INTRODUCTION-Palliative.docx

PHYSICAL ASSESSMENT OF CRITICALLY ILL PATIENTS SUBMITTED BY Group 1 MEMBERS IMAN WAHEED: 205100 BOWOFOLUWA FAKAYODE: 206837 PRECIOUS OGUNSEYE: 213440 FUNMILAYO ADEGOROYE: 205083 AJEWOLE OLUWAKEMI: 205097 COMFORT BADMOS: 205090 COURSE CODE: NSG 528 COURSE: PALLIATIVE CARE NURSING LECTURER-IN-CHARGE:...

PHYSICAL ASSESSMENT OF CRITICALLY ILL PATIENTS SUBMITTED BY Group 1 MEMBERS IMAN WAHEED: 205100 BOWOFOLUWA FAKAYODE: 206837 PRECIOUS OGUNSEYE: 213440 FUNMILAYO ADEGOROYE: 205083 AJEWOLE OLUWAKEMI: 205097 COMFORT BADMOS: 205090 COURSE CODE: NSG 528 COURSE: PALLIATIVE CARE NURSING LECTURER-IN-CHARGE: DR. IFEOLUWAPO KOLAWOLE. INTRODUCTION Assessing critically ill patients as a nurse is a unique undertaking given the wide spectrum of patients that one may be asked to treat in this setting. At a basic level, many of the major components of a physical therapy acute care assessment will remain the same. However, the unique nature and condition of many of the patients in the critical care setting often warrant approaches that differ from the more general acute care population. Below we will address some of the components of the physical therapy assessment as they pertain to the critically ill population. Given that patients in this setting often present and respond to intervention and assessment differently than patients in other settings, there are certain assessment components that may need to be completed additionally, or approached in a different fashion. Critical care is an area of medicine that focuses on the management and treatment of patients who are deemed to have a condition that is either immediately life-threatening or presents the risk of becoming life-threatening. These patients are generally cared for in a dedicated intensive care unit (ICU) or ward where specific monitoring of physiology and organ function is possible at a level above that of other units or wards in a hospital. A good physical therapy evaluation should always begin with a thorough review of patient history, and an examination of the patient's overall body and system functions. One of the major goals of physical therapy in the critically ill population is to address aspects including ICU acquired deficits through the promotion of early mobility. What Makes A Patient Critically Ill? Critical care is an area of medicine that focuses on the management and treatment of patients who are deemed to have a condition that is either immediately life-threatening or presents the risk of becoming life-threatening. These patients are generally cared for in a dedicated intensive care unit (ICU) or ward where specific monitoring of physiology and organ function is possible at a level above that of other units or wards in a hospital. Staffing in ICUs is generally provided at a lower patient to provider ratio (i.e. 1:1). There is also a greater emphasis on multidisciplinary care in ICUs, encompassing individuals from many different backgrounds, and coordinated under a physician with a specialty in critical care medicine. Goals of care often focus on prevention of acute complications, early detection of distress or condition advancement, and immediate response to evolving situations. Assessing A Patient's Mobility Level Early mobility in the ICU is a practice that is becoming more accepted as an integral part of care. Given this, it is important to assess mobility in a way that accurately reflects ability in light of the multitude of additional factors effecting a critically ill patient compared to a patient in the general acute care population. The PERME ICU Mobility Scale is a measure developed specifically for the critically ill population that assesses a patient's ability utilizing 15 items, across 7 categories. The score rendered from completion of this scale provides a measure of a patient's mobility, as well as the presence of potential barriers. A higher score indicated fewer barriers and greater mobility, while a lower score indicated more barriers and reduced mobility. Categories addressed include cognitive status, mobility barriers, functional strength, bed mobility, endurance, gait, and transfers. One of the major goals of physical therapy in the critically ill population is to address aspects including ICU acquired deficits through the promotion of early mobility. Information specifically addressing the assessment of critically ill patients being considered for early mobilization can be found below; EARLY MOBILITY OF CRITICALLY ILL PATIENTS As technology and science evolve in intensive care medicine, more patients are surviving critical illness episodes. However, prolonged stays in intensive care units (ICU) are linked with functional declines, increased morbidity and mortality and increased length of stay in hospital.Patients who survive a stay in ICU often go on to experience various long term challenges on discharge, some psychological (i.e. cognitive impairment, post-traumatic stress disorder, persistent anxiety),as well as social, financial and physical impairments, including ICU acquired weakness, decreased physical function and a decrease in quality of life. These long-lasting sequelae are referred to as post-intensive care syndrome. It has been found that early mobility (EM) programmes can have a positive impact on these factors. Mobilisation is described as physical activity which results in certain physiological effects.It is energy consuming and includes various activities that produce movement (such as actively moving limbs, actively rolling in bed, sitting on the edge of the bed etc). EARLY MOBILITY Early Mobility (EM) is defined as mobilisation started within 24-48 hours of admission into ICU.It is a safe and achievable practice that has the potential to mitigate the effects of critical illness on several body systems.EM consists of a series of planned movements that are progressed in a sequential manner.It is commenced with minimal or no participation from the patient. It can also be safely implemented for mechanically ventilated patients and patients receiving continuous hemofiltration. A comprehensive assessment enables the physiotherapist and other members of the mobility team to make an informed decision on the individual mobility requirement of the patient. LEVEL OF MOBILITY Robust mobility protocols have been developed to guide critical care clinicians in EM.It is important to liaise with every member of the team to ensure a flow of communication when planning interventions. Goals should be set with the patient and these should always follow the SMART (Specific, Measureable, Achievable, Realistic and Time bound) and FITT (Frequency, Intensity, Time and Type) principles. It is important to note that goal setting is not always straightforward.The goal setting process should be undertaken in such a way that the clinician is able to gain an understanding of what is important to the patient. Assessment of the Critically ill Patient Assessment of the critically ill patient incorporates three major categories: History (including investigation of symptoms and review of systems) Systematically gathering past and present data related to why the patient needs physiotherapy should be incorporated in history taking along with the patient’s primary reason for hospitalisation and admission to the ICU. History taking should include: general demographics (including religious and cultural beliefs, as well as any language barriers) general health status presenting condition previous medical and surgical history list of patient’s current medications family history social history By inquiring about the patient’s history, the physiotherapist also becomes aware of the cognitive status of the patient (alert, unconscious, confused) which leads into the next category, the review of the body systems. 2. Systems review (multisystem assessment) refers to the assessment of: the anatomical and physiological status of the cardiovascular, respiratory, neurological, musculoskeletal, integumentary and renal systems the communication ability, language, cognition and learning style of the individual. The assessment of communication ability includes the level of consciousness and the orientation (i.e. person, place and time) of the patient as this will impact the physiotherapy intervention 3. Tests and measures The physiotherapist will select specific tests and measures based on the information gathered from the history and systems review. In the ICU, tests and measures are limited to those necessary for establishing the patient’s level of functioning and those impacting the physiotherapist’s judgment of the diagnosis or treatment plan. These are often incorporated when assessing the multiple body systems and can include spirometry, radiological examinations, sputum analysis, aerobic capacity and endurance, muscle performance (including grip strength, manual muscle testing), etc. The patient’s functional abilities and endurance can be measured objectively using assessment tools such as the Functional Independence Measure (FIM), the Physical Function in ICU Test (PFIT), the Barthel index and the Acute Care Index of Function (ACIF). Evaluation of the various systems of the body is central to the assessment of the patient in ICU and is commonly known as the multi-systems approach. Multi-systems Approach to Assessment The physiotherapy assessment of the critically ill patient is informed by deficiencies at a physiological and functional level as opposed to the medical diagnosis. Assessment, therefore, includes an in-depth multi-system evaluation of the respiratory, cardiovascular, musculoskeletal, integumentary, neurological, renal, haematological and gastrointestinal systems (system-by-system assessment) in order to identify specific impairments amenable to physiotherapy intervention and to alert the team about patient deterioration. Cardiovascular System Assessment of the cardiovascular system should include heart/pulse rate, heart rhythm  (as evident on the electrocardiogram [ECG]) and quality, blood pressure, peripheral oedema and perceived level of exertion at rest and with activity. It is important to also review the cardiac trends over the 12-24 hours preceding the physiotherapy assessment in order to establish a true picture of the patient. Circulation, ventilation and respiration are often assessed concurrently as cardiovascular and respiratory conditions present with similar signs and symptoms. Respiratory System Bed rest, immobility and inflammation in critically ill patients lead to impaired ventilation, increased resistance of the airways and decreased compliance of the lungs, resulting in dysfunction of the respiratory system. These complications are even more pronounced in mechanically ventilated patients. The functioning of the respiratory system is best assessed by analysing measures of oxygenation and ventilation, including oxygen saturation and arterial blood gases. Evaluation of the respiratory system starts with simply observing how the patient breathes - expansion of the thorax, effort of breathing, breathing pattern and the symmetry of breathing. The next step involves measuring the respiratory rate, auscultating the lungs to assess ventilation and abnormal lung sounds, noting the oxygen saturation level, evaluating the patient’s ability to clear secretions and observing the colour, consistency and quantity of the sputum produced. Assessment of the respiratory system also involves a review of chest radiological investigations, awareness of the arterial blood gas analysis, and percussion which determines the integrity of the underlying lung tissue. It is also important to note if the patient requires ventilator support and the level of support needed (full or assisted support, invasive or non-invasive). With the mechanically ventilated patient the mode of ventilation, the level of oxygen, the PEEP level, the inspiration/expiration ratio (I:E), the preset tidal volume, preset pressures, respiratory rate, etc should also be noted together with the patient’s readiness for weaning from the mechanical ventilator. Neurological System Assessment of the neurological system includes various factors such as the level of consciousness (generally measured using the Glasgow Coma Scale), pupils (size, reactivity, and equality), tendon reflexes, muscle tone (any spasticity or rigidity), skin sensation, cerebral perfusion pressure (CPP), intracranial pressure (ICP), and a review of any radiological imaging (cranial computed tomography scan (CT) or magnetic resonance imaging [MRI]). Changes in the size and reactivity of the pupils can be indicative of the neurological integrity of the patient (pupils equal and reactive to light - PEARL). A unilateral fixed dilated pupil is indicative of pressure on the oculomotor nerve and must be investigated urgently. Bilaterally fixed and dilated pupils point towards severe neurological impairment (sustained severe ICP and cerebral oedema) which is sensitive to hypoxia and often a sign of brainstem death. Any of these signs signal the urgent referral for a CT or MRI scan. Musculoskeletal System Prolonged bed rest leads to decreased skeletal muscle strength (including diaphragm strength) and poor endurance of patients. When combined with critical illness, it results in ICU-acquired weakness which has long-term repercussions for patients beyond discharge from the ICU. Assessment of the musculoskeletal system should, therefore, include the evaluation of a patient’s skeletal muscle properties (muscle tone, active and passive joint range of motion, muscle strength and gross symmetry), functional strength (bed mobility and out of bed mobility) as well as neuromuscular control in the form of gross coordinated movement (balance, gait, transfers, motor control). Assessment of functional tasks includes bed mobility (rolling, supine to sit, sitting over the edge of the bed) and out-of-bed mobility (sitting-to-standing transfers, transfers from bed to chair, wheelchair transfers, commode transfers and ambulation on level surfaces and stairs). Assessing a patient’s functional strength will guide the need for further testing and the potential need for ambulatory aids. Integumentary System Reviewing the integumentary system should incorporate the assessment of pliability (ie texture), skin colour, presence of scar tissue and skin integrity. Many factors such as medications (for example corticosteroids), poor nutrition, prolonged bed rest and general age-related changes can lead to more fragile skin which is also more prone to breakdown. It is, therefore, essential to look for areas of skin breakdown, ecchymosis and pressure injuries as these can be potential sites for infection, causing poor patient outcomes and prolonged length of stay.]Skin lesions can be prevented by frequently changing the position of the patient, especially with activities out of the bed. Renal System Measurement of fluid balance including urine output is important as it affects the consistency of the patient’s secretions, as well as cardiac output.  Dehydration can cause constant mucous plugging which in return can block the airway and result in patient distress. Fluid retention can be a sign of acute kidney injury which may require urgent medical attention. The physiotherapist may be the person to identify this sudden change and may need to call the attention of the ICU physician or the nurse. In assessing the renal system, it is important to note if the patient is catheterised or not, the type of catheter used and the length of catheterisation, as this could potentially be a route of infection. Other systems to consider include the: Gastro-intestinal system to ensure adequate nutritional support for optimal energy and prevention of muscle wasting (protein supplements). Haematological and immunological systems - awareness of infection, the organism responsible for the infection and the risk of cross-infection between patients and to the ICU team. Consideration for mechanically ventilated patients One of the first considerations that should be made when mobilizing mechanically ventilated patients (whether for assessment or treatment) is that the safety of the patient is of the utmost concern. Other considerations include: Prior to mobilization, the responsible/appropriate personnel (generally defined by facility policy) should check that any artificial airways are placed properly and secured adequately for the planned activity. For patients requiring supplemental oxygen, an adequate supply should be available to last the expected activity duration with access to a reserve supply pre-planned in the event of delay. Use of an endotracheal tube is not an immediate contraindication, but if one is present, the patient should require an FiO2 of <0.6 with no other contraindication present for mobilization to be considered low risk. If required FiO2 is >0.6, risk is heightened and discussion with the interdisciplinary team should take place to clarify precautions and weight risks vs. benefits of mobilizing the patient. Caution should always be taken when mobilizing patients on vasoactive drugs (i.e. vasopressin, epinephrine, etc) with consideration given to the dosage and any recent changes in dosage, and the impacts this may have on patient safety given the proposed activity. Richmond Agitation-Sedation Scale (RASS) between -1 and +1 is considered low risk for mobilization. Patient exhibiting a percutaneous oxygen saturation (SpO2) of <90% present with high risk of adverse effects during out-of-bed activity, thus this type of mobilization should not take place unless it is approved by a senior ICU specialist in conjunction with the treating therapist. In-bed activity is considered safer than out-of-bed activity under these circumstances, but not low risk. A discussion with the interdisciplinary team should still take place to clarify precautions and weight risks vs. benefits of proposed activity. A safe and appropriate range for Mean Arterial Pressure should be determine by the interdisciplinary team prior to mobilization to allow decisions to be made regarding safety and appropriateness of proposed activity. Patients with bradycardia who are being treated pharmacologically or with a planned pacemaker insertion are at high risk for adverse effects during both in-bed and out-of-bed activity and thus neither type of mobilization should not take place unless it is approved by a senior ICU specialist in conjunction with the treating therapist. Patients with tachyarrythmias resulting in a ventricular rate >150 bpm are at high risk for adverse effects during out-of-bed activity and thus these patients should not undergo this type of mobilization unless it is approved by a senior ICU specialist in conjunction with the treating therapist. In-bed activity is considered safer than out-of-bed activity under these circumstances, but not low risk. A discussion with the interdisciplinary team should still take place to clarify precautions and weight risks vs. benefits of proposed activity. Patients undergoing active management of intracranial hypertension are at high risk for adverse effects during both in-bed and out-of-bed activity and thus neither type of mobilization should take place unless it is approved by a senior ICU specialist in conjunction with the treating therapist. Assessing a Patient for Early Mobility An EM programme must be tailored to suit the patient’s condition. Various mobility protocols have been developed to guide clinical care clinicians (including intensivites, physiotherapists and occupational therapists) when implementing EM.A thorough assessment will enable the clinician to determine what level of mobility is achievable and safe for each patient. Strong communication with the MDT is essential when managing ICU patients. As for goal setting, when deciding on management, the SMART principle should be followed. As discussed in detail below, in order for the therapist to consider the unique factors of every presenting case, the following features should be assessed prior to implementing an EM plan: Medical history Cardio-respiratory fitness / physiological reserve / functional capability Neuromuscular / musculoskeletal status Medications (which may affect mobilisation response) Cognitive function and level of consciousness Motivation and goals, as well as patient expectations Anxiety levels Other procedures required by the patient Existence of any contraindications MEDICAL HISTORY Prior to implementing any physiotherapy intervention, it is essential to find out the patient’s medical history. Much of this information will be obtained from the patient’s notes and communication with the patient’s family.Key points to consider include: Impact of this acute / chronic illness on the patient Current level of acuity Presence of comorbidities that may impact on the management plan Pre-morid fitness to ensure that EM programmes are realistic and safe Functional capability Cardio-Respiratory Fitness and Physiological Reserve Understanding cardio-respiratory fitness and physiological reserves, as well as functional capability, will help the therapist to determine what level of mobility will be sufficient and effective for a particular patient. It is essential to assess the patient’s current physiological status (i.e heart rate, respiratory rate, blood pressure) and to remember that these readings can change rapidly in ICU. Continuously monitoring is, therefore, essential. Neuromuscular and Musculoskeletal Status It is important to assess musculoskeletal status, including strength, balance and coordination in order to plan an EM programme. Insufficient strength of the lower limbs or major balance deficits will impact on your treatment planning. Outcome measures Using outcome measures early in a patient’s hospital stay (i.e. in ICU) can be beneficial as these measures can be monitored and compared over time. There are a number of outcome measures to assess physical function in ICU survivors, but one study by Parry and colleagues found that the Physical Function in Intensive Care Test and Functional Status Score for the ICU appears to be promising. Medications Certain types of medications, such as vasopressors, might hamper the introduction of a mobility programme. Cognitive Function Level of consciousness and cognitive function are also vital considerations. They will provide you with some insight as to how well the patient may be able to follow instructions. Motivation and Goals It is important to consider what the patient’s goals are and his or her level of motivation. Motivation levels will impact patient engagement. It is beneficial to also find out the patient’s expectations. This will help to ensure that the EM programme is patient-centred and enhance cooperation.Once goals are determined, clinicians can identify target areas to direct the intervention (e.g. sitting on the edge of the bed, standing, walking, sitting balance). Anxiety Many patients in ICU have been found to be anxious. One study by McKinely and colleagues reported that some anxiety was reported by 85% of patients using the Faces Anxiety Scale.Good communication about the EM programme may help to alleviate some anxieties. OTHER PROCEDURES Any EM programme will have to fit around other procedures that the patient requires, such as dialysis, CT scans, wound dressings and blood transfusions. It is important to liaise with all members of the MDT, so that the EM programme can be timed effectively around other interventions.The physiotherapist will need to consider if the patient is prepared generally for an EM intervention. Questions to consider include: does the patient need to eat? Will catheters need to be removed or changed? Will the patient need cleaning or covering? SAFETY GUIDELINES FOR EM PROGRAMMES CARDIOVASCULAR SYSTEM Key considerations are the heart rate - the patient should not be tachycardic or bradycardic.It is also necessary to assess for signs of chronotropic incompetence. Chronotropic incompetence is defined as the inability of the heart to increase its rate in relation to increased activity / demand, which is a common problem for patients with cardiovascular disease.When mobilising an ICU patient, it would be expected that the patient’s heart rate increase due to exertion. You must also check the patient’s blood pressure prior to any EM programme. If the patient’s systolic blood pressure is above 180 mm Hg an EM programme would need to be terminated.Most patients in ICU will have a target mean arterial pressure (MAP).MAP indicates the level of blood supply to the organs. According to the American College of Critical Care Medicine (ACCM) guidelines, a MAP of 60-65 mm HG is necessary for organ perfusion. Adler and Malone state that EM should be terminated if MAP is less than 65 mm Hg or more than 110 mm Hg.However, these figures may be individualised to each patient. When carrying out an EM programme, the patient’s BP must remain within the limits of their target MAP. It is also important to check if a patient is on vasopressors as this will provide an indication of their level of stability / dependence. Vasopressors increase vasoconstriction, which results in increased systemic vascular resistance (SVR). This will increase the MAP and, in turn, improve perfusion to the organs.The ACCM guidelines state that if MAP does not increase to around 60 mm HG after fluid resuscitation, then vasopressors should be initiated.Adler and Malone note that the presence of vasopressor medication, new vasopressor and an escalating dose of vasopressor medication is a contraindication to EM. RESPIRATORY STATUS You will need to check the patient’s respiratory status. Respiratory rate will be the first indication of respiratory distress. A respiratory rate of fewer than 5 breaths per minute or greater than 40 breaths per minute would require the EM programme to terminate.SpO2 should be more than 88-90% and a drop of more than 4% would require the session to terminate. When the patient is on a mechanical ventilator, you will need to check the fraction of inspired oxygen (FiO2). Typically, an FiO2 of more than 60 would be unsafe for EM. Any mobility programme increases a patient’s oxygen demand. If the patient’s baseline oxygen demands are very high (i.e. an FiO2 of > 60) the EM programme could destabilise the patient.Positive End Expiratory Pressure (PEEP) levels higher than 10 are not considered safe for an EM programme. Level of sedation is a key consideration before implementing any EM programme. If a patient is deeply sedated, it is not considered safe to mobilise him or her. A Richmond Agitation Sedation Scale (RASS) score of less than 3 is considered unsafe for EM, as are levels of agitation requiring additional sedative medication (i.e. an RASS of > 2). It is also essential to consider what a patient tells you. EM should be terminated if a patient complains of intolerable dyspnoea on exertion.In such cases, it is important to determine if there are other challenges or factors that are causing these symptoms. EM programmes may be carried out safely in ICU and can confer many benefits to patients. However, every patient needs to be carefully and regularly assessed in order to ensure that the programme is safe. For more information on implementing EM programmes in ICU, click here. Assessing Alertness and Cognition Assessing a patient's cognitive status is an aspect of considerable importance when treating critically ill patients. Cognitive status is crucial in not only determining if a patient can safely participate in therapy, but also whether they are experiencing ICU Acquired Delirium. Delirium is common in critically ill patients and can result from factors such as medication given for sedation or pain control. ICU acquired delirium is of key concern for these patients as its development has been associated with reduced cognitive function in the long term following recovery. Assessing Orientation: A simple method of quickly assessing a patient cognitive status is by determining their orientation at the time of treatment or initial assessment. This can be accomplished by asking the patient a series of standard questions: Person - "Can you tell me your name and date of birth?" Place - "Can you tell me where you are right now?" or "Can you tell me what city we are in?" or "What is the name of this hospital?" Time/date - "Can you tell me today's date?" or "What day of the week is it?" or "What year is it?" Situation - "Can you tell me what brought you to the hospital? A patient's level of orientation can convey a lot about their cognitive status, as well as the potential presence of delirium. Richmond Agitation-Sedation Scale (RASS): RASS is a measure used to reflect a patient's level of alertness, which can provide insight as to the patient's appropriateness for therapy. RASS is often assessed by a physician or member of the nursing staff, and should be available to the therapist prior to seeing the patient. A RASS score between -1 and +1 generally indicated that the patient possess a level of alertness that will allow participate in therapy with a minimal risk of adverse effects. However, consideration should always be given to the guidelines set forth by the facility you are treating at (if available) and the general confidence of the treating therapist and other staff participating in a therapy session. Delirium: Multiple scales have been developed to measures, assess, and track delirium in ICU patients. Below are several tools that are useful for physical therapists in the ICU to understand. Assessment Method for ICU (CAM-ICU): The CAM-ICU identifies the presence of delirium in mechanically ventilated patients using non-verbal means. To determine the presence of delirium, patients must exhibit certain behaviors which include: An acute change or fluctuation in mental status Inattention to auditory or visual stimulus Disorganized thinking Altered level of consciousness Delirium Observation Screening Scale (DOSS): DOSS is a 25 item scale designed for early detection of delirium which can be completed by nursing staff during normal patient care. Daily completion of this assessment is achieved by administering the test during three different nursing shifts, with the daily score recorded as the average of the three individual shift scores (each measured on 0-13 scale). A score of >3/13 is an indication of the presence of delirium. References Denehy L, Granger CL, El-Ansary D, Parry SM. Advances in cardiorespiratory physiotherapy and their clinical impact. Expert review of respiratory medicine. 2018;12(3):203-15. DOI:10.1080/17476348.2018.1433034 Gosselink R, Roeseler J. Physiotherapy in critically ill patients. The ESC Textbook of Intensive and Acute Cardiovascular Care. 2015 Feb 26:284. Jevon P, Ewens B, Pooni JS. Monitoring the critically ill patient. 3rd ed. Londres: Wiley-Blackwell; 2012. Lottering M, Van Aswegen H. Physiotherapy practice in South African intensive care units. Southern African Journal of Critical Care. 2016;32(1):11-6.  DOI:10.7196/SAJCC.2016.v32i1.248  Main E, Denehy L, editors. Cardiorespiratory Physiotherapy: Adults and Paediatrics E-Book: formerly Physiotherapy for Respiratory and Cardiac Problems. 5th ed. Elsevier Health Sciences; 2016.  Twose P, Jones U, Cornell G. Minimum standards of clinical practice for physiotherapists working in critical care settings in the United Kingdom: a modified Delphi technique. Journal of the Intensive Care Society. 2019;20(2):118-31. DOI: 10.1177/1751143718807019