objectives today's plan · • hypoxia may impair wound healing and enzymatic processes in the...

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Deteriorating Patient

AIM

To enable health care professionals :

• To recognise the deteriorating patient

• To initiate appropriate interventions

• To initiate timely interventions

Objectives

• For participants to

• Understand the importance & relevance of observations and the underlying physiology

• Be able to recognise & interpret abnormal observations

• To be able to communicate effectively to the right people at the right time

• To feel confident in recognising & managing a deteriorating patient

• To facilitate teamwork within the multidisciplinary team

• To enable nurses, doctors & physiotherapists to develop management plans together

Today's plan

• Background of why we are here

• Early warning score / Intensive Care Outreach

• Airway / Respiratory assessment skills

• Cardiac assessment skills

• Morning tea

• Conscious level assessment skills

• Urinary output assessment

• Temperature assessment / considerations

• ISBAR

• Lunch

• Practical hands on Case Studies/Scenarios

• Importance of teamwork

• http://www.youtube.com/watch?v=BFd54Yzg-

vo

• Are You Safe?

Intensive Care

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• The management of inpatients has become more

complex

• Patients are older, more unwell and have more co-

morbidities

• Previous high risk interventions are now considered

routine

• Historically junior medical staff are asked to assess or

treat the deteriorating patient

• ICU/HDU beds are a limited resource

Background

• Prevention is better than cure

• Organ failure requiring ICU admission increases patient risk of death

• Studies show

o patients receive sub-optimal care prior to ICU

o referrals to ICU are often delayed

• Cardiac arrests are generally preceded by clinical deterioration

Connect the dots…

• Early detection of abnormal vital signs and timely interventions reduces complications and saves lives

• Early and often simple preventative interventions reduce complications and save lives

NZ Health & Disability Commissioner

report 2007 into a patient death (2004) a

few days after pneumonia admission.

– Failure to recognise the severity of symptoms

– Poorly documented incomplete vital signs,

inadequate frequency

– Recommended use of EWS and ICU Outreach

service

Patient example

79 year old female, hx of …

• Admitted with week long history of increasing SOB

• 2nd May found blue by physio passing by in the ward

• Clinical emergency called for respiratory distress.

• No documented observations for 17 hours prior

• Last documented RR was 40 hours prior

• Intubated and transferred to ICU

This is what today is aiming to avoid…

Connect the dots…

• Early detection of abnormal vital signs and timely interventions reduces complications and saves lives

• Early and often simple preventative interventions are not occurring

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Early Warning Score

• Risk management tool

• Used extensively internationally

• Simple tool utilising basic vital signs

• Proven to detect early signs of patient deterioration

• Provides structure for communication

Expected outcome of EWS use

• Improve ward care of patients

• Reduce clinical emergency calls

• Earlier ICU referrals

• Reduction in readmissions to ICU

• Reduction in avoidable hospital deaths

• Improved decision making in NFR status

• Improved multidisciplinary teamwork and

communication

Early Warning Score

• Protocol for increasing frequency of observations

- Complete set of observations each time

• Inbuilt escalation policy

• Provides support for experienced staff

• Empowers nursing and medical staff

Does not replace a CLINCAL EMERGENCY CALL

EWS - Simple Vital Signs

• Airway

• Breathing/Respiratory Rate

• Heart Rate

• Systolic Blood Pressure

• Conscious Level / AVPU

• Urine Output

• Temperature

Quality documentation guidelines

• Colour coded

• Vital signs graphed individually

• Complete set of observations and EWS

calculated each time

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EWS Audit results Dec 2010 n=40

EWS Audit results Oct 2011 n=103

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

EWS audit

Combined results May to Sept 2012

Not compliant

Partial Compliant

Compliant

Observations did increase in freq according to

pathway requirements

If 3 or > evidence in notes of nurse contacting

Clinican for review

If 3 or > evidence in notes of clinican review

according to the pathway time frame

38%

63%

49%

EWS management 2012

n = 112, 83, 82

EWS /Management pathway

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EWS responsibilities

• Increase frequency of observations

• Inform nurse in charge

• Medical review within time frame

• If no medical review within time frame,

contact Intensive Care Outreach

• For EWS ≥ 6 follow management protocol

which includes calling Intensive Care Outreach

Times have changed for ICU

Intensive Care Outreach

• Increasing acuity of ward patients

• Sub-optimal funding of HDU, ICU beds

• Patients that would benefit from HDU remain on the

ward

• ICU discharges can have high care and treatment

needs

• ICU has a commitment to advise and assist in the

care of high acuity ward patients in addition to the

patients own team

Intensive Care Outreach

• ICU Outreach CNS pager 8073

• ICU Outreach Registrar pager 8155

• Receive calls in response to elevated EWS or clinical concerns

• Available 24/7 via pager

• Review all ICU discharges

• Supportive team who liaise directly with an

Intensivist

• Attend all clinical emergencies

Great expectations

• Improve patient outcomes

• Share critical care skills

• Avert ICU admissions

• Timely admission to ICU

• Support ICU discharges to prevent

ICU readmissions

EWS ICU Outreach Summary

• Proven simple, logical system to improve response to

acutely unwell patients

• Improve outcomes for patients

• Improve skills of ward staff in recognition and treatment

of acutely unwell patients

• Improve communication between ICU and ward staff,

with increased appreciation of what each can offer

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Vital signs performed

and interpreted

by nurse

Communicated to Doctor

Interpreted by Doctor

Timely & appropriate review and

management

Tools to assist this flow

• Early warning Score

• ISBAR

• Education and training

Early Warning Score

• Airway


• Heart Rate



• Urine Output

• Temperature

Airway / Respiratory assessment

Vital signs physiology

• Why do we need Oxygen ?

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A&PUpper respiratory tract

Mucocilliary Escalator Lower respiratory tract

The Exchange Surface

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‘Chain’ of Oxygen Delivery

Oxygen delivery =

Arterial Oxygen Content x Cardiac Output

Haemoglobin x Saturation Stroke volume x heart rate

Vital signs physiology

• Oxygen delivery chain

• ATP is a required source of energy for all

cellular function

• Oxygen delivery = Cardiac Output x Arterial Oxygen Content

Stroke volume (SV) x heart rate (HR) (Haemoglobin) (Hb) x

Saturation (Sa02)

(SV x HR) x (Hb x Sa02)

Arterial Oxygen Content – saturation

(A)- Adequate airway

(A) Adequate protection of airway

(B) Effective lung mechanics

-neurological - muscular

(B) Effective lung tissue

(C) Effective pulmonary circulation

(D) Effective haemoglobin


• Arterial Oxygen Content – Haemoglobin

• Adult Hb

• Concentration ( anaemia: causes)

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Airway/Breathing Objectives

• Recognise when difficulties with airway are

compromising oxygen delivery

• Apply the appropriate oxygen delivery device

• Manage the patient with impaired

oxygenation

Early Warning Score

• Airway


• Heart Rate



• Urine Output

• Temperature

Airway

• Is the airway patent?

– Functional airway obstruction

• LOC, obstruction of pharynx by the tongue

– Mechanical airway obstruction

• Aspiration of foreign body

• Bleeding, post-operative haematoma

• Oedema or spasm of the larynx, swelling

Airway

• Management

– Chin lift, jaw thrust, head tilt, airway insertion, suction

– CLINICAL EMERGENCY

Early Warning Score

• Airway


• Heart Rate



• Urine Output

• Temperature

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Breathing/RR

We all require tissue oxygenation to survive. Oxygen

delivery to the tissues requires two things

• Adequate gas exchange

• Good circulation of oxygenated blood to the tissues

Failure of adequate oxygenation causes hypoxic

conditions in the tissues

Airway & Breathing

• Decreased oxygen delivery at the tissue level

• Anaerobic metabolism

• Lactate production

• Acidosis

• Stimulates respiratory drive

• Increases the respiratory rate

Acute Respiratory failure

• occurs when the respiratory system is no

longer able to meet the metabolic demands of

the body

Types of Respiratory Failure

• Hypoxemic or Type 1:

– low arterial partial pressure of oxygen

• Hypercapnic or Type 2:

– High arterial partial pressure of carbon dioxide

Acute respiratory failure can occur in people

with and without chronic respiratory disease

RED FLAG

When the compensatory response is exhausted

your patients respirations will decrease as will

their heart rate

Bradycardia and bradypnoea are pre-terminal

signs.


Arterial Oxygen Content – saturation

(A)- Adequate airway

(A) Adequate protection of airway

(B) Effective lung mechanics

-neurological - muscular

(B) Effective lung tissue

(C) Effective pulmonary circulation

(D) Effective haemoglobin

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Effects of hypoxiaCirculation:• Patients develop tachycardia to compensate for poor oxygen delivery of oxygen to

the tissues

• Severe hypoxia leads to myocardial ischaemia, bradycardia, cardiac arrest

Neurological:• Hypoxia leads to confusion and agitation

• Hypercapneoa leads to ↓ LOC compromising the airway

Renal:• Prolonged hypoxia may cause renal impairment due to cell damage (ATN)

General systemic:• Hypoxia may impair wound healing and enzymatic processes in the body

Breathing/RR

• RR is an early indicator of falling oxygen levels

• Respiratory rate is a sensitive and important

indicator of early patient deterioration and important

“vital sign”

• Respiratory exhaustion requires urgent intervention

• Arterial oxygen content is determined by

haemoglobin and haemoglobin oxygen saturation

• Hb O2 saturation is affected by O2 administration

Breathing/RR

• Look

• Listen

• Feel

Breathing/RR

• Look

– Respiratory rate

– Depth of each breath

– Abdominal breathing

– equal chest movement

– unequal chest movement

– Use of accessory muscles

– Central or peripheral cyanosis

– Sweating

– Dyspnoea

– Hypoventilation

Breathing/RR

• Listen

– speaking in sentences?

– ask how breathing feels

– mentation

– Noisy breathing

• Rattling ?secretions

• Stridor / Wheeze

• Obstruction

– Auscultation

• equal air entry

• bronchial breathing

• Absent or reduced air entry

Breathing/RR

• Feel

– Tracheal deviation

– Surgical emphysema

– Percussion

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Breathing/RR

• Respiratory rate is recognised as an early and very sensitive

indicator of patient deterioration

• Importance of respiration rate previously under emphasized

• Accurate RR essential

• Visually count respirations even if your patient has a

monitored RR (it is generally not accurate)

• O2 delivery & O2 saturations add to the assessment and

remain important

Breathing/RR

Interventions along with the EWS Management Protocol include:

• Sit the patient upright

• Apply oxygen therapy

• Sputum sample if infection suspected

• CXR to establish diagnosis

– Pneumonia, pneumothorax

• ABG (when taking an ABG do not remove oxygen)

– Hypoxia, hypercapnia, acidosis, electrolytes

• Physiotherapy

Breathing/RR - Objectives

• Recognise when difficulties with airway are

compromising oxygen delivery

• Apply the appropriate oxygen delivery device

• Manage the patient with impaired

oxygenation

Oxygen delivery

Nasal cannula are used to delivery one to four litres of oxygen

1 – 2 L/min → 24 - 28 % O₂

2 – 4 L/min → 32 - 36 % O₂

Oxygen delivery

Hudson Mask is used to delivery five to ten litres of oxygen

5 L/min → 40 % O₂

6 L/min → 45 % O₂

7 L/min → 50 % O₂

8 L/min → 55 % O₂

9 L/min → 60 % O₂

10 L/min → 60-65 % O₂

Oxygen delivery

Partial rebreather mask is used to delivery six to 15 litres of

oxygen delivering 60 – 80 % O₂

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Oxygen delivery

HFNP

Oxygen delivery

NIV CPAP

Oxygen delivery

Ventilate via a manual bag mask

(ambu bag)

until help arrives

CO₂ retainers

In a small subgroup of patients who have Chronic Obstructive

Pulmonary Disease (COPD) and are “CO₂ retainers”, high

concentration of oxygen can be disadvantageous by

suppressing their hypoxic drive.

However these patient will also suffer end-organ damage or

cardiac arrest if their blood oxygen levels fall too low.

For these patients the aim is to achieve PaO₂ of ≤ 60mmHg to

maintain saturations of around 90 %

CO₂ retainers points to note

• An increase in respiratory rate can occur with a normal Sa02

• Oxygen flow rates for a Hudson mask must be at least 5 L/min

• Do not remove oxygen when taking ABGs

• Do not rely on machines!

• Patients die of hypoxia not high C02

• In COPD if pC02 > 60mmHg but hypoxic (p02< 60mmHg – Do

not turn 02 down! GET HELP!

Breathing/RR - Pain

• Pain is an important

clinical sign of

deterioration

• Pain is associated with

adverse physical and

psychological effects

such as

– Increased anxiety and lack of

sleep

– Delayed or reduced wound

healing

– Delayed gastric emptying,

paralytic ileus

– Increased energy expenditure, ↑

HR, ↑ BP

– Increased oxygen consumption

– Atelectasis, hypoxaemia,

hypercarbia

– Cough inhibition, retention of

secretions, pulmonary infection,

worsening of blood oxygen levels

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Pain

• Pain relief

– Why pain relief important?

• Regular assessment, pre and post analgesia

• Pain scale at rest and on movement

• Impact on recovery/mobilisation

• How to assess pain

• Pain scale

Proves and relieves (What makes pain worse/better?)

Quality (describe the pain)

Region (Where is the pain)

Severity (at rest and on movement)

Timing (constant/intermittent)

Pain

Commonly used pain relief (PCA, Oral, IV, NG)

• Avoid nephrotoxic drugs in the deteriorating patient and patients with known renal

impairment (NSAIDs)

• Consider fentanyl rather than morphine for the elderly or those with delayed renal

clearance

Side effects, assessment and management

• Sedation score / AVPU (don’t assume patient condition is related to pain relief)

– Glucose level

– Correct dose delivered in relation to sedation level seen / is the PCA

programmed correctly

• Hypotension, RR

– impact on assessment of the deteriorating patient

Pain - Summary

• Accurate pain assessment is vital in the acutely ill

patient

• Give regular pain relief based on your assessment

• Assess pain at regular intervals

• Poor pain control can have harmful side effects

• Assess and treat side effect of pain relief

• Be aware of neprotoxic drugs in the deteriorating

patient and with acute renal failure

Early Warning Score

• Airway


• Heart Rate



• Urine Output

• Temperature

Cardiac function

• The function of the heart is to impart energy to

blood in order to generate and sustain an arterial

blood pressure necessary to provide adequate

perfusion of organs.

• Is achieves by contracting its muscular walls around a

closed chamber to generate sufficient pressure to

propel blood from the cardiac chamber (e.g., left

ventricle), through the aortic valve and into the

aorta.

Cardiac Dysfunction

• Precipitates changes in vascular function and

blood volume. These changes serve as

compensatory mechanisms to help maintain

cardiac output and arterial blood pressure.

However, these compensatory changes over

months and years can worsen cardiac

function.

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Cardiac assessment Cardiac assessment - objectives

• Understand the physiological factors

responsible for BP

• Understand why HR and BP are vital signs

• Understand the need to treat hypotension

• Recognise signs of reduced organ perfusion

• Describe management of hypotension

Heart Rate Heart Rate

• The heart rate reflects the rate blood is

ejected by the heart.

• Normal rate: 60-100bpm (average 70-80bpm)

Heart Rate

• Tachycardia of atrial or ventricular origin

reduces stroke volume and cardiac output

particularly when the ventricular rate is

greater than 160 beats/min.

Heart Rate

• Bradycardia, whether of atrial or ventricular

origin, decreases cardiac output and thereby

decreases arterial pressure.

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Heart Rate Assessment

• Identify artery to be used

Consider

• Radial pulse is the most

efficient way to ascertain

pulse rhythm, amplitude

and volume.

• Note factors that may

influence readings;


• Using the second or third

finger (or both) apply

gentle pressure against

the artery site (the thumb

should not be used, as

the practitioner’s own

pulse may be felt)


• Count the pulse rate

for exactly one minute

(this allows sufficient

time to detect rhythm

irregularities)

• Document the results,

Blood Pressure

Blood Pressure

Physiological factors

BP = cardiac output (CO)x vascular resistance

CO = heart rate x stroke volume

Blood Pressure

• Blood Pressure - the pressure (arterial pressure)

exerted by circulating blood upon the walls of blood

vessels.

• Cardiac output- the amount of blood ejected by the

left ventricle in one minute.

• Vascular resistance - is the resistance to flow within

the arteries that must be overcome to push blood

through the circulation system.

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Cardiac Output

• Heart rate – the rate blood is ejected by the heart

• Stroke volume – the amount of blood ejected with

each beat. This is controlled by:

• Preload – the force exerted by the ventricles at the end

of diastole. Volume of blood effects preload

• Afterload – is the pressure or resistance against which

the ventricles must pump to eject blood

• Contractility - the ability of the myocardial cells to

shorten in response to an impulse (Heart beat).

Consequences of Hypertension

• Increased pressure of blood flowing through arteries

causes damage to cells of your arteries (inner lining)

making them thick and stiff.

• Constant pressure of blood moving through a

weakened artery can cause a section of its wall to

enlarge and form a bulge (aneurysm).

Consequences of hypotension

• Decreased conscious level – drowsiness, agitation,

confusion

• Decreased urine output

• Reduced gut perfusion – bowel ischaemia, nausea

• reduced coronary blood flow – ischaemia, MI

• Decreased skin perfusion – reduced capillary refill,

ischaemia, peripherally cold/pale/blue, prolonged

capillary refill, inability to read oxygen saturations

Consequences of Hypotension

• Decreased oxygen delivery to tissues and organs.

• The pulse becomes weak and rapid.

• The person begins to breathe very quickly.

• A reduction in cerebral perfusion and oxygenation

leads to a reduced level of consciousness indicated

by drowsiness, confusion, irritation and

unconsciousness.

Consequences of Hypotension

• If renal blood flow falls because of a reduced BP,

Glomerular filtration rate is decreased and urine

output falls.

• Reduced gut perfusion – bowel ischaemia, nausea

• reduced coronary blood flow – ischaemia, MI.

• Decreased skin perfusion – reduced capillary refill,

ischaemia, peripherally cold/pale/blue, prolonged

capillary refill, inability to read oxygen saturations

Blood pressure Assessment

• Position arm at the level of the heart and well

supported.

• Sufficient cuff size and correct positioning of cuff

• First reading of automated monitors should be

disregarded.

• Movement, crying and eating can affect the accuracy

of automated blood pressure monitors.

• If a blood pressure reading is consistently high on an

automated monitor, manually measured.

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Blood pressure treatment

• Treated with oxygen supplementation through nasal

cannulas/ face mask. The aim is to have enough

oxygen available for the body to use.

• Transfused blood - if bleeding (hemorrhage) is the

cause.

• Intravenous drugs such as inotropes and

vasopressors can be used to try to bolster blood

pressure and the function of the heart

Blood pressure treatment

• Treated with oxygen supplementation through nasal

cannulas/ face mask. The aim is to have enough

oxygen available for the body to use.

• Transfused blood - if bleeding (hemorrhage) is the

cause.

• Intravenous drugs such as inotropes and

vasopressors can be used to try to bolster blood

pressure and the function of the heart

Cardiac assessment

• The heart as a pump – reduced pulse pressure and a

gallop rhythm.

• Filling volumes and pressure - crackle, peripheral

edema, postral changes in blood pressure.

• Cardiac output – heart rate, blood pressure, pulse

pressure, urine output.

• Compensatory mechanisms – increased filling

volumes, peripheral vasoconstriction and elevate

heart rate.

Cardiac assessment

Arterial circulation:

• Temperature, moistness – controlled by the

autonomic nervous system – under stress the

periphery may be cool and moist and in cardiogenic

shock, skin becomes cold and clammy.

• Capillary refill time – is the estimate rate of

peripheral blood flow. Normal reperfusion is almost

instantly. Where sluggish reperfusion indicates the

ability of the heart to pump blood is affected.

Early Warning Score

• Airway


• Heart Rate



• Urine Output

• Temperature

NEUROLOGICAL

ASSESSMENT

CNS/CNEWARD 28

NEUROSCIENCESCHRISTCHURCH HOSPITAL

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Objectives

Common causes of altered level of consciousness

Consequences of altered level of consciousness

How to assess altered level of consciousness

How to manage altered level of consciousness

Recording tools

Why ‘do’ neurological assessment

To monitor a patients level of consciousness and responseto determine the presence of a neurological deficit which may be

• a direct consequence of intracranial disease

Head Injury Stroke EncephalitisCNS infection Epilepsy

Space occupying lesion Raised Intracranial Pressure•Or may be secondary to systemic condition such a

Dehydration Infection HypoxiaHypotension Metabolic imbalance

Haemorrhage

Liver function

Signs and Symptoms

ANY definite, potential or transient change in:

eye opening drowsiness speech

walking co-ordination continence

swallow sight orientation

sensation reading writing

hearing memory affect

MAY be of neurological origin

Assessment Tools

3 ASSESSMENT TOOLS

AVPU

ABCDE

NEUROLOGICAL OBSERVATIONS

AVPU

AWAKEConscious, eyes open, alert

VERBAL Stimuli required Responds to name

PAIN Stimuli requiredCentral stimuli only

UNRESPONSIVETotally unresponsive to any stimuli

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Recording tools Confusion/Agitation

New confusion/agitation is a serious sign of poor oxygenation and poor cerebral perfusion

Development of, or increase in, confusion, agitation, abnormal behaviour, severe or

increasing headache or persisting vomit needs further investigation

For Urgent Review please!!

ABCDE

AIRWAY

obstruction, positioning

BREATHINGrate, effort, pattern

CIRCULATION

blood pressure

DRUGS

sedatives, opiates

ENDOCRINE / METABOLICBSL, Na, Ca, K

Airway

Is the airway patent?Functional airway obstruction

Obstruction of pharynx by the tongue

Mechanical airway obstructionAspiration of foreign body

Bleeding, post-operative haematomaOedema or spasm of the larynx, swelling

ManagementChin lift, jaw thrust, head tilt, airway insertion, suction, oxygenCLINICAL EMERGENCY

Neurological Observations

The minimum requirement for neurological observations:

Glasgow Coma Scale

Pupillary Response

Vital Signs

Limb Strengths

Glasgow Coma Scale (GCS)

3 Components

Eye Response

Verbal Response

Motor Response

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GCS Eye Response

Eyes (E) are scored on a scale of 1 � 4

Record best response from:

4. Open spontaneously3. Open to verbal command2. Open to pain1. No eye response

GCS Eye Response

GCS Verbal Response

Verbal (V) is scored on a scale of 1 � 5


5. Orientated4. Confused3. Inappropriate words2. Incomprehensible sounds1. No verbal response / Tracheotomy

GCS Verbal Response

Motor Response

Motor (M) is scored on a scale of 1 � 6


6. Obeys commands5. Localises to pain4. Withdraws from pain3. Flexes to pain2. Extends to pain1. No motor response

Flexion and Extension

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GCS Motor Response Calculating the GCS

Document: E?, V?, M?

Add: E, V and M scores

EG: E2, V2, M2 = 6

This is the GCS score out of 15

The lower the score the sicker the patient!!!!

If total GCS score drops by 2 or more points OR the motor score drops by 1 point it is time for an urgent Registrar review!!!

Pupillary Response

Ensure some ambient light is present

Assess pupils: Equal? Round? Nystagmus?

Use a fine beam torch and assess pupillary reaction to light

Do they react to light? Are they consensual?

If normal document as:

Pupils, Equal, Round, (reacting to) Light � (PERL)

Document variants individually

Eg L) > R) by 1 size; L) pupil sluggish; R) ovoid

Pupillary Abnormalities

Vital Observations

Take in the following order

Respiratory Rate

Temperature

Blood Pressure

Heart Rate

Limb Strengths

Test all limbs

Normal PowerMild Weakness

Severe weaknessFlexion

ExtensionNo Response

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Limb Strengths Frequency of Neurological Observations

HOW OFTEN???

15 minute intervals?????

4 hourly intervals?

Inter-rater Reliability

The assessment and interpretation of neurological observations varies slightly from person to person

This affects recording, interpretation and reporting

Inter-rater Reliability is well documented in the literature

Please be aware of it

Summary

Prompt, accurate bedside assessment

plus

clear documentation and handover of

AVPU

ABCDE Neurological observations

allows medical review, investigations, diagnosis and treatment

to be initiated in a timely manner for the deteriorating patient

Early Warning Score

• Airway


• Heart Rate



• Urine Output

• Temperature

Urine Output assessment

• Understand factors for normal urine production and

flow

• Identify causes of decreased urine output

• Identify when to be concerned about urine output

• Describe management of low urine output

There is a small window of opportunity for reversing

low urine output and preventing acute renal failure.

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Early Warning Score

• Airway

• Breathing/Respiratory

Rate

• Heart Rate



• Urine Output

• Temperature

Urine Output assessment

• Understand factors for normal urine production and flow

• Identify causes of decreased urine output

• Identify when to be concerned about urine output

• Describe management of low urine output

There is a small window of opportunity for reversing low urine output and preventing acute renal failure.

Structures of the renal system

• Renal system:

– kidneys

– ureters

– bladder

– urethra

• Kidney functions:

– Acid-Base Balance

– Water Balance

– Electrolyte regulation

– Toxin removal

– BP regulation

– Erythropoeitin

– D vitamin, D activation

Factors needed for urine production

• Pre-renal – adequate

perfusion pressure &

oxygenation of kidneys.

• Renal – the kidney units

must be functioning

properly (glomerulae,

tubules)

• Post-renal – there cannot

be obstruction to blood flow

• Perfusion pressure

– Renal blood flow is autoregulated throughout a wide range of mean

arterial blood pressure (MAP)

– This range is increased in chronic hypertension, these patients require

a higher BP to maintain normal kidney function

– If MAP falls below the lower limit of autoregulation, renal perfusion

will ↓ and urine output will fall

• Oxygen delivery

– To function renal cells require adequate oxygen delivery

– This is reliant on cardiac output and arterial oxygen content

– If oxygen delivery ↓to the kidneys, urine output will ↓

Pathophysiology of urine output What happens when BP falls?

• Poor perfusion & 02 delivery

• Organs most affected by DO2?

– Heart

– Brain

– Kidneys & Liver (15 – 20 mins)

• Kidneys release hormones to

maintain bp

– Aldosterone

– Vasopressin

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Angiotensinogen

Angiotensin 1

Angiotensin 2

Afferent arteriole constriction

aldosteronerelease

Renin (JG)………………………

↓Renal Blood Flow

Angiotensin Converting Enzyme

↑afterload ↑preload

Anti-Diuretic Hormone/Vasopressin

↓Blood volume detected

Pituitary gland

Anti-diuretic hormone

Collecting duct in kidneys

Reabsorption of water in blood

• Decreased renal blood flow

– Decreased blood pressure

– Decreased cardiac output

– Alteration in heart rate

– Change in vascular resistance

– Decreased oxygen delivery

• Obstructed urine flow

– Blocked catheter

– Renal calculus

– Debris / clot

Causes of decreased urine outputCO =SV X HR

Stroke volume (Preload afterload Contractility)

2 hours of oliguria

can cause acute renal

failure…

Early warning signs related to poor urine output

Oliguric 100 - 400ml/day

<200ml/8hours (shift)

Late warning signs related to poor urine output

Anuric < 100ml/day

Absolute anuria nil

What is Oliguria?

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Pre -renal causes of low urine output

Cardiovascular Causes • Hypovolaemia

• Haemorrhage

• Vomiting or diarrhoea

• High Nasogastric or other losses

• Diuretic therapy

• Pulmonary oedema

↓Systemic Vascular Resistance• Sepsis

• Antihypertensive medications

• Side effects of other drugs eg: ACE Inhibitors

Cardiac Pump Failure• Acute myocardial infarction

• Arrythmias

• Cardiomyopathy

• Cardiac Tamponade

Treatment

Treat low perfusion!

• Hypovolemia

• consider IV fluid bolus to restore intravascular

volume

• Systemic Vascular resistance

• May require inotropic support for lowered SVR

• May require antiarrhymics if due to contractility.

• Cardiac pump failure

• Cause?

• Drug therapy

• Experts involved.

Renal causes of low urine output

• Renal disease

– Glomerular and tubular disease

• Avoid Nephrotoxic drugs or adjust dose

• Aminoglycosides (gentamicin)

• NSAID

• Penicillins

• Radiological contrast

• Cyclosporin

• Cephalosporins

• Frusemide - do not give unless definitive signs of fluid overload

• Treatment

- review drug chart for

potential neprotoxicity

-hydration –to minimise nephrotoxicity

-monitor input/output

elderly are vulnerable

Renal causes of low urine output Post Renal Causes of low urine output

Obstruction to flow of Urine

• Prostatic hypertrophy, large

calculi, retroperitoneal fibrosis

or a mass causing bladder neck

obstruction

• Catheter draining? Kinks?

Position? Catheter problem –

blocked? Flush?

Be concerned about urine output when......

• Signs of poor perfusion

• Urine output is to be averaged over the previous four hours if no IDC

• <30ml/hr urine output

• UO: Oliguria, Anuria

• Capillary Refill poor

• Change in colour, consistency, odour (infection?)

• ↓BP ↑HR

• Signs of dehydration

Management of low urine output

• Follow EWS management Protocol

• History

• Commence fluid balance chart

• Abdominal assessment

• Bladder scan

• IDC insertion – indicated for concern of low UO and patient decline

• IDC patency

• Check previous blood results / repeat bloods– Chronic renal impairment or acute renal impairment

• Baseline Creatinine prior to admission

– Potassium (hyperkalaemia is life threatening and requires ECG monitoring)

– Creatinine

– FBC

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Temperature Assessment

Early Warning Score

Airway

Breathing/Respiratory Rate

Heart Rate

Systolic Blood Pressure

Conscious Level / AVPU

Urine Output

Temperature

• Heart rate, Respiratory rate & metabolic rate

increases

• Rigors ↑ metabolic rate and oxygen requirements

• Vasodilation

• Hypotension

• Consideration for blood, urine, sputum cultures

Temperature -Pyrexia Beginning signs of the septic response…

• SIRS: a Systemic Inflammatory Response to an

insult/injury, manifested by 2 or more signs & symptoms:

– Temperature >38C or <36C

– Heart rate >90 bpm

– Tachypnoea: Respiratory Rate >20/min or hypoventilation,

indicated by PaCO2 < 32mmHg

– Altered WBC count >12,000 cells/mm3, < 4,000 cells/mm3

or the presence of more than 10% immature neutrophils

• Sepsis: SIRS + confirmed or presumed infection source

(bacterial, viral, fungal or parasitic)

Fever > 38˚C

• Nursing response:

– Recognition

– EWS

– Medical staff involved

– Outreach call required?

– Regular obs, fluids, blood +/- wound cultures

wound, sputum, urine

– WCC, ABG, Fluid

Temperature - Hypothermia <35°C

• ↓ HR, ↓ RR,& ↓metabolic rate

• Shivering attempts to↑ metabolic rate & DO₂

• Vasoconstriction

• Confusion

• Arrhythmias

• Cardiac arrest

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Contributors to hypothermia

• Sepsis

• Aggressive fluid resuscitation

• Exposure to low temperatures (Intra-

operatively)

• Neurological (stroke, trauma, tumour)

• Skin disease (burns, dermatitis)

• Drug induced (sedatives)

• Neuromuscular insufficiency

Unintentional Perioperative Hypothermia

• Contributing factors:

– Inadequate heat loss replacement

– Surgical technique

– IV fluids, aggressive resus

– Spinal anaesthesia

– Elderly

Unintentional perioperative Hypothermia

What it means for the patient…..

• Longer post-operative recovery

• Shivering & thermal discomfort

• Cardiac arrythmias

• Wound infections (evidence ↓risk infection if warm during post op period)

• Platelet dysfunction & bleeding – ↑blood loss

• Drug metabolism

• ↑ Hospital stay

Unintentional Perioperative Hypothermia

Nursing care

– Rewarm

– Heated blankets

– Hats, socks

– Warm fluids

– Bair Hugger

Take home points….

• Low urine output related to hypoperfusion

is a late sign –treat as a priority

• The EWS pathway is your friend ☺☺☺☺

• Pyrexia –cause?

• Hypothermia –cause?

Team Work

• Why is teamwork an

essential element of

patient safety?

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What is a team?

• “ a distinguishable set of two or more people

who interact dynamically, interdependantly

and adaptively towards a common and valued

goal/objective/mission, who have been

assigned specific roles or functions to perform

and who have a limited lifetime of

membership”

(Salas E et al. 1992)

What makes an effective team?

• Common purpose

• Measurable goals

• Effective leadership

• Effective communication

• Good cohesion

• Mutual respect

Situational Awareness

• Notice

• Understand

• Think ahead

References

ALERT

Compass 2008

Acute Care Training (ACT) 2007

Todays Team

Jo Saunders

Chris Beasley

Janette Dallas

Tony Curran

Margaret Burns

objectives today's plan · • hypoxia may impair wound healing and enzymatic processes in the...

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