1 Early Recognition of the Deteriorating Patient A guide for health care providers

2 Purpose To catch the patient and intervene when compensatory mechanisms are kicking in, not once they have already failed. Early recognition of subclinical signs with resulting interventions produce better patient outcomes

3 What are Subclinical Signs Tell you that the patient is failing. Through compensatory mechanisms, he is still able to maintain and keep his vital signs “normal”. Goal – Recognize and intervene before the crisis occurs.

4 The Look Test How does your patient look in regards to: Color – Skin color is a factor of pigmentation and oxygenation and perfusion in the capillaries. People are not supposed to change color. Effort and Fatigability – How hard is the patient working to maintain his vital signs? – How long will he be able to keep going before his vital signs start to deteriorate? Diaphoresis (Sweating) – Sign of maximal sympathetic stimulation; the patient is using the last of everything he has to maintain vital signs.

5 The Look Test cont. Mentation – One of the earliest signs of inadequate oxygenation is a change in mentation. Signs of Inadequate Perfusion – Relaxation of Ear and Nose Cartilage: With lack of oxygenation and perfusion, the cartilage becomes soft, causing the ears to lay back against the head. Nasal Cannula keeps falling off. – Knee and Scrotum mottling – Generalized Pallor – GI Symptoms: Indigestion, heartburn, constipation, nausea and loss of appetite can all be signs of heart failure due to vasoconstriction in the gut. Voice Quality – Indicates oxygenation and perfusion – Clarity of ideas and strength of the voice – The number of words the patient can string together in a sentence before gasping for breath is an indication of tidal volumes the patient is able to generate

6 Vital Signs – One set of vitals standing alone is meaningless. Evaluate over the course of time – Know a patient’s trend and where that number falls along that patient’s continuum. If the VS number does not make sense, repeat it. If it still does not make sense, get a second nursing opinion. Does the HR on the pulse ox machine correlate with apical HR? How was the measurement taken (manual or automatic)? If you cannot obtain a reading, why? – Check the patient with a manual BP cuff, listen to apical HR, count the respirations. – ask for an order for an ABG if the patient’s SaO2 is not reading.

7 First Two Signs of Compensation HR and RR start to climb

8 Heart Rate An elevated HR is a sign of your patient using a compensatory mechanism. Heart rate will go up when there is a greater need for oxygen by the cell (i.e. response to injury, exercise), or when there is not an adequate supply of oxygen to bring to the cell (hypovolemia, anemia, hypoxia).

9 Respiratory Rate The symptoms of hypoxemia are identical to the symptoms of anxiety, including: restlessness, confusion, agitation, combativeness Never medicate a patient for symptoms of “anxiety” until you rule out hypoxemia as a cause. Most common causes of increased respiratory rate is hypoxemia or compensation for metabolic acidosis.

10 Blood Pressure Change in blood pressure can occur rapidly or gradually based on the presenting condition. Watch trends; know your patient’s baseline. Whether your patient is hyper- or hypotensive, it is all about tissue perfusion. BP that is too high or too low will not adequately oxygenate the tissues. Is the patient symptomatic?

11 Urine Output Urine output starts to drop off long before it becomes too low or abnormal. LOOK AT THE TRENDS FOR URINE OUTPUT. When it starts declining, you may have a perfusion problem.

12 Rapid Response Team Purpose – To provide urgent medical assistance and interventions for patients who experience an acute medical event to promote better patient outcomes. RRT Members: ICU Nurse, Respiratory Therapist, Nurse assigned to patient

13 When to Call RRT “Being worried about a patient” “Having a gut feeling” Acute changes: HR 130 BP<90 and symptomatic Respiratory rate 30 Changes in Neuro status Saturation <90% despite oxygen New onset or repeated seizure activity

14 Calling a RRT Any Patient Care Provider can call an RRT DIAL 71 Ask operator to call Rapid Response and give the patient’s room and bed number