Critical care system assessment
DR –Noha Elsayed
2014- 2015
Critical care system
assessment
Is typically system based
Example:
Subarachnoid hemorrhage …..Required detailed neurologic exam
at least hourly
 Obtained data must be individualized to patients & their
conditions
Generalization of assessment finding may lead to CCTP astray &
impact patient care.
For example:
New born with cyanosis of lips should illicit a different response
from the clinician than an adult with the same.
 Subjective information from the patient & family (Chief complaint,
Review of systems, History of past & present illness) is more
important than objective information obtained during an actual
exam.
These questions should guide the provider to ask other
questions or to examine objective data to qualify the information.
For example:
While being placed on a stretcher …. A patient asks for four
pillows …. An alert CCTP will inquire more about the need for
the pillows
May be Orthopenia …. Shortness of breath (Left ventricular
dysfunction)
The CCTP must then ask …. How long have you been sleeping on
four pillows in attempt to a certain worsening of the condition
Critical care system assessment
A.
B.
C.
D.
E.
F.
G.
H.
General appearance
Cardiovascular assessment
Respiratory assessment
Neurologic assessment
Gastrointestinal assessment
Genitourinary assessment
Musculoskeletal assessment
Psychosocial & Emotional assessment
1.
A.
B.
C.




General appearance:
Apparent age relative to chronological age
Level of consciousness (LOC)
Skin findings
Presence & degree of edema
Skin lesions
State of finger tips & nail beds
Skin temperature

Cool …. Indicates vasoconstriction

Warm or hot …. Fever

May be wet or dry
 Skin Turgor …. This is an indicator of fluid status ….
 May be rapid or sluggish
( Should be assessed over the sternum or forehead)
 May be misleading especially in elderly people or people with
friable skin
D. Presence or absence of gross deformity
E. Stature, Posture, Gait (If the patient is ambulatory)
F. Position of comfort (Such as: Tripod position …. Significant
cardiovascular or respiratory diseases)
Cardiovascular assessment:
A.
Inspection
B.
Auscultation
C.
Palpation
Not included with us
D.
Percussion
Inspection
I.
II.
III.
IV.
V.
VI.
General appearance
Skin color
Edema
Interpretation of ECG rhythm
Assessing pulse (Peripheral pulse)
how many beats are perfused
2. Cardiovascular assessment:
A. Inspection
I.
II.
General appearance (Cachetic, Obese)
Skin color (Cyanosis, Pallor, jaundice)
Cyanosis
 It indicates Hypoxia (Acute oxygen insufficiency)
 When cyanosis combines with clubbing (Angle between the nail
& nail bed > 160 ) …. This may indicate long term hypoxia
associated with chronic obstructive lung disease
 It may be Central or Peripheral
III. Edema (Location & Severity)
 Pedal edema should be evaluated by pressing on the skin
behind the medial malleolous, over the shin of tibia and over
the dorsum of each foot with the thumb and index finger for at
least 5 seconds
 A slight indentation that disappears in a short time …. Trace
edema
 Deep pitting that doesn’t disappear readily ….Grade +3 or +4
 Location of edema & usual position of the patient are used to
differentiate between dependent & non-dependent edema
Example:
Ambulatory & seated patients …. Edema develops in lower
extremities
Where as,
Patients confined to bed …. More edema in sacral area
IV. Interpretation of ECG rhythm is essential
 You must have a copy of 12 lead ECG accompanying the
transfer record
 The answer of these questions must be present:
1. What is the underlying or baseline rhythm??
2. What is the usual monitoring lead & morphology??
3. What arrhythmia has the patient experienced??
4. What arrhythmia has the patient experienced??
5. What effects did the arrhythmia have on the patients & was any
treatment used??
6. Has the patient ever required defibrillation or cardio version??
7. If the patient has a pacemaker &/or implanted cardio
defibrillator??
V. Assessing pulse (Peripheral pulse):
For example:
1. Carotid
5. Popilteal
2. Radial
6. Post. Tibia
3. Brachial
7. Dorsalis pedis
4. Femoral
Pulse should be assessed bilaterally for presence , strength,
pattern
N.B.
Carotid should be palpitated one side at a time & without a
massaging type action …. This may cause vagal response & loss
of consciousness or embolization of carotid plaque deposits
VI. You must know how many beats are perfused by comparing
the rate on ECG monitor with the heart rate on a pulse oximetry
display
Take care:
 Avoid using invasive monitoring equipment because a skilled health
care professional can obtain same data by using assessment skills
For example:-central venous pressure or pressure in the right atrium
……which is indicator of fluid status
Can be obtained by using an invasive triple lumen catheter or just by
observing for jugular venous distension by hepato jugular reflex
(Applying mid abdominal pressure while observing for jugular venous
distension …. If noted → Means +ve = Pressure on abdomen
displaces fluid from an engorged liver indicating volume
overload)
Auscultation:
I. Heart sounds
II. Auscultation over the carotid ,renal and femoral
arteries
III. Blood pressure
B. Auscultation:
I. Heart sounds
Requires years of practice to become proficient
Auscultated areas:
 Aortic, Pulmonic, Tricuspid, Mitral valve …. With diaphragm &
bell of stethoscope
 Heart sound should be evaluated for Pattern, Intensity, Quality,
Pitch & Murmur
N.B.
Systolic murmur appearing after an inferior myocardial infarction is
much more significant than diastolic murmur
II. Auscultation over the carotid ,renal and femoral arteries
Detection of bruits and or loud harsh sounds indicates blood
flow through a narrowed artery
III. Blood pressure
Normal B.P in critically ill patients, is defined by the individual
patient ,not text book SBP =90 mmhg may be normal in 20 years old
but may be abnormal in patients with a recent myocardial infarction
and history of hypertension.
Trends in B.P over time should be noted especially in response to
cardiogenic medications & interventions.
Typically B.P is re-assessed every 5 min. in acutely ill critical care
patients & up to 15 min. in stable critical care patients.
When titrating pressors, 5 min interval should be the maximal safe
interval for B.P management.
 Orthostatic B.P was previously used in the critical care to assess the
need for fluid resuscitation, but nowadays is limited as it requires
sitting & standing measurements of B.P (Impractical)
Passive leg raising (PLR):
 Is used to assess fluid responsiveness in patients with
suspected volume depletion
 Is performed with patients in a supine position by raising
both of patient’s legs to 45o angle & B.P assessed again
while the patient’s legs are raised within 30 seconds
 Results in a reversible auto transfusion of some 150 to 300
ml of blood into central circulation
↙
↘
Improvement in B.P
Non improvement
Administrate fluid
No fluid administration
Take care:
Remember to make head to toe assessment every 4 hours