Intensive care patients are very complex and sick. They also have a confusing array of monitoring and tubes attached that can change in a very short span of time.
The key to clinical examination of ICU patient lies in integrating the information available from the medical technology, and correlate it with patient's clinical findings and arrive at diagnosis and treatment plan.
A large amount of information is available at bedside, in order to assimilate all this, it is important to have a structured approach towards examination of patient. Following approach would be one of the ways towards a structured examination.
- Airway: Tube type, size and position (at which fixed)
- Breathing: Lungs, ventilation, oxygen delivery systems
- Circulation: Heart, vascular devices, cardiovascular drugs
- Disability: Central and peripheral neurological examination, pain, sedation
- Fluids: Status, balance, management
- Gastrointestinal: Abdominal examination, nutritional and renal examination
- Examination of the peripheries.
Approach toward Clinical Examination of the Patient
When one approaches the patient, it is very important to adhere to infection control policies of that intensive care unit (ICU). Hand washing practice is imperative, either with alcohol-based rub or soap and water. Some ICUs insist on gown and gloves for all patients or for contact isolation only. If any respiratory infection precaution is to be taken then it must be strictly adhered to.
The initial urge to approach the patient straight away should be curbed. Take a step back and have a good look at the patient and the patient's surroundings in the cubical. There is a lot of information which one could gain just by been observant. It is most important to know that this information once missed is likely to stay missed and not picked up. This may result on one missing the broad focus of the examination. Sometimes a lead question may be asked as an introduction towards clinical examination. It is important to focus on this lead question when one is approaching clinical examination.
Look at the patient, his position in bed and for any sign of pain, discomfort and distress. Observe the tubes that are attached such as drains, urine and color of drains. Look at the monitors, ventilator settings and the infusion or syringe pumps. Ask relevant questions, if permitted, e.g. dilution of vasopressors, or type of nasogastric feed that is being administered.
Ensure patient privacy, by drawing up curtains. Lower the bed and bed railings to an appropriate height so that you are comfortable. Expose the patient completely for a thorough examination, taking care that private body parts are shielded with bed sheet or towels. Please introduce yourself and any other observers to the patient. Be polite and ask their permission to examine them if the patient is awake. “Hello Sir/Madam, I am Dr ……………, I would like to examine you, are you OK with that? Warn them if you are going to use a stethoscope (often cold due to AC in the ICU), “Sir this might feel a bit cold.” Alternatively you can warm the diaphragm of the stethoscope by rubbing against the back of your hand (after hand-washing of course). Similarly also ask their permission if you are going to expose them, “Sir, I need to see your chest or abdomen, and I need to remove your clothes. May I do that?” Make sure a female nurse or doctor is present when you examine a female patient, particularly if you are going to expose her body. Always draw the curtains of the cubicle closed. A similar warning needs to be given if you are going to perform an ultrasonographic examination, please tell the patient that you are going to use cold and sticky jelly. Make sure you clean the probe with Clinisept® or other antiseptic solution (nonalcohol-based, so as to not damage the probe), and the patient's body part has to be wiped with tissue to clean the jelly after the USG.
Ask them to perform some simple task like opening the mouth. This will immediately give you an idea about the patient's condition especially the neurology, while observing the surroundings you would have definitely checked whether sedation is being administered. Inform them about your plan to examine.
After introduction, assess if the patient is capable of maintaining his airway or not. Examine the airway of the patient: Intubated or not intubated? Is the patient on noninvasive ventilation? A simple way to assess that is to check neurological status, pattern and rate of respiration and clearance of secretions.
If patient has an endotracheal tube in place then, look at the size of tube, smaller size tubes often pose difficulty in suctioning and weaning process. Look at the position of endotracheal tube at angle of mouth and compare it with the insertion position recorded in the chart. Assess the cuff pressure; it should be less than 30 cm H2O. Assess the ties of the tube; make sure they are not too tight or loose. Some patients may have a tracheostomy in place. Quite frequently, it is inserted for comfort and weaning. However, sometimes it may be inserted for anatomical or pathological reasons. In such case understand the reason for insertion of tracheostomy. Complete a cuff and tie check for tracheostomy as well. Look for the skin at the insertion site.
Start the analysis of respiratory system with observation:
- Paradoxical breathing
- Unequal rise of hemithorax with inspiration
- Work of breathing
- Rate of breathing.
Respiratory distress may present with following signs:
- Patient ventilator dyssynchrony: Often obvious to people who possess the knowledge about it, however, the incidence is fairly common. Unfortunately the most common response to ventilatory dyssynchrony is often sedation, which in some cases may be an inappropriate response.
Look at any chest drains that may be present, observe any bubbling, swinging of column, and color of drain fluid.
Study the ventilator:
- Look at settings—note, if patient is breathing spontaneously, or on a controlled mode.
- Study the fraction of inspired oxygen (FiO2), positive end-expiratory pressure (PEEP), mode and other settings on the ventilator.
- Look at the ventilator graphs, loops and understand the resistance and compliance of the lung.
- A detailed look at the history of these graphics will give important information of the respiratory mechanics over time.
- Special tests like compliance, plateau pressure and intrinsic PEEP (iPEEP) may be estimated to have a better understanding of patient's current respiratory status.
- Observe the saturation on monitor and try to correlate it with FiO2 and PEEP settings.
- If available now is the time to look at the arterial blood gas for pH, partial pressure of oxygen (PaO2), partial pressure of carbon dioxide (PaCO2) and bicarbonate.
Palpation and Percussion
- In critically ill ICU patients, both palpation and percussion may be unhelpful in providing you good clinical information
- Specifically if you are wearing gloves, percussion is often difficult to elicit.
- Examine the trachea and determine if it is in center.
- Palpate both sides of the chest and see if the respiratory mechanics are equal.
- Auscultate both the lungs fields completely.
- Quite often this may be challenging, due to presence of dressings, positioning of patients, etc.
- Rolling patients on one side, or in awake patients sitting them up will allow a complete auscultation on the back as well.
- Hear the breath sounds, compare if they are equal on both sides.
- Any ronchi, crepitation or abnormal breath sounds are important findings.
- Look at the quantity, consistency and color of secretions.
- Observe the chart to look at the secretions history.
- A trend is often helpful to determine a decision for extubation, decannulation or development or progress of a new respiratory problem.
- If patient is awake then try and assess the patient's ability to cough. Look at the strength and force of cough.
- Ask patient to take a big breath in and out to determine the forced vital capacity (FVC). Usually if a patient is able to generate more than 15 mL/Kg of tidal volume on minimal ventilator settings then they should be able to breathe comfortably postextubation as well.
- If possible and available and if you know how, and permitted by examiner you should try to do ultrasonography of the lungs. If you do not know how, keep your trap shut!
- Start with a look at the monitor.
- Note the heart rate and blood pressure on the monitor.
- Is the rhythm paced, are there arrhythmias on the monitor?
- Look at the blood pressure, importantly the mean arterial pressure. It is more importantly physiologically.
- If any other indices like central venous pressure (CVP), stroke volume variation (SVV), etc. are being monitored, then study them, note them down and check the trend, if available.
- A very high or low CVP would be of significance. Similarly stroke volume variation and cardiac index assessment will give details about the patient's volume and hemodynamic status.
- Start with peripheral circulation.
- Temperature of the hands and legs, if cold, note up to what level the extremities are cold, ankle, knees, thighs, etc.
- Check that there is no difference in temperature of limbs on either side.
- Check the color of the periphery, note down capillary refill time.
- Check for peripheral pulses.
- Feel for and observe pulsations over the precordium and any other abnormal pulsations elsewhere.
Limited utility in circulatory system examination in the critically ill patient.
- Carefully listen to the heart sounds.
- This may be challenging specifically due to distracting noises and sounds in ICU.
- Other features of circulatory adequacy are mentation in absence of sedation, urine output and the acid-base balance, importantly lactate level.
- If permitted, available and if you know how try to perform a transthoracic echocardiography. Otherwise keep your mouth shut about this too!
- All this needs to be interpreted in the context of several variables.
- Vasoactive drugs
- Intra-aortic balloon pump
- Cardiac medications
- It is important to look at the fluid balance. Especially the cumulative fluid balance and daily weight of patient, if it is possible or the input and output chart.
- Skin turgor, peripheral edema, raised jugular venous pressure (JVP) or CVP are other coarse methods for assessing fluid status.
- Always look at the site of intravascular devices
- Look for signs of infection, thrombosis or ischemia.
- Level of sedation, pain relief with opioids or analogs and use of muscle relaxants (sometimes).
- This needs to be considered before embarking on a neurological examination.
- Start with trying to elicit some response with verbal commands.
- If no response then a gradual graded painful stimulus starting from periphery to central would be necessary to give a good understanding of Glasgow Coma Scale (GCS). Calculate the GCS score for components and total score and note it down.
- If patient is responsive then ask them to perform simple tasks, assess their limb muscle tone and power.
- Spend some time eliciting deep tendon reflexes and plantar response.
- Pupillary examination, looking for size, response to light is important.
- Look at signs which suggest lateralizing signs. This will help in assessing the complete neurological system.
- Look at any neuromonitoring devices, such as intracranial pressure monitors or operative wounds incisions (fresh), scars (old).
- Look in the chart and compare your neurological findings to those noted before, this will give an objective assessment of the further course.
Abdominal, Renal and Nutrition
As opposed to the cardiovascular and respiratory system a continuous monitoring of gastrointestinal and renal system is not possible. However, pathologies may be hidden and could be difficult to assess. Hence a careful examination of the abdomen is absolutely necessary.
- Observe the general shape and respiratory movements of the abdomen.
- Look for any distension, presence of surgical wounds, scars, drains, stoma and their contents.
- Look for Foley's catheter and in male patients always look for any signs of phimosis.
- Make the patient fully supine
- Carefully palpate the abdomen, looking for any organomegaly.
- Watch for any signs of pain or distress during palpation.
- Note if patient is on pain medication or has received muscle relaxant.
- Percussion in ICU patients may help determine the presence of ascites
- Otherwise percussion is of limited clinical benefit.
- Hear carefully for presence or absence of bowel sounds, note if they are abnormally high pitched and increased.
Sometimes the intra-abdominal pressure may be an important marker to measure. It is best measured using a three way Foleys, or special intra-abdominal measuring kits. Remember to note that an absolute value and trend both are important in decision making. Check if it is being measured, not the value and trend of available.
- Look if the patient is being fed by the nasogastric, nasojejunal or by percutaneous gastrostomy or jejunostomy route. Ask and note if the feeds are given as continuous drip or by bolus method.
- Note the type of feeds, volume and rate at which it is delivered.
- It is important to ask for gastric residual volumes which tell a lot about feed absorption.
- Ask for bowel movements, as diarrhea and constipation, both are common in ICU patients.
- Always look for any evidence of gastrointestinal (GI) bleed in form of altered blood in nasogastric tube or melena.
Exposure and Periphery
- Look for any rashes, eschar, ecchymosis, petechiae, blebs, etc. all over the body. If present check for any anatomical distribution.
- Relevant history, bite marks are necessary to be ruled out.
- Note the type, feel and location of rash.
- Some rashes are specific, e.g. malar rash is seen over the face.
- Observe for any ulcers or sore in the pressure areas
- Specific spots, like heels, sacrum and back should be examined meticulously
- Look for any peripheral signs; which may be relevant in the clinical examination like presence of clubbing, cyanosis, icterus or presence of lymphadenopathy.
- Try and correlate these signs with your clinical examination to arrive at a conclusion.
It is important to note down the relevant history points, document positive findings in your examination. Do not rely on memory, write it down for later reference during viva. Always look at the ICU monitoring chart, this gives a wealth of information on trends, medications and how the patient has progressed.
Always review the blood investigations, it is important to review them in a tabular form if possible to understand the trends. Special investigations like echocardiography, computed tomography (CT) scan or magnetic resonance imaging (MRI) should be reviewed and reports seen wherever relevant. Always review the X-ray of chest, airway, breathing and circulation (ABG) and electrocardiograph (ECG) of patient.
Review the medication chart and look at specific medications, like antibiotics, cardiac medicines and their dosages, etc. If trade names are written which are unfamiliar to you, ask for the actual name of the drug.
Fast hug has become a standard for ICU practitioners. A number of variants have been developed and in other units you will hear some of them. Here is an example of what they cover:
Ensuring the patient is appropriately fed is an important care issue. We will deal with this in more detail in a subsequent module, but suffice to say that you should at least consider the need for feeding for each patient.
F is also sometimes used for feces management and fluids.
Check if the patient is formally assessed for their level of pain and note their current analgesia regimen. Perhaps there are other agents you could consider, or even a regional pain solution such as an epidural might help.
Sedation is an important component of ICU care, because it enables patients to tolerate some of the more uncomfortable treatments they require (for example, mechanical ventilation). In the past, clinicians have taken a “if little bit is good, more must be better” approach. Try to note the sedation and delirium score of the patient, if written. If not assess with the score you are familiar with and note the score.
However, it is also important to remember that most therapies also have complications, and so it is true for sedatives. Increasingly, we are becoming aware of the risks of over sedation, including prolongation of mechanical ventilation, and there is evidence that reducing it to the minimum level required results in better outcomes for patients.
All patients in the ICU should be considered high risk for the development of deep venous thrombosis (DVT). In fact, in a sentinel paper of mechanically ventilated patients in ICU, up to 2.7% already had significant proximal leg DVT on admission! The need for chemical and physical thromboprophylaxis should be considered on a daily basis, and the risks versus benefits carefully analyzed.
H—Head up to 30°
It may sound a little strange, but such a simple maneuver (45% head up) can reduce the risk of hospital-acquired pneumonia, an important ICU complication. Unless there is a good reason not to, all ventilated patients should be nursed with their head and torso at 30° from the horizontal.
There are a number of factors common in ICU patients that predispose them to developing gastric stress ulcers, with the consequent potential for gastrointestinal bleeding. Consider the need for prophylaxis, something we will come back to in a later module.
Hyperglycemia has been associated with a higher risk of complications for ICU patients. In fact, this has been associated with worse outcomes in many other patient groups too, such as acute myocardial infarction and stroke. For a while, very tight glycemic control was advocated in ICU patients. However, subsequent research has suggested that tight control is no better than standard range targets, and may even worsen outcome, possibly due to hypoglycemic episodes. You should check your unit's policy on this and ensure it is followed.
Check the patient's blood sugar level if recorded, look at trend and see if the patient is on insulin infusion.
Always complete your examination by thanking the patient and leaving the bedside as neat and clean as possible. Post-examination hand-washing is compulsory.
Try and formulate a problem list, separate the problems which are active and inactive. Formulate a treatment plan or investigation plan as per the priority of problem, e.g. if oxygenation or hypotension is the problem then it needs to be addressed with priority over other non-life-threatening problems.
Remember there are no trick questions in an examination. Usually the lead question is formulated by the examiner with intent to lead the candidate to a problem.
Enjoy your work in ICU so you are happy in your chosen life work; remember there are no shortcuts to success.
All the best for your examinations!!!
If you are exam going soon, we do not wish to see you again next year as a delegate!!!
- Cook DJ, Crowther M, Meade M, Rabbat C, Schiff D, Geerts W, et al. Deep venous thrombosis in medical-surgical ICU patients: prevalence, incidence and risk factors. Crit Care Med. 2005;33:1565–71.
- Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogué S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet. 1999;354(9193):1851–8.
- Robertson L. Recognizing the critically ill patient. Anesth Int Care Med. 2013;14(1):11–4.
- Vincent JL. Give your patient a fast hug (at least) once a day. Crit Care Med. 2005;33(6):1225–9.