Week 2: Evaluation of critically ill pt in the ICU

What is progressive mobility in ICU?

A step by step progression of activity from bed mobility to mobility outside of the bed.

What is the goal of progressive mobility?

To maintain the highest level of physical activity the patient can perform and prevent complications from immobility.

What complications can arise from immobility?

Muscle weakness, pneumonia, skin breakdown.

When does progressive mobility begin?

As soon as the patient is awake and can engage in activity.

Steps of progressive mobility

-Bed rest: turn side to side

-Supine exercises in bed

-Bed mobility: able to move self around in bed

-Dangle legs at bedside

-Stand and get out of bed to a chair

-Walks in the room

-Walks out of the room to the hallway

What should be ensured when standing a patient out of bed?

Grippy socks and gait belt should be used.

O2 switching

-Therapists can keep oxygen above 90% by titrating it

-Ensure at least 1000 in O2 tank→switch it on and attach cannula or non-rebreather on the tank then place on the pt

-Simple mask:6-8Ls

-Non-rebreather: used if pt on ≥10Ls

What is the importance of telemetry in ICU?

It monitors EKG, heart rate, blood pressure, and respiratory rate.

What other factors should PTs consider when reviewing a patient's lab results and making clinical decisions about PT intervention?

-Electrolyte panels might change with intravenous infusions, medications, and diet.

-Cardiac biomarkers

-Acute vs chronic conditions

-Genetic culture and race considerations

-Age

electorlyte panels need to be aware of

-The time the lab was drawn

-Possible drug interactions

-recent meals

cardiac biomarkers

-chemicals are measured in the blood as evidence of a heart attack

-Biomarker to look for: troponin

Race considerations for labs

-sickle cell more prevalent with sub-saharan african ancestry

-Genetic heterogeneity can create differences in the reactivity of a person's DNA, proteins or cells toward nucleic acid probes and antibodies used in reagents creating possible false negatives

-Racial differences in serum creatine kinase and lactate dehydrogenase in adults and serum alkaline phosphatase in children are noted along with higher levels of total protein, serum alpha, beta and gamma globulins, IgD and IgA noted in african americans compared to caucasians

-African americans tend to have lower hemoglobin values than caucasians and

sex considerations for labs

-Reference ranges for age and sex specific values

-Need to consider biological sex/gender to get normal values

-Need to determine if pt is still under treatment if transitioning

-If undergoing HRT, use the transitioned gender to determine reference value

Sequential compression devices

Devices to prevent blood clots in immobile patients.

What is the reference value for WBC?

5.0-10.0 10^9/L.

What does leukocytosis indicate?

A WBC trending up >11.0 10^9/L.

What symptoms may present with leukocytosis?

Fever, malaise, lethargy, dizziness, bruising, weight loss, inflamed joints.

How do acute and chronic conditions differ in lab value response?

Acute conditions may require more conservative care, while chronic conditions may require more time to adapt.

What is the significance of genetic culture in lab values?

Genetic heterogeneity can create differences in reactivity toward nucleic acid probes and antibodies.

Leukocytosis implications

With fever. Consider timing of therapy d/t early morning low level and later afternoon high peak

What is the lab value for leukopenia?

<4.0 10^9/L

What are the symptoms of leukopenia?

Anemia, weakness, fatigue, fever, headache, SOB

What is the value for neutropenia?

<1.5 10^9/L

What are the symptoms of neutropenia?

Low grade fever, skin abscesses, sore mouth, symptoms of pneumonia

implications for neutropenia

What is considered thrombocytosis?

>450 k/uL

What are the symptoms of thrombocytosis?

Weakness, headache, dizziness, chest pain, tingling in hands

thrombcytosis implications

elevated levels can lead to VTE

What is considered thrombocytopenia?

What are the symptoms of thrombocytopenia?

Petechia, ecchymosis, fatigue, jaundice, splenomegaly, risk for bleeding

thrombocytopenia PT implications

-watch for tendency of bleeding

-avoid aspirin or aspirin-containing compounds (blood thinner)

-avoid strenuous exercise

-avoid excessive pressure on soft tissue

-practice good infection control

Hemoglobin reference values

-Male: 14-17.4 g/dL

-Female: 12-16 g/dL

What is the low critical value for hemoglobin in men?

<5.0-7.0 g/dL

What are the implications of low hemoglobin levels?

-Risk of poor perfusion and stress to heart; monitor signs and symptoms.

-Monitor signs and symptoms when determining appropriateness for activity

-Dizziness and pallor

if hemoglobin < 8.0

hold exercise

hemoglin of < 5-7 g/dL) can lead

to heart failure or death.

What is the high critical value for hemoglobin? [polycythemia]

>20 g/dL

What are the symptoms of high hemoglobin levels?

Orthostasis, presyncope, dizziness, arrhythmias, CHF onset/exacerbation, seizure, symptoms of TIA, symptoms of MI, angina

What is the normal range for hematocrit

-Men: 42-52%

-Women: 37-47%

What is the low critical value for hematocrit?

What are the symptoms of low hematocrit levels?

Pale skin, headache, dizziness, cold hands/feet, chest pain, arrhythmia, shortness of breath.

high hematocrit (polycytemia)

> 60% -spontaneous blood clotting

high hematocrit (polycytemia) presentation

Fever

Headache

Dizziness

Weakness

Fatigue

Easy bruising or

bleeding

when to consult for hematocrit levels

<25%

What is the normal range for sodium?

136-145 mEq/L

What is hypernatremia?

Na+ > 150 mEq/L.

What are the symptoms of hypernatremia?

Irritability, agitation, seizure, coma, hypotension, tachycardia, weak pulse, decreased urine output.

What is hyponatremia?

Na+ < 135 mEq/L.

What are the symptoms of hyponatremia?

Headache, lethargy, decreased reflexes, nausea, vomiting, diarrhea, seizure, coma, orthostatic hypotension, pitting edema.

What is the normal range for potassium?

3.5-5.0 mEq/L.

What is hyperkalemia?

K+ > 5.3 mEq/L.

What are the symptoms of hyperkalemia?

Muscle weakness/paralysis

Paresthesia

Bradycardia

Heart Block

V-fib

Cardiac Arrest

What is hypokalemia?

K+ < 3.0 mEq/L.

What are the symptoms of hypokalemia?

Extremity weakness, hyporeflexia, paresthesia, leg cramps, ECG changes, ST depression, inverted Ts, cardiac arrest, hypotension, constipation.

What is the normal range for calcium?

9-10.5 mg/dL.

What is hypercalcemia?

Ca+ > 11 mg/dL.

What are the symptoms of hypercalcemia?

Ventricular dysrhythmias

Heart block

Asystole

Coma

Lethargy

Muscle weakness

Decreased reflexes

Constipation

Nausea/vomiting

What is hypocalcemia?

Ca++ < 8.5 mg/dL.

What are the symptoms of hypocalcemia?

Anxiety

Confusion

Agitation

Seizure

Prolonged QT interval

Fatigue

Numbness/tingling

Hyperreflexia

Muscle cramps

What is the normal range for phosphate?

3-4.5.

What is hypophosphatemia?

<2.4 mg/dL

What is hyperphosphatemia?

>4.8 mg/dL.

What is the normal range for chloride?

98-106 mEq/L.

What is hyperchloremia?

>110 mEq/L.

What are the symptoms of hyperchloremia?

Lethargy

Decreases level of consciousness

Weakness

Edema

Tachypnea

HTN

Tachycardia

What is hypochloremia?

What are the symptoms of hypochloremia?

Agitation

Irritability

Hypertonicity

Hyperreflexia

Cramping

Twitching

What is the normal range for magnesium?

1.3-3.1.

What is hypermagnesemia?

>2.7 mEq/L.

What are the symptoms of hypermagnesemia?

Diaphoresis

Nausea/vomiting

Drowsiness

Lethargy

Weakness/flaccidity

Decreased DTR

Hypotension

Heart block

What is hypomagnesemia?

<1.8 mEq/L

What are the symptoms of hypomagnesemia?

Hyperreflexia

Tremors

Spasticity

Seizures

Nystagmus

Prolonged PR/QT intervals

PVC, VTach, VFib

Emotional lability

What is the normal range for BUN?

10-20 mg/dL.

What does an elevated BUN indicate?

High protein diet, renal failure, hypovolemia, CHF, GI bleed, fever, increased protein catabolism.

What does a low BUN indicate?

Liver disease.

What is the normal range for creatinine?

0.9-1.3 mg/dL.

What does an increased creatinine level indicate?

Renal disease, muscular dystrophy, myasthenia gravis, rhabdomyolysis, dehydration.

What is the normal fasting blood glucose level?

70-100 mg/dL.

Criteria for diagnosis of Diabetes

-FPG >126 mg/dLOR

-2 hour Plasma Glucose >200 mg/dL

What is considered hyperglycemia?

>200 mg/dL.

What are the causes of hyperglycemia?

Diabetes mellitus, sepsis, brain tumors, certain medications, high dose steroids, IV glucose, Cushing's disease, pancreatitis.

What are the symptoms of hyperglycemia?

DKA, severe fatigue.

What is considered hypoglycemia?

<70 mg/dL

What are the causes of hypoglycemia?

Excess insulin, brain injury, pituitary deficiency, malignancy, Addison's disease, benign insulin-producing tumor, starvation.

What are the symptoms of hypoglycemia?

Headache, fatigue, lethargy, hunger, tachycardia, irritability, shaking/tremor, extremity weakness, sweating, anxiety/confusion, loss of consciousness.

What is the recommended glucose target for most patients in noncritical care units while hospitalized?

140-180 mg/dL.

What are the clinical signs of untreated or uncontrolled diabetes?

Polyuria, polydipsia, polyphagia, weight loss, hyperglycemia, glycosuria, ketonuria, fatigue, weakness, blurred vision, poor wound healing, recurrent infections.

What does an HgbA1C test measure?

It measures long-term blood glucose levels, reflecting average levels over the past 2-3 months.

What are the HgbA1C levels for normal, pre-diabetes, and diabetes?

-Normal: < 5.7%

-Pre-diabetes: 5.7-6.4%

-Diabetes: > 6.5%.

What are common complications of diabetes mellitus?

Eye disease, heart disease, kidney disease, nerve damage, stroke, gum disease, non-traumatic amputations.

What are the symptoms of respiratory alkalosis?

-Dizziness, paresthesia, chest pain, confusion, seizure.

-ph≥7.45

-PaCO2 ≤35

respiratory acidosis?

-pH ≤ 7.35

-PaCO2 ≥ 45 mmHg

-Presentation: Confusion Fatigue and/or lethargy, SOB, Somnolence

-Implications: May need to coordinate treatments around ventilation. Expect somnolence and fatigue.

What are the implications of metabolic acidosis?

May need to coordinate mobility around dialysis; risk of arrhythmias with mobility.

Metabolic Alkalosis

-pH ≥ 7.45

-HCO3 ≥ 30 mmol/L

Metabolic Acidosis

-pH ≤ 7.35

-HCO3 < 24 mmol/L

Metabolic Acidosis Implications

-May need to coordinate mobility around

dialysis (CVVHD vs HD).

-Expect increased fatigue levels/somnolence.

-Consider risk of arrhythmias with mobility.

What is the normal range for serum albumin?

3.5-5.2 g/dL.

serum albumin implications

-Assess integumentary daily

-Collaborate with the interprofessional team regarding nutrition

- < 3.0 g/dL nutritionally compromised; < 2.8 g/dL generalized symmetrical peripheral edema, poor wound healing, potential drug toxicity

Serum prealbumin range

19-39 mg/dL13

Serum prealbumin range scores

-0-5 mg/dL = severe protein depletion

-5-10 mg/dL = moderate protein depletion

-10-15 mg/dL (mild protein depletion)