 Hi guys. So today I wanted to do a video on an ICU assessment head-to-toe ICU assessment And I wish I could do this like in the hospital or on like it's a real person real patient or even a mannequin But I'm in my office, and I don't have any patients here. Thank God But before we get started I wanted to mention that this video is sponsored by weave wearables weave wearables Makes custom insoles for your shoes, and you know how important it is as a nurse to have good shoes Good support, which means having good insoles in your shoes. It's so simple All you have to do is download their app and take pictures of your feet Choose the colors and patterns that you want I have this cute rose print on mine And I picked like a turquoise shell here on the back and it has my name custom printed on it And they ship them to your door within 10 days. 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So and I see you head-to-toe assessment is very similar yet very different from a General head-to-toe assessment if you watch my video that I did like years ago I have a head-to-toe assessment video out for like kind of like a med-search patient, but I see patients are so Intense and so I want to talk you through what I do when I walk into a room and Assess my patient so to start off your assessment starts from the second that you lay eyes on your patient And that's the first thing that's so important with any patient But especially I see you patients is right when you get into work and while you're getting report Lay eyes on your patient and look at them look at their monitors look at their ventilators get a brief overview of what's going on when I'm getting report I'm looking at labs and different images and Doctors notes and readings things like that to try and get a comprehensive overview of my patient Well at the same time like looking at them So when I walk into my patients rooms the first thing that I do besides look at them is I am looking at a couple things They're monitors the drips that they're on and the ventilator I'm just gonna pretend that this is like a typical ventilated patient because that's what we do a lot of in the ICU So I'm looking up at my monitor to look at my vitals the heart rhythm the blood pressure their oxygenation How do I plus look and I also make sure that my alarms are correctly set on my monitor because sometimes nurses will turn alarms off or Adjust the parameters and I make sure they're set specifically for what I like and what my patient needs I'm also looking at what medications are running. Is that the same thing that the night shift nurse told me Are they running at the same rates that they told me how much is left in each bag? Is the tubing expired is it not expired and I'm confirming everything that I've just been told in report and Making sure that nothing's gonna run dry I also like to look at the volumes that are programmed into my pumps So if I have a bag that has only 50 cc's left I'm making sure that it's programmed to be less than 50 cc so it beeps before it runs dry because The last thing you need is to have a life-saving medication run dry And then you're like crap in your pants for a couple seconds I also will look at the ventilator and make sure it's the same settings that are ordered or that the previous nurse told me just to get a quick little overview as to what settings my patients on and While I'm doing all this. I'm also starting to assess my patients So starting head to toe the first thing that I'm doing is a brief kind of neuro assessment So I'm shunning my light into their eyes to check their pupils I'm seeing if they have like their corneal reflex I'm seeing if they have a cough a gag basic neuro things so you can suction them to induce a cough or when I'm doing my oral care I am you can put your swab back and see if it will make them gag and some patients will some patients won't if they're sedated Heavily then sometimes they won't do anything. It's really hard to assess facial symmetry when you are Vented or have you know other tubes in your face, but I'm doing my best to assess that everything is equal on both sides I'm also looking at any tubes that are going in and out of the body So my ET to what centimeter is it at is it secured my NG or OG to what centimeter marking is it at are they secured What output is coming out of my ET tube as far as like secretions or like gastric? Fluids what color is it look like how much is coming out? I'm looking at the canister on the wall to see like is my suction hooked up Is it off is it on how much is in the canister so that way I have a good idea as far as like how much outputs Coming out of a patient moving down. I'm assessing if they have a central line But it's the dressing look like what's running into my lines are the meds compatible Are they labeled if they're labeled? Are they actually the labels on the correct? If they're actually labeled are they correct to what med is going through that tubing I can't tell you how many times it may say it's your maintenance IV fluid And then it happens to be like an antibiotic or something different So I'm just confirming that everything is accurately labeled and to continue down. I'm listening to heart and lung sounds What do they sound like? I'm listening to bow sounds. I'm pushing on the belly Feeling the bellies at heart. Is it soft? Is it tender? Is it firm? Do they have any incisions anywhere on their body? Do there need to be any dressings that need to be changed? Are there any drains coming out of anywhere? Are they full? What colors coming out? What do they smell? I know it sounds weird, but as a nurse you're like Keen to smells and as I go down I'm assessing their Foley catheter. Is it paint and Doing peri care to prevent, you know, catheter-associated UTIs I'm looking at their all extremities to see is they're swelling is it pitting is it non-pitting? Are there any skin tears bruises? Do they have good pulses in their arms and their legs and their feet and if I can't feel pulse I will go get a Doppler and make sure I can hear a pulse and if I can't hear a pulse Then you have a problem. You're also checking things like cap refill all those great things. Are they warm? Are they cold are they sweaty? Are they dry and then at some point during my shift I will turn my patient to look at their backside if they have any wounds and he soars Sometimes things get shoved under the sheets and it can cause little dents in patients skin And you just need to make sure their sheets are nice and straight I'm also looking at the Foley to see the urine output. Is it matching with the previous nurse said? What color is it? Does it have a weird like sediment in there or cloudy? Does it look infectious? Does it look like it's a orange color from a medication? Is it brown because they pee out 10 cc's a day because they're end-stage renal? Also, if they are a vented patient occasionally at this time, it depends on the patient But usually we will turn down the sedation and see where they are at Neuro wise, so I will turn my sedation meds down see if the patients can follow commands Can they move their arms? Can they move their legs? Can they squeeze my hands? Can they give me thumbs up? Can they lift their head up? All those great wonderful nursing commands that if you're an ICU nurse you're probably like yes, I do that I do that and I think that's pretty much it. I know I'm probably missing a few things here and there It's hard to like just think about everything that you do when you're not actually doing it Oh also at this time I'm usually checking a blood sugar or drawing any labs that may be due as well and giving my morning medications Flushing my NG tubes making sure things are patent and working well. I can't stress enough How important it is to have a good? Solid first baseline assessment because that way if anything changes later on in your shift You know right away that it's a change and you're not wondering did I miss something earlier on like pupils? Pupils are huge. Pupils can tell you a lot that's going on in the brain And if your patient's pupils suddenly are blown on one side or super constricted or not Reacting then you know that's a change from your previous assessment But you didn't assess your pupils but prior then how would you know that that's a change or not? This video is probably a little overwhelming if you're not in the ICU or if you're a new nurse or If you're just learning or whatever, but I hope it was educational for you guys Make sure you give this video thumbs up and check out we wearables in the description box below I will see you guys in my next video. Bye