A high-technology environment Complex patient problems Typical critical care patient May require total care, including change of position
Is hemodynamically unstable and may require
frequent monitoring of vital signs, respiratory assessments, pressure monitoring, patent IV medications
May be intubated, may need endotracheal
suctioning, ABG assessment, ventilator management FLOW SHEETS FOR RECORDING BEDSIDE MONITORING Vital sign, temperature Intake-oral/IV therapies-TPN, IVs, blood products Vasopressor /antidysrithmic medication administration Output-tubes, drains, urine Clinical data : CVP arterial blood gases Procedurs : ECG, chest x rays Equipment : O2, ventilator setting Lab data/diagnostics Physical assessments/observation as patients condition warrants Nurses notes ECG rhythm strips and hemodynamic May be NPO because of being intubated, having nasogastric suction, postoperative or digestive tract problems, or inability to take oral nutrition.
May need frequent monitoring /
interpretation of laboratory values such as ABGs, clotting studies, complete blood caount (CBC), urinalysis and electrlytes Will be on strict intake and output may have an indwelling catheter and will need frequent urine specific gravity readings
May have several painful incisions or
dressing that require IV analgesia and time consuming dressing changes.
May be neurologically unstable or may
have neurologic deficits. INITIAL ADMISSION/ BASELINE DATA LIST RESPIRATORY SYSTEM :airway integrity, airway adjuncts, respirations, ventilator, cough- effort, secretions, central cyanosis, subjective complaint, color Cardiovascular : Blood pressure, hearth rate, peripheral pulses, skin color, turgor, temperatur, CRT,Swan –Ganz Neurologic : level of conciousness, orientation,Motor function, movements, muscle tones FUNCTIONAL ASSESSMENT OF BODY ORGANS Renal system : urine, skin, acid base balance, admission weight Gastrointestinal : abdominal assessment, stools, nasogastric, nutrition Endocrine : perhistory, perspesific disorder Hematologic : color of mucous membranes, nail beds, signs of bleeding, lesions, ulcerations Musculoskeletal : deformities, movements, muscli tones CRITICAL CARE DOCUMENTATION
1. Priority assessment are directed toward
respiratory, cardiovascular and neurologic system functions 2. Assessment data related to psychologic stressors in critical care environment : a. Lack of control results from physical disability, surgery, trauma, intubation b. Feelings of powerlessness (actual or potential) due to illness, depression, change in mental status, lack of control over environment c. Depersonalization, possibly from being labeled according to one’s disease, cubicle number, chronic characteristics. d. Crowding, lack of space due to design of environment; presence of many doctor, technicians; frequent interruptions
3. Interventions are directed toward life saving
and life maintenance during the time the patient’s condition is unstable 4. Individualized nursing care plans are written and revised as patient’s health status improves or deteriorates.
5. Evaluation statements are directed toward the
patient’s condition, expected or unexpected outcomes, problem resolution, identification of new problems based upon reassessment, and success or failure of other plans and interventions