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Observations and the Deteriorating Patient for Registered Nurses Shane Moody, Lead for Critical Care Services Vikki Crickmore, Sister. Critical Care Outreach.

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Presentation on theme: "Observations and the Deteriorating Patient for Registered Nurses Shane Moody, Lead for Critical Care Services Vikki Crickmore, Sister. Critical Care Outreach."— 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 Competency frameworkObjectives Gain awareness of the national approach and MEWS.Gain awareness of the national approach and MEWS. Discuss observations in detail and physiological relevance.Discuss observations in detail and physiological relevance. Consider appropriate escalation response to deterioration and barriers to this.Consider appropriate escalation response to deterioration and barriers to this. Examine useful communication tools.Examine useful communication tools. Consider additional elements relevant to patient care when considering deterioration.Consider additional elements relevant to patient care when considering deterioration. Carry out a practical assessment of taking observations and management of case studies.Carry out a practical assessment of taking observations and management of case studies.

3 Assessments 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 Competency framework

4 Assessments Presentation ↓ Questions ↓ Station 1 ← → Station 2 Practical taking obs Case studies & and documenting completing competency in pairs document Conclude and finish Competency framework

5 Introduction 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.Failure to measure basic observations. Lack of recognition of the importance of worsening vital signsLack of recognition of the importance of worsening vital signs Delay in response to deteriorating vital signs.Delay in response to deteriorating vital signs. Competency framework

6 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 admissionPhysiological observations at the time of their admission A written monitoring plan (diagnosis, co-morbidities and plan)A written monitoring plan (diagnosis, co-morbidities and plan) Observations taken by staff that have been trained and understand clinical relevance.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.A Track and Trigger system and observations recorded 12 hourly as a minimum – increased if signs of deterioration. Competency framework

7 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. 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. The escalation pathway outlines actions required for timely review ensuring appropriate interventions. Competency framework Modified Early Warning

8 Limitations to MEWS and professional judgment should be usedLimitations to MEWS and professional judgment should be used Taking observations is not just generating numbers – need to understand clinical relevanceTaking observations is not just generating numbers – need to understand clinical relevance Delegating needs to be appropriateDelegating needs to be appropriate Failure to act has significant consequences – effects on patient, ↑ cardiac arrest, ↑ length of stay, ↑ ICU admissions.Failure to act has significant consequences – effects on patient, ↑ cardiac arrest, ↑ length of stay, ↑ ICU admissions. Observe patient – not just using machinesObserve patient – not just using machines MEWS adapted for paediatrics and obstetrics & head injury patientsMEWS adapted for paediatrics and obstetrics & head injury patients Competency framework Applying to practice

9 Respiratory rateRespiratory rate Oxygen SaturationsOxygen Saturations Pulse Pulse Systolic (BP)Systolic (BP) AVPU/GCSAVPU/GCS TempTemp Urine OutputUrine Output Competency framework Vital signs to assess

10 Relevant in a number of compensatory mechanisms within the bodyRelevant in a number of compensatory mechanisms within the body Normal rate should be between 12 and 20.Normal rate should be between 12 and 20. The most sensitive indicator of potential deterioration. Rising rates often early sign.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.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.Position of patient is important. Competency framework Respiratory rate

11 Blood pumped from Heart is rich in O2 (95%-99% saturated) Blood pumped back to heart is low in O2 (65%-70%) Competency frameworkSaturations

12 Oxygen demand 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 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.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.Dependent on intact respiratory and cardiovascular function – limited by other factors ie: peripherally shut down. Be aware of patients ‘target saturations’.Be aware of patients ‘target saturations’. All acutely unwell patients should receive supplementary Oxygen and then titrate to readings.All acutely unwell patients should receive supplementary Oxygen and then titrate to readings. ABG may be required for more in depth assessment.ABG may be required for more in depth assessment. Competency framework Oxygen saturations

14 Should be taken manually for one minute, noting the rate, volume and regularity.Should be taken manually for one minute, noting the rate, volume and regularity. Felt at brachial arteryFelt at brachial artery Normal rate can be considered bpm.Normal rate can be considered bpm. Abnormal findings need investigatingAbnormal findings need investigating Abnormalities should be followed with an ECGAbnormalities should be followed with an ECG Consider ECG monitoring Consider ECG monitoring Competency framework Heart Rate

15 Effects on Heart Rate Haemorrhage / bleedingHaemorrhage / bleeding HypotensionHypotension SepsisSepsis Drugs / medicationsDrugs / medications HypoxiaHypoxia TemperatureTemperature Injury / InsultInjury / Insult ElectrolytesElectrolytes Competency framework

16 Blood pressure = pressure on wall of artery Systolic = pumping pressure Diastolic = resting pressure

17 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. Competency framework Arterial pressure

18 A LATE sign of deterioration – patients will compensate (especially young)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.Adequate BP is essential for delivery of O2 and nutrients to the rest of the body. Be aware of what is normal for patientBe aware of what is normal for patient Organs are very dependent on adequate pressures to ensure perfusion.Organs are very dependent on adequate pressures to ensure perfusion. Manual Blood pressure recording may be appropriate.Manual Blood pressure recording may be appropriate. Competency framework Blood pressure

19 Sensitive indicator of hydration statusSensitive indicator of hydration status Should be 0.5ml/kg/hrShould be 0.5ml/kg/hr Due to high demand for blood supply to the kidneys, urine output is a useful indicator of cardiovascular status.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.Generally is a poorly recorded observation. Monitoring of fluid balance should be appropriate depending on patient condition.Monitoring of fluid balance should be appropriate depending on patient condition. Acute Kidney injury - ↓ urine output, ↑ toxic waste. Needs urgent attentionAcute Kidney injury - ↓ urine output, ↑ toxic waste. Needs urgent attention Competency framework Urine output

20 AVPU or GCS for more in depth assessment.AVPU or GCS for more in depth assessment. Consider at what point do you need help?Consider at what point do you need help? This should include drowsiness, agitation, new changes.This should include drowsiness, agitation, new changes. Assess pupilsAssess pupils Consider reversible causes ie: blood sugarConsider reversible causes ie: blood sugar If only responding to pain or unresponsive – airway is at risk – 2222 adult emergency.If only responding to pain or unresponsive – airway is at risk – 2222 adult emergency. Neuro obsNeuro obs Competency framework Level of Consciousness

21 Can have a significant effect on patients condition.Can have a significant effect on patients condition. High or low can indicate sepsisHigh or low can indicate sepsis > 38 degrees consider blood cultures> 38 degrees consider blood cultures Significant warming can cause vasodilationSignificant warming can cause vasodilation Low can be as important as highLow can be as important as high Competency frameworkTemperature

22 O2 needed?O2 needed? PositioningPositioning IV accessIV access ECGECG CatheterCatheter IV fluidsIV fluids BloodsBloods Escalation statusEscalation status Competency frameworkConsiderations

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

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

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

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

27 Anxious about escalating? Frequency / exposure to deterioration? Knowledge and Skills? Prioritising workload? Difference of opinion? Difference of opinion? Define ‘deterioration’ “To become worse” (English dictionary, 2013) Competency framework Barriers to escalation

28 Individual AccountabilityIndividual Accountability Risk assessment and delegationRisk assessment and delegation ConsentConsent Risk assessmentRisk assessment Privacy and dignityPrivacy and dignity DocumentationDocumentation Infection controlInfection control CommunicationCommunication SafeguardingSafeguarding Updates on amendments to revised policy Competency framework Additional elements in relation to patient care

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


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