SECTION 2: ASSESSMENT AND ADMISSION

Introduction
This section will focus on the assessment, admission and ethical/legal issues in critical care. The
emphasis will be on the application of the nursing process in critical care and the need to consider the
legal implications of admitting the patient to a critical care unit.
Objectives
By the end of this section you will be able to:
Describe the assessment of a critically ill patient and determine their critical pathway
Describe the criteria for admission to a critical care unit
State four ethical/legal issues in critical care nursing
Describe the admittance procedure of a patient in a critical care unit
Assessment of the Critically Ill Patient
It is important to remember the need to assess the patient using a holistic approach. In 1973, Margaret
Ann Berry visualised what the future of the nursing care could be like. In her fantasy she presented a
situation where patients had been fragmented according to their biological, physiological and sociological
needs. There was, however, a puzzling condition still left inside the capsule holding these needs. In her
conclusion, she said that it is clear that a patient is more than the sum total of their biological,
physiological and sociological needs (Hudak et al 1982).
Use the nursing process to identify the critically ill patient. In step one of the nursing process, the main
objective is to assess and interpret presenting clinical signs and assign remedial and nursing
interventions. For example, if a patient has respiratory distress, the remedial action could include the
administration of oxygen by mask, clearing the airways by suction, propping up patients to ease breathing
and putting the patient in a recovery position to facilitate drainage of secretion if the patient is
unconscious. A combination of these interventions could be used to achieve the same objective of
enabling access to adequate oxygen in the body.
Margaret Ann Berry (1973), and Hudak (1982) explain that assessing and dealing only with the patient's
biological, physiological and sociological needs would be inadequate. You need to look at each patient as
an individual with unique needs.
History Taking
While taking medical history you should consider both the present and past medical history of the patient.
For the medical history, attention should be focused on:
The onset of the problem, that is, when it started and how it started
Main presenting signs, including what makes them worse, for example, headaches, dizziness and
vomiting which becomes worse while standing up
Any current medication being used
Previous episode relevant and similar to the current problem the patient faces
Previous medical/surgical treatments the patient may have obtained
Physical Examination
Quick appraisal of the patient's general condition is important to help you to decide where there is need
for immediate life saving intervention. If there is no such need, you should proceed to carry out a
comprehensive examination. Each body system should be checked for impaired function. Attention should
be paid to the respiratory, digestive, circulatory, neural, urinary, endocrine, muscular and skeletal systems.
The objectives in physical examinations are to:
Obtain further evidence to collaborate the history.
Identify other bio-physiological needs of the patient that might have been left out in the history.

Determine life saving and life sustaining interventions, such as medical or surgical, and the
nursing care subsequently required.
Physical examination is done as a continuous process to serve as a tool for evaluating the patient
response to treatment. The findings are documented in the nursing notes and are used to plan the
patient's care.

Investigations
Investigations are best viewed as part of patient management, this will be covered later in relation to
particular conditions. The purpose of history taking includes looking for:
Actual evidence to collaborate history and examination findings
Signs or evidence of improvement of the patient's condition during or after
particular therapy
Evidence of the lack of response to the therapy being provided to the patient and, therefore,
providing the basis of changing the therapy

These are basic requirements in the first step of the nursing process, which deals with assessing
individual needs.

It is important to note, however, that while dealing with the critically ill patient, the evaluation and
interpretation of the presenting clinical signs, assignments of life saving techniques (such as
cardiopulmonary resuscitation) and life sustaining measures (such as maintaining fluids
electrolyte balance), are of paramount importance.

From your clinical experience you must have come across a critically ill patient.
What important signs did you note on the patient?
Did you note down any of the following?
Low blood pressure
Weak peripheral pulse
Cold extremities and peripheral cyanosis. Poor cardiac output produces constriction of arterioles and
stimulation of sweat glands, resulting in characteristically cold, pale and clammy skin. The most
frequent signs of impaired oxygen delivery to the tissues are cerebral function alteration.
Coma is an obvious sign of severe illness. Drastic changes in mental status may indicate serious
haemodynamic or metabolic abnormalities.
Reduced urinary output
Dyspnoea
High temperature
Unexplained fatigue
Chest pain
Tachycardia or palpitation
As a nurse, you must master the fine art of selecting the appropriate critical pathway of patients who enter
the emergency department. According to Ayres et al, (2000), ascribing an abnormal clinical sign to an
unimportant cause may overlook important changes in the patient's condition. As a nurse in the critical
care unit, you would be failing in your role if you noticed an important clinical sign in a patient and failed to

take
the
appropriate action.
As a rule, all critical signs should be considered as very important, while determining the clinical pathway.
One or more aetiological agents can cause these signs and symptoms. Differential diagnosis requires
consideration of all possible aetiological agents, including infection and sepsis, trauma, physical stressors
(for example, hypothermia, hyperthermia, and emotional stress), cardiovascular dysfunction, toxic agents
(for example yellow fever), insect bites, etc.
Once the critically ill patient is identified they must be categorised into the appropriate pathophysiological
state and admitted to a critical pathway, such as:
Trauma
Sepsis
Coma
Cardiac abnormalities
Over-dosage (poisoning)
These critical pathways attempt to establish the diagnosis and the management required. They help to
determine the needs of the patient that require to be addressed immediately in order to sustain and save
life. Each critical pathway has protocols and guidelines for the care of individuals.
Studies indicate that where protocols are adhered to, the mortality rate for patients tends to be low. The
mortality also decreases where high level of educational achievement was present for critical care nurses.
Other studies have found a 52% decrease in intensive care unit deaths when a full time critical care
specialist was recruited and co-ordinated the care of the patients. So as you can see, being
knowledgeable is also very important and it can help to improve the outcome of the critically ill patient.