New chapter 3 ADL Flashcards
New practitioner
Critical care environment
most intimidating setting for new practitioner. Mobility tasks are often called for in ICU
unintended consequences of ICU stay
Neuropsychological effects. Can result in ICU delirium - a state of extreme confusion also known as ICU syndrome or ICU psychosis. - fatigue; confusion; anxiety; and visual, auditory, and tactile hallucinations.
Predisposing factors in ICU delirium
- advanced age
- cognitive impairment
- sensory impairments
- multiple morbidities
Complilcations caused by ICU delirium
- more frequent falls
- longer hosipital stays
- higher hospital costs
- increased patient mortality
early mobility
ICU aquired weakness (ICUAW)
Early progressive mobiliity reduces both ICU delirium and ICUAW. even on a ventilator.
Durring prerounds
Team sets mobility goals for their patients.
Adage in ICU
anything physical can be therapy
13 steps to encourage early mobility in ICU
- Participate in inderdiciplanary communication
- Create a mobility plan
- Check with nursing staff
- Communicate with patient
- Scan the room making note of all equipment, monitors, lines, leads, and tubes.
- Check the patient’s vital signs and ventilator settings
- Check all lines, leads and tubes.
- Visualize the planned activity
- Move equipment and get assistance as needed.
- apply gait belt as needed for out of bed activities.
- group all lines and tubes together
- Engage the patient in the mobility activity, monitoring the patient’s appearance and vital signs.
- End activity - notify nursing staff.
precautions for central lines may be changing
They used to be restricted to bed rest and no hip flexion past 60 to 80 degrees, but studies show that may not be neceassary.
If an arterial line is disloged during a therapy session
apply pressure and notify the nurse immediatly. potential for large amounts of blood loss.
When using NG tube the head of the bed
shourd remain elevated 30 to 45 degrees.
NG tube
tube attached to an electric pump containing liquid nutrition inserted via nasal passages through the esophagus and into the stomach. Held in place near insertion with tape. May be pinned to gown as well. must be postioned upright for 30 min after feeding or 1 hour for pediatric patients.
Enerostromy feeding tube
Feeding tube
inserted via endoscopy
or small surgical opening
in abdomin.
Patient should not lie flat during feeding.
Indwelling urinary catheter
Tube inserted into bladder via urethra, providing continous bladder drainage.
secured internally by a small balloon filled with sterile water.
taped to thigh to prevent accidental removal.
Be careful not to pull on tubing and not to compress tubing.
condom catheter (texas catheter)
Tubing connected to condom fitted over penis, draining urine into collection bag
Can easily become removed. Occasionally taped to skin.
External female catheter
Externally applied device for female patients. Wicks urine into collection canister.
replace every 8 to 12 hours.
Suprapubic catheter, urostomy, nephrostomy
Tube surgically inserted into lower abdoment
suprapubic catheter and urostomy - or lower
back nephrostomy to drain urinary output.
Keep insertion sites dry
avoid putting gait belt on over insertion site.
colostomy, ileostomy bag
bag for collection of fecal matter.
attached directly over surgically created opening in abdomen,
bringing large intestine to abdomen surface
Inspect for secure attachment before and after mobility
Have bags emptied before activities.
avoid motions that would put tension on bag or seal.
avoid disturbance when placing gaitbelt.
Rectal tube
Tubing inserted into rectum and attached to collection bag to drain fecal matter.
tubing can easily become dislodged.
keep bag below tube level.
Cardiac leeds
wires connecting electrodes on patient’s body to recording device monitoring the activity of the heart.
Movement can create artifact or cause leads to become disconnected
alarm may sounds and leads should be reattached by nursing staff.
Temporary transvenous pacemaker
Device used to regulate heartbeat
catheter threaded, through neck vein, into heart’s right ventricle
wire attached to external pulse generator and may be taped to skin or attached to bed.
patient may participate in very limited physical activity.
If pacemaker becomes dislodged - life threatening. call for help immediatly.
IV line
Thin, flexible catheter inserted with needle into peripheral vein to administer drugs and other fluids. Needle is removed after the catheter is introduced.
IVs most commonly placed in forearm or back of the hand, less commonly in neck, groin or foot.
Some may be disconnected by nursing staff before mobility
maintain drip bag above level of insertion
avoid kinking line
doint use bp cuff on IV arm.
Peripherally inserted central venous line (PICC)
Catheter inserted into vein in upper arm, terminating in heart’s superior vena cava.
Allows long-term administration of medications or fluids
avoid using bp on arm with PICC
Axillary crutches are contraindicated.
ROM of involved extremity is permitted
don’t do bp on that side
Tunnel central venous catheter - Hickman/Broviac
Implanted IV catheter used when long tern required. Inserted under skin on chest, tunneled to jugular or subclavian vein and inserted into heart’s superior vena cava. used for chemotherapy. May remain for weeks or months.
Limited ipsilateral shoulder movements.
avoid using BP cuff on side with insertion into subclavian vein.
Exit site should not be submerged into water until fully healed.
Avoid tissue mobilization at catheter sites.
No manual techniques should be used over access point.
Implantable intravascular device (Port-A-Cath, Mediport)
Implantable venous access system consisting of a small catheter placed into large vein, usually internal jugular, subclavian or femoral vein.
No limits on physical activity once site has healed.
Can be submerged, so aquatic therapy is not limited.
Arterial line
Thin catheter inserted into artery and connected via pressure tubing to transducer.
Directly measures BP, withdraw arterial blood, and deliver medication
Brachial, radial, or femoral artery.
splint used to secure line
Displacement of arterial line causes life threatening emergency.
Adjusting height of bed changes BP reading… alert nurse
If in hip, ROM of hip may be restricted to 60 or 80 degrees.
UE insertion more freedom of movement for out of bed activities.
Pulmonary artery catheterization (PA line, Swan-Ganz catheter)
Used to directly monitor cardiac output.
Multilumen catheter with small inflatable balloon is inserted through a large vein and into the pulmonary artery of heart. Directly measures pressures in heart and pulmonary artery.
Dislodgement is life threatening.
Avoid movement of insertion site.
for jugular insertion, avoid head and neck movement
for subclavian insertion, limit ipsilateral shoulder flexion to 90 degrees. contralateral shoulder movement should also be minimal functional.
For femoral insertion hip flexion may be limited to 70 degrees
Intraosseous (IO) venous access
Accesses systemic circulation through bone marrow cavity
commonly inserted in proximal tibia.
used for infusion of medication or fluids in emergency situations when peripheral access is difficult.
short term 6-12 hours.
should be stabilized to prevent accidental dislodgement during physical activity.
Left Ventricular Assist Device (LVAD)
Mechanical pump attached directly to the left heart ventricle
Pump connects to external control unit via drive line that exits through skin
Battery pack is worn on harness.
Always protect driveline.
Sternal precautions may apply
Monitor exercise tolerance. (weight of battery and compromised cardio. )
Peripheral pulse may not be palpable and BP may not be measurable.
Pulse Oximeter
Externally applied device, commonly attached to the patient’s fingertip or earlobe.
Provides indirect measure of peripheral oxygen saturation.
If oxygen levels fall bellow 90% cease activity.
Blood Pressure Cuff
Inflatable cuff for indirect BP measurement.
When in ICU remains on arm and attached to automatic device that periodically checks BP.
Constriction of the arm by BP cuff may be contraindicated, such as when peripheral IV is inserted in that arm.
Sequential compression device
Sleeves placed on patient’s legs and attached to electronic pump that inflates sleeves. Compression greatest at ankle and decreases proximally.
Helps return venous blood to heart to prevent clots in immobilized patient.
Typically warn in bed but may be worn sitting.
May be removed for mobility.
Usually discontinued when patient is regularly out of bed and ambulatory
Endotracheal tube
Large-diameter flexible breathing tube inserted through mouth into trachea
Connected to ventilator or bag device and secured with tape near insertion.
May have additional attachments such as humidifier.
avoid excess head and neck movement
Functional mobility may be possible even while patient is intubated.
Trecheostomy tube
flexible tube surgically inserted through neck into trachea
Maintains open airway
May have humidified air or something to administer medication
avoid excess head and neck movement.
Functional mobility may be possible while patient is intubated.
Nasal cannula/aerosol mask/reservoir system/nonrebreather mask
external devices providing oxygen to patient
Type of device determined by amount of oxygen flow needed. Nasal cannula low - Nonrebreather high flow.
Oxygen levels in blood may be monitored by pulse oximeter during activity.
Check alignment of nasal cannula to be sure oxygen is entering patient’s nostrils.
Watch for skin irritation where tubing contacts skin.
Be sure portable oxygen tanks are full and battery-operated tanks are charged before use, especiallly when using high flow rates.
Nebulizer
Used to administer medication, such as bronchodilators, via inhaled mist.
May be handheld device with mouthpiece or device attached to respiratory tubing or ventilator.
Patients can respond differently to medications delivered via nebulizer treatments. For some, breathing is easier, improving activity tolerance. Others may become very anxious for a brief time following treatment making activity more challenging.
Ventilator
Machine-assisted breathing device connected to tracheal tubing.
Different ventilation modes determine degree and type of brfeathing assistance provided.
Displacement of ET tube is a life threatening situation.
Monitor for displacemtn by noting insertion level of ET tube before and after mobility activities
Activity may cause alarms to sound. Check with the nursing staff to see whether auditory mode can be slilenced.
Some patients on ventilators can participate in out of bed activities but limited to length of tubing.
NG suction tube
Flexible tube inserted via nasal passages and attached to wall suction device to remove stomach contents.
In some circumstances, tube may be disconnected from suction unit and open end capped during mobility activites.
Nursing staff should be notified when activity is completed
Yankauer suction
Rigid suction tube with hook-shaped end that is connected to wall mounted suction unit.
Used to clear secretions from the mouth.
Mobiltiy activities can increase secretion production, placing patient at higher risk of aspirating secretions. Therfore, oral secretions may be suctioned before activity.
Postoperative surgical drain (hemovac)
Disposable, self-contained postoperative suction device that drains fluid from surgical wound.
Accordian-shaped collection canister can be gently compressed to create suction
Autovac is in canister form with suction created by sqeezing bulb integral to the tubing.
If the cap is not secure it may become disconnected, suction lost, and blood spilt.
Have nursing staff empty drains that are more than half-full to avoid tension on insertion site.
Jackson-Pratt drain
Plastic tubing connected to suction bulb.
Used to drain and collect excess fluid from surgical site.
Can be emptied and contents measured.
Fluid may be serous or bloody.
Removing plug in bulb, squeezing out air, and replacing plug creates suction in drainage tubing.
If the cap is not secure it may become disconnected, suction lost, and blood spilt.
Have nursing staff empty drains that are more than half-full to avoid tension on insertion site.
Chest Tube (CT) pleurovac
Large-bore tube inserted into chest to drain exess fluid or to maintain pulmonary infalation
Suction is created by attachment to wall suction unit or water sealed bedside container.
It is important to maintian integrity of closed sytem by keeping drainage container upright.
Accidental removal of CT may result in pneumothorax - life threatening.
Keep drainage canister below insertion site and vertical at all times. If the canister is accidentally turned on its side, right it immediatly and notify nursing staff.
In some cases, nursing staff may be able to disconnect chest tube from wall suction for mobility. Extended tubing may also provide more mobility.
Intracranial pressure (ICP) monitors
Pressure sensor surgically placed inside skull. Monitors vary in sensor location
Some monitors can drain fluid from intracranial space
HoB 30-45 degrees.
Always contact nursing staff before initiating activity.
Lines may be small and hard to see
The following can increase ICP:
coughing, Valsalva, agitation, pain, noxious stimuli, Trendelenburg position, lateral neck flexion, and extreme hip flexion…Changing bed height.
Ask nurse to relevel transducer when bed height is changed.
Ventricular shunt (ventriculopertoneal or ventriculoatrial)
Tube surgically placed into ventricle of the brain to shunt excess cerbrospinal fluid from brain to jugular vein or abdominal cavity.
Tubing contains valves set at specific pressure leves, permitting fluid to flow out of the brain and not back into it.
First 24 hours bedrest
Mobilty permitted after first 24 hours.
Avoid placing direct pressure over shunt
Severe headaches, nausea, and vomiting upon sitting or standing may indicate abnormal fluid levels and shoudl be reported to nursing staff.
Patient-controlled analgesia (PCA)
Electronically controlled pump that delivers prescribed amount of IV analgesic to patient when patient presses button.
Total amount of medication delivered is controlled electronically to prevent overmedication.
Mobility best timed when patient is alert and pain level is decreased.
A patient who is difficult to rouse or who has difficulty staying alert may be oversedated, which should be reported to nursing staff
Avoid occluding tube by kinking, pinching or compressing.
Older adults experiencing homelessness
higher levels of physical illness including trauma, overexposure in hot and cold weather, sleep deprivation, dehydration, urinary incontinece, infectious disease, uncontrolled diabetes, artthritis, fractures, ciculatory foot problems, and malnutrition.
Standard bed
Has capability of adjusting the HOB and foot of bed up and down. most are electric. Rails are typically on both sides. have wheels that can be locked. hooks.
Turning Frame (stryker Wedge Turning Frame)
patients with spinal cord injuries. allows change from supine to prone without patients moving. patient is literly rotated from supine to prone and back again. Can also do Trendelenburg or reverse Trendelenburg.
Can be repositioned without affecting traction.
Only allows patients up to 250 lbs.
Fluidized Support Beds
Clintron - silicone coated beads in matress that are supported by heated air.
air suspension decreases pressure, friction and shearing forces reducing risk of wounds and helping with wounds.
matress can be punctured easily.
patient can become dehydrated from warm air.
old versions can’t be raised or lowered.
Posttrauma Mobility Beds
RotoRest bed (ARJO)
situated on rotating platform.
patient is strapped in while bed rocks the patient back and forth.
bed can rock 62 degrees in either direction.
prevents upper respiratory complications with immobility.
prevents pressure injuries.
Contraindications: post-cardiac surgery, bronchospoasms, intracranial hypertension, rib fractures.
bed can prevent PT mobilization. (bolsters)
Low air Loss Beds
segmented matress with individually filled air bladders. Each bladder can be contrtolled to patient’s needs.
ideal for pressure injuries as individual areas can have pressure reduced.
HOB and other positions adjustable.
Individual bladders can be replaced.
Can still be punctured.
patients with cervical, thoracic, or lumbar traction or fractures cannot maintain proper alignment in this bed.
Bariatric Beds
Wider longer and made of more heavy duty materials.
54 inches wide and 88 inches long
can hold up to 1200 lbs.
Many offer features to help reposition patients.
