Head to Toe Assessment for Ventilated pt in CCU

Nursing Students Student Assist

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I have to do a head-to-toe assessment on my patient that I had in clinical this past week. I know how to do a head to toe on a healthy patient, but this is for a patient in the CCU who is ventilated and sedated and only opens his eyes when he feels pain or when being moved, etc. I was needing some help on how to write a good, thorough head to toe on a patient that is ventilated, unresponsive to normal stimuli, etc. Any info would be greatly appreciated!!

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Specializes in Trauma Surgical ICU.

It is the same as a non vented pt.. You will listen to lungs, abd, note all dressings, ivs, foley, do they have a NG or OG tube? On a vented pt however you would add the ETT size, location, vent settings. Is the pt sedated? What are they on and how much. Neuro checks are a little different. How is the pt, calm, agitated, over sedated, attempting to remove tubes and lines..Does he follow commands off sedation, MAE, are the pupils = and reactive, what size are they... You would chart all of that..

As with any head to toe, start at the top and work your way down, chart it the same way. Note what you see on the pt that they were not born with lol, like foley, SCD's etc..

The more you do it, the better you will becoming at charting it all.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

excellent advice.....Note everything you see on the patient they are not born with. I like that. Note drsgs that cover IV's and IV sites. If the have invasive lines that are monitored be sure toi mention the wave forms....like the arterial line pr CVP.

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Specializes in ER, progressive care.
It is the same as a non vented pt.. You will listen to lungs, abd, note all dressings, ivs, foley, do they have a NG or OG tube? On a vented pt however you would add the ETT size, location, vent settings. Is the pt sedated? What are they on and how much. Neuro checks are a little different. How is the pt, calm, agitated, over sedated, attempting to remove tubes and lines..Does he follow commands off sedation, MAE, are the pupils = and reactive, what size are they... You would chart all of that..

As with any head to toe, start at the top and work your way down, chart it the same way. Note what you see on the pt that they were not born with lol, like foley, SCD's etc..

The more you do it, the better you will becoming at charting it all.

Love the bolded!

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Specializes in Adult Internal Medicine.

Assess them before you plan how to write it up :)

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Specializes in Trauma Surgical ICU.

Thanks everyone for the props :)

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Thank for all of your replies. I have assessed my pt already, I just have not had to write up such an in depth head-to-toe assessment before and all of the different machines/tubes/etc that the patient has is throwing me off. For example, the patient is on a heart monitor and in sinus tach....on a vent with an EOTT...has an NG tube...receiving osmolite. How do you write this stuff in a way that makes sense and is acceptable? Especially the part about the vent...how do I incorporate all of the info about the vent settings and the placement (at the lip) and size of the EOTT? I have searched and searched and SEARCHED until i'm blue in the face for a good example of a critical care patient who is on multiple machines and has all kinds of stuff.... tubes/foley/flexiseal/PICC/vent/NGtube/heart monitor... and i can't find ANYTHING that is helping me with what I am really needing to know. If anyone has any good places online to find this info or has an example of their own, I would be more than grateful! I am really needing to make a good grade on this assessment and unfortunately, with my lack of experience and being my first week ever in a critical care setting, needless to say I am a little lost/overwhelmed! Thanks in advance!

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Specializes in ICU.

Break your assessment down by body systems. Start with neuro (GCS? Pupils? Neuro change? ICP monitor?), move to cardiac (sinus tach, PVCs, ectopy? He is hard wired, but does he have CVP?) respiratory (vent settings, placement), GI (OG tube? Tube feedings?) GU (foley?) skin (IV access, wounds, dressings, central line?) Write each body system on a piece of paper and chart everything you think would fall under each category.

Once you have the framework, begin with your knowledge of what is normal and compare each of your pts body systems to "normal". For example, what do his lungs sound like? Is he on a vent from a traumatic event, from a raging infection, from a deteriorating neuro exam? Many things you can cross off to help narrow your field and get the bigger picture. Examine each of his drips/medications and question the whys... (for ex, is he on an antibiotic? A pressor? How would those each affect his heart? His fluid status? How will his fluid status affect his lungs?)

After the framework of what he actually has on his body, think about the abnormals YOU saw. Then other information such as lab work and CT/MRI scans will help build on your knowledge of this pt.

Hope this helps a little! It is overwhelming at first, but all the supplemental equipment gets easier with familiarity and time :-) Critical Care textbooks and ICUfaqs.org are helpful!

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Specializes in Hospital Education Coordinator.

remember, your assessment is what YOU see and hear and touch (hopefully, no smells!). You will not have patient input. This might be your easiest assessment ever, since you won't be getting into conversations with the patient that may distract you.

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