Page 134 - ACCCN's Critical Care Nursing

Essential Nursing Care of the Critically Ill Patient 111

moved, patients who are in critical care for a long time, assessment, which should include a visual and physical
elderly and frail or malnourished patients, and patients assessment of all limbs and joints. Provided there are no
who are unable to move themselves (e.g. due to sedation, contraindications, function should be stimulated by
trauma, surgery or obesity) are all at risk. Batson et al. regular passive then active movements of all limbs and
identified several significant risk factors: patients receiv- joints to maintain both flexibility and comfort (see
ing adrenaline and/or noradrenaline infusions; patients below).
with restricted movement; and diabetic and unstable
57
patients. However, even previously fit patients who
experience a critical illness can develop severe limitations
in their mobility. The common short- and long-term Practice tip
complications of immobility are pressure ulcers, venous From the perspective of patient comfort, even small re-
thromboembolism and pulmonary dysfunction, each of adjustments in positioning may be advantageous, and often
which carries a significant co-morbidity. 56 can be made without much effort by the nurse or disturbance
to the resting patient. Most electric beds provide for adjust-
POSITIONING AND MOBILISING PATIENTS ments to the backrest angle, knee bend and bed tilt and adjust-
Positioning the patient to achieve maximum comfort, ments can be easily made. In addition to comfort, these
therapeutic benefit and pressure area relief and employ- adjustments will aid in pressure changes between re-positioning
ing active and passive exercises to maintain muscle and of the patient.
joint integrity and progress to regaining mobility are
important nursing activities. Provided there are no spe-
cific contraindications, the immobile patient should be
positioned with the head raised by 30 degrees or more,
58
as research has demonstrated that it improves mortality Practice tip
59
and helps reduce ventilator-associated pneumonia.
When combined with thromboembolic pro phylaxis, When planning to reposition the patient, ensure that there are
gastric ulcer prophylaxis and daily sedation assessment, enough staff to give the patient a feeling of security during the
ventilator-associated pneumonia may be reduced by procedure and that all the patient’s devices (e.g. IV lines) are
59
around 45%. Good body positioning and alignment managed. Check that all devices are placed to accommodate
helps prevent muscle contracture, pressure ulcers and the repositioning before you begin to move the patient.
unnecessary pain or discomfort for the patient. 60,61
Mobilisation for the critically ill patient can be described
as a graduated increase in range of activity from position- Active and Passive Exercises
ing, passive movement, sitting upright in bed, sitting in It takes only seven days of bed rest to reduce muscle mass
a chair to actually ambulating. 49-51,53 Stiller describes a by up to 30%, and physical activity is essential to healthy
64
62
range of safety factors that need to be considered prior to functioning and beneficial for the cardiovascular system.
54
mobilising the critically ill patient, which fall into two Active exercises are those that can be performed by the
groups; those specific to the patient and their physical patient with no, or minimal, assistance. Passive exercises
and physiological condition, and those extrinsic to the are performed when patients are either too weak or inca-
patient such as the environment, staffing and patient pable of active exercise. Exercises can be employed to help
devices attached. Creating an individualised mobility the recovering patient develop power and regain func-
plan which can be adapted according to patient assess- tion, to assist in venous return and maintain the normal
ment and general health progress, will optimise early sensation of movement. They should be performed at
64
movement and mobilisation. 53,54,62,63 least daily. Passive exercises put the main joints through
their range of movement, which helps reduce joint stiff-
Regular musculoskeletal assessment should be made,
focusing on the patient’s major muscles and joints and ness and maintain muscle integrity, preventing contrac-
the degree of mobility. Table 6.5 offers a simple guide to tures. Shoulders, hands, hips and ankles are particularly
64
at risk of stiffness and muscle contracture. It is impor-
tant, however, to ensure that joints and muscles are not
overstretched, as this is painful for patients and can cause
permanent injury. Splints may be used when the patient
64
is resting, to maintain joints in a neutral position. The
TABLE 6.5 Musculoskeletal assessment physiotherapist’s advice should be sought regarding the
correct range of movement and the frequency of passive
Muscles and joints Mobility exercises. This is particularly important for burn-injured
patients. Concern has been expressed about the effects of
● Power/strength ● Degree of independence limb movements on head-injured patients; however,
● Range of movement ● Need for assistance 65
● Symmetry ● Adherence/compliance with Koch et al. detected no significant cardiovascular or
● Tenderness and pain physiotherapy/mobility neurological changes during passive exercises in neuro-
● Inflammation, swelling, regimen surgical patients, and Brimioulle et al. found no detri-
65
wasting ● Need for planned rest periods mental effects on cerebral perfusion or intracranial
● Use of splints or collar 66
pressure (ICP), whether the ICP was raised or not.