Presentation is loading. Please wait.

Presentation is loading. Please wait.

Observations and the Deteriorating Patient for Registered Nurses

Similar presentations

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 Service September 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 nurses Band 7’ and senior nurses to assess own staff CCOS to assess Band 7’s CCOS to do Train the Trainer sessions for senior nurses Band 7’ and senior nurses to assess own staff

4 Assessments ↓ Competency framework Presentation Questions
Station ← → Station 2 Practical taking obs Case studies & and documenting completing competency in pairs document Conclude and finish

5 Introduction Competency framework 2005 – NCEPOD: An Acute problem
2007 – NPSA: Safer care for the acutely ill patent 2007 – NPSA: Recognising & responding appropriately to early signs of deterioration Consistent themes are obvious throughout these documents: Failure to measure basic observations. Lack of recognition of the importance of worsening vital signs Delay in response to deteriorating vital signs.

6 Competency framework 2007 – 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 admission A 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 framework Modified Early Warning Used 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 used Taking observations is not just generating numbers – need to understand clinical relevance Delegating needs to be appropriate Failure to act has significant consequences – effects on patient, ↑ cardiac arrest, ↑ length of stay, ↑ ICU admissions. Observe patient – not just using machines MEWS adapted for paediatrics and obstetrics & head injury patients

9 Vital signs to assess Competency framework Respiratory rate
Oxygen Saturations Pulse Systolic (BP) AVPU/GCS Temp Urine Output

10 Respiratory rate Competency framework
Relevant in a number of compensatory mechanisms within the body Normal 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 back to 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 artery Normal rate can be considered bpm. Abnormal findings need investigating Abnormalities should be followed with an ECG Consider ECG monitoring

15 Effects on Heart Rate Competency framework Haemorrhage / bleeding
Hypotension Sepsis Drugs / medications Hypoxia Temperature Injury / Insult Electrolytes

16 Blood pressure = pressure on wall of artery
Competency framework Blood pressure = pressure on wall of artery Systolic = pumping pressure Diastolic = 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 patient Organs 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 status Should be 0.5ml/kg/hr Due 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 framework Level of Consciousness AVPU or GCS for more in depth assessment. Consider at what point do you need help? This should include drowsiness, agitation, new changes. Assess pupils Consider reversible causes ie: blood sugar If 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 cultures Significant warming can cause vasodilation Low can be as important as high

22 Considerations Competency framework O2 needed? Positioning IV access
ECG Catheter IV fluids Bloods Escalation status

23 Who is at risk? Competency framework Any one in hospital!!
Those with co-existing disease All emergency admissions Elderly people Specific acute illness (sepsis, pancreatitis) Those with altered level of consciousness Major haemorrhage

24 Causes of deterioration
Competency framework Causes of deterioration Sepsis Hospital acquired infections Chronic disease process Co-morbidities Failure to manage complications Iatrogenic Unavoidable complications Palliative / end of life

25 Chain of safety Competency framework
Measure observations and Document ↓ Recognise Deterioration ↓ Communicate Appropriately ↓ Respond efficiently & reassess

26 SBAR Competency framework A tool used to communicate
critical information succinctly and briefly

27 Barriers to escalation
Competency framework Barriers to escalation Anxious 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 framework Additional elements in relation to patient care Individual Accountability Risk assessment and delegation Consent Risk assessment Privacy and dignity Documentation Infection control Communication Safeguarding Updates on amendments to revised policy

29 Practical assessment Competency framework
Complete action plan for scenarios given Discuss rationale for taking observations and increase/decrease frequency Correctly taking a full set of observations Correct documentation and calculation of scores using trust observation charts. Demonstrate awareness of escalation procedures.

Download ppt "Observations and the Deteriorating Patient for Registered Nurses"

Similar presentations

Ads by Google