WK 1- Documentation, Isobar, MEWS scoring & MET Calls PDF

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Health Assessment in Nursing Documentation, ISOBAR, MEWS scoring & MET CALLS WK 1- LECTURE CHAPTER 1-5 (TEXTBOOK)

Objectives  DRABC and observations - First always make sure patient is stable !  Presenting Complaint  COLDSPA  Systems Review  General history taking (i.e. PMHx, FHx, Surg Hx, Gynae Hx, Soc Hx and Drug Hx)  HIPPA depending on the presenting complaint  Then ISOBAR handover and documentation  Be mindful of the correct techniques and guidelines Documentation revision  Objective, stating facts  Patients’ words stated in quotes EG: “patient states”  Done in black pen  Avoid words such as “normal” Documentation formats 1) System approach - Documentation broken into systems - EG: skin, comfort, metabolic, CVS, RESP 2) -

SOAP Subjective Objective Assessment Plan

3) -

DAR Data (objective, subjective) Action (nursing action) Response (patients’ response to action

Example of documentation System approach

DAR approach/ soap

* A systems approach to writing notes and assessment Neurological • pMHx (past medical history) • GCS (eye, verbal, pain response, orientation, limb movement) • Pupils • Drains/monitoring • Drugs

• Pain • Cough, gag • Spinal issues?

Respiratory              

pMHx Drugs Breath sounds Resp rate + effort Sp02 (oxygen sat) ETC02 (end tidal co2: amount of carbon dioxide at end of exhaled breath. Normal 5-6%) ABG. (Arterial blood gas test. Measure’s acidity, O2, CO2 in blood from artery) CXR (chest x ray) Sputum/suction freq Spont-airway (spontatenous airway breathing) DB (difficulty breathing) + coughing + cough strength Chest drain NIV (non-invasive ventilation) 02 delivery device

Cardiovascular System (CVS)           

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PMHx Drugs HR / Rhythm 12 lead ECG BP + NIBP /Artline (non-invasive BP/ arterial line) Alarms CVP measurement (central venous pressure) Temp Peripheral pulses - CWMS (look for colour, warmth, movement & sensation) Cap /capilliary refill time (Time taken for color to return to external capillary bed after pressure applied to nail causing it to go white. Normal less than 2sec. Long refill time can indicate shock, dehydration, decreased peripheral perfusion) Oedema Blood results - FBP, coags, electrolytes, albumin DVT Prophylaxis (Deep vein thrombosis prevention. EG: Use compression stocking) Line management of CVC, infusions & PIV (peripheral iv line)

Gastrointestinal System (GIT)            

pMHx Drugs Abdo: inspect for shape/contour Palpation, percussion Weight / BMI Body condition BSL, insulin, BS NGT/OGT (orogastric) tube Feeding TPN (total parental nutrition) Bowels (BO or BNO) Aperients / laxatives

Renal        

pMHx Drugs Urine output FBC IDC Weight Bloods: urea, creatinine Vascath (if dialysis)

Integumentary

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pMHx Drugs Inspection: oedema, dry, flaky, moist, sweaty Pressure areas Eye, mouth, teeth care Positionin Hair Dressings + wounds

Muscular      

pMHx Drugs Hand/foot splints/support Injuries Muscle strength Spinal stability

Psychosocial      

pMHx Settled / agitated Family / NOK issues Day + night routine Sleep Communication issues

General        

Plan Education Family meetings Tests Allied health interventions/referrals NFR (not for resuss) / code status Discharge planning Infection control

HEALTH ASSESSMENT – OVERALL APPROUCH, SUBJECTIVE & OBJECTIVE INFORMATION & PREPARING PT General Principles of Health Assessment- Objectives  Introduction to health assessment: collecting data –objective and subjective information  Discuss the purposes, sequences and techniques for physical assessment (HIPPA)  Use of the COLDSPA mnemonic to guide questions in health assessment The AIDET FrameworkWhen communicating with the patient / carer / family – use the AIDET framework  A Acknowledge the patient and carer and establish appropriate salutation  I Introduce yourself and your colleague  D Duration of your current role in delivering care to the patient  E Explain what is happening and when you will come back  T Thank you / Tidy up / Time to return Preparing the Patient for Examination Introduce self and explain procedure  Listen: ‘If you listen to the patient, they are telling you the diagnosis’ –William Osler  Hand wash between patients and use corre ct technique  Obtain consent from patient  Ensure patient privacy

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Ensure necessary equipment is close at hand.

General Guidelines Patient o Explain o Empty bladder (abdominal) (bladder scan if necessary) o Assess for pain o Correct position o Cultural considerations  Self o Standard / additional precautions (eg. PPE)  Environment o Privacy o Warmth o Quiet (if possible) o Lighting  Equipment o Clean o In working order o Know how to use it o Gloves / Gown o Stethoscope  Earpiece  Tubing intact  Bell: low pitch (heart, vascular) SMALLER SIDE  Diaphragm: high pitch (bowel, lungs) LARGE SIDE

Equipment Examples Otoscope (ears)  Ophthalmoscope  Pen torch  Tongue depressor  Stethoscope Is your patient stable? DRABS  Cannot assess the pt accurately if they are NOT stable  Use DRABS obtain vital signs  D: DANGER (is the environment safe, are there cords everywhere)  R: response “can you here me”

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S: stand for help, calling help, MET CALL A: airway, his talking.. patent, check for obstruction B: breathing, look listen and feel C: circulation, heart rate, BP

HIPPA- *used when collecting objective data History- subjective information (stated) Inspection Palpation Percussion Auscultation

Subjective- COLDSA *used when collecting subjective data Character Onset Location Duration Severity Pattern Associated Factors

History Taking Collect subjective (stated) data

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Holistic focus o (ie. Consideration of physical, sociocultural and psychological aspects) Consideration of... o Past medical history o Family history o Surgical history o Gynae history (if applicable) o Social history o Drug history Information may come from: o Client o Significant Others o Medical notes o Physical assessment

OBJECTIVE DATA – collection

General Principles and Techniques of Physical Assessment1. Inspection- sight, sound, smell 2. Percussion- touch, sound 3. Palpation- touch, sound 4. Auscultation- sound via stethoscope

Inspection Technique o Systematic, deliberate: vision, smell, hearing. o Look for: Colour, patterns, size, location, consistency, symmetry, movement, behaviour, odour, sounds.  Guidelines for inspection o Good lighting o Look before touch o Expose body parts o Make comparisons eg. between limbs Percussion Techniques o Striking, tapping sound o Elicits a sound or tone o Tone varies according to underlying structure o Solid tissue = dullness o over air and solid = resonance o hyper-resonance = air  Guidelines

o o o o o o

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Use middle finger lying flat against patient skin Short finger nails Use area between MIPJ and DIPJ Firm, rapid, short, sharp strikes Wrist only, forearm still Remove striking finger after strike (like a hammering action)

Purpose

o Determine location, size, shape (determines borders of organs or masses) o Eliciting pain (detects inflamed underlying structures) o Determines density o Detects abnormal masses Compare on both sides Palpation- feeling for texture, hot or cold, dry or wet, thick or movable structures

= feeling with hands or fingers Techniques o Systematic o Very Light (> 1cm) o Moderate (1-2cm) o Deep (2.5cm-5cm) o Deep requires 1-2 hands  Guidelines o Warm hands o Minimise discomfort o Use correct part of hands:  Fingertips (tactile)  Grasp (eg. Abnormal Mass in the abdomen: position, shape, consistency)  Hands  Back (temperature)  Palm (vibrations)-pulses Auscultation- LISTENING  Technique o Listen o Last techniques except in abdominal examination 

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o Sounds are classified as: intensity (loud/soft), pitch (high/low), duration (length) and quality (musical, crackling) Guidelines o Good quality stethoscope o Warm bell (low pitch)  /diaphragm (high pitch) o Eliminate noise o Never listen via clothing o Do not drag to auscultation landmarks

POSTIONS TO ASSESS PT’S IN

Documentation-ongoing AssessmentISOBAR Format-Documenting / Handover Handover tool used for handover situations  Increase safety for pt’s  Can be used for deteriorating patients if immediate attention is required  Provides a useful framework to communicate

Early Warning Scoring“In clinically unstable inpatients early intervention by a medical emergency team significantly reduces the incidence of and mortality from unexpected cardiac arrest in hospital. (Buist et al., 2002)  The monitoring of patients physiological parameters is the cornerstone in the detection of critical illness  Evidence demonstrated that early changes in measured parameters are often not detected  In an attempt to improve the recognition of illness in adult patients “track and trigger” systems were developed Assessment and Monitoring: Track and Trigger Systems Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings o Observations should be monitored at least every o 4-6 hours. o Senior-level decision to increase or decrease the frequency of observations. o Increase (graded response) if abnormal physiology is detected

Mews Scoring (Modified Early Warning System)

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The MEWS looks at all the observations together, not just a single observation in isolation. It includes Respiratory Rate, Oxygen Saturations, Temperature, Blood Pressure, Heart Rate, Sedation Score, and Urine Output. To obtain the total MEWS each individual observations is scored according to criteria. Then each individual score is added to give you a total MEWS. A score of 1 is a trigger point for action, with escalated notification at 4, 6 and 8. MEWS does NOT replace calling the Medical Emergency Team (MET). If the patient meets the MET criteria a MET should be called as per MET protocol.

ESCULATION PATHWAY MEWS

MET CALLS

MET (Medical emergency team) HOSPITAL SAMPLE

MET CALLS….       

Remain Calm, think fast… Communicate, Communicate, Communicate. Have a nominated team leader – usually the Doctor/shift coordinator/MET CNS. Allocate duties to Nurses prior to a shift: Team Leader, Medication Nurse, Scribe, MET Runner. All the other nurses: take care of the rest of the ward, and crowd control. Bedside nurse stays with the patient. Always debrief after a METCALL – Evaluate.

MET CALLS CONTINUED…  Scribe -documents the METCALL (the role of the scribe) o Vitals o bloods taken o Lines o Drugs o Shocks delivered/joules o Everyone needs to communicate - Scribe to repeat the message.  Documentation after event: Riskman, Patient Notes, and EMERGENCY RESPONSE SCRIBE form all needs to be completed immediately....