Nursing Observation and Assessment of Critically Ill Patients

This article discusses nursing observation and assessment of critically ill patients, including recognizing deteriorating older person, measurement and documentation of observations, monitoring plan, and escalation of care. It also includes a case study of a patient named Michael Jones.

Assessment Of Critically Ill Patients 1
Nursing Observation and Assessment of Critically Ill Patients
Student’s Name
Course Name
Professor
Institutional Affiliation
City/State
Date

Assessment Of Critically Ill Patients 2
Nursing Observation and Assessment of Critically Ill Patients
Part 1
A Airway  The patient
struggles to
breath and
feels some
abdominal
pain when
breathing.
 There evident
mouth
swellings
 The airway
partially
blocked.
 The
patient is
snoring,
coughing,
and
gargling.
 Air movement
is evident but
with pain.
 Patient is weak,
 lethargy,
 confusion,
 Abdominal
 Pain
 distension
B Breathing  The chest
wall
movement
not normal
and
symmetric
 The patient
uses neck and
 The
patient
doesn’t
speak
properly
and can
hardly
complete
 The trachea is
centrally
positioned
 The patient is
sweating
profusely
 The patient lost
a lot of water

Assessment Of Critically Ill Patients 3
shoulder
muscles but
the impulses
are very
weak.
a
sentence.
 Some
stridor,
wheezing,
and
gargling
can be
heard
from the
chest.
from most parts
of the body.
C Circulation  Yellowish
skin colour
 Patient’s
central
venous
pressure is
abnormal
 Jugular
venous
pressure is
normal
 The
patient
complains
of
headache
and is
dizzy.
 The
patient’s
blood
pressure is
high
 Heart
sound is
 The patient’s
hands are cold
 Large veins
evident on the
skin periphery.
 Patient’s
peripheral
pulses are
weak,
abnormal, and
of slower rate
 Inconsistent
pulse rate.

Assessment Of Critically Ill Patients 4
abnormal
and heart
rate is
slower.
D Disability  The patient is
conscious but
the level of
consciousnes
s reduces
rapidly with
time.
 The face is
asymmetrical
, he makes
some
abnormal
body
movements
and the limbs
are
weakening as
time goes by.
 The
patient
has slow
response
to the
external
stimuli
and at
times
could not
detect and
feel a
source of
heat.
 His
speech
was
slurred.
 At times the
patient could
feel and
external stimuli
but could not
react due to
weakness in the
muscles (van
der Mars,
Timken, &
McNamee
2018, p. 358).
He struggled to
even raise
hands after
feeling the
source of heat
that was used
for study.
E Exposure The patient has some There were some The lower abdomen

Assessment Of Critically Ill Patients 5
wounds in the mouth
that bleed.
air leaks in the
drains.
Some bowel
sounds could be
noticed
produced some
rumbling sounds.
F Fluids The patient had lost a
lot of fluids through
vomiting and
bleeding through the
wounds. The fluid
lose rate was high
and the patient was
becoming drained.
Urine colour was
concentrated and
little in amount.
The patient
complained for
thirst every time.
Takes water but
loses it almost
instantly through
the drains.
The skin turgor was
not very timely. The
skin takes much longer
time than usual to
come back to normal
after an external
irritation like pinching.
The skin could remain
wrinkled for some
time before returning
to normalcy.
G Glucose The patient suffered
low concentration
level and seemed
confused almost
throughout. This
suggested a low level
of glucose in the
blood.
The patients thirst
was almost
impossible to
quench. The
patient’s
orientation to new
places like the
hospital
environment was
The patient was
sweating throughout
from all parts of the
body.

Assessment Of Critically Ill Patients 6
poor.
Considerations in Recognising deteriorating older person.
There has been a rise in the number of sudden cases of adverse medical conditions among old
members of the society that result into cardiac arrest and or deaths. It should be noted that
such events follow a series of other events that at some points fail to be recognised and dealt
with appropriately. These preceding events can always be noticed and treated within the
required time to prevent deaths (Cionea, Hoelscher, & Ileş 2017, p. 300). Studies show that
most of the unexpected deaths occur due to the fact that the preceding events go unnoticed
and not acted upon appropriately. Response includes appropriate and timely treatment to the
detected conditions. The National Consensus Statement: Essential Elements for Recognising
and Responding to Clinical Deterioration (ACSQHC) sates that recognition should follow the
A-G assessment but other considerations may include
Recording the respiratory rate on every observation made in an old patient whose condition is
considered worsening. Respiratory rate is deemed a sign of early clinical deterioration.
Another consideration to make is the Oxygen Saturations (SpO2) in a patient’s blood
(Coleman, Kearns, & Wiles 2016, p. 970). This consideration can be achieved by measuring
the pulse oximetry.
Recognizing an abnormality in the health condition of an old patient can achieved by
frequently observing the blood pressure of the patient and recording the findings. (Tyson,
Duma, & Rowson 2018, p. 325). This process is normally done using some automated
machines that may be vulnerable to taking inaccurate measurements; and in such a case
manual sphygmomanometer needs to be applied. Another method of detecting an alteration in
the patient’s conditions is taking note of his or her level of concentration on the surrounding

Assessment Of Critically Ill Patients 7
or just a conversation. A sudden decrease in the patient’s concentration and being less alert
should sound an alarm to the handlers.
Some adverse health events affect a patient’s consciousness; this refers to how fast an
individual reacts when irritated by an external condition. The medical team handling an old
patient needs to be keen on the consciousness of the patient; in that any abrupt decrease
should trigger a response (Fisher, Harrison, Bruner, Lawson, Reeder, Ashworth, Sheppard, &
Chad 2018, p. 115). To sum up, the whole process of recognition and response done by
medical staff on the patient’s clinical deterioration should involve a chain of operations.
These include taking and recording observations, proper clinical communication in, and
efficient rapid response in case of detected challenges. If the first aid procedure does not yield
effective results then the patient’s care need to be escalated by transferring the patient to a
more advanced health centre with better technological facilities. Another effective way to
avoid such sudden health malfunctions is to educating the public about the symptoms of the
preceding events to the actual cardiac arrests or sudden deaths.
Measurement and documentation of observations
There are always various observable changes that can be noted in an individual some time
prior to an occurrence of major health deterioration. These alterations in the normal day to
day activities of a victim’s body may include changes in oxygen level in a person, some vital
changes on the skin and conscious rate (Henry, Wilsey, Melnikow, & Iosif 2015, p. 740). It
should be noted there are always long period of time that such symbols occur in an
individual’s body but they are not detected and acted upon. This delay may lead to late
treatment hence the worse result like cardiac arrest or death.
Measurement of observations

Assessment Of Critically Ill Patients 8
Some physiological observations need to be compiled about a patient and any slight
alterations from the normal should be considered and treated with the urgency it deserves.
Such observations include respiratory rate, heart rate, temperature, oxygen concentration,
conscious level, and blood pressure. According to HARREL and REGLIN (2018, p. 40), a
comprehensive assessment needs to be carried out on daily basis to detect any variation from
the normal status.
Monitoring plan
The manner in which the observations are done need to be very simple and straight to the
point. So that the specific diagnoses on the patient’s and changes in the procedure are
documented (Lee, Weathers, Davis, Domino, & Sloan 2017, p. 60). Any modifications to the
monitoring plan need to be documented. These observations need to be taken right from the
point of admission of the patient into the health facility. The number of times observations
and documentations are done to a patient is influenced by the condition of the patient. It can
be done at least ones per shift.
Escalation of care
The observations, measurement and responsive actions taken at early stages of the patient’s
stay at the facility may help prevent any further complications that can lead to cardiac arrest
or death. The procures and systems followed during escalation of a patient’s health care are
done with the intention of assisting patients within the required timeframe after some changes
are detected on the patient. (Patel et al. 2018, p. 900). This process follows as predefined
steps as guided in various health facilities. The protocols should address the following as in
the above case.

Assessment Of Critically Ill Patients 9
 Increasing the frequency of observations of conditions being monitored. This means
that the observations need to be taken more regularly to detect the slightest change
possible.
 The intervention of other senior practitioners to help monitor the patient.
 If the condition continues to worsen then there is the need to review the medical team
that handle him.
 The patient is served with some special facilities so help in assisting and managing the
condition.
 At some points the patient may be transferred to another higher level facility with
better equipments for enhanced care.
Studies show that most of the unexpected deaths occur due to the fact that the preceding
events go unnoticed and not acted upon appropriately (Tighe et al. 2015, p. 570). The
process of recognising and responding assist medical staff to identify the events that precede
these deadly health conditions. The medical staff then take the appropriate actionsimmediatly
to avoid any further damage. Response includes appropriate and timely treatment to the
detected conditions.
An escalation may lead the practitioner to understand some process of growth in order to
know the exact action to take. From the etiological narrative, the client's case may be as a
result of a previous event that led to some undesirable effects. She fears that if the rumors
spread by her peers are not controlled, there is the likelihood of a repetition of a past event
(Pentland, Twyman, Burgoon, Nunamaker, & Diller 2017, p. 980). The case needs to be
solved to avoid future repetition. In such instances in which the psychological development
is put under test, an explanation by Charlotte Buhler explains that the main intentionality in

Assessment Of Critically Ill Patients 10
adults in their effort to live a fulfilling life. At this stage, an individual makes decisions based
on the following strategies (Pitt & Brumberg 2018, p. 960). If the set standards are to prevail,
then informed decisions are made with the help of other superior members of the society, like
the one the client seeks advice from. These standards include but not limited to choosing life
goals, working towards the selected targets, evaluating goal attainment, and the carrying out
revision on the life goals based on the prevailing environment. The last stage involves
adapting to the new experiences and the environment. Butler argues that the life goals need o
to be realistic, proper planning and the hard work to achieve the goals.

Assessment Of Critically Ill Patients 11
Nursing Progress Notes
Date of Examination: 24/10/ 2018
Time of Examination: 2:20
Patient Name: Michael Jones
Patient Number: 0024102018
HISTORY
Status of the patient
Joseph was a little bit worse today
Target Symptoms
Joseph reports that the dizziness and unconsciousness continues even after administering the
medications during the last treatment session. Abnormal body movements and the limbs are
weakening as time goes by (Pitt & Brumberg 2018, p. 963). The condition has lead to Joseph
have some guilty feelings. He keeps mentioning his failure to protect a sister who apparently
died through road accident some few years ago. This confirms that the condition has affected
his mental stability.
Basic Behaviours
Joseph records some good sleep at night. His participation in physical activities is minimal
may be due to lack of energy. But this factor can be attributed to negative attititude he has
developed of late. The patient’s sigma also contributes in his lack of appetite and always
trying distance himself from other patients.

Assessment Of Critically Ill Patients 12
Additional Signs
Sedative effects of the drugs are evident.
Patient reports frequent dry mouth most probably due to lose of much fluid from the body.
The development of some mental instability leading to hallucinations, stigma and sense of
guilt.
MENTAL STATUS
Joseph so far has developed some characteristics that make it more difficult to handle his
situation. He has become more inattentive, glum, and downcast with minimal
communication. He appears restless and less energetic with time. The feeling of guilt
complicates his condition as he keeps making noise uttering words that suggest he feels some
level of stigma (Wilkinson, McCray, Beckmann, & McIntyre 2016, p. 332). His facial
expression and his general demeanour show how depressed he is. The hallucinations he
undergoes complicate the already worse situation in that he becomes very aggitative and not
willing to take the prescribed medicine. This continues till the feeling of guilt comes after
which he becomes inactive and no communicative. He some time exhibit signs of anxiety.
Special Circumstances
Joseph continues to experience gait that is not steady. This condition is more evident at night
after midnight. He has been provided with call lights that are placed within reach. He has
been given instructions to ring the nurse whenever he feels any strange feeling (Yoon,
Shaffer, & Bakken 2015, p. 570). There are standby guards to control him whenever he
becomes restless and can cause harm to other patients.

Assessment Of Critically Ill Patients 13
Hospital Situation
Healthcare Centre being a rural institution faces several challenges just like any other
institution based in the rural area. According to the Chief executive in the facility, some of
these challenges include shortage in the medical work force. This problem is brought by the
fact that many health workers do not like working in the countryside; a fact that complicate
the process of recruitment of the much needed workforce. The challenging working and
living conditions make retention of workers low. Additionally, acquiring funds to facilitate
the rural based health facilities has been difficult as only a few investors agree to invest their
capital in such areas. These factors lead to ineffective and inefficient utilization of the
available resources such are electricity

Assessment Of Critically Ill Patients 14
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Assessment Of Critically Ill Patients 15
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Assessment Of Critically Ill Patients 16
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Assessment Of Critically Ill Patients 17
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