Physiotherapy Assessment of the Patient in ICU

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Top Contributors - Merinda Rodseth, Kim Jackson, Jess Bell, Tarina van der Stockt, Uchechukwu Chukwuemeka and Lucinda hampton  

Introduction

Physiotherapy is an essential component in the management of patients admitted to the intensive care unit (ICU) (Denehy 2018, Lottering 2016). 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 (Denehy 2018, Twose 2019). Studies have found deconditioning (specifically muscle weakness) and not pulmonary function, to be key to impaired functional status following ICU stay (Gosselink 2014). 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, optimize clearance of secretions) in critically ill patients (Gosselink 2014, Main 2016, Cakmak 2019). In order to achieve this, a valid and accurate evaluation of respiratory conditions, deconditioning and related problems is therefore essential (Gosselink 2014). Detailed and regular assessments by the physiotherapist also ensure that patients in the ICU receive the most appropriate physiotherapy treatment relevant to their condition which is also appropriately progressed.

Assessment of the critically ill patient incorporates three major categories:(Malone Daniel 2020)

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 (Malone 2020). History taking should include:

• 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 (Malone 2020)

• 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 (ie person, place and time) of the patient as this will impact the physiotherapy intervention (Malone 2020, Hodgson 2017).

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 (Malone 2020). 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  (Malone 2020, Main 2016). 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) (Malone 2020, Nordon-Craft et al., 2011, ). Evaluation of the various systems of the body lies central to the assessment of the patient in ICU and is commonly known as the multi-systems approach.

Multi-systems Approach to Assessment

The physiotherapy assessment of the critically ill patient is informed by deficiencies at a physiological and functional level as opposed to the medical diagnosis (Gosselink 2014, 2011). Assessment, therefore, includes an in-depth multisystem 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 alert to patient deterioration (Denehy 2018, Lottering 2016).

Cardiovascular system

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 (Malone 2020, Main 2016). It is important to also review the cardiac trends over the 12-24 hours preceding the physiotherapy assessment in order to establish the true picture of the patient (Maline 2020). Circulation, ventilation and respiration are often assessed concurrently as cardiovascular and respiratory conditions present with similar signs and symptoms (Malone 2020).

Respiratory system

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 (Lottering 2016, Swaminathan 2019). These complications are even more pronounced in mechanically ventilated patients (Swaminathan 2019). The functioning of the respiratory system is best assessed by analysing measures of oxygenation and ventilation, including oxygen saturation and arterial blood gases (Main 2016). 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 (Main 2016). 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 (Denehy 2018, Ahmad 2018, Main 2016). 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 (Main 2016).

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) (main 2016). 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. (main 2016)

Neurological system

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)) (Main 2016). 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 (Main 2016). Any of these signs signal the urgent referral for a CT or MRI scan (Main 2016).

Muskuloskeletal system

Prolonged bed rest leads to decreased skeletal muscle strength (including diaphragm strength) and poor endurance of patients and when combined with critical illness it results in ICU-acquired weakness which has long-term repercussions for patients beyond discharge from the ICU (Zhang 2019, Comisso 2018, Vincent 2017, Hodgson 2017). Assessment of the musculoskeletal system should therefore include evaluation of the 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). (malone 2020). 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) (malone 2020). Assessing the patient’s functional strength will guide the need for further testing and the potential need for ambulatory aids (malone 2020).

Integumentary system

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 eg corticosteroids), poor nutrition, prolonged bed rest and general age-related changes can lead to more fragile skin which is also more prone to breakdown (Malone 2020). 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 (malone 2020). Skin lesions can be prevented by frequently changing the position of the patient, especially with activities out of the bed (malone 2020).

Renal system

Measurement of fluid balance including urine output is important as it affects the consistency of the patient’s secretions as well as the cardiac output (Main 2016, Jevon 2012).  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 catheterized or not, the type of catheter used and the length of catheterization, 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) (Comisso 2018)
• 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 (Comisso 2018).

Conclusion

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 (Ahmad 2018). Clinically stable patients have the potential to become unstable during or after mobilisation which stresses the importance of continuously monitoring patients closely in the ICU (Ahmad 2018).

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