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PHST 4000 > ICU > Flashcards

ICU Flashcards

1
Q

Type 1 Resp failure

A

Also called hypoxaemic respiratory failure.
failure of oxygenation d/t gas exchange malfunction
PaO2 < 60 mmHg with normal PaCO2

Acute failure e.g. pneumonia, exacerbation of asthma, lung collapse, pulmonary oedema

Chronic failure e.g. exacerbation of COPD (pink puffer)

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2
Q

Type 2 Respiratory Failure

A

Also called hypercapnic/ventilatory respiratory failure
Failure of ventilation - respiratory pump malfunction

PaO2 < 60 mmHg & PaCO2 > 50 mmHg

Acute failure e.g. severe acute asthma (as tiredness sets in), chest wall/lung parenchyma injuries, drug overdose, postoperative hypoxaemia, neuromuscular disease.

Chronic failure e.g. advanced COPD (blue bloater), restrictive pulmonary disease

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3
Q

Auscultation signs of asthma

A

high pitched wheezing - near total obstruction d/t inflammation

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4
Q

Auscultation signs in supine position

A

Reduced air entry basally

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5
Q

Auscultation signs of a smoker

A

course crackles d/t secretions

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6
Q

Ausc: crackles

A

Crackles – heard in inspiration (ask pt to cough to distinguish, if crackles gone after = secretions, if not = fine (lung pathology)
* Course: early inspiration – sputum retention (eg COPD, broncholitis)
* Fine: late inspiration (hair rubbing)– pulmonary fibrosis/oedema/COPD/resolving pneumonia/lung abscess

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7
Q

Ausc: wheezes

A

Wheezes – heard in expiration, whistling/musical through narrowed airways
* Monophonic – single obstructed airway
o Stridor = high pitched monophonic inspiratory wheezing, typically over anterior neck
o Upper airway partial obstruction (as air moves turbulently over)
* Polyphonic – widespread obstruction
* High pitched – near total obstruction (asthma)
* Low pitched – sputum retention (bronchitis)

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8
Q

Ausc: pleural rub

A

Pleural rub – heard in inspiration & expiration, localised, boots crunch on snow (to distinguish if caused by pleural lining/pericardium ask pt to brief inspiratory hold manoeuvre. If rub present after = pericardial rub
* Rubbing of roughened pleural surfaces caused by inflammation/infection/neoplasm
* Pneumonia, pulmonary embolism

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9
Q

Ausc: Rhonchi

A
  • sonorous wheeze
  • Deep, low pitched rumbling/ course breath sound
  • As air moves through tracheal bronchial passages in presence of mucous/respiratory secretions
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10
Q

CXR - acute asthma

A
  • read in written notes about other conditions

Reduced lung volumes
hyperinflated lungs on CXR and as bronchospasm subsides the lung volumes return to normal.

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11
Q

dynamic compliance

A

compliance is a measure of the lung expandability

Resistance of airways to flow of air
Measured with peak inspiratory pressure
CD = Exp VT/(PIP – PEEP)
Influenced by bronchospasm, blockage of airways, airway compression
(n: 50-80 cmH2O)

  • Low compliance indicates lung stiffness and affects ventilation
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12
Q

Static compliance

A

compliance is a measure of the lung expandability

It represents pulmonary compliance at a given fixed volume when there is no airflow, and muscles are relaxed.
True compliance of lung tissue
Measured with plateau/pause pressure
CS= Exp VT/ (PauseP – PEEP)
Influenced by parenchymal disease, pulmonary oedema, abnormalities in pleural space & chest wall
(n: 70-100 cmH2O)

  • Low compliance indicates lung stiffness and affects ventilation.
  • CS is increased in emphysema due to loss of elasticity of lung fibers
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13
Q

MCT indications

A
  • infants and small children who are unable to voluntarily perform breathing exercises;
  • patients with neuromuscular weakness or paralysis;
  • intellectually impaired patients;
  • patients with suppressed levels of consciousness;
  • mechanically ventilated patients who are unable to perform breathing exercises or are required to maintain immobility due to the nature of their injuries; and
  • patients with retained secretions, in combination with breathing exercises.
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14
Q

MCT CI & precautions

A
  • Frank haemoptysis
  • Excessive pain
  • Acute head injuries with uncontrolled intracranial pressure
  • Multiple rib fractures or flail rib segments
  • Acute bronchospasm that does not respond to bronchodilator therapy
  • Patient with pulmonary embolism not on anti-coagulant therapy
  • Severe clotting disorders such as platelet count below 50 × 109\L (50000 cm3) and international normalised ratio (INR) greater than 1.4 seconds.
  • Manual techniques should be used with extreme caution in patients with unstable spinal cord injuries. Techniques performed bilaterally on the chest wall in the supine position potentially cause less harm to the spinal cord than unilaterally performed techniques.
  • Loss of skin integrity such as recent burns or open wounds on the chest wall
  • Subcutaneous emphysema indicative of an undrained pneumothorax, haemothorax or pleural effusion.
  • Severe osteoporosis, as it may result in rib fractures
  • Unstable angina or cardiac arrhythmias
  • Non-communicating lung abscesses
  • Preterm infants.
  • Pulmonary oedema or unstable pulmonary hypertension
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15
Q

Postural drainage I & CI & precautions

A

gravity assisted clearance of bronchial secretions improve ventilation of lungs

contraindications and precautions:
o severe hypertension
o cerebral edema
o raised inter cranial pressure
o congestive cardiac failure, aortic aneurysms;
o pregnancy and obesity
o frank hemoptysis
o raised (or potentially raised) intracranial pressure or cerebral aneurysms;
o abdominal distension, obesity or a history of gastro-
o oesophageal reflux;
o recent trauma or surgery to the head and neck
o used with caution in the acutely injured patient.
o When positioning critically ill or injured patients, care must be taken not to dislodge lines, drains, tubes or any invasive devices, and to avoid pressure sores resulting from lying on these attachments.

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16
Q

S5Q

A

method of assessing cooperation in a critically ill patients
includes testing 5 aspects & scored out of 5:
* Open and close your eyes
* Look at me
* Open your mouth and stick out your tongue
* Shake yes and no (nod your head)
* I will count to five, frown your eyebrows afterwards

Interpretation of the S5Q score:
* S5Q = 0/5 ̴ No cooperation
* S5Q < 3/5 ̴ No to low cooperation
* S5Q = 3/5 ̴ Moderate cooperation
* S5Q = 4/5 ̴ Close to full cooperation
* S5Q = 5/5 ̴ Full cooperation

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17
Q

ausc: pneumonia

A

Pleural rub indicating inflammation/infection found in areas of consolidation in pneumonia
(consolidation - air filled spaces replaced by water, puss or blood)

decreased sounds can mean:
* Air or fluid in or around the lungs (such as pneumonia, heart failure, and pleural effusion)

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18
Q

CXR - pneumonia

A

Consolidation (localised = infection)– air filled spaced replaced by water, pus, or blood

shadowing in consolidation d/t gravity

Air bronchogram – airways contain air & appears black against a white background

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19
Q

how does MHI improve lung compliance

A

Manual hyperinflation usually consists of the delivery of larger than tidal volume breaths
The squeezing of the resuscitation bag increases the baseline tidal volumes during inspiration by approximately 1L. This increase in tidal volume plus inspiratory hold allows time for alveoli and collateral airways to open, thereby increasing lung compliance and reducing atelectasis

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20
Q

MHI aims

A

PRRIIMM

  • Mobilize peripheral secretions to central airways
  • Re-expand collapsed areas of the lung
  • Improve oxygenation
  • Improve static and dynamic compliance of the lung
  • Reduce airway resistance
  • Prevent atelectasis

eg
- Loss of volume - re-inflate atelactic areas and improve oxygenation
- reduced compliance - increase compliance and tidal volume
- sputum retention - mobilise secretions through P/V distribution
- poor cough effort - quick release will mimic cough/huff
- increased gas exchange and collateral recruitment .’. increased VT and VTE as well as reduced PIP and PEEP

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21
Q

MHI CI

A
  • Acute pulmonary oedema
  • Bullae in patients with COPD or cystic fibrosis
  • Undrained pneumothorax, haemothorax or large pleural effusion or intercostal drain with an air leak (if patent ICD can use MHI)
  • Bronchopleural fistula
  • Obstructing airway tumour or lung tumour
  • Presence of an intra-aortic balloon pump
  • Extra- ventricular drainage device
  • Thoracic surgery with lung resection
  • Presence of inflated gastric and oesophageal balloons
  • Severe bronchospasm
  • Cardiovascular instability
  • MAP < 60 mmHg; total inotropic requirements ≥ 15ml/hr of adrenaline or NA (dilution 3mg/50ml)
  • Patients on extracorporeal membrane oxygenation
  • Frank haemoptysis
  • Care should be taken in pt requiring high PEEP 10- 15cmH2O or high levels of FiO2 e.g. FiO2 > 0.7
  • High frequency oscillatory ventilation
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22
Q

MHI complications

A
  • Reduction in blood pressure
  • Reduced saturation
  • Raised intracranial pressure
  • Reduced respiratory drive
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23
Q

haemodialysis precautions

A

Precautions to Physiotherapy Interventions:

Vitals: Monitor vitals before, during and after intervention especially blood pressure when patient is receiving haemodiafiltration (dialysis)

Catheter: Be wary of catheter dislodging during repositioning and/or mobilising of patient
If the patient is on dialysis, one needs to be aware of the dialysis lines when performing exercises – do not flex the hip (on the side where catheter is placed) more than 30 degrees during exercise.

Haematological results: Monitor potassium, sodium and calcium as well as the urea and creatinine before mobilising

24
Q

BiPAP ventilation mode

A

Bi-Level Positive Airway Pressure (BiPAP)
* Pressure controlled ventilation
* Cycles between two different positive pressure levels
* Inspiratory PAP (IPAP) & Expiratory PAP (EPAP)
* Improves VT as well as FRC
* Can be used as mandatory ventilation as well as a weaning mode

25
Q

SIMV ventilation mode

A

Synchronized Intermittent Mandatory Ventilation (SIMV)
* SIMV = machine breaths (VT & RR or P & RR) are synchronized with patient’s spontaneous RR so as not to ‘stack’ breaths
* This ventilator mode will provide a set number of breaths at a fixed tidal volume, but a patient can trigger a spontaneous breath with the volume determined by patient effort
* A level of PS (5 – 8 cmH2O) added to overcome airway resistance of artificial airway
* SIMV & A/C mode are similar if patient takes spontaneous breaths
* SIMV is a weaning mode.

26
Q

CPAP ventilation mode

A

Continuous Positive Airway Pressure
* One level of positive pressure is maintained in ventilator circuit during inspiration and expiration
* Patient breathes totally spontaneously and generates his/her own VT
* CPAP given through ventilator or wall circuit
* CPAP is a weaning mode

27
Q

Controlled (mandatory) mode

A

Doctor sets RR & Vt or RR & pressure – patient doesn’t participate.

28
Q

Assist-controlled mode

A

Adds trigger sensitivity to controlled mode, thus detects patient’s inspiratory efforts
Indicated: patient with no spontaneous RR or potential loss of breathing efforts (PC mode or VC mode)

29
Q

TBI precautions

A
  • Close monitoring of vital signs as this fluctuates quickly
  • Bolus of sedation/paralysing agent prior to handling
  • When a patient is turned, keep head in midline
  • No direct pressure to bolt, drain, shunt site
  • After craniotomy; bone flap removed, no direct pressure on unprotected brain
  • Short Rx sessions
  • Pre-oxygenate prior to and during treatment
  • Suction as needed
  • Not to noisy
  • Ventricular drains (EVD)
    o Check medical orders
    o Excessive movement/Physiotherapy (closed/raised)
    o If drain must be open; raise 10-20cm when pt cough
  • Cerebrospinal fluid leak (CSF)
    o CSF leak; drainage from nose or ear
    o Avoid nasal suction
30
Q

fracture precautions

A
  • Fracture site must be supported during treatment so as not to cause further harm or injury
  • Avoid rotation of fractured site and be respectful of pain
  • avoid turning the patient directly on to right shoulder.
  • Avoid resistance distal to fracture site
  • Elevate injured limb to reduce oedema, but only to the range allowed as a result of the fracture
  • Do ROM exercises in a pain-free range
31
Q

reducing tenacity of secretions

A
  • Nebulise with mucolytic “mesna”/saline- will thin secretions 10-15 min
  • Suction, use saline to decrease tenacity of secretions, but don’t routinely install saline
32
Q

Enviroment limitations in ICU

A
  • Height of bed inappropriate for patient to get into and out of
  • Noisy and busy- increases fear and anxiety in pt
  • Sleep and rest disruption as a result of health professionals coming in at different times to do treatments
  • Many machines and equipment in the vicinity, making it difficult for pt to move around easily
  • attachments to patient can restrict movement
33
Q

Participation limitations in ICU w/ MV

A
  • Pt cannot walk around ICU and communicate with others
  • Pt cannot speak to family members/health professionals effectively due to ventilator
  • Participating in exercise programmes may be limited due to pain and fear
  • Pt cannot bath, dress or eat independently
34
Q

S&S of ETT obstruction

A
  • Patient anxiety
  • Pt uses accessory muscles and nasal flaring is apparent
  • Very diminished breath sounds in both lungs on auscultation
  • High peak inspiratory pressure (PIP)
  • Low tidal volume readings on MV panel
  • Alarming from MV
35
Q

Type B1 (open book) pelvic girdle facture

A
  • If gap < 2.5cm: bed rest 2-4 weeks until pain subsides then treat as stable fracture
  • If gap > 2.5cm: post surgery bed rest for up to 4 weeks then mobilise PWB or FWB (discuss with surgeon)
  • Pelvic sling: after bed rest mobilise patient PWB for 6 weeks.
36
Q

Type B2 or B3 (ipsilateral and contralateral unstable)

A
  • External fixation or plates: no excessive hip external rotation; no posterior pelvic tilt for 4 weeks; hip flexion limited to 45 degrees for 4 weeks, No weight-bearing until given the “go ahead” from the surgeon
  • Pelvic sling: no sitting for 4 weeks
  • Communication with the surgeon is very important to clarify precautions
37
Q

calculating hypoxemia

A

Calc:
1. PaO2/FiO2 will show VQ mismatch if below normal (n: >/= 400)

  1. Hypoxic hypoxemia (A-a)O2 will show diffusion defect – Implies lung disease or pulmonary dysfunction as only lung disorder can produce a decrease in PaO2
    o PAO2 = FiO2(PB – PH2O) – (PaCO2/RI)
     PB = 625 mmHg (Jhb)
     PH2O = 47 mmHg
     RI=0.8 (ratio of CO2 excretion to O2 uptake)
    o (A – a)O2 ≤ 10 mmHg is normal when breathing spontaneously.
    o (A – a)O2 < 65 mmHg is normal when 100% oxygen is breathed.
  2. Anaemic hypoxemia oxygen content
    * Oxygen content = dissolved O2 + O2 bound to Hb (n: >190, less = anaemic hyposxia)
    * Dissolved O2 = 0.03 x PaO2 (normally ± 3 – 4 ml/L)
    * O2 bound to Hb = 1.34 x Hb x SaO2 (remember to convert g/dL to g/L and % to a number)
    o (1.34 = the amount of O2 bound to 1g of Hb if it were 100% saturated)
38
Q

IMT to strengthen respiratory muscle

A

inspiratory muscle trainer

  • Pt seated in 45 degree head up position
  • Establish pt’s baseline inspiratory muscle strength using a pressure manometer to measure maximal inspiratory pressure
  • Do two measurements of MIP and calculate the average of the 2 readings
  • Attach IMT device to ETT or tracheostomy Tube
  • Attach oxygen tubing to side-port of the device if indicated
  • Set the spring in the IMT device to 30% of the pt’s baseline MIP
  • The patient breaths through the device for 5 minutes twice daily- add lateral costal breathing exercises
  • Inspiratory resistance is increased by 10% of MIP daily as tolerated
38
Q

IMT to strengthen respiratory muscle

A

inspiratory muscle trainer

  • Pt seated in 45 degree head up position
  • Establish pt’s baseline inspiratory muscle strength using a pressure manometer to measure maximal inspiratory pressure
  • Do two measurements of MIP and calculate the average of the 2 readings
  • Attach IMT device to ETT or tracheostomy Tube
  • Attach oxygen tubing to side-port of the device if indicated
  • Set the spring in the IMT device to 30% of the pt’s baseline MIP
  • The patient breaths through the device for 5 minutes twice daily- add lateral costal breathing exercises
  • Inspiratory resistance is increased by 10% of MIP daily as tolerated
39
Q

TT weaning

A
  • Cuff deflation and swallow assessment
  • Fenestrated tube inserted
  • Downsizing of the tube
  • Capping off
  • Decannulation (extubation)
40
Q

inter-disciplinary team importance

A
  • Ensures that the pt is given full attention and that all decisions are made together by all members of the team to ensure effective treatment
  • Pt has neurological problems and cardiopulmonary problems thus all members of the medical staff should make these decisions together so that there is no controversy/contradictions in treatment
  • Orthotist/OT to assist with splints for ankles
  • Pt requires adequate treatment from nurses, doctors, physios and dieticians among others in order for effective management to occur
41
Q

PS function

A
  • Certain level of pressure to the inspiratory circuit when patient starts to inhale.
  • This ‘boosts’ patient’s own respiratory efforts by increasing spontaneous VT & unloading patient’s respiratory muscles
  • Boost stops when inspiratory flow decreases to a certain degree as the end of inspiration is reached
  • Used in conjunction with all ventilation modes
42
Q

PEEP function

A

Positive End-Expiratory Pressure
* Positive pressure added to airways at end of expiration to prevent collapse of alveoli – stabilizes alveoli
* PEEP increases patient’s tidal volume and functional residual capacity (FRC) -
↑ oxygenation
* Used in conjunction with all ventilation modes

43
Q

PT aims of Mx - musculoskeletal system

A
  • maintain and improve ROM of affected joints – indicate outcome & time frame
  • maintain and improve muscle strength, including respiratory muscles – indicate outcome & time frame
  • maintain and improve muscular endurance, including respiratory muscles
  • prevent soft tissue shortening or muscle contractures – indicate which two-joint muscles (hamstrings (biceps femoris): crosses hip & knee; rectus femoris (quadriceps), semitendinosis, semimembranosus: cross hip & knee; gastrocnemius: cross knee & ankle; biceps brachi) are at risk of contracture formation
  • promote functional independence indicate outcome & time frame
  • oedema management
44
Q

PFIT

A

Physical Function in ICU Test
- Developed as an outcome measure to evaluate and prescribe rehabilitation for patients in ICU as not able to perform 6MWT or timed-up-and-go test in ICU
- Components of PFIT:
o Assistance (sit to stand)
o Cadence (during marching on the spot - steps/minute)
o Shoulder (flexion strength - bilateral)
o Knee (extension strength - bilateral)
o Limitations to PFIT: The test can only be performed if the patient is able to sit in a chair, No assessment of respiratory function.

45
Q

CPAx

A

Chelsea Critical Care Physical Assessment Tool (CPAx)
o Bedside scoring system to grade physical morbidity in the critical care population
o Need hand dynamometer to assess hand grip strength
o Newer tool than PFIT – validation studies underway

46
Q

FSS-ICU

A

Functional Status Score for ICU (FSS-ICU)
o Assesses rolling, supine to sit, SOEB, STS, walking
o Out of 35

47
Q

if oxygen saturation drops below 90%

A
  • check pulse oximeter has not shifted – if it has, replace and monitor sats and continue treatment if normal
  • if in situ – cease treatment, monitor sats, if due to treatment and they normalise continue treatment but monitor
  • if sats still decreased, check O2 mask in situ / ventilator still connected – correct if not
  • If all above is normal and sats still reduced, auscultate to see if there are breath sounds 🡪 increase FiO2 on vent, call a nurse/doctor to help
48
Q

explain how chest injuries = intubate & MV

A
  • pain from rib fracture = short, shallow breaths = unable to produce a vital capacity of >15ml/kg
  • rib fractures ↓ lung compliance
  • Haemopneumothorax places ↑ pressure on the lung and ↓ oxygenation and ventilation
  • decreases the amount of negative pressure inside the lung and .’. makes it difficult for O2 to enter the lungs .’. PaO2 could possibly be <60mmHg
  • Pain and fatigue of external and internal intercostal muscles will ↓ ability to inspire or expire, respectively
  • inability to clear secretions independently and effectively and independently due to pain, weakness, and other related causes
49
Q

ICF enviroment & personal in ICU

A

Environment
- Stressful
- sensory overload
- disturbed sleep
- lines and attachments
- unable to communicate effectively

Personal
- depression, anxiety, and fear
- loss of dignity and privacy
- ↓ motivation
- financial support
- family support

50
Q

subjective OM

A

Breathlessness (BORG/MRC scale)
Pain – VAS
Reversal of partial / complete collapse (auscultation
Secretions - auscultation

51
Q

objective OM

A

Cognition – GCS/ICP value
Muscle strength (MRC/Oxford)
Breathing pattern (observed)
Clearance of secretions (amount, consistency, and colour)
Lung collapse – thoracic expansion and chest x-ray

52
Q

DIC definition

A

Haematological System Response - Disseminated Intravascular Coagulation (DIC)

Definition of DIC:
A condition in which small blood clots develop throughout the bloodstream, blocking small blood vessels due to overactive proteins. The increased clotting depletes the platelets and clotting factors needed to control bleeding, causing excessive bleeding.

53
Q

Physiotherapy Precautions and C/I for DIC

A
  • Monitor platelets if less than 50 x 109/L = stop PT and consult with ICU staff
  • Monitor for signs for clotting and DVT (make sure pt has taken daily meds)
  • Monitor for bleeding from facial orifices e.g. nose
  • Do not palpate/handle/apply MCT too vigorously as pt’s bleed and bruise easily
  • MCT and PD are C/I if coughing up blood (haemoptysis)
  • Give slack in any lines, they may pull and rip out, which too may lead to bleeding
  • If any SOB/ Dizziness / Severe fatigue stop PT and allow for recovery. Apply relaxation positions and TEE ( if pt can tolerate)
54
Q

Physiotherapy Management DIC

A

Assessment:
* Monitor any changes in platelets, PTT and INR.
* Monitor for signs of bleeding at any orifices / ask ICU nurse
* Monitor for signs of DVT
* Monitor SOB/Dizziness and fatigue if mobilizing
Treatment:
* Mobilize out of bed – only if patient’s condition is stable enough
* MS and ROM exercises as well as functional exercises – only if patient’s condition allows
* Chest physio: MCT use vibromat if available, ACBT, and any other interventions if and when indicated. Use caution with airway suction and manual hyperinflation.

55
Q

Humidification of MV Circuit:

A

Humidification of MV Circuit:
* Dry gas is delivered through a mechanical ventilator to the patient – increased risk of drying out the mucosal membranes and development of pulmonary infection
* Humidification strategies in ICU:
o Passive heat and moisture exchanger (HME - dry humidification)
o Active humidification (Fisher Paykel system - heated water humidification)

PHST 4000 (4 decks)

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