The bread and butter of ICU care. Your number one tool for assessing your patient whilst they're stable, and more importantly, if they start to deteriorate. The A-E method provides a clear framework of priorities in terms of what needs to be addressed first. If you come across a problem in any of the sections, you should deal with that prior to moving onto the next part (i.e. if they're not breathing, it's best to get a handle on that before you start checking their blood pressure).
This post will take you through what I include in my daily assessment of an ICU patient. This will also apply to ward based patients, minus specific parts such as ETT checks. I will also include a brief section on bedside safety checks, as these go hand in hand with the assessment. List of abbreviations at the end, and any relevant posts linked throughout.
n.b. that aspects of this assessment may be specific to my practice in my local trust- ensure that local policies and procedures are followed when assessing patients. Figures (such as desired range for suction pressure or transducer pressure) are deliberately left out as these may vary between hospital trusts.
Safety checks- PAP BOSS
Patient
is the patient wearing a wristband?
if possible, ask patient to verbally confirm name and DOB. If not possible, check against computer system.
any allergies?
Alarms
monitor alarms- BP, HR, ECG, RR, O2, ETCO2
ventilator alarms- RR, MV, TV, PPeak, apnoea settings
Pumps
what infusions are running?
syringes and lines in date?
lines labelled?
Bag- airway emergency equipment kept at bedside, contents may vary.
guedels (3 sizes)?
bag-valve mask?
non-rebreathe mask?
PEEP valve?
waters' circuit?
clamps and gauze? (to clamp ETT if required)
tracheostomy/larygectomy emergency box (if indicated)
Oxygen
mains working?
cylinder present, more than half full?
correctly stored (valve closed)?
Suction
working?
correct pressure?
correct sized catheters available (in line and fine bore)?- (ETT/trachy - 2) x 2 so size 7 ETT would require size 10 suction (7-2 = 5 x2 = 10). Ensure correct length for ETT vs trachy (trachy is shorter)
Yankeur suckers available?
Slide sheet
present in bedspace?
Assessment- A-E
Airway
ETT secure?- how? Ties and foam, Hollister tapes etc
ETT length at teeth/lips? Compare to earlier assessments.
ETT patent? Able to pass a suction catheter?
any secretions present? colour, consistency, quantity, purulence
ETCO2 trace present? appearance of waveform?
cuff inflated? Check pressure, reinflate if required
trachy- bedhead signs and emergency algorithm present. fenestrated/non-fenestrated, cuffed/non-cuffed, speaking valve
Breathing- look listen feel
bilateral chest rise?
equal chest expansion?
breath sounds- normal sounds in all lung fields? any areas of diminished sounds? any added sounds? e.g. wheeze, stridor, crackles
any secretions felt on chest or heard?
changes to breathing/ventilator settings in previous shift?
mode of ventilation- Mand or Spont
PO2/PCO2 on ABG
Circulation
blood pressure?- invasive (arterial) vs non invasive
arterial line zeroed? check pressure bag for art line- correct fluid, correct pressure?
HR in NSR? any ectopic beats?
12 lead ECG (if required)- assess rate, rhythm, regularity
electrolytes within range? check K+, Mg2+, Ca2+, Na+, PO4-, Cl-. Supplement if indicated.
Hb and Hct on ABG
central temperature
temperature of peripheries
colour of peripheries
peripheral pulses present?
capillary refill- <3 secs?
calves SNT, equal size? any signs of DVT
DVT prophylaxis in situ- TEDS, flowtrons, anticoagulant
urine output- 0.5ml/kg/hr?
I+O- intakes include feed, maintenance fluids, oral intake and medications, outputs include sensible losses (urine, stool, vomit) and insensible losses (sweat, open wounds)
vasoactive medications running? syringe replacement due?
Disability
sedation running? what agents? what rate?
sedation hold if indicated
conscious level- GCS or RASS score.
blood glucose- on insulin? known diabetic?
CAM ICU- delirium present?
pupillary reflexes- PERRL? (Pupils Equal, Round and Reacting to Light)
pain assessment- OLDCART if pain present. CPOT (Critical care Pain Observation Tool) to assess
epidural checks- motor (Bromage) and sensory assessment
Exposure
wounds- healthy, clean, dressings intact? signs of infection? VAC dressing present? what dressings are in situ?
lines, tubes, devices- VIP score? dressings clean and intact? lines in date?
bowels- bowel sounds on auscultation? SNT on palpation?
physiotherapy- level of mobility?
repositioning requirements, pressure area checks- check under lines/devices that may be causing pressure
social considerations- family/NOK? living situation?
Abbreviations-
References-
(There's not many references for this because nearly all of it is just my clinical knowledge. Obviously there's sources behind that, but I couldn't even begin to track down where I learnt things from)
Baid, H., Creed, F., Hargreaves, J. (2016) Oxford Handbook of Critical Care Nursing, 2nd edn. Oxford: Oxford University Press
LITFL (2020) ECG Rhythm Evaluation. https://litfl.com/ecg-rhythm-evaluation/
VIPScore.net (2021) VIP Score. http://www.vipscore.net/
Braun (2006) Phlebitis score. http://www.ivteam.com/vipbb.pdf
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