Assessing a

Critically/Complexly Ill
Synthesis
Patient
 History
 Report~SBAR complete
 PA

Playing the Odds on Complications

 Know your patho!!!
 Don’t get caught w/drawers…
 Safety checks
 Neuro assessment

Beyond Basic Neuro Neurotrauma

 LOC  ICP monitoring
 Pupils
 Ventriculostomies
 Movement of extremities
 C-Spine precautions
Sedated patients
Neuro disorders
 Gag, Corneal
 Cough

 Babinski
 Cardiac Assessment
History
 Chest pain? Orthopnea? Dyspnea?
 Risk factors? Co-morbidities? Renal Failure?
Lung Disease? Marfans, SLE, Chemotherapy,
recent viral or bacterial infection?
 Women and Heart Disease
 Cardiac Assessment
 Review and Assess Vital signs
 BP- Mean arterial pressure
 Heart Rate- Continuous Cardiac Rhythm

 Respirations-Character/Spontaneous

 Temperature – Core temp/ear or PAC

 Pain~ PQRST

 Consider
trends ; changes and circumstances around
measurements
 Physical Assessment
General Appearance
 Face,weight,edema,posture
 Cyanosis
 Jugular Vein Distention
Thorasic reference points
 Sternal,midclavicular,axillary,vertebral and scapular
 Point of Maximal Impulse
 Pacemaker generator?scars,deformities, skin changes,respiratory effort
Extremities
 Nail beds, clubbing, pretibial alteration of pigmentation or edema
 Peripheral Pulses
 Graded
 Correlation to systemic pressures
 Heart sounds
S1, S2
Clicks, rubs, gallops
S3~Ventricular gallop
 Apex,w/ pt on left side
 Dull,low pitched,early diastole
 May be early sign of HF

S4~Atrial gallop
 Apex w/ pt on left side
 Dull,low pitched
 Abnormal in adults-HTN,AS,MI,cardiomyopathy
 Murmurs
Caused by
 turbulent blood flow through either narrowed or
malfunctioning valves
 Shunting of blood thru abnormal passages (VSD)
 Backflow through insufficient valves

Go online and review HT, BS!!!

Take your time,listen, but be sure to
reassure the patient
Don’t be afraid to ask –whats dat?
 Diagnostics
ECG; CXR
Echocardiagrams
PET Scans
Transesophageal Echocardiagram
Stress Tests
Cardiac Catherterizations
 Laboratory Studies
Chemistries
Serial Cardiac Enzymes & Isoenzymes
Troponin I,II
CBC
PT/PTT
BNP
 Hemodynamic Monitoring
Cardiac Output
 – amount of blood ejected per beat.
Preload
 -length tension relationship
Afterload
 -Force velocity relationship
Contractility
 Force of contraction; effect of extrinsic influences on rate
and force of fiber shortening.
Heart Rate
 Increase of CO within limits
 Cardiac Output
CO=HR * SV Case 1:
 A patient has just returened
MAP = (ADP*2) + ASP from CABG –CTO = 150cc; u/?
3 = 575cc.
 CO?
Normal values:
 CI?
 CO = 4-8 L/min
 CVP?
 CI = 2.3-4.5 L/m2/BSA
 ?
 PAP = 15-25 mm
 PAD= 8-15 mm Case 2:
 PAWP = 6-12 mm  Septic post GSW, CO?

 CVP = 4 -7 mm  CI?

 PVR = 150- 250 dynes/sec/m2  SVR 15

 SVR = 1000- 1300 dynes/sec/m2  ?

 Think preload, afterload,
contractility, heart rate
Technology In Assessment
Assisting in assessment & evaluation
 Continuous cardiac monitoring systems
 Pulmonary Artery Catheters~Flo Trac

 Arterial pressure lines

 Intra-aortic Balloon Pump

 Mechanical ventilators

 Continuous Renal Replacement Therapy

Continuous Cardiac Rhythm
Monitoring
Frequent assessment of cardiac
conduction system
Nursing Care
 Maintain reliable monitoring waveforms
 Evaluate rhythm

 Evaluate skin
Pulmonary Artery Catheter
Swan-Ganz
Frequent evaluation of Cardiac Output
Continuous evaluation of preload
 FloTrac
Calculated from arterial waveform
Less invasive
less cardiac complications
lower infection rates?
Arterial pressure monitoring
Used for continuous monitoring of
systemic & mean blood pressure
(MAP); freq lab draws
Radial, Femoral, Brachial artery
Nursing Care:
 Steriledressing changes
 Maintain closed system
Intraaortic Balloon Pump
 Nursing Intervention
Balance myocardial oxygen supply and
demand
Adminstration and Evaluation of
Vasoactive medications
 Inotropic
Agents
 Chromotropic Agents
Increasing Cardiac Output:
Inotrophic Agents
Dobutamine HCL
Dopamine HCL
Vasopressin
Norepinephrine (Levophed)
Neosynephrine
Primacor
 Increasing Supply-
Decreasing Demand
Nitrates
Beta-Blockers
Calcium Channel Blockers
ACE-Inhibitors
Angiotensin II Inhibitors
Thrombolytics
 Pulmonary Assessment

Breathing pattern Tracheal position

Breath sounds Work of breathing
Mechanical Ventiliation
Compliance
 Mode
 Rate

 Tidal volume

 Added oxygen support

(FiO2)
 Gastrointestinal
Nutrition is what it’s all about!
Abdominal
 Bowel sounds-how long do you listen?
 Confirmation, Scars
Nasogastric tubes
 Safety
 Placement
 Residuals
 When to stop TF
PEG tubes
Other tubes/ostomies
Bowel movements (or not!)~what goes in should come out!
 Genitourinary

Urine output-hourly
ATN/Renal Failure
Hemodialysis
CRRT
 Psych-Social
Crisis
Understimulation~Overstimulation
ICU-it is/Dementia
Fear, anxiety, psychosis

Who you gonna call???

What are you gonna do???
 Immobility Syndrome
Pulmonary stasis~stasis pneumonia
Venostasis~DVT (and then what?)
Hyperchloremia~Curling’s Ulcer
Stasis ulcers~decubiti
Demineralization of bone
Sluggish bowel~necrotic bowel
 Websites
www.aacn.org/
www.trauma.org/
Society of Critical Care Medicine
http://www.ccmtutorials.com/
http://www.med.ucla.edu/wilkes/intro.html