Intensive Care Nursing/Systematic Assessment
A systematic and holistic assessment of the intensive care patient are considered necessary skills. Seeing past the monitor, ventilator and other technology can be a daunting task for the nurse new to the ICU environment. Handover of information between healthcare professionals assists the transferring of responsibility and care within the multi-disciplinary team, ensure this important communication is not just considered 'routine'.
First review of the situation
- Airway
- Breathing
- Circulation
- Any signs of deterioration or need for immediate intervention
Systematic
- CNS
- Respiratory (including auscultation for adventitious sounds)
- Cardiac (including auscultation for S1, S2, S3, S4, and murmurs)
- Renal
- GI
- Integumentary
- Medications (drug chart and infusions)
- Social
- Current admission pathway with cause of ICU admission, past medical history, resuscitation status
Give your patient a fast hug every shift as a means of identifying and checking some important key aspects in the general care of critically ill patients.
'FAST HUG' by Vincent (2005):[edit | edit source]
Regardless of the patients medical condition using the popularised FAST HUG mnemonic for identifying issues ensures a systematic review when looking after a critically ill patient. This can be utlised as a tool on a shift to shift basis for prioritising care planning.
- Feeding/fluids
- Analgesia
- Sedation
- Thromboprophylaxis
- Head up position
- Ulcer prophylaxis
- Glycemic control
This provides a standardised baseline that ensures shift to shift issues are being managed for safety, patient progression and future planning.
Reference
Vincent JL. Give your patient a fast hug (at least) once a day. Crit Care Med. 2005 Jun;33(6):1225-9. Review.[1]