ICU evaluations assess patients for complications and risk factors, with nurses often using facility-specific guidelines. The assessment can aid in treatment planning and be reviewed by medical providers to determine a patient’s response to treatment. It can also help identify potential problems early and ensure appropriate treatment is given.
An ICU evaluation is an evaluation of a patient entering or staying in the ICU to check for complications, risk factors, and other issues that may need attention. Nurses often perform the assessment and may follow facility-specific guidelines, including using a hospital-generated form to ensure a range of topics are covered. The documentation of the assessment goes into the patient’s medical record, where it can be reviewed by the medical providers involved in the case and used as a measure to determine how a patient is responding to treatment.
When patients enter an intensive care unit, they have serious illnesses or injuries that require intensive treatment and monitoring. Some may find it difficult to breathe on their own or may need external cardiac pacing to support their hearts. A critical care assessment provides an opportunity to perform a detailed examination, record patient history, and make notes that will contribute to the nursing care plan. Nurses review known history and check respiratory, cardiovascular, gastrointestinal, and other systems.
Information from a critical care assessment can be helpful in planning treatment; for example, a nurse may notice that a patient’s mental state is altered and it would be a good idea to do some follow-up testing. While the patient remains in the unit, changes in status can be noted on ICU evaluation documents. If a patient was breathing comfortably but is starting to have trouble, for example, this is an indicator that something is wrong and the patient needs more evaluation.
When complications arise and the patient receives treatment, medical providers can look at previous critical care assessments for clues. Sometimes they can provide information about what happened; for example, nurses may have noticed a decrease in urine output, suggesting a kidney problem, just before tests revealed a sudden decline in kidney function. Nurses are advised to pay particular attention to signs of delirium and otherwise altered mental status, as changes in cognitive function are a warning sign of serious complications.
Effective critical care assessment can enable nurses to identify potential problems early and treat patients quickly when complications occur. Assessments can play an important role in patient care planning; a hospital may have a policy, for example, that patients with a specific history should receive a particular type of care or supportive treatment. Setting standards of care can ensure that patients receive appropriate treatment while in a facility, to reduce the risk that a problem may be overlooked or ignored.
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