Assessment of the Critically Ill Flashcards
Goals of Care Designation-Comfort (C)
Medical care and interventions that are focused on comfort
Does not mean that you receive less care but rather that the focus on care is on comfort and relieving symptoms and not on prolonging life
Monitoring
A repeated/continuous real-time measurement
Allows for rapid detection of a change in patients condition
Should always be correlated to what you are seeing with the patient as clinical condition may not match the monitor due to errors
Monitors allow us to see the “unseen”
Principal of Monitoring: Errors in Measurement
Errors Includes-Artifact, factitious events, and instrumental drift
Parallel shift-when the difference between the reading and the true value is consistent and constant (carbyhemoglobin will result in a consistent error in the oxygen saturation that is monitored through a pulse oximeter)
Therapist Driven Protocol
Therapist-driven protocol are a set of specific actions that enable respiratory therapists to initiate and adjust therapy on their own (with guidelines set by medical staff).
This is also known as ‘respiratory care protocol’.
GI/ Nutritional Assessment
OG/NG
Gastric residual volumes
Abdominal distention
Bowel sounds
Bowel movements
Accuracy and Precision
Accuracy: How closely the measured reflects the actual value
Precision: Index of dispersion of repeated measure-how often will the machine give you the correct number
Machines with poor accuracy but good precision are not useless as we can still figure out what the real reading is based on how far off the machine normally reads
But is a machine has both poor accuracy and precision then it has to go through maintenance
Cardiovascular
Capillary refill
JVD
Pedal/Pitting Edema
Skin colour
Skin turgor
Renal Assessment
Urine output/colour/concentration
Fluid Balance
Droplet Precautions
Need to apply droplet precautions when you are within 3 feet/ 1 meter of the patient
Need to wear a mask
Non-Patient Assessment
Maintenance of the current patient interventions and/or bedside equipment
Airway maintenance HME change, check ventilator circuit, suction equipment, calibration of monitors, check/stock appropriate bedside equipment
Contact Precautions
Wear gown and glove when in contact with patient or their bedding
Parellel Shift
Parallel Shift: The machine is becoming less and less accurate, which could be something like a clot developing on machine that needs to be cleared
Goals of Care Designation-Resuscitation
Medical care and intervention (ex. Medications, ventilators) including resuscitation followed by the ICU
R1: Can use any type of intervention including resuscitation and ICU care
R2: Can use any type of intervention including resuscitation, intubation and ICU care but excluding chest compression
R3: Can use any type of intervention including resuscitation and ICU care but excluding chest compression and intubation
Background Information Should Include
Patient history
Major clinical events
Current clinical status
Current orders
Patient care
Principal of Monitoring: Risk vs. Benefit
The most useful tests have little or no risk and high potential value. (e.g. Pulse oximeter), but there is a small risk in incorrect measurement
Hemodynamics, specifically PAC has high risks and high potential value. New tech (pico) is allowing us to obtain similar high value information with less risk.
There often is nearly complete trust in a digital value displayed but the monitor may be displaying an incorrect value
Dispersion Error
The machine needs to go through maintenance as there is no pattern as to what the error is
Principal of Monitoring: Calibration
Calibration: To check, adjust or determine by comparison with a standard
Most monitors will use some type of calibration, as callibration will help to reduce systematic errors
E.g. FiO2 analyzers, zeroing transducers (response to pressure changes in the blood), SjvO2 monitors
Instrumental Drift
When something with the monitor need troubleshooting because it is giving a false reading but it will change once the troubleshooting is done (ex. blood gas analyzer can become coated with protein resulting in a false reading)
Newer machines will have built in calibration that will clean the machine on it’s own
Re-calibration is a standard part of trouble-shooting.
Other Systems Assessment
Clinical lab data results
Lines (insertion sites/duration)
Skin (Petechia/ecchymosis/mottling)
Skin integrity
Goals of Care Designation-Medical (M)
Medical care and interventions excluding resuscitation
Factitious Events
Values that are a real measurement but out of the normal range (e.g. airway pressure spike during a cough).
A one time event that does not accurately effect the patients true state
Principal of Monitoring: Error Patterns
If there is occasional random errors this is of minor significance and should be disregarded
Usually the operator just need to repeat the QC sampling
Increases in the frequency of error or systematic errors should be investigated
Types of error patterns accuracy, precision, dispersion error, and parellel shift
Artifact Error
The value is susceptible to variability due to non-physiologic reasons.
Something that is interfering with the measurement due to an outside force and not the physiological state of the patient
Best Monitor
Caregiver who understands the equipment, alarms and, resulting data
Initial Impression
Visual inspection of pt. and bedside monitors
Inspection in IPPA
Gather overall impression of pt. clinical status
Many prefer to do the “monitoring” of the patient before the physical exam as it will allow a collection of “baseline” data before having to disturb the patient.
The visual inspection may reveal the need for an immediate intervention (ex. Coughing/desaturation requiring suctioning etc.)
Systematic Approach in Assessment of Critically Ill
Patient Information/Background
Body systems assessment
Interpreting/Integrating
Planning/Reporting/Communicating
Documentation
