A critical care assessment is an evaluation of a patient entering or staying in intensive care to check for complications, risk factors, and other issues that may require attention. Nurses often perform the assessment and may follow specific facility guidelines, including using a form generated by a hospital to ensure that a series of subjects are covered. Documentation from the assessment goes into the patient’s chart, where it can be reviewed by medical providers involved with the case and used as a measure to determine how a patient is responding to treatment.
When patients enter a critical care unit, they have serious illnesses or injuries that necessitate intensive treatment and monitoring. Some may have difficulty breathing independently, or could be on 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 go over the known history and check respiratory, cardiovascular, gastrointestinal, and other systems.
Information from a critical care assessment may be useful in treatment planning; for example, a nurse may note that a patient’s mental state is altered, and it would be a good idea to perform some follow-up testing. As the patient stays in the unit, changes in status can be noted on the critical care assessment paperwork. If a patient was breathing comfortably but starts having 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 may peruse the earlier critical care assessments for clues. Sometimes they can provide information about what happened; for example, nurses might have noticed a decreased urine output, suggesting a kidney problem, shortly before tests revealed a sudden decline in kidney function. Nurses are advised to be particularly attentive to signs of delirium and otherwise altered mental status, because changes in cognitive function are a warning sign of serious complications.
An effective critical care assessment can allow nurses to identify potential problems early and treat patients rapidly when complications do arise. Assessments can play an important role in patient care planning; a hospital may have a policy, for instance, that patients with a specific history should be provided with a particular type of supportive care or treatment. Setting standards of care can ensure that patients get appropriate treatment while in a facility, to reduce the risk that an issue might be missed or ignored.
