for dehiscence
Grave prognosis transitioning to comfort care
what are the pharmacological treatments for these patients
Vassopressors- vasoconstriction
Ionotropes- Increase heart contractility
How does family participation help patients in sedation?
Open visiting hours and caregiver presence may help reduce over-sedation
Family/caregivers are fully invested as:
Advocates
Motivators
Mood elevators
Family/caregivers can help with:
Hygiene care
Activities of daily living
Range of motion/exercise
A diary of daily events
Family/caregiver presence helps prevent:
Complications
Medication errors
Unnecessary procedures
what are barriers to early mobolization?
Skeptical clinicians culture and beliefs
Rotating, changing, in-experienced personnel
Minimal resources/time
Variation in sedation practices
Timing of PT and OT referrals
Awkward equipment
Unclear progression of activities
Comfort level mobilizing prior to extubation
what is the main take away for this powerpoint slide dec?
ICU Liberation and early mobility
Takes TEAMWORK
Takes TIME
Takes the Drive to do what is the BEST Practice for your patient
