(1)
Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
Keywords
Approach to patientHistoryPhysical examinationPresentationLaboratory testsImagingDaily roundsIntensive care units embody the miraculous advances of modern medicine. An ICU provides an environment where high-quality, compassionate, physiologically orientated, and evidence-based medicine can be practiced. The ICU is an exciting and challenging place to work and provides a remarkable learning environment. The keys to a successful rotation in the ICU are (1) teamwork and (2) a systematic, disciplined, and organized approach to patient care.
Admission History and Physical Examination
It is essential that a detailed and systematic history and physical examination be performed on all patients admitted to the ICU. This should include past medical and surgical history, current mediations as well as details of the current illness. The patient’s code status and the presence of advance directives should be established on admission to the ICU. The initial physical examination frequently serves as the baseline reference, and it should include a basic neurological examination (including reflexes, motor power, evaluation of mental status, and funduscopic examination). Following the history and physical examination, and review of the available laboratory data and chest radiograph, a differential diagnosis and a management plan should be formulated.
The patients’ weight and height should be measured (directly, with a scale and tape measure on admission to the ICU). These values should not be estimated as they are frequently WRONG [1]; the height and weight are used in dosing calculations as well as estimation of GFR and Predicted Body Weight (PBW); so the correct data should be used.
Daily Examination
It is essential that the patients’ flow sheet (paper or electronic) over the last day be thoroughly reviewed and the major events of the last 24 h be documented. Most ICU’s use a 24-h flow sheet which runs from midnight to midnight. Hence when reviewing and documenting the patients’ progress over the “last day” the last 24-h period (midnight–midnight) as well as the progress since midnight should be reviewed. The following serves as a guideline for the daily progress note.
It is important to be systematic and develop a consistent template for your daily progress notes.
General
Primary and secondary diagnoses. Overall condition of patient. Events of the last 24 h.
Vital Signs (24 h Min and Max and Current)
temperature
blood pressure, including MAP
pulse (rate and rhythm)
respiratory rate
arterial saturations
Fluid balance and urine output are VITALLY important in the daily and ongoing evaluation of the ICU patient. The following should be recorded:
24 h in
24 h out
24 h urine
Output of each drain should be noted
Cumulative fluid balance
Additional Observations
The doses of all pressors should be documented
The presence of all pulses and the adequacy of peripheral perfusion
Limb symmetry and swelling (?DVT)
Presence of rashes and decubitus ulcers
The presence of all invasive lines, tubes, and devices should be noted including the duration of each central line
The Ventilator
The ventilator is an extension of the patient and it is therefore essential that the following features be recorded
Mode
assist control (volume or pressure)Related posts:
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