Assessment of The Critically Ill Patients and Their Families

Jefferson C.
Ramos, RMT, RN
ASSESSMENT OF THE CRITICALLY ILL PATIENTS AND THEIR FAMILIES

Critical Care Nursing
Jefferson C. Ramos, RMT, RN
ASSESSMENT FRAMEWORK
ASSESSMENT FRAMEWORK
Starts from awareness of the nurse of the clients admission and continues until transitioning to the next phase of care Stages
Prearrival Admission quick check Comprehensive admission Ongoing assessment
PREARRIVAL ASSESSMENT
Begins when information is received about the pending arrival of the patient
Abbreviated report on patient (age, gender, chief complaint, diagnosis, pertinent history, physiologic status, invasive devices, equipment, and status of laboratory/diagnostic tests)
Complete room setup, including verification of proper equipment functioning
EQUIPMENTS FOR STANDARD ROOM SETUP
ADMISSION QUICK CHECK ASSESSMENT
Done in the first few minutes

General appearance is observed
Assessment of the ABCDEs
AIRWAY AND BREATHING
Have the patient speak

Watch the patients chest rise and fall
If airway is compromised, verify the heads position to verify proper position of the tongue
Inspect airway for the presence of blood, vomitus, and foreign objects before inserting an oral airway, if needed
If artificial airway is present, ensure that the airway is secured properly

Note for depth, pattern, symmetry of breathing Observe for signs of respiratory distress Auscultate for breath sounds
Assess the anterior chest

If connected to a mechanical ventilator, assess for spontaneous breathing and evaluate if additional pressure is needed If chest tube is present, note for the consistency of the tube. It should not be clamped or kinked.
CIRCULATION AND CEREBRAL PERFUSION
Palpate the pulse

Check the electrocardiogram monitor for the VS Assess peripheral perfusion Determine if there are any signs of blood loss and if active bleeding is occurring based on the prearrival report Determining the functional integrity of the brain as a whole
CHIEF COMPLAINT
Data may be gathered from the patient, family, friends, or bystanders

In the absence of a history source, practitioners must depend exclusively on the physical findings and knowledge of pathophysiology to identify potential causes of the admission
DRUGS AND DIAGNOSTIC TESTS
If no IV is inserted yet, prompt placement is vital and start I & O recording

If with current IV medications, verify the correct drug, infusion of desired dosage and rate Obtain critical diagnostic tests
COMMON DIAGNOSTIC TESTS
Serum electrolytes
Glucose CBC with Plateles Coagulation studies ABGs Chest X-ray ECG
EQUIPMENT
Evaluate all vascular and drainage tubes for location and patency
Verify the appropriate functioning of all equipment attached to the patient
COMPREHENSIVE ADMISSION ASSESSMENT
Determines the physiologic and psychosocial baseline

Defines the patients pre-event health status Determines problems or limitations that may impact patient status during this admission
SUMMARY OF COMPREHENSIVE ADMISSION

REQUIREMENTS
Past medical history

Social history
Psychosocial assessment
Spirituality Physical assessment
NERVOUS SYSTEM
Master computer of all systems

Almost all of the critically ill patient is focused on evaluating the CNS The single most important indicator of cerebral functioning if the LOC
Assess pupils for size, shape, symmetry and reactivity to direct light
NERVOUS SYSTEM
If head trauma is involved or suspected, check for signs of fluid leakage around the nose or ears
NERVOUS SYSTEM
Assess orientation to person, place, and time.

Rate of speech is usually consistent with the patients psychomotor status Cognitive impairments are typically exacerbated during critical illness due to physiologic changes, medications, and environmental changes
CARDIOVASCULAR SYSTEM
Evaluating central and peripheral perfusion

Assess the ECG for:

T-wave ST segment changes PR, QRS, and QT interval
Note the color and temperature of the skin Nail color and capillary refill
Rate the quality of edema

Auscultate heart sounds for S1 and S2 quality, intensity, and pitch, and for the presence of extra heart sounds, murmurs, clicks, or rubs Palpate peripheral pulses for amplitude and quality using the 0 (+4) scale
RESPIRATORY SYSTEM
Oxygenation and ventilation are the focal basis of respiratory assessment parameters
Reassess the rate, rhythm, of respirations, and the symmetry of chest wall movement Note color, amount, and consistency of suctioned secretions Palpate for equal chest excursion, presence of crepitus, and any areas of tenderness or fractures
RESPIRATORY SYSTEM
Auscultate all lobes anteriorly and posteriorly for bilateral breath sounds to determine the presence of air movement and adventitious breath sounds Quality and depth of respiration ABGs are usually used diagnostic tests to assess for both interpretation of oxygenation and status, and acid-base balance
RESPIRATORY SYSTEM
URINARY SYSTEM
Urinary characteristics and electrolyte status are the major parameters used to evaluate the function of the kidneys Most critically ill clients have urinary catheter in place Assess the appearance and amount of the urine Get sample for glucose, protein, and blood determination, if applicable
GASTROINTESTINAL SYSTEM
Key factors are nutritional and fluid status

Inspect the abdomen for overall symmetry and contour Nutritional status
Patients weight Muscle tone Condition of the oral mucosa
ENDOCRINE, HEMATOLOGIC, & IMMUNE SYSTEMS
Often overlooked when assessing critically ill patients

Assessment is based on the understanding of the primary function of each of the hormones, blood cells, or immune components of each of the respective systems
INTEGUMENTARY SYSTEM
Evaluation is focused on the intactness of the skin

Can be done while undergoing assessment of other systems
Inspect the skin for overall integrity, color, temperature, and trugor
Inspect for overall integrity
PSYCHOSOCIAL ASSESSMENT
GENERAL COMMUNICATION
PATIENT COMMUNICATION BOARD
PATIENT COMMUNICATION BOARD
VIDATAK BOARD
ANXIETY AND STRESS
Anxiety is both physically and psychologically exhausting

The critical care environment is full of constant auditory, and tactile stimuli, very stressful, and may contribute to the clients anxiety level
Critical care setting may force patients

Isolation from social supports Dependency Loss of control Trust in unknown care providers Helplessness Inability to solve or attend to a problem
Medications
Induce anxiety Mimic anxiety
Other causes
Pain Sleep loss Delirium Hypoxia Fear of death Loss of control High-technology equipment
ONGOING ASSESSMENT
Becomes more focused and the frequency is driven by the stability of the patient
Routine periodic assessments are the norm Can range from every few minutes for extremely unstable patients to every 2 4 hours for very stable patients.

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Jefferson C.

ASSESSMENT OF THE CRITICALLY ILL PATIENTS AND THEIR FAMILIES

Jefferson C. Ramos, RMT, RN

Jefferson C. Ramos, RMT, RN

Complete room setup, including verification of proper equipment functioning

EQUIPMENTS FOR STANDARD ROOM SETUP

Jefferson C. Ramos, RMT, RN

ADMISSION QUICK CHECK ASSESSMENT

Done in the first few minutes

General appearance is observed

Assessment of the ABCDEs

Jefferson C. Ramos, RMT, RN

Jefferson C. Ramos, RMT, RN

Jefferson C. Ramos, RMT, RN

AIRWAY AND BREATHING

Have the patient speak

Watch the patients chest rise and fall

If artificial airway is present, ensure that the airway is secured properly

Assess the anterior chest

CIRCULATION AND CEREBRAL PERFUSION

Palpate the pulse

Data may be gathered from the patient, family, friends, or bystanders

DRUGS AND DIAGNOSTIC TESTS

If no IV is inserted yet, prompt placement is vital and start I & O recording

COMMON DIAGNOSTIC TESTS

Verify the appropriate functioning of all equipment attached to the patient

COMPREHENSIVE ADMISSION ASSESSMENT

Determines the physiologic and psychosocial baseline

SUMMARY OF COMPREHENSIVE ADMISSION

Past medical history

Master computer of all systems

Assess orientation to person, place, and time.

Evaluating central and peripheral perfusion

Assess the ECG for:

Rate the quality of edema

Jefferson C. Ramos, RMT, RN

Jefferson C. Ramos, RMT, RN

Jefferson C. Ramos, RMT, RN

Jefferson C. Ramos, RMT, RN

Key factors are nutritional and fluid status

Jefferson C. Ramos, RMT, RN

Jefferson C. Ramos, RMT, RN

ENDOCRINE, HEMATOLOGIC, & IMMUNE SYSTEMS

Often overlooked when assessing critically ill patients

Jefferson C. Ramos, RMT, RN

Evaluation is focused on the intactness of the skin

Can be done while undergoing assessment of other systems

Inspect for overall integrity

Jefferson C. Ramos, RMT, RN

Jefferson C. Ramos, RMT, RN

Jefferson C. Ramos, RMT, RN

Jefferson C. Ramos, RMT, RN

PATIENT COMMUNICATION BOARD

Jefferson C. Ramos, RMT, RN

PATIENT COMMUNICATION BOARD

Jefferson C. Ramos, RMT, RN

Jefferson C. Ramos, RMT, RN

ANXIETY AND STRESS

Anxiety is both physically and psychologically exhausting

Critical care setting may force patients

Jefferson C. Ramos, RMT, RN

Induce anxiety Mimic anxiety

Jefferson C. Ramos, RMT, RN