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Assessment of the Acutely Ill Patient.

Assessment of the Acutely Ill Patient. HECS 2063. Ian Goulden. Objectives. Explain what is meant by assessment of the acutely ill patient. Describe the process of assessing the acutely ill patient.

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Assessment of the Acutely Ill Patient.

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  1. Assessment of the Acutely Ill Patient. HECS 2063. Ian Goulden Ian Goulden

  2. Objectives. • Explain what is meant by assessment of the acutely ill patient. • Describe the process of assessing the acutely ill patient. • Understand how to undertake a systematic assessment of the acutely ill patient. • Evaluate the nurse’s role in assessment of the acutely ill patient. Ian Goulden

  3. What is Assessment? • A process by which you establish the needs of your patient. • A process by which you establish a baseline of immediate and future needs. • An on-going process - evaluation of interventions and reassessment of need. Ian Goulden

  4. What Does Assessment Involve? • Observation. • Communication. • Monitoring. • Analysis and interpretation. Nursing Diagnosis. Ian Goulden

  5. What do we assess? • Nice draft guidelines 04/2007 – Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospitals. • 19 Recommendations – 7 of which were identified as key priorities. Ian Goulden

  6. Recommendation 1 • Adult patients in acute hospital settings should have: • all appropriate physiological observations recorded at the time of admission/initial assessment. • their physiological observations measured, recorded and acted upon by staff specifically trained to undertake these procedures and understand their clinical relevance. • a clear monitoring plan that specifies which physiological observations to be recorded and how often they should be recorded. This will take account of the: • patient’s diagnosis • presence of co-morbidities • agreed treatment plan. Ian Goulden

  7. Recommendation 2 • The following physiological observations should be carried out as part of routine monitoring: • heart rate • respiratory rate • blood pressure • level of consciousness • oxygen saturation • temperature. Ian Goulden

  8. Recommendation 7 • Additional monitoring may be required in specific clinical circumstances, for example: • hourly urine output • biochemical analysis (for example, lactate, blood glucose, base deficit, arterial pH). Ian Goulden

  9. Recommendation 8 • Staff working with acutely ill patients should have the necessary competencies in monitoring, measurement, interpretation and prompt response to the acutely ill patient, appropriate to the level of care they are providing. Education and training should be offered to ensure staff can demonstrate they have these competencies. Ian Goulden

  10. Mini Patient Assessment. • Know - what you are told. • See - quick visual assessment. • Find- quick physical assessment. (after Norman and Cook 2000) Ian Goulden

  11. Mini Patient Assessment. Ian Goulden

  12. Common Presenting Abnormalities. • Tachypnoea. • Altered level of Consciousness. • Derangement of heart rate. • Derangement of blood pressure. • Derangement of arterial oxygen saturation. • Derangement of urine output. Ian Goulden

  13. Early Warning Systems? • Heart rate. • Blood pressure. • Respiratory rate. • Oxygen saturation. • Respiratory Support / Oxygen Therapy. • Urinary output. • Conscious level. Ian Goulden

  14. LEEDS TEACHING HOSPITALS NHS TRUST CRITICAL CARE OUTREACH ADULT EARLY WARNING SCORING SYSTEM This scoring system has been designed to help both nursing and medical staff identify patients who are seriously ill or at risk ofdeterioration. It should be used on adult patients immediately after their observations have been done. Each measurement is given a score from the table above. If the patient’s total score is 3 or more, the call out algorithm istriggered and you must call for help. Please follow as directed. May 2001 Adapted from the Great Yarmouth Scoring System by Richard Morgan.

  15. MEWS is/becomes 5 MEWS is/becomes 3 No response in 30 mins No response in 30 mins Call Outreach team/NNP and PRHO Call Outreach team/ NNP and registrar Yes Patient deteriorated Local action (guidelines) Contact consultant +/- refer to appropriate specialty No Continue monitoring/ follow-up Patient improved when reviewed after 2 hours No Yes If MEWS greater than 10 contact Patients own Consultant, Outreach team and ICU Directly

  16. Patient Assessment Priorities. • Primary Survey. • Resuscitation. • Secondary Survey. • History. • Intervention/Transfer • Re-evaluation. Occur as one. CPR. Oxygen and airway control. Cannulate. Blood samples. Fluids. Resus’ drugs. Trauma management. Urinary and Gastric catheters. Ian Goulden

  17. Primary Survey. Ian Goulden

  18. Primary Survey. • Level of Consciousness. • Airway. • Breathing. • Circulation. • Disability. • Expose and Examine. Ian Goulden

  19. Primary Survey - Level of Consciousness. • Response to spoken word? • Gentle tactile stimulation. Ian Goulden

  20. Primary Survey - Airway. • NB. Cervical Spine. • Airway obstruction? Paradoxical movement? • Respiratory insufficiency? • Secure airway manually / adjuncts. • Cricothyroid puncture? Ian Goulden

  21. Airway Obstruction. Ian Goulden

  22. Primary Survey - Breathing. • Effectiveness of Breathing. • Work of Breathing. Ian Goulden

  23. Primary Survey - Breathing. • Cyanosis, hypoxia? • Rate, depth, symmetry of chest movement? Use of accessory muscles? • Palpate chest wall for structural integrity. • Chest injury / flail / pneumothoraces? • O2 therapy / Assisted ventilation? • Manage injury / pnuemothoraces. Ian Goulden

  24. Primary Survey - Circulation. • Quick head to toe survey to note and control bleeding. • Skin colour, moisture, temperature. • Pulse quality, rate, regularity, volume. • Blood pressure (if available). • Capillary refill. (should be < 2 seconds) • Chest Compressions / Positioning etc. Ian Goulden

  25. Primary Survey - Disability. • Baseline level of consciousness. • A . V . P. U + GCS • Neurological Examination. • Immobilize fractures / potential fractures. • Pain assessment / Analgesia. Ian Goulden

  26. A . V . P . U • A = Alert. • V = Responds to Vocal Stimuli Only. • P = Responds to Painful Stimuli Only. • U = Unconscious. Ian Goulden

  27. Primary Survey - Expose and Examine. • Thorough examination - all systems. • Dignity / control of temperature. Ian Goulden

  28. Secondary Survey. Ian Goulden

  29. Secondary Survey. Thorough full system assessment. • CVS. Pulse (s) / BP / ECG / Palpation / Auscultation / Jugular veins / Oedema. • Respiratory. Rate / Rhythm / Palpation - Trachea and Thorax / Auscultation / Peakflow? Pulse oximetry / CXR / ABG analysis? Ian Goulden

  30. Secondary Survey. Thorough full system assessment. • Head and neck. Skull / Neck/ Eyes / Ears / Nose / Mouth • Renal. Urine output- 1ml/kg/hour ? 30mls/hr? Ian Goulden

  31. Categories of Urine Output. Ian Goulden

  32. Secondary Survey. Thorough full system assessment. • Abdomen. Inspect / Palpate / Auscultate. • Perineum / Rectum / External Genitalia. Inspect / Examine. Blood in urine? Pregnancy test? Ian Goulden

  33. Secondary Survey. Thorough full system assessment. • Musculoskeletal. Inspect / Palpate / Range of Movement / Motor and Sensory function. Pelvis / Skull / Spine / Limbs / Joints. Ian Goulden

  34. Secondary Survey. Thorough full system assessment. • Metabolic. Urea and electrolytes. Blood sugar. Poisons screen. LFT’s. etc. Ian Goulden

  35. Have We Learned Anything? Ian Goulden

  36. Objectives. • Explain what is meant by assessment of the acutely ill patient. • Describe the process of assessing the acutely ill patient. • Understand how to undertake a systematic assessment of the acutely ill. • Evaluate the nurse’s role in assessment of the acutely ill patient. Ian Goulden

  37. Supporting Reading. • Ahern J and Philpot P (2002). Assessing acutely ill patients on general wards. Nursing Standard. 16:47-54. • Bassett C and Makin L (2000). Caring for the Seriously Ill Patient. Arnold. London. • Docherty B (2002). Cardiorespiratory physical assessment for the acutely ill: 1. British Journal of Nursing. 11:11:750-758 • Docherty B (2002). Cardiorespiratory physical assessment for the acutely ill: 2. British Journal of Nursing. 11:12:800-807 • Field D (1997). Cardiovascular assessment. Nursing Times 93: 35: 45-47. • Field D (1997). Cardiovascular assessment. Nursing Times 93: 39: 55-57. Ian Goulden

  38. Supporting Reading. • Moore T and Woodrow P (2005). High Dependency Nursing Care. Observation, Intervention and Support. Routledge. London. • Norman J and Cook A (2000). Medical Emergencies, In Sheppard M and Wright M (eds). Principles of High Dependency Nursing. Bailliere Tindall. London. • Sheppard M and Wright M (2005), Principles and Practice of High Dependency Nursing (2nd edition) Bailliere Tindall. London. Ian Goulden

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