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Assessment of the Critically Ill
David CHAN
Nurse Specialist (ICU), PWH
What is Health Assessment
Health Assessment is the process of using a
systematic approach in the collection of data
(including physiological and psychosocial data) to
determine the health status of the client.
Component of Health Assessment
1) History taking
2) Clinical presentation
3) Physical assessment, by using :
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Inspection
Palpation
Percussion
Auscultation
Critically ill patients in ICU
Critically ill patients in ICU are suffering
from life-threatening illness/injuries as
well as facing a high level of
psychological stress
Goals of Intensive Care Nursing
To promote optimal adaptation of the
critically ill patient by providing highly
individualized care, so that the critically
ill patients can adapt to their
physiological dysfunction as well as the
psychological stress in the ICU.
Standards for Intensive Care Nursing Practice (2000). College of Nursing Hong Kong.
Assessment tool
Select an appropriate assessment tool
to identify the physiological needs and
psychosocial stress of the critically ill
patient in ICU
Using the RAM approach to assess the
critically ill in ICU
1) Physiological assessment
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Oxygenation
Circulation
Neurological function
Fluid & electrolyte
Nutrition
Elimination
Exercise & rest
Sense (Communication & pain perception)
Protection (Skin integrity)
Endocrine function
Using the RAM approach to assess the
critically ill in ICU
2) Psycho-social assessment
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Self concept (Psychological state)
Role function (Social state)
Interdependence function (Emotional state)
A) Physiological assessment
1) Oxygenation
a) General observation
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Presence of symptoms
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Breathing route
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e.g. Normal, ETT, Tracheostomy tube
Breathing device
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Cough, sputum, haemoptysis, chest pain, dyspnoea, stridor,
cyanosis
O2 mask, O2 cannula, BiPAP, blower humidifier, CPAP circuit
Ventilator : mode, FiO2
Patient response
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Respiratory rate, Exp tidal volume, Airway pressure
Triggered, gag reflex, SaO2/SpO2, PaCO2/ETCO2
1) Oxygenation
b) Exam of the upper respiratory tract
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Dry / dehydrated
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Loose teeth
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Central cyanosis
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Pale (anaemia)
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Deviated trachea
1b) Exam of the upper respiratory tract
1) Check mouth
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Lip
:
Teeth :
Tongue :
Mucosa :
any dehydration
Loosen teeth
Central cyanosis
any anaemia
2) Check for any deviated trachea
Mouth checking
Check for any deviated trachea
1) Oxygenation
c) Exam of the Chest
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Chest shape
Normal, deformed
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Chest expansion
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Normal, asymmetrical
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Chest auscultation
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Breath Sound
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Normal, abnormal (diminished, bronchial breathing)
Added Sound
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Crepitation, rhonchi, wheeze
1c) Examination of the Chest
1) Inspection
Shape of chest wall
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e.g. any asymmetry,
deformity
Shape of Chest Wall
1c) Examination of the Chest
2) Palpation
Chest expansion / excursion
Palpation -
Chest excursion
1c) Examination of the Chest
3) Auscultation
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Breath Sound
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Normal Breath Sound
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Abnormal Breath Sound
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Bronchial BS, Broncho-vesicular BS, Vesicular BS
Augmented BS, Diminished BS
Added Sound
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Traditional classification
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Rales, Rhonchi, Wheeze
Joint Committee on Pulmonary Nomenclature
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Crackle, Wheeze
Use of Stethoscope
Bell
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For low-pitched sound
Diaphragm
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For high pitched sound
Sequence of Auscultation
1) Breath Sound
1) Normal Breath Sound
„ Chx
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soft, diffused, smooth, low pitched, swishing
sound produced when air moves through a
patent airway.
Type
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Bronchial Breath Sound (Large airway)
Bronchovesicular Breath Sound (Medium size
airway)
Vesicular Breath Sound (Small airway)
Bronchial Breath Sound
(Large airway)
Bronchovesicular Breath Sound
(Medium size airway)
Vesicular Breath Sound
(Small airway)
Breath Sound
2) Abnormal Breath Sound
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Abnormally located Bronchial Breath Sound
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Chx : Coarse & augmented sound heard over
peripheral lung areas due to enhanced sound
transmission (e.g. lung consolidation).
Breath Sound
2) Abnormal Breath Sound
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Diminished Breath Sound
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Chx : Breath sound decreases in volume heard
over localized lung area due to diminished airflow
(e.g. pneumothorax, lung collapse, pleural
effusion).
2) Added Sound
a) Crackle / Crepitation / Rales
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fine, crackling, non-musical sounds due to
sudden opening of the closed small airways
which are filled with fluid
heard mainly on inspiration in small airway.
Crackle
Type (a/c phase)
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Early inspiration (fine) crackles
In severe airway obstruction
„Bronchitis, asthma, pulmonary emphysema
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Late inspiration (fine) crackles
In widespread pulmonary deflation
„Pneumonia, pulmonary oedema, pulmonary fibrosis
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Insp & Exp (coarse) crackles
In constricted airway with secretion
„Bronchietasis, Pulmonary oedema
„Bubbling crackle or Gurgling crackle
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Bubbling Crackles
• Low-pitched sounds due to presence of
secretion in large airway
• Heard during expiration
Gurgling Crackles
•Low-pitched sounds due to presence of
secretion in large airway
• Heard during both inspiration & expiration
Added Sound
b) Wheeze
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high-pitched, musical sound due to
narrowing, constriction or spasm of the
small airways.
heard mainly on inspiration in small airway.
Type of Wheeze
1) High-pitched vs low-pitched
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High-pitched (Sibilant rhonchi)
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E.g. asthma
Low-pitched (Sonorous rhonchi)
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E.g. Bronchitis
2) Monophonic vs Polyphonic
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Monophonic (e.g. asthma)
Polyphonic (e.g. obstructive lung disease)
Wheeze
Severity
•Mild
•Moderate
•Severe
2) Circulation
a) General CVS status
„ BP
„ Pulse rate
„ ECG rhythm
„ Temperature
„ CVP
„ PA / PCWP
„ On medication : inotropes, vasopressors, antiarrhythmics
„ On pacemaker
2a) General CVS Assessment
1) Blood pressure
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Blood pressure refers to the pressure
exerted by the circulating blood against
the arterial walls.
2a) General CVS Assessment
1) Blood pressure
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BP = CO x PR
CO = SV x HR
BP = SV x HR x PR
BP is determined by : stroke volume
heart rate
peripheral resistance
2a) General CVS Assessment
1) Blood pressure
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Normal ranges of BP
„ sBP
: 90 mmHg + age
[adult]
70 mmHg + (age x 2) [child]
45-60 mmHg
[infant]
„ dBP
: < 100 mmHg
„ MAP
: 60-120 mmHg
2a) General CVS Assessment
1) Blood pressure
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Watch for changes in BP :
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High sBP --> hypertension, stroke
Low sBP --> shock
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High/low dBP --> coronary insufficiency
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2a) General CVS Assessment
2) Pulse
a) Pulse rate & rhythm
„ Watch for changes in pulse rate & rhythm :
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bradycardia,
tachycardia, or
arrhythmia
2a) General CVS Assessment
2) Pulse
b) Pulse volume & contour
„ Compare the pulse volume on both side for
discrepancies
„ Assess the pulse contour for :
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speed of upstroke
duration of its summit
the speed of downstroke
Normal pulse pressure : 30-40 mmHg
2a) General CVS Assessment
2) Pulse
b) Pulse volume & contour
„ Watch for changes in pulse volume &
contour :
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diminished pulse pressure
increased pulse pressure
bisferiens pulse
pulsus alternans
bigeminal pulse
paradoxical pulse
Changes in
pulse volume
& contour
Diminished pulse pressure
Cause :
„ decreased stroke volume
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Heart failure
hypovolaemia
severe aortic stenosis
increased peripheral resistance
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cold exposure
severe congestive heart failure
Increased pulse pressure
Cause :
„ Increased
stroke volume
peripheral resistance
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decreased
hyperthyroidism,
Increased stroke volume
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fever,
anaemia,
regurgitation
&
bradycardia, complete heart block
Decreased compliance of aortic wall
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aging, atherosclerosis
aortic
Bisferiens pulse
Cause :
„ aortic regurgitation
„ combined aortic stenosis & regurgitation
„ hypertrophied cardiomyopathy
Pulsus alternans
Cause :
„ Left ventricular failure
Bigeminal pulse
Cause :
„ Premature contractions
Paradoxical pulse
Cause :
„ Pericardial tamponade
„ constrictive pericarditis
„ obstructive lung disease
2a) General CVS Assessment
3) Jugular venous pressure (JVP)
„ JVP provides an accurate estimation of
the right atrial pressure (RAP) or central
venous pressure (CVP).
„ Method
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head up @ 30-45 degree
turn patient’s head aside
assess jugular pulsation above the clavicle
More than 3 cm suggests high JVP
JVP
2a) General CVS Assessment
4) Central venous pressure (CVP)
„ CVP reflects right heart filling pressure
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High CVP --> fluid overload, heart failure
Low CVP --> hypovolaemia
Normal range : 5-15 cm H2O
2a) General CVS Assessment
5) Electrocardiogram (ECG)
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ECG is the surface recording of the electrical potential (or
cardiac vector) in association with the cardiac cycle.
Common ECG problems :
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Arrhythmias
Heart block
Bundle branch block
Myocardial hypertrophy
Myocardial infarction
Coronary insufficiency
Miscellaneous ECG disorders
2b) Tissue Perfusion
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MAP > 70 mmHg
Warm periphery
Capillary refill < 2 sec
Urine output > 0.5 ml/kgBW/hour
2) Circulation
b) Tissue perfusion
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Peripheral extremities
Urine output
2) Circulation
c) Heart sound
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Normal
Abnormal
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Added sound
Gallop rhythm
Murmur
2c) Examination of the Heart
Auscultation
Use of stethoscope
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Bell :
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for low-pitched (or low frequency) sound
S3, S4, or murmur of mitral stenosis
Diaphragm :
for high-pitched (or high frequency)
sound
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S1, S2, or murmur of mitral regurgitation
2c) Examination of the Heart
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Auscultation
Patient position
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supine
sitting
left lateral
2c) Examination of the Heart
Auscultation
„ Auscultation area
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Aortic area
Pulmonic area
Tricuspid area
Mitral area
:
:
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:
2nd ICS of RSB
2nd ICS of LSB
4th ICS of LSB
5th ICS of MCL
2c) Examination of the Heart
Auscultation
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Sequence of auscultation
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People vary in their sequence of
auscultation.
Some start at the apex; while others
start at the base.
2c) Examination of the Heart
Auscultation
„ 3 types of auscultation sound
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Normal heart sound
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Added sound
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Sound 1, Sound 2
S3, S4, Opening snap, Ejection click
Murmur
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Systolic, diastolic, & continuous murmur
a) Normal heart sound
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Sound 1 (S1)
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is caused by the closure of mitral &
tricuspid valves during the onset of
ventricular systole.
a) Normal heart sound
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Sound 2 (S2)
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is caused by the closure of aortic and
pulmonic valves during the onset of
ventricular diastole.
b) Abnormal : Added sound
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Sound 3 (S3)
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S3 occurs in early diastole following S2.
S3 is caused by ventricular wall rebound in
ventricular stress or heart failure.
b) Abnormal : Added sound
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Sound 4 (S4)
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S4 occurs in late diastole immediate before the S1 of the
next cardiac cycle.
S4 is caused by forceful atrial contraction in ventricular
stress, atrial hypertrophy or systemic hypertension
b) Abnormal : Added sound
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Ejection click (Ec)
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Ec occurs right after S1.
Ec is caused by the rapid opening motion of a diseased and
stenotic aortic / pulmonic valve.
b) Abnormal: Added sound
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Opening snap (Os)
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Os occurs right after S2.
Os is caused by the rapid opening motion of a diseased
and stenotic mitral / tricuspid valve.
b) Abnormal : Gallop rhythm
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Gallop rhythm
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Tachycardia with the presence of an added sound (e.g. S3
or S4)
b) Abnormal : Murmur
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Murmur is produced by :
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high blood flow rate through the valve
forward flow of blood thru’ a constricted
or irregular valve or into a dilated vessel
or chamber
backward or regurgitant flow of blood
thru’ an incompetent valve, septal
defect or patent ductus arteriosus.
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Intensity of murmur :
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Grade
Grade
Grade
Grade
Grade
Grade
1
2
3
4
5
6
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quiet, just audible by an expert
quiet, is audible by a student
moderately loud
loud (with thrills)
Very loud (with thrills)
Audible even with stethoscope off
the skin.
c) Murmur
Classification :
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Systolic murmur
Diastolic murmur
Continuous murmur
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Systolic murmur
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Early systolic murmur (VSD @ LLSB)
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Systolic murmur
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Mid-systolic murmur (AS @ aortic area)
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Systolic murmur
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Late systolic murmur
(MR@ apex)
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Systolic murmur
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Pan-systolic murmur
(MR @ apex)
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Diastolic murmur
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Early diastolic murmur (AR @ LLSB)
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Diastolic murmur
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Mid-diastolic murmur (MS @ apex)
Late-diastolic murmur (MS @ apex)
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Continuous murmur
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PDA @ LLSB
2) Circulation
d) Arterial occlusion
„ Any presence of ischaemic extremities
e) Venous occlusion
„ Any presence of oedematous extremities
2d) Examination of the Arteries & Veins
1) Peripheral arteries
„ Look for signs of arterial insufficiency
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pain
weakness
sensory impairement
coldness
pallor / cyanosis
gangrene
1) Peripheral arteries
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Major arteries include :
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Carotid
subclavian
abdominal aorta
renal artery
femoral
1) Peripheral arteries
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Inspect and palpate the
major arteries for :
„ presence of pulse
„ any bruits
„ temperature change
„ color change
2) Peripheral veins
„ Watch for s/s of venous occlusion
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pain
discomfort
distended veins
oedema and shiny limbs
3) Neurological Function
a) Level of consciousness (GCS)
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Eye opening response
Best verbal response
Best motor response
b) Pupillary reaction
c) Intracranial pressure (ICP)
3) Neurological Function
a) Level of consciousness
(Glasgow Coma Scale)
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Eye opening response
Best verbal response
Best motor response
Glasgow
Coma
Scale
Best
Motor
Response
b) Pupillary reflex
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Size
Equality on both side
Reactivity to light
Pupillary
Response
3c) ICP
1) Vital Signs
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Blood pressure
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Hypertension
in high ICP
Pulse
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Bradycardia in
high ICP
1) Vital Signs
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Respiration
2) ICP
CPP = MAP - ICP
4) Fluid & Electrolytes
a) Fluid excess
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General oedema
peripheral oedema
b) Fluid deficit
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dehydration
4) Fluid & Electrolytes
c) Electrolytes
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Sodium
Potassium
d) Acid-base balance
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Acidosis
Alkalosis
5) Nutrition
a) Mode of nutrition
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Oral feeding
Tube feeding
TPN
b) Appetite / Tolerance of feeding
c) Bowel sound
d) Food preference / Intolerance
6) Elimination
a) Urinary elimination
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Self voiding, urethral catheter
Chx of urine
Urine analysis
b) Bowel elimination
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Normal bowel pattern
Route
Bowel habit : constipation, diarrhoea
Chx of stool
7) Exercise & Rest
a) Mobility
b) Self care ability
c) Sleeping pattern
8) Sense
(Communication & pain perception)
a) Communication
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Orientation
Visual function
Hearing function
Speech function
b) Pain perception
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Site of pain
Level of pain
Nature of pain
9) Protection
a) Skin condition
b) Pressure sore
c) Surgical wound
d) Drains
(Skin Integrity)
10) Endocrine Function
a) Blood glucose / Haemoglucostix
„ Any DM
„ Blood glucose level
„ Any insulin therapy
b) Other endocrine problems
B) Psycho-social assessment
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Do not only focus on the patient’s
physiological needs.
Avoid < High tech low touch >
Should also look into the patient’s
psychosocial needs.
1) Self Concept (Psychological State)
a) Does the patient understand his disease/injury or
disability ?
b) Does the patient understand the treatment plan
and his progress ?
c) Does the patient feel anxious/depressed about his
problems ?
d) Does the patient accept his illness ?
2) Role Function (Social State)
a) Does the patient have any major change in his
roles due to his illness/injury ?
b) Does the patient feel anxious / depressed about
his role change ?
c) Is the patient the primary bread-winner at home ?
d) Does the patient has any financial problem due to
his hospitalization ?
e) Does the patient or his family need any help from
the MSW ?
3) Interdependence
(Emotional State)
a) Is the patient emotionally stable ?
b) Does the patient has adequate family support ?
c) Does the patient has adequate spiritual support ?
THE END
God is love !