Week 2- ICUAW and Early Mobility Flashcards
(55 cards)
1
Q
ICUAW AND EARLY MOBILITY
A
ICUAW AND EARLY MOBILITY
2
Q
Dedades ago __________ was a primary mode of care for trauma and acute and chronic illnesses. What has happened since then?
A
immobility
-We have improved our understanding of the harm in immobility.
3
Q
_____-_____ complications arise from immobilization. Complications are easier to ___________ than to treat.
A
- multi-system
- prevent
4
Q
Why are patients put on prolonged bed rest in the acute care setting? (2)
A
- alterations in physiology (i.e. trauma or disease condition)
- abnormal physiologic state of bed rest
5
Q
Consequences of Bedrest:
- ______ ________ redistribution
- altered distribution of body _______/________
- _________ inactivity
- ________ deconditioning
A
- fluid volume
- weight/pressure
- muscular
- aerobic
6
Q
Impaired ________ capacity is directly related to duration of bedrest.
A
aerobic
7
Q
Does the rate of cardiovascular decline or musculoskeletal changes occur faster?
A
cardiovascular (especially in older adults)
8
Q
Prolonged Bedrest:
-Metabolic and exercise capacity significantly reduced after __-__ weeks of bed rest.
Survivors of ICU admission experience significant ____-_____ morbidities.
Impairments and limitations often persist _______ to ________ after ICU discharge.
Early mobility in acute care setting may be limited by lack of knowledge and/or protocol.
Physical therapists must establish “________ of _________” in acute care units.
A
- 1-2 weeks
- long-term
- months to years
- “Culture of Mobility”
9
Q
What are some systems affected by bedrest/immobility?
A
- Cardiovascular
- Hematologic
- Musculoskeletal
- Neurologic
- Integumentary
- Many Others
10
Q
Cardiovascular Changes Due to Bedrest:
- reduced _______
- _______ resting HR and ________ CO
- Reduced cardiac vagal tone, increased plasma norepinephrine, enhanced beta-adrenergic receptor sensitivity → resting ____________
- ______volemia
- increased venous compliance → venous _________
A
- VO2Max
- increased, decreased
- tachycardia
- hypovolemia
- pooling
11
Q
Venous pooling leads to __________ _____________.
A
orthostatic hypotension
12
Q
Orthostatic Hypotension:
- decreased ________ position tolerance
- _____volemia
- ____________ reflex dysfunction
- impaired carotid-cardiac baroreflex responses
- impaired vascular vasoconstrictive reserve
A
- upright
- hypovolemia
- autonomic
13
Q
- Orthostatic hypotension (OH) can occur within ___ weeks of bedrest (sooner for elderly).
- How is OH characterized?
A
-3 weeks
- Characterized by drop in BP during a change in position (supine→sitting→standing)
- Drop of more than 20 SBP and 10 DBP accompanied by 10-20% increase in HR
14
Q
Do bed exercises decrease effects of orthostatic intolerance? What does this mean?
A
No, must get them up to help with cardiovascular status.
15
Q
What does treatment of OH involve?
A
- Early Mobilization!
- LE exercises to increase blood circulation
- Compression stockings
- Tilt table for very prolonged immobilization or profound ANS issues (SCI)
16
Q
Does reconditioning or deconditioning take longer?
A
Reconditioning takes way longer than deconditioning.
17
Q
Hematologic:
- RBC mass reduction by __-__%. (decreased total blood volume, RBC mass, and plasma volume)
- _________ HCT → increased risk for ______
- Reduced capillarization of peripheral muscle beds → ?
A
- 5-25%
- elevated HCT → increased risk for DVT
- reduced blood flow to exercising muscles
18
Q
- Patients on bedrest develop 2/3 of Virchows Triad, what is this?
- What is the primary site of DVT?
- _______ of bedrest is directly related to frequency of DVT.
A
- 3 factors important in the development of venous thromboembolism. (venous stasis, hypercoagulability, blood vessel damage)
- calf and soleus sinus
- length
19
Q
- Are there clinical signs of DVT?
- What are a few ways to identify DVTs?
A
- Often no clinical signs (pain and calf tenderness, swelling, redness, positive Homan’s sign)
- Doppler US, contrast venography (gold standard)
20
Q
- What are some treatment methods use to combat hematologic changes due to bedrest?
- What are some prophylactic methods use to combat hematologic changes due to bedrest?
- What are some pharmacology methods use to combat hematologic changes due to bedrest?
A
Treatment
- early ambulation, LE exercise
- compressive stockings
- leg elevation
Prophylactic methods
- low-dose heparin
- intermittent pneumatic compression
Pharmacology
- Unfractionated Heparin (Warfarin (Coumadin))
- Low Molecular Weight Heparin (LMWH) (Lovenox)
21
Q
Musculoskeletal:
- Adaptations to decreased loading occurs within ______ of immobility.
- Atrophy occurs greatest in _________ muscles.
- ____ strength is somewhat spared in comparison to ___ atrophy.
- Changes in muscle fibers such as decreased size and Type IIB (_____ twitch) more affected than type I and type IIA.
A
- DAYS
- antigravity
- UE, LE
- fast twitch
22
Q
Immobilization in a shortened position enhances ________. Immobilization in lengthened position may decrease loss of muscle fiber proteins.
A
atrophy
23
Q
- Are aerobic or anaerobic pathway enzymes decreased?
- What does this lead to?
A
- aerobic
- early fatigue
24
Q
With bedrest/immobility, we are also concerned about joint _________. What are some factors contributing to this?
A
Contractures
- Denervated muscle
- Spasticity
- Improper bed positioning
- Adaptive shortening (cast)
- Disease process
- Elderly
- 2+ joint muscles
25
What are some treatment options for contractures?
- Early mobilization!
- AROM/PROM, manual stretching
- Modalities
- Splinting
- Hinged casts
- CPM
26
Patients on bedrest can also develop disuse osteoporosis/osteopenia, what is this?
Bone loss that results from not enough stress or pressure on the bones.
27
- How quickly can disuse osteopenia occur?
| - Is the loss greater in the UE or LE?
- 1 week
| - LE
28
Neurologic:
- _______ and _______ deprivation
- decreased ________, _________, and ________ levels
- depression, restlessness, insomnia
- decreased balance, coordination, and visual acuity
- increased risk of compression neuropathy
- ________ pain threshold
- sensory, sleep
- dopamine, noradrenaline, serotonin
- reduced
29
Integumentary:
- "Bed sore"; pressure injury (_______ ulcer) are lesions caused by what?
- Where do they usually occur?
- decubitus, caused by unrelieved pressure resulting in damage to underlying tissue
- usually occur over bony prominences
30
What is the pathogenesis of pressure injuries?
- Pressure causes ischemia.
- Excessive pressure can lead to tissue necrosis.
- If pressure relieved, we see temporary reactive hyperemia and no tissue damage.
- If it is NON-BLANCHABLE ERYTHEMA (STAGE 1), then damage has begun.
31
With pressure injuries, _______ is key.
PREVENTION (reposition high-risk patient at least every 2 hours)
32
Respiratory:
- Reduced ______ volumes, _______ rates, respiratory muscle strength, gas exchange.
- ________ position + ________ ________ = diminished vital capacity.
- ___________ respiratory rate.
- Decreased mucociliary _________.
- Increased risk of _________ and ___________.
- ________-________ mismatch.
- lung, airflow
- supine position + prolonged bedrest
- increased
- clearance
- pneumonia and pulmonary embolism
- ventilation-perfusion
33
- Patients will present with ________ on minimal exertion!
- Closely monitor ___ and ______.
- Use ______ as appropriate.
- dyspnea
- RR and O2sat
- RPE
34
Metabolic:
- Overall ________ metabolism.
- What are some specific changes when on prolonged bedrest?
-decreased
- Insulin resistance (diabetes risk)
- Plasma and urinary electrolyte concentrations (kidney/urinary stone risk)
- Endocrine function changes (decreased erythropoietin concentration)
35
What are the thermoregulatory complications associated with bedrest?
-Threshold for vasodilation and sweating are shifted to higher temps leading to increased risk for heat related abnormalities (cramping, fatigue, syncope, heat stroke).
36
Psychiatric:
- More than __% of patients experience mood alterations during prolonged hospitalizations.
- What are some things that can occur?
- 50%
| - anxiety, agitation, delirium, depression
37
ACQUIRED NEUROMUSCULAR DISORDERS
ACQUIRED NEUROMUSCULAR DISORDERS
38
- ________________ and ___________ are overlapping syndromes of diffuse, symmetric, flaccid muscle weakness occurring in critically ill patients and involving all extremities and the diaphragm with relative sparing of the cranial nerves.
- It is very common that patients exhibit _______, a mixed finding of CIP and CIM.
- Critical Illness Polyneuropathy (CIP) and Critical Illness Myopathy (CIM)
- CIPNM
39
Diagnosis of CIP and CIM are ideally confirmed through EMG studies, what is done since this testing is not feasible in the ICU?
-muscle biopsy and examination of phrenic nerve and diaphragm
40
What is the CIPNM: Medical Research Council Scoring System?
A tool used to identify CIPNM?
41
- The CIPNM: Medical Research Council Scoring System looks at the strength of what motions?
- How is it graded?
- shoulder abduction, elbow flexion, wrist extension, hip flexion, knee extension, ankle DF (L and R)
- MMT (0-60 grading), <48 = significant weakness, <36 = severe weakness
42
Steroid Induced Myopathy:
- Occurs ________ or from chronic glucocorticoid maintenance therapy.
- Steroids induce muscle ________ and myocyte __________ leading to atrophy of type 2 muscle fibers (proximal muscles most affected).
- _____ dependent relationship with myopathy.
- Who is at greater risk for steroid induced myopathy?
- _______ and ___________ worsen myopathy.
- acutely
- catabolism, apoptosis
- dose
- elderly, inactive, cancer, nutritional depletion
- fasting and inactivity
43
What is rhabdomyolysis?
Muscle injury that releases toxins into the bloodstream leading to acute kidney injury.
44
- In the hospital setting, rhabdomyolysis is associated with muscle _________ and ________ positioning.
- What are some common manifestations of rhabdomyolysis?
- muscle compression, static positioning
| - myalgia, pimenturia, elevated creatine kinate (CK) levels, acute renal failure
45
EARLY MOBILITY
EARLY MOBILITY
46
- Immobility has long-standing deleterious effects.
- Immobility itself leads to further medical complications, especially __________ compromise.
- Half of patients in ICU unable to return to work __ year after D/C due to weakness and fatigue.
- Patients in ICU spend as little at ___% of time participating in activities.
- cardiovascular
- 1 year
- 11%
47
What are the criteria for beginning PT in the ICU?
- balance benefits/risks of mobility
- examine lab values and other info about pt's hemodynamic state
- gain MD consent
- ICUAW: can begin activities upon achieving medical stability to allow for increased vascular and oxygen demands of PT eval and treatment
48
Pulmonary Parameters Indicating Lack of Readiness for PT Interventions:
- SaO2 = ____% or patient experiences ___% O2 desaturation below resting
- RR = >___ breaths/min
- PEEP >___cm H2O
- FIO2 >/= ___
- 88%, 10%
- 35 breaths/min
- 10cm
- 0.6
49
Lab Values Indicating Lack of Readiness for PT Interventions:
- HTC = ___%
- Hgb = ___-___
- 25%
- 8g/dl
- 20,000
- 2.4-3.0
50
Cardiovascular Measures Indicating Lack of Readiness for PT Interventions:
- Mean Arterial Pressure (MAP) _____mmHg or >/=10mmHg lower than normal SBP or DBP for patients recieving renal dialysis
- Resting HR ___ bpm
- SBP ____mmHg
- New __________ developed
- New onset ______-type chest pain
- <65 or >120mmHg
- <50 or >140 bpm
- <90 or >200 mmHg
- arrhythmia
- angina
51
Metabolic Measures Indicating Lack of Readiness for PT Interventions:
-Glucose levels ____ mg/dL
-<70 or >200 mg/dL
52
Body Structure and Function: What Do I Measure?
Strength
-MMT
-Grip strength: associated with increased risk of ________ and loss of independence.
DTRs
- ____ and ____ associated with altered reflexes
- Deconditioning vs ICUAW
Respiratory Status
- Diaphragm atrophy can occur within ____ hours of mechanical ventilation.
- ________ patterns
- cough effectiveness
- MIP and MEP
Sensory Status
-Provides info on postural control
- mortality
- CIP and CIM
- 18 hours
- breathing
53
What are some tests/measures useful for mobility?
- FIM
- PFIT
- FSS-ICU
- ACIF
- AM-PAC "6-Clicks"
54
What are some intervention strategies for the following?
- Respiratory
- ROM
- Patient Education
- Functional Mobility Training
- Exercise Prescription
Respiratory
- costophrenic assisted coughing
- pursed-lip breathing
- diaphragmatic breathing
ROM
-PROM, AAROM, AROM, RROM, PNF
Patient Education
- safety awareness/falls prevention
- energy conservation
- compensatory strategies
Functional Mobility Training
- bed mobility
- transfer training
- balance
- gait/stairs
Exercise Prescription
- exercise intensity depends on pt tolerance
- Borg RPE
- consider importance of upright positioning
55
It is important to create a "_______ of _________"
Culture of Mobility
