PRESENTATION ON

ASSESSMENT OF
PATIENT IN CCU

PRESENTED BY:
SANDHYA HARBOLA
LECTURER
PCNMS
 Introduction

• Critical care unit, also known as intensive care unit or intensive treatment
unit, is a special department of a hospital or health care facility that provides
intensive care medicine.
• Intensive care units cater to patients with severe or life threatening illness and
injuries which require constant care, close supervision from life support
equipment and medication in order to ensure normal bodily functions.
• In 1950, anaesthesiologist peter Safar established the concept of advanced life
support, keeping patients sedated and ventilated in an intensive care
environment. Safar is considered to be the first practitioner of intensive care
medicine as a speciality.
 CLASSIFICATION OF CCU

• Coronary care unit –

caters to patients
specifically with life-
threatening cardiac
conditions such as a
myocardial infarction or a
cardiac arrest.
• Neonatal intensive care
unit- cares for neonatal
patients who have not left
the hospital after birth.
Common conditions cared
for include prematurity
and associated
complications.
• Paediatric intensive care
unit-paediatric patients are
treated in this intensive
care unit for life
threatening conditions
such as asthma, influenza,
diabetic ketoacidosis or
traumatic neurological
injury.
• Geriatric intensive care
unit- a special intensive
care unit dedicated to
management of critically
ill elderly.
• High dependency unit- an
intermediate ward of patients
who require close observation,
treatment and nursing care that
cannot be provided in a
general ward, but whose care
is not at critical stage to
warrant an ICU.it is utilised
until a patient’s condition
stabilizes to qualify for
discharge to a general ward.
 CLASSIFICATION OF CRITICAL PATIENT

• Level 0 –normal ward care

• Level 1- at risk of deteriorating support from critical care
team
• Level 2- more observation or intervention, single failing
organ or post-operative care.
• Level 3- advanced respiratory support or basic respiratory
support, multi organ failure.
 QUICK ASSESSMENT OF PATIENT IN
CCU

• General appearance- consciousness

• Airway- patency position of artificial airway ( if present)
• Breathing- quantity and quality of respiration (rate, depth,
pattern, symmetry, effort, use of accessory muscles0
breath sounds presence of spontaneous breathing.
• Circulation and cerebral perfusion- ECG (rate, rhythm,
and presence of ectopy) blood pressure, peripheral pulses
and capillary refill skin, colour, temperature, moisture
presence of bleeding level of consciousness,
responsiveness.
• Past medical history
• Medical conditions, surgical procedures.
 Physical assessment of patient in CCU:

• Physical assessment is an
important aspect for
providing quality of care
to patients. Following are
the systems which should
be assessed thoroughly for
patients better outcome:
• Nervous system
• Cardiovascular system
• Respiratory system
• Renal and urinary system
• Gastrointestinal system
• Endocrine system
• Musculo-skeletal system
• Reproductive system
• Integumentary system.
Nervous system- the nervous system
is the part of a human body that
coordinates its behaviour and transmit
signals between different body areas.it
consist of two main parts, called the
central nervous system and the
peripheral nervous system. Physical
assessment of this system includes:
• Observation
• - general appearance
• -mood (e.g. anxious, depressed)
• -facial expression
Stance and gait
 ROMBERG’S TEST

• Romberg's
test, Romberg's sign, or
the Romberg
maneuver is a test used in
an exam of
neurological function for
balance.
 CRANIAL NERVE EXAMINATION
• Olfactory nerve-for
ordinary clinical purposes,
olfaction is tested using a
small number of bottles
containing either a
fragrant or pungent
smelling substance such as
lemon, clove. Each nostril
should be tested
separately.
Optic nerve
• visual fields are assessed by asking
the patient to cover one eye while
the examiner tests the opposite eye.
The examiner wiggles the finger in
each of the four quadrants and ask
the patient to state when the finger
is seen in the periphery. Visual
acuity is tested by using Snellen
chart.
• Visual field defect in one eye
indicates a retinal or optic nerve
disorder.
• Oculomotor nerve-positioned in
and behind the eyes, controls
pupillary constriction. To test the
patient’s pupils, dim the lights,
bring the light of the penlight from
the outside periphery to the centre
of each eye and note the response.
Also use mm chart to describe pupil
size; descriptions such as “small”,
“medium” and “large”. Also check
where he eyelid falls on the pupil.
If it droops, note that the patient is
having ptosis.
• Trochlear nerve-it acts as
a pulley to move the eyes
down-toward the tip of the
nose.to assess the trochlear
nerve, instruct the patient
to follow your finger while
you move it down toward
his nose.
• Trigeminal nerve- it is 5 th

cranial nerve which covers

most of the face. If a patient is
having problem with this
nerve, it usually involves the
forehead, cheek or jaw. Check
sensation in all three areas,
using a soft and a dull object.
Check sensation of the scalp
too.
• -Test the motor function of the
temporal and masseter
muscles by assessing jaw
opening strength.
• Abducens nerve- cranial
nerve 6th controls eye
movement to the sides. Ask
the patient to look toward each
ear. Then have him follow
your fingers through the six
cardinal fields of gaze.
Another easy technique can be
use: with your finger, make a
big “X” in the air and then
draw a horizontal line across
it. Observe the patient for
nystagmus or twitching of the
eye.
• Facial nerve- cranial nerve 7 th

controls facial movements and

expression. Assess the patient
for facial symmetry. Have him
wrinkled his forehead, close
his eyes, smile, plucker his
lips, show his teeth, and puff
out his cheeks. Both side of
the face should move the same
way. When the patient smiles
observe the nasolabial folds
for weakness or flattering.
• Vestibulocochlear nerve- cranial
nerve 8rth located in the ears,
controls hearing. At the bed side, a
crude assessment of hearing can be
achieved by rubbing your index
finger and thumb together close to
the patient’s ear or whispering
numbers close to his ear, with the
contralateral ear occluded. Rinne’s
test is good for distinguishing
between conduction and
sensorineural deafness.
• Glossopharyngeal nerve and
vagus nerve- cranial nerve 9th
and 10th are usually evaluated
together. Whether the palate
elevates symmetrically when
the patient says “AHHHH” is
noted. If one side is paretic the
uvula is lifted away from the
paretic side. A tongue blade
can be used to touch one side
of the posterior pharynx, then
the other, and symmetry of the
gag reflex is observed.
• Accessory nerve- cranial
nerve 11th this nerve controls
neck and shoulder
movement. Ask the patient
to raise his shoulders against
your hands to assess the
trapezius muscle. Then ask
the patient to turn his head
against your hand to assess
the sternocleidomastoid
muscle.
• Hypoglossal nerve-
cranial nerve 12th
innervates the tongue. Ask
the patient to open their
mouth and inspect the
tongue for any wasting or
fasciculation. Ask the
patient to protrude the
tongue and move from
side to side.
 CARDIOVASCULAR ASSESSMENT-

Observation-
• -symptoms and wellbeing: breathlessness, distress
• -body habitus: body mass (obesity, cachexia), -tissue perfusion: skin
temperature, sweating, urine output.
• Radial pulse: rate and rhythm.
• Blood pressure
• Carotid pulse, jugular venous distension
• Face and mouth: look for pallor skin, central cyanosis, malar flush,
• Hands- look for the signs of clubbing, splinter haemorrhages and other
stigmata of infective endocarditis.
MARFAN’S SYNDROME.
• Thorax: the anterior thorax and the posterior thorax are inspected for skeletal
deformities that may displace the heart cause cardiac compromise. The skin
on the chest wall is inspected for scars, bruises, wounds and bulges associated
with pacemaker or defibrillator implants.
• Abdomen: the abdomen is assessed for the sign of ascites or distension
which may be associated with right sided heart failure as abdominal adiposity
is a known factor for CAD.
• Lower extremities: inspected for the sign of peripheral arterial or venous
vascular disease. The visible signs of peripheral arterial vascular disease
include pale and shiny legs with sparse hair growth. Venous disease causes
oedema of the limb, with deep red rubor, brown discoloration.
• Auscultation: cardiac murmurs, s1, s2 sounds, any abnormal
sounds.
 RESPIRATORY SYSTEM
• -observe the patient generally and the surroundings. Look for any medicine,
sputum cups, inhalers, nebulizers or, for example, CPAP machine around the
patient’s bed. Is the patient using oxygen- if so, how much, what is the rate?
• check the face for signs of anaemia or cyanosis and Horner’s syndrome, as
well as evidence of ptosis and miosis.
• -ask the patient’s permission for the examination and ensure he is lying
comfortably at 45 degree.
• -examine the hands for digital clubbing, tar staining, peripheral cyanosis,
signs of occupation co2 retention flap.
• -count the respiratory rate.
• -assess jugular venous pressure.
SHAPE OF CHEST
HORNER’S SYNDROME
• Do percussion to rule out pleural effusion.
• Do auscultation to hear: breath sounds (normal, bronchial, louder
or softer. Added sounds like- wheezes, crackles, rubs), spoken
voice (vocal resonance): absent (effusion), increased
(consolidation).
• check for pitting oedema of ankles, cor pulmonale and venous
thrombosis
 RENAL SYSTEM EXAMINATION
• Health history- ask to the patient regarding history of diseases that are related
to renal or other urologic problems. Like- hypertension, diabetes mellitus,
gout or other metabolic problems.
Inspection:
• Skin- pallor, yellow grey cast, excortions, changes in turgor, bruises, texture
(e.g., rough,, dry).
• Mouth- stomatitis, ammonia breath odor.
• Face and extremities- generalized oedema, peripheral oedema, bladder
distension, masses and enlarged kidneys.
• Abdomen- skin changes described earlier, as well as striae, abdominal
contour for midline mass in the lower abdomen ( may indicate urinary
retention) or unilateral mass ( occasionally seen in adult, indicating
enlargement of one or both kidneys from large tumour or polycystic kidney).
• Palpation: renal palpation identifies masses and areas of tenderness in or
around the kidney. The abdomen is lightly palpated in all quadrants. The
nurse ask about areas of tenderness or discomfort and examines non-tender
areas first.
• Auscultation: the nurse listens for a bruit over each renal
artery on the mid clavicular line. A bruit is an audible
swishing sound produced when the volume of blood
vessel changes. A bruit is usually associated with blood
flowing through a narrowed vessel, in renal artery
stenosis.
 GASTROINTESTINAL SYSTEM
History collection: Location and duration of pain
• Duration and quantity of bleeding
• Associated symptoms
• Previous history
• Change in bowel pattern
• Current medications
• Recent intake of food and what kind
• Past surgical history
Inspection: under this following thing should be checked- Inflammation of gums,
Dental caries, Mouth odor, Lesions, Petechiae, Striae and Signs of dehydration.
• Auscultation: it is done
immediately after the inspection to
prevent alteration in bowel
sounds.it includes listening for
increased or decreased bowel
sounds and vascular sounds. Gently
warm up the stethoscope in the
hands to prevent abdominal muscle
contraction. The diaphragm of the
stethoscope is used to auscultate
high pitched sounds (indicates
hyperperistalsis) and bell to detect
lower pitched sounds.
• Percussion: it is done to
determine the presence of
fluid, distension and masses.
The presence of air produces a
higher pitched hollow sound it
is termed as tympany.
• -Liver percussion should start
below the umbilicus in the
right mid clavicular line and
percuss upward until dullness
is heard.
• Palpation: light palpation is
used to detect tenderness,
muscular resistance, masses
and swelling.
• -during palpation note the
location, size, shape and
presence of tenderness.
• -the patient’s facial expression
should be noted to know the
non-verbal cues of pain or
discomfort.
 ENDOCRINE SYSTEM
• most examination in endocrinology is by observation the emphasis of
examination varies depending on which gland or hormone is thought to be
involved.
• -check height and weight
• -check hands for palmar erythema, tremor, acromegaly, carpal tunnel
syndrome.
• -check skin for hair distribution, dry/greasy pigmentation, pallor, bruising,
vitiligo, striae, and thickness.
• -check head: diplopia, visual field defect, hair, alopecia, frontal balding.
• -check facial feature for hypothyroidism, hirsutism, acromegaly, mental
state-lethargy, depression, confusion.
• check neck: voice-hoarse, virilised, thyroid gland- goitre, nodules.
• -breasts: gynaecomastia, galactorrhoes.
• -body fat: central obesity in Cushing syndrome and growth
hormone insufficiency.
• -genitalia: virilisation, pubertal development, testicular volume.
• -legs: proximal myopathy, myxoedema.
PALMAR ERYTHEMA
GYNAECOMASTIA
ACROMEGALY
MYXEDEMA
 MUSCULOSKELETAL SYSTEM
• Inspection- general appearance, gait, deformity, swelling, redness, rash,
swelling in hands, any deformity, nail changes, tophi Raynaud’s. Check the
trunk for kyphosis, scoliosis, and tender spots.
• Adjacent structures: muscles-wasting of muscles above and below a joint
often accompanies joint disease.
• Palpation of joints:
• Feel for any swelling and its nature
• -hard suggests bone
• -spongy or boggy suggests synovial thickening
• -fluctuance suggests an effusion (fluid).
• -position- joint or periarticular (e.g. bursa)
• Tenderness
• -assess joint margin, related ligaments, tendons and adjacent bony structures.
• Joint crepitus
• -a palpable grating sensation appreciated by a hand placed on the joint during
movement.
• Tendon crepitus
• -a dry, friction rub palpable when tendons move
• Joint movement:
• Range of joint movement
• Active movement
-movement undertaken by the patient alone
• Passive movement
-movement undertaken by the examiner
-the spine should not be moved passively.
• Examination of muscles:
• Evidence of wasting- compare sides ( measures limb circumferences)
• Abnormal bulk- body builders/ muscular dystrophies
• Spontaneous contractions- muscle spasm/ abnormal movements/fasciculation
• Palpate-tenderness (acute injury/ some myopathies).
 REPRODUCTIVE SYSTEM:
• Health history- the health history should include information about
major illness, hospitalization, and surgeries and also inquire about any
infectious involving the reproductive system. The nurse should also
inquire about any infections involving the reproductive system,
including STIs. Women should also have a complete obstetric and
gynaecologic history taken.
• Physical examination:
• -male: the examination of male external genitalia includes inspection
and palpation:
• Pubis-the nurse observe the distribution and general characteristics of
the pubic hair and the skin. Normally the hair is in a diamond shaped
pattern. The hair is usually coarser than scalp hair.
• Penis- note the size and skin texture of penis and any
lesions scars or swelling. The location of urethral meatus,
as well as the presence or absence of the foreskin should
be noted.
• Scrotum: inspect the scrotal skin which is pigmented
compared to the rest of body. The testes lies lower than
the right but both should be visible. The tone of the dartos
muscle is influenced by ambient temperature.
Consequently the normal scrotal appearance varies with
temperature.
• Examination of testes: use
gentle pressure to examine
both testicles.
• using the thumb and first two
fingers.
• note the size and consistency
of the testes.
• to size the testicals you may
use an orchidometer this is a
chart or a set of beads
indicating the size/volume of
the testicles.
• palpate the epididymis situated along the posterolateral
surface.
• This should feel smooth and is broadest superiorly, as its
head.
• finally roll with the finger and thumb to palpate the vas
deferens.
 PHYSICAL EXAMINATION FEMALE:

• Breasts: breasts are

examined first by visual
inspection. Observe the
breasts for symmetry, size,
shape, skin color, vascular
patterns, dimpling and the
presence of unusual
lesions.
• External gentalia: the nurse
uses gloves for examination of
the external genitalia. The
mons pubis, labia majora,
labia minora, perineum and
anal region are inspected for
the characteristics of skin, hair
distribution and contour
lesions, inflammation,
swelling and discharge are
noted.
• Internal pelvic examination: during the speculum examination the nurse
observes the walls of the vagina and the cervix for inflammation, discharge,
polyps and suspicious growths.
 INTEGUMENTARY SYSTEM

• History collection- specific information about the onset, signs and

symptoms, location and duration of any pain, itching rash or other
discomfort experienced by the patient need to be collected. Past
health history of trauma surgery or disease that involves the skin.
• Physical examination: assessment of the skin involves the entire skin area.
Including the mucous membranes, scalp, hair and nails.
• Inspection: the general appearance of the skin is assessed by observing color,
temperature, moisture or dryness, skin texture, lesions, vascularity, mobility
and the condition of the hair and nails.
• Palpation: skin turgor, possible oedema and elasticity are assessed by
palpation.
 RESEARCH ARTICLE
Title- assessment of nurses interventions in the management of clinical alarms
in the critical care unit, Kenyatta national hospital, a cross sectional study.
Authors- Lucy W meng’anyi, Lilian A omondi et.al
Methods- a descriptive cross sectional study was carried out in the month of
June 2014 where 87 nurses were recruited as study respondents. A structured
self-administered questionnaire was used to collect data. The questionnaire
contained some questions in a Likert scale in relation to the actions the nurses
would take in the management of clinical alarms and some on the whether
policies on alarm management existed in hospital, if they filled alarm checklists
and how often and the types pf alarms they would respond to first.
Results- the respondent’s responses were scored and from the results it was
clear that there were some gaps in the management of clinical alarms. Majority
of the nurses reported to alarm of all durations and do not fill alarm checklists
as neither alarm checklists nor protocols are provided. From the findings there
was a statiscally significant association (p= 0.06) between age and whether the
respondents assessed the cause of the alarm beep.
Conclusions- nurses in the unit carry out the standard nursing interventions on
clinical alarms and respond to alarms of all durations and do not fill alarm
checklists. Alarm protocols should therefore be developed in the hospitals, the
nurses should be trained on management of clinical alarms and more nurses
employed.
KOILONCYCHIA
LEUKONCYCHIA
FASCICULATION
ASTERIXIS
NYSTAGMUS
DUPUYTREN’S CONTRACTURES
 REFRENCES
• Suddarth’s and Brunner. Textbook of medical surgical nursing: 13 th
ed. Vol
2.Wolters Kluwer India pvt ltd; PP1566-1571.
• Glynn Michael, drake M William. Hutchison’s clinical methods: an integrated
approach to clinical practice: 24th ed: Elsevier health; PP.178-287.
• Davidson’s principles and practice of medicine. 22nd ed: Elsevier health;
PP.1081-85.
• Phipps. Monahan. Sands et al. Medical surgical nursing: health and illness
perspective: 7th ed: Elsevier health; PP 1521-32.
• Meng’anyi’ LW, omondi LA et al. assessment of nurses interventions in the
management of clinical alarm in critical care unit, Kenyatta national hospital,
a cross sectional study. BMC nurs.2017 Jul 25; 16:41.Availabe on
https://pubmed.ncbi.nlm.nih.gov/28769737.
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