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  • Competency Title : Observations and The Deteriorating Patient for HCAs

    Competency Lead : Vikki Crickmore, Sister, Critical Care Outreach Team

    September 2013

  • ObjectivesDemonstrate normal values of vital signsHave awareness of how to respond to findings and how to escalate care appropriately.Carry out a practical assessment of taking observations and management of case studies.Demonstrate awareness of how to make an emergency call via 2222 system.

  • Vital signs to assessRespiratory rateOxygen SaturationsPulseSystolic (BP)AVPU/GCSTempUrine Output

  • Normal valuesBP: systolic 101-170HR: 51-100RR: 11-20Saturations: >96%Temperature: 36 38 degreesUrine Output: 0.5ml/kg/hr

  • 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.

  • Respiratory rate

    The most sensitive indicator of potential deterioration. Rising rates often early sign.Relevant in a number of compensatory mechanisms within the body Normal rate should be between 12 and 20.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.

  • 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.

  • Oxygen saturationsDependent on intact respiratory and cardiovascular function limited by other factors ie: peripherally shut down.

    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.

    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.

  • Heart Rate

    Felt at brachial arteryNormal rate can be considered 60-100bpm.Should be taken manually for one minute, noting the rate, volume and regularity. Abnormal findings need investigatingAbnormalities should be followed with an ECGConsider ECG monitoring

  • Blood pressureA 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.

  • Urine outputShould be 0.5ml/kg/hrDue to high demand for blood supply to the kidneys, urine output is a useful indicator of cardiovascular status.Sensitive indicator of hydration statusGenerally 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.

  • Level of ConsciousnessConsider at what point do you need help?This should include drowsiness, agitation, new changes.AVPU or GCS for more in depth assessment. Assess pupils Consider reversible causes ie: blood sugarIf only responding to pain or unresponsive airway is at risk 2222 adult emergency.Criteria for Neurological observations

  • When to report findings?

    Abnormal findings

    Change from normal for patient

    Patient looks unwell but observations fine

    New complaint or worsening of symptoms

  • 2222 system

    Cardiac arrest = patient in cardiac arrest

    Adult Emergency = patient critically ill or unconscious

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