Week 2- ICUAW and Early Mobility Flashcards
ICUAW AND EARLY MOBILITY
ICUAW AND EARLY MOBILITY
Dedades ago __________ was a primary mode of care for trauma and acute and chronic illnesses. What has happened since then?
immobility
-We have improved our understanding of the harm in immobility.
_____-_____ complications arise from immobilization. Complications are easier to ___________ than to treat.
- multi-system
- prevent
Why are patients put on prolonged bed rest in the acute care setting? (2)
- alterations in physiology (i.e. trauma or disease condition)
- abnormal physiologic state of bed rest
Consequences of Bedrest:
- ______ ________ redistribution
- altered distribution of body _______/________
- _________ inactivity
- ________ deconditioning
- fluid volume
- weight/pressure
- muscular
- aerobic
Impaired ________ capacity is directly related to duration of bedrest.
aerobic
Does the rate of cardiovascular decline or musculoskeletal changes occur faster?
cardiovascular (especially in older adults)
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.
- 1-2 weeks
- long-term
- months to years
- “Culture of Mobility”
What are some systems affected by bedrest/immobility?
- Cardiovascular
- Hematologic
- Musculoskeletal
- Neurologic
- Integumentary
- Many Others
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 _________
- VO2Max
- increased, decreased
- tachycardia
- hypovolemia
- pooling
Venous pooling leads to __________ _____________.
orthostatic hypotension
Orthostatic Hypotension:
- decreased ________ position tolerance
- _____volemia
- ____________ reflex dysfunction
- impaired carotid-cardiac baroreflex responses
- impaired vascular vasoconstrictive reserve
- upright
- hypovolemia
- autonomic
- Orthostatic hypotension (OH) can occur within ___ weeks of bedrest (sooner for elderly).
- How is OH characterized?
-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
Do bed exercises decrease effects of orthostatic intolerance? What does this mean?
No, must get them up to help with cardiovascular status.
What does treatment of OH involve?
- Early Mobilization!
- LE exercises to increase blood circulation
- Compression stockings
- Tilt table for very prolonged immobilization or profound ANS issues (SCI)
Does reconditioning or deconditioning take longer?
Reconditioning takes way longer than deconditioning.
Hematologic:
- RBC mass reduction by __-__%. (decreased total blood volume, RBC mass, and plasma volume)
- _________ HCT → increased risk for ______
- Reduced capillarization of peripheral muscle beds → ?
- 5-25%
- elevated HCT → increased risk for DVT
- reduced blood flow to exercising muscles
- 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.
- 3 factors important in the development of venous thromboembolism. (venous stasis, hypercoagulability, blood vessel damage)
- calf and soleus sinus
- length
- Are there clinical signs of DVT?
- What are a few ways to identify DVTs?
- Often no clinical signs (pain and calf tenderness, swelling, redness, positive Homan’s sign)
- Doppler US, contrast venography (gold standard)
- 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?
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)
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.
- DAYS
- antigravity
- UE, LE
- fast twitch
Immobilization in a shortened position enhances ________. Immobilization in lengthened position may decrease loss of muscle fiber proteins.
atrophy
- Are aerobic or anaerobic pathway enzymes decreased?
- What does this lead to?
- aerobic
- early fatigue
With bedrest/immobility, we are also concerned about joint _________. What are some factors contributing to this?
Contractures
- Denervated muscle
- Spasticity
- Improper bed positioning
- Adaptive shortening (cast)
- Disease process
- Elderly
- 2+ joint muscles
What are some treatment options for contractures?
- Early mobilization!
- AROM/PROM, manual stretching
- Modalities
- Splinting
- Hinged casts
- CPM
Patients on bedrest can also develop disuse osteoporosis/osteopenia, what is this?
Bone loss that results from not enough stress or pressure on the bones.
- How quickly can disuse osteopenia occur?
- Is the loss greater in the UE or LE?
- 1 week
- LE
Neurologic:
- _______ and _______ deprivation
- decreased ________, _________, and ________ levels
- depression, restlessness, insomnia
- decreased balance, coordination, and visual acuity
- increased risk of compression neuropathy
- ________ pain threshold
- sensory, sleep
- dopamine, noradrenaline, serotonin
- reduced
Integumentary:
- “Bed sore”; pressure injury (_______ ulcer) are lesions caused by what?
- Where do they usually occur?
- decubitus, caused by unrelieved pressure resulting in damage to underlying tissue
- usually occur over bony prominences
What is the pathogenesis of pressure injuries?
- 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.
With pressure injuries, _______ is key.
PREVENTION (reposition high-risk patient at least every 2 hours)
Respiratory:
- Reduced ______ volumes, _______ rates, respiratory muscle strength, gas exchange.
- ________ position + ________ ________ = diminished vital capacity.
- ___________ respiratory rate.
- Decreased mucociliary _________.
- Increased risk of _________ and ___________.
- ________-________ mismatch.
- lung, airflow
- supine position + prolonged bedrest
- increased
- clearance
- pneumonia and pulmonary embolism
- ventilation-perfusion
- Patients will present with ________ on minimal exertion!
- Closely monitor ___ and ______.
- Use ______ as appropriate.
- dyspnea
- RR and O2sat
- RPE
Metabolic:
- Overall ________ metabolism.
- What are some specific changes when on prolonged bedrest?
-decreased
- Insulin resistance (diabetes risk)
- Plasma and urinary electrolyte concentrations (kidney/urinary stone risk)
- Endocrine function changes (decreased erythropoietin concentration)
What are the thermoregulatory complications associated with bedrest?
-Threshold for vasodilation and sweating are shifted to higher temps leading to increased risk for heat related abnormalities (cramping, fatigue, syncope, heat stroke).
Psychiatric:
- More than __% of patients experience mood alterations during prolonged hospitalizations.
- What are some things that can occur?
- 50%
- anxiety, agitation, delirium, depression
ACQUIRED NEUROMUSCULAR DISORDERS
ACQUIRED NEUROMUSCULAR DISORDERS
- ________________ 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.
- Critical Illness Polyneuropathy (CIP) and Critical Illness Myopathy (CIM)
- CIPNM
Diagnosis of CIP and CIM are ideally confirmed through EMG studies, what is done since this testing is not feasible in the ICU?
-muscle biopsy and examination of phrenic nerve and diaphragm
What is the CIPNM: Medical Research Council Scoring System?
A tool used to identify CIPNM?
- The CIPNM: Medical Research Council Scoring System looks at the strength of what motions?
- How is it graded?
- 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
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.
- acutely
- catabolism, apoptosis
- dose
- elderly, inactive, cancer, nutritional depletion
- fasting and inactivity
What is rhabdomyolysis?
Muscle injury that releases toxins into the bloodstream leading to acute kidney injury.
- In the hospital setting, rhabdomyolysis is associated with muscle _________ and ________ positioning.
- What are some common manifestations of rhabdomyolysis?
- muscle compression, static positioning
- myalgia, pimenturia, elevated creatine kinate (CK) levels, acute renal failure
EARLY MOBILITY
EARLY MOBILITY
- 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.
- cardiovascular
- 1 year
- 11%
What are the criteria for beginning PT in the ICU?
- 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
Pulmonary Parameters Indicating Lack of Readiness for PT Interventions:
- SaO2 = ____% or patient experiences ___% O2 desaturation below resting
- RR = >___ breaths/min
- PEEP >___cm H2O
- FIO2 >/= ___
- 88%, 10%
- 35 breaths/min
- 10cm
- 0.6
Lab Values Indicating Lack of Readiness for PT Interventions:
- HTC = ___%
- Hgb = ___-___
- 25%
- 8g/dl
- 20,000
- 2.4-3.0
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
- <65 or >120mmHg
- <50 or >140 bpm
- <90 or >200 mmHg
- arrhythmia
- angina
Metabolic Measures Indicating Lack of Readiness for PT Interventions:
-Glucose levels ____ mg/dL
-<70 or >200 mg/dL
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
- mortality
- CIP and CIM
- 18 hours
- breathing
What are some tests/measures useful for mobility?
- FIM
- PFIT
- FSS-ICU
- ACIF
- AM-PAC “6-Clicks”
What are some intervention strategies for the following?
- Respiratory
- ROM
- Patient Education
- Functional Mobility Training
- Exercise Prescription
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
It is important to create a “_______ of _________”
Culture of Mobility
