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Assessment of the Critically Ill Patient


Title: Assessment of the Critically Ill Patient Author: mariama seray-wurie Last modified by: AAA Created Date: 8/1/2003 9:57:31 PM Document presentation format – PowerPoint PPT presentation

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Title: Assessment of the Critically Ill Patient

Assessment of the Critically Ill Patient
  • Dr Sattam Alenezi
  • ED consultant

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 patients
    condition may become compromised.
  • Demonstrate safe and effective assessment and
    care of the critically ill patient using a
    systematic approach.

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 patients condition.
(DOH, 2001)
  • Patients admitted from the wards to ICU when
    compared to those admitted from AE 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)

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

Underlying principles
  • 1. Use a systematic approach, based on airway,
    breathing and circulation (i.e., the ABCDEs) to
    assess and treat the acutely ill patient.
  • 2. Undertake a complete initial assessment and
    re-assess regularly.
  • 3. Always assess the effects of treatment or
    other interventions.

  • 4. Always correct life-threatening abnormalities
    before moving on to the next part of assessment.
  • 5. Recognize the circumstances when additional
    help is required and ask for it early.
  • 6. Use all members of the multidisciplinary team.

  • 7.Communicate effectively.
  • 8. The underlying aim of the initial
    interventions should be seen as aholding
    measure that keeps the patient alive, and
    produces some clinical improvement, in order that
    definitive treatment may be initiated.

  • 9. Remember that it often takes a few minutes for
    resuscitative measures to have an effect.

Patient Assessment Systems
  • Basic Life support (BLS)
  • Advanced cardiac Life Support (ACLS)
  • The Advanced Trauma Life Support (ATLS) .
  • What about paediatric ( PALS) and neonates

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)

  • Ask the patient a simple question. In assessing
    any patient, a simple question such as How are
    you can provide valuable information.
  • A normal verbal response implies that the
    patient has a patent airway, is breathing and has
    brain perfusion.
  • If the patient can only speak in short
    sentences, they may have extreme respiratory
  • Failure of the patient to respond is a clear
    marker of serious illness.

  • Use vital signs monitoring early.
  • Apply a pulse oximeter.
  • ECG monitor
  • Continuous non-invasive blood pressure monitor
    to all critically ill patients, as soon as is
    safely possible.

  • How do we assess airway and why?

Airway (A)
  • Treat airway obstruction as a medical emergency
    and obtain expert help immediately.
  • Untreated, airway obstruction leads to a lowered
    PaO2 and risks hypoxic damage to the brain,
    kidneys and heart, cardiac arrest, and even death.

  • Look for the signs of airway obstruction.
  • The use of the accessory muscles of respiration.
  • Central cyanosis is a late sign of airway
  • obstruction.
  • In the critically ill patient, depressed
    consciousness often leads to airway obstruction.

  • In the majority of cases, simple methods of
    airway clearance are all that are required (e.g.,
    airway opening maneuvers, airways suction,
    insertion of an oropharyngeal or nasopharyngeal
  • Tracheal intubation may be required, where simple
    airway opening measures fail.

  • Give oxygen at high concentration.

  • Why do we assess breathing and how do we carry
    out a comprehensive respiratory assessment?

Breathing (B)
  • During the immediate assessment of breathing, it
    is vital to diagnose and treat immediately
    life-threatening conditions as
  • Acute severe asthma
  • Pulmonary oedema.
  • Tension pneumothorax.
  • Massive haemothorax.

  • Look for the general signs of respiratory
  • Sweating.
  • Central cyanosis.
  • Use of the accessory muscles of respiration.
  • Abdominal breathing.

  • Count the respiratory rate. The normal rate is
    between 12 and 20 breaths per minute.
  • High rates, and especially increasing rates, are
    markers of illness and a warning that the patient
    may suddenly deteriorate.

  • Assess the depth of each breath, the pattern
    (rhythm) of respiration and
  • whether chest expansion is equal on both sides.

  • Note any chest deformity .
  • Look for a raised JVP (e.g., in acute severe
    asthma or a tension pneumothorax).
  • Note the presence and patency of any chest
  • Abdominal distension may limit diaphragmatic
    movement, thereby exacerbating respiratory

  • Listen to the patients breath sounds.
  • Percuss the chest hyper-resonance suggests a
    pneumothorax, dullness suggests consolidation or
    pleural fluid.

Auscultate the chest
  • The quality of the breath sounds should be
  • Bronchial breathing indicates lung
  • Absent or reduced sounds suggest a pneumothorax
    or pleural fluid.

  • Check the position of the trachea in the
    suprasternal notch.
  • Deviation to one side indicates mediastinal shift
    (e.g., pneumothorax, lung fibrosis or pleural

  • Palpate the chest wall to detect surgical
    emphysema or crepitus (suggesting a pneumothorax
    until proven otherwise).

  • What is the significance of circulation and how
    do we assess the patient?

Circulation (C)
  • Consider Hypovolaemia to be the primary cause of
    shock, until proven otherwise.

  • Look at the colour of the hands and digits are
    they blue, pink, pale or mottled?
  • Assess the limb temperature by feeling the
    patients hands are they cool or warm?

  • Measure the capillary refill time
  • Count the patients pulse rate.

  • Palpate all the peripheral and central pulses,
    assessing for presence,rate, quality, regularity
    and equality.
  • Low volume palpable pulses suggest a poor
    cardiac output, whilst a bounding pulse may
    indicate sepsis.

  • Measure the patients blood pressure.
  • A low diastolic BP suggests arterial
    vasodilatation (as in anaphylaxis or sepsis).
  • A narrowed pulse pressure (difference between
    systolic and diastolic pressures normally
    35-45 mmHg) suggests arterial vasoconstriction
    (cardiogenic shock or hypovolaemia).

  • Auscultate the heart.
  • Look for other signs of a poor cardiac output,
    such as reduced level of consciousness and, if
    the patient has a urinary catheter, oliguria
    (urine volume lt 0.5 ml kg-1 hour-1).

  • Examine the patient thoroughly for external
    haemorrhage from wounds or drains or evidence of
    concealed haemorrhage (e.g., thoracic,
    intraperitoneal or into gut).

Central Venous Pressure
  • Involves insertion of a line to a major vein e.g.
    subclavian, internal jugular under full aseptic
  • 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)

Deficits in neurological status environment
  • How will you assess neurological status and

Disability (D)
  • Common causes of unconsciousness include profound
    hypoxaemia, hypercapnia, cerebral hypoperfusion,
    or the recent administration of sedatives or
    analgesic drugs.

  • Examine the pupils (size, equality and reaction
    to light).
  • Assess the patients conscious level using either
    the AVPU or Glasgow Coma Scales.
  • Measure the blood glucose.

Exposure / Examination (E)
  • In order that patients are examined properly, and
    detail is not missed, full exposure of the body
    may be necessary. Do this in a way that respects
    the dignity of the patient and prevents heat loss.

  • Take a full clinical history from the patient,
    his relatives or friends, and other staff.
  • Review the patient notes and charts
  • Study both absolute and trended values of vital
  • Check that important routine medications are
    prescribed and being administered.

  • Review the results of laboratory or radiological
  • Consider which level of care is required by the
    patient (e.g., ward, HDU, ICU).

  • Consider definitive treatment of the patients
    underlying condition.