Professional Practice Experience

Assessment of The Deteriorating Patient

The identification of a deteriorating patient has been poorly managed within the healthcare setting. Usually there are discernible physiological changes which occur prior to adverse events such as cardiac arrest, unexpected admission to the ICU and unexpected death. As this is a stressful situation it is easy to omit essential strategies. Patients can deteriorate rapidly or over a period of several hours. Health professional often miss the signs of deterioration as they fail to systematically assess their patients.

A set of strategies was developed to identify and manage the deteriorating patient. The first step is to assess the patient using the ABCDE algorithm which is a systematic assessment known as the primary survey and can be used with all patients. The clinical signs of critical conditions are similar regardless of the underlying condition. The initial assessment and treatment are performed simultaneously and continuously. This would also include taking a full set of vital signs and comparing to previous readings. The patient is assessed in the following order

A: Airway

B: Breathing

C: Circulation

D: Disability (neurological function)

E: Exposure

The approach to all deteriorating or critically ill patients is the same. The underlying principles are:

Do a complete initial assessment and re-assess regularly.
Treat life-threatening problems before moving to the next part of the assessment.
Assess the effects of treatment.
Recognise when you will need extra help. Call for appropriate help early.
Use all members of the team. This enables interventions (e.g. assessment, attaching monitors, intravenous access), to be undertaken simultaneously.
Communicate effectively - use the Situation, Background, Assessment, Recommendation (SBAR).
The aim of the initial treatment is to keep the patient alive and achieve some clinical improvement. This will buy time for further treatment and making a diagnosis.
Remember – it can take a few minutes for treatments to work, so wait a short while before reassessing the patient after an intervention.

First steps

Ensure personal safety. Wear apron and gloves as appropriate.
First look at the patient in general to see if the patient appears unwell.
If the patient is awake, ask “How are you?”. If the patient appears unconscious or has collapsed, shake him and ask, “Are you alright?” If he responds normally he has a patent airway, is breathing and has brain perfusion. If he speaks only in short sentences, he may have breathing problems. Failure of the patient to respond is a clear marker of critical illness.
This first rapid ‘Look, Listen and Feel” of the patient should take about 30 s and will often indicate a patient is critically ill and there is a need for urgent help. Ask a colleague to ensure appropriate help is coming.
If the patient is unconscious, unresponsive, and is not breathing normally (occasional gasps are not normal) start CPR according to the resuscitation guidelines. If you are confident and trained to do so, feel for a pulse to determine if the patient has a respiratory arrest. If there are any doubts about the presence of a pulse start CPR.
Monitor the vital signs early. Attach a pulse oximeter, ECG monitor, and a non-invasive blood pressure monitor to all critically ill patients, as soon as possible.
Insert an intravenous cannula as soon as possible. Take bloods for investigation when inserting

How would you recognise an airway obstruction a patient is experiencing is partial or complete?

Ask the patient a question, if the patient is able to answer the question with choking, coughing, and audible gasping for air. Moreover, if the patient is struggling to produce a vocal response, then it is partial airway obstruction. In such cases, the patient might be suffering from too much respiratory distress and the nurse can clearly hear the respiratory sounds such as wheezing or rasping and others. This indicates the air is trying to flow through the partially obstructed airway, but if no sound is heard through the airway it means that the airway is fully obstructed. In such cases, there is no vocal response, a lot of respiratory distress, huge efforts by the patient but still no respiration (Christie, 2020).

How would you assess a patient’s airway?

The patient’s airway will be assessed in different categories – history assessment like recent/reflux meals, concurrent disease or any surgery; general assessment – dysmotility (cervical spine), distortion (edema or infection), disproportion (large tongue or bull neck), and dentition (a receding chin); X-ray, CT/MRI; nasoendoscopy; bronchoscopy; some tests such as upper lip bite test, Mallampati test (modified or original), mouth opening test, Wilson risk score, and thyromental distance test or any combination of these tests (Green et al., 2019).

What are the causes of a compromised airway?

There are many causes of a compromised airway, few are as follows: chronic obstructive pulmonary disease (COPD), cystic fibrosis, emphysema, chronic bronchitis, asthma, the collapse of the tracheal wall, abscesses in the throat or tonsils, swelling of the epiglottis or tongue, respiratory illness, respiratory inflammation, bacterial infections, viral infections, breathing in a large amount of smoke, vocal cord problems, trauma to the airway from an accident, allergic reaction, small object lodged in the respiratory airway, and swallowing or inhaling of a foreign object (Roth et al., 2019).

How do you recognize a deteriorating patient?

The deteriorating patient showsthe following factors: heart rate increases, cardiac contractility increases, respiratory rate rises, more negative intrathoracic pressure, having difficulty breathing, greater chest cavity expansion, rib retractions, and a tracheal tug, paradoxical breathing (or rocking chest motion), unequal chest movement on both sides, and low oxygen saturation levels. The levels of blood pH, oxygen, and carbon-dioxide changes than the normal range, low blood pressure, a measure of peripheral circulation, reduced level of consciousness, and reduced urine output. If there is a retraction of the sternum and rib cagethen it will help the nurse to recognize the deteriorating patient (Detsky et al., 2019).

What are the essential actions to be undertaken in managing a deteriorating patient?

The essential factors to be undertaken in managing the deteriorating patient are as follows: frequent monitoring and reporting of the responses, shared decision-making, document the patient’s health status, delivery of acute life support medical care services, and assessment of cognitive, emotional, and physical functions of the patient (Australian Commission on Safety and Quality in Health Care, 2017). Additionally, there should be the delivery of face-mask ventilation, tracheal intubation, the patient should be told about the complication and related signs for self-management. The immediate essential action to be undertaken also includes 5 back slaps and 5 abdominal thrusts repeatedly in a cyclic manner, until the obstruction clears. There can also be the use of a head-tilt and chin-lift approach for visible obstruction and for liquid obstruction repositioning is helpful in management (Lee et al., 2010).

References for Documentation and Care of the Deteriorating Patient

Australian Commission on Safety and Quality in Health Care.(2017). National Safety and Quality Health Service Standards.Retrieved from: https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf

Christie, J. (2020). Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. International Journal of Nursing Practice, e12805-e12805.https://europepmc.org/article/med/32036623

Detsky, M. E., Jivraj, N., Adhikari, N. K., Friedrich, J. O., Pinto, R., Simel, D. L., & Scales, D. C. (2019). Will this patient be difficult to intubate?: The rational clinical examination systematic review. Jama, 321(5), 493-503.https://jamanetwork.com/journals/jama/article-abstract/2724031

Green, S. M., &Roback, M. G. (2019). Is the Mallampati Score Useful for Emergency Department Airway Management or Procedural Sedation?. Annals of Emergency Medicine, 74(2), 251-259.https://doi.org/10.1016/j.annemergmed.2018.12.021

Lee, A., Herkner, H., Hovhannisyan, K., & Pace, N. L. (2010). Airway physical examination tests for detection of difficult airway management in apparently normal patients. Cochrane Database of Systematic Reviews, (12).https://doi.org/10.1002/14651858.CD008874

Roth, D., Pace, N. L., Lee, A., Hovhannisyan, K., Warenits, A. M., Arrich, J., &Herkner, H. (2018). Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database of Systematic Reviews, (5).https://doi.org/10.1002/14651858.CD008874.pub2

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