Objectives

1. Competency Title : Observations andTheDeteriorating Patientfor HCAsCompetency Lead : Vikki Crickmore, Sister, Critical Care Outreach TeamSeptember 2013

2. Competency framework Objectives • Demonstrate normal values of vital signs • Have awareness of how to respond to findings and how to escalate care appropriately. • Carry out a practical assessment of taking observations and management of case studies. • Demonstrate awareness of how to make an emergency call via 2222 system.

3. Competency framework Vital signs to assess • Respiratory rate • Oxygen Saturations • Pulse • Systolic (BP) • AVPU/GCS • Temp • Urine Output

4. Competency framework Normal values • BP: systolic 101-170 • HR: 51-100 • RR: 11-20 • Saturations: >96% • Temperature: 36 – 38 degrees • Urine Output: 0.5ml/kg/hr

5. Competency framework Modified Early Warning 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.

6. Competency framework Respiratory rate • The most sensitive indicator of potential deterioration. Rising rates often early sign. • Relevant in a number of compensatory mechanisms within the body • Normal rate should be between 12 and 20. • 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.

7. 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 Oxygen demand

8. Competency framework Oxygen saturations • Dependent on intact respiratory and cardiovascular function – limited by other factors ie: peripherally shut down. • 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. • 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.

9. Competency framework Heart Rate • Felt at brachial artery • Normal rate can be considered 60-100bpm. • Should be taken manually for one minute, noting the rate, volume and regularity. • Abnormal findings need investigating • Abnormalities should be followed with an ECG • Consider ECG monitoring

10. Competency framework Blood pressure • 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.

11. Competency framework Urine output • 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. • Sensitive indicator of hydration 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.

12. Competency framework Level of Consciousness • Consider at what point do you need help? • This should include drowsiness, agitation, new changes. • AVPU or GCS for more in depth assessment. • Assess pupils • Consider reversible causes ie: blood sugar • If only responding to pain or unresponsive – airway is at risk – 2222 adult emergency. • Criteria for Neurological observations

13. Competency framework When to report findings? • Abnormal findings • Change from normal for patient • Patient looks unwell but observations fine • New complaint or worsening of symptoms

14. Competency framework 2222 system Cardiac arrest = patient in cardiac arrest Adult Emergency = patient critically ill or unconscious