competency title : observations and the deteriorating patient for hcas c competency title :...
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Competency Title : Competency Title : Observations andObservations and TheThe Deteriorating PatientDeteriorating Patient for HCAsfor HCAs
CCompetency Lead : Vikki Crickmore, Sister, Critical Care Outreach Team
September 2013
ObjectivesObjectives• Demonstrate normal values of vital signsDemonstrate normal values of vital signs• Have awareness of how to respond to Have awareness of how to respond to
findings and how to escalate care findings and how to escalate care appropriately.appropriately.
• Carry out a practical assessment of taking Carry out a practical assessment of taking observations and management of case observations and management of case studies.studies.
• Demonstrate awareness of how to make Demonstrate awareness of how to make an emergency call via 2222 system.an emergency call via 2222 system.
Competency framework
Competency framework
Vital signs to assessVital signs to assess• Respiratory rateRespiratory rate• Oxygen SaturationsOxygen Saturations• PulsePulse• Systolic (BP)Systolic (BP)• AVPU/GCSAVPU/GCS• TempTemp• Urine OutputUrine Output
• BP: systolic 101-170• HR: 51-100• RR: 11-20• Saturations: >96%• Temperature: 36 – 38 degrees• Urine Output: 0.5ml/kg/hr
Competency framework
Normal valuesNormal values
Used to aid recognition of deteriorating patients, Used to aid recognition of deteriorating patients, and are based on physiological parameters. and are based on physiological parameters.
An aggregated score calculated. Escalation An aggregated score calculated. Escalation pathway activated if specific scores. Track and pathway activated if specific scores. Track and Trigger approach.Trigger approach.
The escalation pathway outlines actions required The escalation pathway outlines actions required for timely review ensuring appropriate for timely review ensuring appropriate interventions.interventions.
Competency framework
Modified Early WarningModified Early Warning
Competency framework
Respiratory rateRespiratory rate• The most sensitive indicator of potential The most sensitive indicator of potential
deterioration. Rising rates often early sign.deterioration. Rising rates often early sign.• Relevant in a number of compensatory Relevant in a number of compensatory
mechanisms within the body mechanisms within the body • Normal rate should be between 12 and 20.Normal rate should be between 12 and 20.• Using in conjunction with other evidence ie: use Using in conjunction with other evidence ie: use
of accessory muscles, increased work of of accessory muscles, increased work of breathing, able to speak?, exhaustion, colour of breathing, able to speak?, exhaustion, colour of patient.patient.
• Position of patient is important.Position of patient is important.
Oxygen demandOxygen 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
Competency framework
Oxygen saturationsOxygen saturations• Dependent on intact respiratory and cardiovascular function Dependent on intact respiratory and cardiovascular function
– limited by other factors ie: peripherally shut down. – limited by other factors ie: peripherally shut down.
• All cells are dependent on an adequate constant supply of All cells are dependent on an adequate constant supply of O2 as they are unable to store it. A reduction can lead to O2 as they are unable to store it. A reduction can lead to organ dysfunction and death.organ dysfunction and death.
• Be aware of patients ‘target saturations’.Be aware of patients ‘target saturations’.
• All acutely unwell patients should receive supplementary All acutely unwell patients should receive supplementary Oxygen and then titrate to readings. Oxygen and then titrate to readings.
• ABG may be required for more in depth assessment.ABG may be required for more in depth assessment.
• Felt at brachial arteryFelt at brachial artery• Normal rate can be considered 60-100bpm.Normal rate can be considered 60-100bpm.• Should be taken manually for one minute, noting Should be taken manually for one minute, noting
the rate, volume and regularity. the rate, volume and regularity. • Abnormal findings need investigatingAbnormal findings need investigating• Abnormalities should be followed with an ECGAbnormalities should be followed with an ECG• Consider ECG monitoringConsider ECG monitoring
Competency framework
Heart RateHeart Rate
Competency framework
Blood pressureBlood pressure• A LATE sign of deterioration – patients will A LATE sign of deterioration – patients will
compensate (especially young)compensate (especially young)• Adequate BP is essential for delivery of O2 and Adequate BP is essential for delivery of O2 and
nutrients to the rest of the body. 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 Organs are very dependent on adequate
pressures to ensure perfusion.pressures to ensure perfusion.• Manual Blood pressure recording may be Manual Blood pressure recording may be
appropriate. appropriate.
• Should be 0.5ml/kg/hrShould be 0.5ml/kg/hr• Due to high demand for blood supply to the Due to high demand for blood supply to the
kidneys, urine output is a useful indicator of kidneys, urine output is a useful indicator of cardiovascular status.cardiovascular status.
• Sensitive indicator of hydration statusSensitive indicator of hydration status• Generally is a poorly recorded observation.Generally is a poorly recorded observation.• Monitoring of fluid balance should be appropriate Monitoring of fluid balance should be appropriate
depending on patient condition. depending on patient condition. • Acute Kidney injury - Acute Kidney injury - ↓ urine output, ↑ toxic ↓ urine output, ↑ toxic
waste. Needs urgent attention. waste. Needs urgent attention.
Competency framework
Urine outputUrine output
• Consider at what point do you need help?Consider at what point do you need help?• This should include drowsiness, agitation, new This should include drowsiness, agitation, new
changes.changes.• AVPU or GCS for more in depth assessment. AVPU or GCS for more in depth assessment. • Assess pupils Assess pupils • Consider reversible causes ie: blood sugarConsider reversible causes ie: blood sugar• If only responding to pain or unresponsive – If only responding to pain or unresponsive –
airway is at risk – 2222 adult emergency.airway is at risk – 2222 adult emergency.• Criteria for Neurological observations Criteria for Neurological observations
Competency framework
Level of ConsciousnessLevel of Consciousness
• Abnormal findingsAbnormal findings
• Change from normal for patientChange from normal for patient
• Patient looks unwell but observations finePatient looks unwell but observations fine
• New complaint or worsening of symptomsNew complaint or worsening of symptoms
Competency framework
When to report findings?When to report findings?
Competency framework
2222 system2222 system
Cardiac arrest = patient in Cardiac arrest = patient in cardiac arrestcardiac arrest
Adult Emergency = patient Adult Emergency = patient critically ill or unconsciouscritically ill or unconscious