ICU

After you’ve worked in acute care for a bit, perhaps you’d like to try working in the ICU.

You might enjoy ICU if you have high attention to detail, enjoy collaborating closely with a team of healthcare professionals, and are confident and calm under pressure. (And enjoy doing very thorough chart reviews.)

Some people prefer ICU to working on the floors because of lower nursing to patient ratios and monitors constantly showing the patient’s vitals. Therapy in this setting also tend to be cotreats with PT or with a rehab aide. ICU specific knowledge is required to work in this setting.

In general, there are 3 major things to check; respiratory status and support, sedation and arousal levels, lines, and blood pressure support.

Respiratory system

Importance of FiO2 readings. Check with RT (respiratory therapy) for titrating O2 during your session.

• Nasal cannula
• High flow nasal cannula
• BiPAP
• Trach mask
• Ventilator In general, RT will need to be present during your treatment sessions for patients on BiPAP and ventilators.

Level of sedation

• RASS scores range fromk +4 to -4 and decribe how agitated or somnolent your patient is
  • +4 is a very agitated patient
  • -4 is a unarousable patient
• For patients with a low RASS score, titrating sedation 30 min before your session is important to optimize your session
  • If nursing notices increased agitation, or the patient fighting against the ventilator breaths, the sedation may have to be restarted or increased. It is a sign the patient may not be appropriate to see or you need to work around their previous arousal level.

Blood pressure

• Vasopressors are medicines given through a patient’s IV that can raise their blood pressure to an appropriate level
  • Patient max out at 3 vasopressors. You want to make sure there is wiggle room for increasing the vasopressor dosage if your patient becomes hypotensive. Therefore, I would recommend trialing head of bed up for patients with 2 vasopressors and possibly not seeing a patient that has 3.
    • Exception is if the patient is on 3 vasopressors but they are low dose.

Lines

To say there are may lines in the ICU would be an understatement. The important thing is to make sure not to yank it out! Here is a general list of some you may encounter:

• arterial lines - usually in the radial artery (forearm) sometimes in the inner leg (femoral artery). It gives you constant blood pressure readings in real time.
• Swann Ganz, PA catheters - lines that literally reach into a patient’s heart to monitor blood flows and pressures. Usually inserts into a patients jugular (neck). Needs to be zeroed out by nursing before therapy and can have inaccurate readings if not placed not at the level of the patient’s heart. Some hospitals have tranducers that can clip onto a patients gown to keep it at the correct height.
• Ventilators, BiPAPs - will need respiratory therapy in the room during your session
• Rectal tubes - collects fecal matter
• hard stop in general for femoral lines besides a femoral art line
  • the important thing to ask is if the femoral line is rigid or flexible. This will affect whether the patient can perform hip flexion.

Cognition

RASS levels are used to assess a patient’s currently state ranging from agitated to sedated

The CAM ICU is the most commonly used assessment for delirium in this setting because it allows the patient to answer without talking. Patients on a ventilator will not be able to vocalize words. It involved several questions:

General treatment session

Depending on the patient’s level of acuity, your session is going to vary. Patients that are in ICU after a major surgery may be able to mobilize to a chair. Patients who are very sick may only tolerate an edge of bed dangle with PT and OT cotreating. Here are some points to follow when encountering very sick patients:

Lines should be arranged towards the direction the patient is moving.

For pts with tenous BP or on a high amount of vasopressors: Ask nursing if they can trial head of bed fully elevated before your session. It’ll give you some idea if they’ll be stable enough to try sitting edge of bed.

You can get an idea of a patient’s trunk control when the head of bed is raised. You’ll be able to see how long they are able to maintain midline or if they’re able to at all.

For patients with delirium, make sure to open blinds so that natural light comes in, and to reorient them frequently. Instruct family to bring pictures in and to update the patient on what’s going on at home and in the hospital.