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)