Assessment Of Critically Ill Patient PDF

Assessment Assessment Of Of Critically Critically Ill Ill Patient Patient Saturday, October 22, 2022 1  General Rules Mobiles off Sh...

Assessment Assessment Of Of Critically Critically Ill Ill Patient Patient Saturday, October 22, 2022 1  General Rules Mobiles off Share ideas Ask questions Listen actively Saturday, October 22, 2022 2 Saturday, October 22, 2022 3  Objectives At the end of the lecture each student will be able to:- Define key terms (Critical Care Nursing, Critically Ill Patient , Critical Care Environment and Assessment) Identify approaches for assessing critically ill patient Recognize types /stages of assessment of critically ill patient Develop a plan of care for critically ill patient Saturday, October 22, 2022 4  Outlines Introduction Definition of key terms. Approaches of assessing critically ill patient Stages of assessment. Saturday, October 22, 2022 5  Introduction Assessment of critically ill patients are essential competency for critical care practitioners. Information obtained from assessment identify the immediate and future needs of patient so plan of care can be initiated to resolve these needs. Saturday, October 22, 2022 6  Introduction This assessment should be done with consistent and systematic approach without this it would be easy to miss subtle signs or details. Assessing of critically ill patient begins from the moment the nurse is made aware of the pending admission of the patient and continuous until the next phase of care Saturday, October 22, 2022 7  Definitions Critical care nursing: Specialty within nursing that deal with human responses to life threating problems. Critically ill patient: Patients who are at high risk for actual or potential life threatening health problem. Saturday, October 22, 2022 8  Bedside examination for cardinal features of critical illness. Saturday, October 22, 2022 9  Definition cont. Critical care environment: Specially equipped hospital area designed for treatment of patient with sudden life threatening conditions. Saturday, October 22, 2022 10  Definition cont., Assessment It is process of gathering information about the patient`s physiological ,psychological and spiritual state. It is the first step of nursing process Saturday, October 22, 2022 11 Each step of the Nursing Process is dependent upon the accuracy of the preceding step. The steps are also overlapping because you may have to move more quickly for some problems than others  Approaches of patient assessment Traditional approaches (ideal but rarely). A. Complete evaluation of the patient history B. Comprehensive Physical examination of all body system. Standard approaches A. Head to toe approach B. Body systems approach Saturday, October 22, 2022 13 Traditional medical approach  The ABCDE approach Airway & oxygenation Exposure & examination Breathing & ventilation Disability due to neurological Circulation & deterioration shock management Saturday, October 22, 2022 15  Assessment framework (stages): Pre arrival Comprehensive Assessment admission Assessment Ongoing Admission Quick Assessment Check Assessment Saturday, October 22, 2022 16  Prearrival assessment Begins the moment information is received about the upcoming admission of the patient. Pre arrival report on patient Provide key information about: Chief complaint or reason of admission and Diagnosis Age ,gender , physiological status, invasive devices , status of laboratory and diagnostic tests. Saturday, October 22, 2022 17  It allow the critical care nurse to: Begin anticipating the patient physiological needs. Determine the appropriate resources needed to care for the patient Prepare the environment to meet the specialized needs of the patient. Complete room setup ,verification of proper functioning of equipment needed prior to the patient's arrival Equipment for standard room setup Saturday, October 22, 2022 18 Saturday, October 22, 2022 19 Admission quick check assessment Obtained immediately upon arrival and is based on assessing the parameters represented by the ABCDE acronym It done to ensure and validates that basic cardiac and respiratory function is sufficient to ensure early intervention for any life- threatening situations Saturday, October 22, 2022 21  connect to monitor and support equipment, administer critical medication ,essential laboratory &diagnostic tests are ordered simultaneous with ABCDE assessment Airway Circulation Drugs Breathing Equipmen t Saturday, October 22, 2022 22  General appearance (immediately observed ) Airway Patency Position of artificial airway (if present) Saturday, October 22, 2022 23  Breathing Quantity and quality of respirations (rate, depth, pattern, symmetry, effort, use of accessory muscles) Breath sounds Chest tube fluctuation (if present ) Synchrony with MV or not (if connected to MV) Presence of spontaneous breathing Saturday, October 22, 2022 24  Circulation and cerebral perfusion ECG (rate, rhythm, and presence of ectopy) Blood pressure Peripheral pulses and capillary refill Skin( color, temperature) Presence of active bleeding Level of consciousness, responsiveness Saturday, October 22, 2022 25  Drugs and diagnostic tests Check IV access Start record intake & output Drugs prior to admission (prescribed, over-the- counter, illicit) Review diagnostic test results for abnormalities Saturday, October 22, 2022 26  Common diagnostic tests Serum electrolytes Coagulations studies CBC ABG Glucose Chest x-ray ECG Saturday, October 22, 2022 27  Equipment Patency of vascular and drainage tubes for location &patency Appropriate functioning and labeling of all equipment connected to patient Saturday, October 22, 2022 28  Comprehensive admission assessment It is an in-depth assessment of the past medical and social history and complete physical examination of each body system So future change can be compared to determine whether the status is improving or deteriorating Saturday, October 22, 2022 29  Past Medical History Medical condition Medication(prescription, over the counter , illicit) Previous Hospitalizations Allergies Operation “dates, diagnosis, indications, complications if occurred” Saturday, October 22, 2022 30  Social history  Patient’s name (full name)  Age.  Nationality.  Marital status (Married, Single, Widow Divorced).  Place of residence (Address).  Religion’ “Moslem/ Christian/ others  Occupation  Level of Education: (Illiterate, Read and write)  Patient’s Position In The Family (husband / wife, son / daughter, parents, grandfather / grandmother). Saturday, October 22, 2022 31  Physical assessment  Nervous system  Cardiovascular system  Respiratory system  Renal system  GIT system  Endocrine ,hematologic ,and immune systems  Integumentary system  Pain Saturday, October 22, 2022 32  Psychological assessment General communication Coping style Anxiety and stress (dependency ,loss of control) Current stresses( pain , sleep loss , fear of death) Saturday, October 22, 2022 33  Spirituality Spiritual preferences Healing process Saturday, October 22, 2022 34  Ongoing assessment All subsequent assessments are used to determine trends ,evaluate response to therapy , and identify new potential problems or changes from comprehensive baseline assessment. More Focused and frequency according to stability of the patient. Every few minutes for extremely unstable patients to every 2 hours for very stable patients. Saturday, October 22, 2022 35  Nursing care plan Nursing Evaluation Nursing objective Nursing rationale implementation diagnosis Assessment Short Unhealthy term response Evaluation Rationale goal related to of of your Interventions contributin objective interventio Long term g n goal Factor Health  education Subjective data  Saturday, October 22, 2022 Objective36  Example of nursing diagnosis Impaired gas exchange related to Accumulation of bronchial secretions secondary to chest infections Risk for impaired skin integrity related to immobility secondary to disease process Risk for fluid volume excess Related to increased sodium and water retention, decreased organ perfusion Saturday, October 22, 2022 37  Questions? Saturday, October 22, 2022 38