Presentation on theme: "Observations and the Deteriorating Patient for Registered Nurses"— Presentation transcript:
1 Observations and the Deteriorating Patient for Registered Nurses Shane Moody, Lead for Critical Care Services Vikki Crickmore, Sister.Critical Care Outreach ServiceSeptember 2013
2 Objectives Competency framework Gain awareness of the national approach and MEWS.Discuss observations in detail and physiological relevance.Consider appropriate escalation response to deterioration and barriers to this.Examine useful communication tools.Consider additional elements relevant to patient care when considering deterioration.Carry out a practical assessment of taking observations and management of case studies.
3 ↓ Assessments Competency framework ↓ CCOS to assess Band 7’s CCOS to do Train the Trainer sessions for senior nursesBand 7’ and senior nurses to assess own staffCCOS to assess Band 7’s↓CCOS to do Train the Trainer sessions for senior nursesBand 7’ and senior nurses to assess own staff
4 Assessments ↓ Competency framework Presentation Questions Station ← → Station 2Practical taking obs Case studies &and documenting completing competencyin pairs documentConclude and finish
5 Introduction Competency framework 2005 – NCEPOD: An Acute problem 2007 – NPSA: Safer care for the acutely ill patent2007 – NPSA: Recognising & responding appropriately to early signs of deteriorationConsistent themes are obvious throughout these documents:Failure to measure basic observations.Lack of recognition of the importance of worsening vital signsDelay in response to deteriorating vital signs.
6 Competency framework2007 – NICE published - Acutely Ill patients in hospital – recognition of and response to acute illness in adults in hospital.The key priorities of this document are:Physiological observations at the time of their admissionA written monitoring plan (diagnosis, co-morbidities and plan)Observations taken by staff that have been trained and understand clinical relevance.A Track and Trigger system and observations recorded 12 hourly as a minimum – increased if signs of deterioration.
7 Modified Early Warning Competency frameworkModified Early WarningUsed to aid recognition of deteriorating patients, and are based on physiological parameters.An aggregated score calculated. Escalation pathway activated if specific scores. Track and Trigger approach.The escalation pathway outlines actions required for timely review ensuring appropriate interventions.
8 Applying to practice Competency framework Limitations to MEWS and professional judgment should be usedTaking observations is not just generating numbers – need to understand clinical relevanceDelegating needs to be appropriateFailure to act has significant consequences – effects on patient, ↑ cardiac arrest, ↑ length of stay, ↑ ICU admissions.Observe patient – not just using machinesMEWS adapted for paediatrics and obstetrics & head injury patients
10 Respiratory rate Competency framework Relevant in a number of compensatory mechanisms within the bodyNormal rate should be between 12 and 20.The most sensitive indicator of potential deterioration. Rising rates often early sign.Using in conjunction with other evidence ie: use of accessory muscles, increased work of breathing, able to speak?, exhaustion, colour of patient.Position of patient is important.
11 Saturations Competency framework Blood pumped from Heart is rich in O2 (95%-99% saturated)Blood pumped backto heart is low in O2(65%-70%)
12 Oxygen demand Competency framework If oxygen delivery to the body falls below what is demanded, the tissues extract more oxygen from the haemoglobin and the saturation of blood falls.
13 Oxygen saturations Competency framework All cells are dependent on an adequate constant supply of O2 as they are unable to store it. A reduction can lead to organ dysfunction and death.Dependent on intact respiratory and cardiovascular function – limited by other factors ie: peripherally shut down.Be aware of patients ‘target saturations’.All acutely unwell patients should receive supplementary Oxygen and then titrate to readings.ABG may be required for more in depth assessment.
14 Heart Rate Competency framework Should be taken manually for one minute, noting the rate, volume and regularity.Felt at brachial arteryNormal rate can be considered bpm.Abnormal findings need investigatingAbnormalities should be followed with an ECGConsider ECG monitoring
16 Blood pressure = pressure on wall of artery Competency frameworkBlood pressure = pressure on wall of arterySystolic = pumping pressureDiastolic = resting pressure
17 Arterial pressure Competency framework The pressure in the arteries is carefully regulated by the body. If it drops, immediate circulatory changes occur:► Heart rate increases► Constriction of vessels (so BP may remain adequate) - ↓ CRT, ↓ Urine output.
18 Blood pressure Competency framework A LATE sign of deterioration – patients will compensate (especially young)Adequate BP is essential for delivery of O2 and nutrients to the rest of the body.Be aware of what is normal for patientOrgans are very dependent on adequate pressures to ensure perfusion.Manual Blood pressure recording may be appropriate.
19 Urine output Competency framework Sensitive indicator of hydration statusShould be 0.5ml/kg/hrDue to high demand for blood supply to the kidneys, urine output is a useful indicator of cardiovascular status.Generally is a poorly recorded observation.Monitoring of fluid balance should be appropriate depending on patient condition.Acute Kidney injury - ↓ urine output, ↑ toxic waste. Needs urgent attention
20 Level of Consciousness Competency frameworkLevel of ConsciousnessAVPU or GCS for more in depth assessment.Consider at what point do you need help?This should include drowsiness, agitation, new changes.Assess pupilsConsider reversible causes ie: blood sugarIf only responding to pain or unresponsive – airway is at risk – 2222 adult emergency.Neuro obs
21 Temperature Competency framework Can have a significant effect on patients condition.High or low can indicate sepsis> 38 degrees consider blood culturesSignificant warming can cause vasodilationLow can be as important as high
22 Considerations Competency framework O2 needed? Positioning IV access ECGCatheterIV fluidsBloodsEscalation status
23 Who is at risk? Competency framework Any one in hospital!! Those with co-existing diseaseAll emergency admissionsElderly peopleSpecific acute illness (sepsis, pancreatitis)Those with altered level of consciousnessMajor haemorrhage
24 Causes of deterioration Competency frameworkCauses of deteriorationSepsisHospital acquired infectionsChronic disease processCo-morbiditiesFailure to manage complicationsIatrogenicUnavoidable complicationsPalliative / end of life
26 SBAR Competency framework A tool used to communicate critical informationsuccinctly and briefly
27 Barriers to escalation Competency frameworkBarriers to escalationAnxious about escalating?Frequency / exposure to deterioration?Knowledge and Skills?Prioritising workload?Difference of opinion?Define ‘deterioration’“To become worse” (English dictionary, 2013)
28 Additional elements in relation to patient care Competency frameworkAdditional elements in relation to patient careIndividual AccountabilityRisk assessment and delegationConsentRisk assessmentPrivacy and dignityDocumentationInfection controlCommunicationSafeguardingUpdates on amendments to revised policy
29 Practical assessment Competency framework Complete action plan for scenarios givenDiscuss rationale for taking observations and increase/decrease frequencyCorrectly taking a full set of observationsCorrect documentation and calculation of scores using trust observation charts.Demonstrate awareness of escalation procedures.