Recognising... draft 3 - Portrait

Recognising and Responding to Clinical Deterioration

How to use this guide

1. If this is an emergency, call emergency services immediately by dialling ‘0’ (to get an outside line) on a desk phone, then dialing ‘000’.

2. Click on the most-relevant section below: Acute Deterioration

Breathing difficulties other content goes here and here...

3. For more information, click on the following links: Objectives

Applies to

Definitions

Internal Documents, References & Legislation

Acute Deterioration

Act Immediately

Signs & Symptoms

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.)

Actions - Act Immediately

Circulation

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

2. Check BGL

3. Check Advance Care Directive or plan

4. Notify Consumer Representative/ Legal Substitute Decision maker

5. Call ambulance for hospital transfer per Advance Care Directives

6. Call the GP

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

8. Prepare transfer documents

9. Ensure appropriate staff member with the consumer at all times

Breathing difficulties

Act Promptly

Signs & Symptoms

• Increasing shortness of breath

• Cough

• Unexplained fever or sweats

• Decreased food or fluid intake

• Decrease in usual function or activities

• Increasing confusion

• Fatigue

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

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

3. Notify the GP

4. Notify Consumer Representative/ Legal Substitute Decision maker

5. Monitor food & fluid intake

6. Encourage fluids if not contraindicated

Signs & Symptoms

• 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

1. Sit consumer upright

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

3. Give consumer any prescribed regular or prn puffers or nebulisers

4. Check Advance Care Directive or plan

5. Notify Consumer Representative/ Legal Substitute Decision maker

6. Call ambulance for hospital transfer per Advance Care Directives

7. Call the GP

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

9. Prepare transfer documents

10.Ensure appropriate staff member with the consumer at all times