Assessment of an ICU patient

Presented by Dr. EL Gaeedy Gehad

Objectives
 Explain what is meant by assessment of the acutely ill
patient.

 Describe the process of assessing the acutely ill patient.

 Understand how to undertake a systematic assessment of

the acutely ill patient.

 Evaluate the doctor’s role in assessment of the acutely ill

patient.
What is assessment?

֎ A process by which you establish the needs of your patient.

֎ A process by which you establish a baseline of immediate and future

needs.

֎ An on-going process - evaluation of interventions and reassessment of

need.
What Does Assessment Involve?
 Observation.

 Communication.

 Monitoring.

 Analysis and interpretation

 Diagnosis
Patient Assessment Priorities
 Primary Survey.
Occur as one
 Resuscitation.

 Secondary Survey.  CPR

 Oxygen and airway control
 Cannulate
 History.
 Blood samples
 Fluids
 Intervention  Resus’ drugs
 Trauma management
 Urinary and Gastric catheters
 Re-evaluation.
Outcome in the ICU is predominantly determined by initial management of
patients.

Early identification of the patient at risk of life-threatening illness is

essential to manage them appropriately and prevent further deterioration.

“Time is tissue” in critically ill patients, and a prompt and protocolized

resuscitation regimen will help in salvaging these patients.
Step 1
Assign responsibilities

1) Quickly make a team and assign job responsibilities to every member clearly and
appropriately.

2) In the initial phase, the patient should be seen by a senior member of the ICU team for
initial resuscitation, investigation, management planning, and family briefing.

3) Assign two residents for initial resuscitation.

4) Assign two nurses initially for unstable patients.

5) Take early assistance whenever needed from other members of the team.
Step 2
Start initial assessment and resuscitation
1) Initial aim is to determine immediate life-threatening problems. Time is usually short and no
enough to be certain about the cause of the problem, and correcting physiological abnormalities
should take precedence over arriving at an accurate diagnosis. However, a working diagnosis is
essential for deciding treatment options once physiological stability is achieved.

2) For the patient in cardiorespiratory arrest, follow ACLS protocol.

3) History taking, physical examination, sending investigations, and resuscitation need to be

carried out simultaneously rather than sequentially as time is limited.

4) For hemodynamically unstable patients, resuscitation should be systematic and aimed

Toward assessment and management of A (airway), B (breathing), and C (circulation).

5) All three components can be managed simultaneously; sequential approach is not necessary.
Step 3
Take focused history
1) Obtain history from relatives and medical and nursing staff in the unstable patient.

2) Review patients’ clinical chart and perioperative note.

3) Presenting problem in chronological order with duration and temporal profile of illness
needs to be documented.

4) Take history of mechanism of injury in trauma patients.

5) Ask for significant comorbidities such as cardiac, pulmonary, renal diseases, previous
surgery, or any other significant past medical problem.

6) Enquire about previous hospitalization or use of NIV at home.

7) Enquire about functional state at home bedbound, ambulatory with support or
independent.

8) Enquire regarding exercise tolerance.

9) In the elderly, enquire about mental state and cognition.

10) Take detailed medication history with doses and duration. Enquire about any
recent change of medication, drug allergies, over-the-counter medications,
alternative medication, and self-administration of medications.

11) Ask for any routine use of sedatives or psychiatric medication.

12) Enquire about addictions such as alcohol and tobacco.

13) A problem list of active and inactive problems needs to be documented in the
clinical notes.

14) Ascertain patients’ resuscitation status as per family’s wish.

Step 4
Perform focused physical examination

1) Check for vital signs.

2) Look for warning signs of severe illness.
3) Examine for any life-threatening or limb-threatening abnormalities systematically.
4) Examine for pallor, cyanosis, jaundice, clubbing, or pedal edema.
5) Examine skin for rash, petechiae, urticaria, and eschar.
6) Examine other organ systems systematically.
7) Examination needs to be repeated frequently for any new features or findings
missed previously. In neurological patients, Glasgow coma score needs to be
assessed frequently.
8) Patients should be fully exposed with proper privacy during initial examination.
9) A detailed physical examination should be performed later once the patient
stabilizes after initial resuscitation.
Step 5
Send basic investigation
Send screening investigations during initial resuscitation.

1) Complete blood count, blood sugar, sodium, potassium, urea, creatinine, aspartate
transaminase (AST), alanine transaminase (ALT), PT, APTT, arterial blood gas, and lactate level
in septic patients are important initial investigation.

2) Chest X-rays and a 12-lead ECG should be performed.

3) Appropriate microbiology cultures should be sent.

4) Further investigations should be based on finding from history and physical examination.
5) In unstable patients, investigations should be performed at the bedside as much as possible.

6) If transport outside the ICU is needed, the patient should be properly monitored
and accompanied by qualified personnel.

7) Maintain an investigation flow sheet in chronological order.

8) Red flag investigations require immediate corrective actions. Blood sugar <80 mg/dL
Sodium <120 or >150 mmol/L
Potassium <2.5 or >6.0 mmol/L
pH < 7.2
SpO 2 < 90%
Bicarbonate < 18 mmol/L
Step 6
Recognize the patient at risk

Take special precautions in the following group of patients:

 The elderly and immunocompromised may not show features of decompensation

such as fever and tachycardia.

 Polytrauma patients, due to multiple injuries and effect of distracting pain, are
difficult to assess.

 In young adults, decompensation is late due to physiological reserve.

Step 7
Assess response to initial resuscitation

1) Assess changes in vital signs with initial resuscitation—pulse rate, rhythm, blood
pressure, oxygen saturation, urine output, and mental state.

2) Continuous assessment is mandatory, and one needs to be vigilant and present at

the bedside.
Step 8
Assess intensity of support
1) Inspired oxygen fraction needed to maintain saturation above 90%

2) Intensity of ventilatory support—positive end-expiratory pressure, minute ventilation

3) Dose of vasopressor & inotrope needed to maintain mean arterial pressure above 60 mmHg

4) Need for volume support to keep adequate urine output

5) Need for blood transfusion to keep hemoglobin above 8 g/dL

6) Need for sedation in agitated patients

7) Need for dialysis support or Worsening biochemistry

Step 9
Seek help for specific problems that might require expertise
1) Cardiologist—complete heart block, acute coronary syndrome, cardiogenic shock, intra-
aortic balloon pump insertion, pericardial tamponade, massive pulmonary embolism

2) Nephrologist—dialysis

3) Neurologist—acute stroke or undiagnosed depressed conscious level

4) Neurosurgeon—intracranial hemorrhage, head injury, severe cerebral edema

5) Trauma surgeon—polytrauma, abdominal trauma, thoracic trauma, compartment syndrome

6) Obstetrician—ruptured ectopic pregnancy, postpartum hemorrhage

Step 10
Construct a working diagnosis and plan for further management

1) After initial resuscitation, assessment, investigation, and response, a differential

diagnosis should be arrived at.

2) Reassess the patient frequently to modify initial plan if needed.

Step 11
Brief relatives

1) After initial resuscitation, assessment, investigation, and response, the family should be
briefed about the:
 likely diagnosis,
 treatment plan,
 approximate prognostication,
 approximate duration of stay and
 consent should be taken for any invasive procedures.

2) Family briefing should be documented in clinical notes.

Primary Survey
 Airway

 Breathing

 Circulation

 Disability

 Expose and Examine

Primary Survey
Airway

Cervical Spine

∞ Airway obstruction? Paradoxical movement?

∞ Respiratory insufficiency?
∞ Secure airway manually / adjuncts
∞ Cricothyroid puncture?
Airway Obstruction
 Inspiratory stridor
is a rasping sound heard during inspiration and is a result of obstruction above or involving the
larynx

 Wheeze
is usually heard on expiration as a result of the lower airways collapsing

 Gurgling
occur when secretion or liquid is present in the upper airways

 Snoring
occurs during partial occlusion of the oropharynx due to relaxation of the oropharyngeal muscles
and tongue

 High pitched crowing sounds

occur during laryngeal spasm
Primary Survey
Breathing

 Effectiveness of Breathing

 Work of Breathing
Primary survey
Breathing

☆ Cyanosis, hypoxia?

☆ Rate, depth, symmetry of chest movement? Use of accessory muscles?

☆ Palpate chest wall for structural integrity

☆ Chest injury / flail / pneumothoraces

☆ O2 therapy / Assisted ventilation

☆ Manage injury / pnuemothoraces

Primary Survey
Circulation

Ω Quick head to toe survey to note and control bleeding

Ω Skin colour, moisture, temperature

Ω Pulse quality, rate, regularity, volume

Ω Blood pressure

Ω Capillary refill (should be < 2 seconds)

Ω Chest Compressions / Positioning etc.

Primary Survey
Disability
 Baseline level of consciousness
 Response to spoken word?
 Gentle tactile stimulation

 A . V . P. U + GCS

 Neurological Examination

 Immobilize fractures / potential fractures

 Pain assessment / Analgesia

 A . V . P . U
Helpful mnemonic exists to assist in a brief neurologic assessment

֎ A = Alert.
Pt is awake, alert, responsive to voice and is oriented to person, time, and place

֎ V = Responds to Vocal Stimuli Only

Pt responds to voice but is not fully oriented to person, time, or place

֎ P = Responds to Painful Stimuli Only

Pt does not respond to voice but does respond to painful stimulus

֎ U = Unconscious
Pt does not respond to voice or painful stimulus
Primary Survey
Expose and Examine

 Thorough examination - all systems

 Dignity / control of temperature

Secondary Survey.
Done after primary exam and primary threats addressed

☆ Measurement of VS

☆ Pain Assessment

☆ History

☆ Head to Toe

☆ Posterior surface inspection

Secondary Survey
History
 AMPLE mnemonic

 A- Allergies
Record severity and type of reaction

 M- Medications
Rx, OTC, Herbal, Recreational, unprescribed

 P- Past Health History

 L- Last Meal Eaten

 E- Events leading to injury/illness

 Secondary Survey
Thorough full system assessment

☆ Head and neck

Skull / Neck/ Eyes / Ears / Nose / Mouth

☆ Renal
Urine output - 1ml/kg/hour ? 30mls/hr?
Secondary Survey.
Thorough full system assessment

☆ Abdomen
Inspect / Palpate / Auscultate

☆ Perineum / Rectum / External Genitalia

Inspect / Examine
Blood in urine?
Pregnancy test?
☆ Musculoskeletal.
Inspect / Palpate / Range of Movement /
Motor and Sensory function.

Pelvis / Skull / Spine / Limbs / Joints

☆ Metabolic
Urea and electrolytes.
Blood sugar.
Poisons screen.
LFT’s.
etc.
Glasgow Coma Scale

The Glasgow Coma Scale is based on a 15 point scale used for estimating and
categorizing the severity of brain injury following a traumatic brain
injury (TBI).

The test measures the

 motor response,
 verbal response, and
 eye opening response

with the following scoring scheme:

 Spontaneous eye opening 4 points

Opens to verbal command, speech, or shout 3 points

Eye Response
Opens to pain, not applied to face 2 points

No eye opening 1 point

Alert and oriented 5 points

Confused conversation, but able to answer questions 4 points

Verbal Response
Inappropriate responses, jumbled phrases, but discernible words 3 points

Incomprehensible speech 2 points

No sounds 1 point

Obeys commands for movement fully 6 points

Localizes to noxious stimuli 5 points

Withdraws from noxious stimuli 4 points

Motor Response Abnormal flexion, decorticate posturing 3 points

Extensor response, decerebrate posturing 2 points

No response 1 point
 Modified Infants Verbal Response Points
Babbles 5
Irritable 4
Cries to pain 3
Moans 2
None 1

The levels of brain injury severity are classified as:

GCS FOUR
Severe 3-8 0-7
Moderate 9 - 12 8 - 14
Mild 13 - 15 15 - 16
GCS shortcomings
The GCS has been widely used and is considered a standard assessment tool,
it has a number of shortcomings.
The usefulness of a verbal component in assessing level of consciousness can
be questioned.

֎ First, the verbal component of the GCS tests primarily

orientation, which quickly becomes abnormal in agitated and
confused patients without impaired consciousness.
Conversely, many patients with little or no verbal response are
alert.
Moreover, the verbal response component of the GCS cannot be
assessed in critically ill patients who have undergone intubation.

֎ Second, the GCS does not assess brainstem reflexes, eye

movements, or complex motor responses in patients with altered
consciousness.
FOUR Score
The FOUR score aims to overcome these shortcomings with a scale that is

 Alternative scale,

 Easily taught,

 Simple to administer, and

 Provides essential neurologic information that allows an accurate

assessment of patients with altered consciousness.

 Can diagnose a locked-in syndrome mimicking coma and

 Can test the vigilance of the patient by using simple hand signals.
 The FOUR score accurately predicts which patients will have a poor
outcome and can detect the occurrence of brain death in a critically ill
patient.
In contrast, the GCS cannot assess these conditions because it uses only
eye opening and motor response to pain as measures of impaired consciousness in
intubated patients.

 Useful for patients with acute metabolic derangements, sepsis, or shock

or with other nonstructural brain injuries because it detects early changes in
consciousness (eg, inability to follow specific commands, inability to track
examiner's finger movements, and Cheyne-Stokes respiration).

 The frequent use of mild sedation in the medical and surgical ICU could
affect eye opening and motor response but not brainstem reflexes and
respiration.
In contrast, all 3 components of the GCS are affected by sedation.
 eyelids open or opened, tracking, or blinking to command 4 points

eyelids open but not tracking 3 points

Eye response eyelids closed but open to loud voice 2 points
eyelids closed but open to pain 1 points
eyelids remain closed with pain 0 points
thumbs-up, fist, or peace sign 4 points
localizing to pain 3 points

Motor response flexion response to pain 2 points

extension response to pain 1 points

no response to pain or generalized myoclonus status 0 points

pupil and corneal reflexes present 4 points

one pupil wide and fixed 3 points
Brainstem reflexes pupil or corneal reflexes absent 2 points
pupil and corneal reflexes absent 1 points
absent pupil, corneal, and cough reflex 0 points
not intubated, regular breathing pattern 4 points

not intubated, Cheyne–Stokes breathing pattern 3 points

Respiration not intubated, irregular breathing 2 points
breathes above ventilator rate 1 points
breathes at ventilator rate or apnea 0 points
The levels of brain injury severity
are classified as:
GCS FOUR

Severe 3-8 0-7

Moderate 9 - 12 8 - 14

Mild 13 - 15 15 - 16
Mini Patient Assessment

Know - what you are told

See - quick visual assessment

Find - quick physical assessment

Know See Find
Airway patency
Present and past Pallor
medical history
Respiratory rate

Sweating Blood pressure

Social history
Pulse
Mental state and
posture
Obvious hemorrhage
Previous medical
interventions
Facial expression Temperature

Vomiting
Patients known normal
parameters General condition Monitor changes in any
of the above parameters
Common Presenting Abnormalities

 Tachypnoea

 Altered level of Consciousness

 Derangement of heart rate

 Derangement of blood pressure

 Derangement of arterial oxygen saturation

 Derangement of urine output

Early warning systems?

 Heart rate.

 Blood pressure.

 Respiratory rate.

 Oxygen saturation.

 Respiratory Support / Oxygen Therapy.

 Urinary output.

 Conscious level.
Scoring systems
Pain scales

I. Unidimensional scales
i. verbal rating scale
ii. visual analogue scale
iii. numeric rating scale

II. Multidimensional scales

i. McGill Pain Questionnaire
ii. Wisconsin Brief Pain Questionnaire.
Sedation goal
The ideal sedation goal is for the patient to be awake and comfortable with
minimal to no distress (eg, 0 on the RASS scale),
although some patients may require a deeper level of sedation for optimal
management.

The sedation goal should be ascertained at the bedside for each patient;
there is no one size that fits all.
The notion that all mechanically ventilated patients should receive sedatives
targeted to a specific sedation score, such as a RASS score of -2, will lead
to the over sedation of many patients and may slow recovery.

The goal depth of sedation should be frequently reassessed and adjusted as

the patient's sedation requirement becomes more apparent. Some patients
require no sedation, while others require deep sedation to be mechanically
ventilated without discomfort, agitation, or asynchrony.
Sedation scales
€ Richmond Agitation-Sedation Scale (RASS)

€ Riker Sedation-Agitation Scale (SAS)

€ Motor Activity Assessment Scale (MAAS)

€ Minnesota Sedation Assessment Tool (MSAT)

€ Ramsay Sedation Scale

€ Bizek Agitation Scale

€ Sheffield Scale

€ COMFORT Scale
Richmond agitation-sedation scale (RASS)
Score Term Description

+4 Combative Overtly combative or violent, immediate danger to staff

+3 Very agitated Pulls on or removes tubes or catheters, aggressive behavior toward staff

+2 Agitated Frequent nonpurposeful movement or patient-ventilator dyssynchrony

+1 Restless Anxious or apprehensive but movements not aggressive or vigorous

0 Alert and calm

-1 Drowsy Not fully alert, sustained (>10 seconds) awakening, eye contact to voice

-2 Light sedation Briefly (<10 seconds) awakens with eye contact to voice

-3 Moderate sedation Any movement (but no eye contact) to voice

-4 Deep sedation No response to voice, any movement to physical stimulation

-5 Unarousable No response to voice or physical stimulation

The Ramsay sedation scale
Clinical score Patient characteristics

1 Awake; agitated or restless or both

2 Awake; cooperative, oriented, and tranquil

3 Awake but responds to commands only

4 Asleep; brisk response to light glabellar tap or loud auditory stimulus

5 Asleep; sluggish response to light glabellar tap or loud auditory stimulus

6 Asleep; no response to glabellar tap or loud auditory stimulus

Delirium scales

∮ The Confusion Assessment Method for the ICU (CAM-ICU)

∮ The Intensive Care Delirium Screening Checklist (ICDSC)

Delirium key features
 disturbance of consciousness with reduced ability to focus, sustain or shift
attention.

 A change in cognition or the development of a perceptual disturbance that is

not better accounted for pre-existing, established or evolving dementia.

 Develops over a short period of time and tends to fluctuate over the course
of the day.

 There is evidence that the disturbance is caused by a medical condition,

substance intoxication or medication side effect.
Dementia is a chronic progressive form of brain injury,
whereas delirium has an acute onset.

Up to 60% of mechanically ventilated patients will develop delirium,

Delirium increases
 Mechanical ventilation days
 Length of stay
 Mortality
 Hospital costs

Cognitive impairment is substantial and often persists one year after

hospital discharge.
So many terms
 Acute confusional state

 ICU psychosis

 Acute brain syndrome

 Altered mental status

 Toxic or metabolic encephalopathy

 Sun downing

 Delirium
Symptoms of ICU delirium

1) Hallucination and delusions

2) Sleep disturbances

3) Abnormal psychometric activity (agitation, lethargy)

4) Emotional disturbances (fear, anger, depression, apathy)

Delirium subtypes
1) Hyperactive
Combative
Agitated
Restless

2) Hypoactive Lethargic
Sedated
Stupor

3) mixed
Alert and
Calm
Initial Assessment
Primary Secondary

 Ensures that potentially life threating  Done after primary exam and primary
conditions are identified and addressed threats addressed

 Evaluates

Airway
Breathing
Circulation Measurement of VS
Disability Pain Assessment
Exposure History
Head to Toe
Posterior surface inspection
As patient
arrives to
ICU
Presented by Dr. EL Gaeedy Gehad
 Patient assessment process
ASSESSMENT
Airway Type of airway, position at teeth stated, CXR results stated. Auscultate the lungs
and check ETCO2

Breathing Spontaneous or assisted, ventilator parameters and alarm limits reviewed, patient
compliance and SpO2 and ETCO2 values reviewed. Auscultate lungs,
confirm presence of air entry. Review ABG results.

Circulation Assess current vital signs. Discuss management. Document hemodynamic goals.
Assess for patient pulse, pedal pulses and skin colour, warmth. Obtain 12-lead ECG
if new admission / post-operative patient.

Disability Review GCS (including limb strength and pupillary response); and type of stimuli
required.
Assess and document the RASS and CAM ICU score. If relevant, review ICP, CPP,
EVD settings.
Electrolytes Electrolytes: review latest results and ongoing management.

Fluids/renal Assess number, types and status of lines; check for correct IV
Gastrointestinal Assess IAP / Feeding / Bowels / BGL: Abdominal assessment results, bowel so
und status and when bowels last opened/interventions required. State the type
of feeds patient is receiving and the goal rate. Assess BGL and if patient is on
insulin.

Haematology Review results of FBC and Coagulation profile, management plan for abnormal
results.
Infection Review infection status, presence of wounds, drains and dressing requirements
Presence of pressure ulcers.

JVP/CVP Review volume status and fluid balance. Assessment of fluid losses during
surgery, pre and post-admission and from wound drains.

Kelvin Review patient’s temperature and interventions if hypo or hyperthermic.

Lines Review lines - position, dressing, signs of infection, date of placement and need
for change.

Medications Review medication chart to ensure all charted drugs have been administered
following the 5 rights. Allergy/adverse drug reaction status.

Nutrition Review feeding regimen, fasting status, feed rate and goal rate. Discuss feed t
olerance. Review enteral tube position and post-operative directions.
Old notes Ensure these are available for review.
Pain score, pain relief Assess pain score using the behavioral scale if unconscious/uncooperative or
visual scale if able to respond to directives. Intervene as per guideline and
patient need for analgesia

Query Ensure that the management plan for the patient and goals are stated, and any
queries are answered.
Relatives Ensure relatives are located and notified of patient admission to the ICU.
Contact numbers are recorded. Ensure communication is clearly documented in
the health care record.

Sedation Assess Sedation score using the RASS. Have a documented sedation goal.
Skin Perform a Waterlow Score for skin integrity and risk of pressure ulcers,
ensure measures are in place to minimise pressure ulcers.

Trauma Handover results from primary/ secondary/ tertiary surveys. Obtain

information regarding current pathways and spinal precautions, movement
limitations.
X-Rays, scans Review CXR results and assess for correct tube and line position.

Y Why? Raise further questions re patient care with transferring team /ICU team.

Zzzz: sleep Review patient’s emotional, spiritual and rest status.

 Checklist/Summary:
Receiving a Patient into the ICU from OT/Other Area
Action
 Post-op patient: 20 minute call received from OT or recovery.

 ICU registrar/consultant notified to attend admission.

 Bed area and equipment prepared

 Safety equipment checked and functioning
 Bedside monitor off standby, alarms reviewed and activated, modules present,
calibrated.
 IV fluids present
 Blood collection tubes, ABG syringe ready
 Flowchart and other charts ready
 Spare cables for a 12 Lead ECG via monitor

 Team Leader notified of Expected Time of Arrival and assistant nurse identified.
 Ventilator off standby, parameters set on SIMV.

 On arrival, 2 nurses present and ICU registrar/consultant

 Fast primary survey completed:
 Airway: secure, patent, position/depth noted.
 Breathing: air entry heard, SpO2 and ETCO2 reviewed.
 Circulation: established with HR, ECG waveform, BP.
 Disability: assess GCS, pupils and limb strength.
 Patient transferred to ICU bed with manual handling assist devices and personnel.

 Receiving RN or Anaesthetist connects patient to ventilator, checking parameters with

Anaesthetist and ICU registrar/consultant.

 Auscultate lung fields for air entry and chest rise/fall, patient colour and comfort, vitals st
able (Assistant nurse).

 Clarify chosen ventilator parameters and alarms with Anaesthetist/ICU registrar, and/or de
termine immediate ventilation requirements.

 Listen to handover, events, and patient history after placing transport modules into
monitor, one at a time, starting with SpO2 and then as per patient need. Re-zero as required.

 Clarify parameters for vitals, set alarm limits and ETCO2 level, in conjunction with ICU
registrar/consultant.