Assessment – Knowledge Adjuncts

NU2ICU V3 logoASSESSMENT – KNOWLEDGE ADJUNCTS

Capillary refill is used to evaluate the ability of the circulatory system to restore blood to the capillary system (perfusion).  Capillary refill is used primarily in the assessment of paediatric patients. Refill time in adults is not considered as accurate due to differences in circulation from medications and various other factors. This can still be used as a simple test of perfusion to the extremities, but many factors must be considered, such as the age of the patient and the environment (eg cold will decrease capillary refill time)

Capillary refill is evaluated at the nail bed in a finger (or if profoundly shutdown press similarly on the central sternum)

  • Place your thumb on the patient’s fingernail and gently compress
  • Pressure forces blood from the capillaries
  • Release the pressure and observe the fingernail
  • As the capillaries refill, the nail bed returns to its normal deep pink colour
  • Capillary refill should be both prompt and pink
  • Colour in the nail bed should be restored within 2 seconds or about the time it takes to say “capillary refill.”

 

LUNG DISEASE

Does your patient have Chronic Obstructive Pulmonary Disease or COPD (otherwise called COAD or CAL)?  This is where a patient suffers chronic bronchitis and or emphysema, and is one of the most dangerous diseases that can make your routine interventions cause harm as some COPD patients can develop Type 2 respiratory failure (sometimes known as being a CO2 retainer) which will alter your use of oxygen

Your assessment of established COPD patients should include levels of activity that the patient achieves usually, supplemental oxygen if used at home – how much and how long, any known causative factors like smoking and triggers such as cool night air or pollution

In these patients’ osteoporosis, pulmonary hypertension, heart disease, muscle wastage and depression are common

               http://www.alternativetreatments.net/copd viewed online 03/10/2014

http://www.drugs.com/health-guide/images/205041.jpg viewed online 09/11/2014

COPD patients often present with increased work of breathing.  Work of Breathing is a term that requires a clear understanding and starts with comparison of patients current condition verses the usual (noting always that every COPD patient will have a different version of what is ‘usual’)

  • Assessment of body position – increased need to be upright, restless, wanting to sit out of bed
  • Visible movements of chest/abdomen and uneven breathing pattern
  • Listen for abnormal audible airway sounds (snoring, hoarse speech, grunting and wheezing)
  • Abnormal posture (ie. sniffing position, tripod position, head bobbing)
  • Between rib retractions
  • Nasal flaring
  • Prolonged forced exhalation
  • Pursed lip breathing
  • Grunting, gasping
  • Tachypnoea

These all reflect the adequacy of airway, oxygenation and ventilation and the effort of the patient to maintain them

CLASSICAL COPD PATIENT

 “Signs and symptoms of COPD” (modified from Black, J.M & Matassarin-Jacobs, E (1993) Luckmann and Sorensen’s Medical-Surgical Nursing 4th ED, Saunders)

 

SKIN TURGOR

All skin should be uniformly thick (or thin) and to assess turgor gently squeeze the skin on the forearm or back of the hand to raise it from it’s usual position as shown.If it takes over 30 seconds or stays tented the patient has poor turgor  Decreased skin turgor is a late sign in dehydration.  It occurs with moderate to severe dehydration.  Fluid loss of 5% of the body weight is considered mild dehydration, 10% is moderate, and 15% or more is severe dehydration

  • Decreased fluid intake
  • Dehydration
  • Diarrhoea
  • Diabetes
  • Extreme weight loss
  • Heat stroke (excessive sweating without enough fluid intake)
  • Vomiting

Connective tissue disorders, such as scleroderma, can also affect the elasticity of the skin.  This does not have to do with fluids, but is a change in the elastic properties of the skin tissue

 

SHOCK

As previously discussed, shock is usually defined as a mean arterial blood pressure (roughly a third of the average between systolic and diastolic pressures) of less than 60mmHg.  This pressure, like everything else with assessment, is relative to the patient’s normal however at this pressure it is recognised that decreased perfusion to the renal, cardiac and cerebral systems will begin to display symptoms.  Of all the things that can kill you, if caught early shock is one of the most easily remedied
There are 3 stages of shock;

  • Compensated – where body mechanisms are activated to maintain adequate BP and tissue perfusion
  • Progressive – compensatory mechanisms begin to fail and symptoms become apparent
  • Decompensated or irreversible – without extreme treatment the patient will soon die

Shock is generally caused by 3 main issues; pump failure (cardiogenic), intravascular fluid depletion (hypovolaemic – bleeding or dehydration) or systemic vasodilation (sepsis or distributive).  As the body self regulates in a delicate balance it will trigger internal responses to maintain homeostasis
Symptoms of Compensated Shock As adrenaline/noradrenaline is released by the body to raise the BP it causes; tachycardia, rising diastolic BP, cool peripheries / decreased capillary refill, anxiety, nausea, decreased urine output, tachypnoea, raised BGL, pupillary dilation
This is all due to systemic vasoconstriction and increased sympathetic activity, the body is working hard to maintain normality and to support its compensatory systems.As the body exhausts its reserves the systems begin to obviously fail, BP dramatically drops and SaO2 drops as a decreasing flow of oxygenated blood perfuse the body
Time to consider just how many of the above symptoms of shock we would detect in the 12 second “good to go” assessment?  You’d see a slightly panicked patient, breathing fast and looking pale – this would trigger you to perform vital signs or if not immediately available then talk to your patient and assess their ability to respond if they normally can or listen to and count their breathing, determine capillary refill time by pressing on their sternum for 5 seconds – if refill is longer than 4 seconds that alone means time to act (add O2, raise patient legs / call for help etc).As part of your plan of action include a quick BGL (as hypoglycaemia looks very much like this too) and within the next 10 minutes your initial assessment would have led to a cascade of care that may indeed actually save your patients life!

HYPOGLYCAEMIA

As stated above hypoglycaemia may have very similar symptoms to shock in its early stages and if left untreated may cause eventual coma and death

  • Hypoglycaemia < 3.5mmol/L
  • Normal levels 4 – 6mmol/L before meals and 4 – 8mmol/L after meals

If the patient is a known diabetic and you are unable to check BGL immediately treat as hypoglycaemic event as well as continuing as for shock.  A temporary hyperglycaemia is far, far better than a temporary hypoglycaemia

 

REFERENCES

Oh’s Intensive Care Manual 7th Edition 2014 by Andrew Bersten, Neil Soni

The ICU Book 4th Edition 2015 by Paul L Marino

Pilbeam’s Mechanical Ventilation: Physiological and Clinical Applications 6th Edition by J M Cairo

ACCCN’s Critical Care Nursing 2nd Edition 2012 by Doug Elliott, Leanne Aitken and Wendy Chaboyer

More reading

NU2ICU GENERAL ASSESSMENT

NU2ICU PRIMARY ASSESSMENT

NU2ICU SECONDARY ASSESSMENT

NU2ICU AUSCULTATION SKILLS

NU2ICU NORMAL VALUES

NU2ICU RRS / MET VALUES

NU2ICU ASSESSMENT PRACTICE TOOL