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occupational therapy in the icu

The Critical Role of Occupational Therapy in the Intensive Care Unit

Occupational therapy has a unique and important role in the intensive care unit (ICU). A history of OT in the ICU, the environment, specialized equipment, diagnoses, and the importance of OT’s contribution in the ICU, as well as evaluation and intervention, will be covered in this article. Early treatment proposes the opportunity to decrease ICU length of stay (LOS), hospital LOS, and readmission rates (Deng et al., 2020; Falkenstein et al., 2020).
职业治疗在重症监护病房(ICU)中扮演着独特而重要的角色。本文将介绍 ICU 中职业治疗的历史、环境、专业设备、诊断以及职业治疗在 ICU 中的重要贡献,以及评估和干预。早期治疗提供了减少 ICU 住院时间、医院住院时间和再入院率的机会(Deng 等,2020 年;Falkenstein 等,2020 年)。

The Role of Occupational Therapy in the Intensive Care Unit

In the United States, admissions to the intensive care unit (ICU) are 4.1 million a year for people over the age of 18 with a high rate of survival (Weinreich et al., 2017). Patients are admitted initially for critical injury, surgery, or disease in the ICU due to medical instability. Care is multifaceted, offering specialized nursing, surgeons, and physicians 24 hours a day (Clark, 2017).
在美国,每年有 410 万名年满 18 岁以上的人入住重症监护室(ICU),生存率较高(Weinreich 等,2017 年)。患者最初因为严重受伤、手术或疾病在 ICU 中入住,由于医疗不稳定。护理是多方面的,提供 24 小时专业护理、外科医生和医生(Clark,2017 年)。

The ICU Environment ICU 环境

The intensive care unit is a highly specialized area for the treatment of life-threatening conditions. The medical team operates equipment to monitor the patient’s vital signs and bodily functions. Each room has a specialized patient bed set up with multiple system hook ups, a curtain for privacy and rooms have a curtained bathroom plus an area for the family member(s) to participate or observe (Clark, 2017).

Diagnoses Typically Seen in the ICU
ICU 常见的诊断

Life-threatening conditions admitted to the critical care unit include (in order of typical occurrence):

1. Pulmonary conditions requiring mechanical ventilation

2. Cardiac disorders telemetry closely monitors
2. 心脏疾病心电监护密切监测

3. Post-surgical complications with respiratory or cardiac involvement

4. Systemic infections are treated with an inflammatory response causing cardiopulmonary compromise.

5. Neurologically based conditions include, cardiovascular accidents, traumatic brain injuries, and spinal cord injuries (Clark, 2017)
5. 基于神经系统的疾病包括心血管意外、创伤性脑损伤和脊髓损伤(Clark,2017)

Monitoring Vital Signs in the ICU

occuptional therapy icu vitals

Vital signs are closely monitored with these invasive and non-invasive devices:

Noninvasive Techniques 非侵入性技术

  • Urinals and hats for output measurement
  • Telemetry with imaging 带成像的遥测
  • Blood pressure instruments with sphygmomanometers
  • Pulse oximetry 脉搏血氧饱和度检测
  • Oral or axillary temperature gauges
  • Respirations 呼吸
  • Electroencephalograms 脑电图
  • Electrocardiograms 心电图
  • Ultrasound 超声波

Invasive Techniques 侵入性技术

  • Foley catheters or rectal tubes for output,
  • Central lines and pulmonary catheters,
  • Intracranial pressure gauges with extra ventricular drains or bolts, and
  • Blood pressure with arterial lines (Clark, 2017, p.117).
    动脉插管测血压(Clark,2017,第 117 页)。

OT’s Role in Reducing ICU-Acquired Weakness

Critically ill patients have commonly experienced general weakness (ICU-acquired weakness) created by mechanical ventilation more significant than five days and the immobilization in the ICU (Clark, 2017). Some studies relate the critical illness immobility to a neurological myopathy if muscles are affected or polyneuropathy if sensory innervation is limited.
危重病人通常会经历由机械通风引起的持续五天以上的普遍虚弱(ICU 获得性虚弱)和在 ICU 中的固定(Clark,2017)。一些研究将危重疾病的固定与神经肌病(如果肌肉受到影响)或多发性神经病(如果感觉神经受限)联系起来。

According to Clark (2017), “ICU-acquired weakness is a generalized weakness developed during critical illness for which there is no explanation except the critical illness itself” (p.125). Occupational therapy is an essential component with early mobilization to prevent patients from acquiring ICU-acquired weakness (Falkenstein et al., 2020).
根据 Clark(2017)的说法,“ICU 获得性虚弱是在危重疾病期间发展出的一种全身性虚弱,除了危重疾病本身外没有其他解释”(第 125 页)。职业治疗是早期康复运动的重要组成部分,可以预防患者患上 ICU 获得性虚弱(Falkenstein 等,2020)。

Occupational Therapy and ICU Delirium

Like ICU-acquired weakness, ICU delirium can result from acute cognitive disruption from altering states of alertness, medications, sleep cycle disturbances, and loss of natural light. The occurrence of delirium in the ICU is 30-60%, with 80% of those incidences are from those who received mechanical ventilation (Deng et al., 2020).
ICU 谵妄可能源于急性认知障碍,由于警觉状态改变、药物、睡眠周期紊乱和自然光丧失而导致。ICU 中谵妄的发生率为 30-60%,其中 80%的发生率来自接受机械通气的患者(邓等,2020 年)。

occuptional therapy icu mobility

Delirium can increase hospital length of stay, readmissions, and mortality. OT is truly unique in offering early treatment, including cognitive processing, early sensory integration, and functional performance of daily activities while also addressing early mobilization.
谵妄可能会增加住院时间、再入院率和死亡率。 OT 在提供早期治疗方面确实独一无二,包括认知处理、早期感觉整合和日常活动的功能表现,同时也关注早期康复。

The History of Occupational Therapy in the Intensive Care Unit

Occupational therapy (OT) and physical therapy (PT) are components of the medical rehabilitation team and grouped as one profession in the literature. Solely recorded OT has been in the ICU since 2005 (Weinreich et al., 2017). This study suggests this profession has been in the ICU since the early 1900s but only recognized with physical therapy (PT).
职业治疗(OT)和物理治疗(PT)是医疗康复团队的组成部分,并在文献中被归为同一职业。自 2005 年以来,仅有职业治疗被记录在重症监护室(ICU)中(Weinreich 等,2017)。这项研究表明,这一职业自 20 世纪初就存在于 ICU,但只有物理治疗(PT)得到认可。

Evidence indicates OT is a feasible, safe, and valuable component to the medical team in critical care. The authors promote further research solely for occupational therapy evidence-based practice (Weinreich et al., 2017). OT education in physical, psychological, and social sciences place the therapist in a distinct role for the patient and family care in the ICU (Clark, 2017).
证据表明,职业治疗在重症监护中是一个可行、安全和有价值的医疗团队组成部分。作者们提倡进一步研究,专门用于职业治疗的循证实践(Weinreich 等,2017 年)。职业治疗在物理、心理和社会科学方面的教育使治疗师在重症监护病房中扮演着独特的角色,为患者和家庭提供照护(Clark,2017 年)。

The intensive care environment with multiple tubes and monitors is challenging to manage initially. Constant alarms sounding and lights flashing to monitor all the critical care patients’ vital signs can be difficult for the new therapist Clark (2017). Experienced therapists suggest collaboration with the patient’s nurse is vital because they know what the team priorities are to monitor specific to the individual at that time.
多管道和监视器的重症监护环境在初始阶段是具有挑战性的。持续响起的警报声和闪烁的灯光用于监测所有危重病人的生命体征,这对新治疗师克拉克(2017 年)可能会很困难。经验丰富的治疗师建议与病人的护士合作至关重要,因为他们知道团队在特定时间内监测个体时的优先事项是什么。

Recommendations are any referred service and team collaboration, consult the nurse first on the patient’s status, and how much activity the patient can tolerate Clark (2017). The nurse also knows the current team objective to progress the patient, or they communicate if a treatment session is contra-indicated. Team collaboration is essential in the ICU due to the patient’s critical state and the specialized equipment (Clark, 2017).

Occupational Therapy Evaluation in the ICU
ICU 中的职业治疗评估

The traditional occupational therapy process involves assessment, treatment planning, goal setting, and intervention with performance-based measurements documented for comparison. Risk factors affecting critical care are the patient’s medical stability, cognitive skills, restrictions of the vital parameters, activity prescription, and the attached lines.

The OT evaluation at the primary level, according to Clark (2017), “Therapists collect the following data: Vital signs before, during and after the session; Cognition and vision; Range of motion; and, Basic activities of daily living; noting the position of the patients and attached lines, tubes and drains” (p. 125).
根据 Clark(2017)的说法,初级水平的职业治疗评估中,“治疗师收集以下数据:会话前、中、后的生命体征;认知和视觉;活动范围;以及日常生活基本活动;注意患者的位置以及连接的管线和引流管”(第 125 页)。

If the family is present, it helps determine the set-up of the patient’s home, relationships, and prior level of function for daily living activities—cognition, delirium, and pain assessments.

Goal Strategizing and Occupational Therapy Intervention

In the ICU, goals are short term to show progression in therapy (Clark, 2017). For example, the patient attempts to keep their eyes open for 60 seconds after scanning to determine an object’s location. The completion of an entire activity in one session is often more activity than the patient can tolerate; therefore, attending to a portion may be the initial focus then build-up to the entire task. Patient increased activity tolerance can be another goal set, for instance, the mobility advance to sitting tolerance with the bed at sit mode, with no dizziness for a certain amount of time (Falkenstein et al., 2020).
在重症监护室,目标是短期的,以显示治疗的进展(Clark,2017)。例如,患者尝试在扫描后保持眼睛睁开 60 秒,以确定物体的位置。在一个会话中完成整个活动通常超出了患者的耐受范围;因此,首先关注一部分可能是最初的重点,然后逐步发展到整个任务。患者增加的活动耐受力可以是另一个设定的目标,例如,移动性提高到床位坐姿耐受力,一定时间内没有头晕(Falkenstein 等,2020)。

Findings to prevent delirium also place OT at the forefront with incorporating family participation (Deng et al., 2020). This study’s findings indicate family participation has positive effects on patient recovery with reinforcement by the family.
预防谵妄的研究结果也将康复治疗放在首位,包括家庭参与(邓等,2020 年)。本研究结果表明,家庭参与对患者康复有积极影响,并得到家庭的支持。

occuptional therapy icu family

OT educates the family to assist management for instance, decreasing patient agitation with a familiar voice. The relative increases patient awareness, short-and long-term recall for cognitive processing by sharing past event memories. Improved awareness increases patient motivation to participate in functional activities, such as, pursed lip breathing or self-feeding. These tasks require the endurance and strength to sit upright for therapy progression and thought processing with sensory input Deng et al. (2020).
OT 教育家庭协助管理,例如,通过熟悉的声音减少患者的焦虑。亲属通过分享过去的事件记忆,增加患者对认知加工的短期和长期回忆的意识。提高意识增加了患者参与功能活动的动力,例如,缩唇呼吸或自我进食。这些任务需要耐力和力量,以便坐直进行治疗进展和感觉输入的思维加工(邓等,2020 年)。

Prescribed exercise programs support the early movement, cognitive processing, and functional activities to progress the patient toward daily living’s (ADLs). Family education in medical literacy increases family confidence in care-giving and psychological support for patient healing Deng et al. (2020); Falkenstein et al. (2017).

The Early Mobility Program (EMP) is a multi-disciplinary project promoting team collaboration for critical care. The program develops daily mobilization standards with a mobility scale that recognizes activity tolerance parameters, increased team communication, and focusing on the patient. Due to increased team involvement, nursing participates at levels 1 and 2, which require less mobility and build up patient endurance for upright positions. This progression allows patient participation in PT and OT to increase patient skills for gait and functional ADLs. The EMP has positive team-building components for patient-centered care (Falkenstein et al., 2020).
早期活动计划(EMP)是一个跨学科项目,促进危重护理团队合作。该计划制定了每日运动标准,使用一种活动耐受参数识别的移动量表,增加团队沟通,并专注于患者。由于团队参与度增加,护理人员参与 1 级和 2 级,这需要较少的移动,并增加患者直立姿势的耐力。这种进展允许患者参与物理治疗和职业治疗,提高患者步态和功能性 ADLs 的技能。EMP 对于以患者为中心的护理具有积极的团队建设组成部分(Falkenstein 等,2020 年)。

In Conclusion 总之

Occupational therapy in the ICU has exclusive education as a vital component to the medical team to approach the patient and their family holistically. The involvement of sensory-motor integration with cognitive processing and graded motion minimize delirium. Improved patient awareness decreases the length of days on mechanical ventilation, one of the significant barriers in critical care.

Incorporation of early mobility with functional activities evolves into the performance of necessary activities of daily living and eventual instrumental tasks such as medication management. OT has evidence of decreased hospital readmissions (Rogers et al., 2017).
将早期活动与功能活动结合起来,演变为进行日常生活必需活动和最终进行药物管理等工具性任务的表现。职能治疗有减少住院再入院的证据(Rogers 等,2017 年)。

Early OT intervention can prevent future debilitation, minimize depression, prevent the overall weakness associated with immobilization, and regain higher-level skills for functional return to the community. Increased occupational therapy is a cost-effective service for patient-centered care and return of investment for the organization.

References 参考资料

Clark, K. (2017). Intensive care unit. In Smith-Gabai, H., and Holm, S. E. (Eds.), Occupational Therapy in Acute Care (2nd ed., Chapter 9). Occupational Therapy Association Press.
Clark, K. (2017). 重症监护室. 在史密斯-加拜, H. 和霍尔姆, S. E. (Eds.) 编, 急性护理职业治疗 (第 2 版, 第 9 章). 职业治疗协会出版社.

Deng, L.-X., Cao, L., Zhang, L.-N., Peng, X.-B., & Zhang, L. (2020). Non-pharmacological interventions to reduce the incidence and duration of delirium in critically ill patients: A systematic review and network meta-analysis. Journal of Critical Care, 60, 241–248. https://doi.org/10.1016/j.jcrc.2020.08.019 IF: 3.7 Q2

Falkenstein, B. A., Skalowski, C. K., Lodwase, K. D., Moore, M., Olowski, B. F., & Rojavin, Y. (2020). The economic and clinical impact of an early mobility program in the trauma intensive care unit: A quality improvement project. Journal of Trauma Nursing, 27(1), 29-36, https://doi.10.1097/JTN.0000000000000479
Falkenstein, B. A., Skalowski, C. K., Lodwase, K. D., Moore, M., Olowski, B. F., & Rojavin, Y. (2020). 创伤重症监护病房早期运动计划的经济和临床影响:质量改进项目。《创伤护理杂志》,27(1),29-36,https://doi.10.1097/JTN.0000000000000479

Rogers, A.T., Bai, G., Lavin, R. A., & Anderson, G. F. (2017). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review, 74(6), 668-686. https://doi.org/10.1177/1077558716666981 IF: 2.5 Q3

Smith, K., Day, M., Muir, S., & Dahl-Popolizio, S. (2020). Developing Tailored Program Proposals for Occupational Therapy in Primary Care. The Open Journal of Occupational Therapy, 8(1), 1-13. https://doi.org/10.15453/2168-6408.1630

Weinreich, M., Herman, J., Dickason, S., & Mayo, H. (2017). Occupational Therapy in the intensive care unit: A systematic review. Occupational Therapy in Healthcare, 31(3), 205-213, https://doi.org/10.1080/07380577.2017.1340690 IF: 0.9

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