Module 2-Acute Care ICU-rev May 2015 final change

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The Intensive Care Unit:

The Intensive Care Unit Dr. Elisabeth McGee , DPT, MOT, CHT, MTC Dr. Karen Rathgeber, PhD, OTR/L Maureen Johnson, MS, OT/L University of St. Augustine

ICU Staff:

Interdisciplinary team Intensivist -physician with training in internal medicine, anesthesia, surgery Hospitalist-specialize in care of hospitalized patient; rounds on patients, follows patient in hospital from ICU to acute to d/c Nurses-critical care nurse specialist Respiratory Therapists-ventilator specialists, breathing treatments Pharmacists-emergent medications Dietitians-patients nutritional needs-IV, tube feeding, oral feeding Occupational therapist-feeding, simple self-care, UE functioning Physical therapist-mobility, body and LE functioning Speech pathologist-swallowing, cognition, communication Information contributed by Maureen Johnson, OTR, USA, CA campus University of St. Augustine ICU Staff

Common Medical Consultants in the ICU:

Anesthesiologist Sedation and pain management Cardiologist Heart management Placement of heart catheterizations Cardiovascular surgeon Surgical management of heart and large vessels Gastroenterologist Management of GI system: stomach, intestines, colon, rectum, pancreas, liver, gallbladder Procedures: endoscopy Placement of feeding tubes Hematologist/oncologist Blood disorders/cancer Infectious disease specialist Infectious disease-determines isolation precautions Interventional radiologist Diagnostic, fluoroscopically guided Procedures: angiograms, Placement of central catheters and central lines Nephrologist Kidneys and renal functions-determines dialysis Neurologist CNS/PNS-brain, spinal cord & peripheral nerves Orthopedic surgeon Musculoskeletal system-bones, joints, ligaments, tendons, muscles and nerves Otolaryngologist Medical and surgical management of head & neck: mouth, ears, nose, throat, and face Placement of tracheotomy Repair of trauma to head/neck Pathologist Body tissues and fluids Pulmonologist Medical management of lungs Placement of chest tubes, biopsy, bronchoscopy, tracheostomy Urologist Management of urinary system Placement of urinary catheters Vascular surgeon Management of peripheral veins & arteries Placement of dialysis catheter and femoral-popliteal bypass graft Created by Maureen Johnson, OTR, USA-CA campus University of St. Augustine Common Medical Consultants in the ICU

ICU Characteristics:

Hospital follow several models regarding the arrangement of medical staff 3 different ICU models Open-attending physician Closed-ICU physician (literature supports) Co managed-blend between both University of St. Augustine ICU Characteristics

Common Diagnoses:

According to the Society of Critical Care Medicine (2006), the top 5 admitting diagnoses are: Respiratory Insufficiency or failure Postoperative Management Cardiac Ischemia Sepsis Heart Failure Other common primary diagnoses include: gastrointestinal hemorrhage, multiple organ system failure, and shock University of St. Augustine Common Diagnoses

Basic Vital Signs:

Vital Sign Normal Ranges Abnormal Ranges Heart rate 60-100 beats per minute Bradycarida < 60 Tachycardia > 100 Blood pressure Systolic: 90-120 mm Hg Diastolic: 60-80 mm Hg Hypotension < 90 systolic Prehypertension: 120-140/ 80-89 Stage 1 Hypertension: 140-159/90-99 Stage 2 Hypertension: >160/>100 Oxygen saturation 95%-99% <95% Respiratory rate 12-20 breaths per minute <12 breaths >20 breaths Mean arterial pressure 70-110 mm Hg   University of St. Augustine Basic Vital Signs This chart was created by Maureen Johnson, OTR, USA-CA campus

Basic Vital Signs:

*Remember , the nurse typically takes the patient’s vitals in supine. Therapists need to take vitals in all positions, document for each position, and communicate the changes to the primary nurse . *Clinical Tip: When taking patient’s vitals in the ICU, be mindful of the patients activity level. For example, is their HR high while supine in bed sleeping? Or is it high when they are performing a stressful activity? *Clinical Tip: When the patient brushes their teeth they may be holding their breath->oxygen saturation may decrease causing heart rate to increase. University of St. Augustine Basic Vital Signs

Common Conditions Found in the ICU:

Pulmonary Cardiac Post-Operative Conditions Neurological ICU Psychosis and Delirium University of St. Augustine Common Conditions Found in the ICU

Pulmonary Conditions:

Acute Respiratory Distress Syndrome (ARDS) Often occurs 24-72 hours after onset of a catastrophic illness or injury (air bags, bicycle accident, chest tubes) leading to vent acquired illness Almost 100% of patients will need life support; 40-50% mortality rate with higher rates in the elderly and those with severe infections The patient may be sedated for a period to improve ventilatory status Initial OT services focus on PROM and positioning due to fragility Once client no longer requires sedation and is medically stable, they can participate in therapy Assess cognition since 45 % of ARDS survivors demonstrate neurocognitive deficits 1 year later (Hopkins et al., 2005 ) and these cognitive deficits are frequently missed because the initial focus is on survival University of St. Augustine Pulmonary Conditions

Cardiac Conditions:

All patients are admitted on telemetry Cardiac enzymes are frequently checked On various cardiac medicines while in the ICU University of St. Augustine Cardiac Conditions wikimediacommons

Postoperative Management:

Admissions to ICU due to unexpected complications, eg CVA before or after a fall or as a precautionary measure due to a history of cardiac or respiratory conditions May include weight bearing, hip movement restrictions, sternal precautions Educate client and family to follow precautions University of St. Augustine Postoperative Management wikimediacommons

Neurological Conditions:

Common conditions include TBI, CVA w/ TPA, SCI, and other diagnoses requiring neurosurgery, eg . t umors. Doctor’s orders may include restrictions for head-of-bed (HOB) angle due to intracranial pressure, activity orders, need for thromboembolic deterrent (compression) stockings or an abdominal binder when getting out of bed (OOB) Reasons for precautions may include: High risk for aspiration (keep HOB at 30 degrees or more except for brief changes to assist with scooting up in bed; disconnect feeding tubes if bed lowered to a flat position ) Goal: Stabilize the neurological injury and prevent secondary injuries that result due to lack of perfusion, edema, or seizures University of St. Augustine Neurological Conditions

Neurological Conditions:

Risk for vasospasm Narrowing of the vessels->ischemia due to decreased blood flow ( hypoperfusion ) Usually occurs within 3-4 days after a subarachnoid hemorrhage Know baseline vitals of the patient-remember nursing typically takes vitals while supine, therapy initiates early mobilization Symptoms-confusion, decreased arousal, and worsening of neurological deficits, stroke, coma, and death University of St. Augustine Neurological Conditions

Neurological Conditions:

Reasons for precautions, continued: Risk for Seizure In patients with a TBI, risk factors include: Glasgow Coma Scale Score (GCS) of less than 10, cortical contusion, depressed skull fracture, subdural hematoma (SDH), intracerebral hematoma, penetrating head wound or seizure within 24 hrs. of injury Therapist must be ready to transfer client to a safe position and notify medical staff immediately Read this US News and World Report article on energy drinks http:// health.usnews.com/health-news/news/articles/2013/01/16/er-visits-linked-to-energy-drinks-double-report University of St. Augustine Neurological Conditions

Neurological Conditions:

25-33% of all ischemic strokes convert to hemorrhagic strokes (FYI-ischemic strokes receive TPA, whereas hemorrhagic do not) Therapists need to recognize potential deterioration of a client’s status and report changes promptly to the medical team Managing HTN in a person with an acute stroke is done cautiously; gradual increase of movement. Do not want to cause an extension of the CVA. Doctors will address HTN gradually and may accept much higher numbers in client’s just sustaining an acute stroke vs. the general population due to the risk for neurological decline with fluctuations of more than 20mmHg (AHA/ASA Stroke Council et al., 2007) Check orders for blood pressure parameters during treatment University of St. Augustine Neurological Conditions

ICU Psychosis and Delirium:

Mechanically ventilated ICU patients have an elevated risk for developing delirium Disturbance of consciousness, change in cognition, and unexpected fluctuations during the course of the day Long-term cognitive impairments have also been associated with delirium experienced during critical illness Assess cognition and use reorientation and cognitive-based interventions University of St. Augustine ICU Psychosis and Delirium

Common ICU Equipment:

University of St. Augustine Common ICU Equipment Smith- Gabai (2011)

Common ICU Equipment:

• Monitor screen — displays heart rate, breathing, b/p, and intracranial pressure. • Head dressing — a bandage to keep the injury or surgical incision clean and dry. • ICP monitor — a small tube placed into or just on top of the brain through a small hole in the skull. It measures amount of intracranial pressure inside the brain. • EKG lead wires — connected to chest with small patches; measures HR and rhythm. • Nasogastric tube — inserted through the nose and into the stomach that can be used to suction the stomach or provide liquid food into the stomach. • Endotracheal tube — inserted through the patient’s nose or mouth into the trachea (windpipe) to help with breathing and suctioning. • Intravenous catheter (IV) and intravenous fluid — a flexible tube through which fluid, nutrients, and medicine are given. • Ventilator – helps with breathing or breathes completely for a patient. • Anti-embolism stockings (often called TEDS or TED hose) — long white stockings which help prevent blood clots from forming in the legs. • Sequential compression stockings (also called SCD hose) — plastic leg wraps that inflate and deflate to help prevent blood from pooling in the legs. • Foley catheter — a drainage tube from the bladder allowing urine to be collected and measured. University of St. Augustine Common ICU Equipment

Common Tubes and Lines seen in the ICU:

Body Structure Concerns Tubes/Lines Gastrointestinal Aspiration/dysphagia Diet types Staying upright /p eating for 30 min Nasogastric tubes/drains Oral suctioning Yankauer Genitourinary Continence         Colostomy Indwelling Foley Condom Catheter Intermittent Catheterization   Colostomy bags Rectal bags Endocrine Blood glucose   Osteoporosis     Electrolytes/hydration Finger stick   Fracture precautions Bracing (body/extremities)   IV lines (IV and PICC) Immune System Isolation Infections     Respiratory Yellow gown Gloves Mask   Trach Chest tubes Skin Wounds Decubitis ulcers Bandaging Wound vacs Edema (weeping) Hospital beds Speicalized mattresses Cardiac System Circulation Central lines for hemodynamics Telemetry Pulsoximetry Pulmonary Breathing Supplemental oxygen Created by Maureen Johnson, OTR, USA-CA campus Ventilators: Endotracheal Tube (mouth) Tracheostomy Tube (neck) Chest tubes Nasal Cannula University of St. Augustine Common Tubes and Lines seen in the ICU

Ventilators:

85-90% ICU patients require mechanical ventilation 3 types of connections to the ventilator Endotracheal Intubation (MOUTH) Most commonly used airway access Nasotracheal Intubation (NOSE) Used in cases of jaw, neck, mouth, or facial trauma that preclude use of the mouth for airway access Tracheostomy (THROAT) Most often initiated for extended ventilator weaning University of St. Augustine Ventilators

Endotracheal tube:

University of St. Augustine Endotracheal tube www.wikimedia.org

Nasotracheal Intubation:

University of St. Augustine Nasotracheal Intubation wikimediacommons

Tracheostomy:

University of St. Augustine Tracheostomy Wikimediacommons

Ventilators:

Tubing has hash marks with numbers indicating the distance in cm until the end of the tubing (the position should not change!) Take note of the positioning and measurement of the tubing before treatment and monitor it throughout your treatment (transfers) Use the assistance of a nurse or respiratory therapists to monitor tube placement and vitals University of St. Augustine Ventilators

Ventilators:

If an accidental disconnection occurs, an alarm will sound so staff can immediately reconnect the device If an accidental extubation occurs, follow the hospital action plan Call the nurse, place the pt. in a safe position ( supine in the bed or chair), maintain pt.’s physical safety, retrieve ambu bag and attach to O2, then begin providing respirations University of St. Augustine Ventilators

Ventilators:

Benefits over the other two types of intubation: improved comfort, more secure airway and effective airway suctioning, decreased airway resistance, enhanced patient mobility, increased opportunities for articulated speech, ability to eat orally Increases ability to have daily trial periods off the ventilator Respiratory therapists will put the patients back on the ventilator if they show signs of respiratory fatigue Respiratory rate > 30 breaths/min Use of accessory muscles Complaints of respiratory distress Collaborate with respiratory therapists and nurses to plan a good time for therapy Initially “trach collar trials” will not be done during OT intervention, but as client has improved tolerance, OT intervention can occur during these trials University of St. Augustine Ventilators

Oral Suctioning & Yankaurer:

Yankaurer: a tapered hard plastic tube about 8-10 inches long with the circumference of a pen/marker Suctioning toothbrushes Both can be used for suctioning oral secretions Kept at bedside Can be a high infection risk if not properly used, cared for, or replaced regularly Patients and family can be taught how to use device University of St. Augustine Oral Suctioning & Yankaurer wikimediacommons

Temporary Pacemaker:

Patients commonly have temporary pacemakers after cardiac surgery Keeps the heart rate stable Some initiate every beat while others are only activated if the HR dips below a preset level The pacemaker box will be locked but the leads entering the body are only secured by tape and care should be taken not to disturb them during therapy OT to monitor EKG University of St. Augustine Temporary Pacemaker http://longviewcardiacvascularconsultants.com/resources/patient/pacemakersdefibrillators/ wikimediacommons

ICU Hospital Beds:

See Table 2.6 for hospital bed features, therapeutic uses, and precautions (get a visual in lab of a 30 degree angle looks like University of St. Augustine ICU Hospital Beds wikimediacommons

OT Clinical Monitoring:

Pulse Oximetry Observe Telemetry Heart Rate Blood Pressure University of St. Augustine OT Clinical Monitoring

Activity Intolerance: Table 2.8:

Warning Signs Possible Causes Increased anxiety Acute change in mental status (eg. Somnolence, confusion, agitation) Increased discomfort and pain Acute chest pain Mild SOB: Respiratory Rate >20breaths/min or mild desaturation (pulse ox <3-5%) Increased work of breathing (use of accessory respiratory muscles, respiration rate >30, increased anxiety) Light-headedness Dizziness or feeling faint Increased fatigue Change in Vision Any change in the patient’s perception of their body: feeling hot/cold/heavy/”funny”/etc. Acute diaphoresis (sweaty) University of St. Augustine Activity Intolerance: Table 2.8

Slide32:

The next slide includes a list of a small sample of medicines used in ICU ’ s and the clinical symptoms are only briefly described. Each patient is unique and their individual medicine and clinical side effects will need to be reviewed . Common meds may be different per location. University of St. Augustine

Common Meds Used in the ICU with Side Effects:

Generic & Brand Names Indication Clinical Side Effects Acetylsalicylic Acid (Aspirin) Anti-inflammatory Prophylaxis for thromboemboli GI discomfort Furosemide (Lasix) Diuretic Hypotension, fatigue, frequent urination Metoprolol (Lopressor) Beta blocker, slow heart rate, reduces blood pressure Dizziness, fatigue, nausea, slow pulse, depression, asthma attacks Clopidogrel (Plavix) Platelet-inhibiting agent Chest pain, abdominal pain, fatigue, diarrhea, hemorrhage, skin bruising, edema, dizziness Alteplase (tPA-tissue plasminogen activactor) Thrombolytics used to break down and dissolve blood clots GI or intracranial bleeding, headache, fever, low back pain * bedrest 24 hrs after administration Warfarin (Coumadin); enoxaparin (Lovenox) Anticoagulant used for prevention and treatment of clots Easy bruising, excessive bleeding, joint pain, difficulty breathing and swallowing Clonazepam (Klonopin) Phenytoin (Dilantin) Phenobarbital, Carbamazepine (Tegretol) Antiseizure Anti-epileptic (post surgery) Anticonvulsant Dizziness, fatigue, depression, difficulty concentrating, decreased memory Carbidopa and levodopa (Sinemet) Used for Parkinson’s disease Orthostatic hypotension, HTN, syncope, depression, back and shoulder pain Fluoxetine (Prozac) Sertraline (Zoloft) Antidepressants Drowsiness, blurred vision, orthostatic hypotension, tremors Diazepam (Valium) Baclofen (Lioresal) Antispasticity and muscle relaxant Dry mouth, constipation, hypotension, edema, headache, dizziness Zofran Anti-emetics used for treatment of nausea and vomiting Blurred vision, dizziness, constipation, fatigue Colace Laxative Rectal bleeding, nausea, adominal pain, dizziness Aspirin Acetaminophen Fentanyl (Duragesic) Ibuprofen (Advil, Motrin) Morphine (MS contin) Naproxen sodium (Aleve) Oxycodone (oxycontin) Percocet Vidodin Hydromorphone (Dilaudid) Tramadol (Ultram) For pain relief     Decrease fever too Mod-severe pain Mild-mod pain Mod-severe pain Mod-severe pain Mod-severe pain Mod-severe pain Mod-severe pain Stomach irritation Liver toxicity   Confusion, dizziness GI discomfort Ulcers, internal bleeding Depression, dizziness Slow HR, syncope Slow HR, syncope, confusion, nausea Seizure, weak pulse Created by Maureen Johnson, OTR, USA-CA campus   University of St. Augustine Common Meds Used in the ICU with Side Effects

Peripheral Intranvenous Catheter (PIV):

Venous access to infuse medication or fluid Enters somewhere in the extremities University of St. Augustine Peripheral Intranvenous Catheter (PIV) www.wikimedia.org

Peripherally Inserted Central Catheter (PICC):

Venous access Used for long-term medications needs or if unable to insert a PIV Enters at the antecubital fossa and ends in the superior vena cava or subclavian or axillary vein University of St. Augustine Peripherally Inserted Central Catheter (PICC) wikimediacommons

Non-tunneled Central Venous Catheter (“Triple Lumen”):

Venous access Provides central venous access and multiple access ports Enters at the subclavian or internal jugular and ends in the superior vena cava or right atrium University of St. Augustine Non-tunneled Central Venous Catheter (“Triple Lumen”) www.wikipedia.org

Tunneled Central Venous Catheter (“Hickman”):

Provides central venous access Used for caustic medication such as chemotherapy Enters subclavian vein or internal jugular University of St. Augustine Tunneled Central Venous Catheter (“Hickman”) wikimediacommons

Vascular Access Device (VAD) (Port-A-Cath):

Provides c entral venous access Less noticeable due to port being under the skin Requires less daily care Insertion sites same as tunneled catheter University of St. Augustine Vascular Access Device (VAD) (Port-A-Cath) wikimediacommons

Central Venous Pressure Catheter (CVP) :

Provides vascular access Measures function and circulatory ability of the right side of the heart Measures fluid balance Enters subclavian region and ends above the right atrium University of St. Augustine Central Venous Pressure Catheter (CVP)

Pulmonary Artery Catheter (Swan Ganz):

Measures intracardiac pressures and O2 saturation Assists with measuring other hemodynamic parameters such as cardiac output Enters subclavian or internal jugular and ends in the pulmonary artery University of St. Augustine Pulmonary Artery Catheter (Swan Ganz)

Arterial Line (A-Line):

Blood pressure monitoring Blood draws Arterial blood gases Radial or femoral artery University of St. Augustine Arterial Line (A-Line)

Goal Setting:

As with all goals, they must be measurable, attainable, and have reasonable time limits Critically ill clients may not be appropriate for traditional ADL goals ICU goals may focus on even the smallest gains to demonstrate progress EX: Set a goal for improved orthostatic stress tolerance when the client is asymptomatic and systolic BP remains higher that 95 when the HOB is at 60 degrees and the client performs a grooming task with Max A. University of St. Augustine Goal Setting

Treatment Planning:

Communicate with nurse to discuss the patient’s ability to participate in therapy and potential physical demands of the planned intervention Monitor vitals before, during and after each intervention Anticipate and be prepared for fluctuation of medical and cognitive status Simple occupation-based activities can be used in bed, edge of bed (EOB), or out of bed (OOB) Basic ADLs can be graded according to the client’s tolerance and interest Treatment activities may include: brushing teeth or hair, washing face or body, using a suctioning toothbrush, writing a letter, designing an “about me” or “interests” board, keeping a journal, manicure, applying make-up, completing crossword puzzles and word searches, watching game shows while answering questions University of St. Augustine Treatment Planning

Progression of Therapeutic Activity in Critically Ill Clients:

Participation in therapy has multiple barriers—be prepared Initial daily sessions range from 10-30 minutes Frequent rest breaks with vital sign checks May only tolerate one tx /day so consider a co- tx with PT or SLP Progress to multiple treatments throughout day Progress activities from supine to sitting EOB or in a chair position, and finally standing University of St. Augustine Progression of Therapeutic Activity in Critically Ill Clients

Summary of OT assessment and interventions:

Chart review (lab activity) Physician’s Orders Patient precautions (WB, isolation, post hip,) Common diagnostic tests to look for results (Doppler, MRI, CT scan) Special procedures Current Medical History Past Medical History (PLOF before this event) Non-appropriate patients (coma, intubated and sedated, agitated, non- arousable ) Patient assessments (ONLY after RN Ok)   Simple hygiene and grooming tasks, maybe don hospital socks (dentures?) Bed mobility Supine to sit EOB Transfers (EOB to chair or sit to stand) Functional mobility ( amb in room w/ or w/o device) UE functioning (ROM, strength, coordination) Visual and Hearing assessment (glasses? Hearing Aids?) Cognition (orientation, attention, sequencing, safety, judgment, memory) Language (conversation-discuss home environment, home routine-work, play, sleep habits) *Created by Maureen Johnson, OTR, USA-CA campus   University of St. Augustine Summary of OT assessment and interventions

OT Assessment and Intervention:

Designing treatment interventions, goals, and discharge recommendations Simple self-care skills w/ appropriate equipment (teeth, hair, washing face + hands) Simple bed mobility (rolling, side-lying, supine to sit) Possible functional mobility (sit EOB, xfer to chair, stand w/ FWW at bedside) Therapeutic exercise/activity (AROM, AAROM, BUE fxl use ); however, not the focus of tx Cognitive activity (orientation, problem solving) Communication (nurse call light access [tape gauze over button to make more prominent], communication board) Vision (low, glasses) Ongoing clinical assessments Discharge recommendations (SNF, SNF rehab, acute rehab, medical floor, home w/ HH, outpatient, sub-acute/long term care facility )   OT early interventions (beginning segment of whole patient rehabilitation)   Selecting appropriate OT interventions from assessments based on medical condition at the moment of intervention Ongoing Clinical Assessments (vitals, cognition, observation of performance, etc ) Created by Maureen Johnson, OTR, USA-CA campus   University of St. Augustine OT Assessment and Intervention

Bonus:

University of St. Augustine Bonus

References:

US News and World Report. (Jan 16, 2016). ER Visits Linked to Energy Drinks Double: Report. Retrieved from http ://health.usnews.com/health-news/news/articles/2013/01/16/er-visits-linked-to-energy-drinks-double-report University of St. Augustine References

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