**4. Theory the symptom management**

Symptom management model first was introduced at the University of California, San Francisco (UCSF) by Larson in 1994, and developed by Dodd, M., Janson, S., Facione, N., Faucett, J., Froelicher, ES, Humphreys, J., Taylor, D. in 2001 in the publication of the Journal of Advanced Nursing with the title Advancing the Science of Symptom Management. (Dodd et al., 2001) Symptoms are defined as subjective experiences that reflect changes in the biopsychosocial function, sensation, or cognition of the individual. Signs and symptoms are defined as disease indications detected by individuals or other people. (Smith & Liehr, 2014) Signs and symptoms of problems are in the form of cognitive and physical dysfunction, which are important aspects of health status and diseases that interfere with the health of other patients such as social function. Acute symptoms that often appear will make patients come back to health services to have their health checked and make the patient's quality of life decrease (**Figure 3**).

Patients during treatment in the ICU may develop symptoms or a group of symptoms that can be the first indication in identifying the prognosis of further disease progression. These symptoms are the effect of previous treatment while in the ICU or symptoms of decreased health function can also be caused by pharmacologists or nursing services performed by health personnel. Theory of Symptom Management can help provide information to relieve or prevent symptoms or to minimize the stress of experiencing symptoms that can occur while a patient is in the ICU. This middle-range theory serves to guide symptom assessment and Interventions in nursing practice [20, 43].

Three important concepts of Symptom Management Theory (SMT) namely, symptom experience, symptom management strategies, and symptom status outcomes. This concept focuses on three domains of nursing science, namely the domain of people, environment, and health or disease (person domain, environmental domain, and health/illness domain) as contextual considerations for nursing research [43].

**Figure 3.** *Symptom management [44].*

Critical patients in the ICU will have various illness symtoms, depending on age and reproductive status as well as other factors. These factors include genetic risk factors (person domain), cultural beliefs, the representative meaning of a symptom based on reported laboratory and the diagnosis of the disease (health or disease domain). Experience history of pain while in the ICU is a simultaneous perception, evaluation, and response to changes in a person. Changes can be identified how often (frequency) the condition is sick or how severe (how bad) the condition or illness is. The frequency or severity may not change, but the stress associated with symptom problems in the ICU can be altered by preventive intervention strategies. Symptomatic experiences can include not one but several synergistic symptoms. Strategies Symptom management to prevent, delay, or minimize the experience of symptoms of patient problems while in the ICU should be applicable. This strategy can be effective in three ways: (1) reducing the frequency of symptom experiences, (2) minimizing symptom severity, or (3) eliminating the pain associated with symptoms (**Figure 3**) [44].

### **5. Result**

In this work, our objective is to prove that physical-cognitive therapy (PCT) affects towards increasing physical and cognitive functions to critical patients in ICU with design was Randomized Controlled Trials (RCTs). This research data was obtained by determining the criteria for respondents. The Inclusion criteria include Patients who have been treated in ICU ≥ 24 hours, RASS -5 to +1, No visual disturbance, and hearing. Exclusion criteria include RASS +2, +3, and + 4, Patients who change RASS values to +2, +3 and + 4 when intervened or different days, Patients screening scores change during intervention, Patient forcibly return home or refer to another hospital, Patient dies, Initial assessment or ongoing intervention in patients is found with Cardiac Surgery, Neurodegenerative

**59**

*Notes: a*

**Table 1.**

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

**No Characteristic Group Z P-Value** 

**2 Age** ( *x* ± SD) 59.9 ± 10.94 48.03 ± 11.4 <0.001 12–16-Year-old — 1 (3.1%) 3.78

**(N = 32)**

Female 13 (40.6%) 16 (50%)

26–35-Year-old — 2 (6.4%) 36–45-Year-old 4 (12.5%) 10 (31.3%) 46–55-Year-old 7 (21.9%) 11 (34.4%) 56–65-Year-old 11 (34.4%) 7 (21.9%) > 65-Year-old 10 (31.3%) 1 (3.1%)

CHD- OMI 11 (34.4%) 7 (21.9%)

HHF 3 (9.4%) 3 (9.4%) Pneumothorax 2 (6.3%) — Acidosis metabolic 1 (3.1%) — DKA 1 (3.1%) — COPD 1 (3.1%) —

> 0 16 (50.0%) 19 (59.4%) -1 — 4 (12.5%) -2 10 (31.3%) 6 (18.8%) -3 4 (12.5%) — -4 1 (3.1%) —

> No 9 (28.1%) 10 (28.1%)

*unstable angina; OMI: old myocardia infarct; HHF: Hypertension heart failure; DKA: diabetic ketoacidosis; COPD:* 

Asthma Attack Emergency 1 (3.1%) — Observation Ileus — 2 (6.3%) Stroke Hemorrhagic — 1 (3.1%) GEA — 1 (3.1%) Hyperglycemic — 1 (3.1%)

**(N = 64) Intervention** 

**Control (N = 32)**

Male 19 (59.4%) 16 (50%) 0.74 0.455

CHD -UA 5 (15.6%) 10 (31.3%) 1.01 0.312

7 (21.9%) 7 (21.9%)

+1 1 (3.1%) 3 (9.4%) 2.06 0.039

Yes 23 (71.9%) 22 (68.8%) 3.07 0.002

*: Mann- Whitney test; Z: Z count (Z table: 1.96); CHD: Coronary Heart Disease; UA:* 

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

**1 Gender**

**3 Diagnose**

**4 RASS**

**5 Sedation**

*: Chi-Square test, b*

*Respondent characteristic.*

*chronic obstructive Pulmonary Disease; GEA: gastroenteritis acute.*

decomp cordis phase class III-IV


*Connectivity and Functional Specialization in the Brain*

Critical patients in the ICU will have various illness symtoms, depending on age and reproductive status as well as other factors. These factors include genetic risk factors (person domain), cultural beliefs, the representative meaning of a symptom based on reported laboratory and the diagnosis of the disease (health or disease domain). Experience history of pain while in the ICU is a simultaneous perception, evaluation, and response to changes in a person. Changes can be identified how often (frequency) the condition is sick or how severe (how bad) the condition or illness is. The frequency or severity may not change, but the stress associated with symptom problems in the ICU can be altered by preventive intervention strategies. Symptomatic experiences can include not one but several synergistic symptoms. Strategies Symptom management to prevent, delay, or minimize the experience of symptoms of patient problems while in the ICU should be applicable. This strategy can be effective in three ways: (1) reducing the frequency of symptom experiences, (2) minimizing symptom severity, or (3) eliminating the pain associated with

In this work, our objective is to prove that physical-cognitive therapy (PCT) affects towards increasing physical and cognitive functions to critical patients in ICU with design was Randomized Controlled Trials (RCTs). This research data was obtained by determining the criteria for respondents. The Inclusion criteria include Patients who have been treated in ICU ≥ 24 hours, RASS -5 to +1, No visual disturbance, and hearing. Exclusion criteria include RASS +2, +3, and + 4, Patients who change RASS values to +2, +3 and + 4 when intervened or different days, Patients screening scores change during intervention, Patient forcibly return home or refer to another hospital, Patient dies, Initial assessment or ongoing intervention in patients is found with Cardiac Surgery, Neurodegenerative

**58**

symptoms (**Figure 3**) [44].

**5. Result**

**Figure 3.**

*Symptom management [44].*

*Notes: a : Chi-Square test, b : Mann- Whitney test; Z: Z count (Z table: 1.96); CHD: Coronary Heart Disease; UA: unstable angina; OMI: old myocardia infarct; HHF: Hypertension heart failure; DKA: diabetic ketoacidosis; COPD: chronic obstructive Pulmonary Disease; GEA: gastroenteritis acute.*

#### **Table 1.**

*Respondent characteristic.*


**Table 2.**

*Differences of physical function test results between intervention group and critical patient control group (N = 64).*

disease, Post cardiac arrest with suspected anoxic brain injury, Unstable fracture, long bones and open abdomen, Psychotic disorder. The population in the study were all critical patients treated at Kediri Baptist Hospital. Based on ICU RS. Baptist Kediri in May–June 2017 there were 267 patients treated in ICU. The samples were critical patients in ICU of Baptist Hospital Kediri as many as 64 critical patients according to inclusion and exclusion criteria. Independent variable in this research is physical-cognitive therapy. Dependent variable in this research is physical function and cognitive function. The research tool in this research is physical function measurement tool (PFIT) and cognitive function. Data collection has been done after completing the research proposal. Researcher get ethical clearance from KEPK Medical Faculty of Diponegoro University, and Researcher apply research permission from Diponegoro University Semarang to Director of RS. Baptist Kediri. The Wilcoxon test was used to determine differences in cognitive-physical function before and after physical cognitive therapy in each group, whereas the Mann Whitney test was used to determine the posttest of cognitive-physical function between the intervention group and the control group. The value of confidence interval applied is 95% with significance level 5% (α = 0.05). The data obtained is used to support the discussion regarding factors that can affect the research variables.

The characteristic information of subjects is listed in **Table 1**. There were slightly gender differences in the two groups; including more than 50% male in the intervention group while balanced amount between male and female sex in the control group. The subjects of the study in both groups had an average adult age to the early elderly. Diagnosis symptoms varied in the two groups; for example, less than 50% (34.4%) had diagnoses of OMI CHD for the intervention group of the research subjects, while only 21.9% in the control group. More than 50% Research subjects in the two groups had a calm and alert awareness level of 0 (RASS = 0). Majority subjects received sedation in the intervention group (71.9%) and the control group (64%) (**Table 1**).

The result of the test result is the mean rank of the control group is 16.91 and the intervention group is 48.09, with each sum rank is 1539.00 and 541.00. The mean rank result is known that the physical function in the intervention group is better than the control group. The value of U arithmetic is (13 < 105) with the significance of P-value (<0.001), indicating that there was a significant influence difference in the physical function between the intervention group and the control group (**Table 2**).

The result of the test result is the control group's mean rank is 19.28 and the intervention group is 45.72, with each sum rank is 1463.00 and 612.00. The mean rank result is known that cognitive function in the intervention group is better than the control group. The value of U arithmetic is (13 < 105) with significance P-value (<0.001), which means that there is a significant effect difference in the cognitive function between the intervention group and the control group (**Table 3**).

**61**

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

Intervention 45.72 1463.00 Control 19.28 617.00

Brain function will be impairment if there is not preventive intervention in ICU. Patients will get impairment cognitive, physical functional, delirium, impairment hormone in the brain. The brain will release oxidative stress, the body compensates by reducing oxidative metabolism in the brain. As a result, brain dysfunction occurs which causes delirium symptoms. This condition also triggers the formation of reactive oxygen and nitrogen which worsens the damage to brain tissue. This damage is permanent and causes complications in the form of permanent cognitive decline. Disturbance in Critically ill patients will also create an imbalance of neurotransmitters, especially acetylcholine and dopamine. Acetylcholine levels were found to be decreased in delirium patients in the ICU. These levels return to normal after the patient is no longer delirium. Additionally, anticholinergic drugs (acetylcholine blockers) have been shown to cause delirium. Dopamine and acetylcholine have a reciprocal (opposite) relationship. There is an increase in dopamine levels in delirium. The administration of dopamine blockers can also reduce symptoms of delirium. Serotonin is increased in hepatic encephalopathy and septic delirium. Serotonin agonists (hallucinogenic drugs) can also cause delirium. In critically ill patients with delirium, changes in gamma-aminobutyric acid (GABA) and histamine levels occur. Changes can be either increasing or decreasing, depending on the cause of the delirium. Neuroendocrine disorders can also occur where this hormone is associated with increased proinflammatory cytokines in the brain and neuronal damage. The neuroendocrine hypothesis also explains the development of delirium in patients receiving exogenous glucocorticoids. Circadian cycle disruption can affect sleep quality and physiology. Lack of sleep can lead to delirium, memory deficits, and psychosis. Melatonin is a hormone that regulates the circadian cycle. One study shows a link between low melatonin levels and the incidence of delirium. Another study says that administering exogenous melatonin to hospitalized patients

**Group Mean Rank Sum Rank U P-value** Cognitive Function 89.00 <0.001

*Results of differences in cognitive function assessment of intervention groups and critical patient control groups* 

Physical Cognitive Therapy significantly affects physical function in critically ill patients in the ICU. The subjects of the study intervention group increased physical function after intervention with a mean difference of the increase in the intervention group of 3.2, whereas in the control group decreased physical function with a mean of 0.2. The intervention group increased physical function because of physical exercise that is done properly and regularly. Physical exercise at each joint can increase the activity of mechanisms neuromuscular Critically ill patients during bed rest. Physical activity done regularly prevents apoptosis activity. The control group decreased physical function due to a decrease in neuromuscular muscle-debilitating up until the occurrence of cell apoptosis. Improved physical function occurs along with increased functionality and functional use of aid mobilization, step, shoulder strength, and the strength of the knee. Physical-cognitive therapy is expected to be physiologically capable of activating mechanical neuromuscular patients, it is supported by the theory that in principle, the physical exercises to stimulate muscle

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

**6. Discussion**

**Table 3.**

*(N = 64).*

reduces the incidence of delirium.

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


**Table 3.**

*Connectivity and Functional Specialization in the Brain*

Intervention 48.09 1539.00 Control 16.91 541.00

that can affect the research variables.

(64%) (**Table 1**).

**Table 2.**

*(N = 64).*

(**Table 2**).

(**Table 3**).

disease, Post cardiac arrest with suspected anoxic brain injury, Unstable fracture, long bones and open abdomen, Psychotic disorder. The population in the study were all critical patients treated at Kediri Baptist Hospital. Based on ICU RS. Baptist Kediri in May–June 2017 there were 267 patients treated in ICU. The samples were critical patients in ICU of Baptist Hospital Kediri as many as 64 critical patients according to inclusion and exclusion criteria. Independent variable in this research is physical-cognitive therapy. Dependent variable in this research is physical function and cognitive function. The research tool in this research is physical function measurement tool (PFIT) and cognitive function. Data collection has been done after completing the research proposal. Researcher get ethical clearance from KEPK Medical Faculty of Diponegoro University, and Researcher apply research permission from Diponegoro University Semarang to Director of RS. Baptist Kediri. The Wilcoxon test was used to determine differences in cognitive-physical function before and after physical cognitive therapy in each group, whereas the Mann Whitney test was used to determine the posttest of cognitive-physical function between the intervention group and the control group. The value of confidence interval applied is 95% with significance level 5% (α = 0.05). The data obtained is used to support the discussion regarding factors

*Differences of physical function test results between intervention group and critical patient control group* 

**Group Mean Rank Sum Rank U P-value** Physical Function 13.00 <0.001

The characteristic information of subjects is listed in **Table 1**. There were slightly gender differences in the two groups; including more than 50% male in the intervention group while balanced amount between male and female sex in the control group. The subjects of the study in both groups had an average adult age to the early elderly. Diagnosis symptoms varied in the two groups; for example, less than 50% (34.4%) had diagnoses of OMI CHD for the intervention group of the research subjects, while only 21.9% in the control group. More than 50% Research subjects in the two groups had a calm and alert awareness level of 0 (RASS = 0). Majority subjects received sedation in the intervention group (71.9%) and the control group

The result of the test result is the mean rank of the control group is 16.91 and the intervention group is 48.09, with each sum rank is 1539.00 and 541.00. The mean rank result is known that the physical function in the intervention group is better than the control group. The value of U arithmetic is (13 < 105) with the significance of P-value (<0.001), indicating that there was a significant influence difference in the physical function between the intervention group and the control group

The result of the test result is the control group's mean rank is 19.28 and the intervention group is 45.72, with each sum rank is 1463.00 and 612.00. The mean rank result is known that cognitive function in the intervention group is better than the control group. The value of U arithmetic is (13 < 105) with significance P-value (<0.001), which means that there is a significant effect difference in the cognitive function between the intervention group and the control group

**60**

*Results of differences in cognitive function assessment of intervention groups and critical patient control groups (N = 64).*
