ST. MARY’S COLLEGE OF TAGUM, INC.

NURSING PROGRAM

LEARNING
NCM 118 - CARE OF CLIENTS WITH LIFE-THREATENING CONDITIONS,
ACUTELY ILL/MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY

MODULE
SITUATION
BSN4

Lesson 2: Assessment of Critically

Ill Client

Prepared by:
JOSEFINA S. BALOTE,RN,MN
 Module 1 – Lesson 1

Timothy 5:8 “Then your

light will break forth like
the dawn, and your
healing will quickly
appear; then your
righteousness will go
before you and the glory
of the Lord will be your
rear guard.”

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 Module 1 – Lesson 1

Ignacian Core/ Related

Values:,
Excellence; service, Faith

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 Module 1 – Lesson 1

Learning Outcomes
At the end of the lesson the students can:

1. With a given scenario, assess clients with Life-

threatening Conditions, Acutely Ill/Multi-Organ Problems,
High Acuity and Emergency Situation based on medical
history and physical examination techniques (IPPE)
 
2. With a given scenario formulate a plan of care to
address the nursing needs and problems of the client.

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 Introduction

This unit introduces basics in the assessment of

critically ill clients. care nursing. Prompt assessment
and accurate diagnosis is vital in acutely ill patients.
It is important to follow an orderly and efficient and
logical approach when assessing critically ill patients

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 Learning Contents

Prompt assessment and accurate diagnosis is

vital in acutely ill patients.

It is important to follow a systematic and logical

approach when assessing this group of patients.

 This approach should encompass airway,

breathing, circulation, disability and exposure
(ABCDE)

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 Learning Contents

Critically ill are usually those stable patients

manage previously and who have abruptly
deteriorated and become acutely eventually and
typically developed life threatening,
neurological, or cardio-respiratory instability,
usually as a result of their presenting
condition.

Physical Assessment is done in an order,

accurate, and prompt manner using the IPPA
- inspection, palpation, percussion, and
auscultation. Use them in sequence—unless
you're performing an abdominal assessment.

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 Learning Contents

1. Inspection
Inspect each body system using vision, smell, and
hearing to assess normal conditions and
deviations. Assess for color, size, location,
movement, texture, symmetry, odors, and sounds
as you assess each body system.

2. Palpation
Palpation requires you to touch the patient with
different parts of your hands, using varying
degrees of pressure. Because your hands are
your tools, keep your fingernails short and your
hands warm. Wear gloves when palpating
mucous membranes or areas in contact with body
fluids. Palpate tender areas last.

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 Learning Contents

Types of palpation
Light palpation  
Use this technique to feel for surface
abnormalities.
▪ Depress the skin ½ to ¾ inch (about 1 to 2 cm)
with your finger pads, using the lightest touch
possible.
▪ Assess for texture, tenderness, temperature,
moisture, elasticity, pulsations, and masses.

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 Learning Contents

 Deep Palpation
Use this technique to feel internal organs and
masses for size, shape, tenderness, symmetry,
and mobility.
▪ Depress the skin 1½ to 2 inches (about 4 to 5
cm) with firm, deep pressure.
▪ Use one hand on top of the other to exert firmer
pressure, if needed.

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 Learning Contents

3. Percussion
Percussion involves tapping your fingers or hands
quickly and sharply against parts of the patient's
body to help you locate organ borders, identify
organ shape and position, and determine if an
organ is solid or filled with fluid or gas.

Types of percussion
Direct percussion
This technique reveals tenderness; it's commonly
used to assess an adult's sinuses.

▪ Using one or two fingers, tap directly on the

body part.
▪ Ask the patient to tell you which areas are
painful, and watch his face for signs of discomfort.

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 Learning Contents

Indirect percussion
This technique elicits sounds that give clues to the
makeup of the underlying tissue. Here's how to do
it:
▪ Press the distal part of the middle finger of your
non-dominant hand firmly on the body part.
▪ Keep the rest of your hands off the body
surface.
▪ Flex the wrist of your non-dominant hand.
▪ Using the middle finger of your dominant hand,
tap quickly and directly over the point where your
other middle finger touches the patient's skin.
▪ Listen to the sounds produced.

Direct Indirect

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 Learning Contents

4. Auscultation
Auscultation involves listening for various lung,
heart, and bowel sounds with a stethoscope.

Getting ready
▪ Provide a quiet environment.
▪ Make sure the area to be auscultated is exposed
(a gown or bed linens can interfere with sounds.)
▪ Warm the stethoscope head in your hand.
▪ Close your eyes to help focus your attention.

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 Learning Contents

How to AUSCULTATE

▪ Use the diaphragm to pick up high-pitched

sounds, such as first (S1) and second (S2) heart
sounds. Hold the diaphragm firmly against the
patient's skin, using enough pressure to leave a
slight ring on the skin afterward.

▪ Use the bell to pick up low-pitched sounds, such

as third (S3) and fourth (S4) heart sounds. Hold
the bell lightly against the patient's skin, just hard
enough to form a seal. Holding the bell too firmly
causes the skin to act as a diaphragm, obliterating
low-pitched sounds.

▪ Listen to and try to identify the characteristics of

one sound at a time.

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 Learning Contents

Six Initial Nursing Actions that should be taken

when responding to clinical deterioration.

A-Call for Help,

B-Collect More Data,
C-Patient Positioning,
D-Oxygen Therapy,
E-Prepare for RRS/MET (Rapid Response
System/Medical Emergency Team) and F-
Handover. (referral)

Call for emergency help like “Code Blue”

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 Learning Contents

How to Assess Deteriorating Patients

Breathing
Look – Observe the rate, rhythm and depth of
the patient's respirations over a period of one
minute. ...
Listen – Listen to the patient's breathing using a
stethoscope or auscultate the patient's lower
airways and lungs if competent in these skills. ...
Feel – Palpate the patient's chest.

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 Learning Contents

Three (3) Signs of Clinical Deterioration:

These are the physiologic changes preceding

cardiac arrest:

 abnormal breathing,
abnormal pulse, and
abnormal systolic blood pressure.

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Learning Contents

Early Signs of Clinical Deterioration Every

Student Must Recognize to Save a Life

Failure to rescue occurs when a patient dies

following a life-threatening complication which could
have been avoided if timely recognition and
appropriate intervention by the bedside nurse and
healthcare team had taken place.

Most patients (84%) do not suddenly code and go

straight into cardiac arrest. Observable evidence of
vital sign instability and visible patient deterioration
changes occur in most patients from 6 to 24 hours
before cardiac arrest and happens most frequently on
medical-surgical units.

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 Learning Contents

Early Signs of Clinical Deterioration Every

Student Must Recognize to Save a Life

The essence of critical thinking is the ability of

the nurse to ACT on what they know and
understand.

When a nurse fails to deeply understand

essential content and apply it to the bedside they
are not able to critically think like a nurse.

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 Learning Contents

Most Common Problems Needing Rescue

most common initial complaints that a patient

reports that trigger a rapid response page:

Chest pain
Shortness of breath
Hypotension
Neuro changes or altered mental status
Patient fall

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 Learning Contents

To Assess Pain:
The numerical scale: Measures pain on a scale
of 1–10.
The visual analog scale: Categorizes pain along
a horizontal line, ranging from mild to severe.
Faces pain scale – revised (FPS–R): Uses a
horizontal line, illustrated by facial expressions to
represent different pain levels.

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 Learning Contents

To Assess Pain:

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 Learning Contents

Assessment RED FLAGS

The term RED FLAGS (PDF 113KB) refers

to clinical features that help to identify the
presence of potentially serious conditions.
Such conditions include tumors, infection, fractures
and neurological damage.

Respiratory

Abnormal respiratory rate

(either too high or too low)
Decreased O2 sat with
increasing oxygen needs
Shortness of breath

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 Learning Contents

Assessment RED FLAGS

Cardiac

Reduced systolic blood

pressure
Abnormal pulse
Complaint of chest pain
.

Misc.

Abnormal temperature
Neurologic
changes/altered mental
status

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 Learning Contents

Nursing Interventions for Critically Ill Patient and

Family

The patient-focused nursing interventions (Larsen

et al 2021) varied in , scope, length of the
intervention, length of follow-up and outcome
measures, were:
 communication,
patients' needs relating to pain relief or sleep or
 recovery care, or
the more long-term psychological effects of an
ICU stay, such as PTSD, digestion or emergency
actions.

Family-focused interventions
The family-focused interventions were more
homogenous in content and focused mostly on
the families' need for information and staff
cooperation in the ICU.

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 Learning Contents

The cornerstones of intensive care management

are the optimization of a patient's physiology, the
provision of advanced organ support, and the
identification and treatment of underlying
pathological processes. This is best achieved
through a multidisciplinary team approach, with
shared responsibility between the admitting
‘parent’ team and a specialized critical care team
coordinated by a critical care physician.

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Learning Contents

LEVELS OF CARE

High-dependency unit (HDU) or ‘level 2’: 

Admission for single-organ support (not including

invasive ventilation) and should not require a
dedicated critical care nurse for each patient.
Provides an environment for close monitoring of
patients with or at risk of developing organ failure:
•
respiratory: non-invasive ventilation, arterial blood
gases
•
cardiovascular: low dose vasopressors, invasive
arterial pressure monitoring
•
renal: close fluid balance control, certain renal
replacement therapies.

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 Learning Contents

LEVELS OF CARE

Intensive care unit (ICU) or ‘level 3’: Admission

for multi-organ support or delivery of advanced
monitoring techniques requiring at least one
dedicated critical care nurse for each patient:
•
respiratory: invasive and non-invasive ventilation,
extra-corporeal membrane oxygenation (ECMO) or
carbon dioxide removal (ECCO2R) in selected
centres
•
cardiovascular: vasopressor and inotropic support,
advanced cardiac output monitoring, intra-aortic
balloon pump, ventricular assist devices, ECMO
•
renal: renal replacement therapies
•
neurological: intracranial pressure monitoring, EEG,
advanced neurological monitoring.

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 Learning Contents

Critical Care Organ Support

Airway and respiratory support

High flow oxygen therapy is a form of respiratory
support used in the hospital where oxygen, often in
conjunction with compressed air and humidification, is
delivered to a patient at rates of flow higher than that
delivered in traditional oxygen therapy.

*The high flows of up to 60 litres/min are thought to

reduce work of breathing and improve respiratory
mechanics by providing a small amount of positive end
expiratory pressure (PEEP) and washing out dead space
gases

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 Learning Contents

Critical Care Organ

Support

Airway and respiratory support

Non-invasive ventilation (NIV): is a form of respiratory
support that obviates (prevent) the need for endotracheal
intubation. It is most commonly delivered by application of
positive airway pressure via a facial interface utilizing
either continuous positive airway pressure (CPAP) or bi-
level positive airway pressure (BiPAP).

continuous positive bi-level positive airway

airway pressure
pressure

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 Learning Contents

Critical Care Organ

Support

Invasive ventilation: mandates tracheal intubation in one

form or another. Securing the airway in critically ill patients
poses significant additional challenges compared with the
controlled environment of an elective theatre list. This may be
due to profound physiological derangement (often paired with
a rapid decline), the presence of anatomical difficulties (e.g.
airway burns), external factors (e.g. cervical in-line stabilization
in trauma), significant time pressures, suboptimal positioning,
unfamiliar environments, and limited availability of equipment
and help.

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 Learning Contents

Critical Care Organ

Support

Cardiovascular support
Haemodynamic monitoring is the study of
how blood flows through the cardiovascular
system (i.e. the heart and blood vessels). The
purpose of the cardiovascular system is to deliver
blood carrying oxygen and other vital nutrients to
the cells and tissues the body.

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 Learning Contents

Critical Care Organ

Support

Cardiovascular support
Fluid management
When there is a heart failure, the heart does not
pump out enough blood. This causes fluids to
build up in your body. too many fluids, cause
symptoms such as swelling, weight gain, and
shortness of breath

VASOPRESSOR and INOTROPIC agents are short-term to

medium-acting drugs that are used to enhance vascular
tone or cardiac output in a variety of critical illness
conditions. They are used as a temporary measure until
sufficient cardiovascular function returns on resolution
of the pathological process. (norepinephrine,
epinephrine, metaraminol, phenylephrine, dopamine
(via α-adrenoceptor effect) and vasopressin (via
vasopressin V1 receptors).)

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Assessment

Written Exam

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 Synthesis

With great power comes great responsibility. The

bedside nurse must embrace this responsibility and
recognize what is at stake when a nurse fails to think
like a nurse. Failure to rescue can occur, and a patient
can needlessly die as a result.

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 References

Source: Health Assessment made Incredibly Visual!,

Lippincott Williams & Wilkins, 2007.
https://journals.lww.com/nursing/Fulltext/2006/1100
2/Assessing_patients_effectively__
Here_s_how_to_do.5.aspx

Early Signs of Clinical Deterioration Every Student

Must Recognize to Save a Life
By Keith RischerMarch 20, 2018.
https://www.keithrn.com/2018/03/failure-to-
recognize/

Nursing interventions to cover patients' basic needs

in the intensive care context – A systematic review
Marie Hamilton Larsen,Gudrun Irene
Johannessen,Kristin Heggdal
First published: 02 November 2021
 https://doi.org/10.1002/nop2.1110

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References

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