Assessment of the Critically Ill Patient

1. Assessment of the Critically Ill Patient

2. Learning outcomes: • Identify the correct sequence of priorities in assessing the critically ill patient. • State why it is important to have a systematic approach to assessment and care, with rational for each step. • Identify clinical situations in which a patient’s condition may become compromised. • Demonstrate safe and effective assessment and care of the critically ill patient using a systematic approach.

3. Introduction Healthcare workers should be competent in undertaking a systematic and comprehensive approach to patient assessment to enable early recognition of potential or actual deterioration in the patient’s condition. (DOH, 2001)

4. Facts • Patients admitted from the wards to ICU when compared to those admitted from A&E have a higher percentage mortality (Goldhill, 2001). • Nearly 80% of hospital inpatients who experience a cardiorespiratory arrest have documented observations of deterioration in the 8hours before the arrest (Bristow et al 2000)

5. The 3 key stages of recognition and treatment of a critically ill patient: • Understanding that an emergency exists • Identifying and prioritising problems. • Action and evaluation

6. Assessment • Assessment is the first step in caring for a patient, and assessing the critically ill patient is an essential part of their care. • Careful assessment is fundamental in order to recognise when a patient is becoming compromised. • The nurse acts as patient advocate, monitoring, anticipating potential problems, planning, implementing and constantly evaluating care, and communicating with other MDT staff involved in the patient care.

7. Patient Assessment Systems • Basic Life support (BLS) • Advanced Life Support (ALS) • Acute Life-threatening Events, Recognition and Treatment (ALERT) • The Advanced Trauma Life Support (ATLS)

8. All of these assessment systems use a systematic approach in a strict order: • A: airway (with C-spine protection in trauma) • B: breathing • C: circulation • D: deficits in neurological status • E: environment (exposure)

9. Airway How do we assess airway and why?

10. Breathing Why do we assess breathing and how do we carry out a comprehensive respiratory assessment?

11. Circulation What is the significance of circulation and how do we assess the patient?

12. Central Venous Pressure • Involves insertion of a line to a major vein e.g. subclavian, internal jugular under full aseptic technique. • Patient is placed in supine or Trendelenburg position – promotes venous filling,aids catheter placement and reduces risk of air embolism. • Following insertion a check x-ray is required to confirm position and absence of pneumothorax.

13. CVP (contd.) • It is a direct measurement of pressure within the right atrium. • Readings should not be used in isolation, but as part of full haemodynamic assessment. • Used as a guide in fluid replacement. • Used to establish deficits in blood volume. • Used for drug administration, maintaining nutrition (TPN)

14. CVP (contd.) • What is the nursing management of CVP lines?

15. Deficits in neurological status & environment (exposure) How will you assess neurological status and environment?

16. Current practice in critical care services • Development of outreach services from critical care specialists to support ward staff in managing patients at risk. • Improved patient monitoring through the use of early warning scores (EWS) or modified early warning scores (MEWS)

17. QUIZ • What do you now know?