Brain Injury in ICU

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Brain Injury in ICU
2014-03-25 22:57:56

review of week 7 lecture 2
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  1. 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
  2. How should you speak to brain injury clients in ICU?
    as if they are awake and understanding
  3. ICU precautions:
    • bedrest
    • ICP devices
    • cervical, thoracic, and lumbar precautions
    • 'clear' for mobility
  4. 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?
  5. 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
  6. Mechanical ventilators purpose:
    • airway created thru mouth, nose, mask, throat (trach): long term
    • deliver oxygen enriched air to body and then removes carbon dioxide
  7. How are mechanical ventilators controlled?
    by computer to match client capabilities (wean off slowly)
  8. 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
  9. 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
  10. If tube falls out on mechanical ventilator, therapist should:
    replace immediately (some have to be held in place when pt is upright)
  11. 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
  12. Therapist should remain calm when working with client on mechanical ventilator, alarming client will:
    cause more anxiety and more problems with breathing
  13. Vital sign monitors purpose:
    mechanical check of blood pressure, heart rate, O2 sats, respiratory rate, heart waves
  14. Therapist should monitor vital sign changes with:
    • mobility and function
    • stop or slow as necessary
  15. Before working with a client in the ICU, check with the nurse for:
    normal vital sign values
  16. Nasogastric tube (NG):
    passes nose-esophagus-stomach: for short term nutrition
  17. What are common problems with NG tube?
    • nosebleeds
    • pt/therapist pull it out
  18. 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
  19. 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
  20. 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)
  21. Restraints are often used to:
    prevent client from harming self, removing tubes (vent, PEG)
  22. How often is a restraint order done and by who?
    24 hrs by nursing
  23. Chemical restraints used routinely as well:
    fast acting, leave pt lethargic -- difficult to do therapy, so schedule around meds when possible
  24. 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)
  25. Sequential compression devices purpose:
    prevention of DVT in post surgical, orthopedic, and trauma pts, by preventing blood statis from prolonged bedrest
  26. How do sequential compression devices work?
    sequential inflation from ankle to knee or mid thigh
  27. What is the duration of sequential compression devices?
    11 seconds w/ 60 seconds relaxation
  28. 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
  29. Walk in the room and complete:
    interview w/ family
  30. ICU therapy basics
    • physiologic stability
    • pain
    • motor issues
    • functional mobility
    • self care considerations
    • vision eval
    • low level cognitive eval and communication
  31. 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
  32. 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
  33. Tone following TBI
    • unilateral and bilateral
    • flexion and extension tone
    • highly variable and can be related to stress of client
    • Modified Ashworth Scale
  34. 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
  35. 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
  36. Tone Managagement
    • usually extreme and difficult to manipulate
    • high risk for contracture and orthopedic injury
  37. Mod-severe tone managed w/:
    casting, dynasplints
  38. Mild tone managed w/:
  39. 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
  40. 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
  41. Extreme Attention ROM for which diagnosis?
    ortho injuries (many TBI have cervical precautions initially)
  42. Needs more attention:
    • neck/face ROM
    • Oral ROM
    • trunk rotation
    • Chest expansion
    • scapular mobility
    • UE/LE PROM
    • Hand ROM
  43. Positioning: nursing perspective-
    • comfort, pressure prevention, ease w/ multiple medical lines
    • reposition every 2 hours (supine and sidelying)
    • regular checks for pressure
  44. 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
  45. Functional mobility in ICU:
    slowly progressive and dependent on medical stability
  46. 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
  47. What is sitting good for?
    • normalizing tone and for arousal
    • activates reticular activating system
  48. 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
  49. 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
  50. 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
  51. 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
  52. Double vision:
    eyes must point precisely at the same point in space (convergence) to prevent diplopia or double vision
  53. Each eye has __ external mm that move the eyes together as a team
  54. If control is impaired in one or more of the external eye mm, the eyes...
    cannot maintain alignment in all positions of gaze
  55. Eyes cannot maintain alignement due to damage to:
    the control centers for III, IV, and VI CNs
  56. Is double vision constant or intermittent?
  57. If you are examining a client and their eyes are not focused in the same direction, they likely are:
    seeing double
  58. 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
  59. 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