Critical Care Assessment

Original Editor - Justin Bryan Top Contributors - Justin Bryan, Rachael Lowe, Karen Wilson and Adam Vallely Farrell

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (14/01/2023

Introduction

A general physical therapy assessment of a patients who are considered critically ill will follow many of the same components as an acute care assessment, however there are certain aspects that will differ given the complex and unique situations that come with this patient population.

What makes a patient critically ill?

Critical care is an area of medicine that focuses on the management and treatment of patients who are deemed to have a condition that is immediately life-threatening or possesses the risk of becoming life-threatening. These patients are generally cared for in a dedicated intensive care unit (ICU) or ward where specific monitoring of physiology and organ function is possible at a level above that of other units or ward in a hospital. Staffing in ICUs is generally provided at a lower patient to provider ratio (i.e. 1:1). There is a greater emphasis on multidisciplinary care, encompassing individuals from many different backgrounds, and coordinated under a physician with a specialty in critical care medicine. Goals of care often focus on prevention of acute complications, early detection of distress or condition advancement, and immediate response to evolving situations.

History, Systems Review, and Review of Systems

A good physical therapy evaluation should always begin with a through review of patient history, and an examination an examination of the patient's overall body and system functions. More information on these aspects of PT Evaluation in the ICU can be found on the following page: Physiotherapy Assessment of Patients in the ICU.

Physical Therapy Goals and Early Mobility

One of the main goals of physical therapy in the critically ill population is to address aspects including ICU acquired deficits through the promotion of early mobilization. Information specifically addressing the assessment of critically ill patient being considered for early mobilization can be found on the following page: Early Mobility Assessment for Critically Ill Patients.

Assessing Alertness and Cognition

Assessing a patient's cognitive status is an aspect of considerable importance when treating critically ill patients. Cognitive status is important in not only determining if a patient can safely participate in therapy, but also whether they are experiencing ICU Acquired Delirium. Delirium is common in critically ill patients and can result from factors such as medication for sedation and pain control. ICU acquired delirium is of key concern for this patient population as it development has been associated with reduced cognitive function in the long term following recovery.

Assessing Orientation: A simple method of quickly assessing a patient cognitive status is by assessing their orientation at the time of treatment or evaluation. This can be accomplished by asking the patient the standard person, place, time, and situation line of questions. A patient's level of orientation can convey a lot about their cognitive status and the presence of delirium.

Richmond Agitation-Sedation Scale (RASS): RASS is a measure used to reflection a patient's level of alertness, and can provide insight as to the patient's appropriateness for therapy. A RASS score of -1 or greater is sometimes used as an indication that a patient possesses the required level of alertness for participation in therapy. However, consideration should be given to the guidelines set forth by your facility (if available) and the general confidence of the treating therapist and other staff participating in a therapy session.

Assessing Pain

As with most patient in the acute care setting, pain can be a significant barrier, as well as a factor that needs to be address during a physical therapy assessment. If a patient possesses the given cognition and communication abilities, pain should be assess using a standard self report tools such as a Numeric Pain Rating Scale or a Visual Analog Scale. However, many ICU patients are not appropriate for these scale due to factors such as sedation or mechanical ventilation. In these instances several objective measures of pain have be found to be valid and effective for critically ill patients.

Critical Care Pain Observation Tool (CPOT): CPOT is an 8 point scores measure that utilizes 4 basic behaviors (facial expressions, body movement, muscle tension, and ventilator compliance (intubated)/vocalizations (extubated)) to assess a patients level of pain.

Behavioral Pain Scale (BPS): The BPS is a scale intended for use in patient undergoing mechanical ventilation. BPS is a 12 point scale the uses 3 basic behaviors (facial expression, upper extremity movement, and ventilator compliance) to assess pain.

Assessing Muscular Strength

Assessing a patient's strength is a component of the physical therapy assessment that is not only crucial for assessing function, but also for determining the presence of ICU Acquired Weakness. Several measures can be utilized for this purpose, as well as generally assessing strength in the critically ill population. It should be noted that a adequate level of cognition and alertness is required for patients to properly participate in these measures.

Medical Research Council (MRC) Scale: MRC scale is a strength scale that has been developed and validated in critically ill patients. Standard procedure for the MRC scale involved bilateral assessment of six motions:

• UE abduction
• Forearm flexion
• Wrist extension
• Hip Flexion
• Knee extension
• Ankle dorsiflexion.

Scoring of the MRC scale utilizes a 5 point scale for the Classic MRC, and 3 point scale for the Simplified MRC for each motion giving an overall score out of 60 points or 36 point, respectively.

Cutoff scores for ICU Acquired Weakness are <48/60 for the Classic MRC scale.

Handheld Dynamometry: Grip strength can also be used, but more specifically as a measure to determine the presence of ICU Acquired Weakness. A cutoff score of less than 11 Kg for men and 7 Kg for women is used to determine the presence of ICU Acquired Weakness.