At-Risk Patient Assessment

Failure to Rescue

the inadequate or delayed response to clinical deterioration in hospitalized patients

The quality of the response to adverse events…

varies widely across institutions

A high quality response is essential to…

halt the potential transition from the initial serious complication to a progressive cascade of adverse occurrences that can lead to death or “failure to rescue”

This tragic ending to a patient’s clinical trajectory is…

not abrupt or wholly unexpected - instead these failures are preceded by a steady accumulation of small clinical clues

System factors

nursing staffing (communication, clinical reasoning, training of nursing staff and skill mix), hospital technology, training

Rapid response system

a set of hospital-wide interventions that attempt to reduce failure to rescue by improving patient monitoring - high quality recording of vital signs, education and mind-set of staff at the bedside to recognize pathological patterns, the reporting/communication of abnormality to the team, timely response and effective interventions

Clinical judgment model

noticing, interpreting, responding, reflecting

Emergency care

HIRAID system - history, identify red flags, assess, intervene, diagnostics, reassessment, communication

History

patient’s presenting problem, symptoms and focused health history

Identify red flags

physiologic signs, critically ill or injured, chronic, contributing problems (HTN, MI, possible stroke, DM, asthma, COPD, and more), detecting deterioration and determining the urgency of treatment

Assess

ABCs, then the area of concern ongoing status and changes - LOC, fall risk, trends, pain, etc.

Intervene

based on above - assess first

Airway

decreased air movement, open airway (injury, asthma attack, etc.)

Breathing

is the patient in respiratory distress? resp. rate, effort and rhythm - how does the patient look? - level of consciousness, try to talk to them (if they can talk they can breather), tachypnea or bradypnea, hypoxia (decreased pulse ox), accessory muscle use, retractions, nasal flaring, grunting, breath sounds, cyanosis (central and/or peripheral), capillary refill (>3 seconds abnormal)

Circulation

are they moving any blood? pulse rate and rhythm, blood pressure - bradycardia, tachy, arrhythmia, BP - extreme rates (dangerously high or low) - cardiac sounds - other areas = peripheral pulses, edema, urine output, some are same as respiratory, visible blood loss

LOC

neuro - pupil size and PERRLA

First, look at the patient and…

identify your patient, degree of distress/injury - how bad are they and how fast to get treatment, safety of the situation, LOC, skin color, reason for seeking care and a focused history

Simultaneously or second

vital signs - pulse, resp, pulse ox, BP (temperature and pain when able)

Next

provide supplement oxygen if needed (intervention) - continue assessing the heart and lungs

Assessment sequence

heart or lungs - either first (pump and O2)

• lungs - vitals, distress or not, sounds, efficiency, etc (apex to base, posterior and anterior)

• heart - vitals, distress sounds, efficiency, etc. (apical pulse, valves - base to apex)

• brain (LOC, neck circ, carotids, jugular, etc.)

• periphery follows - pulses, color, temperature (0 to faint 1+, warm and pink, cold and blue, etc.

• detailed history and other care after the patient is stable and comfortable

Ongoing focused physical exam

assess vitals and ongoing for abnormals and trends

Vital signs

RR, HR, BP, temp, O2 sat

Lungs

crackles, wheezing, diminished or absent BS, stridor - respiratory accessory muscle use

Heart

JVD, murmur, muffled heart sounds, S3, S4

Neurologic

focal neurologic deficits

Mental status

alert, confused, lethargic

Extermities

edema, unilateral leg swelling

Abdomen

hepatomegaly, ascites

Skin

diaphoresis, cyanosis

Oxygenation

cardiac and respiratory system’s work together

Oxygen transportation

amount of O2 into the lungs, blood flow through the lungs and tissues, rate of diffusion and the oxygen-carrying capacity

Ventilation

moving gases into and out of the lungs, oxygen and carbon dioxide, inspiration and expiration with pH, PaCo2 and PaCo2

Perfusion

cardiac and peripheral circulation moves oxygenated blood to the tissues and deoxygenated blood back to the heart and lungs, the transport mechanism

Pulmonary circulation

right ventricle to lungs and pulmonary arterioles, pulmonary capillaries, alveolar capillary membrane, and the exchange of gases, pulmonary venules, pulmonary veins and into the left atrium

Diffusion

exchange of gases in the alveoli of the lungs and the capillaries of the tissues, moving the gases through concentration gradients

Oxygen-carrying capacity

depend on the amount of dissolved O2 in the plasma, the amount of hemoglobin and the ability of the Hgb to bind to oxygen

Carbon dioxide transport

a product of cellular metabolism, diffuses, etc.

Regulation of ventilation

neural and chemical, O2, CO2, pH (H+) concentrations stimulate receptors to regulate rate and depth of ventilation and maintain normal arterial blood gas levels

Circulation with…

oxygenated and de-oxygenated blood

Pumping of 4 chambers

unidirectional - one direction

Stroke volume

volume of blood ejected from the ventricles during systole, influenced by blood volume (lower with dehydration and hemorrhage), lower volume leads to lower stroke volume

Normal stroke volume

50-75 mL per contraction

Cardiac output

amount of blood ejected from the left ventricle each minute - stroke volume x pulse

Normal cardiac output

4-8 liters/minute

Preload

amount of blood in the left ventricle at the end of diastole and before contraction (systole)

Afterload

resistance to the ejection of the blood from the left ventricle

Factors influencing oxygenation

lower O2 capacity (anemia, high altitude environment), lower hypovolemia (blood volume), lower inspired O2 (COPD, asthma), higher metabolic rate, increases O2 demand (exercise, healing, fever, pregnancy), lower chest wall movement (diaphragm not able to fully descend, pregnancy, obesity, skeletal abnormalities, neuromuscular disease, brain and CNS changes, trauma, chronic lung disease)

Factors that alter function

hypoventilation, hyperventilation, hypoxia (COPD, too much O2, anxiety, chemicals), cardiac rhythm, strength of contractions, amount of blood, blood pressure, mechanisms of circulation - conduction, valves, peripheral circ, damage to the muscle, chronic disease, developmental, hydration, nutrition, stress, smoking, medications, substances, environmental, access to care

Causes of hypoxemia

lower oxygen, lower blood capacity to transport O2 or lower perfusion - anemia, high altitude, congenital heart defects in children and adults, trauma, resp. depressing medications and more

Respiratory conditions that can lead to hypoxema

ARDS (acute respiratory distress syndrome), asthma, COPD (chronic obstructive pulmonary disease), interstitial lung disease (conditions that scar the lungs), pneumonia, pneumothorax, pulmonary edema, pulmonary embolism, pulmonary fibrosis, sleep apnea, muscle paralysis

Urgently life threatening

upper airway obstruction (foreign body, angioedema/anaphylaxis, asthma attack), tension pneumothorax, pulmonary embolism, neuromuscular weakness

Respiratory distress signs and symptoms

dyspnea, orthopnea, fatigue and possibly anxious, resp. rate higher then lower, resp. effort higher (use of accessory muscles, intercostal retractions, nasal flaring, tripod position to facilitate breathing, etc.), pulse oximeter readings lower, pulse rate higher then lower, skin changes (color pale to cyanotic, diaphoresis), LOC lower, thoracic expansion may become uneven, auscultate (possible adventitious breath sounds), changes in blood gas results (hypoxia, etc.)

Interventions for respiratory distress

oxygen, monitor closely

Life-threatening causes of chest pain

acute coronary syndromes (MI), aortic dissection, severe asthma attack, pneumothorax, pneumonia, pulmonary embolism, esophageal rupture

Benign causes of chest pain

musculoskeletal (broken ribs, costochondritis, etc.), GI- esophagitis (GERD), respiratory (bronchitis - chest pain secondary to cough, asthma - controlled, brief episode), skin (infection, shingles, etc.), non-specific chest pain common complaint

Chest pain location

central, left or right

Chest pain associated symptoms

SOB, sweating, nausea

Chest pain timing

gradual or sudden onset

Chest pain provocation

what makes worse or better

Chest pain quality

visceral vs somatic

Chest pain radiation

back, neck, arm

Chest pain severity

scale of 1-10

Chest pain history

• PMH - refer to health history form

• meds

• allergies

• social - smoker, alcoholic, cocaine

• family - sudden death, early MI, DVT, PE

Chest pain signs and symptoms

general appearance (distress?), vital signs, heart (muffled? regular? fast?), lungs (equal? wet?), neck (JVD?), abdomen (distention?), LE/DVT (edema? calf tenderness?), anxiety, pain, angina

Chest pain assessment - if cardiac problem suspected

focused history, focused assessment (ABCs), testing (EKG, portable CXR)

Chest pain interventions

follow chest pain protocols - timing is critical, ASA (probably), oxygen, pain meds, nitroglycerin (not with viagra - lowers BP)

Higher bleeding risk

personal or family history of bleeding after surgical procedures, dental procedures, childbirth or trauma, etc.

Medical problems contributing to higher bleeding risk

anemia (low erythrocytes), thrombocytopenia (low platelets), hemophilia (hereditary bleeding disorder), chronic inflammatory disease (ex. Lupus), Hodgkin’s disease, leukemia, septicemia (sepsis, infection), coagulation and/or clotting defects, endocarditis, liver disease, spleen disorders, vitamin K deficiency, nutritional deficiency (B12, folate, iron (anemia))

Medications that increase bleeding risk

some penicillins and cephalosporins, calcium channel blocker, alcohol, warfarin, heparin, thrombolytic agents, NSAIDs, ASA, OTC (vitamin E, ginger)

Bright red bleeding

lots of oxygen, may be new

Darker red to brown/black bleeding

old blood, decreased O2

Local of bleeding

single site of bleeding, usually rapid with minimal coagulation test abnormalities

Hemostatic failure

excessive or persistent bleeding and hemorrhage, multiple site or unusual pattern, abnormal coagulation, platelets number and activity, DIC, hypovolemic shock (with overwhelming hemorrhage)

Platelet disorders

low number or abnormal function - generally have immediate onset of bleeding after trauma - bleeding is predominantly in skin, mucous membranes, nose, GI tract and urinary tract - bleeding may be observed as petechiae (<3mm) or ecchymosis (>3mm)

Coagulation factor disorders

deep bleeding (in the joint spaces, muscles and retroperitoneal spaces) is common - observed on exam as hematomas and hemarthroses

Labs for increased bleeding

complete blood count, PT/PTT

PT/PTT

• PT = prothrombin time

• PTT = partial thromboplastin time

• tests used for measuring the time taken for the blood to clot

Iron-deficiency anemia

lower hemoglobin usually

S&S of mild anemia

asymptomatic at rest, but increased symptoms with activity or exertion

S&S moderate anemia

dyspnea, palpitations, diaphoresis, easily bruising, gum bleeds, chronic fatigue

S&S of severe anemia

pallor (check mucous membranes and conjunctiva), exhaustion, weakness, dizziness, syncope, headache, cardiac complications, orthostatic hypotension, SOB, sensitivity to cold, esp. hands and feet, tingling in extremities, hair loss, brittle nails, decreased immunity, pica

Anemia

causes are varied - assess also = meds, diet, exercise tolerance, malabsorption, areas that may have internal bleeding - cardiac, GI-ulcer, bowels, etc. - infections, cancer, sickle cell anemia, excessive blood loss, etc.

Normal hemoglobin lab

males = 13.2 to 18 g/dL, females = 12 to 16

Normal hematocrit lab

males = 40-54%, females = 36-48%

Normal RBC count lab

males = 4.35 to 5.65 10^6/mcL, females = 3.8 to 5.1

Normal platelet count lab

adults = 150,000 to 400,000/mL

Anemia lab results

lower Hgb <10 g/dL, lower HCT <36%, lower RBCs

Interventions for anemia

iron and diet (with protein and vitamins), rest and lower O2 needs, fall precautions, control bleeding (pressure, monitor, look for contributing factors), transfuse blood and/or platelets if severely diminished and/or S&S are severe

Shock

sudden reduction of O2 and circulatory perfusion

S&S of shock

lower blood volume, lower cardiac output, higher pulse tachycardia - compensation then lower, lower peripheral pulses (blood stays central), lower respirations - dyspnea, lower BPs possible - orthostatic hypotension, lower urinary output, pallor, cyanosis, cool and clammy skin with lower capillary refill, lower temperature, weakness, anxiety, lethargy, proceeds to cardiac insufficiency/arrest, worsening LOC, etc.

Causes of shock

hypovolemic - lower volume with excessive bleeding; cardiogenic - MI, heart failure, obstructive; lower vascular tone - anesthesia, pain, insulin shock, injury, anaphylaxis, infection, burns, etc.

Interventions for shock

vitals - P, R, pulse ox, BP, temp, LOC; monitor - H&H, RBCs, platelets, ABGs, I&O, IVFs, meds, etc.; replace volume with fluids and blood

Wounds

location, size, closure, dressing and REEDA

REEDA

scale for wound/incisional healing and infection - redness, edema, ecchymosis, discharge/drainage, approximation

Petechiae

tiny hemorrhages - typical of platelet disorders, do not blanch with pressure

Purpura

extensive patches of petechiae and ecchymosis (blood leaks from capillaries and diffuses through dermis)

Ecchymosis

blood extravasation into the skin

Bruise

contusion - same color - results from trauma - bleeding beneath intact skin

Erythema

redness in color of the skin - higher blood

Hematoma

blood extravasation into the skin, like ecchymosis, but more like a blood blister or pocket of blood - typical of coagulation factor disorders