Bedside assessment in the PICU

Pediatric Critical Care Columnist · Aug 4, 2008

It's always easier to go top to toe, if you know what I mean. And you'll be observing things as you go along that you won't necessarily be consciously assessing.

Patient ID!! Where's their armband? Allergy notifications?

CNS: Your primary survey will tell you a lot... alertness/sedation, spontaneous movement and irritability are obvious... secondary assessment includes pupil check, temperature (in infants it's mainly neuro medicated), muscle tone, ability to follow requests or move purposefully (age-appropriate), speech (if intubated, head nodding or gestures in response to questions passes), sleep patterns, prn sedation doses and frequency. IF the patient is in with neurological injuries, you'd also assess ICP and CPP (if monitoring is in place), eye opening and gaze, cough, gag, corneal reflexes, response to voice or pain, therapeutic cooling. (Not typical to measure head circumference unless specifically ordered, even in neonates.)

CVS: Color, HR and rhythm, pulses (central and peripheral) cap refill, vasoactive drugs, pressures (art, CVP, LAP, RAP, occasionally PAP), pacemaker settings, heart tones, chest tube and drainage, vascular access.

Resp: Intubated/trached or noninvasive ventilation, settings, chest wall movement and WOB, saturation, ETCO2, nitric, air entry and adventitia, secretions.

GI: Abdominal distension, incisions/ostomies, drains, volume and appearance of drainage, feeds, bowel sounds, tension in abdominal wall.

GU: Edema, Foley, volume and quality of urine, fluid balance, dialysis (CRRT/peritoneal/hemo).

Skin: Color, temperature, integrity, pressure injuries, wounds and dressings, rashes, line sites.

ID: Temperature trends, lab work, signs and symptoms, antibiotics, immunosuppressants.

Psychosocial: Family's location, visiting patterns, issues and concerns.

You can either do your safety checks (bagger, suction, face mask, spare trach (prn), drug sheets, infusions and what-have-you first, or after your head to toe. But try to do it the same way all the time so that you don't forget a step.

If you organize your assessment and your reporting in the same way, you won't miss too much. Most units have some sort of assessment document that tells you what you should be assessing and documenting at the beginning of your shift, and that's a great template for you.

CANewRN · Aug 4, 2008

Thanks for the tips Jan, I appreciate it!!

NurseLay · Aug 5, 2008

Jan you are so God's gift to us PICU newbies!!!! I start with my preceptor tomorrow. I'm thinking once we kind of set the guidelines as to what she expects from me and vice versa and maybe set some sort of plan that I'll be taking patients. Hopefully, it will be tomorrow!!! I'm so excited. I'm doing drug cards now!

Pediatric Critical Care Columnist · Aug 6, 2008

I'll be waiting to hear how Day 1 went...

NurseLay · Aug 6, 2008

Jan:

I enjoyed my first day. Of course, we had pretty much the most stable patient. He was trached and vented. He was on fentanyl and versed drips and tube feeds and that was pretty much it. He had a couple of meds this morning, not too many. He also had an A-line, CVL, and right pleural CT. Initially, I was a little uncomfortable and I was feeling like I was in my first clinical rotation with my teacher telling me to do a head-to-toe assessment in front of her, but as the day progressed, so did my confidence level. I think my preceptor was just trying to get a feel for me. I asked a lot of questions, some I thought were VERY stupid, but I asked anyway. My preceptor seems to be pretty knowledgeable and she didn't mind explaining things to me. Today was pretty much assessments and charting. As far as charting, I found myself I guess asking her permission to write my opinion, kind of like how it was in clinical, and she just said, nursing is very subjective, she said that I had to learn what I thought was important enough to write and what wasn't. I'm happy she was like that though. I am so used to being in nursing school, and charting with my instructor or nurse and getting an opinion on what I should or shouldn't chart. Hopefully, I will start to become more comfortable with it and know what kinds of things to write sooner rather than later. Other than that, nothing much really went on. I think it was a good day. Oh, and I asked if there was anything that she thought I should have or could have done differently and she said no, so hopefully she was being honest with me. Haha

Pediatric Critical Care Columnist · Aug 6, 2008

Good first day for you NurseLay. Be very thankful you had "the most stable patient in the unit". That's a perfectly appropriate assignment for you to get your feet wet with. I get really frustrated with the people in my unit who make the assignments for new staff and preceptor teams based on what the preceptor wants (as in don't give me a chronic because I'm too good for that, or don't give me something "boring" like a simple ASD repair because I'll be bored) or has to have because of the acuity level in the unit. New staffers don't learn anything from the sickest of the sick until they've been there long enough to at least feel comfortable doing the basics. You need a foundation to build your skills on and you can't get that with an unstable patient. All you'd be doing is watching your preceptor work and that's not good for anyone.

You work on getting comfortable with the routine of working there, learning the charting, learning the hierarchy and the level of nursing autonomy. Work on becoming skilled and comfortable with drawing and interpreting ABGs, doing central line care, suctioning and hand-ventilating, hanging unfamiliar meds and titrating infusions, understanding what you're doing and why, and the rest will follow in the natural progression of things. As time passes and you're not so task-oriented and can start "seeing" your patient, suddenly all that physiology you studied and memorized for exams will actually mean something. But you do ahve to walk before you can run. You'll be happier and safer if you do. Keep me updated...

NurseLay · Aug 6, 2008

I was happy to have that patient for the exact reasons you mentioned! I am going to keep a day to day log of things so I can keep track of what I'm doing and what I am comfortable with and uncomfortable with. Thanks for the advice as usual, and I will definitely keep you updated!