Observations and the Deteriorating
Patient for Registered Nurses
Shane Moody, Lead Nurse & Vikki Crickmore,
Sister. Critical Care Outreach Service
September 2013

Competency framework
• Gain awareness of the national approach and
MEWS.
• Discuss observations in detail and physiological relevance.
• Consider appropriate escalation response to deterioration and barriers to this.
• Examine useful communication tools.
• Consider additional elements relevant to patient care when considering deterioration.
• Carry out a practical assessment of taking observations and management of case studies.

Competency framework
CCOS to assess Band 7’s
CCOS to do Train the Trainer sessions for senior nurses
Band 7’ and senior nurses to assess own staff

Competency framework
Presentation
Questions
Station 1
Practical taking obs and documenting in pairs
Station 2
Case studies & completing competency document
Conclude and finish

Competency framework
2005 – NCEPOD: An Acute problem
2007 – NPSA: Safer care for the acutely ill patent
2007 – NPSA: Recognising & responding appropriately to early signs of deterioration
Consistent themes are obvious throughout these documents:
• Failure to measure basic observations.
• Lack of recognition of the importance of worsening vital signs
• Delay in response to deteriorating vital signs.

Competency framework
2007 – NICE published Acutely Ill patients in hospital – recognition of and response to acute illness in adults in hospital.
The key priorities of this document are:
• Physiological observations at the time of their admission
• A written monitoring plan (diagnosis, co-morbidities and plan)
• Observations taken by staff that have been trained and understand clinical relevance.
• A Track and Trigger system and observations recorded 12 hourly as a minimum – increased if signs of deterioration.

Competency framework
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
• Limitations to MEWS and professional judgment should be used
• Taking observations is not just generating numbers – need to understand clinical relevance
• Delegating needs to be appropriate
• Failure to act has significant consequences – effects on patient, ↑ cardiac arrest, ↑ length of stay, ↑ ICU admissions.
• Observe patient – not just using machines
• MEWS adapted for paediatrics and obstetrics & head injury patients

Competency framework
• Respiratory rate
• Oxygen Saturations
• Pulse
• Systolic (BP)
• AVPU/GCS
• Temp
• Urine Output

Competency framework
• Relevant in a number of compensatory mechanisms within the body
• Normal rate should be between 12 and 20.
• The most sensitive indicator of potential deterioration. Rising rates often early sign.
• 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
Blood pumped from
Heart is rich in O2
(95%-99% saturated)
Blood pumped back to heart is low in O2
(65%-70%)

Competency framework
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
• 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.
• Dependent on intact respiratory and cardiovascular function – limited by other factors ie: peripherally shut down.
• 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
• Should be taken manually for one minute, noting the rate, volume and regularity.
• Felt at brachial artery
• Normal rate can be considered 60-
100bpm.
• Abnormal findings need investigating
• Abnormalities should be followed with an
ECG
• Consider ECG monitoring

Competency framework

Competency framework
• Haemorrhage / bleeding
• Hypotension
• Sepsis
• Drugs / medications
• Hypoxia
• Temperature
• Injury / Insult
• Electrolytes

Competency framework
Systolic = pumping pressure
Diastolic = resting pressure

Competency framework
The pressure in the arteries is carefully regulated by the body. If it drops, immediate circulatory changes occur:
► Heart rate increases
► Constriction of vessels (so BP may remain adequate) ↓ CRT, ↓ Urine output.

Competency framework
• 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
• Sensitive indicator of hydration status
• 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.
• 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
• AVPU or GCS for more in depth assessment.
• Consider at what point do you need help?
• This should include drowsiness, agitation, new changes.
• Assess pupils
• Consider reversible causes ie: blood sugar
• If only responding to pain or unresponsive – airway is at risk – 2222 adult emergency.
• Neuro obs

Competency framework
• Can have a significant effect on patients condition.
• High or low can indicate sepsis
• > 38 degrees consider blood cultures
• Significant warming can cause vasodilation
• Low can be as important as high

Competency framework
• O2 needed?
• Positioning
• IV access
• ECG
• Catheter
• IV fluids
• Bloods
• Escalation status

Competency framework

Competency framework
• Any one in hospital!!
• Those with co-existing disease
• All emergency admissions
• Elderly people
• Specific acute illness (sepsis, pancreatitis)
• Those with altered level of consciousness
• Major haemorrhage

Competency framework
• Sepsis
• Hospital acquired infections
• Chronic disease process
• Co-morbidities
• Failure to manage complications
• Iatrogenic
• Unavoidable complications
• Palliative / end of life

Competency framework
Measure observations and Document
Recognise Deterioration
Communicate Appropriately
Respond efficiently & reassess

Competency framework
A tool used to communicate critical information succinctly and briefly

Competency framework
(English dictionary, 2013)

Competency framework
• Individual Accountability
• Risk assessment and delegation
• Consent
• Risk assessment
• Privacy and dignity
• Documentation
• Infection control
• Communication
• Safeguarding
Updates on amendments to revised policy

Competency framework
• Complete action plan for scenarios given
• Discuss rationale for taking observations and increase/decrease frequency
• Correctly taking a full set of observations
• Correct documentation and calculation of scores using trust observation charts.
• Demonstrate awareness of escalation procedures.