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ACtJrE CARE HANDBOOK FOR PHYSICAL TI-IERAI'ISTS

include a history of dementia, Alzheimer's disease, substance abuse,

and chronic illness as well as advanced age, severe infection, fluid

and electrolyte imbalance, hypoxia, and metabolic disorders."

Treatment for delirium consists of antipsychotic medications (e.g.,

haloperidol), the discontinuation of nonessential medications,

proper oxygenation and hydration, and the company of family or

others. 13

• The patient'S family is usually overwhelmed by the ICU. Family

members may experience fear, shock, anxiety, helplessness, anger,

hostility, guilt, withdrawal, or disruptive behaviors.!O Like the

patient, the family may be overwhelmed by the timuli and technology of the ICU, as well as the Stress of a loved one's facing a critical or life-threatening illness .

• The transfer of a patient from the ICU to a general floor can

also be a stress to the patient and family. Referred to as transfer

anxiety, the patient and family may voice concerns of leaving

staff that they have come to recognize and know by name; they

may have to learn to truSt new staff,!O or fear that the level of

care is inferior to that in the leu. To minimize this anxiety, the

physical therapist may continue to treat the patient (if Staffing

allows), slowly transition care to another therapist, or reinforce

with the patient and family that the general goals of physical

therapy are unchanged.

CriricalIllness PolyneuropatlJY

Critical illness polyneuropathy is the acute or subacute onset of widespread symmetric weakness in the patient with critical illness, most commonly with sepsis or multisyStem organ failure, or both.!' The

patient presents with distal extremity weakness, wasting, and sen ory

loss, as well as parasthesia and decreased or absent deep tendon

reflexes.15 The clinical features that distinguish it from other neuromuscular disorders (e.g., Guillain-Barre syndrome) are a lack of ophthalmoplegia, dysauronomia, and cranial nerve involvement and normal cerebrospinal fluid analysis,'4.'5 Nerve conduction studies

show decreased motor and sensory action potentials.!S The specific

pathophysiology of critical illness polyneuropathy is unknown; however, it is hypothesized to be related to drug, nutritional, metabolic,

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759

and toxic factors, as well as prolonged leu stay, the number of invasive procedures, increased glucose level, decreased albumin level ' and the severity of multisystem organ failure. IS

eriticalllllless Myopathy

Critical illness myopathy, otherwise known as acule quadriplegic

myopathy or aClile steroid n1)'opathy, is the acute or subacute onset of

diffuse quadriparesis, respiratory muscle weakness, and decreased

deep tendon reflexes IS in the serring of exposure to short- or longterm high-dose corticosteroids and simultaneous neuromuscular blockade. I. It is postulated that neuromuscular blockade causes a

functional denervation that renders muscle fibers vulnerable to the

catabolic effects of steroids. I. Diagnostic tests demonstrate elevated

serum creatine kinase levels at the onset of the myopathy, and, if

severe, myoglobinuria or renal failure can ensue; a myopathic pattern

with muscle fibrillation on electromyography; and a necrosis with

dramatic loss of myosin (thick) filaments on muscle biopsy. I.

Sleep Pattern Disturbance

The interruption or deprivation of the quality or hours of sleep or rest

can interfere with a patienr's energy level, personality, and ability to

heal and perform tasks. The defining characteristics of sleep pattern

dis/llrbollce are difficulry falling or remaining asleep, with or without

fatigue on awakening, dozing during rhe day, and mood alterations.17

In the acute care setting, sleep disturbance may be related to frequent awakenings related to a medical process (e.g., nocturia or pain) or the need for nursing intervention (e.g., vital sign monitoring), an inability to assume normal sleeping position, and excessive daytime sleeping related to medication side effects, stress, or environmental changes."

The physical therapist should be aware of rhe patient who has

altered sleep patterns or difficulty sleeping, as lack of sleep can impact

a patient'S ability to participate during a therapy session. The patient

may have rrouble concentrating and performing higher-level cognitive

tasks. The pain threshold may be decreased, and the patient may also

exhibit decreased emotional control.17

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AClITE CARE HANDBOOK FOR PHYSICAL TIIERAIIISTS

Confusion

Confusion may be acute or chronic (e.g., related to a neurodegenerative process). Acute confusion frequently occurs in the acute care setting, especially in the elderly. AClIle cotlf"siotl is defined as "the state in which there is abrupt onset of a cluster of global, Auctuating disturbances in consciousness, attention, perception, memory, orientation, thinking, sleep-wake cycle, and psychomotor behavior. n18 Risk factors for confusion related to medications include the use of analgesics, polypharmacy, noncompliance, and inappropriate self-medicating."

Other risk factors include dehydration, electrolyte imbalance, hypoxia, infection, and poor nutrition. Acute or acute on chronic disease states can result in confusion, especially if metabolic in nature.

Additionally, a change in environment can exacerbate medical risks

for confusion. This includes unfamiliar surroundings, noises, procedures,

and staff or a change in daily routine, activiry level, diet, and sleep.

Substance Abuse and Withdrawal

The casual or habitual abuse of alcohol, drugs (e.g., cocaine), or medications (e.g., opioids) is a known contributor of acute and chronic illness, traumatic accidents, drowning, burn injury, and suicide.20 The patient in the acute care setting rnay present with acute intoxication

or drug overdose or with a known (i.e., documented) or unknown

substance abuse problem.

The physical therapist is not initially involved in the care of the

patient with acute intoxication or overdose until the patient is medically stable. However, the physical therapist may become secondarily involved when the patient presents with impaired strength, balance,

coordination, and functional mobility as a result of chemical toxicity.

It is the patient with unknown substance abuse who is hospitalized

for days to weeks who is a challenge to the hospital staff when withdrawal (commonly referred to as the DTs, for delirillm Iremetls) occurs. It is beyond the scope of this text to list the symptoms of withdrawal of the many different types of drugs. For the purposes of this text, alcohol withdrawal will be discussed because of its relatively

high occurrence.

Alcohol withdrawal sY/ldrome is the group of signs and symptoms

that occur when a heavy or prolonged u er of alcohol (ethanol or

ethyl alcohol) reduces alcohol consumption." The signs and symp-

APPENDIX 1-8: AClITE CARE Sl:.TT1NG 761

tolllS of alcohol withdrawal are the resllit of a hyperadrenergic state

from increased central nervous system neuronal activity that attempts

to compensate for the inhibition of neurotransmitters with chronic

alcohol lIse.20 The signs and symptoms of alcohol withdrawal syndrome, which begin 5-10 hours after alcohol use is decreased, are21