It is essential to be able to identify the deteriorating patient, as unrecognised deterioration can result in a preventable cardiac arrest, a preventable admission to ICU, or even an unnecessary death. It is important to consider who is at risk of deterioration so that you can monitor them closely.

• The elderly

• The young (who hide acute illness until the very last minute)

• The immunosuppressed patient

• Patients with an infection (sepsis)

• Post - operative patients

• Patients with an epidural or PCA

• Patients with pre-existing health problems (e.g. asthma, angina, renal impairment)

The above list provides examples of those patients who may deteriorate, but in truth any patient is vulnerable. Every patient needs regular and comprehensive monitoring. Clinical observations may reveal signs of instability, which must be stabilised, and accumulatively provide us with clues to the possible causes of deterioration.

Once deterioration has been recognised, patients are assessed and managed using the ABCDE approach. It is a simple and effective way to improve care and outcome, and it stands for:

This process leads the nurse or doctor through a comprehensive clinical assessment which ensures that life threatening problems are rapidly identified and effectively managed.

This method ensures that these are done in a specific order, a life-saving order so that any problems with the airway are managed before breathing, circulation, disability, and exposure. It is a systematic, universal approach and it forms a common language to help structure communication. You will find nurses and doctors speaking in these terms so become familiar with this simple checklist.

The initial view of the patient as you approach them and introduce yourself can be enlightening. It gives an overview of the patient's general condition. If the patient is sat upright with eyes open, and is able to respond appropriately without pausing to breathe in mid sentence you know that - the airway is patent, they are not in severe respiratory distress, and they are perfusing their brain.

A full assessment using the ABCDE method must now be undertaken as this is more in-depth and requires the use of sight, sound and touch – known universally as the look, listen, feel and treat approach. Initially these assessment skills are underdeveloped but as you become more practised they will become stronger, enabling the experienced practitioner to undertake a detailed ABCDE assessment very quickly.

The airway is a hollow passage carrying airflow to the areas which can exchange oxygen and carbon dioxide in the lungs. The airway is approximately 200mls of redundant space, which means that other than carrying air it has no absorbent properties. This means that it has to remain clear at all times, and any degree of obstruction is dangerous. Obstruction can be incomplete or partial to a total, complete loss of patency. They can be corrected with appropriate care, but can be made worse through inappropriate care or even lack of attention.

The common perception is that the most manageable part of the airway is the upper airway which lies between the mouth/nose and the pharynx. Whilst this is true to some extent, it is important to remember that the airway stretches down through the larynx, trachea and bronchus to the alveoli and the lower airway can also be managed.

Look

Look for condensation in the mask. It will appear as though the mask is steaming up and this is a good sign of air flow.

Look inside the mouth to see if anything is causing an obstruction. If there is mouth soiling, such as vomit, assume that the patient has aspirated. It would be dangerous to perform a blind mouth sweep in case the obstruction is worsened, but if it is safe to do so you may remove any solid foreign body visible in the mouth.

Look for evidence of 'see saw' breathing pattern also known as paradoxical breathing. In normal breathing the abdomen and the chest move in the same direction during inspiration (outwards) and expiration (inwards). If the airway is obstructed the abdomen and chest move in different directions so on inspiration the abdomen moves inward as the chest moves outward and for expiration the reverse pattern is seen.

Listen

The first assessment is speech – if the patient can speak clearly the airway is patent. It can also be identified in other ways, such as the baby who cries at delivery or the patient who shouts out for assistance. However, other noises can be heard in clinical practice, which call for urgent action. Their sound often pinpoints the part of the airway causing concern, and thereby directing correct action.

Listen for snoring the most recognisable noise – it happens in everyday life when people are sleeping as it is a sign of deep unconsciousness. The noise occurs when air intermittently passes over and behind the collapsed tongue, which under normal circumstances is held in place by muscles attached to the floor of the mouth. The brain regulates and controls these muscles but when the person becomes unconscious, for whatever reason, the tongue falls back against the pharynx causing life threatening obstruction.

Listen for gurgling, the noise made when air is flowing back and forth over fluid. This is usually sputum, but it can also be fluid such as vomit, which can submerge the lungs or irritate them causing aspiration pneumonia. The noise can occur along the length of the airway – in the upper airway they sound like gurgles, and can be removed with a Yankeur Sucker (Image 1), but they can also be heard on auscultation in the lower respiratory tract, using a stethoscope. Patients who retain secretions can become tired and at some point will deteriorate rapidly. The conscious patient needs to be re-positioned in a semi-upright position, given plenty of humidification and encouraged to take some deep breathes as the stimulus for coughing. You need to promote effective coughing but this may be difficult as it relies upon muscle strength and compliance. If the patient has a weak cough, or is unconscious the doctor must be alerted urgently.

Image 1.

Stridor is an inspiratory noise which comes from air flowing through the swollen, narrowed larynx. It can be caused by viral or bacterial infection, anaphylaxis or thick sputum, and so the problem needs to be resolved whilst the patient is supported through with oxygen.

Wheeze is another common but concerning noise. It is usually heard on expiration and is caused by conditions such as asthma or pulmonary oedema. This signifies narrowing of the tracheobronchial tree through either bronchospasm or becoming flooded with fluid, which is managed in different ways. A wheeze arising from bronchospasm, (the uncontrolled tightening of the bronchus) should be managed by bronchodilator nebulisers.

Finally, there is silence. This is a sign of complete obstruction and goes hand in hand with seesaw breathing, and is an imminent sign of respiratory arrest. This is a medical emergency.

Feel

The only recommendation is to feel for airflow by placing your cheek or hand gently over the mouth. This works on the same principle as an oxygen mask which has condensation from breath – you can feel the airflow and occasionally the moisture from each breath.

Treat

Treat any problems you find with airway as you go along. Open the airway using head tilt chin lift. If there are secretions in the oropharynx use the Yankeur Sucker to remove them. If the patient cannot maintain their own airway without you applying head tilt chin lift then insert an oropharyngeal (Image 2) or nasopharyngeal airway (Image 3). Always apply 100% oxygen at A (Airway).

It is important that you have successfully managed the airway before moving onto focus upon breathing, otherwise whatever you do will be futile regardless of the correct treatment.

At a very basic level breathing describes the essential exchange of oxygen and carbon dioxide. This is described as external respiration as it is the point when the atmosphere meets the circulation, at the interface known as the alveolar-capillary membrane. The effectiveness relies upon two working systems, the expansion of the alveoli and the flow of the blood around the lungs, the pulmonary vasculature. In practice, this is known as the V:Q ratio (V for Ventilation and Q for Perfusion) and when assessing a patient it is interesting to consider which side of this equation is being adversely affected as this will help to make sense of the deterioration.

Look

Look for the patients' respiratory rate as this has been recognised as the most sensitive and early marker of deterioration. Breaths must, therefore, be counted accurately with every set of clinical observations. The usual rate is 12-18 respirations per minute.

Look at the patient's respiratory pattern as this should normally be symmetrical, effortless, and regular with a medium depth. This must be assessed as patterns can become erratic and shallow.

Watch the patient's respiratory effort. Does it look as though the patient is working really hard – are they using their accessory muscles, the muscles in the neck and chest (sternocleidomastoids and pectoral), and those in the space between each rib (intercostals). This patient will tire quickly needs a close eye keeping upon them – increase the time between each set of clinical observations. Monitor the oxygen saturations (SpO²) using a pulse oximeter.

It is important to record the oxygen saturations accurately and compare this with the amount of oxygen the patient is receiving. This is known as the oxygen demand and it is important to think about the impact of these recordings - are the patient's needs climbing or reducing?

The deteriorating patient requires optimal oxygenation, and this is given at 15 L/min via a reservoir bag, offering as close to 100% as possible.

High flow oxygen and the patient with COPD

Nurses and doctors are often reluctant to give COPD patients high concentrations of oxygen in case they are carbon dioxide retainers. Carbon dioxide is our normal stimulus to breathe. If CO₂ rises we breathe more rapidly. However in a small minority of COPD patients who have high CO₂ levels all the time this no longer works and the body then uses a low oxygen level as the stimulus to breathe. If these patients have high concentrations of oxygen they may loose their stimulus to breathe and their respiratory rate will drop and their carbon dioxide levels will rise. However in the acute situation it is regarded as safe practice to give high flow oxygen to all patients initially whilst you summon medical help in order to protect the patient from becoming hypoxic. Hypoxia is more dangerous than high carbon dioxide levels and will cause patients to have a cardiac arrest if severe or prolonged.

Listen

The patient's speech needs to be further analysed. This time it isn't just the presence of speech but how fluent the sentences are. Normally, speech is continuous with subtle breaths at appropriate times. Consider your own speech and you will realise that normal breathing aids this practised activity.

A patient who is suffering respiratory distress will experience an uncontrolled deterioration in their speech. An involuntary need to breathe will interrupt the sentence, and with some perceivable difficulty they will continue the sentence after the breath has finished.

This patient needs close and vigilant monitoring. Subsequently the next deterioration may be short sentences, just two or three words and finally they are unable to speak. The airway is patent but the patient has no amount of energy, or breath left to create speech. Consider this an emergency as it is a sign of imminent respiratory arrest.

Feel

The patient's breathing pattern can be confirmed by placing hands on the chest, one on each side and checking for symmetry and regularity.

The tissues require a constant supply of oxygen. This is delivered via the cardiac output - the amount of blood pumped by the left ventricle in a minute (4 - 7 Litres / min). Cardiac output is determined by the heart rate and the stroke volume (amount of blood ejected by the left ventricle each beat). Stroke volume is affected by the total blood volume, the pumping ability of the heart, and the tone of the blood vessels. These terms describe preload, contractility and afterload. Cardiovascular instability can be life threatening so assessment is essential.

Look

Monitor the blood pressure as this is crucial to blood flow but remains a late sign as the body employs several compensation techniques to preserve the volume within the circulation. These are thirst, common to everyone but diminished in the elderly, Antidiuretic hormone and the renin-angiotensin-aldosterone pathway. It is not essential to know about these in detail, but just be aware that the body is remarkable at compensating for poor perfusion to the tissues and organs resulting from blood loss, poor cardiac contractility or vasodilation of the blood vessels. For example in a bleeding patient blood pressure does not start to drop until the volume is diminished by approximately a quarter, which in real terms means that we are behind the race to achieve stability, so it must be corrected promptly. In addition, relate this to the individual so try and establish their normal blood pressure, as patients become hypotensive at different levels and not when the systolic blood pressure becomes as low as 100mmHG, as everyone assumes. The Dynamap is commonly used on the wards and gives accurate electronic readings – in the event of hypotension, check both arms as there can be a discrepancy.

There are three variables to blood pressure:

1. Systolic blood pressure (SBP) is the pumping pressure of the heart felt within the blood vessels.

2. Diastolic blood pressure (DBP) is the resting pressure within the blood vessels when the heart is not pumping.

3. Mean arterial pressure (MAP). This is the average pressure in the blood vessels and is an indicator of how effectively each organ is perfused, such as the kidneys.

Watch the urine output vigilantly as the incidence of acute renal dysfunction in hypotensive patients is often avoidable in many instances. The kidneys need to have a good blood flow to ensure adequate pressure within the glomerulus, the filter of the kidney. The kidneys demand ~25% of cardiac output, regardless of the body's activity. The MAP demonstrates the efficiency of this flow, as the kidneys require a minimum MAP of 70mmHg. In fact the MAP required is often higher as the arteries become less flexible with age.

The urine output should be watched hourly in the acutely ill patient, and even in the interim time. The gold standard relates to body weight. Ascertain the individual's weight and halve this to gain the minimum hourly urine output – if the patient weighs 80kgs, the urine output should be a minimum of 40mls/hour. This works on the principle that individuals are different. However, in clinical practice nurses and doctors work on the bare minimum standard of 30mls/hr regardless of individual weight. Ensure the kidneys are not poisoned by the drugs you are giving and check the catheter regularly for signs of obstruction as this can cause back pressure to the kidneys and also lead to false conclusions and treatment. If you are unsure flush the catheter according to local policy. Maintain hourly measurements until the danger passes and record accurately on the fluid balance chart.

Feel

Feel for the pulse at the commonest sites. This is usually the radial pulse; however with any signs of cardiovascular instability, always check the central pulse at the carotid artery. Abnormalities can come in the form of rate, rhythm and strength, and it is always worth requesting an ECG.

The heart rate should be between 60-100 bpm and is described as sinus rhythm. The pulse should be felt at the common sites, radial, brachial, femoral or carotid, and should always be felt as a firm and regular pulsatile flow. A bradycardia below 60bpm also requires monitoring and intervention, particularly if it is a new symptom as this could be a sign of heart block. Tell the doctor immediately. On the other hand the patient may be on digoxin which is over effective. A tachycardia rate above 100bpm is also a concern

The risk of myocardial ischaemia is one of many reasons why oxygen should be given to these acutely ill patients. The nature of the pulse could vary from weak and thready showing poor flow, to a bounding feeling demonstrating an uncontrolled torrent of flow, which is unsustainable. This is a worrying sign as it could be a symptom of sepsis.

Check the capillary refill time (CRT). This is a method of checking peripheral circulation because any delay demonstrates that the circulation is insufficient to reach the peripheries effectively. Lift the finger or toe above the level of the heart and firmly press on the nail bed for 5 seconds. This occludes the circulation and now you are watching to see how quickly it returns, release and count. The pink colour should return within 2 seconds; any delay causes concern. Clearly the greater the time, the worse the patient is and they will be peripherally shutdown – this means the circulation has been preserved centrally to protect vital organs. Be careful though because hypothermic patients or those with peripheral vascular disease can give false readings.

Finally in this sequence, feel the peripheral temperature of the limb as this will confirm the patient's peripheral circulation. Feeling fingers, then hand, wrist and forearm and judge where you think the patient becomes cool or cold.

This is noted and commented upon alongside the core temperature which is an important sign.

The patient may need new peripheral access if their current cannula is too small or isn't patent. Ideally a large cannula either Orange or Grey are best for giving large volumes of fluid quickly. Insertion of a large cannula in an acutely ill patient is difficult and in reality a green cannula will suffice. A full set of bloods should be taken, including Full Profile (FP). This incorporates U&E and LFT which measure kidney and liver function. Full Blood Count (FBC), and Clotting Screen (CLS).

If a patient has a suspected infection or sepsis it is a good idea to also take blood cultures and a lactate sample. These need to be sent urgently so the results are given priority over other routine tests.

As this treatment becomes effective the patient's observations should improve so you should see the tachycardia settle, the systolic BP, capillary refill time and urine output should improve and the peripheries become warmer. This makes sense as the patient's circulation is now more effective. But be careful, because the patient may be tachycardic, hypotensive and oliguric but warm, even hot, and when you feel the pulse it is bounding, a thudding feeling. These signs can be seen in patients with severe sepsis.

The brain needs normal levels of oxygen, carbon dioxide and an adequate blood pressure to work effectively. It is important at this stage to pause and reconsider the effective management of ABC before looking specifically at D.

The nurse must monitor the conscious level in the form of A(C)VPU. This determines whether the patient opens their eyes spontaneously, to voice, with painful stimuli or remains unresponsive. The tool also allows us to assess if the patient is newly confused. The patient who responds to painful stimuli, or worse is a severe concern as the patient is deeply unconscious and will be unable to protect their airway, and may suffocate or inhale any vomit. This must be referred to doctors immediately, and a formal assessment using the more advanced scale, the Glasgow Coma Scale (GCS) should be undertaken. This awards points for eye, verbal and physical (motor) reactions and can earn as little as 3 out of 15 and a maximum of 15 out of 15. Scores below 9 are a major concern, as well as any patients whose score falls quickly by 2 points. These patients need an urgent CT head scan.

Check the pupils for regularity of size, shape and reaction. They must be recorded accurately and abnormalities reported.

Finally, check the blood glucose (BG) level as this is the energy source of the brain, but it is unable to store it so the brain has to rely on a passing circulation. Hypoglycaemia is a dangerous state and must be identified and managed quickly. Record a BG reading and if the level falls below 3mmols/L a bolus of 25-50 mls of Glucose 50% should be prescribed and given promptly.

The final assessment is an opportunity to review any aspect of the patient or their care which may be contributing to the deterioration. Look at the patient from head to toe for clues to the cause of the deterioration - eg rashes, swellings, cellulitis, bruising, wounds, bleeding into drains or the bed, melaena etc.

Please watch this film made with Sheffield Teaching Hosptials Foundtaion Trust which demonstrates a comprehensive ABCDE assessment and escalation.

Example of Nursing Management Plan

• Support the medical management plan

• Devise a monitoring schedule

• Give oxygen as required

• Fluid replacement via a controlled infusion through a pump

• Try to arrange for an experienced member of staff to care for patient or directly overview care.

• Position the patient close to the nurses' station for easy visual observation

• Is the patient in the right location, on the ward as a level 1 patient, or are they level 2 whose needs should be met within a High Dependency Unit?

Example of a Medical Management Plan

• Continue Oxygen at ......

• Continue Fluids at ......

• Contact me on bleep ..... if the oxygen saturations fall below 94%, SBP falls below ...... or the urine output falls below ......

• I will ask my colleague to review in an hour

• I will inform my seniors about this episode