Introduction
A critically ill patients are one at imminent risk of death. The severity of the illness must be recognized early and appropriate measures should be taken promptly to assess, diagnose, and manage the illness. Critical illness is any disease process that causes physiological instability leading to disability or death within minutes or hours.
Definition
Assessment of the critically ill refers to an understanding of the significance of undertaking continuous thorough physical, functional, and psychological examinations specific to intensive care unit (ICU) patients.
Purposes
- Early recognition of a deteriorating patient.
- Evaluation of the effectiveness of treatment.
- Modification of the treatment plan and identification of any new problems.
Indication
Assessing critically ill patients requires careful evaluation of their clinical indications to determine the appropriate interventions. Here are some key considerations:
1. Indications for Critical Care Assessment
- Hemodynamic instability (e.g., severe hypotension, shock)
- Respiratory distress (e.g., acute respiratory failure, need for mechanical ventilation)
- Neurological deterioration (e.g., altered mental status, coma, stroke)
- Severe metabolic imbalances (e.g., electrolyte disturbances, acid-base imbalances)
- Multi-organ dysfunction (e.g., sepsis, acute kidney injury, liver failure)
- Post-surgical complications requiring intensive monitoring
2. Assessment Components
- Vital signs monitoring (continuous tracking of heart rate, blood pressure, oxygen saturation)
- Neurological evaluation (Glasgow Coma Scale, pupil response, reflexes)
- Cardiovascular assessment (ECG, echocardiography, central venous pressure monitoring)
- Respiratory function (arterial blood gases, lung auscultation, ventilator settings)
- Renal and metabolic status (urine output, electrolyte levels, blood glucose monitoring)
3. Specialized Assessment Tools
- APACHE II Scoring System – Predicts patient outcomes based on physiological parameters.
- Sequential Organ Failure Assessment (SOFA) – Evaluates the severity of organ dysfunction.
- FAST HUGS BID Principle – A systematic approach covering feeding, analgesia, sedation, thromboembolism prophylaxis, and more.
| Categories for Assessment of Critically III Patients | ||
| Assessment | Observation | Abnormal Findings |
| A: Airway Look for the signs of airway obstruction. | Airway obstruction. Altered ventilation. Poor secretion clearance. Atelectasis (lung collapse). Impaired muscle function. | Secretion, blood vomit, or foreign Body-gentle. suction under direct vision. Airway obstruction-paradoxical chest and abdominal movements. Central cyanosis-a late sign of airway obstruction. Airway noises-gurgling, snoring, grunting, hoarseness, wheeze, stridor, silent. |
| B: Breathing. | Breath sound. Position of trachea. Adjunct-pulse oximetry, capnography. | Respiratory distress Breathlessness. Tachypnea. Inability to talk. Open mouth breathing. Flaring of alae nasi. Paradoxical breathing. Use of accessory muscles Respiration. RR >30/min (or <8/min). Agitated, confused, or comatose. Cyanosed or SpO2 <90%. |
| C: Circulation. | Assessment of adequacy of the circulation. Peripheral and central pulse (rate, rhythm, volume, symmetry). Skin temperature. Heart rate. Blood pressure. Capillary refill. JVP. Urine output. Advanced monitoring-bedside ECHO, CVP, IBP. | Hypotension, late feature of shock Assess tissue perfusion.Consciousness level.Peripheries.Urine output.ABG-lactate. |
| D: Disability. | The patient’s drug chart checked for reversible drug-induced causes of depressed consciousness. | Appropriate antagonist, measurement of the blood glucose using a rapid glucose meter or stick method-exclude hypoglycemia. |
| E: Exposure. | Checktemperature. Hypothermia and no indication for therapeutic cooling. | Look all over the body including groin and back for rash or injuries. |
Evaluation
The patient expressed feeling of comfort and cooperated well during the assessment (conscious patient).
Special Considerations
Critically ill patients require frequent reassessment to detect subtle changes in their condition. This includes:
- Vital signs monitoring (heart rate, blood pressure, oxygen saturation)
- Neurological assessments (Glasgow Coma Scale, pupil response)
- Hemodynamic monitoring (central venous pressure, arterial blood gases)
2. Multisystem Assessment
Since critically ill patients often have multiple organ dysfunctions, assessments should cover:
- Cardiovascular system (risk of shock, arrhythmias)
- Respiratory system (mechanical ventilation needs, oxygenation status)
- Renal function (fluid balance, electrolyte levels)
- Gastrointestinal system (risk of stress ulcers, nutritional support)
3. Pain and Sedation Management
- Pain assessment can be challenging in non-verbal or sedated patients.
- Use behavioral pain scales and physiological indicators.
- Sedation levels should be monitored to prevent over-sedation or agitation.
4. Infection Control
- Critically ill patients are at high risk for infections due to invasive procedures.
- Strict hand hygiene and aseptic techniques are essential.
- Monitor for sepsis indicators (fever, increased white blood cell count, hypotension).
5. Ethical and Legal Considerations
- Decisions regarding end-of-life care and advanced directives should be respected.
- Family involvement is crucial in decision-making.
- Nurses must advocate for patient dignity and comfort.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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