Recognising a sick patient in a hospital

1. Recognising & Managing the
acutely ill patient
SHIBU CHACKO
Critical Care Outreach Team

2. Background
• Hospitalised patients may be at risk of clinical
deterioration
• Events like cardiopulmonary arrest are often
preceded by abnormalities in vital signs
• Patients who are sub-optimally managed in
hospital, prior to ICU admission have an
increased mortality.

3. The ‘AT RISK’ patient
Certain patients are more likely to develop
problems whilst in hospital:
• Emergency admissions
• The elderly
• Patients with chronic conditions - Diabetes,
Heart Disease, COPD etc
• Patients who are slow to respond to
treatment or develop complications
• Etc ….

4. What are we trying to stop?
PATIENT DETERIORATIONPATIENT DETERIORATION
Recognise the signs & symptoms
of critical illness early !!

5. Systematic Assessment ToolSystematic Assessment Tool
AA AIRWAYAIRWAY
BB BREATHINGBREATHING
CC CIRCULATIONCIRCULATION
DD DISABILITYDISABILITY
EE EXPOSUREEXPOSURE
(Resus Council UK 2000)(Resus Council UK 2000)

6. Assessing the Critically Ill PatientAssessing the Critically Ill Patient
Only progress fromOnly progress from
A to E when eachA to E when each
stage has been completedstage has been completed

7. Airway

8. Causes of Airway Problems
• CNS depression
• Blood, vomit, foreign body
• Trauma
• Infection, inflammation
• Laryngospasm
• Bronchospasm

9. AIRWAY
• OBSTRUCTION OF THE AIRWAY IS ANOBSTRUCTION OF THE AIRWAY IS AN
EMERGENCY!EMERGENCY!
• USE THEUSE THE
• LOOKLOOK
• LISTENLISTEN
• FEELFEEL
APPROACHAPPROACH

10. LOOKLOOK
• Is the patient conscious?Is the patient conscious?
USE THE AVPU SYSTEMUSE THE AVPU SYSTEM
• A – ALERTA – ALERT
• V – responds to VOICEV – responds to VOICE
• P – responds to PAINP – responds to PAIN
• U – UNRESPONSIVEU – UNRESPONSIVE
TIP – If the patient can answer the question ‘Are youTIP – If the patient can answer the question ‘Are you
ok?’, then he is alert and his AIRWAY is notok?’, then he is alert and his AIRWAY is not
blocked!blocked!

11. LISTEN FOR:LISTEN FOR:
• Gurgling – liquid in the mouth or upper
airways
• Snoring – tongue is partially blocking
the airway
• Stridor – harsh, high pitched sound
heard on breathing in, indicating a
partial blockage of the windpipe

12. FEEL FOR:
• The presence of Air movement
• Position of Trachea
• Chest Expansion

13. ANY PROBLEM WITH “A’’
SEEK HELP IMMEDIATELY
HOW????

14. You will be asked to get:
• Suction Equipment
• Equipments from the Airway
drawer on the resuscitation trolley
• Oxygen masks, tubing etc

15. Airway adjuncts
• Nasopharyngeal airway

16. Oropharyngeal (Guedel) Airway

17. Endotracheal tube

18. Breathing

19. Physiology of Gas Exchange
Oxygenated Blood
Pulmonary Vein to
Left Atrium

20. Breathing Problems - Causes
• Decreased respiratory drive
 CNS depression
• Decreased respiratory effort
 Neurological lesion
 Muscle weakness / exhaustion
 Restrictive chest defect
• Pulmonary disorders
 Pneumothorax, lung pathology, Infection

21. BREATHING
• Shortness of breath at rest or with
minimal exertion is an important sign of
serious illness.
• USE THELOOK
• LISTEN
• FEEL
• APPROACH

22. LOOK
• Rate of Breathing
• Rhythm / Work of breathing
• Oxygen Saturation / Cyanosis
• Depth
• Unilateral or Inadequate Chest
Expansion
• Use of Accessory Muscles
• SEE-SAW BREATHING

23. LISTEN
• Is the patient struggling to speak?
• Rattling noises from the chest
• Wheezes

24. FEEL
• Depth of Chest movements
• Position of Trachea
• Surgical emphysema

25. ANY PROBLEM WITH ‘’B’’ SEEK HELP
IMMEDIATELY

26. Nasal Cannula
Simple Face Mask
Fixed Concentration Mask (Venturi System)
Quattro Humidification System
Non-Rebreather Mask & Bag (High Concentration Mask)
•Uncontrolled Oxygen Delivery System
•Flow Rate: 0.5 – 4 lpm (litres per minute)
•Suitability: All patients who require low flow oxygen therapy
•Uncontrolled Oxygen Delivery System
•Flow Rate: Minimum 5 lpm (litres per minute)
•Suitability: General purpose
•Controlled Oxygen Delivery System
•Flow Rate: Indicated on each venturi (different colours for different O2 %)
•Should be the system of choice
•Controlled Oxygen Delivery System
•Flow Rate: Indicated for each oxygen percentage
•System of choice for patients requiring oxygen for 6 hours (excluding nasal cannulae)
•Uncontrolled Oxygen Delivery System
•Flow Rate: Minimum 15 lpm (litres per minute)
•System of choice for acutely unwell patients
January 2006 Catherine Plowright, Nurse Consultant Critical Care. Jane Kindred, Respiratory Nurse. Zoe Dennett, Critical Care Educator.

27. Why we need to give oxygen??
• All patients undergoing resuscitation forAll patients undergoing resuscitation for
whatever reason will have some degree ofwhatever reason will have some degree of
hypoxia.hypoxia.
• How much?How much?
 As much as you possible – aim for >85%As much as you possible – aim for >85%
• Are there any exceptions?Are there any exceptions?
 No – even pts with chronic lung disease areNo – even pts with chronic lung disease are
hypoxic at the time of resuscitation.hypoxic at the time of resuscitation.
 CO2 kills slowly but no O2 killsCO2 kills slowly but no O2 kills
quicklyquickly..

28. Circulation

29. CIRCULATION
• A compromised circulation means that
there is not enough blood travelling to
the major organs of the body
• This is CLINICAL ‘SHOCK’ and may be
due to fluid loss through bleeding, burns
or chronic diarrhoea.

30. CIRCULATION
• USE THEUSE THE
LOOK
LISTEN
FEEL
APPROACHAPPROACH

31. LOOK
• Look for a drop in blood pressure
and a rise in the pulse rate
Causes:
• Dehydration
• Loss of fluid- Bleeding, Diarrhoea,
Vomiting
• Sweating, High output stoma, drains
• Need for more fluid – Sepsis
• A weak heart muscle

32. LOOK
• Is the patient passing urine?
• Normal urine output?????
• Quality of Urine – Urine Dip
• Look for excessive drainage from
wounds or drains
• Look at the patient's conscious level
• Signs of bleeding

33. LISTEN
• Listen to the patient – is he or she complainingListen to the patient – is he or she complaining
of heaviness or tightness in the chest?of heaviness or tightness in the chest?
This could be due to a variety of reasons -:This could be due to a variety of reasons -:
• ASTHMAASTHMA
• HIATUS HERNIAHIATUS HERNIA
• ANGINAANGINA
• HEART ATTACK - How to diagnose??HEART ATTACK - How to diagnose??

34. FEELFEEL
• Does the patient have cool, pale limbs
and digits?
• Central / Peripheral pulses – how easily
is it to feel and measure the patient’s
radial pulse?
• Capillary refill time / Limb Temperature
• Blood Pressure

35. The Hypotensive Patient

36. ANY PROBLEM WITH ‘’C’’ SEEK
HELP IMMEDIATELY

37. Monitor
• ECG
• Blood Pressure
• Give Oxygen
• Cardiac MONITOR
• Large bore IV Access
• Bloods
• Fluids

39. Causes of Disordered Conscious
Level
• Drug / Alcohol Intoxication
• Head Injury
• Stroke / Bleed / Tumour
• Hypoxia
• Hypercapnoea
• Acid Base Imbalance
• Hypotension
Disability

40. Disability / Altered Conscious Level
• What is your patients AVPU / GCSWhat is your patients AVPU / GCS
• PAIN SCOREPAIN SCORE
• Pupillary Reaction
• BLOOD GLUCOSE – Always do a BM on a– Always do a BM on a
patient with altered level of consciousnesspatient with altered level of consciousness

41. Recovery Position

42. Exposure

43. Assessing the patient =EXPOSURE
• Exposure of the patient – Always
consider Hypothermia and Dignity
• Bleeding / Trauma
• Haematomas
• Fractures
• Rashes / Allergies
• Drains / High output stoma’s
• Drug patches

44. Don’t Forget Your
Patients Charts & Info !
• Observations / MMEWS SCORE
• Special Investigations
• Blood tests & X-rays
• Fluid Balance
• Drug Chart
• Nursing Notes

45. Handover
• Grab their attention by telling them
the Situation
• Give them a little relevant Background
on what's happened
• Tell them your Assessment of the
patient
• Recommend to them what you want
the to do
It is not to be used to call for emergency
assistance e.g. unconscious patient
Cardiac arrest, Any other medical
emergency
You then must call 2222

46. Sepsis
• Body's response to infection
• Normally, the body's own defense
system fights infection
• But in severe sepsis, the body's normal
reaction goes into overdrive, setting off
a cascade of events that can lead to
widespread inflammation and blood
clotting in tiny vessels throughout the
body.

47. Who is at risk?
• The very young
• The very old
• Those with "compromised" immune
system
• Those with wounds or injuries
• Alcoholics or drug abusers
• Those receiving certain treatments or
examinations (e.g., IV catheters, wound
drainage, urinary catheters

48. Systemic Inflammatory Response Syndrome
(SIRS)
• Systemic inflammatory response to
various stresses.
Meets 2 or more of the following criteria
• Temperature of >38C/<36degree C
• Heart rate of more than 90 beats/min
• RR >20 breaths/min
• WBC >12,000/mm3 or <4000/mm3

49. SEPSIS
• Evidence of SIRS accompanied by
known or suspected infection.
SIRS PLUS a documented infection
• Positive CXR
• Positive Urinalysis
• Cellulitis /Abscess /Infected Lines
• Positive Blood Culture / Urine / CSF

50. Sepsis screening tool
• If patients have a
history
• of suspected
infection
PLUS
• Two or more of the
following (and it is
new ) they may have
an infection which
could lead to
sepsis.
Temperature
>38 C or <36OC
Pulse
>90 beats per
minute
Respiratory rate
>20 breaths per
minute
White Blood Cells
>12 or <4
Mean arterial
pressure
<65 mmHg

51. Sepsis resuscitation Bundle
• Give oxygen – lots of
• Good IV access (How would you do this??)
• Serum lactate measured
• Blood cultures prior to antibiotics
• Broad-spectrum antibiotics administered within 1
hours of documented diagnosis (VITAL)
• If hypotension (MAP < 65) or lactate > 4 mmol/L, initial
fluid resuscitation with 500mls PLASMALYTE
• Consider vasopressors – noradrenaline

52. Case Study
• Mrs Davies is a 48yrs old lady who has returned from
a recent holiday in Spain with pneumonia. She is
admitted to hospital for treatment with IV antibiotics.
Her admission observations are
• Level of Consciousness ALERT
• Resp Rate 23b/m
• Saturations 92% on air
• BP 130/60
• Pulse rate 92b/m
• Temperature 38.4

53. Mrs. Davies’ problem
• It’s 18.30 hrs, it’s been a very busy day and there is
still plenty to do before the end of the shift. Mrs D is in
bed but her venflon has ‘tissued’. SN doing some
routine observations
• Level of Consciousness ALERT
• Resp Rate unrecorded
• Saturations 92% on 60% oxygen
• BP 95/45 mmHg
• Pulse rate 102b/m
• Temperature 38.0

54. • During the night shift at 5 am, Mrs Davies becomes
more unwell. Her obs are-:
• Level of Consciousness Drowsy
• Resp Rate 38 p/m
• Saturations 85% on 100% oxygen
• BP 86/40 mmHg
• Pulse rate 116b/m
• Temperature 38.8

55. • On call doctor is called, and a chest x ray is
ordered which shows a worsening
pneumonia.
• A new drip is sited, rapid fluids are given and
the antibiotics are changed.
• The on-call physiotherapist is asked to treat
Mrs Davies however she is too drowsy to
comply.
• Critical care is informed and arrangements
are made for transfer.

56. • Tell me what went wrong in this
situation?
• 1.
• 2.
• 3.
• 4.
• HOW CAN WE IMPROVE?

57. Remember
• Think ABCDE
• Think AVPU
• Use SBAR
• Documentation/ MMEWS
• Inform Doctor
• Involve specialist nurses i.e. Outreach/Site
• Implementation of early treatment
• Prioritise
• GET HELP!!

58. ‘Early recognition, Treatment and escalation
improves patient experience and survival’
QuestionsQuestions