Intensive Care Nursing/Systematic Assessment

A systematic and holistic assessment of the intensive care patient are considered necessary skills. Seeing past the monitor, ventilator and other technology can be a daunting task for the nurse new to the ICU environment. Handover of information between healthcare professionals assists the transferring of responsibility and care within the multi-disciplinary team, ensure this important communication is not just considered 'routine'.


First review of the situation

  • Airway
  • Breathing
  • Circulation
  • Any signs of deterioration or need for immediate intervention


Systematic

  • CNS
  • Respiratory (including auscultation for adventitious sounds)
  • Cardiac (including auscultation for S1, S2, S3, S4, and murmurs)
  • Renal
  • GI
  • Integumentary
  • Medications (drug chart and infusions)
  • Social
  • Current admission pathway with cause of ICU admission, past medical history, resuscitation status


Give your patient a fast hug every shift as a means of identifying and checking some important key aspects in the general care of critically ill patients.

'FAST HUG' by Vincent (2005):

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Regardless of the patients medical condition using the popularised FAST HUG mnemonic for identifying issues ensures a systematic review when looking after a critically ill patient. This can be utlised as a tool on a shift to shift basis for prioritising care planning.

  • Feeding/fluids
  • Analgesia
  • Sedation
  • Thromboprophylaxis
  • Head up position
  • Ulcer prophylaxis
  • Glycemic control


This provides a standardised baseline that ensures shift to shift issues are being managed for safety, patient progression and future planning.


Reference

Vincent JL. Give your patient a fast hug (at least) once a day. Crit Care Med. 2005 Jun;33(6):1225-9. Review.[1]


Acknowledgments

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https://en.wikiversity.org/wiki/User:ICUnurses


ICUnurses (discusscontribs) 12:30, 24 August 2014 (UTC)