Page 80 - ACCCN's Critical Care Nursing

Recovery and Rehabilitation 4

Doug Elliott
Janice Rattray

reconsideration and re-conceptualisation of critical care
Learning objectives as only one component in the continuum of care for a
critically ill patient. An episode of critical illness is now
After reading this chapter, you should be able to: viewed as a continuum that begins with the onset of acute
● discuss the physical, psychological and cognitive sequelae clinical deterioration, includes the ICU admission, and
present for some survivors of a critical illness continues until the patient’s risk of late sequelae has
● outline the common functional, psychological and returned to the baseline risk of a similar individual who
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health-related quality of life (HRQOL) instruments used to has not incurred a critical illness (see Figure 4.1). Timing
assess patient outcomes after a critical illness of this recovery trajectory is variable, and related to a
● describe the benefits and challenges for implementing number of individual, illness and treatment factors.
rehabilitation interventions in-ICU, in hospital after Reviews of numerous observational studies confirm
ICU-discharge, and after hospital discharge delayed recovery in HRQOL, e.g.3-5 with both physical and
psychological symptoms prevalent:
6
● weakness: 46% ; 25–60% in patients ventilated
>7 days 10
● delirium: up to 67% 11
Key words ● anxiety: 12–43% 12
● depression: median 28% 13
cognitive dysfunction ● posttraumatic stress symptoms: 5–64% 14
health-related quality of life (HRQOL) The effects of a critical illness on cognitive functioning
intensive care unit-acquired weakness (ICU-AW) are now also beginning to be examined and discussed in
posttraumatic stress symptoms the literature as an important patient outcome. 11,15-19
psychological sequelae While significant sequelae therefore exist for a substantial
proportion of critical illness survivors, little evidence is
currently available to support specific interventions for
improving their recovery. 9,20
INTRODUCTION A further and more recent re-conceptualisation of holistic
critical care practice promotes a unifying approach for
A critical illness requiring admission to a general inten-
sive care unit (ICU) affects approximately 113,000 adults minimising intensive care unit acquired weakness (ICU-
11,21
1
in Australia and 17,000 in New Zealand per year. AW) and delirium, reflected in the acronym ABCDE,
Although survival rates approximate 89% at hospital dis- to minimise physical, psychological and cognitive
2
charge, functional recovery for individuals is delayed sequelae:
3-5
often beyond six months post-discharge. Physical A Awaken the patient daily
6,7
de-conditioning and neuromuscular dysfunction as B Breathing trials (to minimise mechanical ventila-
8
well as psychological sequelae are common, adding to tion duration)
the burden of illness for survivors, carers, the health care C Coordination (of daily awakening and spontane-
system and broader society. 9 ous breathing trials) 22
D Delirium monitoring
While ICU clinicians have traditionally focused on sur-
vival as the principal indicator of patient outcome and E Exercise/Early mobility (requires a patient to be
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unit performance, physical and psychological function- awake, alert and co-operative).
ing and health-related quality of life (HRQOL) have now Further chapters in this book discuss psychological issues
emerged as legitimate patient outcomes from both prac- including sedation management and delirium monitor-
4
tice and research perspectives. With this shifting focus ing while in ICU (Chapter 7), and breathing trials and
towards long-term health and wellbeing has also come a weaning from mechanical ventilation (Chapter 15). This 57