Download 3-patient-assessment-process-pptx-ver-2

Critical Care Outreach
Objectives for the Session
 Identify the importance of assessment and
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reassessment of the sick patient
Use of ABCDE to assess patients
Understand the basic interventions required to
minimise the risk of further deterioration
Understand simple monitoring interventions that
can be useful in sick patients
Understand observations and EWS
Appreciate the need for help and who to call
The use of SBAR
Assessing the Patient
Why use an assessment tool?
In an acute situation it is important that a complete initial
assessment is undertaken as soon as possible to establish;
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What & where the problem is
What the impact of the problem is
How quickly a response is required
What intervention is required
Assessing the Patient
There are many different assessment tools available,
however in the acutely unwell patient using a
standardised, easy to use tool that is common to all
members of the multidisciplinary team (MDT) is
paramount.
With everyone using the same tool this ensures a
common language, reduces the risk of
miscommunication and ensures effective team
working.
Assessing the Patient
In an acutely unwell patient the clinical
condition is likely to change quite rapidly, so
it is important to do an initial assessment
but also to keep re-assessing on a regular
basis, allowing recognition of changes and
an appropriate rapid response.
Assessing the Patient
 If at any point when assessing the patient you feel that you need
help or assistance ASK!
 You will be working with a team of nurses who have differing
skills and experience and may be able to offer assistance.
Consider your ward physio’s if an appropriate area for them to
assist with.
 If you need more help, or more specialist help, consider Critical
Care Outreach (08.00-24.00), or SNP’s.
 Don’t be afraid to put out a Priority Call (2222) if you feel that
your patient has seriously deteriorated and needs emergency
help!
Assessing the Patient
The ABCDE approach is a systematic approach to the
immediate assessment of patients,
A- Airway
B- Breathing
C- Circulation
D- Disability
E- Exposure
Assessing the Patient
 The ABCDE allows for a systematic review of a patient
 Begin with A as without an airway the patient cannot
breathe B, and without the ability to breathe the
patient would very quickly not have a circulation C.
 So there is no point focusing, for example, straight on
circulation C if the patient’s airway A is obstructed.
Airway Assessment
Any obstructed
airway is a medical
emergency and
needs immediate
expert assistance.
PRIORITY CALL
2222!
Airway Assessment
 Obstruction can happen at
any level of the respiratory
tract and can be partial
(some air passing the
obstruction) or complete
(no air passing the airway).
 Can be due to an object
physically blocking the
airway or a narrowing of
the airway itself.
Airway Assessment
LOOK
 Complete airway obstruction
leads to ‘See –saw’
respirations, inspiration is
accompanied by outward
movement of the chest, but
in-drawing of the abdomen
(and vice versa during
expiration).
Other visual signs to look for
include;
 Use of accessory muscles in
the neck and shoulders and
tracheal tug
Airway Assessment
LISTEN
 If the airway is completely obstructed then there will be
no breath sounds as no air is passing through the airway.
 In a partial obstruction air entry is diminished and often
noisy as air passes either through a narrowed airway or past
a foreign object sitting in the lumen of the airway.
 Gurgling – liquid present in mouth or upper airway
 Snoring – the tongue partially obstructing the pharynx
 Inspiratory stridor – obstruction above or at the level of
the larynx
 Expiratory wheeze – airways collapsing e.g. asthma
Airway Assessment
FEEL
 Assess for airway patency by placing the back of your
hand or your cheek immediately in front of the
patient’s mouth. In a partially obstructed airway, air
movement can be felt, however in a patient with a
completely obstructed airway or who has stopped
breathing no air movement will be felt.
Airway Assessment
Immediate Management
Simple interventions may be all that is required to open an
obstructed airway.
 Suction
 Head tilt/chin lift
 Recovery position
 Oropharangeal or nasopharangeal airway (if confident).
Do you need to call for help yet?
Airway Assessment
While waiting for help to
arrive,
 continue basic airway
manoeuvres
 give 85% oxygen via a
non rebreathe mask
Airway Assessment
If the patient has stopped
breathing or their
respiratory rate slows use
a bag valve mask (BVM)
to breathe for them
If you have done ILS and
are competent.
Airway Assessment
Ensure the
resuscitation
trolley is to
hand and that
the equipment
for intubation
is checked and
working
Breathing Assessment
 After fully assessing the airway, then move on to
breathing
 Do not move onto breathing assessment if the airway
is obstructed, solve that problem first
 Remember to use look listen and feel to assess
breathing
Breathing Assessment
LOOK : visual clues include,
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Cyanosis, is the patient peripherally or centrally blue?
Use of accessory muscles for respiration
Mouth breathing / nasal flaring
Abnormal respiratory rate
Abdominal breathing
Depth of breathing
Equality of chest movement
Irregular breathing pattern
Any drains already in situ
Breathing Assessment
 Respiratory rate is the most useful indicator that a
patient’s breathing is compromised.
 An increasing or raised respiratory rate over 20
breaths per minute, is a warning that the patient may
suddenly deteriorate.
 Persistently high respiratory rates may lead to
respiratory fatigue and failure.
 Always attempt to measure the SpO2 reading via a
pulse oximeter, however in unwell patients you may
not get this reading.
Breathing Assessment
LISTEN
Listen to the patients breathing a short distance from
their face. Added noises usually indicate an airway
issue and compromised breathing.
 Rattling noises may indicate airway secretions that
cannot be cleared.
 Presence of wheeze or stridor suggests partial airway
narrowing/obstruction
Breathing Assessment
 Listen to the chest with a
stethoscope if you feel
confident
 The breath depth and
equality of chest movement
should be assessed, noting
the quality of breath sounds
in each lung lobe.
 Practice to increase
confidence!
Breathing Assessment
FEEL
 Feel the chest for equal sided chest movement.
 Feel for any secretions within the lungs.
 The chest wall can be palpated to detect surgical
emphysema.
Breathing Assessment
IMMEDIATE MANAGEMENT
Oxygen therapy should be titrated to maintain target oxygen
saturations, if known.
However in the emergency situation give maximal oxygen therapy
15l/min via a reservoir mask as hypoxia will kill long before
hypercapnia.
Position the patient in as upright a position as possible to ensure
optimal lung expansion.
Breathing Assessment
Consider,
Humidifying the oxygen
Chest physiotherapy / cough assist
Good upright positioning
Nebulisers
Breathing Assessment
Do you need help yet?
If the patient’s work of breathing is inadequate, or
absent,
CALL FOR HELP!
If you are trained (ILS) use a bag valve mask with
15l/min flow of oxygen to take over their breathing.
Aim for a respiratory rate of 12 per minute
Circulation Assessment
In most medical and surgical emergencies, consider
hypovolaemia to be the primary cause of shock, unless
proven otherwise.
Unless there are obvious signs of a cardiac cause, give
intravenous fluid to any patient with cool peripheries
and a fast heart rate.
Check the patient for any obvious signs of fluid losses.
Again use LOOK-LISTEN-FEEL
Circulation Assessment
LOOK
Assess the general
appearance of the
patient, look for pale,
mottled or blue
peripheries, a sign of
reduced peripheral
circulation.
Circulation Assessment
LOOK
Assess the capillary refill time
(CRT). A prolonged CRT
suggests poor peripheral
perfusion and potentially
impaired tissue oxygenation.
Central assessment is best.
Circulation Assessment
 Visual signs of poor cardiac
output also include urine
output.
 If the patient has a urinary
catheter look at the urine
output, aim for <0.5ml/kg/hr.
 If newly catheterised look at
residual volume and colour of
urine.
 Look back at fluid balance
charts and check for
documented urine output.
Circulation Assessment
LISTEN
In the presence of a low blood
pressure (BP) ensure the
blood pressure is measured
manually. Mechanical
measurements of blood
pressure will either fail to
read or give inaccurate
readings at low levels.
Circulation Assessment
FEEL
 Palpate the peripheral and central
pulses assessing for,
 Presence – in patients who are
very shocked or peri-arrest it is
often not possible to palpate a
peripheral pulse, in this case
palpate a central pulse at the neck
(carotid) or groin (femoral).
 If peripheral pulses are not
palpable this is an extreme
sign of critical illness and
needs immediate treatment
Circulation Assessment
 Rate – assess for tachycardia (heart rate greater than 100bpm)
or a bradycardia (heart rate less than 60bpm)
 Quality – is the pulse weak and thready (poor cardiac output)
or bounding (possible sepsis)
 Regularity – an irregular rhythm suggests a cardiac arrhythmia
e.g. atrial fibrillation (AF)
 Equality – assess presence of pulses in limbs, inequalities may
indicate localised circulatory impairment e.g. clots
Circulation Assessment
IMMEDIATE MANAGEMENT
Immediate management should be directed at restoration of
tissue perfusion through fluid replacement and haemorrhage
control.
If you can,
 Access- 1 or 2 cannula as large as possible to give fluids quickly
 Bloods- a full range of samples, consider a cross match sample
 Fluids- a rapid fluid challenge of 500ml, followed by further
challenges as appropriate, as prescribed by the medical team
 Consider 12 lead ECG.
Do you need help yet?
Disability Assessment
In a patient with a reduced level of
consciousness consider common causes
including hypoxia, hypercapnia,
cerebral hypoperfusion as discussed in
the A-C sections.
Disability Assessment
 We also need to consider
any recent
administration of
sedatives or opiate type
medications.
 Does the patient need a
reversal agent?
Disability Assessment
 At this point we should
also consider any
recent falls or head
trauma?
 Any other likely intra-
cerebral cause?
 Do we need to consider
imaging?
Disability Assessment
 AVPU is used
within the trust.
 Easy to follow.
 The AVPU method
is recommended for
a rapid assessment.
Disability Assessment
 Glasgow Coma
Score can also be
used.
 More difficult to
interpret
 More difficult to
remember!
Disability Assessment
 Check the patient’s
blood sugar level for
hypoglycaemia. Even
if the patient is not a
known diabetic,
critically ill patients
often develop
deranged blood sugar
levels.
Disability Assessment
 Assess the patient’s
neurological state
by examining the
pupils – size,
equality and
reaction to light.
Disability Assessment
IMMEDIATE MANAGEMENT
 Treat any identified cause of neurological impairment
e.g. opiate overdose or blood sugar below 3.5mmol/l.
 Other potential causes such as hypercapnia or hypoxia
should have already been identified and managed.
Do you need help yet?
Exposure Assessment
 At this stage fully examine the patient and
ensure no important details are missed, a
thorough examination of the patient is
required.
 Please remember to ensure the patient’s
dignity and be conscious of the potential loss
of body heat.
Exposure Assessment
 At this stage of the
assessment, the
examination should be
focused on the most likely
area of the body to be
causing the patient’s poor
condition e.g. the
abdomen would be the
likely source if the patient
is post abdominal surgery.
 Check any drains.
Exposure Assessment
 Ensure all other parts of
the body are assessed for
any obvious signs of new
symptoms e.g. swellings,
rashes, inflammation,
discolouration, heat,
redness or tenderness.
 Also consider the patients
temperature if not already
assessed.
Do you need help yet?
Calling For Help
 A life threatening
emergency a priority call
“2222”
 Unfamiliar situations or
something you feel
overwhelmed by ask nurse
in charge, call outreach
(Blp 71-1111), the patients
team or out of hours SNP.
Calling For Help
When you are asking for help ensure that all relevant &
appropriate information is available,
 Examine the patients’ observations charts (TPR
charts & fluid balance)
 Drug prescription chart-what is prescribed, have they
been given?
 Patients case notes-identify current condition and any
co-morbidities
Ask someone not involved in the patient care to
gather this together.
Following Initial Assessment
 At this stage a full A, B, C, D, E assessment should
have been completed and depending on the findings a
range of initial interventions should have been
started.
 If needed continue with the A,B,C,D,E assessment,
until you are happy with some response or until
assistance arrives, ensure that you have contacted all
the appropriate people to help you in this situation.
Definitive Care
 If the patient is not responding to interventions or
you are unsure, reassess and call for help. By
reassessing you may find a key point that was
overlooked.
 Up to this point, interventions such as intravenous
fluid boluses and oxygen have been ‘holding
measures’, while definitive treatment is identified and
initiated.
 The patient may need to be transferred for optimum
ongoing treatment.
Observations and Early Warning
Scoring
Observations and National Early
Warning Scoring
Acutely Ill Patients in Hospital – NICE 2007
Adult patients in acute hospital settings (including A&E)
should have;
 Physiological observations recorded
 A clear written monitoring plan
These observations should be recorded and acted upon
by health professionals who have been trained and are
competent.
Observations and Early Warning
Scoring
A physiological track and trigger system should be used
to monitor all adult patients in acute hospital settings,
observations should be checked;
 At least every 12 hours
 A senior level should make the decision to change the
frequency that observations are recorded
 There should be an increase in frequency (a graded
response dependent on risk category) if abnormal
physiology is detected.
Observations and Early Warning
Scoring
 At the RSCH we have an National Early Warning
Scoring System which is used on every patient and
every time a set of observations are taken.
 Vital pac is the recording tool for standard observations
and will automatically calculate an NEWS in response to
the information that you input.
 This score is used to trigger a response, including
frequency of observations and an escalation plan
depending on the severity of the score.
 Observations for PCA, epidural and blood administration
are still recorded on paper form and require you to add up
the early warning score.
National Early Warning Scoring System
3
Resp
rate
<8
Oxygen
sats
<91
Any
supplem
ental
oxygen
2
92-93
1
9-11
12-20
94-95
>96
Yes
Temp
<35
Systolic
<90
2
3
21-24
>25
No
35.1-36.0
91-100
1
36.1-38.0 38.1-39.0
101-110
111-219
41-50
51-90
>39.1
>220
BP
Heart
rate
Level of
consciou
sness
<40
A
91-100
111-130
>131
V,P or U
Referral Pathway
NEWS SCORE
RISK BAND NORMAL
SCORE 0
TOTAL 1-4
OBS
5 or more SCORE
Min 1 hourl y
RISK BAND
EMERGENCY
SCORE 7 OR MORE
15min of
vital signs
Min 12
hourl y
Continue w ith routine NEWS Observati ons
Inform Trained Nurse or the Nurse in charge if concerned
Min 4-6
hourl y
Inform registered nurse w ho must assess the pati ent
Registered nurse to decide if increased frequency of monit oring and or
escalation of care i s required
Contact medical team if concernd
Bleep SHO from parent team
Bleep (71-1111) Outreach Nurse
( At Night) Bleep NNP
Team should arri ve in 15 minutes
1 o Observations of SaO2, HR, Bp, RR, Temp, Urine, CNS
High risk of Cardio - pulmonar y arrest, consider I CU transfer
Bleep Reg from parent team
Bleep (71-1111) Outreach Nurse
( At Night) Bleep NNP
Team should arri ve immediatel y (if not Priorit y Call Bleep 71 -2222)
15 Minute Observat ions of SaO2, HR, Bp, RR, Temp, Urine, CNS
High risk of Cardio - pulmonar y arrest, consider I CU transfer
Alw ays seek advice from Outreach if you are concerned about the patient
for any reason.
Action is required i f the patient’s score deteriorat es by 2
Action is required i f the CNS drops by 2 regardl ess of ot her observations
Action is required i f the urine output falls regardless of other observations
WHILE WAITING FOR OUTREACH
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Give Oxygen
Continue Observati ons
and Chart
Do 12 Lead ECG
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Cannulate
Prepare Blood Bottles (FBC, U&E,
Clotting, Glucose)
Prepare notes and X -rays
Referral Pathway
 Refer all patients to outreach as the protocol advises
 Refer any patients you are concerned about to
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outreach, we may question you but we won’t dismiss a
referral!!
Use SBAR for referrals.
Bleep 71-1111- & ext no.
Available 08:00-24:00 7 days per week.
Out of these hours the bleep is carried by the SNP, also
available for support and advice.
Referral Pathway
 Referrals should be made in an ordered manner to
allow a full handover of information.
 A full handover of information allows us to assess and
prioritise our workload, at times we are lone workers
and are needed in more than one location at a time.
 Use SBAR, being used across the trust.
SBAR
SBAR
 Inadequate communication is a common cause of
serious errors.
 Communication is often found to be more effective in
teams were there are structures for communication.
 SBAR has now been rolled out across the trust and
should be used to refer all patients that you are
concerned about to medical, and surgical teams and to
us.
SBAR
 SBAR is an easy to remember framework that you can
use to frame conversations, especially critical ones,
requiring a clinician's immediate attention and action.
It enables you to clarify what information should be
communicated between members of the team.
 The tool consists of standardised prompt questions
within four sections, to ensure that staff are sharing
concise and focused information. It allows staff to
communicate assertively and effectively,
S- Situation
 Identify yourself and the ward/ area that you are
calling from
 Identify the patient by name and the reason for your
call
 Describe what is your immediate concern about the
patient.
State early on in the conversation if it is an
emergency situation
Situation
“This is Sally calling from Frensham Ward.
I am calling about Mr Johnson in room 1 bed 4.
He currently has a low blood pressure and low
oxygen saturations, he is scoring an Early
Warning Score of 9.
I am concerned about this patient but I do not
consider the need to put out a priority call.”
B- Background
 When was the patient admitted to hospital?
 What was the admitting complaint?
 What was the diagnosis and what we are treating the
patient for?
 Has the patient had any relevant investigations?
 Do they have any significant past medical history?
 Is the patients condition deteriorating?
B- Background
“Mr Johnson has been in hospital for 8 days, he
came in with abdominal pain, had a CT scan that
showed obstruction and he had an emergency
laparotomy a week ago. He has had a CT scan
earlier today as he is still vomiting.
He has known asthma, a previous MI, and normally
has a high blood pressure.
He seems to have become worse over the last 4
hours”
A - Assessment
 What is the patients Early Warning Score (EWS)?
 What are the patients observations to total that score?
 What is the fluid balance? Does the patient have any
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IV fluids running? Any other infusions? Are they
drinking?
What is the urine output for the last hour? The last 6
hours? Any other output, vomiting, diarrhoea, drains?
AVPU assessment?
Blood glucose?
Are they hot, sweaty, clammy?
A - Assessment
“ Mr Johnson has an EWS of 9 made up of a blood
pressure of, 78/55mmHg, a pulse of 109 bpm, Sp02
91% on 2l 02 via nasal specs, resps of 22 bpm, his
temp is 36.7 c.̊ He has an IVI running at 83 ml/hr,
but he is NBM, and he is vomiting. Urine output
was 20ml’s the last hour and in the last 6 hours he
has only passed about 90 mls. He is a little drowsy
but wakes up when you talk to him, we’ve checked
the blood glucose and it is 6.2 mmol/L. His hands
feel cold to touch”
R – Recommendation
 Explain how quickly do you want the patient to be
seen, urgently? Within the next 30 minutes?
 Ask for an escalation and ongoing management plan.
 Ask if there is anything that you need to do before the
Doctor arrives?
R – Recommendation
“ I would like you to see this patient urgently.
I would like to know what the on-going
management and escalation plan is? The patient
is for active treatment and resuscitation. Is there
anything that I can do before you arrive to see this
patient?”
SBAR Exercise
 Mr Brown is a 54 yr old man on EAU, admitted the previous day,
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following a collapse at home (sweats, diarrhoea, poor swallow),
known AML undergoing chemotherapy, last 10/7 ago. Being
treated as neutropenic sepsis, likely chest.
Has had bloods, blood cultures, stool, chest x-ray.
Passing diarrhoea frequently unsure if he has passed any urine not
catheterised.
Persistently raised temperature, up to 38.9 c̊. On IV antibiotics.
Sleepy but easily woken, disorientated.
Ongoing nausea, limited oral intake. BM is 5.1 mmol/l.
Blood pressure 72/44 mmhg and pulse 136, regular.
Had 1 litre of IV fluid and 250ml plasmolyte bolus awaiting further
fluid prescription.
Cold hands to touch.
Requiring 15l 02 to maintain sp02 90%, RR 30-32.
Conclusion
 A structured approach to assessing the patient allows
for a methodical and safe assessment, ensuring that
you don’t move along before each sub-section of the
assessment is complete A-B-C-D-E.
 Re-assess if you become more concerned at any point.
 Recognising that you need help and asking for this
help early will help to improve outcomes.
 Use anyone you can to help, senior nurses on ward,
SNP’s, outreach, physio as well as patients
medical/surgical teams.
Conclusion
 Using simple manoeuvres to help patients can ensure
safety until help arrives.
 Regular observations as guided but increase the
frequency if the patient deteriorates as the risk
banding guides.
 Use SBAR to communicate concerns about patients.
 If you are in doubt put out a priority call!
Any Questions