Intensive Care Unit and Early Mobility Flashcards
What is the care improvement ABCDEF bundle
- Assess, prevent, and manage pain
- Both spontaneous awakening trials and spontaneous breathing trials
- Choice of sedation
- Delirium
- Early mobility and Exercise
- Family engagement and empowerment
What are the PAD symptoms (AKA ICU triad)
- Pain
- Agitation
- Delirium
Triad of anesthesiia
- Hypnotics
- Analgesics
- Muscle relaxants
Sedatives should be used only when ______ and __________ have been addressed with the use of specific pharmacologic and nonpharmacologic strategies.
- Pain and delirium
Describe the activity and mobility promotion (AMP) scale
- 1 = lying in bed
- 2 = bed activities/dependent transfer
- 3 = sit at edge of bed
- 4 = move to chair/commode
- 5 = standing (1 or more minutes)
- 6 = walk 10 steps or more
- 7 = walk 25ft or more
- 8 = walk 250ft or more
Mobility and rehab guidelines for PT in ICU; physician should be contacted before starting PT if any of the following conditions exist
- RASS score = -4, -5, or ≥+3
- Pulse Oxi <88% OR FiO2 >0.6 and PEEP >10 OR HFO ventilation
- RR >45
- Most recent arterial pH <7.25
- MAP <55 or >140
- Duration of anti-coagulation <36hrs
Safety screen assessment MOVES stands for
- Myocardial
- Oxygenation
- Vasoactive
- Engaged
- Special considerations
What does the CPOT (Critical Care Pain Observation Tool) include
- Facial expression
- Body movements
- Muscle tension (eval by passive flexion/extension of UEs)
- Compliance with the ventilator (intubated pts) OR vocalization (extubated pts)
Behavioral Pain Scale (BPS) in intubated pts scoring
- Facial expression: (1) relaxed, (2) partially tightened (brow lowering), (3) fully tightened (eyelid closer), (4) grimacing (folded cheek)
- Movements of UEs: (1) no movement, (2) partially bent, (3) very bent w/finger flexion, (4) retracted/opposition to care
- Compliance w/ventilation: (1) tolerating ventilation, (2) coughing but tolerating ventilation most of the time, (3) fighting ventilator but ventilation possible sometimes, (4) unable to control ventilation
Richmond Agitation Sedation Scale (RASS) grading
- +4 combative: immediate danger to staff
- +3: very agitated: pulls on/removes tubes
- +2 agitated: frequent non-purposeful movement
- +1 restless: anxious/apprehensive
- 0 alert and calm
- -1 drowsy: >10 secs awake with eye contact to voice
- -2 light sedation: <10 secs awake with eye contact to voice
- -3 moderate sedation: no eye contact but any movement to voice
- -2 deep sedation: no response to voice but any movement to physical stimuli
- -1 unarousable: no response to voice or physical stimulation
Describe critical illness myopathy
- Evolving myopathy in an ICU setting where pts are typically exposed to high dose steroids with or w/o prolonged neuromuscular blockade
Who is prone to develop critical illness myopathy (CIM)
- pts with systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction w/respiratory insufficiency
Risk factors for critical illness myopathy
- Severity of illness and prolonged ICU length of stay
- Sepsis, SIRS
- Multi-organ failure
- Female sex
- Malnutrition, ionic abnormalities
- Low serum albumin, parental nutrition, vasopressor catecholamine support
Findings of a physical exam for critical illness myopathy
- Diffuse symmetric proximal muscle weakness (neck flexors and respiratory muscles)
- Flaccid tone
- NO sensory involvement
- Facial weakness should raise concern for other neurologic disorders as it is rare for CIM
- Normal/reduced DTRs
- Normal/mildly elevated creatinine kinase (CK)
What are the 4 levels in the American Academy of Critical Care Nursing (AACN) mobility protocol
- (1) Elevated supine
- (2) Sitting EOB
- (3) Sitting in chair
- (4) Ambulation
Signs and symptoms of respiratory disturbance in acidosis and alkalosis
- Acidosis: hypercapnia, visual disturbances, drowsiness, V-fib, depressed tendon reflexes
- Alkalosis: hypocapnia, lightheadedness, tetany, convulsions, numbness/tingling of digits
Signs and symptoms of metabolic disturbance in acidosis and alkalosis
- Acidosis: hyperventilation, coma, stupor (near unconsciousness), deep respirations, mental dullness
- Alkalosis: depressed respirations, dizziness, tetany, convulsions, hypokalemia, mental confusion, numbness/tingling of digits
Patients who are on ________________ typically require continuous blood pressure management
- vasoactive drips
An arterial line is most commonly inserted through the _________ artery, but can also be inserted through the _________ artery
- Radial
- Femoral
Mean arterial pressure (MAP) can be an important indicator of hemodynamic tolerance and should be at least
- 60 mmHg
- Typically 70-110 mmHg
The transducer for an arterial line should be positioned at the level of the ______________ to assure accurate pressure values
- Right atrium
Implications if an arterial line transducer in placed too high versus too low
- If transducer is too low: blood pressure will read higher
- If transducer is too high: blood pressure will read lower
What should you do if an arterial line is dislodged accidentally
- Apply pressure immediately & notify nursing staff
Inaccuracies in the pulse oximetry readings may be seen in
- Low perfusion states (low cardiac output, vasoconstriction, & hypothermia)
- Anemia
- Abnormal Hb
- Jaundice
- Arrhythmias, including atrial fibrillation
- Intravascular dyes such as methylene blue
- Dark nail polish
- Fluorescent light
- Motion artifact
- Dark skin pigmentation
ECG indications of declining cardiac status
- ST changes: elevation or depression
- Onset/increase/change of foci of premature ventricular contractions (PVCs)
- Onset of ventricular tachycardia or fibrillation
- Onset of arterial flutter or fibrillation
- Progression of heart block
- Loss of pacer spike
Slide 53
Describe a temporary pacemaker
- Epicardial: inserted during surgery
- External transcutaneous: big patch over chest/back attached to defibrillator
- Transvenous: electrodes to RA, RV for bradycardia
- If dislodged call for help immediately & start CPR if systole occurs
The central line is a central venous catheter inserted most commonly through the __________ or __________ vein; however, the femoral access may also be used if the need arises.
- Subclavian or Jugular vein
The catheter is placed by a physician and is advanced to rest in the proximal __________ vena cava. The central venous catheter allows for direct and continuous monitoring of ___________ venous pressure (CVP) or _______ atrial pressure (RAP) to assess cardiac function and intravascular fluid status.
- Superior
- Central
- Right
What can a central line be used for
- Medication or fluid administration
- Blood sampling
- Emergency placement of a temporary pacemaker
What is used for interventions requiring a prolonged placement of a central line
- Peripherally inserted central catheter (PICC or PIC line) or a tunneled catheter
What peripheral veins is a PIC line inserted into and advanced through increasingly larger veins toward the heart until the tip rests in the ________________________
- Cephalic, basilic, or brachial vein insertion
- Advanced to the distal superior vena cava
Define a tunneled catheters
- Long term catheter that aer tunneled under the skin before entering a central vein
Tunneled catheters rarer associated with a ________ rate of infections
- Lesser
In addition, the cuff around the tunneled catheter causes fibrin and collagen deposition under the skin that provides stability and provides a second internal ________________________
- Barrier against infection
Risks associated during insertion of central venous access
- Pneumothorax
- Bleeding
- Arrhythmias
- Arterial entry
Delayed risks associated with central venous access
- Infection
- Catheter fracture
- Catheter dislodgment
- Catheter occlusion
- Air in the catheter
A pulmonary artery catheter (Swan-Ganz) allows monitoring of
- Direct measurement of Right Atrial Pressure (RAP)
- Direct measurement of pulmonary arterial pressure (PAP) and pulmonary capillary wedge pressure (PCWP)
- Indirect measurement of left atrial pressure (LAP)
- Determination of mixed venous oxygen saturation (SvO2) and cardiac output (CO)
- Calculation of systemic and pulmonary vascular resistance (PVR)
- Pacing of the atrium and ventricles
What structures does a pulmonary artery catheter (Swan-Ganz) pass through
- Central venous access point
- Vena cava
- Right atrium
- Right atrioventricular (tricuspid) valve
- Right ventricle
- Pulmonary valve
- Pulmonary artery
What are pulmonary capillary wedge pressures monitored
- Assess severity of left ventricular failure
- Assess mitral and aortic valve dysfunction
- Assess and treat pulmonary edema (PCWP >20 mm Hg)
- Assess pulmonary hypertension
- Assess and treat hypovolemic state
Presence of a pulmonary artery catheter (Swan-Ganz) is not a contraindication to mobilization (True/False)
- True
Complications of insertion and dislodgement of the Swan-Ganz catheter include
- Malignant arrhythmias
- Pulmonary artery rupture
- Pulmonary valve tear
- Infection
Activities that may increase ICP (intracranial pressure)
- Isometric exercise
- Valsalva maneuver
- Extreme hip flexion
- Lateral neck flexion
- Coughing
- Prone position
- Head position below 15 degrees horizontal (ideal position for venous drainage: HOB >30 degrees)
- Occlusion of the tube
- Pain
Describe ventriculostomy/EVD
- Measures ICP & drains cerebrospinal fluid
- Indicator line/light must line up with the external auditory meatus
- Mobility is safe
- Ensure secure connection prior to mobility
- Goal is ICP <20 mmHg
- Must be clamped by RN prior to mobility
- Elevate head of bed to 30º after placement and attach EVD CSF collection system to a pole near the head end of the bed
- LIFE THREATENING if dislodged
Contraindications to mobilizing with EVD
- hemodynamic instability
- active bleeding or angioedema
- heart rate greater than 120bpm
- ICP higher than 25mm Hg or as deemed unstable by the treating NSICU/neurosurgery team
- a cerebral perfusion pressure lower than 50mm Hg
- resting heart rate of 50% age-predicted maximum or less
- systolic blood pressure lower than 90 or higher than 180, diastolic blood pressure higher than 105
- peripheral oxygen saturation of 90% or less
- marked diaphoresis, facial pallor, intense anxious or painful facial expression (especially in patients who were aphasic)
- active bleeding from lines, catheters, or wounds
Describe a lumbar drain
- Small flexible tube that is placed in the lumbar spine
- Drains some of the CSF that fills the ventricles of the brain & surrounds the brain and spinal cord
- Draining CSF for a few days is helpful in determining if the pt will benefit from a shunt
- Drain must be CLAMPED prior to mobilizing
Describe a urinary catheter
- Collects urine
- Keep collection bag below bladder
- Ensure catheter is secure
Types of urinary catheters
- Condom: frequently fall off, ask nursing staff to reapply
- External: connected to suction, remove prior to mobility
- Foley and suprapubic if dislodged call RN immediately as they are secured with balloon in bladder
Describe fecal management systems
- Typically used in pts with excessive loose stools in order to protect skin
- Avoid shearing with transfers
- Held in place with balloon in rectum
- If dislodged notify RN
Descrive Gastrointestinal (GI) tubes
- Drain GI contents or administer internal feedings & medication
- Inserted in nose, mouth, or abdomen
- Shot or long term use
- Turn OFF feeding if HOB is <30º
- If dislodged immediately alert RN
What are the different types of GI tubes
- NG: nose to stomach
- ND: nose to duodenum
- NJ: nose to jejunum
- Gastric tube (G-tube): directly inserted into stomach
- GJ: gastric to jejunum
- PEG: percutaneous endoscopic gastrostomy (flexible feeding tube is placed through the abdominal wall & into the stomach)
- Jejunal (J-tube): inserted directly into jejunum
Describe surgical drains
- Placed during surgery to drain pus, blood, or other fluids
- Active vs passive drain, closed system: vacuum vs nonvacuum
- Open system
- Ensure drains are secure prior to mobility
- If dislodged cover area with hand, apply pressure, and call RN immediately
Describe a wound VAC
- Type of closed active drainage system used foe wounds
- Vacuum assisted closure (VAC) of a wound
- Negative pressure wound therapy to promote healing in acute/chronic wounds
- Commonly used on skin flaps/grafts, ulcers after debridement, and surgical closings
Reasons for insertion of a chest tube
- Thoracotomy
- Pleural effusion
- Pneumothorax, hemothorax, or chylothorax
- empyema
- Chemical pleurodesis
Describe the purpose of a chest tube
- Used to remove and prevent the reentry of air or fluid from the pleural or mediastinal space & provide negative intrapleural pressure
Presence of a chest tube is NOT a contraindication to mobilization (True/False)
- True
For effective mobilization with pts with chest tubes you need to
- Ensure that the pt is premeditated for pain
- Always keep chest tube drainage system below the chest level
- Check for air leaks
- Always discuss with doctor or nurse before disconnecting suction
- A portable suction device may be used when indicated
- Changes in the quantity & quality of exudates should be noted by the PT before, during, & after changes in position & therapeutic interventions
- After chest tube removed hold therapy until X-ray rules out pneumothorax
Individual with at least 2 of the following indicates strong consideration for ICU admission due to organ dysfunction (sepsis)
- RR >22 breaths/minute
- Change in mental status
- SBP <100 mmHg
Reasons to stop PT intervention with acute coronary syndrome/MI patients
- Unable to comfortably speak
- RR >40 breaths/minute
- Onset of S3 heart sound
- HR decreased >10 bpm
- SBP decreased >10 mmHg
- MAP increased >10 mmHg
- CVP decrease/increase >6 mmHg
- SpO2 <90% or a decrease ≥4%
- New onset or worsening of cardiac dysrhythmia
- Return of pre-MI angina like pain
Common indications for vasopressors
- Shock (septic, cariogenic, anaphylactic)
- Heart failure
Positive inotropes
- Beta Agonists
- Cardiac Glycosides
- Dobutamine
Neuromuscular blocking agents
- Nimbex
- Rocuronium
General anesthetics
- Propofol
- Ketamine
