Critically ill patients are those whose health have drastically deteriorated and in a life-threatening state. The deterioration can cause long term multisystem breakdown causing significant morbidity or mortality. In most cases, the patients of critical illness show physiological deterioration first before it develops to a more severe condition. However, evidence suggests that the other signs of critical illness are often missed. Serious illness has many different causes. They include surgery, trauma, organ dysfunction, respiratory dysfunction, and severe infection. Of the reasons, acute infection remains of the highest concern as it is a common contributor to critical illness. The cause provides the link between the critical condition, for instance, circulatory failure and the underlying disease. For patients with critical illness, intensive care is inevitable if their lives are to be saved. At times, the intensive care is required for the admissions made on unsuspecting patients.
For example, in Australia, of all the patients admitted in the hospitals, two and a half percent need the intensive care for the life-threatening conditions. This prompts one to be taken to the intensive care units (ICU). An ICU is the unit of a hospital where specially trained staff care for the critically ill patients. The team comprises doctors, respiratory therapists, nurses, physician assistants, dietitians, pharmacists, physical therapists, social workers, nurse practitioners, and chaplains. The ICU ensures that the patients receive observation and monitoring in their states. The rooms could be fitted with specialized equipment based on the uniqueness of the condition of the patient. The worse the condition, the more sophisticated the equipment required for support. The ICU equipment looks overwhelming as the patient is connected to machines that monitor blood pressure, heart rate, and respiratory rate. For the patients who cannot breathe on their own, ventilators are used until they regain the ability to breathe.
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Effect of Acute Care
As they stay in the ICU, acute care patients are at risk of developing a condition known as “ICU-acquired weakness.” The condition is linked to the prolonged bed rest (Nordon-Craft, Moss, Quan, & Schenkman, 2012) . On average, a healthy person alters their posture after about eleven minutes during sleep. The alterations make the organs in the body to be activated and worked up. When there is prolonged immobility, the organs in the body system deteriorates due to inactivation. Nevertheless, there is a connection between the physiological impacts of aging and the severe systemic effects of the body from too much immobility. Prolonged bed rest affects various organ systems. The most important system is the musculoskeletal system. The comparison between a healthy bone and that of the sick patient shows a significant distinction in the marrow development. The bone of the patient shows reduced bone marrow component and a collapsing structure.
In the advent of critical illness, the immobilized for an excess of few days develop musculoskeletal weakness even if they receive full supportive care. Physical therapy is the general care that is offered to the patients. The patients who are exposed to mechanical ventilation for a time longer than seven days develop intensive care unit-acquired weakness at the rate of between twenty-five and sixty percent (Nordon-Craft, Moss, Quan, & Schenkman, 2012) . The complication creates the need for increased exposure to the mechanical ventilation resulting in a prolonged stay in the ICU. The prognosis of the people who stay longer in the immobility state becomes mostly dwindled regarding recovery rate. The survivors develop a poor quality of life and more complications in the future life. There is a lack of a medical therapy to solve the ICU-acquired weakness once it has happened. However, nurses play a significant role in ensuring the patient in the intensive care unit are medically stable. They do this by administering several doses of medication and regularly checking on the patients to observe their medical conditions.
The use of corticosteroids and neuromuscular blocking agents have been at some point introduced to minimize the risk of developing such complications, but there is no medical evidence supporting the claim. In some cases, insulin has been used to alleviate the catabolic syndrome for it is well known of its anabolic characteristics and the stimulation of muscle protein synthesis. It also attenuates the protein break down. In a study of patients who were admitted in the ICU after surgery for seven days, the ones who received insulin therapy had a lower risk of developing CIPNM than the ones who received common conventional treatments. The former had a rate of 29 percent chance of developing CIPNM while the latter had a 52 percent chance. On further analysis, the patients who received the therapy had high chances of resolution upon the development of CIPNM. The research marked the landmark of intensive insulin studies. In independent research on ICU patients, intensive insulin therapy was found to reduce the risk of developing CIPNM from 51 percent to 39 percent. In other studies, however, the international randomized control study on ICU patients reported that the intensive glucose control was linked to the increased mortality.
Also, some interventions can be employed to save the patients and improve their lives. The interventions can also reduce the cost of healthcare. These responses are based on physical therapy. Physical therapists assume a crucial part in the rebuilding of the capacity of individuals who have an ICU-acquired weakness (Fell, Burnham, & Dockery, 2012) . Physical therapists are sought to give practical restoration interventions simultaneously. They provide the best proficient abilities for accomplishing ambulation of patients in the ICU. One of the many interventions is early mobilization (EM) where the mobility of patients is achieved during the start of days possible from admission (Engel et al., 2013) .
Early Mobilization
EM includes the usage of different methods of physical therapy at the initial stages. The methods are delivered more regularly than the regular practice. It also entails the usage of innovative mobilization processes like transcutaneous electrical muscle stimulation and the use of cycle ergometer. Physiologically, the logic of EM is applied to those patients who would otherwise be rendered almost entirely immobile. The process is also safe and feasible to the ICU patients. Early mobilization has proved to be effective in restoring the functional recovery, reduce readmission due to reduced risk of recurring complications, lessen the duration of stay under intensive care and hospital, and improving the survival rate of critical illness cases (Drolet et al., 2012) . Though, there has been a limited application of systemic attention and analysis has led to limited understanding and assessment of early mobilization.
The usual guidelines for physical therapy based on the traditional approach, vary from the recent rapid mobilization plan. The former involves the passive application of mobility ranges and the proposal of an effective forms of mobility during the early stages of ICU stay. The active mobilization approach is always avoided until after the resolution of the acute phase of the illness. Whereas patients are fundamentally sick plus on mechanical ventilation, various breathing qualities are regularly checked, a few being especially essential to the physical therapist. The therapist continues with the physical examination and mediation just when the person is adequately steady (Fell, Burnham, & Dockery, 2012) . The traditional approach assumes that the patient may be too weak or too sick to receive the therapy while undergoing mechanical ventilation. Hence the strategy commenced after the discharge from ICU. Most of these treatment practices were based on the views of experts. They lack the basis of high-quality evidence. However, the opinions of the experts on the attitudes and practices associated with physical therapy and mobilization vary widely within a country and the world.
The use of inactive means as measure of physical therapy of early mobilization has an insignificant supporting evidence (Engel et al., 2013) . The evidence shows that the passive movements may lead to prevention of degradation of protein molecules, reducing inflammatory profile in the body, and maintaining muscle body mass. In a study conducted with twenty subjects, the patients were exposed to thirty minutes of predominantly passive exercise. The population exposed to the passive movement activity preserved a fat-free mass. Additionally, they had a decrease in their IL-6 and IL-10 levels as related to the control population whose fat-free mass reduced by 7.2 percent within the seven days of admission to the ICU. Despite the changes, the evidence is not clear whether the approach solely led to the results. Therefore, the research requires further studies and investigation. According to various clinical observations, more than mere passive movement approach should be employed when dealing with the acute care patients. This renders the traditional physical therapy a non-reliable approach of maintaining and preserving muscle strength.
Thus, EM may present an alternative and better approach than the traditional passive movements which are delayed till the discharge from the ICU. Various researchers have written about mediation procedures for individuals with ICU-acquired weakness and other related complications. An essential concentration of ICU physical treatment is to help patients in recovering the capacity to carry out crucial day by day exercises. In spite of the fact this capability is the objective, individuals who acquire this kind of weakness additionally need adequate capacity in the systemic levels keeping in mind the end goal to finish particular physiological processes. In that capacity, mediation methodologies are demonstrated for the rectifications of impairments of the neuromuscular, musculoskeletal, and cardiopulmonary frameworks.
Interdisciplinary Collaboration
By definition, as the name suggests, EM is the escalation and early introduction of the physical therapy or movements given to the patients in the intensive care unit (Engel et al., 2013) . The goal of EM in the ICU is connected to keeping up or reestablishing musculoskeletal quality and capacity, subsequently possibly enhancing functional, patient-focused results. A noteworthy setback in the capacity to decide the results taking after EM is the assortment of various methods utilized, and the absence of standardization and their meaning of them crosswise over studies. The success of early mobility would need collaboration from different professionals within the healthcare field. Physical therapists, nurses, and occupational therapists are the three relevant groups (Hu, 2012) . These groups can work together inter-professionally to ensure the condition of the patient under critical care is replenished and restored. The Interprofessional joint effort is necessary to guarantee that health services groups are useful and furthermore, ready to give clients the highest nature of care regarding quality.
Interprofessional coordinated effort and cooperative practice are characterized as the procedure of coordination, coordinated effort, and joint decision-making between the customer and the therapeutic services group in every aspect of treatment planning and execution, keeping in mind the end goal to achieve a decided objective, paying little attention to the health care setting or sort (Hu, 2012) . Although some barriers can hinder the development of a successful work plan, the groups can integrate their effort to make several changes that would see the alignment of the process involved. Some of these challenges, however, should not go unnoticed. They include safety concerns, traditional staff practice patterns, staff skepticism, among others. Some of the changes that the groups can make include creation of inter-professional champions, education, and promotion of the approach within the institution. Interprofessional education improves interdisciplinary correspondence and understanding, makes universal regard, and develops shared qualities (Hu, 2012) . This training may happen in either a formal setting, for example, an instructive course talking about various spaces in the social insurance industry. It can also occur in a casual setting, where individuals from different fields find out around each other's particular territory of practice so as to work together in teams and achieve the best results in customer social insurance.
Professionals who have been instructed in this way get and esteem the interventions and areas of practice of different disciplines. These experts do not only utilize clinical thinking in their particular practice, yet they are also mindful of how each discipline identifies with the continuum of customer care in general. Information about the domains and routine of contrasting disciplines takes into consideration appropriate referrals to be made and also, sets the establishment for collaboration-oriented practice in therapeutic services. Also, they can reference other established programs to ensure they are at par with what is being practiced by other specialists. The nurses, physical and occupational therapists should make sure they have the updated literature review on the files containing information about the approach (Hu, 2012) . The nurse and the physical therapists should have a simple prompt for the referrals of such patients as they (the professionals) are responsible for the ICU order set regarding referrals.
Standards of care
In the ICU, several practices are carried out by the interdisciplinary team to ensure effective patient-based outcomes. These are the practices that prevent complications or treat them during their onset. The standards ensure early mobilization of patients (Engel et al., 2013) . The first one is the use of cycle ergometer. The instrument has static cycle with a programmed component that can adjust the quantity of work the patient performs. Its sequence can be utilized inactively, where there is no effort from the individual, or actively. The idea has been tried in stable patients as a component of the program for space investigation. Cycle ergometry has been found to protect the thickness of the thigh muscles amid delayed immobilization ( Bein et al., 2016) . In subjects suffering from chronic obstructive pneumonia sickness, and in studies during hemodialysis, the strategy has likewise been proved to be safe and practical.
Another standard of care for nursing is the transcutaneous electrical muscle stimulation (TEMS). TEMS has been utilized to protect quantity of muscles and their quality in patients with endless obstructive respiratory infection and those with chronic heart failure. A current orderly audit, found TEMS to enhance disease-particular wellbeing status, muscle quality and strength, and practice capacity. TEMS is especially compelling in the ICU setting due to the extreme and faster rate in which muscle wastes away than in any other constant condition. What's more, the TEMS system can be effectively used on those patients that are immobile after sedation. In spite of the functional allure and guarantee of TEMS, the trials that are done in a controlled random way to assess the impacts of early mobility by the method for TEMS which started in the initial seven days in the ICU revealed clashing outcomes (Drolet et al., 2012) . Contrasts inpatient determination, the consideration or avoidance of subjects with sepsis, the utilization of TEMS to various populaces, and varying review philosophy have most likely added to disparities in revealed results.
In ambulation, the nurses should use a technological aid that is custom-made. Ambulation is a particular EM system utilized as a part of the ICU to enhance functional recuperation. Standard healthcare facility equipment may mostly be sufficient. While moving a patient under mechanical ventilation, however, the typical gear may not boost security and adequacy. As an example, a few healthcare facilities have had their particular specialists plan a handcrafted walker for such individuals that consolidates a free edge on wheels, an oxygen crate, an intravenous post, and a stage to bolster a ventilation gadget, wholly in a unitary implement (Drolet et al., 2012) . This sort of hardware may enhance the security of the patient as the physical therapist and medical attendant put their hands away from the gear and can focus on the patient's stride, adjust and functional reaction to work out, for example, their respiratory rate (Fell, Burnham, & Dockery, 2012) . No evidence shows whether patients need electrocardiogram checking amid early mobilization.
There are other standards of care to which a nurse is entitled. These include continuous turning of the patient after every two hours and carrying out the daily routine passive range of motion (PROM). The PROM should be as determined by the physical therapist. The therapist would perform the positioning where a more skilled PROM is required, such as in the patients with burns. For the occupational therapist, the standard of care suggests that all patients should be screened for delirium (Hu, 2012) . The assessment should be done in an inter-disciplinary approach with help from nursing staff, psychologists and pharmacists.
Complications and Their Remedies
During the extended stay in the ICU, the patients can develop several complications. One is ventilator-associated pneumonia (VAP). It occurs after about forty-eight hours after initiation of mechanical ventilation. VAP has been linked to increased antibiotic use, escalated rate of multidrug-resistant infections, increased ICU length stay due to the increased ventilation time, and overall longer hospital length stay. Despite a clear linkage to patient mortality, VAP prevention has its benefits, and the hospital staff can intervene. The first intervention can be the use of non-invasive positive pressure ventilation. NPPV has been shown to reduce the risk of developing VAP. Also, daily weaning trials and sedation holidays are helpful in managing the occurrence. By doing the weaning trials, the staff can reduce the length of mechanical ventilation ( Bein et al., 2016) . Another intervention is elevating the head of the patient at thirty degrees. Re-intubation is related with a higher danger of VAP because of higher rates of aspiration. Sufficient ICU staffing ought to be kept up to limit unplanned extubations requiring re-intubation, and arranged extubations ought to be precisely considered.
Another complication is the deep vein thrombosis (DVT). A DVT is a blood coagulation in the deep veins of the leg or crotch. The most severe occurrence of this complication is a pulmonary embolism, where the blood clotting goes into the lung, which can be life debilitating ( Malato et al., 2015) . To prevent DVT, patients in ICU are treated with low levels of blood thinners if it is protected to do as such. In patients who can't take blood thinners, uncommon tights are utilized to press the legs until blood thinners are sound to use. If a DVT happens, it is usually treated with higher measurements blood thinners.
Finally, skin breakdown or ulcers is another common complication resulting from longer ICU stay. Lying in bed can put weight on the skin, particularly in ranges where bones are near the surface, for example, the tailbone. This pressure causes the skin to be denied of blood supply, which can bring about skin breakdown. This procedure can prompt to weight injuries, also called skin ulcers. Immobilization, which is regular in ICU patients is the essential hazard from which skin breakdown is drawn out. The emphasis on remedy is on counteracting weight bruises where possible because they are exceptionally hard to treat once they have happened. Endeavors are rolled out to alter the position of patients as often as possible to differ the pressure points. Physiotherapists work to amplify quality and mobility, and dieticians endeavor to enhance patient nutrition.
In conclusion, ICU survivors recovering from a delayed ailment frequently have muscle weakness and major practical hindrance. Early mobilization is a physiologically legitimate hopeful intervention to lessen such weakness (Drolet et al., 2012) . Studies recommend successful interprofessional cooperation brings about enhanced results for patients in the acute care settings. The professionals from distinguished fields can work together inter-professionally to ensure the condition of the patient under critical care is replenished and restored.
References
Nordon-Craft, A., Moss, M., Quan, D., & Schenkman, M. (2012). Intensive Care Unit-Acquired Weakness: Implications for Physical Therapist Management. Physical Therapy , 92 (12), 1494-1506. http://dx.doi.org/10.2522/ptj.20110117
Hu, D. (2012). Occupational therapists' involvement views, and training needs of evidence-based practice: a rural perspective. International Journal of Therapy and Rehabilitation , 19 (11), 618-628. http://dx.doi.org/10.12968/ijtr.2012.19.11.618
Fell, D., Burnham, J., & Dockery, J. (2012). Determining where physical therapists get information to support clinical practice decisions. Health Information & Libraries Journal , 30 (1), 35-48. http://dx.doi.org/10.1111/hir.12010
Engel, H., Tatebe, S., Alonzo, P., Mustille, R., & Rivera, M. (2013). Physical Therapist-Established Intensive Care Unit Early Mobilization Program: Quality Improvement Project for Critical Care at the University of California San Francisco Medical Center. Physical Therapy , 93 (7), 975-985. http://dx.doi.org/10.2522/ptj.20110420
Drolet, A., DeJuilio, P., Harkless, S., Henricks, S., Kamin, E., & Leddy, E. et al. (2012). Move to Improve: The Feasibility of Using an Early Mobility Protocol to Increase Ambulation in the Intensive and Intermediate Care Settings. Physical Therapy , 93 (2), 197-207. http://dx.doi.org/10.2522/ptj.20110400
Malato, A., Dentali, F., Siragusa, S., Fabbiano, F., Kagoma, Y., Boddi, M., & Napolitano, M. (2015). The impact of deep vein thrombosis in critically ill patients: a meta-analysis of major clinical outcomes. Blood Transfusion , 13 (4), 559.
Bein, T., Grasso, S., Moerer, O., Quintel, M., Guerin, C., Deja, M., & Mehta, S. (2016). The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia. Intensive care medicine , 42 (5), 699-711
