Nursing Observation and Assessment of Critically Ill Patients

Assessment Of Critically Ill Patients 1
Nursing Observation and Assessment of Critically Ill Patients
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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