Role of PT in ICU is very important, provided they assess
the patients reports and co relates it.
Keeing APACHE in mind i.e. the acute physiology and chronic
health evaluation (APACHE), a system for prognosis development for critically ill
patients which has been developed using a number of lab and other values; we
discussed the importance of lab values and its special implications for PTs in
Intensive care unit.
Length of stay in the intensive care unit (ICU) can also
be predicted using the data’s. To begin with we talked about the importance of
lab reports.
The value of RBCs and WBCs is important. RBC, Hb and HCT
reading is important as it is the only simpler means to assess the capacity of
blood to carry oxygen, correlate with a person's endurance and orthostatic
tolerance. A relative decrease in the capacity of blood to carry oxygen is
termed anemia. Several additional tests may be required to determine the cause
of anemia, including intrinsic factor, vitamin B12, and folic acid, which are
necessary for erythropoiesis. Patients exercise capacity reduces with a drop in
the RBC count. Onset of fatigue is fast in patients with low RBC count. Fatigue
onset can be soon with a patients having low immunity. Continues monitoring
during and after exercise is important. Monitoring fatigue levels during and up
to 8 hours after exercise may be warranted if immune is low. Ideally its case
specific and different in males and females. Borderline RBC counts (4-4.5
mil/mm3) patients ideally should not be stressed.
Also if the Hb level is below 8 g/dl it’s a relative
contraindication to exercise apart from passive movements. If the WBC count is
below 5000 per mm3 10000 per mm3 patient shouldn’t be exercised except for passive
movements with positioning. Also a mask becomes mandatory while dealing with
them. Physiotherapists are supposed to use gloves while handling them as they
are susceptible to infections. Also if the platelet counts are less than 20,000 per mm3
patients shouldn’t be exercised. For normal unrestricted activities the normal
range is 1,50,000 – 4,50,000 per mm3.
Before making any physical contact with patients keeping a
track of TLC is important. PPE(Personal Protective Equipment’s) is to be used
in case of increases TLC values. Increased TLC counts and related increase in body
temp can be signs of infections. If PT observes changes in sputum, its
important to report to the Intensivist/Physician.
The TLC will be increased with severe disease along with
lung hyperinflation (seen on chest radiograph). Obstructive lung diseases result
in air trapping and associated symptoms. The TLC will be increased with severe
disease along with lung hyperinflation. Obstructive disease is also characterized
by increased RV and FRC. Restrictive disease is characterized by diminished volumes
of all types and difficulty taking a deep breath, although FEV1/FVC may be
normal or greater than normal because of excessive stiffness of the lungs.
Functional testing also includes the maximal ability to
ventilate test, in which the person is asked to breathe as deeply and quickly
as possible. This test is referred to as the maximum voluntary ventilation
(MW).
A simple device frequently used for screening persons with
asthma is the peak flow meter. The person expires as forcefully as possible for
one breath. The device is individualized for a given person with areas of the
scale marked with colors to indicate whether function is adequate (green), some
intervention is needed (yellow), or emergency care should be sought (red). The
red zones on Peak flow meter reading is a medical emergency related to
narrowing of airways.
Weaning is a process that must include a multidisciplinary
approach. PT plays the most important role. If a patients has history of airway
obstruction, gradual weaning can be helpful. Complete support- partial support-
T piece. Advance techniques can always be applied (provided we are good at the
basic ones :) ) like inspiratory hold, PNF, early mobilization.
Bronchodilator therapy along with a good chest PT works
wonders for patients. Patients with a history of COPD, should be given
priority.
Patients with increased values of PCo2, may require PEEP.
Consult with on call Doctor and discuss the use of CPAP/BIPAP.
At times, people don't report the ABG values. PTS should
constantly monitor ABG, any swings should be reported. Ventilator parameters
should always be correlated to the ABG values in ICU. Important tool to assess
disorders.
The therapist must observe clients at risk for acid-base imbalance
for any early symptoms. This is especially true for people with known
pulmonary, cardiovascular, or renal disease; clients in a hypermetabolic state,
such as occurs in fever, sepsis, or burns; clients receiving total parenteral
nutrition or enteral tube feedings that are high in carbohydrates; mechanically
ventilated clients; clients with insulin-dependent diabetes; older clients
whose age-related decreases in respiratory and renal function may limit their
ability to compensate for acid-base disturbances; and clients with vomiting, diarrhea,
or enteric drainage.
Client and family education in the prevention of acute
episodes of metabolic acidosis, particularly diabetic ketoacidosis, is
essential. A fruity breath odor from rising acid levels (acetone) may be
detected by the therapist treating someone who has uncontrolled diabetes. The
therapist should not hesitate to ask the client about this breath odor, since
immediate medical intervention is required for diabetic ketoacidosis.
Dehydration occurs rapidly as a result of severe hyperglycemia. A rising pulse
rate and a drop in blood pressure are critical (and often late) indicators of a
fluid volume deficit caused by dehydration. Safety measures to avoid injury
during involuntary muscular contractions are the same as for convulsions or
epileptic seizures. Vigorous restraint can cause orthopedic injuries as the
muscles contract strongly against resistance. Placing padding to protect the
person is a key to prevention of injury.
Measures that facilitate breathing are essential to client
care during respiratory acidosis. Frequent turning, coughing, and deep
breathing exercises to encourage oxygen-carbon dioxide exchange are beneficial.
Postural drainage, unless contraindicated by the client's condition, may be
effective in promoting adequate ventilation.
In the case of respiratory hyperventilation, rebreathing CO
2 in a paper sack is helpful, as well as encouraging the individual to hold the
breath. Oxygen may be given to reduce respiratory effort and the resultant
blowing off of CO2 by the person who has anoxia caused by pulmonary infection
or CHF. Individuals with COPD may retain CO2 ; the use of oxygen is
contraindicated in these clients because it can further depress the respiratory
drive, causing death.
Any client receiving diuretic therapy must be monitored for
signs of potassium depletion (e.g., postural hypotension, muscle weakness, and
fatigue and alkalosis. Decreased respiratory rate may be an indication of
compensation by the lungs, but the physician must make this assessment. Signs
of neural irritability, such as Trousseau's sign may be seen when taking blood
pressure measurements, and they are helpful in detecting early stages of tetany
due to calcium deficiency.
The use of steroids may increase the risk for complications,
such as infection, impaired wound healing, ICU-acquired paresis.
Latex-induced rhinitis & occupational asthma are new
forms of occupational illness secondary to airborne latex allergens from ICU.
Thank you note -
We are really grateful to Nitin Nair Sir for sparing time and sharing his knowledge with us.
Thank you.
https://www.facebook.com/PhysioOnlineCourses
Feel free to comment.
Thank you note -
We are really grateful to Nitin Nair Sir for sparing time and sharing his knowledge with us.
Thank you.
https://www.facebook.com/PhysioOnlineCourses
Feel free to comment.
