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3/24/2020 Study plan: Week 1 – Advanced patient assessmenthttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585799 1/13Study plan: Week 1 – Advanced patient assessment
Flinders Learning OnlineShared NURS8741 Professional Experience in Resuscitation Across the Lifespan (PEP) – 2020 S1 (Int + Dist)Study plan: Week 1 – Advanced patient assessment
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Tuesday, 24 March 2020, 11:47 PM
3/24/2020 Study plan: Week 1 – Advanced patient assessmenthttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585799 2/13Table of contentsRecognising the deteriorating patient and the chain of survivalTriageReading ResourcesApproach to Clinical AssessmentAdvanced patient assessmentPaediatric Primary SurveySummary3/24/2020 Study plan: Week 1 – Advanced patient assessmenthttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585799 3/13Study Plan by Diane ChamberlainRecognising physiological deteriorationThe onset of clinical deterioration refers to the stage when the person’s clinical state becomes physiologically unpredictable and unstable. It can result in incapacity ordeath within minutes or hours. Several conditions can lead to sudden and/or unexpected deterioration of patients, and clinicians must possess knowledge and clinicalexperience of specific critical illness states to be able to identify key early warning signs and symptoms indicating physiological deterioration.The clinical signs of critical illness and deterioration are usually similar regardless of the underlying cause, because they reflect compromise of major body systems. Theidentification of abnormal clinical signs [together with the patient’s history, examination and appropriate investigations] is central to objectively identifying patients who areat risk of deterioration. These signs and symptoms are often subtle and can go unnoticed. Therefore developing assessment skills that are alert to the signs and risk ofdeterioration in a patient is essential in specialist clinical practice.Learning OutcomesUpon successful completion of this section, you should be able to:explain the importance for the assessment of critically ill patientsdescribe the key elements of advanced clinical assessmentdescribe the principles and practice of clinical assessmentunderstand the importance of recognising and preventing further deterioration in patient careEarly recognition of clinical deterioration, followed by prompt and effective action, can minimise the occurrence of adverse events such as cardiac arrest, and may mean that a lower level of intervention is required to stabilise a patient.Prevention of deterioration that results in respiratory and cardiac arrest represents the most important and most effective step in the chain of survival. It is widelyrecognised that cardiac arrest in patients in unmonitored ward areas most commonly occur following a period of progressive physiological deterioration rather than asudden unpredictable event.The consensus statement of the Australian Quality and Safety Health Care Commission (2010) recommends that all facilities have systems in place for measurement anddocumentation of vital signs and escalation of care including rapid response systems with organisational support.Nature of the deficiencies in the recognition and response to patient deterioration often include: infrequent, late or incomplete vital signs assessments; lack of knowledgeof normal vital signs values; poor design of vital signs charts; poor sensitivity and specificity of ‘track and trigger’ systems; failure of staff to increase monitoring orescalate care, and staff workload. There is also often a failure to treat abnormalities of the patient’s airway, breathing and circulation, incorrect use of oxygen therapy,poor communication, lack of teamwork and insufficient use of treatment limitation plans.One of the most important directives of the ARC Guidelines include increased emphasis on the use of ‘track-and-trigger systems’ to detect the deteriorating patient andenable treatment to prevent in-hospital cardiac arrest in order to improve survival.Figure 1: Early recognition and access are essential components of effective resuscitationThe Chain of Survival represents the link between the essential elements in resuscitation which, if performed effectively, can lead to an increase in the number of personswho survive a cardiac or respiratory arrest.Zimlichman: Early recognition of patien…3/24/2020 Study plan: Week 1 – Advanced patient assessmenthttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585799 4/13Triage, by definition, is a dynamic process, as the patient’s status can change rapidly. Patients may enter the triage stream at any point—for example, patients with critical illness and injury not infrequently walk in to emergency departments. Even though Pre-hospital and EDlocations use Triage processes continuously, the process and concept should be used continuously with all patients at risk of deteriorationin all clinical areas. At each stage of the triage process, certainty can be added by measurement of physiological parameters and theintroduction of structured clinical examination. Triage may be either focused or comprehensive. Comprehensive triage refers to taking acomplete history, checking vital signs, determining allergies, and, where appropriate, performing a physical examination. Focused triage isgenerally used for more minor illnesses or injuries and includes a more limited history and screening prior to assessing patient priority.Triage is essential for the early recognition of the seriously ill patient and rapid initiation of therapy, which reduces morbidity and mortality.Triage means sorting and treating patients according to priority. Primary and Secondary Survey follow after the sorting of patientsaccording to priority, but in reality the primary survey is often performed simultaneously with Triage or immediately and rapidly after.In Australia the Australasian Triage Scale (ATS) is predominantly used. The ATS has five levels of acuity:2 • Immediately life-threatening(category 1) • Imminently life-threatening (category 2) • Potentially life-threatening or important time-critical treatment or severe pain(category 3) • Potentially life-serious or situational urgency or significant complexity (category 4) • Less urgent (category 5).Table 1: ATS categories for treatment acuity and performance thresholdsKey Points:Identifying and managing risks to self, patients and the environment is the first principle of safe triage practice and is relevant to all clinicalpractice not only the ED and Pre-hospital areas. The primary survey approach is used to identify and correct life-threatening conditions attriage.Paediatric Physiological DiscriminatorsThe clinical priorities and the principles of urgency for infants, children and adolescents are the same as those for adults.• Determining urgency will require recognition of serious illness, some features of which may be different in infants and children.• The value of parents and their capacity to identify deviations from normal in their child’s level of function should not be underestimated.Refer to the Reading “Emergency Triage Education Kit” Commonwealth of Australia 2009. for more comprehensive outline of Triage.3/24/2020 Study plan: Week 1 – Advanced patient assessmenthttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585799 5/13Reading1. “Emergency Triage Education Kit” Commonwealth of Australia 2009 – Click Here This includes both Adult and Paediatric Triage, PrimarySurvey and Secondary Survey.2. ACCCN National Adult Advanced Life Support Program Manual – Section three; pp 11-123.. Aitken, A, Marshall, A, & Chaboyer, W., 2015, ACCCN’s critical care nursing, 3nd edn, Elsevier, Australia, Chapter 23, pp 739-745. Eachsystem based chapter incorporates an assessment chapter prior to or included in the management chapter. Refer to these for specificsystems assessment.4., Bickley, Lynn S., and Szilagyi, Peter G. 2013, Chapter 3, Beginning the Physical Examination: General Survey and Vital Signs in Bates’Guide to Physical Examination and History Taking / Lynn S. Bickley. Peter G. Szilagyi. 10th ed. Philadelphia: Lippincott Williams & Wilkins. –eReading – Click Here3/24/2020 Study plan: Week 1 – Advanced patient assessmenthttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585799 6/13The initial assessment and management of an acutely ill patient is one of the most challenging tasks that a clinician can undertake. Decisions must be made and actionsperformed rapidly in conditions of uncertainty. There can be uncertainty about the disease process, the correct interventions, the likely outcome, and one’s own abilities tomanage the situation appropriately. In this environment, a structured approach to providing safe care is essential.‘Patients do not die of their disease. They die of the physiologic abnormalities of their disease’Sir William OslerBetween these two extremes however, is the complex and non-linear problem of the acutely ill or deteriorating patient. For management of these patients, there is nostandardised management protocol or comforting algorithm to follow.An continual approach involves initial identification of physiological abnormality, initiation of treatment and repetitive review while conducting other tasks to define thediagnosis and treatment. Traditional approach is more linealThe continuous model requires that initial treatment precedes diagnosis. Using this approach to managing the acutely ill patient, a clinician must be able to prioritiseissues in relation to clinical care. Neither a patient with a known diagnosis who dies from inadequately treated physiological abnormalities, nor a patient who is madephysiologically stable but then subsequently dies due to lack of specific treatment for the underlying disease process is a satisfactory clinical outcome. The central point isthe importance of establishing and maintaining a safe environment for the patient through immediate evaluation and manipulation of physiology to optimise tissue oxygendelivery.This approach has several important merits. First, it makes clinicians attend to the essential task of optimising tissue oxygen supply. Second, unlike the traditionalmethod, the requirement to’fix the physiology’ reduces the number of possible problems and interventions to manageable proportions. This simplifies initial managementand reduces opportunities for error. Diagnostic possibilities begin to open up with the process of iterative review, and then close down as information is obtained from thehistory, laboratory tests, and from monitoring the response to treatment. The third advantage is that it makes clinicians focus on global aspects of patient safety as aprimary goal, rather than on the diagnosis as an end in itself.Elective medical care follows the traditional, comparatively leisurely, pathway of taking a history, performing an examination, arranging laboratory investigations toconfirm or refute a diagnosis, starting treatment, and evaluating outcomes (see traditional linear approach, below). Emergency care is less predictable, but withinthis arena some clinical activities, trauma care and cardiopulmonary resuscitation for example, have developed management strategies which reduce the clinicalproblems to their basic elements using well-established algorithms.3/24/2020 Study plan: Week 1 – Advanced patient assessmenthttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585799 7/13Phases of Care in clinical assessment – Click Here(Adapted from “Clinical Examination” ESICM3/24/2020 Study plan: Week 1 – Advanced patient assessmenthttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585799 8/13Advanced patient assessment skill is part of the surveillance skills that specialist nurses develop to recognise the patient at risk of deterioration.B = BREATHINGC = CIRCULATIOND = DISABILITYE = ENVIRONMENT & EXCRETION (Both internal – fluids and electrolyte and external – clear surroundings related to danger)F = FULL SET OF VITAL SIGNS & FLUIDSSecondary survey and comprehensive general patient assessmentThis refers to a more general assessment rather than a surveillance tool such as primary survey..This includes presenting problems, drugs and diagnostic tests, equipment and technological devices and allergies. A full safety check ofthe patient and the patient environment especially at the beginning of patient care is routine. Then a thorough head to toe, system bysystem assessment process is performed including psychosocial assessment.Primary Survey as surveillance method3/24/2020 Study plan: Week 1 – Advanced patient assessmenthttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585799 9/13Critical Care Assessment3/24/2020 Study plan: Week 1 – Advanced patient assessmenthttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585799 10/13The pediatric primary survey is an approach for a comprehensive, hands-on assessment of an ill or injured child regardless of complaint.As in adults, the primarysurvey provides a specific sequence for treating life-threatening problems as they are identified, before moving to the next step. The stepsin the survey are the same as with adults, but there are differences in the specific signs of distress or physiologic instability.Characteristics of appearanceThe child’s general appearance is the single most important parameter when assessing severity of illness or injury. Appearance reflectsthe adequacy of ventilation, oxygenation, brain perfusion, body homeostasis and CNS function. It is more accurate than any other clinicalcharacteristic of the patient in predicting overall distress, need for treatment and response to treatment.Components of appearance are : Tone, Interactability, Consolabilty, Look/Gaze, and Speech/Cry.Figure 1: Components of appearance summarised.Components of the pediatric primary survey: airway and breathingFirst determine airway patency by observing work of breathing and listening for abnormal audible breath sounds such as stridor, wheezingand grunting as part ofperforming the PAT. The loudness of the stridor or wheezing is not strongly correlated with the degree of airway obstruction. For example,asthmatic children in severe distress may have little or no wheezing. Similarly, children with an upper airway foreign body below the vocalcords may have minimal stridor. Abnormal breath sounds merely indicate whether there is any degree of upper or lower airwayobstruction.Figure 2: Airway sounds summarisedFigure 3: Skin color summarisedFigure 4: Work of breathing summarisedAlso, evaluate tidal volume and effectiveness of work of breathing, by listening for air movement bilaterally over the midaxillary line. Achild with increasedwork of breathing and poor tidal volume may be in impending respiratory failure.3/24/2020 Study plan: Week 1 – Advanced patient assessmenthttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585799 11/13Determine the respiratory rate, but interpret the respiratory rate cautiously. Rapid rates may simply reflect high fever, anxiety, pain orexcitement. Normal rates, on the other hand, may occur in a child who has been breathing rapidly for some time to overcome an airwayobstruction and is now becoming fatigued. Finally, interpret respiratory rate in light of what is normal for age. A very rapid respiratory rate(>60/min for any age), especially in association with abnormal appearance or marked retractions, indicates respiratory distress andpossibly failure. An abnormally slow respiratory rate is always worrisome and suggests respiratory failure. Red flag respiratory rates are<20/min for child <2 years, and <10 for children >2 years.Frank cyanosis is a late finding. A hypoxic child is likely to show other abnormalities, such as increased work of breathing, agitation orlethargy long before they look “blue”. Do not wait for cyanosis to initiate treatment with supplemental oxygen. However, if cyanosis ispresent, immediately intervene.Components of the pediatric primary survey: circulationNext, assess circulation. Appearance will have provided important visual clues about adequacy of circulation. Appearance and work ofbreathing may also be altered if the child is in shock. Appearance will be abnormal because of inadequate perfusion of the brain. Thecombination of abnormal appearance and decreased circulation to skin suggests shock, either compensated or decompensated.However, abnormal appearance may also result from many severe stress states, such as hypoxia, hypercarbia, head trauma, infection, ordrugs. In addition, sometimes children in shock seem remarkably alert, although careful observation of appearance will always indicatesome abnormality such as listlessness or restlessness.Children in shock will often be tachypneic, without retractions, as they attempt to compensate for metabolic acidosis (due to poorperfusion) by blowing off CO2. This pattern of rapid respiration may be termed “effortless tachypnea”, and is distinct from the rapidlabored respirations with retractions seen with underlying airway/breathing problems.Heart rate (HR) and blood pressure (BP) have a limited but still useful role in evaluating core circulation. Parameters commonly used toassess adult circulatory status, i.e. HR and BP, have important limitations in children. First, normal HR varies inversely with age. Second,tachycardia may be an early isolated sign of hypoxia or low perfusion, but, it may also be present because of benign conditions such asfever, anxiety, pain and excitement. HR must therefore be interpreted in the context of the overall history, PAT and comprehensivephysical exam. A trend of increasing or decreasing HR may be quite useful, and may suggest worsening hypoxia or shock, orimprovement after treatment.When hypoxia or shock becomes critical, HR falls to frank bradycardia. Bradycardia means critical hypoxia and/or ischemia. When the HRis above 180/min, HR cannot be accurately determined without the assistance of an electronic monitor.BP determination is difficult in children because of lack of cooperation, difficulty remembering the proper cuff size and errors ininterpretation. For patients less than three years of age these technical difficulties reduce the value of a BP. When shock is suspected inthis age group based on other parameters (e.g., history, mechanism, PAT), attempt BP once, but do not delay management further.BP may be misleading. Although a low BP definitely indicates decompensated shock, a “normal” BP frequently exists in compensatedshock. An easy formula for determining the lower limit of acceptable blood pressure by age is: minimal systolic blood pressure = 70 + 2 xage (in years).Circulatory assessment also entails further detection of signs of decreased circulation to skin. This includes hands-on evaluation of skintemperature, capillary refill time (CRT) and pulse quality. To quickly assess circulation, lay your hand on the kneecap or forearm and feelfor skin temperature. Be sure the child is not cold from exposure, because skin signs will be deceptive if the child is not warm.Next, feel the pulse and check the capillary refill time (CRT). Signs of circulation to the skin, i.e. skin temperature and color, CRT, andpulse strength, are tools to assess a child’s circulatory status, especially when performed serially on a child who is not cold. In a normalinfant, you can easily palpate the brachial pulse, the extremities are warm and have a uniform color (not “mottled”), and the CRT is lessthan two seconds.Figure 5 : Summary of circulation assessmentComponents of the pediatric primary survey: disability or neurological status3/24/2020 Study plan: Week 1 – Advanced patient assessmenthttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585799 12/13Assessment of neurologic status involves rapid evaluation of both cortical and brainstem function. Assess neurological status byobservation of appearance, pupillary responses to light, level of consciousness, and motor activity. In theevaluation of motor activity, assess purposeful movement, symmetrical movement of extremities, seizures, posturing, or flaccidity.The AVPU pneumonic is a rapid method of assessing level of consciousness that is quite consistent with different observers. Itcategorizes motor response based upon simple responses to stimuli. The child is either Alert, responsive to Verbal stimuli, responsiveonly to Painful stimuli, or Unresponsive.Figure 6: AVPU summarisedAbnormal appearance and altered level of consciousnessA child with altered level of consciousness on the AVPU will always have abnormal appearance, because any patient so sick that she isno longer “alert” and will only respond to verbal stimuli is already moderately to critically ill. Therefore, the signs of abnormal appearanceare most useful in identifying distress in the alert child who has mild to moderately severe distress. The AVPU is simply not a verysensitive method to identify children in early stages of system stress from illness or injury. Assessing appearance using the characteristicsas described for the PAT allows a more subtle appreciation of compensated illness and injury, facilitates early intervention and avertsprogression to more advanced states of neurologicdeterioration on the AVPU scale. A child who has an abnormal appearance or who is not alert on the AVPU, yet has no increased ordecreased work of breathing or abnormal circulation to skin, probably has a focused insult to the brain.As in adults, vital signs can impart important information. Obtaining and interpreting vital signs in children however may present moredifficulty because it is difficult to obtain accurate values. Children may be uncooperative and properly sized equipment may not beavailable. Normal values vary with age, making recognition of abnormalities more challenging. Remember, vital signs are just a piece ofthe overall clinical picture, which includes history of illness, mechanism of injury, and a comprehensive clinical evaluation. Often using anapproach of Appearance, Work of Breathing and Circulation to the Skin can help priortise in a timely way the urgent needs of achild or infant.3/24/2020 Study plan: Week 1 – Advanced patient assessmenthttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585799 13/13This module content pertains to the assessment of the deteriorating adult and child. It provides a primary and secondary assessmentframework. Continue now with the tutorial as a question and answer session that role plays the management of a deteriorating patient.Attend a class or listen to the online class to consolidate your learning.
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