Chapter 10: Physical Examination in the ICU

KEY POINTS

The presence of advanced medical technology and sophisticated laboratory tests allow healthcare practitioners to provide the highest standard of care to patients particularly in the acute care setting. However, the importance of the physical examination should not be underestimated. The key to a good physical exam in the intensive care unit (ICU) setting is the ability to interface this medical technology with the patient's clinical presentation. Performing both planned and quick focused (ie, unplanned or emergent) exams can make the difference in timely diagnosis and treatment, thus having a positive impact on patient outcome.

Performing a physical exam in the ICU is often difficult. The bedside examination in an ICU may be hindered by various conditions. These include noisy alarms (eg, monitor, ventilator, IV pumps, etc), limited assessment due to sedation or analgesia, inability to easily change the patient's position, wounds, dressings and multiple invasive lines or tubes. Amid these obstacles, this exam should be performed quickly and efficiently. This chapter will demonstrate how to perform a physical examination on routine assessment and in certain critical situations in the acute care setting.

PLANNED PHYSICAL EXAMINATION

Physical examination on daily rounds is a vital part of ICU management. Before performing a physical exam, review the patient's chart; obtain a history and gather information from the patient, relatives, medical staff, or review of notes. For all patients whether awake or unresponsive, it is best to begin the exam by introducing yourself and explaining what you intend to do. In the ICU, it is easy to divert attention from the patient and focus on the alarming monitors and machines. The main focus should remain on the patient's clinical presentation while integrating information from the monitors and diagnostic tests. The patient's current illness and status will prioritize the exam. Use a structured method to the examination by reviewing all major organ systems; this will avoid omitting important information. Accurate documentation of physical exam findings will identify trends or any change in a patient's clinical status.

Central Nervous System

Frequent evaluation of pain, sedation and delirium in the ICU is generally underestimated. There are various scales to assess level of sedation and pain and choosing 2 reliable scales, for example the Sedation-Agitation Scale (SAS)¹ (Table 10–1) to assess the level of sedation and the Wong-Baker FACES Pain Rating Scale^2...