Treatment & Intervention > Evaluation & Treatment

Evaluation & Treatment

Initiate OT intervention as appropriate given the patient's medical status, precautions, and activity orders. Before beginning, confirm RN clearance and ensure the nurse understands the physical demands of the planned session. Refer to the contraindications & considerations page for exclusion and yield criteria.

Patients in the ICU may tolerate only 10–30 minutes of activity initially. Sessions typically progress from bed-level tasks to supported sitting, unsupported sitting, and standing. At every level, ADL — grooming, feeding, dressing — serve as both assessment and treatment.

Before You Enter the Room

Complete a chart review before each session. The goal is to know the patient's status before asking the nurse — it demonstrates clinical preparedness and leads to a more focused conversation.

Chart Review Checklist

  • Activity & mobility orders — what is currently ordered? Any recent changes?
  • Vitals trend — BP parameters, HR, ICP, MAP, SpO₂, vent settings
  • Sedation — current medications, RASS target, whether a sedation hold is planned
  • Lines, leads, and drains — location, type, and any restrictions
  • Recent procedures or upcoming tests — timing matters
  • Precautions — fall, aspiration, spinal, isolation, weight-bearing
  • Consults — has PT or SLP been involved? What are they working on?
  • Goals of care / code status — is there an active family meeting or anticipated change?

Focus Starting from Admission

Early and consistent involvement across disciplines is critical. The following should be prioritized from the time of ICU admission:

  • Medical optimization: ICP, BP, weaning of sedation, nutrition, sleep/wake cycle

  • ROM and positioning to prevent contracture and pressure injury

  • Environmental and sensory regulation

  • Early consults for OT, PT, and SLP as appropriate

  • Early mobility to reduce risk of delirium, deconditioning, and ICU-acquired weakness

  • Use of standardized neuro assessments(GCS & CRS-R) to establish baseline and track change

  • Interdisciplinary rounds to coordinate care and identify discharge barriers early

  • Family education and counseling

Evaluation

The ICU OT evaluation is not a single event — it is a process that unfolds across multiple sessions, times of day, and examiners. Inconsistency between assessments is expected and clinically meaningful; it is a hallmark of minimally conscious states and should be documented rather than resolved by averaging.

Key principles:

  • Evaluate at the patient's optimal time of day (late morning tends to be best — medications have stabilized, nursing tasks are done)

  • Assess before and after any sedation hold when possible

  • Use multiple modalities: behavioral observation, standardized scales, functional task performance

  • Involve the full team — OT, PT, SLP, nursing, and medicine should each contribute observations

What to assess:

  • Arousal and consciousness: use the CRS-R as the primary tool; Rancho Los Amigos to contextualize level of function; GCS is useful for team communication but insufficient for guiding therapy

  • Orientation and cognition: use the CAM-ICU to screen for delirium; the ACE for higher-level patients; informal yes/no reliability screen (see General Tips below)

  • Motor function: tone, ROM, strength, symmetry, posture in bed and sitting; note any posturing patterns

  • Sensory and perceptual function: visual tracking, response to auditory stimuli, tactile awareness; screen for cranial nerve deficits and hemispatial neglect

  • Communication: verbal output, alternative communication attempts, ability to signal yes/no; involve SLP early

  • ADL performance: even at low levels, grooming and feeding tasks reveal command following, object use, and purposeful motor behavior

Confounders

Do not interpret a low or inconsistent assessment as the patient's true level of function without first ruling out the following. These can suppress or mask conscious awareness and should be documented at each evaluation.

Medical Factors

  • Sedating or psychoactive medications (opioids, benzodiazepines, antiepileptics, propofol)
  • Hypoactive delirium
  • Fever (>99°F within 2 hours of exam)
  • Subclinical seizures or recent ictal event
  • Hydrocephalus, UTI, urinary retention, or pneumonia
  • General anesthesia within 24 hours

Known Performance Impairments

  • Motor deficits (paralysis, spasticity, posturing)
  • Cranial nerve or visual deficits (e.g., CN III palsy)
  • Hearing impairment
  • Aphasia or apraxia

Other

  • Primary language barrier
  • Environmental interruptions or excessive stimulation
  • Assessment timing relative to nursing care, procedures, or family visits

Considerations When Working with the Patient

(Hamby, 2017; 2024; Padilla & Domina, 2016)

Implement a systematic approach to both assessment and treatment. Evaluation of a low-level patient should focus on identifying subtle signs in response to sensory stimulation, and a standard body function evaluation should be paired with careful observation of vital sign changes during task performance. The overall goal is to facilitate the patient's ability to interact with their environment and progress toward meaningful occupational participation.

General Tips

  • Give simple, 1-step commands that are 5 words or fewer, allowing 30–60 seconds for the patient to process before repeating.
  • A quick yes/no screen can help assess cognition: "Is the sky green?" "Is the ocean blue?" "Are there fish in the sea?"
  • Reduce demands, minimize distractions, and regulate sensory input to account for decreased attention span and frustration tolerance.
  • Provide structure, consistency, and orienting information throughout the session.
  • Use gross motor activities or movement to help mitigate agitation.
  • Refrain from drawing repeated attention to deficits — this can increase frustration.
  • Redirect unsafe behaviors without arguing. When possible, switch topics or tasks rather than engaging in confrontation.

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References

Esbrook, C., Laxton, L., & Morrow, M. (2024). Critical care and early rehabilitation. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (3rd ed., pp. 115–137). AOTA Press.

Hamby, J. (2017). The Nervous System. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (2nd ed.). AOTA Press.

Hamby, J. R. (2024). The nervous system, part 1: Traumatic brain injury, spinal cord injury, and stroke. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (3rd ed., pp. 365–448). AOTA Press.

Padilla, R., & Domina, A. (2016). Effectiveness of sensory stimulation to improve arousal and alertness of people in a coma or persistent vegetative state after traumatic brain injury: A systematic review. The American Journal of Occupational Therapy, 70(3), 7003180030p1-7003180030p8. https://doi.org/10.5014/ajot.2016.021022

Popovich, K. (2011). The Intensive Care Unit. In H. Smith-Gabai (Ed.), Occupational Therapy in Acute Care (1st ed., pp. 41–73). AOTA Press.