NURS1002 - Lecture 3 PDF

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NURS1002 – LECTURE 3 BETWEEN THE FLAGS AND CRITICAL DECISION MAKING DETECT D – detect deterioration -

Recognise that you have a problem by gathering patient information Use A-G assessment (look, listen, feel) Identify early and late warning signs

E- evaluate -

Likely cause of deterioration Whether your skills and other skills meet the patients’ needs If and when to call for help  urgency of response Consider early communication of any problems identified

T- treat -

Prioritise interventions using A-G assessment to guide decision making Commence simple treatments (oxygen, repositioning patient and IV access) Call for help Begin life support  check oxygen administration Ensure large-bore IV access and administer resuscitation fluids

E – escalate and -

Observed signs of further deterioration Know how and who to call for more assistance Know when patient’s clinical management requires advanced skills  notify senior doctor

C – communicate with your -

Provide leadership where appropriate Coordinate activities within team Use ISBAR assessment to communicate clearly Document patient’s outcome in healthcare record Revise, prepare and communication patient’s care plan, assess outcomes of intervention

T – team (see above)

A-G ASSESSMENT TOOL AIRWAY -

LOOK for any signs of airway obstruction (mouth, neck, swelling, haematoma) LISTEN for noise breathing (gurgling, wheezing, snoring or stridor) FEEL for presence of air movement

BREATHING -

LOOK at chest wall movement to see if it is normal or symmetrical See if patient is using neck and shoulder muscles to breathe (accessory muscles) Look at the patient to measure their respiratory rate LISTEN to patient talking to see if they can complete full sentences (plus noisy breathing) FEEL for position of trachea to see if its central Feel for surgical emphysema or crepitus If patient is diaphoretic

CIRCULATION -

LOOK at skin colour for pallor and peripheral cyanosis LOOK at capillary refill time LOOK at patient’s central venous pressure and jugular venous pressure LISTEN to patient for complaints of dizziness and headaches For patient’s BP and heart sounds FEEL patients’ hands and feet (hot or cold?) Feel for peripheral pulse for presence, rate, quality, regularity and equality

DISABILITY -

LOOK at level of consciousness, facial symmetry, abnormal movements or seizure activity LOOK at pupil size, equality and reaction to light LISTEN to patient’s response to external stimuli and pain LISTEN for slurred speech, orientation to person, place and time FEEL for patient’s response to external stimuli FEEL for muscle power and strength

EXPOSURE -

LOOK for any bleeding (e.g. investigate wounds/drains that may be hidden) LISTEN for air leaks in drains and for bowel sounds FEEL patient’s abdomen

FLUIDS -

LOOK at observation/fluid charts, noting fluid input and output LOOK at losses from all drains and tubes + amount of colour in patient’s urine LISTEN for patient’s complaints of thirst FEEL skin turgor

GLUCOSE -

LOOK at BC levels (low glucose including confusion and decreased conscious state) LOOK at medication chart for insulin and oral hypoglycaemics

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LISTEN for patient’s complaints of thirst and for their orientation to person, time and place FEEL if patient is diaphoretic

Key Signs of Deterioration 1. 2. 3. 4. 5. 6.

Respiratory rate Altered conscious state Tachycardia (abnormal heart rate) Hypotension (low blood pressure) Decreases urine output Desaturation (oxygen levels)

Key Predictors -

RR < 10 or > 25 = 5 times more likely to have an adverse event than for any other physiological trigger HR > 110bpm = 2 times as likely to have an adverse event than other predictors Decrease in GCS (Glasgow Coma Scale) by < 2 points

When things are not going as planned -

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Call for help Never leave a deteriorating patient Document and communicate all treatment provided such as; o Outcomes of treatment implemented o What care is still required The plan should include expected outcomes and when patient will be reviewed again

Based on assessment of using A-G assessment

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Decide on an appropriate oxygen flow rate. If in doubt commence on 4L/min on a Hudson mask and increase as indicated by oxygen saturation or patient condition Position patient to optimise their breathing – usually this is as upright position as possible Place them in the left lateral position if they are unconscious

The Slippery Slope

Calling criteria and warning signs Track and trigger Observations -

RR Oxygen saturations Blood pressure Heart rate Level of consciousness Temperature Pain score as a minimum

Normal Respiratory Rates -

Newborn – 30-60 Breaths PM Infant – 30 – 50 breaths PM Toddler – 25-32 breaths PM Child – 20-30 breaths PM Adolescent – 16-29 breaths PM

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Adult – 12-20 breaths PM

Normal peripheral oxygen saturation -

SpO2 95-100% for a healthy adult  SpO2 affected by factors that interfere with ventilation and perfusion Always interpret measurement in relation to patient’s oxygen requirement and record amount of supplemental oxygen being delivered Patient who needs supplemental oxygen to maintain oxygen saturation > 90% hypoxemic

Normal Heart Rates -

Infants – 120-160 Toddlers – 90-140 Pre-schoolers – 80-110 School-aged – 75-100 Adolescents – 60-90 Adults – 60-100

Normal BP -

Newborn (3000g) 40 (mean) 1 month – 85/54 1 year – 95/65 6 years – 105/65 10-13 years – 110/65 14-17 years – 120/75 Adult < 120/80

WARNING SIGNS EARLY Partial airway obstruction SpO2 90%-95% RR 5-9bm or 30-40bpm PR 40-50 or 120-140 Systolic BP 80-100mmHg or 180-240 mmHg Urine output < 200ml over 8 hours Greater than expected drainage fluid loss A drop in GCS of 2 points or GCS < 12 or seizure

LATE Airway obstruction or stridor SpO2 < 90% RR < 5bpm or > 40bpm PR < 40 or > 140 Systolic BP < 80 or > 240 mmHg Urine output < 200ml in 24 hours or anuria Excess blood loss not controlled by ward staff Unresponsive to verbal command or GCS < 8

Key features of Standard Observation Charts include: -

Trigger zones are colour-coded to draw attention to when calling criteria are met

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Flexibility for variation to standard calling criteria for individual patient, as deemed clinically appropriate

Frequency of Observations -

Patient must have complete set of vital sign observations conducted 3 times a day (8 hourly intervals) Frequency of observations should be increased as indicated by their condition and clinical judgement Frequency of observations must be increased for patients with observations in blue (paeds), yellow or red zones on standard observational chart

Level of Consciousness – AVPU scale -

A = Alert V – Responsive to verbal stimuli P = Responsive to pain U = Unresponsive

How to escalate your patient? -

Identify – yourself, the patient and person you are talking to Situation – state reason you are calling and urgency Background – provide relevant history and examinations Assessment – your own assessment of problem Recommendation and restate – provide your recommendation then close loop by summarising plan

If a clinical review is called: -

Reassess patient and escalate according to your local CERS if call is not attended to within 30 mins Document an A-G assessment, reason for escalation, treatment and outcome in your patient healthcare record Inform Attending Medical Officer that a call was made as soon as it is practicable

Clinical Emergency Response Systems (CERS) -

A clinical review (yellow) process that has capacity to respond within 30 mins to a breach in clinical review criteria A rapid response (red) process that is immediately available in response to a breach in rapid response criteria Necessary equipment is available to perform advanced resuscitation An escalation process for transferring patients that require a higher-order of care to a facility that can provide it

ISBAR...