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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
