Marie Joyce Faith V.

Relucio IV-8 1st Bibliography

Critical Care Nursing

Ms. Tongol June 26, 2012

Examining the positive effects of exercise in intubated adults in ICU: A prospective repeated measures clinical study By Chris Winkelman, et al. Intensive and Critical Care Nursing (2012)

I.

Introduction Establishing patent airway and stabilizing the respiratory capacity of the patient is the most sought-after physiologic intervention of the health practitioners; the first intervention that a nurse must ensure before she attends to the other physiologic parameters. However, under the holistic approach in delivering care to patients, nurses should also be competent enough not to overlook the other health aspects-----emotional, psychosocial, interpersonal, and spiritual aspects of nursing. The research study has given the readers the opportunity to know the beneficial effects of mobility exercises, not just addressing the physiologic aspect, but the psychosocial benefits of it as well. Determining the optimal timing and progression of mobility exercise, the study has pointed out its potential to affect functional recovery of critically ill adults who experience prolonged mechanical ventilation. Methodology The research study, with a purpose of comparing standard care versus an early mobility protocol in ICU adults, was a prospective, repeated measures study with which its experimental design and timeline include three phases: 1) a control phase; (2) a run-in phase; and (3) a protocol implementation/intervention period. During a control (standard) phase, in which 20 control subjects were enrolled to receive standard care, a common approach to mobility exercise was not in place in either unit, nor did participants routinely receive exercise from a physical therapist. In the run-in phase of the study, wherein five new subjects were enrolled, intervention was refined for feasibility, and research assistants were trained to implement the refined protocol in a standard manner. During the implementation/intervention period, a consistent research protocol was implemented and provided a focused exam to determine patients readiness and the mode of exercise (in-bed or out-ofbed).The 55 new subjects received 20-minute exercise once daily for 2 to 7 days. All in-bed and outof-bed exercises were assisted with/initiated by research assistants based on the protocols criteria: ability to follow three out of five directions, lift both arms off the bed and/or lift each leg off the bed. The following parameters were monitored to maintain physiologic stability: P/F ratio > 100, FiO2 < 60% and positive end-expiratory pressure (PEEP) < 10 cm H2O, heart rate 50-125bpm, mean arterial pressure (MAP) 60100 mm Hg, SpO2 > 88%, and no active upward titration of vasoactive (e.g. dopamine, dobutamine, neosynepherine, epinephrine) or sedative (e.g., midazolam, propofol)) intravenous drugs in the previous four hours.

II.

III.

Summary, Key points Three major findings have arisen regarding early, progressive mobility for intubated patients in the ICU throughout the course of the research study. First finding confirms that exercise in relatively stable, intubated adults in the ICU is safe.

 Second result shows that exercise does not appear to contribute to a pro-inflammatory milieu in serum. Instead, 20 minutes of low level exercise was associated with increase IL-10, an anti-inflammatory biomarker. Third, patients enrolled in the mobility protocol had significantly fewer ICU days. There were also few complications typically associated with prolonged bed rest such as venothromboembolism or pressure ulcer, but these findings may be attributed to VTE and pressure ulcer prevention protocols that were well-established in the setting. Moreover, the study has concluded that once-daily exercise was not statistically associated with adverse changes in vital signs or unsafe events. In this study, the use of a protocol promoted early and progressive exercise compared to standard care. Improved progression to out-of-bed activity has been reported when a dedicated staff initiates exercise in intubated adults. In addition, the protocol was also clinically useful as evidenced by a number of results from the intervention group: reduced number of missed opportunities for exercise; increased duration of exercise; and more episodes of out-of-bed exercise. The psychosocial aspects of mobility (e.g., following directions or hearing conversational cues about sensation and movement), a chance of patient-nurse verbal interaction during an exercise, are very beneficial in preserving the cognitive function during prolonged critical illness and recovery. The high level of acceptance and high consent rate by patients and their surrogates, which became consistent throughout the 14-month data collection, is evidenced by patients eagerness to engage in exercises, and surrogates enthusiasm in asking instructions about exercise strategies to use after ICU discharge. IV. Significance Nursing Education. The in-bed (passive or active ROM and combined active/passive ROM), and outof-bed (chair sitting, standing, or walking) mode of exercises should also be incorporated in the nursing education for students to be aware of the other independent nursing actions that they could execute to patients in the intensive care units. Furthermore, additional information such as the reduction of ICU length of stay for every 20-minute episode of exercise daily for two or more days, and the positive increase in Interleukin-10 in every brief periods of low-intensity exercise, should also be taught to students together with the other benefits and advantages of the mobility exercises, for them to appreciate even more the healthy aspects of it; thus, leading to more eagerness and enthusiasm in implementing it in the intensive setting. Nursing Practice. The development of deep vein thrombosis or venothromboembolism, pressure ulcers and other complications brought about by uninterrupted bed rest in intubated adults, may be prevented with the use of mobility protocol which promotes both earlier initiation and increased progression of exercise. This protocol may be implemented by nurses themselves, provided that they are equipped with the necessary knowledge regarding mobility and rehabilitative exercises (e.g., active and passive ROM, and out-of bed exercises). Since these exercises are proven to be safe and can be executed without associated adverse and perilous events, clinicians, even the student nurses, may routinely implement it not only in the ICU or critical care areas, but in the ward as well. Nursing Research. The findings of this study may serve as an encouragement to the future researchers to have additional study on other exercise therapies appropriate for the care of the patients experiencing prolonged mechanical ventilation in the ICU.