Transcript 1 of 2

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)
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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)
Once monitoring equipment is in place,
transfer any infusions to the transport
unit infusion pumps.
Be certain to read labels of bags.
Skill Drill 5-1: Packaging Procedures
for an Interfacility Transport (2 of 3)
Be certain to trace infusion tubings
completely between the bag and the
connection to the patient.
Label the distal end of the tubing with the
infusion name. Reassess for
hemodynamic stability and transfer the
patient to the transport unit stretcher.
Skill Drill 5-1: Packaging Procedures
for an Interfacility Transport (3 of 3)
Once the patient is comfortably
positioned on the transport stretcher,
transfer any other necessary equipment.
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.
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)
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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)
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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.