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S4- Acute Care > Week 2- ICUAW and Early Mobility > Flashcards

Week 2- ICUAW and Early Mobility Flashcards

1
Q

ICUAW AND EARLY MOBILITY

A

ICUAW AND EARLY MOBILITY

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2
Q

Dedades ago __________ was a primary mode of care for trauma and acute and chronic illnesses. What has happened since then?

A

immobility

-We have improved our understanding of the harm in immobility.

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3
Q

_____-_____ complications arise from immobilization. Complications are easier to ___________ than to treat.

A
  • multi-system

- prevent

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4
Q

Why are patients put on prolonged bed rest in the acute care setting? (2)

A
  • alterations in physiology (i.e. trauma or disease condition)
  • abnormal physiologic state of bed rest
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5
Q

Consequences of Bedrest:

  • ______ ________ redistribution
  • altered distribution of body _______/________
  • _________ inactivity
  • ________ deconditioning
A
  • fluid volume
  • weight/pressure
  • muscular
  • aerobic
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6
Q

Impaired ________ capacity is directly related to duration of bedrest.

A

aerobic

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7
Q

Does the rate of cardiovascular decline or musculoskeletal changes occur faster?

A

cardiovascular (especially in older adults)

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8
Q

Prolonged Bedrest:
-Metabolic and exercise capacity significantly reduced after __-__ weeks of bed rest.
Survivors of ICU admission experience significant ____-_____ morbidities.
Impairments and limitations often persist _______ to ________ after ICU discharge.
Early mobility in acute care setting may be limited by lack of knowledge and/or protocol.
Physical therapists must establish “________ of _________” in acute care units.

A
  • 1-2 weeks
  • long-term
  • months to years
  • “Culture of Mobility”
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9
Q

What are some systems affected by bedrest/immobility?

A
  • Cardiovascular
  • Hematologic
  • Musculoskeletal
  • Neurologic
  • Integumentary
  • Many Others
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10
Q

Cardiovascular Changes Due to Bedrest:

  • reduced _______
  • _______ resting HR and ________ CO
  • Reduced cardiac vagal tone, increased plasma norepinephrine, enhanced beta-adrenergic receptor sensitivity → resting ____________
  • ______volemia
  • increased venous compliance → venous _________
A
  • VO2Max
  • increased, decreased
  • tachycardia
  • hypovolemia
  • pooling
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11
Q

Venous pooling leads to __________ _____________.

A

orthostatic hypotension

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12
Q

Orthostatic Hypotension:

  • decreased ________ position tolerance
  • _____volemia
  • ____________ reflex dysfunction
  • impaired carotid-cardiac baroreflex responses
  • impaired vascular vasoconstrictive reserve
A
  • upright
  • hypovolemia
  • autonomic
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13
Q
  • Orthostatic hypotension (OH) can occur within ___ weeks of bedrest (sooner for elderly).
  • How is OH characterized?
A

-3 weeks

  • Characterized by drop in BP during a change in position (supine→sitting→standing)
  • Drop of more than 20 SBP and 10 DBP accompanied by 10-20% increase in HR
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14
Q

Do bed exercises decrease effects of orthostatic intolerance? What does this mean?

A

No, must get them up to help with cardiovascular status.

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15
Q

What does treatment of OH involve?

A
  • Early Mobilization!
  • LE exercises to increase blood circulation
  • Compression stockings
  • Tilt table for very prolonged immobilization or profound ANS issues (SCI)
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16
Q

Does reconditioning or deconditioning take longer?

A

Reconditioning takes way longer than deconditioning.

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17
Q

Hematologic:

  • RBC mass reduction by __-__%. (decreased total blood volume, RBC mass, and plasma volume)
  • _________ HCT → increased risk for ______
  • Reduced capillarization of peripheral muscle beds → ?
A
  • 5-25%
  • elevated HCT → increased risk for DVT
  • reduced blood flow to exercising muscles
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18
Q
  • Patients on bedrest develop 2/3 of Virchows Triad, what is this?
  • What is the primary site of DVT?
  • _______ of bedrest is directly related to frequency of DVT.
A
  • 3 factors important in the development of venous thromboembolism. (venous stasis, hypercoagulability, blood vessel damage)
  • calf and soleus sinus
  • length
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19
Q
  • Are there clinical signs of DVT?

- What are a few ways to identify DVTs?

A
  • Often no clinical signs (pain and calf tenderness, swelling, redness, positive Homan’s sign)
  • Doppler US, contrast venography (gold standard)
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20
Q
  • What are some treatment methods use to combat hematologic changes due to bedrest?
  • What are some prophylactic methods use to combat hematologic changes due to bedrest?
  • What are some pharmacology methods use to combat hematologic changes due to bedrest?
A

Treatment

  • early ambulation, LE exercise
  • compressive stockings
  • leg elevation

Prophylactic methods

  • low-dose heparin
  • intermittent pneumatic compression

Pharmacology

  • Unfractionated Heparin (Warfarin (Coumadin))
  • Low Molecular Weight Heparin (LMWH) (Lovenox)
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21
Q

Musculoskeletal:

  • Adaptations to decreased loading occurs within ______ of immobility.
  • Atrophy occurs greatest in _________ muscles.
  • ____ strength is somewhat spared in comparison to ___ atrophy.
  • Changes in muscle fibers such as decreased size and Type IIB (_____ twitch) more affected than type I and type IIA.
A
  • DAYS
  • antigravity
  • UE, LE
  • fast twitch
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22
Q

Immobilization in a shortened position enhances ________. Immobilization in lengthened position may decrease loss of muscle fiber proteins.

A

atrophy

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23
Q
  • Are aerobic or anaerobic pathway enzymes decreased?

- What does this lead to?

A
  • aerobic

- early fatigue

24
Q

With bedrest/immobility, we are also concerned about joint _________. What are some factors contributing to this?

A

Contractures

  • Denervated muscle
  • Spasticity
  • Improper bed positioning
  • Adaptive shortening (cast)
  • Disease process
  • Elderly
  • 2+ joint muscles
25
Q

What are some treatment options for contractures?

A
  • Early mobilization!
  • AROM/PROM, manual stretching
  • Modalities
  • Splinting
  • Hinged casts
  • CPM
26
Q

Patients on bedrest can also develop disuse osteoporosis/osteopenia, what is this?

A

Bone loss that results from not enough stress or pressure on the bones.

27
Q
  • How quickly can disuse osteopenia occur?

- Is the loss greater in the UE or LE?

A
  • 1 week

- LE

28
Q

Neurologic:

  • _______ and _______ deprivation
  • decreased ________, _________, and ________ levels
  • depression, restlessness, insomnia
  • decreased balance, coordination, and visual acuity
  • increased risk of compression neuropathy
  • ________ pain threshold
A
  • sensory, sleep
  • dopamine, noradrenaline, serotonin
  • reduced
29
Q

Integumentary:

  • “Bed sore”; pressure injury (_______ ulcer) are lesions caused by what?
  • Where do they usually occur?
A
  • decubitus, caused by unrelieved pressure resulting in damage to underlying tissue
  • usually occur over bony prominences
30
Q

What is the pathogenesis of pressure injuries?

A
  • Pressure causes ischemia.
  • Excessive pressure can lead to tissue necrosis.
  • If pressure relieved, we see temporary reactive hyperemia and no tissue damage.
  • If it is NON-BLANCHABLE ERYTHEMA (STAGE 1), then damage has begun.
31
Q

With pressure injuries, _______ is key.

A

PREVENTION (reposition high-risk patient at least every 2 hours)

32
Q

Respiratory:

  • Reduced ______ volumes, _______ rates, respiratory muscle strength, gas exchange.
  • ________ position + ________ ________ = diminished vital capacity.
  • ___________ respiratory rate.
  • Decreased mucociliary _________.
  • Increased risk of _________ and ___________.
  • ________-________ mismatch.
A
  • lung, airflow
  • supine position + prolonged bedrest
  • increased
  • clearance
  • pneumonia and pulmonary embolism
  • ventilation-perfusion
33
Q
  • Patients will present with ________ on minimal exertion!
  • Closely monitor ___ and ______.
  • Use ______ as appropriate.
A
  • dyspnea
  • RR and O2sat
  • RPE
34
Q

Metabolic:

  • Overall ________ metabolism.
  • What are some specific changes when on prolonged bedrest?
A

-decreased

  • Insulin resistance (diabetes risk)
  • Plasma and urinary electrolyte concentrations (kidney/urinary stone risk)
  • Endocrine function changes (decreased erythropoietin concentration)
35
Q

What are the thermoregulatory complications associated with bedrest?

A

-Threshold for vasodilation and sweating are shifted to higher temps leading to increased risk for heat related abnormalities (cramping, fatigue, syncope, heat stroke).

36
Q

Psychiatric:

  • More than __% of patients experience mood alterations during prolonged hospitalizations.
  • What are some things that can occur?
A
  • 50%

- anxiety, agitation, delirium, depression

37
Q

ACQUIRED NEUROMUSCULAR DISORDERS

A

ACQUIRED NEUROMUSCULAR DISORDERS

38
Q
  • ________________ and ___________ are overlapping syndromes of diffuse, symmetric, flaccid muscle weakness occurring in critically ill patients and involving all extremities and the diaphragm with relative sparing of the cranial nerves.
  • It is very common that patients exhibit _______, a mixed finding of CIP and CIM.
A
  • Critical Illness Polyneuropathy (CIP) and Critical Illness Myopathy (CIM)
  • CIPNM
39
Q

Diagnosis of CIP and CIM are ideally confirmed through EMG studies, what is done since this testing is not feasible in the ICU?

A

-muscle biopsy and examination of phrenic nerve and diaphragm

40
Q

What is the CIPNM: Medical Research Council Scoring System?

A

A tool used to identify CIPNM?

41
Q
  • The CIPNM: Medical Research Council Scoring System looks at the strength of what motions?
  • How is it graded?
A
  • shoulder abduction, elbow flexion, wrist extension, hip flexion, knee extension, ankle DF (L and R)
  • MMT (0-60 grading), <48 = significant weakness, <36 = severe weakness
42
Q

Steroid Induced Myopathy:

  • Occurs ________ or from chronic glucocorticoid maintenance therapy.
  • Steroids induce muscle ________ and myocyte __________ leading to atrophy of type 2 muscle fibers (proximal muscles most affected).
  • _____ dependent relationship with myopathy.
  • Who is at greater risk for steroid induced myopathy?
  • _______ and ___________ worsen myopathy.
A
  • acutely
  • catabolism, apoptosis
  • dose
  • elderly, inactive, cancer, nutritional depletion
  • fasting and inactivity
43
Q

What is rhabdomyolysis?

A

Muscle injury that releases toxins into the bloodstream leading to acute kidney injury.

44
Q
  • In the hospital setting, rhabdomyolysis is associated with muscle _________ and ________ positioning.
  • What are some common manifestations of rhabdomyolysis?
A
  • muscle compression, static positioning

- myalgia, pimenturia, elevated creatine kinate (CK) levels, acute renal failure

45
Q

EARLY MOBILITY

A

EARLY MOBILITY

46
Q
  • Immobility has long-standing deleterious effects.
  • Immobility itself leads to further medical complications, especially __________ compromise.
  • Half of patients in ICU unable to return to work __ year after D/C due to weakness and fatigue.
  • Patients in ICU spend as little at ___% of time participating in activities.
A
  • cardiovascular
  • 1 year
  • 11%
47
Q

What are the criteria for beginning PT in the ICU?

A
  • balance benefits/risks of mobility
  • examine lab values and other info about pt’s hemodynamic state
  • gain MD consent
  • ICUAW: can begin activities upon achieving medical stability to allow for increased vascular and oxygen demands of PT eval and treatment
48
Q

Pulmonary Parameters Indicating Lack of Readiness for PT Interventions:

  • SaO2 = ____% or patient experiences ___% O2 desaturation below resting
  • RR = >___ breaths/min
  • PEEP >___cm H2O
  • FIO2 >/= ___
A
  • 88%, 10%
  • 35 breaths/min
  • 10cm
  • 0.6
49
Q

Lab Values Indicating Lack of Readiness for PT Interventions:

  • HTC = ___%
  • Hgb = ___-___
A
  • 25%
  • 8g/dl
  • 20,000
  • 2.4-3.0
50
Q

Cardiovascular Measures Indicating Lack of Readiness for PT Interventions:

  • Mean Arterial Pressure (MAP) _____mmHg or >/=10mmHg lower than normal SBP or DBP for patients recieving renal dialysis
  • Resting HR ___ bpm
  • SBP ____mmHg
  • New __________ developed
  • New onset ______-type chest pain
A
  • <65 or >120mmHg
  • <50 or >140 bpm
  • <90 or >200 mmHg
  • arrhythmia
  • angina
51
Q

Metabolic Measures Indicating Lack of Readiness for PT Interventions:
-Glucose levels ____ mg/dL

A

-<70 or >200 mg/dL

52
Q

Body Structure and Function: What Do I Measure?
Strength
-MMT
-Grip strength: associated with increased risk of ________ and loss of independence.

DTRs

  • ____ and ____ associated with altered reflexes
  • Deconditioning vs ICUAW

Respiratory Status

  • Diaphragm atrophy can occur within ____ hours of mechanical ventilation.
  • ________ patterns
  • cough effectiveness
  • MIP and MEP

Sensory Status
-Provides info on postural control

A
  • mortality
  • CIP and CIM
  • 18 hours
  • breathing
53
Q

What are some tests/measures useful for mobility?

A
  • FIM
  • PFIT
  • FSS-ICU
  • ACIF
  • AM-PAC “6-Clicks”
54
Q

What are some intervention strategies for the following?

  • Respiratory
  • ROM
  • Patient Education
  • Functional Mobility Training
  • Exercise Prescription
A

Respiratory

  • costophrenic assisted coughing
  • pursed-lip breathing
  • diaphragmatic breathing

ROM
-PROM, AAROM, AROM, RROM, PNF

Patient Education

  • safety awareness/falls prevention
  • energy conservation
  • compensatory strategies

Functional Mobility Training

  • bed mobility
  • transfer training
  • balance
  • gait/stairs

Exercise Prescription

  • exercise intensity depends on pt tolerance
  • Borg RPE
  • consider importance of upright positioning
55
Q

It is important to create a “_______ of _________”

A

Culture of Mobility

S4- Acute Care (15 decks)

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