ST. MARY’S COLLEGE OF TAGUM, INC.
NURSING PROGRAM
LEARNING
NCM 118 - CARE OF CLIENTS WITH LIFE-THREATENING CONDITIONS,
ACUTELY ILL/MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY
MODULE
SITUATION
BSN4
Lesson 2: Assessment of Critically
Ill Client
Prepared by:
JOSEFINA S. BALOTE,RN,MN
Module 1 – Lesson 1
Timothy 5:8 “Then your
light will break forth like
the dawn, and your
healing will quickly
appear; then your
righteousness will go
before you and the glory
of the Lord will be your
rear guard.”
2
Module 1 – Lesson 1
Ignacian Core/ Related
Values:,
Excellence; service, Faith
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Module 1 – Lesson 1
Learning Outcomes
At the end of the lesson the students can:
1. With a given scenario, assess clients with Life-
threatening Conditions, Acutely Ill/Multi-Organ Problems,
High Acuity and Emergency Situation based on medical
history and physical examination techniques (IPPE)
2. With a given scenario formulate a plan of care to
address the nursing needs and problems of the client.
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Introduction
This unit introduces basics in the assessment of
critically ill clients. care nursing. Prompt assessment
and accurate diagnosis is vital in acutely ill patients.
It is important to follow an orderly and efficient and
logical approach when assessing critically ill patients
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Learning Contents
Prompt assessment and accurate diagnosis is
vital in acutely ill patients.
It is important to follow a systematic and logical
approach when assessing this group of patients.
This approach should encompass airway,
breathing, circulation, disability and exposure
(ABCDE)
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Learning Contents
Critically ill are usually those stable patients
manage previously and who have abruptly
deteriorated and become acutely eventually and
typically developed life threatening,
neurological, or cardio-respiratory instability,
usually as a result of their presenting
condition.
Physical Assessment is done in an order,
accurate, and prompt manner using the IPPA
- inspection, palpation, percussion, and
auscultation. Use them in sequence—unless
you're performing an abdominal assessment.
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Learning Contents
1. Inspection
Inspect each body system using vision, smell, and
hearing to assess normal conditions and
deviations. Assess for color, size, location,
movement, texture, symmetry, odors, and sounds
as you assess each body system.
2. Palpation
Palpation requires you to touch the patient with
different parts of your hands, using varying
degrees of pressure. Because your hands are
your tools, keep your fingernails short and your
hands warm. Wear gloves when palpating
mucous membranes or areas in contact with body
fluids. Palpate tender areas last.
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Learning Contents
Types of palpation
Light palpation
Use this technique to feel for surface
abnormalities.
▪ Depress the skin ½ to ¾ inch (about 1 to 2 cm)
with your finger pads, using the lightest touch
possible.
▪ Assess for texture, tenderness, temperature,
moisture, elasticity, pulsations, and masses.
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Learning Contents
Deep Palpation
Use this technique to feel internal organs and
masses for size, shape, tenderness, symmetry,
and mobility.
▪ Depress the skin 1½ to 2 inches (about 4 to 5
cm) with firm, deep pressure.
▪ Use one hand on top of the other to exert firmer
pressure, if needed.
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Learning Contents
3. Percussion
Percussion involves tapping your fingers or hands
quickly and sharply against parts of the patient's
body to help you locate organ borders, identify
organ shape and position, and determine if an
organ is solid or filled with fluid or gas.
Types of percussion
Direct percussion
This technique reveals tenderness; it's commonly
used to assess an adult's sinuses.
▪ Using one or two fingers, tap directly on the
body part.
▪ Ask the patient to tell you which areas are
painful, and watch his face for signs of discomfort.
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Learning Contents
Indirect percussion
This technique elicits sounds that give clues to the
makeup of the underlying tissue. Here's how to do
it:
▪ Press the distal part of the middle finger of your
non-dominant hand firmly on the body part.
▪ Keep the rest of your hands off the body
surface.
▪ Flex the wrist of your non-dominant hand.
▪ Using the middle finger of your dominant hand,
tap quickly and directly over the point where your
other middle finger touches the patient's skin.
▪ Listen to the sounds produced.
Direct Indirect
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Learning Contents
4. Auscultation
Auscultation involves listening for various lung,
heart, and bowel sounds with a stethoscope.
Getting ready
▪ Provide a quiet environment.
▪ Make sure the area to be auscultated is exposed
(a gown or bed linens can interfere with sounds.)
▪ Warm the stethoscope head in your hand.
▪ Close your eyes to help focus your attention.
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Learning Contents
How to AUSCULTATE
▪ Use the diaphragm to pick up high-pitched
sounds, such as first (S1) and second (S2) heart
sounds. Hold the diaphragm firmly against the
patient's skin, using enough pressure to leave a
slight ring on the skin afterward.
▪ Use the bell to pick up low-pitched sounds, such
as third (S3) and fourth (S4) heart sounds. Hold
the bell lightly against the patient's skin, just hard
enough to form a seal. Holding the bell too firmly
causes the skin to act as a diaphragm, obliterating
low-pitched sounds.
▪ Listen to and try to identify the characteristics of
one sound at a time.
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Learning Contents
Six Initial Nursing Actions that should be taken
when responding to clinical deterioration.
A-Call for Help,
B-Collect More Data,
C-Patient Positioning,
D-Oxygen Therapy,
E-Prepare for RRS/MET (Rapid Response
System/Medical Emergency Team) and F-
Handover. (referral)
Call for emergency help like “Code Blue”
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Learning Contents
How to Assess Deteriorating Patients
Breathing
Look – Observe the rate, rhythm and depth of
the patient's respirations over a period of one
minute. ...
Listen – Listen to the patient's breathing using a
stethoscope or auscultate the patient's lower
airways and lungs if competent in these skills. ...
Feel – Palpate the patient's chest.
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Learning Contents
Three (3) Signs of Clinical Deterioration:
These are the physiologic changes preceding
cardiac arrest:
abnormal breathing,
abnormal pulse, and
abnormal systolic blood pressure.
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Learning Contents
Early Signs of Clinical Deterioration Every
Student Must Recognize to Save a Life
Failure to rescue occurs when a patient dies
following a life-threatening complication which could
have been avoided if timely recognition and
appropriate intervention by the bedside nurse and
healthcare team had taken place.
Most patients (84%) do not suddenly code and go
straight into cardiac arrest. Observable evidence of
vital sign instability and visible patient deterioration
changes occur in most patients from 6 to 24 hours
before cardiac arrest and happens most frequently on
medical-surgical units.
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Learning Contents
Early Signs of Clinical Deterioration Every
Student Must Recognize to Save a Life
The essence of critical thinking is the ability of
the nurse to ACT on what they know and
understand.
When a nurse fails to deeply understand
essential content and apply it to the bedside they
are not able to critically think like a nurse.
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Learning Contents
Most Common Problems Needing Rescue
most common initial complaints that a patient
reports that trigger a rapid response page:
Chest pain
Shortness of breath
Hypotension
Neuro changes or altered mental status
Patient fall
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Learning Contents
To Assess Pain:
The numerical scale: Measures pain on a scale
of 1–10.
The visual analog scale: Categorizes pain along
a horizontal line, ranging from mild to severe.
Faces pain scale – revised (FPS–R): Uses a
horizontal line, illustrated by facial expressions to
represent different pain levels.
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Learning Contents
To Assess Pain:
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Learning Contents
Assessment RED FLAGS
The term RED FLAGS (PDF 113KB) refers
to clinical features that help to identify the
presence of potentially serious conditions.
Such conditions include tumors, infection, fractures
and neurological damage.
Respiratory
Abnormal respiratory rate
(either too high or too low)
Decreased O2 sat with
increasing oxygen needs
Shortness of breath
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Learning Contents
Assessment RED FLAGS
Cardiac
Reduced systolic blood
pressure
Abnormal pulse
Complaint of chest pain
.
Misc.
Abnormal temperature
Neurologic
changes/altered mental
status
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Learning Contents
Nursing Interventions for Critically Ill Patient and
Family
The patient-focused nursing interventions (Larsen
et al 2021) varied in , scope, length of the
intervention, length of follow-up and outcome
measures, were:
communication,
patients' needs relating to pain relief or sleep or
recovery care, or
the more long-term psychological effects of an
ICU stay, such as PTSD, digestion or emergency
actions.
Family-focused interventions
The family-focused interventions were more
homogenous in content and focused mostly on
the families' need for information and staff
cooperation in the ICU.
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Learning Contents
The cornerstones of intensive care management
are the optimization of a patient's physiology, the
provision of advanced organ support, and the
identification and treatment of underlying
pathological processes. This is best achieved
through a multidisciplinary team approach, with
shared responsibility between the admitting
‘parent’ team and a specialized critical care team
coordinated by a critical care physician.
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Learning Contents
LEVELS OF CARE
High-dependency unit (HDU) or ‘level 2’:
Admission for single-organ support (not including
invasive ventilation) and should not require a
dedicated critical care nurse for each patient.
Provides an environment for close monitoring of
patients with or at risk of developing organ failure:
•
respiratory: non-invasive ventilation, arterial blood
gases
•
cardiovascular: low dose vasopressors, invasive
arterial pressure monitoring
•
renal: close fluid balance control, certain renal
replacement therapies.
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Learning Contents
LEVELS OF CARE
Intensive care unit (ICU) or ‘level 3’: Admission
for multi-organ support or delivery of advanced
monitoring techniques requiring at least one
dedicated critical care nurse for each patient:
•
respiratory: invasive and non-invasive ventilation,
extra-corporeal membrane oxygenation (ECMO) or
carbon dioxide removal (ECCO2R) in selected
centres
•
cardiovascular: vasopressor and inotropic support,
advanced cardiac output monitoring, intra-aortic
balloon pump, ventricular assist devices, ECMO
•
renal: renal replacement therapies
•
neurological: intracranial pressure monitoring, EEG,
advanced neurological monitoring.
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Learning Contents
Critical Care Organ Support
Airway and respiratory support
High flow oxygen therapy is a form of respiratory
support used in the hospital where oxygen, often in
conjunction with compressed air and humidification, is
delivered to a patient at rates of flow higher than that
delivered in traditional oxygen therapy.
*The high flows of up to 60 litres/min are thought to
reduce work of breathing and improve respiratory
mechanics by providing a small amount of positive end
expiratory pressure (PEEP) and washing out dead space
gases
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Learning Contents
Critical Care Organ
Support
Airway and respiratory support
Non-invasive ventilation (NIV): is a form of respiratory
support that obviates (prevent) the need for endotracheal
intubation. It is most commonly delivered by application of
positive airway pressure via a facial interface utilizing
either continuous positive airway pressure (CPAP) or bi-
level positive airway pressure (BiPAP).
continuous positive bi-level positive airway
airway pressure
pressure
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Learning Contents
Critical Care Organ
Support
Invasive ventilation: mandates tracheal intubation in one
form or another. Securing the airway in critically ill patients
poses significant additional challenges compared with the
controlled environment of an elective theatre list. This may be
due to profound physiological derangement (often paired with
a rapid decline), the presence of anatomical difficulties (e.g.
airway burns), external factors (e.g. cervical in-line stabilization
in trauma), significant time pressures, suboptimal positioning,
unfamiliar environments, and limited availability of equipment
and help.
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Learning Contents
Critical Care Organ
Support
Cardiovascular support
Haemodynamic monitoring is the study of
how blood flows through the cardiovascular
system (i.e. the heart and blood vessels). The
purpose of the cardiovascular system is to deliver
blood carrying oxygen and other vital nutrients to
the cells and tissues the body.
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Learning Contents
Critical Care Organ
Support
Cardiovascular support
Fluid management
When there is a heart failure, the heart does not
pump out enough blood. This causes fluids to
build up in your body. too many fluids, cause
symptoms such as swelling, weight gain, and
shortness of breath
VASOPRESSOR and INOTROPIC agents are short-term to
medium-acting drugs that are used to enhance vascular
tone or cardiac output in a variety of critical illness
conditions. They are used as a temporary measure until
sufficient cardiovascular function returns on resolution
of the pathological process. (norepinephrine,
epinephrine, metaraminol, phenylephrine, dopamine
(via α-adrenoceptor effect) and vasopressin (via
vasopressin V1 receptors).)
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Assessment
Written Exam
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Synthesis
With great power comes great responsibility. The
bedside nurse must embrace this responsibility and
recognize what is at stake when a nurse fails to think
like a nurse. Failure to rescue can occur, and a patient
can needlessly die as a result.
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References
Source: Health Assessment made Incredibly Visual!,
Lippincott Williams & Wilkins, 2007.
https://journals.lww.com/nursing/Fulltext/2006/1100
2/Assessing_patients_effectively__
Here_s_how_to_do.5.aspx
Early Signs of Clinical Deterioration Every Student
Must Recognize to Save a Life
By Keith RischerMarch 20, 2018.
https://www.keithrn.com/2018/03/failure-to-
recognize/
Nursing interventions to cover patients' basic needs
in the intensive care context – A systematic review
Marie Hamilton Larsen,Gudrun Irene
Johannessen,Kristin Heggdal
First published: 02 November 2021
https://doi.org/10.1002/nop2.1110
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References
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