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ICU Initial Evaluation
- Thorough chart review
- visual scan
- general cognition/visual skills/behavior
- communication abilities
- A/PROM
- sitting balance
- sample ADL
- standing balance, transfers, and gait
- vital sign responses
- pain
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How should you speak to brain injury clients in ICU?
as if they are awake and understanding
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ICU precautions:
- bedrest
- ICP devices
- cervical, thoracic, and lumbar precautions
- 'clear' for mobility
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Before touching client w/ brain injury in ICU:
- chart review and review w/ nurse
- check pain, sleeping, arousal levels
- do you need 2nd person to help?
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What specialized medical equipment is encountered in the ICU w/ TBI clients?
- mechanical ventilators
- vital sign monitors
- nasal and stomach feeding tubes
- restraints
- sequential compression devices
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Mechanical ventilators purpose:
- airway created thru mouth, nose, mask, throat (trach): long term
- deliver oxygen enriched air to body and then removes carbon dioxide
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How are mechanical ventilators controlled?
by computer to match client capabilities (wean off slowly)
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Therapist management of mechanical ventilators:
- move tubes slowly and away from limbs as moving; move mechanical arm to place in best position
- when alarm sounds, check O2 sats, and stop or slow activity. If client is coughing, assist them into a position to support this
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On mechanical ventilator: coughing may produce phlegm or increased oral secretions therapist should:
use wall suction device to vacuum up excess fluid and keep airway clear
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If tube falls out on mechanical ventilator, therapist should:
replace immediately (some have to be held in place when pt is upright)
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On mechanical ventilator, client can ambulate to extent of tube or:
with a 2nd person aiding the breathing w/ ambu bag. can be done by experienced therapist or respiratory therapist
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Therapist should remain calm when working with client on mechanical ventilator, alarming client will:
cause more anxiety and more problems with breathing
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Vital sign monitors purpose:
mechanical check of blood pressure, heart rate, O2 sats, respiratory rate, heart waves
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Therapist should monitor vital sign changes with:
- mobility and function
- stop or slow as necessary
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Before working with a client in the ICU, check with the nurse for:
normal vital sign values
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Nasogastric tube (NG):
passes nose-esophagus-stomach: for short term nutrition
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What are common problems with NG tube?
- nosebleeds
- pt/therapist pull it out
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Therapist management of NG tube:
- ask if it can be turned off during tx
- keep taped onto face to avoid pulling pressure and keep client from pulling on it
- avoid getting tape wet in shower
- head of bed greater than 30 degrees
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Percutaneous endoscopic gastrostomy (PEG):
- non-operative but done by surgeon and/or gastro doc
- goes through skin and mm straight to stomach for feeding
- for long term nutrition or if longer than 2-3 weeks on NG tube
- highly nutritive liquid diet sent thru tubes
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Therapist management of PEG:
- prevent person from pulling out
- if intermittent feedings, may be able to turn off for therapy - check w/ nurse
- tuck unconnected tube in pants w/ slack during gait or other activity
- be careful w/ prone positions (but don't avoid)
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Restraints are often used to:
prevent client from harming self, removing tubes (vent, PEG)
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How often is a restraint order done and by who?
24 hrs by nursing
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Chemical restraints used routinely as well:
fast acting, leave pt lethargic -- difficult to do therapy, so schedule around meds when possible
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Therapist management of restraints:
- remove those in the way of successful therapy, but may want to keep some in place if alone or pt is hard to manage
- document amount of time off (federal requirement) and when placed back on
- check routinely for sores or skin problems from use
- when reapplying, make sure not too tight or restrictive (but not too loose)
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Sequential compression devices purpose:
prevention of DVT in post surgical, orthopedic, and trauma pts, by preventing blood statis from prolonged bedrest
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How do sequential compression devices work?
sequential inflation from ankle to knee or mid thigh
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What is the duration of sequential compression devices?
11 seconds w/ 60 seconds relaxation
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Therapist management of sequential compression devices:
- turn off machine before removal to prevent obnoxious beeping
- generally expected that we remove during session and put back on immediately after
- when redonning, velcro straps should be on top of leg; turn machine back on
- can apply orthotics on top of devices
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Walk in the room and complete:
interview w/ family
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ICU therapy basics
- physiologic stability
- pain
- motor issues
- functional mobility
- self care considerations
- vision eval
- low level cognitive eval and communication
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Non-verbal pain indicators
- disruptive behaviors (agitation, restlessness, verbalizations, aggression, wandering)
- resistance to care
- facial grimacing or wincing
- bracing, rubbing, rocking
- limping, gait changes, shifting in body weight, holding on to supports
- decreased appetite, insomnia, apathy
- changes in typical behavior
- inactivity or lying down
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Motor Issues
- loss of strength, endurance, response and movement speed
- lack of coordination in gross and fine mvmt
- muscle tone changes usually significant w/ mod-severe brain injury
- capsular flexibility issues
- unilateral and bilateral motor issues so may present w/ hemiplegia or quadriplegia
- tone
- decorticate posturing
- decerebrate posturing/rigidity
- splint use in ICU
- edema management
- extreme attention ROM
- positioning
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Tone following TBI
- unilateral and bilateral
- flexion and extension tone
- highly variable and can be related to stress of client
- Modified Ashworth Scale
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Decorticate posturing
- UE adduction, int rot, pron, elb/wrist and finger flexion
- LE extension, adduction, and internal rot of hip, knee ext, ankle PF
- If painful stimulation elicits flexion of hips/knees -- spinal reflex known as triple flexion
- damage to internal capsule or cerebral hemispheres causing damage to corticospinal pathways
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Decerebrate posturing/rigidity
- UE ext, add, int rot, elb ext, hyperpronation, wrist and finger flexion
- LE ext, add, int rotation, knee ext, ankle PF and inversion; trunk and neck extension
- damage to upper midbrain and lower pons; can also be a sign of bleeding in the brain or brain herniation, far more serious than decorticate posturing
- it is possible to have alternative decorticate and decerebate posturing on one side of the body or the other
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Tone Managagement
- usually extreme and difficult to manipulate
- high risk for contracture and orthopedic injury
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Mod-severe tone managed w/:
casting, dynasplints
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Mild tone managed w/:
splints
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Splint use in ICU - Hypertonus
- splint in opposite position of tone, usually near neutral
- wearing time varies from 2-4 hrs/day to 23 hrs/day
- post written schedule in room for splint wear
- mark splint L/R, mark straps, wrist, fingers, ankle for knowing which jt it should cross
- **Provide low load prolonged stretch
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Edema management:
- elevation: pillow to 45 degrees or greater for hand
- manual edema mobilization if lymphatics are intact
- A/PROM
- UE resting hand splints to prevent shortening of intrinsics
- bed elevation for LE
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Extreme Attention ROM for which diagnosis?
ortho injuries (many TBI have cervical precautions initially)
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Needs more attention:
- neck/face ROM
- Oral ROM
- trunk rotation
- Chest expansion
- scapular mobility
- UE/LE PROM
- Hand ROM
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Positioning: nursing perspective-
- comfort, pressure prevention, ease w/ multiple medical lines
- reposition every 2 hours (supine and sidelying)
- regular checks for pressure
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Positioning: therapy perspective-
- all others plus tone, edema
- elevation, compression garments, and splints
- use of splints and positioning to relieve tone, minimize risk of contracture and increase comfort; check behind neck braces frequently for pressure
- when you leave client, make sure all lines are hooked back up and they are at the top of the bed
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Functional mobility in ICU:
slowly progressive and dependent on medical stability
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Sitting on EOB
- check bed brakes, glance at vitals and remember to monitor; keep pt clam
- position tubes wisely prior to sitting
- get spot help the first time
- first sit w/o activity
- then add light ADL (to rouse pt; meet ADL goal; add dynamic sitting)
- progressive and individually prescribed exercise
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What is sitting good for?
- normalizing tone and for arousal
- activates reticular activating system
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Standing/gait in ICU
- make sure vitals are stable and lines are long enough
- expect short sessions
- do w/ clients that are not alert to force arousal
- good for briefly normalizing mm tone, stretching jts
- progress to standing w/ activity
- gait as tolerated
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Transfers in ICU
- sitting up is used to build endurance, often starting w/ as little time as 15 minutes up out of bed
- cover transfer surface w/ linen (incontinence)
- recline chair back as needed if balance is poor or safety is an issue
- if restrained in bed, restrained in chair
- give them something to do while up if awake
- make sure everything is reconnected
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Self-care considerations:
- progressive ADL (hand over hand; w/ or w/o AE or use of assistance; sitting w/ bed support-sitting in chair-sitting EOB w/o support-standing; number of activities done; attention to task)
- eating
- toileting
- bathing
- grooming
- dressing
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Evaluation of Vision: Vision screening
- when alert/aware w/ eyes open:
- visual fixation and tracking
- visual field
- visual accommodation
- rule out double vision
- in most simplistic terms, if the person does not have these skills, incorporate them in your activities
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Double vision:
eyes must point precisely at the same point in space (convergence) to prevent diplopia or double vision
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Each eye has __ external mm that move the eyes together as a team
6
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If control is impaired in one or more of the external eye mm, the eyes...
cannot maintain alignment in all positions of gaze
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Eyes cannot maintain alignement due to damage to:
the control centers for III, IV, and VI CNs
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Is double vision constant or intermittent?
either
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If you are examining a client and their eyes are not focused in the same direction, they likely are:
seeing double
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Most in the ICU cannot report double vision but may demonstrate:
- fear, anxiety or agitation w/ mvmts or requests to attend visually
- Try tx for double vision to check for change in behavior
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Double vision treatment:
- prisms
- patching (causes person to become monocular creating other problems)
- -spot patching (small patch of translucent tape placed on inside of lenses of glasses and directly in line of sight)
- yellow glasses
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