ICU Assessment Flashcards
(91 cards)
Name 4 critical care areas
- Intensive care units
- step down/high acuity/intermediate unit
- Operating rooms
- Recovery rooms
Critical care areas have the highest _____
staff to patient ratio
What are the two more typical patient populations found in the critical care units
- Respiratory failure requiring mechanical ventilation
- Cardiovascular instability requiring invasive hemodynamic monitoring
3 sources of information for ICU patients
Charts
Monitors
Nurses
4 questions you consider when first assessing a patient
- What brought them in
- Do they have any mobility orders or ROM restrictions?
- What is their current status
- What is the plan for today for them? (i.e. tests, ventilator weaning, OR, dressing changes, etc.)
What is a peripheral intravenous line? where is it inserted? how does it work?
- Inserted into a peripheral vein
- Enables administration of fluids and meds
- is gravity driven or on a pump
What is a PICC line? Purpose? Where does it insert?
- Peripherally inserted central catheter
- To give medications that will corrode peripheral veins and require mixing with larger blood volumes quickly such as chemotherapy or antibiotics
- Can also use to take blood samples
- Inserted in peripheral vein but travels all the way into superior vena cava so that it can mix with more blood
Why do you need to assess Level of consciousness
Need to know how much can this patient participate in treatment vs how much will be passive
What are 2 commonly used sedation scales
- Richmond agitation sedation scale (RASS)
- Glasgow coma scale
Scoring on the RASS
Grading -5 to +4.
0 is normal (alert and calm)
+4 is combative violent danger - calling security and police
-5 is unarousable, no response to voice of physical stim
What is a useful tool for assessing pain in ICU patients
Behavioural pain scale S
Scoring of the behavioural pain scale?
3-12
12 = most pain
What is normal ICP?
5-10mmHg
What ICP will lead to brain damage
> 20mmHg for over 5 minutes
What is the purpose of an extraventricular drain?
To monitor and drain ICP as needed
What are important considerations when working with a patient with a extraventricular drain
- Always check physicians orders regarding target ICP and ability to change patients position or do chest physiotherapy
- Activity Will be pretty limited especially if stopcock is open, if we change position and in turn change how gravity is working with these drains we can get into trouble
- always make sure stopcock is closed before any position changes
- Increased BP will increase ICP - be careful what you do
What are 3 things you need to know when assessing spinal stability
- ASIA
- If injury is stable or not, especially if it is getting worse
- Orders around collar and braces
What is very important to screen for when assessment cognition and behaviour? Why?
Delirium
The earlier we can catch it the better, has effect of morbidity and mortality
70-80% of patients have some _____ at discharge from ICU
Cognitive deficit
What are some examples of cognitive deficit faced by people upon discharge from ICU
- Attention, concentration & memory
- Depression
- High level functioning
- ordering
- Impaired judgement
- Decreased awareness
- Apraxia
How do you assess Patients emotional and behavioural changes
Ask friend or family is they are different from before the event
What is different in an IPPA of a ventilated patient
- Inspection: Should include the position/stability or airway and ventilator settings
- Palpation - Passive ventilation will follow path of least resistance and preferentially ventilate upper areas
- Auscultation - On a ventilator all breath sounds will be significantly louder
Why do you inspect and palpate the chest and abdomen
Because these will both affect diaphragm function, ability to cough and clear, ability to get air in.
How are secretion measurements done in ICU
Amount: 1,2,3 (small, med, large)
Description: Mucoid (M), Mucopurulent (MP), purulent (P), Bloody (B)