Four stages of assessment framework are commonly used

1. Pre- arrival assessment

2. Admission- quick check
3. Comprehensive admission assessment
4. On – going assessment

The patient undergo cholecystectomy kaya yung patient ay walang pinag store-ran ng bile. Yung bile
kasi yung nag b break down ng fats, kahit naman matanggal yung gallbladder mo the liver will still make
enough bile, but might have difficult processing fatty foods. Magkakaroon ng trouble sa digestion.

 Liver and nag po produce ng bile tapos gall bladder ang storage.

CASE SCENARIO

LOLA NIDORA, 65 F

- Had laparoscopic cholecystectomy 3 days prior

---- invasive surgery to remove the gallbladder,
 Was last seen and described by her husbands as “NORMAL” at 10PM Right before sleeping
- According to her husband PATIENT awoke at 2AM nudging at him when he discovered her face
in a state of panic and was mumbling words to understand.
 She seemed to have trouble speaking and moving her right side of the body “The husband
stated” AS SUCH HE DIALED 161 IMMEDIATELY
- She was brought by EMS to the ED at 2:15 am
- The initial CT scan shows an occlusion of the left MCA Stem
“Blockage or closing of a blood vessel in the MIDDLE CEREBRAL ARTERY”
 Middle cerebral artery (MCA) Stroke occurs when the middle cerebral artery becomes
blocked
- The nurse noted LOLA NIDORA ineligibility (NOT QUALIFIED) for Alteplase IV tPA and her NIHSSS
was 19.
 Alteplase IV TPA – is an enzyme, which works to break up and dissolve blood clots that can
block arteries used in the treatment of an acute heart attack or pulmonary embolism.
------ TPA is given to the patients through and IV in the arm, and it works by dissolving blood
clots that block blood flow to the brain.
------ Used immediately after symptoms of a heart attack occur to improve patient survival,
also used after symptoms of a stroke and to treat blood clots in the lungs (PULMONARY
EMBOLISM)
 - The CT angiogram confirmed occlusion of the left MCA, as such patient was taken emergently to
the neuroendovascular unit.
- She was planned to undergo mechanical thrombectomy with stent retriever and suction
aspiration with TICI (Thrombolysis in Cerebral Infarction) revascularization.

------ CT angiogram – type of medical test that combines a CT scan with an injection of a special dye to
produce pictures of blood vessels and tissues in a part of our body. The dye is injected through an IV line
started in your arm or hand.

 Angiogram usually takes 30 – 60 minutes, but could take up to 2 hours.

----- Neuroendovascular surgery unit – Procedure using advance technology and medical
experts. To treat patients with neurological diseases of the head, neck and spine. Surgery is
done from inside the blood vessels.

----- Mechanical thrombectomy is type of minimally invasive procedure in which an

interventional radiologist uses specialized equipment to remove a clot from a patient’s artery.
Using fluoroscopy, or continuous x-ray, the doctor guides instruments through patients’
arteries to the clot, extracting the clot all at once.
 Indicated for patients with acute ischemic stroke due to a large artery occlusion in the
anterior circulation who can be treated within 24hours of the time last known to be well.

ASSESSMENT

 Assessment skills must be systematic to be able to effectively progress to the patient care.
 Assessment approach should emphasize the collection of assessment data in organized
manner consistent with patient care priorities
 Assessment should focus first on the patient and then on the technology
 TWO STANDARD APPROACHES:
1. Head to toe approach
2. body system approach
 The assessment process can be viewed as four distinct stages
- Pre arrival stage
- Admission quick check
- Comprehensive admission
- Ongoing assessment

PRE-ARRIVAL STAGE
 - Begins the moment information is received about the upcoming admission of patient
- It helps in painting the initial picture of the patient
- It allows CCN to begin anticipating the patients physiologic and psychologic needs.
- It allows the CCN to determine appropriate resources that are needed to care for the patient.
- It allows the CCN to adequately prepare the environment to meet the specialized needs of the
patients and family.

EQUIPMENT FOR STANDARD ROOM SETUP

 Bedside ECG and invasive pressure monitor

 ECG electrodes
 Blood pressure cuff
 Pulse oximetry
 Suction gauges and canister setup
 Suction catheter
 Bag valve mask/ rebreathing bag
 Oxygen flow meter, appropriate tubing and delivery device.
 IV poles and infusion pumps
 Bedside supply cart that contains such things like alcohol swabs, non-sterile loves, syringes
etc.
 Admission kit which contains bath basin and general hygiene supplies
 Admission and critical care documentation forms.

ADMISSION QUICK CHECK

- It is obtained immediately upon patient arrival

- It is based on assessing the parameters represented by the ABCDE
 A – AIRWAY
 B – BREATHING
 C – CIRCULATION, CEREBRAL PERFUSION, CHIEF COMPLAINT
 D - DRUGS AND DIAGNOSTIC TEST
  E – EQUIPMENT

 General appearance (LOC)

 Airway
- Patency of airway
- Position of artificial airway
 Breathing
- Quantity and quality of respiration
- Breath sounds
- Presence of spontaneous breathing.
 Circulation and cerebral perfusion
- ECG (rate and rhythm)
- BP
- Peripheral pulses and capillary refill
- Skin color, temperature and moisture
- Presence of bleeding
- LOC, responsiveness
 Chief complaint
- Primary body system
- Associated symptoms
 Drugs and diagnostic test
- Drugs prior to admission
- Current medications
- Review diagnostic test results
 Equipment
- Patency of vascular and drainage systems
- Appropriate functioning and labeling
 Allergies
 Quick overview of ABCDE ensure early interventions for any life-threatening situation
 It validates that cardiac and respiratory functions are sufficient.

COMPREHENSIVE ADMISSION ASSESSMENT

 A comprehensive admission assessment is performed ASAP

 It is an in-depth assessment of the past medical and social history and complete physical
examination of each body system.
 It provides the nurse invaluable insight into pro active interventions that may be needed.

 Past medical history

- Medical conditions, surgical procedures
- Psychiatric/ emotional problems
- Hospitalizations
- Previous medications
- Allergies
- Review of body system

 Social history
- Age, gender
- Ethnic origin
- Height, weight
- Occupation
- Marital status
- Primary family member/ significant other
- Religious affiliations
- Advance directives, Power of attorney
- Substance Abuse

 Psychosocial assessment
- General communications
- Coping styles
- Anxiety and stress
- Current stressors
- Family needs

 Spirituality
- Faith/ Spiritual preference
- Healing practices

 Nervous system
- LOC (by assessing GCS)
- Pupils
- Motor strength of extremities

 Cardiovascular system
- BP, HR, RR, heart sounds
- Capillary refill peripheral pulses
- Patency of IV’s and verification of IV meds
- Hemodynamic pressure and waveforms.

 Respiratory system
- Respiration rate and rhythm
- Breath sounds
- Color and amount of secretions
- Mechanical ventilation parameters
- Arterial and venous blood gases

 Renal system
- Intake and output
- Color and amount of urinary output
- Lab values

 Gi System
- Bowel sounds
- Contour of the abdomen
- Position of drainage tubes
- Color and amount of secretion
- Bilirubin and albumin values

 Endocrine, hematologic and immunologic system

- Fluid and electrolyte imbalance
- CBC and coagulation values
- Temperature and WBC with differential count

 Integumentary system
- Color and skin temperature
- Intactness of skin
- Area of redness

 Pain/ Discomfort
- Assessed in each system
- Response to interventions

 Psychosocial
- Mental status and behavioral responses
- Reaction to critical illness experience (Stress, anxiety, coping mechanism)
- Presence of cognitive impairments (dementia, delirium, depressions)
- Family functioning and needs
- Ability to communicate needs
- Ability to participate in care
- Sleep patterns

ON GOING ASSESSMENTS

 After the baseline comprehensive assessment is completed, ongoing assessments are

performed at varying intervals
 It should be done after every few minutes for unstable patients and after 4 to 6 hours for
stable patients
 Additional assessment should be done when:
- When caregiver change
- Before and after any major procedural interventions (intubation etc.)
- Before and after transport out of the critical care unit for diagnostic procedures or events
- Deterioration in physiologic or mental status
- Initiation of any new therapy.