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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 : 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 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 Self concept (Psychological state) Role function (Social state) Interdependence function (Emotional state) A) Physiological assessment 1) Oxygenation a) General observation Presence of symptoms Breathing route e.g. Normal, ETT, Tracheostomy tube Breathing device Cough, sputum, haemoptysis, chest pain, dyspnoea, stridor, cyanosis O2 mask, O2 cannula, BiPAP, blower humidifier, CPAP circuit Ventilator : mode, FiO2 Patient response Respiratory rate, Exp tidal volume, Airway pressure Triggered, gag reflex, SaO2/SpO2, PaCO2/ETCO2 1) Oxygenation b) Exam of the upper respiratory tract Dry / dehydrated Loose teeth Central cyanosis Pale (anaemia) Deviated trachea 1b) Exam of the upper respiratory tract 1) Check mouth 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 Chest shape Normal, deformed Chest expansion Normal, asymmetrical Chest auscultation Breath Sound Normal, abnormal (diminished, bronchial breathing) Added Sound Crepitation, rhonchi, wheeze 1c) Examination of the Chest 1) Inspection Shape of chest wall 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 Breath Sound Normal Breath Sound Abnormal Breath Sound Bronchial BS, Broncho-vesicular BS, Vesicular BS Augmented BS, Diminished BS Added Sound Traditional classification Rales, Rhonchi, Wheeze Joint Committee on Pulmonary Nomenclature Crackle, Wheeze Use of Stethoscope Bell For low-pitched sound Diaphragm For high pitched sound Sequence of Auscultation 1) Breath Sound 1) Normal Breath Sound Chx soft, diffused, smooth, low pitched, swishing sound produced when air moves through a patent airway. Type 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 Abnormally located Bronchial Breath Sound Chx : Coarse & augmented sound heard over peripheral lung areas due to enhanced sound transmission (e.g. lung consolidation). Breath Sound 2) Abnormal Breath Sound Diminished Breath Sound 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 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) Early inspiration (fine) crackles In severe airway obstruction Bronchitis, asthma, pulmonary emphysema Late inspiration (fine) crackles In widespread pulmonary deflation Pneumonia, pulmonary oedema, pulmonary fibrosis Insp & Exp (coarse) crackles In constricted airway with secretion Bronchietasis, Pulmonary oedema Bubbling crackle or Gurgling crackle 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 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 High-pitched (Sibilant rhonchi) E.g. asthma Low-pitched (Sonorous rhonchi) E.g. Bronchitis 2) Monophonic vs Polyphonic 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 Blood pressure refers to the pressure exerted by the circulating blood against the arterial walls. 2a) General CVS Assessment 1) Blood pressure 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 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 Watch for changes in BP : High sBP --> hypertension, stroke Low sBP --> shock High/low dBP --> coronary insufficiency 2a) General CVS Assessment 2) Pulse a) Pulse rate & rhythm Watch for changes in pulse rate & rhythm : 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 : 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 : 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 Heart failure hypovolaemia severe aortic stenosis increased peripheral resistance cold exposure severe congestive heart failure Increased pulse pressure Cause : Increased stroke volume peripheral resistance decreased hyperthyroidism, Increased stroke volume fever, anaemia, regurgitation & bradycardia, complete heart block Decreased compliance of aortic wall 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 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 High CVP --> fluid overload, heart failure Low CVP --> hypovolaemia Normal range : 5-15 cm H2O 2a) General CVS Assessment 5) Electrocardiogram (ECG) ECG is the surface recording of the electrical potential (or cardiac vector) in association with the cardiac cycle. Common ECG problems : Arrhythmias Heart block Bundle branch block Myocardial hypertrophy Myocardial infarction Coronary insufficiency Miscellaneous ECG disorders 2b) Tissue Perfusion MAP > 70 mmHg Warm periphery Capillary refill < 2 sec Urine output > 0.5 ml/kgBW/hour 2) Circulation b) Tissue perfusion Peripheral extremities Urine output 2) Circulation c) Heart sound Normal Abnormal Added sound Gallop rhythm Murmur 2c) Examination of the Heart Auscultation Use of stethoscope Bell : for low-pitched (or low frequency) sound S3, S4, or murmur of mitral stenosis Diaphragm : for high-pitched (or high frequency) sound S1, S2, or murmur of mitral regurgitation 2c) Examination of the Heart Auscultation Patient position supine sitting left lateral 2c) Examination of the Heart Auscultation Auscultation area Aortic area Pulmonic area Tricuspid area Mitral area : : : : 2nd ICS of RSB 2nd ICS of LSB 4th ICS of LSB 5th ICS of MCL 2c) Examination of the Heart Auscultation Sequence of auscultation 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 Normal heart sound Added sound Sound 1, Sound 2 S3, S4, Opening snap, Ejection click Murmur Systolic, diastolic, & continuous murmur a) Normal heart sound Sound 1 (S1) is caused by the closure of mitral & tricuspid valves during the onset of ventricular systole. a) Normal heart sound Sound 2 (S2) is caused by the closure of aortic and pulmonic valves during the onset of ventricular diastole. b) Abnormal : Added sound Sound 3 (S3) S3 occurs in early diastole following S2. S3 is caused by ventricular wall rebound in ventricular stress or heart failure. b) Abnormal : Added sound Sound 4 (S4) 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 Ejection click (Ec) 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 Opening snap (Os) 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 Gallop rhythm Tachycardia with the presence of an added sound (e.g. S3 or S4) b) Abnormal : Murmur Murmur is produced by : 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. Intensity of murmur : Grade Grade Grade Grade Grade Grade 1 2 3 4 5 6 : : : : : : 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 : Systolic murmur Diastolic murmur Continuous murmur Systolic murmur Early systolic murmur (VSD @ LLSB) Systolic murmur Mid-systolic murmur (AS @ aortic area) Systolic murmur Late systolic murmur (MR@ apex) Systolic murmur Pan-systolic murmur (MR @ apex) Diastolic murmur Early diastolic murmur (AR @ LLSB) Diastolic murmur Mid-diastolic murmur (MS @ apex) Late-diastolic murmur (MS @ apex) Continuous murmur 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 pain weakness sensory impairement coldness pallor / cyanosis gangrene 1) Peripheral arteries Major arteries include : Carotid subclavian abdominal aorta renal artery femoral 1) Peripheral arteries 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 pain discomfort distended veins oedema and shiny limbs 3) Neurological Function a) Level of consciousness (GCS) 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) Eye opening response Best verbal response Best motor response Glasgow Coma Scale Best Motor Response b) Pupillary reflex Size Equality on both side Reactivity to light Pupillary Response 3c) ICP 1) Vital Signs Blood pressure Hypertension in high ICP Pulse Bradycardia in high ICP 1) Vital Signs Respiration 2) ICP CPP = MAP - ICP 4) Fluid & Electrolytes a) Fluid excess General oedema peripheral oedema b) Fluid deficit dehydration 4) Fluid & Electrolytes c) Electrolytes Sodium Potassium d) Acid-base balance Acidosis Alkalosis 5) Nutrition a) Mode of nutrition Oral feeding Tube feeding TPN b) Appetite / Tolerance of feeding c) Bowel sound d) Food preference / Intolerance 6) Elimination a) Urinary elimination Self voiding, urethral catheter Chx of urine Urine analysis b) Bowel elimination 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 Orientation Visual function Hearing function Speech function b) Pain perception 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 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 !