Role of physiotherapists in ICU Care with bed ridden patients

Professor of Anaesthesia MRI Alex. University

E mail: saharelkaradawy@yahoo.com

They are responsible for providing patients with rehabilitation regimens.

Decrease incidence of complications. Decrease ICU stay. Decrease cost.

Role of physiotherapist in ICU

Risk factor for immobilisation in ICU Disadvantages of immobility Pressure sores in critically ill patients Prevention of bed sores Treatment of bed sores

Objectives

The musculoskeletal system is designed to keep moving; it takes only seven days of bed rest to reduce muscle bulk by up to 30%.

Immobilisation and muscle weakness

Any serious problems: Neurological deficit, and general debilitation

and weakness. Polyneuropathy or myopathy after the acute

phase of multiple organ dysfunction. Patients with severe congestive heart failure. Respiratory faliure. Myocardial infarction Controlled ventilation and administration of

sedative and neuromuscular blocking agents.

Causes of immobilisation in ICU

Cardiovascular Venous stasis Increased risk of venous thrombosis pulmonary embolism RespiratoryDecreased functional residual capacityDecreased lung complianceRetained secretionsAtelectasis

Disadvantages of immobility

Metabolic Increased excretion of nitrogen, calcium,

potassium, magnesium, and phosphorusOsteoporosisKidney stonesGastrointestinal tractLack of digestionconstipation

Disadvantages of immobility

MusculoskeletalDecrease in muscle bulkLoss of bone densityDecreased range of joints movementPressure sores

Disadvantages of immobility

Encourage active movement in the bed. active assisted movement passive movements (shoulders, hands, hips,

and ankles ) to avoid contractures.

Role of physiotherapists

Patients do not move regularly develop pressure sores on dependent areas.

The most vulnerable areas are the tissues over bony prominences.

The cost to heal a single full-thickness pressure sore may be as high as 70,000 dollars.

Bed sores

Pressure is exerted on surface beneath ( pressure points).

These pressures are often in excess of capillary filling pressure (approximately 32 mm Hg).

prolonged exposure to pressures just slightly above capillary filling pressure initiates a series leads to tissue necrosis and ulceration.

Pathophysiology

Shear forces and friction aggravate the effects of pressure and are important components of the mechanism of injury

Maceration may occur in a patient who has incontinence, predisposing the skin to injury

Pathophysiology

Suspected Tissue Injury:

This stage is described as a "purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear."

Stages of bed sores

Stage I: intact skin with signs of

impending ulceration. Initially there is

blanchable erythema indicating reactive hyperemia.

Reactive hyperemia should resolve within 24 hours of the relief of pressure.

Finally, the skin may appear white from ischemia.

Stages of bed sores

Stage II: A partial-thickness

loss of skin involving epidermis and dermis that appears as an open shallow ulcer with a pink wound bed.

Stages of bed sores

Stage III: A full-thickness loss of

skin with extension into subcutaneous tissue but not through the underlying fascia. This lesion presents as an ulcer that may include undermining and tunneling of adjacent tissue. Bone, tendon, and fascia are not exposed.

Stages of bed sores

Stage IV: full-thickness tissue

loss with extension into muscle, bone, tendon, or joint capsule. Slough or eschar may be present in the wound. Osteomyelitis with bone destruction and dislocations or pathologic fractures may be present.

Stages of bed sores

Inability to move Muscle wasting Depressed cardiac function Malnutrition, hypoproteinemia Incontinence or presence of a fistula

contributes to ulceration in several ways.

Factors increase developing pressure sores in critically ill patients

Turn or ask patients to turn every 2 hours. Skin lubricant Avoid hypoxia Active or passive exercise to enhance blood

supply good nutrition.

Prevention of bed sores

Management of pressure ulcers relies on key principles, including:

pressure reduction, adequate debridement of necrotic and

devitalized tissue, control of infection, and meticulous wound

care.

Management of bed sores

Pressure reduction Turning and repositioning the patient

remains the cornerstone of prevention and treatment through pressure relief.

Repositioning should be performed every 2 hours, even in the presence of a specialty surface or bed.

Patients who are bed ridden should be positioned at a 30 degree angle when lying on their side to minimise pressure over the ischial tuberosity and greater trochanter.

management

Use specialized surfaces for bed and wheelchair; foam mattress, air-filled mattress, water-filled mattress, gel-filled mattress.

Give over care for pressure points of the body

Relieve skin pressure by changing position or being positioned so that pressure is taken off a bony area.

RELIEVE SKIN PRESSURE FROM THE FOOT

Head: Small, foam support under head.

Hips: Pad placed above and below the hip joint. When pads are placed correctly, a flat hand can be slid between the body and the bed to be certain that pressure has been relieved.

Ankle: Pad placed above the ankle joint

Between Lower Legs: Pillow placed lengthwise between legs to prevent pressure on the knees and ankle joint.

Side Position Padding

Head: Small, foam support under the head.

Back: Place pad under lower back to provide elevation of the sacrum

Knees: The bend at the knee is a natural curvature. Use a pad above the area behind the knee.

Ankles: A small pad is necessary at the back of the heel to relieve tension on the calf of the leg.

Heels must be off the bed to prevent skin breakdown.

Between Lower Legs: Foam pad or pillow placed between the knees to present possible breakdown at the knee and ankle joints.

Supine (Back) Position Padding

Head: Small, foam support under head.

Chest: Use one or more pillows according to comfort.

Thighs: Foam pads placed above the knees to prevent redness of knees

Between Knees: Pads placed between knees to keep knees and ankles apart so pressure sores do not develop.

Prone Position Padding

Weight reduction is the most essential technique for preventing pressure on the skin and muscle of the sacrum and each hip

Cushions: Air, foam, gel or fluid A cushion for wheelchair is essential.

Cushions provide pressure relief and weight distribution and thus aid in the prevention of pressure sores

RELIEVE SKIN PRESSURE IN A WHEEL CHAIR

The third way to prevent skin sores, the most serious problem in SCI, is to keep skin healthy.

Health skin is skin which is intact, well lubricated with natural oils, and nourished by a good blood supply.

Skin stays healthy with good diet, good hygiene, regular skin inspection, and regular pressure relief.

Take Routine Care of Your Skin

Nutritional status should be evaluated and optimized to ensure adequate intake of calories, proteins, and vitamins.

Cessation of smoking, adequate pain control, maintenance of adequate blood volume, and correction of anemia.

The wound must be kept clean and free of urine and feces

Other treatment

Bacterial contamination must be assessed and treated appropriately.

Wound dressings: the goal is to achieve a clean, healing

wound with granulation tissue. A stage I lesion may not require dressing.

Wound debridement

Other treatment

Christian N Kirman, Lars M Vistnes Pressure Ulcers, Nonsurgical Treatment and Principles Treatment & Management. Medscape 2010

Sheila Adam, Sally Forrest Clinical ReviewABC of intensive care, Other supportive

care BMJ 319 : 175 (Published 17 July 1999)

References

Thank you