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.)
• 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