PE unit 4: ICU and long term care hospital

what are the 4 key features of an ICU

specialized equipment

highly trained staff

comprehensive monitoring

support for multiple organ systems

who is the ICU designed for

patients who may be experiencing failure or sever impairment of one or more organ systems

what is the typical nurse ratio for patients in the ICU

usually 1:1

what is a level 1 ICU

provides basic intensive care and monitors patients with a lower acuity of illness

what is a level 2 ICU

offers a higher level of monitoring and intervention for more critically ill intervention

what is a level 3 ICU

equipped to have the highest level of intensive care such as advanced like support and management of complex and severe conditions

BWICU

burn wound intensive care unit

CCU

coronary (cardiac) care unit or critical care unit

CSICU

cardiac surgery intensive care unit

CVICU

cardiovascular ICU

ER/ED

emergency room/emergency department

GICU

geriatric ICU

MICU

medical ICU or mobile ICU

MSICU

medical surgical ICU

NCU

Neurological ICU or Neonatal ICU

OHRU

open heart recovery unit

OIR

overnight intensive recovery

PACU

post anesthesia care unit

PICU

pediatric ICU or Psychiatric ICU

RICU

respiratory ICU

SCN

special care nursery

SICU

surgical ICU

STICU

surgical trauma ICU

TICU

trauma ICU

TNCC

trauma neruointensive care unit

how often do intensivists see the patients in the ICU

daily

how is admission to the ICU deterined

if the intervention required is only available in the ICU

severity of the illness

is intervention required immediately

is it beneficial

when should referral to the ICU be done

as early as possible to increase survival chances

what are common conditions seen in the ICU

neuro and ortho traumas

Cardiopulmonary conditions

multi organ failure

sepsis

GI conditions

COVID

severe pneumonia

oncology

bariatric conditions

what are the emotional and ethical issues with the ICU

there are decisions regarding endo of life care, use of life sustaining treatments, and communications with family that are emotionally and ethically challenging

what are ICU patients at higher risk of

hospital aquired infections

what is tele-ICU

remote monitoring and consultation services that extend the reach of ICU specialists

what are personalized medicines in the ICU

medications that is tailored based on the genetic and molecular profile of patients

when is PT ordered in the ICU

as soon as the pt can tolerate movement

what are the physiological effects of prolonged bed rest in the ICU

Decreased muscle strength and bone mass

increased incidence of lung infection

DVT

cardiac deconditioning

postural hypotension

what are the psychological effects of prolonged bed rest in the ICU

loss of self esteem and confidence

boredom

depression

difficulty concentrating

what are the benefits of early mobilization in the ICU

improve the pts recovery and discharge

what is ICU acquired weakness (ICUAW)

skeletal muscle disorder with symmetrical weakness in limbs and respiratory muscles (often effected more) that prolongs hospitilizaition

what are the 3 subsets of ICUAW

critical illness neuromyopathy

critical illness polyneuropathy

critical illness myopathy

what is ICU acquired delirium

fluctuating disturbance of consciousness and cognition that is a manifestation of acute brain dysfunction in critically ill patients

what is hypoactive deliriu

pts are withdrawn, have a flat affect and decreased responsiveness

disorganized thinking, inattention, and perceptual disturbances

what is hyperactive delirium

restless

agitated

impulsive

what is mixed delirium

mixture of hypoactive and hyperactive delirium

what are ICU factors contributing to ICU acquired delirium

sedatives and analgesics

what environmental factors can contribute to ICU acquired delirium

unfamiliar surroundings

excessive noise

sensory monotony

light variation

what can help prevent ICU acquired delirium

early mobilization

what are the effects of early mobilization in the ICU

decreased incidence of ICUAW

increased pts who can stand

increased ventilator free days

increased walk distance in pts

increased discharged to home rate

what should be documented to initiate a PT exam in the ICU

the receipt of the referral

what should be reviewed in the medical chart in the ICU

confirm the orders (activity and patient precautions)

medications

lab values

imaging

Physician notes

what is included in the physician or healthcare provider nots of a chart in the ICU

pt history of illness

PMH

PLOF

medical assessment

what is the first thing that should be done when working at a PT in the ICU

confirm the active physical therapy order in the chart

after confirming pt orders what should be done next

double check the specific pt activity orders and precaution

what should be done if a pt has bed rest orders but also had a PT consult

discuss with the ICU, RN, or physician

where are infection prevention precautions located in the ICU

posted on or near the door of the pts room if they are not in the chart already

what is important to know regarding medications when doing a chart review in the ICU

what condition the meds are for

potential side effects

time of last dose

what are the common meds in the ICU that can impact PT

vasopressors (norepinephrine, dopamine, and vasopressin)

neuromuscular blocking agents

high dose opioids

if a pt is administered sedatives what should be considered

If administered in the last 30 min PT should not be done due to alertness and ability to follow commands diminishing

what common lab values are seen during a chart review in the ICU

blood gases

CBC

electrolytes

coagulation studies

kidney and liver function tests

what should be considered when looking at lab values before doing PT

consider if PT is contraindicated or if a bed level exam is indicated

what does the medical assessment in the ICU identify

Current medical priorities

what medical note should first be reviewed

the admission note

what is the admission note

the history and physical notes

contains info about why the pt is in the ICU, history, and PLOF

who writes the admission note in the ICU

the admitting physician

after reviewing the admission note what should be reviewed

any other physician notes to see more recent notes that provide changes in the pt's health

what notes can be reviewed to see more minute to minute status changes in the ICU

nursing notes

what is intubation

inserting a tube to establish an airway if a pt cannot breath on their own can breath

what is the preferred intubation method for most short term trauma respiratory cases

endotracheal tube

what is an endotracheal tube

tube that established an airway by being inserted through the mouth and through the trachea

how is an intubation tube held in place

there is a cuff at the bottom of the tube that is inflated

where does air go in an endotracheal tube

directly into the trachea an down into the lungs

what can be put on an endotracheal tube when attempting to revive a pt

a bag that can be squeezed

what is a nasotracheal tube

an intubation tube that goes through the nose

when is a nasotracheal tube used

if the pt has mouth trauma or a tumor in the mouth

when is a pt transferred from a endotracheal tube to a tracheal tube

when they wake up

what is a tracheal tube

an intubation tube that requires surgery where a stoma is cute and the tracheal tube is inserted at the level of the trachea to make it less agitating

what is mechanical ventilator

a device used to administer breaths to a pt who is intubated or through a face mask connected to the ventilator

what is extracorporeal membrane oxygenation (ECMO)

a life supporting machine used in the ICU that replaces the function of the heart and lungs by pumping blood from the pt body to an artificial lung and then pumped back into the pt

when is EMCO used

pts who:

lungs can't provide enough oxygen to the body

lungs who can't get rid of CO2

heart that can't pump enough blood to the body

what is completed after confirming PT orders and reviewing the pt medical chart

discuss the pt with the ICU, RN, or physician

what is discussed when talking about the pt to the ICU, RN, or physician before seeing the pt

check in

assess how the pt is doing

are they appropriate for PT that day

determine any changes that weren't updated on the cart

what should first be done when entering the pts room

take inventory of all lines and equipment

assess the pt readiness to particapte in the PT exam

what is the progression of assessing physical function during an ICU PT exam

bed mobility

supine to sit

sitting on EOB

out of bed transfers

ambulation

what is the last part of the PT exam in the ICU

perform outcome measures and develop the pt problem list

what needs to be done to tubes and lines during a PT exam

maintain all line and tubes free of occlusion and tension

how is pt consent obtained

explain the purpose, risks, and advantages of the exam to the pt and ask if they will participate

what is done if the pt cannot express consent due to their critical condition

it must be obtained from the pt designated decision maker

what are the three main components for determining pt readiness to do a PT exam

review and evaluate pt pulmonary, cardio and metabolic status

identift contraindications

assess pt alertness and ability to follow direction

how is the pts pulmonary status assessed

review oxygen saturation

respiratory rate

positive end expiratory pressure

fraction of inspired oxygen

how is a pts cardiovascular status assessed

MAP

HR

BP

new arrythmias

new chest pain

how is a pts metabolic status assessed

blood glucose

electrolyte levels

what are common contraindications for PT exam in the ICU

new administration of a pressor agent or antiarrhythmic agent

ventilator setting change

nonsecured airway

active GI blood loss

elevated ICP

agitation required sedatives in the last 30 min

how is the pt alertness and ability to follow direction assessed

assess for sedation, agitation, or delirium

determine if simple directions can be followed

what is the Richmond Agitation and Sedation Scale (RASS)

a tool designed to assess the pt level of sedation of agitation

what does a RASS level 0 mean

indicates the pt is alert and calm

what does a score above 0 on the RASS indicate

the pt is agitated

what does a score below 0 on the RASS indicate

sedation levels

what does a score between -1 and 1 mean on the RASS

the pt has an appropriate level of sedation or agitation to safely perform PT exam

if the pt shows agitation or sedation on the RASS what needs to be done

consult with the rehab team before initiating the PT exam

what are the common screening tools for delirium

Confusion Assessment method for the ICU (CAM-ICU)

Intensive Care Delirium screening check list (ICDC)

how can a pts ability to follow directions be assessed

the awakening criteria:

if the pt responds appropriately to 3/5 commands they can follow directions