Nursing Standard of Practice Protocol: Comprehensive Assessment and Management of the Critically Ill
Michele C. Balas, PhD, RN, CCRN, CRNP, BC, Colleen M. Casey, BS, RN, CCRN, Mary Beth Happ, PhD, RN
Evidence-Based Content - Updated July 2012
Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. The text is available here.
The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:
Parameters of Assessment
Nursing Care Strategies
Evaluation and Expected Outcome
Relevant Practice Guidelines
To restore physiologic stability, prevent complications, maintain comfort and safety, and preserve pre-illness functional ability and quality of life (QOL) in older adults admitted to critical-care units.
Caring for an older adult who is experiencing a serious or life-threatening illness often poses significant challenges for critical care nurses. Although older adults are an extremely heterogeneous group, they share some age-related characteristics that leave them susceptible to various geriatric syndromes and diseases. This vulnerability may influence both their ICU utilization rates and outcomes. Critical care nurses caring for this population must not only recognize the importance of performing ongoing, comprehensive physical, functional, and psychosocial assessments tailored to the older ICU patient, but also must be able to identify and implement evidence-based interventions designed to improve the care of this extremely vulnerable population.
Critically ill older adult. A person, age 65 or older, who is currently experiencing, or at risk for, some form of physiologic instability or alteration warranting urgent or emergent, advanced, nursing/medical interventions and monitoring.
1. More than half (55.8%) of all ICU days are incurred by patients older than the age of 65.1
2. Older adults are living longer, are more racially and ethnically diverse, often have multiple chronic conditions, and more than one-quarter report difficulty performing one or more ADLs. These factors may affect both the course and outcome of critical illness.
3. Once hospitalized for a life-threatening illness, older adults often:
a. Experience high ICU, hospital, and long-term crude mortality rates and are at risk for deterioration in functional ability and post-discharge institutional care (Ref 10; de Rooij et al., 2005; Ford et al., 2007; Hennessy et al., 2005; Hopkins and Jackson, 2006; Kaarlola et al., 2006; Marik, 2006; Wunsch et al., 2010).
b. Older age is also a factor that may lead to:
i. Physician bias in refusing ICU admission. 4, 5 .
ii. The decision to withhold mechanical ventilation, surgery, or dialysis.6
iii. An increased likelihood of an established resuscitation directive. 7
c. Most critically ill older adults:
i. Demonstrate resiliency.
ii. Report being satisfied with their QOL postdischarge.
iii. Would reaccept ICU care and mechanical ventilation if needed (Ref 8; Hennessy et al., 2005; Kleinpell & Ferrans, 2002). 8
d. Chronologic age alone is not an acceptable or accurate predictor of poor outcomes after critical illness (Nagappan & Parkin, 2003; Milbrant et al., 2010).
e. Factors that may influence an older adult’s ability to survive a catastrophic illness include the following:
i. Severity of illness
ii. Nature and extent of comorbidities
iii. Diagnosis, reason for/duration of mechanical ventilation
a) Prehospitalization functional ability
b) Vasoactive drug use
c) Pre-existing cognitive impairment
f) Decreased social support
g) Critical care environment (de Rooij et al., 2005; Ford et al., 2007; Marik, 2006; Mick & Ackerman, 2004; Tullmann & Dracup, 2000; Wunsch et al., 2010)
Parameters of Assessment
A. Preadmission: Comprehensive assessment of a critically ill older adult’s preadmission health status, cognitive and functional ability, and social support systems helps identify risk factors for cascade iatrogenesis, the development of life-threatening conditions, and frequently encountered geriatric syndromes. Factors that the nurse needs to consider when performing the admission assessment include the following:
1. Preexisting cognitive impairment: Many older adults admitted to ICUs suffer from high rates of unrecognized, preexisting cognitive impairment (Ref 23; Balas et al., 2007). 23
a. Knowledge of preadmission cognitive ability could aid practitioners in:
i. Assessing decision making capacity, informed consent issues, and evaluation of mental status changes throughout hospitalization. 23
ii. Making anesthetic and analgesic choices
iii. Considering one-to-one care options
iv. Weaning from mechanical ventilation
v. Assessing fall risk
vi. Planning for discharge from the ICU
b. Upon admission to the ICU, nurse should ask relatives or other caregivers for baseline information about the older adult’s:
i. Memory, executive function (e.g., fine motor coordination, planning, organization of information), and overall cognitive ability. 25
ii. Behavior on a typical day; how the patient interacts with others; their responsiveness to stimuli; how able they are to communicate (reading level, writing, and speech); and their memory, orientation, and perceptual patterns prior to their illness. 26
iii. Medication history to assess for potential withdrawal syndromes (Broyles, Colbert, Tate, Swigart, & Happ, 2008).
c. Psychosocial Factors: Critical illness can render older adults unable to effectively communicate with the health care team, often related to physiologic instability, technology that leaves them voiceless, and sedative and narcotic use (Happ, 2000, 2001). Family members are therefore often a crucial source for obtaining important preadmission information. Upon ICU admission, the nurse needs to determine the following:
i. What is the older adult’s past medical, surgical, and psychiatric history? What medications was the older adult taking before coming to the ICU? Does the elder regularly use illicit drugs, tobacco, or alcohol? Do they have a history of falls, physical abuse, or confusion?
ii. What is the older adult’s marital status? Who is the patient’s significant other? Will this person be the one responsible to make decisions for the elder if they are unable to do so? Does the elder have an advanced directive for health care? Is the older adult a primary caregiver to an aging spouse, child, grandchild, or other person?
iii. How would the elder describe his or her ethnicity? Do they practice a particular religion or have spiritual needs that should be addressed? What was their QOL like before becoming ill?
d. Preadmission functional ability and nutritional status: Limited preadmission functional ability and poor nutritional status are associated with many negative outcomes for critically ill older adults (REf 5; 21; Marik, 2006). 5, 21 Therefore, the nurse should assess the following:
i. Did the older adult suffer any limitations in the ability to perform his or her ADLs preadmission? If so, what were these limitations?
ii. Does the older adult use any assistive devices to perform his or her ADLs? If so, what type?
iii. Where did the patient live prior to admission? Did he or she live alone or with others? What was the elder’s physical environment like (house, apartment, stairs, multiple levels, etc.)?
iv. What was the older adult’s nutritional status like preadmission? Does he or she have enough money to buy food? Does he or she need assistance with making meals and obtaining food? Does he or she have any particular food restrictions or preferences? Was he or she using supplements and vitamins on a regular basis? Does he or she have any signs of malnutrition, hair loss, or skin breakdown?
B. During ICU stay: There are many anatomic and physiologic changes that occur with aging (See Table 30.1). The interaction of these changes with the acute pathology of a critical illness, comorbidities, and the ICU environment leads not only to atypical presentation of some of the most commonly encountered ICU diagnoses but may also elevate the older adult’s risk for complications. The older adult must be systematically assessed for the following:
1. Comorbidities and common ICU diagnoses
a. Respiratory: chronic obstructive pulmonary disease, pneumonia, acute respiratory failure, adult respiratory distress syndrome, rib fractures/flail chest
b. Cardiovascular: acute myocardial infarction, coronary artery disease, peripheral vascular disease, hypertension, coronary artery bypass grafting, valve replacements, abdominal aortic aneurysm, dysrhythmias
c. Neurologic: cerebral vascular accident, dementia, aneurysms, Alzheimer’s disease, Parkinson’s disease, closed head injury, transient ischemic attacks
d. Gastrointestinal (GI): biliary tract disease, peptic ulcer disease, GI cancers, liver failure, inflammatory bowel disease, pancreatitis, diarrhea, constipation, and aspiration
e. Genitourinary (GU): renal cell cancer, chronic renal failure, acute renal failure, urosepsis, and incontinence
f. Immune/hematopoietic: sepsis, anemia, neutropenia, and thrombocytopenia
g. Skin: necrotizing fasciitis, pressure ulcers
2. Acute pathology: thoracic or abdominal surgery, hypovolemia, hypervolemia, hypothermia/hyperthermia, electrolyte abnormalities, hypoxia, arrhythmias, infection, hypotension/hypertension, delirium, ischemia, bowel obstruction, ileus, blood loss, sepsis, disrupted skin integrity, multisystem organ failure
3. ICU/environmental factors: deconditioning, poor oral hygiene, sleep deprivation, pain, immobility, nutritional status, mechanical ventilation, hemodynamic monitoring devices, polypharmacy, high-risk medications (e.g., narcotics, sedatives, hypnotics, nephrotoxins, vasopressors), lack of assistive devices (e.g., glasses, hearing aids, dentures), noise, tubes that bypass the oropharyngeal airway, poorly regulated glucose control, Foley catheter use, stress, invasive procedures, shear/friction, intravenous catheters
4. Atypical presentation: Commonly seen in older adults experiencing the following: myocardial infarction, acute abdomen, infection, and hypoxia
Nursing Care Strategies
A. Preadmission: Based on their preadmission assessment findings, nurses should consider the following:
1. Obtaining appropriate consults (i.e., nutrition, physical/ occupational/speech therapist)
2. Implementing safety precautions
3. Using pressure-relieving devices
4. Organizing family meetings
5. Providing older adults with a consistent primary nurse
B. During ICU: Nursing interventions that may benefit:
1. Multiple organ systems:
a. Encouraging early, frequent mobilization/ambulation
b. Providing proper oral hygiene
c. Ensuring adequate pain control
d. Reviewing/assessing medication appropriateness
e. Avoiding polypharmacy/high-risk medications (See Table 30.2).
f. Securing and ensuring the proper functioning of tubes/catheters
g. Actively taking measures to maintain normothermia
h. Closely monitoring fluid volume status.
a. Encourage and assist with coughing, deep breathing, incentive spirometer use; use alternative device when appropriate (e.g., positve expiratory pressure [PEP])
b. Assess for signs of swallowing dysfunction and aspiration
c. Closely monitor pulse oximetry and arterial blood gas results
d. Consider the use of specialty beds
e. Advocate for early weaning trials and extubation as soon as possible
f. Exercise standard VAP precautions (AACN, 2004; ATS & IDSA, 2005; Dezfulian et al., 2005; IHI & 5 Million Lives Campaign, 2008; Krein et al., 2008):
i. Keep the head of the bed elevated to more than 30 degrees.
ii. Provide frequent oral care.
iii. Maintain adequate cuff pressures.
iv. Use continuous subglottic suctioning devices.
v. Do not routinely change ventilator circuit tubing.
vi. Assess the need for stress ulcer and deep venous thrombosis (DVT) prophylaxis.
vii. Turn the patient as tolerated.
viii. Maintain general hygiene practices.
a. Carefully monitor the older adult’s hemodynamic and electrolyte status.
b. Closely monitor the older adult’s ECG with an awareness of many conduction abnormalities seen in aging. Consult with physician regarding prophylaxis when appropriate.
c. Advocate for the removal of invasive devices as soon as the patient’s condition warrants. The least restrictive device may include long-term access.
d. Recognize that both preexisting pulmonary disease and manipulations of the abdominal and thoracic cavities may lead to unreliability of traditional values associated with central venous pressures (CVPs) and pulmonary artery occlusion pressures (PAOPs).29
e. Because of age-related changes to the cardiovascular system, the nurse should acknowledge 29:
i. Older adults often require higher filling pressures (i.e., CVPs in the 8-10 cm range, PAOPs in the 14-18 cm range) to maintain adequate stroke volume and may be especially sensitive to hypovolemia.
ii. Overhydration of the older adult should also be avoided because it can lead to systolic failure, poor organ perfusion, and hypoxemia with subsequent diastolic dysfunction.
iii. Certain drugs commonly used in the ICU setting may prove to be either not as effective (e.g., isoproterenol and dobutamine) or more effective (e.g., afterload reducers).
a. Closely monitor the older adult’s neurologic and mental status.
b. Screen for delirium and sedation level at least once per shift.
c. Implement interventions to reduce delirium:
i. Promote sleep, mobilize as early as possible, review medications that can lead to delirium, treat dehydration, reduce noise or provide “white noise,” close doors/drapes to allow privacy, provide comfortable room temperature, encourage family and friends to visit, allow the older adult to assume the preferred sleeping positions, discontinue any unnecessary lines or tubes, and avoid the use of physical restraints, using least restraint for minimum time only when absolutely necessary.
ii. Maximize the older adults’ ability to communicate his or her needs effectively and interpret his or her environment.
- Promote the older adult wearing glasses, hearing aids, and other appropriate assistive devices.
- Face the patients when speaking to them, get their attention before talking, speak clearly and loud enough for them to understand, allow them enough time (pause time) to respond to questions, provide them with a consistent provider (i.e., a primary nurse), use visual clues to remind them of the date and time, and provide written or visual input for a message (Garrett, Happ, Costello, & Fried-Oken, 2007).
- Provide older adults with alternate means of communication (e.g., providing him or her with a pen and paper, using nonverbal gestures, and/or using specially designed boards with alphabet letters, words, or pictures) (Garrett et al., 2007; Happ et al., 2010).
- Provide translators/interpreters as needed.
d. Provide adequate pain control while avoiding oversedation or undersedation. For a full discussion, see topic, Pain Management.
a. Monitor for signs of GI bleeding and delayed gastric emptying and motility.
i. Encourage adequate hydration, assess for signs of fecal impaction, and implement a bowel regimen.
ii. Avoid use of rectal tubes.
b. Advocate for stress ulcer prophylaxis.
c. Provide dentures as soon as possible.
d. Implement aspiration precautions.
i. Keep the head of the bed elevated to a high Fowler’s position, frequently suction copious oral secretions, bedside evaluate swallowing ability by a speech therapist, assess phonation and gag reflex, monitor for tachypnea.
e. Advocate for early enteral/parental nutrition.
f. Ensure tight glucose control.
a. Assess any GU tubes to ensure patency and adequate urinary output. If the older adult should experience an acute decrease in urinary output, consider using bladder scanner (if available), rather than automatic straight catheterization, to check for distension.
b. Advocate for early removal of Foley catheters. Use other less invasive devices/methods to facilitate urine collection (i.e., external or condom catheters, offering the bedpan on a scheduled basis, and keeping the nurse’s call bell/signal within the older adult’s reach).
c. Monitor blood levels of nephrotoxic medications as ordered.
a. Ensure the older adult is ordered appropriate DVT prophylaxis (i.e., heparin, sequential compression devices)
b. Monitor laboratory results, assess for signs of anemia relative to patient’s baseline.
c. Recognize early signs of infection--restlessness, agitation, delirium, hypotension, tachycardia--because older adults are less likely to develop fever as a first response to infection.
d. Meticulously maintain infection control/prevention protocols.
a. Conduct thorough skin assessment.
b. Vigilantly monitor room temperature, make every effort to prevent heat loss, and carefully use and monitor rewarming devices.
c. Use methods known to reduce the friction and shear that often occurs with repositioning in bed.
d. In severely compromised patients, the use of specialty beds may be appropriate.
e. Techniques such as frequent turning, pressure-relieving devices, early nutritional support, as well as frequent ambulation may not only protect an older adult’s skin, but also promote the health of their cardiovascular, respiratory, and GI systems.
f. Closely monitor IV sites, frequently check for infiltrations and use of nonrestrictive dressings and paper tape.
1. Hemodynamic stability will be restored.
2. Complications will be avoided/minimized.
3. Preadmission functional ability will be maintained/optimized.
4. Pain/anxiety will be minimized.
5. Communication with the health care team will be improved.
1. Employ consistent and accurate documentation of assessment relevant to the older ICU patient.
2. Provide consistent, accurate, and timely care in response to deviations identified through ongoing monitoring and assessment of the older ICU patient.
3. Provide patient/caregiver with information and teaching related to his or her illness and regarding transfer of care and/or discharge.
C. Institution: includes quality assurance/quality assessment (QA/QI)
1. Evaluate staff competence in the assessment of older critically ill patients.
2. Utilize unit-specific, hospital-specific, and national standards of care to evaluate existing practice.
3. Identify areas for improvement and work collaboratively across disciplines to develop strategies for improving critical care to older adults.
Relevant Practice Guidelines
Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists (ASHP), and American College of Chest Physicians ACC/AHA 2006 guideline update on perioperative beta-blocker therapy: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anasthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology.
Nursing Standard of Practice Protocol:
Comprehensive Assessment and Management of the Critically Ill
Michele C. Balas, Colleen M. Casey, Mary Beth Happ
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Last updated - July 2012