Intensive Care Nursing/Deteriorating Patient Assessment

Caring for the ICU patient is a challenging experience with assessment focusing on distinguishing normal and abnormal. Addressing these findings in the complex ICU patient plan of care and treatment strategies.

Quick Glance

Entering the bedspace, notice environmental factors such as equipment, infusions, monitor and ventilator values
Patient situation and safety

Acute Situations

Treat any life threatening problems and monitor vital signs continuously.

Airway

Intact or obstructed?
Difficulty breathing or distressed?
Can the patient talk in sentences or single words?
Auscultation - listen for stridor, wheeze, gurgling
Remember if the patient is trying to breath but you hear no sound- urgent, urgent, urgent, get the anaesthetist and prepare emergency airway equipment
Airway manoeuvres
Head tilt, chin lift, jaw thrust
Adjuncts- oropharyngeal, nasopharyngeal
Check ETT/Trache patency
Advanced airway techniques
Intubation
Supraglottic device- LMA, Combitube, I-Gel

Breathing

Look, listen and feel
Effort- rate, accessory muscles, see saw respiratory pattern
Auscultation
Oxygen
Aim sats 94-98%
88-92% if COAD

Circulation

BP
Heart rate and pulse checks
ECG and continuous monitoring
IV access
Baseline bloods and VBG
Consider fluid challenge

Disability

Blood glucose level
Level of consciousness- use AVPU scale (Alert, Vocal, Pain, Unresponsive)
Pupil check
Check drug chart- any opioid, recent medication, allergy

Exposure

Check the patient from top to bottom, front and back
Check for signs of trauma, entry/exit wounds, drain sites, wounds, rashes or sores, injection marks

References:

Australian Resuscitation Council (2014) http://www.resus.org.au/

ICUnurses (discuss • contribs) 12:54, 4 September 2014 (UTC)