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In this second article of a seven-part series on critical care medicine, we discuss patient assessment. One well-established and reliable way is to use the airway, breathing, circulation, disability and exposure ABCDE approach. We describe how this can be used to prioritise and manage life-threatening clinical problems and reduce the risk of patient harm.
Citation: Hill K Essential critical care skills 2: assessing the patient. Nursing Times [online]; 12, A structured, systematic assessment of a patient who is critically ill is fundamental to good patient care, management and experience. The airway, breathing, circulation, disability and exposure ABCDE approach is a well-established, reliable assessment tool used in the systematic assessment of critically ill patients to prioritise and treat life-threatening clinical problems.
Information from this should be communicated, escalated, and actioned as appropriate Baid et al, Early recognition of a deteriorating patient, together with a structured response and appropriate escalation, can reduce patient harm and the risk of adverse events Massey et al, The critical care nurse makes a systematic assessment of the patient on admission, after shift handover and in response to clinical deterioration Baid et al, This article — the second in a seven-part series on critical care — will outline how to make a systematic assessment of a patient who is critically ill, using the ABCDE approach.
Once personal and patient safety is established, an airway assessment is the first stage in the ABCDE systematic approach. This is to assess airway patency, checking for signs of full or partial airway obstruction Cathala and Moorley, A patient who can talk in a normal voice and full sentences has an airway that is patent.
Box 1 lists causes of airway obstruction. Appropriate infection control measures should be followed to reduce the risk of contamination, for example, when caring for patients with Covid The clinical signs of a partial airway obstruction include:.
With complete airway obstruction, there is no air entry on chest auscultation or breath sounds at the nose and the mouth Baid et al, A complete or partial airway obstruction is a medical emergency and, initially, can be managed using simple airway manoeuvres, such as:. In a critical care unit, patients may have an endotracheal or tracheostomy tube in place to maintain their airway and help deliver mechanical ventilation. Positioned in the trachea, endotracheal and tracheostomy tubes are artificial airways that have an inflatable cuff at the end of the tube to create a closed system, which reduces the risk of aspiration or an air leak.
The patency of the airway is assessed through:. EtCO2 monitoring is a non-invasive method of measuring exhaled carbon dioxide. It is a standard monitoring tool in patients who are mechanically ventilated, as it can detect a misplaced endotracheal and tracheostomy tube, and aid in the monitoring of respiratory function Kerslake and Kelly, As part of the airway assessment, the critical care nurse does several safety checks when caring for a patient with an endotracheal or tracheostomy tube to reduce the risk of patient complication and harm.
Tables 1 and 2 list these checks and the reasons for doing them. Respirations should be effortless, at a rate of 12 to 20 breaths per minute. Lung auscultation using a stethoscope will provide information on air entry and added sounds such as wheeze and respiratory secretions, which will offer a possible explanation of respiratory distress Cathala and Moorley, Audible respiratory secretions, increased respiratory rate, respiratory distress or reduction in oxygen saturations are indications for tracheal suctioning.
Suctioning is required in critical care patients with an endotracheal or tracheostomy tube to reduce the risk of secretion retention, airway obstruction, infection, and low oxygen saturations. If the patient has a chest drain, the critical care nurse will review and document chest-drain activity and volume of drainage. In the critical care unit, continuous oxygen saturations and EtCO2 measurements are monitored as, together, they provide valuable information on oxygenation and ventilation.
In addition, arterial blood gases ABGs are obtained and analysed as required. Haemodynamic monitoring is a cornerstone in the management of patients who are critically ill, as they can become very unstable due to hypovolaemia, changes in vasomotor function or cardiac dysfunction. This can result in organ dysfunction, multiorgan failure and death.
The level of haemodynamic monitoring in critical care can vary from non-invasive including continuous three- or five-lead electrocardiogram monitoring, hourly non-invasive blood-pressure monitoring and continuous oxygen saturation monitoring to more advanced continuous invasive blood pressure and central venous pressure CVP monitoring Huygh et al, Patients who are critically ill often require invasive methods of monitoring — such as insertion of an arterial line and central venous catheter CVC — to obtain a more accurate representation of their haemodynamic status.
The critical care nurse will confirm these invasive devices are patent and re-calibrated at least twice per shift to ensure readings are accurate Pinsky and Payen, The medical management of a patient who is critically ill includes therapeutic treatments, such as fluid resuscitation and titration of medications that support blood pressure, which are guided by haemodynamic monitoring to improve patient outcomes.
Advanced haemodynamic monitoring, such as continuous cardiac output monitoring, is sometimes used in complex clinical situations and with patients who are not responsive to initial therapeutic treatments Huygh et al, Disability is focused on assessment of neurological status, with close consideration given to causes of reduced consciousness, such as low oxygen saturations, increased carbon-dioxide levels, cerebral hypoperfusion, hypoglycaemia, syncope, sedatives or analgesic medication.
Pupils should be of equal size and reactive to light Bit.
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