1. Focused History and Physical Exam:
Critically Ill Patients
Nelia B. Perez RN MSN
PCU Mary Johnston College of Nursing

2. Focused History and Physical Exam
• Pt Hx
• Pt story of significant events related to current
problem
• Usually begins with pt C/C
• Many disease conditions are 1st suspected by
symptomology
• MI
• Diabetics
• Allergic rxn
• OD

3. Focused History and Physical Exam:
Medical Patients
• What:
• Rapid assessment of medical conditions that may require
emergency care OR early hospital tx.
• Who:
• Non traumatically injured pt with medical c/c
• How:
• Focus
• C/C
• Signs/Symptoms
• SAMPLE history
• Medical PAST
• OPQRST history
• Medical PRESENT
• Baseline vitals
• Plan of FUTURE treatment

4. SAMPLE HISTORY
• S= Signs and Symptoms
• A = Allergies
• M = Medications
• P = Past pertinent medical hx
• L = Last oral intake
• E = Events prior to the condition

5. OPQRST HISTORY
• OPQRST Hx
• Branch of SAMPLE Hx
• Focuses on Signs and Symptoms
• Gives a clearer picture of pt C/C and its severity

6. OPQRST Hx
Onset
• O = Onset
• When the complaint first started.
• The pt activities at the time of onset/immediately
before
• “What were you doing when this started”
• Chest pain pt – mowing lawn
• Anaphylaxis pt – stung by bee
• Diabetic pt – Working in hot day without food

7. OPQRST Hx
Provocation
• P = Provocation
• What actions make the symptoms better/worse
• “Is there anything that makes it better?
Anything that makes it worse?”
• Chest pains – Worse with activity Better
with rest
• SOB – Better when sitting Worse when
lying flat
• Etc…

8. OPQRST Hx
Quality
• Q = Quality
• Subjective description of
complaint in pt own words
• “Would you please
describe the pain. What
does it feel like”
• Chest pains –
Crushing, vice-like,
elephant
Crushing
Stabbing
Burning

9. OPQRST Hx
Radiation
• R= Radiation
• Is the pain local or does it travel
to another part of the body
• “Is the pain in one place or
does it spread to other parts
of your body?”
• Chest pains
• L shoulder, arm, jaw,
neck ,back

10. OPQRST Hx
Severity
• Severity
• 1-10 scale gauging pain
• “On a scale of 1-10, 1
being the least pain
you’ve felt and 10
being the worst pain
you’ve ever felt can
you rate the pain?”

11. OPQRST Hx
Time
• T = Time
• Duration of the C/C and assoc complaints
• “How long has this been going on?”
• Chest pains – Woke pt from sleep that night
• Allergic rxn- 15-20 min

12. Problem Focused Medical
Assessment
• Responsive Medical Pt
• Problem Focused Medical Assessment
• SAMPLE Hx
• OPQRST Hx
• Focused Physical Exam
• Chest/neck- chest pains
• Pharynx/chest- SOB
• Etc…
• Baseline Vitals

13. Rapid Medical Assessment
• Unresponsive/AMS Medical Pt
• Rapid Medical Assessment
• Rapid assessment of ALL body regions (DCAP-BTLS)
• Try to define C/C or ID trauma
• Rule in/out trauma
• Medical ID tags
• Baseline Vitals
• SAMPLE & OPQRST Hx when/if possible
• Tx in recovery position

14. Focused History and Physical Exam:
Medical Pt Recap
• S – Signs/Symptoms
• A - Allergies
• M - Medications
• P – Past pertinent medical hx
• L – Last oral intake
• E – Events leading to condition
• O - Onset
• P - Provocation
• Q - Quality
• R – Radiation
• S - Severity
• T – Time
• BASELINE VITALS

16. INITIAL ASSESSMENT OF THE
CRITICALLY ILL PATIENT

17. A critically ill patient is one at
imminent risk of death; the severity
of illness must be recognized early
and appropriate measures taken
promptly to assess, diagnose and
manage the illness.

18.  The approach required in managing the critically ill
patient differs from that required in less severely ill
patients with immediate resuscitation and
stabilization of the patient s condition taking
precedence: patient’s
PHILOSOPHY OF MANAGEMENT

19. 1. Prompt resuscitation & adhering to advanced life
support guidelines
2. Urgent treatment of life threatening emergencies
such as hypotension, hypoxaemia , hyperkalaemia ,
hypoglycaemia and dysrhythmias life-hypoxaemia,
hyperkalaemia,
PRIORITIES

20. cont.;
3. Analysis of the deranged physiology
4. Establish a complete diagnosis as history & further
diagnostic results are available
5. Careful monitoring of the patient s condition and
response to treatment patient’s
PRIORITIES

21. CARDIOVASCULAR SIGNS
1. HR
2. BP
3. PERFUSION
4. OLIGURIA
5. ARREST
How To Recognize?

22. 1. RATE
2. DISTRESS
3. THREATENED OBSTRUCTION/OBSTRUCTION
4. RISING PaCO2
5. DECREASING SPO2
6. ARREST
RESPIRATOY SIGNS

23. 1. THREATENED AIRWAY OBSTRUCTION/OBSTRUCTION
2. SUDDEN DETERIORATION IN CONSCIOUSNESS
3. GCS
4. ABSENT GAG/COUGH
5. FAILURE TO OBEY COMMANDS
6. REPEATED SEIZURES
NEUROLOGICAL SIGNS

24. 1. Initial assessment
2. Immediate management
3. Monitoring
4. Initial investigations
What are the steps to be followed?

26.  Basic hemodynamic monitoring
ECG, BP, CVP, PAP, CO
 ABGs, lactate, H ion,
 Urine output
 Fluid balance
 Lung mechanics, capnography
 Peripheral skin temp
 O2 transport
MONITORING

29. FLUID MANAGEMENT

30.  Failure to supply sufficient oxygen to meet the
metabolic requirements of the tissues is the cardinal
feature of circulatory failure or ‘shock’.
SHOCK & LOW CO

32. ALGORITH OF SHOCK

33. Level of consciousness
Level of consciousness should also be assessed upon
initial contact with your patient and continuously
monitored for changes throughout your contact with
the patient.
THE COMMON VITAL SIGNS

34.  a. AVPU. The AVPU scale is a rapid method of
assessing LOC. The patient's LOC is reported as A, V,
P, or U.
Level of Consciousness

35.  b. Glasgow Coma Scale. The Glasgow Coma Scale is
an assessment based on numeric scoring of a
patient’s responses based on the patient's best
response to eye opening, verbal response, and motor
response. The patient's score (3 to 15) is determined
by adding his highest eye opening, verbal response,
and motor response scores.
Level of Consciousness (CONT)

37.  c. PEARRL. Use the guide PEARRL when assessing the
pupillary response of the patient's eyes.
Level of Consciousness (CONT)

38. BLOOD PRESSURE
several factors that can affect a patient's blood pressure.
a. Condition of Cardiovascular System.
b. Age.
c. Gender.
d. Physical Fitness.
e. Obesity.
f. Pain.
VITAL SIGNS

39. g. Emotion.
h. Gravity.
i. Exercise.
j. Disease.
k. Drugs.
l. Eating.
m. Bleeding.

40. FACTORS NOTED WHEN TAKING A PATIENT'S
BREATHING RATE AND QUALITY
a. Rate.
b. Depth.
c. Rhythm.
d. Quality.
e. Unusual Position.
RESPIRATORY RATE

41. f. Coughing.
g. Sputum.

42. FACTORS NOTED WHEN TAKING A PATIENT'S
PULSE
a. Pulse Rate.
b. Strength.
c. Rhythm.
PULSE RATE

43. A Regular.
B Tachycardia.
C Bradycardia,
D Bounding.
E Weak (thready).
F Irregular.
G Intermittent (irregular).

44. WHAT CAUSES ABNORMAL TEMPERATURES?
a. Infection.
b. Environmental Conditions.
BODY TEMPERATURE

45. PQRST
PAIN

46. Thank You for
Bearing with
me!