401020 Documentation And Care Of Deteriorating Patient Assessment 2 Answer

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Assessment 2

Documentation and Care of the Deteriorating Patient

Assessment of the deteriorating patient

The identification of a deteriorating patient has been poorly managed within the healthcare setting. Usually there are discernible physiological changes which occur prior to adverse events such as cardiac arrest, unexpected admission to the ICU and unexpected death. As this is a stressful situation it is easy to omit essential strategies. Patients can deteriorate rapidly or over a period of several hours. Health professional often miss the signs of deterioration as they fail to systematically assess their patients.

A set of strategies was developed to identify and manage the deteriorating patient. The first step is to assess the patient using the ABCDE algorithm which is a systematic assessment known as the primary survey and can be used with all patients. The clinical signs of critical conditions are similar regardless of the underlying condition. The initial assessment and treatment are performed simultaneously and continuously.  This would also include taking a full set of vital signs and comparing to previous readings. The patient is assessed in the following order

A:             Airway

B:            Breathing

C:             Circulation

D:             Disability (neurological function)

E:             Exposure

 The approach to all deteriorating or critically ill patients is the same. The underlying principles are:

  • Do a complete initial assessment and re-assess regularly.
  • Treat life-threatening problems before moving to the next part of the assessment.
  • Assess the effects of treatment. 
  • Recognise when you will need extra help. Call for appropriate help early.
  • Use all members of the team. This enables interventions (e.g. assessment, attaching monitors, intravenous access), to be undertaken simultaneously.
  • Communicate effectively - use the Situation, Background, Assessment, Recommendation (SBAR).
  • The aim of the initial treatment is to keep the patient alive and achieve some clinical improvement. This will buy time for further treatment and making a diagnosis. 
  • Remember – it can take a few minutes for treatments to work, so wait a short while before reassessing the patient after an intervention.

First steps

  • Ensure personal safety. Wear apron and gloves as appropriate.
  • First look at the patient in general to see if the patient appears unwell.
  • If the patient is awake, ask “How are you?”. If the patient appears unconscious or has collapsed, shake him and ask, “Are you alright?” If he responds normally he has a patent airway, is breathing and has brain perfusion. If he speaks only in short sentences, he may have breathing problems. Failure of the patient to respond is a clear marker of critical illness.
  • This first rapid ‘Look, Listen and Feel” of the patient should take about 30 s and will often indicate a patient is critically ill and there is a need for urgent help. Ask a colleague to ensure appropriate help is coming.
  • If the patient is unconscious, unresponsive, and is not breathing normally (occasional gasps are not normal) start CPR according to the resuscitation guidelines. If you are confident and trained to do so, feel for a pulse to determine if the patient has a respiratory arrest. If there are any doubts about the presence of a pulse start CPR.
  • Monitor the vital signs early. Attach a pulse oximeter, ECG monitor, and a non-invasive blood pressure monitor to all critically ill patients, as soon as possible.
  • Insert an intravenous cannula as soon as possible. Take bloods for investigation when inserting

Watch the video below on the ABCDE assessment practical skills (10 min video)

Activity 1: AssessmentPractical Skills Guide

How would you recognise an airway obstruction a patient is experiencing is partial or complete?

How would you assess a patient’s airway?

What are the causes of a compromised airway?

How do you recognize a deteriorating patient?

What are the essential actions to be undertaken in managing a deteriorating patient?


Clinical Handover

Clinical handover is an integral part of clinical communication. It needs to be structured and be appropriate for the clinical context in which the handover occurs. Clinical handover is the effective "transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis".

ISBAR is a tool to assist with structuring of the clinical handover and is able to be adapted to suit various clinical situations. The most important information needs to be delivered first and needs to include relevant detailed patient information.communication within health care team

Watch the following video regarding the clinical handover and answer the question below clinical handover

Activity 2:

Compare the two handovers and outline how you would structure the handover.

Activity 3:

Complete the table below by using ISBAR outline the handover you would give to the RMO related to a deteriorating patient. A 76-year-old male has been admitted with pneumonia three days ago. He has been relatively stable until this am when you went check on him after receiving handover. The patient has become drowsy, his work of breathing has increased. His heart rate has increased from 65bpm to 100 bpm, his respiratory rate has increased from 14 - 22bpm, His saturation is now being maintained at 95% with oxygen via nasal 2L, the patient is now febrile at 38OC and his BP is now 90/60 from 110/60


Activity 4: Please answer the following questions.

What is the recommended format for a clinical handover?

Outline the steps of a clinical handover.


Nursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the patient care team to deliver optimal patient care.  It is also a legal requirement of nursing practice and demonstrates accountability for your actions and decisions. Please access the following PowerPoint on clinical documentation.

The primary tool for recording information relating to vital signs which assists with the identification of patients at risk is the “Between the Flags” observation chart. This chart was developed by the Australian Commission on Safety and Quality in Healthcare to support the identification of clinical deterioration and prompts actions in response to the observed physiological abnormalities.

The between the flags chart is divided into different zones which is standardized, provides specific calling criteria. The colour coded zones on the chart indicate when a patient is showing early and late signs of clinical deterioration. Vital signs out of the normal range will fall in either the yellow or red zones.  The yellow zones represent early warning signs and the red zones represent late warning signs of clinical deterioration. Early identification and ithe early introduction of interventions can prevent patient deterioration.Nursing documentation

When the patient’s signs fall in either the yellow (clinical review) or red Rapid response) zones or you are concerned about your patient activate the hospital’s clinical emergency response system. Any decision that is made to escalate or not escalate patient’s care should always be made in consultation with the nurse in charge.

The following need to be considered if a clinical review is required

  • What is usual for the patient?
  • Are there documented ALTERATIONS TO CALLING CRITERIA? 
  • Does the trend in observations reflect deterioration?
  • Is there more than one Yellow Zone observation or additional criteria?

If the decision is made not to escalate care you need to implement the following

  • Initiate appropriate clinical care
  • Repeat and increase the frequency of observations as indicated by the patient’s condition.
  • The frequency should be above the minimum requirement of 8 hourly
  • Document relevant information including actions taken and the rationale for not escalating in       the patient’s health care record.

If a Clinical Review is CALLED, you MUST: Initiate appropriate clinical care

  • Repeat your patient’s observations
  • Increase the frequency of observations as indicated by the patient’s condition
  • Document an A-G assessment, reason for escalation, treatment and outcome in the Health Care Record
  • Inform the RMO as soon as practicable

If you become more concerned or if the call is NOT attended within 30 minutes: Reassess your patient and escalate according to your local clinical emergency response system.

If the patient’s vital signs fall within the red zone, deterioration has not been reversed within ONE HOUR of a clinical review or you have serious concerns about your patient a rapid response is indicated.

MANDATORY escalation

  • If your patient has any RED Zone observations or additional criteria you MUST call for a rapid response
  • Initiate appropriate clinical care
  • Inform the NURSE IN CHARGE that you have called for a Rapid Response
  • Repeat and increase the frequency of observations
  • ALWAYS Remain with your patient
  • Document an A-G assessment, treatment, escalation process and outcome in the patient’s healthcare record
  • In form the RMO as soon as practicable

Activity 5: Answer the following questions:

Which criteria should nurse documentation fulfil?

The nurse recognises that incorrect spelling in the patient’s records results in the following:

What are the nurses legal and ethical obligations for the patient information obtained through examination, observation, conversation or treatment?

What are the basic rules of documentation?

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