A systematic approach and use of checklists can improve outcomes.

Use of ‘FAST HUGS-BID’ should be incorporated in patient assessment.

Best evidence and current ‘care bundles’ should be incorporated.

Good communication and documentation are vital.

During initial assessment and in cases of emergencies, airway, breathing, circulation, disability and exposure (ABCDE) approach is appropriate.

Head-to-toe assessment approach is important for scheduled and subsequent examinations.

Initial Assessment

Subsequent Assessment

History

Focused History

Detailed History

Physical Examination

ABCDE Approach

Head to Toe Assessment

Investigations

Focused Investigation

Detail investigation

Diagnosis

Physiological diagnosis and diagnosis of life-threatening issues

Definitive Diagnosis

Treatment

Resuscitation and stabilization

Definitive Treatment

Reassessment

Response to resuscitation

Recovery

Avoid focusing intently on monitors and charts. Patients are important! Don’t ignore them!!

Traditional wisdom that 90% of the diagnosis is in the history is equally applicable to ICU patients.

If awake, patients can explain their problem, making identification of problems easier.

Sometimes, patients might be awake only for a short time before deterioration. So, timely history taking is vital sometimes.

Detailed history must be taken at admission only after stabilization. Sometimes old documents and referral letters might be the only sources for history.

History regarding new issues and problems should be taken at the start of each shift.

Information regarding a patient's physiological reserve, their quality of life, and their attitude towards treatment is equally important.

A systematic approach must be used and a ‘Head-to-Toe’ system is appropriate.

The type and frequency of monitoring should be based on the underlying disease process, the physiological reserve of the patient, and the degree of clinical suspicion.

Height or length of the patient should be measured and documented.

Predicted body weight (PBW) should be calculated and recorded.

If possible, actual body weight (ABW) of the patient should be measured and documented daily.

Try to avoid making assumptions about what other medical staff has done. Perform your own examination.

Glasgow Coma Scale (GCS): Frequency of examination might depend upon the disease condition. In most instances, it is monitored hourly. If the patient is sedated, for example to control intra cranial pressure (ICP) or in severe acute respiratory distress syndrome (ARDS), GCS should be assessed only after stopping the sedatives. If the patient has no neurological issues, GCS can be assessed only 1-2 times a day to promote sleep.

Full Outline of UnResponsive Score (FOUR) score can be used alternative to GCS, if decided by clinical team.

Pupils: Size and reaction should be performed and recorded. It should be assessed and recorded every hour in patients who are sedated or have any neurological issues. In patients, with no neurological issues, assessment frequency can be changed.

Pronator Drift: Pronator drift should be assessed every hour in patients with neurological issues or patients who might develop neurological issues.

Grip, Motor Power and Sensory examination to touch: Should be done every hour in patients with neurological issues or patients who might develop neurological issues.

A full cranial and peripheral nerve Examination: Should be performed once daily when indicated. e.g., Guillain Barre Syndrome (GBS)

Sedation Score (Richmond Agitation Sedation Scale (RASS): Target and achieved RASS, both should be recorded. Any change in RASS should also be recorded.

Pain Score: Numeric Rating Scale (NRS)/Visual Analogue Scale (VAS)/Critical Care Pain Observation Tool (CPOT) should be assessed and recorded every hour in all patients receiving analgesics. If there are no issues of pain, assessment frequency can be changed.

Delirium: Confusion Assessment method for the ICU (CAM-ICU) Score should be assessed once every 6 hours or more frequently if indicated.

Sleep Pattern: Should be observed and recorded.

Seizure episodes: Record if any seizure occurs. The type of seizure should be recorded.

Intracranial Pressure (ICP) Monitoring: Should be measured continuously or as indicated. Cerebral Perfusion Pressure (CPP) should be recorded. Monitor External Ventricular Drain (EVD) in terms of level/height, open/clamped, drain volume and characteristics.

Airway: Self maintained or endotracheal intubated or tracheostomized.

Endotracheal Tube: Record Size/ length fixed/ position.

FiO ₂ and mode of O ₂ delivery should be assessed and recorded.

Pattern of Respiration: Assess for respiratory distress: regular/irregular respiration; labored breathing or not; accessory muscles used or not at least 6 hourly.

Chest Auscultation: Lungs should be auscultated for air entry and added sounds (wheeze or crackles) every hour in all mechanically ventilated patients and at least 6 hourly in non-ventilated patients.

Mechanical Ventilation: Mode and Settings should be assessed and recorded.

Plateau pressure/Peak airway pressure/Driving pressure/Tidal Volume/Minute ventilation/I:E ratio should be monitored and recorded every hour.

Monitoring:

SpO₂: Should be monitored continuously and recorded every hour.

Respiratory Rate: Should be measured and recorded every hour.

PaO₂/FiO ₂ Ratio: Should be measured at least once daily in mechanically ventilated patients or more frequently as indicated.

PaCO₂: Should be measured at least once daily in mechanically ventilated patients or more frequently as indicated.

EtCO₂: Should be monitored continuously in all mechanically ventilated patients.

In non-intubated patient, cough, secretion load and swallow function should be assessed every 6 hours.

In a mechanically ventilated patient:

Assess oral and tube secretion every hour or as indicated.

Assess and maintain Cuff pressure every hour.

Chest Physiotherapy: Record if done.

Chest Drain: Monitor and record-Site, drain Volume, column movement and bubbling.

Note any surgical emphysema.

Heart Rate/ Pulse Rate: Should be monitored continuously and recorded every hour.

Electrocardiogram (ECG): Rhythm, pacing, arrhythmias should be monitored continuously.

Blood Pressure:

Monitor Invasive or Non-invasive methods of recording.

Systolic Blood Pressure (SBP)/Diastolic Blood Pressure (DBP)/Mean Arterial Pressure (MAP): Should be measured and recorded every hour. The frequency can be changed to less frequent once the patient is stable and ready for transfer-out in the next 24-48 hours.

Support for Blood Pressure: Vasopressors and required doses should be recorded.

Peripheral perfusion:

Capillary refill time should be examined and recorded as Brisk, Sluggish or Absent at least 6 hourly or more frequently if indicated.

Peripheral pulses: Dorsalis Pedis and Radial pulses should be examined at least 6 hourly or more frequently if indicated.

Peripheral edema: Should be examined at least once in a shift. Grading of edema should be done.

Jugular Venous Pressure (JVP): Raised JVP should be looked for at least once a day.

Mucosal dryness: Mucus membrane should be examined for dryness at least every 6 hours.

Temperature: Should be measured and recorded hourly.

Auscultation of the heart: Should be done at least once a day.

Hemodynamic Monitoring (when indicated and available):

Central Venous Pressure (CVP)/Right Atrial Pressure (RAP).

Cardiac Output (CO)/Cardiac Index (CI).

Systemic Vascular Resistance (SVR)/Pulmonary Vascular Resistance (PVR).

Left Atrial Pressure (LAP)/Pulmonary Capillary Wedge Pressure (PCWP).

Pulse Pressure Variation (PPV).

Full Abdominal examination: Should be done at least once daily.

Surgical Drains: Volume and drain characteristics should be monitored continuously. The drain amount should be recorded once a day or more frequently if indicated.

Bowel Sound: Assess and record every 6 hours.

Abdominal Girth: Measure and record every 6 hourly when indicated.

Intra-Abdominal Pressure (IAP): Measure and record every 6 hourly when indicated.

Bowel Movement and Stool characteristics: All bowel movements and date and time of last bowel movement should be recorded.

Nasogastric/Orogastric Tube:

Confirmation of position should be done daily.

Monitor drain volume and character if used for drainage.

Nutrition:

Daily Calorie and protein target should be calculated and recorded

Last 24-hour calorie and protein intake should be calculated and recorded.

Route and volume of feeding should be assessed and recorded.

Urine Output: Measure and record every hour where appropriate.

Foley Catheter: Duration of placement and need of continuation should be assessed daily.

Daily and cumulative fluid balance should be calculated.

Renal Replacement Therapy (RRT): Ultrafiltrate (UF) and duration should be recorded.

Blood Glucose should be monitored as per protocol.

Calculate Braden Score daily.

Any incision mark, scars or sore: Assess and document if present.

Look for signs of Deep Vein Thrombosis (DVT): Unilateral swelling, usually painful, warm and red.

Look for any swelling, wound, discharge or dressing.

Assess and record the insertion date, any dressing change, functioning of Central Venous Catheter, Arterial line, Peripherally Inserted Central Catheter (PICC), Dialysis Catheter, Endotracheal Tube/Tracheostomy Tube, Foley Catheter, Orogastric/Nasogastric/Percutaneous Endoscopic Gastrostomy (PEG) tube, Peripheral Intravenous lines.

Assess and document any signs of infection, fever, local redness, swelling, tenderness.

Look for laboratory parameters of infection: WBC, CRP, Procalcitonin and other markers.

Review investigation reports: Gram stain (GS)/culture sensitivity (CS) of appropriate fluids and samples, Polymerase Chain Reaction (PCR), etc.

Isolation: Review and implementation of isolation protocol

Surrogate Decision Maker (SDM) should be identified.

Goals of care or any advance directives, if any should be documented.

Assessment of frailty is important.

Feeding: Ensure nutrition has been assessed and that the patient’s nutrition needs are being met.

Analgesia: Patient should be assessed and pain relief given for the patient’s disease process.

Sedation: Sedation should be assessed and patients should not be over sedated. Daily sedation breaks should be considered.

Thromboprophylaxis: All patients should receive prophylactic dose subcutaneous low molecular weight heparin (or unfractionated heparin) unless contraindicated. Mechanical sequential compression devices should be used if heparin is contraindicated.

Head of Bed (HOB): Should be elevated to 30-45 degrees.

Ulcer (Stress) prophylaxis: All ventilated patients should receive stress ulcer prophylaxis.

Glycemic Control: Blood glucose should be maintained <180 mg/dL using ICU blood glucose management protocol.

Spontaneous breathing trial.

Bowel care.

Indwelling Catheters: Assess the need of Indwelling Catheters daily.

De-escalation of Antibiotics: Assess if the patient’s antibiotics can be narrowed or discontinued.

Point of Care Ultrasonography (POCUS) should be used for assessment whenever possible.

Review of investigations and imaging.

Follow-up of awaited reports.

Review of medications.

Route of administration and dosing.

Drug interactions.