Chapter 10: Physical Examination in the ICU

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.

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 Scale² to communicate how much pain the patient is experiencing. In the ICU, most patients are unable to self-report pain or communicate, which makes this exam more challenging. If the patient cannot participate in this exam then look for signs of pain such as facial cues, restlessness/positioning, and/or physiological changes (rise in heart rate and blood pressure). However, vital signs are not used solely to assess for pain. Make note of the analgesic or sedative agent the patient is receiving, titrate and taper to maintain goal. In an adult ICU, light levels of sedation are recommended and daily interruptions can reduce the amount of time on a ventilator and the ICU stay.³

Critically ill patients may be obtunded, agitated, or delirious. For patients who are not sedated, assess whether they are alert and oriented. For critically ill patients, the cause in cognitive impairment can be variable and include, but is not limited to, metabolic disturbances or medications such as analgesics and sedatives. According to the 2013 clinical practice guidelines for Pain, Agitation, and Delirium (PAD), delirium should be assessed daily in mechanically ventilated patients.⁴ Delirium can occur in nearly 60% to 80% of mechanically ventilated patients and is associated with increased mortality in the ICU and long-term cognitive impairment.⁴ Adult ICU patients can be assessed for delirium by using The Confusion Assessment Method for the ICU (CAM-ICU)⁵ (Figure 10–1).

Patients admitted to the ICU with intracranial pathology should have a more focused and detailed neurological assessment adjusted to their diagnosis and presentation. For all patients, pupils should be checked for size, equality, and reaction to light.

Respiratory System

Routine examination of the respiratory includes examining the airway and auscultating the lungs. Further evaluation includes inspecting the patient's overall appearance, work of breathing, accessory muscle use, bilateral chest rise, oxygen saturation, and arterial blood gas findings. The patient may require supplemental oxygen and the decision for such support (nasal cannula, nonrebreathing mask, noninvasive, and invasive ventilation) should be based on clinical presentation and laboratory findings.

For intubated and mechanically ventilated patients, examine the endotracheal tube (ETT) position both on exam (eg, 21 cm at the lips) and on chest x-ray (CXR) (eg, ETT tip 5 cm above the carina) and review the ventilator settings and the output information. Basic ventilator settings include the ventilator mode, respiratory rate, tidal volume, fraction of inspired oxygen (FiO₂) and positive end expiratory pressure (PEEP). Make note of the measured or output tidal volumes, minute volumes, flow rate and peak, and plateau pressures. Other parameters to include during respiratory examination are correlating the patient's current condition with their chest x-ray, lung sonogram (if available), and any chest tubes or drains. Most importantly, take this opportunity to assess the readiness of the patient's ability to wean off the ventilator, which should be the ultimate daily goal.

Cardiovascular System

An assessment of the cardiovascular system should be obtained which includes auscultation of heart sounds, evaluation of pulses, capillary refill, and edema. Most ICU patients are continuously monitored with beat-by-beat measurements via the electrocardiogram (ECG) and blood pressure (via noninvasive cuff or invasive arterial catheter monitor). Use this information and integrate it with the patient's clinical status. Observe the medications, especially continuous infusions that the patient is receiving such as inotropic agents, vasopressors and antiarrhythmic medications. A bedside transthoracic echocardiogram is relatively quick and useful in the evaluation of the right and left ventricular function and can guide the use of intravenous fluids, vasopressors, or other cardiac agents.

Abdomen

The routine abdominal exam is very important, owing to the fact that it tends to mask infection. The abdomen should be thoroughly examined by checking tenderness, distention, and bowel sounds. Pay close attention to any surgical incisional sites or wounds for erythema or other signs of infection or perforation, for example, purulent, enteric, or bilious drainage. Make note of any drains or stomas and trend the output volumes and color. If clinical findings are consistent with abdominal hypertension or compartment syndrome, then perhaps intraabdominal pressure measurements may be further warranted.

The patient's nutritional status should be addressed including daily weights and whether the patient's nutritional needs are being met. Bowel function should also be noted and the output recorded.

Renal

The necessity for an indwelling urinary catheter should be addressed daily. A patient on strict input and output measurements should have recorded urine output hourly. Note the type of fluid therapy the patient is receiving and whether the amount or rate is accurate or appropriate based on the patient's clinical status, weight, cardiac status, and sensible and insensible fluid losses. Daily laboratory trends in renal function should be monitored and if indicated, assess the need for renal replacement therapy.

Skin

Points of particular interest during this exam are the color of the skin (cyanosis or pallor), temperature, and presence of any rash. In patients that have indwelling catheters (ventriculostomy or lumbar drains) and vascular access (central or arterial catheters), examine these sites routinely for signs of infection and determine whether the catheter is still indicated based on the patient's clinical status. Check common sites such as bony prominences and the sacrum for decubiti ulcers or evidence of skin break down.

In addition to the physical exam, recent laboratory tests, microbiology findings, imaging results, and current medications should be reviewed frequently for appropriate management of the critical care patient. Table 10–2, modified from Runcie et al⁶ provides a quick guide for the physical examination.

Almost all ICU patients are continuously observed on cardiac and hemodynamic monitors, which is cornerstone of management in critically ill patients. Continuous observation of vital parameters such as heart rate, blood pressure, respiratory rate, and oxygen saturation allows the medical staff to stay apprised of any acute changes and the general condition of the patient.

Acute situations in the ICU are inevitable. In most instances, there are a plethora of possible diagnoses for a patient's presenting symptoms and time is of the essence. Therefore, thoughtful and timely examination is imperative. The following circumstances are frequent life-threatening conditions that may arise in the ICU that warrant immediate attention. A stepwise guide to follow upon reaching the bedside is provided below with the intent of offering a template that the reader may customize to their practice environment.

You Are Called to the Bedside for…

Acute Bradycardia

Visual examination—The first thing you do as you walk into the room is observe the patient, their overall condition (eg, level of distress) and whether or not they are on oxygen or mechanical ventilation. Glance at the monitor to assess the ECG rate and rhythm, arterial blood pressure, and waveform or the noninvasive blood pressure (NBP) reading (may need to be cycled), the pulse oximetry reading/waveform, and respiratory rate. This assessment should take less than 10 seconds.

Physical examination—Then look more closely at the patient and note the level of alertness and distress. Is the patient awake or unresponsive? Is the patient in no acute distress (NAD) or in distress? Quickly glance at the patient's skin and lips for signs of cyanosis. Manually check for a pulse. Does the monitor accurately reflect the patient's pulse and clinical condition? Is the patient showing signs and symptoms of hypoxia? Quickly auscultate the chest for bilateral breath sounds and verify that the patient is receiving adequate oxygenation and ventilation. Is the patient on a ventilator or breathing spontaneously? If the patient is on a ventilator look for the following: What are the settings? Do the ventilator inputs (ie, tidal volume) match the outputs? Are the alarms going off? If so, which alarms- high pressure, low pressure, and/or low tidal volume? What is the breathing pattern and are the ventilator waveforms synchronous or dyssynchronous? Also, is the patient receiving the set tidal volume? Does the patient's ETT or tracheostomy need to be suctioned?

Acute management—If the patient is awake and in NAD, spontaneously breathing, not hypotensive and no complaints, obtain a 12 lead ECG and analyze rhythm, perform further testing if necessary, assess for drug-induced causes, and discontinue the offending medication depending on the diagnosis and clinical scenario. If the patient is stable continue to monitor and observe closely. However, if the patient is unstable and symptomatic with a change in mental status, hypotension, and complaints of chest pain, then treatment should focus on optimizing the patient's hemodynamic status by initiation of the Advanced Cardiovascular Life Support (ACLS) protocol for bradyarrhythmia and treat the underlying cause.

If the underlying cause is hypoxia and the pulse oximeter shows desaturation, patient-ventilator dyssynchrony and/or the ventilator is alarming, refer to the section on Acute Respiratory Distress.

Acute Tachycardia

Visual examination—The first thing you do as you walk into the room is observe the patient and their overall condition. Observe the oxygen-ventilator-patient interface (are they connected to oxygen or the ventilator?). Glance at the monitor to assess the ECG rate and rhythm, the arterial blood pressure, and waveform or NBP reading and the pulse oximetry reading. This assessment should take less than 10 seconds.

Physical examination—Connect the oxygen or ventilator if disconnected. At the same time observe the patient and note the level of alertness and distress. Is the patient awake or unresponsive? Is the patient in NAD or in distress? Manually check the pulse. Does the monitor accurately reflect the patient's pulse and clinical condition? Simultaneously, assess the skin: hypothermic/hyperthermic, poor skin turgor, cold, and clammy. Is the patient febrile and/or in shock (hypovolemic, cardiogenic, obstructive, or distributive)?

Acute management—Obtain a 12-lead ECG and analyze rhythm. Your management will depend on the rhythm and whether the patient is stable or unstable. If the patient is stable then proceed with further testing if necessary, discontinue, and/or adjust medications depending on the diagnosis and clinical scenario and treat the underlying cause. If the patient is unstable, initiate the ACLS protocol, prepare for synchronized cardioversion and further pharmacologic treatment.

Acute Hypotension

Visual examination—The first thing you do as you walk into the room is observe the patient, the oxygen-ventilator-patient interface (are they connected to oxygen or the ventilator?) and glance at the monitor to assess the ECG rate and rhythm, the arterial blood pressure and waveform or the NBP reading, and the pulse oximetry reading. This assessment should take less than 10 seconds.

Physical examination—Connect the oxygen or ventilator if disconnected. Assess for accuracy of the blood pressure reading by checking cuff or arterial catheter placement. Note the mean arterial pressure and quickly check for signs of organ perfusion. At the same time, look at the patient and note their level of alertness and distress. Is the patient awake or unresponsive? Is the patient in NAD or in distress? Is there an arrhythmia associated with hypotension? Is the patient in shock (hypovolemic, cardiogenic, obstructive, or distributive)? Has the patient received any medications that can cause hypotension?

Acute management—If there is an arrhythmia associated with hypotension, obtain an ECG and analyze rhythm, perform further testing if necessary, assess for drug-induced causes, and discontinue the offending medication depending on the diagnosis and clinical scenario. If the patient is in truly in shock, begin resuscitation and treatment of the underlying cause. Perform a bedside echocardiogram to evaluate right and left ventricular function and volume status to direct treatment.

Acute Chest Pain

Visual examination—The first thing you do as you walk into the room is observe the patient and glance at the monitor to assess the ECG rate and rhythm, the arterial blood pressure and waveform or NBP reading, and the pulse oximetry reading. This assessment should take less than 10 seconds.

Physical examination—At the same time, look at the patient and note the level of alertness and distress. Is the patient awake or unresponsive? Is the patient in NAD or in distress?

If the patient can participate in the exam: Follow OPQRST algorithm: Onset of the event, provocation or palliation, quality of pain, region and radiation, severity, and time.

Acute management—Obtain 12-lead ECG for rhythm assessment specifically to rule out ST-changes, new onset left bundle branch block, or any arrhythmia. If EKG is noted for ST-elevation myocardial infarction, obtain an immediate cardiology consultation for possible need of emergent percutaneous catheter intervention. Make note of any arrhythmia (stable or unstable rhythm). If the patient is unstable and presumed cardiac ischemic etiology, start necessary pharmacologic treatment and initiate the ACLS protocol if needed. If the cause of chest pain is less likely due to cardiac etiology then rule out chest etiology. Auscultate bilateral breath sounds, assess for bilateral chest rise and perform an ultrasound of the chest to evaluate lung sliding or B-lines. Other unstable etiologies of acute chest pain that need to be considered include thoracic aneurysm, pulmonary embolus, pneumothorax, and mediastinitis. If the patient is stable, consider ultrasound, computed tomography (CT) scan and/or ventilation perfusion scan of the chest. If a pneumothorax is present, determine if the patient is stable or unstable. If the patient is unstable and experiencing signs of obstructive shock, immediate intervention for decompression is warranted.

Acute Respiratory Distress (Not on a Ventilator)

Visual examination—The first thing you do as you walk into the room is observe the patient, are they connected to supplemental oxygen, if so what type? Then glance at the monitor to assess the ECG rate and rhythm, the arterial blood pressure and waveform or the NBP reading, respiratory rate, and the pulse oximetry reading. This assessment should take less than 10 seconds.

Physical examination—Apply supplemental oxygen as needed. At the same time, look at the patient and note their overall appearance, level of consciousness, skin color (cyanosis), work of breathing, accessory muscle use, airway resistance, airflow, and ability to speak in full sentences or not. Auscultate the lungs for any adventitious sounds, which may include the following: wheezing (asthma, bronchospasm), rales, or stridor. Has the patient been recently extubated and not tolerating it well? Has the patient had any recent intervention that may have caused a pneumothorax? Is the patient high risk for pulmonary embolism and experiencing any associated symptoms? Is the patient exhibiting signs of anxiety and agitation? Is there any known previous pertinent medical history that could be attributing to this distress?

Acute management—If there are no signs of imminent respiratory failure, you have some time to retrieve an arterial blood gas sample, review valuable laboratory results and diagnostic findings (CXR or CT Chest) and bedside lung ultrasonography to assess for lung sliding to rule out pneumothorax, B-lines to rule out fluid overload and pleural effusion. This will help provide a list of differential diagnoses for the patient's respiratory status.

There are multiple strategies to treating a patient in respiratory distress whether it is close observation, medication, supplemental oxygenation, the need for an advanced airway, or an emergent intervention (chest tube thoracostomy). The patient's clinical status and arterial blood gas findings will help guide the management decisions.

Acute Respiratory Distress (on a Ventilator)

Visual examination—The first thing you do as you walk into the room is observe the patient and glance at the ETT or tracheostomy tube making sure it is connected and not dislodged. Then look at the monitor to assess the ECG rate and rhythm, the arterial blood pressure waveform or the NBP reading, and the pulse oximetry reading. Quickly look at the ventilator, its waveforms (tidal volume, pressure, and flow) and make note of which ventilator alarms are being triggered. This exam should take less than 10 seconds.

Physical examination—At the same time, look at the patient and note the overall appearance, level of consciousness, skin color (cyanosis), work of breathing, accessory muscle use, airway resistance, and airflow, and if there is ventilator synchrony versus dyssynchrony. Auscultate the lungs for bilateral and any adventitious sounds.

The main focus should always be on the patient rather than solely the ventilator. If the patient is rapidly deteriorating or abruptly unstable, disconnect the patient from the ventilator and hand ventilate with a bag valve mask providing 100% oxygen and use a PEEP valve if the patient was receiving PEEP. If the patient is orally intubated with an ETT, note the position of tube at lips or teeth. Check the cuff of the ETT and listen for a leak, if there is a leak, inflate air using an empty syringe to assess for adequate filling. Determine if the patient needs suctioning of their ETT from possible obstruction or mucous plug. If the patient has a tracheostomy, assess for adequate placement in airway, adequate cuff volume, and inner cannula for patency.

If there is enough time to troubleshoot the ventilator, observe the ventilator waveforms, settings and alarming parameters. The ventilator alarms that are being triggered will give insight to why the patient may be in respiratory distress. Common ventilator alarms are high pressure, low pressure, high/low minute volume, apnea, disconnection in the circuit, and high-exhaled tidal volume. Check the current settings: ventilator mode, tidal volume, respiratory rate, FiO₂, PEEP, and inspiratory to expiratory ratio. Make note of the measured tidal volumes, minute volumes, and peak and plateau pressures.

High-pressure alarms may indicate the following: mucus plug, pneumothorax, mainstream intubation, obstructed ETT (patient biting or mucus plug), asynchrony, or abdominal compartment syndrome affecting ability of adequate ventilation.

Low-pressure alarms may indicate the following: air leak, extubation, tube, or ventilator disconnection; note that there are many areas on the ventilator circuit tubing that can allow for a disconnection and the tubing must be examined carefully fully along its path.

Acute Lethargy/Unresponsiveness

Visual examination—The first thing you do as you walk into the room is observe the patient and glance at the monitor to assess the ECG rate and rhythm, the arterial blood pressure and waveform or the NBP reading, and the pulse oximetry reading. This assessment should take less than 10 seconds.

Physical examination—At the same time, look at the patient and note the level of consciousness and/or distress. If there is no contradiction, gently rub the patient's sternum with a closed fist to stimulate the patient. This will help assess whether they are awake, alert, and able to move extremities. Quickly assess the patient's pulses, extremities, and respiratory status. If the patient is receiving any sedative or analgesic, discontinue the offending agent and consider a pharmacologic reversal agent if indicated (flumazenil or naloxone).

Is there concern for hepatic encephalopathy or metabolic encephalopathy?

Is the patient in acute respiratory distress? Is the patient obtunded or experiencing signs of herniation?

Is the patient having a seizure? Assess pupillary response, eye movement, nystagmus, or spontaneous movement of bilateral eyes?

Is the patient exhibiting any signs or symptoms of a stroke (cerebral vascular accident/transient ischemic attack)? If the patient can cooperate with a neurological exam, assess for facial drooping, arm drift, and slurred speech.

Acute management—If the patient is unresponsive, unstable, or experiencing signs of a stroke, initiate the ACLS protocol. If the patient is obtunded or unable to protect their airway, then consider intubation and initiation of mechanical ventilation. If the patient is in respiratory distress, refer to the section above on acute respiratory distress. Support the patient and treat the underlying cause.

Seizure

Visual examination—The first thing you do as you walk into the room is observe the patient and glance at the monitor to assess the ECG rate and rhythm, the arterial blood pressure and waveform or the NBP reading, and the pulse oximetry reading. This assessment should take less than 10 seconds.

Physical examination—At the same time, look at the patient for abnormal movements or shaking and note the level of consciousness and/or distress. Perform a quick assessment of the patient's respiratory status. Some patients need an advanced airway for airway protection. Observe the type of seizure activity: partial seizure, tonic clonic seizure, grand mal seizure, or status epilepticus.

Acute management—Provide a safe environment and administer a first line agent, such as an intravenous benzodiazepine (lorazepam, midazolam, or diazepam). Do not place anything in the patient's mouth. Review current medications and possible side effects that may have precipitated the seizure. Obtain a neurology consultation. For ongoing status epilepticus, continue further seizure treatment and consider airway protection with intubation and mechanical ventilation.

Acute Extremity Symptom or Coolness

Visual examination—The first thing you do as you walk into the room is observe the patient and glance at the monitor to assess whether the vital signs are stable.

Physical examination—Is the patient in distress and experiencing severe pain, weakness, numbness, or paresthesias of the extremity? Is the patient at risk for ischemic limb or compartment syndrome? Does the patient have a history of vascular disease or recent vascular surgery in the affected extremity? Check for indwelling catheters (peripheral intravenous catheter and arterial catheters) that may cause vascular compromise. Has the patient any recent surgery or trauma to the affected extremity? Assess any surgical or nonsurgical dressings that may be compressing the area.

Perform a thorough assessment of the affected extremity's proximal and distal pulses, coolness and capillary refill. Consider using a doppler if the pulse is unable to be palpated.

Acute management—Remove any invasive catheter, dressing, cast or splint that may be compromising the extremity. For concerns of ischemia or compartment syndrome call the appropriate consult.

Acute Abdominal Distention

Visual examination—The first thing you do as you walk into the room is observe the patient and glance at the monitor to assess the ECG rate and rhythm, the arterial blood pressure and waveform or the NBP reading, and the pulse oximetry reading.

Physical examination—At the same time, look at the patient and note the level of alertness and distress. Is the patient awake or unresponsive, in NAD or in distress? Pay close attention to the patient's general appearance, examine for pain, and note any recent fevers. A patient with peritoneal irritation is likely to remain still, contrary to a patient with obstruction, who usually presents with restlessness. Assess the abdomen and skin. Has the patient had recent abdominal surgery? Recent large volume resuscitation? Risk for intra-abdominal bleeding? Recent anticoagulation and possible skin ecchymosis? Be sure to ask about the patient's last bowel movement or recent vomiting. Has the urine output abruptly decreased or was there a change in color? Does the patient have any intraabdominal surgical drains in place and is there any fluid output? Are you having any difficulty ventilating the patient with oxygen? If the patient is on mechanical ventilation and experiencing respiratory distress and desaturation from inadequate ventilation, are the peak inspiratory pressures elevated? Is the patient experiencing signs of obstructive hypotension and shock?

Acute Management

If the patient is stable, consider an abdominal x-ray, CT scan, or surgical consult. Review medications that could be further potentiating an obstructive process or gastroparesis. Obtain an intra-abdominal pressure via bladder pressure measurement. If the etiology is primary abdominal compartment syndrome, immediate surgical intervention is required for abdominal decompression. For unstable patients, especially those experiencing signs of obstructive shock, provide adequate oxygenation, ventilation, and cardiovascular support.

Acute Anuria

Visual examination—The first thing you do as you walk into the room is observe the patient and glance at the monitor to assess the ECG rate and rhythm, the arterial blood pressure and waveform or the NBP reading, and the pulse oximetry reading.

Physical examination—At the same time, look at the patient and note their level of consciousness and/or distress. Check the Foley catheter for kinks and hand irrigate to assess patency. Evaluate the patient's volume status; is the patient volume depleted, hypoperfused, or has a low cardiac output? Is the patient hypotensive or in shock? Is there an obstruction? Is the patient exhibiting signs of acute renal failure?

Assess abdomen for distention, tenderness, rigidity, or a possible complication or failure of drains, such as an ileal conduit or nephrostomy tube. Obtain intra-abdominal pressures to rule out compartment syndrome. Review laboratory and chemistry information.

Acute management—If there in an indwelling urinary catheter, consider mechanical obstruction and frequently administer saline flushes to assure patency. Administer a fluid bolus challenge to assess the response to fluid. If the patient has oliguric or anuric acute renal failure further testing is required. Obtain a bedside renal ultrasound to assess for signs of obstruction, for example, bladder distension and hydronephrosis. If a patient's clinical status is deteriorating, consider a nephrology consultation and possible initiation of renal-replacement therapy.