competency title : observations and the deteriorating patient for hcas c competency title :...

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Competency Title : Competency Title : Observations and Observations and The The Deteriorating Patient Deteriorating Patient for HCAs for HCAs C Competency Lead : Vikki Crickmore, Sister, Critical Care Outreach Team September 2013

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Page 1: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

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

Page 2: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

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

Page 3: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

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

Page 4: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

• 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

Page 5: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

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

Page 6: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

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.

Page 7: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

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

Page 8: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

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.

Page 9: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

• 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

Page 10: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

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.

Page 11: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

• 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

Page 12: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

• 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

Page 13: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

• 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?

Page 14: Competency Title : Observations and The Deteriorating Patient for HCAs C Competency Title : Observations and The Deteriorating Patient for HCAs Competency

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