Observations and the Deteriorating
for Registered Nurses
Shane Moody, Lead for Critical Care Services
Vikki Crickmore, Sister.
Critical Care Outreach Service
September 2013
Competency framework
• Gain awareness of the national approach and
• Discuss observations in detail and physiological
• Consider appropriate escalation response to
deterioration and barriers to this.
• Examine useful communication tools.
• Consider additional elements relevant to patient
care when considering deterioration.
• Carry out a practical assessment of taking
observations and management of case studies.
Competency framework
CCOS to assess Band 7’s
CCOS to do Train the Trainer sessions for senior
Band 7’ and senior nurses to assess own staff
Competency framework
Station 1
Practical taking obs
and documenting
in pairs
Station 2
Case studies &
completing competency
Conclude and finish
Competency framework
2005 – NCEPOD: An Acute problem
2007 – NPSA: Safer care for the acutely ill patent
2007 – NPSA: Recognising & responding appropriately to
early signs of deterioration
Consistent themes are obvious throughout these documents:
• Failure to measure basic observations.
• Lack of recognition of the importance of worsening vital signs
• Delay in response to deteriorating vital signs.
Competency framework
2007 – NICE published - Acutely Ill patients in hospital –
recognition of and response to acute illness in adults
in hospital.
The key priorities of this document are:
• Physiological observations at the time of their admission
• A written monitoring plan (diagnosis, co-morbidities and plan)
• Observations taken by staff that have been trained and
understand clinical relevance.
• A Track and Trigger system and observations recorded 12
hourly as a minimum – increased if signs of deterioration.
Competency framework
Modified Early Warning
Used to aid recognition of deteriorating patients,
and are based on physiological parameters.
An aggregated score calculated. Escalation
pathway activated if specific scores. Track and
Trigger approach.
The escalation pathway outlines actions required
for timely review ensuring appropriate
Competency framework
Applying to practice
• Limitations to MEWS and professional judgment
should be used
• Taking observations is not just generating
numbers – need to understand clinical relevance
• Delegating needs to be appropriate
• Failure to act has significant consequences –
effects on patient, ↑ cardiac arrest, ↑ length of
stay, ↑ ICU admissions.
• Observe patient – not just using machines
• MEWS adapted for paediatrics and obstetrics &
head injury patients
Competency framework
Vital signs to assess
Respiratory rate
Oxygen Saturations
Systolic (BP)
Urine Output
Competency framework
Respiratory rate
• Relevant in a number of compensatory
mechanisms within the body
• Normal rate should be between 12 and 20.
• The most sensitive indicator of potential
deterioration. Rising rates often early sign.
• Using in conjunction with other evidence ie: use
of accessory muscles, increased work of
breathing, able to speak?, exhaustion, colour of
• Position of patient is important.
Competency framework
Blood pumped from
Heart is rich in O2
(95%-99% saturated)
Blood pumped back
to heart is low in O2
Competency framework
Oxygen demand
If oxygen delivery to
the body falls below
what is demanded,
the tissues extract
more oxygen from the
haemoglobin and the
saturation of blood
Competency framework
Oxygen saturations
• All cells are dependent on an adequate constant supply of O2 as
they are unable to store it. A reduction can lead to organ
dysfunction and death.
• Dependent on intact respiratory and cardiovascular function –
limited by other factors ie: peripherally shut down.
• Be aware of patients ‘target saturations’.
• All acutely unwell patients should receive supplementary Oxygen
and then titrate to readings.
• ABG may be required for more in depth assessment.
Competency framework
Heart Rate
• Should be taken manually for one minute,
noting the rate, volume and regularity.
• Felt at brachial artery
• Normal rate can be considered 60100bpm.
• Abnormal findings need investigating
• Abnormalities should be followed with an
• Consider ECG monitoring
Competency framework
Effects on Heart Rate
• Haemorrhage /
• Hypotension
• Sepsis
• Drugs / medications
• Hypoxia
• Temperature
• Injury / Insult
• Electrolytes
Competency framework
Blood pressure = pressure on wall
of artery
Systolic = pumping pressure
Diastolic = resting pressure
Competency framework
Arterial pressure
The pressure in the arteries is carefully
regulated by the body. If it drops,
immediate circulatory changes occur:
► Heart rate increases
► Constriction of vessels (so BP may
remain adequate) - ↓ CRT, ↓ Urine output.
Competency framework
Blood pressure
• A LATE sign of deterioration – patients will
compensate (especially young)
• Adequate BP is essential for delivery of O2 and
nutrients to the rest of the body.
• Be aware of what is normal for patient
• Organs are very dependent on adequate
pressures to ensure perfusion.
• Manual Blood pressure recording may be
Competency framework
Urine output
• Sensitive indicator of hydration status
• Should be 0.5ml/kg/hr
• Due to high demand for blood supply to the
kidneys, urine output is a useful indicator of
cardiovascular status.
• Generally is a poorly recorded observation.
• Monitoring of fluid balance should be
appropriate depending on patient condition.
• Acute Kidney injury - ↓ urine output, ↑ toxic
waste. Needs urgent attention
Competency framework
Level of Consciousness
AVPU or GCS for more in depth assessment.
Consider at what point do you need help?
This should include drowsiness, agitation, new changes.
Assess pupils
Consider reversible causes ie: blood sugar
If only responding to pain or unresponsive – airway is at
risk – 2222 adult emergency.
• Neuro obs
Competency framework
• Can have a significant effect on patients
• High or low can indicate sepsis
• > 38 degrees consider blood cultures
• Significant warming can cause
• Low can be as important as high
Competency framework
O2 needed?
IV access
IV fluids
Escalation status
Competency framework
Who is at risk?
Any one in hospital!!
Those with co-existing disease
All emergency admissions
Elderly people
Specific acute illness (sepsis, pancreatitis)
Those with altered level of consciousness
Major haemorrhage
Competency framework
Causes of deterioration
Hospital acquired infections
Chronic disease process
Failure to manage complications
Unavoidable complications
Palliative / end of life
Competency framework
Chain of safety
Measure observations and Document
Recognise Deterioration
Communicate Appropriately
Respond efficiently & reassess
Competency framework
A tool used to
critical information
succinctly and briefly
Competency framework
Barriers to escalation
Anxious about escalating?
Frequency / exposure to deterioration?
Knowledge and Skills?
Prioritising workload?
Difference of opinion?
Define ‘deterioration’
“To become worse”
(English dictionary, 2013)
Competency framework
Additional elements in relation to
patient care
Individual Accountability
Risk assessment and delegation
Risk assessment
Privacy and dignity
Infection control
Updates on amendments to revised policy
Competency framework
Practical assessment
• Complete action plan for scenarios given
• Discuss rationale for taking observations and
increase/decrease frequency
• Correctly taking a full set of observations
• Correct documentation and calculation of scores using
trust observation charts.
• Demonstrate awareness of escalation procedures.

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