**1.1 Background**

Critically ill patients with impaired physical function have a picture of the weakness of muscle quadriceps femoris, decreased strength, and decrease in daily activities. Critically ill patients will experience mechanical unloading and decreased neuromuscular activity. Patients critical during Intensive Care Unit (ICU) will lose 20% of muscle volume, and 70% of protein for 1 week are admitted to ICU. The study also found 476.862 patients (60% -80% of the total Critically ill patients in ICU with 30% of them unable to return to work (nonproductive) due to loss of muscle strength of 1% -2% each day after patient out of ICU [1–13]. Critically ill patients with decreased physical and cognitive functioning are caused by various

treatment measures and the accompanying illness. Patients with physical and cognitive impairment were caused by a history of using a mechanical ventilator (33%), infection or sepsis (50%), patients receiving treatment 2 days up to >1 week in ICU (> 50%), delirium and critical illness or sepsis (70%), coronary heart disease (CHD) (36.6%), Unstable Angina (UA) (41.5%), Hypertension (19.5%), Supraventricular Tachycardia (SVT) (2.4%) [1, 2, 14, 15]. The main causal factors causing it are long-term care (≥2 days) and minimal mobilization. Other causative factors include previous medical history (health status and previous disease history), acute illness, critical illness (delirium, hypoxia, hypotension, glucose dysregulation, respiratory failure, shock, Congestive Heart Failure (CHF), sepsis and others), severity diseases, inflammation, loss of muscle strength, sedation, and anxiety levels (communication dissatisfaction, sleep disturbances) [4, 7, 9, 16, 17]. The critically ill patient decline in physical and cognitive functioning if not promptly prevented during ICU treatment may have an impact on increasing health problems when treated in the ICU and when out of the ICU. Critically ill patients with reduced physical and cognitive functioning if not promptly prevented during ICU may have the effect of aggravating and weakening the function of other organs.

Critical illness is associate with impaired brain function like cognitive impairment and mental health [9]. Brain function will reduce and patients in ICU will be Delirium. Neurotransmitters involved in delirium. There are a number of neurotransmitters believed to be involved in the pathogenesis of delirium, including acetylcholine, serotonin, dopamine, and gamma-aminobutyric acid (GABA) [18]. Peripheral inflammation (due to infection, surgery, or trauma) can induce brain parenchyma cells to release inflammatory cytokines. As a result, neurons and synapses dysfunction. In delirium patients, elevated levels of C-Reactive Protein (CRP), Interleukin-6 (IL-6), Tumor Necrois Factor alpha (TNF-α), Interleukin 1 Reseptor Antagonist (IL − 1RA), Interleukin-10 (IL-10), and Interleukin-8 (IL-8) were found. Critically ill patients may experience hemodynamic disturbances, blood pressure, heart rate, and other heart and brain conditions. This can worsen the critical condition of the patient while in the ICU.

Critically ill patients with decreased physical function were a condition that often arose. Which is characterized by a decrease in muscle and functional function [19]. Critically ill patients with decreased function can experience muscle atrophy which is caused by many factors, including inflammatory processes and responses, immobilization, nutritional deficiencies, administration of corticosteroids, and so on. Critically ill patients with impaired physical function have a picture of weakness in the musculus quadriceps femoris, decreased strength, and decreased in carrying out daily activities. Critically ill patients will experience mechanical unloading and decreased activity neuromuscular. Critically ill patients who experience decreased activity neuromuscular at a later stage experience stimulation of a complex adaptation response by producing a mechanism process protein synthesis, increased protein degradation, and increased apoptosis of muscle cells which are major contributors to muscle atrophy, decreased or lost muscle strength in patients.

Critically ill patients with decreased cognitive function can be described as a decrease in memory function and brain function, attention, executive function, mental processing speed visuospatial ability. Critically ill patients with decreased cognitive function are caused by a lack of knowledge about ICU care, ICU delirium, sedation, sleep disturbances, and hypoxia [3]. Critically ill patients with decreased cognitive function are associated with decreased brain oxidative metabolism that causes changes in regional neurotransmitters in the brain. Prefrontal and subcortical or there is a decrease in cholinergic and increased dopaminergic activity when the levels of serotonin and levels of GABA (Gamma-Aminobutyric Acid) are significant. The results of the study found that patients with decreased cognitive function

**49**

impairment.

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

occurred in 24% -34% of critically ill patients and were similar to the symptoms of traumatic brain injury (34%) and patients were similar to Alzheimer's disease and delirium (24%) [3–6, 8–11]. Decreased physical function can have an impact on weakness in other functions and reduce the quality of life of Critically ill patients. Critically ill patients with decreased physical and cognitive function caused by various treatment measures and also the accompanying diseases. Critically ill patients with decreased physical and cognitive function due to a history of using mechanical ventilators (33%), infection or sepsis (50%), patients receiving 2 days to >1 week in ICU (> 50%), delirium and various critical illnesses or sepsis (70%), coronary heart disease (CHD) (36.6%), Unstable Angina (UA) (41.5%), Hypertension (19.5%), Supraventricular Tachycardia (SVT) (2,4%) [2, 14, 20, 21]. The main contributing factors that cause it are prolonged care (≥2 days) and minimal mobilization. Other contributing factors are previous medical history (health status and previous medical history), acute illness, critical illness (delirium, hypoxia, hypotension, glucose dysregulation, respiratory failure, shock, CHF (Congestive Heart Failure), sepsis. and others), disease severity, inflammation, loss of muscle strength, sedation, and anxiety levels (communication dissatisfaction, sleep disturbances) [4, 5, 22, 23]. Critically ill patients with decreased physical and cognitive function if not immediately prevented during ICU treatment can have an impact on increasing health problems while being admitted to the ICU and when

Critically ill patients with physical and cognitive decline if not prevented immediately while in the ICU, it can have an impact in the form of worsening and weakening the function of other organs [24]. Critically ill patients with decreased physical and cognitive function can have an impact on prolonged treatment time, decreased cognitive function, physical function (organs, muscle contractility, functional capacity and pain, vitality, fatigue) that persist, and worsening mental health (anxiety), emotional response, depression, reflection, loneliness, disability doing activities and using instruments in everyday life [4, 9, 23, 25–27]. Critically ill patients with the phenomenon of decreased physical and cognitive function based on the accompanying impact indicate the need for strategi preventive interventions while the patient is in the ICU. Function improvement in critically ill patients in the ICU increases with interventions given to each problem patient in the ICU and post

Problems of Critically ill Patients in the ICU is a health problem in the form of physical to psychological disorders that often appear and persist for a long time in patients who are through critical conditions in the ICU or when the patient is discharged from the ICU. The problem can be described as a collection of symptoms or an acute condition worsening the status of weakness in physical, cognitive, or mental health functions in the form of anxiety (physical, cognitive, and mental health) during critical illness. is a collection of symptoms from the patient's experience after the patient survives or is out of a critical period and/or at least ≥2 days in the ICU [4, 30, 31]. Problems during treatment in the ICU can be concluded in the form of a collection of symptoms shown in patients who have successfully passed critical conditions. From ICU and 3 symptoms or areas of damage shown, namely physical function impairment, cognitive impairment in the form of impaired orientation, registration, attention, calculation and language, and mental health

Causes of various patient problems while being treated until the patient is discharged from the ICU are Critically ill patients who have successfully passed their

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

leaving the ICU.

ICU [3, 10, 20, 26, 28, 29].

**1.2 Critical patient health problems**

*Connectivity and Functional Specialization in the Brain*

the critical condition of the patient while in the ICU.

Critically ill patients with decreased physical function were a condition that often arose. Which is characterized by a decrease in muscle and functional function [19]. Critically ill patients with decreased function can experience muscle atrophy which is caused by many factors, including inflammatory processes and responses, immobilization, nutritional deficiencies, administration of corticosteroids, and so on. Critically ill patients with impaired physical function have a picture of weakness in the musculus quadriceps femoris, decreased strength, and decreased in carrying out daily activities. Critically ill patients will experience mechanical unloading and decreased activity neuromuscular. Critically ill patients who experience decreased activity neuromuscular at a later stage experience stimulation of a complex adaptation response by producing a mechanism process protein synthesis, increased protein degradation, and increased apoptosis of muscle cells which are major contributors to muscle atrophy, decreased or lost muscle strength in patients. Critically ill patients with decreased cognitive function can be described as a decrease in memory function and brain function, attention, executive function, mental processing speed visuospatial ability. Critically ill patients with decreased cognitive function are caused by a lack of knowledge about ICU care, ICU delirium, sedation, sleep disturbances, and hypoxia [3]. Critically ill patients with decreased cognitive function are associated with decreased brain oxidative metabolism that causes changes in regional neurotransmitters in the brain. Prefrontal and subcortical or there is a decrease in cholinergic and increased dopaminergic activity when the levels of serotonin and levels of GABA (Gamma-Aminobutyric Acid) are significant. The results of the study found that patients with decreased cognitive function

treatment measures and the accompanying illness. Patients with physical and cognitive impairment were caused by a history of using a mechanical ventilator (33%), infection or sepsis (50%), patients receiving treatment 2 days up to >1 week in ICU (> 50%), delirium and critical illness or sepsis (70%), coronary heart disease (CHD) (36.6%), Unstable Angina (UA) (41.5%), Hypertension (19.5%), Supraventricular Tachycardia (SVT) (2.4%) [1, 2, 14, 15]. The main causal factors causing it are long-term care (≥2 days) and minimal mobilization. Other causative factors include previous medical history (health status and previous disease history), acute illness, critical illness (delirium, hypoxia, hypotension, glucose dysregulation, respiratory failure, shock, Congestive Heart Failure (CHF), sepsis and others), severity diseases, inflammation, loss of muscle strength, sedation, and anxiety levels (communication dissatisfaction, sleep disturbances) [4, 7, 9, 16, 17]. The critically ill patient decline in physical and cognitive functioning if not promptly prevented during ICU treatment may have an impact on increasing health problems when treated in the ICU and when out of the ICU. Critically ill patients with reduced physical and cognitive functioning if not promptly prevented during ICU may have the effect of aggravating and weakening the function of other organs. Critical illness is associate with impaired brain function like cognitive impairment and mental health [9]. Brain function will reduce and patients in ICU will be Delirium. Neurotransmitters involved in delirium. There are a number of neurotransmitters believed to be involved in the pathogenesis of delirium, including acetylcholine, serotonin, dopamine, and gamma-aminobutyric acid (GABA) [18]. Peripheral inflammation (due to infection, surgery, or trauma) can induce brain parenchyma cells to release inflammatory cytokines. As a result, neurons and synapses dysfunction. In delirium patients, elevated levels of C-Reactive Protein (CRP), Interleukin-6 (IL-6), Tumor Necrois Factor alpha (TNF-α), Interleukin 1 Reseptor Antagonist (IL − 1RA), Interleukin-10 (IL-10), and Interleukin-8 (IL-8) were found. Critically ill patients may experience hemodynamic disturbances, blood pressure, heart rate, and other heart and brain conditions. This can worsen

**48**

occurred in 24% -34% of critically ill patients and were similar to the symptoms of traumatic brain injury (34%) and patients were similar to Alzheimer's disease and delirium (24%) [3–6, 8–11]. Decreased physical function can have an impact on weakness in other functions and reduce the quality of life of Critically ill patients.

Critically ill patients with decreased physical and cognitive function caused by various treatment measures and also the accompanying diseases. Critically ill patients with decreased physical and cognitive function due to a history of using mechanical ventilators (33%), infection or sepsis (50%), patients receiving 2 days to >1 week in ICU (> 50%), delirium and various critical illnesses or sepsis (70%), coronary heart disease (CHD) (36.6%), Unstable Angina (UA) (41.5%), Hypertension (19.5%), Supraventricular Tachycardia (SVT) (2,4%) [2, 14, 20, 21]. The main contributing factors that cause it are prolonged care (≥2 days) and minimal mobilization. Other contributing factors are previous medical history (health status and previous medical history), acute illness, critical illness (delirium, hypoxia, hypotension, glucose dysregulation, respiratory failure, shock, CHF (Congestive Heart Failure), sepsis. and others), disease severity, inflammation, loss of muscle strength, sedation, and anxiety levels (communication dissatisfaction, sleep disturbances) [4, 5, 22, 23]. Critically ill patients with decreased physical and cognitive function if not immediately prevented during ICU treatment can have an impact on increasing health problems while being admitted to the ICU and when leaving the ICU.

Critically ill patients with physical and cognitive decline if not prevented immediately while in the ICU, it can have an impact in the form of worsening and weakening the function of other organs [24]. Critically ill patients with decreased physical and cognitive function can have an impact on prolonged treatment time, decreased cognitive function, physical function (organs, muscle contractility, functional capacity and pain, vitality, fatigue) that persist, and worsening mental health (anxiety), emotional response, depression, reflection, loneliness, disability doing activities and using instruments in everyday life [4, 9, 23, 25–27]. Critically ill patients with the phenomenon of decreased physical and cognitive function based on the accompanying impact indicate the need for strategi preventive interventions while the patient is in the ICU. Function improvement in critically ill patients in the ICU increases with interventions given to each problem patient in the ICU and post ICU [3, 10, 20, 26, 28, 29].

## **1.2 Critical patient health problems**

Problems of Critically ill Patients in the ICU is a health problem in the form of physical to psychological disorders that often appear and persist for a long time in patients who are through critical conditions in the ICU or when the patient is discharged from the ICU. The problem can be described as a collection of symptoms or an acute condition worsening the status of weakness in physical, cognitive, or mental health functions in the form of anxiety (physical, cognitive, and mental health) during critical illness. is a collection of symptoms from the patient's experience after the patient survives or is out of a critical period and/or at least ≥2 days in the ICU [4, 30, 31]. Problems during treatment in the ICU can be concluded in the form of a collection of symptoms shown in patients who have successfully passed critical conditions. From ICU and 3 symptoms or areas of damage shown, namely physical function impairment, cognitive impairment in the form of impaired orientation, registration, attention, calculation and language, and mental health impairment.

Causes of various patient problems while being treated until the patient is discharged from the ICU are Critically ill patients who have successfully passed their

#### **Figure 1.**

*Intensive care syndrome problems.*

critical condition, being treated in the ICU ≥2 days with experiences that respond to patients [4]. A collection of symptoms of problems in the ICU can appear until the patient out of the ICU and the patient after being discharged from the hospital. Other causes include Critically ill patients who are treated in the ICU for a minimum period of 2 days with minimal mobilization, acute disease conditions, sepsis, and delirium. The impact is increasing the length of treatment time, mental health damage in the form of anxiety, physical function, and cognitive function [4, 10]. Critically ill patients with prolonged immobilization have an impact on physical function during the patient's stay in the ICU and after discharge from the ICU. These effects result in decreased organ function and decreased muscle contractility, functional capacity, and quality of life for patients [26]. Other causes based on the research include patients experiencing these problems, including Critically ill patients with acute illness, heart failure, Congestive Heart Failure (CHF), patients with sepsis, delirium, shock, etc. [3]. The results of research on Critically ill patients in the ICU found that 60% -80% of patients have functionally impaired, 50–70% patients have cognitively impaired (executive function, memory, and attention), and 10–40% of patients have experienced health deficits (anxiety, depression, and posttraumatic stress disorder (PTSD)) [3]. The magnitude of the impact that patients get after receiving treatment in the ICU can disrupt and reduce the patient's quality of life. Critically ill patients who are admitted to the ICU experience a decrease in muscle strength by 1–2% every day [10]. This can weaken physical function in the form of disuse atrophy, weakness in daily activities caused by immobilization or bed rest, ICU acquired illnesses, and age [3, 5, 32]. Post Intensive Care Syndrome (PICS) patients with the impaired physical function will interfere with life and health activities in patients in the form of productivity, activity daily, to the patient's quality of life. Symptoms in the ICU include physical impairment, cognitive impairment, and mental health in the form of degrees of anxiety (**Figure 1**).

## **2. Cognitive and physical impairment**

#### **2.1 Cognitive impairment**

The results of post ICU patient research can cause cognitive impairment, with severity 34% of patients have damage cognitive impairment is similar to traumatic brain injury, and 24% of patients have cognitive impairment similar to Alzheimer's

**51**

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

*2.1.1 Measurement of cognitive function of patients in the ICU*

1.Questionnaire on Cognitive Decline in The Elderly (IQCODE)

Cognitive Decline in The Elderly (IQCODE) has high reliability.

2.The Mini-Mental State Examination (MMSE)

examination (MMSE) for 5–10 minutes [34].

**2.2 Physical impairment**

Critically ill patients have a form of cognitive dysfunction in the long term that still needs further research. This cognitive dysfunction is characterized by pre-existing mild exacerbation deficits, global and executive cognitive function. Long-term cognitive impairment after a patient can pass through a critical illness can become a new problem and reduce the quality of life. The results of the study found that the cognitive function of Critically ill patients can be measured using the Questionnaire on Cognitive Decline in The Elderly (IQCODE). Questionnaire on Cognitive Decline in The Elderly (IQCODE) has 26 question items that have good correlation, test–retest reliabilities [33]. This instrument can also be given to dementia patients, the results of other studies also show that Questionnaire on

Measurement of a patient's cognitive status uses the mini-mental state examination (MMSE). The mini-mental state examination is a tool to measure mental status which in this case is cognitive impairment. The mini-mental state examination is a measuring tool that has high reliability and validity so that it can describe cognitive functions. The mini-mental state examination has 11 questions in which there are five areas of cognitive function, namely orientation, registration, attention, and calculation, recall, and language the maximum score is 30. Scores of 23 and below indicates cognitive impairment. Long duration measurement The mini-mental state

Critically ill patients in the ICU during bed rest will experience mechanical unloading and decreased activity neuromuscular, which in turn stimulates a complex adaptation response by showing protein synthesis, increased protein degradation, and increased apoptosis of muscle cells. This mechanism is a major contributor to muscle atrophy and decreased or loss of muscle strength in patients, it can be seen after the patient's bed rest. Muscle metabolism disorders that occur

disease, and delirium, which is a separate risk factor for long-term cognitive impairment [8]. The study of 637,867 patients who survived the ICU from 1999 to 2008 showed that patients experience cognitive impairment and functional and is

The results investigations Pre and post ICU found that the prevalence of cognitive impairment increased from initially moderate to a more severe scale with an increase in the value of 6.1% [6]. Cognitive impairment in Critically ill patients who are treated in the ICU can have manifestations of acute brain dysfunction to delirium. Delirium is characteristic of changes in mental status and fluctuating course [24]. Long-standing cognitive impairment can lead to cognitive deficits by following the severity of the pain, which in turn worsens and weakens other functions [24]. Decreased cognitive function is also associated with decreased brain oxidative metabolism causing neurotransmitter changes in the prefrontal and subcortical areas. There was a decrease in cholinergic activity and an increase in dopaminergic activity, at a time when the significance of serotonin and GABA

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

increasing significantly [4].

levels remained unclear.

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

*Connectivity and Functional Specialization in the Brain*

critical condition, being treated in the ICU ≥2 days with experiences that respond to patients [4]. A collection of symptoms of problems in the ICU can appear until the patient out of the ICU and the patient after being discharged from the hospital. Other causes include Critically ill patients who are treated in the ICU for a minimum period of 2 days with minimal mobilization, acute disease conditions, sepsis, and delirium. The impact is increasing the length of treatment time, mental health damage in the form of anxiety, physical function, and cognitive function [4, 10]. Critically ill patients with prolonged immobilization have an impact on physical function during the patient's stay in the ICU and after discharge from the ICU. These effects result in decreased organ function and decreased muscle contractility, functional capacity, and quality of life for patients [26]. Other causes based on the research include patients experiencing these problems, including Critically ill patients with acute illness, heart failure, Congestive Heart Failure (CHF), patients with sepsis, delirium, shock, etc. [3]. The results of research on Critically ill patients in the ICU found that 60% -80% of patients have functionally impaired, 50–70% patients have cognitively impaired (executive function, memory, and attention), and 10–40% of patients have experienced health deficits (anxiety, depression, and posttraumatic stress disorder (PTSD)) [3]. The magnitude of the impact that patients get after receiving treatment in the ICU can disrupt and reduce the patient's quality of life. Critically ill patients who are admitted to the ICU experience a decrease in muscle strength by 1–2% every day [10]. This can weaken physical function in the form of disuse atrophy, weakness in daily activities caused by immobilization or bed rest, ICU acquired illnesses, and age [3, 5, 32]. Post Intensive Care Syndrome (PICS) patients with the impaired physical function will interfere with life and health activities in patients in the form of productivity, activity daily, to the patient's quality of life. Symptoms in the ICU include physical impairment, cognitive impairment, and mental health in the form of degrees of anxiety (**Figure 1**).

The results of post ICU patient research can cause cognitive impairment, with severity 34% of patients have damage cognitive impairment is similar to traumatic brain injury, and 24% of patients have cognitive impairment similar to Alzheimer's

**50**

**Figure 1.**

*Intensive care syndrome problems.*

**2. Cognitive and physical impairment**

**2.1 Cognitive impairment**

disease, and delirium, which is a separate risk factor for long-term cognitive impairment [8]. The study of 637,867 patients who survived the ICU from 1999 to 2008 showed that patients experience cognitive impairment and functional and is increasing significantly [4].

The results investigations Pre and post ICU found that the prevalence of cognitive impairment increased from initially moderate to a more severe scale with an increase in the value of 6.1% [6]. Cognitive impairment in Critically ill patients who are treated in the ICU can have manifestations of acute brain dysfunction to delirium. Delirium is characteristic of changes in mental status and fluctuating course [24]. Long-standing cognitive impairment can lead to cognitive deficits by following the severity of the pain, which in turn worsens and weakens other functions [24]. Decreased cognitive function is also associated with decreased brain oxidative metabolism causing neurotransmitter changes in the prefrontal and subcortical areas. There was a decrease in cholinergic activity and an increase in dopaminergic activity, at a time when the significance of serotonin and GABA levels remained unclear.

### *2.1.1 Measurement of cognitive function of patients in the ICU*

1.Questionnaire on Cognitive Decline in The Elderly (IQCODE)

Critically ill patients have a form of cognitive dysfunction in the long term that still needs further research. This cognitive dysfunction is characterized by pre-existing mild exacerbation deficits, global and executive cognitive function. Long-term cognitive impairment after a patient can pass through a critical illness can become a new problem and reduce the quality of life. The results of the study found that the cognitive function of Critically ill patients can be measured using the Questionnaire on Cognitive Decline in The Elderly (IQCODE). Questionnaire on Cognitive Decline in The Elderly (IQCODE) has 26 question items that have good correlation, test–retest reliabilities [33]. This instrument can also be given to dementia patients, the results of other studies also show that Questionnaire on Cognitive Decline in The Elderly (IQCODE) has high reliability.

#### 2.The Mini-Mental State Examination (MMSE)

Measurement of a patient's cognitive status uses the mini-mental state examination (MMSE). The mini-mental state examination is a tool to measure mental status which in this case is cognitive impairment. The mini-mental state examination is a measuring tool that has high reliability and validity so that it can describe cognitive functions. The mini-mental state examination has 11 questions in which there are five areas of cognitive function, namely orientation, registration, attention, and calculation, recall, and language the maximum score is 30. Scores of 23 and below indicates cognitive impairment. Long duration measurement The mini-mental state examination (MMSE) for 5–10 minutes [34].

#### **2.2 Physical impairment**

Critically ill patients in the ICU during bed rest will experience mechanical unloading and decreased activity neuromuscular, which in turn stimulates a complex adaptation response by showing protein synthesis, increased protein degradation, and increased apoptosis of muscle cells. This mechanism is a major contributor to muscle atrophy and decreased or loss of muscle strength in patients, it can be seen after the patient's bed rest. Muscle metabolism disorders that occur

**Figure 2.** *The immobilization-induced catabolic response.*

reduce protein formation to energy breakdown during patient immobilization or bed rest.

Critically ill patients in the ICU show that 70% of the minimum activity will lose muscle mass after bed rest, especially in the lower extremities [19]. The results of a study on Critically ill patients who were treated in the ICU with a research method using RCTs (Randomized Controlled Trials) found that patients who hospitalized in the ICU > 48 hours will experience impaired physical function and sleep disturbances [35]. Critically ill patients in the ICU with minimal mobilization, disease prognosis, unusual environment, and sedation response affect the patient's comfort response and affect the response of the hormone oxytocin.

A decrease in the quality of sleep of a critical patient will increase the patient's anxiety so that the patient is unable to be oriented and cooperative. Physical response muscle weakness can increase the discomfort response so that the patient's body is in a state of oxidative stress. Oxidative stress occurs because several free radicals in the body exceed the body's capacity to neutralize them. The impact of this is that the intensity of the oxidation process in normal body cells becomes higher and causes significant and more damage. Oxidative stress is the main cause, one of which is the emergence of chronic diseases such as cancer, heart disease, Alzheimer's, and others (**Figure 2**).

### *2.2.1 Measurement of physical function of critically ill patients in the ICU*

Measurement of physical function can be done with several measuring instruments including Time up and Go (TUG) Test

#### a.Time Up and Go [36]

TUG is a physical function measuring tool by assessing balance and the risk of falling. The tools used are a stopwatch, a chair, a meter with a minimum length of 3 meters, or 10 feet. The patient is instructed by the nurse and the patient must follow suit. The patient performs mobilization from sitting to standing and walking. The interpretation of Time up and Go (TUG) is the time taken from sitting to standing.

**53**

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

Interpretation of ≤ 10 seconds is normal, ≤ 20 seconds is good mobilization, can walk alone, mobilize without the aid of tools, ≤ 30 seconds is a problem, cannot go independently, requires tool assistance, ≥ 14 seconds the patient has a high risk of falling.

Physical function measurement with instruments 6 Minute Test (6 MWT) to measure the patient's physical functioning endurance. The tools needed for this measurement are a stopwatch, rolling tape, aisle. The measurement carried out is the distance the patient has walked for 6 minutes [37]. The measurement is stopped if it finds the following criteria, signs, and symptoms of angina (chest pain), dizziness, confusion, ataxia, staggering, unsteadiness, pallor, cyanosis, nausea, dyspnea, fatigue, signs of peripheral circulatory insufficiency, claudication or significant pain, and the patient develops distress. Discontinue if there are hemodynamic changes such as systolic blood pressure decreases >10 mmHg, systolic blood pressure increases >250 mmHg, diastolic blood pressure rises >120 mmHg, and HR falls >15

The physical strength of patients in the ICU is usually measured by looking at the patient's ability to perform or meet the needs of daily activities. The physical function of a critical patient can be measured to determine the degree of physical function impairment in the patient. Examination or measurement of physical function is expected to be able to present the real condition of the critical patient's condition in the ICU or after the patient is discharged from the ICU. physical in the ICU are responsibility, reliability and validity can use Physical Function ICU Test (PFIT). Physical Function ICU Test (PFIT) is a physical function measurement tool that can be used by critical nurses in the ICU to identify the condition of critically ill patients in the ICU. The Physical Function ICU Test is proven to be safe with high clinical utility, responsiveness to all changes, and PFIT is recommended in testing the physical function of patients in the ICU [38–40]. PFIT shows good reliability and responsiveness to changes and the respondents who take measurements safe and flexible [39]. The PFIT test was carried out on 20 respondents and all respondents measured the results obtained P < 0.05. The Physical Function ICU Test can show an increase in the progress of muscle function and muscle strength in Critically ill patients [39]. The Physical Function ICU Test can be performed on patients with a tracheostomy attached, a ventilator, the patient can follow orders, can sit, and not. Performed in patients with a fraction of inspired oxygen (Fio2) > 0.6 (> 60%); positive end-expiratory pressure (PEEP) > 8 cmH2O; patients with spinal cord injuries, stroke, and unstable fractures [39]. There are 4 Physical

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

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

b.6 Minute Walk Test (MWT)

c.Physical Function ICU Test (PFIT)

Function ICU Test (PFIT) domains measured, namely:

**3. Physical-cognitive therapy**

**3.1 Definition**

beats per minute.

Interpretation of ≤ 10 seconds is normal, ≤ 20 seconds is good mobilization, can walk alone, mobilize without the aid of tools, ≤ 30 seconds is a problem, cannot go independently, requires tool assistance, ≥ 14 seconds the patient has a high risk of falling.
