ICU Assessments

ICU Assessments

Assessments are critical tools for evaluating patient needs and readiness, especially in intensive care settings. Proper assessments ensure that interventions are appropriate and safe for patients in delicate conditions.

Physical Therapy Examination

Identify Contraindications

The presence of sedation significantly affects therapy decisions. Thus, thorough evaluations of circulation, ventilation, and respiration are essential prior to any physical therapy (PT) interventions. Additional factors that may warrant consideration include:

  • Impaired cognition: This assessment aids in determining the patient’s ability to understand and follow commands.

  • Any other relevant exam parameters tailored to the individual patient's condition (e.g., prior medical history, specific injuries).

Examination to Identify Contraindications to Out of Bed Exercise

Key factors for ICU patients include:

  • Absence of critical values: Critical values must be monitored to prevent further complications.

  • Patient's mental alertness and ability to follow simple commands: This indicates the extent of cognitive impairment.

Decision Making

Other Contraindications

Some specific contraindications that may affect therapy include:

  • Elevated intracranial pressure (ICP), which can place the patient at significant risk if not monitored closely.

  • Changes in ventilator settings that increase support, as these adjustments may indicate patient distress.

  • Administration of sedatives within the last 30 minutes, requiring reassessment for readiness.

Critical Values

  • Mean Arterial Pressure (MAP): Calculated as MAP = (SBP + (DBP x 2)) / 3. A MAP less than 60 mm Hg indicates compromised circulation, posing potential risks to vital organs.

  • Elevated Intracranial Pressure: Values exceeding 25 mmHg, particularly following recent sedative administration, necessitate urgent attention.

Decision Making Process

  • If critical values are present: The patient is not ready for physical therapy intervention.

  • If critical values are not present: The patient may proceed with PT intervention, pending further cognitive assessments.

Cognition Assessment: Verify Instructions and Response

To ensure effective communication and evaluation, simple commands are used, such as:

  • "Open/close your eyes."

  • "Raise your eyebrows when I count to 5." This process assesses various aspects of awareness, confirming the patient's ability to respond:

  • Confirm the patient can open or close their eyes.

  • Ensure they can look at the therapist and follow cues.

  • Further commands could include poking out their tongues or nodding their heads.

  • A minimum of 3 out of 5 responses is needed to confirm wakefulness and cognitive engagement.

Mental Status Assessments in ICU

Tools for Evaluation

Several validated screening instruments are utilized to assess mental status and cognitive function, including:

  • Richmond Agitation-Sedation Scale (RASS): Evaluates levels of agitation and sedation, critical for adjusting therapy.

  • Rancho Los Amigos Levels of Cognitive Function: Classifies head trauma conditions based on observable cognitive behaviors.

  • Glasgow Coma Scale: Measures levels of consciousness in patients with acute brain injuries, providing crucial data for treatment planning.

  • Confusion Assessment Method for the ICU (CAM-ICU): A delirium screening tool specifically designed for ICU settings, helping identify patients at risk of acute confusion.

Recap: Criteria for Active Mobilization

Patients must meet the following criteria before active mobilization is considered:

  • They should be awake and responsive to commands.

  • The patient must be conscious and present a RASS score of ≥ 3 (indicating mild sedation at most).

  • The presence of delirium should be ruled out via CAM-ICU assessments.

  • Consideration should be given to how communication can be achieved, especially for patients relying on endotracheal (ET) tubes, utilizing non-verbal methods as needed.

Examination Components

Identifying Contraindications

During the examination, it’s essential to assess:

  • Presence of sedation

  • Circulation, ventilation, and respiration

  • Patient's cognitive status: both short-term and long-term aspects should be evaluated.

Additional Components of Examination

Further assessments should include:

  • Pain levels, through both subjective and objective measures.

  • Sensory and reflex integrity assessing both skin sensation and nerve function.

  • Balance assessment encompassing both static and dynamic conditions.

  • Gait analysis and strength testing through range of motion (ROM) and Manual Muscle Testing (MMT).

  • Evaluating aerobic capacity employing functional measures such as AM-PAC, JH-HLM, and PFIT to ensure comprehensive assessments of patient function and limits.

Functional Performance Outcome Measures

AM-PAC (6-clicks)

A comprehensive assessment tool aimed at evaluating patient function and activity limitations. It focuses on key functional domains:

  • Basic mobility skills and daily activities, covering various axes of functional performance.

Specific Forms & Their Functions

  • AM-PAC Inpatient Basic Mobility Form: Assesses required assistance for activities such as:

    • Turning in bed.

    • Transitioning from supine to sitting positions.

    • Moving between bed and chair.

    • Climbing stairs safely.

  • AM-PAC Daily Activity Form: Evaluates assistance needed for:

    • Lower and upper body clothing management.

    • Bathing and grooming tasks.

    • Toileting assistance requirements.

AM-PAC Scoring

Scores range from 1 (total assistance required) to 4 (independent performance), providing a total score from 6 to 24, which indicates the level of disability and support needed for essential functions.

Case Example

For instance, Grace is diagnosed with Amyotrophic Lateral Sclerosis, requiring substantial assistance:

  • She is unable to turn herself in bed or sit independently.

  • Relies on mechanical assistive devices for any mobility actions.

Functional Performance Outcome Measures

JH-HLM (Johns Hopkins Highest Level of Mobility Score)

This measure records the actual mobility performed, focusing on the practical capabilities of the patient rather than potential capabilities:

  • Assigns scores based on the highest mobility level achieved during a specific healthcare shift.

Scoring for JH-HLM

Scores reflect the exact mobility actions conducted, independent of the assistance level, thereby giving insight into functional limitations.

PFIT (Physical Function in the ICU Test)

This multifaceted assessment measures both endurance and strength through components such as:

  • Sit-to-stand assessments for basic mobility.

  • Marching in place to assess endurance.

  • Strength evaluations for upper and lower extremities based on specific tasks.

PFIT Criteria for Completion

To complete PFIT, patients must exhibit clear awareness and willingness to cooperate. Each successful action performed while awake contributes points toward evaluation readiness. A minimum score of 3 out of 5 indicates that the patient is generally ready for mobility interventions.

Testing Position for PFIT

The ideal testing position is sitting out of bed, but this can adapt based on the patient’s capabilities. Vital signs must be monitored throughout the testing process to ensure patient safety.

Component Assessments

  1. Component 1: Sit to Stand

    • Evaluate the patient’s stability and strength in the act of transitioning from seated to standing positions.

  2. Component 2: Cadence (Marching on the Spot)

    • Record steps to provide objective measurements for endurance metrics and overall mobility.

  3. Components 3 & 4: Upper and Lower Extremity Strength

    • Assess muscle strength through both active movement examination and resistance tasks, providing comprehensive evaluation data.

PFIT Recording Sheet

All assessments should be documented systematically through a structured recording format, ensuring accurate tracking of vital signs and performance data for ongoing assessments and future reference.

Functional Mobility Interventions

Overview of Patient Needs

Patients in various states of recovery may necessitate tailored interventions based on their specific medical conditions and functional statuses. Each plan should prioritize patient safety and mobility effectiveness.

Instruction and Education

Instructing patients, along with their families, is crucial for ensuring safe practices during mobility. This includes:

  • Comprehensive training on how to properly use mobility devices and carry out transfers.

  • Education on minimizing the risks of pressure ulcers through appropriate positioning and skin care.

  • A structured approach towards training mobility skills, integrating functional exercises tailored to individual requirements.

Transfer Training

The progressive withdrawal of assistance is essential, as it fosters increased independence among patients. This training should:

  • Include structured walking programs designed based on individual capacity and endurance thresholds.

  • Prioritize intensity-based exercises aimed at strengthening and endurance improvement.

Considerations for Walking Reeducation

Close monitoring of physiological responses and oxygenation levels during all mobility activities is crucial. Attention to the safety of the devices and equipment used during therapy must also be prioritized to minimize risks and enhance recovery outcomes.