Daily Assessment 2

Hello. I’m Emma. I’m one of the new FIT’S in ITU. Hi, Emma. I’m one of the advanced critical care practitioners. Are you coming to work with me this morning? Yeah. I’m coming to see this patient, James Hill. Oh, excellent. We could run through our daily assessment together, then. Yeah, that would be great, actually. Because I’ve not examined an ITU patient before. OK, no problem. I’ll just wash my hands with in the Aquagel. So James, this is Emma, and my name is Shona We’re just going to run through an assessment today to see what’s happening, and it’ll only take 15 minutes. OK?

[BEEPING]

OK, so? So you’re going to start with the airway number six– a little bit different in ITU, because something that he’s got– an ET tube. And so how So how about we look at that first? OK. And I know he’s a trauma patient, but we cleared his C spine a few days ago. And it had a CT that confirms it OK, so and this is his ET tube It’s in place, and I can see it’s a size 8. And the cuff looks like it’s filled looks like it’s filled And it’s at 23 centimetres at the lips. OK. And we’ve got capnography on the monitor to show us that it’s in the right place. And that’s is that this one? Yes.

And that looks like a nice trace for every breath that’s happening, so we know that his ET tube’s nice and patent So we’ll move onto breathing. So you want to have a wee look. Sorry, James– we’re just going to have a wee look at your chest and have a look at any injuries, wounds, drains, stressing. Oh, so he does have a drain in there. Yeah, he’s got a drain in here on the left. Shall I have a look at it for you? No. Or is it bubbling or swinging? It’s not bubbling, but it is swinging. So I need to drain it to about 400 mils in there.

So he’s got a wee bit of drainage, and then you want to check for equal expansion. So I can see his chest is rising and falling in his sleep. And let me just have a look at you. And while you’re doing that, look– you can have a look at the ventilator– it’s set on 3. It’s on 60% oxygen. Well, that’s a quite a lot. And we’ve got him on 6 mils a kilogramme of tighter volume. So we’ll lung protect the ventilation. It’s got a respiratory rate of 26 and a peak of 8 just to give him a little more opening his alveoli at the end of inspiration So how did his chest feel?

So he did have equal expansion, and I’m going to cross his chest. [TAPPING]

It’s a wee bit duller at the bases. Do you want to have a wee look at that? Second CU saturation is there at 98. And I think, actually, he had a gas done this morning, I know, we can look at, too.

So I can hear breath sounds throughout, and they’re duller in the axilla and at the bases. Which is quite common for a ITU patient. We’ll have a quick look to it, and this morning his hydrogen ion at 41, and he had a PO2 of 18 and a PC02 of 6. Right, OK.

And his lactate is 1.2 so the ventilator settings are ok.. OK. I’m reasonably happy with that And we’ll have a quick look at his chest X-ray when he must have one and have another look at that. when we’re doing that.. And then from a circulation point of view, we’ll start with the hands. So he feels actually quite warm. Yeah. This side is also nice and warm.

So I think he’s quite well profused. Will I do a cap refill? That sounds good. So 5, 4, 3, 2, 1. 1, 2. Yep, so that’s normal. And we have a feel of his radial pulses while we’re here. Is this an arterial line? It is an arterial line. OK. So sometimes you can can’t feel as well. Yeah, it’s a bit difficult. Yeah.

He’s got a good pulse here. And that’s the arterial tree? Yes. So it looks like it’s quite good, and his blood pressure is 120 over 79. And we could probably come up and– although when I think about circulation– we could look at his JDP– something quite difficult in ITU patients, because they often have lines in– but we can have a look, and he’s got a CBP– which is telling us 9.5. OK. let’s listen for some heart sounds. OK.

His heart sounds are clear. He’s on a little bit of noradrenaline for his blood pressure. He’s on 5 mils an hour, so we’ll keep that in mind when we’re thinking. So that’s probably why his blood pressure’s so nice. [LAUGHS] OK. And if we have a quick look and just check about his edoema in these legs and the circulation Sorry, James– just lifting these sheets. So I don’t see any peripheral oedema, and he’s well profused. And he’s beginning to swell. And I think he’s got an ECG this morning, actually, as well. So we can have a quick look at that and see what you think.

He’s got some t-wave invertion. So we should probably compare that to a previous one and make sure that’s not new. Yeah, yeah. OK. But the rate and rhythm are normal. He’s in a sinus rhythm.

And then moving on to disability now– [LAUGHS] well, we’ve prompted with the pumps. [LAUGHTER] So he’s on bit of propofol at 10 and fentanyl at 2. It’s for a bit of sedation and just to let him tolerate that ET tube. OK. But we should probably start with the GCS] and see what he’s doing. OK. Hello, James. Can you hear me? Can you open your eyes for me? So he’s not opening his eyes spontaneously or to voice. So try and stimulate him with pain So just a trapezius squeeze– hello, James! He’s still not doing anything. Do you think that’s because of the propofol. Could be.

Possiblt but we can have a wee look Do you want to have a quick look at his pupils? There’s a torch there.

Pupils are size 3 and they are reactive [ Sorry, James. I’m sorry. Now, did you say you’ve done a motor score? No, so [V he’s got the ET tube in . And then for motor response.

That would be slight localizations of pain so that’ll make him a four.

And we’re going to have a wee feel of his tummy. Sorry, James. I’ll try and keep you decent. And he had a pelvic fracture that’s been fixed in theatre. Yes. So he’s got a rhythm there as well.

James, I’m going have a gentle feel of your tummy here.

So his tummy’s nice and soft, and the wound dressing looks clean. And we’ve got an NG tube in him. Just now, but we’re not feeding him yet. So we need to keep that in mind for we can check it’s position. Do you like to have a wee listen and see if he’s got bowel sounds. Yeah.

Yeah, I can hear them. Sorry, James. We’ll cover you up now. A nifty bit– we should probably think about your blood sugar as well and make sure that’s normal. So let me check that one next. So you had his blood sugar done half an hour, and it was 7.6. OK. So that’s normal. And you, are you happy with disability? Should we move on to E which is everything else? [LAUGHS] Which we should probably include temperature, microbiology– any lines that he’s gotten in intensive care. We’ll have a look at his Kardex initially Yeah, quickly and I’ll just check his calves. They’re nice and soft.

And then his urometer has got about a litre of fluid. So let’s have a wee look at what his fluid balance was from–

OK. So you can see all the fluid that he’s had, and this is positive 92 mils at the moment. It was negative yesterday. Yeah. And temperature wise? Temperature was 37.2, and that’s been checked recently. And we can have a look at when his lines went in as well. Because that’s an important thing in ICU. So if that’s his intubation That’s his intubation, and then we’ve got our central line. OK. And then his arterial line. internal jugular vein and that was yesterday. And then we’ve got an arterial line there as well. OK. We’ll just have a look at these just to make sure and then And then make sure the cannulas It’s the arterial line, it looks like.

The cannula is ok there is no extravasation.

And then the central– it looks up here as well, that’s not moved.

Make sure we have a a quick look at his Kardex context and see if there’s anyhting that needs to be discontinued So this is James Hill. It doesn’t have any drug allergies. He’s on propofol infusion and fentanyl infusion there, and we’ve got the noradrenaline there for his blood pressure. And then he’s on ranitidine? That’s for stress ulcer prophylaxis. Well, we’re not not feeding him. OK, so we’ll need to think about when we want to start– To start feeding– OK. And then we’ll prescribe TEDs for thromboprophylaxis]. OK.

And if you have a quick look when his bubbles bust open as well, but he’s only at day 3 in the ICU And he’s got a EWI form there that’s covering his medical and nursing care while he’s in the intensive care unit. OK. Well done, Emma. So we’ll go and look at his chest X-ray now. Yes. And I don’t think there’s anything else I need to look at on the computer. No, I think we’ve covered those things. And then we can make a plan for what we’re going to do for the rest of the day. OK. Thank you for your help.