Week2 6671/6611 Flashcards
Moderate exercise
___ METS
3-6 METS
Congestive heart failure
S/S
Engorgement and distention of jugular veins
Increased fluid retention:
Weight gain
Dependent putting edema
Increased fatigue w/ activity
Parameters indicating lack of readiness for PT (ICU-AW)-
Pulmonary
SaO2 < 88% OR 10% desaturation below resting SaO2
RR > 35 breaths/min
PEEP > 10 cm H2O
FiO2 => 0.6
Factors affecting heart rate-
Gender
Males < Females
Medical clearance and exercise testing- screening
Low/Mod/High Risk?
Low:
Men < 45, Women < 55
Only 1 risk factor and no symptoms
Moderate:
Men => 45, Women =>55
2 or more risk factors
High:
Known CV, pulmonary or metabolic disorders, or s/s of CV disease (SOB at rest/mild exertion; syncope; ankle edema; palpitations)
Moderate risk and vigorous exercise or High risk = physician supervised testing
Becks anxiety scoring
0-21 low
22-35 moderate
36+ high/concerning
Normal adult resting breathing rate
10-20 breaths/min
Bradypnea
Rate < 12 breaths/min (adult)
Parameters indicating lack of readiness for PT (ICU-AW)
Metabolic measures
Glucose levels <70 or >200 mg/dL
Factors related to dysrhythmias (8)
- Ischemia/hypoxia of myocardium
- Sympathetic discharge (anxiety; exercise)
- Acidosis
- Alterations in electrolytes (decrease K+)
- Excessive stretch of myocardium (ie. CHF)
- Pharmacologic agents
- Sympathomimetics (caffeine; anti arrhythmia drugs; digitalis)
CIP/CIM (critical illness polyneuropathy/myopathy)
Pathogenesis
Circulatory, cellular level, and metabolic changes
Impaired O2 delivery-total body microcirculatory issues
Impaired mitochondrial function- reduced ATP, energy production
Diaphragmatic weakness from ventilation (combined sedation)
Immobility- muscle wasting
Pulse Assessment Scale 0-3
0 : absent
1 : weak, thread
2 : normal
3 : full, bounding
CIP/CIM (critical illness polyneuropathy/myopathy)
Dx
Weaning difficultly Clinical presentation Imaging Labs Tissue studies
CIP/CIM (critical illness polyneuropathy/myopathy)
Prognosis
Not great: 22% die in hospital; 33% die w/in 6 mo
Institutionalization
The younger, the better
Dyspnea
Labored or difficult breathing
Tachypnea
Rate > 20 breaths per minute (adult)
Do NOT mobilize the critically ill patient if…?
- Standard contraindication and precaution
- New onset of cardiac arrhythmias or s/s of MI
- New additions or adjustments to vasoactive medications
- Intermittent hemodialysis
- Intra-aortic balloon pump
Multi Organ Dysfunction Syndrome (MODS)
Progressive failure of 2 or more organ systems over 24 hours
Typically a complication of critical illness
Hypopnea
Normal respiratory rate but decreased volume
Factors affecting heart rate-
Environmental
Core temperature
Hydration
Medical clearance and exercise testing- Low/Mod/High Risk screening
Risk factors?
- Family hx of CV disease (before age 55 in father or first-degree male relative; before 65 in mother or first-degree female relative)
- Smoking (current or quit w/in 6 mo)
- HTN (SBP => 140; DBP => 90; or in HTN rx)
- Dyslipidemua (LDL > 130, HDL < 40; total cholesterol > 200)
- Fasting glucose => 100 on 2 separate occasions
- Obesity (BMI > 30)
- Sedentary lifestyle
7 sites for pulses
- Radial
- Brachial
- Carotid
- Femoral
- Temporal
- Popliteal
- Posterior tibial artery
Factors affecting heart rate-
Age
Higher- infants
Lower- age >65
Multi Organ Dysfunction Syndrome (MODS)
Medical management
Prevention and early detection
Pharmacologic: antibiotics, inotropic agents
Supplemental O2 and ventilation
Fluid replacement and nutritional support
Prognosis 60-90% mortality, approaching 100% with 3 or more organ involvement and sepsis plus > 65 y/o
Parameters indicating lack of readiness for PT (ICU-AW)-
CV measures?
Mean arterial pressure < 65 or > 120 mmHg
OR => 10 mmHg lower than normal SBP or DBP for pts renal dialysis
RHR <50 or >140 bpm
SBP <90 or >200 mmHg
New arrhythmia
New onset angina-Type chest pain
S/S hypo or hyper tension
HA (usually occipital and present in am)
Vertigo
Flushed face
Spontaneous epistaxis (nose bleed)
Blurred vision
Nocturnal urinary frequency
Multi Organ Dysfunction Syndrome (MODS)
Clinical presentation
Low grade fever Tachycardia Dyspnea Systemic inflammatory response Altered mental status
Lungs typically first organ to fail- leading to ARDS
Followed by GI bacteremia, liver and kidney failure
Ultimately CV collapse can occur
Vigorous exercise
___ METS or ___% VO2max
6 METS
> 60% VO2max
Classic cardiac symptoms of decompensation
Angina
Palpitations
Dyspnea or SOB
Fatigue
Orthostatic hypotension
Symptoms and Management
Lightheadedness
Rubbery legs
Feelings of syncope
Sit/Lie down
Ankle pumps
Notify medical personnel as needed
Discontinue standing activities
Factors affecting heart rate-
Medications
Beta-blockers
Calcium channel blockers/Beta-receptor stimulators
Chemicals- caffeine
Hormones- thyroid
Hyperpnea
Normal respiratory rate but increased volume
Multi Organ Dysfunction Syndrome (MODS)
Physical therapy management
Usually only seen in critical care or burn unit
Severe protein catabolism of skeletal muscle
Lean body mass depleted
Need skin precautions and skincare
Risk often outweighs benefits
Very little in literature
Parameters indicating lack of readiness for PT (ICU-AW)-
Lab values
No exercise:
Hematocrit < 25%
Hemoglobin < 8 g/dL
Platelets < 20,000/mm
If INR => 2.5-3.0 discuss w/ physician
Dyspnea scale
Inhale normally and count to 15 out loud
Level 0: single breath Level 1: requires 2 breaths Level 2: requires 3 breaths Level 3: requires 4 breaths Level 4: unable to count
CIP/CIM (critical illness polyneuropathy/myopathy)
Key finding
Muscle weakness:
Often rapid onset;
Failure to wean from mechanical ventilation;
Motor and sensory impairment:
CIP: Symmetrical, distal and diaphragm more impacted than proximal
CIM: Symmetrical, motor only, proximal more than distal
Critical illness and PT
Prevent and treat
Early rehab (in ICU- sedation must be controlled)
Focus on functional limitations, respiratory capacity and cardiac reserve
Facilitate communication
Risk vs benefit
Classic cardiac signs of decompensation
Dysrhythmias Syncope Dyspnea or SOB Dependent edema Hemoptysis Cyanosis
Hypoventilation
Decreased rate and volume
Cheyne-Stokes
Hyperventilation followed by hypoventilation, then apnea, with cycle repeating
Multi Organ Dysfunction Syndrome (MODS)
Causes?
Most commonly sepsis, but infection not required
Also caused by ARDS (Acute respiratory distress syndrome), severe inflammatory processes, shock, and traumatic injury
BMI
< 18.5 underweight 18.5-24.9 normal 25-29.9 over weight 30-34.9 obese I 35-39.9 obese II > 40 obese III
Apnea
No breathing
Patient with lung disease
Therapist should stop activity if?
- SaO2 decreases by 5% or more of resting value
- SaO2 =< 88% in patients with R side heart failure
- SaO2 < 80% in patients with lung disease
Patients with lung disease SaO2 < 88% use supplemental O2
Factors affecting heart rate-
Pathology
Anemia
Congestive heart failure
Autonomic dysfunction (SCI, DM, Fever)
Pulse Assessment Scale 0-4
0- absent 1- markedly reduced 2- slightly reduced 3- normal 4- bounding
BP- medical emergency
No BP
Extremely low BP
BP > 200/110 at rest
CIP vs CIM (critical illness polyneuropathy vs myopathy)
Key distinguishing feature/ finding
Motor and sensory impairment:
CIP: Symmetrical, distal and diaphragm more impacted than proximal
CIM: Symmetrical, motor only, proximal more than distal
SaO2 or SpO2 < 90%
Stop performing physical activity Check device is on properly Retake measurement with pt still Notify medical personnel if measurement valid Continue to monitor pt
Orthopnea
Difficulty breathing while horizontal, with ease of breathing with vertical positioning
Parameters indicating lack of readiness for PT (ICU-AW)
- Pulmonary
- CV
- Lab values
- Metabolic measures
If these are ok-
5. Cognition? (Able to follow directions)
Hyperventilation
Increased rate and volume
CIP/CIM (critical illness polyneuropathy/myopathy)
Prevention
Blood glucose control
Electrolyte and nutritional balance
Accelerated ventilation weaning
