**3.1 Definition**

Early activity therapy intervention in the ICU is an effort to prevent the worsening of the patient's muscle condition or weakness after the patient is discharged from the ICU [41]. Cognitive therapy is therapy in Critically ill patients to reduce the possibility and insecurity of the patient while in the ICU. Due to decreased cognitive function [24]. Physical-cognitive therapy is a critical ICU patient intervention that allows cognitive and physical damage due to short or long bed rest [24]. Based

on the results of the study showed that cognitive therapy was effective in improving cognitive function in ICU patients.

Physical-cognitive therapy-pharmacological is a nonprevention and management to improve cognitive quality and physical function (Miller and Ely, 2007) intervention physical-cognitive therapy can improve the cognitive and physical function of Critically ill patients in the ICU and after the patient leaves the ICU. Therapy is given for no more than 20 minutes due to the response fatigue patients during ICU treatment and the response to hemodynamic changes during fatigue.

Physical and cognitive exercise interventions are appropriate and recommended by the Nursing Interventions Classification (NIC). Physical exercise can be done by teaching exercise prescribing (5612), positioning (0840), neurological positioning (0844), increasing strength training (0201), stretching exercises (0202), improving body mechanics (0140), and rehabilitative cardiac care (4046). Cognitive exercise can be done with delusional management (6440) which supports the comfort and orientation to the reality of the patient [42].

#### **3.2 Physical-cognitive therapy screening**

Interventions Physical-cognitive therapy (PCT) is implemented to the patient once a day at ±10.00 a.m. because at that time it is the body's metabolic response in the best conditions. Intervention is carried out for a maximum of 20 minutes for 3 days according to the patient's condition or adjusted to the Richmond Agitation Sedation Scale (RASS) so that patients get intervention according to their needs and abilities because muscle and neurotransmitter metabolism can achieve maximum function if therapy is carried out continuously.

Physical-cognitive therapy can be performed in Critically ill patients with respiratory failure, patients on noninvasive ventilators pressure ventilation, high flow nasal cannula, shock (Dopamine ≥7.5 mcg/kg/min, Norepinephrine ≥5 mcg/kg/ min, Dobutamine ≥5 mcg / kg / min, Phenylephrine ≥75 mcg/kg/min, Epinephrine, Vasopressin >0.03 mcg/min). This intervention should be avoided in patients >72 hours after the development of respiratory failure or shock, cardiac surgery, and post-cardiac arrest. This intervention is only given a maximum of 20 minutes [24].

The first intervention procedure physical-cognitive therapy, namely Critically ill patients in the ICU, is first assessed by RASS. Patients with RASS score of -5 to −4 and − 3 to −2, started to physical therapy intervention using passive Range of Motion (ROM). Patients with RASS score of −3 to −2 patients started to learn cognitive training in the form of space, place, time, and people orientation. The patients with RASS score of −1, 0, +1, would start for physical exercise in the form of active exercise, including sitting beside the bed, standing or moving, Activity Daily Living (ADL) training such as eating, drinking, eliminating, changing positions and finally walking. Meanwhile, for the patient's cognitive training, orientation training Interventions were carried out, digit span forward, matrix puzzle, digit span reverse, noun list recall, paragraph or story recall, letter-number sequences, pattern recognition. Patients with RASS score of −3 to −2 started to learn cognitive training in the form of space, place, time, and people orientation. The patients with RASS score of −1, 0, +1 would start physical exercise in the form of active exercise, including sitting beside the bed, standing or moving, training of Activity Daily Living (ADL) such as eating, drinking, eliminating, changing positions, and finally walking.

#### **3.3 Intervention procedures cognitive therapy**

Intervention therapy Cognitive is a cognitive exercise given to patients for a maximum of 20 minutes for 1 time a day for at least 3 days of implementation.

**55**

*Physical and Cognitive Therapy (PCT) in Critically Ill Patient*

Before implementing the intervention, an assessment of the patient's level of consciousness was carried out using RASS. The goal intervention cognitive therapy is to increase or prevent cognitive decline during treatment in the ICU or after being discharged from the ICU. The patient was not intervened if the patient was stupors or comatose (RASS -4 to −5). The patient was able to respond to sound but was unable to maintain it (awake) or maintain eye contact for >10 seconds (RASS -3 to −2), then the patient was subjected to orientation training intervention. A series of exercises given to the patient's alert (RASS -1 to +1). The patient is subjected to cognitive stimulation from orientation exercises to the stages for a maximum of 20 minutes. Patients are given Interventions

Patients are asked to answer 10 orientation questions and are assessed. Five questions are questions related to time orientation (current year, season, month, date, and day). The next five questions assessed the orientation of the place including city, state, province, where the patient is (ICU hospital), and what floor the patient is currently hospitalized for. The orientation of time and place is instantaneous. Correctly answered questions were repeated starting over for all or 10

The patient is asked to repeat a sequence of numbers, starting with a 4-digit sequence (for example, 4–1–2-8) and advancing to a 9-digit sequence (for example,

Patients are asked to choose the correct answer from a series of five answers that

Similar to "Digit Span-Forward" above, the patient is asked to repeat the sequence in reverse order. For example, suppose the patient is given the sequence 5–7 − 3, and the patient is asked to repeat it in the reverse order, "3–7-5". Exercises

The patient reads a series of seven words and is asked to repeat them in any

Patients read a story that contains many details and are asked to repeat it back to the nurse or researcher as they have read. For example, "On March 14, two cows escaped from their pen through a hole in the fence and went to a busy highway, three cars collided trying to avoid the cow, fortunately, no one was injured. After

start with a 3-sequence digit and progress to an 8-sequence digit.

order, for example, "cat, cat, clock, foot, guitar, knife, button".

four hours the cow just went down. can be caught".

to the extent that the patient achieves them within a time limit of

*DOI: http://dx.doi.org/10.5772/intechopen.94154*

20 minutes [24, 29].

orientation questions.

6–1–4 − 2-9- 3- 5-7-8).

3.Matrix Puzzle

complete a matrix pattern.

4.Digit Span Reverse

5.Noun List Recall

6.Paragraph or Story Recall

2.Digit Span-Forward

1.Orientation Exercises

### *Physical and Cognitive Therapy (PCT) in Critically Ill Patient DOI: http://dx.doi.org/10.5772/intechopen.94154*

Before implementing the intervention, an assessment of the patient's level of consciousness was carried out using RASS. The goal intervention cognitive therapy is to increase or prevent cognitive decline during treatment in the ICU or after being discharged from the ICU. The patient was not intervened if the patient was stupors or comatose (RASS -4 to −5). The patient was able to respond to sound but was unable to maintain it (awake) or maintain eye contact for >10 seconds (RASS -3 to −2), then the patient was subjected to orientation training intervention. A series of exercises given to the patient's alert (RASS -1 to +1). The patient is subjected to cognitive stimulation from orientation exercises to the stages for a maximum of 20 minutes. Patients are given Interventions to the extent that the patient achieves them within a time limit of 20 minutes [24, 29].
