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CONTINUING PROFESSIONAL DEVELOPMENT
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Patient deterioration
multiple choice
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Prevention of deterioration
in acutely ill patients in hospital
NS555 Steen C (2010) Prevention of deterioration in acutely ill patients in hospital. Nursing Standard.
24, 49, 49-57. Date of acceptance: May 18 2010.
Summary
The shift towards providing critical care in general wards has
changed the way acutely ill patients are identified, treated and
managed in hospital. This requires the expertise of knowledgeable,
informed and capable staff. Effective education and appropriate
knowledge and skills are required to aid identification of the
deteriorating patient and provide prompt, timely and appropriate
intervention to prevent further deterioration and possibly death.
This article provides information about a systematic approach
that will enable healthcare professionals to intervene to prevent
deterioration in acutely ill patients.
Author
Colin Steen, lecturer in critical care and acute care pathway leader,
School of Nursing, Midwifery and Social Work, University of
Manchester. Email: colin.steen@manchester.ac.uk
Keywords
Acute care, morbidity and mortality, track and trigger
systems, vital signs
These keywords are based on subject headings from the British
Nursing Index. All articles are subject to external double-blind peer
review and checked for plagiarism using automated software. For
author and research article guidelines visit the Nursing Standard
home page at www.nursing-standard.co.uk. For related articles
visit our online archive and search using the keywords.
Introduction
Evidence suggests that hospital patients and
expectant mothers who experienced cardiac
arrest or acute deterioration showed signs of
clinical deterioration for many hours before this
event, and that intervention could have been
august 11 :: vol 24 no 49 :: 2010 49
Literature review
The Department of Health (DH) (2000) review
of critical care services illustrated a deficiency in
the ability of healthcare professionals to care
for acutely ill adults. This resulted in
suboptimal care, inappropriate admissions
to ICU and increased mortality and morbidity
(Goldhill et al 1999b, McGloin et al 1999,
50 august 11 :: vol 24 no 49 :: 2010
Time out 1
List the observations that should
be recorded for an adult patient
in an acute hospital setting?
Time out 2
Identify the normal ranges for
the following physiological
measurements:
4Normal respiratory rate.
4Tachypnoea.
4Bradypnoea.
4Tachycardia.
4Bradycardia.
4Normal blood pressure.
4Hypotension.
4Hypertension.
4Pyrexia.
4Hypothermia.
4Oxygen saturation.
TABLE 1
Vital signs recorded on initial assessment
Parameter
Normal
Abnormal
Apnoea* 0
Bradypnoea <12
Tachypnoea >20
Breathing
Rate
<94%
88-92% in patients at
risk from hypercapnic
failure respiratory
Peak flow
Circulation
Pulse rate
60-100 in normal
healthy resting adult
Blood pressure
100-140/60-90mmHg
Hypotension
systolic <100mmHg
Hypertension
>140/90mmHg
(continuously over
a certain period)
>2 seconds
Neurological
Alert (A)
Voice (V)
Pain (P)
Unresponsive (U)
(AVPU tool)
Alert
Any deterioration in
conscious level is a
warning sign and must
be acted on
Glasgow Coma
Scale
15
<8
Temperature
35.5-37.5oC
Hypothermia <35oC
Pyrexia >37.5oC
Blood glucose
Exposure
Skin temperature
Warm to touch
Skin turgor
Skin colour
Well perfused
Pallor and/or
peripheral cyanosis
Level 2
Medium-score group
Level 3
High-score group
Causes
Pathology
Hypovolaemic
Haemorrhage.
Burns.
Cardiogenic
Obstructive
Cardiac tamponade.
Tension pneumonthorax.
Compression of heart
obstructing the filling
of the cardiac chambers.
Valve disorders.
Mediastinal shift
obstructing blood flow
through the great vessels.
Distributive
Septic shock.
Anaphylactic shock.
Neurogenic shock.
Time out 4
Using the look, listen and feel
approach, describe how you
would assess a patients
neurological status. Compare
your answer with the text below.
Disability The causes of neurological dysfunction
can be split into two categories. Primary injuries
include brain injury, compressive lesions,
epilepsy and infection. Secondary injuries
include hypoxia, arising from either a lack of
oxygen or a lack of perfusion of the brain, and
metabolic disorders, such as diabetic coma
or alcohol, drug or gas intoxication.
Look, listen and feel In this category look, listen
and feel can be grouped together. Observation
begins with assessment of the patients conscious
level. A simple, but effective and descriptive tool
is the AVPU tool. Patients are given an A if they
are alert, V if they only respond to voice
commands and P if they only respond to painful
stimuli. They are given a U if they do not
respond. If there is an indication of neurological
deficit then assessment using the Glasgow Coma
Scale is necessary.
A reduced conscious level is associated with
potentially life-threatening complications. Any
patient displaying a reduced or worsening level
of consciousness is at risk of airway obstruction
and loss of the gag or cough reflex, resulting in
occlusion of the airway and aspiration of gastric
contents. In these circumstances, the airway needs
to be reassessed to ensure airway protection.
Limb weakness, changes in mood or agitation,
pupil size and reaction, or the presence of
seizures indicate deterioration in brain function.
To exclude a hypoglycaemic coma, blood glucose
should be checked and if less than 3mmol/L,
50mL 10% glucose should be administered,
blood glucose rechecked and treatment repeated
if required. A blood glucose of greater than
4mmol/L is the therapeutic end point
(Stanisstreet et al 2010).
Acute pain can cause severe complications.
Pain can be assessed, investigated and treated
accordingly through the use of an objective
scoring tool. For example, the numerical rating
scale of 0-10 (where 0 represents no pain and
10 represents the worst pain imaginable) allows
NURSING STANDARD
Time out 5
Having reviewed the literature,
reflect on the importance of
your role in the management
of acutely ill patients.
Completion of assessment
At the end of the assessment process, ongoing
planning is required to prevent recurrence and to
ensure the patient is making progress. Planning
for frequency of observations of respiratory rate,
oxygen saturation, blood pressure, pulse and
temperature is required. Pain and sedation scores
may also be necessary. It is helpful to try to
identify the cause of the acute event. A review of
the following should be performed as required:
august 11 :: vol 24 no 49 :: 2010 55
4X-rays or scans.
TABLE 4
SBAR tool to aid communication between members of the multidisciplinary team
Category
Process
Situation (S)
4Identify yourself and the site or unit from which you are calling.
4Identify the patient by name and give the reason for your report. Include the
consultants details and the patients diagnosis if known.
4Describe your concern. Be specific and avoid the use of colloquial language or jargon.
Background (B)
Assessment (A)
4Vital signs.
4Review the patients vital signs and be prepared to present the findings in some detail.
Recommendation (R)
4Offer suggestions.
4Clarify expectations.
4Offer your recommendations.
4Have a clear idea about what you want to obtain at the end of the conversation.
4Orders given over the telephone should be repeated back to ensure accuracy.
(NHS Institute for Innovation and Improvement 2010)
References
Andrews T, Waterman H (2005)
Packaging: a grounded theory
of how to report physiological
deterioration effectively. Journal of
Advanced Nursing. 52, 5, 473-481.
Berlot G, Pangher A, Petrucci L,
Bussani R, Lucangelo U (2004)
Anticipating events of in-hospital
cardiac arrest. European Journal of
Emergency Medicine. 11, 1, 24-28.
Chellel A, Fraser J, Fender V et al
(2002) Nursing observations on
ward patients at risk of critical
illness. Nursing Times. 98, 46, 36-39.
Confidential Enquiry into
Maternal and Child Health (2004)
Why Mothers Die 2000-2002
The Sixth Report on Confidential
Cullinane M, Findlay G,
Hargraves C, Lucas S (2005)
An Acute Problem? National
Confidential Enquiry into Patient
Outcome and Death, London.
Department of Health (2000)
Comprehensive Critical Care:
A Review of Adult Critical
Care Services. The Stationery
Office, London.
Department of Health (2005)
Quality Critical Care: Beyond
Comprehensive Critical Care.
A Report by the Critical Care
Stakeholder Forum. The Stationery
Office, London.
Department of Health, NHS
Modernisation Agency (2003)
NURSING STANDARD
Conclusion
Timely detection of a deteriorating patient
and appropriate intervention using a systematic
NURSING STANDARD
Time out 6
Now that you have completed the
article, you might like to write a
practice profile. Guidelines to help
you are on page 60.
Report back
This activity has taken me ____ hours to
complete.
b) Unresponsive
c) Unwell
d) Underweight
b) Heart rate
7. Breathing needs to be
assessed to exclude:
a) Central nervous system
depression
b) Phrenic nerve problems
c) Exacerbation of existing disease
d) All of the above
Other comments:
NURSING STANDARD
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