Week 1: Examination of a Critically Ill pt in the ICU

What is required for a patient to be a candidate for early mobilization?

The patient must tolerate the increased physiological stress of mobilization.

What does good cardiac reserve indicate in the context of mobilization?

It indicates that the patient can handle the increased oxygen demands during mobilization.

What are the implications of pneumonia on oxygen transport?

Pneumonia can cause fluid buildup in the alveoli, blocking gas exchange and impairing oxygen transport.

What physiological consequences can result from prolonged bed rest?

Rapid cardiovascular and respiratory deconditioning, muscle atrophy, and increased risk for further pathologies.

What risk is associated with decreased mobility in ICU patients?

Increased risk of deep vein thrombosis (DVT).

prolonged bed rest Implications

-Decreased mobility

-Decreases Plasma and blood volume

-Decreased Heart and ventricular volumes

-Decreased muscle: mass, strength, power and endurance

-Bone demineralization

-Skin ulcers

-Aerobic deconditioning such as increased resting HR and VTE risk, decreased CO, conditioning, VO2 max, SV

How does bed rest affect blood volume?

It decreases plasma and blood volume.

What are the effects of mechanical ventilation on Mr. Jones' mobility?

Ventilation and the endotracheal tube may limit body mobility and position changes.

What is the significance of a high FIO2 level in mechanical ventilation?

High FIO2 (>50%) can contribute to atelectasis and possibly lung damage.

What intrinsic factors should be assessed for mobilization tolerance?

-Medical history: identify mobilization TOLERANCE (reserve limited?)

-Meds: affecting response to mobilization

-Pao2/Fio2:

-Respiratory pattern

-Hypercapnea

-DVT/PE

-BMI

-S&S and condition history

-HR >50-60% of age predicted max may indicate limited cardiac reserve

-BP: increase or decrease of 20% or more may represent hemodynamic instability

-ECG monitorring

-SPO2>90%,

What does a Pao2/Fio2 ratio of >300 indicate?

o sufficient respiratory reserve

What does a Pao2/Fio2 ratio of 200-300 indicate?

marginal reserve

What does a Pao2/Fio2 ratio of

It indicates little to no respiratory reserve.

HR >50-60% of age predicted max may indicate

limited cardiac reserve

What are the signs of limited cardiac reserve during mobilization?

Heart rate >50-60% of age-predicted max and blood pressure changes of 20% or more.

What laboratory value indicates that mobilization should be deferred?

-Hemoglobin: less than 7g/dl = mobilization should be deferred

-Platelet count: 20,000 safe lower limit

-WBC count: >10,800 or

Extrinsic factors

-Lines, leads and tubes

-Environment

-Staffing

-Pt consent

-Bed Rest

-Bed type

-Medications

-Surgical factors

-ventilation

What is ICU-acquired weakness?

A condition characterized by decreased muscle strength and function due to prolonged ICU stay.

RASS scoring

+4 combative

+3 very agitated

+2 agitated

+1 restless

0 alert and calm

-1 drowsy

-2 light sedation

-3 moderate sedation

-4 deep sedation

-5 unarousable

What should be monitored to assess Mr. Jones' neurological status?

His ability to follow commands and participate in care.

What is the relationship between oxygen delivery and consumption during mobilization?

Oxygen delivery must exceed oxygen consumption to ensure adequate transport.

What is the purpose of telemetry in the ICU?

To monitor heart activity through EKG leads and communicate with nurses before physical therapy.

telemetry PT implications

-Communicate with nurses before PT

-Electrodes can be dislodged

-Artifact can be caused by movement, electrode poor contact or manual bronchopulmonary techniques

-Be sure not to dislodged electrode

-Watch when entering to get baseline HR and BP and assess changed

mechanical ventilator PT implications

-This population is at risk for developing pulmonary complications, skin breakdown, joint contractures, and deconditioning from bed rest.

-Physical therapy intervention can help prevent, minimize, or reverse these complications despite ongoing mechanical ventilation and assist with the weaning process.

What are the risks associated with mechanical ventilation?

Patients are at risk for pulmonary complications, skin breakdown, joint contractures, and deconditioning from bed rest.

What should be done before moving a patient with a tracheostomy?

Moisture or pulmonary secretions may collect in the mask or tubing and should be drained before moving the patient or lowering the head of the bed (HOB)

What precautions should be taken with a feeding tube during therapy?

-The tube often hangs in front of the patient's mouth and may also hinder airway clearance.

-Tube is easily dilosged

-Aspiration precautions: Keep HOB minimum 25-30º during feedings

Foley catheter PT implications

-be aware of position

-collection bag should be below level of bladder

-secure to walker or pt's leg to prevent tripping

-keep off floor

What is the significance of a pulse oximeter reading below 88%?

It indicates a need for supplemental oxygen.

pulse oximiter PT implications

-Less than 88% indicates a need for supplemental O2

-Monitor during therapy and exercise

-Certain medical conditions (e.g., peripheral vascular disease, anemia, cardiac dysrhythmia, sepsis, hypothermia, vasoconstriction, hypotension, and carbon monoxide poisoning), sunshine or excessive ambient light, poor probe position, motion artifact, dark skin pigmentation, or nail polish may lead to a false or unreliable readings

What should be monitored when using an arterial line during therapy?

Changes in the waveform, as a dampened waveform may indicate hypotension or line occlusion.

A-line PT implications

-If displaced, can cause significant bleeding

-Normal curve is sharp rise with gradual fall

-Dampened waveform=hypotension or line occlusion

-If the waveform changes during therapy, reposition and re-assess

-Femoral A-line: see at bedside d/t limited hip flexion 60-80º

-UE lines can be mobilized but line limits amount

What are the implications of a peripheral intravenous line for physical therapy?

The site should be covered, and axillary crutch use is contraindicated.

BP cuff PT implications

Alternative sites include: distal to the elbow with auscultation of the radial artery, proximal to the popliteal space with auscultation of the popliteal artery, and proximal to the ankle with auscultation of the posterior tibial artery.

Controlled Ventilation characteristics

-Controls Ventilation rate, FIO2, Tidal volume and flow rate, Inspiratory to expiratory ratio

-Pts may be sedated and there is no active respiratory muscle activity necessary

Assist Ventilation characteristics

-All breaths initiated by pt

-Pressure assistance by vent calculated and proportional to measurements of respiratory system compliance and resistance

-Increased pt autonomy

Assist Control ventilation Characteristics

-Pt initiates breaths and RR which can be augmented with a preset volume/pressure and flow rate

-Respiratory muscles are still active

-If pt triggers too many RRs, can lead to dynamic hyperinflation, respiratory alkalosis and auto PEEP

SIMV characteristics

-Delivers breaths at preset time intervals with preset RR, Tidal volume and flow rate

-Pt can breathe spontaneously

-Mandatory breaths only delivered when pt not initiating sufficient amount of breaths for adequate minute vent

pressure-supported ventilation

-Pt initiated breaths are augmented with a preset flow of pressure.

-Pt controls the RR, Inspiratory time and flow.

-Pt and vent determine tidal volume and min vent

What is the normal range for PEEP in mechanical ventilation?

Normal is 5 cm H2O, maintained by surfactant in the alveoli.

PEEP characteristics

-Pressure maintained by Vent in the airways at the end of expiration

-Normal is 5cm H20 maintained by surfactant in alveoli

-Closure of the alveoli results in blood shunting away=decreased gas exchange

What does FiO2 represent in mechanical ventilation?

The percentage of inspired air that is oxygen, with normal at sea level being 21%.

FIO2 Characteristics

-Percentage of inspired air that's Oxygen

-Normal at sea level is 21% yields an PaO2 of 95-100mmHg

-Increase in FiO2 delivered to alveoli results in greater PaO2 and therefore greater driving force of O2 diffusion

-FiO2 of 60 is threshold to avoid toxicity for prolonged use

What is the role of the ICU Mobility Scale?

To assess bed mobility and walking to track mobility achievements in the ICU.

RR characteristics of ventilators

-Set # based on spontaneous efforts initiated by pt.

-Pts who can't generate spontaneous breaths are fully ventilated at 12-20 BPM

What is the risk of dynamic hyperinflation during assist control ventilation?

It can lead to respiratory alkalosis and auto PEEP if patients trigger too many respiratory rates.

What are the contraindications for physical therapy in patients with a SaO2 < 88%?

Physical therapy should be avoided if SaO2 is below 88%.

Vitals/Lab value contraindications for mobility

-RHR >50% Age predicted max

-RR>45 BPM

-BP: >20% increase or drop from baseline or over 180

-ECG: No acute mI

What is the normal range for arterial blood gas (ABG) pH?

The normal pH range is 7.35-7.45.

What does a PaO2 of 300 indicate in terms of respiratory reserve?

It indicates optimal respiratory reserve.

What should be done if an arterial line is displaced?

It can cause significant bleeding; immediate action is required.

What is the importance of monitoring respiratory rate (RR) in the ICU?

RR should be adjusted based on spontaneous efforts and can indicate patient stability.

What does a blood pressure increase of over 20% from baseline indicate?

It may indicate instability and requires further assessment.

What is the role of physical therapy in patients on mechanical ventilation?

To prevent, minimize, or reverse complications despite ongoing mechanical ventilation.

What is the purpose of using a hospital bed in the ICU?

To assist with bed mobility and positioning.

What are the implications of a Foley catheter during mobilization?

The bag should be kept below the bladder and secured to prevent tripping.

What is the normal range for PaCO2 in arterial blood gases?

The normal range for PaCO2 is 35-45 mmHg.

What is the significance of monitoring lab values like hemoglobin and platelets?

Values below certain thresholds can indicate contraindications for therapy.

What is the normal range for HCO3 in arterial blood gases?

22-26

Vent setting contraindications

-SaO2

devices contraindicated

Temporary pacemakers, IABP, Sengstaken-blakemore

platelets unsafe range