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Observations and the Deteriorating Patient for Registered Nurses Shane Moody, Lead for Critical Care Services Vikki Crickmore, Sister. Critical Care Outreach Service September 2013

Observations and the Deteriorating Patient for Registered Nurses

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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. - PowerPoint PPT Presentation

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Page 1: 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

Page 2: Observations and the Deteriorating Patient for Registered Nurses

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.

Page 3: Observations and the Deteriorating Patient for Registered Nurses

AssessmentsCCOS to assess Band 7’s

↓CCOS to do Train the Trainer sessions for senior

nurses

↓ Band 7’ and senior nurses to assess own staff

Competency framework

Page 4: Observations and the Deteriorating Patient for Registered Nurses

AssessmentsPresentation

↓Questions

Station 1 ← → Station 2

Practical taking obs Case studies & and documenting completing

competencyin pairs document

Conclude and finish

Competency framework

Page 5: Observations and the Deteriorating Patient for Registered Nurses

Introduction2005 – NCEPOD: An Acute problem2007 – 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

Page 6: Observations and the Deteriorating Patient for Registered Nurses

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

Page 7: Observations and the Deteriorating Patient for Registered Nurses

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

Modified Early Warning

Page 8: Observations and the Deteriorating Patient for Registered Nurses

• 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

Applying to practice

Page 9: Observations and the Deteriorating Patient for Registered Nurses

• Respiratory rate• Oxygen Saturations• Pulse• Systolic (BP)• AVPU/GCS• Temp• Urine Output

Competency framework

Vital signs to assess

Page 10: Observations and the Deteriorating Patient for Registered Nurses

• 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

Respiratory rate

Page 11: Observations and the Deteriorating Patient for Registered Nurses

Blood pumped fromHeart is rich in O2(95%-99% saturated)

Blood pumped back to heart is low in O2(65%-70%)

Competency framework

Saturations

Page 12: Observations and the Deteriorating Patient for Registered Nurses

Competency frameworkOxygen 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.

Page 13: Observations and the Deteriorating Patient for Registered Nurses

• 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

Oxygen saturations

Page 14: Observations and the Deteriorating Patient for Registered Nurses

• Should be taken manually for one minute, noting the rate, volume and regularity.

• Felt at brachial artery• Normal rate can be considered 60-

100bpm.• Abnormal findings need investigating• Abnormalities should be followed with an

ECG• Consider ECG monitoring

Competency framework

Heart Rate

Page 15: Observations and the Deteriorating Patient for Registered Nurses

Effects on Heart Rate• Haemorrhage / bleeding• Hypotension• Sepsis • Drugs / medications • Hypoxia• Temperature• Injury / Insult• Electrolytes

Competency framework

Page 16: Observations and the Deteriorating Patient for Registered Nurses

Competency frameworkBlood pressure = pressure on wall

of arterySystolic = pumping pressureDiastolic = resting pressure

Page 17: Observations and the Deteriorating Patient for Registered Nurses

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

Arterial pressure

Page 18: Observations and the Deteriorating Patient for Registered Nurses

• 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

Blood pressure

Page 19: Observations and the Deteriorating Patient for Registered Nurses

• 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

Urine output

Page 20: Observations and the Deteriorating Patient for Registered Nurses

• 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

Level of Consciousness

Page 21: Observations and the Deteriorating Patient for Registered Nurses

• 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

Temperature

Page 22: Observations and the Deteriorating Patient for Registered Nurses

• O2 needed?• Positioning• IV access• ECG• Catheter• IV fluids• Bloods• Escalation status

Competency framework

Considerations

Page 23: Observations and the Deteriorating Patient for Registered Nurses

• 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

Who is at risk?

Page 24: Observations and the Deteriorating Patient for Registered Nurses

• Sepsis• Hospital acquired infections• Chronic disease process• Co-morbidities• Failure to manage complications• Iatrogenic• Unavoidable complications• Palliative / end of life

Competency framework

Causes of deterioration

Page 25: Observations and the Deteriorating Patient for Registered Nurses

Measure observations and Document↓

Recognise Deterioration↓

Communicate Appropriately↓

Respond efficiently & reassess

Competency framework

Chain of safety

Page 26: Observations and the Deteriorating Patient for Registered Nurses

SBARA tool used to communicate critical information succinctly and briefly

Competency framework

Page 27: Observations and the Deteriorating Patient for Registered Nurses

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

Barriers to escalation

Page 28: Observations and the Deteriorating Patient for Registered Nurses

• Individual Accountability • Risk assessment and delegation• Consent• Risk assessment• Privacy and dignity• Documentation• Infection control• Communication• Safeguarding

Updates on amendments to revised policy

Competency frameworkAdditional elements in relation to

patient care

Page 29: Observations and the Deteriorating Patient for Registered Nurses

• 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.

Competency framework

Practical assessment