Competency Title : Observations and The
Deteriorating Patient for HCAs
Competency Lead : Vikki Crickmore, Sister,
Critical Care Outreach Team
September 2013
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.
Competency framework
Vital signs to assess
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Respiratory rate
Oxygen Saturations
Pulse
Systolic (BP)
AVPU/GCS
Temp
Urine Output
Competency framework
Normal values
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BP: systolic 101-170
HR: 51-100
RR: 11-20
Saturations: >96%
Temperature: 36 – 38 degrees
Urine Output: 0.5ml/kg/hr
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.
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.
Competency framework
Oxygen demand
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 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.
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
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.
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.
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
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
Competency framework
2222 system
Cardiac arrest = patient in
cardiac arrest
Adult Emergency = patient
critically ill or unconscious