Clinical Decision Making

Haneul Lee, DSc, PT

Patients receiving critical care are surrounded by and attached to a wide array of medical and monitoring devices.

The number of tubes, lines, and wires that appear to emerge from all parts of the patients body, as well as the audible whirs and alarms of medical devices, present a daunting sight for PTs.

PTs must develop a comfort level in providing physical therapy interventions in this environment.

must be familiar with the medical devices

Physical therapy goals during this phase of rehabilitationnecessarily revolve around basic function and the prevention of complications associated with protracted bed rest and debilitation.

1. Maintenance and improvement of pulmonary status

2. Facilitation of bed mobility

3. Maintenance and improvement of joint range of motion

4. Maintenance and improvement of muscle strength and endurance

5. Facilitation of sit-to-stand transfers and early gait

Common goals

Facilitate bed mobility

Facilitate transfers

Improve/maintain ROM and strength

Improve/maintain pulmonary

status

Facilitate gait pregait

activities

Common Goals for Patients with Complex Acute Medial Conditions

Steven B. Skinner, Christina McVey, Clinical making decision for physical therapy assistant, p.157

Why PT in the ICU (Intensive Care Unit)

: PT’s are specialist in the evaluation and treatment of

musculoskeletal, neuralgic, and cardiopulmonary impairments

and their direct impact on the patients, strength, motor control,

sensation, functional mobility, gait, and balance.

History of PT in ICU

Mid 1980’s / Early 90’s

East coast (USA) cardiopulmonary PT’s

▪ Chest physical therapy

Skills Early mobilization of the critically ill

patient receiving mechanical ventilation is an advanced physical therapy practice and requires education areas that affect clinical decision making as well as treatment prescription.

Environment Numerous lines, tubes, monitoring

& ventilator

Sedation, level of alertness, cognition

http://www.thedailysheeple.com/wp-content/uploads/2013/10/ICU.jpg

Device Description Comments

Central line Intravenous catheter passed through a peripheral vessel and ending in the vena cava. Allows for better infusion of concentrated solutions and monitoring of vessel pressures.

Increased risk infection with certain types of central lines. Potential infiltration if tubing disconnected improperly.

Electrocardiogram(ECG)

Mechanical device that monitors electrical activity of the heart via external electrodes placed on the torso and extremities.

The device alarms when electrodes become dislodged or anomalies are detected.

Intracranial pressure(ICP) monitor

Mechanical device that measures intracranial pressure via a surgically implanted pressuresensor.

The device monitors and alarms when intracranial pressure falls outside of normal range.

Intravenous infusion pump

Medical device that controls the infusions of intervenous medication.

The device may alarm when infusion is impaired due topossible infiltration, occlusion,

or other reason.

Mechanical ventilator with intubation

Mechanical device that ventilates a patient’slungs via tubing inserted through the mouth and placed in the airway.

The patient is unable to speak or eat when intubated. The patient is at increased risk for pneumonia.

Nasogastic (NG)tube

Feeding tube inserted through the nose and ending in the stomach

Patient may complain of throatirritation. Possibility of gastricreflux.

Common Medical Equipment and Devices Used in Managing Patients with Acute Medical Conditions

Steven B. Skinner, Christina McVey, Clinical making decision for physical therapy assistant, p.158

PT evaluation Assess level of alertness, ability to follow commands, Active ROM,

motor control or strength, sensation, proprioception, coordination, vital signs, medical stability for mobilization

Assess bed mobility Rolling, scooting, bridging, supine to sit, sitting edge of bed (EOB)

How much can the patient assist?

Is the patient able to follow simple motor

commands?

Assess trunk control,

dynamic sitting balance

http://bloximages.chicago2.vip.townnews.com/nwitimes.com/content/tncms/assets/v3/editorial/6/58/658ca2b7-005d-5b0d-a622-133b4a1b45d7/53925ad2dd610.preview-620.jpg

PTs must be very aware and knowledgeable of different objective physiological indices.

Even small changes in vital signs, serum electrolyte levels, or

complete blood count (CBC) values may significantly affect

patient participation in physical therapy activities.

For example,

PT is providing therapy at the bedside of a 63-year-old woman following a cholecystectomy with postsurgical sepsis. In this case, physical therapy interventions are limited to straight leg raises and weighted-wand exercises for the upper extremities.

Vital Sign Normal Range

Heart rate (pulse)

Newborn 70-90 beats/min

1 year old 80-160 beats/min

2-6 years old 70-125 beats/min

8-12 years old 70-110 beats/min

13-16 years old 60-100 beats/min

Adults 55-100 beats/min

Blood pressure

Birth to 1 month SBP : 60-90 mmHgDBP: 30-60 mmHg

2 months to 3 years SBP: 75-130 mmHgDBP: 45-90 mmHg

3 years through adult SBP: 90-140 mmHgDBP: 50-80 mmHg

Respiratory rate

Birth to 1 month 35-55 breaths/min

3 months to 6 years old 20-30 breaths/min

6-10 years old 15-25 breaths/min

10-16 years old 12-30 breaths/min

Adults 12-20 breaths/min

Oxygen saturation (measured with pulse oximeter)

98% at rest or during exercise.Exercise may be contraindicated at values

ROM activities To prevent contracture

To increase passive/active range of motion

EOB activities Assessments of static and dynamic sitting balance

Seated activities

Reaching outside base of support

Transfer training Sit to stand activities at the edge of bed

Weight shifting with assistive devices

pre gait activities

http://www.medpagetoday.com/upload/2010/4/9/19472_1.jpg

Each of the therapy interventions include ongoing assessments of patient tolerance, ability to participate, measurements of improvement and reevaluation of goals.

PTs must be able to document measurable gain in function and achievement of established goals in order for the intervention to continue as skilled.

There should be periodic reevaluation of patients who may have been placed on a RN program for ROM, out of bed to chair to establish appropriateness for skilled intervention.

Common Signs of

Respiratory Distress

Increased respiration

Cyanosis

Flaring of the nares

Diaphoresis

Audible respiration

and wheezing

Common signs of Respiratory Distress

Steven B. Skinner, Christina McVey, Clinical making decision for physical therapy assistant, p.162

Question?Thank

you

1. Clinical Decision Making for the physical therapist assistance, Steven B. Skinner, Jones and Bartlett Publishers

2. National Physical Therapy Examination, O’sullivan&Siegelman, TherapyEd3. PTEXAM the complete study guide, Scott M Giles, Scorebuilders4. The Challenge of the ICU, Joe Cantlupe, for HealthLeaders Media , May 13, 20115. Physical Therapy Utilization in Intensive Care Units: Results from a National Sur

vey, Katherine E. Hodgin etc. Crit Care Med

http://www.ncbi.nlm.nih.gov/pubmed/?term=Hodgin%20KE%5Bauth%5D