Care of The Acutely Unwell Final

Course Manual
CARE OF THE ACUTELY UNWELL PATIENT

CARE OF THE ACUTELY UNWELL PATIENT / ADULT
STEP 1 ASSESSMENT MANAGEMENT C
Airway Patency Airway is patent and maintained H
Patient's speech Use simple Airway manoeuvres
E
(Head tilt chin lift; Jaw Thrust)
A Added Noises Suction
C
Airway See sawing movement of chest and Airway Adjuncts and position K
abdomen of patient
O2 via high concentration mask A
Rate and Pattern Position patient F
Depth Physiotherapy and nebulisers T
H B Symmetry of chest movement
Accessory muscles
Bag - Valve mask
O2 via high concentration mask
E
Breathing R
E Colour
Oxygen saturation
I
L Pulse and BP Cannulate N
P C
Capillary refill time
Urine output, fluid balance

Take bloods (test)
Blood Cultures
T
Circulation Temperature IV Fluid
E
IV access R
V
Conscious level - AVPU, Coma Scale Recovery position
Blood Glucose Level Correct blood glucose
E
D

Pupils Control Seizures N
Disability Signs of Seizures Control Pain T
Pain
I
E Head to Toe examination Front and

back
Manage abnormal findings (e.g. O
wound bleeding) N
Exposure
If any time you are unsure, call for HELP and reassess using A BCDE

Patient
Review charts (Medicines, Urine
Condition Call for senior review
Output), notes investigations
improving

Further investigation
Provisional Diagnosis? Bloods, ABGs, Microbiology USS/CT/MRI
Obtian expert help

Continue Monitoring, Management Plan, Discuss and communicate with seniors; review progress
2 CARE OF THE ACUTELY UNWELL PATIENT

CONTENTS
Introduction 4
1. Recognition and assessment of the acutely ill patient : 9
A structured approach
2. Assessment and management of the patient with breathing problems : 22
Appendix 1 : Pulse oximetry
Appendix 2 : The three stages of respiration
3. Assessement and management of the patient with hypotension 42
4. Assessment and management of the patient with sepsis and septic shock 50
5. Assessment and management of the patient with a poor urine output 57
6. Assessment and management of the patient with an altered level of consciousness 65
7. Assessment and management of the patient with acute pain 76
8. Communication 87
Abbreviations 94
Glossary of terms 95
CARE OF THE ACUTELY UNWELL PATIENT 3

INTRODUCTION
'Care of the acutely unwell patient' is a highly recognised course for the health care practitioners. This course has
been identified as an essential requirement for nurses to recognise the deteriorating patient and manage the
situation by applying appropriate skills. The main purpose of this course is to equip you with knowledge skills and
attitude to assess and manage a critically ill or deteriorating patient safely and effectively by using the structured
'ABCDE' approach.
The benefits of this course are:-
1. Learning the skills to recognise the critically ill or deteriorating patient.
2. Applying structured method of assessment and management skills.
3. You will gain confidence and competence by practicing the structured approach.
4. You can apply the structured approach to any patient who is deteriorating or clinically unstable.
5. Using the structured approach will put you in a mind frame to reduce or avoid the anxiety related mistakes.
6. Improves the clinical performance of the individual by reducing the time, recognising the deteriorating patient
early and reducing the number of cardiac arrests.
6. Personal and professional development requirement of completing the course
Internationally this course is highly valued for nurses those who can apply the skills and knowledge in a clinical
setting to assess and manage the patient effectively.
Patients at Risk of Deterioration

In 2005 the National Confidential Enquiry into Patient Outcome and Death 1 (NCEPOD) published a report An acute
problem? This was followed in 2007 by the National Patient Safety Agency who published two documents: Safer
Care for the acutely ill patient: learning from serious incidents2. There are similar themes running throughout
all of these documents which demonstrate consistent failings when patients are at risk of deterioration and
acute illness, such as:
Failure to measure basic observations
Lack of recognition of the importance of worsening vital signs
Delay in response to deteriorating vital signs
In July 2007 the National Institute for Clinical Excellence (NICE) published Acutely ill patients in hospital-
recognition of and response to acute illness in adults in hospital3. This document outlined key priorities for
organisations to implement and provided clear strategies to address the identified weaknesses in managing
acutely ill patients.
The Key Priorities
Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical
decision to admit has been made, should have:

Physiological observations recorded at the time of their admission or initial assessment
A clear written monitoring plan that specifies which physiological observations should be recorded and
how frequently
The monitoring plan should take account of the:
Patients diagnosis
Presence of co-morbidities
Agreed treatment plan
The document also states that physiological observations should be recorded and acted upon by staff that have
been trained to undertake the procedures and understand their clinical relevance.
Furthermore the document outlines that requirement for track and trigger systems to be used for all adult
patients in acute hospital settings.
Physiological observations should be recorded 12 hourly as a minimum. The need to increase or decrease
the frequency of clinical observations should be made at a senior level
The frequency of monitoring should increase if abnormal physiology is detected
There is a requirement that staff caring for patients in acute hospital settings should be competent in monitoring,
measurement, interpretation and prompt response to the acutely ill patient which is appropriate to the level
of care they are providing. Competencies have been identified for each level of care and published by the
Department of Health Competencies for Recognising and Responding to Acutely iII Patients in Hospital (2008)4.
These competencies define the knowledge, skills and attitudes required for safe and effective treatment along
the Chain of Response (fig. 1).
Figure 1. Chain of Response
Care of the acutely unwell addresses components of the training requirements needed to support the
competencies outlined in the Recogniser and the Primary Responder roles.
The Recogniser is considered to be someone who monitors the patients condition; interprets designated
measurements, observations and information and adjusts the frequency of observations and the level of
monitoring.
The Primary Responder goes beyond recording and further observation by interpreting the measurements and
initiating a clinical management plan.

The NICE guidance for Acutely III Patients in Hospital (2007)3 also introduced the Graded Response Strategy
which provides clear pathways for patients identified as being at risk of clinical deterioration. The strategy is sub-
divided in to three levels:
Low Score Group - there should be an increase in the frequency of observations and the nurse in charge
alerted
Medium Score Group - requires an urgent call to team with primary medical responsibility. A simultaneous
call should be made to personnel with core competencies incorporating acute illness. These competencies
can be delivered by a variety of models such as critical care outreach, hospital at night or a specialist
trainee
High Score Group - Emergency call to team with critical care competencies and diagnostic skills. The
team should include a medical practitioner skilled in assessment of the critically ill patient, who possess
advanced airway management and resuscitation skills
The graded response strategy assists clinical staff in making appropriate and timely decisions when dealing with
patients at risk of deterioration. The AIM course is able to provide training that supports this strategy.
Training and Education
It is recognised that training and education is key to improving the skills and knowledge required to care for
acutely ill patients. In response to the need for training and education of multi-disciplinary clinically based staff,
courses have evolved to provide skills and knowledge.
Care of the acutely unwell patient' course duration :
1. Short courses
a. 1 day course
b. 2 days course with detailed workshop, practice and assessment
15 weeks programme includes
1. Initial assessment
2. Midpoint review
3. Final assessment with detailed competency assessment
The aims of this course are
To optimise the outcome for patients at risk of developing acute illness.

Enhance the knowledge, confidence and performance of students and staff in dealing with acutely ill adults.
Encourage teamwork and communication.
Promote a multi-disciplinary approach to patient care
Maximise the efficient use of critical care services
Address clinical governance and risk

The manual will provide pre-course reading to facilitate the required learning prior to attendance on the ......
................................. days. It is essential that candidates are familiar with the contents of the manual prior to
attending the course, as not all the content of the manual can be covered on the study day.
This text is designed to provide registered healthcare professionals with the essential underpinning knowledge
necessary to enable them to improve the patient care experience and outcome. The 15 week multi professional
course focuses on communication and team working between disciplines and developing the fundamental
skills necessary for acute illness management, using a variety of teaching strategies. Students and staff will
be equipped with knowledge, skills & attitude to assent & manage acutely unwell patient, through detailed
completely assessment in universal area.
The following chapters are focused on evidence based, practitioner responses to clinical features or signs and
symptoms rather than disease oriented (e.g. the patient with breathing problems or hypotension). You will find
throughout the manual structured style based on the ABCDE approach to assessment and management of the
acutely ill patient. Each chapter describes the skills and underpinning knowledge required at the end of each
chapter you will find a summary to assist in the recall of new knowledge.
This training manual and course provide the foundations for application of the ABCDE principles within the adult
acute care setting, working within the boundaries of professional practice. Delivery of acute care is a team effort,
and early and appropriate senior referral is vital in ensuring the delivery of effective clinical care.
The information within this manual is designed as designed as guidance only. It is intended to supplement patient
management, informed by senior review where appropriate. Staff must always be aware of, and practise within
their own organisations policies and procedures and within their professional scope of practice.
__________

1
Recognition and assessment of

the acutely ill patient :
The ABCDE approach

Recognition and Assessment of the Acutely iII Patient :
The ABCDE Approach
Learning outcomes
To enable the reader to :

Identify those patients at risk of developing critical illness
Describe the structured approach to the assessment and management of the acutely unwell adult patient
Identify, prioritise and manage problems as they arise during the structured assessment
State the importance of reviewing charts and results
State the importance of developing a management plan
Identify the potential need for further investigation and review of results
Identify when help is needed
Identify what help is needed
Which patients are at risk of developing critical illness?

It is relatively easy to identify a patient who has become critically ill. The key to improving standards of care,
morbidity and mortality, is in recognising those patients at risk of developing critical illness, acting in a timely
appropriate manner, so as to reduce the likelihood of deterioration and the subsequent need for admission to a
critical care unit.
Patients at particular risk of developing critical illness include :

Those with co- existing disease e.g (patients with asthma, COPD, ischaemic heart disease, diabetes,
renal failure and who are immunocompromised)
All emergency admissions
Elderly patients
Specific acute illnesses including sepsis, pancreatitis, ruptured viscera, myocardial infarction, major
surgery and significant trauma
Those with an altered level of consciousness
Major haemorrhage or requiring large volumes of fluid / blood replacement
In general, young, healthy patients will compensate for a significant period of time prior to collapse. It is
important to monitor ALL patients who are deemed to be at risk, regardless of their age.
A structured approach to assessing and managing the acutely unwell patient
As with all emergencies, it is essential to undertake a full assessment of the patient, using a structured and
prioritised approach. This approach will enable clinicians to be efficient and thorough, whilst simplifying the
procedure for the whole health care team. It will also facilitate effective communication, which will ensure
that all team members are working towards the same goal. The aim is to identify life threatening problems
and manage them as they arise during the assessment process i.e. problems identified during the assessment
must be dealt with before moving on to the next stage of the assessment. The order of priority ABCDE is no
coincidence, and has been devised so that the problems with the potential to cause death most quickly are
addressed first. It is important to emphasise that, in the emergency situation , contrary to traditional teaching,
the clinical assessment described below must be undertaken prior to obtaining a full patient history3.

Initial assessment
Assessment should be done using the ABCDE approach and the look, listen and feel technique at each stage.
So look, listen and feel for signs of a blocked airway, respiratory distress, poor cardiac output, altered level of
consciousness and perform a head to toe examination.
STEP 1 ASSESSMENT MANAGEMENT

Is the airway patent and maintained ? Ensure airway is patent and maintained
Can the patient speak ? Simple airway manoeuvres
A Are there added noises? Suction

Airway Is there a see - sawing movement Consider using airway adjuncts and
of the chest and abdomen ? position patient
Observe rate and pattern Position patient
Depth of respiration Consider physiotherapy and nebulisers
B Symmetry of chest movement

Use of accessory muscles
Bag - valve mask
Breathing
Colour of patient
Oxygen saturation
Manual pulse and BP Cannulate
Capillary refill time Take appropriate bloods
C Urine output/fluid balance Blood Cultures
Circulation Temperature Fluid bolus - administer - titrate
Ensure patent IV access
Conscious level using AVPU Consider recovery position
Blood glucose level Correct Blood Glucose
D Pupil size and reaction Control seizures
Disability Observe for seizures Control pain
Pain assessment
E Perform head to toe examination, front Manage abnormal findings appropriately

and back
Exposure
ABC and D are inextricably linked, and any primary problem arising in one area will ultimately affect all of the
systems. For example, a patient who is hypotensive will exhibit a state of tissue hypo - perfusion and therefore
develop an increased respiratory rate to remove the subsequent acid load (CO2), even in the absence of
respiratory disease.
Remember that any problems affecting Airway will affect Breathing,

which will affect Circulation and so on.

ASSESSING AND MANAGING THE AIRWAY


The Airway consists of the nose/mouth, oropharyngeal and nasopharyngeal cavities, the pharynx, larynx and
trachea. It provides the route for the passage of air from the atmosphere to the bronchial tree ; therefore, any
obstruction is an immediate threat to life.
On approaching the patient, ask How are you ? If they respond, you have some useful information with regard
to their airway status ( whether it is patent or not ) and their level of consciousness; if they are alert and orientated
then cerebral perfusion is adequate. If they speak in short sentences they may have breathing problems.
Assess all acutely unwell patients using the Look, Listen and Feel approach
LOOK
The most common cause of upper airway obstruction is an altered level of consciousness and pharyngeal
obstruction by the tongue. Left unmanaged, airway obstruction may lead to hypoxia and ultimately death. Look
for any cyanosis. Inpect the mouth for any foreign bodies and remove anything obvious. Well fitting dentures
may be left in place; however, ill fitting dentures should be removed. Check the upper airway for any vomit,
blood or secretions. Obstruction may also be due to swelling caused by trauma or anaphylaxis4.
Observe the pattern of breathing; where complete airway obstruction has occured, a see - saw pattern of
breathing will be evident - paradoxical chest and abdominal movements. A clear airway enables the chest and
abdomen to move outwards during inspiration, and inwards during expiration. See - sawing results in the
chest moving outwards on inspiration whilst the abdomen moves inwards. This is reversed on expiration. Other
accessory muscles such as the sternocleidomastoid, the scalene and abdominal musculature may be used.
Central cyanosis may be evident ; although this is a late sign of hypoxia.
LISTEN
Listen for any added sounds, which may indicate airway problems such as :
Snoring : pharyngeal obstruction by the tongue
Crowing : laryngeal spasm
Gurgling : fluids in the upper airway
Stridor : obstruction of the upper airway

FEEL
Feel for air movement, either by placing the back of your hand or side of your face over the mouth of the patient.
This will enable you to determine whether or not the airway is obstructed.
Management of the airway

If any problems with the patency and maintenance of the airway are identified during the assessment, these
must be dealt with before moving on.
Consider now whether you need senior help
The airway can be opened using head tilt and chin techniques (See photograph 1 ). If there is suspicion of
cervical spine injury, a jaw thrust technique should be used in order to ensure spinal alignment and stablisation
is maintained4. Where there is evidence of secretions/vomit, apply oropharyngeal suction, Suction should be
administered under direct vision and with caution in order to prevent soft tissue damage and stimulation of
the gag reflex. Where the obstruction is thought to be due to the aspiration of a foreign body, alternate the
use of basic manoeuvres such as encouraging coughing, back slaps and abdominal thrusts in accordance with
Resuscitation Council UK guidelines4. More information about the resuscitation guidelines can be obtained from
the Resuscitation Council UK website: www.resus.org.uk
Photograph 1
Using the head tilt and chin lift technique to relieve pharyngeal obstruction.
Airway Adjuncts
Patients who are unable to maintain their own airway and require head tilt and chin lift may benefit from the
insertion of an oropharyngeal (Guedel) airway. These should only be used in unconscious patients, as those with
an intact gag reflex may vomit, resulting in an increased risk of aspiration. The appropriate airway size can be
measured by comparing it to the distance between the angle of the mandible and the level of the incisors. The
airway is inserted concave side uppermost (upside down) and rotated through 180(0) when it has reached the
junction of the hard and soft palate. This prevents displacement of the tongue and reduces soft tissue trauma4.

Where an oropharyngeal airway is deemed unsuitable, e.g. the patient is semi conscious or has clenched
teeth; a nasopharyngeal airway may be used . Size 6-7 mm nasopharyngeal tubes are suitable for adults5. The
nasopharyngeal airway should be sized according to the patients size, sex and race. As a general guide a size 7
mm should be used for a males and size 6 mm in females10. If the tube is too long it may stimulate the laryngeal
or glossopharyngeal reflexes to induce vomiting or laryngospasm. These must not be used in patients with
suspected basal skull fracture, as it is possible to insert the airway in to the cranial vault and so an oral airway is
preferred5. Caution should also be observed in patients with a coagulopathy. Note : Post insertion bleeding may
occur in up to 30% of patients so continue to observe closely5.
Placing the patient in the left lateral (recovery) position will assist in protecting the airway from obstruction by
the tongue and by ensuring secretions drain away from the airway . Following any intervention, you must re-
assess the airway in order to establish the effectiveness of your actions and any adjuncts used.
Where the airway cannot be maintained by these simple manoeuvres, it may be necessary to intubate the
patient. It is essential to call for EARLY AND APPROPRIATE HELP at this stage.
Patients who are acutely ill should be given oxygen to maintain their oxygen
saturations between 94-98% unless they have diagnosed COPD. Patients with COPD
should have a prescribed target saturation between 88-92%
BREATHING ASSESSMENT

Bag - valve mask
Breathing
Colour of patient
Oxygen saturation
LOOK
Count the respiratory rate. Normal resting respiratory rate is between 12 and 20 breaths per minute. Alterations
in respiratory rate are an early and sensitive indicator of developing illness; rising rates are often an early sign
of developing illness1,5,6. The rate may slow down appropriately in response to treatment, however, where the
underlying problem has not been corrected, slowing rates may be indicative of impending respiratory arrest and
the actual respiratory rates must always be considered within the clinical context.
Look for any evidence of respiratory distress and increased work of breathing. Is the patient using their accessory
muscles? Abdominal distension may inhibit respiratory function. Check that both sides of the chest are moving
equally. Unilateral chest movement may indicate pleural effusion, pneumonia or pneumothorax. If the patient
has any chest drains, they should be checked for placement, patency and function . Does the patient appear to
be experiencing severe pain which may inhibit respiratory function?
Check the oxygen saturation with pulse oximetry and look for evidence of central cyanosis. Remember that
oxygen saturation monitoring has some limitations (see chapter 2, appendix 1). Oxygen saturations do not
provide information about the adequacy of ventilation, for this arterial blood gas analysis is essential.

Oxygen saturations do not reflect the adequacy of ventilation.
Arterial blood gas analysis should be considered
LISTEN
Listen to the patients response to communication; is the patient orientated, do they seem agitated or confused?
Patients who can only say a few words at a time, or are unable to complete their sentences without taking a
breath, are in severe respiratory distress. No response clearly indicates a significant problem.
Auscultate the chest to assess breath sounds and added noises. Listen for wheezes and crackles. Bronchial
breathing indicates lung consolidation, absent and reduced sounds may indicate a pleural effusion or a
pneumothorax.
A silent chest is a pre-terminal sign.
FEEL
Check the chest expansion to ensure equal and adequate movement on both sides. Palpate the chest wall
to assess for surgical emphysema. Assess whether the trachea is central - any deviation may indicate tension
pneumothorax or collapse/consolidation. Hyper-resonance on percussion may indicate a tension pneumothorax;
dullness may indicate pleural effusion, haemothorax or consolidation.
Management of breathing problems
The British Thoracic Society guidelines (2008) remind us that Oxygen is a treatment for hypoxaemia, not
breathlessness9. Patients who are acutely ill and hypoxic must receive oxygen immediately, administered via
a high concentration oxygen mask with reservoir, with a goal of maintaining oxygen saturations within a target
range of 94-98%9. In patients with risk of hypercapnic respiratory failure such as COPD, the goal should be to
maintain oxygen saturations closer to their normal range of 88-92% 9. This should be prescribed and documented
in medical notes.
Life threatening conditions such as acute severe asthma and tension pneumothorax must be identified and
treated urgently (discussed in chapter 2). If there is suspicion of retained sputum or lobar collapse/ consolidation,
the patient should be referred for physiotherapy. Where bronchospasm is present, bronchodilators should be
administered via a nebuliser. For patients with asthma, nebulisers should be driven by piped oxygen or from an
oxygen cylinder fitted with a high -flow regulator capable of delivering a flow rate of > 6 L/min 9. When nebulised
bronchodilators are given to patients with hypercapnic acidosis, they should be driven by compressed air and,
if, necessary, supplemental oxygen should be given concurrently by nasal cannulae at 2-4 L/min to maintain an
oxygen saturation of 88-92%9.
Where the respiratory effort is inadequate or absent, use a bag - valve mask device to assist ventilation and
maintain oxygenation. A bag-valve mask enables ventilation with high volumes of oxygen but it is difficult to
obtain a good seal with a single person and a two person technique is preferable.
Call for early and appropriate help

ASSESSMENT OF THE CIRCULATION
Cardiovascular compromise may manifest as airway compromise, an increased respiratory rate, altered level
of consciousness, poor urine output, or ultimately cardiorespiratory arrest due to tissue hypoxia4. Assess the
cardiovascular system using the same look, listen and feel approach.
LOOK
Check the skin colour. Does the patient look cyanosed and/or pale? Is the patient sweating? In cases of sepsis,
patients may appear to be red, pink/flushed and feel warm. Peripheal cyanosis may indicate reduced cardiac
output. Check the capillary refill time (see chapter 3) : prolonged refill indicates cardiovascular compromise.
Conversely, rapid capillary refill may indicate a hyperdynamic state often present in the early stages of sepsis.
Look for any obvious signs of haemorrhage, such as a distended abdomen and check any existing wounds and
drains.
Urine output is a surrogate marker for circulatory adequacy. Normal urine volume is > 0.5mls/kg/hr. Poor urine
output indicates poor renal perfusion in the hypotensive patient. (More information regarding assessment of
urine output can be found in chapter 5 ).
LISTEN
Hypotension is a late sign of deterioration as several compensatory mechanisms act specifically to maintain
blood pressure in the presence of serious compromise. It is important to look at the trend in blood pressure
recordings as a normal value may be low for a patient who is usually hypertensive. Any systolic BP of less than
90mmHg should be treated as low. Young patients in particulars are able to maintain an adequate blood pressure
in the face of severe loss of circulatory volume up to the point when they catastrophically decompensate. Blood
pressure can be maintained until approximately one third of the circulating volume has been lost7. Hypotension
will then ensue as the compensatory mechanisms are overwhelmed.
Hypotension is a late sign of cardiovascular compromise.
A narrow gap between systolic and diastolic pressure is indicative of vasoconstriction (or increased systemic
vascular resistance) as seen initially in hypovolaemia. A low diastolic blood pressure suggests vasodilatation ( as
seen in sepsis).
The frequency of recording vital signs should be increased in the acutely unwell
patient in order to monitor clinical improvement or deterioration. They should be
recorded at least hourly 8

FEEL
Check and compare peripheral and central pulses manually for presence, volume, character and regularity. Weak
and thready pulses may indicate hypovolaemia or cardiogenic shock, whereas bounding high volume pulses may
indicate sepsis or carbon dioxide retention.
An irregular pulse requires further investigation to exclude cardiac arrhythmia as the source of the problem.
Cardiac arrhythmias should be treated in accordance with the Resuscitation Council (UK) guidelines4.
Feel the peripheral limb temperature and compare this to central temperature. Warm, well - perfused peripheries
may indicate sepsis, whereas peripheral cooling and shut down may be present in hypovolaemia and cardiogenic
shock. Peripheral cooling and shut down will occur as shock progresses.
Management of cardiovascular problems
Hypovolaemia is one of the commonest causes of circulatory problems that you will be called to deal with.
All patients should initially receive intravenous fluids whilst attempts are made to identify and treat the specific
cause of the problem e.g. sepsis, haemorrhage. Where haemorrhage is the cause of the problem, an urgent
surgical opinion should be sought as the patient may require immediate surgery.
Adequate venous access must be secured - ideally, two large bore intravenous cannulae should be sited. Blood
can be obtained on cannula insertion for appropriate investigations such as blood cultures, full blood count
(FBC), urea and electrolytes (U & Es), group and cross match, blood glucose and clotting studies. A rapid fluid
challenge should be administered and the response assessed.
Fluid management
Administer 250mls crystalloid/colloid over 5-10 minutes and assess response.
Repeat as necessary.
Evidence of cardiac failure (chest crackles indicating pulmonary oedema) should be sought
following each bolus. Where this occurs, fluid therapy must be reduced or stopped, as an
alternative means of enhancing tissue perfusion may be required
e.g. inotropes and/or vasopressors.
Caution should be taken with renal and cardiac patients.
Patients who require continuous ongoing fluid replacement are not stable.
They require further investigation and specific treatment.
ASSESSMENT OF DISABILITY

Pain assessment

All altered level of consciousness (ALOC) is the commonest cause of
airway obstruction in the acutely ill patient.
LOOK
Look for signs of an ALOC. This may include drowsiness, lethargy, inability to talk, agitation or change in mood,
i.e., aggressiveness (often a sign of hypoxia). Does the patient open their eyes spontaneously on your approach ?
Pupil Size and Response : The pupils response to light from a pen torch is useful in establishing if the problem
lies within the brain. The pupils should be equal and constrict briskly in response to light . This demonstrates that
the reflex arc of the optic nerve and occulomotor nerve are working. If the pupils are dilated, this could indicate
specific drug intoxication . Bilateral constricted pupils are seen in opiate overdose and in brainstem infarction.
Unilateral dilated pupil is seen in some disease states but is an important sign of intracranial haemorrhage and
should not be ignored; it may mean that an urgent CT scan and decompression of the brain are necessary.
Blood Glucose : If the blood glucose level is low then appropriate action should be taken. The Resuscitation
Concil (UK)(2010) advocates that if the blood glucose is found to be below <4mmols intravenous dextrose should
be administered. Refer to your local trust guidelines for dosage. Blood glucose should then be re-checked after
a fifteen minute interval4,5.
LISTEN
Listen for appropriate response to verbal questioning. Is the patient confused or orientated to time, place and
person? Listen for noisy altered breathing patterns (for treatment see Chapter 2).
FEEL
Skin temperature and colour will not only help to identify problems with airway, breathing or circulation it will
help to assess the state of the cerebral circulation and the potential requirement for intervention. For example if
there is central cyanosis the brain is not getting enough oxygen.
It is useful to assess the level of consciousness using a simplified scoring system such as AVPU. If clinically
indicated an in-depth assessment may be used using the Glasgow Voma Score (GCS) (see chapter 6).
A : is the patient Alert?
V : does the patient respond to Voice?
P : does the patient respond to Pain ?
U : is the patient Unresponsive?
Where the patient is only responding to pain, or is unresponsive , care must be taken to protect and maintain the
airway, as the normal protective airway reflexes may be inadequate or absent.
Consider whether you need to call for senior help
Assessment of D must also include an evaluation of pain, Uncontrolled pain may have a detrimental effect on
body systems and increase morbidity. An accurate pain evaluation must therefore be undertaken in order to
ensure effective pain management in the acutely unwell adult (see chapter 7).

EXPOSURE

and back
Exposure
Following assessment of ABC and D it is important to undertake a full systematic patient examination. This
ensures that nothing has been missed which may account for or contribute to the patients current situation.
Always maintain the patients dignity and ensure that the patient is kept warm during the examination process.
Completion of the assessment

At this stage the patient should be stable and improving , if not request expert senior help as a priority and
repeat ABCDE assessment. Information gained through the head to be examination will help inform further
management required.
If at any point during the assessment and management of the patient you are unsure,
call for HELP and reassess ABCDE.
Review charts and notes

It is useful to review all the appropriate documentation available to you. Check the patients:
Vital signs and track and trigger charts
Fluid balance status - including insensible loss
Fluid prescription - establish if all prescribed fluids have been administered
Neurological observation chart
Case notes and previous medical history
Consider any co-existing disease which may inform future treatment or treatment limitations
Check drug prescription chart to determine if all prescribed drugs have been administered -
Consider nil by mouth patients and patients who are vomiting
Check medications the patient was taking prior to hospital admission and consider whether it is appropriate
to continue or re-prescribe in the current clinical setting.
Investigation
Review all recent investigations and blood results; correct any abnormalities. Arterial blood gases are very useful
and should now be considered. Check for evidence of acidosis/alkalosis and determine whether this metabolic
or respiratory or a combined picture. Check PaCO2 levels to establish the adequacy of ventilation. PaO2 should
be maintained within normal parameters and oxygen therapy should be titrated accordingly.
Never remove oxygen therapy to take a blood gas
Undertake/repeat appropriate investigations as necessary, which should include biochemistry, haematology and
microbiology (blood , sputum, wounds, drainage, CSF and tips from invasive medical devices after removal).
Other investigations may include chest and or abdominal x-ray, ECG , ultrasound and CT scans.

Monitoring
Ensure that the patient is adequately monitored. Track and Trigger systems should be routinely used to monitor
patients. The monitoring of physiological observations as determined by NICE (2007)8 should as a minimum
include;
respiratory rate
heart rate
blood pressure
temperature
level of consciousness
oxygen saturation
FiO
2
*
Urine output *
Fluid balance *
* These elements are not stated by NICE as essential; however in order to undertake a comprehensive assessment
on patients who are at risk of deterioration they should be included.
The frequency of observations should be determined by senior staff and stated in the patients management
plan.
Management plan
Diagnosis yes/no - Send for expert help if diagnosis uncertain.
Whether a diagnosis is established or not, a management plan must be implemented. If a diagnosis has not
been established the management plan will include management of symptoms, if a diagnosis has been made
then a more specific treatment plan should be outlined. This must be clearly documented in the case notes
and communicated to those staff caring for the patient. Document and communicate clear instructions about
how often observations should be performed and what clinical parameters are acceptable. Specify the expected
action where the vital signs (including urine output) fall outside of these parameters i.e. do you want to be
contacted to review the patient further of do you want the staff for example, to administer a further bolus of
fluid?
You should send for senior help now if :

The patients remains unstable OR you are unsure of the diagnosis.
Re-commence your assessment.
Specialist Management
You may need to refer the patient for specialist management from the surgical, medical, critical care or radiological
specialists. Seek senior help and ensure that you communicate effectively in order to facilitate this referral
in a timely manner. Ensure that the parent team is informed of the situation and action taken. Complete all
relevant documentation. Where appropriate, discuss treatment limitations and/or do not attempt resuscitation
decisions.

Consider whether the patient is manageable on the ward or needs to be moved to a critical care area. This will
require discussion with critical care staff and you should familiarise yourself with local hospital procedures. If the
patient needs to be transferred, ensure that appropriately trained staff and all necessary equipment and drugs
are available in accordance with local policy. The patient must be stabilised prior to the transfer.
Summary
The reader should be able to:

Identify those patients at risk of developing critical illness
Describe the structured approach to the assessment and management of the acutely unwell adult patient
Identify , prioritise and manage problems as they arise during the structured assessment
State the importance of reviewing charts and results
State the importance of developing a management plan
Identify the potential need for further investigation and review of results
Identify when help is needed
Identify what help is needed.
References
1. McGloin, H., Adams, S.K., Singer, M.,(1997) Unexpected deaths and referrals to critical care of patients
on general wards. Are some cases potentially avoidable ? Journal of The Royal College of Physicians,
Vol.33,pp.255-259
2. National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) (2005) An Acute Problems? A
report of the national confidential enquiry into patient outcomes and death. London: NCEPOD
3. Fatovich, D., (2001) Acute Medical Emergencies: The Practical Approach. London: BMJ Publishing
4. Soar, J., Nolan, J., Perkins, G.., Scott, M., Goodman, N., and Mitchell, S., (2006) Intermediate Life Support,
2nd edition, London: Resuscitation Council (UK)
5. Resuscitation Council UK, (2010) Advanced Life Support Manual, 6 th edition. London: Resuscitation
Council UK
6. Franklin, C., Matthew, J., (1994) Developing strategies to prevent in hospital cardiac arrest: analysing
responses of physicians and nurses in the hours before the event . Critical Care Medicine , Vol.22,pp 244-247
7. Goldhill D., White, S.A., and Summer, A., (1999). Physiological values and procedures in the twenty four
hours before ICU admission from the ward. Anaesthesia, vol.54, pp 529-534.
8. National Institute for Health and Clinical Excellence (NICE), (2007) Acutely ill patients in hospital.
9. Driscoll, B.R., Howard, L.S., and Davison, A.G ., (2008) British Thoracic Society Guide for emergency oxygen
use in adult patients. Thorax, vol.63, Suppl 6 : vi 1-68
10. Roberts, K., and Porter, K., (2003) How to size a nasopharyngeal airway. Resuscitation Journal, vol.56 pp.
19-23.
__________

2
Assessment and
management
of the patients with
breathing problems

Assessment and management of the patient with
breathing problems
Learning outcomes
To enable the reader to:

State the causes of respiratory failure
Discuss the need for oxygen therapy
Describe the different oxygen therapy delivery systems
List the signs and symptoms of respiratory inadequacy
Describe the clinical findings and their significance
Describe the management of the breathless patient
Describe the systematic approach to assessment, monitoring and management of the patient with
breathing problems
Identify when help is needed and who to call for help
Oxygen is essential for life; all tissues require oxygen to perform aerobic respiration, maintain normal cellular
functions and thus ensure tissue survival. Oxygen delivery depends on adequate ventilation, gas exchange and
effective circulatory distribution. Because oxygen reserve in tissue is minimal, failure of any of these systems will
rapidly result in tissue hypoxia (within four minutes). Efficient oxygen delivery is essential therefore not only in
health; but is of paramount importance in acutely unwell patients.
Oxygen delivery depends upon three factors:

Ventilation : the process of moving oxygen from the atmosphere to the alveoli, and removing carbon
dioxide from the alveoli out into the atmosphere
External respiration refers to the gas exchange occurring at the alveoli
Internal respiration: refers to the process of cellular exchange of oxygen and carbon dioxide
(More details on these processes can be found in appendix2)
Respiratory failure
Respiratory failure occurs when the respiratory systems fails to maintain normal physiological parameters for the
patient. Respiratory failure can be defined as type I or type II.
Type I respiratory failure
Clinical features of type I respiratory failure include hypoxia with a normal or low CO2, and is primarily due to
pathology affecting oxygenation alone. Problems affecting oxygenation can be assessed in the A and B part of
the ABCDE assessment.
Type II respiratory failure (hypercapnic)
This type of respiratory failure includes problems resulting in retained carbon dioxide (hypercapnia), acidaemia
(low pH) and a low PO2 and in the majority of cases is due to respiratory muscle failure.
Normal tidal volume (the volume of air we breathe in and out in a single breath) relies on good diaphragmatic
action together with the thoracic muscles creating good bucket handle movement (Diagram 1).

Figure 2
The response to hypoxia is immediate increase of the respiratory rate in an attempt to enhance oxgenation.
Without adequate treatment for this increased work of breathing, the respiratory muscles will become fatigued
and eventually fail to create adequate sized tidal volumes.
When the tidal volume falls, the inspired air fails to fill the more peripheral alveoli, thus preventing the removal
of the carbon dioxide in the expiratory breath. This results in the type I failure developing into a type II failure.
With appropriate treatment, the respiratory muscles can recover and the patient will reverse back to the type I
failure.
This concept is important, as it is the clinicians responsibility to prevent the escalation from type I to type II
failure. It is also important to recognise that in such incidences type II failure is not a chronic pathology.
Common causes of respiratory failure
Conditions/causes of failure Type I Type II
Opiate overdose Acute acidosis
Neurological disorders e.g.
Chronic acidosis
Guillain- Barre Syndrome
Acute on chronic acidosis in exacerbations
COPD
(otherwise chronic with compensation)
Pneumonia/ chest infection Acute hypoxia
Atelectasis/lobar collapse Acute hypoxia
Pnemothorax Acute hypoxia
Pulmonary embolism Acute hypoxia
Pulmonary oedema Acute hypoxia
Oxygen therapy
Oxygen is widely available and commonly prescribed by medical and paramedical staff. Like any drug there are
clear indications for treatment with oxygen and the chosen method of delivery. Inappropriate dose and failure
to monitor treatment can be potentially detrimental to the patient. Vigilant monitoring to promptly detect and
correct adverse effects is essential.

When prescribing oxygen, the potential risk of carbon dioxide retention is secondary to the danger of severe
hypoxaemia: inadequate oxygenation is life threatening. Conversely exposure to high concentrations of oxygen
when not required may be harmful potentially causing vasoconstriction, atelectasis and systemic vascular
resistance (SVR)1. Therefore the aim of oxygen treatment is to maintain oxygen saturations within an optimal
target range.
All critically ill patients should commence oxygen at 15 L/min using a high concentration reservoir mask.
Patients who present with acute medical emergencies who are mildy hypoxic but not critically ill, should
be given oxygen via nasal cannulae 2-4 L/min or a simple face mask starting at 5-10 L/min or a simple face
mask starting at 5 - 10 L/min depending on their acuity and local Trust guidelines.
Aim for target saturations of 94-98%. If the patient has COPD and is at risk of hypercapnic respiratory
failure then aim for target saturations of 88 - 92 %2
Oxygen can be delivered by a number of devices, the choice of which will be determined by a number of
factors including the condition of the patient, the percentage of oxygen to be delivered and patient tolerance. A
description of some of the delivery devices available is provided below.
Oxygen masks
High concentration mask with reservoir
To be used in acutely ill patients
Delivers oxygen concentrations up to 85%
with a flow rate of 15 L/min7
Indication for use:
Hypoxix patients
Acutely unwell patients
Unknown diagnosis
Trauma
Cautions:
Can feel claustrophobic
Requires good fit to deliver high
oxygen concentrations
Atelectasis
User error - ensure bag is inflated
When a patient requires high flow oxygen via a high concentration mask, prompt referral to appropriate
members of the multi professional team is essential. This may include referral to medical staff, midwife,
senior nurse, respiratory physiotherapists, outreach team, anaesthetist or cardiac arrest team.
This mask is used for acute situations only and should be set at 15 L/min. Prior to placing on the patient,
ensure that all the values are working and the reservoir bag inflates and empties. Ensure the bag is inflated
prior to placing the mask on the patient. This ensures that sufficient flow rate is used so the oxygen reservoir
bag does not collapse during inspiration2.
Never reduce the flow of oxygen below 15 L/min as a reduction in flow of oxygen results in an increased
entrainment of room air, thus diluting the delivered oxygen concentration.

Additional Oxygen Devices.
Fixed percentage oxygen masks
Delivers controlled oxygen of
24,28,35,40 or 60 %
Indications:
Hypoxic patients are at risk of hypercapnic
respiratory failure such as those with
COPD. Who are not critically ill. In this
patient group commence oxygen at
24-28% and increase as required to
achieve saturations of 88-92%.
Cautions:
Humidification should be considered
for flow rates of above 4 L/min
Obstructing venturi opening can effect

delivered FiO2
The Venturi are high flow masks that work on the principal of the Bernoulli effect : oxygen passes through a
narrow opening causing a high velocity stream that draws a constant proportion of room air in through the
base of the venturi valve. This air entrainment depends on the jet velocity (the size of the orifice and the
oxygen flow rate) and the size of the valve ports. This ensures that an exact percentage of oxygen is delivered
to the patient.
The practitioner must ensure the correct oxygen flow (L/min) is set for the desired percentage. The correct
Venturi valve must be used to deliver the prescribed oxygen concentration 24-60%3.
Simple face masks

This type of oxygen mask is standard to many areas.
It should always be set at a minimum of 5 L/min because
significant re-breathing of carbon dioxide can occur when
exhaled air is not adequately flushed from the mask3.
Oxygen flow rate L/min % oxygen delivered
5 30
8 35
10 40
15 60
Source : Doherty and Lister (2008)4

Nasal Cannula
Provides low concentration oxygen-
24% - 36%
Indications for use :
Suitable for patients who require
a low concentration of oxygen
Potential hazards :
Nasal irritation
Dry mucosa
Sinus pain
Headaches
Variable FiO2
Estimated flow rate Percentage oxygen delivered
1-2 L/min 24-28%
3 L/min 32%
4 L/min 36%
Nasal cannulae are best suited for the treatment of patients who are stable and require low percentages of
supplemental oxygen. The flow rate can be titrated to the desired response (based on saturations +/- blood gas
analysis). It is not possible to be accurate about the percentage of oxygen being delivered to the patient using
nasal cannulae or the simple face mask as this will change with respiratory rate and tidal volume.
Remember, in the acutely ill and hypoxic patient, oxygen should be delivered through a high
concentration reservoir mask
Signs and symptoms of respiratory failure :

Central cyanosis
This occurs when there is more than 5g of reduced [deoxygenated] haemoglobin per 100ml blood and is
usually detectable when the arterial oxygen saturation is < 85%. It is therefore more easily seen in those with
polycythaemia and masked when anaemia is present. Central cyanosis is assessed by looking at the tongue. The
tongue has a reliable blood supply and has very little pigmentation changes among different ethnic groups. This
makes the tongue a more reliable sign than assessing cyanosis of the lips.
Central cyanosis is a late sign of life threatening hypoxia

Common causes of central cyanosis include:
ACUTE CHRONIC
Airway obstruction COPD
Pneumonia Pulmonary Fibrosis
Acute Severe asthma Right to left cardiac shunt
Pulmonary oedema
Pulmonary embolism

Peripheral cyanosis
This appears at the fingers, toes and ear lobes but may signify a problem with circulation rather than gas
exchange; therefore do not rely on this as a sign of hypoxia. A common problem in acutely unwell patients is
primary or secondary hypovolaemia. This results in compensation mechanisms including peripheral shutdown,
and a prolonged capillary refill and a blue discolouration of the nail beds.
Communication
If the patient is able to speak it can be assumed that the airway is patent and unobstructed. If the patient has
a wet sounding voice this may indicate that the patient is aspirating oropharyngeal secretions. Patients who
have difficulty in breathing may not be able to construct and deliver a full sentence because of the increased
work of breathing for example, elevated RR, accessory muscle use, hypoxia and/or hypercapnia.
Respiratory assessment must be undertaken on all patients as part of routine

clinical assessment, and must include assessment of the airway
Confusion/agitation
As the patient becomes hypoxic and oxygen saturations fall <84% and/or becomes hypercapnic they will
demonstrate signs of confusion and agitation 1; which may lead to an altered level of consciousness, coma,
significant tissue damage and, if untreated, death. Headache, slurred speech and drowsiness are more specific
symptoms of hypercapnic patients.
Using the AVPU score, the healthcare practitioner can assess the risk of actual and potential airway compromise.
The patient is at potential or actual risk of losing the ability to protect the airway if their AVPU score is P or below.
In this case, prompt intervention including the possible use of airway adjuncts and immediate referral for expert
help is paramount ( see chapter 6 for more details).
Patterns of respiration
Healthy sponraneous breathing is quiet and accomplished with minimal effort. This depends upon an intact
airway and neuromuscular system, chest wall and lung compliance, airway resistance, ventilation/perfusion
matching and efficient gas exchange at alveolar level.
Respiratory rate is one of the most important and sensitive indicators of developing illness
Tachypnoea
This can be defined as an abnormally rapid rate of >20 breaths per minute. This is an early indicator of physiological
compromise. During illness, the cells utilise more oxygen, and in response to this increased uptake, respiratory
rate increases to deliver more oxygen.
If the patient continues to be tachypnoeic they are at risk of respiratory muscle fatigue and CO2 retention.
Exhaustion
Patients become exhausted when they can no longer maintain the required respiratory effort, resulting in a
reduced minute volume and CO2 retention.

Signs of exhaustion include:
An altered respiratory pattern

Slow respiratory rate
Sweating
The inability to peak in complete sentences
ALOC
Cyanosis/pallor
Silent chest
The presence of these clinical signs is significant and must be regarded as a medical emergency. Urgent
intervention is required to prevent cardiorespiratory arrest.
Hypoventilation
This can be defined as a reduced minute volume due to a slow respiratory rate or shallow breathing. Possible
causes include fatigue, pain, central nervous system depression and drugs such as opiates. This will result in
hypoxia and hypercapnia. If the respiratory rate is inadequate then strict monitoring, oxygen and assisted
ventilation with the bag valve mask may be required, particularly in the presence of an ALOC.
Cheyne-Stokes
This can be defined as a respiratory pattern in which periods of apnoea alternate with periods of tachypnoea. It
signifies brain stem hypoxia and is usually a terminal event.
Pursed lip breathing
This is when a patient exhales through pursed or nearly closed lips. The physiological aim being to reduce the
work of breathing, and air trapping within the lungs. For patients with COPD it helps improve ventilation and
reduce the work of breathing by keeping the airway open longer.
Paradoxical patterns
This pattern is also known as see - saw breathing. As the patient attempts to inhale the chest and abdomen move
in the opposite direction to normal. On exhalation the opposite occurs. Paradoxical breathing occurs when there
is complete or nearly complete obstruction of the airway. The cause of paradoxical breathing must be identified
urgently and appropriate treatment commenced.
Effects of poor ventilation and hypoxia on other organs
Assessment of heart rate, skin colour and the patients mental status can help to provide an indication of the
adequacy of respiratory effort, and its impact on other organs.
Cardiac: The hypoxia patient will experience a tachycardia initially. Severe hypoxia will result in a
bradycardia and may lead to cardiac arrest. Hypotension may result as a direct effect of intra
thoracic pathology e.g. tension pneumothorax, hypoxia, impaired myocardial function, or as
a result of insensible fluid loss due to tachypnoea or inability to tolerate oral intake.
Renal: Hypoxic insult may impair renal function (see chapter 5).

Cerebral: Altered mental state (agitation, aggression, confusion, drowsiness, and impaired consciousness)
should be treated as hypoxia until proven otherwise. Increased carbon dioxide levels may also
cause confusion and drowsiness.
Skin: Skin manifestation are either those of the hypoxia stress response (catecholamine release and
vasoconstriction) i.e. cold,clammy, sweaty, and grey or, hypercapnia with vasodilatation and
bounding pulses.
Assessment of the patient with breathing problems

The respiratory system is assessed by using the look, listen and feel approach. The primary aim is to ensure
adequate delivery of oxygen to the patient. Without this, all systems fail.
Commence the assessment using the structured approach:
ASSESSMENT MANAGEMENT


LOOK
Check inside the mouth using airway manoeuvres and remove any obvious obstruction. A dry mouth may
indicate a dehydrated respiratory system and hypovolaemia. If this is the case, the patient is at high risk of
sputum retention, lobar collapse and decreased lung compliance, therefore increasing the work of breathing.
Position the patient to maintain airway. Look for central cyanosis.
LISTEN
Listen for any added sounds, which may indicate airway problems such as:
Snoring : pharyngeal obstruction by the tongue
Crowing : laryngeal spasm
Gurgling : fluids in the upper airway
Stridor : obstruction of the upper airway
Assess the quality of the patients vocal sounds and the ability to complete sentences. Listen for signs of confusion
by asking appropriate questions relating to time and place.
FEEL
Feel for air movement, either by placing the back of your hand or side of your face over the mouth of the patient.
This will enable you to determine whether or not the airway is obstructed. If there are no signs of respiration,
follow the U.K. resuscitation guidelines7.

If any problems are identified with the patency and maintenance of the airway these must be dealt with before
moving on. Where the airway cannot be maintained by simple manoeuvres, it may be necessary to intubate the
patient. It is essential to call FOR EARLY AND APPROPRIATE HELP at this stage.
Following any intervention, you must re-assess the airway in order to establish effectiveness of action and use
of adjuncts.
Further detailed information regarding airway management can be found in chapter 1.

Bag - valve mask
Breathing
Colour of patient
Oxygen saturation
LOOK
Count the respiratory rate and assess the trend of the rate when compared to previous recordings.
Rising respiratory rates are a sensitive indicator of developing acute illness
Look for symmetry of chest movement. Asymmetrical movement may indicate a bilateral or unilateral chest
problem. Depth of respiration and chest expansion should also be noted. Shallow breaths may lead to hypoxia
and inefficient removal of carbon dioxide. This may be secondary to a distended abdomen/pain and splinted
diaphragm so examine the abdomen as well as the chest.
Look for evidence of respiratory distress - is the patient using his/her accessory muscles? Take into account his/
her general appearance i.e. position, evidence of cyanosis or pallor, anxiety and any other problem that may
affect adequacy of breathing such as uncontrolled pain. Look for any deformities of the chest; i.e. flail segments,
kyphoscoliosis and pectus carinatum.
LISTEN
If trained in the technique, air entry may be assessed by auscultating the chest. It is important to auscultate
the posterior dependent aspects of the lungs as well as the apices as most problems occur in the peripheral
airways. Breath sounds should be equal, bilateral and audible in all lung fields. Listen for any added breath
sounds. Turbulent flow of air through narrowed bronchi and bronchioles results in the noisy musical sound
termed wheeze, which may be present in asthma, chronic vronchitis, emphysema or left ventricular failure.
Crackles may suggest pulmonary oedema, whilst bronchial breathing may suggest pneumonia. Added sounds
such as stridor, gurgling and snoring may be transmitted from the upper airway so it is best to treat these prior
to auscultation.

Check whether the patient is able to cough adequately to effectively clear secretions. The consistency, colour and
volume of any sputum should be noted.
FEEL
Feel the chest and abdomen to assess possible distension, urinary retention and chest expansion. Sometimes
chest movements are so subtle that symmetry can only be assessed this way. Feel the chest for signs of surgical
emphysema which may highlight a dislodged chest drain or a new pneumothorax. It is also possible to feel
secretions in the chest and it is a good method for those unfamiliar with auscultation. Palpate the trachea and
note if there is any deviation; the trachea should be central within the suprasternal notch. If devitation is present,
then this may indicate a pneumothorax, tension pneumothroax, massive unilateral pleural effusion or complete
lung collapse. A deviation is a late sign so treatment must be immediate.
Cansider now whether you need to send for help
Management of the patient with breathing problems

If respiratory effort is inadequate to achieve effective ventilation, this is an emegency. The first line management
is to use a bag-valve mask device to ensure the patient remains oxygenated and ventilation occurs. Medical staff
should be contacted to attend as a matter of urgency.
High concentration oxygen must be administered to treat hypoxia in patients who are considered peri-arrest or
critically ill. Place a pluse oximeter on finger to monitor oxygen saturations (see appendix 1). where the patient
is breathing spontaneously and does not require support with a bag-valve mask, oxygen should be delivered
initially via a high concentration mask. Subsequent oxygen therapy can be delivered via a number of devices
already described.
In COPD patients high concentrations may depress breathing in approximately 10-15% of patients resulting in
hypercapnic respiratory failure type II5. Nevertheless these patients will also sustain organ damage or cardiac
arrest due to hypoxia. It is therefore recommended that in this group the aim is to deliver sufficient oxygen to
maintain saturation levels at 88-92% 1,6.
In patients with COPD, who are not critically ill or in a peri-arrest situation, oxygen should initially be
given at 28% (4L min via nasal cannuale or 28% via a fixed percentage mask) and reassess. Oxygen should
be increased as required to achieve and then adjusted to maintain target saturations of
88-92% (BTS,20081, RCUK,20107)
These patients should be observed for signs that they are developing hypercapnic respiratory failure, these
signs include warm peripheries, bounding pulse (vasodilation), drowsiness,coma, and flapping tremor
which may be noticed in the woman's arms. These patients require urgent medical review, and treatment
may include reducing the rate of oxygen.
Many first line interventions to aid respiratory distress can be initiated by ward based staff. Positioning the
patient appropriately will ensure the patient is able to maximise ventilation.
This may include sitting the patient upright, leaning them forward on pillows whilst sat on the bed or lying them
on their side to maximise ventilation : perfusion (V/Q) ratios (see chapter 2 appendix 2). Appropriate positioning
may also facilitate postural drainage to aid removal of secretions. To have maximum benefit to the lungs, the

degree of rotation of the side lying position must be 40 degrees or more.
Humidification may be useful in aiding the clearance of secretions. This can be delivered in the form of continuous
nebulised humidification or by intermittent nebulisers. Where sputum retention or lobar collapse is present
or suspected, the patient should be urgently referred to physiotherapy services for their input and advice.
Practitioners who are skilled in these techniques may use oropharyngeal or nasopharyngeal suction as a method
of aiding sputum removal.
Patients receiving high concentration oxygen must receive nebulishers which are driven through
oxygen- not a compressor. Never remove a patients oxygen therapy to administer a nebuliser.
When to get help

Acute respiratory distress and clinical exhaustion are medical emergencies and require urgent action. The patient
may need to be assessed for invasive or non- invasive ventilation, which may result in the patient having to
be transferred to a higher level of care. You should always ensure that you have called for timely help from
appropriate senior colleagues.
Insensible fluid loss and resulting hypovolaemia is a common features in patients with respiratory problems.
Correct hypovolaemia and any circulatory inadequacy (see chapter 3).
Pain assessment

and back
Exposure
Check the patients TPR, fluid balance, fluid prescription and neurological observation charts. Pay particular
attention to the trends in the observations rather than just the obsolute values. Examine the notes carefully (look

at past medical history and co-morbidities) and verbal reports from other members of the health care team to
aid with understanding the patients current condition. In chronic chest conditions, it is useful to try and establish
information which will help to inform treatment decisions. For example, previous exercise tolerance, whether
or not the patient has received invasive or non invasive ventilation, pulmonary function tests and any stable
arterial blood gases.
Investigations
Review recent investigations and blood results; correct any abnormalities. Arterial blood gases are very useful
and should be taken now if you have not already done so during the assessment phase. Check for any evidence
of acidosis/alkalosis and determine whether the cause is metabolic, respiratory or a combined picture. Check
PaCO2 levels to ensure adequate ventilation. PaO2 should be maintained within the normal parameters - titrate
the oxygen therapy accordingly.
Never remove oxygen therapy to take arterial blood gases
Decide whether further investigations are required. This may include:
ECG and chest */ abdo X-ray

Laboratory investigations - haematology and biochemistry as appropriate
Regular arterial blood gases
Microbiology screen including sputum and blood
Ultrasound scan
CT scan
* A chest X-ray will help in establishing the diagnosis. Check for any evidence of pneumonia, pneumothorax etc.
Acutely unwell patients must not be permitted to leave the ward or to go to the X-ray department. A portable
film will provide adequate information to manage immediately life - threatening pathology.
Monitoring
Ensure that the patient is adequately monitored. The minimum monitoring required includes respiratory rate,
non-invasive blood pressure, heart rate, temperature, oxygen saturations, FiO 2, conscious level and urine
output8.
Observations must be recorded regularly and any further deterioration warrants a further assessment of ABCDE.
A track and trigger score should be established and escalated appropriately and management planned and
implemented.
Management Plan
Diagnosis yes/no- Send for expert help if diagnosis uncertain.
then more specific treatment plan should be outlined. This must be clearly documented in the case notes and
communicated to those staff caring for the patient. Leave clear instructions about how often you require the
observations to be performed and what parameters are acceptable. Specify the expected action where the vital
signs (including urine output) fall outside of these parameters i.e. do you want to be contacted to review the

patient further or do you want further action to be taken. Consider further investigations and act upon the
results. Consider referral to other specialities and/or higher level of care?
At any point during the assessment and management of the patient

you are unsure, call for HELP! and reassess A B C D E
Summary

State the causes of respiratory failure
Discuss the need for oxygen therapy
Describe the different oxygen therapy delivery systems
List the signs and symptoms of respiratory inadequacy
Describe the clinical findings and their significance
Describe the management of the breathless patient
breathing problems
Identify when help is needed and who to call for help
References :
1. Driscoll,B.R., Howard, L.S., and Davison, A.G., (2008) British Thoracic Society Guide for emergency oxygen
use in adult patients. Thorax, vol.63, Suppl 6: vi 1-68
2. Jevon, P., (2007) Respiratory procedures: Use of non-re-breathing oxygen mask), Nursing Times,
vol.103no.32, pp.26-27
3. Cooper N (2004) Acute Care: Treatment with Oxygen. Student BMJ, Vol.12, pp 45-88
4. Doherty , L., and Lister, S.E, (2008) Royal Marsden Manual Manual of clinical nursing procedures. 7 th Edition.
Oxford: Wiley -Blackwell
5. Bateman, N.T., and Leach, R.M., (1998) ABC of oxygen therapy. British Medical Journal, vol.317,pp. 798-801
6. National Institute for Clinical Excellence (NICE), (2004) The management of Chronic Obstructive Pulmonary
Disease in Adults in Primary and Secondary care. Clinical Guideline 12, London: NICE
7. Resuscitation Council UK,(2010) Advanced Life Support. 6th edition. London: Resuscitation Council UK
8. National Institute for Health and Clinical Excellence (NICE), (2007) Acutely ill patients in hospital. Costing
report, London: NICE.
__________

Chapter 2 - appendix 1
Pulse oximetry
Learning outcomes
Define oxygen saturation and pulse oximetry
Describe the use of pulse oximetry in the assessment of acutely ill adult patients
Discuss the clinical significance of the oxyhaemoglobin curve
Identify factors that effect the accuracy of pulse oximetry.
All cells are dependant on an adequate supply of oxygen; however, as cells have no means by which to store
oxygen, a constant supply must be delivered by an intact respiratory and cardiovascular system. A reduction in
oxygen delivery can lead to organ dyfunction and ultimately death.
Most oxygen is transported in the blood by haemogolbin with only a small amount dissolved in plasma. Each
haemoglobin molecule can bind with up to four oxygen molecules.
The percentage of total haemoglobin that is oxygenated is termed

oxygen saturation (SaO2 or SpO2)
When considering oxygen delivery in the actuely unwell patient, remember to consider the haemoglobin level,
as this determines the oxygen carrying capacity of the blood.
It is essential a note that the affinity (binding capacity) of haemoglobin for oxygen is dependant on several
factors such as temperature, pH and more importantly, the oxygen saturation of the haemoglobin molecule. In
practice this means that within the lungs, haemoglobin molecules have a high affinity for oxygen and oxygen
molecules readily bind to them.
In the tissues, haemoglobin has a lower affinity for oxygen and is prone to release oxygen molecules to the
tissues. This can be graphically represented as the oxyhaemoglobin dissociation curve (Diagram 1). This curve
demonstrates a relationship between saturation of haemoglobin and the partial pressure of arterial oxygen (PaO2).
This relationship is crude, as the curve will shift to the left or the right in different physiological circumstances,
resulting in differing PaO2 levels for the saturation reading obtained from the pulse oximeter.
Figure 3- The oxyhaemoglobin dissociation curve

Clinical signficance of the oxyhaemoglobin dissociation curve
The sigmoid shape of the curve is clinically important for the following reasons:
Falls in PaO2 may be tolerated provided the saturation stays above 90%
Increasing PaO to above normal has minimal impact on oxygen content unless
2
hyperbaric oxygen is administered
The steep portion (slope) of the curve illustrates that a small decrease in PaO can cause large fallls in
2
oxygen content and conversely, increasing the PaO2 by only small amounts can result in effective increases
in oxygen saturation
The patient may have normal or slightly reduced oxygen saturations in the presence of profound
tissue hypoxia. Oxygen saturation monitoring must be accompained with arterial blood gas
sampling in the acutely ill patient.
Left shift of the oxyhaemoglobin dissociation curve

A shift of the curve to the left results in an increased affinity of haemoglobin for oxygen which means that oxygen
binds more readily to haemoglobin. Thus more oxygen can be picked up in the lungs, but it is less readily released
in the capillaries, resulting in possible tissue hypoxia.
Causes of a left shift include:

pH - a decrease in plasma hydrogen ion content (alkalaemia)
CO - decreases in carbon dioxide
2
Temperature - hypothermia
Right shift of the oxyhaemoglobin dissociation curve

This results in a reduction of affinity of haemoglobin for oxygen, meaning less oxygen can be picked up in the
lungs, but oxygen can be more readily given up to the tissues. This lower affinity means more oxygen is required
to achieve the same saturations.
Causes of a right shift include:

pH- an increase in plasma hydrogen ion content (acidaemia)
CO
2
- increase in carbon dioxide
Temperature - hyperthermia
Carbon Monoxide (CO)

Haemoglobin binds with carbon monoxide 240 times more readily than with oxygen and will therefore reduce the
amount of oxygen that can bind to haemoglobin. It is important to note that individuals with carbon monoxide
poisoning can have a normal PaO2 and SpO2, even in the presence of severe hypoxia. Individuals with suspected
carbon monoxide poisoning (e.g. smoke inhalation) must have an arterial blood gas analysed.
Pulse oximetry
Pulse oximetry is a simple non - invasive method of monitoring the percentage of haemoglobin that is saturated
with oxygen, measured within the peripheral circulation (SpO2). Normal range for healthy young adults is

96-98%3. It has become a routine part of monitoring the actuely ill adult as it offers real - time measurement of
oxygenation.
Haemoglobin changes colour depending on its oxygen saturation. Consider the difference in colour between
arterial and venous blood. Pulse oximetry utilises this characterstic. A probe emits two different wavelenghts of
light (one red the other infra red) and depending on the level of oxygen saturation the light will be absorbed to
a greater or lesser degree. The amount of light absorbed is detected by a light sensitive receptor on opposite
sides of the probe. Probes can come in several shapes and sizes e.g. probes are available for fingers, earlobes
and the forehead. It is important to select the most appropriate probe for the patient and use according to
manufacturers recommendations i.e. never use a finger probe on a patients ear.
The signal from the probe is analysed by a monitoring unit which are available in a variety of product styles.
All pulse oximeters will display SpO2, pulse rate and a quality indicator (waveform or signal strength indicator).
Generally pulse oximetry is accurate within a range of oxygen saturations of 70-100% (+/- 2%).
There are several factors that are known to affect the accuracy of pulse oximetry:
Reduce peripheral perfusion - pulse oximetry requires pulsatile blood flow in the area of the probe. Low
flow states/arrhythmias can result in an inadequate signal for analysis
Nail varnish/false nails - may interfere with the transmission of light signal
Bright overhead lights - may interfere with detection of absorbed light
Methylene blue - is a dye used in some surgical procedures and can affect the accuracy of
pulse oximetry
Carboxyhaemoglobin - pulse oximetry cannot distinguish between different types of haemoglobin

complexes e.g. if a patient has 70% oxyhaemoglobin and 20% carboxyhaemoglobin the pulse oximeter
will give reading of 90% even in the presence of severe hypoxia
Summary
Defined oxygen saturation and pulse oximetry

Described the use of pulse oximetry in the assessment of actuely ill adult patient
Disussed the clinical significance of the oxyhaemoglobin curve
dentified the factors that effect the accuracy of pulse oximetry.
References
1. Bassett C.C and Makin L. (2000) Caring for the Seriously III Patient, Arnold, London.
2. Morton P.G., Fontaine D.K. Hudak C.M and Gallo B.M. (2004) Critical Care Nursing:
A Holistic Approach, 8th Edition, Lippincott Williams and Wilkins, Philadelphia.
3. Driscoll B R, Howard L S and Davison (2008) BTS Guide for emegency oxygen use in adult
patients. Thorax, October 2008, 63.
__________

Chapter 2 - appendix 2
The three stages of respiration
Oxygen is essential for life. It is required to perform aerobic respiration for normal cellular function and tissue
survival. Tissue hypoxia occurs within 4 minutes because the oxygen reserves within the body are relatively
small. Therefore, efficient oxygen delivery is essential not only in healthy individuals but in our compromised and
acutely unwell patients.
Oxygen delivery depends on three factors:
Ventilation
External respiration
Internal respiration
Ventilation
Ventilation is the process of moving gas from the atmosphere to the alveoli and back out again. The process aims
to bring oxygen-enriched gases into the alveoli and to remove carbon dioxide from the alveoli and back into the
atmosphere. To enable effective ventilation the upper airway and conducting airway need to be patent.
Examples of problems that can occur at this stage:

Foreign body
Pharyngeal obstruction
Laryngospasm
This is assessed in the A section of the ABCDE approach
External respiration
External respiration refers to the gas exchange occurring in the alveoli. The oxygen delivered to the alveoli
diffuses into the blood from a high concentration gradient to a low concentration gradient. The oxygen-enriched
air has a higher concentration of oxygen than the blood returning to the lungs via the pulmonary artery resulting
in the movement of molecules into the blood. The pulmonary
artery is the only artery in the body that carries deoxygenated blood. It carries blood which has returned to
the heart from the rest of the body, to the lungs. Carbon dioxide is expelled as a waste product and the blood
is refuelled with oxygen. Two main problems can prevent effective external respiration: the inability of the
inspired gas to reach the alveoli or the inability of the pulmonary artery to deliver blood to the alveoli. These two
potential problems are referred to as ventilation and perfusion (V/Q) respectively.
Ventilation Perfusion (V/Q)

To achieve efficient gaseous exchange, it is essential that the flow of gas and the flow of blood are closely
matched. Unfortunately, neither ventilation nor perfusion is uniformly matched throughout the lung. Blood is
gravity dependent and therefore in an upright lung the base as opposed to the apices is favoured. Conversely,
gas tends to rise and favours the apices rather than the bases, thus creating a slight mismatch of ventilation and
perfusion throughout the lung.

In addition to this, pulmonary blood flow (Q) in the textbook patient is around 5 L/min whereas the alveolar
minute ventilation (V) is on average 4 L/min, creating a V/Q mismatch of 0.8. This is an average assumption
for the whole lung, and in reality, different ratios occur for differing segments. In health, gas exchange is not
compromised by this slight but normal mismatch, however, in disease and the acutely unwell individuals; changes
may occur on either the V or Q aspect of this ratio.
Example:
A collapsed area of lung (V) or a plmonary embolism (Q) will both adversely affect the amount of either air
or blood meeting each other to perform gas exchange. Correct positioning of a patient may help to maintain
adequate blood gas results by maintaining and effectively utilising the functioning area of lung.
Patient positioning
Careful patient positoning may help to reduce the patients work of breathing and optimise their oxygenation
and ventilation.
V/Q mismatch can result in inadequate oxygen being diffused into the blood and/or the inability of the blood to
expel its waste product, carbon dioxide. The lung is able to compensate for a proportion of V/Q mismatch until
large areas of the lung are affected, or the patient becomes fatigued or begins to decompesate. Carbon dioxide
has the ability to diffuse across an aqueous membrane at a ratio of 20:1, in comparison to oxygen.
Examples of problems occurring at this stage are:
Pulmonary embolism - resulting in no perfusion to the alveoli

Pneumonia - resulting in no ventilation to the affected alveoli
Pneumothorax
Pulmonary oedema
Hypovolaemia
This is assessed in the B section of the ABCDE approach
Internal respiration
Internal respiration is the process of cellular exchange of oxygen and carbon dioxide. The haemoglobin in the blood
transports oxygen from the lungs to the tissues where it is released and taken up by the tissues for respiration.
The waste product carbonic acid is then carried in te blood to the lungs, where it is released as carbon dioxide
via the process of external respiration. It follows that for internal respiration to occur, haemoglobin levels need to
be within an acceptable range and quality to ensure adequate carriage of oxygen and circulating blood volume.
Blood pressure also needs to be within normal parameters for the patient, to allow for oxygen delivery. If
either of these elements are inefficient, then the tissues are at risk of being starved of vital oxygen. Normal
cellular metabolism is aerobic; utilising oxygen as an essential ingredient. Without oxygen, tissues continue to
metabolise, but do this anaerobically. Anaerobic activity increases the acidic levels in the blood, which in turn is
sensed by the respiratory centres and chemoreceptors, resulting in attempts to compensate and excrete (blow
off) this exces acid by increasing the respiratory rate and depth. In an actuely unwell individuals, this extra load
on the respiratory muscles will increase the speed of onset of fatigue and respiratory muscle failure.

We are unable to greatly influence cellular utilisatio of oxygen, but we must ensure that adequate oxygen is
available to be delivered in the blood to the tissues.
Figure 4 - Gaseous excange by diffusion in tissues
Examples of problems occurring at this stage are:
Hypovolaemia
Anaemia
This is assessed in the C section of the ABCDE approach
__________

3
Assessment and
management
hypotension

Assessment and management of the patient with hypotension
Learning outcomes
To enables the reader to:

Explain the concept and components of blood pressure
State the effects of hypotension on the major organs
Discuss the importance of early recognition and management of hypotension
Define the classifications of shock
hypotension.
What is blood pressure?
The main function of the circulation is to distribute blood around the body. This allows the delivery of oxygen,
nutrients and hormones to the cells and removes waste products.
Blood pressure (BP) is the pressure exerted on the arterial walls by the volume of blood ejected from the heart.
The peak pressure is called systolic pressure and the minimum value is the diastoli pressure. Normal BP varies
greatly among the population. Rather than relying solely on specific figures to define hypotension, where it is
possible , it is a good idea to compare a previous blood pressure recording with the present value in order to
determine normal pressures for that individual.
The components of BP are cardiac output (CO), which is the flow of blood pumped from the
heart, measured in litres/minute, and systemic vascular resistance (SVR), which is the resistance
offered by the vessels against which the heart must pump. Therefore any factors affecting CO or
SVR will impact on BP.
BP = CO X SVR Pressure=Flow X Resistance
(CO = SV X HR)
The Mean Arterial Pressure (MAP) is the average pressure exerted during the cardiac cycle and is directly related
to vital organ perfusion. Stroke volume (SV) is the amount of blood pumped out from the left ventricle in a single
contraction.
MAP = Diastolic + ( Systolic - Diastolic)

3
Hypotension is a late sign of a compromised circulatory system and occurs as the bodys intrinsic
compensatory mechanisms for maintaining homeostasis begin to fail. In the majority of patients,
it is preceded by an increase in respiration and heart rate.

Three factors determine cardiac output
Preload
Preload is the amount of stretch on the cardiac muscle fibres, which is proportional to the amount of blood
returning to the heart. The greater the stretch (cardiac filling pressure), the greater the volume ejected ( starlings
law). Inadequate filling pressures (preload) can lead to a drop in BP.
Common causes of reduced preload :
Haemorrhage
Excessive diarrhoea and vomiting
Sepsis
Burns
Dehydration
Contractility
Contractility is the effectiveness of the heart as a pump on a given preload. A reduction in the force of contraction
can lead to a reduction in BP.
Common causes of reduced contractility:

Arrhythmias
Myocardial Infarction/ischaemia
Heart valve dysfunction
Metabolic / electrolyte disturbances
Tamponade
Afterload
Afterload is often equated to SVR (described on previous page).
Common causes of reduced SVR :
Sepsis
Anaphylaxis
Neurogenic, loss of sympathetic tone (e.g. epidurals and spinal injuries)
Drug overdose
Alteration or failure of one or more of the above will result in inadequate tissue perfusion and oxygenation
leading to organ dysfunction. This clinical syndrome is known as Shock.
Classifications of sock
Hypovolaemic
Cardiogenic
Septic
Anaphylactic
Neruogenic

Signs and symptoms of hypovolaemic shock (preload)
Increased respiratory rate
Increased heart rate Weak thready pulse
Reduced CVP/JVP
Peripheral shutdown - Increases capillary refill time (>2 seconds)
Pale, cool and clammy
Altered level of consciousness
Reduced BP
Signs and symptoms of cardiogenic shock (contractility)

Increased heart rate Weak thready pulse
Reduced CVP/JVP
Peripheral shutdown - Increases capillary refill time (>2 seconds)
Reduced BP
Signs and symptoms of septic, neurogenic, anaphylactic shock (afterload)

Increased heart rate Bounding pulse
Reduced CVP/JVP
Peripheral shutdown - Increases capillary refill time (<2 seconds)
Reduced BP
The effects of hypotension on organ systems
Respiratory The respiratory rate increases in an attempt to compensate for the ineffective circulatory
distribution and inadequate tissue perfusion by recruiting more oxygen.
Cerebral Cerebral blood flow is maintained by auto-regulation over a MAP range of 50-150mmHg. With
a further reduction in BP, the cerebral perfusion decreases and the patient becomes agitated,
confused, drowsy and eventually unresponsive.
Cardiac A reduction in the diastolic pressure leads to inadequate myocardial perfusion, reducing the
effectiveness of the heart as a pump, which increases the heart rate and myocardial oxygen
demands. This may cause ischaemic chest pain, arrhythmias and eventually lead to infarction.
Renal Idealy kidneys require a MAP of between 65-70mmHg. Hypotension reduces urine output and
ultimately leads to impairment of renal function (build up of toxins).
GI tract Reduction in gut perfusion impairs gut motility and nutrient absorption. It also decreases its
capacity to contain the normak bacterial flora, possibly leading to local or systemic infection.

Skin The stress response centralises circulation to preserve perfusion to vital organs at the expense
of the skin, resulting in cool, clammy, grey, sweaty skin peripherally. The exception to this would
be in sepsis when patients may present pink, warm and flushed.
Initial assessment and management of the hypotensive patient



Bag - valve mask
Breathing
Colour of patient
Oxygen saturation
Assessing the Pulse

The patients pulse should be taken manually for one minute, noting the rate, volume and regularity.
It is now common practice to use a non- invasive blood pressure (NIBP) machine to measure the patients BP.
However, the limitations of these machines must be recognised.
Measurements taken from both shocked patients and patients with arrhythmias can be inaccurate and
therefore unreliable. All patients who are acutely ill or who have a systolic BP of less than 90mmHg should
have a manual BP taken. If in any doubt, confirm by taking a manual BP.
Using a cuff that is too small for the patients arm can lead to false high reading and conversely, too large
a cuff can lead to false low readings

Excessive patient movement can lead to erroneous or no readings.
Assessing capillary refill time

To obtain a capillary refill time, pressure is applied to the fingertip (elevated above the level of the heart) for 5
seconds. The pressure is then released and the colour should return in 2 seconds. A prolonged time indicates poor
peripheral circulation; the patients fingers will feel cool with the most likely cause being due to hypoyolaemia.

Conversely, rapid capillary refill may indicate a hyperdynamic state, as seen in sepsis. Caution should be exercised
when interpreting capillary refill time in the presence of peripheral shut down, Raynauds syndrome, hypothermia
or where the patient is receiving vasopressors.
It is important when assessing if the patient requires more fluids that the input and output is reviewed and
insensible loss taken in to consideration.
Management of hypotension
The majority of hypotensive patients require fluid; it is therefore appropriate to administer an intravenous fluid
bolus.
Fluid management
Administer 250mls crystalloid/colloid over 5-10 minutes and assess response. Repeat as necessary inline
with local Patient Group Directives (PGD) and guidelines. Evidence of cardiac failure (chest crackles
indicating pulmonary oedema) should be sought following each bolus. Where this occurs, fluid therapy
must be reduced or stopped, as an alternative means of enhancing tissue perfusion may be required
e.g. inotropes and/or vasopressors.
Caution should be taken with renal and cardiac patients.
Titrate further fluid in accordance with clinical response (see previous). Continuous monitoring of RR, pulse, BP,
ECG, Temperature, SpO2, AVPU and urine output is then required.
Failure to respond to treatment requires senior medical input as the patient may require further monitoring,
investigation, specific intervention and transfer to an area where level 2-3 care can be provided.

Blood glucose level correct Blood Glucose
Pain assessment

and back
Exposure
On examination, pay particular attention to wound sites, drains and abdomen for any obvious signs of
haemorrhage. Also, observe for excessive fluid loss from catheters and any fistulae.
At any point during the assessment and management of the hypotensive patient
you are unsure, call for HELP! and reassess A B C D

Check the patients TPR, fluid balance, fluid prescription and neurological observation charts. Pay particular
attention to the trends in the observations rather than just the absolute values. Look at the patients case notes
and previous medical history- any co-existing disease may help to inform future management decisions and

assessment of the risk of further deterioration. Check the drug prescription chart to ensure that the patient
has received all drugs prescribed if appropriate. Also, check what medications the patient was taking prior to
admission to hospital and assess whether or not it is appropriate to continue or re - prescribe them in the
current clinical setting.
Examine the notes carefully and consider verbal reports from other members of the health care team to aid
understanding of the patients current condition.
Investigations
Review recent investigations and blood results; correct any abnormalities. Decide whether further investigations
are required. These may include:
FBC/ U& Es/group and save/clotting screen/cardiac enzymes/troponin/lactate

Arterail blood gases
Microbiology (blood, urine, sputum, wounds, drainage, tips from invasive medical devices after removal
and CSF)
Ward urinalysis to determine specific gravity
Chest and / or abdominal X-ray
E.C.G
Ultrasound scan
CT scans
Act upon the results of any investigations undertaken.
Monitoring
non - invasive blood pressure, heart rate, temperature, oxygen saturations, FiO2, conscious level1, fluid balance
and hourly urine output.
Track and Trigger Scores must be utilised.
Management plan
then a more specific treatment plan should be outlined. This must be clearly documented in the case notes and
communicated to those staff caring for the patient. Leave clear documented instructions about now often you
require the observations to be performed and what parameters are acceptable. Specify the expected action
where the vital signs (including urine output) fall outside of these parameters. Consider further investigations
and act upon the results. Consider referral to other specialities and/or higher level of care?

Key points
MAP is an indicator of tissue perfusion and oxygen delivery

Patients with cardiovascular compromise require high flow O2
Hypotension is a late sign of cardiovascular compromise and requires prompt attention
Symptomatic hypotensive patients normally required fluid
Obtain senior review and transfer to higher level of care ASAP if not responding to treatment
Summary

Explain the concept and components of blood pressure
State the effects of hypotension on the major organs
Discuss the importance of early recognition and management of hypotension
Define the classifications of shock
hypotension.
References
1. National Institute for Health and Clinical Excellence (NICE), (2007) Acutely III patients in hospital : Recognition
of and response to acute illness in adults in hopital. NICE clinical guideline 50. London : NICE
__________

4
Assessment and
management
of the patients with sepsis
and septic shock

Assessment and management of the patient with sepsis and septic shock
Learning outcomes
To enable the reader to

Define what is meant by the terms SIRS, sepsis and septic shock
List the signs and symptoms of SIRS, sepsis and septic shock
Recognise the development of sepsis and septic shock
Assess and manage the acutely ill patient with developing sepsis
State the rationale for early goal directed therapy
State the content of the resuscitation care bundle
The sepsis syndrome

Sepsis is a highly complex disease continuum, ranging from a simple uncomplicated infection to the development
of severe sepsis and septic shock associated with organ dysfunction 1,2,3.
Figure 5 - The downward spiral of septic shock
Sources- Survive Sepsis Campaign3

Sepsis is difficult to diagnose and treat and the mortality rates associated with severe sepsis and septic shock
remain unacceptably high, with an estimated 36,800 deaths per year in the United Kingdom3. Severe sepsis kills
more people in the UK than lung cancer alone, and more people than breast and bowel cancer combined3.
The reasons for this high mortality rate are multi - factoral1 but include:
Lack of early recognition of the problem

An increasingly elderly population and therefore patients with co-morbidities
An increasing number of immuno - compromised patients
An increase in the use of invasive procedures and devices.

In October 2002, the first stage of the Surviving Sepsis Campaign1,2 to improve the survival from severe sepsis
was initiated with the Barcelona Declaration4. Critical Care and infectious disease experts representing eleven
international organisations came together to consider the available evidence and develop guidance which would
help clinicians manage the disease spectrum. The resulting Survive Sepsis Campaign identified a number of
treatment interventions which would have a significant impact on the management and outcomes for people
suffering from sepsis. The UK Sepsis Group have adapted these guidelines for practical implementation within
NHS Trusts.
Definitions
Systemic Inflammatory Response Syndrome (SIRS) : SIRS is a syndrome characterised by 2 or more defined
physiological parameters.
Infection : microbiological phenomenon characterised by an inflammatory response in the presence of micro-

organisms or by the invasion of normally sterile host tissue by these organisms.
SIRS + Infection = Sepsis
Merinoff Definition of Sepsis
On the 30th September 2010 experts from around the world came together in New Jersey, USA to form what has
become known as the MERINOFF definition of sepsis5.
Sepsis is a life threatening condition that arises when the bodys response to an infection injuries its own tissues
and organs. Sepsis can lead to shock, multiple organ failure and death especially if not recognised early and
treated promptly. Sepsis remains the primary cause of death from infection despite advances in modern medicine,
including vaccines, antibiotics and acute care.
Severe Sepsis: Acute organ dysfunction secondary to infection.
Sepsis + Organ Dysfunction = Severe Sepsis
Septic Shock : Severe sepsis plus hypotension (mean artetial pressure of < 65mmHg or a systolic BP of <90mmHg)
which is not reversed with fluid resuscitation1,2.
Care Bundle : A care bundle is a group of individual elements of care that have been bundled together in order
to achieve the best clinical outcomes for patients with a specific disease process 6 e.g. sepsis, or are undergoing
certain therapies e.g. invasive ventilation.
Early Goal Directed Therapy : Application of a series of therapies which are targeted to achieve pre-determined
phydiological goals e.g. fluid resuscitation to achieve the goal of a mean arterial blood pressure of > 65mmHg1,2,4,7.
Six Hour Resuscitation Bundle: For those who fail to respond to the Sepsis6, the resuscitation bundle should
be implemented. This requires the placement of a central venous catheter and the administration of vaso-active
drugs which can often only be achieved in a critical care unit.
Severe Sepsis Management Bundle: This bundle of care is for those patients who do not respond to the sepsis6
and the six hour resuscitation bundle. These patients will need specialist management in a critical care unit.

Early Identification of Sepsis
Sepsis is a medical emergency which is under appreciated and under recognised3. All patients who become
acutely ill must be assessed using a structured approach including Airway, Breathing, Circulation, Disability,
Exposure (A,B,C,D,E) as detailed in chapter 1. In addition, where sepsis is suspected, the Survive Sepsis screening
tool (below) should be used 8. This tool will enable staff to quickly assess and identify patients with systemic
inflammatory response syndrome (SIRS) and screen for the presence of sepsis and severe sepsis.
A patient who has any of the listed signs and symptoms of infection in addition to a history suggestive of infection
can be diagnosed as having sepsis. If sepsis is diagnosed, commence the Sepsis 6 and continue to screen for signs
of organ dysfunction which may indicate severe sepsis and septic
shock. If the results of the sepsis screening tool indicate that the patient has sepsis or severe sepsis, then the
Sepsis 6 must be delivered within one hour. Continuous assessment of the patient is necessary during this time
as the patient may continue to deteriorate and require further intervention.
The UK Sepsis Group 8 believes the greatest improvements can be made in outcomes by delivery of goal directed
therapy by those caring directly for the people in the acute hospital setting i.e. non intensive care unit (ICU)
environments.
It is importance to note that the speed and appropriateness of treatment administered in the early development
of the syndrome is highly likely to influence outcomes1,2,3,7,9.

Early Management of Sepsis
Sepsis 6
The first hour care duties are achievable within any acute care setting. The recommendation are based on
early goal directed therapy that is each treatment has a clearly defined goal that should be achieved during
the management of the septic patient as follow:
1. Oxygen: Give high flow oxygen 15L/min via a high concentration mask with reservoir bag.
Goal : The British Thoracic Society guidelines 10 recommend that in acute/critical illness oxygen therapy
should be commenced at 15L/min and then once stable, Oxygen should be titrated to achieve target
saturations of 94-98%. If the patient has been diagnosed with Chronic Obstructive Pulmonary Disease,
the target saturations should be adjusted accordingly upon review by a senior member of the parent
team (see chapter on breathing problems).
2. Blood Cultures: Take percutaneous blood cultures and further blood cultures from any vascular access
device that has been in situ for longer than 48hours. Where possible take blood cultures prior to
administration of antibiotics, however, DO NOT DELAY antibiotics where cultures cannot be obtained.
Take a full microbiological screen; consider sending C&S samples from any suspicious sites e.g. urine,
sputum, throat, wound sites, and take a full blood screen including FBC, U&Es, LFTs clotting screen and
glucose.
Goal: To identify the source of infection to guide ongoing antibiotic therapy and assess organ function.
3. IV Antibiotics: Administer broad spectrum antibiotics in accordance with your Truts policies and
guidelines.
Goal: Antibiotics must be administered within 1 hour of diagnosis. Delays in administration increase
mortality by 7.6% per hour9
4. Fluid Resuscitation : Provide adequate fluid resuscitation. If hypotensive, give boluses of either Normal
Saline 0.9% or Hartmanns Solution 20mls/kg up to a maximum of 60mls/kg and monitor response.
Goal : To maintain MAP> 65mmHg to ensure adequate tissue perfusion and prevent organ dysfunction.
Exercise caution in cardiac and renal patients.
5. Lactate and haemoglobin : Take blood for serum lactate and Hb.
Goal : To optimise tissue oxygenation, monitor tissue hypo - perfusion and response to treatment.
Consider blood transfusion if Hb < 7g/dl. Increasing lactate levels require further senior review.
6. Monitor Urine Output: Measure urine output and consider the need for urinary catheterisation.
Goal: To monitor urine output and detect early organ dysfunction. Aim for at least 0.5ml/kg/hr.

Ongoing Management
Source control
Attempts should be made to establish the source of infection and determine whether any intervention is
necessary e.g. excision and drainage of abscess, remove or replace any suspect intravascular devices. Obtain a
full microbiological screen including blood cultures, swabs, urine and sputum.
Monitoring and management plans
All patients who are receiving treatment for sepsis must have a clear physiological monitoring and clinical
management plan which has been documented in the patients records and communicated to the multi
professional team. Patients should be re-screened regularly for signs of the development of organ dysfunction,
indicating severe sepsis and septic shock. When severe sepsis and septic shock are identified, the six hour
resuscitation bundle should be implemented and escalation to critical care may be necessary.
More detailed information regarding the management of severe sepsis and septic shock can be obtained from
the listed references.

Summary :

Define what is meant by the terms SIRS, sepsis and septic shock
List the signs and symptoms of SIRS, sepsis and septic shock
Recognise the development of sepsis and septic shock
Assess and manage the acutely ill patient with developing sepsis
State the rationale for early goal directed therapy
State the content of the resuscitation care bundle
References :
1. Dellinger, P., Carlet, Masur, JM., Gerlach, H T(2008) Surviving Sepsis Campaign: International Guidelines
for the management of severe sepsis and septic shock. International Surviving Sepsis Campaign Guidelines
Committee 2. Critical Care Medicine, vol. 36, pp. 296 - 327
2. Townsend, S., Dellinger, R.P., Levy, M., and Ramsay. G., (2005) Implementing the surviving sepsis campaign,
International Sepsis Forum. Available at : http://www.survivingsepsis.org
3. Daniels, R., (2009) Survive Sepsis. The UK training programme for the surviving sepsis campaign, 2nd edition,
Sutton Coalfield : Survive Sepsis
4. Dellinger, R.P., Carlet, J.M., Masur, JM., Gerlach, H.T., Calandra, T., Cohen, J., Gea-Banacloche, J., Keh, D.,
Marshall, J.C., Parker, M.M., Ramsay, G ., Zimmerman, J.L., Vincent, J.L., Levy, M.M., (2004) Surviving Sepsis
campaign guidelines for the management of severe sepsis and septic shock. Critical Care Medicine, vol. 32,
pp. 858-873
5. Czura, C., (2011) Merinoff Syposium 2010: Sepsis - Speaking with One Voice. Molecular Medicine, vol. 17 pp.
(1-2) : 2-3 available on line at : http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3022986/
6. http://www.eng.mapofmedicine.com/evidence/map/care_bundles1.html
7. Rivers, M., Nguyen, B., Havstad, S., Knoblich, B., Peterson, E., Tamlanovich, M.,(2001) Early Goal
Directed Therapy in the treatment of severe sepsis ans septic shock. New England Journal of Medicine,
vol.345,pp.1368-1377.
8. UK Sepsis Group (2011) UK Sepsis Group (Homepage). Available from http://www.uksepsis.org/
9. Kumar, A., Roberst, D., Wood, K.E., Light, B., Parrillo, J.E., Sharma, S., Suppes, R., Feinstein, D., Zanotti, S.,
Tailberg, L., Gurka, D.,Kumar, A., Cheang, M. (2006) Duration of hypotension before initiation of effective
antimicrobial therapy is the critical determinant of survival in human septic shock. Critical Care Medicine, vol.
34, pp. 1589 - 1596
10. Driscoll, B.R., Howard, L.S., Davison, A.G., (2008) British Thoracic Society Guide for Emergency Oxygen use in
Adult Patients. Throax, vol.63, Suppl 6 : vi 1-68.
__________

5
Assessment and
management
of the patients with poor
urine output

Assessment and management of the patient with poor urine output
Learning outcomes

List the factors that influence the production of urine
Summarise the definition associated with low urine output
State the causes of renal impairment
List the signs and symptoms associated with poor renal function
Explain the importance of managing oliguria in a timely manner
Describe the systematic approach to assessment, monitoring and management of the patient with a
poor urine output
The kidneys are organs of homeostasis, their main function include :
Filtration of the blood to remove waste products of metabolism such as urea and creatinine
Regulation of the extracellular fluid component
Regulation of electrolyte balance (sodium, potassium)
Regulation of acid base balance
Important endocrine function e.g. Renin - Angiotensin system
The kidneys require significant amounts of oxygen and an adequate perfusion pressure to maintain normal renal
function. To allow glomerular filtration to take place and meet the kidneys metabolic demands, a renal blood
flow of between 1000 - 1200 ml per minute is required. This equates to as much as 25% of the total cardiac
output.
As a result of their high metabolic demands, the kidneys are particularly susceptible to impairment due to
hypoxic insult and low flow (perfusion) states, and therefore urine output offers a useful marker of cardiovascular
function in general, as discussed earlier (see chapter 3).
Acute kidney injury (AKI) manifests as a reduction in urine output and disruption of the main renal function,
leading to uraemia , acidosis, hyperkalaemia and potential fluid overload.
Definitions
Oliguria = < 0.5 mls/kg/hr

Anuria = < 100 mls/24 hours
N.B. Mechanical obstruction to flow must be excluded before a diagnosis of anuria can be made.
Normal renal function and production of urine is dependent on three factors:
An adequate blood flow and perfusion pressure to the kidneys
Normal functioning kidneys
No obstruction to the flow of urine

Adequate blood flow and perfusion :
Renal blood flow is influenced by systolic blood pressure and a mechanism known as auto - regulation, which
allows renal blood flow to remain constant over a range of blood pressures. Problems occur when the mean
arterial pressure falls below the lower limit of the individuals auto-regulation threshold. (N.B.patients who are
normally hypertensive will require higher mean arterial blood pressure for auto-regulation to occur).
Figure - 6 Renal Blood Flow and Urine Output
Acute kidney injury

This is defined as a sudden (and potentially reversible) failure of the kidneys to excrete metabolic waste products.
Acute kidney injury may be due to pre renal causes, post renal causes or intrinsic renal damage. Early recognition,
diagnosis and treatment can reverse potential renal failure, which if allowed to develop, will dramatically increase
mortality and morbidity. In adults, adequate urine output averages 0.5 - 1ml/kg/hr. An output of <0.5mls/kg/hr
for more than 2 consecutive hours is defined as oliguria and may require intervention. All patients admitted as
an emergency should have their electrolytes checked and assessment for AKI should be carried out.
Pre renal causes: inadequate renal perfusion

Causes include hypovolaemia, hypotension, low cardiac output and low renal blood flow. Patients with normal
kidney function may develop acute kidney injury because of reduced renal perfusion, commonly caused by
hypovolaemia, dehydration, shock and sepsis. At particular risk are those patients who already have compromised
renal function, such as the elderly or patients with co-existing pathology e.g. hypertension, peripheral vascular
disease, diabetes, cardiac failure, pancreatitis and liver impairment. If resuscitation is adequate and perfusion is
restored promptly, this type of acute renal failure is entirely reversible.
Post renal causes: obstruction to the flow of urine
Causes include blocked/misplaced catheter, renal stones/calculi, enlarged prostate gland and trauma. The most
likely cause of anuria is mechanical obstruction. Examiantion of the patient may reveal the presence of a palpable
bladder. Patients with indwelling urinary catheters who present with anuria must have the patency of the
catheter checked by an experienced practitioner, as this is often easily managed by flushing and/or repositioning
the urinary catheter. Other causes include a possible obstruction higher in the renal tract e.g. ureteric stricture
and requires imaging (ultrasound) and urological input.

Acute kidney injury may be due to pre-renal, post renal causes or inrinsic kidney damage
Acute Intrinsic Renal Damage

This refers to impairment of renal function despite correction of haemodynamic ( pre renal) and obstructive
(post renal) factors. The many causes include nephrotoxins, glomerular disease, nephritis, rhabdomyolis and
vascular disease within the kidneys and renal arteties. If the diagnosis is in doubt, a nephrologist opinion may
be required. Patients at risk, or suffering from AKI should be identified promptly and receive high quality care in
partnership with specialist teams.
Common nephrotoxins used in clinical practice
Aminoglycosides (Gentamicin)
NSAIDs including Aspirin
ACE inhibitors
Furosemide (Frusemide)
Radiological Contrast Media
Penicillins
Cephalosporins
Cyclosporins
The glomerulli also can be damaged by nephrotic disease processes (glomerulonerphritis) and by rhabdomyolysis
secondary to other factors e.g. uncontrolled seizure activity, crush injury, alcohol withdrawal and burns.
The term acute tubular necrosis (ATN) is often used to describe the acute kidney injury seen in critically ill
patients. However the term is a misnomer as necrosis is not reversible. This form of acute kidney injury is most
often due to pre - renal causes. Once developed it runs a protracted course though renal function often returns.
Signs and symptoms of acute kidney injury
Oliguria / anuria
Failure to excrete metabolic waste such as urea resulting in uraemic sysptoms e.g. nausea, itching,
hiccoughs, twitching, altered level of consciousness and platelet dysfunction
Failure to regulate potassium balance resulting in hyperkalaemia
Failure to regulate acid - base balance resulting in metabolic acidosis
Failure to excrete certain drugs resulting in drug toxicity
Effects of Acute kidney Injury on other organs

Respiratory Metabolic acidosis causes an increase in respiratory rate (compensatory hyperventilation) fluid
overload may result in pulmonary oedema which is characterised by an increase in respiratory
rate,the production of pink frothy sputum (severe), crackles throughout the lung fields on
auscultation and a significant reduction in oxygen saturations.
Cardiac Abnormalities in serum potassium levels may result in cardiac arrhythmias and myocardial
depression causing hypotension. Fluid overload may precipitate cardiac failure. Patients often
develop AKI as a result of significant hypotension due to any cause.
Cerebral With increasing levels of urea the patients becomes confused, drowsy and eventually
unresponsive. Hyponatraemia may cause cerebral oedema resulting in fits and coma. Altered

levels of consciousness may affect the patients ability to maintain a patient airway.
Gl tract Uraemia causes nausea and vomiting, resulting in further fluid depletion and acidosis.
Skin Pruritis may develop as a result of high levels of urea. Scratching can cause superficial skin
infections.
Initial assessment and management of the patient with a poor urine output
The main aim of treatment is to prevent the development of acute kidney injury by early recognition of the
problem and aggressive management of the precipitating cause.
If recognised and treated early, acute kidney injury can be reversed
As with all other acutely ill patients, use the structured AIM approach to assess adverse clinical signs.

As the kidneys are particularly susceptible to hpoxaemia, all patients must receive high flow oxygen via a high
concentration mask and oxygen saturations should be maintained between 94-98%. If a patient is known to
have COPD and has a documented risk of hypercapnic respiratory failure the goal should be to maintain oxygen
saturations closer to their normal range of 88-92%1. If the patient exhibits a reduced conscious level, careful
attention must be paid to the patency of the airway.


Bag - valve mask
Breathing
Colour of aptient
Oxygen saturation
Note any increase in respiratory rate which may be a result of metabolic acidosis. Look for evidence of pulmonary
oedema, including pink frothy sputum and bilateral basal crackles. Respiratory failure may develop.


Poor perfusion is by far the commonest cause of renal impairment; ensure that hypovolaemia is corrected before
considering any other treatment options in the patient with a poor urine output. Exclude mechanical obstruction.
Ensure accurate fluid balance is recorded including the monitoring of hourly urine output volumes.
Cardiac arrythmias may occur in patients with hyper/hypokalaemia and it is important to obtain a manual pulse
rate. In the presence of abnormal electrolytes, an ECG must be recorded and assessed by an experienced clinician.
Where adequate perfusion and oxygenation cannot be achieved,

the patient must be referred to a higher level of care

Pain assessment
Beware of the effects of urameia and electrolyte imbalance on conscious level. Encephalopathy may be a
complication of AKI.

and back
Exposure

you are unsure, call for HELP ! and reassess A B C D E.
Review notes and charts
Pay particular attention to the trends in the observations rather than just the absolute values. Look at the
patients case notes and previous medical history - any co-existing disease may help to inform future management
decisions and assessment of risk of further deterioration. Check what medications the patient was taking prior to
admission to hospital and assess whether or not it is appropriate to continue or re-prescribe them in the current
clinical setting (especially diuretic therapy). Review the type of medication (particularly nephrotoxins) and fluids
that have been prescribed and whether they have been administered. Assess and correct fluid balance status.
Check prescription chart and stop diuretics and nephrotoxic drugs where appropriate.
The dose of some drugs may need to be altered in the presence of acute kidney injury.
Sepsis is a common cause of acute kidney injury - undertake sepsis screen and
follow sepsis guidance (see chapter 4).
Examine the notes carefully (re: co-morbidities) and discuss patient with other members of the health care team
to aid understanding the patients current condition.

Investigations
are required. These may include :
FBC/U&Es/group and save/clotting screen/cardiac enzymes/troponin/lactate/immunology
Arterial blood gases
Microbiology (blood, urine, sputum, wounds,drainage, tips from invasive medical devices after removal
and CSF)
Ward urinalysis to determine specific gravity and detect abnormalities
Chest and/or abdominal X-ray
E.C.G
Ultrasound scan
CT scan
Act upon the results of any investigations undertaken. Pay particular attention to the urea and creatinine values
and trends. Ensure the serum potassium levels are observed and treated where necessary - seek expert help if
you are unsure. U&Es and arterial blood gases may need to be obtained at least twice daily depending upon the
clinical condition.
Monitoring
non - invasive blood pressure, heart rate, temperature, oxygen saturations, FiO2, conscious level and urine
output. Continuous cardiac monitoring will be required if patient hyper/hypokalaemic. Observations must be
recorded regularly and any further deterioration warrants a further assessment of ABCDE. A track and trigger
score should be utilised.
Hourly urine output and fluid balance must be monitored and charted
Management Plan
signs ( including urine output) fall outside of these parameters. Consider further investigations and act upon the


Summary
List the factors that influence the production of urine

Summarise the definitions associated with low urine output
State the causes of renal impairment
List the signs and symptoms associated with poor renal function
Explain the importance of managing oliguria in a timely manner
Describe the systematic approach to assessment, monitoring and management of the patient with a

poor urine output.
Reference
1. Driscoll, B.R., Howard, L.S., and Davison, A.G., (2008) British Thoracic Society Guide for emergency oxygen use
in adult patients. thorax, vol. 63, suppl 6: vi 1-68.
__________

6
Assessment and
management
an altered level of
consciousness

Assessment and management of the patient with an altered level of consciousness
Learning outcomes
To reader should be able to:

Describe general brain anatomy and physiology.
Explain that problems with A,B or C may impact upon D, and that problems with D may impact on A, B
and/or C
Describe the AVPU scale and the Glasgow Coma Score (GCS)
Explain the rationale for checking pupil size and reactivity
State the importance of repeated assessment in order to establish clinical status of the patient
State the importance of recording blood glucose and electrolytes in the patient with an altered level of
consciousness
Describe the end organ effects of an altered level of consciousness
Describe the key treatment interventions for the patient with an altered level of consciousness
Describe the systematic approach to assessment, monitoring and management of the patient with an
altered level of consciousness
An altered level of consciousness (ALOC) is defined as an altered state of awareness, and/or disorientation to time,
place, purpose or person. An ALOC presents in a variety of forms including confusion lethargy, disorientation,
impaired cognition or coma. ALOC can happen suddenly or develop slowly over a matter of hours, days or weeks.
It is absolutely imperative to ensure that an accurate evaluation of the level of consciousness (LOC) is carried out
and documented. A baseline assessment of the patient is useful in establishing whether alterations are indeed
an acute deterioration for the patient, or is in keeping with that which is considered normal for a patient.
A continuous supply of oxygen is required for normal brain function. Lack of oxygen to the brain for 4
minutes or more may result in significant injury and death
The brain uses glucose for its energy requirements and has no ability to store it; therefore a continuous
supply is required for the brain to function normally.
The brainstem (comprising the midbrain, medulla, and pons) controls the cardiac, respiratory, and vasomotor
control centres; as well as visual and auditory impulses. One of the functions of the brainstem (specifically the
reticular activating system in the medulla) is the control and maintenance of consciousness. It is movement and
sensory information from our sensory organs and from other centres in the brain that keep us awake. Without
stimulation, we fall asleep. Coma and anaesthesia differ from sleep because the patient cannot be roused from
them. Anaeshesia is a from of drug - induced coma, which is reversible and controllable.
Everything we normally do whilst conscious, such as keeping warm and moving our limbs to prevent soreness
must be done for us when in coma. Most importantly, the comatosed patient must be considered to have an
actual or impending airway obstruction and, due to the loss of gag/cough reflex they are unable to prevent the
airway from being compromised by aspiration of stomach contents into their lungs.
Alteration in conscious levels, regardless of the cause, renders the patient dependant upon others to maintain
physical safety. In particular, the patient is at potential or actual risk of losing the ability to protect the airway if
their AVPU score is P or below and/or if the GCS is 8 or less.

Neurological assessment
Neurological assessment is undertaken for patient who have an acute or potential neurological injury. Changes
in neurological status can be slow, such as in the case of extension of a cerebral infarction, or rapid, such as
in the case of brain herniation. When used in conjunction with the assessment of ABCDE, it can provide vital
information that, when acted upon, can save lives.
Aims of the neurological assessment include:
The establishment of a baseline
A determination of changes from the baseline
A determination of acute neurological changes
Knowledge of basic anatomy and physiology is vital to carry out an accurate neurological assessment and enables
the comparison and contrast the patients neurological condition. The content of this chapter is intended to
provide an overview and the reader should consult established medical texts for more detailed information.
All altered level of consciousness may be due to a primary brain condition or due to systemic disturbance which
affects the brain (secondary causes).
Primary Secondary
Thrombotic or haemorrhagic event Hypoxia
Seizures/Eclampsia Hypo/hyperglycaemia
Tumour Hypotension
Abscess Drugs
Infection e.g.meningitis Alcohol
Trauma Metabolic e.g. raised urea or ammonia
Please note: This list is not exhaustive.
Tools to assess conscious levels

AVPU
The simplest assessment tool is known as the AVPU scale. This is an objective, user-friendly tool which can
be readily used to communicate information about conscious level. It is not: however, a sensitive method for
charting trends of neurological deterioration.
A Alert - Conscious but may be confused and able to answer correctly: name,
date, time location, what happend
V Responds to Voice - Not alert, is semiconscious but responds to shouts or questions, even
if only groans or moans
P Responds to Pain - Moves or groans in response to pain
U Unresponsive - No response at all is elicited.

Glasgow Coma Scale
A more comprehensive and sensitive tool for assessing patients with ALOC is the Glasgow Coma Scale; it is a semi
- quantitative assessment of goal neurological function. The patients best response to the environment is scored
(eye opening, verbalisation and movement).
GLASGOW COMA SCALE
Type Assessment Score

Eye Opening (E) Spontaneously 4
To Speech 3
To Pain 2
None 1
Best Verbal Response (V) Orientated 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No Response 1
Best Motors Response (M) Obeys 6
Localises 5
Withdraws to pain 4
Abnormal Flexion (Decorticate) 3
Extensor Response(Decerebrate) 2
No Response 1
TOTAL SCORE E+V+B= total score 3-15
A score of 15 denotes a fully conscious patient, less than 8 denotes a coma, and the lowest score obtainable is 3.
Do not confuse verbalisation with vocalisation - a patient with a tracheostomy may be fully orientated and able
to score 5 for best verbal response. For a more accurate handover the score should be described by breaking
down the 3 sections, e.g. If the patients GCS is 12, it provides more information if that is communicated as Eyes
= 4, Motor = 5, Verbal = 3, or you may see it documented as E4, M5, V3. If the total score is being communicated,
to avoid confusion the denominator should be specified, for example 12/15 1.
It is recommended that two persons carry out a neurological assessment together on handover of care to
establish a consensus baseline for the continuation of observations.
In addition it is important to record the blood glucose level as part of a full neurological assessment.
Head injuries:
There are various elements to a thorough assessment that can be used to determine a patients condition. The
NICE guidelines 1 for the management of head injuries state that the minimum documented observations for the
patient presenting with a head injury are as follows:-

Glasgow Coma Scale (GCS)
Pupil size and reactivity
Limb movement
Respiratory rate
Heart rate
Blood pressure
Temperature
Oxygen saturations
It is important to note that Airway, Breathing and Circulation should be stabilised before attending to other
injuries 1.
Frequency of observations
It is recommended that the frequency of observations is as follows :
Half hourly initially until the GCS returns to 15, then if the GCS remains stable reduce to hourly for 4 hours then
2 hourly thereafter. If the patients condition deteriorates, then the frequency of observations must revert to the
original schedule 1.
Use the structured approach to maintain the patients safety

The most common cause of airway compromise in the critically ill is reduced conscious level
The airway MUST be protected in the unconscious patient
LOOK
Use the taught airway manoeuvres to ensure patency of the airway, removing any obstructions. Immediate help
must be sought if there are any signs of narrowing or other severe problems with patency (See Chapter 1 and 2).
This may be in the form of an anaesthetist or the Cardiac Arrest or Medical Emergency Team.
LISTEN
Ask the patient questions to assess orientation to time, place, person, etc.
FEEL
Feel for breathing at the mouth and nose. The UK resuscitation guidelines2 must be followed if no signs of
respiration are felt.

When consciousness is impaired to the point at which the patient cannot be roused (P on AVPU Score or 8 on
GCS scale), placing the patient in the recovery position will protect the airway. As unconsciousness deepens, the
jaw may need to be supported to prevent the tongue and lax airway from obstructing the passage of air in and
out of the trachea. Inserting an airway adjunct enables the movement of gas but does not protect the airway
from gastric aspiration; this can only be achieved by intubation of the trachea with a cuffed endo - tracheal
tube.
The technique of intubation is highly skilled and should only be performed by those competent to do so. It is
particularly important that patients who have suspected raised intracranial pressure are well sedated during
intubation to avoid a sympathetically stimulated increase in intracranial pressure. Also care needs to be taken
with patients who have suspected cervical spine injury and the cervical spine should be immobilised.


Bag - valve mask
Breathing
Colour of patient
Oxygen saturation
Conditions that affect the brain and subsequent ALOC can affect the respiratory rate and pattern. An acute rise
in intracranial pressure would initially cause a slowing of the respiration rate, followed by an increase in rate as
the brain stem becomes affected.
Patients can develop rapid shallow breathing or Cheyne - Stoke pattern of breathing. This may indicate deep
cerebral or cerebellar lesions or upper brain stem involvement . This can cause the patient to become exhausted
and require endotracheal intubation and ventilation.
Positioning of the patient with neurological disorders is extremely important. In the situation where airway
patency is compromised it is recommended that the patient is initially placed in the recovery position where
their condition permits. Otherwise normal body alignment should be maintained together with a head up tilt
of between 30 and 40 degrees. This helps to reduce the intracranial pressure by assisting venous drainage from
the brain and the circulation of cerebrospinal fluid.
It is crucial to ensure adequate oxygenation, and assessment of arterial blood gases is very useful at this stage.
Remember : hypoxia kills quickly, hypercarbia kills slowly
(See Chapter 1 for specific treatment of breathing difficulties).


The brain is dependent upon a narrow margin of blood pressure in order to maintain its homeostasis/auto-
regulation mechanism. A fall in blood pressure does not cause a drop in cerebral perfusion in a normal brain,
because the auto - regulation mechanism maintains the cerebral blood flow at a constant level by adjusting
the blood vessel diameter. The Mean Arterial Blood Pressure (MAP) must be maintained at 50 - 150mmHg to
enable this auto - regulation. Outside these pressure; auto - regulation fails. After brain injury, auto - regulation
is impaired and hypotension may have more drastic effects and must be treated.
If a patient is hypotensive, the blood pressure must be normalised or brought within acceptable ranges before
accurately assessing LOC. Hypotension will cause further brain injury and must be corrected immediately.
(See chapter 3).
Hypertension in the neurological patient may be associated with sympathetic stimulation resulting from massive
hypothalamic discharge or a rising intracranial pressure.
The Cushing reflex is of significance as it is an observable physiological manifestation of the effects of alterations
in intracranial anatomy. It is vital to recognise the gravity of these developments and understand their origin and
significance.
The patient will develop:

Hypertension
Bradycardia
Respiratory irregularity
The discovery of the Cushing Reflex is a final warning that the intracranial pressure is dangerously high and
urgent expert help must be summoned.
Assess the rate, rhythm and quality of the pulse:

Tachycardia may indicate hypoxia, high intracranial pressure or haemorrhage at other sites
Bradycardia occurs in the terminal stages of raised intracranial pressure as part of the Cushing response
Cardiac arrhythmias are seen commonly in patients with blood in the CSF e.g. subarachnoid haemorrhage,
head injury, following posterior fossa surgery and in those with high intracranial pressure.
Damage to the brain stem or the hypothalamus can cause irregularities in temperature control, however, non -
neurological reasons for changes in temperature such as infection must also be considered.

Pain assessment
LOOK
Look for signs of ALOC. Drowsiness, lethargy, inability to talk, agitation, changes in mood, i.e. aggressiveness
(often a sign of hypoxia). Does the person open eyes spontaneously on your approach?

Pupil size and Response
Assess if the pupils are equal and note their reaction to light (brisk or sluggish). Look for consensual response
and pupil abnormalities. The pupils response to light from a pen torch is useful in establishing if the problem
lies within the brain. The pupils should be equal and constrict briskly in response to light. This demonstrates that
the reflex arc of the optic nerve and occulomotor nerve are working. If the pupils are dilated, this could indicate
drug intoxication. A unilateral dilated pupil is seen in some disease states but is an important sign of intracranial
haemorrhage and should not be ignored; it may mean that an urgent CT scan and decompression of the brain
are necessary. Bilateral constricted pupils are seen in opiate overdose and in brainstem infarction.
Blood Glucose: Check a blood glucose level.
If the blood glucose level is low then appropriate action should be taken. Refer to your local trust guidelines.
The Resuscitation Council (UK) (2010) advocates that if the blood glucose is found to be below 4mmol/L
intravenous dextrose should be administered. Blood glucose should then be re- checked after a fifteen
minute interval 2,3.
LISTEN
Listen for answers to specific questions to determine if the patient is confused or orientated to time,place,
person etc.
FEEL
Skin colour and temperature may help to identify problems with airway, breathing or circulation that may require
intervention. For example if there is central cyanosis the brain will not be receiving enough oxygen.
Assess reflexes
The patients muscle tone can be briefly assessed bilaterally. Hypertonus is a sign of CVA or stroke, hypotonic
patients may have spinal cord injury or drug induced coma.
Given enough time, the reflexes can be elicited to identify any unilateral brain or spinal cord problems. They
maybe exaggerated in some metabolic disease states or neurological illnesses.

and back
Exposure
Patients that are immobile are at risk of pressure sores, DVT, pulmonary emboli, pneumonia and heat loss. All
essential care must be given in order to maintain a safe environment and prevent such complications arising.

Patient History is very important in determining the cause of ALOC :

Onset - Ask: What was the patient doing at onset? Activity during onset can reveal several clues e.g.,
strenuous activity in a seventy- two year old might precipitate a CVA. Did it start quickly or did it come on
gradually?
Duration
Course and Character of the condition: static/progressive? Are there any exacerbating/relieving factors?
Associated Symptoms - Are there headaches, nausea, vomiting, pain or seizures?
Diagnosis - Have there been previous diagnostic attempts?
Previous Therapy - What have been the previous interventions and responses to treatments?
Pain - What are the factors: radiation,severity or quantity, quality? Are there any precipitating and relieving
factors?
Particular to the neurological system are:

Mood changes.
Sleep disturbances
Changes in vision taste smell or hearing
Dizziness/blackouts
Balance problems
Numbness/pins and needles in body, arms, legs or face
Weakness, heaviness or clumsiness of limbs
Trouble with walking
Problems relating to sexual function
Changes in bowel function and control
Problems talking, chewing or swallowing
Remember AEIOU TIPS to help determine causes of ALOC

There are many different causes of ALOC. You can use the mnemonic AEIOU TIPS to help determine causes.
A Alcohol or Acidosis
E Epilepsy, Environment or Electricity
I Insulin
O Overdose
U Uraemia[Toxic state of the blood caused by kidney (renal) failure]
T Trauma
I Infection
P Poisoning or Psychosis
S Seizure, Stroke or Shock
Investigations
Hypoxia, hypercapnia, hypotension and hypoglycaemia are all important reversible causes of secondary brain
injury. Pay particular attention to the urea and electrolyte results as abnormalities may assist in the development
of a diagnosis.
are required. This may include:

CT scan: for suspected space-occupying lesions/bleeding or the presence of lateralising signs (e.g.large
pupil)
Lumbar puncture : (exclude raised ICP first) - meningitis, encephalitis
EEG : (specialist interpretation)
Cerebral Angiography
FBC/U & Es/blood glucose/liver function tests/ group and save/clotting screen/ cardiac enzymes/troponin/
lactate
Microbiology (blood, urine, sputum, wounds, drainage, tips from invasive medical devices after removal
and CSF)
E.C.G.
Essential blood tests:

Blood sugar: Diabetes - hypo/hyperglycaemia
U&E : Hyponatraemia and uraemia
ABG : Hypoxia and hypercapnia
Toxicology screen : Overdose
LFT : Encephalopathy
Remember that patients with an altered level of consciousness or deteriorating level of

consciousness must have urgent investigations and treatment
Monitoring
Ensure frequent and repeated recordings of GCS and/or AVPU. Report any deterioration as a matter of urgency.
non - invasive blood pressure, heart rate, temperature, oxygen saturations, FiO 2, conscious level and urine
output.
A Track and Trigger score should be utilised.
Management Plan
Diagnosis yes/no- Send for expert help if diagnosis uncertain

signs (including urine output) fall outside of these parameters. Consider further investigations and act upon the

you are unsure, call for HELP ! and reassess A B C D E
Summary
To reader should be able to:

Describe general brain anatomy and physiology
Explain that problems with A, B or C may imapct upon D, and that problems with D may impact on
A,B or C
Describe the AVPU scale and the Glasgow Coma Score
Explain the rationale for checking pupil size and reactivity
State the importance of repeated assessment in order to establish clinical status of the patient
State the importance of recording blood glucose and electrolytes in the patient with an altered
level of consciousness
Describe the end organ effects of an altered level of consciousness
Describe the key treatment interventions for the patient with an altered level of Consciousness
Describe the key treatment interventions for the patient with an altered level of consciousness
Describe the systematic approach to assessment, monitoring and management of the Patient with an
altered level of consciousness.
References:
1. National Institute for Health and Clinical Excellence (NICE), (2007) Head Injury: Triage, assessment,
investigation and early management of infants, children and adults, Clinical Guideline 56. London: NICE
2. Resuscitation Council UK, (2010) Advanced Life Support Manual, 6th edition. London: Resuscitation Council
UK
3. Soar, J., Nolan, J., Perkins, G..,Scott, M., Goodman, N., and Mitchell, S., (2006) Intermediate Life Support, 2nd
edition. London: Resuscitation Council UK
4. Van den Berghe, Wounters, P., Weekers, F., Verwaest, C., Bruynickx, F., Schetz, and Bouillion, R., (2001)
Intensive Insulin Therapy in Critically III Patients. The New England Journal Medicine, Vol. 345 no. 19 pp.
1359-67
__________

7
Assessment and
management of the
patients with acute pain

Assessment and management of the patient with acute pain
Learning Outcomes

Describe the concept of acute pain
List the effects of uncontrolled pain
Describe how a pain assessment is performed
List the different groups of analgesia
State the various routes of administration
Explain the management of analgesia related side effects
Describe the systematic approach to assessment and management of the patient with acute pain
What is pain?
A well known quote from Mc Caffery1 states that pain is what the patient says it is and occurs whenever the
patient says it does.
Pain is a multidimensional experience which may affect anyone throughout their lives. According to Melzack and
Wall2, it is a complex experience comprising of sensory, emotional and cognitive dimensions. In addition to this,
a number of psychosocial factors influence an individuals pain. Patients may be anxious about the outcome of
surgery or how their pain will be controlled, particularly if they have bad memories of previous pain experience3.
Anxiety in turn exacerbates pain by increasing muscle tension. Providing patients with appropriate support and
information to address these concerns can reduce both anxiety and post - operative pain3.
There are 2 major types of pain which individuals may experience:
Acute - An unpleasant sensory and emotional experience associated with actual or potential tissue damage
such as surgical incisions and muscle strains.
This type of pain eases as healing occurs. Acute pain is defined and specific and settles within a 3
month period and is associated with a hope of recovery
Chronic - Cause by the abnormal processing of sensory input by the peripheral and central nervous system
such as back pain with no acute injury and diabetic neuropathy. This pain is very difficult to treat as
the tissue damage has already healed. Unfortunately chronic pain rarely subsides and consequently
patients may become depressed because of lack of hope for recovery and they often require multi-
professional support.
The treatment for these two types of pain can be very different, therefore the nature of the pain must be
diagnosed before the most effective treatment can be decided upon.
Points for consideration

Individuals who have the same condition will experience differing amounts of pain and require different
amounts and types of analgesia
Morphine should be titrated according to the patients pain assessment and in liaison with the acute pain
team

Pain relief does not obscure clinical signs and symptoms and therefore should not be withheld whilst
awaiting a diagnosis.
Uncontrolled pain is harmful.
Effects of uncontrolled pain

Pain which is uncontrolled may have a detrimental effect on various systems within the body. This becomes more
pronounced if the patient has pre-existing co-morbidities, and may ultimately contribute to the patients death.
Some of these adverse effects are listed below:

Body System Effects
Respiratory: Decreased tidal volume, chest splinting, increased respiratory rate, reduced O2
saturation and hypoxia, Ineffective cough, sputum retention, pyrexia, pulmonary
infection, sepsis.
Cardiac: Tachycardia, hypertension, increased cardiac output, increased peripheral vascular

resistance, increased myocardial O2 consumption leading to potential ischaemia,
hypercoagulation, DVT, and reduced wound healing.
GI/Renal: Reduction in gut and bowel motility, increased risk of paralytic ileus, nausea and
vomiting, retention of urine caused by increased ADH secretion.
Endocrine/ Increase in ADH, epinephrine, nor-epinephrine and cortisol secretion. Fluid retension
Metabolic : and raised glucose.
Musculoskeletal: Muscle spasms, impaired muscle function, fatigue, immobility and increased risk of DVT
Immune : Suppression of WCC production, increased risk of infection and sepsis.
Quality of life: Sleeplessness, anxiety and fear.
Pain assessment
In order to ensure that pain is managed effectively, thereby reducing the risk of problems developing, it is
essential that an accurate pain assessment is made. Pain is difficult to measure objectively as it is a personal and
subjective experience.
Although there are many pain assessment tools available, it is best practice to ask the patient to assess themselves.
Evidence suggests that doctors and nurses assessment of pain is limited6,7 as they often use their own subjective
opinions to assess the patients pain; preferring to rely on behavioural, physiological and psychological signs
which may be misleading and inaccurate 6. However, in the unconscious patient nursing and medical judgment
would need to be used.
Assessment tools:
Formal pain assessment tools are used to facilitate effective communication and assessment by reducing the
chance of error or bias.
It is important to bear in mind that a pain assessment tool is only effective if the patient can use it and understand
it. The most appropriate tool must be chosen in order to ensure accurate pain assessment. Below is an example

of a Verbal Rating Scale, which is quick and easy to use 7.
Plain Score Pain assessment
0 No Pain
1 Mild pain
2 Moderate pain
3 Severe pain
When using these tools, pain should be assessed on movement as well as at rest, to establish the severity. A four
question approach can also be used to ascertain valuable information regarding the pain. These are:
1. Location of the pain
2. Duration of pain
3. Severity
4. Effectiveness of previous medication
When recording routine physiological observations it is important to include pain assessment as this is considered
as the 5th vital sign by The Royal College of Anaesthetists and the Royal College of Surgeons. Oxygen saturation
and conscious levels should also be recorded and acted upon in order to prevent a further deterioration in the
patients condition. It is recommended that all patients receiving analgesia for moderate to severe pain relief
have an intravenous cannula in situ in case of severe adverse effects.
Types of Analgesia
There are several groups of analgesics which can be administered to a patient in acute pain.
Opioids
Opioids exert their effect by attaching themselves to opioid receptors found within the dorsal horn of the spinal
cord, blocking the release of a neurotransmitter (substance P) which is responsible for the transmission of pain
messages to the brain. They can be administered via various routes, and are very effective analgesics which have
no ceiling dose associated with them, however the dose must be titrated to the level of pain to reduce the risk
of severe side effects.
The most common opioid side effects are:
Nausea and vomiting
Sedation
Respiratory depression
Pruritis
However these side effects are easily treated. Examples of opiates used in acute pain include, Morphine, Fentanyl,
Oxycodone and Diamorphine.

Non-opioids
Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs exert their effect by inhibiting prostaglandin production which is involved in the inflammatory process
following tissue damage. By inhibiting prostaglandin production , the numbers of sensitising chemicals which
trigger the firing of the pain impulses along nerve fibres to the brain are reduced. Unfortunately, prostaglandin
is also responsible for a number of protective functions including the maintenance of the protective layer of the
stomach and platelet aggregation. In the longer term their administration may lead to side effects such as gastric
irritation and ulceration, bleeding, breathing problems (in some asthmatics) and renal impairment. It is for these
reasons that NSAIDs should be used with extreme caution in the acutely ill patient.
NSAIDs should be used with extreme caution in acutely unwell adults
Paracetamol
Paracetamol is also a non-opioid which is used widely to treat many painful conditions. The way in which
Paracetamol works is still unknown although it is believed to exert its effect within the central nervous system.
Both NSAIDs and Paracetamol can be administered by the oral, PR and IV routes and when administered in
combination with an opiate provide more effective pain relief with fewer opioid related side effects.
Adjuct Drugs
Local Anaesthetics
Local anaesthetics work by preventing the formation and transmission of pain impluses via nerve fibres. They
can be administered orally, topically, as a local wound infiltration, continuous peripheral nerve block or via
epidural infusion. An increasing number of surgical and orthopaedic procedures are now performed using
regional peripheral nerve blocks with the use of local anaesthetics. Specialist knowledge and training is required
to administer these as when given in high doses, local anaesthetics are known to be toxic.
Inhalation
The inhalational route of analgesic administration is commonly used by paramedics, midwives and Accident and
Emergency departments. This route is often overlooked but can be a very effective method as it allows a fast
onset of action and may be used in conjunction with IV administration in patients with severe pain.
Nitrous Oxide (Entonox)

Nitrous Oxide is a short acting inhalation anaesthetic, which provides rapid (within 20 seconds) and potent
analgesia with minimal depression of the respiratory, cardiovascular and central nervous system6. The exact
mechanism of action is still not fully understood, but it is believed to work centrally. As nitrous oxide expands air
it should not be administered to patients believed to have trapped air within body cavities as this may lead to
perforation. Entonox is contraindicated in some situations and must be used with caution.
Routes of Administration
There are several routes available for the administration of analgesia. The drug and the route of administration
will impact on the length of time to achieve peak plasma levels.

Intravenous (IV)
Administration by the intravenous route ensures a fast onset of action and therefore is the route of choice when
treating severe pain in acutely ill patients.
IV bolus
Intravenous boluses are administered to alleviate severe/unbearable pain within minutes. Doses are titrated at
5 minute intervals until pain relief is achieved. During titration observations of pain score, respiratory rate, O2
saturation and sedation score should be monitored every 5 minutes. The main benefit of this route is its fast
analgesic effect. Disadvantages include peaks and troughs in effectiveness due to the speed of metabolism, and
the duration of action may be shorter.
IV infusion
This route enables constant peak plasma levels to be maintained. The infusion rate must be titrated according
to patient need in order to reduce the risk of unwanted side effects. Patients with continuous IV opiate infusions
need to be nursed on a Critical Care Unit, as close observation of the patient is required at all times using an
ABCDE approach.
Patient Controlled Analgesia (PCA) infusion
This technique enables a patient to administer a pre-set bolus of an opiate intravenously. The pump has a lockout
period which prevents the patient administering more than the prescribed dose within a given time. PCA infusions
give the patient control of their own pain relief, thus providing psychological benefit, whilst avoiding problems
related to delays in the patient receiving analgesia. Patients who receive opioid analgesia via a PCA infusion often
require less opioid than if they had been given analgesia via alternative routes. Unpredictable absorption rates
and high plasma levels, as seen with IV infusions, are avoided. As with all opioid infusions the patient should be
closely monitored throughout the duration of treatment, using a structured ABCDE approach. There is a risk of
respiratory depression and hypotension. It is therefore essential that monitoring of BP and respiratory rate along
with other clinical observations are undertaken regularly in line with Trust policy.
Epidural
Epidural analgesia is considered to be one of the most effective methods of administering analgesia. It involves
the insertion of an epidural catheter into the epidural space. The catheter is then connected to an infusion
enabling the delivery of a combination of local anaesthetics and, in some cases, an opioid. The main advantages
of this route are increased blood flow, reduced sedative effect and minimal respiratory depression. The
disadvantages to this route are the length of time required to insert the epidural catheter before the epidural
can be initiated and lack of expert skill to insert the epidural. Once inserted there are possible complications to
be considered. Headache, nausea and dizziness are often a sign of epidural puncture and must be reported to
the anaesthestist immediately. Hypotension is commonly seen and is due to the sympathetic blockade leading
to vascular dilatation. Monitoring, recording of observations and level of block should be maintained according
to your local hospital policies. Epidural catheters carry the risk of infection as with any other invasive line. The
catheter site should be inspected regularly for signs of infection and removed either when the catheter is no
longer required or when signs of infection are evident.

Oral
If a patient is able to swallow the oral route is the preferred route of administration, as it is less invasive, and can
provide adequate pain relief for a wide range of pain intensities. Oral drugs may be given in tablet or syrup form.
They have slower absorption rates and so take time to reach therapeutic levels. This should be taken into account
when prescribing and administering analgesia orally to patients in acute pain.
Intramuscular (IM)
Although commonly used, the IM route is invasive and painful to administer especially after repeated injection.
The rate of absorption following IM injection is also variable as it is affected by factors such as muscle mass,
temperature and cardiovascular status. This can lead to a delay in onset of action by approximately 30 - 60
minutes when compared to oral administration. This route is therefore not recommended for the management
of acute pain.
Sublingual
Administration via this route enables absorption through the oral mucosa directly into the systemic circulation.
This route is commonly used to administer nitrates to patients experiencing cardiac pain. The sublingual route has
limited value for the administration of many opioids used in the management of acute pain because formulations
are lacking, absorption is poor and high does cannot be given.
Transdermal
Analgesia administered via this route is in the form of a patch, which delivers a continuous release of analgesia
directly into the skin over a period of 48-72 hours. However due to its slow onset of action (12-16 hours following
initial application) it is utilised mainly for the management of chornic and cancer pain.
Rectal
The rectal route offers an alternative to the oral route especially when patients are nil by mouth or vomiting.
When administered by this method approximately 50% of the drug is absorbed directly via the intestinal mucosa8
enabling a larger proportion of the drug administered to reach therapeutic analgesic effect. For the management
of severe acute pain, this route of administration can only be considered as a supplement to IV pain relief. Staff
need to be competent in the placement of suppositories and be mindful of the risks of bowel perforation.
With any route of administration, patient consent should be obtained wherever possible.
Monitoring the effects of analgesia

Following the administration of analgesia the effectiveness should be assessed at regular intervals using your
hospital policy.
Vital observations of respiratory rate, blood pressure, pulse, O2 saturation and, track and trigger scores must be
recorded. Assessment of pain at rest and on movement using a pain scoring tool is best practice. Assessment of
sedation levels is another important component in measuring the effectiveness of analgesia. The patients pain
should be controlled without compromising the patients neurological or respiratory function. Any abnormalities
must result in appropriate action to prevent further deterioration of the patients condition.

Pain score Sedation score
0 = No pain 0 = Wide awake/normal sleep

1 = Mild pain 1 = Occasionally drowsy/easy to rouse
2 = Moderate pain 2 = Frequently drowsy/easy to rouse
3 = Severe pain 3 = Somnolent/difficult to rouse
Management of adverse effects

As with all acutely unwell patients, it is essential to assess the ABCDE using the structured approach in order to
establish the exact cause of the problem.


Bag - valve mask
Breathing
Colour of patient
Oxygen saturation
Respiratory Depression is a possible secondary effect of opioids given by any route!
Respiratory rate <10/min

Review anlgesia prescription
Seek expert advice
Monitor AVPU scores
Sit patient upright if tolerated
Encourage deep breathing if appropriate
Respiratory rate <8/min

Call for URGENT HELP! e.g. anaesthetist or acute pain team
Follow steps as above
Consider Naloxone
*Caution is to be exercised when administering Naloxone as it may antagonise all opiod effects resulting in the
patient experiencing severe pain.

Hypotension
Hypotension may sometimes occur following the administration of opioid boluses, but is more frequently
associated with epidural infusions or local anaesthetics.
If systolic BP between 90 and 100mmHg:

Seek expert advice
Reduce opioid administration/epidural infusion if in situ, and check block level. Only stop epidural
infusion if advised.
Check for signs of haemorrahage
Cautiously increase IV fluids
If systolic BP<90mmHg:
CALL FOR URGENT HELP
Administer 250mls crystalloid/colloid over 5-10 minutes and assess response. Repeat as necessary.
Evidence of heart failure (chest crackles indicating pulmonary oedema) should be sought following
each bolus. Where this occurs, fluid therapy must be reduced or stopped, as an alternative means of
enhancing tissue perfusion may be required e.g., inotropes and/or vasopressors
Increase vital sign monitoring according to hospital policy
Senior expert help may consider the administration of Ephedrine, but it should only be administered if there is
little or no response to a fluid bolus and the patient is closely monitored in a high dependency area.

Pain assessment
Depressed conscious level can be a consequence of opioids given via any route!
If sedation score 2:
Seek senior help
Consider reducing infusion
Increase vital sign monitoring according to hospital policy

If sedation score 3:
. Seek expert help

. Stop infusion and consider titrating Naloxone * 200mcg IV/every 5 minutes
. Increase vital sign monitoring according to hospital policy
. Reassess pain and sedation scores
* Caution must be exercised when administering Naloxone, as it may reverse all opioid effects leaving the patient
in severe pain once more. In addition Naloxone has a relatively short duration of action, and subsequently its
effectiveness should be reviewed on a regular basis.

and back
Exposure
Review notes and charts
Review the type of medication and fluids that have been prescribed and whether they have been administered.
Assess and correct fluid balance status. Examine the notes carefully regarding co-morbidities and verbal reports
from other members of the health care team to aid understanding of the patients current condition.
Review investigations
Review recent investigation and blood results; correct any abnormalities. Decide whether further investigations
are required. This may include:
FBC/U&Es / Group and Save/clotting screen/ cardiac enzymes/troponin/lactate

Microbiology (blood, urine, sputum, wounds, drainage, tips from invasive medical
devices after removal and CSF)
E.C.G.
Ultrasound scan
CT scans
Monitoring
non-invasive blood pressure, heart rate, temperature, oxygen saturations, FiO2, conscious level and urine output.
Observations must be recorded regularly according to hospital policy. Any further deterioration warrants a
further assessment of ABCDE. Track and trigger scores should be utilised.
Management Plan
Diagnosis yes/no-Send for expert help if diagnosis uncertain.

communicated to those staff caring for the patient . Leave clear instructions about how often you require the
signs (including urine output) fall outside of these parameters. Consider further investigations and act upon the
results. Consider referral to other specialities and/or higher level of care.

Document definitive management plan and communicate with other members of the multi-professional team.
Identify what action you want the staff to take in the event of the vital signs deviating from pre-set parameters.
Summary

Describe the concept of acute pain
List the effects of uncontrolled pain
Describe how a pain assessment is performed
List the different groups of analgesia
State the various routes of administration
Explain the management of analgesia related side effects
acute pain
References
1. McCaffery, M., (1972) Nursing Management of the Patient with Pain, Philadelphia : Lippincott
2. Melzack, R., and Wall, P.D., (1965) Pain mechanisms: a new theory, Science, vol. 150, pp. 971-979
3. Audit commission, (1997) Anaesthesia under examination. Oxon: Audit commission
4. Morton, P.G., Fontaine, D.K., Hudak, C.M., and Gallo, B.M., (2004) Critical Care Nursing: A Holistic Approach,
8th edition, Philadelphia: Lippincott Williams and Wilkins
5. Zalon, M.L., (1993) Nurses assessment of postoperative patients pain, Pain, vol 54, pp. 329-334.
6. Carr, E., and Thomas, V.N., (1997) Ethical Issues in Pain Management, cited in V.N. Thomas, (1997) Pain: Its
nature and management, London : Bailliere Tindall
7. McCaffrey, M., Pasero, C.,(1999) Pain: Clinical Manual, New York: Mosby Inc
8. Warren, D.E., (1996) Practical use of rectal medication in Palliative care, Journal of Symptom Management,
vol. 11, no. 6, pp.378-387.
__________

8
Communication

Communication
Learning outcomes
Explain the importance of effective communication

List the barriers to effective communication
Outline the impact of ineffective communication on patient care
Describe an effective communication tool
State the importance of effective teamwork
Communication
Communication is a two way process. Information has to be sent, received and understood in such a way that it
means the same thing to all parties. We all consider ourselves expert communicators because we talk to people
every day, but talking every day is not the same as achieving the desired results through effective communication.
Aims of communication
To convey information, to the appropriate people, in order to achieve a satisfactory outcome by using verbal,
non- verbal and written communication. If your message is not clear, you may not succeed in achieving your
intended goal. For example:
A soldier at the end of a trench during the First World War was asked to pass a message down the line. Send
reinforcements - were going to advance he said. By the time it got to the end of the line it had turned into,
Send three and four pence - were going to a dance. This was not successful communication!
As previously mentioned, there are numerous methods of communication, and each has advantages and
disadvantages as described below.
Types of communication
Verbal
This is a quick way of passing on information and conveying emotion but may not result in the information being
understood. Be careful with the use of professional jargon; unfamiliar terminology without explanation inhibits
the ability of the receiver to understand and respond appropriately. Be aware of cultural and social limitations,
ensure the person receiving the information can hear and understand you. Bear in mind English may not be
his/her first language. Local dialect and colloquialisms must also be considered. Ensure that you speak clearly,
organise what you want to say, and use appropriate language for the listener.
Advantages
In face-to-face exchange, the respondents non-verbal reaction can be seen and interpreted. Tone of voice adds to
effectiveness of communication and conveys emotion. Feedback is obtained straight away and misunderstandings
can be corrected quickly and easily.

Disadvantages
The whole message is presented at one go, with very little time to think carefully and plan what you are saying.
Written
This is most effective when it is used to pass on information that will be used for reference, for example patients
notes and charts. It is essential that documentation is up to date, accurate and legible. This informs others of
the findings, action taken and management plan. It also acts as a historical reference point and assists with
continuity of care. It is an important medico legal document. Ideally, the following should be included:-
Date and time of entry
Summary of the past and present events regarding the patients current problem
Current clinical findings
Action taken
Response to treatment
Communication within multi professional team/patient/relatives
Management plan, including referral for senior advice - ensure you communicate a clear plan, clear
instructions and desired action if certain observation parameters are not met or deviate from what you
have specified
Date and time of next review and by whom
Signature, print name, status and contact details of person documenting the above
Advantages
A permanent record of events is maintained for all members of the team to access thus providing evidence should
it be required at a later stage. It is difficult to prove that events have occurred when there is no documentation.
Writing is a far more formal method of communication than verbal communication.
Disadvantages
If you make a mistake in written communication, it can be difficult to correct and you may not realise your
mistake until later. It often does not convey the rationale for decisions made.
Barriers to communication
It is important to be aware of barriers to communication and overcome them to promote effective exchange of
information. The respondent may be unable to see, hear, write, speak or share a common language; It is the skill
of the communicator that enables these barriers to be crossed effectively.
Communication has been identified as a major cause of adverse events, one American hospital reported that
60-70% of medical errors were due to poor communication1. However, communication problems are not solely
confined to the healthcare setting and in recognising this; the American military developed and introduced a
communication tool to ensure that relevant information is communicated effectively1. This tool is now being
adopted within the NHS to ensure high quality, safe patient care. It is SBAR - situation, background, assessment
and recommendation1. Ordering the information you wish to convey under the four headings will ensure that
concise and clear communication results in a timely response. It has been shown to enhance teamwork and
reduce risk2.
It has been suggested that providing written information combined with verbal communication increases
effectiveness3.

Review of the acutely ill patient
When an acutely ill patient is identified, the importance of obtaining timely and appropriate review is vital3.
Before making any attempt to call for help, ensure you have all the relevant information at hand and are clear
about your objectives. Gather together the observation charts, blood results, investigations and information
about the past medical history. Be polite but assertive emphasise the urgency of the situation and explain what
you want using SBAR to ensure that no information is omitted.
SITUATION - I am ......... Staff Nurse Smith
I am calling about.......Mrs Boggs aged 71
Ward.........21b
BACKGROUND - Admitted with.......She was admitted two days ago with constipation
Currentproblem......She is pale and clammy; MEWS/PARS/EWS score
ASSESSMMENT - ABCDE........... Her airway is patent; her respirations are 32/min, O2 saturation 88%
on 40% O2; BP 85/55, pulse 140bpm, no urine output in the last hour; She is V on
the AVPU score; Her abdomen is distended
RECOMMENDATIONS - Plan of action.......Please can you come as soon as possible? Is there anything I can
do in the meantime? When will you attend?
This successfully described the problem and identified the desired response. Where ineffective communication
occurs, there is a risk that the patient will not receive a timely or appropriate review, resulting in a delay in treatment.
Once a management plan has been decided upon, it is important that this is documented and communicated to
others members of the multi-disciplinary team caring for the patient.
SBAR is a technique designed to communicate critical information succinctly and brieftly
S
ITUATION
Identify yourself, the patient. State the problem concisely
What's going on with the patient right now?
ACKGROUND
B
what's the background on this patient?
How did we get to this point?
Review the chart.
Anticipate questions. (state the relevant medical issues.)
SSESSMENT
A
BCDE
What do I think the issue is?
Why am I concerned? (Provide your observations and evaluations of the patient current
state.)
R
ECOMMENDATIONS
What do you want from the person you are speaking to
What should you do meantime?
Monitoring plan (Suggest what should be done to meet the patient's immediate needs.)

Breaking bad news
The process of breaking bad news should be handled with compassion and sensitivity at a level approriate to the
individuals involved. Bad news broken badly can have devastating effects on the recipients, which may provoke
anger and bitterness, hinder future communications and result in complaints.
When done well, communication assists in generating trust between the multi professional team, patient and
relatives, and may help foster realistic expectations when dealing with bad news. Communication may fail on
both side.
Multi Professional team issues Relatives issues
Lack of communication skills Anxiety

Use of jargon Environment
Not enough time given Anger/resentment
Fear of blame Understanding
Inconsistency Concentration
Lack of documentation Physical impairment
When breaking bad news, honesty and consistency are required. Information needs to be relayed in a manner
understandable to both parties and their families. We need to exhibit effective listening skills and be aware of
non-verbal communication i.e. facial expressions, lack of eye contact etc. There may be times when an interpreter
is required, not just for language translation but also for sign language.
When breaking bad news it is important to ensure you have allowed plenty of time for the interview, ensuring
you will not be disturbed. Choose the environment carefully, it should be quiet and comfortable, and ideally have
a telephone to enable the relatives to make often-distressing calls in private.
Prior to the interview ensure you are aware of all relevant information:
Patients name
Age
Previous medical/surgical history
Current medical/surgical history
Current condition and diagnosis
Significant recent events
Prognosis
Who you are actually interviewing - relationship to patient
Establish what information the family already have
Establish why you are speaking to the family
Be sure to introduce yourself and any accompanying staff at the beginning of interview. Assess how much the
family actually understand, you could start by asking a simple question such as What do you understand so far?
Give information clearly, concisely and honestly. Maintain an open posture and eye contact; this means being
at the same level as the person you are talking to which may be either sitting or standing; this shows that you

are interested in the family and comfortable with the situation. Allow gaps and silences in order to give time for
relevant information to be absorbed.
If the family ask you a question that you do not know the answer to, inform them that you will put them in
contact with someone who can answer their query. Providing inaccurate information can result in bitterness and
misunderstanding and is often the source of anxiety and complaints.
At the conclusion of the interview, ensure you have given enough time to ask any further questions. It is important
that relatives feel able to ask questions after the interview, they may need time to
make sense of events and deal with resulting emotions.
Remember to document in the patients notes clearly and concisely the reason for the interview, staff and
patient/ family present at interview, information given including prognosis and outcome.
Teamwork
A team can accomplish more than its individuals, all of whom can provide an opportunity to develop new areas
of competence and skills for each other. The benefits of team working and pooling of each professional groups
unique expertise is supported by a growing evidence base5.
Combining collective competencies of the team ensures that care delivery can meet the needs of each patient.
Cooperation and communication between members of the multi professional team is paramount in delivering
effective care for the acutely unwell patient as it may have a direct impact on morbidity and/or mortality. The
provision of a seamless service demands multi professional working, communication and learning6.
Each professional has a unique contribution to make to the team effort. Whilst acknowledging the overlap in
skills of different health care professionals, clinicians need to understand and accept the shift in emphasis from
professional identities to a team focus7.
Summary
Explain the importance of effective communication

List the barriers to effective communication
Outline the impact of ineffective communication on patient care
Describe an effective communication tool
State the importance of effective teamwork.
References
1. Shifting Perspectives (2007) www.xnet.kp.org - This reference is to be removed and then all numbers adjusted
in the text accordingly.
2. Leonard, M., Graham, S., Bonacum, D., (2004) The Human Factors: the critical importance of effective
teamwork and communication in providing safe care. Quality and Safety in Healthcare, vol. 13, pp. i85 - i90.

3. Harris, J., (2000) Some introductory thoughts on bioethics and research. Health Care Ethics. Still need to
check this - cant find the reference
4. Franklin, C., Matthew, J., (1994) Developing strategies to prevent in hospital cardiac arrest:
analysing responses of physicians and nurses in the hours before the event. Critical Care Medicine, vol. 22,
pp. 244-247
5. Cook, G., Gerrish, K., Clarke, C., (2000) Decision making in teams: issues arising from two UK evaluations.
Journal of Inter-professional Care, vol. 15, no. 2, pp. 141-151
6. Department of Health, (2000) A health service of all the talents: developing the NHS workforce. London:
Department of Health
7. Department of Health, (2000) Working together. Securing a quality workforce for the NHS. London: Department
of Health
__________

ABBREVIATIONS
ABCDE The structured approach to assessment IM Intra Muscular
Airway Breathing Circulation Disability
IV Intra Venous
Exposure
JVP Jugular Venous Pressure
ABG Arterial Blood Gas
K+ Potassium
ADH Anti Diuretic Hormone
kPa Kilopascal
AIM Acute Illness Management
LFT Liver Function Tests
ALERT Acute Life-threatening Event
Recognition and Treatment L/min Litres per minute
AVPU Alert, Voice, Pain, Unresponsive MAP Mean arterial pressure
AXR Abdominal X-ray ml Millilitres
BP Blood Pressure mmHg Millimetres of mercury
CCRiSP Care of the Critically Ill Surgical Patient mmol Millimoles
CO Cardiac Output
NSAIDs Non Steroidal Anti Inflammatory Drugs
CO2 Carbon Dioxide
O2 Oxygen
COPD Chronic Obstructive Pulmonary Disease
PaCo2 Partial Pressure of Carbon Dioxide in
CSF Cerebrospinal Fluid arterial blood
CVA Cerebrovascular Accident PaO2 Partial Pressure of Oxygen in arterial blood
CVP Central Venous Pressure PCA Patient Controlled Analgesia
CVS Cardiovascular System PE Pulmonary Embolus
CXR Chest X-ray PERL Pupils equal and reacting to light
DNAR Do Not Attempt Resuscitation RR Respiration Rate
DVT Deep Vein Thrombosis SaO2 Oxygen Saturation of Arterial Blood
ECG Electrocardiograph SSI Signs and symptoms of infection
EEG Electroencephalogram SIRS Systemic inflammatory response syndrome
EWS Early Warning Score SpO2 Oxygen Saturation of Peripheral Arteria
FBC Full Blood Count Blood
FiO2 Fraction of inspired oxygen SVR Systemic Vascular Resistance
GCS Glasgow Coma Scale U&Es Urea and Electrolytes
Hb Haemoglobin U/O Urine Output
HR Heart Rate VF/VT Ventricular Fibrillation/Ventricular
ICP Intra Cranial Pressure Tachycardia

GLOSSARY OF TERMS
Acidosis Decreased pH of the blood

Baroreceptor Sensory nerve terminals, sensitive to changes in pressure
Bradycardia HR <60 beats/min
Cardiogenic Cardiac in origin
Chemoreceptor Sensory nerve terminals, sensitive to changes in pH, CO2, and O2
Colloid A synthetic plasma expander with a large molecular weight and a high oncotic pull
(e.g. Haemocel/Gelofusine)
Crackles A dry crackling sound
Crystalloid A clear solution (e.g. 0.9% sodium chloride solution)
CT scan Computed tomography scan
Cyanosed A bluish discolouration due to reduced/unsaturated Hb
Emphysema Enlargement of the air spaces distal to the terminal bronchioles with
destruction of the alveolar walls
Encephalitis Inflammation of the brain
Encephalopathy Disease of the brain
Flail segment Detachment of ribs from sternum (abnormal mobility)
Glomerulus Small mass of capillaries in the nephron
Haematoma Collection of extravasated blood
Hypercapnia Excessive CO2 in the blood
Hyperkalaemia Excessive K+in the blood
Hyper - resonance Increased sound above the normal, and often of lower pitch, on percussion
of an area of the body
Hypertonus Distinct increase in muscle tone or tension
Hypoglycaemia Abnormally low blood glucose level
Hyponatraemia Abnormally low blood Sodium level
Hypotonic Distinct decrease in tone or tension
Hypoxaemia Deficient oxygenation of the blood
Hypoxia Diminished availability of O2 to the tissues
Kyphoscoliosis Abnormal curvature of the spine
Meningitis Inflammation of the meninges

Methaemoglobinaemia A large portion of the Hb converted into methaemoglobin by injury or
toxic agents, which is unable to carry O2
Minute volume Tidal volume multiplied by respiratory rate
Necrosis Cell death
Nephritis Inflammation of the nephron
Paralytic ileus Paralysis of the bowel
Pectus carinatum A deformity of the chest characterised by a protrusion of the sternum and ribs
Perfusion Blood flow through the vessel of an organ
Pleural Effusion Fluid in the pleural cavity
Pneumonia Consolidation and inflammation of the lung
Polycythaemia Increased red cell mass
Rhabdomyolisis Distegration of muscle fibres caused by uncontrolled seizures activity,
crush injury, alcohol withdrawal, and burns
Sepsis The presence of pathogenic organisms or toxins in the blood
Stroke volume The amount of blood pumped out of the left ventricle in a single contraction
Surgical emphysema Air in the subcutaneous tissues
Tachycardia HR>100 beats/min
Tamponade (cardiac) Increased pressure in the pericardium, due to a collection of blood or fluid,
causing cardiac compression
Tension pneumothorax Increasing pressure in the pleural cavity caused by an accumulation of air
If untreated will clause lung collapse and mediastinal shift
Tidal volume The volume of air inspired during each breath
Uraemia Excess build up of urea in the blood
Vasoconstrictor Contracting the lumen of the capillaries and arteries

Notes :

Notes :

Notes :

Care of The Acutely Unwell Final

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Care of The Acutely Unwell Final

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Course Manual

CARE OF THE ACUTELY UNWELL PATIENT

E Head to Toe examination Front and

2 CARE OF THE ACUTELY UNWELL PATIENT

1. Recognition and assessment of the acutely ill patient : 9

2. Assessment and management of the patient with breathing problems : 22

Appendix 1 : Pulse oximetry

Appendix 2 : The three stages of respiration

3. Assessement and management of the patient with hypotension 42

5. Assessment and management of the patient with a poor urine output 57

6. Assessment and management of the patient with an altered level of consciousness 65

7. Assessment and management of the patient with acute pain 76

CARE OF THE ACUTELY UNWELL PATIENT 3

The benefits of this course are:-

1. Learning the skills to recognise the critically ill or deteriorating patient.

2. Applying structured method of assessment and management skills.

6. Personal and professional development requirement of completing the course

Patients at Risk of Deterioration

Failure to measure basic observations

Lack of recognition of the importance of worsening vital signs

Delay in response to deteriorating vital signs

The Key Priorities

4 CARE OF THE ACUTELY UNWELL PATIENT

The monitoring plan should take account of the:

Agreed treatment plan

The frequency of monitoring should increase if abnormal physiology is detected

Figure 1. Chain of Response

CARE OF THE ACUTELY UNWELL PATIENT 5

Training and Education

Care of the acutely unwell patient' course duration :

15 weeks programme includes

The aims of this course are

To optimise the outcome for patients at risk of developing acute illness.

6 CARE OF THE ACUTELY UNWELL PATIENT

CARE OF THE ACUTELY UNWELL PATIENT 7

Recognition and assessment of

The ABCDE approach

CARE OF THE ACUTELY UNWELL PATIENT 9

To enable the reader to :

Which patients are at risk of developing critical illness?

Patients at particular risk of developing critical illness include :

10 CARE OF THE ACUTELY UNWELL PATIENT

STEP 1 ASSESSMENT MANAGEMENT

A Are there added noises? Suction

B Symmetry of chest movement

E Perform head to toe examination, front Manage abnormal findings appropriately

Remember that any problems affecting Airway will affect Breathing,

CARE OF THE ACUTELY UNWELL PATIENT 11

A Are there added noises? Suction

Central cyanosis may be evident ; although this is a late sign of hypoxia.

12 CARE OF THE ACUTELY UNWELL PATIENT

Management of the airway

Consider now whether you need senior help

CARE OF THE ACUTELY UNWELL PATIENT 13

B Symmetry of chest movement

14 CARE OF THE ACUTELY UNWELL PATIENT

Consider now whether you need senior help

Management of breathing problems

Call for early and appropriate help

CARE OF THE ACUTELY UNWELL PATIENT 15

Hypotension is a late sign of cardiovascular compromise.

16 CARE OF THE ACUTELY UNWELL PATIENT

Management of cardiovascular problems