ASSESSMENT OF ASSESSMENT OF CRITICALLY ILL PATIENTCRITICALLY ILL PATIENT

By By

Yasmeen RahimYasmeen Rahim

OBJECTIVESOBJECTIVES By the end of this presentation By the end of this presentation

students will be able to:students will be able to:Define assessment for critically Define assessment for critically patient.patient.Discuss the assessment framework.Discuss the assessment framework.– Prearrival assessmentPrearrival assessment– Admission quick checkAdmission quick check– Comprehensive admission assessmentComprehensive admission assessment– Ongoing assessmentOngoing assessment

ASSESSMENTASSESSMENT

The assessment of critically ill The assessment of critically ill patient and their families is an patient and their families is an essential competency for critical care essential competency for critical care practitioners.practitioners.

Assessment skills must be Assessment skills must be systematic to be able to effectively systematic to be able to effectively progress to the patient care. progress to the patient care.

CONT.CONT.The assessment approach should The assessment approach should emphasizes the collection of emphasizes the collection of assessment data in organized assessment data in organized manner consistent with patient care manner consistent with patient care priorities.priorities.Assessment should focus first on the Assessment should focus first on the patient and then on the technology.patient and then on the technology.Two standard approaches: head to Two standard approaches: head to toe approach and body system toe approach and body system approach.approach.

CONT.CONT.

The assessment process can be The assessment process can be viewed as four distinct stages:viewed as four distinct stages:– Prearrival stagePrearrival stage– Admission quick checkAdmission quick check– Comprehensive admissionComprehensive admission– Ongoing assessment.Ongoing assessment.

PREARRIVAL ASSESSMENTPREARRIVAL ASSESSMENTA pre arrival assessment begins the A pre arrival assessment begins the moment information is received moment information is received about the upcoming admission of about the upcoming admission of patient.patient.It helps in painting the initial picture It helps in painting the initial picture of the patient.of the patient.It allows CCN to begin anticipating It allows CCN to begin anticipating the patient’s physiologic and the patient’s physiologic and psychologic needs.psychologic needs.

CONT.CONT.

It allow CCN to determine It allow CCN to determine appropriate resources that are appropriate resources that are needed to care for the patient.needed to care for the patient.

It allow CCN to adequately prepare It allow CCN to adequately prepare the environment to meet the the environment to meet the specialized needs of the patient and specialized needs of the patient and family.family.

EQUIPMENT FOR STANDARD EQUIPMENT FOR STANDARD ROOM SETUPROOM SETUP

Bedside ECG & invasive pressure monitor.Bedside ECG & invasive pressure monitor.ECG electrodes.ECG electrodes.Blood pressure cuff.Blood pressure cuff.Pulse oximetry.Pulse oximetry.Suction gauges and canister setup.Suction gauges and canister setup.Suction catheter.Suction catheter.Bag valve mask / rebreathing bag.Bag valve mask / rebreathing bag.Oxygen flow meter, appropriate tubing Oxygen flow meter, appropriate tubing and delivery device.and delivery device.

CONT.CONT.

IV poles and infusion pumps.IV poles and infusion pumps.

Bedside supply cart that contains Bedside supply cart that contains such things like alcohol swabs, non such things like alcohol swabs, non sterile gloves, syringes etc.sterile gloves, syringes etc.

Admission kit which contain bath Admission kit which contain bath basin and general hygiene supplies.basin and general hygiene supplies.

Admission and critical care Admission and critical care documentation forms.documentation forms.

ADMISSION QUICK CHECKADMISSION QUICK CHECKIt is obtained immediately upon patient It is obtained immediately upon patient arrival.arrival.It is based on assessing the parameters It is based on assessing the parameters represented by the ABCDE.represented by the ABCDE.– AAirwayirway– BBreathingreathing– CCirculation, irculation, CCerebral perfusion, erebral perfusion, CChief hief

complaintcomplaint– DDrugs and diagnostic testsrugs and diagnostic tests– EEquipmentquipment

CONT.CONT.

General appearance (LOC)General appearance (LOC)

AirwayAirway– Patency of airwayPatency of airway– Position of artificial airwayPosition of artificial airway

BreathingBreathing– Quantity and quality of respirationQuantity and quality of respiration– Breath soundsBreath sounds– Presence of spontaneous breathingPresence of spontaneous breathing

CONT.CONT.

Circulation and cerebral perfusionCirculation and cerebral perfusion– ECG (rate and rhythm)ECG (rate and rhythm)– Blood pressureBlood pressure– Peripheral pulses and capillary refillPeripheral pulses and capillary refill– Skin color, temperature and moistureSkin color, temperature and moisture– Presence of bleedingPresence of bleeding– LOC, responsivenessLOC, responsiveness

CONTCONTChief complaintChief complaint– Primary body systemPrimary body system– Associated symptomsAssociated symptoms

Drugs and diagnostic testsDrugs and diagnostic tests– Drugs prior to admissionDrugs prior to admission– Current medicationsCurrent medications– Review diagnostic test resultsReview diagnostic test results

Equipments Equipments – Patency of vascular and drainage systemsPatency of vascular and drainage systems– Appropriate functioning and labeling Appropriate functioning and labeling

Allergies Allergies

CONT.CONT.

Quick overview of ABCDE ensure Quick overview of ABCDE ensure early interventions for any life early interventions for any life threatening situation.threatening situation.

It validates that cardiac and It validates that cardiac and respiratory functions are sufficient.respiratory functions are sufficient.

COMPREHENSIVE ADMISSION COMPREHENSIVE ADMISSION ASSESSMENTASSESSMENT

A comprehensive admission A comprehensive admission assessment is performed ASAP.assessment is performed ASAP.It is an in depth assessment of the It is an in depth assessment of the past medical and social history and a past medical and social history and a complete physical examination of complete physical examination of each body system.each body system.It provides the nurse invaluable It provides the nurse invaluable insight into proactive interventions insight into proactive interventions that may be needed.that may be needed.

CONT.CONT.

Past medical historyPast medical history– Medical conditions, surgical procedures.Medical conditions, surgical procedures.– Psychiatric / emotional problemsPsychiatric / emotional problems– HospitalizationsHospitalizations– Previous medicationsPrevious medications– AllergiesAllergies– Review of body systemsReview of body systems

CONT.CONT.Social historySocial history– Age, genderAge, gender– Ethnic originEthnic origin– Height, weightHeight, weight– Occupation Occupation – Marital statusMarital status– Primary family member / significant othersPrimary family member / significant others– Religious affiliationsReligious affiliations– Advance directives, Power of AttorneyAdvance directives, Power of Attorney– Substance abuseSubstance abuse

CONT.CONT.

Psychosocial assessmentPsychosocial assessment– General communicationGeneral communication– Coping stylesCoping styles– Anxiety and stressAnxiety and stress– Current stressorsCurrent stressors– Family needsFamily needs

SpiritualitySpirituality– Faith / spiritual preferenceFaith / spiritual preference– Healing practicesHealing practices

PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT

Nervous systemNervous system– LOC (by assessing GCS)LOC (by assessing GCS)– PupilsPupils– Motor strength of extremitiesMotor strength of extremities

Cardiovascular systemCardiovascular system– BP, heart rate and rhythm, heart soundsBP, heart rate and rhythm, heart sounds– Capillary refill, peripheral pulsesCapillary refill, peripheral pulses– Patency of IVs and verification of IV medsPatency of IVs and verification of IV meds– Hemodynamic pressure and waveformsHemodynamic pressure and waveforms

CONT.CONT.Respiratory systemRespiratory system– Respiration rate and rhythmRespiration rate and rhythm– Breath soundsBreath sounds– Color and amount of secretionsColor and amount of secretions– Noninvasive (pulse oximetry, end tidal CONoninvasive (pulse oximetry, end tidal CO22

– Mechanical ventilation parametersMechanical ventilation parameters– Arterial and venous blood gasesArterial and venous blood gases

Renal systemRenal system– Intake and outputIntake and output– Color and amount of urinary outputColor and amount of urinary output– Lab values (BUN, creatinine)Lab values (BUN, creatinine)

CONT.CONT.

Gastrointestinal systemGastrointestinal system– Bowel soundsBowel sounds– Contour of abdomenContour of abdomen– Position of drainage tubesPosition of drainage tubes– Color and amount of secretionsColor and amount of secretions– Bilirubin and albumin valuesBilirubin and albumin values

Endocrine, hematologic and immunologic Endocrine, hematologic and immunologic systemsystem– Fluid and electrolyte balanceFluid and electrolyte balance– CBC and coagulation valuesCBC and coagulation values– Temperature and WBC with differential countTemperature and WBC with differential count

CONT.CONT.

Integumentary systemIntegumentary system– Color and skin temperatureColor and skin temperature– Intactness of skinIntactness of skin– Areas of rednessAreas of redness

Pain / discomfortPain / discomfort– Assessed in each systemAssessed in each system– Response to interventionsResponse to interventions

CONT.CONT.Psychosocial Psychosocial – Mental status and behavioral responsesMental status and behavioral responses– Reaction to critical illness experience Reaction to critical illness experience

(stress, anxiety, coping mechanism)(stress, anxiety, coping mechanism)– Presence of cognitive impairments Presence of cognitive impairments

(dementia, delirium, depression)(dementia, delirium, depression)– Family functioning and needsFamily functioning and needs– Ability to communicate needsAbility to communicate needs– Ability to participate in careAbility to participate in care– Sleep patternsSleep patterns

ONGOING ASSESSMENTONGOING ASSESSMENT

After the baseline comprehensive After the baseline comprehensive assessment is completed, ongoing assessment is completed, ongoing assessments are performed at assessments are performed at varying intervals.varying intervals.

It should be done after every few It should be done after every few minutes for unstable patients and minutes for unstable patients and after 4 to 6 hours for stable patients.after 4 to 6 hours for stable patients.

CONT.CONT.Additional assessment should be Additional assessment should be done when:done when:– When caregiver change.When caregiver change.– Before and after any major procedural Before and after any major procedural

interventions (intubation etc).interventions (intubation etc).– Before and after transport out of the Before and after transport out of the

critical care unit for diagnostic critical care unit for diagnostic procedures or other events.procedures or other events.

– Deterioration in physiologic or mental Deterioration in physiologic or mental status.status.

– Initiation of any new therapy.Initiation of any new therapy.