ASSESSMENT OF AN ICU PATIENT

Dr Nikhilesh Jain
CHL Hospitals,Indore
Objectives

 Explain what is meant by assessment of the

acutely ill patient.
 Describe the process of assessing the acutely ill
patient.
 Understand how to undertake a systematic
assessment of the acutely ill patient.
 Evaluate the doctor’s role in assessment of the
acutely ill patient.
What is assessment?

 A process by which you establish the needs of

your patient.

 A process by which you establish a baseline of

immediate and future needs.

 An on-going process - evaluation of

interventions and reassessment of need.
What Does Assessment Involve?

 Observation.

 Communication.

 Monitoring.

 Analysis and interpretation

 Diagnosis
What do we assess?

 Nice draft guidelines 04/2007 – Acutely ill

patients in hospital: recognition of and response
to acute illness in adults in hospitals.

 19 Recommendations – 7 of which were identified

as key priorities.
Recommendation 1

 Adult patients in acute hospital settings should have:

 All appropriate physiological observations recorded at
the time of admission/initial assessment.
 Their physiological observations measured, recorded
and acted upon by staff specifically trained to
undertake these procedures and understand their
clinical relevance.
 A clear monitoring plan that specifies which
physiological observations to be recorded and how
often they should be recorded. This will take account
of the:
 patient’s diagnosis
 presence of co-morbidities
 agreed treatment plan.
Recommendation 2

 The following physiological observations should be

carried out as part of routine monitoring:
Heart rate
Respiratory rate
Blood pressure
Level of consciousness
Oxygen saturation
Temperature.
Recommendation 3

 Additional monitoring may be required in specific

clinical circumstances, for example:
 Hourly urine output
 Biochemical analysis (for example, lactate, blood
glucose, base deficit, arterial pH)
Mini Patient Assessment

 Know - what you are told

 See - quick visual assessment

 Find - quick physical assessment

Common Presenting Abnormalities

 Tachypnoea
 Altered level of Consciousness
 Derangement of heart rate
 Derangement of blood pressure
 Derangement of arterial oxygen saturation
 Derangement of urine output
Early warning systems?

 Heart rate.
 Blood pressure.
 Respiratory rate.
 Oxygen saturation.
 Respiratory Support / Oxygen Therapy.
 Urinary output.
 Conscious level.
 LEEDS TEACHING HOSPITALS NHS TRUST CRITICAL CARE OUTREACH

ADULT EARLY WARNING SCORING SYSTEM

This scoring system has been designed to help both nursing and medical staff identify patients who are seriously ill
or at risk of deterioration.
It should be used on adult patients immediately after their observations have been done.

Score 3 2 1 0 1 2 3

Heart Rate <40 41-50 51-100 101-110 111-130 >130

- HR

Blood Pressure <70 71-80 81-100 101-179 180-199 200-220 > 220
- BP ( systolic)

Respiratory Rate - <8 8- 11 12- 20 21- 25 26- 30 >30

RR

Oxygen <85% 86-89% 90-94% >95%

Saturations

Respiratory BIPAP/ Hi-Flow Oxygen

Support/ CPAP Therapy
Oxygen Therapy
Urine Output in last <80 80-120 120-200 >800
4 hours/mls

Central Nervous Confusion Awake Responds Responds Unresponsive

System- CNS and Responsive To Verbal to Painful
Command Stimuli

Each measurement is given a score from the table above. If the patient’s total score is 3 or more, the call out algorithm is
triggered and you must call for help. Please follow as directed. May 2001 Adapted from the Great Yarmouth Scoring System by Richard Morgan.
MEWS is/becomes 3 MEWS is/becomes 5

Call Outreach No response in 30 mins Call Outreach team/ No response in 30 mins

team/NNP and NNP
PRHO and registrar

Patient deteriorated Yes

Local action
Contact consultant +/-
(guidelines)
refer to appropriate
No specialty

Continue monitoring/
follow-up Patient improved when
reviewed after 2 hours
Yes No

If MEWS greater than 10 contact Patients own Consultant, Outreach

team and ICU Directly
Patient Assessment
Priorities.

 Primary Survey. Occur as one.

 Resuscitation.
 Secondary Survey. CPR.
Oxygen and airway control.
 History. Cannulate.
Blood samples.
 Intervention/Transfer Fluids.
Resus’ drugs.
 Re-evaluation. Trauma management.
Urinary and Gastric
catheters.

Ian Goulden 14
Primary Survey

 Level of Consciousness

 Airway
 Breathing
 Circulation
 Disability
 Expose and Examine
Primary Survey - Level of Consciousness

 Response to spoken word?

 Gentle tactile stimulation

Primary Survey - Airway

Cervical Spine
 Airway obstruction? Paradoxical movement?
 Respiratory insufficiency?
 Secure airway manually / adjuncts
 Cricothyroid puncture?
Airway Obstruction
Primary Survey - Breathing

 Effectiveness of Breathing

 Work of Breathing
Primary Survey - Breathing

 Cyanosis, hypoxia?
 Rate, depth, symmetry of chest movement? Use
of accessory muscles?
 Palpate chest wall for structural integrity
 Chest injury / flail / pneumothoraces
 O2 therapy / Assisted ventilation
 Manage injury / pnuemothoraces
Primary Survey - Circulation

 Quick head to toe survey to note and control

bleeding
 Skin colour, moisture, temperature
 Pulse quality, rate, regularity, volume
 Blood pressure
 Capillary refill (should be < 2 seconds)
 Chest Compressions / Positioning etc.
Primary Survey - Disability

 Baseline level of consciousness

 A . V . P. U + GCS
 Neurological Examination
 Immobilize fractures / potential fractures
 Pain assessment / Analgesia
A.V.P.U

 A = Alert.
 V = Responds to Vocal Stimuli Only
 P = Responds to Painful Stimuli Only
 U = Unconscious
Primary Survey - Expose and Examine

 Thorough examination - all systems

 Dignity / control of temperature

Secondary Survey.
Thorough full system assessment

 CVS
Pulse (s) / BP / ECG / Palpation /
Auscultation / Jugular veins / Oedema.
 Respiratory
Rate / Rhythm / Palpation - Trachea and
Thorax / Auscultation / Peakflow?
Pulse oximetry / CXR / ABG analysis?
Secondary Survey.
Thorough full system assessment

 Head and neck

Skull / Neck/ Eyes / Ears / Nose / Mouth

 Renal
Urine output - 1ml/kg/hour ? 30mls/hr?
Categories of Urine Output
Secondary Survey.
Thorough full system assessment

 Abdomen.
Inspect / Palpate / Auscultate

 Perineum / Rectum / External Genitalia.

Inspect / Examine
Blood in urine?
Pregnancy test?
Secondary Survey.
Thorough full system assessment

 Musculoskeletal.
Inspect / Palpate / Range of Movement /
Motor and Sensory function.

Pelvis / Skull / Spine / Limbs / Joints

Secondary Survey.
Thorough full system assessment

 Metabolic

Urea and electrolytes.

Blood sugar.
Poisons screen.
LFT’s.
etc.
To summarise
Some more signs????
Refining it further?????