assessment of the critically ill patients and their families

7/27/2019 Assessment of the Critically Ill Patients and Their Families

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ASSESSMENTOFTHE CRITICALLY ILL

PATIENTSAND THEIR FAMILIESCritical Care Nursing

Jeffers

onC.Ramos,RMT,RN


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ASSESSMENT FRAMEWORK

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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



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PREARRIVAL ASSESSMENT

Begins when information is received about the

pending arrival of the patient

Abbreviated report on patient (age, gender, chiefcomplaint, diagnosis, pertinent history, physiologic

status, invasive devices, equipment, and status of

laboratory/diagnostic tests)

Complete room setup, including verification of

proper equipment functioning



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EQUIPMENTSFORSTANDARDROOMSETUP



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ADMISSION QUICK CHECK

ASSESSMENT

Done in the first few minutes

General appearance is observed

Assessment of the ABCDEs



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.Ramos,RMT,RN


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AIRWAYAND 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

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.Ramos,RMT,RN


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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

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.Ramos,RMT,RN


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Assess the anterior chest

If connected to a mechanical ventilator, assess for

spontaneous breathing and evaluate if additionalpressure is needed

If chest tube is present, note for the consistency of

the tube. It should not be clamped or kinked.

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.Ramos,RMT,RN


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CIRCULATIONAND 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 ifactive bleeding is occurring based on the prearrival

report

Determining the functional integrity of the brain as awhole

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.Ramos,RMT,RN


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CHIEF COMPLAINT

Data may be gathered from the patient, family,

friends, or bystanders

In the absence of a history source, practitionersmust depend exclusively on the physical findings

and knowledge of pathophysiology to identify

potential causes of the admission

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.Ramos,RMT,RN


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DRUGSAND DIAGNOSTIC TESTS

If no IV is inserted yet, prompt placement is vital

and start I & O recording

If with current IV medications, verify the correctdrug, infusion of desired dosage and rate

Obtain critical diagnostic tests

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.Ramos,RMT,RN


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EQUIPMENT

Evaluate all vascular and drainage tubes for

location and patency

Verify the appropriate functioning of all equipmentattached to the patient

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.Ramos,RMT,RN


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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

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.Ramos,RMT,RN


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SUMMARYOFCOMPREHENSIVEADMISSION

REQUIREMENTS

Past medical history

Social history

Psychosocial assessment

Spirituality

Physical assessment

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.Ramos,RMT,RN


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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

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.Ramos,RMT,RN


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NERVOUSSYSTEM

If head trauma is involved or suspected, check for

signs of fluid leakage around the nose or earsJeffersonC

.Ramos,RMT,RN


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NERVOUSSYSTEM

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

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.Ramos,RMT,RN


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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

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.Ramos,RMT,RN


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Rate the quality of edema

Auscultate heart sounds for S1 and S2 quality,

intensity, and pitch, and for the presence of extraheart sounds, murmurs, clicks, or rubs

Palpate peripheral pulses for amplitude and quality

using the 0 (+4) scale

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.Ramos,RMT,RN


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RESPIRATORY SYSTEM

Oxygenation and ventilation are the focal basis of

respiratory assessment parameters

Reassess the rate, rhythm, of respirations, and thesymmetry 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

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.Ramos,RMT,RN


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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

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.Ramos,RMT,RN


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RESPIRATORY SYSTEM

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.Ramos,RMT,RN


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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

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.Ramos,RMT,RN


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.Ramos,RMT,RN


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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

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.Ramos,RMT,RN


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.Ramos,RMT,RN


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.Ramos,RMT,RN


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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

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.Ramos,RMT,RN


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.Ramos,RMT,RN


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INTEGUMENTARY SYSTEM

Evaluation is focused on the intactness of the skin

Can be done while undergoing assessment of other

systems

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.Ramos,RMT,RN


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Inspect the skin for overall integrity, color,

temperature, and trugorJeffersonC

.Ramos,RMT,RN


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Jefferson C. Ramos, RMT, RN

Inspect for overall integrity


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PSYCHOSOCIAL ASSESSMENT

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.Ramos,RMT,RN


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GENERAL COMMUNICATION

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.Ramos,RMT,RN


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.Ramos,RMT,RN


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PATIENT COMMUNICATION BOARD

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.Ramos,RMT,RN


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PATIENT COMMUNICATION BOARD

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.Ramos,RMT,RN


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VIDATAK BOARD

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.Ramos,RMT,RN


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ANXIETYAND 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

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.Ramos,RMT,RN


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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

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.Ramos,RMT,RN


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Medications

Induce anxiety

Mimic anxiety

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.Ramos,RMT,RN


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Other causes

Pain

Sleep loss

Delirium

Hypoxia

Fear of death

Loss of control

High-technology

equipment

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.Ramos,RMT,RN


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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.

JeffersonC

.Ramos,RMT,RN

assessment of the critically ill patients and their families

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