iqmentalhealth.co.uk · Web viewIf temperature drops below 35.C = severe shivering – hypothermia (mild, moderate, severe). As hypothermia becomes more sever ability to shiver decreases

Physical Health Observations Workbook

Pre-Read Material for the

PHO Workshop(Including Case Study Exercise &

Competency Assessment Sheets for Recording PHO)

Please ensure you allow time prior to the workshop to read the enclosed information and to complete the case study exercise.

There will be further exercises throughout the workshop to clarify understanding of the enclosed.

Acknowledgements: Somerset Partnership (2018) Recognition and Response to Patient Deterioration Workshop 2gether (2014) Resource Book: Clinical Skills for NEWS

1 PHO Workbook & Pre-Workshop Pre-Read V.9 June 2019 S. Harding, Lead Practice Development Nurse (Physical Health)

Content Page NumberIntroduction 2Physical Health Observations in Mental Health – Why and When? 3-5Airway & Breathing: Respiration Rate (RR) 6-7Airway & Breathing: Oxygen Saturation (Sp02) 8-9Circulation: Heart Rate (HR) 9-10Circulation: Blood Pressure (BP) 10-15Disability: Temperature 16-18Disability: Level of Consciousness: ACVPU 19NEWS2 (Including Case Studies) 20-25SBAR 26Non-Contact Physical Health Observations 27-28Sepsis 29-30Case Study (Jane) Exercise 31-33Medical Devices – The Basics 34-35Suggested Reading 36Quiz Paper (To be completed during workshop) 37-39Competency Assessment Checklists for Recording PHO 40-53

The purpose of this pack is to provide you with reading material to help refresh / increase you knowledge regarding the following;

• Understand the importance of monitoring and recording physical health observations (PHO) within a mental healthcare setting, including best practice considerations

• Overview of how to undertake the PHO required to complete the National Early Warning Score (NEWS)

• Overview of NEWS, SBAR, Non-Contact Physical Health Observations and Sepsis

Please ensure you allow adequate time prior to the workshop to read the information contained in this pack and to complete the case study exercise. There will be further exercises throughout the workshop to clarify your understanding of the enclosed.

NB: Learners should also have successfully completed the AWP NEWS workbook prior to attending the Physical Health Observations Workshop.

Please bring along a hard copy of this pack to the Workshop

Why Pre-Reading for this Workshop?

There is a lot of information we want to share to help you undertake PHO in accordance with current best practice. By asking you to do some reading about the subject matter before the workshop this will limit the amount of time we take you out of clinical practice. It also allows more time for interactive learning during the workshop.

Also included in this pack are links to further resources that you may wish to access to enhance your knowledge further either prior to or following the workshop.

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If you have any queries prior to the workshop please contact; Sarah Harding, Practice Development Nurse at [email protected] or phone: 07795 953647Why are we required to take Physical Health Observations?

We know people with Serious Mental Illness (SMI) die significantly younger and have poorer physical health compared to the general population.

Mortality rates for those under 75 year olds (pre-mortality) is 3.6 times higher (Quality Health watch, 2015) and individuals with SMI die on average 15-20 years earlier than the general population. This is mostly due to physical health problems which are often not diagnosed or not managed efficiently and lifestyle factors which negatively affect physical health.

Contributory factors:

Medication Side Effects: Medicines play a key role in managing symptoms of mental illness, however adverse effects associated with psychotropic medicines play a contributory role in the poor physical health outcomes in SMI. The adverse effects of medicines include an increased risk of metabolic syndrome (see below), cardiovascular adverse effects, weight gain, sexual dysfunction and poor oral hygiene. Some medications prescribed in psychiatry require very close monitoring due to the potential risks associated with their administration – such as clozapine and drugs used during Rapid Tranquilisation.

Poor Monitoring of Physical Health & Diagnostic Overshadowing: It is well documented that monitoring of physical wellbeing is poor amongst those with SMI. This is largely the result of many service users with SMI not accessing services / this not being easily accessible for them.

Lifestyle and Social Factors: Amongst those with SMI there are higher rates of smoking, substance misuse, obesity, poor dietary choices, and inactivity. These all increase the risk of developing sever & chronic physical health problems such as; type 2 (non-insulin dependent) diabetes, heart disease, stroke, and respiratory disorders. Those with SMI are more likely to be early school leavers leaving with less qualifications and they are more likely to be living in lower income households, in temporary rented accommodation (only 7% of those with SMI are in paid employment). There is also a higher rate of relationship breakdowns, higher risk of physical injury / assault, and social isolation amongst those with SMI.

Smoking:1 in 3 cigarettes smoked in the UK is by someone with long term MH problems. Reasons people with mental health problems smoke include; Self medication, Boredom, Social deprivation, & or Culture in mental health care (befriending tool / to help relieve stress). Those with mental health problems tend to be more highly dependent resulting in higher rates of related comorbidities.

Diabetes:The relationship between diabetes and mental health is complex and mechanisms are not fully understood. People with a range of Mental Health problems are 2-4 times more likely to develop type 2 (non-insulin dependent) diabetes and have worse prognosis. For example; Physical health can be neglected for those with SMI which can lead to poor management and complications. Poor diabetic control may worsen psychosis and visa versa depression may impede self-management.

Drug and alcohol intake: Co-existing alcohol and drug misuse is common in patients presenting with mental health problems. Treatment is most effective when mental health and alcohol and drug problems are part of an integrated care plan. For those with substance misuse issues there are enhanced risks to both

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mental and physical health (i.e. suicidal/self-harming behaviour, or risk of Korsakoffs) or specific alcohol or drug related risks (i.e. overdose or blood borne viruses’).Cardio-Metabolic Syndrome: Is a clustering of medical conditions (listed below). People with SMI, (particularly schizophrenia and depression and, to a lesser extent, those with bipolar disorder), are more likely to be exposed to a combination of different risk factors and have a higher level of metabolic syndrome and co-morbidities than the general population. The physical health conditions making up cardio-metabolic syndrome include:

Obesity (especially abdominal) High blood pressure Raised blood sugars (plasma glucose) Abnormal cholesterol levels

Individually, these health conditions can cause damage, but 3 or more together are particularly dangerous, and increase the risk of serious and life threatening illnesses including diabetes and heart disease, which increases the risk of having a heart attack, stroke, and vascular dementia

Metabolic syndrome is particularly common amongst Asian and African-Caribbean people and women with polycystic ovary syndrome. People with metabolic syndrome have a 3-6 fold increased risk of mortality due to coronary heart disease and a 5-6 fold increased risk of developing T2D (non-insulin dependent).

Many psychotropic medicines, particularly second generation antipsychotics, those on polypharmacy and those that are treatment-naive are at increased risk of developing metabolic syndrome. The majority of people receiving antipsychotic treatment are not monitored for metabolic risk factors. This results in metabolic syndrome being under-diagnosed and undertreated among people with SMI. Fortunately this position is starting to change – largely spired on by the recent use of CQUINS around physical health monitoring and interventions for those with SMI (See below under ‘National Standards’).

Lester Tool: This is a Positive Cardio-metabolic Health Resource – An intervention framework for people experiencing psychosis and schizophrenia. The tool aims to improve collaborative and effective physical health monitoring of service users experiencing SMI. It focuses on antipsychotic medication for adults, but many of the principles can be applied to other psychotropic medicines given to adults with long term mental disorders, e.g. mood stabilisers.

The tool requires the practitioner to screen the following parameters;

Smoking Lifestyle and Life skills Body Mass Index (BMI) Weight Blood Pressure Glucose Regulation (fasting blood glucose, random blood glucose or HbA1c) Blood Lipids

If concerns are identified (service user in the “red zone”) then Interventions are required

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For further information regarding the above refer to: DOH (2016) Improving the physical health of people with mental health problems: Actions for mental health nurses.

When are we required to take Physical Health Observations?Minimum requirement:Inpatients: On admission (baseline) and minimum of weekly throughout duration of admissionCommunity: Encourage engagement in Annual Health Check by the GP Improving physical healthcare to reduce premature mortality in people with Serious Mental Illness (SMI) – based on the Lester Tool http://www.rcpsych.ac.uk/pdf/eversion%20NICE%20Endorsed%20Lester%20UK%20adaptation2%20.pdf

Commencing Psychotropic medication: Physical assessment and monitoring (includes BP and Pulse)NB: Prior to prescribing in AWP service user require measurement of weight, height (to calculate Body Mass Index - BMI), BP, HR and relevant blood tests. In some cases ECG also required.

Under any of the following circumstances;• Restrictive Practices (Rapid Tranquilisation / Restraint / Seclusion)• Falls (Query postural hypotension)• Seizures• The Commencement of new / increased medication (including clozapine and acuphase)• Signs of recent confusion or agitation• Staff, carers or the service user states that they suspect that they may becoming physically

unwell

PHO – What we are recording: • Respiration Rate• Heart Rate• Blood Pressure• Temperature• Oxygen Saturation• Level of Consciousness (AVPU)

All Observations within the inpatient settings should be recorded on the NEWS chart

In the PHO workshop we will cover the following observations;Temperature, Heart Rate, Respiration, Oxygen Saturation, Level of Consciousness and Blood Pressure;

• What they are, the ranges, reasons for concern, • Best practice around use of the medical devices, and how to undertake each observation• Demonstration & opportunity to have a practice

NB: For access to training in venepuncture, blood glucose monitoring, weight and height (BMI), and ECG please contact: Sarah Harding, Practice Development Nurse at [email protected]

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http://www.rcpsych.ac.uk/pdf/eversion%20NICE%20Endorsed%20Lester%20UK%20adaptation2%20.pdf

Respiration Rate (RR)Also known as; pulmonary ventilation rate, ventilation rate, breathing frequency, breathing rate

Respiration: Inspiration and expiration, for oxygenation of the tissues and cells and excretion of carbon dioxide

RR is the number of breaths (chest rise and fall) a person takes within a certain amount of time, normally 1 minute. It can be consciously altered (rate and pattern) so when assessing respiration you can pretend to continue taking the pulse.RR is the most sensitive indicators of deteriorating physiology and must be recorded, but often not completed during Physical Observations. Why? ‘over-reliance’ on technology and inappropriate delegation What is the average respiration rate for a resting adult?Normal values: 12-20 breaths (Some sources: 10-18) per minute (likely to vary for those with COPD – Chronic Obstructive Pulmonary Disease)

• When observing ‘normal breathing pattern’, it should look effortless and the lungs should raise and fall equally on both sides

• Also need to observe depth, rhythm and any signs of breathing difficulties

What can affect RR? • Alcohol, drugs, pain, respiratory conditions• Sleep = lower RR (less 02 demand - same applied to pulse/heart rate),• Shortness of Breath = exertion, anxious, fear upset/crying - temporary – reduces following

rest. NB: If continues - sign that body not getting enough oxygen / unable to effectively circulate or too much carbon dioxide in the body

What presentation would you expect to see in someone struggling to breathe?

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Signs of Breathing Difficulties:

• Use of accessory muscles• Nasal flaring and pursed lips• Abdominal movement • Chest movement – uneven • Physical and Mental Exhaustion • Changes in Mental Status

Abnormal values: Below 8 or above 25 = urgent investigation

If concerned:• While awaiting medical / paramedical support, if trained administer oxygen (non-re-breath

mask) • Position: In order to breathe deeply & ventilate fully, good, upright posture is required -

Sitting breathless people upright allows gravity to help the diaphragm to expand. Sitting forward, with forearms resting on a table and pillow, also helps inter-costal muscles expand

• Inactivity (pain inhibiting) - Encourage 6 deep breaths per hour!

Tachyapnoea: regular, but > 20 bpm (Acute COPD)Brady apnoea: regular, but < 12 bpm (neurological or drugs)Apnoea: absence of respiration for several seconds (will lead to resp arrest)Dyspnoea: difficulty breathing, gasping for airCheyenne-stokes: shallow, very slow & laboured with periods of apnoea – dyingHyperventilation: rapid breathing c/o physical or psychological – such as pain or panic

RR - What we are assessing? Chest rise and fall

• Ideally get the service user to rest 5 minutes prior to undertaking observations• Seated position best (can support with pillow)• Rate (breathing rate over a whole minute)*• Effort• Depth (establish adequate chest rise & fall) Pain = shallow / chest infection• Pattern (irregular breathing may cluster)*• Breath Sound (wheezing, bubbling, snoring, stridor (noisy)• Skin Changes in skin colour / texture (blue or clammy)

– Flushed: possible indication of infection or head injury– Pale: possible indication of shock or anaemia– Grey / ashen: possible indicator of cardiac problems– Cyanosed: indicator of hypoxia – clearest in nail beds, lips and mouth, tip of nose and

earlobes. Dark skin best seen in inner eye lids and lips • Cough reflex – Productive? (Encourage clear fluids / warm drink to ease)• Sputum (production) should be clear• Respiratory problems

Demonstration and Practice will be undertaken during the workshop

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Oxygen Saturation (Sp02)Oxygen saturation – refers to the amount of oxygen being carried in the red blood cells, which load up with oxygen in the lungs and then transport it to the rest of the body. People who have medical conditions, such as lung disease, may not have enough oxygen in their red blood cells.Pulse Oximetry:

• Oxygen saturation can be measured by a device called a pulse oximeter (In AWP these are exclusively for attachment to a finger)

• This is a non-invasive method of estimating peripheral oxygen saturation (SpO2) of haemoglobin in arterial blood

• This is judged from: Colour and Pulse • Absorption of light varies between oxygen-rich and oxygen-poor capillary blood (Saturated

haemoglobin is redder) • With every pulse beat the machine compares light detected in a oxygen-rich capillary, to that

of a oxygen-poor capillary, this is done over 5 beats, and the difference is measured as a percentage (this is why it is not appropriate to use a pulse oximeter to measure someone’s heart rate)

What is the ‘normal’ range for oxygen saturation for a resting adult (using a pulse oximeter)?>95-100% (average 98%)Chronic chests (for example COPD) 88-92%Hypoxia = 90% (Cyanosis does not usually appear until saturations fall below 80%)

NB: In a situation where someone has ligatured, 02 saturations may not be reliable. This is because the ligature has affected oxygen getting to the brain and so capillary oxygen in the finger may not reflect brain oxygen levels. If a tight ligature has been applied around the throat, do full NEWS and treat with oxygen as a precaution. Oxygen can be administered by a registered nurse without prescription in an emergency.

What do you need to considerations before applying the Probe?• Choose a finger free of; nail varnish, false nails, excessive staining / dirt• Well perfused site / adequate pulse• No tremors / movement at site• Protect from outside light• Don’t attach the pulse oximeter to the same limb as that being used to measure blood

pressure

What do you think might lead to an inaccurate reading when using a pulse oximeter?• Dirty skin (for example; excessive nicotine staining)• Nail varnish• Thickened / hardened skin• Tattoos• Very dark pigmented skin• Bright room lighting

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• Poor or reduced circulation• Irregular heart beat• Movement (e.g. shivering or general movement of limb with probe attached)• Removal of the probe by the service user• Recent cigarette (Carbon Monoxide: Carboxyhaemaglobin binds 250 times more readily than

Oxyhaemaglobin potentially resulting in false high reading)• Demonstration & Practice• Calibration & cleaning – refer to section on Medical Devices – the basics!


Heart Rate (HR) AKA Pulse Each pulse is generated when the arteries expand and recoil following each heart beatA Series of pressure waves (expansion and contraction) within the arteries, caused by each heart beat (contractions of the left ventricle). The pulse can be felt (palpated) where an artery is near the surface of the body.Heart rate is strongest in the arteries close to the heart (carotid) and becomes progressively weaker as it passes through the arterial system (radial), disappearing at the capillaries.

What is the average HR for a resting adult?

Normal values: 60-90 bpm (some sources state 55 – 90) at rest in adultsHealthy older adult rate tends to be lower than it would have been in their younger adult year

Abnormal values: Tachycardia > 100 bpm (resting adult) usually attempt to compensate for increased 02 demandMay be caused by; elevated body temperature, exertion, stress/anxiety, medication or heart diseaseBradycardia < 60 bpm (resting adult) May be result of; low body temperature, heart failure, or medication. NB: Fit athletes tend to have a lower than average heart rate.

The three main characteristics you should be assessing when taking a HR manually: Rate (over a full minute) Rhythm (regular or irregular sinus rhythm) Strength / Amplitude (reflects elasticity of the arterial wall)

A strong bounding pulse may indicate that the heart is overcompensating / signs of infection A weak and thready pulse may indicate reduced blood volume and low BP

NB: An ECG should be performed as son as possible on any patient who has a new irregular pulse noted, or any other concerns with their pulse

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Extras: Skin colour: flushed, pale, grey/ashen, and cyanosed?Skin temperature (to touch): cold, warm, clammy?Capillary refill: < 2 seconds

Why should we measure HR manually rather than using a machine?• To pick up any abnormal rhythm and strength/amplitude• While counting the rate should also be assessing the rhythm and strength/amplitude

Where can you palpate a pulse?• Most common place to palpate the pulse is at the wrist, the radial pulse• The 3 main places you need to be able to palpate is the radial, brachial and carotid • If difficulty palpating the radial – then palpate the carotid (neck)• The radial (wrist) normally in line with the thumb • The brachial (crook of the arm) is in line with the little finger


Blood Pressure (BP):

• BP is an evaluation of how well the cardiovascular system is functioning• The main purpose of maintaining BP is to ensure adequate perfusion of organs • Without adequate blood supply organs lose their function due to tissue and cell damage,

resulting in long term chronic conditions

Defining Blood Pressure (BP)• The first number is the systolic pressure = pressure produced when the heart is active• The second number is the diastolic pressure = when the heart is not pumping it is relaxing,

allowing blood to flow in, in preparation for the next pump. It is lower than systolic.

• BP is the pressure exerted by blood on the walls of the blood vessel (artery) when the ventricles are contracting the pressure is at its highest – this is known as systolic pressure. When the ventricles are relaxing, the blood pressure is at its lowest – this is known as diastolic pressure.

• The Systolic pressure refers to the greatest pressure exerted on the artery walls as the heart

contracts. Diastolic pressure refers to the least pressure in the arteries as the heart relaxes.

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What is the healthy range for blood pressure in a resting adult?Range: 100-140 / 60-90 mmHg (Millimetre of Mercury)

BP can fluctuate within this range and still be ‘normal’ Ideally take same time of day – BP rises with waking and then tends to fall off through the day BP is lowest in neonates and increases with age and with weight gain However, age does not significantly affect BP – so old formula of 100 + age can result in

dangerous compliancy Hypotension (low BP) adults with systolic BP < 100/ 60 What might cause lowering of BP?

• Dehydration• May be first indicator of shock• Shock, Myocardial Infarct (Heart Attack) and Haemorrhage are factors that cause a fall in BP

as they reduce cardiac output• Blood flow to tissues may be ineffective leading to damage to major organs

Postural Hypotension: A drop in BP due to change in posture (from sitting to standing or from lying to sitting). The change in position causes temporary reduction in blood flow and therefore shortage of oxygen to the brain. This leads to feelings of faintness and sometimes loss of consciousness. It is more common in older adults (as normal mechanisms for maintaining BP become less efficient). Postural Hypotension should be excluded as a cause post falls, especially in older adults. Advice: Gradual position change – For example, on waking sit on side of bed for couple of minutes before getting up. Ensure adequate hydration and avoid sitting / standing for long periods.

Royal College of Physicians – Procedure for measuring lying ad standing BP (2018) Use a manual BP device if possible Lie down for 5 minutes. Take BP 1 Stand up. Take BP 2 in 1st minute After 3 minutes, take BP 3

A positive result is: A drop in systolic BP of 20mmHg or more A drop to below 90mmHg on standing A drop in diastolic BP of 10mmHg with symptoms

For further information visit rcplondon.ac.uk/falls/bp

What might cause increasing BP?

Hypertension (High BP) maybe acute or chronic > 140/90• Common – 30% of people over 50 years

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• Temporary response to stress, anxiety, fever, physical exertion or stress, white coat effect, caffeine, smoking, full bladder, recent heavy meal

• Chronically increased BP can lead to stroke, heart disease and kidney disease (silent killer). Arteries degrade – risk of rupture

NB: A low BP and high pulse can be an early sign that someone is becoming very sick!

If someone has a very high BP ask them about any chest pain, palpitations, headache & / or visual disturbanceIf someone has an abnormal BP reading, the next step after escalation would be to undertake an ECG

How a Sphygmomanometer works …The sphygmomanometer consists of a; • compression bag (bladder) • enclosed in an unyielding cuff, • and inflating bulb, pump or other device by which the pressure is increased, • a manometer from which the applied pressure is read, • and a control valve to deflate the system.• Most commonly used manual sphygmomanometer is the aneroid sphygmomanometer• Calibration & Cleaning

Rationale for using a Manual BP:• In practice most people use an electronic BP – only if problem will they use manual• Expectation that all registered nurses must know how to take a BP manually• Electronic not always reliable i.e., if very low reading c/o internal bleeding – will come up as

“error” and those in VT (ventricular tachycardia)• Need to use correct cuff size. Incorrect size = incorrect reading

Using a Manual Sphygmomanometer - Potential issues that could lead to inaccurate readings?

The Sphygmomanometer is susceptible to inaccuracies or damage – not always noticed: • Non-zeroed or bent indicators• Cracked face plate• Perished tuber tubing

Systematic error:

Poor concentration, poor hearing• Failure to interpret korotkoff sounds• Terminal digit preference: tendency to record BP ending in ‘5’ or ‘0’(should record to the

nearest ‘2’ mmHG)• Bias: recording what we expect to hear

Korotkoff Sounds:

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When we take a manual BP the sounds we hear that represent a BP reading are called the Korotkoff sounds.

There are 5 phases: we record phase 1 systolic and phase 5 diastolic

• Phase 1: A sharp tapping (record after hearing 2 repetitive tapping sounds)• Phase 2: A swishing or whooshing sound• Phase 3: A thump, softer than the tapping in phase 1• Phase 4: A soft blowing muffled sound that fades (often inaccurately recorded as

diastolic)• Phase 5: Silence

To hear the Korotkoff sounds click on below link and start playing video at 5 minutes.https://www.youtube.com/watch?v=pJoP4eq--Hg

Taking a Blood Pressure

Before you start:• Ensure the devise is clean and fit for purpose• Venue and noise (background) and discourage service user from talking during procedure• Good hand hygiene practice

With the service user;• Ideally get service user to sit/ rest for 5 minutes prior to measuring BP (20 minutes post

smoking) and encourage them to empty bladder prior to procedureSeek consent & explain procedure Service user position: Comfort, Clothing, Legs

• Pillow (leaving arm unsupported may increase the Diastolic BP – Muscle contraction in an unsupported arm can raise ‘D’ by up to 10%) and uncomfortable!

• Clothing (tight) may impair blood flow and affect reading (loose clothing OK) • No legs crossed. If seated – ensure both feet on ground

Heart Height: Raising arm above heart level leads to an underestimation by as much as 10mmHG. The arm should be supported in a horizontal position with the cuff at the level of the heart (slight bent arm)

Arm choice: Because BP measurement is used to assess cardiovascular function, it should ideally be taken on the left arm;

• BP should ideally be measured in both arms with the higher values should be used for subsequent measurements. Expect difference of up to 20%

• If differences in both arms > 20 mmHG for ‘S’ and 10 mmHG for ‘D’ on 3 consecutive occasions consider referral to cardiologist (triple abdominal aneurism)

Cuff choice / sizing: If cuff is the wrong size, it could give a reading that is too high or too low.• To avoid this, the air bladder inside the cuff should fit at least 80% of the arm circumference

but not more than 100%• If the cuff is not big enough and less than 80% of the arm is covered by the air bladder, then

the cuff may not be able to completely close off the blood vessels. In this case, the bladder will inflate too much and the monitor will give a higher reading than it should.

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https://www.youtube.com/watch?v=pJoP4eq--Hg

• If the cuff is too large , and the air bladder in the cuff overlaps (covers more than 100% of the arm), then the cuff will inflate on itself - this means that it will cut off the blood supply too easily and the monitor will give a lower reading than it should.

Locate the pulse (radial / brachial)

Cuff and stethoscope placement:

• Cuff placement: Place cuff 2-3 cm above the crook of the arm with the ‘bladder’ centre over the brachial artery

• Apply cuff evenly and smoothly – ensure centre of the bladder covers the brachial artery• Can having tubing upwards to prevent interference with the stethoscope • Not too tight - You should be able to fit 2 fingers under the cuff• Stethoscope: Don’t tuck the bell/diaphragm under the cuff on place thumb/ fingers over

stethoscope bell (can place too much pressure on the brachial artery, which can affect BP

Practical: taking the BP reading

Palpating the artery (radial or brachial) inflate cuff until pulse can no longer be felt

Deflate

Allow 15-30 seconds for artery to refill prior to re-inflating

Leave cuff in situ and place stethoscope over the brachial artery (do not tuck under cuff)

Inflate app. 20-30 mmHg above palpated systolic BP

Deflate 2 mmHg per second

Systolic BP is measured when a minimum of 2 clear repetitive tapping sounds are heard & diastolic BP is measured at point when the sound can no longer be heard

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Afterwards; Clean devices Record observations (and if required report / respond) Concerns about the reading: Wait at least 5 minutes before attempting to retake a BP. Repeat

3 times & disregard the first reading


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TemperatureTemperature is regulated by the hypothalamus situated within the brain (works as a thermostat) which can cause blood vessels to either vaso-dilate or constrict

A relatively constant temperature is maintained by the process of homeostasis (constant process of heat gain and heat loss)

• To release heat – skin and sweat glands – 60% through head• To retain heat - shivering & goose bumps

NB: Temperature changes can indicate the deterioration or improving state of those with infections

This measurement is especially important in neutropenic patients, and for detecting sepsis

Low temperature is as significant as high temperature

What is the average body temperature of an adult?

Normal Values: 36-37.4 (some sources state 37.2)

NB: Everyone has an internal thermostat and individual ‘normal’ temperature for them. So when assessing for changes please refer to the service users baseline temperature

Factors that may affect body temperature:

• Temperature differs morning and evening (0.5-1.5.C) so record time taken and try to take at same time (if weekly, daily)

• Exercise and eating can increase temperature (and ovulation)• In older people there is increased sensitivity to cold and body temperature generally lower

Body temperature above and below ‘normal’ range affects total body function

Low: Causes decline in metabolic rate and results in decline in all body functions. Sudden decrease can be caused by; exposure to the cold, shock states, alcohol or substance misuse, and maybe present with an infection, esp. with older people or with an overwhelming infection such as sepsis.If temperature drops below 35.C = severe shivering – hypothermia (mild, moderate, severe). As hypothermia becomes more sever ability to shiver decreases.Hypothermic patients should be warmed slowly using blankets

High: Pyrexia (>38.C) sudden rise can be caused by; infection (cold/flu or more serious – agranulocytosis, neutropenia), thyroid problems, drug reactions, gout, allergies, epilepsy, alcohol withdrawal, or head injury.

A temperature above 41.C can cause convulsions and a temperature of 43.C render’s life unsustainable.

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A higher temperature will trigger the body to release adrenaline – making the heart beat faster resulting in a higher heart rate.

Fever: ‘An elevation of body temperature above the normal daily variation’The fever will increase the metabolic rate for the body to fight off the illness and infection and hinder the growth of invading viral or bacterial micro-organisms

• When the hypothalamus resets the thermostat to the temperature above 37.C, the body triggers physiological mechanisms to create more heat by causing the body to start shivering and develop goes bumps on the skin

• Feeling cold and hungry, as the body sends messages that it needs more fuel to fight the infection

• Body also relies on human behaviour to help it control the body temperature - feeling cold and shivering may cause desire to put on extra clothing or bedding to maintain the body temperature

Recording Temperature

In AWP we should be using a Tympanic Thermometer to record temperature.

Tympanic = Ear canal (Infrared light to detect thermal radiation) Tympanic thermometers are small hand-held devices that have a disposable probe that is inserted into the service users’ ear canal. The sensor at the end of the probe records the infrared radiation (IRR) that is omitted by the membrane, as a result of its warmth and converts this into a temperature reading presented on a digital screen. The probe is protected by a disposable cover, which is changed between service users to prevent cross-infection. It is suggested that tympanic thermometers are a more accurate representation of actual body temperature because the tympanic regulation centre in the hypothalamus shares the same artery (carotid) as that of the ear canal.

Using a Tympanic Thermometer - Potential issues that could lead to inaccurate readings; • Check probe not getting dirty / cracked• Avoid ear lying on a pillow (warmer) & ear with hearing aid (remove hearing aid and wait 20

minutes before using thermometer)• Check ear canal reasonably clear of obstacles, excessive ear wax or inflammation (can prevent

the thermometers beam reaching the tympanum)• Need snug fit (ear tug manoeuver – straightens the ear canal)• Incorrect installation of the probe (ear tug manoeuver)• Short time intervals between measurements (2-3 minutes)

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Taking a temperature using a tympanic thermometer Before you start;

• Ensure the devise is clean and fit for purpose (calibration and cleaning – refer to section on Medical Devices – the basics!)

• Good hand hygiene practice

With the service user;• Seek consent and explain procedure• Choose ear• Attach probe cover• Straighten ear canal• Insert tympanic thermometer• Press button – wait for beeps and remove – note reading• Dispose of probe cover• Clean device (2 different wipes)• Clean hands• Record observations (and if required report / respond to any concerns)


Introducing the Non-Contact Thermometer:

These thermometers have been trialled in ECT, PICU and later life wards in Wiltshire during 2016. How it works; infrared thermometer's advantage against a conventional probe thermometer is speed and the fact that it is non-contact; it only measures the surface temperature. Infrared thermometers are easy to use, simply point the instrument at the service users’ temple and read the temperature on the screen.

How to use;

Press the start button (the device switches on) after 2 seconds, the display shows that the device is ready for use

The device always starts in body temperature mode (picture of baby’s face)

Hold thermometer 2-3 cm from temple area (if sweating hold thermometer behind the ear lobe)

Press the Start button briefly

Keep the distance until you hear the measurement completion bleep

Temperature will be displayed on LCD screen

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Level of Consciousness (ACVPU)

What does ACVPU stand for?ACVPU Key:A = alert - the person is awakeC = Confused – New onset or worsening confusion, delirium or any other altered mental stateV = the person is responding to verbal stimuliP = the person responds to painful stimuli. For example; the Trapezius Squeeze (gripping and twisting a portion of the trapezius muscle in the casualty’s shoulder)U = unconscious – the person is completely unresponsive

The ACVPU scale (an acronym from "alert, confused, voice, pain, unresponsive") is a system by which we can measure and record a service users’ responsiveness, indicating their level of consciousness. It is a simplification of the Glasgow Coma Scale.

The ACVPU scale has only four possible outcomes for recording. You should always work from best (A) to worst (U) to avoid unnecessary tests on service users who are clearly conscious. The four possible recordable outcomes are:

• Alert - a fully awake (although not necessarily oriented) person. This person will have spontaneously open eyes, will respond to voice (although may be confused) and will have bodily motor function

• Confused – New onset or worsening confusion, delirium or any other altered mental state. This can be assessed by asking a care giver / close relative / friend a single question about whether the service user is more confused than normal - utilising the Single Question in Delirium (SQiD): “Do you think [name of service user] has been more confused lately?

• Voice - the person makes some kind of response when you talk to them, which could be in any of the three component measures of eyes, voice or motor - e.g. person's eyes open on being asked "Are you OK?". The response could be as little as a grunt, moan, or slight move of a limb when prompted by the voice of the assessor

• Pain - the person makes a response on the application of pain stimulus. A person with some level of consciousness (a fully conscious person would not require a pain stimulus) may respond using their voice, by moving their eyes or through moving part of their body

• Unresponsive - Sometimes seen noted as ‘Unconscious’, this outcome is recorded if the person does not give any eye, voice or motor response to voice or pain

The AVPU scale is not suitable for long-term neurological observation of the person; in this situation, the Glasgow Coma Scale is more appropriate

Demonstration and Practice to be undertaken during the workshop

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http://www.google.co.uk/url?url=http://traffic.haryanapolice.gov.in/response.html&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwithZ-fytXPAhXIK8AKHfGTCJQQwW4IIDAE&usg=AFQjCNH3KSZqWeYebhAojcn7m5tzz2vfuw

The National Early Warning Score (NEWS2)A national tool/guidance used to efficiently identify and respond to service users who present with or develop acute (physical) illness based on data derived from physical observations.

The Original NEWSIntroduced by the Royal College of Physicians in 2012 and implemented throughout AWP in early 2013;

• Undertake six physiological observations. Each observation provides a score between 0 and 3. The aggregate of that score provides the clinician with a single score that dictates how well / unwell the patient it at that moment

• An additional score of 2 will be uplifted to patients who require supplemental oxygen to maintain target oxygen saturations

• Repeated physiological observations allow the clinician to track improvement or deterioration and to trigger an appropriate clinical response if required

Introducing NEWS2The Royal College of Physicians published NEWS2 in December 2017; https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2

NEWS2 IS EXACTLY THE SAME with some amendments in relation to;

• OXYGEN SATURATIONS (SpO2)• ACUTE CONFUSION • REDUCED SIGNIFICANCE OF ISOLATED SCORES OF 3 IN A SINGLE PARAMETER

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https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2

Oxygen Saturation (Sp02) NEWS2 StandardMeasurement of amount of oxygen circulating around the body, measured at the periphery. For most people with a healthy respiratory function this level should be above 96%. What can effect oxygen saturations?

– Moderate to severe Chronic Obstructive Pulmonary Disease (COPD)– Commonly bronchitis or emphysema but also includes lung conditions such as

asbestosis and bronchiectasis – Neuromuscular disorders such as Parkinson’s or Motor Neurone Disease– Morbid obesity

Oxygen saturations for this group can clinically expected to be between 88-92%

The NEWS2 chart has a dedicated section (SpO₂ scale 2) for use in those with hypercapnic respiratory failure (usually due to Chronic Obstructive Pulmonary Disease (COPD)) who have clinically recommended oxygen saturation of 88-92%

The decision to use SpO₂ scale 2 should be made by a doctor and should be recorded in the service users’ progress notes. Criteria for considering SpO₂ scale 2 includes;

Service users who are admitted to AWP already being managed using SpO₂ scale 2

Service users who have a documented history of moderate to severe COPD. If unsure decision makers should consult the patients general practitioner (GP) or a respiratory physician

Service users who consistently generate a score for low oxygen saturation using SpO₂ scale 1, who have medical conditions or contributing factors which the medical team deems to directly impact on their respiratory function. Examples of this may include neuromuscular

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conditions or morbid obesity. Any decisions made in this regard must include consultation with a respiratory physician

In all other circumstances, SpO ₂ scale 1 should be used. For the avoidance of doubt, the SpO ₂ scale not being used should be clearly crossed out across the chart

NEWS2 Sp02 Case Study (Barry)

Barry is a 62 year old male called Barry has been admitted to your ward from an acute NHS trust. He has been managed at the acute trust using SpO2 scale 2 and has a documented history of moderate COPD along with a documented history of hypercapnic respiratory failure. Barry’s oxygen saturations during his initial Physical Health Assessment (NEWS2) are 90% on air. This is reviewed by the Medical Team and a decision is made to continue using SpO2 scale 2 for Barry’s future Physical Health Observations (NEWS2).

Three days post admission Barry appears breathless at rest. The Registered Nurse decides to undertake an assessment and NEWS2 score. His oxygen saturations are found to be 85% on air and his respiratory rate is 22 per minute. All other PHO are within normal ranges.

1) What is Barry’s total NEWS2 score?

The RMN administers 2 litres of oxygen via a nasal cannula as per the Medicine Chart (DPAR) and requests a medical review. Re-assessment 15 minutes later and Barry’s oxygen saturations are now 94% on 2L Oxygen, his RR is now 18 and all other PHO remain normal.

2) What is Barry’s total NEWS2 score now?

Barry’s oxygen delivery is reduced to 1L and his oxygen saturations stabilise at 92%, RR and other PHO remain the same.

3) What is Barry’s score now?

Acute Confusion NEWS2 Standard:NEWS2 has the addition of ‘new confusion’ (which includes disorientation, delirium or any new alterations to mentation) to the AVPU score, which becomes ACVPU (where C represents confusion).

Acutely altered mental state may occur as a consequence of sepsis, hypoxia, hypotension or metabolic disturbance. Such a presentation should always be considered to be ‘new’ until assessed and confirmed to be otherwise.

Sudden Confusion (Delirium) is a state of confusion means not being able to think clearly or quickly, feeling disorientated, and struggling to pay attention, make decisions or remember things (NHS Choices, 2018).

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New-onset or worsening confusion, delirium or any other altered mental state should score a 3 and prompt concern about potentially serious underlying causes and warrants urgent clinical evaluation

Diagnosed chronic confusion at baseline should score ‘0’AWP supports the assessment of new confusion using the Single Question in Delirium (SQiD) tool to identify new-onset of confusion. The criteria for this includes asking a single question directed at carers or care providers asking whether the service user is more confused than normal.

Single Question in Delirium (SQiD): “Do you think [name of patient] has been more confused lately?

NEWS2 ‘Confusion’ Case Study (Mary)

Mary is an inpatient on a later life ward. One morning she does not get up at her normal time and when roused appears not herself. The Registered Nurse performs an assessment and NEWS2. She is scoring on her SpO2 and heart rate and although awake and answering questions appears disorientated to time and place. The Registered Nurse is not familiar with Mary and asks a colleague if this is normal for her? The reply is “no, this is not normal”

Mary scores 3 for “New Confusion” under ACVPUThis score of 3 along with the remaining additional scores means that Mary’s NEWS2 = 6. This prompts an urgent clinical review where it is discovered that Mary has a Urinary Track Infection.

NEWS2 ‘Confusion’ Case Study (Stanley)

Stanley arrives on the ward with an ambulance transport crew where he has come in from his home. He lives independently and has no immediate family. The ambulance crew have never met him before. On initial assessment he seems confused with regards to why he is there and cannot recall the Month or Year.

1) What is Stanley’s NEWS2 score for consciousness?

The medical team assess Stanley and find no physiological cause for his confusion such as infection or metabolic disturbance and blood results appear unremarkable. The medical team consult with Stanley’s GP who confirms that his cognitive function has declined over the last few months and that Stanley had missed a referral appointment with a local memory clinic recently. The medical team update Stanley’s progress notes, NEWS2 chart (variants section), care-plan, and progress to reflect that Stanley’s confusion has been investigated and appears normal for him. He can be scored as ‘0’ on his NEWS2 chart for consciousness in the future.

NEWS2 Clinical Risk

These have changed slightly. Score of 3 in a single parameter has been lowered from medium to low-medium risk with a lower Clinical Response requirement.

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NEWS Clinical Response:

AWP have four different ‘Clinical Responses’ for NEWS2 Triggers;

1) Inpatient service users2) Eating Disorders3) ECT4) Community

Below is the Clinical Response for Inpatients;

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NEWS2 ‘Clinical Response to Score of 3 in a single parameter’ Case Study (Millie)Millie is 19 and is an inpatient on a PICU. During her routine weekly physical health assessment you note that her blood pressure is 81/43. Her baseline is between 100 and 110 systolic and there are no variants noted on the NEWS2 chart. All other PHO are within normal ranges and she appears well.

1) How would you escalate Millie’s care?

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NEWS2 ‘Clinical Response to Score of 3 in a single parameter’ Case Study (Mark)Mark is 52 and is an inpatient on a medium-secure ward. He presents to staff with sudden onset of palpitations, shortness of breath and dizziness. On assessment and NEWS2 scoring, Mark has a heart rate of 158. All other PHO are currently within normal ranges.

2) How would you escalate Mark’s care?

SBAR: To aid practitioners in the prompt and effective communication of clinical concerns the following tool is recommended;

SBARD (Situation, Background, Assessment, Recommendation, Decision):To support clinical handover to medical team

Situation State name, position and location.Service user details, state reason for calling, describe your concerns

Background Any recent relevant events, Reason for admission, significant medical history, medications, investigations / treatments

Assessment Vital signs (physical health observations), clinical impression / concernsRecommendation Be specific, explain what you need, make suggestions, clarify expectations

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Decision Confirm actions to be taken (we have agreed you will … in the meantime we will…)Record what has been agreed in the service users progress notes on RIODo not hesitate to call 999 if the service user is rapidly deteriorating or you have major concerns

Example below;

SBARD (Situation, Background, Assessment, Recommendation, Decision):To support clinical handover to medical team

Situation My name is …I’m phoning from ward …I’m phoning about Mr Smith, a 56 year old with new confusion

Background He was admitted a couple of days ago. Brought in by the police after being found naked in a fountain. Homeless. Has recently arrived from Poland. Has been complaining of feeling generally unwell since admission. Today has been in his room all morning complaining of a sore throat. He has a dry, chesty cough, complaining of feeling cold and shivering.

Assessment I have undertaken his NEWS and the score is 6RR = 22 (score 2)Temperature = 38.2 (score 1)Sp02 = 96% (Scale 1)BP = 125/75HR = 90AVPU = CONFUSED (score 3)Skin feels warm and clammy

Recommendation I am concerned about this patient’s physical health.Please can you review this patient?Please can you advise what I can do before your arrival?

Expectation that all staff (including registered nurses, students & healthcare assistants) responsible for undertaking PHO within the inpatient setting will complete the AWP NEWS Workbook Exercise on how to use the NEWS and SBAR will be undertaken during the workshop

Non-Contact Physical Health Observations:Background:

National Patient Safety Alerts:

• The importance of vital signs during and after restrictive interventions/manual restraint (December 2015)

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• Resources to support safer care of the deteriorating patient (adults and children) July 2016

Need for guidance and a tool to ensure monitoring of physical wellbeing for those whom; • It is not safe to approach the service user,• Approaching the service user would antagonise the situation or,• The service user is resting / sleeping after a prolonged period without rest / sleep*• The service user declines NEWS (PHO) for any reason• To assess pain during end of life care

*Differentiating between unconsciousness and sleep: • Being asleep is not the same as being unconscious. • If someone is asleep we would expect them to occasionally change position while sleeping

and for them to have a “normal” complexion for them.• If you are at all concerned that the service user is not sleeping, and may be unconscious

refer to a senior clinician / evoke full AVPU assessment of consciousness

If it is not possible to undertake a full set of NEWS Physical Health Observations you should still;

• Record Level of consciousness (AVPU*) and if possible Respiration Rate on the NEWS Chart• Note on front of NEWS chart – ‘Non-Contact PHO’• Record your observations on the PHO Non-Contact tool - based on the ABCDE model of

assessment (Airways, Breathing, Circulation, Disability, Exposure). To asses the patient utilise your following senses; eyes, noise and ears!

• Observations falling into the Green category indicate no concern. Observations falling into the Red category require escalation – to the medical team (using SBAR) / Dial (9)999. However, if you get all green responses, but are still not happy, ESCALATE!

• A brief summary and reference to the form being used should be made at the end of the shift within the progress notes on RIO

• NB: Non-contact forms in use should be attached to patients individual NEWS charts and once complete uploaded onto RIO

The Non-Contact tool can be accessed here: http://ourspace/Skills/Nursing/Documents/Non-Contact%20PHO%20Guidance%20and%20Assessment%20Framework.docx

Exercise on how to use the Non-Contact PHO Tool will be undertaken during the workshop

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http://ourspace/Skills/Nursing/Documents/Non-Contact%20PHO%20Guidance%20and%20Assessment%20Framework.docx

http://ourspace/Skills/Nursing/Documents/Non-Contact%20PHO%20Guidance%20and%20Assessment%20Framework.docx

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What is Sepsis?Sepsis is a common and potentially life-threatening condition where the body’s immune system goes into overdrive in response to an infection, setting off a series of reactions that can lead to wide spread inflammation, swelling and blood clotting. This can lead to a significant drop in BP, so blood supply to vital organs – brain, heart, and kidney’s reduces – potentially leading to death or long term disability

Sepsis is recognised as a significant cause of mortality and morbidity in the NHS. 1 in every 2-3 deaths in hospital (most have sepsis on admission)

There are at least 260,000 cases of sepsis in the UK every year. It kills 44,000 people every year in the UK (this is more than bowel, breast and prostate cancer combined). Half could be prevented if sepsis promptly recognised and responded too.

Think! and Ask the Question: “Could it be Sepsis?”

What can cause Sepsis: Sepsis develops when chemicals in the immune system get released into the bloodstream to

fight an infection and causes inflammation throughout the entire body• Usually your immune system keeps an infection limited to one place (localised infection). Your

body produces WBC which travel to the site of infection to destroy the bacteria causing the infection. Series of biological processes occur, such as tissue swelling (inflammation), to help fight the infection and prevent spreading.

• If immune system weak or the infection severe, it can quickly spread through the blood throughout the body

• Results in immune system going into overdrive - the inflammation effects entire body – this can cause more problems than the initial infection – widespread inflammation damages tissue an interferes with blood flow. Interruption in blood flow leads to severe drop in BP, preventing adequate oxygenation to the organs and tissues (Severe Sepsis = Septic Shock)

Sepsis is a serious condition than can initially look like flu, gastroenteritis or a chest infection

Who is vulnerable to developing Sepsis?Everyone is potentially at risk of developing sepsis from a minor infection. You are at higher risk if you belong to one of the following groups;

Vulnerable groups:

Medical condition that weakens immune system, Long term health condition (for example diabetes) Recent surgery Open wounds Indwelling catheter Intravenous access / IV drug user Older adults and the very young Pregnant or childbirth within the past 6 weeks*

*For young children and those under the care of maternity services refer to NICE Guidance 51

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Think Sepsis if your service user;

Is triggering an NEWS (National Early Warning Score)Looks ill (They feel dreadful)

Has any signs of infection (Source may be unknown and fever may not be present)

SEPSIS RED FLAG SIGNS (UK Sepsis Trust)• Slurred Speech• Extreme shivering / muscle pain• Passing no urine (in a day)• Severe breathlessness• “I feel like I might die”• Skin mottled / discoloured

PHO – Signs of Likely Sepsis (Amber):(Are any Amber Flags present?)

RR 21-24 per minute / appears short of breathHR 91-129 per minute, OR new onset dysrhythmia (abnormal heart beat)BP (Systolic) 91-100 mmHgTemperature (tympanic) <36.0C

Also,

Change in mental state / behaviourReduced urine outputSigns of wound, device or skin infection; Redness / swelling, wound breakdown

PHO – Red Flag Sepsis (Is there one red flag present?) Your service user is at risk of death from sepsis if;

RR > 25 per minuteNew need for oxygen to maintain Sp02 >92 (88% in COPD)HR > 130 per minuteBP (Systolic) < 90 mmHg or 40 mmHg below baseline

Also,

New deterioration in AVPU/ConfusionNot passing urineAshen/mottled/cyanosis/non blanching rash

Sepsis NICE guideline (NG51), July 2016

Action if Sepsis Suspected: Depending on level of deterioration (utilise AWP NEWS Chart and AWP Recognition and Response Sepsis Screening and Action Tool to aid decision making)

Contact on-call doctor (Likely Sepsis) stating “Likely Sepsis” or call 999 stating “Provisional diagnosis is Suspected Sepsis” request “Blue Light Transfer ” Ambulance

If trained and available administer emergency oxygen whilst awaiting medical support Treat any ABCDE problems If time allows test urine / swab any wounds for infect and send for urgent testing Inform Next of Kin

If Red Flag Sepsis / Septic Shock aim to get the service user transferred to an acute hospital for IV antibiotics and fluids within an hour to maximise chance of survival

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Case Study (Jane): To be completed prior to attending the workshop

To help consolidate the aforementioned here is a case study with questions for you to complete prior to attending the workshop, where we will run through the answers.

Jane is a 56 year old lady, admitted to acute adult psychiatric ward under Section 2. She had refused to eat and drink for 6 weeks due to fears she is being poisoned with bleach. She had lost 3 stone in the last 3 months. Impression was psychotic depression.

When she was admitted she appeared very dehydrated, and complained of cough with green sputum. She was sent to the local acute hospital where she was treated with IV fluids for dehydration, and had blood tests and a chest X-ray. She returned to the ward one day later on no treatment. Background:

• COPD (Chronic Obstructive Pulmonary Disease) – Sp02 scale 2• Current smoker (60 cigarettes per day)• Borderline Personality Disorder• Self-inflicted burns with widespread scarring

From the history above, which factors put this lady at risk of developing Sepsis?

Assessment:Having returned from the local acute trust on a Friday afternoon, Jane complained of feeling weak and unsteady, and was coughing green sputum. She had eaten some lunch, and was passing normal amounts of urine.

PHO: • RR =22• Sp02 = 93% (Scale 2)• HR = 112• BP = 124/79• Temp = 38.2

What is this ladies total NEWS score?

Does she have any signs of Sepsis (Amber/Red)?

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https://www.google.co.uk/url?url=https://www.dreamstime.com/stock-images-womna-suffering-cold-hispanic-woman-bed-virus-middle-aged-woman-blowing-her-nose-form-sick-lady-bed-image34998044&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjNuvTkoYXQAhXIKMAKHWZvCW44KBDBbggoMAk&usg=AFQjCNHJ4ZpXhiFJorYv5_GU46ZyRfnybQ

Jane was reviewed by the ward medic. On examination she appeared slightly breathless, and looked a little dehydrated. She was alert, but felt tired. Her hands and feet were warm and capillary refill time (CRT) was less than 3 seconds. She complained of cough with green sputum, and had crackles on her chest which suggested a chest infection. The doctor reviewed her blood tests and chest X-ray.The doctor felt Jane had a chest infection, and started oral antibiotics. The doctor made the following plan, which was discussed with the ward team:

• Start antibiotics for chest infection (Co-Amoxiclav 625mg TDS)• Twice daily PHO please over weekend. If BP falls <100sys or HR increasing, or low

temperature please arrange urgent medical review. If signs of sepsis or deterioration she may require admission for IV antibiotics and IV fluids

• Encourage oral fluids

If this lady developed sepsis/ septic shock what symptoms or signs might you expect to see?

On Monday morning, the ward doctor went to review Jane. She had refused to accept PHO for the whole weekend, so none had been recorded on the NEWS chart. No information was handed over except that she had “kept a low profile over the weekend”. When the doctor saw her she appeared very unwell.

Using the principle of Non-Contact Observations, what signs of sepsis could have been monitored over the weekend?

When Jane was reviewed by the doctor on Monday morning, she was lying on her bed vomiting. She verbalised very little, only answering in yes or no answers. Her breathing was rapid and shallow. She appeared pale and clammy with mottled skin on her hands. Her lips were slightly cyanosed and very dry. She had reportedly spent the whole weekend in her room, mobilising and eating very little. She had not passed urine for 18 hours.

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PHO:RR = 30 SP02 = 92% (Scale 2)HR = 140 bpm BP = 105 / 56Temp = 35.9ACVPU = CONFUSED Capillary Refill Time = 4 seconds

What is Jane’s NEWS Score?

Is Sepsis Suspected?

What is the next most appropriate action?

What information would be useful to handover to ambulance crew?

Jane was transferred to the local acute trust via emergency ambulance. She was treated for Septic Shock due to a likely chest infection. She experienced organ failure and required two weeks on Intensive Care Unit.

Evidence suggests that earlier recognition of deteriorating patients can reduce mortality from Sepsis and reduce transfers to Intensive Care Unit.

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Medical Devices – The Basics!

Medical Devices: “Covers all products that are not medicines for use in the diagnosis, treatment or prevention of injury or disease and for contraception.” (Guidance for the use of Medical Devices, AWP 2015)

In relation to the Physical Observation workshop:

Manual, Aneroid Sphygmomanometer (& stethoscope) Electronic Tympanic Thermometer Pulse Oximeter Vital Signs Monitor

*Maintenance:

Clinical Equipment Services (Service Level Agreement (SLA) Provider) covers:

Acceptance Testing (new devices) + AWP requirement to log new items on F2 System + AWP Medical Devices Sticker (blue & silver) + SLA provider asset number and next test due stickers

Calibration (to test for accuracy) Maintenance (If problem send to SLA provider) Advice & Guidance (Avril Stallard, AWP Medical Devices Lead)

*Clinical areas should also record in Medical Devices Log Book (Optional)http://ourspace/ClientServices/MedDevSharps/EquipControllers/Medical%20Devices%20Log%20Book%20-%20OPTIONAL.doc

Calibration: Aneroid Sphygmomanometer – 6 monthly Electronic Tympanic Thermometer – 12 monthly Pulse Oximeter – 12 monthly Vital Signs Monitor – 12 monthly

Asset number on device indicates date last calibrated

The Equipment Controller: Purchase of Medical Devices via AWP Clinic List

http://ourspace/ClientServices/MedDevSharps/Pages/ClinicList.aspx Maintenance & Repair Cleaning & Decontamination Record Keeping (Medical Devices Log Book)

For further information refer to AWP Equipment Controller Reference Guide, (2015) http://ourspace/ClientServices/MedDevSharps/EquipControllers/Medical%20Equipment%20Lead%20Reference%20Guide.docx?d=w825722a8aac04d65b5901fcfee6ea43c

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http://ourspace/ClientServices/MedDevSharps/EquipControllers/Medical%20Equipment%20Lead%20Reference%20Guide.docx?d=w825722a8aac04d65b5901fcfee6ea43c

http://ourspace/ClientServices/MedDevSharps/EquipControllers/Medical%20Equipment%20Lead%20Reference%20Guide.docx?d=w825722a8aac04d65b5901fcfee6ea43c

http://ourspace/ClientServices/MedDevSharps/Pages/ClinicList.aspx

http://ourspace/ClientServices/MedDevSharps/EquipControllers/Medical%20Devices%20Log%20Book%20-%20OPTIONAL.doc

http://ourspace/ClientServices/MedDevSharps/EquipControllers/Medical%20Devices%20Log%20Book%20-%20OPTIONAL.doc

Decontamination: is the process which removes or destroys contamination and thereby prevents micro-organisms or other contaminants reaching a susceptible site in sufficient quantities to initiate infection or any other harmful response. (AWP, 2009)

Before and after each use (if not in regular use – minimum of weekly);

Aneroid Sphygmomanometer:

Wipe the cuff (both sides) with detergent wipe (Clinell)

Stethoscope:

Clean earpieces and chest piece (bell/diaphragm) with detergent wipe (Clinell)

If contaminated with blood, wipe with detergent wipe (Clinell), allow to dry, then use alcohol wipe (Sani-cloth 70)

Tympanic Thermometer:

Dispose of single use probe cover between useClean any soiled parts on handset with detergent wipeOnly clean probe with alcohol wipe (Alcohol 2% Chlorhexidine)

Pulse Oximeter:

Clean outside of device with detergent wipe (Clinell) Only clean inside of pulse oximeter (where finger inserted) with alcohol wipe (Alcohol 2% Chlorhexidine)

Protective Clothing: Disposable gloves and apron to be worn during the decontamination procedure of any soiled medical device (AWP, Universal Precautions policy)

UNDER REVIEW CQC Requirements: The Care Quality Commission (CQC) require all clinical areas to have an accessible medical devices cleaning record which details:

Item of Equipment Weekly cleaning procedure Date Signature

No AWP template. Individual areas should have own (CQC look for each medical device to have own sheet)

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Suggested Reading

Avon & Wiltshire Mental Health Partnership NHS Trust (2018) Care of the Deterirating Patient Procedure. AWP

Avon & Wiltshire Mental Health Partnership NHS Trust (2016) Hand Hygiene Procedure. AWP

Clinicalskills.net online resource to help practitioners put evidence-based best practice into practice. The online tool is produced in the UK and based on NHS practice (most of the contributing authors are practicing in the NHS). The 220 procedural resources (displayed in the format of illustrated step-by-step guidance articles) include many physical procedures such as: Blood pressure, Temperature, Pulse and Respiration

Editors: Collins et al., (2013) The Physical Care of People with Mental Health Problems: A guide for best practice. Sage. London.

Mutsatsa, S (2016) Physical Healthcare and Promotion in Mental Health Nursing. Sage. London.

Nash, M (2014) Physical Health and Well-Being in Mental Health Nursing: Clinical Skills for Practice. Second Edition. Chippenham: Open University Press

Royal College of Physicians. National Early Warning Score (NEWS): Standardising the assessment of acute- illness severity in the NHS. Report of a working party. London: RCP, 2012

Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. London: RCP, 2017

Smith & Roberts (2011) Vital Signs for Nurses: An Introduction to clinical Observations. Wiley-Blackwell. Sussex

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Quiz Paper (To be completed during workshop)

Physical Health Monitoring / Observations:

1. People with Serious Mental Illness (SMI) die in average 15-20 years younger than the general population. What factors could be contributing toward this?

2. When are we required to undertake PHO with our service users?

3. What 6 PHO are we required to record to calculate a National Early Warning Score (NEWS2)?

Respiration Rate (RR)

4. What is the average RR for a resting adult?

5. What else should you be observing when assessing RR?

6. What can affect RR?

7. What presentation are you likely to see if someone is struggling to breathe?

8. What would you do if you were concerned about someone’s breathing?

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Oxygen Saturation (Sp02)

9. What is the normal range for Sp02 for an adult (using a pulse oximeter)?

10. What would you do if you were concerned about the Sp02 percentage recorded on the pulse oximeter?

Heart Rate / Pulse

11. What is the average heart rate for a resting adult?

12. What are the 3 main characteristics you should be assessing when taking a heart rate manually?

13. Why should you measure heart rate manually over a full minute?

14. What can cause the heart rate to rise (tachycardia)?

15. What can cause the heart rate to fall (bradycardia)?

16. What would you do if concerned about a service users pulse?

Temperature:

17. What is the average body temperature of an adult?

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18. What factors may affect body temperature?

Low (Hypothermia) High (Pyrexia)

19. What action should you take if temperature reading is low?

20. What action should you take if temperature reading is high?

Level of Consciousness

21. What does ACVPU stand for?

A:C:V:P:U:

Blood Pressure (BP)

22. What is the healthy range for BP in a resting adult (Systolic and Diastolic)?

23. What might cause low blood pressure (hypotension)?

24. What might cause high blood pressure (hypertension)?

25. What would you do if concerned about a service users BP?

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COMPETENCY Assessment Checklist for Recording Respirations

Name: Date of Assessment:

Name of Assessor: Signature of Assessor:

Outcome: Pass / Referral

Upon successful completion of your assessment of competency please give a copy to your line manager

Skill for Assessment TheoryObtained through reading / training*

PracticalAbility determined through supervised observation

Tick Initial Tick InitialDemonstrate appropriate infection prevention & control measures (including handwashing / cleansing) throughout the procedure as per trust policy

Understand the importance of informed consent and demonstrate obtaining consent prior to examination: Explain procedure to the patient (explain that you are going to take their pulse and respiration rate)

NB: Complete procedure covertly and discretely - It is best to monitor and record respirations immediately after taking the pulse – this will aid in a more accurate recording, as the patient will be unaware that you are observing their respirations (awareness can lead to altered breathing)

For those patients who decline / it is unsafe to undertake contact physical observations (NEWS) refer to Non-contact physical observations

Ensure the patient is comfortable and as relaxed as possible.Remove / adjust any clothing necessary to facilitate the correct recording

Answer any questions within own sphere of competence, refer any questions outside your responsibility to an appropriate

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member of the care team Observe the rise and fall of the chest (inspiration and expiration) this counts as one breath

Note the; pattern of breathing depth of the breathsAny signs of breathing difficulties

Observe the patient throughout, reporting any cause for concern

Count the respirations for a full minute to gain an accurate reading

Before leaving ensure the patient is comfortable

Record the respiration rate clearly and accurately ensuring the date and time are legible. Ensure the NEWS score is clearly documented and accurate on the patients NEWS chart. Recognise and report any measurement which falls outside normal levels

Describe to assessor the normal range for respirations and when / how to report concerns

*Theory can be achieved by reading the Physical Health Observations Pre-Workshop Reading http://ourspace/Skills/Nursing/Documents/Physical%20Health%20Observations%20-%20Pre-Workshop%20Reading.doc and or reading related articles on: ClinicalSkills.net . Practical skills can be learnt / refreshed at the AWP Physical Health Observation workshops

Sarah Harding (Lead PDN) V2 2019. Adapted from AWP Clinical Skills Assessors Resource Pack (2010) and Bradford District Hospital Care Trust Mental Health Competency Workbook (2016)

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http://ourspace/Skills/Nursing/Pages/ClinicalSkillsNet.aspx

http://ourspace/Skills/Nursing/Documents/Physical%20Health%20Observations%20-%20Pre-Workshop%20Reading.doc

COMPETENCY Assessment Checklist for Recording Oxygen Saturation (Sp02)








Understand the importance of informed consent and demonstrate obtaining consent prior to examination: Explain procedure to the patient



Answer any questions within own sphere of competence, refer any questions outside your responsibility to an appropriate member of the care team

Collect the equipment required ensuring electrical equipment is fully charged and working correctly. Ensure it is clean in accordance with trust Infection prevention & control policy

Use the correct technique to obtain an accurate Sp02

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measurement (NEVER record the pulse using the Sp02 device), ensuring you fit any equipment to the patient correctly.

Understand how to use a vital signs monitor. Understand which part of the screen relates to which reading.Observe the patient throughout, reporting any cause for concern to an appropriate member of the care team


Describe and demonstrate how to maintain and clean equipment between patients and when not in use

Record the oxygen saturation rate clearly and accurately ensuring the date and time are legible. Ensure the NEWS score is clearly documented and accurate on the patients NEWS chart. Recognise and report any measurement which falls outside normal levels

Describe to assessor factors that can affect a reading (what do you need to consider before applying the probe and what might lead to inaccurate readings). Also the normal range for oxygen saturation and when / how to report concerns



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COMPETENCY Assessment Checklist for Recording Heart Rate (Pulse)












Manual Heart Rate (Pulse) reading:For convenience and ease, it is usually best to record the radial pulse. This is located in the wrist normally in line with the patients thumb

Demonstrate on assessor that you can also locate the carotid 45

pulse, located to side of the neck

Count the pulse for a full minute: in order to detect any abnormal rhythms

- Rate- Rhythm ( regular or irregular)- Strength (strong/bounding, normal, or weak/thread)


Electric Heart Rate (Pulse) reading: Collect the equipment required ensuring electrical equipment is fully charged and working correctly

Ensure it is clean in accordance with trust Infection prevention & control policy

Understand how to use a vital signs monitor, select appropriate sized cuff. Understand which part of the screen relates to which reading

Use the correct technique to obtain an accurate measurement, ensuring you fit any equipment to the patient correctly. Observe the patient throughout, reporting any cause for concern to an appropriate member of the care team



Record the heart rate (pulse) clearly and accurately ensuring the date and time is legible. Ensure the NEWS score is clearly documented and accurate on the patients NEWS chart. Recognise and report any measurement which falls outside normal levels

Describe to assessor hat the normal range for HR (pulse) is and when / how to report concerns



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COMPETENCY Assessment Checklist for Recording Electronic Blood Pressure







Tick Initial Tick InitialDemonstrate appropriate infection prevention & control measures (including handwashing / cleansing) throughout the procedure as per trust policyUnderstand the importance of informed consent and demonstrate obtaining consent prior to examination: Explain procedure to the patient

For those patients who decline / it is unsafe to undertake contact physical observations (NEWS) refer to Non-contact physical observations Ensure the patient is comfortable and as relaxed as possible.Remove / adjust any clothing necessary to facilitate the correct recordingAnswer any questions within own sphere of competence, refer any questions outside your responsibility to an appropriate member of the care team Collect the equipment required ensuring electrical equipment is fully charged and working correctly. Ensure it is clean in accordance with trust Infection prevention & control policyElectric BP reading:

Collect the equipment required, ensuring electrical equipment is fully charged and working correctly

Ensure equipment is clean in accordance with trust Infection prevention & control policy

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Understand how to use a vital signs monitor Understand which part of the screen relates to which

reading Position the patient’s arm level with the heart,

supported on a flat surface (for example, place a pillow under the arm if seated)

Ensure you select the correct cuff size Ensure the cuff is empty of air (deflate if necessary) Apply the cuff – the centre of the cuff should cover the

brachial artery Once the device has provided a BP reading remove the

cuff from the patient’s arm

Use the correct technique to obtain an accurate measurement, ensuring you fit any equipment to the patient correctly. Observe the patient throughout, reporting any cause for concern to an appropriate member of the care teamBefore leaving ensure the patient is comfortable (if required, assist the patient to replace any removed clothing)Describe and demonstrate how to maintain and clean equipment between patients and when not in useRecord the BP clearly and accurately ensuring the date and time is legible. Ensure the NEWS score is clearly documented and accurate on the patients NEWS chart. Recognise and report any measurement which falls outside normal levelsDescribe to assessor normal ranges for BP and when / how to report concerns when / how to report concerns



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COMPETENCY Assessment Checklist for Recording Manual Blood Pressure







Tick Initial Tick InitialDemonstrate appropriate infection prevention & control measures (including handwashing / cleansing) throughout the procedure as per trust policyUnderstand the importance of informed consent and demonstrate obtaining consent prior to examination: Explain procedure to the patient

For those patients who decline / it is unsafe to undertake contact physical observations (NEWS) refer to Non-contact physical observations Ensure the patient is comfortable and as relaxed as possible.Remove / adjust any clothing necessary to facilitate the correct recordingAnswer any questions within own sphere of competence, refer any questions outside your responsibility to an appropriate member of the care team Collect the equipment required ensuring electrical equipment is fully charged and working correctly. Ensure it is clean in accordance with trust Infection prevention & control policyManual BP reading:Accurately obtain a manual blood pressure using the correct cuff size selection and appropriate use of sphygmomanometer and stethoscope;

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- Position the patient’s arm level with the heart, supported on a flat surface (for example, place a pillow under the arm if seated)

- Ensure you select the correct cuff size- Ensure the cuff is empty of air (deflate if necessary)- Apply the cuff – the centre of the cuff should cover the

brachial artery- Ensure you can see the sphygmomanometer and it is in

line with the patients heart- Palpate the brachial (or radial) pulse and inflate the cuff

until the pulse can no longer be felt (this will give an estimate of the systolic pressure)

- Deflate the cuff and re-inflate 20-30mmHg higher than estimate

- Position the stethoscope over the brachial artery and slowly deflate the cuff at 2mmHg per second

- Note the first beating sound (systolic)- Continue to deflate the cuff – the last sound heard

(diastolic)- Remove the cuff & stethoscope from the patient’s arm

Use the correct technique to obtain an accurate measurement, ensuring you fit any equipment to the patient correctly. Observe the patient throughout, reporting any cause for concern to an appropriate member of the care teamBefore leaving ensure the patient is comfortable (if required, assist the patient to replace any removed clothing)Describe and demonstrate how to maintain and clean equipment between patients and when not in useRecord the BP clearly and accurately ensuring the date and time is legible. Ensure the NEWS score is clearly documented and accurate on the patients NEWS chart. Recognise and report any measurement which falls outside normal levelsDescribe to assessor normal ranges for BP and when / how to report concerns



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COMPETENCY Assessment Checklist for Recording Temperature













Tympanic Temperature Reading:

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Accurately obtain a temperature using a tympanic (ear) thermometer

Choose an ear and ensure you have good access Apply a disposable probe cover to the tympanic thermometerGently place the probe into the ear – ensure a snug fit (demonstrate the ear tug manoeuvre) Measure the temperatureDispose of the probe cover

Non-Contact Thermometer Reading: Only to be completed by those wards that stock this thermometer

Accurately obtain a temperature using a non-contact thermometerPress the start button. After 2 seconds, the display will show device ready for useNB: The device always starts in body temperature mode (picture of a baby’s face)Hold thermometer 2-3 cm from the temple (if patient sweating place thermometer behind the ear lobe)Press the start button Keep thermometer in place until you hear a completion bleepTemperature will display on LCD screen

Use the correct technique to obtain an accurate measurement, ensuring you fit any equipment to the patient correctly. Observe the patient throughout, reporting any cause for concern to an appropriate member of the care team



Record the temperature clearly and accurately ensuring the date and time is legible. Ensure the NEWS score is clearly documented and accurate on the patients NEWS chart. Recognise and report any measurement which falls outside normal levels

Describe to assessor potential issues that could lead to an inaccurate reading. Also the normal range for temperature and when / how to report concerns



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COMPETENCY Assessment Checklist for Recording Level of Consciousness (ACVPU)







Tick Initial Tick InitialDemonstrate appropriate infection prevention & control measures (including handwashing / cleansing) throughout the procedure as per trust policyUnderstand the importance of informed consent and demonstrate obtaining consent prior to examination. NB: For those patients who are not obviously ‘Alert’ explain procedure even though they may be unconscious and unable to verbally consent

For those patients who decline / it is unsafe to undertake contact physical observations (NEWS) refer to Non-contact physical observations Have general understanding of level of consciousness and be able to perform the Alert, Confusion (SQiD), Voice, Pain (Trapezius Squeeze / Sternum Rock), Unresponsive (ACVPU) assessment correctlyBefore leaving ensure the patient is comfortable. NB: If the patient scores A, C, V, P or U ensure a member of staff remains with them and that help is summoned urgentlyRecord the level of consciousness clearly and accurately ensuring the date and time is legible. Ensure the NEWS score is clearly documented and accurate on the patients NEWS chart. Recognise and report any measurement which falls outside normal levelsDescribe to assessor what the normal ranges for Sp02 are and when / how to report concerns

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