Observations and the Deteriorating Patient for Registered Nurses

Observations and the Deteriorating Patient for Registered Nurses

Observations and the Deteriorating Patient for Registered Nurses Shane Moody, Lead for Critical Care Services Vikki Crickmore, Sister. Critical Care Outreach Service September 2013 Competency framework Objectives 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. Competency framework Assessments CCOS to assess Band 7s CCOS to do Train the Trainer sessions for senior

nurses Band 7 and senior nurses to assess own staff Competency framework Assessments Presentation Questions Station 1

Practical taking obs and documenting in pairs Station 2 Case studies & completing competency document Conclude and finish

Competency framework 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. Lack of recognition of the importance of worsening vital signs Delay in response to deteriorating vital signs. 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. 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. Competency framework Applying to practice 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 Competency framework Vital signs to assess

Respiratory rate Oxygen Saturations Pulse Systolic (BP) AVPU/GCS Temp Urine Output Competency framework Respiratory rate 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. Competency framework Saturations Blood pumped from Heart is rich in O2

(95%-99% saturated) Blood pumped back to heart is low in O2 (65%-70%) Competency framework 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. Competency framework Oxygen saturations 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.

Competency framework Heart Rate Should be taken manually for one minute, noting the rate, volume and regularity. Felt at brachial artery Normal rate can be considered 60100bpm. Abnormal findings need investigating Abnormalities should be followed with an ECG Consider ECG monitoring Competency framework

Effects on Heart Rate Haemorrhage / bleeding Hypotension Sepsis Drugs / medications Hypoxia

Temperature Injury / Insult Electrolytes Competency framework Blood pressure = pressure on wall of artery Systolic = pumping pressure Diastolic = resting pressure Competency framework Arterial pressure 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 Blood pressure 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. Competency framework Urine output 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 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

Competency framework Temperature 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 Competency framework Considerations O2 needed?

Positioning IV access ECG Catheter IV fluids Bloods Escalation status Competency framework Who is at risk?

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 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 Competency framework Chain of safety Measure observations and Document Recognise Deterioration Communicate Appropriately

Respond efficiently & reassess Competency framework SBAR A tool used to communicate critical information succinctly and briefly 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) 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 Competency framework Practical assessment 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.

Recently Viewed Presentations

  • Reforming China's human rights regime: Can business play a role?

    Reforming China's human rights regime: Can business play a role?

    What is the political risk for businesses operating in China with regards to human rights and corruption? To what extent can foreign MNCs influence the human rights regime in the Mainland? Private Sector Corruption Slide 13 Findings Reforming China's human...
  • Penyakit Trofoblast - Weebly

    Penyakit Trofoblast - Weebly

    Jinak, Mola Hidatidosa 2. Ganas, Mola Destruens/PTG Vilosum 3. Sangat Ganas, Koriokarsinoma/PTG Non Vilosum Mola Hidatidosa Dapat mengadakan invasi mola invasif/mola destruen ( lokal ) Dapat menyebar ke organ lain korio ca Diagnosis Mola : 1. Hamil 2. uterus lebih...
  • AO3: First final piece idea - The De Montfort School

    AO3: First final piece idea - The De Montfort School

    A,B and C for final piece ideas. 6. Research: A mind map variety of images and testing that show the student has considered every detail in their response: Theme, Artist influence, materials, style, mood, techniques.
  •  Launched Winter Meeting 2010  Clinical Leadership to improve

    Launched Winter Meeting 2010 Clinical Leadership to improve

    Launched Winter Meeting 2010 Clinical Leadership to improve Stop Smoking services in Secondary Care Recommendations for Hospital Stop Smoking Services (updated from 2006) Practical demonstration of the ROI Calculator Wendy Preston What else?
  • Production Possibility Frontier - Cornell University

    Production Possibility Frontier - Cornell University

    Market Equilibrium. We will consider the market for compact disc players. Recall that we will define the following for our market: The type and style of CD players.
  • 1 Resources To Accelerate Growth In International Markets

    1 Resources To Accelerate Growth In International Markets

    Export Express. 90% guarantee for amounts up to $350,000 (for up to 7 years) 75% guarantee for amounts between $350,000 and $500,000 (for up to 7 years) Lender uses its own loan approval process and documents. For financing of inventory,...
  • The New York City Health Literacy Campaign: From

    The New York City Health Literacy Campaign: From

    The New York City Health Literacy Campaign: From Knowledge to Action Nutrition Results The Mayor's Office of Adult Education Summary We surveyed adult learners at two adult education sites about their drinking habits and knowledge of healthy drinks.
  • Folie 1 - Userpage

    Folie 1 - Userpage

    FU Berlin Constanze Donner / Ludwig Pohlmann 2014 * Adsorbierte Spezies Einfachster Fall: nur die adsorbierten Zustände sind elektroaktiv Folgerungen: Diffusion spielt keine Rolle die Peaks verschieben sich nicht mit der Scanrate Hin- und Rückpeak an der gleichen Stelle Peakhöhe...