1
Q
What is a common code red emergency code?
A
Fire
2
Q
What is a common code gray emergency code?
A
Severe weather
3
Q
What is a common code pink emergency code?
A
Abducted child or baby
4
Q
What is a common code silver emergency code?
A
Active shooter
5
Q
What is a common code black emergency code?
A
External emergency
6
Q
What are some codes that require the action of a PT?
A
- Code Blue
- Rapid Response
- Sepsis Alert
- Stroke Alert
- NSTEMI Alert
- Trauma Alert
7
Q
What the therapist role inn the codes that require their action?
A
Recognizing the need for the
activation, initiating action, or assisting the teams as needed
8
Q
What are the codes not traditionally initiated by therapy team?
A
Sepsis, NSTEMI, trauma
9
Q
What are the codes that can be initiated by therapy team?
A
- Code Blue
- Rapid Response
- Stroke Alert
10
Q
What is the goal of a code blue?
A
Perform resuscitation efforts after a person has stopped breathing or after the heart has stopped beating
11
Q
Who initiates a code blue?
A
Anyone with CPR certification or who can verify that a person has stopped breathing or has no pulse
12
Q
When is a code blue initiated?
A
- Person has stopped breathing
- Person has no pulse
- Unable to determine if the person has a pulse or breathing, and person unresponsive
- Unsure of what to do and have dire concern for the life of the person
13
Q
Who are the team members involved in a code blue?
A
- Critical care MD
- Hospitalist
- Primary RN
- Nursing supervisor
- RT, PCT/CNA
- Recorder
- Runner
- Security
14
Q
What are the characteristics of a code blue as it relates to a PT?
A
It is possible that you as the therapist, after calling code,
may have to initiate CPR until team arrives!
15
Q
What is the goal of a rapid response?
A
Intervene before the onset of injury, respiratory arrest, or cardiac arrest
16
Q
Who initiates a rapid response?
A
Anyone, including family, hospital staff, nursing staff, physicians, visitors
17
Q
When is a rapid response called?
A
• HR>140 or <40 • RR>28 or <8 • Systolic BP>180 or <90 • Urine output <50 cc over 4 hrs • Staff, family, or visitor has significant concern about the pt’s condition
18
Q
Who are the team members involved in a rapid response?
A
- Critical care MD
- Hospitalist
- Primary RN
- Critical care RN
- Nursing supervisor
- RT
19
Q
What are the similarities between a code blue and a rapid response?
A
- Alert team of highly trained clinicians to respond to a medical emergency
- May be called by therapy staff
20
Q
What is the main difference between a code blue and a rapid response?
A
- Rapid response = Goal is prevention of decline
* Code blue = Goal is resuscitation
21
Q
What is the goal of a stroke alert?
A
Quickly notify the appropriate team of providers about an acute stroke and dedicate hospital resources to the immediate diagnosis and treatment of these patients
• Timely CT scan
• Neuro eval
• Determining need to administer tPA and/or surgical intervention
22
Q
Who initiates a stroke alert?
A
EMS in route to hospital, ER team upon arrival in hospital, anyone on medical floor noting
stroke symptoms
23
Q
When is a stroke alert initiated?
A
Patient exhibits signs of acute stroke: FAST
24
Q
Who are the team members involved in a stroke alert?
A
- Neurologist
- Hospitalist/ER physician
- ICU nurse
- RT
- Radiologist
- Radiology tech
- Neurosurgeon (if needed)
25
What does the FAST acronym stand for when used to exhibit signs of an acute stroke?
- Face. Look for an uneven smile
- Arm: (check if one arm is weak)
- Speech (listen for slurred speech)
- Time (call 911 right away)
Anyone could mean a stroke
26
What is an advanced directive?
Legal documents that specify decisions about end-of-life care
27
What does an advanced directive: Living will do?
Outlines what treatments a patient wants in the event of life threatening conditions and/or the inability to express those desires him/herself; also may contain information regarding organ or tissue donation
28
What does an advanced directive: Durable power of attorney for health care do?
Document that names a trusted
| health care proxy to make health care decisions when the patient is unable to do so
29
What are the characteristics of an advanced directive?
* Part of the routine questions asked of hospitalized patients on admission
* Not always available in emergency situations, though
30
What is a DNR?
Order indicating patient’s wishes to not perform CPR or other life saving measures in the even of a cardiopulmonary arrest
31
When is a DNR applicable?
Unless an out-of-hospital DNR exists, usually only applicable in the hospital situation
• In both cases, in/out of hospital, look for special patient identifiers
32
What are some other terminologies used to address a DNR?
* Allow Natural Death (AND)
| * AND-I (allows specified interventions that can be performed)
33
What does a DNI result from?
Resulted from separating wishes of no CPR from no mechanical ventilation (MV)
• Pulmonary compromise CAN occur in setting of no cardiac compromise
• Pulmonary compromise, when left untreated, can lead to need for CPR
• What are pt’s wishes when this is the case?
34
What are the characteristics of a DNI?
* At times, a trial of MV appropriate (i.e., pt. w/pneumonia where trial of MV could make a difference in quality of life and ultimately result in full recovery)
* Up to physician to thoroughly explain these scenarios to get a full understanding/consent from patient
35
What are the safety precautions of a NPO(no food or drink) in place for?
• Minimize risk of aspiration from stomach contents or vomiting during or
immediately following a procedure
• Protect a patient from dangerous swallowing conditions
• Enforce bowel rest in the case of an obstruction or dysfunction in the GI system
36
In what situation will a patient have a NPO?
* Awaiting surgery
* Bowel blockages
* Severe diarrhea or vomiting
* Swallowing/aspiration precautions
37
What kind of conditions require a 1 on 1 care for the patient?
Medical, mental health, or behavioral conditions necessitate 1-on-1 care for the
patient
• Delirium and extreme confusion
• Suicide risk
• Situational (i.e., during meals due to aspiration precautions)
• Medical conditions that may impair judgement or create an unsafe circumstance
• Extreme fall risk
• Patient is a danger to others or is in danger FROM others (may involve law enforcement or
hospital security)
38
What are the restrictions put in place for a patient on 1 on 1 supervision?
NEVER leave the patient alone
• Family members sometimes asked to be the supervision, otherwise, may need a sitter
• As a PT, you may be the appropriate 1-on-1 supervision while performing treatment
• In cases where you feel uncomfortable being alone with the patient, certainly appropriate to request additional person in the room
39
How is a personal protective equipment (PPE) selected?
Based on what the provider is doing for the patient, or based on what type of transmission based precaution the patient is in
40
What are the items needed for a PPE?
- Gown
- Face mask or respirator
- Goggles or face shield
- Gloves
41
What does a gown do as a PPE?
Helps protect clothing from any type of splashes of fluid
42
What are some key points to keep in mind when donning and doffing a PPE?
- Put on PPE before entering the patient's room
- Keep hands away from face, and don't touch PPE
- Avoid touching areas in the patient's room
- Remove PPE at patient's doorway or outside of the room, and perform hand hygiene immediately
- Remove the respirator outside of room after closing the patient's door
- If hands become contaminated during PPE removal, stop and perform hand hygiene and then proceed with PPE removal
43
What is the sequence of donning a PPE?
- Hand hygiene
- Gown
- Mask/respirator
- Goggles/ face shield
- Gloves
44
What are some tips for when wearing a respirator?
- Always follow the manufacturer's instructions
- Perform an annual "mask fit test" with your employer
- After donning your mask, perform a seal check to ensure a proper seal and fit
45
How do you perform a seal check with a respirator?
Place hand over the mask, and gently inhale and exhale feeling for any leakage
46
What is the order for doffing the PPE?
- Gloves
- Goggles or face shield
- Gown
- Mask or respirator
- Perform hand hygiene
47
What are the contaminated areas of the PPE?
- Outside of gloves
- Front of the gown
- Gown's sleeves
- Front of face shield/ goggles
- Front of mask or respirator
48
What are the clean areas of the PPE?
- Inside of gloves
- Back of the gown
- Gown's ties
- Straps of face shield/ goggles
- Straps of mask or respirator
49
What are the risk factors of a health care- associated infection?
```
• Age
• Immunodeficiency
• Immunosuppression
• Misuse of antibiotics
• Use of invasive diagnostic
or therapeutic procedures
• Agitation
• Surgery
• Burns
• Length of hospitalization
```
50
____ is the single most effective way to prevent the spread of infection
*Hand Hygiene* is the single most effective way to prevent the spread of infection
51
When should hand hygiene be done?
• Before and after eating
• Before and after caring for patients
• Before and after treating a cut or wound
• After using the toilet
• After blowing your nose, coughing, or sneezing
• After touching garbage, soiled linens, or other dirty
objects
52
What are the guidelines for hand hygiene with soap?
• Wet hands with warm or cold clean, running water
and apply soap
• Lather hands by rubbing them together w/soap. Make sure to get the backs of hands, between fingers, and under nails
• Scrub hands for at least 20 sec (“Happy Birthday” song x 2)
• Rinse hands under running water
• Dry hands w/towel and turn off water with towel
53
What are the guidelines for hand hygiene without soap?
• If running water and soap not accessible, use alcoholbased hand sanitizer containing at least 60% alcohol
• Although acceptable in the health care environment,
sanitizers DO NOT eliminate all types of germs, remove
harmful chemicals, nor are as effective when hands are
visibly dirty.
54
What is the techniques for the application of hand sanitizer?
• Apply gel or foam into palm of one hand
• Rub hands together
• Rub product over all surfaces of hands and fingers
until hands are dry
55
What are the good
| cough and sneeze etiquette?
• Cover your mouth and nose when your cough or
sneeze with a tissue or by suppressing in your
antecubital space of elbow
• Wear a mask if you have a cough or cold that does not
preclude you from being at work
• HAND HYGIENE!!
• Instruct your patients to do this as well
56
What is the standard precaution for preventing a health care- associated infection?
Treat all patient situations as if they are potentially
infectious
• Wash hands before and after each and every patient contact
• Wear different sets of gloves with each patient
• Use personal protective equipment (PPE) such as a mask, face shield, gown, if contact w/body fluids possible (blood, urine, feces, emesis, wound exudate, etc)
• Follow respiratory hygiene and cough etiquette
• Use aseptic technique
57
What are the characteristics of the standard precaution for preventing a health care- associated infection?
• Terminology should be STANDARD precautions– mistake to use “Universal
Precautions” terminology
• ALWAYS FOLLOW THESE PRECAUTIONS NO MATTER WHAT OTHER PRECAUTIONS IN PLACE!
58
What is an airborne infection?
Contagious pathogens transmitted by airborne droplet
nuclei that have ability to remain suspended in the air for extended time:
• Measles, varicella (until lesions
dry/crusted), TB
59
What are the precautions to avoiding an airborne infection?
* Standard precautions plus
* Wear fitted N95 respirator mask or positive air purifying respirator (PAPR)(if N95 mask not available or does not fit properly)
* Eye protection if splash/spray to eyes likely
* Airborne infection isolation room required = negative pressure airflow
60
What is a droplet infection?
Transmission involves contact of the conjunctiva or mucous membranes in nose or mouth w/large-particle droplets (>5µm) generated from coughing, sneezing, talking, or suctioning.
• Influenza, meningitis, mumps, rubella, certain types of pneumonia
61
What are the precautions to avoiding a droplet infection?
* Standard precautions plus
| * Mask with or w/o face shield depending on proximity to patient
62
When do contact precautions occur?
* Direct physical contact w/infected/colonized person
* Indirect contact with an object or reservoir
* Examples: MRSA, Shingles (herpes zoster), VRE, c-diff
63
What are the precautions to avoiding a contact infection?
* Standard precautions plus
* Gown and gloves required
* In the case of c-diff, MUST use soap and water for hand hygiene as alcoholbased sanitizers do not kill the bacteria
64
What are the characteristics of a neutropenic precaution?
* For patients with low # neutrophils (severe = < 500 cells/cubic mm)
* Wash hands before/after entering pt room
* Wear gloves and possibly a mask
* Care providers with illness symptoms not allowed
* No fresh fruits/vegetables or flowers allowed in room
65
What are the characteristics of a radiation precaution?
• Similar to neutropenic
• Items brought into room must remain in room for duration of pt’s stay
• May have time limits for visitors and caregivers d/t radiation exposure
• Likely shoe covers, gown, gloves, surgical mask– all of which must be disposed of
prior to leaving room
66
What is the normal range for PaO2?
75-100
67
What happens to the normal range for PaO2 with age?
Decreases after 70, it decreases each decade by ten
68
What is the normal range for PaCO2?
35-45
69
What is the normal range for pH?
7.35-7.4-7.45
70
What are the functions of arterial blood gases?
* Measures the acidity and the levels of oxygen, carbon dioxide, and bicarbonate within the blood
* Quantifies the magnitude of gas exchange abnormalities
* Identify type of respiratory failure
71
What is the sequence in which arterial blood gases are written?
pH/PaCO2/PaO2/HCO3-/SaO
72
What is acidemia?
pH < 7.35
73
What is alkalemia?
pH > 7.45
74
What is the abg in the presence of respiratory acidosis?
pH: decreased
PaCO2: increased
HCO3: normal
75
What is the abg in the presence of respiratory alkalosis?
pH: increased
PaCO2: decreased
HCO3: normal
76
What is the abg in the presence of metabolic acidosis?
pH: decreased
PaCO2: normal
HCO3: decreased
77
What is the abg in the presence of metabolic alkalosis?
pH: increased
PaCO2: normal
HCO3: increased
78
What are the characteristics of PaO2?
Normal: 80-100 mmHg
• Hypoxemic states are due to a variety of disorders (e.g. shunt,
hypoventilation, ventilation-perfusion mismatch)
79
What are the characteristics of SaO2?
Called SaO2 (88% or greater) when measured with an ABG, SpO2 when measured with a pulse oximeter.
80
What is normal PaCO2?
Normal: 35-45 mmHg
81
What are the characteristics of pH?
Normal: 7.35-7.45
• Compensated states
• Uncompensated states
82
What is normal bicarbonate HCO3?
Normal: 22-26 mEq/L)
83
What is metabolic acidosis?
Increased H+ due to a drop in HCO3-
84
What is metabolic alkalosis?
Decreased H+ due to increased renal absorption of HCO3
85
What is respiratory acidosis?
Increased H+ due to excessive CO2 and decreased alveolar ventilation
86
What is respiratory alkalosis?
Decreased H + due to a decrease in CO2 when too
| much is blown off
87
What are the indications for mechanical ventilation?
• RespiratoryFailure
• Cardiopulmonary arrest
• Trauma (especially head, neck, and chest)
• Cardiovascular impairment (strokes, tumors, infection, emboli, trauma)
• Neurological impairment (drugs, poisons, myasthenia gravis)
• Pulmonary impairment (infections, tumors, pneumothorax, COPD, trauma,
pneumonia, poisons)
88
What is type 1 (acute) respiratory failure?
Hypoxemic
| • Failure of oxygen exchange at alveoli/capillary interface
89
What is type 2 (acute) respiratory failure?
Hypercapnic
| • Failure to exchange or remove carbon dioxide (may also have hypoxemia)
90
What is type 3 respiratory failure?
Perioperative
| • Atelectasis, Often results in type I or type II respiratory failure (after procedure)
91
What is type 4 respiratory failure?
Shock
92
What are the characteristics of type 1 (acute) respiratory failure?
- Low PaO2 (<55mmHg)
| - Normal PCO2 (35-45mmHg)
93
What are the characteristics of type 2 (acute) respiratory failure?
- Low PaO2 (< 55 mmHg)
- High PCO2 (> 45mmHg)
- Low pH (< 7.3)
94
___ is contraindicated during acute respiratory failure
*Inspiratory muscle training* is contraindicated during acute respiratory failure
95
What is indicated during acute respiratory failure?
Resting respiratory muscles, to reduce the work of breathing
96
What are the causes of acute respiratory failure?
- Pulmonary embolism
- Pneumonia
- Restrictive lung disease
- Obstructive lung disease
- Neuromuscular disease
- Congestive heart failure
- Unstable arrhythmia
- Pulmonary edema
- CVA
- Overdose
97
What is the treatment method for an acute respiratory failure?
Respiratory support
98
What are the goals of respiratory support?
- Correct hypoxia and hypercapnia
| - Rest respiratory muscles
99
What are the methods of respiratory support?
• Non invasive pressure ventilation
- CPAP:continuous positive airway pressure
- BiPAP: bi-level positive airway pressure
• Invasive: mechanical ventilation
100
What are the settings and terms of mechanical ventilation?
* Tidal Volume usually set at 400-1200cc, dependent on body mass
* Ventilator rate: breaths/min, set at lowest rate to keep PaCO2 between 35-45 mmHg
* Fraction of inspired oxygen (FiO2): lowest value to meet satisfactory paO2
* Positive end-expiratory pressure (PEEP)
101
What are the characteristics of Controlled Mandatory Ventilation (CMV)?
* Ventilator has total control of FiO2, tidal volume, flow rate
* Patients likely sedated/pharmacologically paralyzed
* No respiratory effort by patient
* Critical cases
* Machine take control
102
What are the characteristics of Assist Control Ventilation (ACV)?
* Rate and tidal volume set by RRT
* Patient controls respiratory rate but ventilator assists every breath
* Once patient initiates breath, preset volume or pressure of flow rate is delivered by ventilator
* Can be set so that machine will initiate breath if patient initiated respiratory rate is too low to meet rate set by therapist
* Machine does 90-100% of work
* Risk for hyperventilation and barotrauma (it doesn't perceive breath)
103
What are the characteristics of Synchronous Intermittent Mandatory Ventilation (SIMV)?
• Rate and tidal volume set by RRT
• Ventilator assists patient with breath if needed
• Patient can breathe spontaneously on their between ventilator breaths
• Used as weaning mode
- SIMV of 2: patient almost breathing independently
- SIMV of 15: mostly relying on ventilator
104
What are the characteristics of Pressure Support Ventilation (PSV)?
• Patient initiated breaths are augmented by ventilator to maintain a certain inspiratory pressure and tidal volume
• The greater the PSV the less effort by the patient
- Usual range 5-25cmH20
• Used as a weaning mode
- Can reduce pressure support volume
- Can increase time spent with this reduced assistance to address impaired endurance
105
What are the characteristics of Continuous Positive Airway Pressure (CPAP)?
* Weaning mode
* Completely spontaneous
* Positive pressure maintained to prevent alveolar collapse
* Usually 5-7cm H20
106
What are the characteristics of weaning criterias?
• Mode: spontaneous breathing with natural respiratory rate
- <25breaths/min on
• PaCO2 35-45mmHg
FiO2: at less than 40-50% with a PaO2 >60mmHg
• PEEP < 5-7cmH2O
• MIP of at least -20 (diaphragmatic strength)
107
When does oxygen toxicity occur?
Occurs when the partial pressure of alveolar O (P O ) remains elevated above 2A2
normal levels prolonged period of time (>24 hours)
108
___ concentrations of O2 can cause a state of hyperoxia
*Supraphysiologic* concentrations of O2 can cause a state of hyperoxia
109
What are the characteristics of hyperoxia?
• Development of reactive O2 species (ROS)
- Damage to cells and tissues
- Inflammation with diffuse alveolar damage
• Absorption Atelectasis
110
What does prolonged controlled mechanical ventilation (CMV) result in?
A rapid diaphragmatic atrophy.
Ventilator-Induced Diaphragmatic Dysfunction (VIDD)
111
What are the characteristics of rapid diaphragmatic atrophy?
• In as few as 12-18 hrs of CMV; significant fiber atrophy in
• Significant atrophy in both both slow and fast muscle fibers of the diaphragm (12 hours)
• Occurs before atrophy in peripheral skeletal muscles
- It would take approximately 96 hrs to achieve the same level of atrophy in unloaded locomotor skeletal muscles as observed in the diaphragm after 12 hrs of CMV.
• CMV-induced atrophy exceeds the rate reported for the diaphragm after denervation.
112
Key contractile proteins, such as ___ and __, are oxidized in the diaphragm during prolonged CMV.
Key contractile proteins, such as *actin and myosin,* are oxidized in the diaphragm during prolonged CMV
113
Redox disturbance; CMV leads to increased levels of ___ production
Redox disturbance; CMV leads to increased levels of reactive oxygen species (ROS) production
114
What are the characteristics of diaphragm recovery from VIDD?
Muscle fiber size and contractile properties, returns to near normal levels within 24 hours after returning to spontaneous breathing
115
When does (VIDD) muscle atrophy of diaphragm occur?
Within 18-24 hours on mechanical ventilation
116
What are the characteristics of Ventilator-Induced Diaphragmatic Dysfunction (VIDD)?
* Most rapid loss of muscle strength occurs over first week, in particular ankle dorsiflexors and knee extensors, within 96hrs
* Loss of lean body mass estimated as 1% per day in patients with critical illness
* Muscle dysfunction can be seen on EMG within a few days of bedrest
* Those with ICU acquired weakness report strength deficits, fatigue, and cognitive changes 6 months to a year after hospital discharge
117
What is the relationship between supplemental oxygen and FiO2 of room/ambient air?
FiO2 of Room/Ambient Air 20.9% (78% Nitrogen ;1% CO2)
• Each liter of increase with supplemental O2, increases FiO2 by approx 4% (if you have someone on 1L, it increases FiO2= 24%, 2L+ 28%...)
118
What are the characteristics of low flow delivery of supplemental oxygen?
FiO2 is approximation and varies with RR and TV (how much they breathe and the amount)
119
What are the characteristics of high flow delivery of supplemental oxygen?
Precise O2 delivery, does not vary with RR and TV
120
What is the maximum amount of supplemental oxygen used for vents to avoid O2 toxicity?
60%. Can go up to 80%, but it is rare
121
What are the methods of low flow oxygen delivery?
- Nasal Cannula
- Simple face mask
- Partial rebreather
- Non breather
122
What are the characteristics of a nasal cannula?
```
• Easily portable
• Can only really deliver 22- 44% FiO2
- Thus don’t use above >6L
• Can dry out nasal passages.
- Often humidified when >3L given (keep nasal moist)
• Most common
```
123
What are the characteristics of a simple face mask?
* Delivers approx. 35-55% FiO2 at 5-10/min Flow
* Easily mobile with portable O2
* Makes talking and eating difficult (often have to be used while exercising and a cannula during the day)
* Directly over face
124
What are the characteristics of a partial rebreather?
* Delivers 40-60% FiO2 at 10- 15L/min flow
* Patients inspire from resevoir bag attached to mask (can breathe more of a consistent amount)
* Air entering bad from trachea and primary bronchi, where no gas exchange occurs, the patient rebreathes O2 “just expired”
* Easily mobile
125
What are the characteristics of a non-rebreather?
* Delivers 80-90% FiO2 at 10- 15L/min flow.
* Works similar to partial rebreather, however has one way valve that exhalation into reservoir bag, which results in a higher concentration in the bag.
* Only used in seriously ill patients, and possibly during exercise in patients with ESLD
* Always breathing 80-90, but it can vary with RR and TV
126
What are the types of high flow oxygen delivery?
- Venturi mask
| - Transtracheal catheters "trach masks"
127
What are the characteristics of a venturi mask?
* A Venturi mask mixes oxygen with room air, creating high-flow enriched oxygen of a settable concentration.
* Delivered at a higher pressure, uses a wider tube.
* It provides an accurate and constant FI,O2. Flow is set by gauges in the tube-mask manifold
* Typical FI,O2 delivery settings are 24, 28, 31, 35 and 40% oxygen.
* The Venturi mask is often employed when there is concern about CO2 retention. (not moving air effectively)
* Usually around 40%
128
What are the characteristics of a transtracheal catheters "trach masks"?
• Trandeliver oxygen directly into the trachea.
- Basically the same thing as the Venturi mask but it is delivered directly into the tracheostomy.
• High-flow transtracheal catheters may reduce the work of breathing and augment CO2 removal.
• Patients who have been extubated and taken of ventiliators may benefit from an interim of high-flow transtracheal oxygen to better ensure weaning success
129
What is the PVC limit to stop exercise and have the patient sit and if worsens return to bed?
6
130
What should be done if a patient's rhythm deteriorates into an arrhythmia?
Return to the room
131
What is orthostatic intolerance?
Hypotension associated with a change in position, typically when moving from supine to standing (take vital sign gradually)
132
What are the symptoms of orthostatic intolerance?
Dizziness, change in mentation, postural instability, and possibly loss of consciousness
- Post-operative, bedrest, cardiogenic insufficiency, medications (anti-hypertensives, antidepressants, and drugs used to treat Parkinson’s disease and erectile dysfunction), the elderly
(before stand up move legs in bed)
133
What are the causes of orthostatic intolerance?
* Depletion of blood volume
| * Impairment of baroreflex- mediated vasoconstriction (laying supine)
134
Who is usually the 1st to identify orthostatic intolerance in patients?
Physical therapy. Alert the medical team
135
What will reduce the risk of orthostatic intolerance?
Early mobility
136
What is the response of HR in the presence of orthostatic intolerance?
Increase of greater than or equal to 20 beats/min
137
What is the response of systolic BP in the presence of orthostatic intolerance?
Decrease of 20 mmHg or greater with associated onset of symptoms
138
What are the PT indications for ICU rehab?
* Getting patient moving, prevents de-conditioning, reduces risk of atelectasis>consolidation>pneumonia, reduces risk of bed sores and DVT
* Goal to determine stability for ambulation, transfers, stairs, ADLs, assistive device needs, tolerance to activity, PLOF
* D/C planning (always ask ptdo they live alone/family, floors in home, steps to needs, can ptestablish self of 1stfloor bathroom) may need to talk to family if pton vent)
139
What are the outcomes associated with team based ICU care?
* Lower mortality (Wheelan, et al -2003)
* Reduced nosocomial infection, adverse events and costs (Jain, 2006)
* Rating of team function is correlated with Ventilator Associated Pneumonia and Incidence of Pressure Ulcers (Manojlovichet al –2009)
* Improved interprofessional communication related to identifying risk factors early, increasing referrals, clear understanding of patient and family input
140
What are the characteristics of the mobilization of a mechanically ventilated patient?
• Approximately a quarter of the total inpatient cost for hospital stay*
• 1 ICU day = 3-6 non-ICU days depending on treatment provided
- For recovery
- Longer someone is in there, the longer the recovery
141
What are the implications of mechanical ventilation for over 48 hours?
After 1 year...
• 69% limitations in their ADL’s
• 50% had returned to work
• Other sequelae include depression, post-traumatic stress syndrome, and anxiety\
• Pulmonary function tests normal to near normal
• Decreased quality of life scores compared to normative values
• 48% of patients had returned to work 1 year after hospitalization, 65% two years afterward
142
What are the contraindications to mobilization of a patient in the ICU?
•Patients who require significant doses of vasoactives for hemodynamic stability
- (maintain MAP> 60)
• Mechanically ventilated patients who require FiO2 80% and/or PEEP >12, or have acutely worsening respiratory failure (want them at 60%)
• Patients maintained on neuromuscular paralytics
• Neurologic instability or acute event (<24 hours)
• Patients who are unresponsive/ unable to reduce sedation
• Patients with unstable spine or extremity fractures
• Patients transitioning to comfort care
• Patients with rigid femoral catheters
• Patients with open abdomen, at risk for dehiscence
• Patients with recent autograft or flap placement (plastic surgery)
143
What is the typical series of assessments to determine progression of mobility of an ICU patient?
• Awake, participatory, initiation, following commands
• Moving limbs against gravity
->resistive exercises
• HOB elevated/ LE’s dependent/ chair position
• Sitting EOB
• Standing to chair
• Marching ->Walking
144
What kind of patient is an incentive spirometer useful for?
Patients who can't move around 1st
145
What does an incentive spirometer do for patients?
It helps to facilitate surfactant production to keep the alveoli from collapsing
146
How is an incentive spirometer used?
* Breathe out (exhale) normally.
* Breathe in (inhale) SLOWLY.
* Goal is to get this marker to rise as high as possible.
* Make sure this ball stays in the middle of the chamber while you breathe in.
* Hold your breath for a 3 to 5 seconds.
* Then slowly exhale.
* 10 to 15 breaths spirometer every 1 to 2 hours.
* Good for preventing atelectasis (alveolar collapse) and mobilizing secretions
147
What is the typical progression of an ICU patient?
• Post op day 0 pt transfers to chair with RN in AM then B2B
• Post op day 1 pt transfers from sit to stand, get to doorway, pre gait
- Afternoon ambulation
• Post op day 2-3 chest tubes d/c, cardiac pacer d/c (pt must be supine for either and remain still for 1hr with pacer d/c)
- Stairs assessment
- Independent ambulation assessment
• Consider using a standardized assessment, six clicks PAC, POMA/Tinetti, 5mGS, DGI, 6MWT
148
What are the usual discharge times for common cardiopulmonary procedures?
* CABG: 4-5days
* Valve Replacement: 2-3 days
* PCI: 1-2days
* VATS lobectomy 4-5days possibly earlier
* Thoracotomy: 4-5days
* Heart Transplant: 1week
149
What are algorithms used for in cardiopulmonary procedures?
Can be used as a basic screening tool, especially with initiation of hospital mobility program
150
What are the other considerations to take for ICU patients?
* Symptoms
* Vitals
* Critical Lab values
* Change in medical status
* Hospital policy
* Individual comfort level in ICU
* Risk/Benefit
151
What is the role of a RN in an ICU?
Always check in, make a schedule, nurses can transfer patients and ambulate once PT determines safety
152
What is the role of a MD/DO in an ICU?
Must establish good communication for referrals and d/c plan
153
What is the role of a RRT: (respiratory therapist) in an ICU?
Manages mechanical vent, and other supplemental O2 device.
154
What is the role of a CSW (Social Worker) in an ICU?
D/C planning
155
What is Post-intensive Care Syndrome (PICS)?
A collection of health problems that remain after critical illness which can involve the patient’s body, thoughts, feelings, or mind and may affect the family.
• ICU-acquired weakness
• Cognitive or brain dysfunction
• Other mental health problems
156
What is ICU -acquired weakness (ICUAW)?
Muscle weakness that develops during an ICU stay. Other terms include critical illness myopathy
/polyneuropathy
• 33% of all patients on ventilators
• 50% of all patients admitted with severe infection (sepsis)
• Up to 50% of patients who stay in ICU for at least one week
May take more than a year to recover fully, making ADL’s difficult and increasing burden of care
157
What is cognitive dysfunction?
Problems connecting with remembering, paying attention, solving problems, and
organizing and working on complex tasks.
• 30-80% of ICU patients
• In some cases this may be permanent
May affect whether the patient can return to work, balance a
checkbook, or perform other tasks that involve organization
and concentration.
158
What are other mental health problems associated with an ICU?
```
Critically ill patients may develop
• Problems staying asleep/falling asleep
• Nightmares or unwanted memories
• Anxiety/depression
• Can be similar to PTSD
```
159
What are some ways to help manage mental problems following an ICU discharge?
May benefit from psychotherapy and/or psychiatry following ICU discharge
• Speech therapy can also assist with strategies to deal with impaired memory and attention
160
What is the impact of Post-intensive Care Syndrome (PICS) on family and caregivers?
• Change in social role within the family and in society
• Change in ability to hold a job
– financial implications
• Change in ability to control and convey emotions
• Shame and fear regarding cognitive and mental health changes
• Neglect own self care
161
What are the some strategies to minimize Post-intensive Care Syndrome (PICS): family?
* Talk about familiar things, people and events
* Talk about the day, date, and time
* Bring in pictures and favorite items for home
* Read aloud at bedside
* ICU diaries
* Involved in care – EXERCISES
* Take care of themselves
* Seek out resources/ support groups
162
What is delirium?
A disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time
• Up to 80% of mechanically ventilated ICU patient
163
What are the types of delirium?
1. Hyperactive (ICU pychosis)
2. Hypoactive
3. Mixed
164
____ was an independent predictor of higher 6-month mortality and longer hospital stay
*Delirium* was an independent predictor of higher 6-month mortality and longer hospital stay
165
What do efforts to prevent or treat ICU delirium do?
Have the potential to improve patient outcomes and reduce cost of care
Acute care
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