Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
DO
NO
T WR
ITE IN
THIS
BIN
DIN
G M
AR
GIN
DO
NO
T W
RIT
E IN
TH
IS B
IND
ING
MA
RG
IN
Emergency call if:• Airway Threat• Respiratory or
cardiac arrest• Q-ADDSScore≥8• Any observation in
a purple area (E)• O2 saturation <90%
without response tooxygen
• Seizure >2 minutes• Sedation score of 3
(severe)• You are concerned about
the patient but they do notfittheabovecriteria
AdultDate
Time
Respiratory Rate
(breaths / min)Measure for a
full minute
E ≥35 E3 30–34 32 25–29 21 21–24 1
0 17–20 013–161 9–12 1E ≤8 E Indicate which systolic BP scoring
preference is in use (Usual or Default). If the Usual systolic BP is selected, write the Usual systolic BP in the space provided:
Usual systolic BP: ......................... mmHg Default systolic BP: 120mmHg
Name:
Signature:
Designation: Date:
Target Systolic BP (SMO / Registrar ONLY):
mmHgName:
Signature:
Designation: Date:
O2 Saturation(%)
0 ≥98 095–971 90–94 12 85–89 23 ≤84 3
Oxygen* (L / min or
% delivered)*If on HF / NIV use % delivered
E NRM E3 >11 >50% 32 >5–11 >40–50% 21 2–5 28–40% 10 <2 <28% 0
FM Face mask NP Nasal prongs HFNP HighflowHF Highflow NRM Non re-breather nasal prongsNIV Non invasive RA Room air
Mode Circle the column showing the patient’s Usual / Default / Target systolic BP
HighflowrateinL/min Actual BP 180s 170s 160s 150s 140s 130s 120s 110s 100s 90s 80s
Blood Pressure
(mmHg)
Score systolic BP
≥200 ≥200190s 190s 0 0 1 1 1 2 2 3 3 4 4180s 180s 0 0 0 0 1 1 2 2 3 3 4170s 170s 0 0 0 0 1 1 2 2 3 3 3160s 160s 1 0 0 0 0 0 1 1 2 2 2150s 150s 1 1 0 0 0 0 0 1 1 2 2140s 140s 1 1 1 0 0 0 0 0 1 1 1130s 130s 2 1 1 0 0 0 0 0 0 0 1120s 120s 2 2 1 1 0 0 0 0 0 0 0110s 110s 2 2 2 1 1 0 0 0 0 0 0100s 100s 3 3 2 2 2 1 1 0 0 0 0
90s 90s 3 3 3 2 2 2 2 1 1 0 080s 80s 1 070s 70s60s 60s
Systolic BP score
Heart Rate(beats / min)
E ≥140 E3 130s 3
2 120s 2110s1 100s 1
0
90s
080s70s60s50s
2 40s 2E 30s E
Temperature(°C)
2 ≥39.5 238.5–39.41 38–38.4 1
037.5–37.9
037–37.436.1–36.9
1 35.1–36 12 34.1–35 23 ≤34 3
ConsciousnessIf necessary, wake
patient before scoring
0 Alert 01 Voice 14 New confusion / agitation 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
E Pain EUnresponsive
Modifications in use M
TOTAL Q-ADDS SCORE
Interventions (e.g.‘A’)
Initials
EMERGENCY CALL
(Affixidentificationlabelhere)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
Page 2 of 4 Page 3 of 4
v6.00-09/2016
© S
tate
of Q
ueen
slan
d (Q
ueen
slan
d H
ealth
) 201
6Licensedunder:http://creativecom
mons.org/licenses/by-nc-nd/3.0/au/deed.en
Contact:P
SQIS_C
omms@
health.qld.gov.au
Score Legend0 Score 01 Score 12 Score 23 Score 34 Score 4E Emergency call
EMERGENCY CALL
ÌSW
150d
ÎSW150
Mat.N
o.:10234583
Actions Required for Tertiary and Secondary FacilitiesQ-ADDS
ScoreObservations
(minimumfrequency) Notify Escalate(if no review)
Intra-hospitalEscort
0 8hourly
1–3 4 hourly • Team Leader
4–5 1 hourly• Team Leader• Resident review within
30 minutes
• If no review after30 minutes call Registrar Nurse
6–7 ½ hourly
• Team Leader• Registrar review within
30 minutes
• If no review after 30 minutes,or if concerned, initiateEmergency Call, notifyConsultant and Nurse Manager
Nurse
≥8 or E 10 minutely• Initiate Emergency Call• Registrar to ensureConsultantisnotified
• Registrar to ensure Consultantisnotified Nurse and
MedicalOfficer
Interventions Relating to observations from page 2 or the Pain at Rest Table on page 4If an intervention is administered, record here and note letter in Intervention row on page 2 in appropriate time column
A
B
C
D
E
F
G
TRAINING ONLY
DO
NO
T WR
ITE IN
THIS
BIN
DIN
G M
AR
GIN
Q-A
DD
S
(Affixidentificationlabelhere)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
Queensland Adult Deterioration Detection System (Q-ADDS)
Facility:
Page 1 of 4 Page 4 of 4
Pain and Sedation Assessment(Affixidentificationlabelhere)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
Date
Time
Pain Score at RestSevere 10
987
Moderate 654
Mild 321
None 0Functional Activity Scale (FAS) Score (perform during cough / movement)Activity severely limited by pain CActivity mild to moderately limited by pain BActivity unlimited by pain AInterventions(documentonpage3e.g.‘B’)* If scores conflict, follow the highest score
• Notify team leader• Administer analgesia• Notifymedicalofficertoreviewifnoimprovement
within 30 minutes of administering analgesia
• Administer analgesia• Considerteamleader/medicalofficer
review if no improvement within 60minutes of analgesia
• Consider simpleanalgesia
Sedation Score (for patients receiving potentially sedating medication)Patient must be woken to assess sedation score
Note: DO NOT add the Sedation Score to theQ-ADDSScore.Followactionsbelow.
0123
0 = Awake • Continue to monitor patient’s Q-ADDS, Sedation and Pain Score in accordance withindividual monitoring plan
1 = Mild (easy to rouse, able to keep eyes open for 10 secs)
• Increase monitoring of Q-ADDS, Sedation and Pain score• Recheck Sedation score before administering potentially sedating medication
2 = Moderate (rouseable, but unable to keep eyes open for 10 secs)
• Ensure patient receives oxygen andmonitor oxygen saturation
• Withhold additional sedatingmedication (until medical review)
• Notify team leader
• Notifymedicalofficertoreviewwithin15minutes(remainwithpatientuntilreview)
• Monitor Q-ADDS, Sedation and Pain score(minimum15minutely)
• If concerned, initiate Emergency Response3 = Severe (difficulttorouseorun-rouseable)
• Initiate Emergency Response• Ensure patient receives oxygen and monitor oxygen saturation• Determineneedforreversalagent(naloxone,flumazenil)
Additional ObservationsDate
Time
Height (cm) BowelsPassed urine
Weight (kg)
Other (e.g.urinalysis)
General Instructions» YoumustrecordallobservationsincludingPain,FunctionalActivityScaleandSedationscores(p4)atafrequencyappropriatetothepatient’sclinicalcondition.
» You must calculate a Total Q-ADDS Score for each set of observations and record it in the Total Q-ADDS Score box, evenifthescoreiszero.(RespiratoryRate+O2Saturation+O2FlowRate+BloodPressure+HeartRate+Temperature+Consciousness).
» ATargetsystolicBPcanbedocumentedintheappropriateboxonpage3bythetreatingRegistrarorSMO.TheTargetsystolicBPwillsupersedetheUsualsystolicBP.
» If there is no Target systolic BP the nurse admitting the patient should determine the patient’s Usual systolic BP and recorditintheappropriateboxonpage3.IftheNurseisunabletodeterminethepatient’susualBPtickthe“DefaultsystolicBP:120mmHg”boxonpage3.
» When graphing observations, place a dot (•)intheappropriateboxandjointotheprecedingdot(e.g. ).Forbloodpressure, use the symbols indicated ( ).Youmustwriteanyobservationoutsidetherangeofthegraphasanumber.
Modifications for Patients with Chronic Abnormal Physiology» ModificationscanONLYbemadeonthebasisofchronicabnormalphysiology.Thatis,physiologicalparametersthatareusualforthepatientathome.
» ModificationsmustbeauthorisedbyaSMO/registrar/PHO(orequivalent).» NB:documenttheletter“M”intherowabovetheTotalQ-ADDSScoreonpage2toindicatemodificationsinuse.Diagnosiswhichjustifiesmodification(e.g.chronicobstructive pulmonary disease):
Authorised by (SMO / registrar / PHO):
Doctor’s name (please print):
Designation: Signature:
Date: Time:
Write the acceptable range (will score zero) below:
Respiratory Rate to breaths / min
O2 Saturation to %
O2 Flow Rate to L / min
Heart Rate to beats / min
Scoringnote:forobservationsoutsidethemodifiedrange,reverttotheoriginalscoreonQ-ADDS.For example: if an O2 saturation of 90–94% is tolerated (score of zero), and the O2saturationfallsto89%,itwouldscore2.NB:documenttheletter‘M’intherowabovetheTotalQ-ADDSScoreonpage2toindicatemodificationsinuse.
Temporary Modifications» TemporaryModificationcanonlybemadetoONE of the following - Blood Pressure, Heart Rate or Respiratory Rate» MusthaveexplanationanddetailedmanagementplandocumentedbyMedicalOfficer(MO)inthecasenotes(headed:“TemporaryModificationPlan1,2or3”).
» CautionshouldbeexercisedinprescribingTemporaryModificationsforpatientswithsuspected Sepsis.» TemporarymodificationsmustbeauthorisedbytheSMOaccountableforthepatientorafterconsultationbetweenatleasttwomembersoftheMedicalEmergencyTeam.
» Eachmodificationwilllastamaximumof2hours(1box),sequentialmodificationsarepermittedformaximum6hours(all3boxes)butonly1boxcanbecompletedforeachMOreview(i.e.MUSThaveMOreviewevery2hoursandmodificationprescribedintonextbox).
» ATotalQ-ADDSScoremustbedocumentedatleastevery30minutes.» Documenttheletter“M”intherowabovetheTotalQ-ADDSScoreonpage2toindicatemodificationsinuse.Temporary Modification 1Write the acceptable range (will score zero)
Systolic BP to mmHg
OR (can NOT be modified <80 mmHg)
Heart RateOR
to beats / min
Resp.Rate to breaths / min(can NOT be modified >34 bpm)
Modifying Doctor Name:
Authorising Doctor Name:
Start Date: Time:
Cease Date: Time:
Contact number:
Temporary Modification 2Write the acceptable range (will score zero)
Systolic BP to mmHg
OR (can NOT be modified <80 mmHg)
Heart RateOR
to beats / min
Resp.Rate to breaths / min(can NOT be modified >34 bpm)
Modifying Doctor Name:
Authorising Doctor Name:
Start Date: Time:
Cease Date: Time:
Contact number:
Temporary Modification 3Write the acceptable range (will score zero)
Systolic BP to mmHg
OR (can NOT be modified <80 mmHg)
Heart RateOR
to beats / min
Resp.Rate to breaths / min(can NOT be modified >34 bpm)
Modifying Doctor Name:
Authorising Doctor Name:
Start Date: Time:
Cease Date: Time:
Contact number:
TER
TIAR
Y AN
D S
EC
ON
DA
RY
For tertiary and secondary facilities
• If the patient reports any level of chest pain,please follow local chest pain procedure
• If you are concerned about the patient’s painbuttheydonotfitthebelowcriterianotifyMedicalOfficer
• If documenting pain and sedation on a PCA/Epidural Monitoring form, this section does not need to be completed
TRAINING ONLY