1. Dr Nikhilesh Jain CHL Hospitals,Indore

2. Objectives  Explain what is meant by assessment of the acutely ill patient.  Describe the process of assessing the acutely ill patient.  Understand how to undertake a systematic assessment of the acutely ill patient.  Evaluate the doctor’s role in assessment of the acutely ill patient.

3. What is assessment?  A process by which you establish the needs of your patient.  A process by which you establish a baseline of immediate and future needs.  An on-going process - evaluation of interventions and reassessment of need.

4. What Does Assessment Involve?  Observation.  Communication.  Monitoring.  Analysis and interpretation  Diagnosis

5. What do we assess?  Nice draft guidelines 04/2007 – Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospitals.  19 Recommendations – 7 of which were identified as key priorities.

6. Recommendation 1  Adult patients in acute hospital settings should have:  All appropriate physiological observations recorded at the time of admission/initial assessment.  Their physiological observations measured, recorded and acted upon by staff specifically trained to undertake these procedures and understand their clinical relevance.  A clear monitoring plan that specifies which physiological observations to be recorded and how often they should be recorded. This will take account of the:  patient’s diagnosis  presence of co-morbidities  agreed treatment plan.

7. Recommendation 2  The following physiological observations should be carried out as part of routine monitoring: Heart rate Respiratory rate Blood pressure Level of consciousness Oxygen saturation Temperature.

8. Recommendation 3  Additional monitoring may be required in specific clinical circumstances, for example:  Hourly urine output  Biochemical analysis (for example, lactate, blood glucose, base deficit, arterial pH)

9. Mini Patient Assessment  Know - what you are told  See - quick visual assessment  Find - quick physical assessment

10. Common Presenting Abnormalities  Tachypnoea  Altered level of Consciousness  Derangement of heart rate  Derangement of blood pressure  Derangement of arterial oxygen saturation  Derangement of urine output

11. Early warning systems?  Heart rate.  Blood pressure.  Respiratory rate.  Oxygen saturation.  Respiratory Support / Oxygen Therapy.  Urinary output.  Conscious level.

12. LEEDS TEACHING HOSPITALS NHS TRUST CRITICAL CARE OUTREACH ADULT EARLY WARNING SCORING SYSTEM This scoring system has been designed to help both nursing and medical staff identify patients who are seriously ill or at risk of deterioration. It should be used on adult patients immediately after their observations have been done. Score3210123 Heart Rate - HR <4041-5051-100101-110111-130>130 Blood Pressure - BP ( systolic) <7071-8081-100101-179180-199200-220> 220 Respiratory Rate - RR <88- 1112- 2021- 2526- 30>30 Oxygen Saturations <85%86-89%90-94%>95% Respiratory Support/ Oxygen Therapy BIPAP/ CPAP Hi-FlowOxygen Therapy Urine Output in last 4 hours/mls <8080-120120-200>800 Central Nervous System- CNS ConfusionAwake and Responsive Responds To Verbal Command Responds to Painful Stimuli Unresponsive Each measurement is given a score from the table above. If the patient’s total score is 3 or more, the call out algorithm is triggered and you must call for help. Please follow as directed. May 2001 Adapted from the Great Yarmouth Scoring System by Richard Morgan.

13. MEWS is/becomes 3 Call Outreach team/NNP and PRHO Patient deteriorated MEWS is/becomes 5 No response in 30 mins Call Outreach team/ NNP and registrar Yes No Local action (guidelines) Continue monitoring/ follow-up Patient improved when reviewed after 2 hours Yes No No response in 30 mins Contact consultant +/- refer to appropriate specialty If MEWS greater than 10 contact Patients own Consultant, Outreach team and ICU Directly

14. Ian Goulden 14 Patient Assessment Priorities.  Primary Survey.  Resuscitation.  Secondary Survey.  History.  Intervention/Transfer  Re-evaluation. Occur as one. CPR. Oxygen and airway control. Cannulate. Blood samples. Fluids. Resus’ drugs. Trauma management. Urinary and Gastric catheters.

15. Primary Survey  Level of Consciousness  Airway  Breathing  Circulation  Disability  Expose and Examine

16. Primary Survey - Level of Consciousness  Response to spoken word?  Gentle tactile stimulation

17. Primary Survey - Airway Cervical Spine  Airway obstruction? Paradoxical movement?  Respiratory insufficiency?  Secure airway manually / adjuncts  Cricothyroid puncture?

18. Airway Obstruction

19. Primary Survey - Breathing  Effectiveness of Breathing  Work of Breathing

20. Primary Survey - Breathing  Cyanosis, hypoxia?  Rate, depth, symmetry of chest movement? Use of accessory muscles?  Palpate chest wall for structural integrity  Chest injury / flail / pneumothoraces  O 2 therapy / Assisted ventilation  Manage injury / pnuemothoraces

21. Primary Survey - Circulation  Quick head to toe survey to note and control bleeding  Skin colour, moisture, temperature  Pulse quality, rate, regularity, volume  Blood pressure  Capillary refill (should be < 2 seconds)  Chest Compressions / Positioning etc.

22. Primary Survey - Disability  Baseline level of consciousness  A. V. P. U + GCS  Neurological Examination  Immobilize fractures / potential fractures  Pain assessment / Analgesia

23. A. V. P. U  A = Alert.  V = Responds to Vocal Stimuli Only  P = Responds to Painful Stimuli Only  U = Unconscious

24. Primary Survey - Expose and Examine  Thorough examination - all systems  Dignity / control of temperature

25. Secondary Survey. Thorough full system assessment  CVS Pulse (s) / BP / ECG / Palpation / Auscultation / Jugular veins / Oedema.  Respiratory Rate / Rhythm / Palpation - Trachea and Thorax / Auscultation / Peakflow? Pulse oximetry / CXR / ABG analysis?

26. Secondary Survey. Thorough full system assessment  Head and neck Skull / Neck/ Eyes / Ears / Nose / Mouth  Renal Urine output - 1ml/kg/hour ? 30mls/hr?

27. Categories of Urine Output

28. Secondary Survey. Thorough full system assessment  Abdomen. Inspect / Palpate / Auscultate  Perineum / Rectum / External Genitalia. Inspect / Examine Blood in urine? Pregnancy test?

29. Secondary Survey. Thorough full system assessment  Musculoskeletal. Inspect / Palpate / Range of Movement / Motor and Sensory function. Pelvis / Skull / Spine / Limbs / Joints

30. Secondary Survey. Thorough full system assessment  Metabolic Urea and electrolytes. Blood sugar. Poisons screen. LFT’s. etc.

31. To summarise

32. Some more signs????

33. Refining it further?????