i bc27f85be50b71b1 (235 page)

incontinence. Decreased glomerular filtration rate.

Endocrine

Altered temperature and swearing responses, circadian

rhythm, regulation of hormones, and impaired

glucose intolerance.

Musculoskeletal

Muscle: increased muscle weakness (especially in

antigraviry muscles), atrophy, risk of contracture,

weakened myotendinous junction, and altered muscle

excitation. Bone: osteoporosis. Joints: degeneration

of cartilage, synovial atrophy, and ankylosis,

Neurologic

Sensory and sleep deprivation. Decreased balance,

coordination, and visual acuiry. Increased risk of

compression neuropathy.

Neurovascular

Orthostatic hyporension.

Body composition

Increased calcium, potassium, phosphorus, sulfur, and

nitrogen loss; increased body fat and decreased lean

body mass.

Vozmax = maximum oxygen uptake.

Source: Adapted from RM Buschbacher, CD Porter. Decondirioning, Conditioning, and

the Benefits of Exercise, In RL Braddom (ed), Physical Medicine and Rehabilitation

(2nd ed). Philadelphia: W.B. Saunders, 2000;704.

APPENDIX [-B: AClITE CARE SEITING

755

tions, medical-surgical prognosis, and quality of life as well as personal values and beliefs.' End-of-life issues facing patients, family, and caregivers include the following:

Decisioll to Declare Resuscitatioll Status as Do Not Resuscitate

or Do Not bltl/bate

Do 1I0t resuscitate (DNR) is the predetermined decision to decline cardiopulmonary resuscitation, including defibrillation and pharmacologic cardioversion in case of cardiorespiratory arrest. Do not intubate (DNl)

is the predetermined decision to decline intubation for the purpose of

sub equem mechanical ventilation in case of respiratOry arrest. DNR or

DNl status is officially documented in the medical record by the attending physician. The physical therapist must be aware of each patient's resuscitation or "code" status. DNRlDNI orders do nOt directly impact

on the physical therapy plan of care.

Withholdillg alld Withdrawillg Medical Therapies

Withholdillg sup/lort is not initiating a therapy for the patient,

whereas withdrawillg sup/lort is the discontinuation of a therapy

(usually after it has proven un beneficial to the patient).6 Forgoillg

therapy is the combination of withholding and withdrawing suppOrt

in which disease progression is allowed to take its course.6 In the case

of forgoing medical-surgical therapies, an order for "comfort measures only" (CMO) is written by the physician. The patient with comfort measures only status receives medications for pain control or sedation, or to otherwise eliminate distress. The patient on comfort

measures only status does not receive physical therapy.

Collta, Persistellt Vegetative State, alld Brain Death

The diagnosis of coma, persistent vegetative state, or brain death can be

devastating. These conditions are very similar in that there is unconsciousness and absent self-awareness, bur distinctions do exist in terms of neurologic function and recovery (Table I-B.2). Coma is characterized by a lack of responsiveness to verbal stimuli, variable responsiveness to painful stimuli, voluntary movement, and the potential for abnormal respiratory patterns and pupillary responses to light.7 Characteristics of /lersistellt vegetative state include the presence of sleep-

Table I-B.2. Comparison of Coma, Persistent Vegetative State (PVS), and Brain Death

'-'

'"

'"

Sleep-Wake

Respiratory

Cerebral

Condition

Cycle

Moror Control

Control

EEG Activity

Metabolism

Prognosis

g '"

Coma

Absent

Lacks

Present, vari-

Present

Reduced by

Usually recovers.

�

'"

purposeful

able, usually

50% or more

Can progress to

'"

movement

depressed

PVS or death in

J:

�

2-4 wks.

o

PVS

Present

Lacks

Present, normal

Present

Reduced by

g

purposeful

50% or more

Variable recovery.

"

movement

Cl

'"

Brain death

Absent

None or spinal

Absent

Absent

Absent

No recovery.

i

reflex move-

;;j

ments only

r;!

r

EEG electroencephalogram.

:i!

=

Source: Adaprcd from LA Thclan. LD Urden, ME Lough, Kt"1 Stacy (eds). Neurological Disorders. In Critical Care Nursing: Diagnosis and

�

>

Management (3rd ed). St. Louis: Mosby, 1998;797.

�

APPENDIX 1-8: AClITE CARE SETIlNG 757

wake cycles and partial or complete hypothalamic and autonomic

brain stem functions but a lack of cerebral cortical function for longer

than I momh afrer acute traumatic or nontraumatic brain injury or

metabolic or degenerative disorders.s The initial clinical criteria for

brain death include coma and unresponsiveness, absence of brain stem

reflexes, and cerebral motor responses to pain in all extremities, apnea,

and hypothermia.' Brain death is usually confirmed by cerebral angiography, evoked potential testing, electroencephalography, or transcranial Doppler sonography.' Refer to Chapter 4 for more information on

these neurologic diagnostic tests.

Intensive Care Unit Setting

The ICU, as its name suggests, is a place of intensive medical-surgical

care for those patients who require continuous monitoring, usually in

conjunction with thcrapies such as vasoactive medications, sedation, circulatory assist devices, and mechanical ventilation. ICUs may be named according to the specialized care that they provide, such as the coronary

care unit (CCU) or surgical ICU. The patient in the ICU requires a high

acuity of care; thus, the nurse to patient racio is onc to one or one to two.

Com mOil Patiellt and Family Respo1tses to the /lIte1tsiue Care Ullit

• Behavioral changes or disturbances can occur in the patient who

is critically ill as a result of distress caused by physically or psychologically invasive, communication-impairing, or movement-restricting procedures.'o When combined with the environmental and psychological reactions to the ICU, mental status and personality

can be altered. Environmental stresses can include crowding, bright

overhead lighting, strong odors, noise, and touch associated with

procedures or from those the patient cannot see.IO Psychological

stresses can include diminished dignity and self-esteem, powerlessness, vulnerability, fear, an.xiety, isolation, and spiritual distress. 10

• ICU psychosis is a state of delirium that occurs between the third

and seventh day in the ICU and is described as a "fluctuating state of

consciousness characterized by features such as fatigue, confusion,

distraction, anxiety, and hallucinations." II Delirium in the leU,

which is reversible, is thought to be caused by pain, the side effects

of drugs, and the ICU environment." Precipitants to delirium