Page 92 - ACCCN's Critical Care Nursing

Recovery and Rehabilitation 69

BOX 4.1 Purpose of an intensive care TABLE 4.7 Sample clinic assessment tool
follow-up service
Subject area Rationale
● Review and assess patient progress
● Early identification of problems and refer to appropriate General health Assessed on a linear analogue or forced
choice response to elicit a patient’s
specialties where necessary subjective account of how they view
● Coordinate care their general health and how it has
● Support a rehabilitation program changed since critical illness
● Discuss the intensive care experience and offer patient the Medications Review of medications commenced during
opportunity to comment on care the critical illness and continued
● Offer patient opportunity to visit the ICU post-discharge, with advice provided to
146
● Provide a forum for relatives to ask questions the patient’s General Practitioner
● Use information to inform delivery of intensive care Movement and Assess mobility problems, often due to
mobility, continuing fatigue and weakness, but
household also perhaps joint problems; 190,191
management identify impact on daily activities 109,192,193
and joints
Common practice is to invite patients to attend a first Breathing and Breathlessness is common after critical
192
clinic appointment approximately 2–3 months after dis- tracheostomy illness and there are a number of
charge from intensive care or hospital, although timing potential difficulties post-tracheostomy;
has to be flexible given the length of hospital stay for these can be identified and the patient
referred to the appropriate specialist
152
some patients. For many, one appointment is sufficient,
but others have continuing problems and may need to Sleep and eating Sleep and concentration disturbances are
return on a number of occasions. Some clinics routinely common, and muscle loss and weakness
are important contributors to delayed
offer return appointments up to one year after discharge, recovery 109
determined on an individual patient basis. Attendance 192,194
can be problematic; only 70–90% in some studies. 146,153 Urology/ Patients may have sexual problems
192
reproduction,
and skin and nail problems
Non-attendance can occur because a patient has no iden- skin and senses
tified problems (shorter ICU LOS; less ill); or more
importantly because of individual limitations (limited Recreation, work Patients may experience difficulties
and lifestyle
reintegrating into society and in
mobility; living a distance away from the clinic, or signifi- change particular returning to work 192
cant post-traumatic stress symptoms including avoidant
behaviours). 153 Intensive care Patients rarely remember factual events of
experience
their time in ICU, but their memories are
While these services developed in a relatively ad hoc often of unpleasant and disturbing
54,58,85
manner, tended to be underfunded and used a variety of events; offering an opportunity to
discuss actual events and sometimes
models in their delivery, the purposes for such a service distressing memories can be
are similar (see Box 4.1). beneficial 152
Quality of life The ultimate aim of treatment and care is
Clinic Activities to return a patient to an acceptable and
Patient progress is reviewed for identification of subse- optimal quality of life; it is important to
gauge how patients perceive their life
quent problems, and timely referral to appropriate ser- quality, and may identify areas for
vices for further treatment. A major advantage of follow-up practice improvement 53
clinics is the increased understanding of patient recovery,
as a range of physical and psychological assessments can
be conducted (see an example in Table 4.7). Content of
assessment is informed by the understanding and knowl- status can also be assessed using a number of neuro-
edge of the problems patients commonly face during cognitive tests including Ravens Progressive Matrices,
their recovery period. Critical care and rehabilitation Hayling Sentence and the Six Element test. The issue of
77
staff, however, need to ensure that issues are not ‘prob- respondent burden must be considered and question-
lematising’ for aspects of recovery that is not of concern naire fatigue recognised. This can be managed in part by
to the patient. asking patients to bring completed questionnaires with
them to the clinic appointment. Administration, scoring
Content of an assessment tool structures the clinic visit and interpretation of questionnaires must also be
and identifies any patient problems. These assessments managed in accordance with instrument guidelines.
can include the use of standardised questionnaires of
HRQOL and psychological status, and other free-text Referral to appropriate specialties using a systematic
responses that incorporate patient comments and other approach and timely response times are necessary, as
issues. Use of standardised questionnaires is however other healthcare professionals will not usually be present
151
inconsistent which limits evaluation and comparisons when patients attend the clinic. Delays in treatment fol-
of clinic outcomes. Common examples of questionnaires lowing identification of significant post-traumatic symp-
were previously listed in Tables 4.1 and 4.3. Cognitive tomatology can result in PTSD that is enduring and lasts