Physiotherapy Assessment of the Patient in ICU

Original Editor - Merinda Rodseth

Top Contributors - Tarina van der Stockt and Uchechukwu Chukwuemeka  

Introduction[edit | edit source]

Physiotherapy is an essential component in the management of patients admitted to the intensive care unit (ICU).[1][2] Traditionally, the role of physiotherapy in the ICU was limited to respiratory management, but over the last decade rehabilitation and mobilisation have become the priority for patients admitted to the ICU.[1][3] Studies have found that deconditioning (specifically muscle weakness) and not pulmonary function is key to impaired functional status following ICU stay.[4] Physiotherapists are, therefore, responsible for the prevention and treatment of deconditioning (musculoskeletal function), as well as management of the respiratory system (maintain lung volume, improve oxygenation and ventilation, optimise clearance of secretions) in critically ill patients.[4][5][6] In order to achieve this, a valid and accurate evaluation of respiratory conditions, deconditioning and related problems is, therefore, essential.[4] Detailed and regular assessments by the physiotherapist also ensure that patients in the ICU receive the most appropriate physiotherapy treatment for their condition and that this intervention is also appropriately progressed.

Assessment of the Critically Ill Patient[edit | edit source]

Assessment of the critically ill patient incorporates three major categories:[7]

  1. History (including investigation of symptoms and review of systems)

Systematically gathering past and present data related to why the patient needs physiotherapy should be incorporated in history taking along with the patient’s primary reason for hospitalisation and admission to the ICU.[7] History taking should include:[7]

  • general demographics (including religious and cultural beliefs, as well as any language barriers)
  • general health status
  • presenting condition
  • previous medical and surgical history
  • list of patient’s current medications
  • family history
  • social history

By inquiring about the patient’s history, the physiotherapist also becomes aware of the cognitive status of the patient (alert, unconscious, confused) which leads into the next category, the review of the body systems.

2. Systems review (multisystem assessment) refers to the assessment of:[7]

  • the anatomical and physiological status of the cardiovascular, respiratory, neurological, musculoskeletal, integumentary and renal systems
  • the communication ability, language, cognition and learning style of the individual. The assessment of communication ability includes the level of consciousness and the orientation (i.e. person, place and time) of the patient as this will impact the physiotherapy intervention[7][8]

3. Tests and measures

The physiotherapist will select specific tests and measures based on the information gathered from the history and systems review. In the ICU, tests and measures are limited to those necessary for establishing the patient’s level of functioning and those impacting the physiotherapist’s judgment of the diagnosis or treatment plan.[7] These are often incorporated when assessing the multiple body systems and can include spirometry, radiological examinations, sputum analysis, aerobic capacity and endurance, muscle performance (including grip strength, manual muscle testing), etc.[6][7] The patient’s functional abilities and endurance can be measured objectively using assessment tools such as the Functional Independence Measure (FIM), the Physical Function in ICU Test (PFIT), the Barthel index and the Acute Care Index of Function (ACIF).[7]

Evaluation of the various systems of the body is central to the assessment of the patient in ICU and is commonly known as the multi-systems approach.

Multi-systems Approach to Assessment[edit | edit source]

The physiotherapy assessment of the critically ill patient is informed by deficiencies at a physiological and functional level as opposed to the medical diagnosis.[4][9] Assessment, therefore, includes an in-depth multi-system evaluation of the respiratory, cardiovascular, musculoskeletal, integumentary, neurological, renal, haematological and gastrointestinal systems (system-by-system assessment) in order to identify specific impairments amenable to physiotherapy intervention and to alert the team about patient deterioration.[1][2]

Cardiovascular system[edit | edit source]

Assessment of the cardiovascular system should include heart/pulse rate, heart rhythm  (as evident on the electrocardiogram [ECG]) and quality, blood pressure, peripheral oedema and perceived level of exertion at rest and with activity.[6][7] It is important to also review the cardiac trends over the 12-24 hours preceding the physiotherapy assessment in order to establish a true picture of the patient. Circulation, ventilation and respiration are often assessed concurrently as cardiovascular and respiratory conditions present with similar signs and symptoms.[7]

Respiratory system[edit | edit source]

Bed rest, immobility and inflammation in critically ill patients lead to impaired ventilation, increased resistance of the airways and decreased compliance of the lungs, resulting in dysfunction of the respiratory system.[2][10] These complications are even more pronounced in mechanically ventilated patients.[10] The functioning of the respiratory system is best assessed by analysing measures of oxygenation and ventilation, including oxygen saturation and arterial blood gases.[6] Evaluation of the respiratory system starts with simply observing how the patient breathes - expansion of the thorax, effort of breathing, breathing pattern and the symmetry of breathing.[6] The next step involves measuring the respiratory rate, auscultating the lungs to assess ventilation and abnormal lung sounds, noting the oxygen saturation level, evaluating the patient’s ability to clear secretions and observing the colour, consistency and quantity of the sputum produced.[1][6][11] Assessment of the respiratory system also involves a review of chest radiological investigations, awareness of the arterial blood gas analysis, and percussion which determines the integrity of the underlying lung tissue.[6]

It is also important to note if the patient requires ventilator support and the level of support needed (full or assisted support, invasive or non-invasive).[6] With the mechanically ventilated patient the mode of ventilation, the level of oxygen, the PEEP level, the inspiration/expiration ratio (I:E), the preset tidal volume, preset pressures, respiratory rate, etc should also be noted together with the patient’s readiness for weaning from the mechanical ventilator.[6]

Neurological system[edit | edit source]

Assessment of the neurological system includes various factors such as the level of consciousness (generally measured using the Glasgow Coma Scale), pupils (size, reactivity, and equality), tendon reflexes, muscle tone (any spasticity or rigidity), skin sensation, cerebral perfusion pressure (CPP), intracranial pressure (ICP), and a review of any radiological imaging (cranial computed tomography scan (CT) or magnetic resonance imaging [MRI]).[6] Changes in the size and reactivity of the pupils can be indicative of the neurological integrity of the patient (pupils equal and reactive to light - PEARL). A unilateral fixed dilated pupil is indicative of pressure on the oculomotor nerve and must be investigated urgently. Bilaterally fixed and dilated pupils point towards severe neurological impairment (sustained severe ICP and cerebral oedema) which is sensitive to hypoxia and often a sign of brainstem death.[6] Any of these signs signal the urgent referral for a CT or MRI scan.[6]

Musculoskeletal system[edit | edit source]

Prolonged bed rest leads to decreased skeletal muscle strength (including diaphragm strength) and poor endurance of patients. When combined with critical illness, it results in ICU-acquired weakness which has long-term repercussions for patients beyond discharge from the ICU.[8][12][13][14] Assessment of the musculoskeletal system should, therefore, include the evaluation of a patient’s skeletal muscle properties (muscle tone, active and passive joint range of motion, muscle strength and gross symmetry), functional strength (bed mobility and out of bed mobility) as well as neuromuscular control in the form of gross coordinated movement (balance, gait, transfers, motor control).[7] Assessment of functional tasks includes bed mobility (rolling, supine to sit, sitting over the edge of the bed) and out-of-bed mobility (sitting-to-standing transfers, transfers from bed to chair, wheelchair transfers, commode transfers and ambulation on level surfaces and stairs).[7] Assessing a patient’s functional strength will guide the need for further testing and the potential need for ambulatory aids.[7]

Integumentary system[edit | edit source]

Reviewing the integumentary system should incorporate the assessment of pliability (ie texture), skin colour, presence of scar tissue and skin integrity. Many factors such as medications (for example corticosteroids), poor nutrition, prolonged bed rest and general age-related changes can lead to more fragile skin which is also more prone to breakdown.[7] It is, therefore, essential to look for areas of skin breakdown, ecchymosis and pressure injuries as these can be potential sites for infection, causing poor patient outcomes and prolonged length of stay.[7] Skin lesions can be prevented by frequently changing the position of the patient, especially with activities out of the bed.[7]

Renal system[edit | edit source]

Measurement of fluid balance including urine output is important as it affects the consistency of the patient’s secretions, as well as cardiac output.[6][15]  Dehydration can cause constant mucous plugging which in return can block the airway and result in patient distress. Fluid retention can be a sign of acute kidney injury which may require urgent medical attention. The physiotherapist may be the person to identify this sudden change and may need to call the attention of the ICU physician or the nurse. In assessing the renal system, it is important to note if the patient is catheterised or not, the type of catheter used and the length of catheterisation, as this could potentially be a route of infection.

Other systems to consider include the:

  • Gastro-intestinal system to ensure adequate nutritional support for optimal energy and prevention of muscle wasting (protein supplements)[13]
  • Haematological and immunological systems - awareness of infection, the organism responsible for the infection and the risk of cross-infection between patients and to the ICU team.[13]

Conclusion[edit | edit source]

Assessment of the critically ill patient in the ICU is an ongoing process with continual re-assessment to evaluate the effectiveness of treatment, modify the treatment plan and identify any new problems.[11] Clinically stable patients have the potential to become unstable during or after mobilisation, which highlights the importance of continuously monitoring patients closely in the ICU.[11]


Resources[edit | edit source]

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 Denehy L, Granger CL, El-Ansary D, Parry SM. Advances in cardiorespiratory physiotherapy and their clinical impact. Expert review of respiratory medicine. 2018;12(3):203-15. DOI:10.1080/17476348.2018.1433034
  2. 2.0 2.1 2.2 Lottering M, Van Aswegen H. Physiotherapy practice in South African intensive care units. Southern African Journal of Critical Care. 2016;32(1):11-6.  DOI:10.7196/SAJCC.2016.v32i1.248 
  3. Twose P, Jones U, Cornell G. Minimum standards of clinical practice for physiotherapists working in critical care settings in the United Kingdom: a modified Delphi technique. Journal of the Intensive Care Society. 2019;20(2):118-31. DOI: 10.1177/1751143718807019
  4. 4.0 4.1 4.2 4.3 Gosselink R, Roeseler J. Physiotherapy in critically ill patients. The ESC Textbook of Intensive and Acute Cardiovascular Care. 2015 Feb 26:284.
  5. Çakmak A, İnce Dİ, Sağlam M, Savcı S, Yağlı NV, Kütükcü EÇ, et al. Physiotherapy and Rehabilitation Implementation in Intensive Care Units: A Survey Study. Turkish thoracic journal. 2019;20(2):114. DOI:10.5152/TurkThoracJ.2018.18107  
  6. 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 Main E, Denehy L, editors. Cardiorespiratory Physiotherapy: Adults and Paediatrics E-Book: formerly Physiotherapy for Respiratory and Cardiac Problems. 5th ed. Elsevier Health Sciences; 2016.
  7. 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 7.13 7.14 7.15 Malone DJ, Bishop KL. Acute Care Physical Therapy : A Clinician’s Guide, Second Edition [Internet]. Vol. Second edition. Thorofare, NJ: SLACK Incorporated; 2020 [cited 2021 Mar 5].
  8. 8.0 8.1 Hodgson CL, Tipping CJ. Physiotherapy management of intensive care unit-acquired weakness. Journal of physiotherapy. 2017;63(1):4-10. DOI:10.1016/j.jphys.2016.10.011
  9. Gosselink R, Clerckx B, Robbeets C, Vanhullebusch T, Vanpee G, Segers J. Physiotherapy in the intensive care unit. Neth J Crit Care. 2011;15(2):66-75.
  10. 10.0 10.1 Swaminathan N, Praveen R, Surendran P. The role of physiotherapy in intensive care units: a critical review. Physiotherapy Quarterly. 2019;27(4):1-5. DOI:10.5114/pq.2019.87739
  11. 11.0 11.1 11.2 Ahmad AM. Essentials of physiotherapy after thoracic surgery: What physiotherapists need to know. A narrative review. The Korean journal of thoracic and cardiovascular surgery. 2018;51(5):293. DOI:10.5090/kjtcs.2018.51.5.293
  12. Zhang L, Hu W, Cai Z, Liu J, Wu J, Deng Y, et al. Early mobilization of critically ill patients in the intensive care unit: A systematic review and meta-analysis. PloS one. 2019;14(10):e0223185. DOI:10.1371/journal.pone.0223185
  13. 13.0 13.1 13.2 Comisso I, Lucchini A, Bambi S, Giusti GD, Manici M. Nursing in Critical Care Setting. Switzerland: Springer International Publishing; 2018. DOi:10.1007-978-3-319-50559-6
  14. Vincent JL, Abraham E, Kochanek P, Moore FA, Fink MP. Textbook of Critical Care. 7th ed. Philadelphia: Elsevier; 2017.
  15. Jevon P, Ewens B, Pooni JS. Monitoring the critically ill patient. 3rd ed. Londres: Wiley-Blackwell; 2012.
  16. Crit IQ. Daily Assessment of an ICU patient. Published 3 July 2014. Available from: https://www.youtube.com/watch?v=6eTQ1MxBcGg [last accessed 8 Mar 2021]
  17. MRU: Focus on Teaching & Learning. Advanced Critical Care Nursing:General Assessment. Published 18 June 2018. Available from: https://www.youtube.com/watch?v=JF-94zLg2QQ [last accessed 8 Mar 2021]