One of the major tasks of the Advanced Nurse Practitioner is to examine their patients.
This is not just the critical care patient, but may also be the patients out on other departments who may need review or admission by the critical care team. It is important therefore that the practitioner is competent to carry out all the examinations in full.
It maybe that they are never fully performed, but if learned in their entirety then those parts of the examination which are considered relevant for the patient being examined can be easily utilised.
The pages here cover all the major systems as well as the many resources available on the internet generally and You Tube more specifically.
The respiratory, cardiovascular and abdominal examination all start with the same process which can be summed up on this page.
All examinations should begin with the same process, whether you are examining the respiratory system or the musculo-skeletal system.
If you are in an OSCE situation points are valuable and there are some easy points to be earned if you firstly wash your hands and secondly introduce yourself to the patient, explaining who you are and what you are about to do. This is not only the courteous thing to do but also helps in getting the patients trust and co-operation and gains their consent for some of the procedures you are about to put them through.
I make an assumption here that the patient is either lying on an examination couch or, as is more likely in the role of the critical care practitioner, in a hospital bed. If you find yourself in a slightly different situation then you may have to make some adaptations to your approach. The general principles should always apply however.
Having made the introductions then, the first thing you should do is go to the end of the bed and observe the patient from a distance. At this point you are observing both the patient and the environment in which you find them.
When teaching this subject I always get people to imagine that the patients environment is surrounded by a big bubble and you are working from the outside in to elicit any useful information which may provide you with some clues as to their current status. The main point to note here is that the assessment does not start by immediately going to the patient and putting your hands/stethoscope on them.
So what clues may you get from the patients environment? There will be many, but some of the more obvious ones will be:
- Are there signs that the patient may be a smoker? Cigarette packets, tobacco pouches, lighters, matches etc.
- Is the patient already on any oxygen therapy? If so are they using it correctly? Are they any other adjuncts visible? CPAP masks, NIV boxes for example.
- Does the patient having any intravenous drips attached to them or indeed are there any old ones which have been disconnected? If so why are they are intravenous therapy? Is it for the replacement of fluid or for the infusion of something else, for example antibiotics?
- Are there any drains hanging from the bed or chair? What kind of drain are they? Chest drains or abdominal drains for example. Both will have some kind of impact on their respiratory status.
- Are there any walking aids next to the patient or their bed? This could be a walking stick or a walking frame. If so you need to find out why they need such and aid. Is it because they are compromised from a respiratory viewpoint or is it related to a musculo-skeletal problem?
- Are they attached to any monitoring? If so, why did someone consider them sick enough to do so? Do they still need that level of monitoring or has that question not been asked yet?
- Is there any sign around the bed that the patient may not be eating and drinking as well as they might? A plate which still has most of the food on it, or a jug and cup which look like they have not been touched. Are there supplementary type drinks which might indicate that the dieticians certainly think they are compromised? Is there any evidence of TPN feeding?
- Does the patient have a urinary catheter? If so what type? If it is an hourly bag then someone thought this patient sick enough to warrant keeping a very close eye on their output. If this is so, has the input/output chart been updated regularly and does it therefore provide a meaningful record of their fluid status?
We can then go on to look at the patient within their environment. Again this is from a distance and we are yet to actually put our hands on the patient.
- What is the patient’s position? Are they in bed or are they sitting by the bed? This can tell you a lot about their current status. If they are sitting out in a chair this maybe because they cannot breathe well without actually sitting completely upright. If they are lying in bed are they in a good upright position or are they slumped in bed?
- Do they look distressed or agitated or are they looking comfortable?
- What does their breathing look like? Do they appear to be struggling for breath? Do they seem to be using any of their accessory muscles to help them to breathe? Are they in the classic tripod position to help them fill their compromised lungs?
- Does their colour look good, or do they look cyanosed. Are they pursed lip breathing which is an effort to increase the positive pressure in their lungs to make their breathing easier.
- Peak and Plateau Pressure
- AC versus SIMV mode
- Positive End Expiratory Pressure (PEEP)
- Increase the rate or tidal volume?
- Phases of a breath- I:E ratio and cycle time
- Ventilation screen- what do those numbers mean?
- Pressure Support
- Modes of ventilation I
- Modes of ventilation II
- Physiologic effects
- Physiologic goals
- How do I describe how my patients ventilation?
- Trigger, Limit and Cycle
- Pressure support ventilation graphs
- ARDS and Proning
- 6 ways to be better with Bag-Valve-Mask
- Phase Variables
- Airway Pressure Release Ventilation (APRV)
- Pressure Volume Loop
- Lung compliance in volume controlled ventilation
- Pressure/Volume/Flow graphs
- A-a gradient
- Goals and Indications
- Anatomy of the Endotracheal Tube
- Lung Compliance
- Ventilation/Perfusion V/Q matching
- Ventilator Induced Lung Injury (VILI)
- Ventilator Associated Pneumonia (VAP)
- Phase variables...again...
Guidelines for the management of tracheal intubation in critically ill adults
Having read the guidelines I made these infographics. They are FREE. Just click on the button below.