Lyell Brougham NEF

Operating Room Services

Royal Adelaide Hospital

Recognising the Deteriorating

Patient

RECOGNISING the DETERIORATING PATIENT

The primary purpose of the recovery

room is the critical evaluation of the

postoperative patient with the

emphasis on the anticipation and

prevention of complications.

Drain and Shipley 1987

POSTANAESTHETISIA RECOVERY UNIT

RECOGNISING the DETERIORATING PATIENT

How we educate and how

we clinically practice,

effects competence!

RECOGNISING the DETERIORATING PATIENT

50% of what we know is

probably wrong, our

problem is which 50%?

RECOGNISING the DETERIORATING PATIENT

Standard 9:

Recognising and responding

to the Deteriorating Patient

A = AIRWAY

B = BREATHING

C = CIRCULATION

D = DISABILITY

E = EXPOSURE

DETERIORATING PATIENT

WHAT IS THE ESSENCE OF

INFECTION CONTROL?

QUESTION

WHAT IS THE ESSENCE OF

INFECTION CONTROL?

A: Transmission

Prevention

QUESTION

WHAT IS THE ESSENCE OF

DETERIORATING

PATIENT?

QUESTION?

ASSESSMENT?

NURSING the DETERIORATING PATIENT

ASSESSMENT?OR

ASSESSING?

NURSING the DETERIORATING PATIENT

ASSESSMENT

PLANNING

IMPLEMENTATION

EVALUATION

THE NURSING PROCESS

STRUCTURE

PROCESS

OUTCOME

MANAGEMENT MODEL

STRUCTURE + PROCESS =

OUTCOME

MANAGEMENT MODEL

STRUCTURE PROCESS

OUTCOME

EVALUATION MODEL

1. ASSESSMENT

2. CURING

MEDICAL MODEL

2 Steps

1. ASSESSING

2. CLINICAL

INTERVENTION

PARU NURSING MODEL

2 Steps

RECOGNISING the DETERIORATING PATIENT

Standard 9:

Recognising and responding

to the Deteriorating Patient

A = AIRWAY

B = BREATHING

C = CIRCULATION

D = DISABILITY

E = EXPOSURE

DETERIORATING PATIENT

Check for loose dentures, teeth etc

Is the airway clear?

A = AIRWAY

Respiratory rate

SpO2

Observation

CXR

ABG

Auscultation

B = BREATHING

Heart Rate

Rhythm

BP

12 lead ECG

Capillary Return > 3 seconds

Bloods

IV Access

Fluids

Urinary Output

Fluid Balance Chart

C = CIRCULATION

BSL

AVPU (Alert, Voice, Pain,

Unresponsive)

GCS

MEDICATION CHART

Anything else that doesn’t fit into

‘ABC’

D = DISABILITY

Pull back the blankets and look!

E = EXPOSURE

RECOGNISING the DETERIORATING PATIENT

ASSESSMENTOR

ASSESSING?

NURSING the DETERIORATING PATIENT

The primary purpose of the recovery

room is the critical evaluation of the

postoperative patient with the

emphasis on the anticipation and

prevention of complications.

Drain and Shipley 1987

POSTANAESTHETISIA RECOVERY UNIT

You walk into a 6 bed bay.

There are 5 patients asleep and

one who has had a cardiac arrest!

HOW CAN YOU TELL WHICH PATIENT HAS

ARRESTED?

CLINICAL INTERVENTION

QUESTION

Monitor the Patientnot

the machines!

ICU Mantra

We need to learn to

read the patient like a

book.

WHAT WE NEED TO UNDERSTAND?

We need to learn to

read the patient like a

book.

WHAT WE NEED TO UNDERSTAND?

EVERYTHING HAS MEANING?

1. ASSESSING

2. CLINICAL

INTERVENTION

PARU NURSING MODEL

2 Steps

What is the most valuable vital

sign of

a deteriorating patient?

QUESTION

What is the most valuable vital

sign in a deteriorating patient?

A: STATE OF CONSCIOUSNESS

QUESTION

State of Consciousness

Movement

Colour

Skin

Vital signs

OBSERVATIONS

Problem:

No scales that accurately

reflect the SOC!

STATE OF CONSCIOUSNESS

Awareness – Face,

eyes

Arms

Legs

Seizure / TIA

MOVEMENT

Awareness – Face,

eyes

Arms

Legs

Seizure / TIA

MOVEMENT

The trend is of more value

than the number!

COLOUR

Movement

Colour

Temperature

Moisture (dry –

clammy)

SKIN

Respiratory rate

SpO2

Observation

CXR

ABG

Auscultation

OBSERVATIONS

83 yrs

#NOF

36 hrs from fall

Aramine throughout theatre

VIGNETTE

83 yrs

#NOF

36 hrs from fall

Aramine throughout theatre

VIGNETTE

The primary purpose of the recovery

room is the critical evaluation of the

postoperative patient with the

emphasis on the anticipation and

prevention of complications.

Drain and Shipley 1987

POSTANAESTHETISIA RECOVERY UNIT

The Australian Resuscitation Guidelines, December 2010• www.resus.org.au

• Thanks also to Kym Mart (NEF SDD)

References