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Early Recognition of the Deteriorating Patient

A guide for health care providers

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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

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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.

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The Look TestHow 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.

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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

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Vital Signs• 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.

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First Two Signs of Compensation

•HR and RR start to climb

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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).

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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.

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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?

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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.

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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

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When to Call RRT

• “Being worried about a patient”• “Having a gut feeling”• Acute changes: HR <40 or >130 BP<90 and symptomatic Respiratory rate <6 or >30 Changes in Neuro status Saturation <90% despite oxygen New onset or repeated seizure activity

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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