Occupational Therapy EPA1 Assess the upper limbs of the critically ill patient
The Novice Critical Care Occupational Therapist will be able to assess the function, ability and kinesiology of a critically ill patients upper limbs:
- Fully assess a critically ill persons upper limb and identify any risk and/ or injury to function and kinesiology.
- Recognise dysfunction, impairment and disability of an upper limb on critical care.
- Advise on further assessments and or scope of investigations for upper limb management
Limitations
- Intervention/ Treatment of upper limb impairments or rehabilitation is not within the scope of this novice competency.
- This does not include assessment of patients intubated and sedated or are clinically unstable as per the Medical Team.
- This document does not include condition/ diagnostic specifics assessments relating to injuries commonly seen on critical care. This is a generic upper limb assessment.
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EPA reference
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EPA overview information
- Required knowledge
- C3Framework Shared AHP Competencies
- C3Framework OT Domains:
- Upper Limb Assessment
To demonstrate a competent understanding of the upper limb (kinesiology and function), critical care complications or risks for a persons upper limb on critical care. How to identify impairments and report on said impairments for treatment. They will have a sound awareness/ knowledge of upper limb function and its potential disability.
- Information to assess progression
- Verbal and/ or written feedback on knowledge obtained from learning(self-directed or senior directed) to supervisor for sign-off
- Senior supervision (informal)
- Observational sessions with senior support (2-3 sessions)
- Demonstration of skills session with senior (2-3 sessions)
- Clinical supervision
- Supervision
- Entrustment decision made at level 4
- Documentation of self-assessment and senior sign- off through supervision
- Basis for formal entrustment decisions
An entrustment decision should be made by an experienced critical care OT after observing this EPA completed on more than one patient.
Use the EPA Completion Template (PDF, 88KB) for this.
| Self assessment | Senior assessment | |
|---|---|---|
Safety | ||
Infection Prevention and Control: | ||
Able to demonstrate knowledge of general infection control prevention and control including hand hygiene, aprons, masks and aseptic non-touch technique | ||
Patient Emergency Management: | ||
Has completed Basic Life Support Training as per local trust policy | ||
Describes how they would summon help in an emergency and locate crash bells | ||
Describes how to call a medical emergency call via switch | ||
Describes own role and expected contribution in medical emergency eg. Basic Life Support, providing assistance to MDT as able | ||
Patient ID: | ||
Demonstrates positive patient identification and awareness of allergies | ||
Monitoring Vital Signs: | ||
Demonstrates how to monitor vital signs (Temp, HR, SpO2, RR, blood pressure, MAP) | ||
Interprets observations in an ICU setting, considering trends and normal ranges for all (Temp, HR, SpO2, RR, blood pressure) | ||
Able to troubleshoot difficulties with taking vital signs eg. poor trace on pulse oximeter, missing ECG leads, positional sensitivity of arterial line | ||
Awareness of who to escalate concerns to in relation to patient safety with recognition of different levels of urgency and reporting to different staff members dependent on situation | ||
Orientation: | ||
Can describe the bed numbering, storage location of safety equipment, location of offices and other key areas within the critical care unit | ||
Can describe the shift patterns and handover process of other MDT members | ||
Able to identify key MDT members by their role, including critical care nurses, nurse in charge, consultant on call | ||
Demonstrates how to locate the local protocols and guidelines relevant to own role | ||
Has an awareness of key ICU meetings relevant to role e.g. MDT meetings, handovers, safety briefings, teaching sessions. | ||
Can identify standard ICU bedspace equipment and location of equipment necessary for role | ||
Communication | ||
Communication with patient: | ||
Describe barriers to communication in ICU including those associated with PPE, illness and ICU interventions. | ||
Awareness of communication aids with patients to overcome communication barriers i.e. PPE + oral intubation | ||
Communication with family + friends: | ||
Describe the support services available to help liaise with family including family support nurses, PALS, psychology services as appropriate. | ||
Describe barriers to communication with family and methods to improve this | ||
Knows importance of confidentiality and consent to share information with friends and family | ||
Communication with colleagues: | ||
Awareness of peer support and psychological support | ||
Documentation | ||
Local IT Training: | ||
Demonstrates how to access and document in patient records using local IT systems | ||
Demonstrates how to view results and imaging on local IT systems | ||
Moving and Handling | ||
Awareness of Falls prevention and who to escalate to if concerned regarding falls risks | ||
Compliant with Manual Handling training as per local trust policy. | ||
Non-technical skills | ||
Teamwork: | ||
Demonstrate working in an MDT by building and maintaining relationships with other professions | ||
Aware of the roles and responsibilities of other members of the MDT | ||
Clarifies, accepts and executes tasks delegated by the team leader | ||
Explains the importance of highlighting safety issues / concerns to a member of your team in a prompt manner | ||
Uses appropriate level of assertiveness for the clinical situation | ||
Demonstrates a logical and systematic handover using local format | ||
Outline how to escalate and to whom if there are patient / safety concerns | ||
Identify and respond to patient / staff safety issues appropriately | ||
Clinical Assessment and Basic Life Support | ||
Airway: | ||
Demonstrate ways to open up airway using simple manoeuvres (inc. repositioning, head tilt chin lift, jaw thrust) | ||
Demonstrates how to deliver manual ventilation using two person bag-valve-mask (BVM) technique | ||
Recognise and escalate airway compromise in a tracheostomised patient | ||
Mouth care: | ||
Demonstrates how to perform and document oral hygiene | ||
Oxygen: | ||
Knows the types of oxygen delivery system and their limitations (including reservoir mask, simple face mask, venturi system and nasal cannulae) | ||
Demonstrates how to deliver oxygen urgently (including reservoir mask, simple face mask, venturi system and nasal cannulae) | ||
Describe how to escalate or de-escalate oxygen therapy in a step wise manner eg. nasal cannulae to face mask. | ||
Lines and attachments: | ||
Recognise different lines and their location relevant to local population (eg arterial lines, central line, vas-cath) | ||
Nutrition: | ||
Identify enteral feeding tube in situ, whether it is connected to feed and whether the feed pump is running | ||
Knows to discuss plans with nursing staff prior to moving or reposition a patient with NG feed running | ||
Aware of events which can displace feeding tubes and to escalate accordingly | ||
Describes how to check enteral feeding length and escalates if tube length has changed | ||
Describe how to recognise dysphagia and an escalation plan including referral to SLT | ||
Demonstrates how to assist patients with eating and drinking | ||
Have an awareness of modified diets or thickened fluids in line with SLT recommendations | ||
Delirium: | ||
Demonstrate how to categorise neurological status using the AVPU scoring | ||
Describe factors that may cause or contribute to delirium | ||
Describes how to recognise delirium | ||
Demonstrates how to complete a CAM-ICU score | ||
Demonstrates an understanding of non-pharmacological management of delirium | ||
Demonstrates knowledge of the Mental Capacity Act, when capacity assessment is indicated, how to assess capacity and when specialist communication support is required eg. referral to SLT | ||
Pain: | ||
Demonstrates how to use pain faces or a similar visual analog scale | ||
Demonstrates an understanding on the impact of pain on patient presentation eg. agitation | ||
Demonstrates an understanding of the impact of pain medication on patient presentation eg. sedative effect | ||
Sedation: | ||
Demonstrates an understanding of RASS (or alternative sedation) scoring system | ||
Able to access and read using ICU drug charts | ||
Demonstrates an awareness of common ICU sedative medications | ||
Demonstrates a basic knowledge of common ICU medications and their role e.g. sedatives, vasopressors, inotropes | ||
| Self assessment | Senior assessment | |
|---|---|---|
Upper Limb Assessment | ||
Knowledge and awareness of common upper limb impairments and conditions on critical care | ||
Impaired power | ||
Impaired sensation | ||
Biomechanical changes | ||
Impaired coordination | ||
Subluxations | ||
Oedema | ||
Pain | ||
Tonal changes | ||
Impaired proprioception | ||
Nerve issues: eg. brachial plexus injuries | ||
Skin | ||
Outcome measures | ||
To have an awareness of formal upper limb assessments (if/when appropriate). Consider: Chedoke, ARMA etc. *unit specific | ||
Awareness of suitable upper limb outcome measures, *unit specific: CAHAI/ Chedoke; MTHAS; Fugl- Meyer | ||
MDT working | ||
To be able to feedback assessment to senior OT to implement appropriate intervention | ||
To be able to escalate any concerns regarding pain, skin, necrosis etc. to MDT | ||
Risk Assessment | ||
To complete Risk Assessment prior to assessment based on admission and presenting conditions | ||
ROM and joint integrity | ||
Assesses passive range of movement: Goniometry or Neutral- O method | ||
Uses subluxation measurements | ||
Power | ||
Active range of movement: Oxford Scale (OS) | ||
Assess grip using: | ||
Cylindrical | ||
Spherical | ||
Palmer | ||
Hook | ||
Lateral | ||
Tiper/Pincer | ||
Tripod | ||
Tone | ||
Demonstrates use of Modified Ashworth Scale (MAS) - Rigidity vs spasticity? | ||
Sensation | ||
Dermatome knowledge and awareness. Patient reporting- sharpness, numbness, dull aches, pins and needles - patterns | ||
Demsontrates assessment of light touch | ||
Demsontrates assessment of deep touch | ||
Demsontrates assessment of temperature | ||
Demsontrates assessment of distinction | ||
Demsontrates assessment of discrimination | ||
Proprioception | ||
Assess proprioception using thumb | ||
Assess proprioception using arm positioning matching | ||
Assess proprioception using joint position sense | ||
Coordination | ||
Assesses coordination using 9 hole peg test | ||
Assesses coordination using finger nose test | ||
Assesses coordination using digit tapping | ||
Assesses coordination using DDK | ||
Pain | ||
Assess pain using Pain Scale (VAS, Numerical Pain scale and Clinical Pain Observation Tool) | ||
Assess pain using verbal pain descriptions i.e. sharp, numbness, tingling, pins/ needles, dull, old/ new pain | ||
Skin integrity | ||
Stretched, taut, shiny, dry, cracked, weeping, pale, red, erythema (rash) bruised, temperature, healed. Necrosis and TVN advise adherence | ||
Assessing Impact on ROM in function. | ||
Functional Assessment | ||
Teeth brushing | ||
Drinking/ Feeding tasks | ||
Oral care | ||
Putting on glasses | ||
Using a phone | ||