few steps taken to develop a Clinical Action Plan for the assessment



The aim of this case is to explore effective assessment for a critically ill patient.
After working through this case, you will be able to:
1. Develop systematic skills for initial assessment of ICU patients
2. Identify problems arising from inadequate assessment
3. Consider outcomes to patient/staff/organisation as a consequence of these problems
4. Recognise strategies for maximising patient-centred care.




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As a nurse attending Ms. Johnson, I need to make sure that she receives quality, patient-centred care. Following are few steps taken to develop a Clinical Action Plan for the assessment of Ms. Johnson.


Concept Map


Patient - The first critical factor to look at in the assessment is the service the patient needs to receive. Once the patient arrives in ICU he should undergo visual scanning, greetings from the staff, monitoring chest rise and fall as well as observing the transport monitor values. Patient should be moved from transport stretcher to manually assisting devices. There should be a medical handover of the patient in the mandatory presence of the patient. The receiving report should be obtained from the nurse to assess his ventilatory needs, appropriate entry of air through tracheal nodes etc (ICU Medical Director, 2014). 
Diagnosis – The staff involved in the Patient assessment needs to assess the patient’s airway, that is to check whether the patient is conscious or not, his C-spine is clear, is the air passage natural or through endotracheal tube, and if the voice has little gurg or is it clear. Patient’s breathing will be checked for spontaneity or assistance, enhanced respiratory rate as well as lung auscultation. In case, the patient is on ventilator, its parameters also need to be checked. The respiration rate will also be monitored, and chest X-ray should be conducted. 
Circulation will be checked through heart rate and blood pressure. Trachyardia rate, rhythm, and QRS waves would be monitored. The arterial pressure, diaphoteric, urine output, and potential fluid loss will also be estimated. Patient will also be checked for bleeding and external haemorrhage. The disability levels such as consciousness, pupil size and its response to bright light, abnormal posture, muscle tones and headaches will also be measured. For effective assessment of the patient, it is necessary that he should be exposed to the surroundings where his treatment will be conducted. Patient’s privacy needs to be preserved and wound assessment must be followed by dressings (ICU Medical Director, 2014). 
Organization – The prime considerations for the organization for the patient in ICU is inclusive of contractors, physicians, and nurses providing the services, what kind of tests they should perform over the patient, the treatment procedures that need to be followed for the data and the related outcomes. The payment procedures also need to be easy for the patient.
Staff – It is the responsibility of the staff members to take care of the ICU Patient while conducting assessments. Hence, the staff should strictly follow the safety policies and maintain the culture of safety within the organization. 
Legal & Ethical – The ethical principles that need to be followed by the nurses must involve autonomy, beneficence, nonmalifecence, justice, veracity, and fidelity. However, legally, the nurses can only oprate the patient with his or her consent. Consent needs to be given on the basis of voluntariness, capacity, awareness, and informed decision making (Nursing Path, 2013).
Monitoring & Analysis – The organization must possess the equipments to regularly monitor the patient’s health and then deciding when he needs to get discharged. 
Significant Issues
One critical issue that the staff faces generally is in case of the patient’s assessment and death while undergoing treatment and the related documentation that the nurses have to do in this case. Studies show that the nurses tend to change their behavior regarding patient’s assessment and monitoring as the health of the patient become worse. It is also noted that the behavior and attitude of nurses while recording the patient’s health condition reflects her concern for the patient. 
As the change in behavior of nurses tends to change the quality of treatment, the patients are suggested to undergo ABCDEF bundle through team- and evidence-based care. This ICU Liberation Program consists of the guidelines regarding the pain and restlessness experienced by the patients. It renounces the traditional notion of the patients being unconscious in ICU and prefer them to be more cognitively active and mobile with friends and family members such that there could be a quality improvement in their health conditions after treatment.

Studies reveal that the presence of nurses in ICU increases the patient’s endurance for undergoing mechanical ventilation in ICU and brings hope and relief for them for a quick recovery from their illness, and gets strengthened to fight against the disease causing for long term survival (Rushton, 2016; Turner, 2016). 
Therefore, it is recommended for the nurses and other staff members to empathize with patients and follow the mnemonic ‘Fast Hug everyday’. It is applicable for all Intensive Care patients at any time during the day and to all the patients. It should be followed by all the nurses attending the ICU patients depending upon the results and outcomes of this therapy on their health conditions. This can be an easy way to prevent nurses from changing their behavior while monitoring the ICU patients (Vincent, 2005). 
This will help the nurses tackle the postoperative issues in patients such as the patients experiencing inadequately managed postoperative pain, delirium etc. This will also assist the nurses in recognizing the sources of infection, if any, around the patient and planning the reduction of antibiotics in their medication (Vincent, 2009; Schwartz, 2009).
If any protocol of the mnemonic is not being followed for the patient, the reason for the same must be stated in his progress report. This is quite critical for the anaesthesiologist handling the patients of surgical ICU to not miss any relevant step in the patient’s treatment. Following this would also not bring any conflicts of interest (Collins, 2013; Cato, 2013; Albers, 2013; Scott, 2013; Stetson, 2013; Bakken, 2013; Vawdrey, 2013).
Another issue with the patient’s treatment is the personal interest of the organization regarding its revenue, governance, board of directors, leadership structure, and high focus on Community Support. The main step it can take for cost cutting is to hire the workforce from the third parties and other volunteering contractors. 
It is a problem in the service of the organization if it has a dual leadership structure for the sake of its interests. It can have both administrative and medical set up. It is very difficult to create an organizational chart for such organization. The only trick that works for such organizations is to keep both the aspects separate from each other.
In the critical decisions regarding the patient’s treatment the board of the organization tend to interfere as per its governance system and the decisions are mostly inclined towards their suggestions. If the organization is under a joint venture or partnership, it is again quite tough to agree every partner regarding the costing of the resources and services provided by the organization. However, sometimes the minor decisions are taken on ad hoc basis with the patient by the nurses and other staff members. 
In terms of Community Support, the organization seeks to leverage its core competencies for improving its own community and they go beyond their capacity to strengthen the involvement of their key communities and worry about their health conditions more. Nevertheless, there are many ways by which they identify a right community for themselves such as screening programs, health education training, immunizations, vaccination programs, customized health care provided at the expense of financial loss to the organization. This can make the staff compromise on their services.
Also, if the organization enrolls a third party to provide services, then quality of service majorly depends upon the active involvement of those service workers. This may include the workers related to health care and support. Also after their involvement it is difficult to decide a single contact point for the patient (NIST, 2017).




Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., &Vawdrey D.K.   (2013).Relationship between nursing documentation and patients’ mortality. American Journal of Critical Care, 22(4), 306-313. doi: 10.4037/ajcc2013426
Ely, W. E. (2017). The ABCDEF Bundle: Science and philosophy of how ICU liberation serves patients and families. Critical Care Medicine, 45(2), 321-330. doi: 10.1097/CCM.0000000000002175
Karlsson, V., Bergbom, I., & Forsberg, A., (2012). The lived experiences of adult intensive care patients who were conscious during mechanical ventilation: A phenomenological-hermeneutic study. Intensive and Critical Care Nursing, 28(1), 6-15. doi: 10.1016/j.iccn.2011.11.002 
Rushton, C.H., & Turner, K. (2016). Ethics in everyday practice: pick up your stethoscope. AACN Advanced Critical Care. 27(4), 482-464.doi: 10.4037/aacnacc2016663 
Vincent, J. (2005). Give your patient a fast hug (at least) once a day. Critical Care Medicine, 33 (6), 1225-1229. doi: 10.1097/01.CCM.0000165962.16682.46
Vincent, W. R. & Schwartz, A. (2009). Critically ill patients need FAST HUGS BID (an updated mnemonic) Critical Care Medicine, 37(7), 2326-2327. doi: 10.1097/CCM.0b013e3181a9eefb 
Considerations for Health Care Organization. Retrieved from https://www.nist.gov/sites/default/files/documents/2017/08/16/considerations_for_health_care_organizations_at_site_visit.pdf 
Nursing Path (2013, April 11), Legal and Ethical Issues in critical care nursing. Retrieved from https://www.slideshare.net/drjayeshpatidar/legal-and-ethical-issues-in-critical-care-nursing 
ICU Medical Director (2014, February), Receiving a patient in ICU, Liverpool Hospital, South Western Sydney Local Health District. Retrieved from https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0008/306449/liverpoolReceiving_a_patient_to_ICU.pdf 

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