Recognizing Medical Emergencies at the Bedside A guide for bedside nurses to make their days go better!

Objectives  At the end of this presentation the learner will be able to:  Identify and summarize signs and symptoms of most common bedside emergencies  Verbalize actions needed to prevent bedside emergencies  Recognize steps and interventions to treat bedside emergencies and utilization of Rapid Response Teams

What is an Emergency  Most facilities define their criteria for “emergency intervention”.  Keep in mind most of these are changes from the patients’ baseline  HR > 140/min or < 40/min  RR > 28/min or < 8/min  SBP > 180 mmHG or <90 mmHG  Oxygen Saturation <90% (with supplementation)  Change in Level of Consciousness or Mental Status  Urine output <50 ml over 4 hours  Threatened airway  Seizure  Uncontrolled pain  Significant behavioral changes  *** The nurse just has a concern about the patient’s condition

Prevention is Key  A patient’s baseline condition begins to deteriorate a mean of 6.5 hours before an unexpected event  70% of those events are preventable  Often overlooked  Missed from shift to shift

What is a Change in Condition  Anything that is different or unusual for that patient  You must be able to trend information  You must discuss with the patient/family to understand what “normal” for the patient  It may not be an emergency for that patient  You must determine the impact of the finding for the patient  Symptomatic  Asymptomatic

Common Changes in Condition  Vital Signs: must be trended in order to see the subtle changes before they become acute  Often completed by NA or Aide  Changes must verified/repeated and then reported to RN  Standards must be flexible to patient history/situation  Example: BP reading is 86/54, but patient is sitting in chair talking without symptoms. Patient baseline BP has been  Neurological Status  Restlessness  Sleeplessness/sleepiness  Disorientation  Pain

When does it become an emergency?  Airway/Breathing:  Acute change in respiratory rate  Unexpected Pulse Oximetry of <85-90% for more than 5 minutes  Consider rates 28  Heart Rate:  Acute change in baseline heart rate or rhythm  <40 or greater than 160 BPM  >140 BPM with symptoms  Blood Pressure:  Range of <80 or greater than 180 systolic  Greater than 100 diastolic

When does it become an emergency?  Neurological changes  Change is Level of Consciousness  Seizure activity  Unexplained onset of lethargy or agitation  Symptoms of a stroke:  Loss or change of speech  Sudden loss of movement in face, arms legs (or weakness)  Numbness and tingling

When does it become an emergency?  Pain  Chest pain unresponsive to Nitroglycerin  Acute new onset of pain  Bleeding

Early Warning Score  Early Warning Score (score of 3 indicates need for assistance) Score Heart Rate< >130 Blood Pressure systolic < >220 Respirations< >30 Urine Output (in last 4 hours) <80 ml80-120ml ml>800 ml Central Nervous System ConfusionAwake/respo nsive Responds to verbal Responds to pain Unresponsive Oxygen Saturation <85%86-89%90-94%>95% Resp Support/Oxygen Therapy Bi- Pap/CPA P Hi-FlowOxygen Therapy

Other Early Detection Systems  Many facilities are moving towards an early detection bundle  Sepsis Bundle  Perinatal Bundles  Stroke  These bundles function similarly as the Early Warning Score system. Patients are reviewed and scored  Thought process: early detection and intervention will reduce progression of event

What should I do now that I know?  Are there other tests that you may need?  ABG  ECG  CBC  Chemistries  WBG  Xrays  Are there other assessments that I need to do?  GCS  Auscultation  NHISS

Immediate Treatments Always remember the A-B-C’s”  Maintain the airway  Positioning  Maintain respirations  Positioning  Support  Maintain circulation  Positioning  Fluids/IV Therapy  Always maintain a safe and calm environment

Who should I notify?  You should always communicate changes to the provider.  Do not be afraid of calling the provider even if the changes are subtle  Trust your instincts when working with patients  Establish a patient centered approach to healthcare  Activate Rapid Response Team quickly

What do I need to tell the Provider/RRT?  Use SBAR or some other structured communication tool  What is going on right now (Situation)  What is the patient history (Background)  What do they look like (Assessment )  What do you need (Recommendation)  Most recent VS and trends  Most recent labwork and tests  What have you already done to mitigate the situation?

After it is over  Debriefing  Discuss with co-workers, physicians, nurses, nursing aides what happened  Review objectively how things could/should have been different  Utilize the situation as a learning tool for all parties involved

Resources  Institute for Clinical Systems Improvement. (2011). Health Care Protocols: Rapid Response Teams. Retrieved July 17, 2015, from  Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation  Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; (Available on   Institute for Healthcare Improvement. (2015). Retrieved July 17, 2015, from IHI.org:  Johnson, C. (2009, November-December). Bad Blood: Doctor-Nurse Behavior Problems Impact patient Care. Physicians Executive Journal.  Rapid Response Teams: Challenges, Solutions, Benefits. (2007, February). Critical Care Nurse, pp