Recognising & Responding to Clinical Deterioration

Recognising and Responding to Clinical Deterioration

Objective

To ensure that all consumers are observed and care is planned with treatment actioned and evaluated on all occasions where there is potential for a decline in health status. Health Status as defined by the World Health Organisation includes physical, mental, emotional and social well-being (WHO 2002).

Applies to: Carers, Home Support Workers, Team Leaders, Respite Team Leaders, Senior Team Leaders, Live Every Day Assistants, Live Every Day Co-ordinators, Enrolled Nurses, Registered Nurses, Podiatrist, Physiotherapist, Occupational Therapist.

Responsibilities

Allied Health

• Observe signs and symptoms of the consumer’s physical, mental, emotional and social health and well-being and report changes to the Senior RN

Carer/Live Every Day Assistant/ Home Support Worker

• Work under the guidance of the Enrolled Nurse (EN)/Registered Nurse (RN)

• Observe signs and symptoms of the consumer’s physical, mental, emotional and social health and well-being, and report changes to the EN/RN

• Document issues and outcomes on the appropriate chart

Responsibilities

Enrolled Nurse

• Observe signs and symptoms of the consumer’s physical, mental, emotional and social health and wellbeing,and report changes to the RN

• Undertake clinical observations and compare to baseline observation and medical direction

• Report relevant clinical issues to the senior RN

• Communicate with Medical Officer (MO) regarding acute illness/ clinical deterioration, mental state deterioration under the direction of RN

• Document all assessments, observation and interaction with the consumer whilst there is acute clinical/mental statedeterioration.

Responsibilities

Enrolled Nurse (Cont’d)

• Make progress note entries regarding relevant outcomes of medical visits e.g. changes, orders

Registered Nurse

• Provide guidance to the Enrolled Nurse(s)/carer(s)/Live Everyday Assistant(s)/Home Support Worker(s)

• Communicate with Medical Officer (MO) regarding acute illness/clinical deterioration /complex issues

• Daily check progress notes

- Follow up on identified issues

- Assess consumer status as required

- Commence assessment/care plan changes as required

Responsibilities

Registered Nurse (cont’d)

• Check incident reporting for requirement to prevent of further clinical/mental state deterioration

- Diarise follow-up of assessments

- Follow-up care plan changes

• Generate Care Plan / Care Plan changes

- Conduct assessments

- Evaluate assessment data

- Make progress note entry

- Ensure staff are notified of change

• Action all acute deterioration in line with this guideline using sound clinical reasoning

Senior RN/Clinical Nurse/LED

Coordinators

• Daily monitoring of all care/clinical staff

Acute Deterioration

Circulation

• Heart rate is greater than 120, or less than 50 beats per minute

• Systolic blood pressure is less than 90, or more than 180 mm/Hg

• Diastolic blood pressure more than 110 mm/Hg

Breathing

• Respiratory rate greater than 26, or less than 8 breaths per minute

Neurological

• Sudden fall in level of consciousness or unresponsive

• Repeated or extended seizures

Other

• Chest pain – see Chest Pain section

• Urine output less than 600ml in 24 hours (approx.)

Circulation

• Give oxygen at 2-4litres per minute via nasal specs or 6 litres per minute by mask

• Check BGL

• Check Advance Care Directive or plan

• Notify Consumer Representative/ Legal Substitute Decision maker

• Call ambulance for hospital transfer per Advance Care

Directives

• Call the GP

• Monitor closely, check observations every 5 minutes until stable or medical order.

• Prepare transfer documents

• Ensure appropriate staff member with the consumer at all times

Breathing difficulties

• Increasing shortness of breath

• Cough

• Unexplained fever or sweats

• Decreased food or fluid intake

• Decrease in usual function or activities

• Increasing confusion

• Fatigue

Circulation

• Assess general health status e.g. colour, skin turgor, intake & output, peripheral circulation

• Check observations (including oxygen saturation levels) and repeat 2 to 4 hourly for 24 hours or until stable

• Notify the GP

• Notify Consumer Representative/ Legal Substitute Decision maker

• Monitor food & fluid intake

• Encourage fluids if not contraindicated

Breathing difficulties

• Breathing rate below 8 breaths per minute OR more than 26 breaths per minute

• Unable to say more than a few words due to breathlessness

• Chest pain

• Heart rate more than 120 beats per minute

• Systolic blood pressure below 90 mm/Hg

• Use of accessory muscles to breathe

• Newly noted peripheral cyanosis

• Sit consumer upright

• Give oxygen at 2-4 litres per minute via nasal prongs or 6 litres per minute by mask

• Give consumer any prescribed regular or prn puffers or nebulisers

• Check Advance Care Directive or plan

• Notify Consumer Representative/ Legal Substitute Decision maker

• Call ambulance for hospital transfer per Advance Care Directives

• Call the GP

• Monitor closely, check observations (TPR, BP, and oxygen saturation levels) initially, then every 5 minutes until stable or medical order.

• Prepare transfer documents

• Ensure appropriate staff member with the consumer at all times

Chest Pain

New or undiagnosed episode of chest pain, central tightness with or without associated arm or jaw pain

• Monitor closely, check observations (TPR, BP and oxygen saturation levels) initially, then pulse and BP every 10 minutes until resolved

• ‘Nurse initiated’ anginine

• Oxygen via mask at 6 litres per minute or via nasal prongs at 2-4 litres per minute

• Ask consumer to rest

• Notify Consumer Representative/ Legal Substitute Decision maker

• Notify the GP

• Check Advance Care Directive or plan

Chest Pain

• Diagnosis of Angina

• AND

• 2 episodes of chest pain in one day AND

• relieved by anginine or GTN spray and Oxygen

• Monitor closely, check observations (TPR, BP and Oxygen saturation levels) 2 to 4 hourly for 12 to 24 hours

• Check Advance Care Directive or plan

• Call the GP - discuss

• Notify Consumer Representative/ Legal Substitute Decision maker

Chest Pain

An episode of chest pain and/or left arm, shoulder or jaw pain unrelieved by anginine or prescribed GTN spray and oxygen at 6 litres per minute by mask or 2 litres per minute by nasal prongs or chest pain with syncope or heart failure.

Including any of the following:

• Heart rate is greater than 120 or less than 40 beats per minute

• Systolic blood pressure is less than 90 or more than 180 mm/Hg

• Sweaty or clammy

• Respiratory rate is greater than 26 breaths per minute

• Change in skin colour or turgor

• Increasing agitation

• Increasing anxiety

• Signs of indigestion, belching, nausea, vomiting or regurgitation

• Check Advance Care Directive or plan

• Notify Consumer Representative/ Legal Substitute Decision maker

• Call ambulance for hospital transfer per Advance Care Directives

• Prepare transfer documents

• Notify the GP

• Monitor closely, check observations (TPR, BP and Oxygen saturation levels) initially then pulse and BP every 10 minutes

• Ensure appropriate staff member with the consumer at all times

Constipation

• Bowels not open for 3 days or 4 days

• Loss of appetite

• Abdominal bloating or discomfort

• Nausea

• Excessive wind

Bowels not open for 3 days

• Observe abdomen for signs of distension and palpate to detect discomfort, pain, tenderness or firmness

• Give prescribed or nurse initiated aperient

Bowels not open for 4 days

• Observe abdomen for signs of distension and palpate to detect discomfort, pain, tenderness or firmness

• Give suppositories as ordered/or nurse initiated and discuss with the GP

• Ensure outcome of aperients monitored/continue Bowel Chart

• Review nutrition and hydration assessment and increase oral fluid and fibre if appropriate

• Discuss regular aperient with the GP

Constiptation

The consumer has been assessed as constipated e.g. small bowel motions, abdominal pain or distension, pain or discomfort on palpation of abdomen AND HAS ANY OF THE FOLLOWING:

• Vomiting

• Increasing abdominal pain

• Decreased level of consciousness/ drowsiness

• Systolic blood pressure less than 90 or more than 180 mm/Hg

• Not passing wind

• Heart rate above 110 beats per minute

• Increasing agitation or confusion

• RN unable to hear bowel sounds

• Check Advance Care Directive or plan

• Notify the GP

• Notify Consumer Representative/ Legal Substitute Decision maker

• Call ambulance for transfer to hospital as per Advance Care

Directives if not conflicting with above

• Continue to observe & monitor while waiting for ambulance

Dehydration

Mild to moderate

• Headache

• Thirst

• Dry nasal passages, lips, mucous membrane

• Dry, warm, flushed skin

• Unexplained fever

• Reduced urinary output with dark coloured urine (high specific gravity on urinalysis)

• Weakness, tiredness or dizziness

• Increasing confusion

• Muscle cramps

• Decreased skin turgor

• Constipation

• Monitor closely, check observations (TPR, BP and Oxygen saturation levels) initially and continue 2 to 4 hourly for at least 24 hours or until condition is stable

• Check blood glucose level

• Notify the GP

• Notify Consumer Representative/Legal Substitute Decision maker

• Commence fluid balance chart

• Encourage fluids if not contraindicated including fruit juice, soup, water and consider electrolyte replacement drinks e.g. Gastrolyte or similar

Dehydration

Moderate to severe

• Febrile

• Confusion, delirium or convulsions

• Rapid breathing, more than 26 breaths per minute

• Poor skin turgor

• Sunken eyes

• Moist, cool extremities

• Muscle contractions in arms, legs, stomach or back

• Tachycardia – more than 110 bpm

• Systolic blood pressure below 90 mm/Hg

• Functional impairment

• Lack of urine output (less than 600ml in 24 hours approx.)

• Monitor closely, check observations (TPR, BP and Oxygen saturation levels) initially then pulse and BP every 10 minutes thereafter

• Check Advance Care Directives or plan

• Check Blood Glucose level

• Notify Consumer Representative/ Legal Substitute Decision maker

• Notify the GP

• Call ambulance if not conflicting with above

• Prepare transfer forms

Delirium

May be secondary to an existing illness or infection

• Decreased ability to focus attention e.g. unable to count backwards from 10 to 1 or cannot hold a simple conversation

• Increased agitation or aggression

• Change in functional status

• Monitor closely, check observations (TPR, BP and Oxygen saturation levels) initially and continue to record 2 hourly for 12 to 24 hours

• Check blood glucose level

• Notify the GP

• Notify Consumer Representative/Legal Substitute Decision maker

• Offer frequent reassurance and reorientate in a calm and quiet manner

• Give clear instructions and maintain eye contact

• Complete delirium screening tool

• Refer to speech pathologist if difficulty swallowing

• Consider constipation/check urinalysis /pain

• Consider any new medication or significant change in medication –check allergies

The consumer has new or worsening confusion AND one or more of the following:

• An identified risk of harm to themselves, staff or others

• Change in level of consciousness

• Systolic blood pressure below 90 mm/Hg

• Heart rate above 130, or less than 40 beats per minute

• Respiratory rate greater than 26 or less than 8 breaths per minute

• Check Advance Care Directive or plan

• Notify the GP

• Notify Consumer Representative/ Legal Substitute Decision maker

• Ensure consumer has glasses and hearing aids if applicable

• DO NOT restrain

• Call ambulance for transfer as per Advance Care Directive if not conflicting with above

• Continue to observe & monitor while waiting for ambulance

• Monitor all behavioural interventions

Within 24 to 72 hours of a fall if ONE of the following is present:

• Increased unsteadiness

• Persistent pain

• Decline in functional status

• Increased confusion or agitation

• Monitor closely, check observations (TPR, BP and Oxygen saturation levels)

• Commence pain charting

• Check Advance Care Directive or plan

• Call the GP to discuss a possible radiological assessment and follow up

• If unsteady or headache present or any bodily weakness attend to neurological observations i.e. Glasgow Coma Scale.

• Continue to monitor neurological observations if any change in conscious state

• Notify Consumer Representative/Legal Substitute Decision maker

Consumer is found on floor (witnessed or unwitnessed fall) AND one or more of the following is present:

• Severe or increasing pain or weakness on movement

• Difficulty moving a limb, or obvious deformity e.g. shortening & rotation of a leg

• Obvious head injury

• Drowsiness, agitation or a decreased level of consciousness

• Heart rate greater than 120 or less than 40 per minute

• Systolic blood pressure less than 90 mm/Hg

• Respiratory rate more than 26 breaths per minute or less than 8 breaths per minute

• Decline in functional status

• DO NOT move off floor until assessed by RN (or EN team leader)

• RN to conduct a physical assessment and check for bruising, lacerations, fractures or signs of head injury

• If head injury is obvious or suspected, or fall was unwitnessed, conduct neurological observations

• Immobilise head and neck if applicable

• Monitor closely, check observations (TPR, BP, Oxygen saturation and blood glucose levels)

• If fracture is suspected, immobilise affected limb, administer analgesia if ordered

• Ensure a suitable staff member stays with consumer to offer reassurance, make comfortable and cover with a blanket

• Call ambulance for transfer as per ACD

• Notify Consumer Representative/Legal Substitute Decision maker

• Notify the GP

• Continue to monitor pain, blood pressure, pulse, resps and attend neurological observations while awaiting transfer to hospital.

Gastronomy (PEG) tubes

• Redness, pain or itching around tube insertion site

• Oozing of fluid around tube insertion site

• Increased resistance to flushing of tube (e.g. blocked)

• Dislodgement – tube has moved further into GIT tract causing reflux of gastric contents into tube

• Diarrhoea, signs of feeding intolerance

• Check tube for kinking

• If tube blocked insert 30 to 50ml of warm water and use gentle plunger action. If blockage remains leave syringe of warm water in place and repeat gentle plunger action after 10 to 20 minutes

• Use syringe to gently exert pressure alternating with suction

• Gently milk the tubing from the insertion site outwards, taking care not to pull on the tube

• Contact outreach service or the GP if unsuccessful

Gastronomy (PEG) tubes

Tube has fallen out OR There is a problem with the tube AND one or more of the following:

• Temperature above 38°C or below 35.5°C

• Heart rate above 130, or less than 40 beats per minute

• Systolic blood pressure less than 90 mm/HG

• Respiratory rate more than 26 breaths per minute

• Increased abdominal pain or bloating

• Vomiting

• Cough

• Worsening agitation or distress

• If tube has fallen out, clean stoma and abdomen with normal saline and insert a temporary Foley catheter. Do not give medications via tube.

• Check Advance Care Directive and plan

• Call ambulance for hospital transfer as per ACD

• Prepare transfer papers

• Notify the GP

• Monitor closely, check observations (TPR, BP and Oxygen saturation levels)

• Notify Consumer Representative/ Legal Substitute Decision maker

Supra Public Catheter

• Redness, pain or itching around catheter or insertion site

• Increasing ooze of fluid around the catheter insertion site

• Decreased flow of urine from catheter

• Check that catheter is not kinked or clamped

• Monitor closely, check observations (TPR, BP and Oxygen saturation levels)

• Call the GP

• Notify Consumer Representative/Legal Substitute Decision maker

• Offer fluids frequently unless contraindicated

• Continue to monitor urine output - Assess for signs of dehydration

Supra Public Catheter

There is a catheter is not draining/well AND one or more of the following is present:

• Catheter has fallen out

• Temperature is above 38°C or below 35.5°C

• Heart rate is greater than 130, or less than 40 beats per minute

• Systolic blood pressure is less than 90 or more than 180 mm/Hg

• Respiratory rate is greater than 26 breaths per minute

• Increased pelvic or abdominal pain or vomiting

• Worsening agitation or distress

• Abdominal distension

• If tube has fallen out, suitably trained staff may replace it with a similar size catheter within 30 minutes.

• For all other signs and symptoms listed:

• Check for Advance Care Directive or plan

• Check that catheter is not kinked or clamped

• Notify the GP

• Notify Consumer Representative/ Legal Substitute Decision maker

• Call ambulance

• If blocked, flush the catheter with 60ml of normal saline

Urinary Tract Infection

• Burning or stinging on passing urine

• Blood-stained or cloudy urine

• Offensive-smelling, thick or dark urine

• Passing urine more frequently

• Increasing confusion or agitation

• Abdominal or flank pain or rubbing groin or abdomen

• Chills, fevers, or rigors

• Confusion may be the ONLY sign in the elderly

• Take a clean urine sample and perform a urinalysis

• Check consumer’s blood glucose level

• Offer oral fluids if able to swallow

• Check observations 2 to 4 hourly

• Commence fluid balance chart

• Call the GP

• Notify Consumer Representative/ Legal Substitute Decision maker

Urinary Tract Infection

If you suspect a urinary tract infection AND one of the following is present:

• Temperature is above 38.°C or below 35.5°C

• Heart rate is greater than 130, or less than 40 beats per minute

• Systolic blood pressure is less than 90 or more than 180 mm/Hg

• Respiratory rate is greater than 26 breaths per minute

• Take a clean urine sample and perform a urinalysis test

• Check consumers blood glucose level

• Offer oral fluids if able to swallow

• Notify the GP

• Check Advance Care Directive or plan

• Continue to record TPR, BP every 10 minutes

• Notify Consumer Representative/ Legal Substitute Decision maker

• Call ambulance for transfer to hospital as per ACD

• Prepare transfer documents

• Notify Consumer Representative/ Legal Substitute Decision maker

Neurovascular Status

A neurovascular assessment is required for each affected limb. If the assessment shows:

• Increase in pain OR

• Decrease in sensation OR

• Decrease in motor function OR

• Decline in perfusion (colour, temperature, capillary refill, swelling, pulses)

• Elevate the effected limb

• Neurovascular assessment- repeat 2 to 4 hourly for 24 hours

• Check observations (including oxygen saturation levels) and repeat 2 to 4 hourly for 24 hours

• Notify the GP

• Notify Consumer Representative/ Legal Substitute Decision maker

Neurovascular Status

A neurovascular assessment is required for each affected limb. If the assessment shows:

• Increase in pain which is disproportionate or new to the injury OR

• Decrease in sensation specifically pins and needles, tingling or numbness OR

• Pallor indicating arterial insufficiencies below the level of injury, appearing cold and pale OR

• Temperature of the skin with coolness of the limb distal to injury indicating decreased arterial supply OR

• Capillary refill more than 3 seconds indicating inadequate limb perfusion OR

• Pulselessness: Absent pulse indicating tissue death OR

• Swelling and increased pressure of the affected limb: presenting as tight and shiny skin and indicating intercompartment pressure.

• Elevate the effected limb

• Give consumer any prescribed regular or prn analgesics

• Call ambulance for hospital transfer per Advance Care Directives

• Call the GP

• Take a photo of the effected limb

• Monitor closely, check observations (TPR, BP, and oxygen saturation levels and neurovascular observations) initially, then every hour until an ambulance arrives or per medical order.

• Prepare transfer documents

• Check Advance Care Directive or plan

• Notify Consumer Representative/ Legal Substitute Decision maker

Mental State Deterioration

Assessing Change

Identifying and tracking change relies on the availability of individual baseline information to which a person’s current mental state can be compared.

Baseline information