Assessment Techniques

Basically I go from head-toe.

start with loc, pupils, checking facial symettry etc

-heart tones, apical pulse, lung sounds, bowel sounds,

-lower exterm., pedal pulses

you get the idea omit what you don't need to do.

good luck

Where I work, we teach new nurses to go in essentially the following order:

Start with a "safety check" of the room - O2 available, ambu bag, suction setup, check alarm limits on the monitor, vent settings, check IV pumps and drips.

Next go from head to toe. General appearance (calm, aggitated, distressed,...). Brief neuro exam, pupils reactivity, extremity strength.

Then the chest: heart tones, lung sounds, work of breathing, position and size of ETT (if pt has one), chest tubes,... Then abdomen: listen, palpate, check placement of NGT/OGT. Then foley and color/quality of urine. Then to the extremities: pulses, cap refill, temperature, IV locations and ease of flush, presence/absence of blood return; level and zero hemodynamic monitoring lines, if present; check correlation of auscultated BP to NIBP on monitor and to A-line (if pt has one). Then lastly a skin assessment for wounds, surgical drains, and breakdown.

I echo the previous poster, the only thing I would add is...."Why is the pt in the ICU and what is the plan"...Nothing is more frustrating in nursing then RNs who fly on auto-pilot and give the same canned assessment everytime without telling the most important details:angryfire:angryfire don't get me started, I have a real beef with the way some nurses give report, too much meaningless chatter and too little substance. You should know why your pt is in the ICU and what the plan is to get them out of the ICU. It will change every so many minutes or hours, but keep informed and report off appropriately. Best of luck in the ICU

-Smiley

I always check my vent settings and then my drips and alarm limits. Then assess from head to toe and everywhere inbetween.

I echo the previous poster, the only thing I would add is...."Why is the pt in the ICU and what is the plan"...Nothing is more frustrating in nursing then RNs who fly on auto-pilot and give the same canned assessment everytime without telling the most important details:angryfire:angryfire don't get me started, I have a real beef with the way some nurses give report, too much meaningless chatter and too little substance. You should know why your pt is in the ICU and what the plan is to get them out of the ICU. It will change every so many minutes or hours, but keep informed and report off appropriately. Best of luck in the ICU

-Smiley

Good post. I would also add, why are they on the drips that they are. If something seems kooky........it probably is.

For example - a couple of weekends ago I took report on a pt that has NS with 2 amps of bicarb added at 250 cc/hr. This had been going on for almost 48 hours, KOOKY! I asked the nurse giving me report why is this pt getting this amount of bicarb. Answer=I dunno, acidotic I GUESS! Bad answer, this poor pt was extremely alkalotic by this time.

I guess what I am trying to say is try to understand why you are doing what to your patient when you pass it off in report.

as a new icu nurse, i agree with the assessments above. i always do things in the order of ABCs.

the first thing i do when i walk in a room is give the ETT or the vent tubing a tug and make sure its secure, the vent settings, the bagger/mask/o2 apparatus and suction, then the monitor set and make sure the limits are tight! all the drips are next- and agree with the 'why are they using them'. i've made it good habit to find the original orders for all 'major' drips just to make sure! (we all know we make mistakes, i wont let it be mine!) head to toe for the rest!

good luck with your own system, just be safe!

Also add why is the patient on these meds? Especially antibiotics. What are the bugs and are they covered?

Good post. I would also add, why are they on the drips that they are. If something seems kooky........it probably is.

For example - a couple of weekends ago I took report on a pt that has NS with 2 amps of bicarb added at 250 cc/hr. This had been going on for almost 48 hours, KOOKY! I asked the nurse giving me report why is this pt getting this amount of bicarb. Answer=I dunno, acidotic I GUESS! Bad answer, this poor pt was extremely alkalotic by this time.

I guess what I am trying to say is try to understand why you are doing what to your patient when you pass it off in report.

I agree, I am relatively newto ICU also, but by knowing why you are doing what you are doing you can potentially pick up mistakes before they happen.

Also....

check the lines and the connections (why is my patient agitated? oh we have been giving M&M to the bed for the last 2 hours)

Always check the pumps when you reset them... had a patient in our unit who ended up on 47 units of insulin per hour instead of 4.7 (not my patient thank god!)

Always make sure you check the safety things... suction, oxygen, ambubag, masks. Think what is the worst that can happen and what will I use if it happens? Then forget about it.

Do a thorough top to toe assessment. And don't overlook things because the patient is not in ICU for that.... I do vascular obs regardless but a lot of my colleagues don't.

Ask questions!!! Ask the doctors why things are happening. Or why they are doing what they are doing. It is not outside the realms of possibility that you are right and the doctors are wrong. It's not too hard to phrase a question in a way that will save their ego. But generally the more questions I ask the more I learn, it is like fitting a jigsaw puzzle together.

Check anything that feels wrong. Chances are it is.

Talk to your workmates. My colleagues are generally fantastic people who will happily help with information etc. This is the best way to learn.

The last thing is.. the thing that you feel is your weakness (mine is auscultating breath sounds), keep doing it until you feel confident!

Oh this is the real last thing. With some relatives all you can do is smile and nod and wait for the shift to end.

Good luck!