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 (discusscontribs) 12:54, 4 September 2014 (UTC)