Acute deterioration is an evolving, predictable and symptomatic process of worsening physiology towards critical illness (Lavoie et al., 2014). It poses an immediate threat to the vital systems. Critical illness is the point in which immediate threat to life becomes imminent unless condition is addressed as soon as possible (eg. anaphylaxis). Unfortunately, acute deterioration often goes unrecognised, is misinterpreted, or not dealt with in a timely manner. Delaying care in the acute deterioration phase may result in mortality.
Nurses are responsible in preventing, identifying and managing acute deterioration. This reduces morbidity and mortality, as well as the need for intensive care.
Prevent – Identify – Address
Prevent Acute Deterioration
To prevent acute deterioration, nursing care should include:
- respiratory care
- proper nutrition and hydration
- mobility
- skin protection
- protection against pathogens
- thermal regulation
Identify Acute Deterioration
Identifying acute deterioration should include:
- monitoring of the ABCDEF for development of life-threatening conditions
- monitoring of the EWS for identification for deterioration in physiological measurements
Address Acute Deterioration
- Address life-threatening problems in a timely manner]
- Address clinical priorities
- Ask for assistance
- Prepare for escalation of care
On Admission: Physiological Measurements
Airway & Breathing = monitor Respiratory Rate & SP02
Circulation = monitor Pulse Rate & Blood Pressure
Disability = monitor AVPU (Level of Response)
Exposure = monitor Temperature
Following admission, continue monitoring at least every 12 hours unless when comparing readings, deterioration is suspected; in that case, monitoring frequency should be escalated...
EWS 1-4 = increase clinical nursing care and discuss patient condition with Charge Nurse or senior colleague.
EWS 5-6, or EWS 3 in one parameter = evaluate adequacy of monitoring facilities and FY (junior doctor) or BST (basic specialist trainee)
EWS 7 or more = evaluate need for continuous monitoring and high-dependency or intensive care and BST (basic specialist trainee) or HST (higher specialist trainee)
7 Steps to Managing Acute Deterioration
- Address immediate life-threatening problems
- Ask for additional help
- Gather more information – Main complaint? Current treatment? Vital signs charts? Treatment charts? Medical notes?
- Position the patient appropriately
- Consider oxygen administration
- Prepare additional equipment
- Give a comprehensive report
Oxygen
- Target range of SPO2 in the average person is 94%-98%
- An SPO2 of 92% in the elderly (>70 years old) is acceptable
- An SPO2 of 88%-92% is acceptable in patients with COPD, long term smokers or with a history of breathlessness on minor exertion
Before administering oxygen think…
Can you note clinical signs of hypoxia or shock?
Is the patient’s SPO2 within the target range?
Is the patient at risk of hypercapnic failure?
High Concentration Oxygen (the closest possible to 100%) = Non-Rebreather Mask 12-15lpm
Medium Concentration Oxygen (40%-60%) = Normal Mask 4-6lpm
Low Concentration Oxygen (24%-28%) = Nasal Cannula 2-4lpm (if patient is at risk of hypercapnic failure use a Venturi Mask with flow as per manufacturer’s instructions)
When the patient’s SPO2 returns within normal range…
Administer a lower concentration of Oxygen; monitor SPO2 & patient’s condition until further assessment by physician.
Additional Equipment Required
- IV access + Infusion
- Blood investigations
- Treatment to be administered
- Resuscitation equipment
ISBAR Handover
ISBAR is a mnemonic created to improve safety in the transfer of critical information. ISBAR stands for Identify, Situation, Background, Assessment and Recommendation…
Further Information on Oxygen Therapy
BTS Guideline for Oxygen Use in Adults in Healthcare and Emergency Settings: https://thorax.bmj.com/content/72/Suppl_1/ii1
Emergency Treatment of Anaphylaxis: https://www.resus.org.uk/sites/default/files/2021-05/Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf
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Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
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