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'''Developed by the SAFEMOB Task Force:''' <br> Dr. Elizabeth Dean, Dr. Darlene Reid, Frank Chung, Simone Gruenig, Rosalyn Jones, Jocelyn Ross, Maylinda Urbina, Alison Hoens. | '''Developed by the SAFEMOB Task Force:''' <br> Dr. Elizabeth Dean, Dr. Darlene Reid, Frank Chung, Simone Gruenig, Rosalyn Jones, Jocelyn Ross, Maylinda Urbina, Alison Hoens. | ||
'''A Physical Therapy Knowledge Broker project supported by:''' University of British Columbia Department of Physical Therapy (Faculty of Medicine), Physiotherapy Association of BC, Vancouver Coastal Research Institute and Providence Healthcare Research Institute. | |||
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=== SAFE PRESCRIPTION OF MOBILIZING PATIENTS IN ACUTE CARE SETTINGS === | === SAFE PRESCRIPTION OF MOBILIZING PATIENTS IN ACUTE CARE SETTINGS === | ||
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{| cellpadding="2" border="1" style="border: 1px solid darkgray;" | {| cellpadding="2" border="1" style="border: 1px solid darkgray;" | ||
|- | |- | ||
! scope="col" width="400" style="background: #FFFF9A;" | The Chart | ! scope="col" width="400" style="background: #FFFF9A;" | | ||
! scope="col" width="400" style="background: #FFFF9A;" | The Patient, Family, and Team Member | ===== The Chart ===== | ||
! scope="col" width="400" style="background: #FFFF9A;" | | |||
===== The Patient, Family, and Team Member ===== | |||
|- valign="top" | |- valign="top" | ||
| width="400" style="background: #FFFF9A;" | | | width="400" style="background: #FFFF9A;" | | ||
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<br> | <br> | ||
== When to Consider Not Mobilizing<ref name="Morris 2008">Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine,fckLR2008; 36:2238-43.</ref><ref name="Stiller 2007">Stiller, K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin 2007; 23, 35-53.</ref><ref name="Schweickert 2009">Schweickert WD, Pohlman MC, Pohlman NS Nigos C, Pawlik AJ, Esbrook CL et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: an RCT. Lancet. 2009; 373:1874-82.</ref><ref name="ACSM 2010">ACSM Guidelines for Exercise Testing and Prescription. 8th edition. Lippincott Williams & | == When to Consider Not Mobilizing<ref name="Morris 2008">Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine,fckLR2008; 36:2238-43.</ref><ref name="Stiller 2007">Stiller, K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin 2007; 23, 35-53.</ref><ref name="Schweickert 2009">Schweickert WD, Pohlman MC, Pohlman NS Nigos C, Pawlik AJ, Esbrook CL et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: an RCT. Lancet. 2009; 373:1874-82.</ref><ref name="ACSM 2010">ACSM Guidelines for Exercise Testing and Prescription. 8th edition. Lippincott Williams & Wilkins. Philadelphia 2010 pp.209-10.</ref><ref name="Timmerman 2007">Timmerman, RA. A mobility protocol for critically ill adults. [DIMENS CRIT CARE NURS. 2007; 26(5):175-9.</ref><ref name="Singh 2009">Singh C, Fletcher R, Cunningham K, and Szlivka M. Mobilization with a Deep Vein Thrombosis. Clinical Practice Guideline (DRAFT in process). Fraser Health Authority. 2009.</ref> == | ||
{| cellpadding="2" border="1" style="border: 1px solid darkgray;" | {| cellpadding="2" border="1" style="border: 1px solid darkgray;" | ||
|- | |- | ||
! scope="col" width="400" style="background: #FFC6B9;" | Cardiovascular Status | ! scope="col" width="400" style="background: #FFC6B9;" | | ||
! scope="col" width="400" style="background: #FFC6B9;" | Respiratory Status | ===== Cardiovascular Status ===== | ||
! scope="col" width="400" style="background: #FFC6B9;" | | |||
===== Respiratory Status ===== | |||
|- valign="top" | |- valign="top" | ||
| width="400" style="background: #FFC6B9;" | | | width="400" style="background: #FFC6B9;" | | ||
*'''''Mean arterial pressure''''': <65<ref name="Morris 2008" | *'''''Mean arterial pressure''''': <65<ref name="Morris 2008" /><ref name="Schweickert 2009" /> or >110<ref name="Schweickert 2009" /> | ||
*'''''BP''''': A drop in systolic pressure (>20 mm Hg) or below pre-exercise level OR a disproportionate rise i.e. >200 mm Hg for systolic or >110 mm Hg for diastolic<ref name="ACSM 2010" /> | *'''''BP''''': A drop in systolic pressure (>20 mm Hg) or below pre-exercise level OR a disproportionate rise i.e. >200 mm Hg for systolic or >110 mm Hg for diastolic<ref name="ACSM 2010" /> | ||
*'''''HR''''': <40<ref name="Schweickert 2009" /> or >130<ref name="Schweickert 2009" /><ref name="Timmerman 2007" />; requiring temporary pacer. | *'''''HR''''': <40<ref name="Schweickert 2009" /> or >130<ref name="Schweickert 2009" /><ref name="Timmerman 2007" />; requiring temporary pacer. | ||
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|- | |- | ||
! scope="col" width="400" style="background: #FFC6B9;" | Neurological Status | ! scope="col" width="400" style="background: #FFC6B9;" | | ||
! scope="col" width="400" style="background: #FFC6B9;" | Other | ===== Neurological Status ===== | ||
! scope="col" width="400" style="background: #FFC6B9;" | | |||
===== Other ===== | |||
|- valign="top" | |- valign="top" | ||
| width="400" style="background: #FFC6B9;" | | | width="400" style="background: #FFC6B9;" | | ||
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{| cellpadding="2" border="1" style="border: 1px solid darkgray;" | {| cellpadding="2" border="1" style="border: 1px solid darkgray;" | ||
|- | |- | ||
! scope="col" width="400" style="background: #E1E1FF;" | Subjective | ! scope="col" width="400" style="background: #E1E1FF;" | | ||
! scope="col" width="400" style="background: #E1E1FF;" | Objective | ===== Subjective ===== | ||
! scope="col" width="400" style="background: #E1E1FF;" | | |||
===== Objective ===== | |||
|- valign="top" | |- valign="top" | ||
| width="400" style="background: #E1E1FF;" | | | width="400" style="background: #E1E1FF;" | | ||
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|- | |- | ||
! scope="col" width="400" style="background: #E6FFB3;" | Step 1: Prepare | ! scope="col" width="400" style="background: #E6FFB3;" | | ||
! scope="col" width="400" style="background: #E6FFB3;" | Step 2: Safety First | ===== Step 1: Prepare ===== | ||
! scope="col" width="400" style="background: #E6FFB3;" | | |||
===== Step 2: Safety First ===== | |||
|- valign="top" | |- valign="top" | ||
| width="400" style="background: #E6FFB3;" | | | width="400" style="background: #E6FFB3;" | | ||
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|- | |- | ||
! scope="col" width="400" style="background: #E6FFB3;" | Step 3: When to Quite While You are Still Ahead | ! scope="col" width="400" style="background: #E6FFB3;" | | ||
! scope="col" width="400" style="background: #E6FFB3;" | Step 4: Monitor and Progress | ===== Step 3: When to Quite While You are Still Ahead ===== | ||
! scope="col" width="400" style="background: #E6FFB3;" | | |||
===== Step 4: Monitor and Progress ===== | |||
|- valign="top" | |- valign="top" | ||
| width="400" style="background: #E6FFB3;" | | | width="400" style="background: #E6FFB3;" | | ||
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|} | |} | ||
<br> | <br> | ||
== How to Progress<ref name="Morris 2008" /><ref name="Schweickert 2009" /><ref name="Chung 2009">Chung F, Fletcher R, Lavoie K, Parrent L, Perret D, Roy L, Urbina,M. Members of the physiotherapy professional practice council critical care practice stream for the Fraser Health Authority. Canada. Forthcoming. 2009.</ref><ref name="Bailey 2007">Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007; 35:139-45.</ref><ref name="Collard 2003">Collard HR, Saint S, Matthay MA. Prevention of ventilator-associated pneumonia: an evidence based systematic review. Ann Intern Med. 2003;138:494-501.</ref><ref name="Dodek 2004">Dodek P, Keenan S, Cook D, MD, Heyland D, Jacka M, Hand L et al. Evidence-based clinical practice guideline for the prevention of ventilator associated pneumonia. Ann Intern Med. 2004; 141:305-13.</ref><ref name="Needham 2008">Needham D. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008; 300:1685-90.</ref><ref name="Perme 2009">Perme C, Chandrashekar R. Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care. 2009; 18:212-21.</ref> == | |||
''Continue to monitor vitals to guide progression'' | |||
{| cellpadding="2" border="1" style="border: 1px solid darkgray;" | {| cellpadding="2" border="1" style="border: 1px solid darkgray;" | ||
|- | |- | ||
! colspan="2" scope="row" style="background: #FFFF65;" | | ! colspan="2" scope="row" style="background: #FFFF65;" | | ||
'''Level I''''' | ===== '''Level I<ref name="Morris 2008" />''''' '' ===== | ||
|- | |- | ||
! scope="col" width="400" style="background: #E6FFB3;" | Target Level of Consciousness (RASS) | ! scope="col" width="400" style="background: #E6FFB3;" | Target Level of Consciousness (RASS)<ref name="Sessler 2002" /> | ||
! scope="col" width="400" style="background: #FFE1FF;" | Strength Criteria for Entering this Level | ! scope="col" width="400" style="background: #FFE1FF;" | Strength Criteria for Entering this Level | ||
|- valign="top" | |- valign="top" | ||
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*Keep HOB >30° | *Keep HOB >30° | ||
*Apply splints, other positioning devices as per OT/PT instructions | *Apply splints, other positioning devices as per OT/PT instructions | ||
*Focusing on preventing pressure ulcers, especially on heels and sacrum | *Focusing on preventing pressure ulcers, especially on heels and sacrum | ||
|- | |- | ||
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|- valign="top" | |- valign="top" | ||
| width="400" style="background: #CCECFF;" | | | width="400" style="background: #CCECFF;" | | ||
*PROM | *PROM exercises to incorporate into patient care (e.g. during washing, turns) | ||
*Additional exercise/mobilization as per physio assessment | *Additional exercise/mobilization as per physio assessment | ||
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|- | |- | ||
! colspan="2" scope="row" style="background: #FFFF65;" | | ! colspan="2" scope="row" style="background: #FFFF65;" | | ||
'''Level II''''' | ===== '''Level II<ref name="Morris 2008" />''''' '' ===== | ||
|- | |- | ||
! scope="col" width="400" style="background: #E6FFB3;" | Target Level of Consciousness (RASS) | ! scope="col" width="400" style="background: #E6FFB3;" | Target Level of Consciousness (RASS)<ref name="Sessler 2002" /> | ||
! scope="col" width="400" style="background: #FFE1FF;" | Strength Criteria for Entering this Level | ! scope="col" width="400" style="background: #FFE1FF;" | Strength Criteria for Entering this Level | ||
|- valign="top" | |- valign="top" | ||
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|- valign="top" | |- valign="top" | ||
| width="400" style="background: #CCECFF;" | | | width="400" style="background: #CCECFF;" | | ||
*Encourage | *Encourage patient assist with ROM during patient care (e.g. during washing, turns) | ||
*Consider inclusion of: | *Consider inclusion of: | ||
**Breathing exercises | **Breathing exercises | ||
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|- | |- | ||
! colspan="2" scope="row" style="background: #FFFF65;" | | ! colspan="2" scope="row" style="background: #FFFF65;" | | ||
'''Level III''''' | ===== '''Level III<ref name="Morris 2008" />''''' '' ===== | ||
|- | |- | ||
! scope="col" width="400" style="background: #E6FFB3;" | Target Level of Consciousness (RASS) | ! scope="col" width="400" style="background: #E6FFB3;" | Target Level of Consciousness (RASS)<ref name="Sessler 2002" /> | ||
! scope="col" width="400" style="background: #FFE1FF;" | Strength Criteria for Entering this Level | ! scope="col" width="400" style="background: #FFE1FF;" | Strength Criteria for Entering this Level | ||
|- valign="top" | |- valign="top" | ||
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|- valign="top" | |- valign="top" | ||
| width="400" style="background: #CCECFF;" | | | width="400" style="background: #CCECFF;" | | ||
*Encourage | *Encourage patient assist with ROM with more active involvement | ||
*Breathing, stretching, and balance/coordination exercises as prior with more active involvement | *Breathing, stretching, and balance/coordination exercises as prior with more active involvement | ||
*Consider inclusion of arm ergometry | *Consider inclusion of arm ergometry | ||
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*Initially OD, progress to BID as patient tolerates | *Initially OD, progress to BID as patient tolerates | ||
*As per physio assessment of patient strength, assist physio with sit to stand, walking in place; +/- walker | *As per physio assessment of patient strength, assist physio with sit to stand, walking in place; +/- walker | ||
*Patients with neuro/ortho status precluding | *Patients with neuro/ortho status precluding weight-bearing require individualized mobilization prescription | ||
|} | |} | ||
{| cellpadding="2" border="1" style="border: 1px solid darkgray;" | {| cellpadding="2" border="1" style="border: 1px solid darkgray;" | ||
|- | |- | ||
! colspan="2" scope="row" style="background: #FFFF65;" | | ! colspan="2" scope="row" style="background: #FFFF65;" | | ||
'''Level IV''''' | ===== '''Level IV<ref name="Morris 2008" />''''' '' ===== | ||
|- | |- | ||
! scope="col" width="400" style="background: #E6FFB3;" | Target Level of Consciousness (RASS) | ! scope="col" width="400" style="background: #E6FFB3;" | Target Level of Consciousness (RASS)<ref name="Sessler 2002" /> | ||
! scope="col" width="400" style="background: #FFE1FF;" | Strength Criteria for Entering this Level | ! scope="col" width="400" style="background: #FFE1FF;" | Strength Criteria for Entering this Level | ||
|- valign="top" | |- valign="top" | ||
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| width="400" style="background: #CCECFF;" | | | width="400" style="background: #CCECFF;" | | ||
*Q2H | *Q2H | ||
*Focus on training to promote | *Focus on training to promote patient's independence | ||
| width="400" style="background: #CCECFF;" | | | width="400" style="background: #CCECFF;" | | ||
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|} | |} | ||
<br> | Q2H = Every 2 Hours; HOB = Head of Bed; BID = Twice daily; TID = Three times daily; OD = Once daily | ||
<br> | |||
== Richmond Agitation Sedation Scale (RASS)<ref name="Sessler 2002">Sessler CN, Gosnell M, Grap MJ, Brophy GT, O'Neal PV, Keane KA et al. The Richmond Agitation Sedation Scale: validity and reliability. Am J Respir Crit Care Med 2002; 166:1338-44.</ref> == | |||
{| style="text-align: left; width: 100%;" border="0" cellpadding="1" cellspacing="1" | |||
|- | |||
| style="width: 10px; height: 25px;" | +4 | |||
| style="width: 300px; height: 25px;" | Combative; violent, immediate danger to staff | |||
|- | |||
| style="width: 10px; height: 25px;" | +3 | |||
| style="width: 300px; height: 25px;" | Very agitated; pulls or removes tubes/lines; aggressive | |||
|- | |||
| style="width: 10px; height: 25px;" | +2 | |||
| style="width: 300px; height: 25px;" | Agitated; frequent non-purposeful movement, fights ventilator | |||
|- | |||
| style="width: 10px; height: 25px;" | +1 | |||
| style="width: 300px; height: 25px;" | Restless; anxious but movement not aggressive or vigorous | |||
|- | |||
| style="width: 10px; height: 25px;" | 0 | |||
| style="width: 300px; height: 25px;" | Alert and calm | |||
|- | |||
| style="width: 10px; height: 25px;" | -1 | |||
| style="width: 300px; height: 25px;" | Drowsy; not fully alert, sustained wakening (eye-opening/contact) to voice >10 sec | |||
|- | |||
| style="width: 10px; height: 25px;" | -2 | |||
| style="width: 300px; height: 25px;" | Light sedation; briefly awakens with eye contact to voice <10 sec | |||
|- | |||
| style="width: 10px; height: 25px;" | -3 | |||
| style="width: 300px; height: 25px;" | Moderate sedation; Movement or eye opening to voice but no eye contact | |||
|- | |||
| style="width: 10px; height: 25px;" | -4 | |||
| style="width: 300px; height: 25px;" | Deep sedation; No response to voice but movement or eye opening to physical stimulation | |||
|- | |||
| style="width: 10px; height: 25px;" | -5 | |||
| style="width: 300px; height: 25px;" | Unarousable; No response to voice or physical stimulation | |||
|} | |||
<br> | |||
== References == | == References == | ||
<references /> | <references /> | ||
[[Category:Acute Care]] | |||
[[Category:Older People/Geriatrics]] | |||
[[Category:Assessment]] | |||
[[Category:PT Knowledge Broker Project]] |
Latest revision as of 13:38, 15 February 2022
Developed by the SAFEMOB Task Force:
Dr. Elizabeth Dean, Dr. Darlene Reid, Frank Chung, Simone Gruenig, Rosalyn Jones, Jocelyn Ross, Maylinda Urbina, Alison Hoens.
A Physical Therapy Knowledge Broker project supported by: University of British Columbia Department of Physical Therapy (Faculty of Medicine), Physiotherapy Association of BC, Vancouver Coastal Research Institute and Providence Healthcare Research Institute.
SAFE PRESCRIPTION OF MOBILIZING PATIENTS IN ACUTE CARE SETTINGS[edit | edit source]
What to Assess, What to Monitor, When not to Mobilize, and How to Mobilize and Progress
Purpose, Scope, & Disclaimer[edit | edit source]
The purpose of this document is to provide physical therapists with guidance on safe mobilization of the patient in acute care settings. This decision-making guide is evidence informed and where there is insufficient evidence, expert informed. It is not intended to replace the clinician’s clinical reasoning skills and interprofessional collaboration. Mobilization, for the purposes of this document, has been defined as “To work towards the functional task of locomotion”.
What to Assess[edit | edit source]
The Chart[edit | edit source] |
The Patient, Family, and Team Member[edit | edit source] |
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When to Consider Not Mobilizing[1][2][3][4][5][6][edit | edit source]
Cardiovascular Status[edit | edit source] |
Respiratory Status[edit | edit source] |
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Neurological Status[edit | edit source] |
Other[edit | edit source] |
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- Please note: The cited values are not absolute criteria for withholding mobilization but are within the range of concern that could benefit from team discussion.
What to Consider During Mobilization[edit | edit source]
Subjective[edit | edit source] |
Objective[edit | edit source] |
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How to Mobilize and Progress[7][edit | edit source]
Step 1: Prepare[edit | edit source] |
Step 2: Safety First[edit | edit source] |
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Step 3: When to Quite While You are Still Ahead[edit | edit source] |
Step 4: Monitor and Progress[edit | edit source] |
|
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How to Progress[1][3][8][9][10][11][12][13][edit | edit source]
Continue to monitor vitals to guide progression
Level I[1] [edit | edit source] | |
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Target Level of Consciousness (RASS)[14] | Strength Criteria for Entering this Level |
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Turning & Bed Mobility | Positioning & Devices |
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Exercise Program | Mobilization |
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Level II[1] [edit | edit source] | |
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Target Level of Consciousness (RASS)[14] | Strength Criteria for Entering this Level |
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Turning & Bed Mobility | Positioning & Devices |
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Exercise Program | Mobilization |
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Level III[1] [edit | edit source] | |
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Target Level of Consciousness (RASS)[14] | Strength Criteria for Entering this Level |
|
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Turning & Bed Mobility | Positioning & Devices |
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Exercise Program | Mobilization |
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Level IV[1] [edit | edit source] | |
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Target Level of Consciousness (RASS)[14] | Strength Criteria for Entering this Level |
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Turning & Bed Mobility | Positioning & Devices |
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Exercise Program | Mobilization |
|
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Q2H = Every 2 Hours; HOB = Head of Bed; BID = Twice daily; TID = Three times daily; OD = Once daily
Richmond Agitation Sedation Scale (RASS)[14][edit | edit source]
+4 | Combative; violent, immediate danger to staff |
+3 | Very agitated; pulls or removes tubes/lines; aggressive |
+2 | Agitated; frequent non-purposeful movement, fights ventilator |
+1 | Restless; anxious but movement not aggressive or vigorous |
0 | Alert and calm |
-1 | Drowsy; not fully alert, sustained wakening (eye-opening/contact) to voice >10 sec |
-2 | Light sedation; briefly awakens with eye contact to voice <10 sec |
-3 | Moderate sedation; Movement or eye opening to voice but no eye contact |
-4 | Deep sedation; No response to voice but movement or eye opening to physical stimulation |
-5 | Unarousable; No response to voice or physical stimulation |
References[edit | edit source]
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine,fckLR2008; 36:2238-43.
- ↑ 2.0 2.1 Stiller, K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin 2007; 23, 35-53.
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 Schweickert WD, Pohlman MC, Pohlman NS Nigos C, Pawlik AJ, Esbrook CL et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: an RCT. Lancet. 2009; 373:1874-82.
- ↑ 4.0 4.1 ACSM Guidelines for Exercise Testing and Prescription. 8th edition. Lippincott Williams & Wilkins. Philadelphia 2010 pp.209-10.
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Timmerman, RA. A mobility protocol for critically ill adults. [DIMENS CRIT CARE NURS. 2007; 26(5):175-9.
- ↑ 6.0 6.1 Singh C, Fletcher R, Cunningham K, and Szlivka M. Mobilization with a Deep Vein Thrombosis. Clinical Practice Guideline (DRAFT in process). Fraser Health Authority. 2009.
- ↑ Reid WD, Chung F. Clinical management notes and case histories in cardiopulmonary physical therapy. New Jersey: Slack; 2004.
- ↑ Chung F, Fletcher R, Lavoie K, Parrent L, Perret D, Roy L, Urbina,M. Members of the physiotherapy professional practice council critical care practice stream for the Fraser Health Authority. Canada. Forthcoming. 2009.
- ↑ Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007; 35:139-45.
- ↑ Collard HR, Saint S, Matthay MA. Prevention of ventilator-associated pneumonia: an evidence based systematic review. Ann Intern Med. 2003;138:494-501.
- ↑ Dodek P, Keenan S, Cook D, MD, Heyland D, Jacka M, Hand L et al. Evidence-based clinical practice guideline for the prevention of ventilator associated pneumonia. Ann Intern Med. 2004; 141:305-13.
- ↑ Needham D. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008; 300:1685-90.
- ↑ Perme C, Chandrashekar R. Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care. 2009; 18:212-21.
- ↑ 14.0 14.1 14.2 14.3 14.4 Sessler CN, Gosnell M, Grap MJ, Brophy GT, O'Neal PV, Keane KA et al. The Richmond Agitation Sedation Scale: validity and reliability. Am J Respir Crit Care Med 2002; 166:1338-44.