icu assessment review of systems current diagnosis pertinent lab data pertinent physical examination...
TRANSCRIPT
ICU Assessment
• Review of systems• Current diagnosis• Pertinent lab data• Pertinent physical examination findings• Allergies/sensitivities• Airway Assessment• Surgical/anesthesia history• Medication history• Social history
• Other
Patient History:
• General state of well-being• Daily activity level• The patient’s understanding of:
• Medical condition • Coexisting medical conditions
• Review of old records
Present Illness:
• Diagnostic studies• Presumptive diagnosis
• Treatments • Responses to treatments• Review available vital sign data• Review available fluid balance data
Coexisting medical conditions:
• Evaluate in a systems approach• Assess recent changes in symptoms• Assess current treatment regimens• Specialty consultation when needed
Medications:Medications:
• Review medications, doses, schedules• Cardiac • Seizure• Endocrine • Anticoagulants• Antidepressants
• Decision to continue/discontinue
Allergies and drug Allergies and drug reactions:reactions:• True allergic reactions• Non-allergic responses
• Adverse reactions• Side effects• Drug-drug interactions
Alcohol:• Self-reporting of use typically
underestimates actual use• Withdrawal
• Increase anesthetic requirements• Hypertension• Tremors• Delirium• Seizures
Review of Systems: (continued)
• Gastro/intestinal• / hiatal hernia
• Increased risk of pulmonary aspiration
Review of Systems: (continued)
• Pregnancy• All women of childbearing age should be
questioned regarding last menses and the likelihood of current pregnancy.
Physical Exam: (continued)
• Baseline Vital Signs:• Height and weight• Blood pressure • Resting pulse • Respirations
Physical Exam: (continued)
• Airway assessment• Size of oral opening and tongue• Observe/document loose or chipped teeth,
“caps”, dentures, other orthodontic devices, piercings
• Observe/document range of cervical motion in flexion, extension, and rotation
• Observe/document tracheal deviation, masses
Physical Exam: (continued)
• Lungs• Wheezes• Rhonchi• Rales• Correlate what you hear with
observation of how patient is breathing…. easy vs. labored
• Use of accessory muscles
Physical Exam: (continued)
• Neuro• Document neuro status• Cranial nerve function• Cognition• Peripheral sensorimotor function
labs:
• Hematocrit and Hemoglobin• Evaluate each pt. individually for the
etiology and duration of their anemia
EKG:• All patients over 40 years old• New Q waves• ST-segment depression/elevation• T-wave inversions• Rhythm disturbances
• PVC’s• A-fib, a-flutter• LBBB• 2nd or 3rd degree AV block