Documentation and Care of The Deteriorating Patient - Nursing Assignment Help

Assignment Task

Assessment of the deteriorating patient

The identification of a deteriorating patient has been poorly managed within the healthcare setting. Usually there are discernible physiological changes which occur prior to adverse events such as cardiac arrest, unexpected admission to the ICU and unexpected death. As this is a stressful situation it is easy to omit essential strategies. Patients can deteriorate rapidly or over a period of several hours. Health professional often miss the signs of deterioration as they fail to systematically assess their patients.
A set of strategies was developed to identify and manage the deteriorating patient. The first step is to assess the patient using the ABCDE algorithm which is a systematic assessment known as the primary survey and can be used with all patients. The clinical signs of critical conditions are similar regardless of the underlying condition. The initial assessment and treatment are performed simultaneously and continuously.  This would also include taking a full set of vital signs and comparing to previous readings. The patient is assessed in the following order
A:  Airway
B:  Breathing
C:  Circulation
D:  Disability 
E:  Exposure
 The approach to all deteriorating or critically ill patients is the same. The underlying principles are:
• Do a complete initial assessment and re-assess regularly.
• Treat life-threatening problems before moving to the next part of the assessment.
• Assess the effects of treatment. 
• Recognise when you will need extra help. Call for appropriate help early.
• Use all members of the team. This enables interventions (e.g. assessment, attaching monitors, intravenous access), to be undertaken simultaneously.
• Communicate effectively - use the Situation, Background, Assessment, Recommendation (SBAR).
• The aim of the initial treatment is to keep the patient alive and achieve some clinical improvement. This will buy time for further treatment and making a diagnosis. 
• Remember – it can take a few minutes for treatments to work, so wait a short while before reassessing the patient after an intervention.
First steps
• Ensure personal safety. Wear apron and gloves as appropriate.
• First look at the patient in general to see if the patient appears unwell.
• If the patient is awake, ask “How are you?”. If the patient appears unconscious or has collapsed, shake him and ask, “Are you alright?” If he responds normally he has a patent airway, is breathing and has brain perfusion. If he speaks only in short sentences, he may have breathing problems. Failure of the patient to respond is a clear marker of critical illness.
• This first rapid ‘Look, Listen and Feel” of the patient should take about 30 s and will often indicate a patient is critically ill and there is a need for urgent help. Ask a colleague to ensure appropriate help is coming.
• If the patient is unconscious, unresponsive, and is not breathing normally (occasional gasps are not normal) start CPR according to the resuscitation guidelines. If you are confident and trained to do so, feel for a pulse to determine if the patient has a respiratory arrest. If there are any doubts about the presence of a pulse start CPR.
• Monitor the vital signs early. Attach a pulse oximeter, ECG monitor, and a non-invasive blood pressure monitor to all critically ill patients, as soon as possible.
• Insert an intravenous cannula as soon as possible. Take bloods for investigation when inserting
Clinical Handover
Clinical handover is an integral part of clinical communication. It needs to be structured and be appropriate for the clinical context in which the handover occurs. Clinical handover is the effective "transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis".
ISBAR is a tool to assist with structuring of the clinical handover and is able to be adapted to suit various clinical situations. The most important information needs to be delivered first and needs to include relevant detailed patient information.
Documentation
Nursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the patient care team to deliver optimal patient care.  It is also a legal requirement of nursing practice and demonstrates accountability for your actions and decisions. Please access the following PowerPoint on clinical documentation.
https://youtu.be/wG9RtOgcy-8
The primary tool for recording information relating to vital signs which assists with the identification of patients at risk is the “Between the Flags” observation chart. This chart was developed by the Australian Commission on Safety and Quality in Healthcare to support the identification of clinical deterioration and prompts actions in response to the observed physiological abnormalities.

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