Chapter 5 Patient Assessment

Patient Assessment in Critical Care Environment (1 of 2) Requires CCTP to have: –Thorough understanding of clinical scenario –Sharp clinical assessment skills –Interpersonal communications and diplomacy –Balanced approach to assessment, treatment

Patient Assessment in Critical Care Environment (2 of 2) Assessment process that ensures appropriate management of patient’s critical care needs to limit morbidity and mortality, improve patient outcomes Familiarity with assessment process establishes initial care plan

Differential Diagnosis Lists all possible diagnoses that could be causing patient’s symptoms –Excluding projected diagnosis Provides useful framework for both clinicians and CCTPs Informs treatment decisions Helps assess effectiveness of treatments

Paramedic vs Medical Assessment Model (1 of 2) Combining two models provides ideal critical care transport environment Paramedic model –Treats major problems as symptoms found –Uses standardized assessment approach based, sequences immediate threats to life, patient survival

Paramedic vs Medical Assessment Model (2 of 2) Medical and nursing model –Does not always provide treatment during assessment process –Provides wealth of information to target treatment toward known list of problems –Can be more effective than treating symptoms alone without knowing causes

Bridging Environments and Disciplines (1 of 2) Systems assessment –Comprises detailed physical exam –Not always feasible if patient declines, requires resuscitation Prehospital assessment –“Find a life threat—fix a life threat” works well in acute emergency care. –Less appropriate for patients with interrelated, multisystem complications

Bridging Environments and Disciplines (2 of 2) Critical care assessment –Treat the patient, not the machine. –Look at and listen to patients and their families. –Make decisions and solve problems by balancing personal and clinical observations with technology.

Scene vs Interfacility Transport (1 of 2) Scene transport –Requires awareness of patient care provided before CCTP’s arrival –Requires expeditiously assessing, treating, packaging, and transporting patient to definitive care –Requires deferring comprehensive assessment, sophisticated treatment until arrival at definitive care facility

Scene vs Interfacility Transport (2 of 2) Interfacility transport –Often includes voluminous patient information –Requires transfer team to have general understanding of patient’s situation –Requires knowledge of anticipated transport time to differentiate “need to know” from “helpful to know” information

Hospital Medical Record Components (1 of 2) Admission orders Advance directives Operative notes Postoperative notes Progress notes Consultation notes

Hospital Medical Record Components (2 of 2) Preoperative notes Procedure notes Discharge summary Lab reports Medication administration records Nurses’ notes and flow sheets

Scene Transport Information (1 of 2) CCTP should evaluate the following: –Mechanism of injury details –Current interventions –Patient’s response to interventions (observe and record) –Patient status (Glasgow Coma Scale)

Scene Transport Information (2 of 2) Credit line: © Dan Myers

Patient Assessment at the Scene Follows same general process as assessment used by field provider Includes more sophisticated patient monitoring devices and technologies –On scene –During transport

Patient Packaging for Transport Depends on many variables, including: –Patient physical location, care in progress on arrival, temperature, weather, type of CCTP transport vehicle Requires adherence to local practice protocols, procedures Involves multiple CCTPs Requires expediency

Interfacility Transport Information (1 of 2) CCTP should scan “scene” for initial first impressions CCTP should evaluate the following: –Ventilator settings, medication infusions, monitoring equipment –Current interventions and patient’s response –Patient status

Interfacility Transport Information (2 of 2)

Patient Assessment at Transferring Facility (1 of 2) Ensure travel routes will accommodate patient, equipment, and personnel. Transfer patient’s monitoring to transport monitoring equipment. Follow various policies regarding transfer of narcotics or controlled substances.

Patient Assessment at Transferring Facility (2 of 2) Conduct patient assessment –Use transferring facility’s report –Follow outline “General Patient Overview for Interfacility Transfer” –Develop individualized critical care plan based on elements unique to patient

Skill Drill 5-1: Packaging Procedures for an Interfacility Transport (1 of 3) Be certain to read labels of bags. Once monitoring equipment is in place, transfer any infusions to the transport unit infusion pumps.

Skill Drill 5-1: Packaging Procedures for an Interfacility Transport (2 of 3) Label the distal end of the tubing with the infusion name. Reassess for hemodynamic stability and transfer the patient to the transport unit stretcher. Be certain to trace infusion tubings completely between the bag and the connection to the patient.

Skill Drill 5-1: Packaging Procedures for an Interfacility Transport (3 of 3) Secure all equipment, bundle the patient as appropriate for weather conditions, and reassess. Before leaving, be certain that all necessary equipment adapters and connectors are with the patient. Ensure that family members have directions to the receiving facility. Provide transferring staff with contact information for follow-up. Once the patient is comfortably positioned on the transport stretcher, transfer any other necessary equipment.

Critical Care Assessment Overview (1 of 2) Uses observational skills and clinical parameters of physiologic status Uses technologic monitoring to support observations, provide greater specificity and/or differentiation Reviews major body systems

Critical Care Assessment Overview (2 of 2) Bases level of detail on patient’s individual condition Includes subjective history supplied by patient, family –Chief complaint –Review of systems –History of past and present illnesses

Assessment of General Appearance (1 of 2) Includes: –Data from medical records –Determination of apparent age relative to chronological age, LOC, skin findings –Presence or absence of gross deformity –Stature –Posture –Gait (if patient is ambulatory)

Assessment of General Appearance (2 of 2) Includes: (continued) –Presence and degree of edema –Skin lesions –State of fingertips and nail beds –Position of comfort –Skin temperature (cool, warm, hot) –If skin is wet or dry –Turgor (rapid or sluggish)

Cardiovascular Inspection (1 of 2) Assess patient’s skin color. –Central, peripheral Note location and severity of edema (if present). –Trace, deep pitting Interpret ECG rhythm. Observe for jugular venous distention. –Hepatojugular reflex test

Cardiovascular Inspection (2 of 2)

Pulse Assessment (1 of 2) Assess peripheral pulses for presence, strength, and pattern. –Bilateral assessment of carotid, radial, brachial, femoral, popliteal, posterior tibial, dorsalis pedis –Palpate carotid pulses one side at time Note trends in assessment findings over time. –Crush injuries

Pulse Assessment (2 of 2) Note patterns of pulsations. –ECG rhythms –Sinus or atrial arrhythmias

Cardiovascular Auscultation (1 of 3) Occurs at aortic, pulmonic, tricuspid, mitral valve locations: –Use carotid, renal, femoral arteries in critically ill patients Requires stethoscope with diaphragm, bell

Cardiovascular Auscultation (2 of 3) All content reproduced with permission of 3M.

Cardiovascular Auscultation (3 of 3) Requires experience and thorough understanding of anatomy and physiology Requires paying attention to new murmurs Includes blood pressure assessment

Blood Pressure Assessment (1 of 3) Definition of “normal blood pressure” is related to individual critically ill patient Trends in blood pressure over time should be noted before transport. –Consider response to cardiogenic medications, interventions. –Compare pretransport measurements with trends before patient packaging. –Reassess at intervals

Blood Pressure Assessment (2 of 3) Patients with suspected volume depletion should undergo PLR to assess fluid responsiveness. Every parameter is not assessed on each patient, nor checked on same patient at each assessment.

Blood Pressure Assessment (3 of 3)

Respiratory Inspection (1 of 3) Assess patient and inspect chest for the following: –Mental status –Skin color and temperature –Presence of an artificial airway –Breathing spontaneously vs need for mechanical ventilation –Equal chest expansion with each breath

Respiratory Inspection (2 of 3) Assess patient and inspect chest for the following: (continued) –Use of accessory muscles (scalene, sternocleidomastoid, intercostals) –Work of breathing (labored, unlabored) –Presence of chest tubes, central lines, dressings –Presence of signs of injury (bruising, laceration, penetrating wounds)

Respiratory Inspection (3 of 3) Assess chest wall’s shape for evidence of: –Trauma, congenital anomalies, COPD Assess work of breathing –Inspect use of accessory muscles, intercostal retractions or bulging, nasal flaring –Aggressively intervene if pediatric patient shows signs and symptoms of increased work of breathing.

Respiratory Palpation Palpate for tracheal alignment. Inspect chest excursions. –Unequal or asymmetrical excursion may indicate disease. Palpate for subcutaneous emphysema. –May indicate disease state, air leak in chest tube, dislodged chest tube, too much tidal volume or positive end-expiratory pressures from mechanical ventilator

Respiratory Percussion (1 of 3) Requires CCTPs to have sound knowledge of: –Anatomy –Physiology –Percussion technique Performed using one or two hands Attention given to sound made by percussion

Respiratory Percussion (2 of 3)

Respiratory Percussion (3 of 3)

Respiratory Auscultation (1 of 2) Auscultate lungs –Anteriorly, posterially, medially Assess lung fields for presence of normal breath sounds –Tracheal, bronchial, vesicular, bronchovesicular Assess for adventitious sounds –Crackles, rhonchi, stridor, wheezing

Respiratory Auscultation (2 of 2) Note current settings and measurements prior to transport. –Ventilator settings, parameters, baseline arterial blood gas measurements Maintain airway and adequate ventilation as first priority.

Neurologic Assessment (1 of 5) Includes general neurologic assessment for critical care setting Establishes patient’s baseline status Establishes patient’s LOC –Glasgow coma scale Assesses pupils to determine variations from normal

Neurologic Assessment (2 of 5)

Neurologic Assessment (3 of 5)

Neurologic Assessment (4 of 5)

Neurologic Assessment (5 of 5)

Gastrointestinal Assessment (1 of 3) Inspection includes: –Review of oral mucosa and abdominal areas for abnormalities Auscultation includes: –Review and presence of bowel sounds in all four quadrants

Gastrointestinal Assessment (2 of 3) Percussion –Establishes size, location of liver and (sometimes) spleen Palpation –Documents tenderness or rebound tenderness –Murphy’s sign (cholecystitis)

Gastrointestinal Assessment (3 of 3)

Genitourinary Assessment Includes mammary, testicular, and prostate glands for patients in special circumstances –Burns, trauma, spinal cord injuries Assesses kidney function –BUN-creatinine ratio helps determine renal failure. –Usually secondary diagnosis in critical care

Musculoskeletal Assessment In critical care, often secondary diagnoses that involve: –Maintaining stability of joints using soft or hard casts and splints –Assessing for neurovascular compromise of distal extremities

Psychosocial and Emotional Assessment Pertinent aspects relative to CCTPs include whether patient has: –Previously diagnosed psychiatric disorder –Significant coping needs related to present illness –High level of anxiety

Documentation Document assessment findings –When patient is first encountered –Routinely as patient condition warrants –Upon arrival at destination Proper documentation ensures –Continuity of care –Patient safety –Protection from potential legal issues

Communicate With Transferring Hospital Call in patient changes immediately. Obtain and implement orders. Assess and document patient response(s). Alert receiving hospital of events occurring en route.